OpenUCT :: Browsing by Subject "Orthopaedic Surgery"

Browsing by Subject "Orthopaedic Surgery"

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Open Access
A Cross Sectional Evaluation of a Shoulder and Elbow Fellowship in a Low to Middle Income Country: Fellows' Perspective
(2022) Boskovic, Viseslav-Willy; Roche, Stephen
Background: There is a growing trend towards sub specialization and fellowship training in orthopaedic surgery. Data from the United States has shown that over 90% of orthopaedic residents plan to pursue fellowship training and there is a trend in the orthopaedic job market toward seeking fellowship-trained orthopaedic surgeons. Objectives: This study aimed to elucidate graduate perceptions of how undertaking the shoulder and elbow fellowship offered by the Department of Surgery, University of Cape Town (UCT) impacted their professional and personal development and to identify potential means of improving the quality of the programme. Methods: A descriptive, cross-sectional survey analysis was performed using an online questionnaire posing questions related to various aspects of the training programme. Subjects consisted of nine qualified orthopaedic surgeons who had completed the UCT Shoulder and Elbow fellowship. Survey questions were predetermined through discussion and agreement among the researchers. Results: All emails sent drew responses to the survey. An overall good to excellent level of satisfaction with the various aspects of the training program was reported by the fellowship candidates. Post-fellowship increase in arthroscopic and open surgical skill level, as well as understanding of research, was found to be significant. The majority agreed that the fellowship had adequately prepared them for work in their current setting. The candidates strongly agreed that the fellowship enhanced their abilities, when compared to their peers, in pre-operative decision making, intra-operative decision making, formulating ethical judgements, operative surgical skills and teaching ability. Conclusion: The results confirm the positive impact of the fellowship on post-training levels of confidence across clinical, research, decision-making and educational domains by Fellows. The study highlights the benefits of post-graduate fellowship training with the analysis being broadly applicable to similar training programmes globally. It underscores the importance of continuous evaluation of fellowship programmes.
Open Access
Adherence to Standard Operating Procedure for patients with Acute Cervical Spine Dislocated Injuries: A case of a teaching central referral hospital in South Africa
(2022) Ayik, Goud; Kruger, Nicholas
1.1.1 Aims: To analyse the impact that the adoption of our institutional standard operating procedure (SOP) for cervical spine dislocations had on the timing of closed reduction at our hospital. 1.1.2 Patients and methods: The study was a retrospective review of patients who presented to our institution with cervical dislocation injuries and were managed with closed reduction. The patient records of acute cervical spine dislocations from 2015 to 2018, Data from the Acute Spinal Cord Injury database along with patient's demographic information were gathered and compared. Participants within the study time frame were diagnosed with a cervical facet dislocation based on clinical examination findings and radiological confirmation. Patients who had reduction performed at other referring hospitals were excluded from the study. 1.1.3 Results: The practice within all tertiary hospitals in the Western Cape is to perform closed reduction of cervical fracture dislocations as soon as possible after injury. In this study the time between injury and closed reduction before introducing the SOP was13 h 13 min and after introducing the SOP, the time increased to an average of 14 h 28 min. The main cause of delay was the transfer time from the site of injury to emergency ward. Other reasons for the delay include missed diagnosis, orthopaedic registrar unavailability, and incomplete reduction bed. 1.1.4 Conclusion: This study found that the time taken for orthopaedic management of cervical dislocations increased by an hour after introduction of the SOP. Additionally, the overall time to reduction also increased This was due to delays in transfer to the emergency ward and referral to Orthopaedics. We recommend that in our setting, reduction could be initiated within an hour of patient arrival, if emergency ward doctors rapidly identified the problem and commenced cervical traction when the orthopaedic team was not immediately available. Our impression was that there was poor adherence to the new SOP guidelines on time management by the trauma team, and possibly transport delays prior to hospital admission. A further study to investigate the bottlenecks of the referral system is advisable.
Open Access
An alternative treatment for type B Ulnar Polydactyly
(2009) Maree, Michelle Nerine; Dix-Peek, Stewart
Rudimentary 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.
Open Access
Amputation rate following tibia fractures with associated popliteal artery injuries
(2017) Roussot, Mark; Maqungo, Sithombo; Roche, Stephen
Objectives: 1. Determine the amputation rate; and 2. identify risk factors in patients with tibia fractures and associated popliteal artery injuries. Intervention: Amputation or limb salvage. Design: Retrospective case-control study. Setting: Level 1 trauma center. Patients: Thirty popliteal artery injuries with ipsilateral tibial fractures. Outcome measures: Primary and delayed amputation rates were determined. Risk factors tested for significance (Fischer's Exact) included: mechanism of injury, signs of threatened viability, compartment syndrome, fracture pattern, surgical sequence, and time delay from injury or presentation to revascularization. Results: The study group consisted of 22 males and 8 females, with a mean age of 31 years. Motor vehicle accidents and gunshot wounds constituted the mechanism in 17 and 11 patients respectively. Twenty-one were polytrauma victims. Intra/extra16 articular metaphyseal fractures (OTA 41 A-C) were recorded in 19 and diaphyseal (OTA 42 A-C) in 7 patients. Primary amputation was performed in 7 and delayed in 10 patients (overall rate 57%). No individual risk factors were predictive of amputation; however, the "miserable triad" of a proximal tibia fracture (OTA 41) with signs of threatened viability, and delay to revascularization ≥ 6 hours from injury or ≥ 2 hours from presentation was predictive of amputation (p = 0,036 and p = 0,018 respectively). Conclusions: We should aim to intervene within 6 hours following injury or 2 hours following presentation to reduce the risk of amputation. This provides a target for trauma teams even with uncertain time of injury. Level of Evidence: III.
Open Access
An assessment of undergraduate musculoskeletal training at Medical Schools in South Africa
(2012) Dachs, Robert; Roche, Stephen
Includes abstract. Includes bibliographical references.
Open Access
Clinical outcomes following reduction and pinning of lesser arc injuries without repair of the scapholunate interosseous ligament
(2016) HIlton, Thomas; Held Michael; Maree, Michelle
Study Rationale: Purely ligamentous lesser arc, Mayfield grade 3 and 4, perilunate dislocations (PLD's) are uncommon. Current recommendations are for open reduction and repair of the interosseous ligaments to prevent the development of scapholunate dissociation and degeneration to a scapholunate advance collapse (SLAC) wrist. This study proposes a less invasive treatment method which includes closed reduction and pinning alone without repair of the scapholunate interosseous ligament. We propose that the majority of patients will obtain good function and pain scores and the few that develop instability may still have a reconstruction performed through a naïve surgical field. Methods: Dislocations were reduced anatomically and held with buried k-wires which were removed at 6 weeks with no specific rehabilitation protocol observed. Subjective assessment included MAYO wrist scoring system, wrist range of movement, instability and grip strength testing. Radiological measurements included scapholunate distance, scapholunate angle, radiolunate angle and osteoarthritis. Results: 10 male patients, median age of 35, were followed-up for a median of 22 months. 7 patients underwent a closed reduction and anatomical pinning while 3 underwent open reduction due to unachievable reduction by closed means. All of these patients presented at a median of 14 days after the injury occurred. None of the patients had their scapholunate ligaments repaired or reconstructed. MAYO scores included, 3 excellent scores, 2 good scores and 5 fair scores. Instability was found clinically in 1 asymptomatic patient who had a positive Watson shift test. Radiological scores include a median scapholunate distance of 2mm, a scapholunate angle of 70° and a radiolunate angle of 15°. Osteoarthritis was found in 2 patients, all of whom were asymptomatic. Discussion: Current recommendations in the literature are that PLD's should be reduced via an open surgical technique with repair of the SLIL and percutaneous pinning. However the results of this treatment strategy are not optimal and do not confer uniformly good results. We propose a closed anatomical reduction and percutaneous pinning of the PLD. Our study shows that the majority of patients will demonstrate good function and pain scores when managed this way. A smaller number of these injured wrists will go on to develop instability. However the advantage of our method over the current recommendations is that when this happens the reconstruction of the SLIL will be made easier through a naïve surgical field. Conclusion: We recommend the closed reduction and anatomical pinning of a purely ligamentous lesser arc injury. This treatment strategy yields good results at medium term follow-up and preserves the option for the reconstruction of the scapholunate interosseous ligament should instability develop.
Open Access
Displaced intracapsular neck of femur fractures: dislocation rate after total hip arthroplasty
(2015) Shituleni, Sibasthiaan Gometomab; Maqungo, Sithombo
Background: Dislocation is one of the most common orthopaedic complications after primary total hip arthroplasty (THA). The reported dislocation rate in elective THR is 5 - 8%. This number increases up to 22% for THA done for neck of femur fractures. Larger femoral head sizes increase the head-neck ratio and range of motion before impingement, therefore reducing the dislocation rate. Due to the reported increase in dislocation for trauma, some surgeons prefer to do a hemi-arthroplasty or open reduction and internal fixation (ORIF). Methods: A retrospective review of all THA done for neck of femur fractures during 2006 - 2012 was undertaken at a large referral hospital. Records were reviewed for patient related and surgical risk factors. We excluded all pathological fractures, extra-capsular fractures and failed ORIF. Results: A total of 96 cases were identified as suitable for analysis. Average age at surgery was 73.2 years (range 30 - 81). Delay to surgery was 5.3 days (range 1 - 63). Average follow up period was 18.3 months (range 3 months - 4.3years). Four patients (4.3%) had a confirmed dislocation. The four patients who had confirmed dislocation had the following characteristics, 28 mm femoral head size, age over 60 years, 2 posterior approaches and 3 females, although not statistically significant. Conclusion: The outcomes of THR in patients with neck of femur fractures can be favourable and provide good long-term prosthesis survival. We report on low dislocation rate post total hip replacement for intra-capsular neck of femur fractures.
Open Access
Does the Intra-operatively measured Leg Length Correction compare to the Post-operative radiograph in Total Hip Replacement surgery?
(2021) Moonda, Zaheer; Nortjie, Marc
Aims This study aims to compare the leg length correction (LLC) measured intra-operatively using the Vertical Measurement SystemTM (VMS) in total hip arthroplasty (THA), with the LLC measured on a 6-week post-operative Xray. We also wanted to quantify any residual leg length discrepancy (LLD) using this method. Patients and Methods A prospective cohort study was conducted, in which patients undergoing primary THA were enrolled at two centres in Cape Town, over a period of 19 weeks. THA's were performed by four surgeons. Pre-operative leg length discrepancy measurements were obtained in 92 patients. The VMS was used to predict intra-operative leg length correction (LLC), and this measurement was compared to the post-operative leg length correction measured on the 6-week follow-up X-ray. These measurements were statistically compared using Mann-Whitney U Test. Results The difference between the intra-operative VMS calculation and the 6-week radiological measurement was not significant (p>0.05), with the difference in their mean values being 0.07 ± 3.26mm. In the cohort, 81.52% of the patients (n=75) were within 5mm of the target LLC, and 95.65% of patients (n=88) were within 10mm of the target LLC. The mean absolute residual LLD at 6 weeks was 3.22 ± 3.13mm. Conclusion The intra operative LLC measurement obtained using the VMS accurately predicts the 6-week post op radiographic LLC measurement.
Open Access
The effect of a change in plastering technique on the rate of Major Surgery in Congenital Talipes Equinovarus(CTEV)
(2016) Horn, Anria; Dix-Peek, Stewart
The Ponseti technique of manipulation and casting is reported to have almost eliminated the need for extensive soft tissue release in the treatment of idiopathic clubfoot. This technique of treatment has however not been universally adopted and results of treatment vary significantly between treatment centres. Furthermore, surgical decision making in the treatment of clubfoot is currently largely based on clinical findings as opposed to radiographic parameters. The Ponseti method of manipulation and casting was introduced at our institution in 2002, prior to which we used the Kite method. Both prior to, and following the introduction of Ponseti casting, surgical decision making was based on pre-operative radiology, and intra-operative clinical assessment. We propose to determine the impact on this change of plastering technique on the rate of major surgery performed primarily in our patients with idiopathic clubfoot. We also aim to determine whether or not pre- operative radiographs have any bearing on the surgery performed on these patients.
Open Access
Evaluating basic knee arthroscopy skills in orthopaedic trainees in a limited resourse setting
(2023) Berry, Kirsty; Held, Michael
Background: 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)
Open Access
Evaluation of diagnostic advances in musculoskeletal tuberculosis; the automated xpert MTB/RIF assay
(2016) Held, Michael; Zar, Heather; Dunn, Robert
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.
Open Access
French osteotomy for cubitus varus in children: a long term study over 27 years
(2016) North, David Martin; Hoffman, E B
Background: Cubitus varus is a cosmetically unacceptable complication of supracondylar fractures of the elbow in children. We have performed the lateral closing wedge (French) osteotomy to correct the varus for 27 years. More complex osteotomies have been described to correct the associated hyperextension and internal rotation deformities and to prevent a prominent lateral condyle. Methods: We retrospectively reviewed 90 consecutive patients (1986-2012). The mean age of the patients at surgery was 8.2 years (3 to14 years). The varus angle (mean 21.4°, range 8°- 40°) was assessed pre-operatively with the humero-elbow-wrist (HEW) angle. The postoperative carrying angle (mean 10.4) and the pre- and postoperative range of movement were assessed clinically. The lateral condylar prominence index (LCPI) was retrospectively measured at union. Results: Seventy five (93.3%) of the patients had a good or excellent result. Six (6.7%) had a poor result (residual varus, loss of >20°of pre-operative range of flexion or extension or a complication necessitating repeat surgery). There were no neuro-vascular complications. The mean LCPI was +0.14. Conclusions: The results of the French osteotomy are comparable to the more technically demanding dome, step-cut translation and multi-planar osteotomies, with a lower complication rate. The literature reports adequate remodelling of the hyperextension deformity ( ≤ 10 years) patient. Level of evidence: Level IV: Case series
Open Access
Functional outcomes and patient satisfaction after fasciotomy performed for chronic exertional compartment syndrome
(2017) Marais, Christoff de Villiers; Maqungo, Sithombo
Study Rationale: Chronic exertional compartment syndrome often forces patients to change their sporting activities or reduce their level of participation. Many undergo surgery with the aim to return to their activities symptom free. The aim of the study was to determine if fasciotomies for chronic exertional compartment syndrome are a reliable treatment option with a predictable outcome to allow patients to return to the same level of activities. Objective: The evaluation of the functional outcomes and patient satisfaction in an active population who had surgery, namely fasciotomies, for chronic exertional compartment syndrome (CECS) of the lower leg. Design: A retrospective descriptive cohort study with a telephonic follow-up interview. Patients: A consecutive series of 41 patients that were surgically treated for CECS by a single orthopaedic surgeon from July 2005 to October 2013. Main Outcome Measures: Patient records were reviewed to determine their presenting symptoms, diagnostic investigations and surgical procedures performed. A questionnaire was completed by each participant to assess pain and level of activity before and after surgery, level of improvement after surgery and patient satisfaction with surgical outcomes. Results: Twenty-one of the 41 patients that were included in the study were categorized as active sportsmen, participating at a competitive or a non-competitive level. The remaining 20 were experiencing symptoms during leisure activities. The majority of all the patients (63%) had to stop their activity due to their symptoms. After surgery 95% were able to return to participate in the same level of activities as before surgery. Ninety percent of the active sportsmen were able to return to participation at a competitive or non-competitive level, with 45% reporting an increase in the level of intensity that they could maintain. Overall satisfaction was reported by 80% of participants although only 46% were completely pain free. Conclusions: Fasciotomies are a viable surgical treatment option for chronic exertional compartment syndrome in active patients, including athletes. There is an 87% return rate to previous activities within 6 months and an 80% satisfaction rate reported by patients post-surgery. We do acknowledge that some of the data collected regarding symptomology is subject to recall bias due to the interval between surgery and completion of the questionnaire.
Open Access
How does pre-reduction MRI affect surgeon's behaviour when reducing Distraction-Flexion injuries of the cervical spine?
(2013) Fleming, Mark Alexander; Dunn, Robert
Includes abstract. Includes bibliographical references.
Open Access
Humeral stem loosening following reverse shoulder arthroplasty - systematic review and meta-analysis
(2017) Grey, Barend Christiaan; Roche, Stephen
Background: Aseptic stem loosening following reverse shoulder arthroplasty (RSA) is an uncommon complication. The majority of literature on RSA consists of case series with short follow-up periods. It remains unknown which factors contribute to aseptic stem loosening in RSA. Our analysis aimed to compare the incidence of aseptic stem loosening, humeral radiolucent lines (RLL) and revision for stem loosening between: 1) cemented and uncemented stems, and 2) different etiological subgroups Methods: In a systematic review 75 articles were included after assessment of study methodology and a meta-analysis of 1660 cemented and 805 uncemented stems was performed. We compared the incidence of aseptic stem loosening, humeral RLL, and revision for stem loosening between: 1) cemented and uncemented stems from cohorts with short (< 5 years) mean follow-up periods, long (≥ 5 years) mean follow-up periods, and all cohorts combined; and 2) different etiological subgroups. Results: The overall incidence of aseptic stem loosening was 1%. When comparing cemented to uncemented stems, there was no significant difference in the incidence of aseptic stem loosening or of revision for stem loosening in both the short and long term follow-up groups. Humeral RLL were more common with cemented stems (15.9% versus 9.5%, p = 0.002). The highest incidence of aseptic stem loosening occurred in the tumor subgroup (10.81%), followed by RSA as revision for failed arthroplasty (3.66%). No stem loosening was seen in the acute fracture or fracture sequelae groups. Conclusion: Aseptic stem loosening occurred more commonly in cohorts with long follow-up times (2% vs 0.8%, p = 0.01). There was no difference in the incidence of aseptic stem loosening or revision for stem loosening between cemented and uncemented stems. Humeral RLL occurred more frequently when cemented stems were used. Patients treated with RSA following excision of proximal humerus tumors and RSA as revision for failed arthroplasty were at greater risk of aseptic stem loosening.
Open Access
The influence of different connecting rod configurations on the stability of the Ilizarov Frame: A biomechanical study
(2017) Thiart, Gerhard; Laubscher, Maritz
Background: The Ilizarov external fixator (IEF) is frequently used in trauma and elective orthopaedics. Many of its biomechanical variables (ring size; wire diameter; wire number; half pins versus wires; etc.) and their influence on stability and stiffness have been investigated. There is however a paucity in the literature regarding the influence of the connecting rod numbers and configurations between the rings on IEF stability. Objectives: Primarily to compare the stability between four and three rod IEF configurations. Secondarily to assess the difference in stability between symmetrical and asymmetrical spacing of the IEF rods. Methods: A custom jig was designed to facilitate mounting of a basic two ring IEF in a hydraulic press. Controlled centre and off centre (thus simulated bending) axial loading was then applied across the frame. The configurations were loaded up to 4000 Newtons. The frame deformation was plotted and the data was then analysed and interpreted. Results: Negligible differences were observed between different four and three rod configurations as long as the applied force at the loading point (LP) was within the area of support (AOS) created by the rods. The different four rod constructs were always more stable than the three rod constructs during bending. Conclusions: There is comparable stiffness between a four rod and a three rod IEF construct as long as the loading point (LP) is within the area of support (AOS) created by the rods. A four rod IEF is stiffer than a three rod IEF in bending.
Open Access
An investigation into the intramedullary pressure rise during femoral nailing: does the level and type of fracture determine peak pressures during the procedure?
(2010) McCollum, Graham; Kruger, Nicholas
First introduced by Kuntshner, femoral nailing has become the 'Gold Standard' of treatment for femur fractures. The efficacy and benefit of early osteosynthesis by this technique is well established. Some of the acute complications of intramedullary manipulation and nailing are fat embolism syndrome, pulmonary dysfunction and Adult Respiratory Distress Syndrome (ARDS). One of the causes of fat embolism is a raised intramedullary pressure. Investigators have shown the direct correlation of intramedullary pressure with fat intravesation and embolism in both animal and human studies. Fat embolism syndrome is unpredictable and the true incidence is unknown. Mortality from fat embolism syndrome ranges from 10-35%. The incidence is increased with associated pulmonary trauma and in the multiply injured patient. The aim of our study was to investigate the intramedullary pressure rise during reamed prograde femoral nailing and determine whether fracture level and complexity affect the peak pressures. The relevance is that certain fracture types or levels that result in the highest pressures can be identified before the operation. Measures could be taken to reduce the intramedullary pressure during the procedure, particularly in those patients at greatest risk of pulmonary complications from fat embolism. We hypothesised that more proximal, simple fractures generate higher pressures during nailing because there is a long 'closed tube' distal to the fracture. Pressure proximal to the fracture does not reach the same high levels because the intra-medullary content is able to decompress through the fracture as the reamer moves distally. With proximal fractures there is a greater volume of medullary content distal to the fracture which can enter the venous system and embolize. Fracture comminution and complexity should lead to lower intramedullary pressures because there is a greater length of the femur through which the intramedullary content can decompress. The study sought to answer the question of whether fracture level makes a difference with respect to the intramedullary pressure rise during reamed prograde nailing. The results of this study have not been submitted for publication at the time of submission of these results for the thesis.
Open Access
Knee pain, swelling and stiffness after total knee replacement : a survey of South African knee surgeons
(2011) Garrett, Benjamin R; Walters, J
Includes bibliographical references (leaf 60).
Open Access
Late-onset Blount's disease
(2011) White, Clive David; Hoffman, EB
In 1937 WP Blount published a review of tibia vara or osteochondrosis deformans of the proximal tibia. Late-onset Blount's disease is varus deformity of the proximal tibia that occurs at or after 6 years old (excluding late presenting infantile Blount's) and has an associated femoral varus.
Open Access
Locking plates for distal femur fractures does an increased working length improve healing?
(2013) Koller, Ian M; Maqungo, S; Walters, J
Distal 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.

Browsing by Subject "Orthopaedic Surgery"

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