BACKGROUND: Paediatric diaphyseal femoral fractures account for less than 2% of all paediatric fractures. Studies suggest that children aged 5-11 years who weigh < 49 kg with femoral diaphyseal fractures may be the best candidates for titanium elastic nails. Elastic flexible nailing has gained wide use because it offers good results with minimal complications in stable femoral diaphyseal fractures. However, the effectiveness of titanium elastic nails for the management of unstable paediatric femoral fractures remains debatable. This study aimed to elicit the effectiveness of titanium elastic nails in unstable paediatric femoral diaphyseal fractures when combined with postoperative immobilisation with skin traction METHODS: This retrospective review included paediatric patients aged 3-11 years with unstable femoral shaft fractures treated with titanium elastic nails who were admitted to the paediatric orthopaedic department at a tertiary academic hospital between January 2017 and December 2020, and had a minimum follow-up of six months. The unstable fractures were spiral, comminuted, or long oblique fracture patterns RESULTS: A total of 67 patients were reviewed, with a mean age of 6 (4-7) years. Fracture union was noted at eight (8-9) weeks. Fifty patients (75%) had excellent overall outcomes according to the Flynn score CONCLUSION: Retrograde titanium elastic nailing may be indicated for the management of unstable paediatric femoral fractures when supplemented by postoperative immobilisation with skin traction in the initial two weeks LEVEL OF EVIDENCE: 4
BACKGROUND: The aim of this study was to retrospectively review adolescent idiopathic scoliosis (AIS) patients treated surgically at a tertiary institution in the Western Cape. Additional objectives were to determine whether clinical parameters prior to surgery are associated with specific peri- and postoperative outcomes, and to determine crude costs of AIS treatment in this spinal unit METHODS: A retrospective observational study of clinical and radiological records was performed for 62 AIS patients treated between 1 January 2011 and 31 December 2019 at a tertiary academic hospital. Patient demographics and clinical characteristics were recorded, and appropriate correlation and associations were investigated, with post-hoc tests being performed where necessary, to investigate differences between multiple groups RESULTS: The median age was 13.5 (interquartile range [IQR] 12-15) years and the cohort included predominantly females. It took a median of 405.5 (IQR 227-1 019) days before patients presented at the spinal clinic, after which they waited a median of 275 (IQR 207-379) days for surgery. The mean Cobb angle at presentation was 63.3° ± 18.5°, compared to 71.2° ± 18.3° prior to surgery, with 18% of participants progressing from a 'non-severe curve' (< 70°) to 'severe' (> 70°) while awaiting surgery. A weak positive correlation was observed between the curve magnitude prior to surgery and the total theatre time, with larger curves requiring more theatre time. As expected, a significant association between the curve magnitude and the number of vertebrae levels requiring fusion (p < 0.001) was observed. The cost of treatment for the total study cohort amounted to more than R9 million, with a crude estimate of R89 807 per patient CONCLUSION: AIS patients treated in this study demonstrated long waiting times for surgery with a significant use of financial and physical resources. Eighteen per cent of patients progressed from a non-severe to a severe curve type due to prolonged waiting times. Early detection of AIS could potentially result in significant reduction of patients requiring surgery and as such, school and other screening programmes should be investigated as a potential tool to identify at-risk patients LEVEL OF EVIDENCE: 4
BACKGROUND: Radiofrequency ablation (RFA) is a well-established treatment for spinal facet joint pain, especially in developed countries. However, several aspects of RFA lack high-quality evidence and the treatment remains contentious. In South Africa, little is known about the perception of RFA or how widely it is utilised. This study investigated the knowledge, attitude and practices of South African spine surgeons concerning the use of RFA to treat chronic axial back pain METHODS: A survey was conducted at the 2023 South African Spine Society Congress. Spinal orthopaedic surgeons and neurosurgeons were eligible to participate. Responses were presented using descriptive statistics: overall and by subgroups who did and did not practise RFA. Factors associated with conducting RFA were investigated in univariate and multivariate analyses RESULTS: Eighty-nine spine surgeons completed the survey, of which 43 (49%) conducted RFA. Full-time private practice had the strongest association with conducting RFA (adjusted risk ratio 2.52, 95% confidence interval [CI] 1.23-5.16). Overall, 62 of 87 (70%) respondents regarded RFA as a good treatment option in certain patients, including 19 of 45 (42%) of respondents who do not conduct the procedure. RFA training was heterogeneous, with course attendance the most common source of training (16 of 41, 39%). RFA practitioners conducted a median of 50 RFAs per year (interquartile range [IQR] 20-80 RFAs per year), although ten practitioners conducted ≥ 100 RFAs per year CONCLUSION: Among the spine surgeons surveyed, there was majority support for the use of RFA in certain patients, and approximately half of respondents conducted the procedure. Findings of potential concern included heterogeneity in RFA training and the observation that a few surgeons conducted particularly high volumes of RFA. Further research should explore whether RFA is used appropriately and effectively in the South African setting by investigating patient selection and technique LEVEL OF EVIDENCE: 3
The main impetus for value-based care in South Africa, without a doubt, started with the forced introduction of the programme in 2018 by Discovery Health. At the time, a limited number of hospitals (per hospital group) and a limited number of surgeons (based on volume) were to be included in the programme. The work by Michael Porter and Elizabeth Teisberg (Harvard Business School) and the adoption of the system in the United States fast-tracked the process.1 It has long been known that higher volume centres achieve better results with primary hip and knee arthroplasty.2 What exactly the cut-off in a South African context should be remains debatable. This change in direction of funding prompted several healthcare groups (Life Healthcare and Mediclinic) to start their own programmes. Third party funders like ICPS (Improved Clinical Pathway Services) and JointCare also gained momentum.
BACKGROUND: Bioceramics are gaining popularity as dead space management in chronic osteomyelitis. They are bioabsorbable, have good antimicrobial activity, promote bone healing, and have a low complication profile. Several bioceramics are available in South Africa. This study investigates our experience of bioceramics in terms of outcomes and complications in managing osteomyelitic dead space. METHODS: A retrospective review was conducted on bioceramics in the management of chronic osteomyelitis of the appendicular skeleton between January 2016 and November 2022. The bioceramics used as dead space management strategies are: bioactive glass (S53P4 - BonAlive Biomaterials), and antibiotic-impregnated bone substitutes, i.e. Cerament G/V (Bonesupport) or Osteoset with added gentamycin (Wright Medical Group). RESULTS: The final cohort comprised 90 patients with a mean age of 34 years. The mean follow-up was 12 months (12.7 ± 8.6). Most patients were classified as Cierny and Mader (C&M) type 3 (61%), followed by C&M type 4 (37%). A total recurrence rate of 3% was noted. The recurrence rate per bioceramic used was 0% for Osteoset, 2% for bioactive glass, and 5% for Cerament. CONCLUSION: Bioceramics are a popular alternative to PMMA in the management of osteomyelitic voids, especially in the setting of single-stage surgery. Several bioceramics are currently available in South Africa. Outcomes of bioceramics in the management of chronic osteomyelitis are encouraging and in keeping with international literature.
BACKGROUND: Proximal interphalangeal joint (PIPJ) contractures are common sequelae following trauma to the hand and represent a treatment impasse in South Africa's resource-constrained setting. Various splinting techniques are advocated for first line management, but there is no consensus on the optimal splint, and many studies report equivocal outcomes between modalities with only moderate improvements. This proof-of-concept study aimed to describe the design, production and use in a single case, of a 3D-printed splint, within an environment with limited access to therapy. METHODS: The evolution in the design idea that yielded the final concept is described and a case in which the splint was used for a patient with a PIPJ flexion contracture, secondary to soft tissue trauma of a single finger, outlined. RESULTS: The splint was designed using computer-assisted design (CAD) software, printed to custom-fit the patient, applied, and contracture improvement serially monitored. The PIPJ contracture was fully corrected and maintained at three months post cessation of splint use. No complications were experienced by the patient. CONCLUSION: We describe a custom 3D-printed cable tie-assisted static progressive splint from conception to application to a patient. The patient had a 15° flexion contracture of his PIPJ which corrected uneventfully. Further investigation is warranted to determine applicability and safety of the splint for use among patients with PIPJ contractures of variable severity, chronicity and aetiology.
BACKGROUND: Hand infections can cause serious morbidity and financial implications to patients and healthcare systems. This retrospective cohort study investigates the epidemiology of bacterial hand infections at a tertiary institution over a year, with a secondary objective of investigating factors that modify risk for complications METHOD: Patient demographics, clinical information, microbacterial spectrum, timeframes of patient's pathway, and risk factors for complication development were investigated. Data related to antibiotic cover and any resistance to commonly used antibiotic therapy, specifically co-amoxiclav (Augmentin) and cloxacillin, was also captured. Relationships between risk factors and complications were investigated with a chi-squared or Fisher's exact test at an alpha-level of 0.05 RESULTS: Overall, 529 patients (mean age of 33.0 ± 15.6 years; 73% male) were included. A delay of a median of 6.0 (IQR 3.0-9.0) days between onset of symptoms and admission occurred. Complications were experienced by 23% (n = 124) patients. These patients required soft tissue cover (55%, n = 69), relook-debridement alone (34%, n = 42), or an amputation (10%, n = 13). Methicillin-sensitive Staphylococcus aureus (MSSA) was most frequently cultured, at 79% (n = 281) of all cultured organisms. More of the cultured organisms were sensitive to co-amoxiclav (86%, n = 305) than they were to cloxacillin (78%, n = 278). Patients with necrotising fasciitis and co-amoxiclav resistance had a statistically significant increase in complications CONCLUSION: The findings of this study highlight a high burden of hand infections as well as a high rate of complications following treatment. Furthermore, co-amoxiclav was an appropriate choice of antibiotic cover in this population. Finally, patients with necrotising fasciitis and those with co-amoxiclav-resistant infections are more at risk of complications. These findings should be taken into consideration when treating patients with hand infections LEVEL OF EVIDENCE: 3
BACKGROUND: Registries have been created to accrue comprehensive clinical data for evaluation, with purported benefits for clinical governance, public health and scientific investigation. As has been the experience internationally, orthopaedic surgeon contribution to data collection for the South African Orthopaedic Registry (SAOR) has been moderate. Due to this response, several awareness initiatives were implemented by the South African Orthopaedic Association (SAOA) to encourage surgeons to engage with SAOr. This study aimed to evaluate the efficacy of these initiatives. METHODS: This retrospective study evaluated SAOR's operational data between 1 August 2019 and 30 June 2022. For each month, the number of new surgeons registering, new patients captured, and new registry pathways initiated were evaluated. These monthly increases were evaluated relative to the implementation of several awareness initiatives. Multiple linear regression was performed to determine if any initiative significantly increased recruitment rates. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist was used for reporting. RESULTS: Thirty-five months of SAOR operational data were analysed. The cumulative number of surgeons enrolled to use the registry by June 2022 was 108, the number of patients captured 9 992, and the number of pathways initiated 9 585. Thirty-three awareness initiatives of four types took place in the period from January 2021 until June 2022. No interventions increased the recruitment of surgeons. Group promotional sessions and virtual group demonstrations significantly increased the number of patients captured on the registry. Group promotional sessions significantly increased the number of pathways initiated. CONCLUSION: The SAOR was established in 2019 by the SAOA with the intent to improve orthopaedic practice in South Africa. Several awareness initiatives have been implemented to engage surgeon contributions to the registry, none of which increased enrolment of new surgeons, but some of which increased the number of patients captured and pathways initiated. Ways to improve surgeon engagement with registries should be the focus of future research.
BACKGROUND: Paediatric diaphyseal femoral fractures account for less than 2% of all paediatric fractures. Studies suggest that children aged 5-11 years who weigh < 49 kg with femoral diaphyseal fractures may be the best candidates for titanium elastic nails. Elastic flexible nailing has gained wide use because it offers good results with minimal complications in stable femoral diaphyseal fractures. However, the effectiveness of titanium elastic nails for the management of unstable paediatric femoral fractures remains debatable. This study aimed to elicit the effectiveness of titanium elastic nails in unstable paediatric femoral diaphyseal fractures when combined with postoperative immobilisation with skin traction METHODS: This retrospective review included paediatric patients aged 3-11 years with unstable femoral shaft fractures treated with titanium elastic nails who were admitted to the paediatric orthopaedic department at a tertiary academic hospital between January 2017 and December 2020, and had a minimum follow-up of six months. The unstable fractures were spiral, comminuted, or long oblique fracture patterns RESULTS: A total of 67 patients were reviewed, with a mean age of 6 (4-7) years. Fracture union was noted at eight (8-9) weeks. Fifty patients (75%) had excellent overall outcomes according to the Flynn score CONCLUSION: Retrograde titanium elastic nailing may be indicated for the management of unstable paediatric femoral fractures when supplemented by postoperative immobilisation with skin traction in the initial two weeks LEVEL OF EVIDENCE: 4
BACKGROUND: Tenofovir disoproxil fumarate (TDF) is classified as a nucleoside reverse transcriptase inhibitor (NRTI). TDF is integral to several first-line treatment regimens for HIV and post-exposure prophylaxis. This case details an example of severe tenofovir-induced osteopaenia. We hope to raise awareness of this side effect so that it may be screened for more effectively and to provide an approach to management in secondary care. CASE REPORT: We present the case of an HIV-positive, 52-year-old woman who had been on TDF treatment for over ten years. She presented complaining of progressively worsening weakness, bone pain and immobility and sustained spontaneous fractures of multiple long bones. Tenofovir-induced hypophosphaetemic osteomalacia and osteopaenia was diagnosed based on clinical, radiographic and laboratory findings. DISCUSSION: The patient was successfully treated through the fixation of her long bone fractures with intramedullary nails and prophylactic nailing of the remaining long bones in her lower extremities. She received calcium and phosphate supplementation, and the causative agent was stopped. CONCLUSION: HIV-positive patients on TDF should be screened routinely for renal function, and symptoms such as bone pain should not be ignored. Cessation of the causative agent and correct supplementation are critical adjuncts to surgical intervention for improved outcomes in these patients. In cases of severe osteopaenia, orthopaedic surgeons should consider prophylactic fixation of long bones and use intramedullary fixation where possible.
BACKGROUND: Total joint arthroplasty (TJA), including total knee arthroplasty (TKA) and total hip arthroplasty (THA), are successful orthopaedic procedures, with survivorship reported at 98% at ten years and 95% at 20 years. The development of robotic-assisted total joint arthroplasty (RA-TJA) is one example of the continual evolution in technology in an attempt to improve these numbers. The use of RA-TJA is increasing, with little known about the potential factors which may impact the decision of surgeons to integrate robotic-assisted technology into their clinical practice. The aim of this study is to assess the usage and opinions of orthopaedic surgeons in South Africa regarding RA-TJA METHODS: An anonymous online survey was distributed via email to all orthopaedic surgeons registered with the South African Orthopaedic Association (SAOA). Analysis was subsequently undertaken to establish factors which might influence opinions regarding RA-TJA RESULTS: In total, there were 155 responses, with 37% (n = 57) of respondents being fellowship-trained in arthroplasty, either nationally, internationally or both. Seventy-one per cent (n = 110) of respondents were in private practice only, 6% (n = 9) in state practice only, and 23% (n = 36) in both. Forty-four per cent (n = 68) of surgeons are using RA-TJA, with 8% (n = 13) using both RA-THA and RA-TKA, 1% (n = 2) using RA-THA only, and 34% (n = 53) using RA-TKA only. The most common reason for using RA-TJA was higher precision in reproducibility of the procedure, at 91% (n = 62). The most common reason for hesitation in using RA-TJA is cost, at 69% (n = 60). Forty-seven per cent (n = 73) of surgeons believe it takes 11 to 20 cases to become competent using RA-TJA. The formation of an RA-TJA special interest group was agreed to by 71% (n = 110) of respondents CONCLUSION: The usage of RA-TJA in South Africa is higher than in other nations but it follows the same trend that there are more surgeons not using RA-TJA. Cost, lack of long-term data proving superiority, and the learning curve are the most common reported obstacles to RA-TJA, with improved precision a common reason for adopting RA-TJA. RA-TJA is a broad term, and further analysis of the type of systems currently in use and their possible perceived benefits will provide more information regarding the use of RA-TJA LEVEL OF EVIDENCE: 3
BACKGROUND: The purpose of conducting this review was to determine the optimal medical and surgical management of patients in the adult population with foot and ankle tuberculosis from the available literature. METHODS: A systematic literature search was undertaken through PubMed, Web of Science, Scopus, and the Cochrane Library. The phenomenon of interest was defined as tuberculosis of the foot and/or ankle in patients over 14 years of age. A qualitative data description was performed and reported as per Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines. RESULTS: The median total duration of medical treatment was 12 months (range 6-18). Most studies used a combination of rifampicin, isoniazid, pyrazinamide and ethambutol as intensive phase treatment for a median duration of two to three months. The continuation phase involved two or three agents for up to 16 months. The most common indication for surgery in active disease was failure to respond to medical treatment alone. In quiescent disease, surgery was employed for impending midfoot collapse or painful, deformed joints. It was found that 17% of patients (32 of 184) required arthrodesis. CONCLUSION: Medical treatment remains a mainstay of management. Evidence supporting surgical management in early disease is limited. No single approach, implant or fixation method for the purpose of arthrodesis has been proven superior to another. Further research is needed, specifically comparative studies to address the lack of consensus surrounding surgical intervention.
BACKGROUND: Hand infections are exceedingly common conditions that are associated with significant morbidity. Sound anatomical and microbiological knowledge is required to effectively manage these entities and to prevent or limit disability. The cornerstones of treatment remain surgical drainage of pus collections, judicious use of antimicrobial agents, and rehabilitation. Empiric antibiotic guidelines should target common organisms based on regional aetiological patterns, with strong consideration of host factors. The aim of this study was, therefore, to evaluate the epidemiology and suitability of empiric antibiotics in hand infections requiring surgical drainage at a centre in the Northern Cape province of South Africa. METHODS: A retrospective chart review of patients with hand infections requiring surgical drainage was conducted over a 24-month period between 1 January 2018 and 31 December 2019. The data was collected at an institution in the Northern Cape, which serves as the referral centre for the majority of the rural areas in the province. Culture results were obtained from the specimens collected during surgical drainage and debridement, and were accessed from the National Health Laboratory Service (NHLS) website. RESULTS: Of the 414 specimens, 388 yielded positive cultures and 26 had no growth. In total, 403 organisms were cultured. This consisted of 374 Gram-positive organisms (93%), and 29 Gram-negative organisms (7%). Staphylococcus was the most common organism isolated in 368 cases. Three-hundred and forty (84%) of these were methicillin-sensitive Staphylococcus aureus (MSSA), and 24 (6%) were methicillin-resistant Staphylococcus aureus (MRSA). With the low rates of MRSA cultured, caution should be exercised when generalising these results for the population. The mean age of patients was 31 years 10 months (standard deviation 14 years 5 months), with a 4:1 ratio of males to females, and the most common site of infection was the webspace (27%). CONCLUSION: Staphylococcus is still overwhelmingly the most common causative organism in hand infections in this population. Low numbers of MRSA were detected, but this still represents a five-fold increase in the region over the past decade. Urgent surgical drainage and bacteriological sampling before empiric antibiotics that target local common organisms remains the mainstay of treatment. Consultation with an infectious disease specialist to maximise efficacy of antibiotic selection and dosing can limit the growing problem of antibiotic resistance. In this setting, the use of cloxacillin as a single empiric agent is still recommended, though the increasing prevalence of MRSA needs to be monitored
BACKGROUND: Periprosthetic joint infection (PJI) following shoulder arthroplasty is costly and difficult to treat. Effective perioperative infection prevention is thus of utmost importance. Recent years have seen advances in the scientific literature pertaining to infection prevention in shoulder arthroplasty, including an International Consensus Meeting (ICM). However, little is known about infection prevention practices in South Africa and to what extent they reflect the latest evidence. Therefore, the aim of this study was to investigate the current perioperative infection control practices for primary total shoulder arthroplasty among South African orthopaedic surgeons METHODS: This cross-sectional study involved a survey conducted at the annual South African Shoulder and Elbow Surgeon Society Congress in 2023. The survey was developed based on the study aim and the existing literature. Surveys were distributed to delegates in paper-based form, and responses captured electronically for descriptive analysis RESULTS: Fifty-two of 75 (69%) orthopaedic surgeon delegates completed the survey. Forty-one (79%) were in full-time private practice. Among preoperative measures surveyed, 30 of 47 (64%) respondents used chlorhexidine only as a preadmission skin preparation, 46 of 51 (90%) used cefazolin only as a preoperative antibiotic, and 28 of 51 (55%) used 0.5% chlorhexidine gluconate in 70% isopropyl alcohol as a pre-incision skin scrub. Among intraoperative measures, 51 of 52 (98%) used double gloving, 26 of 52 (50%) used iodine-impregnated adhesive drapes, 37 of 52 (71%) always used tranexamic acid (TXA), 42 of 52 (81%) always used antibiotic impregnated cement, and 37 of 52 (71%) always redosed antibiotics for procedures > 2 hours. Postoperatively, 41 of 46 (89%) administered antibiotics for up to 24 hours CONCLUSION: There was a majority response for most of the items surveyed, indicating reasonable consensus in shoulder arthroplasty infection prevention practices. Most responses were generally in keeping with ICM recommendations, except routine use of TXA and antibiotic-impregnated cement. These measures were deemed by the ICM to have insufficient evidence. A minority of respondents indicated practices that show room for improvement in reducing periprosthetic joint infection risk LEVEL OF EVIDENCE: 3
