Browsing by Department "Division of Orthopaedic Surgery"
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- ItemOpen AccessAn alternative treatment for type B Ulnar Polydactyly(2009) Maree, Michelle Nerine; Dix-Peek, StewartRudimentary ulnar polydactyly is one of the most common congenital hand anomalies. These are conventionally treated by suture ligation in the neonatal period or by formal excision, when the child is one year of age. For the last three years, the Congenital Hand Unit at Red Cross Children’s Hospital has used vascular clip ligation as an alternative method of treatment for rudimentary ulnar polydactyly, based on the same principle as suture ligation, but with less associated complications. A study was performed at the unit, where two hundred and nineteen supernumerary digits were treated over a two-year period. The digits were ligated using a vascular clip, as an outpatient procedure.
- ItemOpen AccessAnterior-posterior view by full-body digital X-ray to rule out severe spinal injuries in Polytraumatized patients(2021-03-05) Häckel, Sonja; Hofmann, Elena; Anwander, Helen; Albers, Christoph E; Basedow, Jasmin; Bigdon, Sebastian F.; Exadaktylos, Aristomenis K; Keel, Marius J B; Dunn, Robert N; Maqungo, Sithombo; Benneker, Lorin M; Held, Michael; Hoppe, SvenBackground Spinal injuries are present in 16–31% of polytraumatized patients. Rapid identification of spinal injuries requiring immobilization or operative treatment is essential. The Lodox-Statscan (LS) has evolved into a promising time-saving diagnostic tool to diagnose life-threatening injuries with an anterior-posterior (AP)-full-body digital X-ray. Methods We aimed to analyze the diagnostic accuracy and the interrater reliability of AP-LS to detect spinal injuries in polytraumatized patients. Therefore, within 3 years, AP-LS of polytraumatized patients (ISS ≥ 16) were retrospectively analyzed by three independent observers. The sensitivity and specificity of correct diagnosis with AP-LS compared to CT scan were calculated. The diagnostic accuracy was evaluated by using the area under the ROC (receiver operating characteristic curve) for sensitivity and specificity. Interrater reliability between the three observers was calculated using Fleiss’ Kappa. The sensitivity of AP-LS was further analyzed by the severity of spinal injuries. Results The study group included 320 patients (48.5 years ±19.5, 89 women). On CT scan, 207 patients presented with a spinal injury (65%, total of 332 injuries). AP-LS had a low sensitivity of 9% (31 of 332, range 0–24%) and high specificity of 99% (range 98–100%). The sensitivity was highest for thoracic spinal injuries (14%). The interrater reliability was slight (κ = 0.02; 95% CI: 0.00, 0.03). Potentially unstable spinal injuries were more likely to be detected than stable injuries (sensitivity 18 and 6%, respectively). Conclusion This study demonstrated high specificity with low sensitivity of AP-LS in detecting spinal injuries compared to CT scan. In polytraumatized patients, AP-LS, implemented in the Advanced Trauma Life Support-algorithm, is a helpful tool to diagnose life-threatening injuries. However, if spinal injuries are suspected, performing a full-body CT scan is necessary for correct diagnosis.
- ItemOpen AccessApplication of Cones Calipers for cervical spine injuries(2017-06-01) Medical students 2017This describes the indication and application of cones calliper to reduce or immobilize a cervical spine injury.
- ItemOpen AccessAn assessment of undergraduate musculoskeletal training at Medical Schools in South Africa(2012) Dachs, Robert; Roche, StephenIncludes abstract. Includes bibliographical references.
- ItemOpen AccessBokSmart : medical management of suspected serious acute spinal cord injuries in rugby players(Academy of Science of South Africa, 2012) Dunn, Robert NInjury to the spinal cord with paralysis during rugby is rare but remains an emotionally charged issue, especially at schoolboy level. The game has evolved over the years with rule changes to reduce injury risk. Scrums were originally perceived as the high-risk phase of play and rule changes in the early 1990s have reduced the number of scrums per game by as much as 40%. Over time the ferocity of play has also increased with bigger, fitter players and possibly more at stake with professionalism. Catastrophic injury rates are low but still occur. Although risk and injury cannot be totally avoided in a contact sport, it does appear that there are deficits in the management of this risk and subsequent injury. SA Rugby has introduced an educational programme (BokSmart) to increase the level of understanding by players and support staff. This article was prepared for the BokSmart programme in an effort to highlight the deficits and provide a basic understanding of spinal injury. Terminology, diagnosis and appropriate investigations are dealt with. The early emergency management is discussed as would occur at the first medical point of contact. This allows standardisation of injury assessment so communication between personnel is clear. An algorithm has been suggested to provide an appropriate management strategy should an injury occur.
- ItemOpen AccessBokSmart:medical management of suspected serious acute spinal cord injuries in rugby players(2009) Dunn, Robert NInjury to the spinal cord with paralysis during rugby is rare but remains an emotionally charged issue, especially at schoolboy level. The game has evolved over the years with rule changes to reduce injury risk. Scrums were originally perceived as the high-risk phase of play and rule changes in the early 1990s have reduced the number of scrums per game by as much as 40%. Over time the ferocity of play has also increased with bigger, fitter players and possibly more at stake with professionalism. Catastrophic injury rates are low but still occur. Although risk and injury cannot be totally avoided in a contact sport, it does appear that there are deficits in the management of this risk and subsequent injury. SA Rugby has introduced an educational programme (BokSmart) to increase the level of understanding by players and support staff. This article was prepared for the BokSmart programme in an effort to highlight the deficits and provide a basic understanding of spinal injury. Terminology, diagnosis and appropriate investigations are dealt with. The early emergency management is discussed as would occur at the first medical point of contact. This allows standardisation of injury assessment so communication between personnel is clear. An algorithm has been suggested to provide an appropriate management strategy should an injury occur.
- ItemOpen AccessEvaluating basic knee arthroscopy skills in orthopaedic trainees in a limited resourse setting(2023) Berry, Kirsty; Held, MichaelBackground: Orthopaedic training in Southern Africa is largely focused on trauma, although elective procedures, such as knee arthroscopy are increasing. This is especially true in the private sector where most trainees will practice. The primary aim of this study was to assess the arthroscopic competency of orthopaedic trainees in a setting of limited resources. Methods: A prospective observational cohort study was carried out. Orthopaedic trainees of a Southern African university hospital performed basic arthroscopy on a knee model. Their surgical competency was assessed by two surgeons proficient in arthroscopy using the modified Basic Knee Arthroscopy Skill Scoring System (mBAKSSS). Results: A total of 16 trainees (12 male) were included (6 junior and 10 senior trainees). The median age of participants was 36 (34.8, 37). The median mBAKSSS was 28.0 (20.3, 32.5) but showed a large variability (12.0-42.5). The overall reliability was excellent with Cronbach's Alpha of 0.91 and interclass correlation of 0.91 [95% CI 0.75, 0.97]. Conclusions: The average knee arthroscopy proficiency of our trainees is comparable to those of international training programs, but there was great variability with inconsistent skills amongst the trainees. This calls for improved and reproducible arthroscopy training and skills transfer, exposure to procedures and ongoing assessment. Level of Evidence: II (Prospective observational cohort study)
- ItemOpen AccessEvaluation of diagnostic advances in Musculoskeletal Tuberculosis; the automated xpert MTB/RIF assay(2019) Held, Michael; Dunn, R; Zar, HeatherBackground Xpert MTB/RIF (Xpert) is a rapid, automated, onsite nucleic acid amplification test for tuberculosis (TB). It is effective for the diagnosis of pulmonary TB but there is limited evidence for its usefulness in extrapulmonary TB, particularly musculoskeletal TB. Aims and hypothesis The aim of this thesis was to investigate the diagnostic accuracy of Xpert for musculoskeletal TB and for rifampicin resistance against a gold standard of culture or histology. Site of disease, HIV status, and age of patients, and accuracy in spinal compared to extraspinal TB were investigated as secondary objectives. The overarching hypothesis was that Xpert is more accurate and would provide results faster than the gold standard for musculoskeletal TB, and that it would have a higher yield in HIV infected patients, adult patients, and patients with spinal disease. Methods Prospective studies of patients with suspected musculoskeletal TB, at the tertiary care hospitals Groote Schuur and Red Cross Children’s Hospital in Cape Town, South Africa, were undertaken from June 2013 to March 2015. The diagnostic accuracy of Xpert was compared to culture or histopathology. Findings 206 biopsies of 201 patients older than 13 years of age (23% HIV positive) were analysed. The sensitivity and specificity of Xpert was 92.3% and 99.1% respectively. Xpert detected 8 cases more than culture (p = 0.069) and positive results were available 17 days earlier (<0.001). The sensitivity of Xpert in HIV positive patients was 96.9% (31/32) versus 89.6% (43/48) in HIV negative patients (p=0.225). The sensitivity of Xpert for spinal biopsies was 93.8% (95% CI 86.0-97.9) with specificity of 97.6% (95% CI 87.4 – 99.9), compared to extraspinal biopsies with a sensitivity of 81.8% (95% CI 48.2 – 99.7, p=0.164) and specificity of 100% (95% CI 95.1 – 100%, p=0.186). 109 osteoarticular samples of children 12 years of age or younger, with a median age of 5.6 years (IQR 2.2 – 8.7) were analysed. Xpert provided a sensitivity of 73.9% (95% CI 51.6-89.8) with a specificity of 100% (95% CI 95.7 - 100) and was available at a mean of 0.8 days (0.46- 1.4) compared to 21 days (19 – 30) for culture (p< 0.001). All rifampicin resistant cases were correctly diagnosed. A trend towards higher sensitivity in spinal tissue as well as HIV infected patients was observed. This study also provides evidence that Xpert has a lower sensitivity in children than in adults, yet, still detects more cases of paediatric musculoskeletal TB and is faster than culture. Histology was a useful test for the diagnosis of musculoskeletal TB, especially in children, and should be used alongside Xpert to provide the highest yield possible to detect TB. Conclusion: These first large studies on the accuracy of Xpert for musculoskeletal TB provide evidence for the usefulness of Xpert in the diagnosis of spinal TB, extraspinal TB, in HIV positive patients, and in childhood musculoskeletal TB. Based on these results, Xpert should be recommended as the initial test for diagnosis as it is more sensitive and faster than the gold standard of liquid culture.
- ItemOpen AccessExamination of the Shoulder by 5th years 2015 08(2017-06-12) 5th year MBChB studentsShoulder examination
- ItemOpen AccessGunshot injuries of the spine(2005) Le Roux, J C; Dunn, R NThe Acute Spinal Injury Unit, relocated from Conradie Hospital to Groote Schuur Hospital in mid-2003, admitted 162 patients in the first year of its existence. A large number of these injuries were the result of interpersonal violence, particularly gunshot wounds. Aim. To review patients with gunshot injuries to the spine, with reference to neurological injury, associated injuries, need for surgery and complications. Methods. A comprehensive database is maintained to collect data on all spinal injury admissions. These data, as well as case notes and X-rays, were reviewed for all gunshot spine patients admitted to the Acute Spinal Injury Unit over a year. Forty-nine patients were identified. Thirty-eight were male and 11 female with an average age of 27.5 years (range 15 - 51 ± 8.53). The average stay in the acute unit was 30 (4 - 109 ± 28) days. Results. The spinal injury was complete in 38 and incomplete in 8, with 3 having no neurological deficit. The level was cervical in 13, thoracic in 24 and lumbar in 12. Only 9 patients improved neurologically. The spine was considered stable in 43 cases. Stabilisation was performed in the 6 unstable cases. The bullets were removed in 11 cases as they were in the canal. There were 55 significant associated injuries, viz. 14 haemo-pneumothoraces, 16 abdominal visceral injuries, 3 vascular injuries, 4 injuries of the brachial plexus and 3 of the oesophagus, 2 tracheal injuries, 1 soft palate injury and 11 non-spinal fractures. Complications included 3 deaths and discitis in 3 cases, pneumonia in 6 and pressure sores in 6. Conclusion. Gunshot injuries of the spine are a prevalent and resource-intensive cause of paralysis. There is a high incidence of permanent severe neurological deficit, but usually the spine remains mechanically stable. Most of the management revolves around the associated injuries and consequences of the neurological deficit.
- ItemOpen AccessHow does pre-reduction MRI affect surgeon's behaviour when reducing Distraction-Flexion injuries of the cervical spine?(2013) Fleming, Mark Alexander; Dunn, RobertIncludes abstract. Includes bibliographical references.
- ItemOpen AccessIntramedullary nailing of tibial non-unions using the suprapatellar approach: a case series(2021) Botma, Nicolaas; Laubscher, MaritzBackground: A number of treatment options are available for diaphyseal non-unions of the tibia, including intramedullary (IM) nailing. An infrapatellar entry point with the knee in deep flexion can make this procedure challenging, especially with associated deformity or an obliterated canal. The suprapatellar approach allows nail insertion with the knee extended, which facilitates correction of malalignment in the sagittal and coronal planes. The aim of our study was to review the outcome of diaphyseal tibia non-unions, treated with an intramedullary nail, using the suprapatellar approach. Method: We retrospectively reviewed consecutive cases with non-union of the tibial shaft, treated with a suprapatellar entry nail between May 2016 and January 2018. Patients who were previously managed with a nail or who had active sepsis were excluded. The rate and time to union, as well as complications were assessed. Results: Thirteen cases were included and followed up until union at a mean of 5.8 months. All were performed percutaneously, without opening of the non-union site. Two patients developed complications, although bony union was still achieved. Conclusion: A suprapatellar entry tibial nail is an acceptable treatment option for tibial non-unions not previously treated with a nail.
- ItemOpen AccessJoint Examination Videos for Medical Students(2015-08-05) Kruger, NickThe University of Cape Town Orthopaedic Department undertook to record a short series of medical student level training videos for Orthopaedic Examination. These included the spine, shoulder, elbow, hand, hip, knee, foot and ankle examinations. They are adequate for medical student level OSCE examinations and general practitioner level. An systematic approach to each joint examination is illustrated as well as attention to the specific provocative tests.
- ItemOpen AccessKnee pain, swelling and stiffness after total knee replacement : a survey of South African knee surgeons(2011) Garrett, Benjamin R; Walters, JIncludes bibliographical references (leaf 60).
- ItemOpen AccessLocking plates for distal femur fractures does an increased working length improve healing?(2013) Koller, Ian M; Maqungo, S; Walters, JDistal femur locking plates have become a very popular means of internal fixation because of their ability to provide stable distal periarticular fixation. In spite of this enthusiasm however several studies have reported significant problems with healing. In the distal femur it is recognized that locking plate fixation may be too rigid if used in certain configurations that limit the essential micro movement required for biological healing. Implant failure may arise from rigid configurations that cause excessive hardware stress concentrations. In an attempt to address these problems longer plates and an increased working length have been proposed to reduce construct rigidity. The purpose of our study is to investigate whether an increased working length translates into improved healing.
- ItemOpen AccessMinimally invasive CT-guiding excision of benign bone tumours(2018) Sluis-Cremer, Timothy Richard; HIlton, Thomas; Held, MichaelBackground: The management of osteoid osteoma (OO) and other small primary benign lesions of bone has evolved over the past 50 years from open surgery with wide resection margins to less invasive surgical techniques such as image guided intralesional excision and percutaneous radiofrequency ablation. We aim to evaluate the outcomes of patients treated with computerised tomography (CT guided) intralesional excision and bone grafting of small benign lesions of bone. Method: A retrospective folder review of patients treated in a large academic hospital in Cape Town, South Africa, between March 2012 and May 2016 was performed. Patient demographics, details of presentation, clinical information and outcome following treatment were analysed descriptively. Pre-operative diagnosis based on radiological examination was compared with histological diagnosis. Result: Eleven patients (5 male) with a median age of 16 years (range 5-33) were included. Pain was the most common presenting feature. A histological diagnosis of OO was confirmed in 5 of 9 patients with a suspected diagnosis of OO preoperatively. Of the 4 patients whose diagnosis changed after the procedure the diagnoses included a benign spindle cell lesion, a benign fibrous histiocytoma, subacute osteitis and an osteochondral defect with geode cyst formation. Of the 2 patients where OO was not suspected preoperatively, chondroblastoma was confirmed in one while a benign spindle cell lesion was reported in the other. Overall histological yield was thus 100%. There were no complications or repeat procedures at a median follow up of 42 months (range 30-52 months). Conclusion: CT guided intralesional curettage is a safe and minimally invasive technique. This is especially useful in less accessible regions of the skeleton as it provides a means of accurately locating the lesion with minimal risk of complications and morbidity to the patient. We consider this to be the optimal method of treatment in our setting as it provides high success rates, few complications and a histological diagnosis without the need for any additional and expensive equipment.
- ItemOpen AccessOsteonecrosis: Cape wine as an aetiological agent(1994) Makan, PradeepIschaemic necrosis of bone, particularly of the femoral head appears to be an increasing cause of musculoskeletal disability in relatively young people (Hungerford 1981). The disease is usually progressive, resulting in the destruction of major weight-bearing joints requiring arthrodesis or arthroplasty. A decade ago it was hoped that joint replacement would solve most of these problems, however, failure of such arthroplasties have often been associated with catastrophic consequences (Chandler 1979).
- ItemOpen Access“Out with the old and in with the new” - A retrospective review of paediatric craniocervical junction fixation: indications, techniques and outcomes(2019) Swan, Adrian Kenneth; Dunn, Robert NBackground: The paediatric craniocervical junction has anatomical, physiological and biomechanical properties that make this region unique to that of the adult spine, vulnerable to injury, and contribute to the complexity of management. Traditionally, on-lay fusion with external Halo immobilisation has been used. Instrumented fusion offers intra-operative reduction and immediate stability. Methods: A retrospective review of a single surgeon’s prospectively maintained database was conducted for all cases of paediatric patients that had undergone a fusion involving the occipito-atlanto-axial region. Case notes were reviewed and a radiological analysis was done. Results: Sixteen patients were managed with on-lay fusion and external immobilisation and twentyseven patients were managed with internal fixation using screw-rod constructs. The fusion rates were 80% and 90.5% respectively. Allograft bone grafting was found to be a significant risk factor for non-union. Conclusion: The screws can be safely and predictably placed as confirmed on radiological follow-up with a high fusion rate and an acceptable complication rate. Uninstrumented onlay fusion with Halo immobilization remains an acceptable alternative. Allograft in the form of bone croutons or demineralised bone matrix is a significant risk factor for non-union and posterior iliac crest graft should be used preferentially.
- ItemOpen AccessPelvic osteotomies for exstrophy : a review of techniques and outcomes at Red Cross Children's Hospital(2007) Dix-Peek, Stewart; Hoffman, EBIncludes bibliographical references (leaves 28-31).