404 not found 404 not found 404 not found orthopaedics vol3 no4 sa orthopaedic journal autumn 2015 | vol 14 • no 1 page 13 acceptance speech m e s s a g e f r o m t h e p r e s i d e n t dear colleagues iwas deeply humbled to be nominated the president of the south african orthopaedic association for the year2014–2015. i take this appointment as a call to serve the saoa, its membership and all its interests more than as a personal honour. i believe that leadership is never an avenue to be self-serving but rather a platform to render service to people. i therefore pledge to serve you and the association to the best of my ability. i am fortunate to have worked with members of the saoa executive in the past three years. during that period i was exposed to the diverse skills, commitment and good work that go on behind the scenes in the running of our association. i plan to continue harnessing and maximising those skills in advancing the saoa. i also have the past presidents and presidents of our sister international orthopaedic associations from whom to take advice. more importantly though, i am looking forward to the inputs each one of you will be making in taking the saoa forward. in order to be successful in what we do as an association, it is very important that we focus on the correct goals. i believe that if we focus on the patients and the community we are serving, everything else will fall into place. this will call on us among other things to embrace professionalism; practise evidence-based medicine; and execute our trade with the ultimate skill and ethics. access to good quality orthopaedic service for all south africans will be one of the major drives during my term of office. franklin roosevelt during his presidency in the usa said, ‘the test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have little’. dr jan de vos in his valedictory speech alluded to one of the challenges to access to quality health care services which was: the reserve demand and supply ratios in our two healthcare systems. it is clear that both systems need attention and it is important that we as orthopaedic surgeons participate in mapping the way forward in both these systems before somebody else does it for us. orthopaedics is one of the few specialties where it has been demonstrated that intervention is cost effective. as the saoa we have to demonstrate in both our public and private healthcare systems this ‘value for money’ to all the relevant stakeholders (policy makers, regulatory bodies and funders) to win this battle. it will have to start by addressing the quality of training at our various academic orthopaedic departments to ensure good quality and relevance to the south african population. we have to ensure that the patients with insurance have access to surgeons of their choice and not funderpreferred services. this will require us to function as a unit while retaining our individual independence when we advocate for this group of patients. in doing so we have to listen to the warnings given to us by prof t briggs, past president of the british medical association, and improve our arguments instead of raising our voices when engaging with them in order to avoid comebacks. the orthopaedic association should continue to support those colleagues who are working in state hospitals. recently the association has engaged with the deans of universities and heads of the department of health in provinces where there have been delays in the appointment of heads of departments of orthopaedics. attention must also be paid to the non-academic hospitals where specialists are expected to deal with large volumes of work with very few resources. this may mean that we establish a portfolio in exco to deal with public sector orthopaedic issues and to engage with the ministry of health and the office of health standard compliance on acceptable minimum standard of orthopaedic care for patients in public hospitals. as part of improving access to orthopaedics services we should embrace and participate in outreach programmes to the needy areas in the country. key words: access for all, training, professionalism, autonomy, engaging, accountability saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 13 page 14 sa orthopaedic journal autumn 2015 | vol 14 • no 1 engagement with stakeholders will be very important going forward. it is the best way to protect our autonomy together with professionalism and accountability. participating in the newly relaunched national joint registry is but one low-hanging fruit which will demonstrate our accountability to all our stakeholders. engaging in peerreview processes and practising evidence-based medicine is part of the professionalism that can only take us to greater heights. references 1. schneler es, wilson na. professionalism in the 21st century professional practice: autonomy and accountability in orthopaedic surgery. clinical orthopaedics and related research 2009; 467(10):2561-69. 2. department of orthopaedic surgery at nyu langone medical center 2013 quality and outcome report. 3. saoa congress 2014. prof m lukhele mbchb, fcs(orth)sa, mmed(orth) president: south african orthopaedic association saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 14 south african orthopaedic journal obituary page 130 sa orthop j 2022;21(3) remembering prof. roelie gräbe (7 february 1930–4 april 2022) roland peter gräbe was born in volksrus on 7 february 1930. roelie, as he was fondly called, grew up in the vicinity of amersfoort and attended the local farm school where his father was the headmaster. he later moved to springs, and completed his high school education at the hoërskool hugenote. he qualified as a medical doctor from the university of pretoria in 1954, and completed his orthopaedic training with the degree mmed(chir) (in orthopaedics) (pretoria) in 1961. he then moved into private practice in pretoria for 12 years but decided that the full-time academic environment was more challenging for him. in 1973 he became the head of the ‘satellite’ department of orthopaedic surgery at the newly built kalafong hospital next to atteridgeville, pretoria. he led the national council for the care of cripples (as it was known then) travelling fellows team to various major orthopaedic centres in europe and the uk in 1977. in 1979 he was promoted to the overall head of the department of orthopaedic surgery of the university of pretoria at the academic hospital (the then hf verwoerd hospital, now steve biko hospital). his special interests were the conservative management of back pain, painful conditions of feet, and especially the management of children with cerebral palsy, which are reflected in his numerous publications on these topics. after his retirement as departmental head in 1996, he continued in the department as a consultant, teaching the preand postgraduate students, until finally taking full retirement in april 2016 at the age of 86 years. in august 2002, prof. gräbe initiated the south african orthopaedic journal, and was the first editor-in-chief, a position he held for many years. probably more orthopaedic surgeons have qualified under prof. gräbe than under any other professor of orthopaedics in south africa. he not only became a legend as a mentor in his lifetime but was also regarded as an orthopaedic father figure. in 2009 prof. gräbe was awarded the south african orthopaedic association’s educational medal ‘for his work as a leading educator’. his publications won him the saoa presidential medal in 1978, 1979 and 1980. on a more personal note, i got to know oom roelie (as we preferred to call him, rather than ‘professor’) in 1968, in my fourth mbchb year. this was through the ‘junior christen geneesheers bond’ (jcgb), of which he was the patron. over the years i had the privilege to know him quite well, first as a medical student, then as a postgraduate, later as a colleague and even later as his doctor, when he became a patient of mine. he was an excellent clinical teacher, a doctor with sincere compassion for his patients, and with utter integrity. even under difficult and stressful occasions, which happen when running a large department with ‘clever’ and mischievous registrars, he would never raise his voice; his admonishment was gentle but very clear and unambiguous. on one occasion while he assisted me when i was a registrar, he reprimanded me to stop a nasty habit i had. but being nervous and his being my mentor watching every step and movement, i did it again out of habit. very firmly, and using the strongest swear word i ever heard him utter, he said: ‘dêksels, ulrich, moenie!’ this was oom roelie. he was an exemplary family man, a husband, father and grandfather, and insisted when he was hod, that all the registrars should not neglect their families. we had to take our annual leave to spend quality time with our loved ones. if not, he would allocate ‘compulsory leave’ to those who failed to submit their leave forms. roelie was married to rina (née van rooyen), who died in 1986 after suffering a debilitating illness, with whom he had two sons – chris, also an orthopaedic surgeon, practising in pretoria, following his dad as a foot and ankle surgeon, and pieter, a minister of religion and professor, living in the usa. roelie then married susan (née strydom) in 1987. they have a son, roland, an engineer, presently working in belgium. our condolences to susan and her family. ‘oom roelie, ons almal gaan jou baie mis, en sal jou altyd onthou vir wat jy vir ons beteken het.’ prof. ulrich mennen my first contact with prof. gräbe was in 1978 when i did a spinal fellowship with the late prof. george dommisse at the pretoria academic hospital. at that stage prof. gräbe was head of the department at the kalafong hospital which was part of the academic complex in pretoria. his contributions to the academic discussions were of a very high standard. he was very involved with the national council of cripples and the south african orthopaedic association. he took a group of upcoming young orthopaedic surgeons on a tour of the major orthopaedic centres in europe and the uk. i had the privilege to be part of this group and could appreciate his masterful handling of us with fatherly care. he proved his leadership abilities when they refused to let us into holland because of their ban against south african academic interaction. we were confined to the airport until he could make other arrangements to fly us to liverpool to continue our tour in the uk. during the tour he joined in all our social activities and enjoyed having a beer with us. in 1979 he was appointed as head of the orthopaedic department at pretoria academic hospital which he led until his retirement in 1996. he maintained excellent relations with all the other orthopaedic departments including stellenbosch and was regularly invited as external examiner. he was a much respected and fair examiner. during this time, he always stayed with us at home and we enjoyed his company very much. i was also warmly welcomed as a guest by him and susan in later years. prof. gräbe made a huge contribution to orthopaedics in this country which includes his work with cripple care, the orthopaedic association and especially the south african orthopaedic journal, of which he was the first editor-in-chief. oom roelie, i shall always remember you as an outstanding academic educator but, more importantly, as a very good friend. prof. gert vlok orthopaedics vol3 no4 page 72 sa orthopaedic journal summer 2015 | vol 14 • no 4 expert opinion on published articles this study compared short-term (12-month) functional outcomes in pronation external rotation (per) iv ankle fractures with and without a dislocation. ankle fractures were categorised using the lauge-hansen classification. preoperative mri scans were obtained to accurately identify the osseoligamentous injuries and help with the correct classification. pronation external rotation iv injuries are uncommon but serious (16–22% of ankle injuries). per iv injuries are defined as having: • deltoid ligament rupture or a medial malleolus fracture • anterior inferior tibiofibular ligament (aitfl) rupture • anterosuperior to posteroinferior fibula fracture • posterior inferior tibiofibular ligament (pitfl) or a posterior malleolus fracture all fractures were treated by a single surgeon in an injuryspecific manner. fixation included: • fibula – antiglide plate • posterior malleolus – mini-fragment reconstruction plate • pitfl – 3.5 mm cortical screw with a soft tissue washer • medial malleolus – 2.0 mm fragment reconstruction plates • deltoid ligament ruptures repaired with suture anchors • syndesmotic repair with one or two syndesmotic screws catching four cortices bilateral ankle computed tomography scans were obtained prior to discharge to confirm reduction of the syndesmosis. postoperatively all patients were immobilised in a lower leg splint; at the two-week follow-up they were placed in a controlled ankle motion (cam) boot and range of motion (rom) exercises were started. all patients were kept nonweight-bearing for a total of six weeks. syndesmotic screws were removed no earlier than four months. clinical outcome was assessed using the foot and ankle outcome score (faos). secondary clinical outcomes included rom, presence of articular and syndesmotic malreduction, complete synostosis, postoperative infection and wound complications. the per iv fracture dislocation group had statistically and clinically poorer outcomes in all five subcategories of the faos. a fracture of the posterior malleolus may predispose to instability and risk of articular malreduction, and have inferior outcomes. this article highlights the severity of a per iv fracture associated with a dislocation and the importance of reducing the articular surface. fracture-dislocations demonstrate poorer postoperative functional outcomes among pronation external rotation iv ankle fractures stephen j warner, md, phd, patrick c schottel, md, richard m hinds, md, david l helfet, md, and dean g lorich, md foot and ankle international 2015,36(6):641–47 reviewer: dr p greyling department of orthopaedic surgery steve biko academic hospital tel: 012 354 2851 the per iv fracture dislocation group had statistically and clinically poorer outcomes in all five subcategories of the faos saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 72 page 74 sa orthopaedic journal summer 2015 | vol 14 • no 4 the authors retrospectively assessed 33 patients who underwent perioperative halo-gravity traction as an adjunct to modern instrumentation methods in the treatment of severe scoliosis and kyphosis. stagnara popularised halo-gravity traction as a safe alternative using the weight of the patient as a counterforce. the traction force can be transferred between the patient’s bed, a wheelchair and a walking frame. other methods of traction are halo-femoral, halo-tibial and halo-pelvic which provide significant corrective forces but require prolonged periods of bed rest. the purpose of the study was as follows: 1) to review the safety and efficacy of halo-gravity traction; 2) to review complications associated with traction; and 3) to establish a safe protocol for halo-gravity traction. the placement of the halo device was done in theatre. the pins were tightened to 6to 8-inch pounds of torque. the duration of perioperative traction is usually two to twelve weeks depending on the patient’s overall medical condition. if an anterior spinal release and fusion is performed, the patient is placed back in traction during the recovery period. often two to eight more weeks of traction is provided before a definitive posterior instrumentation and fusion with ultimate curve correction. the authors achieved a significant improvement in sagittal and coronal alignment with segmental pedicle screw construct. the authors should be applauded for this work, which raises a greater sense of awareness for the need for halogravity traction before surgical treatment of severe congenital kyphoscoliosis. rapid correction of severe kyphoscoliosis can increase the risk of neurological compromise, especially if there is a significant kyphotic component. their work underscores the need for thorough preoperative preparation and evaluation of the patient. patients were analysed by age at date of examination, gender, major coronal curve magnitude, major compensatory coronal curve magnitude, major sagittal curve magnitude, traction protocol and procedure type. halo-traction-related, early and late complications were noted in each case. complications were classified into halo-ring related, traction-force related or pathology-patient related. complications related to the halo itself include pin loosening, and superficial and deep pin tract infections. two forms of cranial nerve involvement have been reported. cranial nerve 6 palsy (abduscent) was most common, probably due to kinking of the nerve at the petrosphenoidal junction. the palsy presented as a loss of lateral gaze. the second pattern, a combination of cranial nerves 9, 10 and 12 (glossopharyngeal, vagus and hypoglossal) palsies, presented as dysphagia, loss of palatal and pharyngeal reflexes and weakness of tongue protrusion. in terms of halo-related symptoms, there were four cases of halo-pin loosening requiring replacement, one infected pin site, one case of pin site, one case of nystagmus and one case of nausea and dizziness. these symptoms resolved immediately with lowering of the amount of traction. the treatment of severe scoliosis can be very challenging despite the benefits of modern instrumentation methods. halo-gravity traction is a safe, well-tolerated method of applying gradual, sustained traction to maximise postoperative correction in this difficult population. reviewer: dr sj mabusha university of kwazulu-natal department of orthopaedic surgery nr mandela school of medicine perioperative halo-gravity traction in the treatment of severe scoliosis and kyphosis anthony rinella, md, lawrence lenke, md, camden whitaker, md, yongjun kim, md, soo-sun park, md, michelle peelle, md, charles edward, md, and keith bridwell, md spine 2005;30(4):475–82 the authors should be applauded for this work, which raises a greater sense of awareness for the need for halo-gravity traction before surgical treatment of severe congenital kyphoscoliosis • saoj saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 74 page 54 south african orthopaedic journal http://journal.saoa.org.za saoj south african orthopaedic journal. cpd questionnaire. march 2019 vol 18 no 1 body mass index and blount’s disease: a single academic hospital experience (kgoedi mn, rischbieter p, goller r) 1. which of the following is a feature of blount’s deformity? a. external tibial rotation a b. genu valgus b c. genu recurvatum c d. genu procurvatum d e. none of the above e 2. which of the following is not a risk factor for the development of blount’s disease? a. african ethnicity a b. male sex b c. obesity c d. early walking age d e. none of the above e 3. which statement regarding blount’s disease is true? a. the mean bmi of patients with blount’s disease is not statistically different from the bmi of the general population a b. there is a relationship between early-onset blount’s disease and bilateral involvement b c. there is a relationship between bmi and the severity of blount’s deformity c d. male patients with blount’s disease have a higher bmi than their female counterparts d e. none of the above e reactivation of chronic haematogenous osteomyelitis in hivinfected patients (siyo z, marais lc) 4. what is the prevalence of hiv infection among adult patients presenting with haematogenous chronic osteomyelitis vs adults with chronic osteomyelitis from other causes? a. 31% vs 23% a b. 23% vs 31% b c. 32% vs 13% c d. 13% vs 32% d e. none of the above e 5. which of the following groups of chronic osteomyelitis has a lower hiv infection prevalence compared to the general population or any other causes in south africa? a. chronic post-open fracture osteomyelitis a b. chronic haematogenous osteomyelitis b c. chronic post-operative osteomyelitis c d. chronic contiguous osteomyelitis d e. all of the above e 6. which type of chronic osteomyelitis was thought to be associated with reactivation of quiescent osteitis infection in adults? a. chronic post-operative osteomyelitis a b. chronic post-open fracture osteomyelitis b c. chronic contiguous osteomyelitis c d. chronic haematogenous osteomyelitis d e. all of the above e minimally invasive ct-guided excision of osteoid osteoma and other small benign bone tumours: a single centre case series in south africa (sluis cremer t, hosking k, held m, hilton tl) 7. regarding the natural history of osteoid osteoma, which statement is correct? a. malignant transformation is a rare complication. a b. progression to osteoblastoma is common. b c. osteoid osteoma is a transient condition that rapidly resolves. c d. spontaneous resolution does not occur. d e. spontaneous resolution occurs in all cases over a period of a number of years. e 8. which of the following treatment options for a small benign lesion of bone, such as an osteoid osteoma, has the highest risk of iatrogenic fracture? a. percutaneous intralesional curettage under image guidance a b. wide local resection through an open surgical approach b c. percutaneous image-guided radiofrequency ablation c d. open intralesional resection or the ‘burr-down’ technique d e. arthroscopic assisted resection of intra-articular lesions e 9. regarding the management of osteoid osteoma, what is the most common indication for surgical management? a. failure of medical management to bring symptomatic relief a b. biopsy specimen for histological confirmation of diagnosis b c. prevention of malignant transformation occurring c d. prevention of growth disturbance in juxta-articular cases d e. to address associated fractures e burden and profile of spinal pathology at a major tertiary hospital in the western cape, south africa (miseer s, mann t, davis jh, marais lc) 10. the primary cause of spinal trauma noted in the study was: a. interpersonal violence a b. falls b c. motor vehicle accidents c d. pedestrian vehicle accidents d e. blunt trauma e page 56 south african orthopaedic journal http://journal.saoa.org.za subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm.co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online • once you have completed the answers, go back to the top of the page next to the registration option. there is another icon “find my cpd certificate”. (you will have to answer the two questions regarding your internship and last cpd audit once you have completed a questionnaire and want to retrieve your certificate). • if you click on that icon it will open your certificate which you can print or save on your system. • please call mpc helpdesk if you have any questions: 0861 111 335. 11. what percentage of spinal tuberculosis patients demonstrated an associated human immunodeficiency virus co-infection? a. 12.6% a b. 22% b c. 10% c d. 44% d e. 16% e 12. which one of the following is not mentioned as an option for decreasing overall patient burden and resource use? a. improved surgical skills of district level surgeons to manage minor cases a b. dedicated anaesthetic teams for spinal surgery cases b c. stricter road traffic laws to reduce the incidence of motor vehicle accidents c d. use of district spinal units to manage spinal trauma and infection d e. employment of more spinal surgeons e incidence and risk factors for extended post-operative length of stay following primary hip arthroplasty in a south african setting (dlamini nf, ryan pv, moodley y) 13. reducing post-operative length of stay: a. reduces hospital expenditure a b. increases hospital expenditure b c. reduces hospital resource utilisation c d. increases hospital resource utilisation d e. both (a) and (c) e 14. the following are risk factors for extended post-operative length of stay following primary hip arthroplasty in south african patients: a. female sex, patient’s minimum walking distance, extended duration of surgery a b. diabetes, hypertension, female sex b c. extended duration of surgery, posterior surgical approach, general anaesthesia c d. none of the above d e. all of the above e 15. with regard to differences in risk factors for extended post-operative length of stay between south african and overseas hip arthroplasty patient populations: a. all the risk factors are the same between south african and overseas patient populations a b. only certain risk factors are shared between south african and overseas patient populations b c. differences in risk factors between south african and overseas settings necessitate setting-specific identification of risk factors c d. both (b) and (c) d e. none of the above e pharmaceutical management of bone catabolism: the bisphosphonates (raubenheimer ej, noffke cee, lemmer lb, slavik t, van heerden wfp, miniggio hd) 16. the principal anti-resorptive action of bisphosphonates is related to: a. improvement of the blood flow in bone a b. increase of the mineral content of bone b c. suppression of osteoclast activity c d. facilitation of calcium uptake in the gastrointestinal tract d e. activation of vitamin d e 17. identify the false statement: a. care should be taken with the administration of bisphosphonates in renal patients a b. bisphosphonates may be associated with the induction of jawbone osteonecrosis b c. second and third generation bisphosphonates do not contain nitrogen c d. pyrophosphates are naturally occurring bisphosphonates d e. intravenous administration should be considered in patients with gastroesophageal irritation e 18. bisphosphonates are incorporated in: a. the hydroxyapatite in bone a b. the collagen in bone b c. cells in the bone marrow c d. the periosteum d e. none of the above e medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 page 10 sa orthopaedic journal summer 2016 | vol 15 • no 4 e d i t o r i a l changing world yet business as usual? despite the changing trends in orthopaedic surgery, our training and subsequent practice organisation has remained the same for as long as i have been around, and probably well before. our tried and trusted approach may well no longer be adequate. focusing initially on the training, we have had the same college syllabus for at least 20 years. yes, we focus on the safe reasonable surgeon, but train on a public health based platform for independent practice in a largely clinically uncontrolled private environment where surgeons of any skill level can take on any surgery without peer review. as with any assessment process, one is only sampling areas of competency. i think we have done well in assessing candidates’ theoretical knowledge and clinical assessment skills on basic orthopaedic surgery. all surgeons however don’t all restrict themselves to practise in their competent areas. at the cape town comoc in april, there was a poorly attended but excellent canadian orthopaedic association symposium on registrar training and assessment. here all the global regions presented where they were, and what they were striving for. there was a lot said on competencybased training as opposed to time-based training, the latter being the model that we follow. in sa we assume being in training for 4 years will provide sufficient exposure to the spectrum of orthopaedic pathology, but this is no longer necessarily the case in many of our trauma-skewed training hospitals. i would like to avoid completing an app-based questionnaire every time my registrar sees an outpatient or performs a procedure, which is where the australians are heading! what i take from this though are the non-clinical areas of competence that we ignore. they were referred to as foundation competencies and include communication, teamwork, conflict management, professionalism, leadership, organisational skills, advocacy, education and research. now many of you will see these as obvious skills, self-learnt, and why should we bother – it’s all about operating isn’t it? these attributes are, however, where we seem to fail once in independent practice. anyone providing expert opinion in medico-legal matters will identify with this. it is not usually the lack of orthopaedic knowledge that results in the legal matter. many of these competencies were previously subconsciously learnt from mentors, both in and out of our medical environment. as our training facilities have increasingly suffered under overwhelming trauma loads and chronic underfunding, many have lost strong and long-serving mentors to rapidly changing junior consultant staff who cannot provide the same osmotically learnt behaviour. as president of the orthopaedic constituent college, i have introduced examination changes on the basis that the assessment process drives learning. for decades we used multiple long questions as our written assessment. this makes it difficult to interrogate these foundation competencies, despite some of them being listed in the syllabus. with a staged approach, we have adopted single best answer multiple choice based on a scenario, a short question paper and only one long question paper. not only is this a much fairer assessment model, reducing candidates’ concern about bias, but it allows us to assess candidates on ethics, professionalism and the like. this will hopefully encourage them to consider these areas during the training phase of their careers at the very least. the next area of concern is the subsequent private practice organisational structure. for some reason we all train in a team-based, peer-reviewed, load-sharing environment yet many aim for totally independent, solobased practice. it makes no sense to me that each surgeon has expensively decorated rooms and a contingent of two to three staff members when they are unused for two to three days while they are operating. we want autonomy but sacrifice a lot for this. although the global and local orthopaedic surgical landscape is rapidly changing. we are confronted daily withincreasing implant options, intra-operative navigation technology, and a variety of reconstructive techniques with promised technical gains but short on convincing clinical advantage. this was highlighted by prof dick van der jagt’s fp fouche lecture recently in skukuza. the need for newer and better solutions are further fuelled by the growing elderly population’s demand for higher levels of function and quality of life. these co-existing factors are exponentially driving health care cost at an unsustainable rate which is resulting in funders responding with a variety of restrictive and risk-sharing strategies, mostly to the detriment of the solo orthopaedic surgeon. saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 10 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 11 we may share calls, our patients are always ‘ours’ – so you are seldom off. as popular as you are, you have nothing to sell other than some depreciated furniture and outdated it. thus you only generate income while working with no capital wealth generation. this also makes negotiation with funders onerous and difficult. as we are repeated told by the saoa and the legal community, we have to avoid being anti-competitive, i.e. we are not allowed to stand together financially – bizarre but so it is. we are facing increasing financial headwinds. it started with designated provider status, all based on price not quality of service – short-term strategy at its best. this has now escalated to pressure from a large administrator to shift risk by soliciting bids for total cost arthroplasty models. this forces each surgeon to negotiate with other role players of disproportionate power over opaque costs and profit distribution, blinded by the law to what his peers are charging. taking the risk of future lowerthan-cpi increases and ‘partner ’ pressure to reduce the surgeon’s fee out of it, where is this clinician meant to find the time to analyse the model, costs and then administer it? in all likelihood he missed those foundation competencies! i think it high time that we re-consider our private practice organisational structure. i have seen the benefits of a local general surgical practice with many partners. it allows extracting the benefits of economy of scale, i.e. turnover growth in excess of cost growth, resulting in higher profit. it also allows salaried positions for surgeons within the practice who may or may not become partners. this creates a feasible and respectable private career path for our newly qualified surgeons. this should reduce supplier induced demand, i.e. the temptation to over-service to survive, as they benefit from the overflow of an existing well-established group practice. with at least cost sharing and possible profit sharing, there is less competition allowing free sharing of skill and knowledge, restoration of in-house clinical meetings, case discussions and local peer review. an entity will be built that has value beyond yourself, giving you something to sell when you retire. this does come at the price of some loss of autonomy. not every surgeon can disappear at short notice on a long weekend or school holiday. you will have to answer to your partners/peers as to your practice, implant choices and complications – but this is a good thing. i do not see why the private practice should be so different from the state academic organisational model. a very real benefit of such re-organisation would be that the group can negotiate with funders and other role players, providing a greater impact than any individual surgeon can. in fact, it could more than likely employ a financially astute negotiator, and it would be legal, freeing the surgeons to do what they do best. as our world continues to evolve at a rapid rate, it is not business as usual. professor robert dunn consultant spine and orthopaedic surgeon pieter moll and nuffield chair of orthopaedic surgery: university of cape town head: division of orthopaedic surgery saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 11 the discussion as to which patients would benefit more from ankle arthrodesis and which from ankle arthroplasty continues and is not resolved. these discussions consist mainly of people’s opinions and quoting of some articles with very few scientific surveys. this current article is a very good article comparing the biomechanical changes in the forefoot between the two procedures. the authors looked at the range of movement of the foot relative to the lower leg and from this extrapolated movement at the talo-navicular joint. what comes out very clearly in the article is that the movement at the talo-navicular joint is greatly increased in patients with an arthrodesis of the ankle with the mean movement in these patients of 22°. this is far more than the 10.5° movement in the arthroplasty group. this excessive movement after an arthrodesis is probably a significant contributing factor to patients developing secondary osteoarthrosis in the lesser foot joints after an ankle arthrodesis. the patients were also assessed with regard to their subjective feelings about the results and both procedures. these assessments show that the patients perceive being better after both operations but the improvement after the arthroplasty group is more than in the arthrodesis group. this article, in my opinion, is a significant contribution to our understanding of the role and position of arthroplasty with regard to degenerative joint disease of the ankle. total ankle arthroplasty versus ankle arthrodesis di pedowitz, jm kane, gm smith, hl saffel, c comer, sm raikin bone & joint journal may 2016;98b:634 page 74 sa orthopaedic journal spring 2016 | vol 15 • no 3 expert opinion on published articles the dorsal wedge osteotomy for freiberg’s disease in paediatric patients was initially described in 1979 by gauthier and elbaz and has shown good results. the question that always arose is what the long-term results of this procedure would be. this article is a retrospective view of 23 patients who were diagnosed with freiberg disease and treated operatively by the technique of a dorsal osteotomy as described by gauthier et al. between january 1982 and january 1999. twenty of the 23 original patients were contacted. the mean age at the time of surgery was 15.2 years and the internal fixation used in those days was a figure-of-eight stainless steel wire loop. the patients suffered no significant complications and no non-unions. the aofs score at the last follow-up was 96.8. eighty per cent of patients reported an excellent result and 20% a good result. these are excellent results in patients with a mean follow-up of 23.4 years and with a very high final aofs score. this type of follow-up is not often published and the article, therefore, is an important one proving that the long-term results of this treatment are good. long-term follow-up of dorsal wedge osteotomy for paediatric freiberg disease bruno s pereira et al. foot & ankle international, january 2016, page 90 reviewer: dr jj van niekerk orthopaedic surgeon morningside clinic sandton email: josniekek@mweb.co.za intra-articular fractures are the greatest cause of ankle arthritis and the injury is usually an intra-articular fracture. obviously treatment initially should have consisted of the best possible anatomical reduction but in spite of this there is a nearly 20% incidence of significant degenerative arthritis. the cause of this has, to date, never been clearly understood. the authors set out to investigate whether early inflammatory response could be the cause of the problem. the study was done on 21 patients. all the patients had a normal contralateral joint. there was no history of prior trauma in either ankle. the ankles were aspirated and lavage was performed. blood was also collected. the article clearly sets out all the different early precursors of inflammatory response that were tested in the aspirate from both ankles. it records that 12 of the 18 measurements were increased in the fluid from the fractured ankle. the authors feel that this gives some indication of why the joints degenerate and also gives a possible route for further research to decrease the acute intra-articular inflammation via antagonists to the pro-inflammatory and denegation mediators. this is an important article indicating a specific breakthrough with regard to a vexing problem. this article received the j leonard golder award at the 2015 annual meeting of the american orthopaedic foot & ankle society, giving some indication of how highly it was regarded. inflammatory cytokines and matrix metalloproteinases in the synovial fluid after intra-articular ankle fracture samuel b adams et al. foot & ankle international, november 2015;36:1264 saoj spring 2016_bu.qxp_orthopaedics vol3 no4 2016/08/02 14:05 page 74 page 76 sa orthopaedic journal spring 2016 | vol 15 • no 3 an increasing trend to treat clavicle fractures in adolescents by open reduction and internal fixation has recently been documented in the literature.1 this probably follows reports that advocate the operative treatment of certain middle third clavicle fractures in adults.2 in keeping with these trends, i am sometimes asked what my approach is to clavicle fractures in older children and adolescents. the article under review is the most recent outcome study in this respect and has offered some insight. as the title suggests, the purpose of the study was to determine the long-term outcome after a clavicle fracture in older children and adolescents. the study has merit in that it was a patient-reported outcome study. the authors conducted a retrospective review of 185 patients aged 10 to 18 years (median age 14.4 years) treated at their institution with an isolated clavicle fracture. thirteen had lateral fractures and 172 had midshaft fractures. outcomes were assessed using the oxford shoulder score (oss), the quick version of the disability of arm, shoulder and hand questionnaire (quick-dash score) and a visual analog score for pain, cosmesis and overall satisfaction. of the midshaft fractures, 122 patients (70.9%) responded to the questionnaires. of the lateral fractures, 8 patients (61.5%) responded to the questionnaires. the mean age of the respondents was 18.7 years and this was at an average of 4.7 years after injury. sixty-five midshaft fractures were displaced. nine of these displaced midshaft fractures were treated surgically. seven were operated on as primary treatment; however, the actual indication for surgery in these cases was not stated. an additional patient was operated at 23 days for increasing pain and displacement, and another because of symptomatic nonunion at 163 days. the nine operated fractures did not have any difference in terms of initial shortening, displacement or angulation compared to the non-operative group. of the nine operated patients, six had local irritation which prompted plate removal. one had a disfiguring scar and one complained of decreased sensation distal to the incision. no patient with a lateral fracture was treated surgically. of the lateral fracture group of patients at follow-up, one complained of general shoulder discomfort and one of pain while carrying a backpack. with respect to the overall patient-reported outcomes, 95 per cent of the respondents with conservatively managed fractures reported good to excellent outcomes on both the oss and quick-dash score. however, in the group of midshaft fractures managed non-operatively, shortening of the fracture had a small but statistically significant negative effect on the oss, cosmetic and overall satisfaction scores. the degree of angulation and displacement had no effect on the outcome scores in this group. the authors’ opinion was that the overall functional result after non-operatively treated clavicle fractures was good to excellent for most patients. the inferior result associated with shortening was small and most likely of limited clinical significance. the authors also note that non-union of the clavicle at this age is very rare and therefore cannot be used as an argument to justify operative treatment. the level of evidence in this study is low, with a high rate of non-responders. the number of operative cases was too small to provide an acceptable comparative group. however, the results support earlier literature3,4 with regards to good functional outcomes of non-operatively treated clavicle fractures in children and adolescents. we must take cognisance of the available literature, and it is for this reason that i continue to advocate non-operative management as the mainstay of treatment in this age group. i support the authors’ recommendation to reserve operative treatment for fractures with absolute indications such as threatened skin integrity, open fractures or associated neurovascular injuries. whether other selected cases will benefit from operative treatment still needs to be defined. references 1. yang s, werner bc, gwathmey fw, jr. treatment trends in adolescent clavicle fractures. j pediatr orthop. 2015;35(3):22933. 2. canadian orthopaedic trauma s. nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. a multicenter, randomized clinical trial. j bone joint surg am. 2007;89(1):1-10. 3. schulz j, moor m, roocroft j, bastrom tp, pennock at. functional and radiographic outcomes of nonoperative treatment of displaced adolescent clavicle fractures. j bone joint surg am. 2013;95(13):1159-65. 4. bae ds, shah as, kalish la, kwon jy, waters pm. shoulder motion, strength, and functional outcomes in children with established malunion of the clavicle. j pediatr orthop. 2013;33(5):544-50. reviewer: prof ajf robertson division of orthopaedic surgery wits medical school 7 york road, parktown, 2193 (apologies for attributing this opinion to the incorrect author in the winter 2016 edition of this journal) long-term patient-reported outcome after fractures of the clavicle in patients aged 10 to 18 years ph randsborg, hf fuglesang, jh rotterud, ol hammer, ea sivertsen journal of pediatric orthopaedics 2014;34(4):393-99 • saoj saoj spring 2016_bu.qxp_orthopaedics vol3 no4 2016/08/04 10:59 page 76 page 14 sa orthopaedic journal august 2002 education, training and accrj;:ditation education, training and accreditation the training of registrars froj;ll a consultant's perspective drwjwade department of orthopaedic surgery, university of stellenbosch d uring the last few years we have experienced rapid changes in the teaching methods of medicine and surgeryin general which will have a profound inflnence on academics and the teaching of registrars in orthopaedic training in future. the primary objective of a consultant in a teaching capacity is to impart to the registrar the basic principles of musculoskeletal evaluation to enable him or her to accurately identify the problem in order to suggest or apply the appropriate treatment for the benefit of the patient. with the information technology explosion, the public is very aware of the management modalities for musculoskeletal disorders and, together with the increasing tendency to litigation and health care accountability, more people are looking over the shoulders of the orthopaedic surgeon monitoring treatment decisions, skills and results. these aspects, in conjunction with the rapidly expanding knowledge in the many subspecialties of orthopaedic surgery, leave the consultant with the daunting task of assisting the registrar to effectively prepare for his career. the transition from teaching hospital practice to private practice is large and the registrars must be prepared to fit into a new world of health care delivery. this implies that the consultant should also be aware of the demands of a private practice. selection of registrars the successful completion of a teaching programme begins with the correct selection of a registrar. interviews are essential but can be misleading. ever so often unknown candidates discontinue their training for various reasons within the first year thereby upsetting the whole programme strategy. it is always comforting to be able to appoint a registrar who has completed his pre-graduate training at your institution as his or her worth and values are known. we have found that by rotating applicants through accredited secondary institutions under supervision for six months or a year the selection is easier. this allows for the evaluatiqn not only of competency and patient care skills, but 'also preparation for the trauma load he or she will be expected to handle during the first six months of clinical rotation. age should also be a prerequisite. after the age of forty years registrars struggle with the rigours of the service and academic demands. before the age of thirty years we find the level of experience and responsibility to be lacking to a certain extent. programme requirements the format of the present system of postgraduate clinical training seems to have survived the test of time but undoubtedly needs refining in certain areas. the development and implementation of outcomes-based study programmes is essential to keep abreast of newer teaching and study methods. we must not cling to a curriculum and values that may fast become outmoded. at the university of stellenbosch, planning is already underway to establish an outcomes-based programme module. the five-year period for training allows sufficient and relatively consistent exposure to the diverse facets of the musculoskeletal system. the six-monthly rotation system normally includes 18 months of trauma, 24 months of elective surgery and 6 months each in paediatric orthopaedics and hand surgery. the latter two rotations are more suited to enhancing registrar responsibility. six months rotation through a general surgical discipline prior to the intermediary examination is a hpc prerequisite. page 16 sa orthopaedic journal august 2002 the primary examination, which includes anatomy, physiology and general pathology principles, is essential and should be completed within the first year of the programme if possible, to allow the registrar to get down to the basics of orthopaedic surgery. preferably this should be completed prior to admission to the programme if at all possible. the teaching of anatomy and physiology has become more applied to the musculoskeletal system and quite rightly so. the presentation and evaluation of these modules should remain the responsibility of the respective disciplines with orthopaedic programme observation. lacking in the first year of training is a structured basic physical examination course and evaluation thereof which could possibly be incorporated in the primary examination. the intermediate examination comes at the correct time in the programme at the end of three years. i feel that three months spent in the surgical leu brushing up on essential general surgical principles is imperative. the question as to whether the further three months should be spent rotating through neurosurgery or plastic surgery remains unresolved as both disciplines have principles to offer which are applicable to orthopaedic surgery. an outcomes-based curriculum is long overdue for this rotation in the programme concentrating on general surgical principles and not specific surgical pathology. the orthopaedic pathology section of this rotation also needs a more structured approach. the pathologists are not actively involved in the student preparation but expect the basic evaluation of a pathological slide in the examination. clinical teaching material the gradual but constantly changing profile of patients attending the teaching hospitals has had a profound effect on the teaching of postgraduate students. trauma dominates the clinics and theatre lists at the expense of elective orthopaedics. apart from the geriatric orthopaedic patient, the clinics are devoid of the pathology normally encountered in a private practice. the serious question therefore arises whether the available clinical teaching material sufficiently equips the newly qualified orthopaedic surgeon to confidently commence his private practice with the necessary expertise. the solution for the registrar lies in the compilation of the socalled "log book" ensuring exposure to the majority of and the essential clinical procedures thereby affording him or her clinical privileges. clinical teaching registrars enjoy the teaching and flourish in the clinical environment. ward rounds and clinics should be structured around this concept wherever possible. (it is however naive to think this implementation is always possible in our high service load hospitals.) apart from assisting in applicable journal references, the consultant is not responsible for spoon-feeding the registrar but rather placing a clinical problem in perspective. at tygerberg hospital approximately 8 hours per week is allocated to structured registrar teaching. this includes an hour every morning where x-rays of the previous day's admissions are reviewed and the day's preoperative cases are discussed. the teaching here is directed to problem-based solutions. two hours are spent on clinical presentations and problem-solving and only one hour on structured lecturing. the emphasis in postgraduate teaching is moving away from long formal lectures towards shorter and more concise presentations. i believe that it is to the registrar's advantage to compile and present a short literature summary of the problem following his clinical case presentation. education, training and accreditation an undeniable fact however, is that the expertise of many of the sub specialties have developed and blossomed outside the academic institutions. regardless of the reasons for this trend, such expertise must at all costs be incorporated into our postgraduate teaching programmes. the answer to this lies in accrediting either outside institutions or surgeons to our teaching programmes whereby registrars in training are afforded rotation opportunities. this concept has been applied successfully at our institution regarding shoulder and knee problems. the ideal situation from a teaching perspective would be of course the development of such specialised clinics in the teaching hospitals. research and educational activities most consultants and students feel that registrar and departmental or even faculty participation in research is insufficient and should be increased. a number of factors contribute to this situation. although there is no paucity of clinical research material available in a predominantly third world country, the workload invariably offsets the time available for research activities. the research environment regarding data capturing, electronic infrastructure, secretarial assistance and appropriate funding is sadly lacking in the academic environment and could only become logistically viable should private funding be incorporated into research. an excellent example of this is the present multicentre study on the effect of growth hormone and bmp on the union rate of fractures in which our department is participating. very little encouragement to attend congresses and educational meetings is forthcoming from the hospital authorities, which is fully understood within a stringent budget environment and understaffed clinical departments. the primary research project of each and every registrar at our institution is the compilation of a dissertation which constitutes one facet of the final examination. a prerequisite for registration is that the dissertation be evaluated and deemed acceptable by an external examiner. the objective is that the dissertation not be just an audit of clinical work done but a scientific document acceptable for publication. the standard of the dissertations has improved markedly during past years. the focus of registrar training should primarily be on quality education, patient care and to a certain extent, research and academic productivity which pertain to our cultural and demographic environments. the service to education ratio is in jeopardy of favouring the former at the expense of education. i favour the mmed system of postgraduate orthopaedic training for a number of reasons. i feel the registrar should be evaluated in a number of core competency areas which not only include orthopaedic knowledge but also cognitive ability, affective ability and psychomotor skills. patient care skills, professionalism, interpersonal and communication skills are under acute scrutiny of the public at large and in many instances are sadly lacking in the orthopaedic fraternity in south africa. deficiency in these areas can be identified and rectified early on in the course and should carry some weight in the final examination. the aspect of the final examination of the mmed candidate which incorporates plaster and surgical technique (the basis of our trade) is constantly under criticism but is one of the most important core competency areas and should be recognised as such. . orthopaedic surgery at tygerberg hospital and the university of stellenbosch is in the very fortunate position of still attracting registrars from the best talent pool and combining this with a fine education in order to contribute to the future of our specialty in the interests of comprehensive musculoskeletal care of our patients. oj pages from wade_14.pdf pages from wade_16cropped orthopaedics vol3 no4 page 46 sa orthopaedic journal winter 2017 | vol 16 • no 2 subungual amelanotic melanoma of the hallux: review of the literature with a case report mj tladi mbchb(ul medunsa campus), fcs (sa)ortho, mmed(orth surg)(smu) dr george mukhari academic hospital, ga-rankuwa, pretoria and sefako makgatho health science university, ga-rankuwa, pretoria, south africa np saragas mbbch(wits), fcs(sa)ortho, mmed(ortho surg)(wits) netcare linksfield orthopaedic sports & rehabilitation centre (clinic), johannesburg and orthopaedic department, university of the witwatersrand, johannesburg, south africa pnf ferrao mbchb(pret), fcs(sa)ortho netcare linksfield orthopaedic sports & rehabilitation centre (clinic), johannesburg and orthopaedic department, university of the witwatersrand, johannesburg, south africa a strydom mbbch(wits), fcs(sa)ortho, mmed(ortho surg)(wits) orthopaedic department, university of the witwatersrand, johannesburg, south africa corresponding author:  dr mj tladi department of orthopaedics sefako makgatho health science university po box 25  0204 medunsa tel: 012 521 4049 fax: 012 521 4284  email: mphojohn@webmail.co.za introduction subungual melanoma was first fully described in 1886 by sir hutchinson,1 yet in the 21st century this condition is still misdiagnosed resulting in a high morbidity and mortality. the famous reggae singer, bob marley, succumbed to an aggressive subungual malignant melanoma of the hallux at the age of 36 years.2,3 lack of pigmentation in amelanotic subungual melanoma further complicates an already difficult diagnosis.4-6 case report clinical history we present an 80-year-old caucasian female who presented with an 18-month history of a lesion under her right hallux toenail. she consulted a podiatrist who initially diagnosed it as an ingrown toenail and managed it accordingly. the lesion did not resolve and she continued to have episodes of bleeding with closed shoes. abstract subungual melanoma of the hallux is a rare malignancy occurring mainly in elderly black africans and asians. it is often misdiagnosed as a benign lesion. we present a review of the english literature and report on a case of an 80-year-old caucasian female patient who presented with a rare subungual amelanotic malignant melanoma of the hallux that was initially misdiagnosed as an ingrown toenail. due to lack of pigmentation, amelanotic melanoma poses a huge dilemma in diagnosis. upon comparing this case with the current literature, we propose that unlike most acral subungual melanomas, subungual amelanotic melanoma occurs mainly in elderly caucasian females. level of study: iv case series key words: subungual melanoma, melanoma, amelanotic, acral lentiginous melanoma http://dx.doi.org/10.17159/2309-8309/2017/v16n2a5 sa orthopaedic journal winter 2017 | vol 16 • no 2 page 47 the patient was referred to a dermatologist who performed a biopsy. the diagnosis of an amelanotic melanoma was made upon histology. there was no history of previous trauma to the nail or positive family history of melanoma (5%–10% reported incidence of a positive family history).7 examination examination revealed a generally well elderly caucasian female. a granulomatous type lesion, measuring 2 cm by 1.5 cm, was present overlying the nail bed of the right hallux (figures 1a and 1b). the lesion was tender to palpation. no ipsilateral inguinal lymph nodes were palpable and the foot was neurovascularly intact. special investigations no bony involvement was evident on plain radiographs (figure 2). a pet ct scan (figure 3) showed no metastases. management once the case was discussed with an oncologist, informed consent was obtained from the patient to perform a partial amputation of the hallux. the hallux was amputated at the level of the mid-shaft of the proximal phalanx, allowing for at least a 15mm clear margin from the tumour edge (figures 4a and 4b). the histology report once again confirmed the amelanotic melanoma, stage iib (figure 5), with 20 mm clear margins. the patient was referred to the oncology unit for further treatment as required. figure 1. a granulomatous lesion of the hallux 1a 1b figure 2. x-ray showing no bony involvement figure 3. pet ct scan with no evidence of metastasis figure 4a. level of amputation figure 4b. post-operative x-ray figure 5. histology showing amelanotic melanoma 5a 5b page 48 sa orthopaedic journal winter 2017 | vol 16 • no 2 discussion pigmentation of the toenails can be due to benign, systemic disease manifestation or malignant conditions, with melanoma being one of the rare malignancies (3.2% of foot and ankle tumours).8,9 generally there are four types of melanoma, with acral melanoma affecting the hands and feet. this usually occurs in black african and asian populations contrary to the other types which are more common in fair-skinned populations.7,9 delayed diagnosis of subungual melanoma is largely due to misdiagnosing the lesion as being benign (table i).4,8-12 table ii shows all case reports of subungual amelanotic melanoma affecting the hallux, all of which had a delay in the diagnosis. only five case reports were identified after an extensive search of the english literature. the incidence of subungual melanoma is high in black africans and asians between the ages of 50 to 70 years. males and females are equally affected.4,7,8 our case, however, was in an 80-year-old caucasian female. upon reviewing the literature reporting on subungual amelanotic melanoma of the hallux, all patients were caucasian, with 60% being female. we thus propose that subungual amelanotic melanoma actually has a higher incidence in caucasian females. symptoms in most cases are vague and the lesion resembles other conditions. the abcdef rule was described by levit et al. to reduce misdiagnosing subungual melanomas and improve early detection (table iii).16 hutchinson’s sign describes a black discoloration of the proximal nail fold which is suggestive of subungual melanoma. this sign has inherent flaws as it has no role in amelanotic melanoma due to absence of pigmentation, as was seen in our patient. hutchinson’s sign can also be associated with laugier-hunziker syndrome, ethnic pigmentation, infections or the use of certain medications. when present, however, it is indicative of a poor prognosis.8,16 management of subungual melanoma of the hallux is usually amputation of the digit, which can cause functional and emotional problems, such as in the case of bob marley who refused amputation due to religious reasons and only agreed to local excision of the tumour.2,4,17 this ultimately resulted in metastasis and his demise. as the diagnosis is often delayed with resultant local invasion, amputation is the recommended management.17 the tissue must be sent for histology and the report should include: histological type, presence of ulceration, presence of infiltrative lymphocytes, regression, microsatellite lesions, margins, micro-staging (tumour thickness according to breslow and level of invasion according to clark) which are helpful with final staging.7,10 melanoma is staged according to the american joint committee on cancer (ajcc).7 a sentinel lymph node (sln) biopsy is recommended for melanomas stage 1b and above.7 recurrence of foot melanoma is 37% at approximately 3 years and survival rate after recurrence is shorter than 41 months.18 prognosis of subungual melanoma in general is poor. the 5-year survival rate of subungual melanoma of the toe is 40% as compared to 72% in the finger.17 table i: common benign conditions resembling subungual melanoma subungual haematoma paronychia ingrown toenail granuloma ethnic pigmentation onychomycosis nigricans glomus tumour benign naevus subungual exostosis mucous cyst subungual fibroma keratoacanthoma dermatofibroma wart table ii: literature case reports of hallux subungual amelanotic melanoma race age (years) sex initial diagnosis author surgical management caucasian 71 female in-growing toenail cahill et al.11 amputation caucasian 35 female in-growing toenail winslet et al.13 amputation caucasian 31 male mass gosselink et al.6 amputation caucasian 61 male pyogenic granuloma, squamous cell carcinoma, amelanotic malignant melanoma, deep fungal infection, verruca or cutaneous leishmaniasis arican et al.14 amputation caucasian 72 female fungal infection koch et al.15 amputation table iii: steps to follow when suspecting subungual melanoma a age: range 20–90 y, peak 5th–7th decades race: african-american, native american, asian b band (nail band): pigment (brown-black) breadth (≥3 mm) border (irregular/blurred) c change: rapid increase in size/growth rate of nail band lack of change: failure of nail dystrophy to improve despite adequate treatment d digit involved: thumb > hallux > index finger single digit > multiple digits dominant hand e extension: extension of pigment to involve proximal or lateral nail fold (hutchinson’s sign) or free edge of nail plate f family or personal history: of previous melanoma or dysplastic naevus syndrome sa orthopaedic journal winter 2017 | vol 16 • no 2 page 49 the 5-year survival rate for melanoma in general is 74.3% in the foot and 85.2% in the leg.18 the survival rate is directly related to the staging by the ajcc. conclusion subungual melanoma is rare, especially in the caucasian population. however, the incidence of subungual amelanotic melanoma has only been reported in caucasians, contrary to other subungual melanomas which occur mainly in black africans and asians. there is also a predilection for the female gender. we thus propose that subungual amelanotic melanoma occurs mainly in elderly caucasian females. the diagnosis is often delayed, as it can mimic a variety of hallux nail conditions. due to lack of pigmentation, amelanotic melanoma poses a huge dilemma in diagnosis. a high index of suspicion is thus imperative. the use of the abcdef rule can help in increasing awareness and reducing the delay in diagnosing subungual amelanotic melanoma. an incisional biopsy should be performed early. once histological confirmation is made, amputation is the treatment of choice and the patient should be referred to an oncology unit for further management according to the ajcc staging. acknowledgements the authors wish to acknowledge dr b wium for providing the histological pictures used in this manuscript. compliance with ethics guidelines conflict of interest statement the authors declare they have no conflict of interests in writing this article. no financial support was received for this study. the content of the article is the original work of the authors. references 1. hutchinson j. melanosis often not black: melanotic whitlow. br med j 1886;1:491. 2. bob marley explained. http://everything.explained.today /bob_marley/ [accessed on 16 june 2016]. 3. menon s. an incidental finding. jfponline.com 2013;62(11):655-59. 4. briggs j. subungual malignant melanoma: a review article. british journal of plastic surgery 1985;38:174-76. 5. mark d, yoong s, reid j, khan k. amelanotic melanoma presenting as a neuropathic ulcer in a non-diabetic patient. j med cases 2012;2:146-48. 6. gosselink c, sindone j, meadows b, mohammadi a, rosa m. amelanotic subungual melanoma: a case report. journal of foot & ankle surgery 2009;48(2):220-24. 7. de braud f, khayat d, kroon b, valdagni r, bruzzi p, cascinelli n. malignant melanoma. critical reviews in oncology/haematology 2003;47:53-63. 8. patel g, ragi g, krysicki j, schwatz r. subungual melanoma: a deceptive disorder. acta dermatovenerol croat 2008;16(4):236-42. 9. chou l, ho y, malawer m. tumors of the foot and ankle: experience with 153 cases. foot and ankle international 2009;30(9):836-41. 10. dunki-jacobs e, callender g, mcmaster k. current management of melanoma. current problems in surgery 2013;50:351-82. 11. cahill s, cryer j, otter s, ramesar k. an amelanotic maligant melanoma masquerading as a hypergranulation tissue. foot and ankle surgery 2009;15:158-60. 12. fortin p, friberg a, rees r, sondak v, johnson t. malignant melanoma of the foot and ankle. the journal of bone and joint surgery 1995;77-a(9):1396-403. 13. winslet m, tejan j. subungual amelanotic melanoma: a diagnostic pitfall. postgrad med j 1990;66:200-202. 14. arican o, sasmaz s, coban y, ciralik h. subungual amelanotic malignant melanoma. saudi med j 2005;27(2):247-49. 15. koch s, lange j. amelanotic melanoma: the greater maquerader. j am acad dermatol 2000;42:731-34. 16. levit e, kagen m, scher r, grossman m, altman e. abc rule for clinical detection of subungual melanoma. j am acad dermatol 2000;42:269-74. 17. cohen t, busam k, patel a, brady m. subungual melanoma: management considerations. american journal of surgery 2008;195:244-48. 18. talley l, soong s, harrison r, mccarthy w, urist m, balch c. clinical outcomes of localised melanoma of the foot: a case control study. j clin epidemiol 1998;51(10):853-57. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj tanwar y et al. sa orthop j 2020;19(1) doi 10.17159/2309-8309/2020/v19n1a7 south african orthopaedic journal http://journal.saoa.org.za orthopaedic oncology and infections citation: tanwar y, potgieter m, oosthuizen m, schubert p, ferreira n. bursal synovial chondromatosis overlying a solitary osteochondroma of the distal femur: a case report. sa orthop j 2020;19(1):46-49. http://dx.doi.org/10.17159/2309-8309/2020/v19n1a7 editor: prof. t le roux, university of pretoria, pretoria, south africa received: june 2019 accepted: september 2019 published: march 2020 copyright: © 2020 tanwar y, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: there are no funding sources to declare. conflict of interest: all authors confirm they have no conflicts of interest to declare. abstract synovial chondromatosis and osteochondromas are frequently encountered benign cartilaginous lesions. the concomitant occurrence of these lesions is rare. we report one such case in an 11-year-old female patient and speculate on the common underlying pathogenetic mechanisms which might be involved. level of evidence: level 5 keywords: synovial chondromatosis, secondary synovial chondromatosis, bursal synovial chondromatosis, osteochondroma bursal synovial chondromatosis overlying a solitary osteochondroma of the distal femur: a case report tanwar y¹ , potgieter m² , oosthuizen m³ , schubert p4 , ferreira n5 1 mbbs, ms, dnb, mrcs; stellenbosch university limb reconstruction fellow, division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 2 mbchb, fc orth(sa), mmed(orth); consultant orthopaedic surgeon, division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa ³ mbchb; registrar, division of anatomical pathology, tygerberg hospital, national health laboratory service, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 4 mbchb, fcpath(anat)(sa), mmed(anat path), mscmedsc(cytopathology), mphil(paed path), miac; associate professor and consultant anatomical pathologist, division of anatomical pathology, tygerberg hospital, national health laboratory service, faculty of medicine and health sciences, stellenbosch university, cape town, south africa 5 bsc, mbchb, fc orth(sa), mmed(orth), phd; associate professor, consultant orthopaedic surgeon and head of tumour, sepsis and reconstruction unit, division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: prof. nando ferreira, division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, tygerberg hospital, stellenbosch university, cape town, 7505, south africa; tel: +27 (21) 938 5456; email: nferreira@sun.ac.za https://orcid.org/0000-0003-4606-7801 https://orcid.org/0000-0002-9611-4859 https://orcid.org/0000-0001-6820-9482 https://orcid.org/0000-0003-4422-7349 https://orcid.org/0000-0002-0567-3373 page 47tanwar y et al. sa orthop j 2020;19(1) introduction osteochondroma, a benign cartilaginous neoplasm, consisting of a cartilage-capped bony projection on the surface of bone, is one the most common benign bone tumours encountered by orthopaedic surgeons.1-3 unlike chondroblastomas, they are not locally aggressive and do not invade the adjacent soft tissues. since osteochondromas stop growing after physeal fusion, surgical treatment for asymptomatic lesions is rarely warranted.2 however, they may cause symptoms secondary to mechanical irritation or compression of adjacent soft tissue structures like tendons, nerves or vessels, in which case excision might be required. progressive enlargement of an osteochondroma after skeletal maturity or a rapid increase in size at any age, might indicate malignant transformation of the overlying cartilaginous cap and will require surgical resection.4 synovial chondromatosis represents a benign neoplasm presenting as multiple hyaline cartilage nodules in the subsynovial tissue of a joint, tendon sheath or bursa.5 initially, investigators speculated whether osteochondromas and synovial osteochondromatosis represented a true neoplastic condition or merely metaplastic or hamartomatous lesions.1,5 cytogenetic studies, however, have confirmed the true neoplastic nature of both these two conditions (especially multiple osteochondromas) with constant underlying genetic abnormalities.6,7 there have been few case reports of concomitant existence of osteochondromas and synovial chondromatosis.8-14 we report one such case in an 11-year-old female patient and speculate on the common underlying pathogenetic mechanisms which might be involved. case report an 11-year-old female patient presented with the history of a firm, painless mass involving the medial aspect of the right distal thigh that had gradually been enlarging over the preceding year. systemic examination did not reveal any other lesions, showed no distal neurovascular deficit and a normal gait. local examination confirmed a 10×15 cm mass on the medial aspect of right distal femur that consisted of a bony component that was adherent to the underlying femur and an overlying soft tissue component. the soft tissue component was cystic and fluctuant with multiple loose bodies palpable within it. knee range of motion was normal and painless. laboratory investigations were unremarkable. plain radiographs revealed a pedunculated osteochondroma over the medial aspect of right distal femur and multiple well circumscribed soft tissue calcifications over the adjacent soft tissue (figure 1). a magnetic resonance imaging (mri) scan showed a pedunculated osteochondroma with a cartilage cap measuring 8 mm in maximum thickness. a large surrounding bursa displacing and attenuating the vastus medialis muscle and containing multiple loose bodies of variable sizes was also noted. a solitary pedunculated osteochondroma with bursal formation and secondary synovial chondromatosis was diagnosed (figures 2 and 3). surgical excision of the lesion was performed through a subvastus approach. the osteochondroma and overlying bursa were resected en masse (figures 4–6). histopathological evaluation showed nodules of variable sizes, with smaller nodules being embedded in hyperplastic subsynovial tissue with granulation tissue and fibrosis (figure 7). the larger nodules were circumscribed, loose lying, rounded masses of hyaline cartilage with clusters of chondrocytes that demonstrated mild nuclear atypia with nuclear enlargement and occasional binucleation (figure 8). pleomorphism, necrosis and mitotic figures were absent. sections of the femur mass revealed figure 1. anteroposterior radiograph showing a pedunculated osteochondroma over the medial aspect of the right distal femur and multiple, well-circumscribed soft tissue calcifications over the adjacent soft tissue figures 2 and 3. mri scan coronal and axial views showing an osteochondroma and a large surrounding bursa containing multiple loose bodies figure 4. intra-operative clinical image showing a pedunculated osteochondroma arising from the medial aspect of the distal femur page 48 tanwar y et al. sa orthop j 2020;19(1) a benign cartilage tumour comprising a cartilage cap composed of mature hyaline cartilage with overlying fibrous perichondrium. transition between bone and cartilage cap resembled the growth plate, demonstrating endochondral ossification into mature bone. no features of malignancy were seen. histological features combined with a review of the radiological images supported the diagnosis of an osteochondroma with associated bursal synovial chondromatosis. discussion the concomitant existence of two primary neoplastic conditions is a rare occurrence. there are only seven case reports of concurrent synovial chondromatosis and an underlying osteochondroma.8-14 bursa formation over the osteochondroma is secondary to mechanical irritation of the osteochondroma and the overlying tendons. whether the bursal chondromatosis represents a secondary pathology due to the underlying osteochondroma or a true primary benign neoplastic process, is still unclear. secondary synovial chondromatosis on the other hand results from mechanical trauma to the hyaline cartilage of a joint, which leads to disassociation of the cartilage cells and secondary seeding over the synovium. secondary, intra-articular synovial chondromatosis (loose bodies) is a common condition and is seen in osteochondritis dissecans, neuropathic osteoarthropathy, osteoarthritis, or previous insult of a joint by infection or inflammatory arthritis. secondary bursal or extra-articular chondromatosis is much less common and is rarely reported. all reported cases have been associated with an underlying osteochondroma. if these lesions were to be truly classified as ‘secondary’, some mechanical insult to the cartilage cap, leading to disassociation of the cartilage cells and secondary seeding into the bursa would be expected. dislodgement of lobulated osteochondroma nodules from constant friction is potentially possible, but that does not appear to be the case in this instance. histologically, secondary synovial chondromatosis is similar in appearance to the primary but the former is thought not to be clonal and has an identifiable articular primary cause. the histology shows hyperplastic synovium, in which cartilaginous foci form, with the chondrocytes showing mild atypia, binucleation, clustered or diffuse growth in a hyaline cartilage background with areas of calcification. pleomorphism, necrosis and mitotic figures are absent. patients with osteochondromas and synovial chondromatosis have been shown to have underlying genetic abnormalities. mutations in genes extostin 1 (ext-1) and extostin 2 (ext-2) are common in patients with osteochondromas. both sporadic and multiple (hereditary) osteochondromas have been associated with loss of heterozygosity (or somatic loss of function of the wild type allele) of one or more of the ext loci.7 the proteins encoded by ext-1 and ext-2 genes help in the formation of heparin sulphate, which in turn binds to hedgehog protein ligands in the matrix of hyaline cartilage. the indian hedgehog signalling pathway inhibits the terminal differentiation of growth plate chondrocytes. decreased heparin sulphate secondary to mutations in ext genes leads to abnormal diffusion of hedgehog ligands, which in turn leads to misdirected growth plate chondrocytes resulting in the formation of osteochondromas.15 dysregulation of the indian hedgehog signalling pathway has also been implicated as a causative factor in synovial chondromatosis.6 thus, the underlying mechanism remains common to both the distinct pathologies with the end result being diffusion of chondrocytes into the extra-cellular matrix resulting in either formation of synovial chondromatosis or an osteochondroma. therefore, concomitant synovial chondromatosis figure 5. resected and opened bursa that was overlying the osteochondroma figure 6. multiple synovial chondromas found within the bursa figure 7. low magnification view of hypercellular hyaline cartilage nodule embedded in hyperplastic subsynovial tissue with granulation tissue and fibrosis figure 8. high magnification view of hyaline cartilage with clusters of chondrocytes that demonstrate mild nuclear atypia page 49tanwar y et al. sa orthop j 2020;19(1) and osteochondromas might present more than just what meets the eye, and that is a common underlying pathogenetic mechanism. lin et al. described a case of bursal osteochondromatosis which developed several years after osteochondroma excision.16 they postulated that it could be due to proliferation of cartilage debris shed from the cartilaginous cap during surgery or biopsy. however, it seems very unlikely to be the case as there was a latent period of several years between the osteochondroma excision and development of bursal chondromatosis. what does seem to be a more plausible explanation is the possible presence of an underlying genetic abnormality, leading to an increased propensity to develop chondral tumours such as synovial chondromatosis and osteochondromas. the simultaneous occurrence of chondromatosis with osteochondroma also poses a diagnostic dilemma, due to the confusing radiographic imaging that may be mimicking sarcomatous change in an osteochondroma.8 both synovial chondromatosis and chondrosarcoma may show extension into nearby soft tissues and cortical erosion of the bone. an mri is usually recommended to ascertain the diagnosis, with a clear margin between the underlying cartilage cap and the overlying calcified mass. a permeative pattern and infiltration of the marrow is a strong indicator of malignant transformation. with regard to the present case, we have presented the concomitant existence of osteochondroma with synovial chondromatosis and speculate on a common underlying genetic abnormality for this co-occurrence. careful radiographic and histological analysis is necessary to exclude sarcomatous change which the latter might mimic. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. ethical approval for this study was obtained from the stellenbosch university health research ethics committee (c19/02/006). declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions yt: primary author, drafting of the work, final approval of the version submitted to the journal. mp: conception and design of the work, revising it critically for important intellectual content; final approval of the version submitted to the journal. mo: review of histopathological specimens, critical revision of work for important intellectual content; final approval of the version submitted to the journal. ps: review of histopathological specimens, critical revision of work for important intellectual content; final approval of the version submitted to the journal. nf: primary surgeon and corresponding author; conception and design of the work, drafting of the work, revising it critically for important intellectual content; final approval of the version submitted to the journal. orcid tanwar y http://orcid.org/0000-0003-4606-7801 potgieter m http://orcid.org/0000-0002-9611-4859 oosthuizen m http://orcid.org/0000-0001-6820-9482 schubert p http://orcid.org/0000-0003-4422-7349 ferreira n http://orcid.org/0000-0002-0567-3373 references 1. d’ambrosia r, ferguson ab, jr. the formation of osteochondroma by epiphyseal cartilage transplantation. clin orthop relat res. 1968;61:103-15. 2. mavrogenis af, papagelopoulos pj, soucacos pn. skeletal osteochondromas revisited. orthopedics. 2008;31(10). 3. giudici ma, moser rp, jr., kransdorf mj. cartilaginous bone tumors. radiol clin north am. 1993;31(2):237-59. 4. tong k, liu h, wang x, zhong z, cao s, zhong c, et al. osteochondroma: review of 431 patients from one medical institution in south china. j bone oncol. 2017;8:23-9. doi: 10.1016/j.jbo.2017.08.002. 5. neumann ja, garrigues ge, brigman be, eward wc. synovial chondromatosis. jbjs rev. 2016;4(5). doi: 10.2016/jbjs. rvw.o.00054. 6. hopyan s, nadesan p, yu c, wunder j, alman ba. dysregulation of hedgehog signalling predisposes to synovial chondromatosis. j pathol. 2005;206(2):143-50. doi: 10.1002/path.1761. 7. hameetman l, bovee jv, taminiau ah, kroon hm, hogendoorn pc. multiple osteochondromas: clinicopathological and genetic spectrum and suggestions for clinical management. hered cancer clin pract. 2004;2(4):161-73. doi: 10.1186/1897-4287-2-4-161. 8. schofield td, pitcher jd, youngberg r. synovial chondromatosis simulating neoplastic degeneration of osteochondroma: findings on mri and ct. skeletal radiol. 1994;23(2):99-102. doi: 10.1007/ bf00563200. 9. errani c, jutte pc, de paolis m, bacchini p, mercuri m. secondary synovial chondromatosis in a bursa overlying an osteochondroma mimicking a peripheral chondrosarcoma -a case report. acta orthop. 2007;78(5):701-704. 10. khandwala k, waheed aa, alvi mi, mirza wa, umer m, khurshid e. bursal synovial chondromatosis secondary to underlying osteochondroma in a child. cureus. 2017;9(12):e1944. doi: 10.7759/cureus.1944. 11. wang y, li l, chen m, yang c. osteochondroma with secondary synovial chondromatosis in the temporomandibular joint. br j oral maxillofac surg. 2016;54(4):454-56. doi: 10.1016/j. bjoms.2015.07.014. 12. peh wc, shek tw, davies am, wong jw, chien ep. osteochondroma and secondary synovial osteochondromatosis. skeletal radiol. 1999;28(3):169-74. doi: 10.1007/s002560050495. 13. gould es, baker ks, huang m, khan f, hoda s. osteochondroma of the hip with adjacent bursal chondromatosis. skeletal radiol. 2014;43(12):1743-48. doi: 10.1007/s00256-014-1954-y. 14. shallop b, abraham ja. synovial chondromatosis of pes anserine bursa secondary to osteochondroma. orthopedics. 2014;37(8):e735-38. doi: 10.3928/01477447-20140728-90. 15. jones kb, morcuende ja. of hedgehogs and hereditary bone tumors: re-examination of the pathogenesis of osteochondromas. iowa orthop j. 2003;23:87-95. 16. lin yc, goldsmith jd, gebhardt mg, wu js. bursal synovial chondromatosis formation following osteochondroma resection. skeletal radiol. 2014;43(7):997-1000. doi: 10.1007/ s00256-014-1821-x. http://orcid.org/0000-0003-4606-7801 http://orcid.org/0000-0002-9611-4859 http://orcid.org/0000-0001-6820-9482 http://orcid.org/0000-0003-4422-7349 http://orcid.org/0000-0002-0567-3373 _goback _enref_36 _enref_2 _enref_5 orthopaedics vol3 no4 page 48 sa orthopaedic journal winter 2015 | vol 14 • no 2 corticosteroid usage in hand and wrist surgery mw solomons mbchb, fcs(orth)(sa) martin singer hand unit, groote schuur hospital, university of cape town corresponding author: dr mw solomons h49 omb groote schuur hospital anzio rd observatory cape town general how does cortisone work? short answer: it interferes with the inflammatory process by blocking cytokine production. long answer: glucocorticoid gets taken up into cell and binds with receptor. this receptor–ligand complex binds to specific genes causing upregulation of annexin-1. annexin-1 is a potent phospholipase inhibitor that blocks the production of prostaglandins and leukotrienes, the primary mediators of inflammation. what are the fundamental differences in the different preparations? there are essentially two different groups: soluble and insoluble. all are derivatives of prednisolone with different side chains or chemical tweaking. the phosphate group are soluble and are absorbed rapidly giving them a short onset of action and a more substantial systemic effect. these include betamethasone sodium phosphate which is one of the components of betamethasone injectable suspension. the ester side chain group include methylprednisolone acetate injectable suspension and betamethasone acetate which makes up the other component of betamethasone injectable suspension. these compounds are insoluble and tend to aggregate and form crystals that take a while to dissolve and exert their effect. the crystals can irritate the synovium causing substantial discomfort. what is the risk of sepsis? the reported incidence ranges from 1 in 3 000 to 1 in 50 000. the author advocates a ‘no-touch’ technique to minimise the risk of this dreaded complication. what is the effect on blood sugar? the literature is confusing. most suggest there will be some hyperglycaemic effect in iddm patients for as much as five days. they should be warned to keep a close eye on control. introduction hand and wrist surgery probably leads the other orthopaedic disciplines in corticosteroid usage. despite widespread usage there still remains some scepticism among patients and surgeons about the ‘poison ‘of steroid injections. for various (often fiscal!) reasons patients are not offered cortisone injections as a simple, quick and effective conservative option to many common hand/wrist maladies. key words: cortisone, corticosteroids, trigger finger, carpal tunnel, de quervain’s the author advocates a ‘no-touch’ technique to minimise the risk of the dreaded complication of sepsis http://dx.doi.org/10.17159/2309-8309/2015/v14n2a7 saoj winter 2015_press_orthopaedics vol3 no4 2015/05/11 10:00 am page 48 sa orthopaedic journal winter 2015 | vol 14 • no 2 page 49 any other risks or side effects? one common, one rare. about 25% of patients will develop an acute post-injection flare. it is the author’s opinion that this is much more substantial and dramatic with methylprednisolone acetate injectable suspension than betamethasone injectable suspension. it can present as a sepsis-like presentation with pain, redness and warmth. sometimes the acetate component of betamethasone injectable suspension can precipitate a similar but usually less dramatic clinical picture. a rare complication is hypopigmentation and skin atrophy at the injection site. it is more common with subcutaneous injections (de quervain’s and trigger) than with intra-articular injections. trigger digit why does it occur? following mechanical trauma the inner gliding layer of the pulley undergoes chondroid metaplasia ultimately replacing it with fibrous tissue. in other words the pathology is in the pulley not the tendon or tenosynovium. what is the term tenovaginitis? as the ‘inflammation’ is in the pulley rather than the tendon or tenosynovium, a better name for trigger finger is tenovaginitis. if no synovitis then why do steroids work? hyperplasia of the outer vascular layer ultimately invades the inner layer causing thickening. this process must be cytokine-mediated inflammation. steroids will reverse the thickening of the pulley. is it necessary to inject into the sheath? a study by taras et al. showed no benefit to injecting the bolus under the pulley into the sheath versus injecting outside the sheath (figure 1).1 what are the results in the literature? sixty to 90% positive long-term response to cortisone injections depending on who you read. worse results are reported in diabetics and in triggering going on for more than 4 to 6 months. obviously it becomes difficult for the steroids to reverse the fibrocartilaginous metaplasia once it has occurred. any point in a second or third injection? yes! it has been shown that there can be a 36% positive response to a second injection. a study by benson and ptaszek showed no response to a third injection.2 are there risks associated with injection? raised blood sugar in diabetics for up to five days so warn them. tendon rupture very, very rare. despite widespread usage only a handful of cases have been reported. de quervain’s why does it occur? once again the pathology of de quervain’s is myxoid degeneration rather than acute inflammation. the tendon sheath can be five times thicker than normal. the incidence of a separate sub-sheath for epb is 70% in patients with de quervain’s versus 20% in a random selection of cadavers.3 careful exploration at the time of surgery is therefore mandatory to ensure a successful outcome. what is the natural history? in a study by schnellen and ring,4 95% of patients offered non-interventional treatment including splints and nsaids had symptom resolution by one year. a separate study with 6-month follow-up resulted in only 36% resolution in the splint-alone group. although the natural history is incompletely understood, de quervain’s tenosynovitis seems to be self-limited in the majority of patients. figure 1. injection just proximal to proximal palmar crease figure 2. de quervain’s injection from distal to proximal between two tendons saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 49 page 50 sa orthopaedic journal winter 2015 | vol 14 • no 2 results of steroid injection? effective in 75% to 85%! (figure 2) does ultrasound help in guiding the injection? yes it appears so. at least two studies show improved outcomes with us-guided injection techniques. it is the author’s opinion that the cost and hassle does not justify the marginal increase in efficacy.5,6 what about splints? in a three-armed study, weiss et al. studied the use of corticosteroid injections and splinting together and separately to determine their clinical effect. they observed a 67% improvement with injection alone, 57% improvement with both injection and splinting, and 19% improvement with splinting alone.7 carpal tunnel what are the risks of injecting the carpal tunnel? other than the risks of systemic corticosteroids as mentioned earlier, the author has seen numerous cases of inadvertent intraneural injection. while all resolved over time, the pain and temporary neurological deficit was a substantial cause of treatment morbidity. any severe pain at the time of injection or resistance while injecting may be an indication of an intra-neural position of the needle. if this occurs, immediately remove the needle and reinsert in a more ulnar direction (figure 3). a carpal tunnel injection should not be painful! what are the long-term benefits? it is widely accepted that no more than 10 to 15% of patients with clinically suspected cts will have long-term meaningful response to cortisone injections.8 in certain selflimiting conditions such as pregnancy, cortisone injections can temporise while awaiting resolution. what about using injections for diagnosis? patients whose symptoms improve after a steroid injection to the carpal tunnel also have a significantly better response to surgery than those who do not respond to the injection. tfcc tears how do i make the diagnosis? point tenderness deep in the ulnar snuff box (figure 4) and pain on end range supination and/or pronation. note that the literature mentions pain on end range pronation being more specific but it is the author’s opinion and experience that this is incorrect. injection techniques there are no papers in the literature reporting the techniques and outcomes of tfcc injection. the author prefers an injection from mid lateral on the ulnar side immediately volar to the ecu tendon. the ulnar-sided joint should accept a 2 to 3 cm bolus without any resistance. my outcomes? the author presented a series of injections for tfcc pain at the sassh and saoa meeting 2013. he reports 60% resolution after a single injection and a further 28% of patients were only occasionally symptomatic and did not require any further intervention. what does the literature say? preciously little. the wrist literature is replete with every conceivable form of operative intervention including open and arthroscopic debridements and repair. is there a place for mri? lordache9 took 103 asymptomatic volunteers and submitted them to mris. the tfcc was reported as abnormal in 39 with 23 reported as having a complete tear! haims et al. reported on mri arthrography having a sensitivity of 17%, specificity of 79% and an accuracy of 64%.10 figure 3. injection technique for cts – ulnar edge of palmaris longus figure 4. the ulnar snuff box a carpal tunnel injection should not be painful! saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 50 base of thumb arthritis do steroids work? studies continue to show statistical improvement in pain scores from baseline but a prospective randomised blinded study out of new york failed to show any difference between steroid, hyaluronic acid and placebo!11 the author’s experience is that the average response is 4 to 6 weeks with about 20% of patients reporting long-term effects. in a study by day et al.,12 steroid injection with splinting for the treatment of basal joint arthritis of the thumb provided reliable long-term relief in thumbs with eaton stage 1 disease but provided long-term relief in only seven of 17 thumbs with eaton stage 2 and stage 3 basal joint arthritis. dorsal wrist syndrome what is it? dws is a clinical entity of dorsal wrist pain directly over the dorsal scapholunate interosseous ligament (figure 5). the pain is exacerbated by loading in wrist extension such as a push-up. it represents an irritation of the terminal fibres of the posterior interosseous nerve by bony impingement or an occult dorsal wrist ganglion. treatment? eighty-six per cent good and excellent results after one or two cortisone injections into the point of maximal discomfort on the dorsum of the wrist. conclusion accurate diagnosis is critical. obviously steroid injections can only offer a therapeutic option if the clinical problem is correctly identified and attention is placed on accurate placement of the needle. steroid injections play a pivotal role in the conservative management of soft tissue and joint wrist and hand conditions. fifty to 90% of patients can be expected to have meaningful long-term effects. failure to incorporate this modality into your practice must be construed as over-servicing. the content of this article is the sole work of the author. no benefits of any form have been or are to be received from a commercial party related directly or indirectly from this article. references 1. taras js, raphael js, pan wt, movagharnia f, sotereanos dg. corticosteroid injections for trigger digits: is intrasheath injection necessary? j hand surg am. 1998 jul;23a(4):712–22. 2. benson ls, ptaszek aj. injection versus surgery in the treatment of trigger finger. j hand surg 1997;22a:138–44. 3. alemohammad am, yazaki n, morris rp, buford wl, viegas sf. thumb interphalangeal joint extension by the extensor pollicis brevis: association with a subcompartment and de quervain’s disease. j hand surg 2009;34a:719–23. 4. ring d, schnellen a. patient-centered care of de quervain’s disease. j hand microsurg. 2009;1(2):68–71. 5. mcdermott jd, ilyas am, nazarian ln, et al. ultrasoundguided injections for de quervain’s tenosynovitis. clin orthop relat res.2012;470(7):1925–31. 6. kume k, amano k, yamada s, et al. in de quervain’s with a separate epb compartment, ultrasound-guided steroid injection is more effective than a clinical injection technique: a prospective open-label study. j hand surg eur vol. 2012;37(6):523–27. 7. weiss ap, akelman e, tabatabai m. treatment of de quervain’s disease. j hand surg 1994;19a:595–59. 8. graham rg, hudson da, solomons mw, singer m. a prospective study to assess the outcome of steroid injection and splinting for the treatment of carpal tunnel syndrome. plast reconstr surg. 2004 feb; 113(2);550-56. 9. lordache sd, rowan r, garvin gj, osman s, grewal r, faber kj. prevalence of triangular fibrocartilage complex abnormalities on mri scans of asymptomatic wrists. j hand surg am. 2012 jan;37(1):98-103. 10. haims ah, schweitzer me, morrison wb, deely d, lange r, osterman al, bednar jm, taras js, culp rw. limitations of mr imaging in the diagnosis of peripheral tears of the tfc of the wrist. ajr am j roentgenol. 2002 feb;178(2):419-22. 11. heyworth be, lee jh, kim pd, lipton cb, strauch rj, rosenwasser mp. hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: a prospective,randomized, double-blinded clinical trial. j hand surg am. 2008 jan; 33(1):40–48. 12. day cs, gelberman r, patel aa, vogt mt, ditsios k, boyer mi. basal joint osteoarthritis of the thumb: a prospective trial of steroid injection and splinting. j hand surg am. 2004 mar;29(2):247-51. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. sa orthopaedic journal winter 2015 | vol 14 • no 2 page 51 • saoj figure 5. dorsal wrist syndrome point of maximal tenderness is 1 cm distal to lister’s tubercle with wrist slightly flexed saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 51 orthopaedics vol3 no4 sa orthopaedic journal winter 2015 | vol 14 • no 2 page 29 instructional course lecture: spondylolysis na kruger bsc, mbchb, frcs(ed), fcs(orth)(sa) consultant orthopaedic spinal surgeon, head of acute spinal cord injury unit, uct student orthopaedic training co-ordinator, groote schuur hospital corresponding author: dr nicholas a kruger orthopaedic dept h49 old main building groote schuur hospital main road, observatory cape town, 7925 tel: 021 404 5118 email: nicholas.kruger@uct.ac.za website: www.orthopaedics.uct.ac.za incidence the general population incidence is 6%.1 most studies have reported ethnic and sex differences. skeletal studies: roche et al.2 found a white male incidence of 6.4%, white women 2.3%, african-american men 2.8% and african-american women 1.1%. eisenstein3 looked at south african skeletons and found a general population incidence of 3.5% (white males 3.8%, white women 5.7%, african men 3.5% and african women 2.6%). in contrast, indigenous residents of greenland were found to have an overall incidence of 54% (men 61.9%, women 48%).4 radiographic studies: fredrickson et al.5 looked at 500 unselected first-grade children prospectively with plain radiographs and found an incidence of 4.4% spondylolysis at 6 years which increased to 6% in adults. other studies reviewed large numbers of radiographs (sonne-holm et al. 4 001 canadian adults; amato et al. 1 500 plain radiographs) with an incidences of 4.6% and 3.7% respectively.6,7 japanese studies of 2 000 subjects (age 20–92 years) with ct for non-lumbar conditions found lumbar spondylolysis 5.9% and male:female ratio of 2:1.8 other ct studies in unselected populations reported a 5.7–11.5% incidence of spondylolysis.9,10 familial incidence most studies suggest a genetic component to spondylolysis. fredrickson et al.5 found a 32–34% incidence in family members. albanese11 reported on 70 patients and 222 firstdegree relatives with a 22% incidence. other authors reported up to 70% incidence in first-degree relatives.11-13 spondylolisthesis and sport the association of spondylolysis with sport is well documented. athletes have a much higher incidence than non-athletes, with certain sports being particularly high risk. the incidence of spondylolysis was found to be 11% in female gymnasts (jackson et al.14) college football players had a 20.7% incidence of spondylolysis (semon and spengler).15 akimoto16 looked at 1 966 unselected adolescents with plain radiography and found 10.3% in athletes and 3.2% in non-athletes. ohba17 found reported on 536 japanese athletes with lower back pain, with a 32.3% incidence. micheli and wood18 found 47% of young athletes with lower back pain had lumbar spondylolysis. introduction spondylolysis is a defect of the pars interarticularis of the vertebral arch. its cause is often multifactorial but mostly thought to be as a result of a stress fracture. most fractures occur at l5 (71%–95%) and l4 (5%–23%).1 key words: spondylolysis, pars fracture, imaging, management http://dx.doi.org/10.17159/2309-8309/2015/v14n2a3 saoj winter 2015_press_orthopaedics vol3 no4 2015/05/11 9:59 am page 29 page 30 sa orthopaedic journal winter 2015 | vol 14 • no 2 skeletal and neuromuscular conditions spina bifida occulta has an increased incidence most probably due to genetic factors, not mechanical predisposition. osteogenesis imperfecta does not seem to have an increased incidence of spondylolysis (5.3%).19 osteopetrosis has been found to have as high as 71.4% incidence of spondylolysis.20 scheuermann’s disease has been reported having an incidence of 32–50% possibly due to compensatory lumbar hyperextension.21,22 scoliosis fisk et al.23 found a 6.2% incidence in 539 patients with idiopathic scoliosis. however seitsalo et al.22 reported on 190 young patients with an incidence of 44%. cerebral palsy: athetoid cerebral palsy has been associated with a 60% incidence spondylolysis.24 takada et al.25 found 48.6% spondylolysis in non-ambulatory cerebral palsied patients. lumbar spondylolysis by all accounts appears to be a stress fracture and this was proposed by wiltse et al.26 in 1975. supporting the stress fracture theory are findings that it is more common in athletes with repetitive trunk movements, especially repetitive hyperextension and rotation. it is common in patients with involuntary trunk movements such as athetoid cerebral palsy. radiologically it behaves similarly to a stress fracture in long bones. it is not detected in foetuses, infants and non-ambulatory patients. the two proposed mechanisms are: 1. repetitive extension stresses (nutcracker mechanism) with the inferior articular process of the cranial vertebra impacting the pars interarticularis of the caudal vertebra. biomechanical studies found greatest loading with flexion/extension at l5/s1 and the highest mechanical stresses occurring at the pars interarticularis.27 2. pars failure through a tension mechanism.28-31 natural history spondylolysis is almost never present at birth. it develops in early school-age years (4.4% incidence) and gradually increases to the adult incidence of 6%.5 concerns are that the defect predisposes individuals to the development of lower back pain and progression to spondylolisthesis. spondylolisthesis has a benign course. the general incidence of 6% does not change with increasing age from 20–80 years and the overwhelming majority of cases are asymptomatic. there does not appear to be a significant association between the presence of spondylolysis and lower back pain (lbp) in the general non-athletic population. athletes with back pain, however, present with an increased incidence of spondylolysis. micheli and wood18 reported 47% spondylolysis in a sports medicine clinic in adolescents compared with 5% of the adult control population. thus it is in young athletes that painful spondylolysis is particularly a problem. another concern with spondylolysis is the risk of progressive spondylolisthesis. unilateral pars defects are usually inconsequential. bilateral pars defects may progress to slip; however, the risk of progression is small in most studies. only about 4% of pars defects tend to progress to significant slips of more than 20% over several years. the propensity to slip correlates with the adolescent growth spurt and decreases with age over 16 years.5 slip progression in child and adolescent athletes has shown similar rates to the general population. muschik et al.32 reported only one in 86 patients progressing more than 20%, and concluded that there was no increased risk with active sports participation. clinical presentation most people have radiographic spondylolysis with few or no clinical symptoms. in children the most common identifiable cause of lower back pain is spondylolysis. symptoms include lower back pain with or without radiation to the buttocks and posterior thigh. the pain may be exacerbated by spine hyperextension. often insidious, there may be a history of an acute injury in 40%. examination may demonstrate hyperlordosis, localised tenderness, decreased range of lumbar extension and hamstring tightness. the stork test is a provocative test combining extension of the lumbar spine with side flexion and rotation, while standing on the leg of the symptomatic side. neurological examination is usually normal but occasionally the spondylolysis may cause root irritation. algorithm for spondylolysis symptoms include lower back pain with or without radiation to the buttocks and posterior thigh. the pain may be exacerbated by spine hyperextension saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 30 sa orthopaedic journal winter 2015 | vol 14 • no 2 page 31 imaging x-rays: standing ap and lateral views are the usual screening investigations when evaluating lower back pain (figure 1). oblique films may demonstrate the classic ‘scotty dog neck’ which is pathognomonic of a pars fracture with a broken neck or collar. twenty per cent of pars defects are only shown on oblique films (figure 2). bone scan and spect: bone scan and spect show increased sensitivity over x-rays; however, their specificity is often low. they do have prognostic value whereby a ‘cold scan’ of a radiological pars fracture represents a non-union and a positive scan represents active healing or healing potential. ct scan: ct is significantly more sensitive than plain radiography (figure 3) and provides information about the nature of the defects as well as demonstrating other pathology causing lbp. ct can help differentiate between an acute fracture or a chronic fracture with little healing potential. ct is valuable to assess healing on follow-up scans. mri scan: mri is increasingly used in the diagnosis of lower back pain. thin slice mri has been shown to have sensitivity of 57% to 86% and specificity of 81% to 82%. furthermore mri has prognostic value with marrow oedema and signal changes in adjacent pedicles representing an acute or sub-acute fracture with healing potential. mri may also detect a pars stress response before fracture occurs. non-operative treatment the mainstay of conservative management is activity restriction. non-steroidal anti-inflammatories are used for analgesia as required. the pain-producing sporting activities need to be restricted and active competition stopped for 4–12 weeks.33-35 athletes need to be pain-free with full range of spinal motion before returning to active competition. bracing is controversial and no consensus exists. there are multiple bracing regimens available with rigid and nonrigid braces. it is possible that bracing simply enforces rest rather than providing structural stability. brace compliance is also problematic. rest and activity restriction are more important than bracing in the conservative management of spondylolysis.36 bone stimulators have been used in some studies but further trials are needed to evaluate them. figure 1. standing ap and lateral views are the usual screening investigations when evaluating lower back pain the mainstay of conservative management is activity restriction figure 2. ‘scotty dog’ as seen on oblique films figure 3. ct scan of pars defect saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 31 page 32 sa orthopaedic journal winter 2015 | vol 14 • no 2 outcomes about 75% to 100% of acute lesions heal. l5 lesions are the least likely to heal. all unilateral acute lesions heal and up to 50% of bilateral acute lesions heal. chronic pars defects remain as a non-union. most patients do well on conservative treatment and more than 90% return to their previous activity levels. it is debatable whether radiological evidence of union is required as most non-unions are asymptomatic.37 operative treatment surgery is indicated with failed conservative treatment after 9–12 months. the standard operation which has been extensively reported with good-to-excellent long-term results is the l5–s1 posterior uninstrumented fusion with posterior iliac crest bone graft.38-40 this does however sacrifice motion segments in young patients who are often sportspeople. fixation pars fixation has the theoretical advantages of motion segment preservation and adjacent level protection. for spondylolysis repair, the pain should be isolated to the lysis which can be confirmed with local anaesthetic injections. a degenerate disc, more than 3 mm spondylolisthesis or patient age over 20 years are relative contraindications to pars repair. numerous techniques exist, including interfragmentary fixation, tension band constructs, pedicle screws and hooks. none has any clear advantages in outcomes and choosing a technique is a matter of personal preference, technical ease of hardware placement and lowest risk of complications. buck screw technique is popular (figure 4) but when there are deficient posterior elements a pedicle screw-sublaminar hook construct (figure 5) may be employed. more importantly, a thorough debridement of the fibrous defect and bone grafting is required. post-operative bracing for six weeks helps restrict activity to allow union. pars repair has shown 84% return to sports activity after 5–12 months.41 figure 4. bucks screws figure 5. pars repair with pedicle screw and sublaminar hook important points: • spondylolysis is a common condition and the majority of cases are asymptomatic. • it is caused by repetitive micro-trauma in the growing spine. • in symptomatic spondylolysis, rest and activity modification are usually successful. • a chronic symptomatic spondylolysis may be directly fixed if the patient is young and there is no secondary disc degeneration. bracing is controversial and no consensus exists saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 32 sa orthopaedic journal winter 2015 | vol 14 • no 2 page 33 fusion when there are relative contraindications to pars repair, posterior fusion is the gold standard. in-situ posterolateral arthrodesis via the wiltse musclesplitting approach has yielded good-to-excellent results in up to 75% to 100% of cases. the advantage of instrumented fusion in spondylolysis is unclear. there are no studies showing an advantage for instrumented fusions in this young patient group. instrumentation is generally less necessary in the paediatric population for spondylolysis since they have higher fusion rates and the spine is inherently stable. there may be a role for instrumentation in the older patient especially if a decompression is indicated. instrumentation may prevent the need for post-operative immobilisation and bracing. the choice of approach and instrumentation remains the surgeon’s choice; in general posterior pedicle screw fixation should be adequate. when considering fixation vs fusion, it is worth considering the findings of schlenzka et al.,42 who found no advantage of repair over segmental fusion after 15 years. post-operative activity restriction is for three months with return to contact sport after one year when there is full pain-free range of motion. outcomes the functional return to pre-morbid sporting level is not known. most athletes will return to some level of sporting activity and 20% of patients do not return to full contact sport.43,44 the content of the article is the original work of the authors. no benefits of any form have been or are to be received from a commercial party related directly or indirectly to the subject of the article. references 1. toshinori sakai et al. incidence and etiology of lumbar spondylolysis: review of the literature. j orthop sci 2010;15:281–88. 2. roche mb, rowe gg. the incidence of separate neural arch and coincident bone variations: a survey of 4,200 skeletons. anat rec 1951;109:233–52. 3. eisenstein s. spondylolysis: a skeletal investigation of two population groups. j bone joint surg br 1978;60:488–94. 4. simper lb. spondylolysis in eskimo skeletons. acta orthop scand 1986;57:78–80. 5. fredrickson be, baker d, mcholick wj, yuan ha, lubicky jp. the natural 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repair for treatment of symptomatic spondylolysis and low-grade isthmic spondylolisthesis in young patients. eur spine j 2006;15:1437–47. 43. eck jc, riley 3rd lh. return to play after lumbar spine conditions and surgeries. clin sports med 2004 jul;23(3):367–79. 44. rubery pt, bradford ds. athletic activity after spine surgery in children and adolescents: results of a survey. spine 2002;27(4):423–27. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 34 elhadi as et al. sa orthop j 2018;17(4) doi 10.17159/2309-8309/2018/v17n4a2 south african orthopaedic journal http://journal.saoa.org.za trauma citation: elhadi as, gashi yn. unstable intertrochanteric fracture in elderly patients: outcome of primary cemented bipolar hemiarthroplasty versus internal fixation. sa orthop j 2018;17(4):22-26. http://dx.doi.org/10.17159/2309-8309/2018/v17n4a2 editor: prof n ferreira, stellenbosch university received: march 2018 accepted: august 2018 published: november 2018 copyright: © 2018 elhadi as. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: the aim of this study was to evaluate the outcome of internal fixation in comparison with primary cemented bipolar (pcb) hemiarthroplasty in elderly patients with unstable intertrochanteric fracture. methods: a prospective cohort multicentre study compared cemented bipolar (n=60) to osteosynthesis (n=57) in unstable intertrochanteric fracture (ao/ota classification) in the elderly. peri-operative mortality, complications and functional outcome were used as main outcome measures. results: the two groups were comparable in age, sex, comorbidity, mode of trauma, and classification of fracture. in hemiarthroplasty, 93.3% of patients were able to start partial weight bearing on post-operative day 1, while in the internal fixation group, 75.4% of patients started partial weight bearing after two weeks post-operatively. at the final follow-up, one year after surgery, the mortality rate did not differ between the two groups, but general and mechanical complications were more common in the internal fixation group. the mean harris hip score at final follow-up was better in the hemiarthroplasty group (91.14 vs 74.33). conclusion: primary cemented bipolar hemiarthroplasty was superior to internal fixation in terms of lower complication rates and better functional outcome. level of evidence: level 4 key words: unstable intertrochanteric fracture, osteosynthesis, hemiarthroplasty, internal fixation unstable intertrochanteric fracture in elderly patients: outcome of primary cemented bipolar hemiarthroplasty versus internal fixation elhadi as,¹ gashi yn² 1 md; department of orthopaedics, ibrahim malik teaching hospital, khartoum, sudan 2 md; assistant professor, faculty of medicine, university of khartoum, soba university hospital corresponding author: dr ahmed siddig elhadi, department of orthopaedics, ibrahim malik teaching hospital, alsahafa east, khartoum, sudan; tel: +249913955175 +249123255175; email: ahmedsiddig625@yahoo.com page 23elhadi as et al. sa orthop j 2018;17(4) introduction the intertrochanteric fracture is one of the most common fractures of the hip in the elderly, and usually is a result of low-energy trauma;1 it accounts for up to 48% of all hip fractures.2 these fractures are associated with substantial morbidity and mortality, mechanical complications, and great financial burden to patients and their families.3,4 stable fractures can be easily treated with osteosynthesis with predictable results. however, the management of unstable intertrochanteric (evans type ii and ao/ota type 31-a2.2 and 2.3)5,6 fractures in elderly patients is a challenge because of the difficulty in obtaining anatomical reduction and the increased rates of morbidity and mortality. in the literature, a variety of methods have been used to manage intertrochanteric fractures; however, each method has its own limitations.7,8 hemiarthroplasty replacements have been shown to achieve early rehabilitation of the patient and good long-term results.9-12 however, the ideal treatment method for intertrochanteric fractures is still unclear because of the poor quality of bone mass, comorbid disorders, and difficulty in rehabilitating patients. the aim of this study was to compare the outcome of primary cemented bipolar (pcb) hemiarthroplasty with internal fixation in the management of comminuted intertrochanteric hip fractures in elderly patients. methods this was a prospective cohort hospital-based study conducted at three main tertiary hospitals. the study was conducted over a period of two years (january 2014 to february 2016). a total of 117 patients were enrolled in the study, all 65 years of age and above, with unstable intertrochanteric fracture. those with stable fractures, age less than 65 years and with pathological fractures were excluded from the study. the study patients were treated by orthopaedic surgeons with a minimum of three years’ experience in hip trauma. fifty-seven patients were treated with internal fixation (dynamic hip screw and proximal femoral nail) and 60 patients were treated with pcb hemiarthroplasty; the method of treatment was selected according to hospital policy. personal data, mode of trauma and comorbidity were reported using a structured questionnaire. fractures were classified according to ao/ota classification.6 details about intra-operative events (e.g. duration of surgery and blood loss) were reported. partial weight bearing, hospital stay, full weight bearing, infection, and other complications were used as predictors of post-operative improvement and complications. all patients received pre-operative prophylactic antibiotics (1.5 mg of cefuroxime with induction of anaesthesia) and post-operative anticoagulant treatment (4 000 iu of low-molecular-weight heparin). all patients were seen at 2 weeks, 6 weeks, and 12 weeks post-operatively, and at the final follow-up, which was one-year post surgery in both groups. all patients were evaluated using the harris hip score13 at 3 months and at the final follow-up to assess functional outcomes. peri-operative mortality, complications and functional outcome were used as main outcome measures. surgical procedure dynamic hip screw (dhs) on the traction table, through a direct lateral femoral approach with vastus lateralis reflection in the majority of cases (94.7%), the lag screw was applied after reduction, and its position checked with a c-arm. tip apex distance (tad) was taken into consideration and within accepted limits. thereafter, a side plate was fixed to the femoral shaft with cortical screws. the device used was sh pitkar orthotools pvt ltd, pimpri-chinchwad, india (figure 1). proximal femoral nail (pfn) on the traction table, a minimal incision was made above the greater trochanter, under c-arm viewing, through the trochanteric entrance. canal opening and serial reaming were performed and the size and length of the proximal femoral nail (pfn) was chosen. intramedullary nailing (imn) was introduced with two proximal lag screws through handle (jig), then two distal locking screws applied. the outcome was assessed with the c-arm. the device used was produced by mj surgical, ahmedabad, gujarat, india (figure 2). (a) pre-operative (b) immediately post-operative (c) at 3-months follow-up figure 1. anteroposterior radiographs of 73-year-old male showing unstable intertrochanteric fracture fixed with dhs page 24 elhadi as et al. sa orthop j 2018;17(4) pcb hemiarthroplasty all arthroplasties were performed through the lateral hardinge approach in the decubitus position. the head and bony fragments were removed except for the greater trochanter. the greatly fragmented calcar was removed and remodelled with cement in three cases (figure 3); the lesser trochanter was not removed. thereafter, the greater trochanter was reattached with cerclage wire and a cemented bipolar prosthesis was applied. the implant used was the link sp ii hip prosthesis produced by waldemar linkhamburg, germany (figure 4). data analysis the collected data were analysed with the statistical package for social sciences version 21 (ibm, armonk, ny, usa). the level of significance was set as p≤0.05. variables were analysed using the chi square and fisher’s exact tests. results there were no significant differences between the two groups in terms of demographic data (age, sex), fracture type (classification), mode of trauma, comorbidities and mean follow-up duration (table i). allocation of patients to either of the two groups depended on the protocol used in the hospital where the treatment was performed. the duration of surgical operation with hemiarthroplasty was less compared to fixation. this difference was significant as only four patients in the hemiarthroplasty group, compared to 12 patients in the fixation group, needed more than 2 hours of surgery (p=0.044). regarding intra-operative complications, the need for blood transfusion was less in the fixation group (28 patients) than in the hemiarthroplasty group (37 patients); however, this difference was statistically non-significant (p=0.209). considering post-operative outcome parameters, patients who underwent hemiarthroplasty had a shorter post-operative hospital stay compared to patients that underwent fixation; 56 patients in the hemiarthroplasty group, compared to 30 patients in the fixation group, needed hospital admission for less than 1 week, and the difference between both groups was significant (p=0.002). most patients in the hemiarthroplasty group (56 patients ) were able to start partial weight bearing on the first post-operative day. this contrasted with the observation in the fixation group where 43 patients were able to start partial weight bearing after 15 days (p<0.001). most patients who underwent hemiarthroplasty (52 patients) started full weight bearing at the end of the first week postoperatively, while patients who underwent fixation started full weight bearing at 6 to 12 weeks post-operatively (p<0.001). (a) immediately post-operative (b) at 3-months follow-up (c) at 6-months follow-up figure 2. anteroposterior radiographs of 69-year-old female showing unstable intertrochanteric fracture fixed with pfn (a) intra-operative image figure 3. unstable intertrochanteric fracture in elderly female treated with cemented bipolar hemiarthroplasty showing removed part of comminuted calcar, built up with cement and the greater and lesser trochanter reconstructed with cerclage wire (b) ap fluoroscopic radiograph page 25elhadi as et al. sa orthop j 2018;17(4) the mean harris hip score at 12 weeks post-operatively was 77.85 (49–93) for the hemiarthroplasty group and 53.9 (32–81) for the fixation group (p=0.001). at the final-follow up, which was 13.66 (10–18) months in the hemiarthroplasty group and 12 (10–15) months in the internal fixation group, nine out of the 57 patients who underwent internal fixation had died and seven patients were lost to follow-up. ten patients developed infection, of whom six had superficial infection, which was managed with debridement and intravenous antibiotics. four patients had deep infection that necessitated the removal of implants and revision with external fixation. eight patients had general complications, four had deep venous thrombosis (dvt), and four had bedsores. seven patients had cut-out and penetration into the acetabulum, and all were later revised with arthroplasty. one patient with pfn had periprosthetic fracture, one had non-union revised with hemiarthroplasty, one had delayed union, four had varus malunion, and two patients ended with medialisation (dynamic hip screw – dhs) (table ii). at the final follow-up, ten out of the 60 patients who underwent hemiarthroplasty had died and two were lost to follow-up. three patients had infections: two had deep infections that necessitated removal of the implants; one was left as a girdle stone and the other revised later after exclusion of the infection; one patient had superficial infection. two patients had dvt. five patients had bedsores, three of whom had the bedsores before surgery. only one patient had dislocation of the hip, which was reduced surgically (table ii). the mean harris hip score at time of final follow-up was 74.33 (42–96) for the internal fixation group and 91.14 (73–99) for the hemiarthroplasty group (p<0.001). the re-operation rate was significantly less (p=0.012) in the hemiarthroplasty group; 12 patients in the fixation group, compared to three patients in the hemiarthroplasty group, needed re-operation. discussion for several decades, the treatment of choice for unstable intertrochanteric fractures in elderly patients has been internal fixation, although several studies have shown mechanical and technical failures.14-16 surgeons use different fixation modalities, both extramedullary and intramedullary, with the aim of reducing these complications taking into account different biomechanics. however, reindl et al.17 reported no differences in functional outcome between extraand intramedullary fixation. other surgeons have recommended prosthetic replacement for the treatment of unstable intertrochanteric fractures because of the improved outcomes noted.9-12,18-23 the present study showed better results with hemiarthroplasty than with internal fixation for the treatment of unstable hip fracture in elderly patients, in terms of clinical and functional outcomes. in this study, the duration of surgery was less in hemiarthroplasty. huang and yee24 reported a similar result in their study that compared dhs, proximal femoral nail anti-rotation (pfna), and hemiarthroplasty. partial and full weight bearing started earlier in the hemiarthroplasty group and this was also observed in other studies by huang and yee24 and kayali et al.25 the latter25 reported full weight bearing at four weeks, while in our series, full weight bearing commenced at the end of the first week. this may be explained by the fact that they used a cone medullary prosthesis, while we used a cemented stem. the hospital stay was also less in the hemiarthroplasty group due to the earlier weight bearing. (a) pre-operative (b) post-operative figure 4. ap radiograph of 74-year-old male showing unstable reverse oblique fracture treated with cemented bipolar table i: main demographic and clinical data hemiarthroplasty (n=60) internal fixation (n=57) mean age (range) years male:female fracture type: 31 a 2.2 31 a 2.3 mode of trauma: domestic fall mean follow-up (range) month comorbidities: dm asthma none 76.15 (65–91) 23:37 23 37 58 13.66 (10–18) 17 0 41 77.21 (65–105) 26:31 25 32 52 12 (10–15) 11 2 44 dm = diabetes mellitus table ii: clinical and mechanical complications in the two groups complication hemiarthroplasty internal fixation infection: deep superficial dvt bedsore cut-out periprosthetic fracture dislocation non-union malunion: varus malunion medialisation 5% 3.3% 1.7% 3.3% 8.3% 0 0 1.7% 0 0 0 17.5% 10.5% 7% 7% 7% 12.3% 1.8% 0 1.8% 7% 3.5% page 26 elhadi as et al. sa orthop j 2018;17(4) in the present study, there was no significant difference in mortality rate and the occurrence of deep venous thrombosis between the hemiarthroplasty and fixation groups. similar results were noted in other studies.25-27 kayali et al.25 reported a one-year mortality rate of 24% in the hemiarthroplasty group versus 16% in the fixation group. parker et al.26 in their systematic review reported 18 versus 14 cases of mortality in arthroplasty versus fixation respectively; bonnevialle et al.27 reported three-month mortality to be 21% versus 21.2% in both groups. blood loss was higher in the hemiarthroplasty group, but the difference was non-significant. the re-operation rate was higher in the internal fixation group, and a study by bonnevialle et al.27 reported similar outcomes. in the fixation group, the cut-out was 12% and was similar to the findings of kayali et al.25 the mean final harris hip score was significantly higher in the hemiarthroplasty group both at 3 months and at the final follow-up. the main limitation of this study is the short duration of follow-up. in addition, the cost of the implant and the exposure to radiation, which are important parameters in the overall evaluation of each method, were not included in this study. in conclusion, the clinical results of hemiarthroplasty seemed superior to those of internal fixation in terms of duration of surgery, early mobilisation, re-operation rate, infection rate, and mechanical complications, although similar outcomes were noted in the oneyear mortality rate and dvt. ethics statement ethical approval (smct 006/11/14) from the sudan medical specialisation board research ethics committee was granted before starting this research and informed consent was obtained from all participants. all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. informed consent was obtained from all individual participants included in the study. references 1. yang yh, wang yr, jiang sd, jiang ls. proximal femoral nail antirotation and third-generation gamma nail: which is a better device for the treatment of intertrochanteric fractures? singapore med j. 2013;54:446-50. 2. yoon bh, lee yk, kim sh, ha yc, koo kh. epidemiology of proximal femoral fractures in south korea. arch osteoporos. 2013;8:1-5. 3. kulkarni gs, limaye r, kulkarni m, kulkarni s. intertrochanteric fractures. indian j orthop. 2006;40:16-23. 4. unger ac, wilde e, kienast b, jürgens c, schulz ap. treatment of trochanteric fractures with the gamma3 nail methodology and early results of a prospective consecutive monitored clinical case series. open orthop j. 2015;9:466-73. 5. evans em. the treatment of trochanteric fractures of the femur. j bone joint surg am. 1949;31:190-203. 6. marsh jl, slongo tf, agel j, broderick js, creevey w, decoster ta. fracture and dislocation classification compendium: orthopedic trauma association classification, database and outcomes committee. j orthop trauma. 2007;21:s1-133. 7. huang h, xin j, baotong m. analysis of complications of intertrochanteric fracture treated with gamma 3 intramedullary nail. int j clin exp med. 2014;7:3687-93. 8. maru n, sayani k. unstable intertrochanteric fractures in high risk elderly patients treated by primary bipolar hemiarthroplasty: retrospective case series. gujarat med j. 2013;68:68-72. 9. tronzo rg. the use of an endoprosthesis for severely comminuted trochanteric fractures. orthop clin north am. 1974;5:679-81. 10. harwin sf, stern re, kulick rg. primary bateman-leinbach bipolar prosthetic replacement of the hip in the treatment of unstable intertrochanteric fracture in the elderly. orthopedics. 1990;13:1131-36. 11. broos pl, rommens pm, deleyn pr, geens vr, stappaerts kh. pertrochanteric fractures in the elderly: are there indications for primary prosthetic replacement? j orthop trauma. 1991;5:446-51. 12. chan kc, gill gs. cemented hemiarthroplasties for elderly patients with intertrochanteric fractures. clin orthop relat res. 2000;371:206-15. 13. harris wh. traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. an end-result study using a new method of result evaluation. j bone joint surg am. 1969 jun;51(4):737-55. 14. haynes rc, poll rg, miles aw, weston rb. failure of femoral head fixation: a cadaveric analysis of lag screw cut-out with the gamma locking nail and ao dynamic hip screw. injury. 1997;28:337-41. 15. wolfgang gl, bryant mh, o’neill jp. treatment of intertrochanteric fracture of the femur using sliding screw plate fixation. clin orthop relat res. 1982;163:148-58. 16. simpson ah, varty k, dodd caf. sliding hip screws: modes of failure. injury. 1989;20:227-31. 17. reindl r, harvey ej, berry gk, rahme e. intramedullary vs extramedullary fixation for unstable intertrochanteric fractures: a prospective randomized controlled trial. j bone joint surg am. 2015;97:1905-12. 18. saoudy ee, salama am. bipolar hemiarthroplasty for the treatment of unstable trochanteric fracture femur in the elderly. egypt orthop j. 2016;51:323-18. 19. naik lg, badgire ks, sharma jm, qureshi f. treatment of unstable intertrochanteric fractures with cemented bipolar prosthesis a prospective study. indian j orthop surg. 2017;3(1):27-30. 20. puttakemparaju kv, beshaj nr. unstable intertrochanteric fracture in elderly treated with bipolar hemiarthroplasty: a prospective case series. afr j trauma 2014;3(2):81-86. 21. chang jd, kim is, lee ss, yoo jh, hwang jh. unstable intertrochanteric versus displaced femoral neck fractures treated with cementless bipolar hemiarthroplasty in elderly patients; a comparison of 80 matched patients. orthop traum surg res. 2016;102(6):695-99. 22. pradeep c, anuj a, abhishek g. treatment of comminuted unstable inter trochanteric fracture in elderly patients with cemented bipolar prosthesis. indian j orthop surg. 2015;1(4):255-60. 23. abdelgadir ah, awadelsied mh, elbushra em, gashi yn. outcome of cemented bipolar as primary management of comminuted unstable intertrochanteric fracture femur in elderly sudanese patients. univers j public health. 2016;4:133-38. 24. huang cg, yee jj. comparison of three methods for the treatment of aged femoral intertrochanteric fracture. zhongguo gu shang. 2012;25:549-53. 25. kayali c, agus h, ozluk s, sanli c. treatment for unstable intertrochanteric fracture in elderly patients: internal fixation vs. cone hemiarthroplasty. j orthop surg. 2006;14:240-44. 26. parker  mj, handoll  hh. replacement arthroplasty versus internal fixation for extracapsular hip fractures in adults. cochrane database syst rev. 2006;19:cd00086. 27. bonnevialle p, saragaglia d, ehlinger m, et al. trochanteric locking nail versus arthroplasty in unstable intertrochanteric fracture in patients aged over 75 years. orthop traumatol surg res. 2011;97:95-100. for commentary and more information on this article, please refer to the letter to the editor on page 57. south african orthopaedic journal trauma and general orthopaedics doi 10.17159/2309-8309/2021/v20n3a5pretorius hs et al. sa orthop j 2021;20(3) citation: pretorius hs, ferreira n, burger mc. a computer tomography-based anthropomorphic study of forearm osteology: implications for prosthetic design. sa orthop j 2021;20(3):162-166. http://dx.doi. org/10.17159/2309-8309/2021/ v20n3a5 editor: prof. sithombo maqungo, university of cape town, cape town, south africa received: september 2020 accepted: january 2021 published: august 2021 copyright: © 2021 pretorius hs. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background the aim of this study was to accurately establish the variability in the anatomy of the radius and ulna in the context of the design of an intramedullary nail for both bones. methods forearm computed tomography scans were used to measure the specific internal and external anatomy of the radius and ulna in adult patients. patients with fractures or dislocations involving either the radius and/or ulna were excluded. results a total of 97 scans, comprising 84% male and 16% female patients, were included. the mean radius length was 238.43±18.38 mm (95% ci 234.60–241.74 mm). the mean curvature was an arc with a radius of 561.43±93.49 mm (95% ci 543.09–580.78 mm). the smallest measurement of the canal width was 5.17 mm (95% ci 4.87–5.47 mm). the ulna showed a mean length of 259.90±19.88 mm (95% ci 255.89–263.91 mm). the smallest measurement of the canal width was 4.80±1.30 mm (95% ci 4.53–5.87 mm). the mean proximal shaft angle was 11.39±3.30° (95% ci 10.76–12.82°). conclusion this computed tomography scan-based anthropomorphic study has identified novel anatomical features and associations of human forearm bones. this information will be used in the design and manufacture of anatomic intramedullary devices to better manage radius and ulna fractures or pathology. level of evidence: level 4 keywords: radius, ulna, anatomy, osteology, radius of curvature, intramedullary design a computer tomography-based anthropomorphic study of forearm osteology: implications for prosthetic design henry s pretorius,* nando ferreira, marilize c burger division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa *corresponding author: hsp359@sun.ac.za introduction the radius and ulna are commonly fractured bones,1 but despite the frequency with which these bones are injured, studies that describe their anatomy are limited. the specifically relevant anatomy of the internal osteology makes the design of new implants challenging as few studies relate to the canal size or radius of curvature.2-4 in-depth anatomical studies can be used to design the shape and size of implants and will also take advantage of the anatomical relationships that relate implant size or length, which can be extrapolated by measuring specific areas of anatomy, for example, measuring the ulna to extrapolate the radial length.5-7 due to the diverse injury patterns and numerous strategies of surgical management, a thorough understanding of the anatomy is of paramount importance. in support of this, studies by beşer et al. and others explored the anatomy of the ulna at the elbow joint and concluded that correctly measured angulations can help the design surgeon develop better prostheses and thereby maintain function of the elbow joint.8-12 this study, however, was limited to analysis of cadaveric specimens. the challenge of anatomical studies is that the architecture of the bone often has to be destroyed in order to measure specific parameters.4 to circumvent this, itamura et al.2 used computed tomography (ct) scans of the proximal radius of cadaveric specimens. the results demonstrated a clear shape mismatch of the native radial head and available radial head replacement prostheses which could lead to jamming at the radio-capitellar and proximal radioulnar joints.2 the paucity in the literature regarding radius and ulna anatomy is noted as well as previously reported studies with numbers less than 40,2,13 with the notable exception of rouleau et al. who scanned only the proximal ulna (n=100).14 the morphology of the proximal and distal radius has been studied in great detail. limited literature on the radius of curvature of the radius makes accurate reconstruction of this curvature when treating forearm fractures challenging.11 the clinical significance is that the union rates are improved for fractures where the anatomy https://orcid.org/0000-0002-7419-0885 page 163pretorius hs et al. sa orthop j 2021;20(3) has been restored.15,16 apart from the radius of curvature of the radius that remains to be better defined, the relationship and relative length of the radius and ulna also need to be established. the aim of this study was therefore to describe the anatomy of the radius and ulna of individuals that underwent forearm ct scans. methods a retrospective anatomical study of the radius and ulna of patients that underwent forearm ct scan was conducted. institutional ethics committee approval as well as institutional clearance was obtained prior to commencement of data collection. the hospital picture archiving and communication system (pacs) database was searched for all forearm scans that fitted the study criteria. specifically, all patients older than 18 years, presenting between january 2014 and october 2015, who subsequently received a ct scan of their forearm were considered for inclusion. any patients with fractures of the radius and/or ulna or any other anatomical deformities were excluded. all ct scans were performed with a siemens somatom emotion 6 with minimum slice thicknesses of 0.23 mm. the image files were stored as digital imaging and communications in medicine format (dicom) files. all measurements were made using radiant 4.2.1 (medixant, poland) dicom viewing software. the collected images were processed using image processing software, and measurements were taken by a single investigator. to standardise the measurements, the images were visualised in a multiplanar reconstruction mode (mpr). measurements of specific anatomical areas were taken to highlight the pertinent anatomy, and included (figures 1–5): the radius: 1. overall length from the midpoint of the wrist to the centre of the radial head 2. radius of curvature of the shaft of the radius (length from the middle of the shaft proximally where the neck ends and the curved shaft begins, and the distance from the previous line to the apex of the arc) the radius of curvature uses the arc height (h) and curve length (w) in the formula: radius of curvature = h + w 2 2 8h 3. canal diameter in the middle of the bone and at the midpoints of the proximal and distal shafts 4. cortical diameter of the radius at the neck, proximal, middle and distal shaft 5. size of the radial head in height and diameter measured in relation to the radial tuberosity 6. maximum angle between the radius neck and radius shaft 7. radius tilt, inclination and styloid length of the distal radius 8. distal radial height including lister’s tubercle, and width of the distal radius the ulna: 1. overall length from the midpoint of the olecranon to the centre of the distal ulna 2. olecranon articular angle 3. cortical thickness of the ulna at the proximal, middle and distal shaft 4. canal diameter of the ulna at the proximal, middle and distal shaft 5. size of the ulna head measured in the plane of the styloid and at 90° to the plane 6. angle between the olecranon and ulna shaft figure 1. periarticular measurements of a) radius styloid length; b) ulna styloid length; c) radial inclination; d) radial tilt; e) proximal ulna olecranon angle figure 2. axial ct cuts showing the measurements of the a) radial head in the plane of the tuberosity; b) radial head 90° to the plane of the tuberosity; c) ulna head 90° to the plane of the styloid; d) ulna head in the plane of the styloid; e–f) the height and width of the distal radius; g–j) medulla and cortical measurements of the shafts of both bones page 164 pretorius hs et al. sa orthop j 2021;20(3) data was analysed using statistica (v13, tibco software). considering the anatomical nature of the measurements taken, all data was normally distributed as expected. data is described as means ± standard deviations (sds) with 95% confidence intervals (ci) indicated in parentheses. categorical data is described as frequencies with the count indicated in parentheses. results a total of 97 scans were included with an equal distribution between left (49%, n=47) and right (51%, n=49) forearms. the cohort consisted of predominantly male patients (84%, n=82) with a mean age of 34.91±13.33 years (95% ci 32.22–37.59). the majority of scans (84%, n=81) were performed following trauma, which included 54 (56%) stab wounds, and 22 (23%) gunshot-related injuries. the non-traumatic indications (16%, n=16) scans were performed for vascular or other medical reasons (figure 6). table i shows the measurement results for the radius and ulna. the mean radius length was 238.43±18.38 mm (95% ci 234.60–241.74 mm), with the mean curvature being an arc with a radius of 561.43±93.49 mm (95% ci 543.09–580.78 mm) and the smallest measurement of the radial canal width being 5.17 mm (95% ci 4.87–5.47 mm). the study shows the radial styloid length of 10.55±2.13 mm (95% ci 10.12–10.98 mm) and the radial inclination 20.99±2.50° (95% ci 20.48–21.49o) as well as volar tilt 12.94±3.68° (95% ci 12.20–13.68°). the distal radius height including lister’s tubercle measured 23.06±2.80 mm (95% ci 22.49–23.62 mm). the ulna showed a mean length of 259.90±19.88 mm (95% ci 255.89–263.91 mm) with the smallest measurement of the ulna canal width being 4.80±1.30 mm (95% ci 4.53–5.87 mm). the mean proximal shaft angle was 11.39±3.30° (95% ci 10.76– 12.82°). discussion the aim of this study was to accurately establish the variability in the anatomy of the radius and ulna in the context of the design of intramedullary nails for both bones by assessing ct scans. when considering the anatomy of the radius, the results are useful in the context of implant design. when the curvature of the radius is discussed, the coronal curve of the radius is not the same as the measurement referred to as the bow of the radius. the bow of the radius is measured as the distance from a longitudinal line connecting the cortex at the level of the radial tuberosity and the ulna border of the distal radius at the radioulnar joint to the radius cortex at its furthest point. as the medullary canal and figure 3. showing a) the proximal ulna shaft angle; b) ulna length measurement figure 4. shows measurement of a) radial neck length; b) head height; c) the radial neck– shaft angle figure 5. scan indicating the radius length in red and how to calculate the radius of curvature in green figure 6. indications for ct scans stab knife or glass 56% gsw 23% medical reasons 16% pva/crush/fracture 3% dog bite 2% page 165pretorius hs et al. sa orthop j 2021;20(3) cortical margin of the radius are not parallel, and the radius of curvature is related to the canal of the radius, it stands to reason that the measurements should be in the medullary cavity of the radius or parallel to that on the outer cortex. this is done using the centre of the canal at the start and end of the curve with the mathematical formula given above. the clinical relevance is that an intramedullary implant with a curvature that recreates the bow of the radius will lead to better union rates.15 our findings confirm a mean radius of curvature for most forearms of 561.93 mm, with the 95% ci between 543.09 and 580.78 mm. when considering nail length, we can be confident that an implant length ranging from 220 to 270 mm (radius 238.43±18.38, ulna 259.9±19.88) would represent the shortest radius and the longest ulna in our study population. additionally, by using 10 mm increments, the nails will be appropriate for most individuals that might require treatment. with respect to canal size, an implant size of 4.5 mm would allow passage through the 5 mm canal observed in our cohort. the distal height of the radius and the proximal diameter of the ulna allows enough space for the 6 mm nail locking block. the mean distal radius height was found to be 23.06 mm (sd 2.80, range 14.70–33.30) with the 95% ci being between 22 and 24 mm. this observed height can potentially be extrapolated to the length of screws one might need for distal locking plates, thus alleviating the need to manufacture screws far outside of the observed range. this limited range might potentially lead to a cost and inventory advantage for implant manufacturers. the study confirms some features of previous studies on the rule of 11 with the styloid length, volar inclination and radial inclination being 11 mm, 11° and 22° (2×11), where this is used for decision-making in distal radius fractures.17 the study shows the radial styloid length of 10.55±2.13 mm (95% ci 10.12– 10.98 mm) and the radial inclination 20.99±2.50° (95% ci 20.48– 21.49°), which are in keeping with previously held ideas. the volar tilt of 12.94±3.68° (95% ci 12.20–13.68°) is larger than previously described as 11° and this may have relevance to distal radius fracture management. although the sample size of 97 scans is limited, this sample is significantly larger than previously reported studies which included a cadaver study (n=12)13 and a similar ct study (n=22)2 with the table i: measurement results for radius and ulna variable mean±sd (95% ci) n=97 radius length mm (centre of head to centre of distal radius) 238.43±18.38 (234.72–242.13) radius of curvature mm (height) 8.64±1.31 (8.37–8.90) radius of curvature mm (curve length) 194.43±15.12 (191.38–97.48) radius of curvature 561.93±93.49 (543.09–580.78) radial head diameter mm (plane of tuberosity) 23.97±2.32 (23.50–24.43) radial head diameter mm (90° to plane of tuberosity) 23.30±2.41 (22.82–23.79) radial neck max angle deg 10.84±2.58 (10.32–11.36) radial neck length mm 35.40±9.44 (33.5–37.3) radial neck cortical thickness mm 4.51±1.19 (4.27–4.75) radial neck canal max diameter mm 7.55±1.89 (7.17–7.93) radial head height mm 8.24±2.55 (7.72–8.75) radial canal max diameter mm (proximal 1/3 of curved canal) 6.33±1.57 (6.01–6.65) radial canal max diameter mm (middle of curved canal) 5.53±1.58 (5.21–5.84) radial canal max diameter mm (distal 1/3 of curved canal) 8.76±2.65 (8.23–9.3) radial canal min diameter mm 5.17±1.48 (4.87–5.47) radial inclination deg 20.99±2.50 (20.48–21.49) volar tilt deg 12.94±3.68 (12.20–13.68) distal radius styloid length mm 10.55±2.13 (10.12–10.98) distal radius max width mm 30.46±3.15 (29.83–31.10) distal radius max height mm (including lister) 23.06±2.80 (22.49–23.62) varus angulation proximal deg 11.39±3.13 (10.76–12.02) ulna length mm (centre of olecranon to centre of ulna head) 259.9±19.88 (255.89–263.91) ulna max styloid length mm 5.41±1.40 (5.13–5.69) ulna head diameter mm (plane of styloid) 19.54±2.15 (19.1–19.97) ulna head diameter mm (90° to plane of styloid) 16.77±2.07 (16.35–17.19) ulna canal max diameter mm (proximal 1/3 of curved canal) 7.25±2.45 (6.75–7.74) ulna canal max diameter mm (middle of curved canal) 5.4±1.5 (5.09–5.70) ulna canal max diameter mm (distal 1/3 of curved canal) 5.33±1.38 (5.05–5.61) ulna canal min diameter mm 4.80±1.30 (4.53–5.06) page 166 pretorius hs et al. sa orthop j 2021;20(3) notable exception of rouleau et al. who scanned only the proximal ulna (n=100). although most patients included in the current study were male, this is potentially the population group that would most require the use of a forearm intramedullary nail. future studies could potentially repeat these investigations in female-dominated samples. although our tertiary institution serves a mixed demographic of patients, it is still only including measurements from one geographical area surrounding our hospital; however, we do not anticipate that patient demographics within south africa will play a large role in variation. there might, however, be variation in other population groups outside of south africa, which should be the target of future investigations. this study formed part of a larger study that aims to investigate statistical shape modelling for future predictive models. the present study was the first and investigated the anatomical features of the two most often fractured forearm bones. conclusion this ct scan-based anthropomorphic study has identified novel anatomical features and associations of human forearm bones. this information will be used in the design and manufacture of anatomic intramedullary devices to better manage specific radius and ulna fractures or pathology. acknowledgements dr nabeela adam for the initial measuring and data capturing; dr rudolph venter was integral in the study design for ct anatomical studies. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study ethical approval was obtained from the following ethical review board: stellenbosch university health research ethics committee (s17/10/097). all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was waived by the ethics committee for all patients included in the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions: hsp: study conceptualisation, data capture, data analysis, first draft preparation, manuscript revision and final draft preparation nf: data analysis, language and grammar correction and final draft review mb: data analysis, language and grammar correction and final draft review orcid pretorius hs https://orcid.org/0000-0002-7419-0885 ferreira n https://orcid.org/0000-0002-0567-3373 burger mc https://orcid.org/0000-0003-2831-4960 references 1. ilyas am. surgical approaches to the distal radius. hand (n y). 2011;6(1):8-17. 2. itamura jm, roidis nt, chong ak, et al. computed tomography study of radial head morphology. j shoulder elb surg. 2008;17(2):347-54. 3. malone psc, shaw og, lees vc. anatomic relationships of the distal and proximal radioulnar joints articulating surface areas and of the radius and ulna bone volumes – implications for biomechanical studies of the distal and proximal radioulnar joints and forearm bones. front bioeng biotechnol. 2016;4(july):1-7. https://doi.org/10.3389/fbioe.2016.00061. 4. barrier ilo, l’abbé en. sex determination from the radius and ulna in a modern south african sample. forensic sci int. 2008;179(1):85.e1-7. 5. köse a, aydın a, ezirmik n, et al. alternative treatment of forearm double fractures: new design intramedullary nail. arch orthop trauma surg. 2014;134(1):1387-96. https://doi.org/10.1007/s00402-014-2058-9. 6. alao u, liew i, yates j, kerin c. correlation between the length from the elbow to the distal interphalangeal joint of the little finger and the length of the intramedullary nail selected for femoral fracture fixation. injury. 2018;49(11):2058-60. https://doi.org/10.1016/j.injury.2018.08.024. 7. badkur p, nath s. use of regression analysis in reconstruction of maximum bone length and living stature from fragmentary measures of the ulna. forensic sci int. 1990;45(1-2):15-25. 8. beşer cg, demiryürek d, özsoy h, et al. redefining the proximal ulna anatomy. surg radiol anat. 2014;36(10):1023-31. 9. akpinar f, aydinlioglu a, tosun n, tuncay í. morphologic evaluation of the ulna. acta orthop scand. 2003;74(4):415-19. 10. yong wj, tan j, adikrishna a, et al. morphometric analysis of the proximal ulna using three-dimensional computed tomography and computer-aided design: varus, dorsal, and torsion angulation. surg radiol anat. 2014;36(8):763-68. 11. pall singh ts, sadagatullah an, yusof ah. morphology of distal radius curvatures: a ct-based study on the malaysian malay population. singapore med j. 2015;56(10):562-66. 12. vroemen jc, dobbe jgg, jonges r, et al. three-dimensional assessment of bilateral symmetry of the radius and ulna for planning corrective surgeries. j hand surg am. 2012;37(5):982-88. https://doi.org/10.1016/j.jhsa.2011.12.035. 13. lamas c, llusà m, méndez a, et al. intraosseous vascularity of the distal radius: anatomy and clinical implications in distal radius fractures. hand. 2009;4(4):418-23. 14. rouleau dm, canet f, chapleau j, et al. the influence of proximal ulnar morphology on elbow range of motion. j shoulder elb surg. 2012;21(3):38488. https://doi.org/10.1016/j.jse.2011.10.008. 15. yörükoğlu a çağdaş, demirkan af, akman a, et al. the effects of radial bowing and complications in intramedullary nail fixation of adult forearm fractures. jt dis relat surg. 2017;28(1):30-34. 16. dave mb, parmar kd, sachde ba. the radial bow following square nailing in radius and ulna shaft fractures in adults and its relation to disability and function. malaysian orthop j. 2016;10(2):12-15. 17. hanley en. instructional course lectures. j bone jt surg. 2004;86(11):258 7-88. _hlk495656736 _hlk495656837 _hlk495657356 _hlk495657643 _hlk495657678 _hlk495657697 _hlk68842322 south african orthopaedic journal knee doi 10.17159/2309-8309/2022/v21n1a4le roux ja et al. sa orthop j 2022;21(1) citation: le roux ja, bezuidenhout cw, klopper j, hobbs h, von bormann r, held m. not strong enough? movements generated during clinical examination of sagittal and rotational laxity in a cadaver knee. sa orthop j 2022;21(1):30-33. http://dx.doi.org/10.17159/23098309/2022/v21n1a4 editor: dr david north, paarl hospital, western cape, south africa received: march 2021 accepted: july 2021 published: march 2022 copyright: © 2022 le roux ja. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors confirm there are no conflicts of interest, financial or otherwise, to declare with regard to this study. abstract background injury to the anterior cruciate ligament (acl) is associated with sagittal and rotational laxity, which is exacerbated by damage to the anterolateral capsuloligamentous structures, also known as the anterolateral ligament (all). the amount of laxity reported in biomechanical studies might be clinically insignificant during a surgeon’s examination, possibly influencing clinical judgement. we aimed to measure whether the motion generated by clinicians in a cadaver model after the acl and all were transected is clinically significant. methods a group of orthopaedic surgeons and trainees examined a cadaver knee for sagittal and rotational laxity at 30° and 90° with intact ligaments, after the acl was transected, and after the acl and all were transected. the examiners were blinded to the dissection process. rotational and sagittal movements during these examinations were recorded by a computer-assisted surgery (cas) system. results twenty-four orthopaedic surgeons took part in the study. the median sagittal plane motion captured by cas at 30° flexion was 7 mm (iqr 2 mm, p-value 0.32) in the intact knee, 9 mm (iqr 1 mm, p-value 0.34) after the acl was cut and 9 mm (iqr 3 mm, p-value 0.63) after acl and all were cut. the median arc of rotational motion at 30° was 19° (iqr 7°, p-value 0.12) in the intact knee, 24° (iqr 5°, p-value 0.56) after the acl was cut, and 22° (iqr 6°, p-value 0.8) after the acl and all were cut. none of the differences in these movements was significant. conclusion the surgeons could not generate significant differences in sagittal or rotational motion in a cadaver model, which could be objectively detected by cas, when examining the intact knee, acl deficient (only), or combined acl and all deficient knee. this challenges the utility of known clinical tests and calls for improved objective laxity assessment tools to provide input in clinical decision-making and measure outcomes of these injuries. level of evidence: level 5 keywords: knee, anterolateral ligament, anterior drawer’s test, pivot shift, rotatory instability, anterior cruciate ligament, iliotibial band, kaplan fibres not strong enough? movements generated during clinical examination of sagittal and rotational laxity in a cadaver knee johan a le roux,1 carel w bezuidenhout,2 juan klopper,1 hayden hobbs,3 richard von bormann,4 michael held1,4* ¹ orthopaedic research unit, department of orthopaedic surgery, groote schuur hospital, university of cape town, south africa ² department of orthopaedics, kimberley hospital complex, south africa ³ life vincent palotti hospital, cape town, south africa ⁴ netcare christiaan barnard hospital, cape town, south africa *corresponding author: michael.held@uct.ac.za introduction one of the most intriguing questions in the management of anterior cruciate ligment (acl)-deficient knees is whether we can define abnormal translation or rotation.1 the anatomic and biomechanical complexities to answer this question have challenged surgeons for more than a century after paul segond described the anterolateral ligamentous structure of the knee.2 their role in rotatory stability has gained significant interest recently;3 nevertheless, clinical testing remains controversial. an anterolateral ligament (all) injury affects knee stability, which can potentially be diagnosed by the pivot-shift manoeuvre, anterior translation and increased internal rotation of the tibia in relation to the femur.3-5 however, none of these clinical tests could be validated with high accuracy to diagnose an all injury.6 most surgeons therefore utilise clinical factors and associated injuries such as hypermobility, high grade meniscal tears, expected patient compliance or age to decide on all reconstruction.6 previous biomechanical studies have managed to confirm a statistically significant contribution of the all to the stability of the knee, but these movements were insignificant, considering their detectability in millimetres and degrees by clinicians.3,5 external devices such as the kt-1000 (med-metric, san diego, ca, us) or the telos stress device (telos gmbh, laubscher, holstein, https://orcid.org/0000-0002-5658-6827 https://orcid.org/0000-0002-0671-0439 page 31le roux ja et al. sa orthop j 2022;21(1) switzerland) for anterior-posterior knee laxity may measure knee laxity more objectively but significant differences have been found when compared to actual tibio-femoral translation measured by optic tracking devices or roentgen stereophotogrammetry (rsa).7-9 currently no studies have evaluated the motion generated by a large group of clinicians after sequential sectioning of knee ligaments. a decision for further objective evaluation and magnetic resonance imaging (mri) is often based on the clinical examination by the surgeon, who will likely decide against further investigations with insignificant motion generated. also, in resource-constrained settings without access to mri or external ligament stress devices, the clinical exam is the only way to detect pathologic ligament laxity. the goal of our study was therefore to determine if an acl and all deficiency would cause significant clinical laxity in a knee, using an optic motion tracker device. are clinicians strong enough to generate clinically significant motion in an acl and all-deficient knee? methods this study protocol was formally approved by the local institutional review board and written consent was obtained from all participants. an optical tracker system in the form of a computer-assisted surgery (cas) navigation system (pi-galileo, smith and nephew, memphis, tennessee) was used to measure sagittal and rotational movements generated during clinical examination of a cadaver knee with intact ligaments, at 30° and 90° of flexion. for this a previously described protocol by martelli et al. was adapted.10 this was then compared to movements generated after sectioning of the acl and finally the all. the examination was performed by 24 members of an orthopaedic department at a university hospital with various levels of clinical experience, who were blinded to the ligamentous stability of the knee, and the sectioning of ligaments (table i). a fresh frozen and thawed cadaver, with a normal hip and knee range of motion, and intact collateral and cruciate ligaments, was used. the specimen was donated for use by smith and nephew. the pelvis and both lower limbs were preserved to determine the hip centre of rotation for calibration. a midline skin incision and mini medial parapatellar arthrotomy was done to confirm the presence of an intact acl, posterior cruciate ligament (pcl), iliotibial band (itb), and anterolateral joint capsule. optical sensors for cas were secured percutaneously to the femur and the tibia, in such a manner that it would not be in the way while performing an examination of the knee (figure 1). twenty-four clinicians with various levels of expertise were asked to assess the sagittal and rotational stability of the leg, with the results captured by the cas system. the acl was cut mid-substance, ensuring the pcl or anterior horn of the lateral meniscus were not damaged. the knee was then again examined by the 24 study participants. after this the anterolateral capsule with the all was cut from the anterior border of the lateral collateral ligament (lcl) sub-meniscal to the posterior border of the itb at its insertion of gerdy’s tubercle. the medial arthrotomy and skin were sutured each time after the initial inspection of the ligaments and sequential sectioning of the acl and all. in this study, the term ‘laxity’ was used to describe a passive response, described as ‘motion’ of the knee to an external force or torque applied by clinicians.1 the sample size was calculated for a power of 0.8 using lin’s concordance correlation coefficient power analysis with an alpha value of 0.05. the normality of the data was determined by drawing a histogram, using a shapiro–wilk test and the levene test. normal data was summarised with parametric analysis. the wilcoxon rank test was used to compare non-parametric data to detect differences in measurements after each ligament was cut. a p-value of < 0.05 was defined as statistically significant. sagittal plane movement of more than 5 mm (the upper limit for grade 1 table i: demographics of participants in terms of number of examiners involved in each part of the study as well as the corresponding level of orthopaedic training level of participant ligamentous intact knee acl cut knee acl and all cut knee medical officer 3 2 1 junior orthopaedic registrars in first two years of specialisation 4 4 4 senior orthopaedic registrars in final two years of specialisation 10 9 9 orthopaedic specialists not primarily involved in knee surgery 4 4 4 fellowship-trained orthopaedic knee specialists 3 3 3 total 24 22 21 acl: anterior cruciate ligament; all: anterolateral ligament figure 1. the setup of the cadaver knee with optical trackers and computer-assisted surgery (cas) navigational system page 32 le roux ja et al. sa orthop j 2022;21(1) injury) and rotational movement of more than 10° was chosen as a clinically significant difference. box-and-whisker plots were used to illustrate the comparison of the median and interquartile ranges (iqr) of data of each group. results twenty-four participants with a wide range of clinical experience took part in this study (table i). the median sagittal plane laxity of the tibia in relation to the femur as captured by cas at 30º flexion was 7 mm (iqr 2 mm, p-value 0.32) in the intact knee, 9 mm (iqr 1 mm, p-value 0.34) after the acl was cut and 9 mm (iqr 3 mm, p-value 0.63 ) after the acl and all were cut. at 90° flexion the translation was 7 mm (iqr 3.2 mm, p-value 0.6) in the intact knee, 10 mm (iqr 7.2 mm, p-value 0.24) after the acl was sectioned, and 15 mm (iqr 5, p-value 0.12) after the acl and all were cut. the largest difference was found after sectioning of the acl, with minimal difference after the all was also sectioned. the median arc of internal rotational laxity measurements as captured by cas at 30º was 19º (iqr 7º, p-value 0.33) in the intact knee, 24º (iqr 5º, p-value 0.13) after the acl was cut and 22º (iqr 6º, p-value 0.06) after the acl and all were cut, and 22 mm (iqr 15 mm, p-value 0.26), 30 mm (iqr 18.7 mm, p-value 0.5) and 40 mm (iqr 20 mm, p-value 0.1) with the knee in 90° flexion. the greatest increases occurred after the acl was cut with minimal change after the all was cut (figures 2–5). discussion this study showed that clinicians generated negligible translational and rotational movement in a cadaver knee after the acl and all were sectioned. other biomechanical studies performed with constant load generators have shown similar results.3-5,11 the findings of these in vitro studies are similar to ours and interesting when considering the anterior drawer and lachman tests have been validated to be sensitive tests for diagnosing an acl injury.12 miura et al. conducted an in vivo study comparing laxity of both knees in patients with confirmed ipsilateral acl injuries. a side-toside difference of 8.6 mm during the lachman test in 30° flexion was reported, but only a 4.2 mm difference when comparing anterior tibial drawer tests in 90° of flexion.13 a study by bull et al. also recorded only a 4.2 mm difference with an anterior drawer test at 30° and 90° knee flexion, when comparing knee laxity before and after an acl reconstruction.14 similarly, the motion differences in our study were below 3 mm in translation and 3° in internal rotation before and after sectioning of the acl and the all. these are minute compared to commonly used clinical classification systems of at least 5 mm increments in translation and 10° in rotation.12,15 the second finding was that sectioning of the all had little effect on the internal tibial rotation and anterior translation compared to 40 35 30 25 20 15 10 5 0 all ligaments intact acl cut both ligaments cut x x x figure 3. comparison of rotational displacement at 90° knee flexion 35 30 25 20 15 10 5 0 all ligaments intact acl cut both ligaments cut x x x figure 2. comparison of the rotational displacements at 30° knee flexion 16 14 12 10 8 6 4 2 0 all ligaments intact acl cut both ligaments cut figure 5. comparison of the sagittal displacements at 90° knee flexion x x x 12 10 8 6 4 2 0 all ligaments intact acl cut both ligaments cut figure 4. comparison of the sagittal displacements at 30° knee flexion x x x page 33le roux ja et al. sa orthop j 2022;21(1) author contributions jar: primary author, design, data contribution, manuscript preparation cwb: conceptualisation, design, manuscript preparation jk: conceptualisation, design, data analysis, manuscript preparation hh: conceptualisation, design, data collection rb: conceptualisation, design, manuscript preparation mh: supervisor, conceptualisation, design, data collection, manuscript preparation orcid le roux ja https://orcid.org/0000-0002-5658-6827 bezuidenhout cw https://orcid.org/0000-0001-7024-4914 klopper j https://orcid.org/0000-0002-7325-1906 von bormann r https://orcid.org/0000-0002-4546-3143 held m https://orcid.org/0000-0002-0671-0439 references 1. musahl v, hoshino y, becker r, karlsson j. rotatory knee laxity and the pivot shift. knee surg sport traumatol arthrosc. 2012;20(4):601-602. https://doi.org/10.1007/ s00167-011-1844-y. 2. segond p. recherches cliniques et experimentales sur les epanchements sanguine der genou par entorse [clinical and experimental research on board effusions of knee sprain. prog med vii. 1879;7:297-99, 3:319-21. 3. sonnery-cottet b, lutz c, daggett m, et al. the involvement of the anterolateral ligament in rotational control of the knee. am j sports med. 2015;44(5):1209-14. https://doi. org/10.1177/0363546515625282. 4. monaco e, maestri b, labianca l, et al. navigated knee kinematics after tear of the acl and its secondary restraints: preliminary results. orthopedics. 2010;33(10 suppl):87-93. https://doi.org/10.3928/01477447-20100510-58. 5. ferretti a, labianca l, maestri b, et al. navigated knee kinematics after cutting of the acl and its secondary restraint. knee surg sports traumatol arthrosc. 2012;20(5):870-77. https://doi.org/10.1007/s00167-011-1640-8. 6. sonnery-cottet b, daggett m, fayard jm, et al. anterolateral ligament expert group consensus paper on the management of internal rotation and instability of the anterior cruciate ligament-deficient knee. j orthop traumatol. 2017;18(2):91-106. https://doi. org/10.1007/s10195-017-0449-8. 7. fleming bc, brattbakk b, peura gd, badger gj, beynnon bd. measurement of anteriorposterior knee laxity: a comparison of of three techniques. j orthop res. 2002;20(3):42126. https://doi.org/10.1016/s0736-0266(01)00134-6. 8. monaco e, labianca l, maestri b, et al. instrumented measurements of knee laxity: kt-1000 versus navigation. knee surg sports traumatol arthrosc. 2009;17(6):617-21. https://doi.org/10.1007/s00167-009-0724-1. 9. jonsson h, kärrholm j, elmqvist lg. laxity after cruciate ligament injury in 94 knees: the kt-1000 arthrometer versus roentgen stereophotogrammetry. acta orthop scand. 1993;64(5):567-70. https://doi.org/10.3109/17453679308993694. 10. martelli s, zaffagnini s, bignozzi s, et al. validation of a new protocol for computerassisted evaluation of kinematics of double-bundle acl reconstruction. clin biomech. 2006;21(3):279-87. https://doi.org/10.1016/j.clinbiomech.2005.10.009. 11. geeslin ag, chahla j, moatshe g, et al. anterolateral knee extra-articular stabilizers: a robotic sectioning study of the anterolateral ligament and distal iliotibial band kaplan fibers. am j sports med. 2018;46(6):1352-61. https://doi.org/10.1177/0363546518759053. 12. makhmalbaf h, moradi a, ganji s, omidi-kashani f. accuracy of lachman and anterior drawer tests for anterior cruciate ligament injuries. arch bone jt surg. 2013;1(2) 94-97. 13. miura k, ishibashi y, tsuda e, et al. intraoperative comparison of knee laxity between anterior cruciate ligament-reconstructed knee and contralateral stable knee using navigation system. arthroscopy. 2010;26(9):1203-11. https://doi.org/10.1016/j.arthro.2010.01.002. 14. bull amj, earnshaw ph, smith a, et al. intraoperative measurement of knee kinematics in reconstruction of the anterior cruciate ligament. j bone jt surg br. 2002;84(7):1075-81. https://doi.org/10.1302/0301-620x.84b7.13094. 15. scholten rjpm, opstelten w, van der plas cg, et al. accuracy of physical diagnostic tests for assessing ruptures of the anterior cruciate ligament: a meta-analysis. j fam pract. 2003;52(9):689-94. 16. kittl c, el-daou h, athwal kk, et al. the role of the anterolateral structures and the acl in controlling laxity of the intact and acl-deficient knee. am j sports med. 2016;44(2):345-54. https://doi.org/10.1177/0363546515614312. the acl-deficient knee. this is in line with the findings of kittl et al., who defined the posterior fibres of the iliotibial tract (itt) as the main structure restricting internal rotation of the tibia and not the all as previously thought.16 however, the contribution to an increase in laxity for each ligament was quantified in percentages, and not in millimetres or degrees, and exact values are not available. similar findings were reported by sonnery-cottet et al., confirming the itb as the primary restrictor to internal rotation of the tibia.³ an interesting finding of the study was the range and maximum displacements generated with the knee in 30° and 90° of flexion before sectioning of the ligaments, namely 11 mm (range 4–9) and 13 mm (range 2–13). despite this large initial range, the increase in the maximum and average displacements were, however, minimal after the acl was cut (figures 4 and 5). the study had limitations. only one cadaver was used, and the inherent laxity, or presence of hyperlaxity, was unknown. however, it allowed a standardised evaluation of movement generated by various clinicians in a controlled fashion and was mainly used for assessment before and after sectioning of ligaments. secondly, the movement generated might be influenced by the sectioning technique used to prepare the cadaver. although the anterolateral capsule was sectioned, the itb and posterior kaplan fibres were not cut, even though they are described as a stabiliser against translational and rotational instability.16 yet, the cadaver set-up and dissection was done in a similar way to previous biomechanical cadaver studies to allow comparison.3 future studies should address this by a further sectioning of the posterior kaplan fibres. thirdly, this artificial injury to the acl or all might not have taken into account the associated muscular, capsular, meniscal or ligamentous injuries which are often present in a clinical scenario and which could generate increased laxity. however, mapping movement with cas by a large number of clinicians in a clinical scenario is not feasible. lastly, it might have been beneficial to include a pivot-shift test to test the translational movement during the pivot-shift test. we only tested movement in single planes, i.e. sagittal and translational translation. furthermore, the 24 participants were only asked to assess for sagittal translation in 30° and 90° knee flexion, and rotational laxity in 30° and 90° of knee flexion, without a specific brief to assess the extremes of motion or perform specific tests (i.e., the pivot-shift test). this could have reduced the difference of movements. conclusion this observational study showed that no significant rotational and sagittal motion was generated by clinicians when comparing a cadaver knee with intact ligaments to sequential sectioning of acl and all – findings that are in keeping with similar studies on the topic and contrary to laxity generated when these injuries happen in vivo. future cadaver studies should include the pivot-shift test and sectioning of the posterior kaplan fibres, but ideally these findings should be confirmed in true acl injuries to maximise the clinical benefit. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, ethical approval was obtained from the university of cape town human research ethics committee (hrec), number 472/2016. written consent was obtained from all participants. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. https://orcid.org/0000-0002-5658-6827 https://orcid.org/0000-0001-7024-4914 https://orcid.org/0000-0002-7325-1906 https://orcid.org/0000-0002-4546-3143 https://orcid.org/0000-0002-0671-0439 https://doi.org/10.1007/s00167-011-1844-y https://doi.org/10.1007/s00167-011-1844-y https://doi.org/10.1177/0363546515625282 https://doi.org/10.1177/0363546515625282 https://doi.org/10.3928/01477447-20100510-58 https://doi.org/10.1007/s00167-011-1640-8 https://doi.org/10.1007/s10195-017-0449-8 https://doi.org/10.1007/s10195-017-0449-8 https://doi.org/10.1016/s0736-0266(01)00134-6 https://doi.org/10.1007/s00167-009-0724-1 https://doi.org/10.3109/17453679308993694 https://doi.org/10.1016/j.clinbiomech.2005.10.009 https://doi.org/10.1177/0363546518759053 https://doi.org/10.1016/j.arthro.2010.01.002 https://doi.org/10.1302/0301-620x.84b7.13094 https://doi.org/10.1177/0363546515614312 orthopaedics vol3 no4 sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 87 cell signalling and bone remodelling part ii: developments in the pathogenesis and principles of management of selected skeletal disease states ej raubenheimer mchd, phd, dsc pathology: metabolic bone disease unit, faculty of health sciences, smu, south africa c noffke msc faculty of health sciences, smu, south africa radiology unit, faculty of health sciences, smu, south africa *part i was published in sa orthopaedic journal summer 2015 vol 14 no 4 corresponding author: prof ej raubenheimer pathology: metabolic bone disease unit faculty of health sciences 0204 smu email: ejraub@fox5.co.za tel: +27 12 5214838 fax: +27 12 5215274 introduction the study of rare genetic skeletal diseases exposed a wealth of information on the autocrine, paracrine and endocrine control of bone metabolism. mapping of the pathways which control bone remodelling (covered in part i*) provides exciting new possibilities in the prevention and management of common skeletal deficiency states like osteoporosis. the field of regenerative medicine is growing rapidly and it is therefore no surprise that the pharmaceutical industry is investing large sums of money in the development of patented drugs and auto-antibodies which modulate the establishment of a specific skeletal outcome. gene delivery to bone with viral vectors, plasmids or mesenchymal stem cells is certain to develop as potent tools in the manipulation of bone and treatment of skeletal disease. mesenchymal bone marrow stem cells have the potential to form bone, are chemically attracted to the skeleton after peripheral administration and are therefore ideal vehicles to deliver transgenes which induce anabolic or block catabolic cytokines.1 reconstruction of large bone segments without cortico-cancellous bone grafts, which comes with the risk of disease transmission, infection and rejection, remains the prime goal of researchers in the field of tissue engineering. using osteoconductive matrices seeded with osteogenic progenitor cells and osteoinductive and vasoproliferative factors to achieve this goal is no longer unrealistic from a scientific point of view.2 this article is aimed at providing practitioners with insight into recent advances on the impact of modulation of cell signalling on the management of selected skeletal disease states. abstract mapping of the bone remodelling signalling pathways contributed significantly to the establishment of a scientific basis for the development of pharmaceuticals which have the potential to induce or suppress bone formation. enhancing bone healing and the establishment of a pre-determined skeletal phenotype are now within reach of the medical profession. this manuscript provides practitioners with an overview of recent developments in the quest for uncovering the molecular mechanisms involved in the pathogenesis of selected bone disease states and the role these discoveries play in the future management of bone healing and skeletal health. key words: bone remodelling, osteoporosis, metastatic bone disease, paget’s disease, osteopetrosis. http://dx.doi.org/10.17159/2309-8309/2016/v15n1a11 page 88 sa orthopaedic journal autumn 2016 | vol 15 • no 1 osteoporosis the persistent loss of bone with age ultimately culminates in osteoporosis. although the fracture risk of young males is higher than females, in older populations significantly more women are affected than men.3 the societal consequences of osteoporosis are devastating and the cost implications of the more than 2 million fractures recorded in the usa in 2005 are projected to rise to $25 billion by 2025.4 commercial interest in developing patented drugs that target this disease is flourishing. the most popular medication used in the prevention of osteoporosis are drugs in the bisphosphonate group, which can be administered orally, and directly inhibit osteoclasts and indirectly decrease osteoblast activity, thereby downregulating bone metabolism. denosumab,5 a monoclonal human antibody directed against rankl that prevents osteoclastogenesis and bone catabolism, was approved in 2010 by the fda (us food and drug administration) for use in postmenopausal women at risk for osteoporosis. parathyroid hormone (pth) administration is the only fda-approved anabolic therapy for fracture prevention in postmenopausal women.6 cd8+ t-cells produce wnt ligand under intermittent stimulation by pth. this activates the cananonical wnt signalling pathway in preosteoblasts and supresses the production of sclerostin by osteocytes, facilitating osteoblast differentiation and bone formation (readers are referred to part i* for more information on cell signalling involved in bone remodelling). the activation or inactivation of steps in wnt signalling in osteoblasts can induce bone anabolism or – catabolism. stimulation of bone formation can be achieved through auto antibodies directed against endogenous wnt-antagonists such as dickkopf-1 and sclerostin. inhibition of cytoplasmic kinases involved in wnt signalling by lithium stimulates bone formation.7 vascular endothelial growth factor8 (vegf) improves vascularisation and facilitates bone formation. suspending the osteoblast-suppressing property of serotonin with drugs which antagonise its action may be the key to the development of a novel approach in preventing osteoporotic fractures.9 although innovative research on laboratory animals shows promising results in many of these fields of research, interference with these pathways runs the risk of long-term secondary complications such as the induction of tumours. the ultimate goal is to manipulate steps in wnt signalling which is bone-specific, thereby negating the development of unintended secondary pathology. inflammation in the past decade the accumulation of data on the influence of inflammation on the skeleton has led to the development of a dedicated field of study referred to as ‘osteoimmunology’. monocytes are attracted to a site of inflammation and induced to differentiate into macrophages which have the capacity to elaborate the osteoclastogenic nuclear factor κb (nf-κb) ligand, rankl.10 although several factors released during inflammation promote osteoclast activation, rankl and its inhibitor, osteoprotegerin (opg), are the final downstream cytokines that control osteoclast differentiation and bone resorption (see part i*). the sost gene which encodes for sclerostin is the only part of the wnt pathway expressed exclusively by osteocytes and a monoclonal antibody, which inactivates sost, is promising as interference in other cell processes appears to be limited.11 inflammatory-associated bone loss not only occurs in the area of inflammation, but also through osteoclastogenic cytokines released in circulation by distant inflammations, such as rheumatoid arthritis.12 resolution of a site of inflammatory-induced bone loss follows upon the elaboration of cytokines, such as proteins belonging to the transforming growth factor beta (tgf β) family,13 which stimulate bone formation. human recombinant bmp7 (available commercially under the brand name op1) is used to facilitate fusion of vertebrae to prevent neurological trauma.14 rhbmp2 is however more widely used to treat non-union of fractures as it appears to be superior in inducing new bone formation than the other bmps.15 bmp7 has a potential future role in the management of chronic kidney disease through its inhibition of fibrosis and restoration of healthy epithelial cell populations.16-18 mineralisation of the newly formed bone is mediated by bone sialoprotein,14 carboxylated osteocalcin19 or other cytokines (see part i*). mapping of these pathways exposed specific receptor binding sites on bone cells which can potentially be activated or blocked in order to either limit bone resorption or accelerate bone formation and mineralisation, impacting directly on the process of bone healing. carrier systems which deliver bioactive molecules locally, such as the biocoating of implant surfaces with bone morphogenic protein (bmp) (a protein of the tgf β family) and other osteogenic cytokines can facilitate integrative bone repair.20 ceramic microsphere carriers are injectable, biodegradable and can be coated to become osteoinductive21,22 thereby decreasing the post-infection healing time of bone. hiv and antiretroviral therapy antiretroviral therapy has changed the fate of hiv infection from a fatal to a manageable chronic disease. with this advancement the co-morbidities resulting from skeletal catabolism are now more prominent in this cohort of patients than in the past. highly active antiretroviral therapy (haart), chronic inflammation, the virus itself and dietary factors contribute to bone loss23 and the increase in the incidence of fractures reported in aids patients.24 a contributing factor is hypovitaminosis d which is prevalent among hiv-positive subjects.25 although the mechanisms involved in the skeletal anabolism of hiv patients on haart are not fully understood, data now indicate that these patients should be sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 89 included in screening programmes as high risk for osteoporosis. recent focus on the prominent role the immune system plays in skeletal health makes the influence of the residual immune dysregulation syndrome in treated hiv patients26 an unexploited field for research. generalised bone forming diseases osteopetrosis is a heterogenous disease with several molecular and genetic defects leading to dysfunctional osteoclasts and unopposed bone formation. among others, mutations of m-csf and rank are involved, as well as over-expression of opg, as the rankl/opg ratio is a major determinant of bone mass.27 the clinical severity varies from neonatal onset with bone marrow displacement and fatal pancytopaenia to an incidental finding of bone sclerosis on a radiograph. repopulation of the bone marrow with normal stem cell populations provides some hope for patients suffering the infant-onset types. the duplication of the signalling peptide (tnfrsf11a) of the gene that encodes for rank, is associated with a rare panostotic expansile bone disease (distinguished from fibrous dysplasia by an absence of gnas mutation).28 similar rank insertion mutations were reported in other expansile bone conditions.29 sclerosing bone dysplasias (sclerosteosis, worth syndrome and van buchem disease) are linked to a genetic mutation which either incapacitates osteocytes to produce sclerostin30 or modulates lrp5 or its receptors.31,32 simulation of these mutations through gene transferral may form a basis for the development of therapeutic agents that facilitate bone formation and improve bone healing after surgical procedures. paget’s disease of bone although a decline in the incidence has been reported in several communities in which paget’s disease is endemic, it remains an important diagnosis in orthopaedic practice. in the advanced stage, it is earmarked by disordered bone formation which leads to skeletal deformity, pathological fractures and neurologic pains and deafness due to compression of nerves which pass through the enlarging bony structures. paget’s disease is the result of a combination of a genetic mutation in the sqstm1/p62 gene and the impact of an environmental factor, most likely chronic measles virus infection.33 the mutation increases the response of osteoclasts to rank-nf-κb signalling, leading to osteoclast activation.34 this explains the initial resorptive phase of the disease and provides a feasible rationale for the use of bisphosphonates35 and denosumab, a rankl antibody36 in the treatment thereof. the abnormal osteoclasts show increased sensitivity to vit d3 and its precursors and other transcription factors.37 elevation of fibroblast growth factor-2 (fgf-2) as well as its influence on osteoblast precursors is related to the disorganised bone formation in the later stages of the disease.38 malignant disease manipulation of the bone microenvironment is a field in which the next thrust in anticancer therapy is predicted. the influence of metastatic deposits of solid malignancies on bone is resorption, bone formation or both. breast cancer is the prototype of the bone-resorbing and prostate cancer of the bone-forming phenotype. factors produced by malignant deposits that stimulate osteoclasts include parathyroid hormone related protein (pthrp), several of the interleukins and rankl.39 the bisphosphonate group of drugs (which block the effects of pthrp) and denosumab are effective in addressing the skeletal morbidity and hypercalcaemia resulting from the production of osteoclastogenic cytokines by metastatic malignant clones in bone. inactivation of osteoclasts is however not without complications as patients may develop osteonecrosis (particularly of the jaws), especially those on intravenous nitrogen containing bisphosphonates.40 transforming growth factor β (tgf β) is released from the matrix of bone during resorption41 and stimulates the elaboration of several catabolic cytokines by tumour cells. the blocking of tgf β production in breast cancer through the therapeutic administration of sd-208, an inhibitor of tgf β, may therefore decrease the skeletal morbidity of breast cancer patients. prostate cancer metastasis dysregulates bone remodelling and the nett outcome is bone formation, often described as an ‘osteoblastic’ response. the neoplastic cells produce growth factors such as insulin-like growth factor, plateletderived growth factor, adrenomedullin and a recently discovered vasoactive peptide et-1.39 the mechanism of stimulation of osteoblasts by et-1 is unclear. blocking of the endothelin a receptor (etar) by atrasentan, an etar antagonist, reduced skeletal morbidity in patients with advanced prostate cancer.42 this discovery in a rapidly advancing field of research is likely to introduce a new chapter in the management of this disease. conclusion the study of bone has moved beyond morphology, and exciting fields of research have been uncovered in the last decade. cell signalling pathways can now be linked to specific disease states and, through intervention, a specific bone phenotype can be induced by cytokine modulation. more studies are, however, required as the long-term effects of interfering in skeletal metabolism, which is part of systemic metabolic pathways, are as yet unknown. conflict of interest statement the authors have no conflict of interest to declare and received no direct funding for the writing of the article. references 1. evans ch. gene delivery to bone. adv drug deliv rev 2012;64:1331-40. 2. drosse i, volkmer e, capanna r et al. tissue engineering of bone deficit healing: an update on a multi-component approach int j care injured 2008;39s2:s9-s20. page 90 sa orthopaedic journal autumn 2016 | vol 15 • no 1 3. eisman ja, bogoch r, dell r et al. making the first fracture the last fracture: asbmr task force report on secondary fracture prevention. j bone min res 2012;27:2039-46. 4. burge r, dawson-hughes b, solomon dh et al. incidence and economic burden of osteoporosis-related fractures in the united states, 2005-2025. j bone min res 2007;22:465-75. 5. mcclung mr, liwiecki em, cohen sb et al. denosumab in post-menopausal women with low bone mineral density. n engl j med 2006;354:821-31. 6. neer rm, arnaud cd, zanchetta jr et al. effect of parathyroid hormone (1-34) on fractures and bone mineral density in postmenopausal women with osteoporosis. new engl j med 2001;344:1434-41. 7. kim jh, liu x, wang j et al. wnt signalling in bone formation and its therapeutic potential for bone diseases. ther adv musculoslelt dis 2013;5:13-31. 8. street j, bao m, deguzman l et al. vascular endothelial growth factor stimulates bone repair by promoting angiogenesis and bone turnover. proc natl acad sci usa 2002;99:9656-61. 9. yadav vk, balaji s, suresh ps et al. pharmacological inhibition of gut-derived serotonin synthesis is a potential bone anabolic treatment for osteoporosis. nat med 2010;16:308-12. 10. abu-amer y. nf-κb signalling in bone resorption. osteoporos int 2013; doi:10.1007/s00198-013-2313-x 11. rossini m, gatti d, adami s. involvement of wnt/β-catenin signalling in the treatment of osteoporosis. calcif tissue int 2013;93:121-32. 12. weitzmann mn. review article. the role of inflammatory cytokines, the rankl/opg axis, and the immunoskeletal interface in physiological bone turnover and osteoporosis. scientifica 2013; doi.org/10.1155/2013/125705 13. chen d, zhoa m, mundy gr. bone morphogenetic proteins. growth factors 2004;22:233-41. 14.. vaccaro ap, whang pg, patel t et al. the safety and efficacy of op-1 (rhbmp-7) as a replacement for iliac crest autograph for posterolateral lumbar arthrodesis: minimum 4-year follow-up of a pilot study. spine j 2008;8:457-65. 15. even j, eskander m, kang j. bone morphogenetic protein in spine surgery: current and future uses. j am acad orthop surg 2012;20:547-52. 16. gould se, day m, jones ss et al. bmp-7 regulates chemokine, cytokine, and hemodynamic gene expression in proximal tubule cells. kidney int 2002;61:51-61. 17. kalluri r, weinberg ra. the basics of epithelial-mesenchymal transition. j clin invest 2009;119:1420-28. 18. zeisberg m, bottiglio c, kumar n et al. bone morphogenic protein-7 inhibits progression of chronic renal fibrosis associated with two genetic mouse models. am j physiol renal physiol 2003;285:f1060-f1067. 19.. gordon ja, tye ce, sampaio av et al. bone sialoprotein expression enhances osteoblast differentiation and matrix mineralisation in vitro. bone 2007;41:462-73. 20. karsenty g, ferron m. the contribution of bone to whole organ physiology. nature 2012;481:314-20. 21. jennisen hp. accelerated and improved osseointegration of implants biocoated with bone morphogenetic protein 2 (bmp2). ann ny acad sci 2002;961:139-42. 22. tiffany nv, kasper fk, mikos ag. strategies for controlled delivery of growth factors and cells for bone regeneration. adv drug deliv rev 2012;64:1292-1309. 23. de mendez barbosa eg, de paulo fj, machado aa et al. impact of antiretroviral therapy on bone metabolism markers in hivseropositive patients. bone 2013;57:62-67. 24. shiau s, broun ec, arpadi sm, yin mt. incident fractures in hiv-infected individuals: a systematic review and metaanalysis. aids 2013;27:1949-57. 25. pinzone mr, di rosa m, malaguarnera m et al. vit d deficiency in hiv infection: an underestimated and undertreated epidemic. eu rev med pharmacol sci 2013;17:1218-32. 26. lederman mm, funderburg nt, sekaly rp et al. residual immune dysregulation syndrome in treated hiv infection. adv immunol 2013;119:51-83. 27. hofbauer lc, shoppet m. clinical implications of the osteoprotegerin/rankl/rank system for bone and vascular diseases. jama 2004;292:490-45. 28. schafer al, mumm s, el-sayed i et al. panostotic expansile bone disease with massive jaw tumor formation and a novel mutation in the signalling peptide of rank. j bone miner res 2014;29:911-21. 29. crockett jc, mellis dj, scott di et al. new knowledge on critical osteoclast formation and activation pathways from study of rare genetic diseases of osteoclasts: focus on the rank/rankl axis. osteoporos int 2011;22:1-20. 30. moester mj, papapoulos se, lȍwik cw et al. sclerostin: current knowledge and future perspectives. calcif tissue int 2010;87:99107. 31. wang c, zhang bh, zhang h et al. the a242t mutation in the low-density lipoprotein receptor-related protein5 gene in one chinese family with osteosclerosis. intern med 2013;52:187-92. 32. van bezooijen rl, bronckers al. gortzak ra et al. sclerostin in mineralized matrices and van buchems disease. j dent res 2009;88:569-74. 33. galston dl, roodman gd. pathobiology of paget’s disease of bone. j bone metab 2014;21:85-98. 34. ralston sh. pathogenesis of paget’s disease of bone. bone 2008;43:819-825. 35. kim kc. intravenous zoledronate for a patient with paget’s disease. j bone metab 2014;21:223-26. 36. grasemann c, schündeln mm, hövel m et al. effects of rankligand antibody (denosumab) treatment on bone turnover markers in a girl with juvenile paget’s disease. j clin endocrinol metab 2013;98:3121-26. 37. sun q, sammut b, wang fm et al. tbk1 mediates critical effects of measles virus nucleocapsid protein (mvnp) on pagetic osteoclast formation. j bone miner res 2014;29:90-102. 38. sundaram k, senn j, reddy sv. socs-1/3 participation in fgf2 signalling to modulate rank ligand expression in paget’s disease of bone. j cell biochem 2013;114:2032-38. 39. guise ta, mohammed ks, clines g et al.basic mechanisms responsible for osteolytic and osteoblastic metastases. clin cancer res 2006 doi:10.1158/1078-0432.ccr-06-1007 40. woo sb, hellstein jw, kalmar jr. systematic review: bisphosphonates and osteonecrosis of the jaws. ann intern med 2006;144:753-61. 41. dallas sl, rosser jl, mundy gr, bonewald lf. proteolysis of latent growth factor-β (tgf-β)binding protein-1 by osteoclasts: a cellular mechanism for the release of tgf-β from bone matrix. j biol chem 2002;277:21352-60. 42. carducci ma, padley rj, breul j et al. effect of endothelin-a receptor blockage with atrasentan on tumor progression in men with hormone refractory prostate cancer: a randomized, phase ii placebo-controlled trial. j clin oncol 2003;21:679-89. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj page 4 south african orthopaedic journal http://journal.saoa.org.za page 4 south african orthopaedic journal http://journal.saoa.org.za conferences, courses & symposia sassh (sa society for surgery of the hand) refresher course 23-25 february 2018 pretoria 18th congress sa spine society 24-26 may 2018 elangeni hotel, durban 64th congress of the south african orthopaedic association 3-6 september 2018 csir, pretoria january 2018 2nd international consensus meeting on orthopaedic infections 25 january 2018 26 january 2018 philadelphia, united states focus on arthroplasty symposium: unicondylar knee replacement 26 january 2018 27 january 2018 frankfurt am main, germany 19th annual aaos/aana/aossm sports medicine course 31 january 2018 04 february 2018 park city, united states february 2018 bernese hip symposium 2018 01 february 2018 03 february 2018 bern, switzerland paris shoulder symposium 2018 01 february 2018 03 february 2018 paris, france scandinavian hand surgical dissection course 05 february 2018 06 february 2018 copenhagen, denmark endoprosthetics congress berlin 2018 22 february 2018 24 february 2018 berlin, germany march 2018 aaos 2018 annual meeting 06 march 2018 10 march 2018 new orleans, united states kiel arthroscopy course 2018 09 march 2018 10 march 2018 kiel, germany utrecht spine course: complex paediatric spine 09 march 2018 10 march 2018 utrecht, netherlands annual meeting of the orthopaedic research society – ors 2018 10 march 2018 13 march 2018 new orleans, united states 12th international congress of sports medicine society of greece / 12th hellenic-cypriot conference 16 march 2018 18 march 2018 thessaloniki, greece 12th international meeting of the austrian foot society 22 march 2018 24 march 2018 going am wilden kaiser, austria european pelvic course 2018 22 march 2018 24 march 2018 hamburg, germany local international conferences, courses & symposia local sassh (sa society for surgery of the hand) annual congress 31 august 2018 – 02 september 2018 csir, pretoria 64th congress of the south african orthopaedic association 03 september 2018 – 06 september 2018 csir, pretoria international october 2018 12th efas international congress 2018 04 october 2018 – 06 october 2018 geneva, switzerland isha 2018 annual scientific meeting 04 october 2018 – 06 october 2018 melbourne, australia 39th sicot orthopaedic world congress montreal 2018 10 october 2018 – 13 october 2018 montreal , canada annual meeting of the american shoulder and elbow surgeons ases 2018 11 october 2018 – 14 october 2018 chicago, united states annual meeting of the orthopaedic trauma association ota 2018 17 october 2018 – 20 october 2018 orlando, united states 26th european pediatrics congress 22 october 2018 – 23 october 2018 amsterdam, netherlands november 2018 6th world congress on controversies, debates & consensus in bone, muscle & joint diseases (bmjd) 08 november 2018 – 10 november 2018 klongsan-bangkok, thailand 4th international conference on sports medicine and fitness 14 november 2018 – 16 november 2018 edinburgh, united kingdom the bristol hip arthroplasty course – bhac 2018 15 november 2018 – 16 november 2018 bristol, united kingdom instructional lower limb trauma course 19 november 2018 – 20 november 2018 sheffield, united kingdom december 2018 the 17th oswestry foot & ankle course 03 december 2018 – 05 december 2018 oswestry, united kingdom khan f et al. sa orthop j 2018;17(3) doi 10.17159/2309-8309/2018/v17n3a6 south african orthopaedic journal http://journal.saoa.org.za traumaspine citation: khan f. sacroiliac joint involvement in spinal tuberculosis. sa orthop j 2018;17(3):47-52. http://dx.doi.org/10.17159/2309-8309/2018/v17n3a6 editor: prof lc marais, university of kwazulu-natal, durban received: may 2017 accepted: december 2017 published: august 2018 copyright: © 2018 khan f. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no benefits in any form have been received or will be received from any commercial party related directly or indirectly to the subject of this article. conflict of interest: the authors have no conflicts of interest to declare with respect to this article. abstract background: a discussion of the incidence and pathogenesis of tuberculosis of the sacroiliac joint and a description of an association with spinal tuberculosis. methods: a retrospective chart review was conducted in the spine unit on all inpatients admitted between 1 july 2014 and 30 june 2015. patients with confirmed tuberculous spondylitis and/or sacroiliitis, who underwent adequate radiological examination of their sacroiliac joints, were included in the study. available clinical and radiological investigations including plain x-rays, ct and mri scans, were scrutinised to actively exclude sacroiliac joint involvement. results: sixty-six patients with tuberculous spondylitis and one patient with isolated tuberculous sacroiliitis were included in the study. seventeen patients had multilevel (>2 levels) contiguous involvement, while 14 patients had multilevel non-contiguous lesions. thirty-four patients had associated iliopsoas abscesses. thirteen patients (19.4%) were identified as having involvement of their sacroiliac joint(s). six had bilateral involvement, five with right-sided and two patients with left-sided involvement. eleven of the patients identified had associated iliopsoas abscesses, two of whom had gluteal and iliopsoas abscesses. the patient with isolated sacroiliac joint involvement had a gluteal abscess. conclusion: concurrent radiographic evidence of sacroiliac joint involvement is not uncommon in patients with spinal tuberculosis, more so when abscess formation is associated, and should be actively looked for and excluded in such cases. level of evidence: level 4 key words: tuberculous, sacroiliac, tuberculosis, spondylitis, sacroiliitis sacroiliac joint involvement in spinal tuberculosis khan f¹, govender s² ¹ mbchb(ukzn), fc(orth)sa; orthopaedic consultant/fellow; department of orthopaedic surgery, school of clinical medicine, college of health sciences, university of kwazulu-natal, durban ² mbbs, md, frcs, fc(orth)pr; professor and orthopaedic surgeon, spinal unit, king dinizulu hospital, durban; fellow of university of kwazulu-natal, durban corresponding author: dr f khan, cell: 0726947947; email: faraazk786@gmail.com page 48 khan f et al. sa orthop j 2018;17(3) introduction tuberculous involvement of the sacroiliac joint is reported as rare in the literature and is estimated to account for 0.3 to 0.5 % of all tuberculosis cases.1-4 while this may be true in the developed world or when looked at in isolation, the incidence is much higher in less developed countries,5,6 with ever-increasing rates of retroviral disease (rvd) associated with atypical pathology and multifocal skeletal involvement. involvement may be further underestimated due to a recognised vague presentation,1,2,4,5,7-10 and the sacroiliac joint being a region that is easily overlooked during routine clinical and radiological examinations.1,4-9 numerous studies have noted an association of tuberculous sacroiliitis with concurrent spinal tuberculosis.1,2,5,11,12 an association with paraspinal and/or gluteal abscesses has also been demonstrated in the literature.1,2,4,5,10-12 kim et al. proposed a four-stage classification as a guide to the management approach (table i), differentiating cases that may benefit from surgery, from those that could be managed conservatively with chemotherapy alone.2 the aim of this study was to discuss the incidence and pathogenesis of tuberculosis involvement of the sacroiliac joint and describe an association with spinal tuberculosis and abscess formation. table i: classification of sacroiliac joint tuberculosis proposed by kim et al.4 types were defined according to the severity of clinical and radiographic findings. type description i widening of the joint space and blurring on the margin of the sacroiliac joint ii erosion of the sacroiliac joint iii severe destruction of the sacroiliac joint with cyst formation of the ilium and sacrum, and marginal sclerosis iv a lesion of the sacroiliac joint with abscess formation or other affected vertebra materials and methods a retrospective chart review was conducted in the spine unit on all inpatients admitted between 1 july 2014 and 30 june 2015. patients with confirmed tuberculous spondylitis and/or sacroiliitis, who underwent adequate radiological examination of their sacroiliac joints, were included in the study. available clinical and radiological investigations including plain x-rays, computed tomography (ct) and magnetic resonance imaging (mri) scans, were scrutinised for sacroiliac joint involvement. patients with spondylitis and/or sacroiliitis arising from pathogens other than mycobacterium tuberculosis, outpatients, and those with confirmed tuberculous spondylitis without adequate radiological visualisation of their sacroiliac joints were excluded from the study. results ninety-one patients with spinal tuberculosis and one patient with isolated tuberculous sacroiliitis were admitted over the 12-month period. histological confirmation of tuberculosis was attained in 71 patients revealing chronic granulomatous inflammatory tissue with patchy infiltration of acid-fast bacilli, giant and epithelioid cells, varied degrees of caseous necrosis and tubercle formation. among these, 16 patients had positive cultures for mycobacterium tuberculosis on lowenstein jensen medium. in the remaining patients, diagnosis was based on clinical, haematological and radiological findings. twenty-five patients were excluded from the study due to inadequate radiological visualisation of their sacroiliac joints. these included six patients with cervical spine and 16 patients with upper-to-mid thoracic spine involvement with incomplete inclusion of their sacroiliac joints on ct and/or mri studies. although plain x-rays were performed in all patients, adequate and complete visualisation of both sacroiliac joints was not possible due to overlying bowel shadows (figure 1). the 67 patients in our study group included 37 females and 30 males with ages ranging from 2 to 74 years. the thoracic and lumbar regions were affected in the majority of patients with seven patients having involvement at or below the lumbosacral junction and three patients with cervical spine involvement. seventeen patients had multilevel (>2 levels) contiguous spinal involvement and 14 patients had multilevel non-contiguous involvement. thirtyfour patients had associated abscess formation. all patients were investigated with plain x-rays and ct, while mri was performed in 29 patients. thirty-two patients had multifocal disease having either active pulmonary and/or extrapulmonary involvement, or previous history of tuberculosis. forty-two patients had clinical evidence of partial or complete neurological deficit. twenty-one patients had documented tenderness of their sacroiliac joint(s); however, the lateral pelvic compression, gaenslen and faber tests were performed in only 16 patients for obvious reasons. forty-six patients had confirmed rvd and a further 14 patients had an unknown retroviral status. erythrocyte sedimentation rates ranged from 8 to >140 mm/hr. five patients were diagnosed with multidrug resistant (mdr) tuberculosis. thirteen patients (19.4%) were identified as having involvement of their sacroiliac joint(s), including the patient with isolated sacroiliitis (table ii). there were eight females and five males whose ages ranged from 13 to 64 years. eight patients had lower back and/or buttock pain without neurological deficits, three patients had partial neurological deficit with lower limb weakness, and two patients had spastic paraplegia. of the 12 patients with spondylitis, eight were atypical with multilevel contiguous or non-contiguous lesions. one patient had skip lesions involving all regions of the spine (figure 2) and 11 patients had involvement of the lumbar region. one of the 13 patients identified was hiv negative and one patient had an unknown retroviral status. figure 1(a) and (b). plain x-rays demonstrating inadequate visualisation of the sacroiliac joints due to overlying bowel shadows page 49khan f et al. sa orthop j 2018;17(3) radiological bony changes varied from erosions, cyst formation and sclerotic margins (figure 3), to marked joint destruction and sequestration (figure 4). questionable joint space widening or blurred margins were regarded as being uninvolved. destructive lesions were predominantly seen in the antero-inferior aspects; however, inconsistent distributions were seen in three joints. bony changes were best seen on ct with several patients having inadequate plain x-rays. mri was performed in five patients with associated neurological deficit. eight of the 13 patients had open biopsies of their sacroiliac joints. in three patients, including two patients with early sacroiliac joint changes, biopsies of the spinal lesions were performed. in the remaining two patients, the diagnosis was based on classic radiological vertebral changes demonstrating two body disease suggestive of tuberculosis as well as grade 2 sacroiliac joint changes. histopathology confirmed chronic granulomatous inflammatory tissue, varied degrees of caseous necrosis and tubercle formation with/without giant and epitheloid cells. microscopy did not reveal the presence of any other pathogens and acid-fast bacilli were demonstrated in two cases. polymerase chain reaction was not available for use at the time and no record of such results were found. six patients had bilateral sacroiliac joint involvement, five with right-sided and two patients with left-sided involvement. twelve of the 13 patients had associated abscess formation. eleven patients had iliopsoas abscesses, two of whom had both gluteal and iliopsoas abscesses. the patient with isolated sacroiliac joint involvement had a gluteal abscess. three patients presented with draining sinuses, one of whom demonstrated mdr disease. according to the kim classification (table i), all 13 patients had type iv disease. eleven patients underwent surgical interventions ranging from debridement and drainage of abscesses to spinal decompression and stabilisation. eight patients underwent open biopsies of their sacroiliac joints and six patients required sacroiliac joint debridement with/without arthrodesis. negative pressure figure 2(a). coronal ct scan showing non-contiguous (skip) lesions in all regions of the spine figure 2(b). coronal ct scan with magnification of the sacrum revealing involvement of both sacroiliac joints, more so on the left side table ii: data sheet of the 13 patients with sacroiliac joint involvement. twelve patients had associated vertebral involvement and one patient had isolated sacroiliitis. age sex rvd status abscess formation spinal level(s) involved sacroiliac joint evaluation clinical x-ray ct scan mri scan 13 m positive psoas t10–12; l2–s2 non-tender; sensory deficit inadequate adequate adequate 19 f unknown psoas + gluteal l5, s1 tenderness adequate adequate _ 28 f positive psoas t10,11 non-tender; spastic paraplegia inadequate adequate adequate 28 m positive psoas c3, 4; t9, 10; l1, 2 tenderness; sinus inadequate adequate _ 32 f positive psoas t1–3, 5, 6, 11, 12; l3, 4 non-tender; spastic paraplegia inadequate adequate adequate 33 m positive psoas l3–s2 tenderness adequate adequate _ 36 m positive psoas t11–l3 tenderness inadequate adequate _ 37 f positive psoas l1–3 tenderness inadequate adequate _ 44 m positive psoas + gluteal l2, 3 non-tender; sinus; sensory deficit inadequate adequate adequate 44 f positive gluteal _ tenderness inadequate adequate _ 46 f positive _ l5, s1 tenderness adequate adequate _ 49 f positive psoas l1–s1 tenderness; sinus inadequate adequate _ 64 f negative psoas l2, 3 non-tender; sensory deficit inadequate adequate adequate page 50 khan f et al. sa orthop j 2018;17(3) wound therapy was used in all patients with sinuses. outpatient follow-up and treatment outcomes however, are beyond the scope of this study. two patients had no documented involvement of their sacroiliac joints and were treated primarily for their spinal lesions. however, both patients had early radiographic joint changes not requiring surgical intervention, and were treated adequately with antituberculous chemotherapy. discussion the relative paucity of available literature on tuberculosis of the sacroiliac joint has been largely attributed to its rarity.1-4,10,12 a large proportion of the published literature from the developed world is limited to sporadic case reports4,5,8,10,12,13 with studies of significance conducted over several years.1,2,11 in a landmark study,2 16 cases were identified over a period spanning two decades. however, a more recent study6 in an endemic area identified 35 cases over a 4-year period. the substantial discrepancy is a result of significantly lower rates of underlying immune-suppressive conditions like rvd, low socio-economic status, malnutrition, etc., in the developed world. the rates of both rvd and tuberculosis in south africa, are among the highest in the world.14,15 improved awareness and availability of antiretroviral therapy has transformed the expression of rvd from a rapidly progressive affliction with a high mortality rate, to one that presents more like a chronic medical condition with improving survival rates.16 tuberculosis, on the other hand, has become more difficult to treat over recent years with everincreasing rates and the emergence of drug-resistant strains. the combined effect of these factors contributes to the increasing number of patients with atypical pathology and multifocal disease. almost half of the 67 patients in our study group and eight of the 13 patients with sacroiliac joint involvement, presented with atypical pathology. numerous studies1,2,4,10-12,17-19 have demonstrated an association of tuberculous sacroiliitis with spinal tb and abscess formation, to the extent of inclusion as a subtype (type iv), in the proposed classification. this is the first study to look at identifying sacroiliac joint involvement in this particular subgroup of patients, highlighting several factors requiring consideration. mycobacterium tuberculosis may reach the sacroiliac joints via haematogenous or lymphatic routes from other primary sites of infection. the most common sites are the pulmonary system or spine, with the spine well recognised as the commonest skeletal site. it may spread contiguously through surrounding soft tissues or less commonly, mycobacteria may lodge as latent foci during the primary infection and activate at a later stage. therefore, in a patient with vertebral involvement and iliopsoas abscesses, spread to the sacroiliac joints may occur via all possible figure 3 (a)–(f). axial ct scans showing six cases with varying degrees of sacroiliac joint involvement including joint space widening, erosions, cysts and marginal sclerosis figure 4 (a)–(b). axial ct scans of two cases with (c)–(d) corresponding coronal ct images, showing extensive changes with joint destruction and sequestra formation. note the lumbar spine involvement and bilateral iliopsoas abscesses in both cases. page 51khan f et al. sa orthop j 2018;17(3) routes, and a higher risk of transmission would be expected. this is further supported by our findings, with almost a fifth (19.4%) of the patients having sacroiliac involvement, and 12 of these 13 patients having abscess formation. on the other hand, in a patient with isolated tuberculous sacroiliitis without other active sites of involvement, the infection originates from activation of latent foci which occurs less frequently, especially in developed countries. tuberculous sacroiliitis may present in various clinical settings. isolated sacroiliac joint involvement often presents as a patient with refractory, poorly localised lower back or buttock pain with/without constitutional symptoms. patients are usually neurologically intact or at worst have evidence of radiculopathy. in patients with vertebral involvement however, a wide spectrum of presentations may occur, ranging from mild backache to obvious spinal deformity with complete neurological deficit. while sacroiliac joint pathology is well renowned for being elusive to clinical detection and prone to late diagnosis even when it occurs in isolation,5,6,8-10,13 concurrent vertebral involvement adds a host of challenges to the clinical and radiological evaluation. patients often present with symptoms from their spine pathology including pain, deformity and neurological compromise. a patient with a high level sensory deficit, may not complain of sacroiliac joint pain and the clinical focus is on performing a spinal and neurological assessment. furthermore, provocative testing of the sacroiliac joints would be extremely difficult and is often excluded in patients with spinal instability, to near impossible in patients with complete neurological lesions. the radiological evaluation of the sacroiliac joints in these patients must also be considered. the higher the level of the spinal lesions, the less likely that the sacroiliac joints would be included in imaging studies. this was evident in our findings as 22 of the 25 exclusions were patients with vertebral lesions above the mid-thoracic spine. these patients are incidentally more likely to have significant neurological deficits, are often immobile and have associated bladder or bowel involvement. the accompanying faecal loading often obscures complete visualisation of their sacroiliac joints on plain x-rays. if plain radiography is the only available imaging modality, prior bowel preparation and the use of oblique views6 is advised. depending on the route of transmission to the sacroiliac joint, infection may originate in the sacral or ileal sides, or from the synovium. the resultant inflammatory exudate and bone oedema radiographically appears as haziness or blurring of the joint margins and widening of the joint space, which are the earliest identifiable changes described. further disease progression causes subchondral erosions with formation of periarticular cysts in the sacrum and/or ilium. if untreated, marginal sclerosis occurs with eventual joint destruction and sequestra formation. concurrent periarticular soft tissue involvement manifests as abscesses, through various tissue planes and directions, with eventual sinus formation. while mri has been shown to be useful in the detection of early disease,6,12 it is less freely available and affordable in the developing world where delayed presentation is common. as a result, mri is not routinely performed in all patients with vertebral pathology but usually reserved for those with associated neurological deficit. furthermore, while soft tissue pathology is best seen on mri, subtle bony changes are less clearly defined (figure 5). computed tomography has been shown to demonstrate the best definition and extent of bony pathology,1,2,10,19 as appreciated in this series, identifying sacroiliac joint involvement in all cases. regardless of the extent of sacroiliac joint changes, all 13 cases identified had type iv disease, as 12 patients had other affected vertebra and the patient with isolated sacroiliitis had a gluteal abscess. a closer look at the classification (table i) reveals that types i to iii are based on the severity of radiographic bony changes, ranging from a blurred and widened joint space in type i, to cyst formation, marginal sclerosis and joint destruction in type iii disease. type iv however, was defined as, ‘a lesion of the sacroiliac joint with abscess formation or other affected vertebra’.2 patients with type iv disease may thus have variable degrees of sacroiliac joint changes, as illustrated in our findings. furthermore, spinal tuberculosis with or without abscess formation may occur prior to sacroiliac joint involvement, as seen in this study, where several patients demonstrated advanced vertebral involvement with iliopsoas abscesses and only early radiographic changes in their sacroiliac joints. for these reasons, we recommend that the classification be modified to three types, and to include vertebral involvement or abscess formation as a subclass of all types (table iii). this modification may assist in formulating more accurate guidelines to the management plan. table iii: modification of the classification to three types with abscess formation and/or other affected vertebra added as a subclass to all types type subtypes with description i ia – widening of the joint space and blurring on the margin of the sacroiliac joint ib – ia with abscess formation and/or other affected vertebra ii iia – erosion of the sacroiliac joint iib – iia with abscess formation and/or other affected vertebra iii iiia – severe destruction of the sacroiliac joint with cyst formation of the ilium and sacrum and marginal sclerosis iiib – iiia with abscess formation and/or other affected vertebra thus, concurrent vertebral involvement exposes numerous additional challenges to a condition known to have a difficult and often late diagnosis. furthermore, the mainstay in the treatment of tuberculous sacroiliitis is conservative and most symptomatic patients will resolve completely on chemotherapy alone. consequently, a significant number of patients in this subset of patients may be easily overlooked, thereby further underestimating the overall incidence. a major drawback of this study is that only a particular subgroup of patients was used, in whom the incidence of tuberculous sacroiliitis would be expected to be higher. our results therefore only reflect the incidence among this particular subgroup of patients and not that of the general population. another drawback was that the diagnosis of tuberculous sacroiliitis was not confirmed with complete certainty in all cases. other pathogens or aetiologies, although less likely, were still possible, and as outpatient follow-up was not included, treatment responses could figure 5. (a) axial t2-weighted mri scan showing improved soft tissue enhancement and, (b) the axial ct scan demonstrating defined bony changes page 52 khan f et al. sa orthop j 2018;17(3) not be assessed or discussed. we therefore recommend that more prospective studies be conducted among this subgroup of patients. conclusion concurrent radiographic evidence of sacroiliac joint involvement is not uncommon in patients with spinal tuberculosis, more so when abscess formation is associated, and should be actively looked for and excluded in such cases. computed tomography is the recommended imaging modality in the evaluation and diagnosis of tuberculous sacroiliitis. ethics statement this study received full ethics approval by the biomedical research ethics committee of the university of kwazulu-natal. references 1. ramlakan rjs, govender s. sacroiliac joint tuberculosis int. orth 2007; 31(1):121-24. 2. kim nh , lee hm, yoo jd, suh js. sacroiliac joint tuberculosis – classification and treatment clin orth rel research 1999;358:215-22. 3. daies pdo, humphries mj, byfield sp, et al. bone and joint tuberculosis. a survey of notifications in england and wales. j bone joint surg, 1984; 66b:326-30. 4. garg i.k, kumar l, gaurav j, case report. tuberculosis of sacroiliac joint a rare case. j, advance researches in biological sciences 2012;4(1):85-87. 5. gupta r, beimenstoch h, morano p, gupta a. tuberculosis of sacroiliac joint an unusual presentation. j natl med assoc 2005;97(8):1174-76. 6. j prakash. sacroiliac tuberculosis a neglected differential in refractory low back pain j clin orthop trauma. 2014 sep;5(3):146-53. 7. pouchot j, vinceneux p, borge j, boussougeut y, pierre j, carbon c, kahn mf. tuberculosis of the sacroiliac joint – clinical features, outcome and evaluation of closed needle biopsy, am journal of medicine 1988;84(3 pt 2):622-28. 8. chen ws. chronic sciatica caused by tuberculosis sacroiliitis a case report. spine 1995;20:1194-96. 9. laeslett m, williams m. the reliability of selected pain provocation tests for sacroiliac joint pathology. spine 1994;19:1243-48. 10. papagelopoulos pj, padapoulos ec, mavrogenis af, themistocleous gs, korres ds, soucacos pn. tuberculous sacroiliitis. a case report and review of the literature. eur spine j 2005;14(3):683-88. 11. soholt st. tuberculosis of the sacro-iliac joint am jbjs 1951;33a:119-30. 12. gelal f, sabah d, dogan r, avci a. multifocal skeletal tuberculosis involving the l-spine and a sacro-iliac joint. diagn inter radiology 2006;12(3):139-41. 13. nakase m. tuberculosis of the sacroiliac joint: a case report. japanese journal of joint diseases 2009;28(2):261-64. 14. dye c, floyd k, uplekar m. who report 2008. global tuberculosis control: surveillance, planning, financing. world health organization, geneva, switzerland 15. who report 2011. global tuberculosis control: surveillance, planning, financing. world health organization, geneva, switzerland 16. herbst aj, cooke gs, barnghausen t, kanykany a, tanser f, newell ml. adult mortality and antiretroviral roll-out in rural kwazulu-natal, south africa. bull who 2009;87(10):754-62. 17. richter r, nubling w, kobler g, ilinski a. tuberculosis of the iliosacral joint. treatment, results prognosis and differential diagnosis. z orthop ihre grenzeb 1983;121:564-70. 18. benchakroun m, el badouni a, zaddoug o. tuberculous sacroiliitis: four cases. joint bone spine 2004;71:150-53. 19. osman aa, govender s. septic sacroiliitis. clin orthop 1995;313:214-19. page 12 south african orthopaedic journal http://journal.saoa.org.za editorial i was humbled by my most recent past fellow who quoted aristotle in her thank you card: ‘the one exclusive sign of thorough knowledge is the power of teaching.’ although i am no philosopher, and nor have i ever professed to be one, these are my thoughts. for a teacher to be passionate, enthusiastic, knowledgeable, approachable and nurturing is a given. however, this is not enough. teaching should not be a dry act of imparting knowledge and spewing out information. it should be made interesting, pertinent, colourful and interactive so that the student is challenged to think out the box and take an integral part in the learning process. the student must not become a clone of the teacher but rather be given the foundation to ultimately surpass the teacher and promote further knowledge for the advancement of the profession. the student should look up to the teacher, and ultimately become a peer. the subject should not be taught superficially but with depth so that core knowledge and all its subtleties is applied and long remembered. the teacher must impress upon the student an ethos of excellence, responsibility, accountability and humility. philosophy and medicine often go hand in hand; teaching therefore, transcends many levels. the young doctor must create a relationship with god, the patient and him or herself: 1. he must be thankful to god for allowing him the privilege to be a member of this noble profession. at the end of the day he must go to bed with a clear conscience in that he has served god and his fellow man to the best of his ability. although medicine is predominantly a science, hippocrates refers to it as an (medical) art and the doctor as a servant of the art. 2. when it comes to patients the young doctor needs to reiterate the hippocrates dictum, ‘practice two things in your dealings with disease: either help or do not harm the patient’. he must never lose sight of the fact that the patient is a human being with emotions, fears, expectations and an anxious family praying for his or her recovery. one of the most common complaints i hear from a patient consulting me for a second or even a third opinion, is that ‘the previous doctor did not listen to me’. make the patient feel comfortable and create a professional relationship based on trust. listen to the patient and allow the patient to ‘combat the disease in co-operation with the doctor’. 3. be true to yourself. go to bed with a clear conscience that you have done the very best you could possibly have done for all your patients. two of the biggest scourges in life, least of all in surgery, is complacency and mediocrity. ‘oh, i have put in thousands of intrapedicular screws, i don’t need x-rays’. this is when the screws are found sitting in the spinal canal. ‘the alignment of this toe is not quite optimal but it’s ok’. this is when the recurrence of a hallux valgus deformity or iatrogenic hallux varus occurs. instil into students to always keep good records as there may come a day when they have to be accountable for their actions. emphasise to the student that the day he thinks he knows everything, is the day he will fall hard. there is no shame in asking for advice or help. besides the hippocratic dictum of ‘ώϕελεϊν ῆ μή βλάπτείν‘ (to help or do no harm), more recently charles mayo said, and i quote, ‘the primary approach to a patient in my teaching is “can i justifiably get the patient out of having an operation, not into having one?” the surgeon who i would select to attend my family or me must first know when not to cut, then when and where to cut, how to cut, and when to stop cutting’. lastly my feelings towards fellowships, a subject close to my heart. knowledge in orthopaedics is growing exponentially. the days of a generalist are rapidly coming to an end. i strongly advise the senior registrar or young consultant to reflect on their residency time and decide what subspecialty has piqued their interest and do a sixmonth to one-year fellowship at a reputable centre. this, in my opinion, will be the best investment they will make in their career. references 1. van der eijk pj, university of newcastle upon tyne. medicine and philosophy in classical antiquity. doctors and philosophers on nature, soul, health and disease 3 to help, or to do no harm. principles and practices of therapeutics in the hippocratic corpus and in the work of diocles of carystus. publisher: cambridge university press. 2005. pp 101-18. https://doi.org/10.1017/ cbo9780511482670.006 2. lloyd, g (ed). hippocratic writings (2nd ed). 1983. london: penguin books p94. isbn 0140444513 teaching philosophy prof np saragas mbbch(wits), fcs(sa)ortho, mmed(ortho surg)(wits) university of the witwatersrand, johannesburg, south africa yende t et al. sa orthop j 2018;17(4) doi 10.17159/2309-8309/2018/v17n4a4 south african orthopaedic journal http://journal.saoa.org.za traumashoulder and elbow citation: yende t, senoge me and ferreira n. functional outcomes following surgical treatment of chronically unreduced simple elbow dislocations: a retrospective review. sa orthop j 2018;17(4):33-38. http://dx.doi.org/10.17159/2309-8309/2018/v17n4a4 editor: dr c breckon, university of the witwatersrand received: january 2018 accepted: july 2018 published: november 2018 copyright: © 2018 yende t. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: the authors received no funding for this study. conflict of interest: the authors declare they have no conflicts of interest with respect to the publishing of this study. abstract background: chronic elbow dislocations are rare injuries that present late for orthopaedic management. the delay in presentation is frequently due to patients not seeking treatment after the initial injury, poor access to health care, inadequate initial treatment of acute dislocation or initial missed diagnosis. chronic simple elbow dislocations refer to dislocations that remain unreduced for more than two weeks and are not associated with fractures. this study aims to evaluate the outcome of surgically treated chronic elbow dislocations. methods: a retrospective review of all patients who were treated for chronic simple elbow dislocations between september 2009 and august 2014 was undertaken. further information regarding return to function was obtained from the records or telephonic consultation with the patients. nine patients were included for final analysis. results: nine patients were eligible for the study. three patients were employed, three were scholars and three were unemployed. all patients were able to return to premorbid function with minor limitations due to occasional pain. according to the mayo elbow performance index (mepi) score, two patients had excellent outcomes, three good and three fair. one could not be scored as there was no recorded scoring on the file and telephonic contact was unsuccessful. the range of motion varied from 20° of extension to 140° of flexion. one patient developed a stiff elbow but was able to adapt to activities of daily living. conclusion: surgical treatment of chronically unreduced simple elbow dislocations offers satisfactory outcome with minimal complications and should be considered for all patients presenting with this condition. level of evidence: level 4 key words: chronic elbow dislocation, functional outcomes, mepi functional outcomes following surgical treatment of chronically unreduced simple elbow dislocations: a retrospective review yende t¹, senoge me², ferreira n³ 1 biomed technology, mbchb, hdiporth(sa), fcorth(sa); department of orthopaedic surgery, grey’s hospital, university of kwazulu-natal, pietermaritzburg ² mbchb, fcorth(sa); department of orthopaedic surgery, grey’s hospital, university of kwazulu-natal, pietermaritzburg ³ bsc, mbchb, fcorth(sa), mmed(orth)(sa), phd; professor and head clinical unit: tumour, sepsis and reconstruction; division of orthopaedics, stellenbosch university, cape town corresponding author: dr thabiso yende, department of orthopaedic surgery, grey’s hospital, nelson r mandela school of medicine, university of kwazulu-natal, pietermaritzburg, 3201, south africa; tel: +27720827766; email: thabisoy@yahoo.com page 34 yende t et al. sa orthop j 2018;17(4) background acute elbow dislocations are frequently encountered in emergency units. these injuries are as a result of high energy trauma which may be due to falls, sports injuries, assault or motor vehicle accidents, and account for approximately 20% of all articular dislocations. despite the frequency of acute elbow dislocations, chronic elbow dislocations are rare.1,2 patients with chronic elbow dislocations are frequently the result of their not seeking treatment after the initial injury, poor access to health care, inadequate initial treatment of acute dislocation or initial missed diagnosis.1-3 neglected (chronic) elbow dislocations are defined as dislocations left unreduced for more than two weeks.1-4 these injuries are uncommon in developed countries,5 but more frequently encountered in developing countries.3,6 dislocations without concomitant fractures are termed ‘simple dislocations’ while dislocations that are associated with fractures of the coronoid process, radial head or neck, distal humerus or olecranon are termed ‘complex dislocations’.2 patients with chronic elbow dislocations present with disability as a result of a fixed position or decreased range of motion (rom). many of these individuals are of an economically active age group and in many instances are the only breadwinners in the family. available literature has reported favourable to excellent results for surgical management of these injuries using outcome measures which include dash (disabilities of the arm, shoulder and hand), mepi (mayo elbow performance index) and krishnamoorthy scores. these scoring systems provide an idea of the patient’s function, pain and rom but do not provide information regarding patient’s activities of daily living (adls), satisfaction with surgery, return to premorbid function, or if they would recommend surgery to other patients with similar injuries. this study aims to report patient satisfaction following surgical treatment of chronic simple elbow dislocations, evaluate return to premorbid function and gather information that may help in preoperative counselling of patients in terms of the expected outcomes of surgery and rehabilitation. materials and methods a retrospective review of all patients with chronic simple elbow dislocations that were surgically treated between september 2009 and august 2014 was performed. ethical approval was obtained from the institutional ethics committee before commencement of the study. eligible patients were identified from a prospectively collected database. patients were contacted telephonically to ascertain functional recovery and satisfaction with surgery. patients were excluded if dislocations were acute, associated with fractures, lost to follow-up, refused surgery or refused to participate. simple elbow dislocations were defined as dislocations with no associated fractures. chronic dislocations were defined as dislocations that remained unreduced for more than two weeks following the injury. surgery was performed with patients in either a lateral or prone position. a tourniquet was used in all cases. a long posterior incision was followed by identification and anterior transposition of the ulnar nerve in all patients. the medial and lateral paratricipital approach provided access to the distal humerus and elbow joint. a muscle slide procedure was performed for the common flexor and extensor origins. all fibrous tissue in the olecranon fossa was debrided and followed by circumferential capsular release (figures 1 and 2). the elbow was then reduced. the elbow was flexed maximally to stretch the triceps. we planned to proceed with triceps lengthening if intra-operative elbow flexion was less than 130°. no patient required triceps lengthening. one patient had figure 1. circumfential release done; figure shows fibrous tissue in the olecranon fossa figure 2. fibrous tissue excised from the olecranon fossa figure 3. post-operative radiographs of the patient who had a divergent dislocation with humero-radial wire page 35yende t et al. sa orthop j 2018;17(4) medial and lateral collateral ligament repair with suture anchors as reduction was unstable intra-operatively. a 2 mm k-wire was then inserted through the olecranon to the distal humerus (figure 3). one patient with a divergent dislocation had a radiocapitellar wire insertion to prevent lateral subluxation of the radial head. haemostasis was ensured following release of the tourniquet. wounds were closed in layers over a 3 mm drain. an above-elbow plaster of paris backslab was applied for a period of two to three weeks after which rehabilitation under the supervision of the occupational therapist was commenced. patients were considered for indomethacin prophylaxis against heterotopic ossification as per the operating surgeon’s discretion. one patient was initially treated with a hinged external fixator for joint distraction followed by open reduction one week later. rehabilitation was goal-directed and commenced between two and eight weeks post-operatively. the focus was on scar and pain management and initiation of active assisted rom, taking care not to overstretch healing tissues. progressive serial dynamic splinting was used for patients who were not showing improvement in rom without splintage. scars were massaged with aqueous cream at least twice per day and patients were taught how to do this at home. patients were also encouraged to do active assisted exercises at home. at two months following the surgery, rehabilitation focused on improvement of rom, muscle strengthening and functional use. both active assisted and active rom was encouraged and patients were taught how to do this at home. aggressive passive mobilisations were avoided in order to minimise the risk of developing heterotopic ossification. cold packs were used for flare up of inflammation. serial splinting was continued for patients who did not show improvement of rom. results twenty patients with chronic elbow dislocations were treated during the study period. eleven patients were excluded from the study. these included five patients whose files could not be found, four who had associated fractures, one who refused surgery and one who was lost to follow-up immediately following surgery. nine patients with a mean follow-up of 8.1 months ranging from one to 24 months were included for analysis. the study population consisted of three women and six men. the median age was 27 years, ranging from six to 47 years. the median time duration from injury to surgical treatment was 5 months, ranging from 1 to 7 months (table i). eight patients (88.9%) presented with a history of falling while the remaining patient had been assaulted. one was an active smoker and one patient was hiv positive and on antiretroviral treatment. seven patients (77.8%) sought medical treatment immediately post injury while two did not seek any treatment because they thought the injury was not significant. of the seven patients who sought immediate treatment, two were immobilised in a plaster of paris backslab without reduction, three were reduced and placed in a collar and cuff, one had no reduction nor splinting and one patient was reduced, immobilised in a plaster of paris backslab and reduction confirmed on radiographs. this patient was then lost to follow-up and presented seven months after the initial injury with the history that she had fallen again three weeks earlier. four patients (44.4%) had posterior dislocations, four (44.4%) had posterior–lateral dislocations and one patient (11.1%) had a divergent-type elbow dislocation. the patient with the divergent dislocation was initially treated with external fixator for joint distraction. this was followed by open reduction with posterior approach and k-wire one week later. all other patients were treated with open reduction and k-wire as a single stage procedure. concentric reduction of the ulno-humeral and radio-capitellar joints was obtained in all patients following surgery. rom varied from patient to patient with extension to flexion ranging between 20° to 140° (table i). the rom and mepi scores obtained were independent of duration from time of dislocation to surgery. eight patients had full forearm supination and pronation while one developed a stiff elbow with forearm in 30° pronation. complications included heterotopic ossification in one patient, superficial wound sepsis which resolved with oral antibiotics in one patient and early elbow osteo-arthritis in one patient. no neurological injury as a result of the initial injury or surgery was encountered. during telephonic follow-up, only five patients could be reached. all five of the patients reported being satisfied with the outcome of surgery and would recommend surgery to other patients with similar injuries. the sixth patient was satisfied with surgery according to last follow-up notes on the patient’s records but there is no record on whether he would recommend surgery or not. the other three patients could not be reached telephonically and no records could be found on satisfaction or whether they would recommend surgery. of the five patients who could be reached telephonically, one was self-employed and fully functional with no pain or limitation other than not regaining full extension. one patient was a bricklayer and had returned to work eight weeks following the surgery. another patient was a car guard who had returned to work on last follow up but reported struggling with adls despite regaining a rom of 40° to 140°. three patients were unemployed and three were scholars. one unemployed housewife reported struggling with adls due to pain at times despite rom of 20° to 130° (table i). in addition, on her last follow-up she was found to have developed early post-traumatic elbow osteoarthritis (table i). of the three scholars, two reported no complaints of pain or ability to perform adls. the third scholar developed heterotopic ossification and a stiff elbow as a result. the remaining two patients could not be reached telephonically and no records could be found indicating occupation or adls. according to mepi scores, two patients had excellent outcomes (scoring 100 and 95), three good (two scoring 85 and one scoring 80), and three fair (two scoring 60 and one with a score of 65. one could not be scored as there was no recorded scoring on the file and telephonic contact was unsuccessful. discussion this study aims to report on patient satisfaction following surgical treatment of chronic simple unreduced elbow dislocations. in addition we wanted to evaluate return to premorbid function and to gather information that may help in pre-operative counselling of patients in terms of the expected outcomes of surgery and rehabilitation. the majority of acute elbow dislocations (80–90%) are posterior or postero-lateral and result from a fall on outstretched hand with the forearm pronated.2,4,7,8 other mechanisms of injury include high velocity motor vehicle accidents, assaults and sports-related injuries. lateral, posterior medial, medial, anterior and divergent (characterised by displacement of the radius from the ulna) are much less common.4,8 our results concur with the reported literature on the mechanism of injury and the direction of dislocation. our cohort consisted of four posterior, four postero-lateral and one divergent dislocation, most of which were sustained following a simple fall. chronic elbow dislocations usually result from inadequate treatment of the acute injury. these injuries are common in developing countries and are usually treated initially by local bone setters and present late for orthopaedic opinion.1-3,6,7 seven page 36 yende t et al. sa orthop j 2018;17(4) table i: summary of age distribution, clinical presentation, duration from injury to surgery, post-operative assessment, patient satisfaction and mepi scores patient age (years) injury mechanism time to presentation deformity flex/extension/ radiographs rom at presentation time to surgery rom at final follow-up patient satisfaction return to pre-injury function mepi score complications 1 47 foosh in june represented in november backslab and discharged immediately post initial injury elbow extended posterior lateral dislocation ffd 30° full pronation and supination 5 months 30–140° satisfied self-employed; able to carry all activities at 8 months post-op 85 pain on cold weather only 2 40 foosh september, represented in january 2 weeks after re-injury immediately, reduced and treated on collar and cuff; then lost to follow-up extension posterior dislocation 0–80° 7 months from initial injury 20–130° not contactable unemployed housewife. struggles with adls (washing, brushing teeth, dressing) 60 oa changes noted on last follow-up at 26 months 3 27 foosh while playing soccer in february immediately treated with backslab for 2 months. no history of reduction of post reduction radiographs flexion posterior lateral dislocation ffd 90° 5 months 40–140° contact numbers off on multiple attempts car guard. struggles with adls (washing, brushing teeth, dressing) 65 hto which never progressed nor required surgery 4 6 foosh in december immediately reduced, put on collar and cuff. no follow-up given flexion divergent dislocation ffd 90° supination 90°, pronation 40° 5 months stiff elbow not contactable scholar; no record of function on file and not contactable required repeat surgery for manipulation under anesthesia and later developed hto. family refused further surgery and reported the child had adapted to using the limb 5 30 fell off the ladder in february presented 16 days post injury extension posterior dislocation ffd 30° 6 months 20–115° very satisfied bricklayer/ builder. bread winner. returned to full function ±10 weeks post-surgery 95 none reported/ documented 6 12 fell while playing in june immediately treated with backslab, no information on reduction or post reduction radiographs extension posterior dislocation ffd 30° 6 months 40–90° satisfied scholar. able to carry out all activities of age, playing well with other children and never complains of pain 60 superficial wound sepsis hto on ct scan which was done due to poor elbow movement 7 24 assaulted and fell in september presented 15 days post injury. closed reduction attempted but failed extension posterior lateral dislocation jog of rom 1 month 40–120 satisfied unemployed. no limitations 80 none reported/ documented 8 12 foosh in june immediately treated with backslab. no information on reduction and post reduction radiographs extension posterior dislocation ffd 30°, jog of pronation and supination 5 months 30–130° satisfied scholar. full function and plays without limitations 100 none reported/ documented 9 28 assault/ foosh in january. re-injured in june (3 weeks prior to 2nd presentation immediately reduced, backslab no closed reduction attempted on 2nd injury extension posterior lateral dislocation ffd 35° 1 month after re-injury 20°–full flexion satisfied unemployed. able to carry out all daily activities with minimal pain 85 joint crepitations at final follow-up pain in cold weather foosh: fall on an outstretched hand; ffd: fixed flexion deformity; oa: osteoarthritis; hto: heterotopic ossification page 37yende t et al. sa orthop j 2018;17(4) (77.7%) of our patients were treated at emergency units, some of which had no record of reduction nor confirmation of reduction on radiographs. in addition, some patients received inadequate treatment as they were placed in a collar and cuff followed by discharge without an adequate rehabilitation plan. two patients did not seek any treatment as they did not initially recognise the severity of the injury. treatment of old unreduced posterior dislocations of the elbow is one of the challenges that face orthopaedic surgeons in developing countries.1,9,10 clinical findings include an extended or flexed elbow with wasting of the triceps and a palpable bony deformity (figures 4 and 5). common findings at surgery include shortening of the triceps, firm adhesions and contracture of the capsule and collateral ligaments, dense osteo-fibrous tissue in the olecranon fossa (figures 1 and 6), coronoid fossa and trochlea notch and the presence of heterotopic ossification.10 these usually prevent closed reduction in chronic elbow dislocations and hence surgical treatment is advocated by most surgeons. our intra-operative findings were consistent with that described by other authors. successful treatment is a challenge and depends on obtaining and maintaining concentric reduction of the ulno-humeral and radio-capitellar joints as well as a functional arc of motion in order to complete adls.8,9 we achieved concentric reduction on all patients. rom in terms of flexion and extension varied between patients (table i). eight patients had full pronation and supination post-surgery while one patient developed a stiff elbow. bansal et al. reported on three patients treated with open reduction, v–y plasty and intra-articular cortisone injection.1 two of their patients had chronically unreduced simple elbow dislocation while one had chronically complex unreduced elbow dislocation. they reported two excellent results on simple dislocations and one good result on complex dislocation according to the mepi. although chronic complex elbow dislocation was included in their report, their results are comparable to available literature as well as our results. none of our patients required triceps lengthening. a similar observation was made by islam et al. who treated 13 patients, three with associated fractures and ten without.2 twelve of their patients did not require v–y plasty of the triceps. they also report satisfactory outcomes in 11 patients with six excellent, five good, one fair and one poor outcome. we are of the opinion that triceps lengthening should be individualised to patients in whom reduction cannot not be obtained without lengthening. the mepi is a useful score system for these injuries are it assesses pain intensity, motion of the joint, stability and function. a score of more than 90 is considered excellent, 75–89 good, 60–74 fair and less than 60 is considered poor. our results are consistent with results obtained by mehta et al. in their series of ten patients. they reported five excellent, three good and two poor outcomes in a series of ten cases.6 chowdhury et al. managed 15 cases of simple unreduced elbow dislocations.3 they reported four cases with good results, seven fair and four poor according to the krishnamoorthy score. they attributed less satisfactory results to lack of post-operative exercise facilities.3,6 we agree that it is essential to have a facility that can facilitate planned, goal-directed therapy. we faced similar challenges as most of our patients were referred from remote areas and therefore could not fully participate in the rehabilitation programme. jupiter et al. treated five patients with open reduction and the use of hinged external fixator. they reported two excellent and three good results with an average mepi of 89.11 we treated one patient with an external fixator for joint distraction. our patient developed heterotpic ossification and subsequently joint stiffness. he was, however, able to carry out some activies using shoulder joint positioning. a more recent study by anderson et al. included 22 patients treated with medial and lateral approaches to the elbow without triceps lengthening.12 the authors demonstrated 97% of good or excellent results with low complication rate.12 their study also supports preservation of extensor mechanism and allowed for early figure 4. elbow flexion is limited and a lateral bony mass is shown signifying posterior lateral dislocation. figure 5. showing a semi-flexed position of the elbow, wasting of the triceps and prominent olecranon figure 6. triceps is shortened and there is presence of fibrous tissue. page 38 yende t et al. sa orthop j 2018;17(4) rom as there was no risk of rupturing recently repaired soft tissues. we do not have experience with early rom at our institution. there were several limitations to this study. due to the low incidence of these injuries, only a small number of patients were treated. our series does however have similar patient numbers as other published studies in international literature. hospital records at our facility are only kept for five years and not stored on microfilm or electronic records. this unavailability of some patient records impacted our study results. we did not perform formal assessment of dash or patient-rated elbow evaluation (pree) scores for comparison with other studies. mepi scores were obtained from the files as well as after contacting the patients telephonically. most patients were referred from peripheral hospitals far from our institution and were often from poor backgrounds; this resulted in poor follow-up and poor adherence to rehabilitation protocols. conclusion patients with chronic simple elbow dislocation experience improved function following surgical treatment. extensive counselling about surgical treatment and prolonged rehabilitation should be discussed with the patient prior to surgery. emergency practitioners need to be able to diagnose, reduce, check elbow stability post reduction and properly splint patients who present with acute elbow dislocations. furthermore a planned follow-up and rehabilitation should be standardised for each institution and be given to patients after treatment of acute dislocations. we recommend social worker referral and financial support for all patients who require it in order to facilitate adherence to the prolonged rehabilitation programme. where possible, patients should be seen by occupational therapists preand post-operatively. this helps build rapport between the patient and the therapist and ensures adherence to a post-operative rehabilitation programme. ethics statement ethical approval was obtained from the institutional ethics committee before commencement of the study. references 1. bansal p, lal h, khare r, mittal d. treatment of neglected elbow dislocation with combination of speed v-y muscleplasty and intra-articular injection of corticosteroid. kathmandu university medical journal 2010;8(29):91-94. 2. islam s, jahangir j, manzur rm, chowdury aa, tripura n, das a. management of neglected elbow dislocation in a setting with low clinical resources. orthop surg 2012;4:177-81. 3. chowdhury am, hossain ma, rahman mn. treatment of old unreduced posterior dislocation of the elbow. dinajpur med col j 2009;2(2):44-47. 4. donohue kw, mehlhoff tl. chronic elbow dislocation: evaluation and management. j am acad orthop surg 2016;24:413-23. 5. rubino lj, herbenick ma, finnan rp, anloague pal. chronic elbow dislocation treated with open reduction and lateral ulnar collateral ligament reconstruction. am j orthop 2009;38(6):e98-e100. 6. mehta s, sud sa, tiwari a, kapoor sk. open reduction for late-presenting posterior dislocation of the elbow. j orthop surg 2007;15(1):15-21. 7. lyons rp, armstrong a. chronically unreduced elbow dislocations. hand clinic 2008;24(1);91-103. 8. neuhaus v, alqueza a. open reduction and temporary internal fixation of sub-acute elbow dislocation. j of hand surg 2012;37a: 1011-14. 9. rolando i. treatment of chronically unreduced complex dislocations of the elbow. strat trauma limb recon 2009;4(2):49-55. 10. ks naidoo. unreduced posterior dislocation of the elbow. j bone joint surg br 1982;64:603-606. 11. jupiter jb, ring d. treatment of unreduced elbow dislocation with hinged external fixation. j bone joint surg 2002;84-a(9):1630-35. 12. anderson dr. surgical treatment of chronic elbow dislocation allowing for early range of motion: operative technique and clinical results. j orth trauma 2018;32(4):196-203. botma n et al. sa orthop j 2020;19(1) doi 10.17159/2309-8309/2020/v19n1a6 south african orthopaedic journal http://journal.saoa.org.za trauma and general orthopaedics citation: botma n, graham s, held m, laubscher m. intramedullary nailing of tibial non-unions using the suprapatellar approach: a case series. sa orthop j 2020;19(1):40-45. http://dx.doi.org/10.17159/2309-8309/2020/v19n1a6 editor: prof. n ferreira, stellenbosch university, south africa received: march 2019 accepted: september 2019 published: march 2020 copyright: © 2020 botma n, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: there are no funding sources to declare. conflict of interest: all authors confirm they have no conflicts of interest to declare with regard to this article. abstract background: a number of treatment options are available for diaphyseal non-unions of the tibia, including intramedullary (im) nailing. an infrapatellar entry point with the knee in deep flexion can make this procedure challenging, especially with associated deformity or an obliterated canal. the suprapatellar approach allows nail insertion with the knee extended, which facilitates correction of malalignment in the sagittal and coronal planes. the aim of our study was to review the outcome of diaphyseal tibial non-unions, treated with an intramedullary nail, using the suprapatellar approach. method: we retrospectively reviewed consecutive cases with non-union of the tibial shaft, treated with a suprapatellar entry nail between may 2016 and january 2018. patients who were previously managed with a nail or who had active sepsis were excluded. the rate and time to union, as well as complications were assessed. results: thirteen cases were included and followed up until union at a mean of 5.8 months. all were performed percutaneously, without opening of the non-union site. two patients developed complications, although bony union was still achieved. conclusion: a suprapatellar entry tibial nail is an acceptable treatment option for tibial non-unions not previously treated with a nail. level of evidence: level 4 keywords: tibia, non-union, suprapatellar, intramedullary, nail intramedullary nailing of tibial non-unions using the suprapatellar approach: a case series botma n1 , graham s2 , held m3 , laubscher m4 1 mbchb(stell); orthopaedic registrar 2 mbchb, mrcs, msc(res), frcs(tr&ortho); orthopaedic surgeon 3 md, phd, fc orth(sa); orthopaedic surgeon 4 mbchb(ufs), dip pec, fc orth(sa), mmed ortho(uct); orthopaedic surgeon orthopaedic research unit, department of orthopaedic surgery, groote schuur hospital, university of cape town, south africa corresponding author: dr nico botma, orthopaedic research unit, department of orthopaedic surgery, h49 omb, groote schuur hospital, university of cape town, cape town, 7925, south africa; tel: (021) 404 9111; email: nico.botma@gmail.com https://orcid.org/0000-0002-6053-814x https://orcid.org/0000-0002-4091-7548 https://orcid.org/0000-0002-0671-0439 https://orcid.org/0000-0002-5989-8383 page 41botma n et al. sa orthop j 2020;19(1) introduction the reported incidence of tibial shaft non-union ranges from 4 to 48%.1-3 non-unions are costly to treat and add a large financial burden to healthcare services worldwide.4 various options are available to treat tibial shaft non-unions. for aseptic tibial nonunions with an intramedullary nail (imn) in situ, an exchange nail is an excellent treatment option.5 with other failed initial treatment modalities, the use of a circular external fixator with or without bone grafting and a fibular osteotomy is a popular and successful treatment modality.6 yet, although high rates of union can be achieved, this option is not always well tolerated by patients6-8 and is associated with high costs. frequent outpatient visits are often necessary, which makes regular follow-up challenging, especially for patients with low incomes or long travel distances to the hospital. lastly, some patients are reluctant to undergo external fixator treatment, especially those who previously had treatment with an external fixator. literature is limited on the use of imn as treatment for non-union of the tibia in cases which have not previously been treated with a nail,2,8,9 as percutaneous imn insertion across a non-union is challenging and time-consuming. the suprapatellar approach is a recent variation of the traditional infrapatellar approach for the insertion of a tibial nail. the suprapatellar approach allows insertion of the nail in an extended knee, which aids correction of malalignment in the sagittal and coronal planes.10-13 it also creates a straight working channel, allowing the passage of rigid, straight reamers to cross the nonunion site, facilitating imn for shaft non-unions not previously treated with imn. currently there is no literature available on the use of this technique to treat non-unions of the tibia. the aim of this study was to evaluate the outcome in the form of rate and time of union and complications of a series of non-unions treated with suprapatellar entry imn. patients and methods patients with an aseptic tibial non-union, who were treated with a suprapatellar entry imn from may 2016 to april 2018, were reviewed retrospectively. we included non-unions of diaphyseal tibial fractures initially treated with a cast, external fixator or plate. patients initially treated with an im tibial nail, non-union of peri-articular tibial fractures and non-unions with signs of active sepsis were excluded. active infection was defined as the presence of a draining sinus or local clinical signs of infection. inflammatory markers were not routinely used to exclude infection. suspected active infection, using these parameters, was diagnosed by an experienced limb reconstruction surgeon. patients younger than 18 years of age were also excluded. patients in this series were referred to a tertiary care limb reconstruction unit in cape town, south africa. ten (out of 13) patients had their index treatment for the tibia fracture at referral units in district or secondary care facilities. demographic data such as age and sex, as well as risk factors for non-union such as smoking, vitamin d deficiency and open fractures, were recorded. open fractures were graded according to the gustilo-anderson classification.14 modifiable risk factors, such as smoking and vitamin d deficiency, were addressed as per our unit protocol. definition and classification a non-union was defined as a fracture which has not healed within six months of treatment and is unlikely to heal without further intervention.15 the diagnosis of a non-union was based on the clinical and radiological assessment by two orthopaedic surgeons. radiological union was graded using the radiographic union score for tibial fractures (rust) score on post-operative radiographic films.16,17 according to whelan et al.,16 a score is assigned to each cortex on an anteroposterior and lateral x-ray, based on the assessment of healing at each cortex (table i). the individual scores are added. a minimum of 4 indicates a definite non-union and a maximum of 12 indicates a definite union. functional union was defined by the ability of the patient to weight bear on the treated leg without the use of an assistive device and without experiencing pain. ‘stiff’ and ‘mobile’ non-unions were identified on a clinical basis according to the ilizarov classification. procedure treatment with a tibial nail was offered to patients with a mobile non-union without a significant bone defect or in stiff non-unions without a significant deformity. if an external fixation device was used to treat the initial fracture, it was removed prior to the index procedure. no exchange from external fixation to intramedullary fixation was performed in a single sitting. the mean time from removal of external fixator to insertion of an intramedullary nail was 3 months (range1–7). a reamed suprapatellar entry imn was used (metanail, smith & nephew, memphis, tennessee).18 for this, the patient was positioned supine on a radiolucent table with the knee flexed at 10–20°. a 3–5cm midline incision was used extending from the superior pole of the patella proximally. the quadriceps muscle was divided or mobilised to gain access to the patellofemoral joint, thus establishing the suprapatellar portal. tibia alignment was achieved with the use of blocking or poller screws if necessary. three patients required a fibula osteotomy at the same sitting for which a 10 mm section of fibula was excised using an oscillating saw. a fibular osteotomy was only performed if the fibula was united. the non-union site was not opened and bone graft was not added in any cases. a set of solid, elastic reamers was used to cross the non-union site. in all cases the fracture site was compressed. this controlled compression was achieved by performing distal locking first, followed by utilising the dynamic compression tool of the nail19 (figure 1). medullary tissue samples were routinely collected from the intramedullary reaming and sent for microscopy, culture and sensitivity (mcs) in all cases. post-operative management patients were mobilised with partial weight bearing as tolerated from day 1 post-surgery. physiotherapy was initiated to maintain knee and ankle range of motion. cases with subclinical infection confirmed with intra-operative tissue cultures were treated with at least six weeks of culturespecific antibiotics. this included an agent active against biofilmbased infections (rifampicin in gram-positive infections if sensitive; ciprofloxacin in gram-negative infection if sensitive). of note is that these cases did not meet the exclusion criteria of this study, as the infection was not active at time of surgery, but subclinical. patients were routinely followed up with radiographs every six weeks until union (figure 2). table i: rust scoring system16,17 score per cortex callus fracture line 1 absent visible 2 present visible 3 present (bridging) invisible page 42 botma n et al. sa orthop j 2020;19(1) results thirteen cases were included for review. twenty-six tibial nonunions were excluded because of treatment using other treatment modalities. characteristics and treatment of the study group are listed in table ii. all patients achieved functional and radiological union without further intervention. the mean time to radiological union was 5.8 months. all patients were followed up until union was achieved. the median length of follow-up was 7 months (interquartile range 6.5 months) (table iii). complications/sepsis three patients grew a positive bacterial culture on tissue taken at time of surgery. in two this was a methicillin-sensitive staphylococcus aureus species (mssa), and one culture result was positive for a morganella species as well as an mssa species. all three patients were treated with culture-specific antibiotics for at least six weeks. of these three patients, two developed implant sepsis, evidenced by a draining sinus. the third patient did not develop wound complications, nor signs of implant sepsis and was therefore not considered a complication. the implant sepsis resolved in one of the two patients after completion of an antibiotic course, and his implant was removed following union. this patient had no signs of chronic osteitis at his last follow-up. the other patient developed chronic osteitis. this was treated with intermittent suppressive antibiotics until union, after which the implant was removed, followed by reaming and an antibiotic cement nail implantation. of note is this patient previously had chronic osteitis and the non-union was the result of a pathological fracture through figure 1. controlled compression. fluoroscopic picture a) before and, b) after compression. note the obliteration of the fracture gap. a a a b figure 1. controlled compression. fluoroscopic picture a) before and, b) after compression. note the obliteration of the fracture gap. figure 2. a 30-year-old male sustained an open tibia fracture and was initially managed with a biplanar external fixation. other risk factors for his tibia non-union included substance abuse, smoking and a low vitamin d level. he had positive intra-operative cultures but responded well to culture-specific antibiotics. films taken a) before suprapatellar tibial nail; b) day 1 post-operatively; and c) finally, indicating bony union a b c figure 2. a 30-year-old male sustained an open tibia fracture and was initially managed with a biplanar external fixation. other risk factors for his tibia non-union included substance abuse, smoking and a low vitamin d level. he had positive intra-operative cultures but responded well to culture-specific antibiotics. films taken a) before suprapatellar tibial nail; b) day 1 post-operatively; and c) finally, indicating bony union a b c figure 2. a 30-year-old male sustained an open tibia fracture and was initially managed with a biplanar external fixation. other risk factors for his tibia non-union included substance abuse, smoking and a low vitamin d level. he had positive intra-operative cultures but responded well to culture-specific antibiotics. films taken a) before suprapatellar tibial nail; b) day 1 post-operatively; and c) finally, indicating bony union a b c a c b figure 2. a 30-year-old male sustained an open tibia fracture and was initially managed with a biplanar external fixation. other risk factors for his tibia non-union included substance abuse, smoking and a low vitamin d level. he had positive intra-operative cultures but responded well to culture-specific antibiotics. films taken a) before suprapatellar tibial nail; b) day 1 postoperatively; and c) final films, indicating bony union page 43botma n et al. sa orthop j 2020;19(1) the site of chronic osteitis. consideration was given to treat this non-union with a circular external fixator, but the patient refused the application of an external fixator. at this patient’s last follow-up (18 months) the chronic osteitis was quiescent and there were no signs of recurrence of infection (figure 3). no patients developed implant failure, hardware irritation or any other complication in the follow-up period. discussion in this series we achieved union in all cases, using a suprapatellar entry imn. limited recent literature is available regarding the use of interlocking nails for the treatment of tibial non-unions not previously treated with a nail.2,9 a reamed exchange nail is an excellent treatment option for aseptic tibia non-unions with a nail in situ.5 reamed nailing with use of larger nails creates greater stability and is believed to provide local bone graft at the fracture or non-union site that may stimulate healing.3,20 according to tsang et al., the union rate with exchange nailing ranges from 63% (after the first non-union procedure) to 100% following subsequent nonunion procedures.21 megas et al. demonstrated that reamed infrapatellar entry imn resulted in union in all included patients within a period of six table ii: characteristics and treatment of the study group no. age (years) sex initial treatment classification risk factors for non-union operation 1 40 male circular frame mobile gr 3 open fracture vit d deficient sp im nail 2 32 male circular frame stiff gr 3 open sp im nail 3 29 male cast stiff gr 3 open fracture smoker sp im nail 4 43 female circular frame mobile vit d deficient sp im nail 5 29 male circular frame stiff vit d deficient sp im nail 6 43 female cast stiff smoker previous chronic osteomyelitis non-compliance fibular osteotomy & sp im nail 7 36 male circular frame mobile gr 3 open fracture failed masquelet technique sp im nail 8 30 male biplanar ex-fix stiff gr 3 open fracture vit d deficient smoker cannabis fibular osteotomy & sp im nail 9 50 male circular frame mobile gr 3 open fracture smoker fibular osteotomy & sp im nail 10 34 male biplanar ex-fix mobile gr 3 open smoker cannabis sp im nail 11 30 male cast mobile gsw injury with large zone of comminution sp im nail 12 29 male circular frame mobile gr 3 open fracture sp im nail 13 40 male circular frame mobile none sp im nail gr: grade; sp: supra-patellar; im: intramedullary; gsw: gunshot wound non-union classification according to the ilizarov clinical assessment; open fracture grading done according to the gustilo-anderson classification14 table iii: results and outcomes of study group no. time to union (months) length of follow-up (months) complication (y–yes/n–no) details further surgery 1 3 4 n none 2 5 5 n none 3 5 5 n none 4 8 8 n none 5 7 7 n none 6 4 17 y chronic osteomyelitis quiescent after treatment removal of infected nail at union, reaming and antibiotic cement nail 7 8 11 n none 8 6 13 n positive intra-operative cultures no signs of implant sepsis implant removal 9 5 5 n none 10 4 12 y positive intra-operative cultures implant sepsis implant removal 11 5 6 n none 12 7 7 n none 13 3 3 n none page 44 botma n et al. sa orthop j 2020;19(1) months, with a low infection rate (2%).2 yet, in 16 of 50 cases, opening the non-union site was necessary to enable insertion of the nail. the suprapatellar approach is a variation on the standard infrapatellar nail. the advantages of the suprapatellar nail above the standard nail include easier and improved tibial alignment, improved post-operative knee range of motion and a decrease in the incidence of anterior knee pain. no additional complications with the use of the suprapatellar approach had been proven in the literature.10-13 crossing the non-union site is difficult in some cases. it is necessary to have specialised equipment available in the form of solid flexible reamers. we managed closed insertion of the nail in all cases which was facilitated by the suprapatellar nail entry, enabling a straight working channel for reamers in knee extension and facilitating access for intra-operative fluoroscopy. a potential advantage of avoiding extensive debridement of the non-union site by opening it, might be that the ‘biology’ remains undisturbed and, especially with local bone grafting caused by reaming the medullary canal, this might assist healing. by adding controlled compression at the non-union site, the stability is further increased and as such, union was achieved in both hypertrophic and atrophic/oligotrophic non-unions alike by addressing the stability at the non-union site.19,22,23 complications of the three patients with positive intra-operative cultures, two (15%) developed signs of implant sepsis which persisted in one patient. this was subsequently successfully treated with further intervention. at the final follow-up all infections were quiescent and all patients with treated non-unions had united. non-union and chronic sepsis often co-exist in a similar environment and these complications were not specific to the suprapatellar approach. we acknowledge the limitations of this study. this was a retrospective single centre study with a small sample size. due to the novel nature of this treatment option and heterogeneity of cases, a large prospective study was not feasible in our setting but could be considered as a multicentre trial in future. conclusion in cases of tibial shaft non-union, without signs of active sepsis, not previous managed with a nail, suprapatellar entry imn is a safe and reliable treatment option. the use of the suprapatellar approach makes the surgery technically easier, achieving a high union rate with an acceptable low complication rate. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study ethical approval was obtained from the ethical review board: hrec reference number 315/2018. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions nb contributed to the conception and design of the work; the acquisition, analysis and interpretation of the data for the work; drafting the work, and submitting the final version to be published. figure 3. a 43-year-old female’s tibia fracture was managed in a plaster cast. she had positive intra-operative cultures and proceeded to develop active osteitis. she required removal of her implant and the subsequent insertion of an antibiotic-impregnated cement nail and culture-specific antibiotics. the osteitis resolved without further sequelae. radiographic images taken a) before surgery, b) at the first follow-up consultation, c) after insertion of antibiotic impregnated cement nail and, d) at the final consultation. a b c d figure 3. a 43-year-old female’s tibia fracture was managed in a plaster cast. she had positive intra-operative cultures and proceeded to develop active osteitis. she required removal of her implant and the subsequent insertion of an antibiotic-impregnated cement nail and culture-specific antibiotics. the osteitis resolved without further sequelae. radiographic images taken a) before surgery, b) at the first follow-up consultation, c) after insertion of antibiotic impregnated cement nail and, d) at the final consultation. a b c d a c b d figure 3. a 43-year-old female’s tibia fracture was managed in a plaster cast. she had positive intra-operative cultures and proceeded to develop active osteitis. she required removal of her implant and the subsequent insertion of an antibiotic-impregnated cement nail and culture-specific antibiotics. the osteitis resolved without further sequelae. radiographic images taken a) before surgery, b) at the first follow-up consultation, c) after insertion of antibiotic impregnated cement nail and, d) at the final consultation. page 45botma n et al. sa orthop j 2020;19(1) sg contributed to the acquisition of data for the work, revising it critically for important intellectual content and final approval of the version to be submitted to the journal. mh contributed to revising it critically for important intellectual content and final approval of the version to be published. ml contributed to the conception and design of the work; the acquisition, analysis and interpretation of the data for the work; drafting the work, and revising it critically for important intellectual content. orcid botma n http://orcid.org/0000-0002-6053-814x graham s http://orcid.org/0000-0002-4091-7548 held m http://orcid.org/0000-0002-0671-0439 laubscher m http://orcid.org/0000-0002-5989-8383 references 1. ferreira n, marais l, aldous c. the pathogenesis of tibial non-union. sa orthop j. 2016;15(1):51-59. 2. megas p, panagiotopoulos e, skriviliotakis s, lambiris e. intramedullary nailing in the treatment of aseptic tibial nonunion. injury. 2001;32(3):233-39. 3. bhandari et al. randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. j bone joint surg am. 2008;90(12):2567. 4. hak dj, fitzpatrick d, bishop ja, marsh jl, tilp s, schnettler r, et al. delayed union and nonunions: epidemiology, clinical issues, and financial aspects. injury. 2014;45(suppl 2):s3-7. 5. brinker mr, o’connor dp. exchange nailing of ununited fractures. j bone joint surg am. 2007;89(1):177-88. 6. ferreira n, marais lc. management of tibial non-unions according to a novel treatment algorithm. injury. 2015;46(12):2422-27. 7. wiss da, stetson wb. tibial nonunion: treatment alternatives. j am acad orthop surg. 1996;4(5):249-57. 8. richmond j, colleran k, borens o, kloen p, helfet dl. nonunions of the distal tibia treated by reamed intramedullary nailing. j orthop trauma. 2004;18(9):603-10. 9. rosson jw, simonis rb. locked nailing for nonunion of the tibia. j bone joint surg br. 1992;74(3):358-61. 10. chen x, xu ht, zhang hj, chen j. suprapatellar versus infrapatellar intramedullary nailing for treatment of tibial shaft fractures in adults. medicine (baltimore). 2018;97(32):e11799. 11. chan ds, serrano-riera r, griffing r, steverson b, infante a, watson d, et al. suprapatellar versus infrapatellar tibial nail insertion: a prospective randomized control pilot study. j orthop trauma. 2016;30(3):130-34. 12. gelbke mk, coombs d, powell s, dipasquale tg. suprapatellar versus infra-patellar intramedullary nail insertion of the tibia: a cadaveric model for comparison of patellofemoral contact pressures and forces. j orthop trauma. 2010;24(11):665-71. 13. sanders rw, dipasquale tg, jordan cj, arrington ja, sagi hc. semiextended intramedullary nailing of the tibia using a suprapatellar approach: radiographic results and clinical outcomes at a minimum of 12 months follow-up. j orthop trauma. 2014;28(5):245-55. 14. kim ph, leopold ss. gustilo-anderson classification. springer; 2012. 15. ferreira n, marais l, aldous c. challenges and controversies in defining and classifying tibial non-unions. sa orthop j. 2014;13(2):52-56. 16. whelan db, bhandari m, stephen d, kreder h, mckee md, zdero r, et al. development of the radiographic union score for tibial fractures for the assessment of tibial fracture healing after intramedullary fixation. j trauma. 2010;68(3):629-32. 17. leow j, clement n, tawonsawatruk t, simpson c, simpson a. the radiographic union scale in tibial (rust) fractures: reliability of the outcome measure at an independent centre. bone and joint research. 2016;5(4):116-21. 18. jakma t, reynders-frederix p, rajmohan r. insertion of intramedullary nails from the suprapatellar pouch for proximal tibial shaft fractures. a technical note. acta orthop belg. 2011;77(6):834-37. 19. högel f, gerber c, bühren v, augat p. reamed intramedullary nailing of diaphyseal tibial fractures: comparison of compression and non-compression nailing. eur j trauma emerg s. 2013;39(1):73-77. 20. hak dj, lee ss, goulet ja. success of exchange reamed intramedullary nailing for femoral shaft nonunion or delayed union. j orthop trauma. 2000;14(3):178-82. 21. tsang s, mills l, frantzias j, baren j, keating j, simpson a. exchange nailing for nonunion of diaphyseal fractures of the tibia: our results and an analysis of the risk factors for failure. bone joint j. 2016;98(4):534-41. 22. ferreira n, marais lc, aldous c. mechanobiology in the management of mobile atrophic and oligotrophic tibial nonunions. j orthop. 2015;12(suppl 2):s182-7. 23. elliott ds, newman kj, forward dp, hahn dm, ollivere b, kojima k, et al. a unified theory of bone healing and nonunion: bhn theory. bone joint j. 2016;98-b(7):884-91. http://orcid.org/0000-0002-6053-814x http://orcid.org/0000-0002-4091-7548 http://orcid.org/0000-0002-0671-0439 http://orcid.org/0000-0002-5989-8383 _goback text13 text14 _goback mehtar m et al. sa orthop j 2019;18(3) doi 10.17159/2309-8309/2019/v18n3a2 south african orthopaedic journal http://journal.saoa.org.za paediatric orthopaedics citation: mehtar m, ramguthy y, firth gb. profile of patients with blount’s disease at an academic hospital. sa orthop j 2019;18(3):30-35. http://dx.doi.org/10.17159/2309-8309/2019/v18n3a2 editor: prof j du toit, stellenbosch university, cape town, south africa received: october 2018 accepted: april 2019 published: august 2019 copyright: © 2019 mehtar m, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: this study did not require any funding. conflict of interest: the authors declare having no conflict of interest with regard to this study. abstract background: despite an apparent increased burden of blount’s disease in south africa, little is known of its epidemiology and associated features. the aim of this study is to explore the profile of south african patients with blount’s disease seen at an academic hospital, with respect to family history, ethnicity, associated milestones, sex, bilateral involvement and obesity. methods: we retrospectively evaluated the hospital records of children diagnosed with blount’s disease (infantile, juvenile and adolescent groups) over a 14-year period, from 1 january 2003 to 31 december 2016 at chris hani baragwanath academic hospital. demographic information including family history, ethnicity, attainment of milestones, age when the deformity was first noticed, age at presentation, sex, bilateral involvement and body mass index were documented. results: data was available for 108 patients with a total of 172 involved limbs. in this series all patients were of black african origin. data for 60 of the patients regarding family history was available – there were 12 documented cases with a positive family history of significant bow legs (20%). the developmental milestones of patients within all three groups were within normal limits and, in particular, were not early. the majority of the patients in the infantile and juvenile groups were female whereas the adolescent group had a male predominance. there was a similar occurrence of bilateral involvement in all groups (infantile group 64%, juvenile group 53% and adolescent group 61%). there was an increased percentage of individuals who were overweight or obese (according to bmi percentiles) in each of the three groups compared to normative data (infantile 76%, juvenile 86% and adolescent 88%). a greater proportion of male patients were classified as obese compared to female patients (82% versus 50%). there was however no significant difference in the bmi of patients with unilateral or bilateral deformity. conclusion: new findings from this large south african population of children with blount’s disease were an increased occurrence of bilateral involvement in all age groups and no association with early walking – both findings are different from the international literature. similar to other international studies, female preponderance in the infantile group and male preponderance in the adolescent group was confirmed. other findings include an increased occurrence of obesity in male children in all groups as well as an increasing occurrence of obesity as the groups progressed from infantile (42%), to juvenile (76%), to adolescent (82%) using the cdc percentiles for age. no risk factors were found for unilateral involvement. level of evidence: level 4 key words: blount’s disease, family history, ethnicity, milestones, sex, body mass index, obesity profile of patients with blount’s disease at an academic hospital mehtar m1 , ramguthy y2 , firth gb3 1 mbbch, fc orth(sa), mmed(orth); registrar* ² mbbch, fcs(orth); consultant* ³ mbbch, fcs(orth), mmed(orth); consultant* *department of orthopaedic surgery, university of the witwatersrand, chris hani baragwanath academic hospital, johannesburg, south africa corresponding author: dr m mehtar, university of the witwatersrand, chris hani baragwanath academic hospital, department of orthopaedic surgery, johannesburg, south africa; tel: +27823896594; email: mehtarm@hotmail.com https://orcid.org/0000-0002-8372-0446 https://orcid.org/0000-0003-3956-8050 https://orcid.org/0000-0002-1594-2290 page 31mehtar m et al. sa orthop j 2019;18(3) introduction blount’s disease is a developmental disorder presenting in childhood and results in multiplanar deformities of the lower limb. the deformities develop secondary to relative inhibition of the posteromedial aspect of the proximal tibial growth plate and include tibial varus, procurvatum, internal rotation and limb shortening.1-4 blount’s disease can be classified into two groups depending on the age of onset with the early onset or infantile group, occurring under the age of 4 years, and late-onset, occurring after the age of 4 years.5,6 late-onset blount’s disease can be further classified into a juvenile group (onset at age 4 to 10 years) and an adolescent group (onset after the age of 10 years). the current paper will use the three groups as described by thompson and carter6 (figure 1). despite a perceived increased burden of blount’s disease in south africa, the epidemiology and features of the south african population are largely unknown. with regard to ethnicity, it has been reported that there is an increased prevalence of all groups in the african american and hispanic populations compared with european or asian groups.5,7-9 a genetic component of blount’s disease has been proposed with several reports demonstrating a possible hereditary cause for the disease. a direct pattern of inheritance has not yet been demonstrated.10-12 early onset walking age has been proposed as an association with infantile blount’s disease and has been hypothesised to produce increased stress on the medial aspect of the proximal tibia in the predisposed infant with bow legs.9 this has been disputed by other work.11,13 studies regarding sex and blount’s disease also show a mixture of results. the ratio is often affected by the age of the patients in the studies with some showing more female and others more male involvement, depending on age at onset.10,11,13-15 the majority of the international literature shows that bilateral involvement is more common in the infantile group.15,16 in another local study, bathfield and beighton found a high incidence of bilateral involvement in the infantile group.13 as the children get older (juvenile and adolescent groups), a recent review showed that unilateral involvement is more common.5 blount’s disease is associated with an increased body mass index (bmi) – defined by the center for disease control and prevention (cdc) for age as either overweight (bmi between 85th and 95th percentile) or obese (bmi ≥ 95th percentile). a large percentage of patients treated with infantile blount’s disease are obese for age, as reported in a number of studies.5,6,17,18 the aim of this study is to explore the profile of patients with blount’s disease seen at chris hani baragwanath academic hospital (chbah) in south africa. demographic data including family history, ethnicity, attainment of milestones, age when the deformity was first noticed, age at presentation, sex, bilateral involvement and body mass index (bmi) are documented. this study provides further insights into the understanding of this disease, in a south african context. patients and methods this is a hospital-based, retrospective case series with an evaluation of hospital and outpatient records (data sheets) of children diagnosed with blount’s disease (including infantile, juvenile and adolescent groups), over a 14-year period, at chbah from 01 january 2003 to 31 december 2016. demographic information including family history, ethnicity, milestones, age when noticed, age at presentation, sex, bilateral involvement and bmi was documented. all patients diagnosed with blount’s disease were included in the study. diagnosis in the older patients was based on the typical clinical and radiological features of blount’s disease while the metaphyseal diaphyseal angle (mda or angle of drennan) was used to differentiate infantile blount’s disease from physiological bowing (figure 2). only patients with an mda of 16° or higher were included. patients with genu varum attributable to other causes were excluded. this study was approved by the human research ethics committee of the university of witwatersrand (clearance no. m141101). a total of 108 children with blount’s disease were included in the study. there was some missing data in the fields of family history and milestones. data regarding family history was available in 60/108 patients. data regarding milestones was available in 64/108 (sitting), 53/108 (crawling) and 71/108 (walking). figure 1. a. three-year-old female with infantile blount’s disease; b. eightyear-old female with juvenile blount’s disease; c. eleven-year-old male with adolescent blount’s disease figure 2. illustration of metaphyseal diaphyseal angle (mda or angle of drennan) drawn by author page 32 mehtar m et al. sa orthop j 2019;18(3) the center for disease control and prevention (cdc) bmi-forage growth charts were used to convert the body mass index to a percentile based on a patient’s age and sex and compared to normative data.17 the bmi value on its own is not relevant as, with growth, the value will increase normally. a bmi between the 5th percentile and less than the 85th percentile is considered ‘normal or healthy weight’, that from the 85th percentile to less than the 95th percentile is considered ‘overweight’, and that equal to or greater than the 95th percentile is ‘obese’.17 graphpad prism 8 software was used for statistical analyses. demographic and clinical features were described using medians with a range. confidence intervals were not used, as the data was not normally distributed. percentages were reported for categorical variables. statistical significance was calculated using the mannwhitney u-test with a p value <0.05. a kruskal-wallis rank-sum test and dunn’s post hoc test was performed to detect differences between more than two groups for independent variables. results data was available for 108 patients with a total of 172 involved limbs. there were 44 children in the infantile group, 36 children in the juvenile group and 28 children in the adolescent group. basic demographic data is shown in table i. family history and ethnicity all patients in the current study were of black african ethnicity. data from 60 patients was available regarding a family history of blount’s disease. there were 12/60 (20%) documented cases with a family history of significant bow legs (seven in the infantile group and five in the juvenile group) while in the adolescent group there were no patients with a positive family history (table i). milestones developmental milestones of patients for all three groups (infantile, juvenile and adolescent) were within normal limits. the mean age for independent walking was 12 months in each group (total of 69 children) (infantile, juvenile and adolescent) (table i). sex the infantile and juvenile groups had a greater proportion of female patients (82% and 69% respectively) while the adolescent group had a greater proportion of male patients (79%). this difference was statistically significant. (p=0.016) (table i). bilateral involvement the infantile group had 64% bilateral involvement while the juvenile and adolescent groups had 53% and 61% bilateral involvement respectively in 108 children. the high frequency of bilateral involvement in all groups was not statistically significant (p=0.607) (table ii). in all three groups with unilateral involvement, there was a predominance of left-sided involvement (77%) (table ii). obesity the bmi was calculated in 71 children. using the cdc growth charts and based on their guidelines, the infantile, juvenile and adolescent groups were 33% (11 patients), 10% (two patients) and 6% (one patient) overweight for age classification, respectively (85th percentile to less than the 95th percentile) (table iii). those patients classified as obese for age (≥95th percentile) were 42% (14 patients) in the infantile group, 76% (16 patients) in the juvenile table i: patients’ demographic data variable total n=108 infantile n=44 juvenile n=36 adolescent n=28 p-value male 41 (37.4%) 8 (18%) 11 (31%) 22 (79%) p<0.0001 female 67 (62.6%) 36 (82%) 25 (69%) 6 (21%) age first noticed (range) 53 months (12–180) 24 months (12–42) 72 months (53–108) 144 months (126–180) presentation age (range) 98 months (18–192) 67.5 months (18–156) 97.4 months (62–139) 153 months (123–192) starting to sit (range) 5 months (3–10) n=64 6 months (3–11) n=35 5 months (4–8) n=17 5 months (4–9) n=12 p=0.392 starting to crawl (range) 7 months (6–10) n=53 7 months (6–10) n=26 6 months (6–9) n=15 7 months (6–10) n=12 p=0.320 starting to walk (range) 12 months (8–24) n=69 12 months (8–24) n=38 12 months (9–15) n=19 12 months (8–24) n=12 p=0.810 bmi median kg/m2 (range) 24.7 (13.4–70.4) n=71 19.49 (13.4–70.4) n=33 28.5 (16.8–46.1) n=21 33.4 (17.9–64.1) n=17 family history: yes % (n) 12 (20%) n=60 7 (21.9%) n=32 5 (29.4%) n=17 0 n=11 table ii: disease characteristics of patients with blount’s disease laterality total n=108 infantile n=44 juvenile n=36 adolescent n=28 p-value unilateral (n) (right/left) 44 (10/34) 16 (2/14) 17 (4/13) 11 (4/7) p=0.346 bilateral (n) (%) 64 (59.3%) 28 (64%) 19 (53%) 17 (61%) p=0.607 page 33mehtar m et al. sa orthop j 2019;18(3) group, and 82% (14 patients) in the adolescent group. when combining overweight and obese patients for age and comparing them to those patients with a normal bmi (based on cdc normative data) for age, 76%, 86% and 88% of patients had an increased bmi for age in the infantile, juvenile and adolescent groups respectively (table iv). overall, the median bmi was significantly higher in the male patients (33.2 [range 16.8-70.4]) than in the females (22.0 [range 13.4-46.1]) across all ages. significantly, 82% of male patients were classified as obese while 50% of female patients were classified as obese (p=0.016) (table iii). there was no significant difference in the median bmi between those patients with bilateral disease (28.1 [range 13.4-64.1]) and those with unilateral disease (23.9 [range 14.0-70.4]). fifty-two percent with unilateral disease and 67% with bilateral disease were classified as obese (p=0.846) (table iii). discussion epidemiological data regarding blount’s disease in south africa is limited. factors associated with the condition have included ethnicity, early walking age, sex, bilateral involvement and obesity.5 a total of 108 patients with 172 involved limbs were analysed in the current study. all patients in this study were of black african origin consistent with a previous study by bathfield and beighton at the same institution in 1978 during the apartheid era.13 several studies document an increased prevalence among black populations but the reason for this association has not been elucidated.5,8,14 a review by bradway et al. found the deformity more common in the west indies.10 several authors reported a possible genetic component to the disease without demonstrating a direct pattern of inheritance.10,12,19 reviews in south africa by white et al.19 did not reveal any positive family history of patients with late onset blount’s disease, while bathfield and beighton noted that in 110 children with infantile blount’s disease, ten siblings had bow legs and 16 parents were similarly affected during their own infancy.13 in our study, out of 60 children, there were 12 (20%) documented cases with a family history of bow legs (seven in the infantile group and five in the juvenile group) while in the adolescent group there were no patients with a history of affected family members, thus highlighting a possible genetic component in the infantile and juvenile groups. bathfield and beighton reported no difference with regard to early walking age or obesity in children with blount’s disease compared to unaffected children.13 the current study supports these findings which showed a mean walking age of 12 months for the infantile group which is comparable to that of the general population. in the current study, the gross motor developmental milestones (crawling, sitting, walking) of patients within all three groups of blount’s disease were within normal limits. these findings are corroborated by inaba et al.11 this contrasts with findings of a review by janoyer et al.9 the literature regarding sex for both early and late-onset blount’s disease are conflicting. with infantile blount’s disease, some studies found boys and girls to be equally affected while other studies showed either a male or female preponderance.10,11,14,19 table iii. factors affecting the proportion of overweight and obese children variables n overweight n (%) p-value obese n (%) p-value age at onset p=0.0260 p=0.006 infantile 33 11 (33) 14 (42) juvenile 21 2 (10) 16 (76) adolescent 17 1 (6) 14 (82) sex male 27 2 (7) p=0.0827 22 (82) p=0.016 female 44 12 (27) 22 (50) laterality unilateral 24 28 (7) p=0.3496 13 (52) p=0.846 bilateral 46 15 (7) 31 (67) comparisons for overweight and obese children were done compared to children of normal weight from cdc data. table iv: both overweight and obese compared to all others in the group variables n normal bmi for age n (%)  bmi for age (overweight + obese) n (%) p-value age at onset 0.4746infantile 33 8 (24) 25 (76) juvenile 21 3 (14) 18 (86) adolescent 17 2 (12) 15 (88) sex 0.2192 male 27 3 (11) 24 (89) female 44 10 (23) 34 (77) laterality ns unilateral 24 4 (17) 20 (83) bilateral 46 8 (17) 38 (83) ns = not significant page 34 mehtar m et al. sa orthop j 2019;18(3) in the infantile group in the current study we had a high female predominance with a female to male ratio of 4.5:1. this contrasts with bathfield and beighton who had an almost equal female to male ratio of 1:1.2 in their series of infantile blount’s patients.13 inaba et al. found a female preponderance with a female to male ratio of 3:2 in infantile blount’s disease.11 with regard to late-onset blount’s disease, some have reported an increased female to male ratio (white et al. 3:2 and inaba et al. 1.75:1) but this contrasts with most other studies which showed a male predominance with a female to male ratio of 1:4.11,14,19 in the current study the juvenile group had a female preponderance with a 2.3:1 female to male ratio but this was reversed to a male preponderance with a 1:3.7 female to male ratio in the adolescent group. the current study indicates that the sex preference towards female in the juvenile group is similar to that of the infantile group but that this changes as the patients get older and present in the adolescent group. several studies document an increased frequency of bilateral involvement in the infantile group while the juvenile and adolescent groups tend to have more unilateral involvement.10,11,13,15,16 bathfield and beighton in their series of infantile blount’s patients from south africa, had 82% of patients with bilateral involvement.13 inaba et al. had 42% bilateral involvement in the infantile group compared to 19% of patients in the adolescent group.11 the current study failed to affirm these findings with a similar occurrence of bilateral involvement in each group – in the infantile group (64%), juvenile group (53%) and the adolescent group (61%) (table ii). another study from south africa by white et al. had 60% of patients with evidence of bilateral involvement in late-onset blount’s disease which is comparable to the current study.19 sabharwal et al. found similar findings to the current study with 59% of children in the infantile group having bilateral involvement compared to 36% of children in the late-onset group.15 the high occurrence of bilateral involvement in this cohort in every group suggests that blount’s disease is a systemic condition. blount’s disease is documented in many studies to be associated with an increased frequency of increased bmi.5,8,20,21 a large percentage of patients treated with infantile blount’s disease are greater than the 95th percentile of weight for age (obese) as reported in a number of studies in the usa. scott et al. had an average bmi percentile of 97.2% in their study on infantile blount’s disease.16 sabharwal et al. had 88% of infantile blount’s patients and 96% of late-onset blount’s patients classified as overweight.15 richards et al. had 67% of infantile blount’s patients with a weight greater than the 95th percentile.20 the heuter-volkmann principle of asymmetric growth inhibition resulting from increased compressive forces on the medial physis helps to explain the pathogenesis of increasing genu varum in blount’s disease with growth.15,16 the compressive forces on the medial aspect of the proximal tibia is markedly increased in obese children with genu varum.18,21 in the current study, a significant proportion of patients (76%, 86% and 88% in the infantile, juvenile and adolescent groups respectively) had an increased bmi for age (≥85th percentile – overweight and obese) (table iv). overall a greater proportion of male patients were classified as obese compared to female patients (82% versus 50%) and this was statistically significant (p=0.016). there was no significant difference in the bmi of patients with unilateral and bilateral deformity. this study could not elucidate why some obese children have unilateral involvement and why some children with blount’s disease are not obese, but increased levels of obesity have been found in all age groups of blount’s disease.5 there were several limitations to this study. the retrospective nature of the study led to a number of missing data points for the patients enrolled in the study (undocumented items were treated as missing values). data for milestone achievements was not available for all children (sitting, n=64; crawling, n=53; and walking, n=69), and a family history was only obtained in 60 children. the cdc normative data was used for comparison with overweight and obesity in the current study; this may be less relevant as the cdc normative data did not come from the same region as the population studied for better comparison. conclusion new findings from this large south african population of children with blount’s disease show an increased occurrence of bilateral involvement in all age groups and no association with early walking – both findings are different from the international literature. similar to other international studies, female preponderance in the infantile group and male preponderance in the adolescent group were confirmed. other findings include an increased occurrence of obesity in male children in all groups as well as an increasing percentage of obesity as the groups progressed from infantile (42%), to juvenile (76%), to adolescent (82%) using the cdc percentiles for age. no risk factors were found for unilateral involvement. ethics statement this study was approved by the human research ethics committee of the university of witwatersrand (clearance no. m141101) and consent was obtained from the ceo of chris hani baragwanath academic hospital. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. acknowledgement the authors would like to thank dr alison bentley for her help with the statistics of this paper. author contributions mm contributed to the conceptualisation of the study, collated and analysed the data, and was responsible for the write-up of the manuscript. yr assisted with study design, data collection and preparation of the manuscript. gbf contributed to the conceptualisation of the study, data collection, and assisted with preparation of the manuscript. orcid m mehtar https://orcid.org/0000-0002-8372-0446 y ramguthy https://orcid.org/0000-0003-3956-8050 gb firth https://orcid.org/0000-0002-1594-2290 references 1. sabharwal s. blount disease. j bone joint surg am. 2009 jul;91(7):1758–76. 2. siffert rs, katz jf. the intra-articular deformity in osteochondrosis deformans tibiae. j bone joint surg am. 1970 jun;52(4):800–804. 3. blount wp. tibia vara. j bone jt surg. 1937;19(1). 4. langenskiold a. tibia vara; (osteochondrosis deformans tibiae); a survey of 23 cases. acta chir scand. 1952 mar 26;103(1):1–22. 5. rivero sm, zhao c, sabharwal s. are patient demographics different for early-onset and late-onset blount disease? results based on meta-analysis. j pediatr orthop part b. 2015 nov;24(6):515-20. 6. thompson gh, carter jr. late-onset tibia vara (blount’s disease). current concepts. clin orthop relat res. 1990 jun;255:24–35. 7. sabharwal s, sabharwal s. treatment of infantile blount disease: an update. j pediatr orthop. 2017 sep;37 suppl 2:s26-s31. 8. burghardt rd, herzenberg je, andre s, bernius p, kazim ma. treatment failures and complications in patients with blount disease treated with temporary hemiepiphysiodesis: a critical systematic literature review. j pediatr orthop part b. 2018 nov;27(6):522-29. https://orcid.org/0000-0002-8372-0446 https://orcid.org/0000-0002-8372-0446 https://orcid.org/0000-0003-3956-8050 https://orcid.org/0000-0003-3956-8050 https://orcid.org/0000-0002-1594-2290 https://orcid.org/0000-0002-1594-2290 page 35mehtar m et al. sa orthop j 2019;18(3) 9. janoyer m. blount disease. orthop traumatol surg res. 2019 feb;105(1s):s111-s121. 10. bradway jk, klassen r, peterson h. blount disease: a review of the english literature. j pediatr orthop. 1987;7(c):472–80. 11. inaba y, saito t, takamura k. multicenter study of blount disease in japan by the japanese pediatric orthopaedic association. j orthop sci. 2014 jan;19(1):132–40. 12. sibert jr, bray pt. probable dominant inheritance in blount’s disease. clin genet. 1977 jun;11(6):394–96. 13. bathfield ca, beighton ph. blount disease. a review of etiological factors in 110 patients. clin orthop relat res. 1978 sep;135:29–33. 14. birch jg. blount disease. j am acad orthop surg. 2013 jul;21(7):408–18. 15. sabharwal s, zhao c, mcclemens e. correlation of body mass index and radiographic deformities in children with blount disease. j bone joint surg am. 2007b;89(6):1275–83. 16. scott ac, kelly ch, sullivan e. body mass index as a prognostic factor in development of infantile blount disease. j pediatr orthop. 2007 dec;27(8):921–25. 17. cdc. about child & teen bmi. cdc.org. 2015. 18. dietz wh, gross wl, kirkpatrick ja. blount disease (tibia vara): another skeletal disorder associated with childhood obesity. j pediatr. 1982 nov;101(5):735–37. 19. white c, dix-peek s, van huyssteen a, hoffman e. late-onset blount’s disease. sa orthop j. 2012;11(2):29–35. 20. richards bs, katz de, sims jb. effectiveness of brace treatment in early infantile blount’s disease. j pediatr orthop. 1998;18(3):374–80. 21. gushue dl, houck j, lerner al. effects of childhood obesity on three-dimensional knee joint biomechanics during walking. j pediatr orthop. 2005;25(6):763–68. _goback _hlk9090080 _hlk11923197 _goback layout 1 page 10 south african orthopaedic journal http://journal.saoa.org.za message from the president professional burnout pradeep makan bsc(med), mbchb, fcs sa, mmed(orth) bsc(med), mbchb, fcs sa, mmed(orth) president: south african orthopaedic association could there be a higher calling than the practice of medicine? medical professionals are entrusted to listen, diagnose, manage, and intervene on behalf of their patients. we unselfishly teach our skills to our students and trainees (registrars and fellows). as surgeons, patients invariably place their ultimate trust in us when they are at their most vulnerable. our perception of ourselves often becomes altered by the sometimes-unrealistic demands of our work and we forget that we are essentially no different from our fellow man. since my junior years at medical school, i was attracted to orthopaedics as a career because it gives one immense job satisfaction. i am certain that there are many times our partners think we are having an affair because we are so passionate about our work that we dedicate too much time and energy to our profession. i was privileged to be brought up in an era where parents and grandparents were always around. although we somehow managed to balance the demands of both work and home, times have changed. in most modern families both parents work, and modern grandparents are often busy with their own lives. if you left having children till late, the grandparents have either passed on or are too old to be of assistance. you are then sandwiched between caring for your young children and your elderly parents. you are therefore at risk of a burnout while trying to balance your busy professional career with family life. what is a good life? this question dates back to the ancient greeks. traditionally we define success by power and material possessions. power and money by themselves are like a two-legged stool – you can balance on them for a while but eventually you will topple over. unfortunately, many professionals topple over at some stage in their lives. robert frost (1874–1963) was one of the most popular american poets of the twentieth century. his wife died in 1938, two of his daughters suffered mental breakdowns, and his son committed suicide. according to robert frost, if you want to burn out or incinerate, you should have the following characteristics or somehow acquire them: 1. be perfectionistic and idealistic and complain if everything is not just right. 2. be time-conscious and always keep in the back of your mind that you have got a lot of things to do before the end of the day. keep these thoughts in your head so that you don’t relax during the day’s appointments. this is called hurry disease. 3. compete with everyone, including yourself. 4. try and control everything from the filing cabinet, reception, outpatients and emergencies to telephone calls. 5. take all interruptions, telephone calls, fit in appointments and overbook your day (known as operating multiphasically). never take time off to organise your days as you will lose income. 6. come to work when you are sick (known as tolerating selfsuffering). 7. try and prime yourself to see the world as full of demands. 8. try and work up a lather and get angry each day when any obstacles get in the way of your achieving your objectives (called free-floating hostility). 9. finally, resist social support or advice if you see someone about your burnout. ‘... but i have promises to keep, and miles to go before i sleep, and miles to go before i sleep.’ leonardo da vinci advised: ‘every now and then go away, have a little relaxation, for when you come back to your work your judgment will be surer. go some distance away because then the work appears smaller and more of it can be taken in at a glance and a lack of harmony and proportion is more readily seen.’ rest should not be an optional leftover activity, for the better you are at resting, so much more will you be capable of accomplishing in the workplace. the saoa, with the assistance of our ceo and congress committee, will for the first time introduce a well-being session at our annual congress in pretoria later this year. 404 not found chivers d et al. sa orthop j 2019;18(3) doi 10.17159/2309-8309/2019/v18n3a5 south african orthopaedic journal http://journal.saoa.org.za traumashoulder and elbow citation: chivers d, lambrechts a, vrettos b, dachs r, roche s. unrepaired rotator cuff tears following acromioplasty. sa orthop j 2019;18(3):47-52. http://dx.doi.org/10.17159/2309-8309/2019/v18n3a5 editor: prof lc marais, university of kwazulu-natal, durban, south africa received: september 2018 accepted: may 2019 published: august 2019 copyright: © 2019 chivers d, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no financial remuneration was received by any of the authors for this study. conflict of interest: the authors declare that there is no conflict of interest regarding the publication of this paper. abstract background: the natural history of rotator cuff tears suggests that not all tears progress and small isolated rotator cuff tears might heal. to date there have been no long-term studies assessing the mri changes of unrepaired full thickness supraspinatus tears after acromioplasty. methods: a database of patients from a single surgeon that have had acromioplasty without rotator cuff repair in the last five to 15 years was reviewed. the number of shoulders examined in this study was 17. patients all completed an oxford score, constant score and had an mri to assess fatty infiltration and atrophy. results: mean follow-up time 7.2 years (range, 5–13 years). the patients were divided into three groups depending on the size of the tear at time of surgery: c1 tears (<1 cm) n=5, c2 tears (1–1.9 cm) n=8, c3 tears (2–3 cm) n=4. in the c2 group, mri evaluation showed there were two patients that had tears that had regressed in size (ci 1.4–36, 4). in the c3 group, mri evaluation revealed that all (100%) of the rotator cuff tears had significant fatty infiltration and atrophy. there was no statistical difference between groups when assessing oxford scores (p=0.75) and constant scores (p=0.69). there was significant association between increase in tear size and fatty infiltration (p=0.028). a possible association was noted between increase in tear size and atrophy (p=0.054). conclusion: patients had good long-term clinical outcomes irrespective of tear size. it showed that not all tears progressed to significant fatty change and atrophy. level of evidence: level 3 key words: unrepaired, full thickness supraspinatus tear, acromioplasty unrepaired rotator cuff tears following acromioplasty chivers d1 , lambrechts a2, vrettos b3, dachs r4 , roche s5 1 mbchb, mmed(uct), fcs(sa)orth; orthopaedic consultant, port shepstone hospital; department orthopaedic surgery, university of cape town, cape town, south africa ² mbchb, mmed(orth); orthopaedic surgeon, constantiaberg hospital, cape town; university of cape town, cape town, south africa ³ mbchb, fcs(sa)orth, frcs; honorary professor, shoulder and elbow unit, groote schuur hospital, university of cape town, cape town, south africa 4 mbchb, fcs(sa) orth; consultant, shoulder and elbow unit, groote schuur hospital, university of cape town, cape town, south africa 5 mbchb, fcs(sa) orth; professor, head of shoulder and elbow unit, groote schuur hospital, university of cape town, cape town, south africa corresponding author: dr d chivers, po box 306, shelly beach 4265, kwazulu-natal; email: davechivers78@gmail.com; cell: 082 903 7691 https://orcid.org/0000-0001-7896-9688 https://orcid.org/0000-0002-4394-6627 page 48 chivers d et al. sa orthop j 2019;18(3) introduction impingement syndrome and its association with rotator cuff tears is well documented. the clinical outcome after acromioplasty has been well researched and the literature reports good long-term results. debate, however, continues regarding the optimal and most cost-effective treatment of the older patient group with an associated rotator cuff tear, with studies reporting good functional outcomes without rotator cuff repair.1 recent studies have assessed the structural changes of unrepaired rotator cuff tears; however, there has been little research into the long-term clinical outcomes and mri changes in isolated full thickness tears of supraspinatus after acromioplasty. the aim of this study was to evaluate the long-term clinical and structural outcomes of a cohort of patients with isolated full thickness tears of supraspinatus who underwent an acromioplasty without rotator cuff repair. methods and material the cohort consisted of patients from a single surgeon database who had been operated on for symptomatic impingement syndrome without repair of a full thickness supraspinatus tear diagnosed at arthroscopy. tears were categorised as c1 (less than 1 cm), c2 (between 1 and 1.9 cm), and c3 (between 2 and 3 cm) according to the snyder classification.2 all c1 and c2 rotator cuff tears at arthroscopy were noted to be within the rotator cable as postulated by burkhart et al.3 all patients had failed conservative treatment, and on examination had full active abduction, forward elevation and external rotation, minimal weakness of supraspinatus and full strength of infraspinatus and subscapularis. exclusion criteria were follow-up of less than five years, rheumatoid arthritis, diabetes, long-term corticosteroid use, and previous surgery to the shoulder. of the 64 patients contacted telephonically, 16 agreed to participate. the other 48 patients were either not contactable, were too ill, had relocated or had passed away. we had 16 patients that met these criteria; of these 16 patients, there was one patient that had bilateral pathology, so the number of shoulders investigated was 17 (n=17). imaging patients did not receive an mri on presentation to the primary surgeon as it was not clinically indicated at the time, but were assessed clinically and had x-ray confirmation of type 3 acromial morphology as described by bigliani et al.2 on follow-up, all study participants had an mri of both shoulders. the mri images were assessed by an experienced musculoskeletal radiologist and a fellowship-trained shoulder surgeon who had no information regarding the patients’ clinical outcome. continuity or rupture was assessed on t2-weighted coronal imaging sequence. a tear was diagnosed if there was no continuity in the muscle fibres of the rotator cuff. the quality and quantity of the rotator cuff was assessed on parasagital t1-weighted turbospin echo images taken parallel to the glenohumeral joint. fatty infiltration was assessed as described by goutallier et al.,5 modified by fuchs et al.6 for mri. supraspinatus atrophy was determined using the tangent sign as described by zanetti et al.7 clinical assessment clinical assessment was done according to a standardised technique using a handheld goniometer and dynamometer. the constant score 8 was recorded where a maximum of 100 points could be obtained. shoulder range of movement was measured using a handheld goniometer as described by constant and murley.8 abduction strength was measured using a handheld dynamometer applied to the wrist. the arm was abducted in the scapular plane, elbow extended, and forearm pronated. three readings were taken and the average of the three readings was recorded. an oxford score9 was completed by all patients examined, where a maximum score of 48 could be obtained. statistical methods the data was analysed using stata 13.0 (statacorp lp, 4905 lakeway drive, college station, tx77845, usa). categorical data between the groups was analysed using the chi-squared test or fisher’s exact test as appropriate. normality of continuous data was assessed using the shapiro wilk test. normally distributed data was summarised using means and standard deviations, and compared using the student’s t-test. skewed data was summarised using medians and ranges, and groups compared using the mannwhitney test. statistical significance was set at p<0.05 and all tests were two-sided. results there were 17 shoulders in 16 patients (nine females). mean followup was 7.2 years (range, 5–13 years). the mean age at surgery was 65.8 years (range, 50–82 years) and the mean age at most recent follow-up was 73 years (range, 60–89 years). the patients were divided into three groups depending on the size of the tear at time of arthroscopy. in this study, we had five c1 tears, eight c2 tears and four c3 tears (table i). c1 tears (n=5) the average age at surgery was 60.4 years (range, 49–75 years). the average age of patients with c1 tears at most recent follow-up was 67.4 years (range, 60–82 years). the median constant score was 86 (range 83–96) and median oxford score was 47 (range 46–48). only one patient in the c1 tear group had significant fatty infiltration (grade iv) and a positive tangent sign indicating significant muscle atrophy. c2 tears (n=8) the average age at surgery was 65.3 years (range, 58–81 years). the average age of patients with c2 tears at most recent follow-up was 76.7 years (range, 69–81 years). the mean constant score was 72.3 (range 62–98) and mean oxford score was 45 (range 42–48). only one patient in this group had significant fatty infiltration (grade iv). on mri two tears in the group had regressed in size and were reported as partial thickness tears. table i: comparison of tear size and age at surgery/follow-up c1 tears c2 tears c3 tears age at surgery (range years) 60.4 years (49–75) 65 years (58–71) 69 years (59–73) age at follow-up (range years) 67.4 years (60–82) 76.7years (69–81) 76.2 years (72–83) page 49chivers d et al. sa orthop j 2019;18(3) c3 tears (n=4) the average age at surgery was 69 years (range, 59–73 years) the average age of patients with c3 tears at most recent follow-up was 76.2 years (range, 72–83 years). the mean constant score was 72.3 (range 65–98). the mean oxford score was 45 (range, 42–48). on mri all four patients had stage 4 fatty infiltration and a positive tangent sign. comparison of clinical parameters there was no significant difference between the three groups when comparing abduction strength: oneway anova p=0.31); internal rotation (kruskall-wallis chi-squared p=0.8); and external rotation kruskall-wallis chi-squared p=0.7). there was, however, a statistical difference in range of motion when comparing forward flexion (oneway anova p=0.04); and lateral elevation (oneway anova p=0.04) between the three categories of tears (table ii). there was no significant difference in oxford (kruskall-wallis chisquared p=0.75) and constant scores (kruskall-wallis chi-squared p=0.69) when comparing the three groups (table iii). comparison of mri findings when assessing the fatty infiltration, atrophy and tear size, the c3 tears did have a statistically higher chance of having fatty infiltration (pearson chi-squared p=0.028). the c3 tears also had significant atrophy (pearson chi-squared p=0.032), as indicated by the tangent sign (tables iv and v). in the c2 group, two of the full thickness tears were now reported as being partial thickness tears and smaller in dimension than reported on initial surgical assessment. this equates to 12% of the total number of shoulders assessed (ci: 1.4–36.4). the association between increasing age and atrophy wilcoxon rank-sum (p=0.05) was also noted to be significant, as well as age and fatty infiltration wilcoxon rank-sum (p=0.008). the comparison between fatty infiltration stages and abduction strength revealed that stage 0 (n=2) had mean strength of 9.4 kg (4.8 kg–14.0 kg); stage 1 (n=6) abduction strength mean 16.0 kg (range 6.6 kg – 22.kg); stage 2 (n=4) mean abduction strength 10.4 kg (range 5.3 kg – 15.3 kg); stage 3 (n=1) abduction strength 3.5 kg; and the stage 4 (n=4) abduction strength was 4.2 kg (range 1.4 kg – 8.4 kg). there was a statistically significant association between muscle atrophy and abduction strength, spearman’s p=0.009 (table vi). table ii: table showing the clinical parameters for the three categories of tear (based on tear size at surgery) (n=17) c1 tears c2 tears c3 tears p-value mean abduction in kg (sd) 11.1 (7.5) 11.9 (7.1) 6.4 (3.3) *p=0.4 mean forward flexion degrees (sd) 168.2 (7.5) 170 (7.8) 157.2 (7.2) *p=0.04 mean lateral elevation degrees (sd) 171 (4.3) 170.8 (5.2) 162.8 (5.9) *p=0.04 median external rotation average (range) *** see key 4 (2–5) 5 (5–5) 4.5 (3–5) **p=0.7 median internal rotation average (range) * see key 5 (5–6) 5 (5–6) 5 (5–6) **p=0.8 *means were compared between the three categories using anova **medians were compared between the three categories using the mann-whitney u test ***external rotation: 1) hand behind head, elbow forward; 2) hand behind head, elbow back; 3) hand to top of head, elbow forward; 4) hand to top of head, elbow back; 5) full elevation *** internal rotation: 1) lateral thigh; 2) buttock; 3) lumbosacral junction; 4) waist; 5) t12 vertebra; 6) interscapular t7 table iii: comparison of median oxford and median constant scores by tear size (n=17) c1 c2 c3 p-value median oxford score (range) 47 (25–48) 45 (37–48) 45 (42–48) p=0.75 median constant score (range) 86 (52–96) 72.3 (78–98) 72.3 (65–86) p=0.69 medians were compared between the three groups using kruskall-wallis chi-squared test. table iv: comparison of tear size and proportion of muscle with fatty infiltration at follow-up, n=17   stage 0 (%) stage 1 (%) stage 2 (%) stage 3 (%) stage 4 (%) c1 tears 40.0 20.0 20.0 20.0 0.0 c2 tears 0.0 62.0 25.0 0.0 12.5 c3 tears 0.0 0.0 0.0 0.0 100.0 (fisher’s exact test, p=0.028) table v: comparison of tear size and proportion atrophy tangent sign negative (%) tangent sign positive (%) c1 tear 80.0 20.0 c2 tear 75.0 25.0 c3 tear 0.0 100.0 (fisher’s exact test, p=0.032) table vi: comparison of fatty infiltration and abduction strength fatty infiltration stage (goutallier5) stage 0 (n=2) stage 1 (n=6) stage 2 (n=4) stage 3 (n=1) stage 4 (n=4) mean abduction strength kg (range kg) 9.4 kg (4.8–14.0) 16.0 kg (6.6–22) 10.4 kg (5.3–15.3) 3.5 kg 4.2 kg (1.4–8.4) spearman’s rho, p=0.009 page 50 chivers d et al. sa orthop j 2019;18(3) discussion the reason for progression of isolated tears of the rotator cuff in impingement syndrome is multifactorial. understanding the natural history of rotator cuff tears is important when evaluating whether acromioplasty has any effect on rotator cuff tear progression. the article by melis et al.10 that looked at the natural history of fatty infiltration and atrophy in tears of the supraspinatus muscle, suggests that tears progressed to stage 2 fatty infiltration by four years and severe fatty infiltration (stage 3/4) by six years. traumatic tears progressed faster, and fatty infiltration of at least stage 2 was present at three years. muscle atrophy was noted in all tear types to occur at an average of 4.5 years post-symptomatic onset. we did not see this progression in atrophy and fatty infiltration in the small isolated tears of the rotator cuff in our study. this assumption that all tears progress is now being disputed. fucentese et al. and maman et al.11,12 have both shown that small tears may get smaller and may even heal if they are isolated tears. the progression of isolated rotator cuff tears in the context of impingement syndrome following acromioplasty and subacromial decompression has not yet been quantified. in this study we confirmed that small tears may appear to heal on mri, and our figure of 12% is in keeping with the literature of 8–9%11,12 healing rates in patients without impingement syndrome. the aetiology of rotator cuff tears in impingement syndrome can be attributed to extrinsic, intrinsic and genetic factors. acromial morphology as an extrinsic cause for rotator cuff tears and their progression is well described. a recent article13 looking at relationship of radiographic acromial characteristics and rotator cuff diseases showed that the presence of an acromial spur is highly associated with a rotator cuff tears in the symptomatic and asymptomatic patient. in bigliani’s4 description of acromial morphology, a type 3 acromion has a higher incidence of rotator cuff tears. however, in the maman et al.12 review there was no statistical correlation between acromial spur and rotator cuff tears. the presence of an acromial spur or abnormal acromial morphology does not always correlate with clinical impingement symptoms. therefore, there has been suggestion that intrinsic causes may be responsible for symptomatic impingement syndrome and rotator cuff degeneration. the intrinsic theories of cuff degeneration and tears suggest that there is a zone of hypovascularity and relative hypoxia that may lead to apoptosis and rotator cuff damage.14-16 this abnormal cuff is now dysfunctional which results in an uncentred high riding humeral head which causes the acromial morphological changes. articular-sided tears are also more common than bursal-sided tears, which may suggest intrinsic pathology. ogata and uhthoff17 showed that cuff degeneration and tears progress with age but acromial degeneration did not. hyvönen et al.18 reported that open acromioplasty did not prevent tear progression in impingement syndrome as they found that tears may appear after acromioplasty in the shoulder where no tear was present at time of surgery. there have also been studies looking at surgical versus nonsurgical or structured exercise regimens for the treatment of impingement syndrome, which have shown that long-term outcomes are similar when comparing acromioplasty versus nonsurgical interventions.19-21 a randomised controlled study performed by kukkonen et al.1 demonstrated that operative treatment is no better than conservative treatment in the management of supraspinatus tears in impingement syndrome. follow-up was one year in this study. kukkonen suggests that conservative treatment be the primary method of treatment.1 these findings may support the theories that cuff degeneration is due to intrinsic mechanisms, and surgery may not alter the natural history of rotator cuff pathology in impingement syndrome. there has been evidence to suggest that rotator cuff pathologies and symptoms may be genetic and there is a subset of patients that have increased genetic susceptibility in developing tears and subsequent tear progression. harvie et al.22 has shown that siblings have a 2.42 relative risk of developing full thickness rotator cuff tears and a 4.65 relative risk of the tears being symptomatic. the variability noted in the healing response of the rotator cuff in a cross-section of patients is now being attributed to alterations in genetic expression. genetic expression which controls cellular, vascular and extracellular matrix formation is controlled by biological and local mechanical factors at the tendon edge. it is postulated that surgical repair alters the biological environment at the tendon edge and therefore modulates gene expression.23 repair of the rotator cuff in sheep and rabbits however, has not shown to reverse fatty infiltration, but early repair may result in partial recovery according to kang and gupta,15 and therefore early repair in the traumatic full thickness tears and early presenting degenerative tears is still of value. established stage 3 and 4 fatty infiltration and atrophy; however, was not reversible with surgical repair.10,11,24 the genetic expression of protein degradation genes which results in proteolysis and muscle degeneration is up-regulated in massive rotator cuff tears.25 this may explain the association with larger rotator cuff tears and significant fatty infiltration and atrophy. the pathophysiology of fatty degeneration is related to unloading of the muscle due to its loss of insertion into bone; this result in changes in physiological structure and function of the muscle and ultimately atrophy.24,26 this unloading of the muscle may ultimately be the reason that the larger tears progressed with respect to fatty changes and atrophy. in smaller tears there is less unloading of the muscle and therefore less propensity to atrophy and degeneration. the rotator crescent and rotator cable theory by burkhart et al.3 describes two distinct areas of the rotator cuff with different load characteristics. the rotator cable which is relatively thicker supports more load and shields the crescent area. burkhart hypothesised that as people age there is progressive thinning of this relatively avascular crescent zone. this hypothesis has been recently supported by kim et al.27 who have shown that most degenerative tears occur in a more posterior location near the junction of the infraspinatus and supraspinatus and not anteriorly as initially thought. the biomechanical relevance of this tear position is that the cable is still intact, which has been shown in biomechanical studies by meisha et al.28 to be the primary load-bearing structure in the supraspinatus. therefore, tear position and not only tear size are important to consider when assessing the clinical effects of rotator cuff tears. in this study it was noted at arthroscopy that all the c1 and c2 tears were within this cable, hence the good clinical parameters achieved by the study participants. the fibrogenic and adipogenic progenitor cells in muscle that are responsible for fatty change are normally inactive in healthy muscle. the activation and differentiation of these cells has been found to be initiated by ageing, oxidative stress and muscle degeneration. this fibroproliferative response in the older patient negatively affects the rotator cuff muscle’s ability to regenenerate.24,26 the age of the patient is therefore important in assessing the healing capability of a rotator cuff tear and is of relevance in this study as we had an elderly patient cohort. in this study it was noted that isolated small full thickness tears had the best outcomes when assessing the clinical parameters of constant and oxford scores. the small tears also had better structural outcomes, whereas the larger tears did considerably page 51chivers d et al. sa orthop j 2019;18(3) worse structurally but not clinically. norlin and adolfsson25 concluded that small full thickness tears do well post acromioplasty at 10 to 13 years post-surgery, which correlates with our findings. ozaki et al.30 showed that 38% of cadavers over 60 years had cuff tears; this figure rose to 80% in cadavers over 90 years of age, where most of these tears are asymptomatic. the prevalence of asymptomatic full thickness tears in the population aged 40–60 years is 4% and patients over 60 years is 24%, according to an mri study by sher et al.31 from this data it can be noted that rotator cuff tears are relatively common and that not all patients with cuff tears present with a loss in function or pain, which might explain the good clinical outcomes we found in this age group of patients. weaknesses of this study include poor patient follow-up, and low numbers available for this study which was due to the fact that 11 patients had died, seven were too ill, eight patients refused, five had moved and 15 were not contactable. the patients were also pre-selected as having good functional capacity prior to surgery which was one of the reasons not to repair the rotator cuff. no preoperative mri was done to evaluate progression of fatty infiltration and atrophy with current mri findings at follow-up. conclusions currently this is the only long-term mri study of patients with full thickness supraspinatus tears that were not repaired at the time of acromioplasty. this small cohort of patients had good long-term clinical outcomes irrespective of tear size. it also showed that not all tears progressed to significant fatty change and atrophy in the long term. full thickness tears may progress or heal despite surgical intervention. the process of muscle regeneration or degeneration in muscles with tears seems to be more influenced by local biological factors, genetic expression and tear location, and therefore acromioplasty in isolation does not influence rotator cuff tear healing. the recommendation that can be made from this study is that small tears within the cable do not need to be fixed and in this elderly population this would facilitate less rehabilitation and earlier mobilisation. larger c3 tears, upon discussion with the patient, can be treated without repair and with shorter rehabilitation time if patients are willing to accept some functional loss. ethics statement this study received approval by the human research ethics committee, university of cape town: ref number 183/2013. declarations the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions dc was the primary author and researcher. al was the primary surgeon in all the cases mentioned and provided the patient data base. bv reviewed the written submission. rd contributed in data collection and research. sr provided the original idea and assisted in writing the article. orcid d chivers http://orcid.org/0000-0001-7896-9688 r dachs http://orcid.org/0000-0002-4394-6627 references 1. kukkonen j, joukainen a, lehtinen j, mattila kt, tuominen ek, kauko t, et al. treatment of non traumatic rotator cuff tears, a randomised control trial with one year clinical follow-up. the bone and joint journal 2014;96-b:75-81. http:// dx.  doi: 10.1302/0301-620x.96b1.32168 2. snyder sj,editor. arthroscopic classification of rotator cuff lesions and surgical decision making. in: shoulder arthroscopy. 2nd edition. philadelphia lipencott williams & wilkins; 2003. pp 201-207. 3. burkhart ss, esch jc, jolson rs. the rotator crescent and rotator cable : an anatomic description of the shoulder’s ‘suspension bridge’. arthroscopy: the journal of arthroscopic and related surgery 1993:9(6):611-16. 4. bigliani bu, morrison es, april ew. the morphology of the acromion and its relationship to rotator cuff tears. orthop trans 1986;10:216. 5. goutallier d, postel jm, bernageau j, lavau l, voisin mc. fatty muscle degeneration in cuff ruptures. pre and postoperative evaluation by ct scan. clin orthop relat res.1994;304:78-83. 6. fuchs b, weishaupt d, zanetti m, hodler j, gerber c. fatty degeneration of the muscles of the rotator cuff: assessment by computed tomography versus magnetic resonance imaging. j shoulder elbow surg. 1999;8:599-605. 7. zanetti m, gerber c, hodler j. quantitative assessment of the muscles of the rotator cuff with magnetic resonance imaging. invest radiol. 1998;33:163-70. 8. constant cr, murley ah. a clinical method of functional assessment of the shoulder. clin or thop relat res.1987;214:160-64. 9. dawson j, fitzpatrick r, carr a. questionnaire on the perception of patients about shoulder surgery. journal of bone and joint surgery. 1996;78:593-600. 10. melis b, defranco mj, chuinard c, walch g. natural history of fatty infiltration and atrophy of the supraspinatus muscle in rotator cuff tears. clin orthop relat res. 2010;468(6):1498-1505. http:// dx. doi: 10.1007/s11999-009-1207-x 11. fucentese sf, von roll al, pfirrmann wa, gerber c, jost b. evolution of nonoperatively treated symptomatic isolated full-thickness supraspinatus tears. j bone joint surg. 2012;94(9):801. http:// dx. doi: 10.2106/jbjs.i.01286. 12. maman e, harris c, white l, tomlinson g, shashank m, boynton e. outcome of nonoperative treatment of symptomatic rotator cuff tears monitored by magnetic resonance imaging. j bone joint surgery am. 2009;91(8):1898-1906. http:// dx.  doi: 10.2106/ jbjs.g.01335. 13. hamid n, omid r, yamaguchi k, steger-may, keener jd, stobb g. relationship of radiographic acromial characteristics and rotator cuff disease: prospective investigation of clinical, radiographic and sonographic findings. j shoulder elbow surg. 2012 oct; 21(10):1289-98. http:// dx. doi: 10.1016/j.jse.2011.09 14. harrison ak, flatow el. subacromial impingement syndrome. j am acad orthop surg. 2011;19(11):701-708. 15. kang jr, gupta r. mechanisms of fatty degeneration in massive rotator cuff tears. j shoulder elbow surg. 2012;21:175-80. http:// dx.oi.org/10.1016/j.jse.2011.11.017 16. lohr jf, uhthoff hk. the microvascular pattern of the supraspinatus tendon. clin orthop relat res 1990;254:35-38. 17. ogata s, uhthoff hk. acromial enthesopathy and rotator cuff tear: a radiologic and histologic post-mortem investigation of the coracoacromial arch. clin orthop relat res. 1990;254:39-48. 18. hyvönen p, lohi s, jalovaara p. open acromioplasty does not prevent the progression of an impingement syndrome to a tear. nine-year follow-up of 96 cases. j bone joint surg br. 1998;80(5):813-16. 19. budoff je, nirschl rp, guidi ej. debridement of partial thickness tears of the rotator cuff without acromioplasty: long-term follow-up and review of the literature. j bone joint surg am 1998;80(5):733-48. 20. ketola s, lehtinen j, rousi t, nissinen m, huhtala m, konttinen yj, arnala i, et al. no evidence of long-term benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome. upper limb 2013;2(7):132-39. http://dx. doi: 10.1302/2046-3758.27.2000163 21. kuhn je. exercise in the treatment of rotator cuff impingement: a systematic review and a synthesized evidence-based rehabilitation protocol. j shoulder elbow surg 2009;18(1):138-60. http:// dx. doi: 10.4085/1062-6050-45.5.483 http://orcid.org/0000-0001-7896-9688 http://orcid.org/0000-0001-7896-9688 http://orcid.org/0000-0002-4394-6627 http://orcid.org/0000-0002-4394-6627 page 52 chivers d et al. sa orthop j 2019;18(3) 22. harvie p, ostlere sj, teh j, mcnally eg, clipsham k, burston bj. genetic influences in the aetiology of tears of the rotator cuff. sibling risk of full-thickness tear. j bone joint surg br 2004;86:696-700. doi:  http://dx.doi. org/10.1302/0301-620x.86b5.14747 23. chaudhury s, carr aj. lessons we can learn from gene expression patterns in rotator cuff tears and tendinopathies. j shoulder elbow surg 2012;21:191-99. http://dx doi:  10.1016/j. jse.2011.10.022 24. barry j, lansdown da, cheung s, feeley bt, benjamin c. the relationship between tear severity, fatty infiltration, and muscle atrophy in the supraspinatus. j shoulder elbow surg 2013;22:1825 http://dx.doi.org/10.1016/j.jse.2011.12.014 25. schmutz s, fuchs t, regenfelder f, steinmann p, zumstein m, fuchs b. expression of atrophy mrna relates to tendon tear size in supraspinatus muscle. clin orthop relat res. 2009;467(2):45764. http://dx.doi.org/10.1016/j.jse.2011.10.022 26. laron d, samagh sp, liu x, kim ht, feeley bt. muscle degeneration in rotator cuff tears. j shoulder elbow surg 2012;21:164-74. http://dx.doi.org/10.1016/j.jse.2011.09.027 27. kim hm, dahiya n, teefey sa, middleton wd, stobbs g, steger m, yamaguchi k. location and initiation of degenerative rotator cuff tears: an analysis of three hundred and sixty shoulders. j bone joint surg am. 2010 may;92(5):1088-96.http://dx.doi.org/10.2106/ jbjs.i.00686 28. meisha mm, derwin ka, sibole sc, erdemir a, mccarron ja. the biomechanical relevance of anterior rotator cuff cable tears in a cadaveric shoulder model. j bone joint surg am. 2013 oct 16;95(20):1817-24. http://dx.doi.org/10.2106/jbjs.l.00784 29. norlin r, adolfsson l. small full-thickness tears do well ten to thirteen years after arthroscopic subacromial decompression. j shoulder elbow surg. 1993;17(1 suppl):12s–16s. 30. ozaki j, fujimoto s, nakagawa y, mashura k, tamai s. tears of the rotator cuff associated with pathological changes in the acromion. j bone joint surg 1988;70:1224-30. 31. sher js, uribe jw, posada a, murphy bj, zlatkin mb. abnormal findings on mri of asymptomatic shoulders. j bone joint surg 1995;77:10-15. _goback ole_link1 ole_link2 _hlk10211914 _goback south african orthopaedic journal acknowledgement of reviewers page 196 sa orthop j 2022;21(4) the south african orthopaedic journal is able to publish good quality, peer-reviewed articles thanks to the valuable input provided by its tireless and generous reviewers. by applying their insights and knowledge gained in their areas of expertise, the reviewers ensure the scientific integrity and research quality of the articles. this they do without any reward, and we wish to thank them most sincerely for their contribution to the journal. paediatric orthopaedics jacques du toit greg firth anthony robertson pieter mare mari thiart anria horn katherine troisi paul rollinson robert fraser ruan goller shekar roopan dina simmons denise potgieter ryno du plessis koshy daniel yammesh ramguthy arthroplasty, hip and knee michael held david north chris snyckers jurek pietrzak ponky firer brad gelbart marc nortje thomas hilton rian smit koos jordaan bryan riemer johan van der merwe adriaan van huysteen muhammed majra johan charilou virsen singh allan van zyl sebastian magobotha jan de vos simon sombili jitesh rajpaul johan van der merwe hennie bosch allan sekeitto thane munting laughter lisenda foot and ankle nick saragas graham mccollum paulo ferrao jos van niekerk fred louw andrew strydom kevin mcintyre ian stead adriaan van zyl meghan dares rob snyders mohammed mehtar mark maritz etienne joubert johan van der merwe craig blake ziyaad mayet jacques jonck matthew workman orthopaedic oncology and infections thomas hilton theo le roux keith hosking bennie lindeque jaco viljoen andré olivier phakamani mthethwa len marais luan nieuwoudt nando ferreira henrik bauer paul kgagudi walid mugla richard kyte andrew johnston alan molloy doron frantzen trauma and general orthopaedics nando ferreira sithombo maqungo franz birkholtz luan nieuwoudt maritz laubscher len marais craig brown brian bernstein norrie gibson gian du preez steven matshidza ryno du plessis jeannie mccaul megan o'connor stefan swanepoel craig blake will harrison erik formanek jan rofling rudolph venter philani ntombela danie hugo phillip de lange etienne joubert thivani naidoo shekar roopan gadi epstein tinus bassoin elsabe britz rainer rosin kirsty berry vuyisa mdingi sebastian magobotha lerato nhlapo research methodology and statistics marilize burger len marais theresa mann hand ajmal ikram duncan mcguire antoinne rocher megan o’connor charles serfontein hentas van zyl michael grundill pieter jordaan nico fang cynthia sathekga tatolo sefeane spine robert dunn johan davis gert vlok mthunzi ngcelwane ravel ramlakan alberto puddu nicolas kruger sanesh miseer yusuf desai marcus van heukelum etienne coetzee fred ukunda vuyu gezengana shoulder and elbow stephen roche cameron anley phillip webster basil vrettos stadler kirsten leon rajah j-p du plessis jan kirsten sean pretorius michael grundill archie rachuene ben grey sachin baba south african orthopaedic journal trauma and general orthopaedics doi 10.17159/2309-8309/2021/v20n4a8strydom s et al. sa orthop j 2021;20(4) citation: strydom s, snyckers ch. minimally invasive subcutaneous anterior fixation of pelvic fractures in the elderly: case report and literature review. sa orthop j 2021;20(4):240-245. http://dx.doi. org/10.17159/2309-8309/2021/ v20n4a8 editor: prof. sithombo maqungo, university of cape town, cape town, south africa received: august 2020 accepted: february 2021 published: november 2021 copyright: © 2021 strydom s. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background as our population ages, the incidence of pelvic fragility fractures will rise accordingly. despite these fractures having similar mortality rates to proximal femur fractures, there exist discrepancies between the management of these injuries. although a number of pelvic fragility fractures can be treated successfully with conservative means, early treatment with appropriate surgical means should be considered in those failing conservative treatment or with unstable fracture patterns. case report we present an 84-year-old female who sustained a pelvic fragility fracture after a low-energy fall. despite adequate conservative treatment, she was unable to mobilise. she was taken for anterior and posterior fixation, using our modified minimally invasive subcutaneous technique (the bridging infix) for anterior fixation. at the six-week follow-up she had regained full independent mobility. she had three syncope-related falls during this period, but radiographs revealed no sign of implant displacement. one year after her surgery she had complete union of her fracture, good function and no desire to have the implant removed. discussion with the expected increase in pelvic fragility fractures due to the growing elderly population, our understanding of these injuries has begun to change. occult posterior ring injuries have been described in up to 80% of cases, while fracture progression to unstable patterns can occur in up to 15% of stable patterns. despite conservative management being the primary treatment of choice, these patients suffer morbidity and mortality rates comparable to proximal femur fractures. early appropriate surgical management should be considered in patients failing to mobilise. various surgical techniques have been described, each with their own advantages and disadvantages. newer minimally invasive techniques are gaining favour, especially for use in elderly patients. these constructs combine the low profile benefits of internal plate fixation with ex-fix principles. conclusion the bridging infix is a modified technique for minimally invasive subcutaneous anterior pelvic fixation. its use can strongly be considered by even the general orthopaedic surgeon in cases where patients are too frail for extensive or invasive surgeries, such as open reduction and internal fixation with plate and screws. level of evidence: level 5 keywords: pelvic fracture, anterior pelvic fixation, elderly, minimally invasive minimally invasive subcutaneous anterior fixation of pelvic fractures in the elderly: case report and literature review sven strydom,¹* christian h snyckers² ¹ department of orthopaedics, university of pretoria, kalafong tertiary hospital, pretoria, south africa ² private practice, eugene marais hospital, pretoria, south africa *corresponding author: svenstrydom@gmail.com introduction as our population ages, the incidence of traumatic and insufficiency pelvic fractures among the elderly is rising.1 this phenomenon highlights the current common misdiagnosis and management of, particularly, the insufficiency pelvic fractures. isolated pubic rami fractures respond well to conservative management with minimal pain and a quick return to mobility. a similar management approach applied to complex lateral compression-type pelvic fractures is fraught with pain and prolonged immobility leading to increased morbidity and even death.1 increased use of computerised tomography (ct) scans has shown that up to 80% of presumed isolated pubic rami fractures are complex lateral compression-type pelvic fractures.2 hopf et al. link neck of femur fractures and pelvic insufficiency fractures in the elderly demographic by stating that they share similar mortality rates.3 despite this, a discrepancy remains between their management. neck of femur fractures enjoy appropriate and aggressive early treatment leading to a marked reduction in mortality, morbidity and complications, whereas insufficiency pelvic fractures remain misdiagnosed and poorly treated. as with neck of femur fractures, a percentage of patients with https://orcid.org/0000-0002-6288-4388 page 241strydom s et al. sa orthop j 2021;20(4) stable pelvic fracture patterns can be treated conservatively. early treatment with appropriate surgery for complex or unstable fractures is, however, essential. transiliac/sacral screw fixation is an effective treatment for most posterior injuries. at the same time, stabilisations with external fixation, open reduction and internal fixation (orif) with sub-muscular plating, retrograde pubic rami screw fixation or newer subcutaneous techniques are possible for anterior instability.1 we propose using a novel internal bridge plate and rod technique that combines the extra-pelvic fixation methods of an external fixator with the low-profile advantages of the pelvic bridge and orif. case report we present an 84-year-old female who sustained a pelvic fracture (figure 1) after a fall while disembarking from a minibus. she was referred to us with a complaint of significant pain and difficulty mobilising despite receiving physiotherapy for the past two days following the injury. before the injury, the patient was living independently with full mobility and without the use of walking aids. on presentation, the x-rays showed a superior and inferior pubic rami fracture, with the superior rami fracture at the level of the medial edge of the obturator foramen with comminution and extension into the pubis. a ct scan revealed a type 2b fragility fracture of the pelvis comprising anterior pubic rami fractures and a posterior sacral fracture (figure 2). she was taken to theatre the following day for fixation (figure 3) and, under general anaesthesia and a spinal block, a single 6.5 mm cannulated screw was used to stabilise the posterior arch. a modified minimally invasive subcutaneous technique was used for the anterior arch. our bridging infix technique is a variant of the pelvic bridge described by hiesterman et al., during which we avoid placing pedicle screws in the pubic tubercle.4 hence the only fixation points are those at the iliac crest, similar to the infix. by avoiding the use of pedicle screws we theoretically reduce the likelihood of patient discomfort caused by prominent screws at the pubis or heterotrophic ossification developing, which was found in around 25–30% of pedicle screw heads which have been removed.5 an additional advantage this construct has over the original pelvic bridge is that it can be used in cases with bilateral pubic rami fractures, as it is not dependent on screw purchase at the pubic tubercle. the patient spent one night in the high care unit for postoperative observations. physiotherapy was initiated immediately with protected weight-bearing allowed. the patient was able to mobilise safely and was discharged seven days after surgery to a step-down facility for continued physiotherapy. at the six-week follow-up, the patient was able to walk unaided and pain-free. she had full active range of motion in her hips and was able to perform active straight leg raises bilaterally (figure 4). she reported having fallen three times since surgery due to syncope and was subsequently referred to a physician for further work-up. she had recovered complete independent mobility but was advised to continue using a walking frame to assist with balance. radiographs revealed good early union and no signs of displacement, despite her having fallen several times. she was assessed for a final follow-up one year after her surgery. at this time, she reported no discomfort from the bridging infix and did not desire the removal of the implant. radiological examination revealed a good bony union (figure 5). her syncope had also improved with appropriate medical therapy. discussion an estimated 7% of all osteoporotic fragility fractures affect the pelvic ring; and it has also been shown that 73% of all pelvic fractures occur in the elderly.6,7 a rapidly growing demographic of older adults is evident as life expectancy increases in developed figure 1. ap radiograph of the pelvis showing left pubic rami fracture, preoperative figure 2. coronal ct scan views demonstrating pubic ramus and sacral (red arrow) fractures, preoperative figure 3. ap and lateral fluoroscopy of pelvis, intraoperative page 242 strydom s et al. sa orthop j 2021;20(4) countries. the accompanying rise in incidence has made these fractures a common, clinically important problem.1,8,9 the number of pelvic ring fractures among older adults in america increased by 24% between 1993 and 2010.10 elderly patients are vulnerable due to their age-related physical condition, pre-existing comorbidities, limited rehabilitation capacity, and impaired coping mechanisms.7 pelvic fractures can have a major impact on their quality of life and result in loss of independence.7-9 rehabilitation to independent mobilisation is of critical importance to improve outcomes and prevent common complications such as decubitus ulcers, pneumonia and urinary tract infections, which occur in 58% of patients treated conservatively.1,7 with conservative management as the primary choice of treatment, it is evident that an average hospitalisation duration ranges from 9.3 to 45 days. the time to pain improvement and independent mobilisation varies from four weeks to more than three months, and nearly 50% of patients report diminished independence afterwards, while only 85% report complete pain relief after nine months of conservative management.1,11 the one-year mortality rate has been reported to reach 27%, while the five-year mortality is as high as 54%, comparable to intertrochanteric and neck of femur fractures among this group.3,7,11 even low-energy trauma such as a fall on the side from a standing position can cause a compression fracture of the lateral mass of the sacrum and associated horizontally running fracture of the superior ramus of the pubic bone.8 differences like this, between young patients with high energy trauma and elderly patients with fragility fractures caused by low energy trauma, combined with the welldocumented change in morphological characteristics of fragility fractures, have led to the proposal of a different classification system for these fractures.8 the fragility fracture of the pelvis (ffp) classification is based on increasing degrees of instability. type i consists of an isolated anterior injury; type ii has a non-displaced posterior ring fracture; type iii, a displaced unilateral posterior element; and type iv, displaced bilateral posterior ring fractures. types ii to iv may or may not have an associated anterior ring fracture.8,12 the literature supports conservative treatment of type i fractures, while type ii fractures are best treated with percutaneous techniques to allow early mobilisation. both types iii and iv fractures require more aggressive surgical management due to the associated displacement.12 fracture progression has, however, been described to occur over time, with previously stable patterns progressing to more complex patterns with greater instability leading to the eventual collapse of the pelvic ring.8,9 rommens et al. found progression in nearly 15% of pelvic fragility fractures that were treated conservatively.9 occult posterior pelvic ring fractures have been described in 54–80% of elderly patients with pubic rami fractures,2,13,14 a statistic highlighting the importance of utilising ct scans to diagnose the fracture pattern correctly. figure 4. patient able to perform straight-leg raises (left) and stand independently (right) at six-week follow-up figure 5. ap radiograph of the pelvis one year after fixation showing good bony union and hardware in situ page 243strydom s et al. sa orthop j 2021;20(4) biomechanically, the anterior portion provides 40% of the pelvic ring’s stability, while the posterior elements are responsible for the remaining 60%.15 traditional methods of fixating the anterior pelvis have included orif, external fixation and retrograde pubic rami screws.4,5 the most significant benefits of orif include allowing for anatomic reduction and there being no need for removal of any implants at a later stage. it remains biomechanically the most rigid construct at the symphysis pubis.16,17 despite the numerous advantages of orif, it requires a more extensive surgical approach with a subsequent increase in approach-related complications.6 longer surgeries with greater blood loss not only result in greater physiological stress on the patient’s cardiovascular system, but are also associated with a prolonged recovery and increased surgical site infection rate.18 both the pfannenstiel and modified stoppa approaches are widely used during anterior pelvic ring orif.6 with more lateral extension of the incision, the risk of damage to the inguinal canal and its content increases, which can result in ongoing pain symptoms.19 it is important to note that there is sparse literature regarding the complications associated with such extensive surgical approaches, specifically in the elderly or frail patient. external fixation, being a minimally invasive technique, serves to preserve the fracture site’s biology and allows for easy removal.5 despite its convenience for the surgeon, it is often unsightly and cumbersome for the patient and has an associated complication rate as high as 62%.20,21 complications include: pin-tract infection in 2.5–50% of cases, osteomyelitis, aseptic loosening in up to 19%, patient discomfort, and poor tolerance due to limitations in activities of daily living or mobility or skin impingement, increased difficulty in nursing care and iatrogenic nerve injury.5,15,20-22 there is also a risk of loss of reduction, which is dependent on the fracture pattern and additional fixation used.20 the presence of obesity further increases the risk of loss of reduction and pin-tract complications.5,20 some authors also recommend against external fixation use in fragility fractures.12 another option of anterior fixation is the use of retrograde pubic rami screws. this technique has grown in popularity because it provides a minimally invasive internal fixation option. these screws are not suitable for all fracture types and have a reported loss of reduction in 15% of cases.23 rommens et al. pointed out that the type of fracture dictates the type of fixation, and starr et al. clearly showed an increase in instability with fractures medial to the lateral border of the obturator foramen.9,23 they also showed an increase in fixation loss with advanced age and female sex. it is common for all these risk factors to coexist in insufficiency fractures of the pelvis, making retrograde percutaneous screw fixation technically demanding in this subgroup of patients.23 this technique also requires a high degree of precision.1 the recent development of minimally invasive anterior subcutaneous internal fixation techniques is proving to be a popular alternative means of fracture fixation.5,15,16,21 the aim is to limit complications associated with external fixator use while retaining the advantages using internal implants but using the same fixation principles.5,15,20 their application requires minimal soft tissue dissection, which reduces operating time, intraoperative blood loss and length of stay when compared to orif.5,21,24 the subcutaneous location also decreases the risk of surgical site infection, eases the burden of nursing care, and avoids interference with rehabilitation and daily activities.5,20,24 biomechanically they provide sufficiently rigid fracture fixation to facilitate bone healing.5 several studies conclusively demonstrated superior stiffness at the pubic symphysis compared to external fixators, while one study by vigdorchik et al. demonstrated these constructs could provide some indirect compression of the posterior pelvic elements.5,16,25 this can prove beneficial when acute stabilisation of the posterior elements is contraindicated.25 long-term follow-up of these techniques show high patient satisfaction and acceptably low complication rates.17,26 the first of these novel techniques was originally described in german literature in 2009, but it was vaidya et al. who described the modified method currently being used, and coined the term infix for this technique.5,27 their technique involved the placement of pedicle screws in the supra-acetabular area with a connecting curved rod in the epifascial plane. a potential drawback is the rod which transverses the inferior abdominal wall, thus creating a potential for iatrogenic compression or impingement injuries. screw placement also requires deep dissection in the interval between the sartorius and tensor fascia latae muscles.5 a more recent variation of this minimally invasive technique is the pelvic bridge described in 2012.4 this method involves spanning the anterior pelvis between two ‘pillars’, usually the ipsilateral iliac crest and either the ipsilateral or contralateral pubic symphysis. the bridge is formed with either a low-profile pre-contoured locking plate or a rod-plate construct (originally used for occipito-spinal fusions).4,5 the bridge is passed subcutaneously, above the external oblique fascia, along the static anatomic structures namely the iliac crest, inguinal ligament and pubic symphysis.4,5,22 the construct design can allow for either selective percutaneous fixation of the compromised hemipelvis without involving the uninjured side, or two separate fixators can be used with an overlap and rod-to-rod connections at the pubic symphysis for bilateral fractures.5 these differences in the course of the connecting rod and construct design provide some advantage over the infix. a cadaver study by reichel et al. compared the infix and pelvic bridge techniques.28 they noted several challenges with the infix application. first, its application was variable and highly dependent on the pedicle screws placement and curvature of the rod, which results in an increased risk of impingement due to the patient’s body habitus or when greater flexion is attempted at the waist. since the connecting rod did not mirror static anatomic structures like the pelvic bridge, there also remained the risk of the rod twisting or being misplaced while securing the locking caps. lastly the pedicle screw depth is a subjective measure as it lies several centimetres above the bone; placement at the incorrect depth can lead to either patient discomfort from prominent hardware or impingement of underlying structures. the pelvic bridge utilises four points of fixation, which aids in reducing the chance of misapplying the device in a manner that impinges neurovascular structures. despite the literature showing that supra-acetabular screws are superior to iliac crest screws, there are no biomechanical studies directly comparing the infix and pelvic bridge constructs.16,28 theoretically the four-point fixation of the pelvic bridge may impart greater overall biomechanical strength when compared to the twopoint fixation of the infix.4,28 another anatomic study demonstrated that despite variations in pelvic anatomy such as pelvic brim width, the pre-contoured rods or plates did not violate any neurovascular structures.29 the pelvic bridge does, however, have a theoretical risk of bladder injury with erroneous drilling and screw placement into the pubic symphysis, but no such case has been described in the literature to date.28 several studies have looked at the complication rates associated with the infix, while literature on the pelvic bridge technique is still sparse. one of the most common complications of the infix found in the literature is lateral femoral cutaneous nerve (lfcn) neuropraxia, which most studies found in 25–32% of all cases.5,15,17,20,21 two studies found even higher rates of lfcn neuropraxia, occurring in 55–57% of cases.30,31 patients will present with numbness over the anterolateral thigh; this is, however, well tolerated by most patients and the majority resolve with time after removal of the implant.5,15,17,21,28 these findings page 244 strydom s et al. sa orthop j 2021;20(4) are well explained by reichel et al., who state that despite the infix having a significantly greater distance from most anatomic structures when compared to the pelvic bridge, it lacks a ‘safety margin’ in 90.9% of specimens between the lfcn and pedicle screws.28 in addition, lfcn injury may be caused by difficulty in locating the nerve during dissection to place the pedicle screws.5,28 a review by vaidya et al. could not find a recommendable solution to prevent this complication with infix application.17 the pelvic bridge was proposed as an alternative to minimise the risk of lfcn neuropraxia, as the implant remains a significantly greater distance from the lfcn when compared to the infix.28 it must, however, be noted that anatomical variations of the lfcn has been described in 2.9 to 4% of the population, which can place the nerve at risk when dissecting near the iliac wing to place the pelvic bridge.5 another common complication noted with the infix is heterotrophic ossification around the pedicle screws, which occurs in 21–36% of cases.5,15,17,20,21 despite being asymptomatic, some authors do recommend the use of preventative measures such as prophylactic use of non-steroidal anti-inflammatory drugs or radiotherapy.15,17,20 other complications occur more rarely and include a surgical site infection rate of 3%, but no documented cases progressed to osteomyelitis.17 acute and delayed onset femoral nerve neuropraxia occurred in 1% due to seating the rod too deep in overweight patients.29 these injuries were more likely to be permanent despite implant removal compared to lfcn injuries, with one study showing total recovery in only one out of eight patients.32 vascular occlusion occurred in one case, but was diagnosed early enough to prevent long-term complications.33 aseptic loosening with loss of reduction and entrapment of the anterior abdominal wall causing severe discomfort has also been described.5 vaidya et al. found up to 7.3% of infixs required early revision due to complications.17 fortunately, the majority of complications were considered minor; however, the potential for devastating complications does exist and this underscores the importance of education on the use and improvement of techniques to decrease the associated risks.5 as mentioned, there are limited studies regarding the complications encountered with the pelvic bridge. cole et al. found the overall complication rate with the pelvic bridge technique to be 4%.5 the complications they encountered included superficial wound infection, one asymptomatic pubic ramus non-union and temporary lcfn neuropraxia.5,33 in another study they also demonstrated significantly less pain and discomfort at follow-up when compared to an external fixator.33 a common disadvantage for both minimally invasive techniques is that hardware needs to be removed in theatre at a later stage. this is recommended as there are no long-term studies available, and potentially deleterious consequences from leaving the device in situ are unknown.5,22 pressure over the device can also cause unnecessary discomfort for the patient.22 current literature recommends removal of the pelvic bridge between eight and 16 weeks, before excessive soft tissue ingrowth can occur.5,34 campbell et al. described a novel endoscopic technique utilising incisions smaller than those of the original procedure, to successfully remove the implant with excellent preliminary results.34 they also noted that the more expensive rod-plate construct was easier and less traumatic to remove compared to the locking-plate construct.34 since the fracture site is not exposed, there is a risk of soft tissue interposition with resultant non-union, and fracture fragments that may cause neural or organ compression cannot be removed.24 being novel techniques, the ideal indications and contraindications of the infix and pelvic bridge are still being defined. current indications include both high and low energy pelvic ring injuries requiring anterior stabilisation, in either isolated anterior injuries or after posterior stabilisation has been achieved. it is also proving to be advantageous in coagulopathic patients to minimise intraoperative blood loss, in patients expected to have a protracted icu course to facilitate nursing care and decrease infection risk, and in those requiring the prone position later for procedures such as spinal surgery.5,22,24 patients with morbid obesity also tolerate subcutaneous devices better than an external fixator; the pelvic bridge has been suggested to be superior to the infix regarding its ease of application as the anatomic landmarks are identified more easily in obese patients.5,22,24 contraindications include pure ligamentous dislocation at the pubic symphysis or iliac wing dislocations; severe degloving soft tissue injuries or active infection in the suprapubic or iliac crest areas; open pelvic fractures with peritoneal contamination; pregnancy; and haemodynamically unstable pelvic ring injuries requiring rapid stabilisation for life-saving reasons.5,24 it has been noted that the pelvic bridge should never be used as the sole fixation method in combined anterior and posterior instability.24 stable pelvic fractures in patients who are able to mobilise effectively with partial weightbearing and acetabular fractures involving the anterior column have also been suggested as potential contraindications.24 a suggested postoperative rehabilitation programme consists of weight-bearing as tolerated in the first six weeks, followed by full weight-bearing. during this time there is no restriction on hip range of motion. 4,22 it is also proving to be an appealing surgical option in the elderly with osteoporotic bone to provide pain relief and allow rapid mobilisation while minimising surgical risk.5,22 the use of bone cement can further augment screw purchase in osteoporotic bone.5,9 taking into consideration that prolonged immobilisation is associated with potentially fatal complications in the elderly, early surgical treatment and mobilisation has been suggested to improve mortality rates.5,6,9 this was confirmed by osterhoff et al. who found that surgically treated patients who survived the initial two years post injury had a better long-term survival compared to conservatively treated patients.35 their slightly higher mortality rate in the first two years may be explained by the perioperative risks inherent with anaesthesia and surgery in the elderly. they thus recommend considering early surgical management for patients with a greater than two-year life expectancy. in addition to the improved long-term survival, surgical fixation is gaining favour due to its better pain relief, faster mobilisation and shorter recovery period compared to conservative management.3 conclusion the incidence of pelvic fragility fractures is on the rise as our population ages. underestimating the seriousness of these fractures and inappropriate identification and management thereof can lead to significant morbidity and mortality. this is comparable to conservative management of proximal neck of femur fractures. this case demonstrates the effectiveness of appropriate, aggressive surgical intervention in complex fragility pelvic fracture. here the use of minimally invasive subcutaneous anterior fixation and percutaneous posterior stabilisation provides for rapid pain relief and allows early mobilisation. as the literature demonstrates, our understanding of pelvic fragility fractures is expanding and with that the place and value of early, aggressive and appropriate surgical fixation is becoming more evident. ethics statement written consent was received to use photos, radiographs and clinical data from the patient and is available on request. page 245strydom s et al. sa orthop j 2021;20(4) declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ss: contributed to the conceptualisation, data collection and writing of the article chs: primary treating surgeon of the case presented, contributed to the conceptualisation, data collection and writing of the article orcid strydom s https://orcid.org/0000-0002-6288-4388 snyckers ch https://orcid.org/0000-0002-6297-894x references 1. oberkircher l, ruchholtz s, rommens p, et al. osteoporotic pelvic fractures. dtsch arztebl int. 2018;115(5):70-80. https://doi.org/10.3238/arztebl.2018.0070. 2. tosounidis g, wirbel r, culemann u, pohlemann t. fehleinschätzung bei vorderer 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https://doi.org/10.1016/j.archger.2016.06.020 https://doi.org/10.1007/s00776-014-0653-9 https://doi.org/10.1177/230949901001800205 https://doi.org/10.1177/230949901001800205 https://doi.org/10.1007/s10195-012-0182-2 https://doi.org/10.1007/s10195-012-0182-2 https://doi.org/10.1038/s41598-019-39068-7 https://doi.org/10.1038/s41598-019-39068-7 https://doi.org/10.1186/1749-799x-7-31 https://doi.org/10.1097/bot.0000000000001248 https://doi.org/10.1097/bot.0000000000001248 https://doi.org/10.21614/chirurgia.112.5.524 https://doi.org/10.1016/j.ocl.2020.02.010 https://doi.org/10.1007/s11999-011-2233-z https://doi.org/10.1051/sicotj/2019019 https://doi.org/10.2106/jbjs.st.15.00085 https://doi.org/10.1097/bot.0b013e318162ab6e https://doi.org/10.1186/1756-0500-7-133 https://doi.org/10.1186/1756-0500-7-133 https://doi.org/10.1007/s00264-013-1890-9 https://doi.org/10.1007/s00264-013-1890-9 https://doi.org/10.1007/s00264-013-2032-0 https://doi.org/10.1097/bot.0b013e318233b8a7 https://doi.org/10.1016/j.injury.2017.12.009 https://doi.org/10.1016/j.injury.2017.12.009 https://doi.org/10.1097/bot.0b013e31823e6b82 https://doi.org/10.1097/bot.0b013e31823e6b82 https://doi.org/10.1302/0301-620x.99b9.bjj-2016-1025.r2 https://doi.org/10.1302/0301-620x.99b9.bjj-2016-1025.r2 https://doi.org/10.1186/s13018-016-0468-9 https://doi.org/10.1097/bot.0000000000000193 https://doi.org/10.1097/bot.0000000000000193 https://doi.org/10.1097/bot.0b013e3182410577. https://doi.org/10.1097/bot.0000000000001267 https://doi.org/10.1097/bot.0000000000001267 https://doi.org/10.1097/bot.0000000000001584 https://doi.org/10.1097/bot.0000000000001584 van heukelum m et al. sa orthop j 2020;19(3) doi 10.17159/2309-8309/2020/v19n3a5 south african orthopaedic journal http://journal.saoa.org.za arthroplasty citation: van heukelum m, blake ca, franken t, burger mc, ferreira n, gobetz g. peri-articular infiltration in the resource-restrained environment – still a worthwhile adjunct to multimodal analgesia post total knee replacement. sa orthop j 2020;19(3):156-161. http://dx.doi.org/10.17159/23098309/2020/v19n3a5 editor: dr michael held, university of cape town, south africa received: may 2019 accepted: march 2020 published: august 2020 copyright: © 2020 van heukelum m. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: none conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: peri-articular infiltrations (pai) in total knee arthroplasty (tka) offer effective analgesia, and are cost effective, safe and easy to perform. currently there is no gold standard technique based on evidence-based medicine; described methods are based on consensus recommendations. the latest literature supports pai including complex and multiple drug combinations, such as liposomal bupivacaine, ropivacaine and ketorolac, which are not available in all settings. this study aims to prove that a basic pai technique using widely available and inexpensive agents offers good and effective outcomes in a resource-poor environment. methods: a double-blind randomised control trial compared the effectiveness of pai with a simple, widely available anaesthetic solution (bupivacaine and adrenalin) to a normal saline control group. infiltration volumes were calculated at 1 ml/kg and the infiltration technique followed a specific protocol. post-operative outcomes included visual analogue scores (vas), ambulation scores, morphine use, knee range of motion (rom) and time to discharge. results: two comparable groups of 26 patients each were included (intervention: 81% female, mean age 64.8±8.8 years vs control: 65% female, mean age 67.0±7.6 years). all pain-related measures favoured the intervention group but failed to reach statistical significance at 24 and 72 hours. mean vas scores at 48 hours were significantly lower in the intervention group. (vas score 3.0±1.6 vs 4.1±1.2, p=0.013). the other parameters measured strongly favoured the intervention group but did not prove to be significant. conclusions: a volume per kilogram pai technique making use of widely available, cost-effective agents provides a statistical reduction in vas scores at 48 hours post tka. this suggests that in a resource-poor environment pai is still a valuable addition to the multimodal analgesia pathway in the post-operative management of tka. maximum drug doses may show even more promising results, specifically in the first 24 hours post-operatively. further studies investigating pai for tka in resource-restrained environments are indicated. level of evidence: level 2 keywords: standardisation peri-articular infiltration, multimodal analgesia, pre-emptive analgesia peri-articular infiltration in the resource-restrained environment – still a worthwhile adjunct to multimodal analgesia post total knee replacement van heukelum m1 , blake ca2 , franken t3, burger mc4 , ferreira n5 , gobetz g6 1 mbchb, da(sa); registrar, division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, tygerberg hospital, stellenbosch university, south africa ² bsc, mbchb, mmed; consultant, division of orthopaedics, faculty of health sciences, university of free state, bloemfontein, south africa ³ mbchb, mmed; consultant, division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, tygerberg hospital, stellenbosch university, south africa 4 bsc, b(med)sc hons, m(med)sc, phd; research coordinator, division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, tygerberg hospital, stellenbosch university, south africa 5 bsc, mbchb, fcorth(sa), mmed, phd; associate professor, division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, tygerberg hospital, stellenbosch university, south africa 6 mbchb, da(sa); registrar, department of anaesthesia and perioperative medicine, faculty of medicine and health sciences university of cape town, groote schuur hospital, south africa corresponding author: dr m van heukelum, division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, tygerberg hospital, stellenbosch university, cape town, 7505, south africa; tel: +27 21 938 4911; email: marcusvanh@gmx.com https://orcid.org/0000-0001-9160-7796 https://orcid.org/0000-0002-3592-4823 https://orcid.org/0000-0003-2831-4960 https://orcid.org/0000-0002-0567-3373 https://orcid.org/0000-0002-2116-6750 page 157van heukelum m et al. sa orthop j 2020;19(3) introduction post-operative pain is the most important concern for patients considering a total knee replacement.1 failure to control pain induces pathophysiological responses which lead to increased morbidity, patient anxiety, impaired rehabilitation, disrupted sleep patterns and decreased patient satisfaction.2 recently the joint commission on the accreditation of healthcare organizations in the united states has declared pain to be the ‘fifth vital sign’ and acknowledges that patients have the ‘right’ to adequate pain management.3 peri-articular infiltration (pai) as part of a pre-emptive multimodal analgesic protocol has gained widespread popularity among arthroplasty surgeons.2 these infiltrations have proven to provide good analgesia, are cost effective, have minimal side effects, and are easy to perform.4-6 in the era of enhanced recovery after surgery (eras), pai protocols play an important role in knee arthroplasty based on the principle of opioid-free anaesthesia and analgesia. post-operative in-patient time is not only inconvenient to the patient but adds to the costs involved with arthroplasty surgery. pai relates to rapid patient rehabilitation and results in shorter length of stay post-surgery.7 current controversy related to pai involves the major heterogeneity surrounding infiltration techniques: each institution or surgeon performs the technique in a different manner using different infiltration ‘cocktails’, varying volumes and non-specific injection techniques and distributions.8-11 the latest literature supports pai including complex and expensive drug combinations, including agents such as liposomal bupivacaine, ropivacaine and ketorolac, which are not available in all settings. as part of a multimodal pain management pathway, our bupivacaine and adrenalin-based pai protocol targets eight areas that have been identified to systematically guide pai based on knee neuroanatomy and the concentrations of mechanoreceptors.8 the aim of this prospective, double-blinded randomised controlled trial was to assess whether pai using drug combinations that are widely available offer effective outcomes in a resource-poor environment. materials and methods a double-blind randomised control trial was conducted at worcester provincial hospital between february 2017 and october 2017. all patients undergoing elective total knee arthroplasty (tka) for osteoarthritis were evaluated for eligibility. patients were included if they were american society of anesthesiologists (asa) grade 3 or less, had a body mass index under 40 and had no contraindications to spinal anaesthesia. patients were excluded if they suffered any anaesthetic complications during or following the surgery. study participants were stratified into one of two treatment groups using a sealed envelope randomisation technique. a dedicated anaesthetist selected an unmarked envelope preoperatively and prepared the relevant medication for peri-articular injection. the intervention group received a solution of 1 ml/kg of local anaesthetic solution (concentration 1 mg/ml bupivacaine and 5 ug/ml of adrenalin), while the control group received 1 ml/kg of normal saline. infiltration volume was calculated on a volume per kilogram (1 ml/kg) basis for each individual patient to standardise volumes and adjust for the large variance in patient size and weight. the preparation of the injectate solution was done away from the attention of the surgeon in order to ensure blinding. the patient, surgical team and physiotherapists as well as everyone involved in data capturing were blinded to the intervention. all study participants received pre-emptive analgesia in the form of paracetamol 1 g six hourly and tramadol 50 mg six hourly in the period leading up the surgery. they received spinal anaesthesia with 2.8 ml of 0.5% hyperbaric bupivacaine and fentanyl 0.2 ml/10 micrograms. cefazolin (2 g) was used for prophylaxis against surgical infection 30 minutes prior to skin incision. clindamycin (600 mg) was used in cases with a penicillin allergy. tka surgery was performed via medial parapatellar approach by one of three consultant orthopaedic surgeons. the sigma posterior stabilised, fixed bearing, cemented system from depuy synthes (west chester, pennsylvania, united states) was used in all cases. the pai was performed according to a specific protocol that targeted eight areas (zones) identified to systematically guide pai (figure 1). a 22-gauge 1½ inch needle was used for infiltration, allowing 2–3 ml to disperse per pass; aspiration was performed prior to any injection; the infiltrate was not allowed to elute from the tissue. once infiltration volumes were calculated (1 ml/kg), 20 ml of the total volume was set aside for surgical wound infiltration. the remaining volume was roughly divided between the eight zones. zone 6 is difficult to infiltrate as the area is mainly metaphyseal bone. this area and the surrounding soft tissues were infiltrated as well as possible, and any remaining infiltrate volume was included in zone 5. posterior, posterolateral, posteromedial and intercondylar areas were infiltrated with the knee in flexion with the laminar spreader in place prior to insertion of the tibial component (figure 2). specific care was taken to avoid the popliteal artery. anterior structures including the quadriceps tendon, suprapatellar pouch and infrapatellar fat pad were injected with the knee in extension while the cement was curing. the infiltration technique also included specific infiltration of the surgical wound post-operatively. although the tka was performed by three different surgeons, all pais in this study were performed by a single surgeon as per specific protocol to ensure continuity in technique. figure 3 shows the minimal equipment required to perform the infiltration. post-operatively both groups received morphine-containing patient-controlled analgesia (pca) pumps together with a standard analgesia protocol, including paracetamol and tramadol, with breakthrough morphine prescribed. bilateral compression stockings, early mobilisation and clexane 40 units daily was standard for deep venous thrombosis prophylaxis. participants were assessed daily for pain, opioid use, range of motion (rom) and mobility during their inpatient physiotherapy session from day 1 post-surgery until discharged. discharge criteria required patients to walk unaided with crutches, climb and descend stairs and achieve rom from 0 to 90 degrees. data was collected by a single dedicated researcher together with a member of the physiotherapy team. audit data was used to calculate sample size. a sample size of 52 participants (26 in each group) was adequate to detect differences between groups at a power of 90% and alpha level of 0.05. ibm spss version 24 was used to analyse the data. the completeness of the randomisation process was tested by comparing the two groups in terms of demographics and baseline parameters and found to be equivalent. therefore, any differences were attributed to the intervention. all primary outcomes were measured quantitatively as continuous variables. their distributions were checked for normality using kologorov-smirnov tests. if found to be normally distributed, parametric tests were used to compare the two groups, i.e. two sample t-tests while a non-parametric test, i.e. mann-whitney u test, was used to compare the two groups when data was not normally distributed. normally distributed continuous data was described as mean±standard deviation (sd) while data that was not normally distributed was described as median and interquartile range (iqr). when continuous data was normally distributed within one group but not the other, median (iqr) was presented for both groups. page 158 van heukelum m et al. sa orthop j 2020;19(3) results fifty-eight patients were consecutively recruited between february 2017 and october 2017. three patients failed to meet the inclusion criteria and three patients were excluded. the final cohort consisted of 52 patients, 26 in each group (figure 4). the mean age of the study population was 65.8 years, the mean bmi 32.2, and 73% of the participants were female. both intervention and control groups were equally distributed for baseline characteristics and were matched for age, height, weight and bmi (table i). the mean surgical time in the intervention group was 80.1±15.5 (95% ci 73.9 to 86.5) minutes and 79.0±16.4 (95% ci 72.4 to 85.6) in the control group. there was no significant difference in terms of surgical time between the groups (p=0.789). at 48 hours post-operatively the visual analogue score (vas) for pain showed a significant reduction in the intervention group (p=0 .023) (median 3.5, 2 to 4) when compared to the control group (median 4, 3 to 5). there was no significant difference in vas score at 24 (p=0.462) and 72 (p=0.808) hours post-operatively (figure 5). the mean time to discharge in the intervention group was 2.1±0.6 (95% ci 1.8–2.3) versus 2.4±1.1 (95% ci 2.0–2.9) in the control group. the mean time to discharge between the two groups was 2.3 days. rom was measured as time (in days) to reach zero degrees extension (p=1.000), 90 degrees flexion (p=0.560) and time to both extension (0°) and flexion (90°) (p=0.743). cumulative ambulation scores (cas) at 24 (p=0.726), 48 (p=0.137) and 72 (p=0.808) hours, total volumes (ml) of patient-controlled morphine consumption (pca) (p=0.146), rom and mean time to discharge showed no statistical significance between the groups (table ii). post-operative drain volumes (ml) showed decreased values in the intervention group (mean 616.2 ml±245.8 [95% ci 516.9– 715.4] ml) compared to the control group (mean 670.0 ml±262.0 [95% ci 72.4–85.6] ml). the difference was not significant (p=0.448) (table ii). complications associated with morphine administration such as pruritus, nausea and vomiting, and urinary retention showed no difference between the groups (p=1.000). there were no complications, which we can attribute to the injected medication. discussion peri-articular infiltration (pai) as part of a pre-emptive multimodal analgesic protocol has gained widespread popularity among zone 1: supra-patella pouch plus quadriceps tendon (saphenous and femoral nerves) zone 2: medial retinaculum (medial retinacular nerve) zone 3: patellar tendon plus fat pad (densely innervated area, receiving nerve contribution from the saphenous, tibial and common peroneal nerves) zone 4: medial collateral ligament plus medial meniscal capsular attachment (saphenous nerve) zone 5: posterior cruciate ligament tibial attachment (posterior articular branch of tibial nerve) zone 6: anterior cruciate ligament femoral attachment (posterior articular branch of tibial nerve) zone 7: lateral collateral ligament plus lateral meniscal capsular attachment (common peroneal nerve) zone 8: lateral retinaculum (common peroneal nerve) figure 1. illustration highlighting the eight infiltration zones (figure adapted from guild et al.8) figure 2. peri-articular infiltration into zone 4 prior to implant insertion figure 3. items needed for peri-articular infiltration (no specific equipment or skills required) page 159van heukelum m et al. sa orthop j 2020;19(3) arthroplasty surgeons.2 these infiltrations offer good efficacy in controlling pain, are cost effective, have minimal side effects, and are easy to perform.4-6 the technique can be used by all surgeons without the need for further training or specialised equipment. for the above reasons, pai using an effective, widely available and cost-effective infiltrate offers a very attractive option in resourcepoor settings. andersen et al. noted that the technique has gained widespread popularity; however, the optimal pai technique (i.e. infiltration drug mixture, technique, use of catheters) has not been adequately evaluated.9 turnbull et al. noted that variation in pai technique such as type of medication used, dose and volume can alter the efficacy of the pai7 while kelley et al. concurred that although several periarticular protocols exist, a gold standard has not been established and that additional research is needed to optimise the technique.10 currently the leading recommendations are based on consensus recommendations.11 in a recent meta-analysis of 12 randomised control trials that included 770 patients, gibbins et al. suggest that pai results in statistically significant reduced pain scores 24 hours after tka. however, there was significant heterogeneity among the studies urging caution in their interpretation. all 12 studies showed significant variation in the technique of performing pai. variations included the location of single intra-operative injections, the content and volume of the injectate and the use of post-operative infusions and boluses via catheter.12 they concluded that further research should focus on the optimum technique for pai. literature supports pai as an effective adjunct to multimodal pain management post tka. issues relating to the heterogeneity and the optimum technique are constantly evolving and may be resolved with time. most sources agree that optimum outcomes rely on the use of infiltrates including liposomal bupivacaine, ropivacaine and ketorolac in varying combinations. liposomal bupivacaine (exparel) is a long-acting, local anaesthetic. efficacy of immediate-release bupivacaine hcl for acute postsurgical pain when administered via wound infiltration is well established; however, exparel offers the advantage of a longeracting local formulation that can be administered as a single dose.13 dasta et al. published a pooled analysis of nine studies evaluating the effect of liposomal bupivacaine on pain intensity scores and opioid consumption. the analysis represented a total of five surgical procedures including tka and compared liposomal patients assessed for eligibility (n=58) participants randomised (n=52) 0.25% bupivacaine and adrenalin group (n=26) completed assessment (n=26) completed assessment (n=26) 0.9% normal saline group (n=26) ineligible (n=6) not meeting inclusion criteria (n=3) bmi>40=3 excluded (n=3) failed spinal=1 blood transfusion=2 figure 4. overview of participant recruitment and randomisation table i: patient baseline demographic data intervention group (n=26) (bupivacaine and adrenalin) control group (n=26) (0.9% ns injection) p-value sex (% female) 81 (21) 65 (17) 0.210 age (years) 64.7±8.8 67.0±7.6 0.317 weight (kg) 85.5±1 5.7 79.0±16.2 0.148 height (cm) 160.2±10.1 161.7±11.9 0.643 bmi (kg/m2) 33.2±4.5 30.3±5.9 0.052 surgical side (% right) 46 (12) 62 (16) 0.266 values are presented as a frequency or mean±standard deviation, with the number of participants in parentheses. 10 8 6 4 2 0 8 6 4 2 0 8 6 4 2 0 cases cases cases a b c v a s ( 2 4 h ) v a s ( 4 8 h ) v a s ( 7 2 h ) controls controls controls figure 5. box-and-whisker plots of visual analogue scale for cases and controls at (a) 24 hours, (b) 48 hours and (c) 72 hours post-operatively page 160 van heukelum m et al. sa orthop j 2020;19(3) bupivacaine with bupivacaine hcl. in all nine studies, patients who received liposomal bupivacaine reported significantly less pain over 72 hours and consumed less opioids compared with patients who received bupivacaine hcl.13 liposomal bupivacaine costs around us$300 for a 20 ml vial14 and is not available in resourcescarce environments such as state healthcare in south africa as well as the rest of the developing world. most articles do not specify the injection sites used during infiltration. this leads to uncertainty regarding its reproducibility and makes comparing studies difficult. by employing knowledge of intra-articular knee innervation and ensuring a systematic, sitespecific approach to peri-articular injection, we aimed to maximise benefits from peri-articular injection and ensure a more reproducible result. our infiltration technique focused on eight zones with increased number of nerve endings as described by guild et al., following a systematic review of available literature focusing on knee neuroanatomy, pain generators, and the concentrations of mechanoreceptors.8 we targeted these specific zones (figure 1) to systematically guide pai. infiltration technique included infiltration of the surgical wound post-operatively. one of the major areas of heterogeneity within pai is the volume of infiltrate used – a wide range of volumes are reported in the literature ranging from 20 ml to 150 ml.12 in most papers, infiltration volumes are pre-set, and patients receive the same volume irrespective of size or weight. we used 1 ml/kg of local anaesthetic solution (concentration 1 mg/ml bupivacaine and 5 ug/ml of adrenalin) calculated for each specific patient. in our experience, we found that these volumes were practical and provided adequate volume to infiltrate each zone thoroughly without having large excess. to our knowledge this is the first trial where infiltration volumes were calculated using a volume per kilogram basis. our bupivacaine concentration of 1 mg/kg is well below the maximum dose of 2.5 mg/kg with adrenalin added (to a maximum dose of 225 mg). higher bupivacaine concentrations may have led to improved outcomes. our study aimed to assess whether pai using drug combinations that are widely available, inexpensive and injected following a welldescribed, systematic ‘eight zone’ infiltration technique, offers effective outcomes in a resource-poor environment. yeunyongviwat et al.15 compared bupivacaine infiltration (20 ml of 0.25% bupivacaine) to saline and showed significantly reduced morphine consumption at six hours post-op but no difference in vas scores. busch et al. showed significantly less patient-controlled analgesia at six hours, at 12 hours, and over the first 24 hours after the surgery. in addition, they found lower visual analogue scores during the first four hours after the operation.16 vendittoli et al. reported that morphine consumption was lower in the pai group compared to the control group for up to 40 hours post-operatively.5 chaumeron et al. suggest that when comparing pai to femoral nerve block, pai provided equivalent pain control for up to 120 hours without the 37% incidence of motor blockade found in the femoral nerve block group.17 our findings showed vas scores, as well as all other pain-related measures recorded at 24 and 48 hours were consistently lower in the intervention group and showed significant improvement in vas score at 48 hours. this may be as a result of the downregulation of pain receptors in the surrounding tissue but may also suggest a prolonged advantage offered by pai compared to what was previously thought, and future research should explore this finding further. other authors support the idea of prolonged advantage following pai.5,15,18 other parameters assessed in our study, including ambulation scores (cas), narcotic usage (pca), rom and time to discharge favoured the intervention group but failed to prove statistical significance. in modern medicine where the cost related to treatment, specifically surgery, is increasingly important not only to the patient but to the hospital and surgeon as well, post-operative days in hospital amount to increased expenses associated with any procedure. in the present study, we report no significant difference in the time to discharge between the intervention and control groups (2.1 days versus 2.4 days). these patients were discharged directly home and did not visit any form of rehabilitation or stepdown facility. the mean time to discharge of 2.3 days between the two groups, however, represents a marked improvement from the mean time to discharge over the past five years in the same centre (mean 3.3 days over the period 2011 to 2016, 295 knees, foxcroft d, unpublished data) this is in keeping with global standards for fast-track discharge protocols, with an average median time table ii: summary of the statistical results of all parameters measured intervention group (n=26) (bupivacaine and adrenalin) control group (n=26) (0.9% ns injection) p-value visual analogue scores (vas) 24 hours (n=26) 4.5 (4.0–6.0) 5.0 (4.0–6.0) 0.462 48 hours (n=22) 3.5 (2.0–4.0) 4.0 (3.0–5.0) 0.023 72 hours (n=6) 3.0 (2.0–5.0) 3.0 (2.0–5.0) 0.808 cumulative ambulation score (cas) 24 hours (n=26) 6.0 (5.0–6.0) 6.0 (5.0–6.0) 0.726 48 hours (n=22) 6.0 (6.0–6.0) 6.0 (6.0–6.0) 0.137 72 hours (n=6) 6.0 (6.0–6.0) 6.0 (6.0–6.0) 0.808 surgical time (min) 80.2±15.5 79.0±16.4 0.789 total volume pca (ml) 35.0 (15.0–45.0) 40.0 (20.0–50.0) 0.146 time to discharge (days) 2.1±0.6 2.4±1.1 0.284 range of motion (time to reach target in days) extension (target=0°) 1.0 (1.0–2.0) 1.0 (1.0–2.0) 1.000 flexion (target=90°) 2.0 (1.0–2.0) 2.0 (2.0–2.0) 0.560 extension (0°) and flexion (90°) 2.0 (1.0–3.0) 2.0 (2.0–2.0) 0.743 drain volume (ml) 616.2±245.8 670.0±262.0 0.448 parametric data reported as mean plus standard deviation; non-parametric data reported as median plus interquartile ranges. values are for all participants (n=26) unless otherwise indicated. page 161van heukelum m et al. sa orthop j 2020;19(3) to discharge of 2.5 days.19 this improvement is most likely the result of a well-structured, specific protocol with multidisciplinary involvement and motivated patients. limitations of our study include that we did not account for patients’ pre-operative medication and therefore cannot adjust for tolerances to narcotics in the peri-operative period; the bupivacaine concentration of 1 mg/kg is well below the maximum dose, and we may have seen improved results had we used higher concentrations. our study has several strengths: it is a well-constructed, randomised, double blind study using an infiltration technique that is widely available, inexpensive and easily reproducible in any centre. additionally, all pais as well as data capturing were performed by one person, providing continuity across the board. conclusion a widely available, inexpensive pai, calculated on a volume per kilogram basis and infiltrated according to a specific, eight-zone infiltration technique, leads to statistically significant improvement of pain scores at 48 hours post-operatively. this suggests that in a resource-poor environment, pai is still a valuable addition to the multimodal analgesia pathway in the post-operative management of tka. maximum drug doses may show even more promising results, specifically in the first 24 hours post-operatively. further studies investigating pai for tka in resource-restrained environments is indicated. ethics statement ethical approval was obtained from the health research ethics committee of stellenbosch university, south africa (protocol number n16/07/087) and the trial was registered with the national health research data base (wc2017rp5679). the author/s declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. the study was conducted in accordance with the declaration of helsinki of 1975, as revised in 2008, south african guidelines for good clinical practice and the medical research council (mrc) ethical guidelines for research. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions mvh: conception and design, data collection, data analysis and interpretation, drafting article, critical revision, final approval of article cab: conception and design, data collection, critical revision, final approval of article tf: conception and design, critical revision, final approval of article mcb: data analysis and interpretation, drafting article, critical revision, final approval of article nf: data analysis and interpretation, drafting article, critical revision, final approval of article gg: conception and design, data collection, critical revision, final approval of article orcid van heukelum m https://orcid.org/0000-0001-9160-7796 blake ca https://orcid.org/0000-0002-3592-4823 burger mc https://orcid.org/0000-0003-2831-4960 ferreira n https://orcid.org/0000-0002-0567-3373 gobetz g https://orcid.org/0000-0002-2116-6750 references 1. lavernia cj, alcerro jc, rossi md. fear in arthroplasty surgery: the role of race. clin orthop relat res. 2010;468(2):547-54. 2. dalury df, lieberman jr, macdonald sj. current and innovative pain management techniques in total knee arthroplasty. j bone joint surg. 2011;93(20):1938-43. 3. american pain society. principles of analgesic use in the treatment of acute pain and cancer pain. american pain society; 1999. 4. toftdahl k, nikolajsen l, haraldsted v, et al. comparison of peri-and intraarticular analgesia with femoral nerve block after total knee arthroplasty: a randomized clinical trial. acta orthop. 2007;78(2):172-79. 5. vendittoli pa, makinen p, drolet p, et al. a multimodal analgesia protocol for total knee arthroplasty. j bone joint surg am. 2006;88(2):282-89. 6. parvataneni hk, shah vp, howard h, et al. controlling pain after total hip and knee arthroplasty using a multimodal protocol with local periarticular injections: a prospective randomized study. j arthroplasty. 2007;22(6):33-38. 7. turnbull za, sastow d, giambrone gp, tedore t. anesthesia for the patient undergoing total knee replacement: current status and future prospects. local reg anaesth. 2017;10:1-7. 8. guild gn, galindo rp, marino j, cushner fd, scuderi gr. periarticular regional analgesia in total knee arthroplasty: a review of the neuroanatomy and injection technique. orthop clin north am. 2015;46(1):1-8. 9. andersen lø, kehlet h. analgesic efficacy of local infiltration analgesia in hip and knee arthroplasty: a systematic review. br j anaesth. 2014;113(3):360-74. 10. kelley tc, adams mj, mulliken bd, dalury df. efficacy of multimodal perioperative analgesia protocol with periarticular medication injection in total knee arthroplasty: a randomized, double-blinded study. j arthroplasty. 2013;28(8):1274-77. 11. joshi gp, cushner fd, barrington jw, et al. techniques for periarticular infiltration with liposomal bupivacaine for the management of pain after hip and knee arthroplasty: a consensus recommendation. j surg orthop adv. 2015;24(1):27-35. 12. gibbins ml, kane c, smit rw, rodseth rn. periarticular local anaesthetic in knee arthroplasty: a systematic review and meta-analysis of randomised trials. sa orthop j. 2016;15(3):49-56. 13. dasta j, ramamoorthy s, patou g, sinatra r. bupivacaine liposome injectable suspension compared with bupivacaine hcl for the reduction of opioid burden in the postsurgical setting. curr med res opin. 2012 oct 1;28(10):1609-15. 14. liposomal bupivacaine (exparel) 2013-01-14 05:00:00 ashley n. lewis, pharmd, bcps. 15. yuenyongviwat v, pornrattanamaneewong c, chinachoti t, chareancholvanich k. periarticular injection with bupivacaine for postoperative pain control in total knee replacement: a prospective randomized double-blind controlled trial. adv orthop. 2012;2012:107309. 16. busch ca, shore bj, bhandari r, et al. efficacy of periarticular multimodal drug injection in total knee arthroplasty. j bone joint surg am. 2006;88(5):959-63. 17. chaumeron a, audy d, drolet p, lavigne m, vendittoli pa. periarticular injection in knee arthroplasty improves quadriceps function. clin orthop relat res. 2013;471(7):2284-95. 18. nair vs, radhamony ng, rajendra r, mishra r. effectiveness of intraoperative periarticular cocktail injection for pain control and knee motion recovery after total knee replacement. arthroplasty today. 2019 sep 1;5(3):320-24. 19. van egmond jc, verburg h, mathijssen nm. the first 6 weeks of recovery after total knee arthroplasty with fast track: a diary study of 30 patients. acta orthop. 2015;86(6):708-13. https://orcid.org/0000-0001-9160-7796 https://orcid.org/0000-0002-3592-4823 https://orcid.org/0000-0003-2831-4960 https://orcid.org/0000-0002-0567-3373 https://orcid.org/0000-0002-2116-6750 _hlk25943874 _hlk26082492 _hlk25896600 _hlk25866289 layout 1 south african orthopaedic journal manwana me et al. sa orthop j 2018;17(1) http://journal.saoa.org.za doi 10.17159/2309-8309/2018/v17n1a6 trauma epidemiology of traumatic orthopaedic injuries at princess marina hospital, botswana manwana me1, mokone gg2, kebaetse m3, young t4 1 division of community health, faculty of medicine and health sciences, stellenbosch university, cape town, south africa; medical doctor, princess marina hospital, ministry of health, botswana 2 senior lecturer and exercise physiologist, faculty of medicine, university of botswana 3 senior lecturer and rehabilitation scientist, faculty of medicine, university of botswana 4 director, centre for evidence-based health care, stellenbosch university, cape town, south africa corresponding author: dr manwana m esperance, division of community health, faculty of medicine and health sciences, stellenbosch university, po box 241, cape town 8000, south africa; tel: (+27) 21 938 9498; fax: (+27) 21 938 9138; email: esperancemanwana@yahoo.com authors’ contributions: designed study: mme, ty, ggm, mk. collected data: mme. analysed the data: mme, ggm, mk. wrote the first draft of the paper: mme. reviewed the paper: mme, ty, ggm, mk. abstract background: traumatic injuries pose a significant and increasing challenge to healthcare systems worldwide. one major type of traumatic injury is the traumatic orthopaedic injury, whose epidemiology is unknown in botswana. the aim of the study, therefore, was to evaluate the age, sex, type, and determinants of traumatic orthopaedic injuries for inpatients at princess marina hospital from august 2014 to january 2015. methods: we performed a descriptive study by retrospectively collecting data on age, sex, date of admission, date of injury, date of discharge, radiological investigation, and injury types and determinants from medical records of patients admitted to orthopaedic wards. results: the median age of patients with traumatic orthopaedic injuries was 33.5 years (n=372). males were more frequently injured than females, with a sex ratio of 7:3. fractures were the most common type of traumatic orthopaedic injury (413 injuries, 75.5%). the most common injury determinants were falls (145 patients/39.0%), road traffic accidents (95 patients/25.5%), and assaults (57 patients/15.3%). conclusions: young adult males were the group most affected by traumatic orthopaedic injuries. fractures were the most common type of traumatic orthopaedic injuries, with falls being the most common injury determinant. these findings may guide efforts to improve healthcare delivery and public health policy. level of evidence: level 4 key words: traumatic orthopaedic injuries, descriptive study citation: manwana me, mokone gg, kebaetse m, young t. epidemiology of traumatic orthopaedic injuries at princess marina hospital, botswana. sa orthop j 2018;17(1):41-46. http://dx.doi.org/10.17159/2309-8309/2018/v17n1a6 editor: prof anton schepers, university of the witwatersrand received: april 2017 accepted: october 2017 published: march 2018 copyright: © 2018 manwana me, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: the lead author conducted the study in partial fulfilment of the msc clinical epidemiology and it was self-funded. conflict of interest: the authors of this article confirm no conflicts of interest to disclose. no benefits of any form have been received from a commercial party related directly or indirectly to the subject of this article. page 42 manwana me et al. sa orthop j 2018;17(1) introduction traumatic injuries pose a significant and increasing challenge to healthcare systems worldwide.1 according to the world health organisation (who), traumatic injuries are one of the main causes of mortality in the world, with 90% of the injuries estimated to occur in low-and middleincome countries.2 a large number of traumatic injuries are orthopaedic in n ature. orthopaedic injuries are injuries that cause damage to the musculoskeletal system, which includes bones, ligaments, joints, tendons, muscles, and nerves.3 orthopaedic injuries can be divided into traumatic and non-traumatic injuries. orthopaedic injuries are common. for example, a survey covering an eight-year period reported that 25% of americans had impairments secondary to musculoskeletal conditions,4 while in kenya one study showed that 221 of 362 (61%) victims of non-fatal road traffic crashes were admitted to the orthopaedic wards.5 furthermore, studies generally show that orthopaedic injuries predominantly affect younger male adults, with fractures being the most common injury.6,7 a limited number of studies have been conducted on the epidemiology of traumatic orthopaedic injuries, especially in lowand middle-income countries. in botswana, a subsaharan african upper middle-income country,8 with an estimated 2014 population of 2.04 million,9 the epidemiology of traumatic orthopaedic injuries is unknown. although there is lack of data on the epidemiology of traumatic orthopaedic injuries in botswana, the country has high rates of road traffic accidents (rtas) and related fatalities.10,11 furthermore, rtas cause traumatic injuries, which could greatly contribute to the number of traumatic orthopaedic injuries in botswana. studies have shown that rtas are the most common determinant of traumatic orthopaedic injuries, with a prevalence of 39.1%12 and 63.6%.7 some researchers report that rtas are the most common determinant of fractures, with a fracture prevalence of 29.4%,13 49.3%14 and 68.4%.15 similarly, falls have been shown to be a serious public health problem worldwide.16-18 studies have shown that falls are the second most common determinant of traumatic orthopaedic injuries, with a prevalence of 21.8%7 and 35.1%.12 however, the contribution and prevalence of falls to traumatic orthopaedic injuries in botswana are unknown. the present study, therefore, aims to evaluate the epidemiology of traumatic orthopaedic injuries for inpatients at princess marina hospital, botswana. this study was conducted with the specific objective to determine the demographic profile, prevalence, and determinants of traumatic orthopaedic injuries. materials and methods study design we performed a retrospective descriptive cross-sectional study at princess marina hospital, one of two tertiary government referral hospitals in botswana, located in gaborone. study period we chose the period august 2014 to january 2015 to include non-festive and festive seasons in botswana. it was hypothesised that more traumatic orthopaedic injuries would be recorded during the festive season.19 participants and data collection our study population consisted solely of patients with orthopaedic injuries and who had been admitted to male and female orthopaedic wards from 1 august 2014 to 31 january 2015. from those patients, we identified those with traumatic orthopaedic injuries as our sample of convenience. a sample of convenience is very easy to carry out and the cost and time required to perform it are small in comparison to probability sampling techniques.20 all arthroplasty patients (such as patients admitted for total knee and hip replacements) were excluded from the study, as most arthroplasty patients’ injuries were due to non-traumatic causes. in addition, joint replacement data could obscure findings because princess marina hospital relies on surgeons from south africa to perform arthroplasty only three or four times a year. admission and discharge registers from male and female orthopaedic wards were used to obtain the patient’s name, age, sex, diagnosis, and medical record number. in the case of patients with no medical record numbers in the registers, their names were used to obtain their medical record numbers through the integrated patient management system (ipms). the ipms is a comprehensive, state-of-the-art healthcare information technology system used for capturing healthcare data on a computer.21 the information collected from the registers in the male and female orthopaedic wards helped us to look for patients’ files in the medical record unit at the princess marina hospital. once the files were obtained, a data collection form was used to record age, sex, date of admission, date of injury, date of discharge, radiological investigations performed, and the type and determinants of orthopaedic injuries from the patients’ files. when a patient had more than one injury, each injury was counted separately. the principal investigator and one of the co-investigators independently reviewed the first 20 patients’ files to assess the reliability of the data collection methodology. each study participant was given a unique identification number. a register of the unique identification numbers and patients’ names was kept locked separately from the data collected. missing data were coded as missing after two unsuccessful searches for files. data were backed up on an external hard drive after each capturing session and kept separately by the principal investigator. statistical analysis kappa statistics were used to determine the reliability of radiological investigations, and types and determinants of orthopaedic injuries data obtained from the first 20 patients’ files between the principal investigator and one of the co-investigators. the data obtained were entered into microsoft excel 2010. stata 13 software was used to perform statistical analysis. for the age of patients enrolled in our study, median and interquartile ranges were calculated and illustrated with histograms. categorical variables (types of traumatic orthopaedic injuries, their determinants, sex and radiological investigation) were described using frequencies, percentages and bar charts. ethics before the commencement of the study, ethics approval was obtained from stellenbosch university (ethics ref no s15/09/211), the health ministry of botswana (ref no hpd me 13/18/1x [193]), and the princess marina hospital research committee (ref no pmh 5/79 [224]). informed consent was waived by the ethics committees since we performed a retrospective chart review and there was no direct contact with the patients. results a total of 693 orthopaedic patients had been admitted to male and female orthopaedic wards at the princess marina hospital during the study period. files were found for only 506 (73.0%) of patients. the remaining 187 patients (27.0%) were thus excluded as their medical records were still missing after two unsuccessful searches. of the 506 patients, 372 (73.5%) had been admitted with traumatic orthopaedic injuries and 134 (26.5%) with non-traumatic orthopaedic injuries. manwana me et al. sa orthop j 2018;17(1) page 43 the kappa statistics for radiological investigations, and types and determinants of orthopaedic injuries data, revealed a statistically significant agreement (p < 0.0001) between the two observers. the median age of the 372 patients with traumatic orthopaedic injuries enrolled in the study was 33.5 years (iqr= 25–50) (figure 1). the admission rates were the highest for adults up to the age of 49 years (n=277, 74.5%). the proportion of males admitted was higher than the proportion of females admitted with a sex ratio of 7:3. younger males were more likely to be admitted than younger females. from 60 years and older, females were more affected than males (table i). most patients were admitted in the months of august (84 patients) and september (80 patients). otherwise, a lower but relatively even number of patients was admitted monthly from october 2014 through january 2015 (figure 2). of the 372 patients admitted with traumatic orthopaedic injuries, 258 patients (69.4%) had fractures only and 38 (10.2%) patients had fractures which were combined with dislocation or subluxation (figure 3). in total there were 547 cases of injury, with the most common injury being fractures (413 cases, 75.5%) and the most common fracture site being the lower limbs (250 cases, 45.7%), followed by the upper limbs (118 cases, 21.6%) and the spine (26 cases, 4.8%) and pelvis (19 cases, 3.5%). there were 55 cases (10.1%) of various dislocations and subluxations. of the 41 (7.5%) cases of soft tissue injury, 22 (4.0%) were tendon injuries, five (0.9%) were nerve injuries, three (0.5%) were ligament injuries, while 11 (2.0%) were unspecific injuries. there were 18 (3.3%) cases of amputations, eight (1.5%) cases of crush injury, seven (1.3%) cases of spinal cord injury, and five (0.9%) cases with other types of injury (table ii). our data show that of the 372 patients with traumatic orthopaedic injuries, 307 (82.5%) were aged between 13 and 59 years (table iii). figure 1. histogram of patients’ age .04 0.3 0.2 0.1 0 d en si ty 20 40 60 80 100 age of patient in years figure 2. patients with traumatic orthopaedic injuries admitted per month 65 60 55 50 45 40 35 30 25 20 15 10 5 0 n u m b er o f p at ie n ts w ith in ju ry august 2014 month the injury occured sex male female september 2014 october 2014 november 2014 december 2014 january 2015 table i: age of patients admitted with traumatic orthopaedic injuries age in years sex number of patients (%)male (%) female (%) 13 to 19 30 (11.5) 8 (7.2) 38 (10.2) 20 to 29 74 (28.4) 26 (23.4) 100 (26.9) 30 to 39 66 (25.3) 23 (20.7) 89 (23.9) 40 to 49 40 (15.3) 10 (9.0) 50 (13.4) 50 to 59 22 (8.4) 8 (7.2) 30 (8.1) 60 to 69 12 (4.6) 11 (9.9) 23 (6.2) 70 to 79 6 (2.3) 9 (8.1) 15 (4.0) 80 to 89 11 (4.2) 10 (9.0) 21 (5.6) 90 to 99 0 (0.0) 4 (3.6) 4 (1.1) ≥100 0 (0.0) 2 (1.8) 2 (0.5) total 261(70.2) 111(29.8) 372 (100) figure 3. types of traumatic orthopaedic injuries among 372 patients 180 160 140 120 100 80 60 40 20 0 n u m b er o f p at ie n ts w ith in ju ry f ra ct u re type of injury sex male female f ra ct u re , d is lo ca tio n an d s u b lu xa tio n s o ft t is su e in ju ry d is lo ca tio n & s u b lu xa tio n a m p u ta tio n c ru sh in ju ry s p in al c o rd in ju ry f ra ct u re & s o ft t is su e in ju ry o th er s s p in al c o rd in ju ry & o th er s f ra ct u re & c ru sh in ju ry s o ft t is su e in ju ry , d is lo ca tio n an d s u b lu xa tio n f ra ct u re , sp in al c o rd in ju ry & o th er s page 44 manwana me et al. sa orthop j 2018;17(1) falls were the most common determinant of traumatic orthopaedic injuries, being responsible for 145 (39.0%) of injuries, followed by rtas in 95 cases (25.5%). other determinants were assault in 57 cases (15.3%), sports injuries in 28 cases (7.5%), machine-related injuries in 24 cases (6.5%), gunshot injuries in four cases (1.1%) and others in 19 cases (5.1%) (table iv). in general, our data showed that the determinants we studied predominantly affected adults aged 13 to 49 years. we note that patients most commonly affected by falls were aged 30 to 39 years (n=23;15.9%), followed by those aged 80 to 89 years (n=19; 13.1%) (table v). generally, patients stayed in the hospital for less than a month (305 patients, 82.0%), with more than 50% staying for less than ten days. two patients remained as inpatients more than 100 days, with one patient staying 107 days and the other 171 days (figure 4). the most common radiological investigation used was x-ray, which was used in 343 patients (92.2%), followed by a combination of x-ray and other investigations (19 patients, 5.1%), computed tomography (ct) scan (six patients, 1.6%), while magnetic resonance imaging (mri) and a combination of ct-scan and mri were the least used (two patients (0.5%)) (table vi). among the 19 patients who underwent a combination of x-ray and other investigations, there were 14 cases of x-ray and ct-scan, four cases of x-ray and mri, and one case of x-ray and ultrasound. discussion the study aimed to evaluate the epidemiology of traumatic orthopaedic injuries for inpatients at princess marina hospital. the results of our study revealed that the highest number of patients admitted with traumatic orthopaedic injuries were young male adults. fractures were the most common type of traumatic orthopaedic injury, with falls being the most common determinant of those injuries. similar to findings from studies conducted elsewhere,6,7,22,23 our study showed that the majority of patients admitted were males,with a male-to-female ratio of 7:3. the sex difference may be due to the fact that males tend to exhibit more risky behaviour15,16 and are perhaps more involved in outdoor activities than females. the mean age of patients with traumatic orthopaedic injuries enrolled in our study was 33.5 years, similar to 34.5 years reported by soleymanha et al.23 the present study revealed that the admission rates were the highest for young adults between the ages of 13 and 49 years (n=277, 74.5%), similar to the findings from other studies,6,7,14 indicating that the majority of people involved in rtas were in the productive age groups. both the mean age and disproportionately higher admission rates for younger adults could lead to loss of productivity and negatively impact the economy. table ii: types of traumatic orthopaedic injuries for admission type of injury number of injuries percentage fracture 413 75.5 lower extremity 250 45.7 upper extremity 118 21.6 spine 26 4.8 pelvic 19 3.5 dislocation and subluxation 55 10.1 soft tissue injury 41 7.5 ligament 3 0.5 nerve 5 0.9 tendon 22 4.0 unspecific 11 2.0 amputation 18 3.3 crush injury 8 1.5 spinal cord injury 7 1.3 others 5 0.9 total 547 100 table iii: types of traumatic orthopaedic injuries by age age (year) fracture dislocation & subluxation spinal cord injury crush injury soft tissue injury amputation others number of patients 13 to 19 43 (10.4) 6 (10.9) 0 (0.0) 0 (0.0) 2 (4.9) 0 (0.0) 1 (20.0) 38 (10.2) 20 to 29 92 (22.3) 20 (36.4) 2 (28.6) 4 (50.0) 24 (58.5) 6 (33.3) 1 (20.0) 100 (26.9) 30 to 39 109 (26.4) 15 (27.3) 2 (28.6) 3 (37.5) 7 (17.1) 6 (33.3) 2 (40.0) 89 (23.9) 40 to 49 63 (15.3) 7 (12.7) 0 (0.0) 1 (12.5) 4 (9.8) 1 (5.6) 0 (0.0) 50 (13.4) 50 to 59 36 (8.7) 3 (5.5) 2 (28.6) 0 (0.0) 3 (7.3) 5 (27.8) 1 (20.0) 30 (8.1) 60 to 69 23 (5.6) 2 (3.6) 1 (14.3) 0 (0.0) 1 (2.4) 0 (0.0) 0 (0.0) 23 (6.2) 70 to 79 18 (4.4) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 15 (4.0) 80 to 89 24 (5.8) 1 (1.8) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 21 (5.6) 90 to 99 3 (0.7) 1 (1.8) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 4 (1.1) ≥100 2 (0.5) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (0.5) total 413 (75.5) 55 (10.1) 7 (1.3) 8 (1.5) 41 (7.5) 18 (3.3) 5 (0.9) 372 (100) table iv: determinants of traumatic orthopaedic injuries determinants number percentage fall 145 39.0 rta 95 25.5 assault 57 15.3 sports-related 28 7.5 machine 24 6.5 gunshot 4 1.1 others 19 5.1 total 372 100 manwana me et al. sa orthop j 2018;17(1) page 45 the present study also showed that females aged 60 years and older were more affected by traumatic orthopaedic injuries than males. this finding might be due to a higher rate of osteoporosis in older females when compared to men, as supported by taylor and young19 and collinge et al.,24 who reported increased incidence or prevalence of osteoporotic fractures in older females. we identified 547 injuries, with the most common type being fractures (75.5%) and the most common site being the lower limbs, consistent with findings from other studies.6,7,14 the reason for the fractures being the most common traumatic injury is perhaps apparent and due to the forceful injury determinants involved (see below). extremities are exposed and thus more susceptible to trauma, usually due to direct trauma in vehicle accidents14 or falls. although others found that falls were the second most common determinant of traumatic injuries after rtas,8 our study revealed that falls were the most common determinant of traumatic orthopaedic injuries, with a prevalence of 39.0%. similarly, soleymanha et al. reported that the highest frequency of traumatic orthopaedic injuries related to falls (prevalence of 38.3%).23 in the present study, we also found the second highest proportion of falls in the very old adults (80 to 89 years). the world health organisation (who) reported that the likelihood of falls increased with age-related biological change, with a high incidence over the age of 80 years.17 older people usually fell due to factors related to their physical environment, which included excessively high or narrow steps, slippery surfaces, darkness or excessive lighting, and random objects on the surface.17 we showed that the second most common determinant (25.5%) of traumatic orthopaedic injuries was rtas, with the vast majority of victims in the 13to 49-year age group. our findings are similar to those of thomas et al.14 and manna et al.,15 who showed that ~75% of rta victims were younger than 45 years. a previous analysis of rtas occurring in gaborone, botswana revealed that casualties were very high in the 20to 39-year age group and that human factors, such as driver/rider negligence, unsafe following distances, failure to comply with signs, and being under the influence of alcohol or drugs were the main causes of traffic accidents, followed by unattended animals on the streets.25 we found that the third determinant of traumatic orthopaedic injuries was assault (15.3%), and that the age group most affected (72%) was 20 to 39 years old. similarly, manoharan et al. showed that assault was more common in the same age group in patients with traumatic orthopaedic injuries.26 we note that in general, the 20to 39-year-old age group was most affected by all types of injury, not just for assault, both in our study and that by manoharan et al.26 we found that the highest admission numbers of patients with traumatic orthopaedic injuries were in august and september. contrary to expectations, a smaller number of patients was admitted during the festive season (december and january). we think that the lower admission rate may be due to the fact that a large number of gaborone residents typically travel out table vi: radiological investigation used for traumatic orthopaedic injuries radiological investigation frequency percentage x-ray 343 92.2 x-ray and others 19 5.1 ct scan 6 1.6 mri 2 0.5 ct scan and mri 2 0.5 total 372 100 figure 4. length of stay of patients with traumatic orthopaedic injuries by sex 125 100 75 50 25 0 n u m b er o f p at ie n ts w ith in ju ry 0-10 days number of days in the hospital sex male female table v: determinants by age group age in years determinants (%) number of patientsrta fall gunshot machine sports-related assault others 13 to 19 13 (13.7) 15 (10.3) 0 (0.0) 1 (4.2) 5 (17.9) 1 (1.8) 3 (15.8) 38 (10.2) 20 to 29 31 (32.6) 18 (12.4) 1 (25.0) 9 (37.5) 15 (53.6) 23 (40.4) 3 (15.8) 100 (26.9) 30 to 39 26 (27.4) 23 (15.9) 3 (75.0) 9 (37.5) 5 (17.9) 18 (31.6) 5 (26.3) 89 (23.9) 40 to 49 16 (16.8) 16 (11.0) 0 (0.0) 2 (8.3) 2 (7.1) 10 (7.5) 4 (21.1) 50 (13.4) 50 to 59 6 (6.3) 18 (12.4) 0 (0.0) 1 (4.2) 1 (3.6) 3 (5.3) 1 (5.3) 30 (8.1) 60 to 69 2 (2.1) 17 (11.7) 0 (0.0) 1 (4.2) 0 (0.0) 1 (1.8) 2 (10.5) 23 (6.2) 70 to 79 1 (1.1) 13 (9.0) 0 (0.0) 1 (4.2) 0 (0.0) 0 (0.0) 0 (0.0) 15 (4.0) 80 to 89 0 (0.0) 19 (13.1) 0 (0.0) 0 (0.0) 0 (0.0) 1 (1.8) 1 (5.3) 21 (5.6) 90 to 99 0 (0.0) 4 (2.8) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 4 (1.1) ≥100 0 (0.0) 2 (1.4) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 2 (0.5) total 95 (25.5) 145 (39.0) 4 (1.1) 24 (6.5) 28 (7.5) 57(15.3) 19 (5.1) 372 (100) 11-20 days 21-30 days 31-40 days 41-50 days 51-60 days 61-70 days 71-80 days 81-90 days 91-100 days >100 days page 46 manwana me et al. sa orthop j 2018;17(1) of the city for holidays, mostly to their home villages and farms, during this period. in contrast, the highest number of patients with traumatic orthopaedic injuries were admitted in june in a district general hospital in england;19 the authors suggested that the high admission rate could be due to the summer activities. our study showed that the vast majority of patients stayed in hospital for less than a month, with 56% staying for up to ten days. similar to our findings, taylor and young showed that the average length of stay for patients was primarily related to the type of injury sustained, and that the majority of patients stayed in the hospital for a relatively short period of time.19 study strengths we used quick and relatively inexpensive study design and methods. although we did not find all charts, we were able to locate and review 73.5% of charts for all patients of interest admitted during the study period. study weaknesses since we collected data retrospectively, we could not always be certain of data accuracy. furthermore, we do not know how the missing charts may have modified the epidemiologic profile of traumatic orthopaedic injuries and study outcomes. in addition, a significant number of rta victims who die before reaching the hospital may have been missed. it is also possible that some patients were admitted under other services, such as general surgery and intensive care, and had orthopaedic injuries, but were discharged from the hospital without being admitted to orthopaedic wards and were thus missed. the collection of data using convenience sampling in a tertiary referral hospital would preclude us from extrapolating findings to a national level. conclusion young male adults sustained traumatic orthopaedic injuries more than any other group studied. fractures were the most common type of the injuries, while falls, rtas, and assaults were the three most common determinants of the injuries. our results may help guide where efforts to improve healthcare delivery and public health policy should be focused. acknowledgements the authors thank dr boikanyo makubate (biostatistician) for assistance with data entry and data analysis and the orthopaedic and medical record teams at princess marina hospital for their assistance during data collection. references 1. hanche-oslen tp, alemu l, viste a, wisborg t, hansen ks. trauma care in africa: a status report from botswana, guided by the world health organization’s ‘guidelines for essential trauma care’ world j surg 2012 oct;36(10):2371-83. 2. gosselin ra, spiegel da, coughlin r, zirkle lg. injuries: the neglected burden in developing countries. bull world health organ 2009 apr;87(4):246-a. 3. orthopaedics-orthoinfo-aaos (american academy of orthopaedic surgeons). [online] available from: http://orthoinfo.aaos.org/ topic.cfm?topic=a00099 [cited: august 2014]. 4. united states bone and joint decade. the burden of musculoskeletal diseases in the united states. rosemont, il: american academy of orthopaedic surgeons. common injuries. [online]. available from: http://www.andrewsinstitute.com/injury prevention/commoninjuries.aspx., 2008, [cited: on 12 february 2015]. 5. gichuchi k. injury pattern among non-fatal road traffic crash victims. eaoj, 2007;1(1):23-25. 6. huda n, gupta p, pant a, iqbal a, julfiqar m, et al. pattern of orthopaedic injuries among patients attending the emergency department in a tertiary care hospital. an analytical study. acta medica international 2014 jan 1;1(1):10. 7. verma v, singh s, singh gk, kumar s, singh a, gupta k. distribution of injury and injury patterns in trauma victims admitted to the trauma centre of csmmu, lucknow. indian j comm health 2013 may 9;25(1):52-60. 8. fasih t, ballal s, macdonald k, mbaya l, mupimpila c, et al. botswana – skills for competitiveness and economic growth, washington, dc: world bank group 2014.9. 9. world population review (2014): population of botswana. [online] available from: http: // wordpopulationreview.com/countries/ botswana-population [cited: 14 june 2014]. 10. sebego m, nauman rb, rudd ra, voetsch k, delinger am, ndlovu c. the impact of alcohol and road traffic policies on crash rates in botswana, 2004-2011: a time-series analysis. accident, analysis and prevention. 2014 sep 30;70:33-39. 11. world health organization. global status report on road safety 2015. world health organization; 2015 dec 17. 12. ahmed e, chaka t. orthopedic and major limb trauma at tikur anbessa university hospital, addis ababa-ethiopia. east cent. afr. j. surg 2005;10(2):43-50. 13. pan r, chang n, chu d, hsu k, hsu y, et al. epidemiology of orthopedic fractures and other injuries among inpatients admitted due to traffic accidents: a 10-year nationwide survey in taiwan. sci world j, 2014 feb. 14. thomas v, lavanya, sridhler. epidemiologic profile of road traffic accident (rta) cases admitted in a tertiary care hospital-a retrospective study in hyderabad, andhra pradesh. ijmps. 2013;3(6):30-36. 15. manna n, mallik s, mandal p, chakraborty d, sardar jc, et al. epidemiological factors of road traffic accidents: a study in a tertiary care setting in india. jpms. 2013;3(1):48-53. 16. world health organization (who). who global report on falls prevention in older age. 2007. geneva (switzerland). 17. alamgir h, muazzam s, nasrullah m. unintentional falls mortality among elderly in the united states: time for action. injury. 2012 dec 31;43(12):2065-71. 18. kalula sz. a who global report on falls among older persons, 2006. 19. taylor a, young a. epidemiology of orthopaedic trauma admissions over one year in a district general hospital in england. ojo. 2015;9:191. 20. etikan i, musa sa, alkassim rs. comparison of convenience sampling and purposive sampling. ajtas. 2016;5(1):1-4. 21. bussmann h, wester cw, ndwapi n, vanderwarker c, gaolathe t, et al. hybrid data capture for monitoring patients on highly active anti-retroviral therapy (haart) in urban botswana. bull world health organ. 2006 feb;84(2):127-31. 22. lawrence je, khanduja v. from cape town to cambridge: orthopaedic trauma in contrasting environments. wjo. 2016 may 18;7(5):308. 23. soleymanha m, mobayen m, asadi k, adeli a, haghparast-ghadim-limudahi z. survey of 2582 cases of acute orthopedic trauma. trauma monthly. 2014 nov;19(4). 24. collinge c, lebus g, gardner mj, gehrig l. osteoporosis in orthopaedic trauma patients: a diagnosis and treatment protocol. j orthop trauma. 2008 sep 1, 22;(8):541-47. 25. pego m. analysis of traffic accidents in gaborone, botswana, 2009. [online] available from: http://hdl.handle.net/10019.1/2395 [cited: 3 april 2015]. 26. manoharan a, selvaraj p, vasanthamani p. epidemiology of orthopedic injuries among patients attending a major trauma centre in tamilnadu. njrcm.2016;5(2):126-31. sluis cremer t et al. sa orthop j 2019;18(1) doi 10.17159/2309-8309/2019/v18n1a3 south african orthopaedic journal http://journal.saoa.org.za tumours and infections citation: sluis cremer t, hosking k, held m, hilton tl. minimally invasive ct-guided excision of osteoid osteoma and other small benign bone tumours: a single centre case series in south africa. sa orthop j 2019;18(1):26-32. http://dx.doi.org/10.17159/2309-8309/2019/v18n1a3 editor: prof lc marais, university of kwazulu-natal, durban, south africa received: april 2018 accepted: july 2018 published: march 2019 copyright: © 2018 sluis cremer t, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. conflict of interest: all named authors hereby declare that they have no conflicts of interest to disclose. abstract background: the management of osteoid osteoma (oo) and other small primary benign lesions of bone has evolved over the past 50 years from open surgery with wide resection margins to less invasive surgical techniques such as image-guided intralesional excision and percutaneous radiofrequency ablation. we aim to evaluate the outcomes of patients treated with computerised tomography (ctguided) intralesional excision and bone grafting of small benign lesions of bone. method: a retrospective folder review of patients treated in a large academic hospital in cape town, south africa, between march 2012 and may 2016 was performed. patient demographics, details of presentation, clinical information and outcome following treatment were analysed descriptively. pre-operative diagnosis based on radiological examination was compared with histological diagnosis. result: eleven patients (five male) with a median age of 16 years (range 5–33) were included. pain was the most common presenting feature. a histological diagnosis of oo was confirmed in five of nine patients with a suspected diagnosis of oo pre-operatively. of the four patients whose diagnosis changed after the procedure, the diagnoses included a benign spindle cell lesion, a benign fibrous histiocytoma, subacute osteitis and an osteochondral defect with geode cyst formation. of the two patients where oo was not suspected pre-operatively, chondroblastoma was confirmed in one while a benign spindle cell lesion was reported in the other. overall histological yield was thus 100%. there were no complications or repeat procedures at a median follow-up of 42 months (range 30–52 months). conclusion: ct-guided intralesional curettage is a safe and minimally invasive technique. this is especially useful in less accessible regions of the skeleton as it provides a means of accurately locating the lesion with minimal risk of complications and morbidity to the patient. we consider this to be the optimal method of treatment in our setting as it provides high success rates, few complications and a histological diagnosis without the need for any additional and expensive equipment. level of evidence: level 4 key words: ct guidance, osteoid osteoma, percutaneous treatment, benign bone tumours, intralesional curettage, radiofrequency ablation minimally invasive ct-guided excision of osteoid osteoma and other small benign bone tumours: a single centre case series in south africa sluis cremer t¹ , hosking k² , held m³ , hilton tl4 1 mbchb(uct), fcorth(sa), mmed(uct); division of orthopaedic surgery, university of cape town and groote schuur hospital, cape town, south africa ² mbchb(uct), fcorth(sa); cape orthopaedic reconstruction unit, life vincent pallotti hospital, pinelands, cape town, south africa ³ md(lmu), phd(uct), mmed(uct)ortho, fcorth(sa); division of orthopaedic surgery, university of cape town and groote schuur hospital, cape town, south africa 4 mbchb(uct), da(sa), dippec(sa), mmed(uct), fcorth(sa); division of orthopaedic surgery, university of cape town and groote schuur hospital, cape town; cape orthopaedic reconstruction unit, life vincent pallotti hospital, pinelands, cape town, south africa corresponding author: dr t sluis cremer, division of orthopaedic surgery, groote schuur hospital, h49 omb, observatory, south africa; tel: 021 404 5118; email: timsluis@gmail.com https://orcid.org/0000-0003-1491-0534 http://orcid.org/0000-0002-3557-0252 https://orcid.org/0000-0002-0671-0439 https://orcid.org/0000-0002-6178-5062 page 27sluis cremer t et al. sa orthop j 2019;18(1) introduction osteoid osteoma (oo) is one of the most important primary benign lesions of bone, due in part to the profound pain and disability it causes patients. it is also the most common, accounting for 12% of primary benign bone tumours.1 its differential diagnosis includes osteoblastoma, chondroblastoma, enchondroma and chondromyxoid fibroma as well as traumatic conditions, such as stress fracture, or infection, in the case of a brodie’s abscess.2 the natural history of an oo is that of spontaneous resolution, and malignant transformation has never been described.3-6 symptomatic relief can be gained with the regular use of nonsteroidal antiinflammatory drugs (nsaids) but side effects, particularly gastric irritation, may hamper this strategy.4-6 in refractory cases surgical excision is usually curative.7 this may be performed in a number of ways: either by open marginal excision or through less invasive techniques, performed under image guidance, such as direct curettage, laser photocoagulation and radiofrequency ablation with or without biopsy.8 novel techniques such as magnetic resonanceguided focused ultrasound (mrgfus)9-11 and arthroscopic excision are also currently being evaluated.12-15 while the use of novel techniques to deal with small benign bone tumours is becoming ever more popular, the additional time and cost are not yet justified by better patient outcomes.16 at our centre, computer tomography (ct) guided percutaneous curettage and bone grafting is performed as this method has a high success rate, a low number of complications, and provides a histological diagnosis without the need for costly additional equipment.17 the aim of this study was to describe the surgical technique and determine the clinical outcomes of patients treated by ct-guided percutaneous curettage. materials and methods following institutional ethical approval (hrec ref: 670/2016) a retrospective folder review was performed. included were all patients who underwent minimally invasive ct-guided intralesional excision of a primary benign bone tumour between march 2012 and may 2016. excluded were extraosseous lesions, inadequate follow-up (less than one year), incomplete records and lesions that were malignant or located outside of bone. patient demographics, details of presentation, clinical information and outcome following treatment were analysed. pre-operative diagnosis based on radiological assessment was compared with histological diagnosis. surgical technique and aftercare a senior surgeon performed the surgery in all cases at a single centre and all patients gave informed consent prior to surgery. patients were admitted on the morning of surgery and discharged on the same day. prophylactic cefazolin 1 g, or clindamycin 600 mg in the case of penicillin allergy, was administered. anaesthesia was induced in theatre after which the patient was transferred to the radiology suite and positioned inside the ct scanner. the location of the lesion was accurately determined in the axial, sagittal and coronal planes. the entry point was planned and marked on the skin (such that the path of the wire would avoid major anatomical structures). a threaded tipped kirschner wire (k-wire) was inserted percutaneously by a qualified radiologist under ct guidance, in a sterile manner, using an orthopaedic drill (figures 1 and 2). the k-wire was then cut to within 3 cm of the skin and covered with a sterile dressing. the patient was then transferred back to theatre, where a full standard preparation and draping was performed. a small skin incision was made to allow a 6 mm cannulated drill bit to be passed over the k-wire and drilled down into the lesion. the k-wire was lubricated with k-y jelly (reckitt benckiser, berkshire, uk) to prevent it from spinning with the drill bit and inadvertently advancing beyond the lesion. a long-handled curette was passed down the drill hole (after removing the k-wire) and the contents of the lesion curetted and sent for histology and microbiological culture. fluoroscopy was used to confirm the position of the k-wire and ensure adequacy of the curettage. allomatrix (wright medical, middlesex, uk) demineralised bone matrix (dbm) calcium sulphate putty was injected into the cavity and the incision closed in a standard fashion. postoperatively patients with lower limb lesions were kept non-weight bearing on crutches for two weeks for comfort with graduated return to full weight bearing status at six weeks. no specific rehabilitation or weight bearing protocol was prescribed. patients had x-rays (xr) postoperatively to assess recurrence and adequacy of healing. statistical analysis due to the small cohort identified, meaningful statistical analysis was not feasible. we therefore report on descriptive statistics only. results all patients presented due to limb pain and had a delay to final diagnosis. a histological diagnosis was available in all cases and there were no complications or recurrence. four of the nine patients with suspected oo had histological diagnosis of a different benign lesion. figure 1. axial view of a dynamic ct scan shows the k-wire tip located within the nidus of a proximal femur oo figure 2. magnified axial view of the same lesion as in figure 4 with k-wire in situ page 28 sluis cremer t et al. sa orthop j 2019;18(1) patients thirteen patients were identified who had undergone ct-guided percutaneous excision of a primary bone lesion. two patients were excluded. these included a biopsy of a metastatic renal cell carcinoma from within the muscles of the shoulder girdle and the other a biopsy of a retroperitoneal schwannoma. demographics overall, there were five male patients and six female, with a median age 16 years (range 5–33). of the five patients with an oo, three were male, the median age of whom was 19 years (range 12–20). symptoms at presentation localised pain was the primary presenting complaint in all patients with a median duration of 6 months (range 1–26 months). in four of the 11 (36%) patients, the pain was associated with a limp; seven of the 11 (63%) complained of night pain; and three (27%) had activity-related pain. six (54%) patients reported pain relief with nsaid use. all five of the patients with oo complained of night pain and three of these reported transient relief of symptoms with nsaid use. one patient with a proximal tibia oo had mechanical knee symptoms including knee locking and an effusion. this patient had a delay in diagnosis of 26 months as meniscal pathology was suspected and the initial magnetic resonance image (mri) failed to diagnose oo. these symptoms resolved following excision of the oo. there was no difference in clinical presentation between patients with oo and those with other diagnoses. imaging studies imaging included conventional xr (figure 3), ct (figure 4) and mri (figure 5). all patients had an xr initially, eight went on to have an mri and three had a ct scan. of the patients who had an mri scan (n=8), three had no further imaging while five patients subsequently underwent a ct scan as the result of the mri was inconclusive but oo was suspected. oo was accurately diagnosed in four of these ct scans. location and histology the location of the lesions as well as the initial and final diagnoses are summarised in table i. no lesion was larger than 20 mm in diameter, with a median of 9 mm (range 4–20 mm). microbial culture was negative in all cases. nine patients were thought to have an oo on clinical and radiological assessment pre-operatively. in two of these patients, subacute osteitis was included in the differential diagnosis. histological examination confirmed oo in five of these nine patients and subacute osteitis (brodie’s abscess) in one. the other three histological diagnoses were an osteochondral defect of the talus with an associated geode cyst, a benign spindle cell lesion and a benign fibrous histiocytoma. two patients had a primary diagnosis that did not include oo. one patient was thought to have a chondroblastoma of the calcaneus that was confirmed on biopsy while the other patient, with a lesion in the ilium adjacent to the sacroiliac joint, had a wider radiological differential diagnosis including osteoblastoma, chondroblastoma or a subchondral geode. histology proved this to be a benign spindle cell lesion.figure 3. xr of an oo in the left proximal femur (arrow) figure 4. coronal ct of the left proximal femur; note the clearly defined nidus figure 5. mri of the same patient as in figure 1; note the poor differentiation of the nidus and marked surrounding bone oedema (pd fat sat) page 29sluis cremer t et al. sa orthop j 2019;18(1) outcomes and follow-up the median follow-up time was 42 months (range 30–52 months). no patients had recurrence of symptoms, surgical complications or secondary surgical procedures. in the patients who had histologically confirmed oo (n=5), all patients had pain relief following surgery and remained symptom-free with no radiological signs of recurrence, as did five of the six patients with other diagnoses. the patient whose symptoms did not resolve had a diagnosis of an osteochondral lesion of the talus and was referred to a foot and ankle specialist for further treatment. discussion the aim of this study was to present our experience with ct-guided intralesional curettage of benign bone tumours, with an emphasis on oo. localised pain is the most common primary presenting complaint (85% of cases) and is classically described as being worse at night and relieved by nsaids.18,19 night pain was present in all of our patients with oo as well two patients with other tumour diagnoses. six of the 11 patients reported symptomatic relief with nsaid use. of these six, three had a final diagnosis of an oo. the natural history of oo is to resolve over time and up to 40% of patients experience long-term relief with nsaids.20 for this reason some authors advocate non-operative management.5 all patients in our series had failed a trial of conservative management prior to surgical intervention. as a tertiary referral centre all patients had at least one form of imaging modality prior to referral to our clinic and presented to us with a differential diagnosis of oo or other small benign lesion. oo has been described mainly in young patients and is most common in the long bones of the lower limbs, especially in the metaphyseal region of the femur and tibia.18,19 we noted similar findings of age and location in our case series, but found that the clinical presentation was neither sensitive nor specific for predicting the diagnosis. hence, we believe histological confirmation should be an essential part of the surgical management of these lesions. the time from onset of symptoms to surgical treatment ranged from 1–25 months (median 14 months). this diagnostic delay is not unique to our setting and is due to the rarity of the condition and wide differential for limb pain in the active young patient. cantwell noted a mean delay to diagnosis of 16 months.21 richardson describes a missed case of intra-articular oo in the hip of an 18-year-old patient where the diagnostic delay was 2.5 years due to inadequate imaging and failure to suspect the diagnosis.22 in our series a young male sportsman with a proximal tibia oo initially presented with knee pain and meniscal symptoms. an mri failed to diagnose an oo and the presumed cause of his pain was meniscal pathology. after a failed course of conservative treatment, a repeat mri and a ct scan diagnosed an oo that was successfully treated by the method described above. skeletal imaging plays a major role in the diagnosis of oo. initially plain x-rays are the modality of choice due to the relatively low cost and radiation exposure, but the diagnostic yield is far superior with ct.23-25 the potential advantage of mri over ct is in decreased radiation exposure, particularly to the paediatric patient, but the diagnostic accuracy has been shown to be inferior.26,27 hosalkar et al. found mri only had a 19% (7/36) accuracy in diagnosing oo, while all lesions in this series were accurately diagnosed pre-operatively on fine cut ct imaging.28 the use of gadolinium enhancement in mri scanning may improve diagnostic accuracy but this increases cost and it has not been shown to be superior to ct.29 in our series, ct was more accurate in diagnosing oo; four of the five patients with an oo had an inconclusive mri but went on to have a ct that accurately diagnosed oo. microbiological culture was negative in all patients, despite one patient having subacute osteitis on histological examination. negative cultures in subacute osteitis are well described.30 the role of surgical management and different techniques the most common indication for surgery is failed medical management.17 other indications include prevention of growth deformity in intra-articular or juxta-epiphyseal lesions and the need for histological confirmation of the diagnosis.18 while some authors advocate treatment without biopsy,8 we believe it is an essential part of management. surgical options range from open marginal resection to less invasive image-guided techniques such as radiofrequency ablation (rfa), laser photocoagulation and intralesional curettage. these are summarised in table ii. marginal resection is associated with prolonged surgical time, local morbidity, fracture in up to 4.5% of cases,31 and a recurrence rate of up to 9%.32 less invasive procedures are therefore preferred.33 open intralesional excision is less invasive, results in less local morbidity and has a more rapid recovery.31,32,34 intraoperative imaging can be augmented with tetracycline labelling table i: summary of patient demographics, lesion location and diagnoses age sex location duration of symptoms (months) provisional diagnosis histological diagnosis 1 19 male calcaneus 3 chondroblastoma chondroblastoma 2 20 female proximal femur 26 osteoid osteoma osteoid osteoma 3 19 male proximal tibia 6 osteoid osteoma osteoid osteoma 4 33 female talus 13 osteoid osteoma ocd/geode cyst 5 16 male proximal tibia 18 osteoid osteoma osteoid osteoma 6 11 female calcaneus 3 osteoid osteoma benign fibrous histiocytoma 7 12 male distal femur 6 osteoid osteoma or subacute osteitis subacute osteitis (brodie’s abscess) 8 19 female proximal femur 3 osteoid osteoma osteoid osteoma 9 9 female pelvis 1 osteoid osteoma, osteoblastoma or osteitis benign spindle cell lesion 10 25 female pelvis 3 osteoblastoma, chondroblastoma or a subchondral geode cyst benign spindle cell lesion 11 12 male tibia 26 osteoid osteoma osteoid osteoma page 30 sluis cremer t et al. sa orthop j 2019;18(1) and intra-operative scintigraphy to improve accuracy where these technologies are available.19 there is no consensus on the benefit of adjuncts (liquid nitrogen, ethanol or pmma) and there is ample evidence that simply removing the nidus is sufficient to bring about symptomatic relief.1,16 the use of ct to accurately localise the nidus allows for a minimally invasive percutaneous surgical approach.23 clinical success is achieved in 84–100% and importantly, histological yield is reported between 50 and 100%.17 complications are rare but fracture has been reported with open lesional excision.35 rfa is considered by many to represent the gold standard of care.36 two techniques are described: an rfa-only technique and a combined technique, comprising biopsy and rfa. histological yield ranges from 17–100% (mean 55%) with the combined technique as the entire lesion is not available for examination.17 lanzo et al. grouped data from 27 published articles including 1 227 patients in an attempt to determine best-practice guidelines for rfa.16 they found a 5% (61/1 227) primary failure rate and a 2% (44/1 227) complication rate. these complications are listed in table iii. the use of laser photocoagulation to induce thermal necrosis has also been described and can be performed under ct guidance or using mri.9-11 the advantage of mri is that there is no ionising radiation but it may be more expensive and is not available in all centres. histological specimens are not usually sent. overall the rate of complications and cure for the percutaneous image-guided techniques are very similar. the possible shorter surgical time of drill curettage may result in more cost-effective treatment. dual technique rf may have equal histological yield and the same cure rates but longer procedural time and possibly higher cost due to the cost of the probes. thermal ablation alone does not allow for histological confirmation. our preferred approach is ct-guided excision, as no additional potentially costly equipment is needed, and it can be performed as day case surgery. intra-articular oo may be approached by arthroscopic means and lesions can be excised by curettage or using a high-speed bur. the use of this technique has been described in the hip (both femoral and acetabular sided lesions), knee, shoulder, ankle and talus.12-15 proposed advantages are the minimally invasive surgical approach and limited articular injury when compared with rfa and open surgical excision. however, arthroscopic surgery is technically demanding and has a prolonged learning curve. mrgfus is a novel treatment of oo that is currently under investigation.37 it is a closed technique and thus avoids some of the complications associated with a surgical procedure but regional or general anaesthesia is still necessary as the procedure is painful. in a series of 29 patients, geiger and colleagues report a 90% primary success rate with no adverse events.38 problems include the high cost of the specialised imaging, interventional equipment necessary to perform the procedure, and the lack of a tissue diagnosis. cost implications of different treatment modalities the cost of health care in both developed and developing economies is increasing at an alarming rate and the importance of cost containment cannot be overemphasised.39 moser et al. found the cost of consumables for laser photocoagulation and rfa to be equivalent,11 while hoffmann et al. found rfa, which table ii: descriptions of interventional techniques for the treatment of benign lesions of bone description technique advantage disadvantage wide marginal resection (‘en-bloc’) extensive open surgical procedure; lesion excised with margin of normal bone no additional equipment needed; technically relatively simple large soft tissue dissection; moderate bone defect; longer recovery time; fracture risk 31,34 open intralesional resection (‘burr-down’) open procedure; nidus directly removed without any margin of bone under image guidance less soft tissue dissection and minimal bone excised difficulty in locating lesion may require the use of adjuncts; recurrence risk31,32,34 percutaneous ct-guided intralesional curettage guide wire placed under ct; nidus removed by indirect means under fluoroscopic guidance percutaneous procedure; minimal soft tissue trauma; low fracture risk; histology specimen requires radiology services to place guide wire17 percutaneous ct-guided rfa ct-guided wire placement followed by rfa; nidus ablated by thermal necrosis percutaneous procedure; minimal soft tissue trauma requires radiology services to place guide wire; lower histological yield; additional equipment needed including rf generator and single use probes36 percutaneous ct (or mri) guided laser photocoagulation as for rfa but uses laser to ablate lesion potentially less radiation than rfa (can be performed under mri guidance) increased cost with no proven benefit over rfa9-11 arthroscopic excision lesion excised under arthroscopic visualisation with a burr a minimally invasive technique requires specialised skill and surgical equipment; only suitable for intra-articular lesions12-15 magnetic resonance guided focused ultrasound mri-guided focused us causes heat necrosis of the lesion a non-invasive, transcutaneous technique requires specialised equipment, not readily available in most centres; as for surgical procedures, regional or general anaesthesia is required; no histology38 table iii: list of complications associated with rf ablation (n=1 227)16 primary failure 61 (5%) skin burn 12 muscle burn 6 nerve injury 3 fracture 2 technical difficulty 5 infection 2 anaesthetic complication 3 delayed healing 2 page 31sluis cremer t et al. sa orthop j 2019;18(1) was performed as an outpatient procedure, to be the most cost effective with a base price of $6 583.00 usd (r81 359.00). open resection $13 826.00 usd (r170 876.00), intralesional resection $10 857.00 usd (r13 4182.00) and ct-guided drill curettage $8 589.00 usd (r106 150.00) were all more expensive.36 however these results from germany cannot be extrapolated to other regions as in different economies certain elements of the treatment package may have different financial weightings. for example, a procedure which takes less theatre time but uses more expensive consumables may be cost effective in one country while being unaffordable in another. also of note is that the cost of ct, mri, fluoroscopy, theatre time, anaesthesia, hospital stay, post-operative rehabilitation and time away from work have not been assessed in the above figures and impact on the economic cost to hospital and patient. overall, the limitations of the study include the small, heterogeneous sample and the retrospective nature of data gathering. no specific pain or functional scores were used, and no specific statistical tests could be applied to our data. ct scan was not performed post-operatively. conclusion as novel techniques to deal with small benign bone tumours are becoming ever more popular, the additional time and cost may not be justified by better patient outcomes. in our series we found these elusive lesions difficult to diagnose based purely on clinical and radiological findings. while ct scan is the imaging modality of choice, histological confirmation remains an essential part of surgical management. for the included patients, ct-guided biopsy and intralesional curettage was a safe, effective, minimally invasive treatment option with high histological yield. future research should focus on cost effectiveness and duration of these procedures compared to conventional techniques. sufficiently powered multicentre trials are necessary to support recommendations for south african orthopaedic surgeons treating these lesions. ethics statement ethics approval was obtained from the university of cape town human research ethics committee (ethics number hrec ref: 670/2016). patient information was obtained from a prospective database at groote schuur and vincent pallotti hospitals. the ethics committee approved these databases, and their reference numbers respectively are r039/2013 and r001/2015. for this study formal consent was not required. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions kh conceived of the research idea and was the primary surgeon in all cases. th assisted with application to the departmental research committee and ethics board. th and tsc developed the study protocol and gathered patient data. tsc, th and mh contributed to writing up the manuscript for submission. orcid sluis cremer t https://orcid.org/0000-0003-1491-0534 hosking k http://orcid.org/0000-0002-3557-0252 held m https://orcid.org/0000-0002-0671-0439 hilton tl https://orcid.org/0000-0002-6178-5062 references 1. kransdorf mj, stull m, gilkey f, moser jr r. osteoid osteoma. radiographics. 1991;11(4):671-96. 2. greenspan a, jundt g, remagen w. differential diagnosis in orthopaedic oncology: lippincott williams & wilkins; 2007. 3. kneisl j, simon m. medical management compared with operative treatment for osteoid-osteoma. j bone joint surg am. 1992;74(2):179-85. 4. moberg e. the natural course of osteoid 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skeletal neoplasia. the orthopedic clinics of north america. 1996;27(3):625-34. 31. sluga m, windhager r, pfeiffer m, dominkus m, kotz r. peripheral osteoid osteoma. jbjs 2002;84(2):249-51. 32. rosenthal di, hornicek fj, wolfe mw, jennings lc, gebhardt mc, mankin hj. percutaneous radiofrequency coagulation of osteoid osteoma compared with operative treatment. the journal of bone & joint surgery. 1998;80(6):815-21. 33. lee eh, shafi m, hui jh. osteoid osteoma: a current review. journal of pediatric orthopaedics. 2006;26(5):695-700. 34. ward wg, eckardt jj, shayestehfar s, mirra j, grogan t, oppenheim w. osteoid osteoma diagnosis and management with low morbidity. clinical orthopaedics and related research. 1993;291:229-35. 35. sans n, galy-fourcade d, assoun j, jarlaud t, chiavassa h, bonnevialle p, et al. osteoid osteoma: ct-guided percutaneous resection and follow-up in 38 patients 1. radiology. 1999;212(3):687-92. 36. hoffmann r-t, jakobs tf, kubisch ch, trumm cg, weber c, duerr h-r, et al. radiofrequency ablation in the treatment of osteoid osteoma—5-year experience. european journal of radiology. 2010;73(2):374-79. 37. masciocchi c, zugaro l, arrigoni f, gravina gl, mariani s, la marra a, et al. radiofrequency ablation versus magnetic resonance guided focused ultrasound surgery for minimally invasive treatment of osteoid osteoma: a propensity score matching study. eur radiol. 2016;26(8):2472-81. 38. geiger d, napoli a, conchiglia a, gregori lm, arrigoni f, bazzocchi a, busacca m, moreschini o, mastantuono m, albisinni u, masciocchi c. mr-guided focused ultrasound (mrgfus) ablation for the treatment of nonspinal osteoid osteoma: a prospective multicenter evaluation. jbjs. 2014 may 7;96(9):743-51. 39. edejer tt-t. making choices in health: who guide to cost-effectiveness analysis: world health organization; 2003. _goback raubenheimer ej et al. sa orthop j 2019;18(1) doi 10.17159/2309-8309/2019/v18n1a6 south african orthopaedic journal http://journal.saoa.org.za traumageneral citation: raubenheimer ej, noffke cee, lemmer lb, slavik t, van heerden wfp, miniggio hd. pharmaceutical management of bone catabolism: the bisphosphonates sa orthop j 2019;18(1):47-52. http://dx.doi.org/10.17159/2309-8309/2019/v18n1a6 editor: dr franz birkholtz, walk-a-mile centre for advanced orthopaedics, pretoria, south africa received: june 2018 accepted: august 2018 published: march 2019 copyright: © 2019 raubenheimer ej. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: the authors received no funding from any agency in the public or commercial domain before or during the preparation of the manuscript. conflict of interest: the authors have no direct or indirect association with any of the companies manufacturing any of the pharmaceuticals or products reflected in the manuscript. abstract background: conditions associated with catabolism of bone are common and progress sub-clinically with devastating skeletal consequences. over the past two decades, bisphosphonates have become increasingly popular for the preventative management of the skeleton in these conditions. methods: recent literature pertaining to the mechanisms of action, clinical indications and complications of bisphosphonate therapy was retrieved using google scholar and pubmed. aims of study: to provide an overview of the mechanisms of action, indications, contraindications and complications of the bisphosphonates available for clinical use in south africa. results: despite the availability of alternative management regimens, bisphosphonates remain the pharmaceuticals of choice for the management of hypercalcaemia and generalised catabolic skeletal disorders such as osteoporosis, skeletal metastatic disease, paget’s disease of bone, glucocorticoid bone disease and osteogenesis imperfecta. although adverse complications such as tachycardia, bowel and oesophageal irritation, pain, jawbone necrosis and atypical femur fractures are well documented, information remains limited on the long-term effects of bisphosphonate therapy on skeletal health. this manuscript provides an update on the mechanisms of action, principles applied to the selection of the most appropriate management regimen, monitoring of the response and complications of the bisphosphonates marketed in south africa. level of evidence: level 5 key words: bisphosphonates, osteoporosis, bone metastases, paget’s disease of bone, glucocorticoid bone disease, osteogenesis imperfecta, jaw bone necrosis pharmaceutical management of bone catabolism: the bisphosphonates raubenheimer ej¹ , noffke cee², lemmer lb³, slavik t4, van heerden wfp5 , miniggio hd6 1 mchd, phd, dsc; ampath histopathology laboratory, pretoria, department of oral pathology and oral biology, university of pretoria, south africa, omfs impath, katholieke universiteit leuven, belgium ² msc; omfs impath, katholieke universiteit leuven, belgium ³ mbchb, m prax med, m med (path), fcfp (sa); ampath histopathology laboratory, pretoria, south africa 4 mbchb, mmed(anat path); ampath histopathology laboratory, pretoria, south africa 5 mchd, phd, dsc; department of oral pathology and oral biology, university of pretoria, pretoria, south africa 6 bds, mscmed (bioethics and health law); faculty of health sciences, sefako makgatho health sciences university, pretoria, south africa corresponding author: prof ej raubenheimer, ampath histopathology laboratory, pretoria, south africa; tel: +27 870870176; cell: +27 829082788; email:ejraub@fox5.co.za and raubenheimere@ampath.co.za https://orcid.org/000-003-0554-2398 https://orcid.org/0000-0003-2494-667x page 48 raubenheimer ej et al. sa orthop j 2019;18(1) introduction despite the development of innovative pharmaceuticals and autoantibodies for the manipulation of skeletal metabolism (reviewed elsewhere1), bisphosphonates (bps) remain the first-line choice for the management of hypercalcaemia and several systemic catabolic skeletal disease states. bps are derived from natural occurring pyrophosphates, which due to their calcium-binding properties, have been used for more than a century to soften water. research performed by procter and gamble in the early 1960s on the prevention of dental caries and calculus deposits on teeth,2,3 exposed their affinity for bone and subsequent incorporation in the skeleton. it has subsequently been shown that approximately one-third of bps absorbed are incorporated in the skeleton where they may persist lifelong. the remainder are cleared by the kidney without being further metabolised.4 during bone resorption, the incorporated bps are released where they exert a profound local influence on the cellular components of the bone metabolic unit (bmu) and in particular the osteoclasts (readers are referred to raubenheimer et al.5 for more information on bone remodelling). these discoveries prompted pharmaceutical companies to manipulate the basic pyrophosphate structure of bp, and several patented drugs with different pharmacokinetics and clinical applications became available in a potentially lucrative market. the purpose of this review is to highlight the mechanisms of action, clinical applications and complications of the bps available in south africa.6 mechanisms of action first generation bps the early non-nitrogen-containing bps, also referred to as the first generation bps (table i), promote osteoclast apoptosis through incorporation in adenosine triphosphate (atp). the nonhydrolysable state of the modified atp results in neutralisation of several enzymatic processes of the osteoclast which ultimately culminate in osteoclast apoptosis, thereby effectively reducing resorptive activity.2,7 the calcium-binding capacity of the first generation bps, which retard mineralisation activity, is an outstanding characteristic which is enhanced by their resistance to neutralisation by alkaline phosphatase. this unique property is the reason for their specific clinical application. clinical applications of first generation bps due to the retardation of mineralising activity and binding of calcium, first generation bps are not suited for the treatment of osteoporosis.2,3 indications for their use are restricted to the management of hypercalcaemia which is commonly associated with disseminated skeletal malignancies and as an adjunct to the management of osteolysis resulting from bone metastases of malignant tumours. during administration (either through the oral or intravenous route) the patient should be monitored for hypocalcaemia and secondary hyperparathyroidism as the drug tends to chelate blood calcium (the reason for its efficiency in correcting hypercalcaemia of malignancy). furthermore, due to the chelating property, ingestion with milk or if the intravenous (iv) route is followed, with calciumcontaining solutions like ringer’s, is contraindicated. similar to the second and third generation bps, it should be used with caution in patients with impairment of renal functions, and regular renal function tests are advised before and during the course of therapy. most of the other precautions and complications of bp therapy, which are discussed later, also apply to the first generation bps. for more detail on the schedule of administration, drug interactions, complications and contraindications readers are referred to the manufacturers’ recommendations. second and third generation bps the second and third generation bps, also known as the nitrogencontaining bps, were developed by adding a nitrogen side chain to the pyrophosphate molecule. this addition increases the efficiency of osteoclast inhibition significantly. various other modifications to the nitrogen-containing backbone contributed to the development of several commercially available bps with differing potencies (table ii). their method of action differs from first generation bps. nitrogen-containing bps bind to a key enzyme in the pathway critical for cytoplasmic stress fibre assembly and membrane ruffling9 and, due to the subsequent osteoclast inhibition, apoptosis is induced.10 the effects are not restricted to osteoclasts only. although their actions on other cells are less clear, they are known to exert a strong anti-apoptotic influence on the osteoblast lineage and therefore play a role in preserving the vitality of bone-forming cells.11,12 unlike first generation bps, these characteristics make second and third generation bps most appropriate for the preservation of bone in catabolic skeletal disease. table ii: commercially available secondand third generation bps6 active ingredient route of administration potency* trade name alendronic acid oral 500 accord alendronate, alendronate unicorn, aldren, boniran, densate, fosagen, fosavance, fosamax, femax, osteonate, osteobon, ran-alendronate, sandoz alendronate risedronate oral 2000 actamax, actonel ibandronate oral & iv 1000 boniva zoledronic acid iv 10 000 zomatron, zolapor, zometa, zobone, aclasta, zolon, zoclasta and others pamidronate iv 100 aredia *potency of osteoclast inhibition relative to etidronate which is empirically set at 18 clinical applications of second and third generation bps osteoporosis pharmaceutical intervention in osteoporosis must always be complemented by lifestyle and dietary measures which include weight-bearing exercise, cholecalciferol administration to patients table i: commercially available first generation bps6 active ingredient route of administration potency* trade name clodronate oral 10 bonefos etidronate oral & iv 1 didronel (not listed in sa**) tiludronate oral 10 skelid (not listed in sa) *potency of osteoclast inhibition is relative to etidronate which is empirically set at 18 **delivery molecule for (99m)tc-based radiopharmaceuticals for skeletal imaging page 49raubenheimer ej et al. sa orthop j 2019;18(1) with low vitamin d concentrations, and calcium supplementation. the latter is mandatory if the daily calcium intake is below 700 mg.7,13 alendronic acid and risedronate are the bps of choice in the majority of men and women with osteoporosis. in cases with poor drug compliance or intolerance to oral bps, the iv route or the use of non-bp regimens such as denosumab, raloxifene or hormone replacement therapy could be considered. several authors reported on the administration of bps in conjunction with other pharmacological agents (for a synopsis see drake et al.7). the combination of initial pth treatment (teriparatide) with maintenance bp therapy seems to provide the strongest anabolic effect on the skeleton.14,15 due to their hydrophilic nature, bps are poorly absorbed from the gastrointestinal tract.16 this is the reason why bps administered intravenously are significantly more effective than those administered via the oral route. although the recent availability of bps allowing once weekly (alendronic acid and risedronate) and even once monthly (risedronate and ibandronate) administration has overcome the disadvantage of poor patient compliance associated with daily regimens, the iv route eliminates the gastrointestinal adverse effects experienced by some patients on oral bps. iv preparations (zoledronic acid, ibandronate, pamidronate) require even less frequent administration but suffer the disadvantage of potentially inducing an acute phase reaction, kidney damage and a higher frequency of osteonecrosis of the jaw than reported with the oral route (see later). the significance of patient compliance should not be underestimated as current evidence suggests that observance of the therapeutic regimen rather than the type of bp used, is of prime importance in minimising fracture risk.17 although there are no recommendations on the monitoring of therapy beyond ten years, treatment review should be performed regularly (at least after three years with iv bps and five years with oral bps).13 in treated individuals, reassessment of fracture risk can be performed using frax with femoral head bone mineral density (bmd).18 short-term non-invasive monitoring of response to therapy is the ideal, and the use of molecular markers for bone metabolism are subsequently gaining momentum. the release of 3-hydroxypyridinium cross links of collagen pyridinoline and deoxypyridinoline during bone resorption can be quantified in blood and urine by high-performance liquid chromatography (hplc). provided a baseline is established on a patient, a decrease can be interpreted as response to therapy. the two components show a high specificity for bone, are not taken up from food, and although variables resulting from volume distribution and metabolic clearance are as yet exploratory, their concentrations are currently viewed as the most appropriate indicators of bone resorption.19 discontinuation of administration is advised in high-risk fracture patients who have been treated with alendronate, risedronate and zoledronic acid for longer than five years. in low-risk fracture patients a ‘drug holiday’ is recommended after one to two years for risedronate, three to five years for alendronate and three to six years for zoledronic acid.20 duration of the skeletal-protective action of bps is related to the potency of the bp used, dosage of administration, metabolism and clearance of the drug. although the determination of the effective half-life is hampered by technical challenges, it has been suggested that after one iv administration, alendronate has a half-life of more than ten years.21 malignancies affecting the skeleton the skeletal morbidity of myeloma is related to osteoclast-induced bone resorption with associated pain and hypercalcaemia. in a consensus statement of the mayo clinic myeloma group, iv pamidronate is recommended as the drug of choice for the management of these morbidities as pamidronate effectively suspends bone resorption, alleviates bone pain and corrects hypercalcaemia. pamidronate is perceived to have a lower risk for inducing jaw osteonecrosis than the alternative, zoledronic acid.22 upon remission, treatment is discontinued after two years. if remission is not achieved, pamidronate administration should be considered every three months at a reduced dosage. in a recent update of 18 trials reporting on 4 843 men with advanced prostate cancer, bp therapy was shown to decrease the number of skeletal events and reduce disease progression.23 although non-opioid and opioid analgesics are employed to manage metastatic bone pain, bps can offer added pain reduction.24 a joint review drafted by an expert panel of cancer care ontario and the american society of clinical oncology suggests that bp administration reduces bone recurrence and improves survival of postmenopausal patients with non-metastatic breast cancer.25 in separate studies, a substantial relief of the skeletal complications and pain have been demonstrated in patients with breast cancer receiving iv bps.26,27 of the oral bps, only daily administration of ibandronate has been shown to be beneficial. the skeletal protecting action of bps is advantageous particularly to women receiving oestrogen ablation therapy for hormone-sensitive breast cancer.28 other clinical applications paget’s disease of bone is characterised by an increase of bone resorption followed by defective bone formation. these processes result in a weak skeleton, deformities, skull enlargement and pain. bps suppress bone resorption with subsequent normalisation of serum alkaline phosphatase concentrations and are therefore recommended for the management of the active and symptomatic phase of the condition.7 a recent practice guideline confirms that oral risedronate, pamidronate and iv zoledronic acid are effective in this regard. bp therapy however does not eradicate the radiological changes, nor does it improve the deformities or reduce pain resulting from the associated osteoarthritis.29 with present data available, bp therapy holds potential for the improvement of the quality of life of children with osteogenesis imperfecta. iv administration of pamidronate results in a significant increase in cortical bone thickness and trabecular bone volume.30 success has also been reported with oral alendronate in the management of the consequences of this devastating genetic disease.31 although the mechanism of action is not clear, it appears that the inhibition of osteoclastinduced resorption augments the defective process of bone formation. although the use of bps in children is cautioned against,7 the net clinical benefit of bp administration to children suffering osteogenesis imperfecta may outweigh its potential disadvantages. glucocorticoid therapy is the most important cause for pharmaceutically induced osteoporosis. glucocorticoids induce skeletal catabolism which is the result of induction of apoptosis of cells of the osteoblast lineage and activation of bone resorption through prolonging the lifespan of osteoclasts.32 patients taking 2.5 mg or more prednisone per day for three months or longer and with a high risk for fractures can benefit from bp administration which should start at the onset of glucocorticoid therapy. risedronate and alendronic acid are first choices and where these drugs are contraindicated, second line agents such as denosumab or teriparatide could be considered.33 because of limited information on the advantages bp intervention in patients taking glucocorticoids, the american college of rheumatology advises vitamin d and calcium supplementation without bp administration in patients with a low fracture risk.34 pamidronate and alendronic acid have been shown to reduce the markers of bone resorption during skeletal immobilisation page 50 raubenheimer ej et al. sa orthop j 2019;18(1) and their protective influence on the skeleton, and reduction of hypercalcaemia and nephrolithiasis is promising.35,36 management of the skeletal morbidity of paediatric conditions such as anorexia, juvenile rheumatoid arthritis and cystic fibrosis is awaiting data of long-term studies on whether the net benefit outweighs the potential complications. the embedding of modifications of bps on implants creating bioactive surfaces which facilitate bio-integration and reduce implant failure will certainly gain momentum in the future. adverse effects despite considerable attention given to bp-related osteonecrosis of the jaw (onj), this complication is rare in patients receiving oral bps: onj occurs in between 0.1% of myeloma patients and 5% of advanced prostate cancer patients on bps.37,38 the majority of cases with onj were described in patients receiving high doses of iv bps for myeloma and breast cancer (for a summary see drake, et al.7). the occurrence of onj is also related to the anti-angiogenic properties of the bp administered,39,40 host factors which include the presence of dormant jawbone infections and the efficiency of the immune response.41 a variety of infective agents are implicated, including actinomyces-like organisms and fungi. it is important to clear all foci of potential jaw bone sepsis before commencement of bp therapy and delay invasive dental surgery in patients receiving the medication. patients with chronic ear infections may likewise develop osteonecrosis of the external auditory canal.42 thigh, hip or groin pain should alert clinicians to another rare and not yet fully understood complication, namely atypical femur fracture.43 an acute phase reaction is experienced by nearly a quarter of patients receiving the first iv dose of nitrogen-containing bp, and the incidence thereafter decreases progressively with each administration.44 this reaction is characterised by pyrexia with concomitant headache, arthralgia, myalgia and influenza-like symptoms, and pre-treatment with histamine receptor antagonists, antipyretics or corticosteroids may provide relief.1 an increase in serious atrial fibrillation (requiring hospitalisation) was reported in patients receiving iv zoledronic acid.44 although verifiable data is not yet available for the other bps, the risk appears to be smaller, if not negligible.7 this complication is an indication for considering one of the non-bp skeletal cytokine modulators or auto-antibodies in the management regimen (summarised elsewhere1). oesophageal irritation and erosions are common in patients on oral bps. patients should be advised to swallow the bp with a full glass of water and remain in an upright position for one hour after ingestion. avoid taking anti-acid drugs containing aluminium or magnesium due to the danger of chelating and neutralising the bp. gastro-oesophageal irritation has not been reported with the iv route which is recommended in patients with uncontrollable oesophageal discomfort. renal function can rapidly deteriorate in patients on iv bps particularly if the creatinine clearance and glomerular filtration rates are below 30 ml/min32,33 and 35 ml/min. respectively.13,45,46 the oral route of administration may be appropriate in patients with mild renal impairment7 or alternatively a cytokine modulator or autoantibody could be considered as second line regimen. concomitant use of non-steroidal anti-inflammatory drugs increases the potential for peptic ulcers47 and renal dysfunction46 and is contraindicated. severe incapacitating musculoskeletal pain, distinct from the acute phase symptoms, has been reported in a small number of patients receiving alendronate and risedronate.48 the risk factors for this complication are unknown. iv administration may precipitate hypocalcaemia particularly in patients with a substantial skeletal tumour burden, paget’s disease, hypoparathyroidism, compromised renal function and hypovitaminosis d.49-51 in order to minimise the risk of hypocalcaemia, albumin-corrected serum calcium concentrations should be determined and corrected before commencing with iv infusion of bps.7 if unresponsive, consider an alternate management regimen.1 conjunctivitis, uveitis, episcleritis and scleritis are rare complications of both oral and iv bps. the incidence is less than 0.1%, appears to be limited to patients receiving risedronate, and resolves within weeks of discontinuation of therapy.48 administration of bps is contraindicated during pregnancy, lactation and in patients manifesting with allergic-type reactions against the drug. conclusion the therapeutic roll-out of bps for the management of generalised skeletal anabolism gained momentum over the past decade. although the benefits of bp therapy outweigh the risks in several progressive skeletal anabolic states, the lack of long-term studies on large patient samples is hampering the generation of accurate data on the advantages and complication of bp therapy in some of the less common conditions. the long-term effects on the skeleton in particular will be interesting as the repair of micro-fractures, which contribute to skeletal strength, is impaired. ethics statement the authors upheld the principles of non-maleficence and an accurate reflection of the literature during the preparation of the synopsis. declaration the authors declare authorship of this article and that they have followed sound scientific research practice during the preparation thereof. this research is original and does not transgress plagiarism policies. acknowledgements gratitude is expressed towards the ampath histopathology laboratory, the catholic university of leuven and the university of pretoria for providing support in the preparation of the manuscript. author contributions all the authors were involved in the collection of relevant information from the literature. rej compiled the manuscript from the data received and all authors contributed to the revision of the manuscript and the final preparation of the submitted copy. 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osteonecrosis of the jaw: an update. j maxillofac oral surg 2014;13:386-93. 42. thorsteinsson a-l, lomholt a, eiken p. bisphosphonate-induced osteonecrosis of the external auditory canal: a case report. j clin med case reports 2015;2:3. 43. saita y, ishijima m, kaneko k. atypical femoral fractures and bisphosphonate use: current evidence and clinical implications. ther adv chronic dis 2015;6:185-93. page 52 raubenheimer ej et al. sa orthop j 2019;18(1) 44. black dm, delmas pd, eastell r, reid ir, boonen s, cauley ja, cosman f, lakatos p, leung pc, man z, mautalen c, mesenbrink p, hu h, caminis j, tong k, rosario-jansen t, krasnow j, hue tf, sellmeyer d, eriksen ef, cummings sr. once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. n engl j med 2007;356:1809-22. 45. smetana s, michilin a, roseman e, biro a, boaz m, katzir z. pamidronate-induced nephrotoxic tubular necrosisa case report. clin nephrol 2004;61:63-67. 46. chang jt, green l, beitz j. renal failure with use of zoledronic acid (letter). n engl j med 2003;349:1676-79. 47. miyake k, kusunoki m, shinji y, shindo t, kawagoe t, futagami s, gudis k, tsukui t, nakajima a, sakamoto c. biphosphonate increases risk of gastroduodenal ulcer in rheumatoid arthritis patients on long-term nonsteroidal antiinflammatory drug therapy. j gastroenterol 2009;44(2):113-20. 48. wysowski dk, chang jt. alendronate and risedronate: reports of severe bone, joint and muscle pain (letter). arch internal med 2005;165:346-47. 49. jones sg, dolan g, lengyel k, myers b. severe increase in creatinine with hypocalcaemia in thalidomide-treated myeloma patients receiving zoledronic acid infusions (letter). br j haematol 2002;119:576-77. 50. mishra a, wong l, jonklaas j. prolonged symptomatic hypocalcaemia with pamidronate administration and subclinical hypoparathyroidism. endocrine 2002;14:159-64. 51. maalouf nm, heller hj, odiva cv, kim pj, sakhahee k. bisphosphonate-induced hypocalcaemia: report of 3 cases and review of the literature. endocrine pract 2006;12:48-53. _goback _hlk534382957 dlamini nf et al. sa orthop j 2019;18(1) doi 10.17159/2309-8309/2019/v18n1a5 south african orthopaedic journal http://journal.saoa.org.za hip citation: dlamini nf, ryan pv, moodley y. incidence and risk factors for extended post-operative length of stay following primary hip arthroplasty in a south african setting. sa orthop j 2019;18(1):40-46. http://dx.doi.org/10.17159/2309-8309/2019/v18n1a5 editor: dr c snyckers, university of pretoria, south africa received: october 2017 accepted: september 2018 published: march 2019 copyright: © 2019 dlamini nf. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: none conflict of interest: all authors declare that there are no conflicts of interest regarding this research. abstract background: this study sought to determine the incidence of extended post-operative length of stay (eplos) and its associated risk factors in south african primary hip arthroplasty patients. methods: this was a retrospective chart review study of 185 adults who underwent primary hip arthroplasty at a quaternary south african hospital. data related to patient, clinical, and surgical characteristics were collected. post-operative length of stay was calculated as the time (in days) between the dates of surgery and discharge from hospital. we defined eplos as any length of stay ≥75th percentile obtained for the entire study population. data were analysed using univariate and multivariate statistical methods. results: the incidence of eplos was 28.1% (95% confidence interval – ci: 22.1–35.0%). risk factors for eplos included: female sex (odds ratio – or: 4.63, 95% ci: 1.74–12.34; p=0.002), patient’s maximum walking distance <100 m (or: 3.05, 95% ci: 1.05–8.89; p=0.041) and extended duration of surgery (or: 3.62, 95% ci: 1.31–10.01; p=0.013). conclusion: we provide a report of eplos and several associated risk factors in south african primary hip arthroplasty patients. level of evidence: level 4 key words: primary hip arthroplasty, primary hip replacement, south africa, extended length of stay, risk factors incidence and risk factors for extended post-operative length of stay following primary hip arthroplasty in a south african setting dlamini nf¹ , ryan pv² , moodley y³ 1 mbchb(uct), mmed, fc orth (sa); consultant orthopaedic surgeon, department of orthopaedics, prince mshiyeni memorial hospital, durban; and department of orthopaedics, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa ² mbchb(uct), mmed, fc orth (sa); consultant orthopaedic surgeon, department of orthopaedics, inkosi albert luthuli central hospital, durban, south africa ³ phd; research fellow, department of anaesthetics, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa corresponding author: dr nf dlamini, department of orthopaedic surgery, king edward hospital, private bagx02, congella 4013, south africa; email: nkanyiso.dlamini@gmail.com; tel: +27723875344 https://orcid.org/0000-0003-2154-0199 https://orcid.org/0000-0002-0957-6482 https://orcid.org/0000-0002-4119-1734 page 41dlamini nf et al. sa orthop j 2019;18(1) introduction increased global life expectancy has been linked to a higher burden of musculoskeletal conditions, including hip fracture and osteoarthritis.1 untreated musculoskeletal conditions impact quality of life in afflicted patients and also have adverse consequences on healthcare expenditure and resource utilisation.1 these conditions would therefore have public health significance in resource-limited settings. aside from non-communicable aetiologies, the global hiv epidemic has also been linked to the growing prevalence of orthopaedic disorders.2 conservative medical therapy might not be effective in a large proportion of patients afflicted with orthopaedic hip conditions. surgical intervention remains the only viable management option in these patients.3 the effectiveness of primary hip arthroplasty in reversing pain and loss of function associated with orthopaedic hip conditions is well described.3,4 utilisation of primary hip arthroplasty as a surgical intervention for orthopaedic hip conditions has increased substantially over the past two to three decades, with this procedure now considered among the most common surgical procedures performed worldwide.4 a survey of orthopaedic surgeon members belonging to the south african orthopaedic association reported that each member in the country performed up to 43 hip arthroplasties each year.5 in addition, a lack of surgical expertise and other essential resources in surrounding countries has resulted in a number of patients from these countries being referred to south african hospitals for the procedure.6 in response to the increasing demand for primary hip arthroplasty, it is possible that many south african orthopaedic surgery units will in future adopt accelerated post-operative care pathways, in which the length of inpatient stay (and subsequent expenditure and resource utilisation for each patient) following surgery is reduced.7,8 an understanding of which patient, clinical, and surgical characteristics are associated with extended postoperative length of stay (eplos) in south african primary hip arthroplasty patients would have important future implications for the development of fast-track or accelerated surgical and recovery protocols implemented at orthopaedic surgery units in the country. therefore, the objectives of this study were to: 1. determine the incidence of eplos in a sample of south african primary hip arthroplasty patients 2. determine which patient, clinical, and surgical characteristics are associated with eplos in a sample of south african primary hip arthroplasty patients. materials and methods study design, study setting, and study population this was a retrospective chart review study involving consecutive adult patients who were admitted for primary hip arthroplasty through a dedicated arthroplasty unit at a quaternary level hospital in kwazulu-natal, south africa, between 23 september 2014 and 28 july 2016. inclusion/exclusion criteria for this study are presented in table i. potential participants were identified from theatre lists during the specified study period. data collection the medical records of all patients included in this study were reviewed and data related to various patient (demographics), clinical (comorbidities, presenting diagnosis, thomas test with fixed flexion deformity [ffd], etc.), and surgical characteristics (nature of surgery, anaesthesia, surgical approach, duration of surgery, and peri-operative blood transfusion) were collected using case report forms. we also collected data related to the occurrence of serious peri-operative complications, which we defined as a grade iii or above peri-operative complication when using the clavien-dindo classification (includes: organ failure, critical care admission, re-operation, and mortality).9 post-operative length of stay was calculated as the time (days) between the date of a patient’s operation and the date that the patient was discharged from hospital. the study outcome was eplos. this was defined as a postoperative length of stay ≥75th percentile calculated for the entire study population. this definition of eplos has been used in similar surgical studies conducted in overseas settings.10,11 data were transferred from the case report forms to a microsoft excel® spreadsheet in preparation for analysis. data analysis the median length of stay for the study population was calculated and is presented with an interquartile range. the incidence of eplos in this study was calculated using conventional epidemiological methods.12 the incidence of eplos in this study is presented as a percentage with 95% confidence intervals (95% ci). potential associations between various patient, clinical, and surgical characteristics and eplos were investigated using univariate (χ2 test, or fisher’s exact test) and multivariate (binary logistic regression) statistical methods. results for the univariate statistical analysis are presented as frequencies and percentages. characteristics with p<0.100 in the univariate analysis were selected for inclusion in the multivariate statistical analysis. this purposeful selection of variables for inclusion in the multivariate analysis was done to obtain the most parsimonious model possible.13 model fit was assessed using a hosmer-lemeshow test. results for the multivariable statistical analysis are presented as odds ratios (or) with 95% ci. a p-value of <0.050 was considered to be a statistically significant result. all statistical analyses were performed using the statistical package for the social sciences (spss) version 24.0 (ibm corp, usa). results derivation of study population and incidence of eplos the derivation of the study population and the incidence of eplos in this study is shown in figure 1. following the application of our study inclusion and exclusion criteria, our final study population consisted of 185 adult patients who underwent primary hip arthroplasty. the median post-operative length of stay for the study population was 5.0 days (interquartile range: 3.0–7.0 days). the 75th percentile for the study population post-operative length of table i: inclusion and exclusion criteria for the proposed study inclusion criteria exclusion criteria patients aged 18 years or older patients younger than 18 years patients who underwent primary hip arthroplasty at ialch between 23 september 2014 and 28 july 2016 patients who did not undergo primary hip arthroplasty at ialch between 23 september 2014 and 28 july 2016 patient not previously included in study patient previously included in study page 42 dlamini nf et al. sa orthop j 2019;18(1) stay was 7.0 days. a total of 52/185 patients experienced eplos following primary hip arthroplasty, with the calculated incidence of eplos being 28.1% (95% ci: 22.1–35.0%). distribution of patient, clinical, and surgical characteristics in the study population the distribution of patient, clinical, and surgical characteristics in the study population is shown in table ii. a total of 43/185 patients were elderly (23.2%). there was a higher proportion of female patients versus male patients in the study population (55.1% versus 44.9%, respectively). with regard to comorbidity, 38.4% (71/185) of the study population were classified as having severe systemic disease (an american society of anesthesiologists score of ≥3). the most prevalent comorbidities in the study population were hypertension (n/n=86/185, 46.5%), obesity (n/n=84/185, 45.4%), and anaemia (n/n=53/185, 28.6%). osteoarthritis was the most common presenting diagnosis (n/n=80/185, 43.2%), followed by osteonecrosis (n/n=61/185, 33.0%) and other miscellaneous orthopaedic diagnoses (n/n=44/185, 23.8%). the most frequent miscellaneous diagnoses reported were hip dysplasia (11/44 patients 25.0%), fracture (9/44 patients, 20.5%), ankylosis (8/44 patients 18.2%), and rheumatoid arthritis (7/44 patients, 15.9%). fixed flexion deformity (as per the thomas test) was established for 138/185 patients (74.6%). overall, 13.5% of the study population were classified as having severe hip deformation (ffd >30 degrees). a total of 138/185 patients (74.6%) used an assistive device for mobilisation. pain scores (visual analogue score – vas) could only be established for 121/185 patients (65.4%). a total of 99/185 patients had a vas ≥7 (53.5%). we could only establish maximum walking distance for 58.4% (n/n=108/185) of the study population. a total of 52/185 patients (28.1%) could not walk 100 m or more. the median duration of surgery for the study population was 100.0 minutes (interquartile range: 75.0–125.0 minutes). urgent/ emergent surgical procedures were rare in the study population (n/n=3/185, 1.6%). surgery was performed under general anaesthesia in 96/185 patients (51.9%). the standard posterior approach was used in 123/185 procedures (66.5%). thirty-five patients (18.9%) experienced surgery of extended duration, which we defined as a surgery with a duration ≥75th percentile calculated for the entire study population. twenty-six patients in the study population required a peri-operative blood transfusion (14.1%). serious peri-operative complications were rare (n/n=5/185, 2.7%). results of the univariate statistical analysis the results of the univariate statistical analysis are also shown in table ii. the proportions of several characteristics were statistically similar (p≥0.050) between patients who experienced eplos and patients who did not experience eplos. these characteristics included: elderly age (p=0.130), american society of anesthesiologists score (p=0.306), current smoker (p=0.061), cardiovascular disease (p=0.999), chronic obstructive pulmonary disease (p=0.327), hiv (p=0.764), diabetes (p=0.999), anaemia (p=0.970), obesity (p=0.807), hypertension (p=0.056), mobilisation with an assistive device (p=0.937), vas (p=0.774), urgent/emergent surgery (p=0.560), general anaesthesia (p=0.739), and posterior surgical approach to the hip (p=0.216). the proportions of the remaining characteristics were statistically different (p<0.050) between patients who experienced eplos and patients who did not experience eplos. these characteristics included: sex (p<0.001), presenting diagnosis (p=0.011), ffd (p<0.011), patient’s maximum walking distance (p=0.009), extended duration of surgery (p=0.003), peri-operative blood transfusion (p<0.001), and serious perioperative complications (p=0.023). we were unable to compute statistics for the characteristic ‘renal impairment’, as we found that no patients in our study population had this characteristic. results of the multivariable statistical analysis the results of the multivariable statistical analysis are shown in table iii. only nine of the characteristics investigated in the univariate analysis met the criteria of p<0.100 for inclusion in the multivariable analysis. these characteristics were sex, being a current smoker, hypertension, presenting diagnosis, ffd, patient’s maximum walking distance, extended duration of surgery, peri-operative blood transfusion, and serious peri-operative complications. of these characteristics, only three were found to be independently associated with eplos. these characteristics were female sex (when compared with males, or: 4.63, 95% ci: 1.74–12.34; p=0.002), patient’s maximum walking distance <100 m (when compared with the reference of walking distance ≥100 m, or: 3.05, 95% ci:1.05–8.89; p=0.041), and extended duration of surgery (when compared with surgery duration <75th percentile obtained for the entire study population, or: 3.62, 95% ci: 1.31–10.01; p=0.013). the result for the hosmer-lemeshow test indicated adequate model fit (p>0.050). discussion the median post-operative length of stay in our south african study population was much shorter than that reported for british, american, and pakistani patient populations undergoing primary hip arthroplasty (median of five days in our study population 1 435 orthopaedic procedures performed during study period 1 435 orthopaedic procedures performed in adults during study period 219 primary hip arthroplasty procedures performed during study period 133 patients without eplos 52 patients with eplos final study population 185 primary hip arthroplasty procedures performed in 185 adult patients excluded: 0 procedures in patients not 18 years old or older excluded: 1 216 procedures not primary hip arthroplasty excluded: 34 procedures in patients already included in study (revision or other hip) eplos: extended post-operative length of stay figure 1. study profile and incidence of eplos page 43dlamini nf et al. sa orthop j 2019;18(1) table ii: distribution of patient/clinical characteristics in the study population and results of the univariate statistical analysis* clinical characteristic sub-category all patients (n=185) no eplos (n=133) eplos (n=52) p-value age >65 years old 0.130 yes 43 (23.2) 27 (20.3) 16 (30.8) no 142 (76.8) 106 (79.7) 36 (69.2) sex <0.001 female 102 (55.1) 60 (45.1) 42 (80.8) male 83 (44.9) 73 (54.9) 10 (19.2) asa score ≥3 0.306 yes 71 (38.4) 48 (36.1) 23 (44.2) no 114 (61.6) 85 (63.9) 29 (55.8) current smoker 0.061 yes 42 (22.7) 35 (26.3) 7 (13.5) no 143 (77.3) 98 (73.7) 45 (86.5) cardiovascular disease 0.999 yes 10 (5.4) 7 (5.3) 3 (5.8) no 175 (94.6) 126 (94.7) 49 (94.2) copd 0.327 yes 21 (11.4) 17 (12.8) 4 (7.7) no 164 (88.6) 116 (87.2) 48 (92.3) hiv 0.764 yes 40 (21.6) 105 (78.9) 40 (76.9) no 145 (78.4) 28 (21.1) 12 (23.1) diabetes 0.999 yes 17 (9.2) 12 (9.0) 5 (9.6) no 168 (90.8) 121 (91.0) 47 (90.4) renal impairment uc yes 0 (0.0) 0 (0.0) 0 (0.0) no 185 (100.0) 133 (100.0) 52 (100.0) anaemia 0.970 yes 53 (28.6) 38 (28.6) 15 (28.8) no 132 (71.4) 95 (71.4) 37 (71.2) obesity 0.807 cnbe 11 (5.9) 7 (5.3) 4 (7.7) yes 84 (45.5) 61 (45.8) 23 (44.2) no 90 (48.6) 65 (48.9) 25 (48.1) hypertension 0.056 yes 86 (46.5) 56 (42.1) 30 (57.7) no 99 (53.5) 77 (57.9) 22 (42.3) presenting diagnosis 0.011 other 44 (23.8) 25 (18.8) 19 (36.6) osteonecrosis 61 (33.0) 51 (38.3) 10 (19.2) osteoarthritis 80 (43.2) 57 (42.9) 23 (44.2) ffd >30 degrees 0.011 cnbe 47 (25.4) 26 (19.6) 21 (40.3) yes 25 (13.5) 18 (13.5) 7 (13.5) no 113 (61.1) 89 (66.9) 24 (46.2) mobilises with assistive device 0.937 yes 138 (74.6) 99 (74.4) 39 (75.0) no 47 (25.4) 34 (25.6) 13 (25.0) vas ≥7 0.774 cnbe 63 (34.1) 47 (35.3) 16 (30.8) yes 99 (53.5) 69 (51.9) 30 (57.7) no 22 (12.4) 17 (12.8) 6 (11.5) table ii continued on page xx page 44 dlamini nf et al. sa orthop j 2019;18(1) walking distance <100 m 0.009 cnbe 77 (41.6) 59 (44.4) 18 (34.6) yes 52 (28.1) 29 (21.8) 23 (44.2) no 56 (30.3) 45 (33.8) 11 (21.2) urgent/emergent surgery 0.560 yes 3 (1.6) 3 (2.3) 0 (0.0) no 182 (98.4) 130 (97.7) 52 (100.0) surgery with general anaesthesia 0.739 yes 96 (51.9) 68 (51.1) 28 (53.8) no 89 (48.1) 65 (48.9) 24 (46.2) posterior approach to hip 0.216 yes 123 (66.5) 92 (69.2) 31 (59.6) no 62 (33.5) 41 (30.8) 21 (40.4) extended duration of surgery 0.003 yes 35 (18.9) 18 (13.5) 17 (32.7) no 150 (81.1) 115 (86.5) 35 (67.3) peri-operative blood transfusion <0.001 yes 26 (14.1) 10 (7.5) 16 (30.8) no 159 (85.8) 123 (92.5) 36 (69.2) peri-operative complication 0.023 yes 5 (2.7) 1 (0.8) 4 (7.7) no 180 (97.3) 132 (99.2) 48 (92.3) *results expressed as frequencies (%). p<0.050 was considered a statistically significant result eplos: extended post-operative length of stay; asa: american society of anesthesiologists; copd: chronic obstructive pulmonary disease; uc: unable to compute; cnbe: could not be established; ffd: fixed flexion deformity; vas: visual analogue score table iii: results of the multivariate statistical analysis* clinical characteristic sub-category or (95% ci) p-value sex female 4.63 (1.74–12.34) 0.002 male reference current smoker yes 1.15 (0.36–3.66) 0.817 no reference hypertension yes 1.36 (0.59–3.11) 0.470 no reference presenting diagnosis other 2.25 (0.83–6.13) 0.113 osteonecrosis 0.70 (0.24–2.01) 0.507 osteoarthritis reference ffd >30 degrees cnbe 4.80 (1.72–13.34) n/a yes 0.52 (0.14–1.91) 0.326 no reference walking distance <100 m cnbe 0.48 (0.15–1.53) n/a yes 3.05 (1.05–8.89) 0.041 no reference extended duration of surgery yes 3.62 (1.31–10.01) 0.013 no reference peri-operative blood transfusion yes 2.35 (0.80–6.88) 0.120 no reference peri-operative complication yes 11.77 (0.95–145.54) 0.055 no reference *results adjusted for confounders. only characteristics with p<0.100 in the univariate statistical analysis included in the multivariable statistical analysis. p<0.050 was considered a statistically significant result. or: odds ratio; ci: confidence interval; ffd: fixed flexion deformity; cnbe: could not be established table ii continued from page 43 page 45dlamini nf et al. sa orthop j 2019;18(1) versus seven to eight days in the other primary hip arthroplasty populations).10,14-16 south africa is severely impacted by high levels of non-communicable disease,17 trauma/injury,18 and hiv infection,19 all of which are associated with the development of musculoskeletal/orthopaedic disease.20-23 this has resulted in a growing demand for hip arthroplasty in the country.6 however there are staffing and economic challenges in running orthopaedic surgical units in the public sector,24 and the availability of beds in these public hospitals might also be a concern.25 in order to cope with the higher demand for hip arthroplasty, some hospitals are beginning to implement fast-track protocols which are aimed at reducing post-operative length of stay while minimising the rate of post-discharge complications in suitable patients who undergo the surgical procedure.26 this might possibly explain the difference in median post-operative length of stay following primary hip arthroplasty between south african and overseas populations.10,14-16 with regard to eplos following hip arthroplasty, the literature is scant. however, there is one american study which reported eplos in this surgical population.10 in that study, the 75th percentile for the population post-operative length of stay was 14.0 days, which is twice that reported for our study.10 furthermore, one-third of the american study population experienced eplos.10 as with our findings for median post-operative length of stay, the discrepancy in eplos between the american study population and our south african study population must be viewed in the context of a growing demand for hip arthroplasty in south africa and the disproportionate availability of healthcare resources between south african and american settings.27 we found statistically significant univariate associations between several characteristics (including: sex, presenting diagnosis, ffd, patient’s maximum walking distance, extended duration of surgery, peri-operative blood transfusion, and serious post-operative complications). these findings are not unique to our study. other overseas studies have reported univariate statistical associations between these/similar characteristics and post-operative length of stay in hip arthroplasty patients.14,16 we found three characteristics to be independently associated with eplos (including: sex, patient’s maximum walking distance and extended duration of surgery). female sex was found to be associated with an almost five-fold increase in the risk of experiencing eplos following primary hip arthroplasty. abbas et al., reported an almost two-fold increase in the risk of eplos for women undergoing hip arthroplasty in a pakistani setting.16 dall et al., also reported a multivariate statistical association (without describing the magnitude of risk) between female sex and longer post-operative length of stay a british hip arthroplasty population.14 therefore, our findings for female sex appear, in general, to be in agreement with the published literature. however, the difference in the magnitude of odds ratios for female sex obtained in our study and the study of abbas et al.16 requires further investigation. the characteristics of patient’s maximum walking distance have not been specifically investigated as potential risk factors for eplos following hip arthroplasty in the published literature. however, these characteristics are components of the pre-operative harris hip score,28 which has been shown by dall et al.,14 to be associated with length of stay following hip arthroplasty. specifically, these characteristics appear to be associated with mobility and functional status in patients with hip conditions.28 therefore, our findings highlight the potential importance of preoperative functional status and ambulation on the post-operative recovery period in south african primary hip arthroplasty patients. lastly, we found extended duration of surgery to be associated with an almost four-fold higher risk of experiencing eplos. this is somewhat in agreement with the british study of foote et al., who also report extended duration of surgery to be independently associated with a higher risk of eplos.15 however, as with the patients’ sex, there appears to be a difference in the magnitude of odds ratios for surgery duration between our study and the study of foote and colleagues.15 attempts to should be made to reduce the duration of hip arthroplasty in our setting, possibly through the application of benchmarks and optimisation of surgical technique. the risk factors identified in our study can be incorporated into future risk stratification systems for eplos in south african orthopaedic units. similar risk stratification systems based on identified risk factors for eplos following primary hip arthroplasty have been proposed by abbas et al.,16 and foote et al.15 these risk stratification systems are required to be developed and validated for performance in a separate surgical cohort.29 this step is beyond the scope of the dataset used in our study and requires further research. there were several characteristics which were not found to be associated with eplos during the univariate statistical analysis, or following inclusion in the multivariable statistical analysis. there are two explanations for the lack of statistical association between these characteristics and eplos in our study. first, it might be possible that these characteristics, while identified as risk factors in overseas settings, are genuinely not associated with eplos in south african hip arthroplasty patients. discordance in clinical risk factors between overseas/south african surgical populations and other post-operative outcomes has been described elsewhere.30 it might be worthwhile to involve overseas collaborators with access to overseas patient data in future research such that valid comparisons of risk factors between our settings can be made. secondly, it is possible that a larger sample size than 185 patients would be required to investigate the impact of these characteristics on eplos. a potential solution to this would be a collaborative study involving as many hospitals which offer orthopaedic surgical services as possible. our study had several strengths. our study is, to the best of our knowledge, the only south african study which specifically investigates eplos following primary hip arthroplasty. another strength of our study is that we included data on hiv infection in our statistical analyses. this is important as the prevalence of hiv is usually much lower in american and british populations,19 and so our study provides important information on the impact of this characteristic in settings with a high burden of hiv infection. the final strength of our study is that while our sample size appeared modest, it still allowed for us to perform a multivariable statistical analysis to determine independent risk factors for eplos without any serious violation of statistical rules of thumb.31 our study also had several limitations. first, as this study was conducted at a single, dedicated arthroplasty unit in a quaternary level hospital with standardised preand post-operative protocols in place, it might be argued that our study findings lack generalisability. as for our solution for the challenge related to the lack of statistical association between several characteristics and eplos, we recommend that collaborative studies involving hospitals at various levels of service delivery are conducted to determine the generalisability of our study findings. in addition, we were unable to investigate the impact of the harris hip score in our study due to poor documentation of this characteristic in the patient medical records. we did, however, find that components of the harris hip score were statistically associated with eplos, and it is therefore possible that the composite harris hip score might also be associated with eplos. prospective research wherein data collection for the harris hip score is standardised is required. finally, we did not report the impact of eplos on healthcare expenditure or post-discharge complications. these outcomes can only be appropriately investigated through the conduct of prospective research studies. page 46 dlamini nf et al. sa orthop j 2019;18(1) in conclusion, we found several risk factors for eplos following primary hip arthroplasty in south african patients. these risk factors included sex, patient’s maximum walking distance, and extended duration of surgery. further research is required to confirm our study findings, as well as address the limitations identified in our study. ethics statement this study was approved by the university of kwazulu-natal biomedical research ethics committee (protocol: be526/17). no benefits of any form have been received from a commercial party related directly or indirectly to the subject of this article. declarations the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions this study formed part of the postgraduate medical studies of nfd. nfd conceptualised the research idea, executed the research protocol, and wrote the manuscript. pvr was involved in the conceptualisation of the research idea and provided a critical review of the manuscript. ym was involved in the conceptualisation of the research idea, performed the statistical analysis, and provided a critical review of the manuscript. orcid dlamini nf http://orcid.org/0000-0003-2154-0199 ryan pv http://orcid.org/0000-0002-0957-6482 moodley y http://orcid.org/0000-0002-4119-1734 references 1. woolf ad, 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population reference values for the oxford and harris hip scores electronic data collection and its implications for clinical practice. hip int 2016. 29. moodley y, naidoo p, biccard bm. the south african vascular surgical cardiac risk index (savs -cri): a prospective observational study. s afr med j 2013;103:746-50. 30. moodley y, biccard bm. predictors of in-hospital mortality following non-cardiac surgery: findings from an analysis of a south african hospital administrative database. s afr med j 2015;105:126-29. 31. vittinghoff e, mcculloch ce. relaxing the rule of ten events per variable in logistic and cox regression. am j epidemiol 2007;165:710-18. _goback page23 page24 page26 page28 page29 page30 page31 page32 south african orthopaedic journal hand doi 10.17159/2309-8309/2023/v22n1a7nkosi cs et al. sa orthop j 2023;22(1) citation: nkosi cs, sefeane ti. a subungual glomus tumour of the finger with five reappearances: a rare case report. sa orthop j. 2023;22(1):48-51. http://dx.doi. org/10.17159/2309-8309/2023/ v22n1a7 editor: dr duncan mcguire, university of cape town, cape town received: august 2022 accepted: october 2022 published: march 2023 copyright: © 2023 nkosi cs. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background a subungual glomus tumour is a rare benign neoplasm that develops in the distal portion of the finger from the glomus body. hand surgeons are most significant in the diagnosis of this tumour. case report we present an atypical case of a patient who experienced multiple recurrences of a subungual glomus tumour of the finger over a period of 26 years. a transungual approach was used to remove the nail during the surgical excision. postoperatively, the patient was symptom-free. discussion the glomus body is the neuromyoarterial histological structure located in the stratum reticularis of the dermis of the skin and the subungual regions. recurrences can be classified as early, delayed and ancient. early recurrences may result from incomplete excision or a second tumour that develops within a year of the initial excision. a year following excision, delayed recurrences are thought to be caused by a new glomus tumour at the fingertip. a tumour that reappears more than three times after excision on the same fingertip in five years can be either a new or incomplete excised tumour, as in our case, and is considered an ancient recurrence. surgical eye loupes should be use intraoperatively to improve complete tumour lesion excision. conclusion to the best of our knowledge, this is the first case of a finger with five recurrences post excision. in the event that excision-related pain is significant, recurrence should be considered. delayed and ancient recurrences are thought to be caused by a new glomus tumour at the fingertip that one cannot prevent with surgery. level of evidence: level 5 keywords: recurrence, glomus tumour, finger, surgery a subungual glomus tumour of the finger with five reappearances: a rare case report collen s nkosi,¹* tatolo i sefeane² ¹ chris hani baragwanath academic hospital, department of orthopaedic surgery, university of the witwatersrand, johannesburg, south africa ² hands unit, chris hani baragwanath academic hospital, department of orthopaedic surgery, university of the witwatersrand, johannesburg, south africa *corresponding author: drcsnkosi@gmail.com introduction a subungual glomus tumour is a rare benign neoplasm that develops in the distal portion of the finger from the glomus body.1 they account for 1–6% of all soft tissue tumours in the upper limb, particularly the hand (50–75%).2 the aetiology of the tumour is unknown.2 because of its rarity, there is usually a significant period between the beginning of symptoms and the diagnosis.1,3 sefeane et al. reported up to 16 years delay in diagnosis in 2013.1 clinically, subungual glomus tumours are characterised by a classic triad of cold intolerance, localised tenderness and paroxysmal pain.3,4 recurrences are seen in 4–15% within one year of excision.5 we present an atypical case of a patient who experienced five recurrences of a subungual glomus tumour of the finger over a period of 26 years. case report a 65-year-old female presented with a worsening pain in the right subungual middle finger for the past six months. the pain was excruciating and affected her activities of daily living. she had had four previous surgical excisions (years: 1996, 2004, 2013 and 2015) with positive histology results of glomus tumour from the same middle finger. the longest period she was symptom-free was six years after resection. figure 1. preoperative clinical image of the right middle finger with a split nail https://orcid.org/0000-0002-6119-8466 page 49nkosi cs et al. sa orthop j 2023;22(1) on clinical examination of the right middle finger, there was typical triad of a bluish discolouration, a positive love’s pin test and a positive hildreth’s test with a split nail plate (figure 1). the range of motion of the distal interphalangeal joint was normal. standard radiography showed an indentation on the dorsal surface of the distal phalanx of the middle finger, most likely due to previous surgery. laboratory findings were within normal ranges. the affected middle finger was scanned using magnetic resonance imaging (mri) and it revealed a subungual high signal intensity on t2 weighted and an isointense signal on t1 weighted images (figure 2). the soft tissue lesion measured 4.3 × 1.7 × 4.1 mm. histopathological assessment of the soft tissue excised from the distal phalanx with haematoxylin and eosin (h & e) × 100 and × 400 stain revealed blood vessels associated with round cells in a myxoid stroma. the tumour was confirmed by an immunostain with s-100 (figure 3). subungual leiomyoma, subungual exostosis and subungual neuroma can be differentiated as subungual glomus tumours based on their clinical presentation. an excisional biopsy was performed under general anaesthesia, and a tourniquet was used to obtain a bloodless field. a transungual approach was used to remove the nail during the surgical excision. using a mcdonald’s dissector, the nail plate was delicately raised from the nail bed and gently peeled out with an arterial forceps. multiple small bluish soft tissue masses were identified on the subungual surface (figure 4a). the tumour lesions were excised completely, and haemostasis was achieved by direct pressure (figures 4b and 4c). the nail bed was closed a b c d e figure 2. mri of middle finger: a) saggital t-1 weighted image showing the indentation; b and c) coronal and axial t-1 weighted images of the tumour; d and e) sagittal and coronal t-2 weighted images showing the tumour (courtesy of the department of radiology, chris hani baragwanath academic hospital) a b c figure 3. microphotographs of tumour histopathological section: a) h&e × 100 stain revealed blood vessels associated with round cells in myxoid stroma; b) h&e × 400 stain revealed blood vessels surrounded by a proliferation of round cells in a myxoid stroma; c) the tumour was confirmed by an immunostain with s-100 (courtesy of the department of histopathology, university of the witwatersrand) a c b d figure 4. a) multiple small bluish soft tissue masses; b and c) soft tissue lesions are completely removed; d) nail plate sutured with monocryl figure 5. middle finger showing healed nailbed page 50 nkosi cs et al. sa orthop j 2023;22(1) with intermittent buried monocryl sutures, and the patient’s nail plate was used as a nailbed dressing sutured with monocryl (figure 4d). the lesions were sent for histopathological analysis, and the diagnosis of a subungual glomus tumour was confirmed. the nailbed healed in 12 weeks (figure 5); postoperative radiographs at 12 weeks showed a similar dimple to the preoperative radiographs (figure 6); and the patient was symptom-free. discussion background the glomus body is the neuromyoarterial histological structure located in the stratum reticularis of the dermis of the skin and the subungual regions. it comprises nerve fibres, modified smooth muscle cells termed glomus cells, afferent arterioles, collecting venules and arteriovenous anastomoses known as the sucquethoyer canal. it regulates the body’s temperature and blood pressure through arteriovenous flow.1,2,4,6-8 glomus tumour was originally described as ‘painful subcutaneous tubercle’ by wood in 1812.9 in 1924, mason et al. named glomus tumour following a histopathology analysis.10 they are commonly found on the distal parts of the fingers.2,11 after excision, there have been reports of a significant recurrence rate.5,6 it affects more middle-aged women than men.2,6 recurrences can be classified as early, delayed and ancient. early recurrences may result from incomplete excision or a second tumour that develops within a year of the initial excision.6,12 a year following excision, delayed recurrences are thought to be caused by a new glomus tumour at the fingertip.6,12 a tumour that reappears more than three times after excision on the same fingertip in five years can be either a new or incomplete excised tumour as in our case, and the cases reported by patel et al. and dailiana et al. are considered an ancient recurrence.2,12 the skincoloured tumours, as opposed to the traditional red, blue or purple glomus tumours, are challenging to distinguish during surgery, which raises the risk of recurrence.13,14 clinical presentation clinically, glomus tumours are classified either solitary or multiple.5,11 multiple tumours are asymptomatic and present in the young patient. in contrast, solitary subungual glomus tumours are characterised by a classic triad of cold intolerance, localised tenderness and paroxysmal pain.3,5 a nail plate deformity or split was previously reported and our case had a split nail plate.5,14 despite a classical presentation and finger assessment, the tumour can be misdiagnosed for up to 15 years due to medical doctors’ lack of exposure to the condition.13 fawzi et al. reported an early diagnosis of the tumour by an experienced hand surgeon.15 the tumour is confirmed using various clinical tests. these include the love’s pin test, which has a 100% sensitivity and 78% accuracy, the hildreth test, which has a 71.4% sensitivity, 91% specificity and 78% accuracy, and a cold sensitivity test, with 100 sensitivity, specificity and accuracy.1,5,6 investigation plain radiographs can reveal a distal phalanx bone erosion or a cortical defect of the underlying bone.2,5,6 our case had an indentation of the cortex. ultrasonography is a valuable tool to use to confirm the site, size and shape of the glomus tumour, but it is highly operator dependent.2,5,6,14 mri is the study of choice to establish the diagnosis; it helps with preoperative planning to assess the tumour size and location, which minimises the risk of incomplete excision.2,5 the classic features on mri include a high signal core dot bordered by a zone of low signal intensity.2,15 the tumour lesion exhibits low signal intensity on t1 weighted, high signal intensity on t2 weighted, and enhancement on t1 weighted images following gadolinium administration.2,5,6,11,13 in this case, the tumour lesion was histologically confirmed as a glomus tumour. when compared to the earlier histology findings for this patient, there was no appreciable difference in the histology characteristics of the tumour that returned. glomus cells present with nest-like epithelioid cells with eosinophilic cytoplasm and round nuclei following haematoxylin adenosine staining. immunohistochemistry staining is used to excluded other tumour lesions from glomus tumour. it is positive for smooth muscle actin and vimentin, whereas cytokeratin and s-100 are immunonegative.7,11,15 treatment the literature reports varying rates of recurrence, but an excisional biopsy is regarded as the gold standard intervention option.15 in this case, the traditional transungual approach was done and it provided excellent exposure. it is advised that skin-coloured tumours be removed piece by piece, including the complete capsule, to prevent recurrence.6,15 surgical eye loupes should be used intraoperatively to improve complete tumour lesion excision. literature supports the use of intraoperative ultrasound or microscope to decrease risk of recurrence. a perioperative single or double tourniquet is advisable to keep a bloodless field during surgery.2,6 recurrence recurrence was previously reported to be 4–15% within one year of excision, but current literature has provided data with a higher recurrence rate of 4–50%.6,10 glomus tumours seldom turn malignant, and there are very few examples that have been documented in the literature.8,11,15 conclusion recurrence of subungual glomus tumour after excision is uncommon, and fewer cases are known to have recurred after five years. in a woman who has historically had a tumour presenting with a triad of symptoms, recurrence of the tumour should be suspected, and an mri must be performed to confirm it. the transungual approach provides excellent clinical outcomes for patients, but patients need to be informed of the possibility of nail deformity. to reduce the risk of missed reappearance, orthopaedic surgeons should not discharge patients with glomus tumours from regular follow-up. a b figure 6. postoperative radiographs: a) anteroposterior view of the distal phalanx middle finger with no bony changes; b) lateral view of the middle finger distal phalanx showing the dimple on the dorsal surface (courtesy of the department of radiology, chris hani baragwanath academic hospital) page 51nkosi cs et al. sa orthop j 2023;22(1) ethics statement ethics committee approval was obtained from the university of the witwatersrand human research ethics clearance certificate (wits): m220778. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was obtained from all patients for being included in the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions csn: conceptualisation, data collection, work design, manuscript preparation tis: conceptualisation, manuscript approval and supervision of the study orcid nkosi cs https://orcid.org/0000-0002-6119-8466 sefeane ti https://orcid.org/0000-0001-6579-7864 references 1. sefeane t, aden a, and peters f. subungual glomus tumours: report on 11 cases. sa orthop j. 2013;12(3):42-45. 2. patel j, vaish a, vaishya r, singhal s. reappearance of a glomus tumour of the finger after nine years-a rare case report and literature review. journal of orthopaedic reports. 2022 mar 1;1(1):38-41. https://doi.org/10.1016/j.jorep.2022.03.014 3. singh d. subungual glomus tumour: rare but real. indian j vasc endovasc surg. 2015;2(3):115-17. https://doi.org/10.4103/0972-0820.166932 4. gandhi j, yang ss, hurd j. the anatomic location of digital glomus tumour recurrences. j hand surg am. 2010;35(6):986-89. https://doi.org/10.1016/j.jhsa.2010.02.019 5. jalan d, elhence a, rathore ds, maley dk. a recurred subungual glomus tumour of the thumb. bmj case rep. 2016;2016:bcr2015212963. https://doi.org/10.1136/bcr-2015-212963 6. morey vm, garg b, kotwal pp. glomus tumours of the hand: review of literature. j clin orthop trauma. 2016 oct 1;7(4):286-91. https://doi.org/10.1016/j.jcot.2016.04.006 7. zanjani lo, shafiee nia b, vosoughi f, et al. an unusual case of chest wall glomus tumor presenting with axillary pain: a case report and literature review. eur j med res. 2021 dec;26(1):1-6. https://doi.org/10.1186/s40001-021-00518-6 8. saaiq m. presentation and management outcome of glomus tumors of the hand. arch bone jt surg. 2021may;9(3):312. https://doi.org/10.22038/abjs.2020.47878.2367 9. wood w. on painful subcutaneous tubercle. edinburgh med j surg. 1812;8:283-91. 10. barre ja, masson pv. anatomy – clinical study of certain painful sub-ungual tumors (tumors of neuromyo-arterial glomus of the extremities). bull soc dermatol syph. 1924;31:48-59. 11. chou t, pan sc, shieh sj, et al. glomus tumor: twenty-year experience and literature review. ann plast surg. 2016;76:s35-40. https://doi.org/10.1097/sap.0000000000000684 12. dailiana zh, drape jl, viet d. a glomus tumour with four recurrences. j hand surg eur vol. 1999 feb 1;24(1):131-32. 13. tang cy, tipoe t, fung b. where is the lesion? glomus tumours of the hand. arch plast surg. 2013 sep;40(05):492-95. https://doi.org/10.5999/aps.2013.40.5.492 14. lin yc, hsiao pf, wu yh, sun fj, scher rk. recurrent digital glomus tumor: analysis of 75 cases. dermatol surg. 2010;36(9):1396-400. https://doi. org/10.1111/j.1524-4725.2010.01647.x 15. fazwi r, chandran pa, ahmad ts. glomus tumour: a retrospective review of 15 years experience in a single institution. malays orthop j. 2011;5(3):8. https://doi.org/10.5704/ moj.1111.007 https://orcid.org/0000-0002-6119-8466 https://orcid.org/0000-0001-6579-7864 https://doi.org/10.1016/j.jorep.2022.03.014 https://doi.org/10.4103/0972-0820.166932 https://doi.org/10.1016/j.jhsa.2010.02.019 https://doi.org/10.1136/bcr-2015-212963 https://doi.org/10.1016/j.jcot.2016.04.006 https://doi.org/10.1186/s40001-021-00518-6 https://doi.org/10.22038/abjs.2020.47878.2367 https://doi.org/10.1097/sap.0000000000000684 https://doi.org/10.5999/aps.2013.40.5.492 https://doi.org/10.1111/j.1524-4725.2010.01647.x https://doi.org/10.1111/j.1524-4725.2010.01647.x https://doi.org/10.5704/moj.1111.007 https://doi.org/10.5704/moj.1111.007 ole_link1 ole_link2 ole_link3 ole_link4 ole_link5 south african orthopaedic journal case report orthopaedic oncology and infections doi 10.17159/2309-8309/2023/v22n2a6 philip s et al. sa orthop j 2023;22(2) citation: philip s, kgagudi mp. cutaneous adenoid cystic carcinoma: clinical conundrum of a lower limb mass. sa orthop j. 2023;22(2):105109. http://dx.doi.org/10.17159/23098309/2023/v22n2a6 editor: dr thomas hilton, university of cape town, cape town, south africa received: july 2022 accepted: november 2022 published: may 2023 copyright: © 2023 philip s. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background adenoid cystic carcinoma is a rare epithelial tumour of the salivary glands. it arises even more rarely in the aerodigestive tract, lacrimal glands and adnexal skin glands. acral metastasis is a rare presentation of carcinoma of unknown origin. head and neck malignancies with acral metastasis are extremely rare. case report we present our case of metastatic adenoid cystic carcinoma presenting in the form of a tumour arising from an adnexal skin gland of the foot. discussion the case is an example of atypical presentation and dilemma in diagnosis of adenoid cystic carcinoma (histopathological confusion). to our knowledge there is no case in the literature with similar clinicopathological highlights. conclusion corroborative information is crucial for accurate diagnosis and appropriate management of patients by multidisciplinary teams. the need for timeous presentation and treatment for masses, even if clinically asymptomatic, is also highlighted. level of evidence: level 5 keywords: cutaneous adenoid cystic carcinoma cutaneous adenoid cystic carcinoma: clinical conundrum of a lower limb mass sujith philip,¹* marule p kgagudi² ¹ department of orthopaedics, klerksdorp hospital, university of the witwatersrand, johannesburg, south africa ² department of orthopaedics, chris hani baragwanath academic hospital, university of the witwatersrand, johannesburg, south africa *corresponding author: sujithgeorgephilip@gmail.com background adenoid cystic carcinoma (acc) is a rare epithelial tumour of the salivary glands.1-3 it arises even more rarely in the aerodigestive tract, lacrimal glands and adnexal skin glands.1,2 acral metastasis is a rare presentation of carcinoma of unknown origin with incidence ranging from 0.007% to 0.3%.1,2 head and neck malignancies with acral metastasis are extremely rare.1-3 case report a 39-year-old male with no known comorbidities presented to our orthopaedic outpatient department with a skin lesion on the left foot, first noted 19 years prior. the lesion was initially excised at his local hospital. there was recurrence of the lesion with progressive involvement of the bones of the foot over ten years, with an increase of associated pain over the last three years. our patient reported recent loss of weight accompanied by a diminished appetite. previous significant medical history noted pulmonary tb in 2010 with occasional alcohol consumption and a five pack/year smoking history. he was previously employed as an underground mine worker. examination the patient appeared well overall, although with bilateral superficial inguinal lymphadenopathy. he had an antalgic gait on the left but walked unaided. the foot had multiple, well-circumscribed, firm to hard, non-tender bony masses of variable sizes. distal lower limb perfusion and sensation were intact. importantly, skin nodules similar to the one initially seen on the left heel were discovered in the left axilla and the left mandibular area. systemic examination was otherwise unremarkable. anteroposterior and lateral views of the left leg showed multiple lytic and cystic lesions of the tibia, fibula and tarsal bones. a large, diaphyseal lytic skip lesion was also noted in the tibia (figure 1). ct of the left leg revealed multiple foci of permeative lytic bone lesions with wide zones of transition and soft tissue expansile components involving the fourth metatarsal, all cuneiforms, cuboid, talus, calcaneus distal tibia, distal fibula and the medullary cavity https://orcid.org/0000-0003-2005-5095 page 106 philip s et al. sa orthop j 2023;22(2) of the proximal tibial shaft, suggestive of diffuse metastatic disease (figure 2). mri of the foot revealed multiple lobulated bony lesions, which were t1 hypointense and t2 hyperintense, involving the distal tibia, distal fibula, tarsals and the first and second metatarsals (figure 3). laboratory and radiological workup all blood investigations were within normal limits. biopsy of the skin lesion of the foot suggested an acc with angiolymphatic invasion but no perineural invasion. the lesion extended to the superficial margin only. staging ct revealed diffuse chest and abdominal metastasis. photomicrographs of the tumour cells showed low, intermediate and high-power magnification views of the tumour stained with haematoxylin and eosin. tumour cells showed positive staining with ck7, cd117 and s100 (figure 4). management with the provisional diagnosis of metastatic acc and extensive involvement of the left foot and proximal tibia, he was offered definitive palliative loco-regional control with an above-knee amputation, followed by chemoradiation treatment with a multidisciplinary team approach. the biopsy specimens from the above-knee amputation had extensive tumour cell degeneration but the features were suggestive of an extraskeletal myxoid chondrosarcoma. subsequent biopsies of skin nodules from the arm and jaw were suggestive of the same chondrosarcoma diagnosis. this posed a diagnostic and therapeutic challenge, since the patient now had to be changed to an anthracyclinebased chemotherapy regimen to address the new diagnosis. all available biopsies were resubmitted to achieve a conclusive diagnosis, which turned out to favour the initial pathology of acc. final histopathology report on the submitted leg specimen showed clear margins. discussion acc is a rare malignancy thought to account for 10% of all salivary gland malignancies.4-9 in 60–70% of cases the minor salivary glands are affected.4,5,7-9 occasionally rare cases can originate from the extra-salivary tissues.5-7 black africans are the second most commonly affected race after caucasians and before asians, although race is usually not documented in most studies.8 the tumour has a slight female predilection in most studies, with one study reporting an equal sex distribution.4,6-9 acc seems to peak in incidence between the fifth and sixth decades of life.4-9 our patient however, in his late 30s, had a primary arising from an adnexal gland in his foot. the latter and his black african descent may also be deemed to be negative prognostic factors. the entity is rarely seen below the age of 30 years.5 acc is notorious for late presentation due to its characteristic slow growth pattern, a presentation similar to our case, accounting for the majority of cases.4-9 the other usually dreaded growth pattern is that of a rapidly progressive tumour with early metastasis and poor clinical outcomes; this is the least common growth pattern noted in literature.4 the development of a painless mass around the head and neck region is by far the most common scenario of presentation.4-9 this may be the reason that most cases present late. our case ironically had a left foot skin nodule as the primary site of the acc. he too, however, presented typically late due to lack of pain from these tumours. the longest duration of time from onset of primary tumour to metastatic symptoms at presentation is 22 years in the literature.5 our patient presented 19 years from the onset of the primary tumour in the foot. histologically three subtypes of acc have been documented, namely: cribriform, tubular and solid types, depending on predominant tissue type appearing microscopically.9 the commonest type, the cribriform type, has a better prognosis over the solid undifferentiated type.4,6-9 our patient’s histology fortunately showed a predominantly cribriform tissue type. ironically, primary head and neck tumours and their visceral metastasis are typically asymptomatic but bone metastases typically present earlier with gradually increasing pain.4-8 the latter was not true with respect to our patient as pain and swelling in his left foot and ankle had only troubled him over the last three years prior to presentation. when head and/or neck pain is a presenting symptom, neural tissue involvement is usually the cause, although nerve palsy could also present in a painless fashion.8 acc has a low local or regional invasion rate compared to other malignancies.6,8 our patient had associated axillary and inguinal nodes at presentation. distant metastases are infrequent and are only documented in 15% of the patients.2,5 when present, however, they are associated with a dismal overall prognosis, which atypically was not true in our case.2,3,5 in the literature, the typical radiological appearance of acral metastasis is similar to our case with a permeative to destructive appearance of the bone involved, with variable soft tissue involvement on ct and mri scans of the affected limb.2,5 traditionally, treatment for patients with acral metastasis is usually palliative, due to disseminated disease at presentation as well the poor outlook with regard to the primary tumour at diagnosis.1-3 our case had disseminated disease on staging workup which typically would spell a grave prognosis with other disseminated tumour figure 1. x-ray of the left leg figure 2. ct images page 107philip s et al. sa orthop j 2023;22(2) figure 3. mri images page 108 philip s et al. sa orthop j 2023;22(2) diagnoses. however, this is not always the case with acc. due to the overall slow, indolent growth pattern, the following phrase has been coined: ‘patient can symbiotically live with their tumour for prolonged periods of time’.4 protocols that involve combinations of surgical excision with postoperative radiotherapy give good results initially; however, in up to 70% of cases the initial outcomes will be negated by local recurrences.7 the recurrence rate seems to worsen the longer the duration is since surgery. for acc acral metastasis, treatment entails wide margin excision in the form of an amputation with postoperative irradiation of the residual stump.10 primary acc is treated similarly with wide margin excision and radiation. the former and latter were both offered to our patient with above-knee amputation and mandibular, axillary and inguinal mass surgical excision.11 however, due to typical late presentation in most cases, the chances of clear marginal excision for the head and neck is limited by local vital anatomical structures in which case palliative radiation therapy may relieve pressure symptoms and also aid with sterilising tumour margins.8-10 our patient consented to an above-knee amputation, which was reported to have clear margins by the pathologist. at last follow-up he was still asymptomatic and ambulant on crutches, awaiting his prosthetic limb fitting. conclusion the case cited above is an example of both atypical presentation (young, male, black african with primary arising in an adnexal skin gland) and dilemma in diagnosis of acc (histopathological confusion). due to conflicting histopathological reports, the management of the patient had to be modified from loco-regional control with radiation to anthracycline-based chemotherapy. this shows how corroborative information is crucial for accurate diagnosis and appropriate management of patients by multidisciplinary teams. our clinical case also highlights the need for timeous presentation and treatment for masses, even if clinically asymptomatic. a c e b d f figure 4. photomicrographs of tumour cells – low, intermediate and high-power magnification views of tumour stained with haematoxlin and eosin. tumour cells show positive staining with ck7, cd117 and s100. a) low power 2.5× magnification, h&e image of the neoplasm; b) intermediate magnification at 10×, h&e image of the neoplasm; c) high power, 40× magnification, h&e image of the neoplasm; d) diffuse positive staining of the neoplastic cells with ck7; e) positive staining of the neoplastic cells with cd117; and f) positive staining of the neoplastic cells with s100 page 109philip s et al. sa orthop j 2023;22(2) ethics statement the author/s declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to the commencement of the study, ethical approval was obtained from the following ethical review board: university of the witwatersrand human research ethics committee (medical) certificate no. m220495. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was obtained from the patient for being included in the case report, as well as for the use of radiological images and histopathology slides; these images were adequately anonymised. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions sp: contributed to case report conceptualisation, data collection, manuscript preparation mpk: contributed to manuscript preparation, ethical clearance and supervision orcid philip s https://orcid.org/0000-0003-2005-5095 kgagudi mp https://orcid.org/0000-0002-0078-3995 references 1. maheshwari av, chiappetta g, kugler cd, pitcher jd. metastatic skeletal disease of the foot: case reports and literature review. foot ankle int. 2008;29(7):699-710. 2. mohanty sn, samanta dp, avinash a, senapati sn. acral metastasis in carcinoma of buccal mucosa: an unusual presentation. oncol j india. 2018;2:35-37. 3. bhandari v, jain rk. a retrospective study of incidence of bone metastasis in head and neck cancer. j can res ther. 2013;9:90-93. 4. tripathi p, mathur h, goel s, khorate m. adenoid cystic carcinoma: a case report. int j health res. 2010;3(3):186. 5. spiers asd, esseltine dlw, ruckdeschel jc, davies jnp. metastatic adenoid cystic carcinoma of salivary glands: case reports and review of the literature. cancer control. 1996;3(4):336-42. 6. gondivkar sm, gadbail ar, chole r, parikh rv. adenoid cystic carcinoma: a rare clinical entity and literature review. oral oncol. 2011;47(4):231-6. https://doi.org/10.1016/j. oraloncology.2011.01.009 7. dillon pm, chakraborty s, moskaluk ca, joshi pj. adenoid cystic carcinoma: a review of recent advances, molecular targets, and clinical trials. wileyonlinelibrary.com. https://doi. org/10.1002/hed.23925 8. nicolai p, bradley pj. anterior skull base tumors. adv otorhinolaryngol. 2020;84:197-209. https://doi.org/10.1159/000457939 9. karimi a, parhiz a, eslamiamirabadi n, khiavi mm. adenoid cystic carcinoma of buccal mucosa: a report of two rare cases and review of literature. clin case rep. 2021;9:23-30. 10. jensen ad, poulakis m, nikoghosyan av, chaudhri n. re-irradiation of adenoid cystic carcinoma: analysis and evaluation of outcome in 52 consecutive patients treated with raster-scanned carbon ion therapy. radiother onc. 2015;114:182-88. 11. andreasen s, kiss k, mikkelsen lh, channir hi. an update on head and neck cancer: new entities and their histopathology, molecular background, treatment, and outcome. apmis. 2019;127:240-64. https://orcid.org/0000-0003-2005-5095 https://orcid.org/0000-0002-0078-3995 layout 1 seron s et al. sa orthop j 2018;17(1) south african orthopaedic journal doi 10.17159/2309-8309/2018/v17n1a3 http://journal.saoa.org.za trauma outcomes of intramedullary nailing for open fractures of the tibial shaft seron s1, rasool mn2 1 mbchb, hdiporth, fc orth(sa); consultant, prince mshiyeni memorial hospital, durban 2 mbchb, fcs orth (sa), phd; professor, king edward viii hospital, department of orthopaedic surgery, university of kwazulu-natal, durban corresponding author: dr s seron, department of orthopaedic surgery, nelson r mandela school of medicine, university of kwazulu-natal; tel: +27 31 2604297; email: sashseron@webmail.co.za abstract aim: to establish superficial and deep infection rates and time to union of open tibial shaft fractures treated with primary debridement and locked intramedullary nails. materials and methods: the clinical records and radiographs were retrospectively reviewed of 74 gustilo-anderson grades 1 to 3a open tibial shaft fractures that were treated by initial debridement and intramedullary nail fixation over a two-year period. sixty-three men and nine women with a mean age of 33 years (range 16–67) were followed up for a mean period of 18 months (range 7–32). results: sixteen patients (22%) sustained grade 1 injuries, 38 (51%) grade 2, and 20 (27%) had grade 3a injuries. thirteen patients (18.1%) were hiv positive. the mean time to surgery was 28 hours (range 8–112). the overall infection rate was 17.6%. superficial infection developed in 10.8% and deep infection occurred in 6.8%. there was no association between time to surgery and infection rate (p=0.878). there was no association between hiv status and infection (p=0.471). there was no association between type of closure and sepsis (p=0.410). the mean time to union was 17 weeks (range 12–50). five patients (6.9%) had delayed union and one patient failed to unite without undergoing secondary procedures. conclusion: the management of gustilo-anderson grade 1 to 3a open tibial shaft fractures with primary debridement and locked intramedullary nailing shows good short-term results with low infection and non-union rates despite delay in surgical management or hiv infection. level of evidence: level 4 key words: open tibial fractures, intramedullary nails, infection, union citation: seron s, rasool mn. outcomes of intramedullary nailing for open fractures of the tibial shaft. sa orthop j 2018;17(1):24-29. http://dx.doi.org/10.17159/2309-8309/2018/v17n1a3 editor: prof anton schepers, university of the witwatersrand received: september 2016 accepted: september 2017 published: march 2018 copyright: © 2018 seron s, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare no conflicts of interest. seron s et al. sa orthop j 2018;17(1) page 25 introduction the treatment of open tibial fractures is difficult and often controversial with no general consensus on their management.1 the subcutaneous nature of the medial border as well as the delicate blood supply increases the vulnerability to open injuries, deep infection, malunion and non-union.2 the complication rate rises exponentially with high energy trauma, soft tissue disruption, wound contamination, altered vascularity and unstable fractures.3 several strategies have been developed to minimise these complications and include the use of prophylactic antibiotics, tetanus toxoid, immediate soft tissue debridement and reconstruction, skeletal stabilisation, prophylactic bone grafting and adjuvant treatment like rhbmp-2.4-7 the ultimate goal is to achieve bony union, without infection, and a fully functional painfree limb.8 the management of open fractures is regarded as an orthopaedic emergency.9 the traditional method of treating open tibial fractures was with an external fixator preferably within six hours of injury.10,11 monolateral external fixation has been employed to treat open tibial fractures with great success; however, not without significant complications.12,13 plate fixation has resulted in an unacceptable high infection rate, hence the pursuit of an alternate modality of fracture stabilisation.14 the recent increase in the use of circular external fixators for open tibial fractures is encouraging especially in high energy injuries but this method has to be individualised on a patient-to-patient basis.15,16 the efficacy of intramedullary nails in the acute management of open tibial fractures is contentious.17,18 the fear of osteomyelitis has previously precluded any form of internal fixation especially in the immune-compromised host and delays in operative management greater than six hours.19,20 reamed nails offer a biological and mechanical advantage, however injurious to the endosteal vasculature with subsequent theoretical increase in infection and non-union.21 with the improvement in antibiotic use and surgical technique, the use of intramedullary nails has evolved from low energy open gustilo grade 1 and grade 2 fractures to more severe gustilo grade 3 injuries, with excellent long-term results.22,23 both reamed and unreamed nails have become the accepted standard of care in many institutions ensuring axial alignment, early weight bearing, bony union and early return to pre-injury function with minimal complications.24-26 the use of locked intramedullary nails in the acute settings for open tibial fractures has been widely reported in the international literature.4,27,28 however, there are no universally accepted guidelines. this study aims to establish superficial and deep infection rates and time to union of open tibial shaft fractures treated with primary debridement and locked intramedullary nails in our local environment. materials and methods we performed a retrospective review of all patients with open tibial shaft fractures that were treated with primary debridement and intramedullary nailing between july 2013 and june 2015 in a single provincial hospital. ethical approval was obtained from the institutional ethics committee prior to embarking on the study. a prospective database was created of all patients with tibial nails for the specified period. files were sourced from the medical records department. all skeletally mature patients with open tibial fractures which were distal to the tibial tuberosity and 5 cm proximal to the ankle joint were included. patients were excluded if they were skeletally immature, had grade 3b or 3c injuries or had an existing external fixator that was exchanged to an intramedullary nail. only 87 patients met the inclusion criteria. twelve patients were eliminated from the study due to incomplete files, poor note keeping and inadequate follow-up. all patients were managed according to a standard protocol. in the emergency department patients were given a stat dose of tetanus toxoid and a first-generation cephalosporin. wounds were cleaned and dressed, and the limb splinted prior to urgent surgical debridement. debridement and stabilisation with a locked intramedullary nail was performed as soon as possible. the transpatellar tendon approach was used under guidance of an image intensifier. the injury was classified intra-operatively according to gustilo and anderson. the decision to ream the intramedullary canal was undertaken by the operating surgeon. wounds were either left open, apposed with nylon interrupted sutures, closed by vacuum-assisted closure, or delayed closure was performed. post-operative antibiotics were individualised based on the severity of injury and continued for a period of 24 to 72 hours. wounds were inspected at 48 hours in the ward and a redebridement was performed if necessary. physiotherapy began on the first post-operative day. weight bearing was allowed based on the degree of comminution and was continued on an outpatient basis. sutures were removed at two weeks and wounds were cleaned and dressed appropriately. outpatient follow-up was scheduled at monthly intervals until clinical and radiological union. wounds were inspected for signs of infection and the erythrocyte sedimentation rate (esr) and c-reactive protein (crp) was taken if there was any clinical suspicion of infection. infection was classified as superficial or deep. superficial infection was defined as any infection of the wound or surgical site and cellulitis. deep infection was defined as an infection involving any tissue deep to the skin and subcutaneous tissue, including bone, at any point in time. resolution of infection was evaluated clinically and radiologically as well as by monitoring of inflammatory markers. bony union was also assessed clinically and radiologically. the ability to fully weight bear in the absence of pain at the fracture site satisfied the clinical criteria. radiological parameters encompassed the presence of bridging callus in a minimum of three cortices on orthogonal views. nonunion was defined as no clinical or radiological evidence of healing after at least six months of treatment. statistical analysis was performed using ibm spss for windows version 22 (armok, new york: ibm corp). a p value of <0.05 was considered to be statistically significant. categorical variables were compared between the three grades by means of pearson’s chi-square tests, while anova tests were used to compare normally distributed continuous variables between the grades. time to surgery data were compared between the three grades using kaplan-meier survival curves and log-rank tests. results seventy-five patients with 77 tibial fractures met the inclusion criteria. three patients were excluded from the study. one patient relocated to another province, one patient died of causes unrelated to the tibial fracture and one patient was imprisoned. the final cohort comprised of 63 men and 9 women with 74 open tibia fractures. the mean age was 33 years (range 16–67). mean follow-up was 18 months (range 7–32). in total, 16 fractures (22%) were classified as grade 1, 38 fractures (51%) as grade 2 and 20 fractures (27%) as gustilo-anderson grade 3a open fractures. the fracture morphology included comminuted (41.3%), oblique (36%), transverse (9.3%), segmental (6.7%) and spiral (6.7%) fractures (table i). the majority of the fractures were located in the middle third (54.7%) of the tibial diaphysis followed by distal third (34.7%) and proximal third (10.7%). the mechanism of injury was motor vehicle-related accidents in the majority of the patients. pedestrian accidents accounted for 56% of the injuries while 13.3% were occupants of the vehicle. there were 14.7% of patients who were assaulted and 8% with gunshot injuries. page 26 seron s et al. sa orthop j 2018;17(1) five patients sustained polytrauma (graph 1). medical comorbidities were identified in eight patients; these included diabetes, hypertension, peptic ulcer disease, schizophrenia and a history of drug abuse. twenty-five patients (34.7%) were smokers. forty-six patients (63.8%) were hiv negative, 13 patients (18.1%) were hiv positive and 13 patients’ (18.1%) status was unknown. of the 13 hiv-positive patients, nine were on antiretroviral therapy and had cd4 counts ranging from 150 to 830 cells/mm3 (mean = 434 cells/mm3). the average time to surgery was 28 hours (range 8–112). the time to surgery for grade 1, grade 2 and grade 3a fractures were 28 hours, 35 hours and 22 hours respectively. the mean operating time was 78 minutes. the average length of stay in hospital was nine days (range 4–30). the overall infection rate was 17.6%. superficial infection developed in 10.8% and deep infection occurred in 6.8% (table ii). there was no association between hiv status and infection (p=0.471). only one hiv-positive patient developed superficial infection and there were no hiv-positive or unknown patients with deep sepsis across all grades (table iii). time to surgery was compared in those patients with and without sepsis within the different grades and overall using non-parametric mann-whitney tests. there was no difference in the time to surgery between those with and without sepsis, either within grades or across grades. this indicated that time to surgery was not associated with the development of sepsis (p= 0.878). gustilo-anderson grade 1 injuries had an infection rate of 6.3%. there was a single patient who developed superficial wound infection that resolved following local wound care and oral antibiotics, (esr 15, crp <10). no patients with grade 1 injuries developed chronic osteomyelitis or deep infection. gustilo-anderson grade 2 injuries had an infection rate of 18.4%. four patients (10.5%) developed superficial infection, (average esr 6, crp <10). one patient required intravenous antibiotics for cellulitis while local wound care and oral antibiotics were sufficient for the remaining three patients. three patients (7.8%) developed deep infections, (average esr 43, crp 14). two patients had chronic draining sinuses at the distal locking screw that resolved after screw removal but did not necessitate nail removal. one patient developed chronic osteomyelitis with a chronic draining sinus on the anterior medial cortex that resolved with nail removal after union (figure 1). pus swab showed no growth in all cases. the overall infection rate in gustilo-anderson grade 3 injuries was 25%. three patients (15%) had superficial sepsis (average esr 23, crp 30). one patient with cellulitis required intravenous antibiotics while two patients were managed with local wound care and oral antibiotics. two patients (10%) developed deep infection, (average esr 82, crp 20). one patient had an abscess collection that underwent incision and drainage with implant retention while the second patient required nail removal and application of a circular external fixator (figure 2). staphylococcus aureus was cultured in both cases. wounds were managed by apposition with nylon interrupted sutures in 60% of cases; left open in 29.3% of cases; vacuum-assisted closure was used in 8% of cases and delayed closure in 2.7% of cases. there is no association between type of closure and sepsis (p=0.410). the trends shown suggest that apposition with nylon was associated with the highest deep sepsis rate (7%) followed by vacuum assisted closure. the numbers are too small to reach any definitive conclusion. table i: different fracture pattern for all grades fracture pattern gustilo grade 1 2 3a total transverse 12.5% 13.2% 0.0% 9.3% oblique 31.3% 39.5% 33.3% 36.0% spiral 6.3% 7.9% 4.8% 6.7% segmental 0.0% 0.0% 23.8% 6.7% comminuted 50.0% 39.4% 38.1% 41.3% graph 1. mechanism of injury across all grades 80 60 40 20 0 p er ce n t (% ) assault fall gsw mva pva soccer mechanism gustilo type i ii iiia table ii: superficial and deep infection rates sepsis gustilo grade 1 2 3a total superficial 6.3% 10.5% 15.0% 10.8% deep/ osteomyelitis 0.0% 7.9% 10.0% 6.8% no sepsis 93.7% 81.6% 75.0% 82.4% table iii: hiv status and superficial and deep infection rates sepsis hiv status negative positive unknown total superficial 8.2% 1.3% 1.3% 10.8% deep/ osteomyelitis 6.8% 0.0% 0.0% 6.8% no sepsis 49.2% 16.6% 16.6% 82.4% figure 1. a patient treated with imil; (a) pre-operative, (b) early post-operative, and (c and d) final radiograph a b c d seron s et al. sa orthop j 2018;17(1) page 27 the average time to union was 15.5 weeks in the grade 1, 17.3 weeks in the grade 2 (figure 3), and 17.8 weeks in grade 3a fractures (figure 4). the mean time to union for all grades was 17 weeks (range 12–50) (table iv). three patients had delayed union but united with full weight bearing. two patients required dynamisation before union could be achieved. there was a statistically significant difference in time to union between the grades (p=0.019). the survival curve shows that grade 1 required the shortest time to union while grade 2 and 3a required longer time on average (figure 5). there was no difference (p=0.410) in time to union between grade 2 and 3a injuries. one patient who sustained a grade 3a injury developed a septic non-union and united by 50 weeks after nail removal, debridement, bone grafting and application of a circular fixator with fibular osteotomy (figure 2). all 16 patients in grade 1 had reamed nails while 20 in grade 2 (52.6%) and 13 in grade 3a (56.3%) had reamed nails. there was no statistically significant difference in mean time to union between those with and without reaming in group 2 (p=0.696) and in group 3a (p=0.643). discussion the treatment of open tibial fractures is complex and successful outcomes are dependent on multiple variables.17 the long-term complications include non-union, chronic osteomyelitis and amputation. despite multiple publications the optimal management of these injuries is still unclear. the circular external fixator has been shown to be an effective option; however, longterm studies are required. the successful treatment of open tibial fractures with intramedullary nailing has been well documented but few studies have been published on this topic in sub-saharan africa. this study reports the outcomes of our local experience of open tibial fractures in the acute setting, in our unique patient population with a high prevalence of hiv, and with limited theatre availability and resources. infection rates are directly proportional to the severity of injury as defined by the gustilo-anderson classification as well as the host comorbidities.29-31 superficial infection usually resolves with minimal intervention; however, deep infection warrants multiple figure 3. ap radiographs of a grade 2 fracture (a), treated with locked intramedullary nail (b). ap and lateral 17 weeks after the nail (c and d) a b c d figure 2. ap radiographs of grade 3a tibial fracture (a) treated with an intramedullary nail (b). intramedullary nail was removed and a circular frame applied (c). ap and lateral showing valgus malunion after 1 year (d, e). a b c d e figure 4. ap radiographs of a grade 3a segmental fracture (a), treated with a locked intramedullary nail (b). ap and lateral showing united fracture (c and d). a b c d table iv: time to union for all grades time to union (weeks) gustilo grade 1 2 3a total median 15.5 17.3 17.8 17.0 25th percentile 14.8 16.0 14.8 15.0 75th percentile 17.3 20.0 20.0 19.8 minimum 13.5 14.0 12.0 12.0 maximum 20.0 24.0 50.0 50.0 figure 5. kaplan-meier survival curve for time to union 1.0 0.8 0.6 0.4 0.2 0.0 c u m u la tiv e p ro b ab ili ty o f n o n -u n io n 0 10.0 20.0 30.0 40.0 50.0 time to union (weeks) gustilo type i ii iiia page 28 seron s et al. sa orthop j 2018;17(1) additional surgical procedures and often results in significant morbidity.32 multiple studies reported infection rates following intramedullary nailing of open tibial fractures. court brown reported infection rates ranging from 1.8% to 12.5%.20 yokoyama et al., agrawal et al. and joshi et al. reported deep infection rates of 6.1%, 10% and 10.1% respectively.33-35 the results in this study show a superficial infection rate of 10.8% and a deep infection of 6.8%, and are comparable to international literature. the current management trend for gustilo grade 1, 2, and 3a open fractures of the tibia is to perform a reamed or unreamed intramedullary nail ideally within six to eight hours of injury.36 however, the traditional ‘six hour rule’ has been challenged in recent literature.11,37 originally described by friedrich in 1898, multiple studies have shown that this narrow time window should not be followed rigidly.38,39 in our local hospitals, the demand for emergency theatre time does not permit surgery in the first six hours due to the high trauma burden and relative staff shortages. the mean time to surgery was 28 hours with 42 patients being operated after 24 hours. although we still advocate surgical debridement and stabilisation as soon as possible, this delay was not associated with the development of infection. the optimal management of open fractures in hiv-positive patients is controversial. harrison et al. attributed hiv as possibly the cause for sepsis and delayed union in his series of 27 patients and advocated the use of an external fixator over an intramedullary device.20 in direct contrast, aird et al. reported that hiv-positive patients with open tibial fractures can be managed with both internal and external fixation methods but cautioned against a certain subgroup in grade 1 injuries with advanced hiv infection.40 howard et al. concluded that hivpositive patients with a cd4 count >350 cells/mm are not at risk of early wound sepsis when compared to hiv-negative patients.41 much of the recent literature denies the relationship between hiv and early wound sepsis in open tibial fractures treated by internal fixation methods but the long-term implant sepsis rates are largely unknown. phaff et al. showed in a long follow-up that averaged 39 months that hiv-positive patients are not associated with late implant sepsis and routine removal should be avoided.42 the current study showed no association between hiv status and infection (p=0.471) but was underpowered to draw strong conclusions. emphasis has been placed on the soft tissue management in open tibial fractures in the recent literature.43-45 evidence suggests that nosocomial infections are the cause of osteomyelitis rather than the index traumatic event.46 open fractures were traditionally left open so as to allow for wound drainage and inspection, and primary wound closure was forbidden due to the fear of osteomyelitis.47 this practice has been challenged due to the recent advances in systemic antibiotic use, local antibiotic beads, the so-called ‘fix and flap’ technique, negative pressure wound care and more effective methods of fracture stabilisation.48,49 in this study there is no association between type of closure and infection yet apposition with nylon interrupted sutures was associated with the highest deep infection rates. rajasekaran et al. closed wounds primarily in high energy open tibial fractures with 86.7% excellent results.43 weitz-marshall et al. condone primary wound closure provided an adequate surgical debridement and stabilisation is performed.44 hohmann et al. reported low infection rates with primary wound closure in low energy open tibial fractures in selected cases.45 one of the primary goals in the management of open tibial fractures is to achieve bony union. this is dependent on multiple host, injury and surgical factors, and the presence or absence of infection. drosos et al. identified fracture gap, comminution, screw failure and dynamisation as potential risk factors for non-union in tibial fractures treated with intramedullary nails.50 adams et al. reported an increase in soft tissue complications and non-union in patients who smoke with open tibial fractures.51 joshi et al. agrawal et al. and bali et al. reported union times that ranged from 20.7 weeks to 32 weeks.34,35,39 average time to union in our study was 17 weeks (range 12–50). three patients had delayed union but required only full weight bearing to achieve union and two patients required dynamisation before union. kakar et al. reported 32 patients with delayed union, of which 16 patients required additional surgical procedures to achieve union.52 in this study one patient who sustained a grade 3a injury developed a septic non-union and eventually united by 50 weeks after secondary procedures. convincing biological and mechanical advantages exist for both reamed and unreamed intramedullary nails in the management of tibial fractures.21 the benefits in open fractures is still uncertain.28 reaming strips the endosteal blood supply and affects the cortical perfusion which contributes to the vascular insult in open fractures.53 there is concern that reaming open fractures may increase the risk of infection by spreading contamination in the medullary canal and osteocyte death by thermal necrosis.21 however proponents of reaming suggests that seeding of bone graft throughout the medullary canal accelerates union rates by enhancing the biological milieu that is conducive to fracture healing.54 reamed nailing allows the use of larger diameter nail and increases the intimacy between the nail-cortex interface, therefore enhancing the biomechanical stability. finkemeier et al. and ziran et al. compared reamed and unreamed nails in open tibial fractures and found no significant differences between the two with regard to union.22,55 keating et al. found similar results between the two methods but found more metalware complications in the unreamed group.56 two meta-analyses on the use of reamed or unreamed nails have demonstrated no superiority of either modality.4,27 this study has shown a mean time to union of 17 weeks in the reamed group and 18 weeks in the unreamed group. there was no statistically significant difference in time to union between the groups. equivocal results in the literature on infection rates and reaming suggest that different variables other than reaming influence the outcomes.22 we were unable to demonstrate the relationship, if any, between reaming of the intramedullary canal and the development of superficial and deep infection. there are numerous limitations to this study including a retrospective review, small sample size and lack of a control group. we are unable to draw definitive conclusions regarding the effect of hiv status on infection following open tibial fractures. conclusion this study demonstrates that grade 1, 2 and 3a open tibial shaft fractures can be treated with primary debridement and locked reamed or unreamed intramedullary nailing with good shortterm results, low infection and non-union rates. this was shown in patients with delayed presentation or a delay in operative intervention and hiv-positive patients. ethics statement ethical approval was obtained from the institutional ethics committee prior to embarking on the study. acknowledgement i would like to thank prof nando ferreira for his contribution to this article. seron s et al. sa orthop j 2018;17(1) page 29 references 1. ryan sp, pugliano v. controversies in initial management of open fractures. scand j surg. 2013;103:132-37. 2. rhinelander fw. tibial blood supply in relation to fracture healing. clin orthop relat res. 1974;105:34-81. 3. gustilo 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fractures of the tibial shaft: ender nailing versus external fixation. a randomized, prospective comparison. j bone joint surg am. 1989;71-a:1231-38. 14. bach aw, hansen jr st. plates versus external fixation in severe open tibial shaft fractures: a randomized trial. clin orthop relat res.1989;241:89-94. 15. dickson d, moulder e, hadland y, giannoudis p, sharma h. grade 3 open tibial shaft fractures treated with a circular frame, functional outcome and systematic review of literature. injury. 2015;46:751-58. 16. inan m, halici m, ayan i, tuncel m, karaoglu s. treatment of type iiia open fractures of tibial shaft with ilizarov external fixator versus unreamed tibial nailing. arch orthop trauma surg. 2007;127(8):617-23. 17. o’brien c, menon m, jomha n. controversies in the management of open fractures. open orthop j. 2014;8(1):178-84. 18. whittle a, russell t, taylor j, lavelle d. treatment of open fractures of the tibial shaft with the use of interlocking nailing without reaming. j bone joint surg am. 1992;74-a:1162-71. 19. khatod m, botte mj, hoyt db, meyer rs, et al. outcomes in open tibia fractures: relationship between delay in treatment and infection. j trauma. 2003;55:949-54. 20. harrison w, lewis c, lavy c. open fractures of the tibia in hiv positive patients: a prospective controlled single-blind study. injury. 2004;34:852-56. 21. pape h-c, giannoudis p. the biological and physiological effects of intramedullary reaming. j bone joint surg br. 2007;89-b:1421-26. 22. finkemeier cg, schmidt ah, kyle rf, templeman dc, et al. a prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. j orthop trauma. 2000;14:187-93. 23. keating j, mcqueen m. infection after intramedullary nailing of the tibia. incidence and protocol for management. j bone joint surg br. 1992; 74-b:770-74. 24. obremskey w, molina c, collinge c, nana a, et al. current practice in the management of open fractures among orthopaedic trauma surgeons. part a: initial management. a survey of orthopaedic trauma surgeons. j orthop trauma. 2014;28:198-202. 25. bhandari m, guyatt gh, tornetta iii p, swiontkowski mf, et al. current practice in the intramedullary nailing of tibial shaft fractures: an international survey. j trauma. 2002;53:725-32. 26. busse jw, morton e, lacchetti c, guyatt gh, bhandari m. current management of tibial shaft fractures: a survey of 450 canadian orthopedic trauma surgeons. acta orthopaedica. 2008;79:689-94. 27. shao y, zou h, chen s, shan j. meta-analysis of reamed versus unreamed intramedullary nailing for open tibial fractures. j orthop surg res. 2014;9:74. 28. investigators sprint. randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. j bone joint surg am. 2008;90-a:2567. 29. bowen tr, widmaier jc. host classification predicts infection after open fracture. clin orthop relat res. 2005;433:205-11. 30. gustilo r, anderson j. prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. j bone joint surg am. 1976;58:453-58. 31. patzakis mj, wilkins. factors influencing infection rate in open fracture wounds. clin orthop relat res. 1989;243:36-40. 32. patzakis mj, zalavras cg. chronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management concepts. j bone joint surg am. 2005;13-a:417-27. 33. yokoyama k, itoman m, uchino m, fukushima k, et al. immediate versus delayed intramedullary nailing for open fractures of the tibial shaft: a multivariate analysis of factors affecting deep infection and fracture healing. indian j orthop. 2008;42:410. 34. joshi d, ahmed a, krishna l, lal y. unreamed interlocking nailing in open fractures of tibia. j orthop surg (hong kong). 2004;12:216. 35. agrawal a, chauhan vd, maheshwari rk, juyal ak. primary nailing in the open fractures of the tibia-is it worth? j clin diagn res. 2013;7:1125. 36. okike k, bhattacharyya t. trends in the management of open fractures: a critical analysis. j bone joint surg am. 2006;88-a:2739-48. 37. kamat as. infection rates in open fractures of the tibia: is the 6-hour rule fact or fiction? adv orthop. 2011. 38. singh j, rambani r, hashim z, raman r, sharma hk. the relationship between time to surgical debridement and incidence of infection in grade iii open fractures. srategies trauma limb reconstr. 2012;7:33-37. 39. bali k, aggarwal s, kumar v, mootha ak, et al. operative management of type ii and type iiia open tibial fractures presenting from 6–24 hours after injury: an indian experience. curr orthop pr. 2011;22:262-66. 40. aird j, noor s, lavy c, rollinson p. the effect of hiv on early wound healing in open fractures treated with internal and external fixation. j bone joint surg am. 2011;93-a:678-83. 41. howard n, phaff m, aird j, wicks l, rollinson p. does human immunodeficiency virus status affect early wound healing in open surgically stabilised tibial fractures? bone joint j. 2013;95:17037. 42. phaff m, aird j, rollinson p. delayed implants sepsis in hiv-positive patients following open fractures treated with orthopaedic implants. injury. 2015;46:590-94. 43. rajasekaran s, dheenadhayalan j, babu j, sundararajan s, venkatramani h, sabapathy s. immediate primary skin closure in type-iii a and b open fractures. j bone joint surg br. 2009;91-b:217-24. 44. weitz-marshall ad, bosse mj. timing of closure of open fractures. j bone joint surg am. 2002;10-a:379-84. 45. hohmann e, tetsworth k, radziejowski m, wiesniewski t. comparison of delayed and primary wound closure in the treatment of open tibial fractures. arch orthop trauma surg. 2007;127:131-36. 46. neubauer t, bayer g, wagner m. open fractures and infection. acta chirurgiae orthopaedicae. 2006;73:301. 47. russell g, henderson r, arnett g. primary or delayed closure for open tibial fractures. j bone joint surg br. 1990;72-b:125-28. 48. gopal s, majumder s, batchelor a, knight s, de boer p, smith r. fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. j bone joint surg br. 2000;82-b:959-66. 49. prasarn ml, zych g, ostermann p. wound management for severe open fractures: use of antibiotic bead pouches and vacuum-assisted closure. am j orthop. 2009;38:559-63. 50. drosos g, bishay m, karnezis i, alegakis a. factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade i open fractures. j bone joint surg br. 2006;88-b:227-31. 51. adams c, keating j, court-brown c. cigarette smoking and open tibial fractures. injury. 2001;32(1):61-65. 52. kakar s, tornetta iii p. open fractures of the tibia treated by immediate intramedullary tibial nail insertion without reaming: a prospective study. j orthop trauma. 2007;21:153-57. 53. reichert i, mccarthy i, hughes s. the acute vascular response to intramedullary reaming. microsphere estimation of blood flow in the intact ovine tibia. j bone joint surg br. 1995;77-b(3):490-93. 54. larsen lb, madsen je, høiness pr, øvre s. should insertion of intramedullary nails for tibial fractures be with or without reaming?: a prospective, randomized study with 3.8 years’ follow-up. j orthop trauma. 2004;18:144-49. 55. ziran bh, darowish m, klatt b, agudelo j, smith w. intramedullary nailing in open tibia fractures: a comparison of two techniques. int ortho. 2004;28:235-38. 56. keating j, o’brien p, blachut p, meek r, broekhuyse h. locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. a prospective, randomized study. j bone joint surg am. 1997;79-a:334-41. 404 not found 404 not found 404 not found 404 not found 404 not found bernstein bp et al. sa orthop j 2019;18(2) doi 10.17159/2309-8309/2019/v18n2a4 south african orthopaedic journal http://journal.saoa.org.za traumatrauma citation: bernstein bp, du plessis jp, laubscher m, maqungo s. management of complex proximal humerus fractures in the elderly: what is the role of open reduction and internal fixation? sa orthop j 2019;18(2):37-43. http://dx.doi.org/10.17159/2309-8309/2019/v18n2a4 editor: prof lc marais, university of kwazulu-natal, durban, south africa received: february 2019 accepted: april 2019 published: may 2019 copyright: © 2019 bernstein bp, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: none. conflict of interest: there were no conflicts of interest for any author with respect to this review. abstract the ultimate goal of management of proximal humeral fractures in the elderly patient is to get the patient independently mobile. this article will review the current literature regarding this cohort of patient. recent cochrane reviews and a large multicentre randomised study question the role of surgical intervention. implant design is evolving rapidly, and many elderly patients now behave more like the younger patient. there remains little compelling evidence to guide decision-making for the complex proximal humeral fracture in the elderly, and the decision needs to be made on a case-by-case basis taking into account the patient’s comorbidities, the fracture pattern and characteristics, the attending surgeon’s skill sets, and the availability of equipment. level of evidence: 5 key words: proximal humerus fracture, fragility fracture, osteoporosis, implant evolution, internal fixation management of complex proximal humerus fractures in the elderly: what is the role of open reduction and internal fixation? bernstein bp¹ , du plessis jp² , laubscher m³ , maqungo s4 1 mbbch(wits)fcs(sa)orth; 1: cape orthopaedic trauma group. life orthopaedic hospital, alexandra road, pinelands, 7405, cape town, south africa; 2: orthopaedic research unit, department of orthopaedic surgery, groote schuur hospital, university of cape town, cape town, south africa ² mbchb(uct), dip pec, fc orth (sa), mmed ortho (uct); 1: orthopaedic research unit, department of orthopaedic surgery, groote schuur hospital, university of cape town, cape town, south africa; 2: orthopaedic department, new somerset hospital, cape town; 3: life orthopaedic hospital, cape town ³ mbchb(ufs), dip pec, fc orth (sa), mmed ortho (uct); orthopaedic research unit, department of orthopaedic surgery, groote schuur hospital, university of cape town, cape town, south africa 4 mbchb(natal), fc orth (sa), mmed ortho (uct); orthopaedic research unit, department of orthopaedic surgery, groote schuur hospital, university of cape town, cape town, south africa corresponding author: dr bp bernstein, life orthopaedic hospital, park road, pinelands, 7405, cape town, south africa; po box 599, constantia, 7848, south africa; email: bb@otg.org.za http://orcid.org/0000-0002-1859-4594 https://orcid.org/0000-0001-6469-7765 http://orcid.org/0000-0002-5989-8383 page 38 bernstein bp et al. sa orthop j 2019;18(2) introduction the ultimate goal of management of proximal humeral fractures in the elderly patient is to get the patient independently mobile. this relies on a multidisciplinary team approach in which operative intervention may or may not be indicated. elderly patients may not tolerate prolonged immobilisation, and in addition, sling immobilisation affects balance and may increase the risk of falling. fixation of osteoporotic bone is different to that of physiologically normal bone. fracture healing takes a longer time, the implant fixation in the bone is compromised, and fracture patterns may be more complex, with surgery becoming more technically demanding. this combination of factors may lead to progressive failure at the bone implant interface, implant migration and fracture displacement.1-4 indications for surgery vary a great deal from study to study, and are often ill defined. identification of risk factors for poor outcomes is important, including the identification of poor bone mineral density and the possibility of developing avascular necrosis. incidence there is an increasing incidence of proximal humerus fracture rates and a decline in hip fractures in patients over 50 years of age.5 proximal humerus fractures are reported to be the third most common osteoporotic fracture excluding spine and the second most common upper extremity fragility fracture. it is reported that 73% occur in females.6,7 in a recent prospective study of 5 147 women with osteoporotic fractures, undisplaced proximal humerus fractures comprised 17.5% and were the third most frequent fracture after distal radius and vertebral fractures. patients over the age of 70 years showed a decrease in the incidence of distal radius and vertebral fractures, but not proximal humerus fractures.8 osteoporosis osteoporosis results in altered microarchitecture and a decreased bone mass which is caused by an imbalance in the bone resorption and formation. in addition, there are intrinsic changes such as altered collagen cross linkage and distribution of mineralisation which contributes to the decreased bone strength and modulus of elasticity. the resultant increased bone fragility increases fracture risk. stiffness of bone alters by 1–2% per decade, and the strength of bone decreases by 2–5% per decade. the energy required to cause a fracture decreases by up to 10% per decade over the age of 35 years.9 osteoporosis is the most common bone disease in the us.10 the costs relating to management of osteoporotic fractures is significant, and these fractures are an important cause of morbidity and mortality. the diagnosis of osteoporosis is largely based around hip and spine bone mineral density, and the diagnostic criteria in relation to proximal humerus fractures is less clear.11 a proximal humerus fracture may be the presenting complaint in a patient with osteoporosis, and allow its diagnosis. this opportunity should not be missed. there is a six-fold increased risk of developing a hip fracture in the first year after a proximal humerus fracture.7 bisphosphonate treatment has been shown to reduce the risk of a fragility fracture by up to 70% in patients with osteoporosis.12,13 despite this, the initiation of anti-osteoporosis treatment following upper limb fragility fractures is low.8,14 this is in contrast to the reported increased initiation of treatment in patients who suffer vertebral or hip fracture.15 this implies that patients with osteoporotic proximal humerus fractures are an important group to identify and manage. the disease burden of osteoporosis is large both in terms of the impact on the individual, and the cost to society. managing these patients appropriately may enable a reduction in the risk of subsequent fragility fractures, and improve the individual patients’ quality of life. as indications for management, including surgery, vary a great deal, a comprehensive classification system is required. many clinical studies base their indications on the amount of displacement as defined by neer in 1970.16,17 other studies have a lower threshold for surgical fixation with indications including 0.5 cm of tuberosity displacement, medial metaphyseal comminution18 or humeral head angulation of >30°,19 and although it has been suggested in some studies that operative management is the preferred method of treatment in displaced fractures, with conservative treatment resulting in ‘consistently inferior results’,1 there is much evidence against this. studies have shown that the surgeon’s interpretation of displacement was variable and arbitrary20 and the benefit of surgery over conservative treatment has been questioned.20,21 classification neer’s modification of codman’s classification relies on identification of four potential parts and their displacement (shaft/ articular surface/greater tuberosity/lesser tuberosity). despite poor intraand inter-observer reliability, it remains the most commonly utilised classification system. more comprehensive classification systems have been developed, including the morphological system by hertel,22 but their usage in clinical practice remains limited. management options as mentioned, the management options include non-surgical and surgical modalities, and we ideally need to know if the bone quality is sufficient for internal fixation to support and maintain fracture reduction. indices utilising the cortical thickness of the proximal humerus on plain radiograph have been validated to predict both local and general decreased bone mineral density.23,24 the cortical index24 is a ratio of medial and lateral cortical thickness to total humeral width measured at 10 cm distal to the tip of the greater tuberosity. the cortical bone thickness average (cbt avg)23 takes measurements of the combined cortical thickness (medial and lateral cortical thickness) at two levels and averages them. the initial level of measurement is the most proximal point on the humeral shaft where the medial and lateral cortices are parallel and the second level is 20 mm below that. these measurements have been shown to be easily reproducible on simple anteroposterior radiographs of the proximal humeral shaft. a recent advance is the ability to quantify the bone mineral density using ct scan evaluation of the proximal humerus.25 it was found that a bone mineral density value of 95 mg/cm3 was the cut-off, below which implant failure was likely to occur. as many centres use ct scan as part of the pre-operative workup, these recommendations could have useful practical implications.26 the mode of failure in osteoporotic bone is more likely to be failure of the bone than of the implant itself. factors which predispose to internal fixation failure in the proximal humerus include low bone mineral density, varus malreduction, avascular necrosis, poor medial column restoration and nonanatomic reduction.27 page 39bernstein bp et al. sa orthop j 2019;18(2) the options available for the surgical management of the proximal humerus are many and varied, which in itself is an indication of the technical difficulty and variable outcomes of each modality. anatomical fixed angle plates, intramedullary nails, minimally invasive screw or wiring constructs and arthroplasty (both hemi and reverse) have all been described. in addition, fixation may be augmented with bone cement, intramedullary fibula strut grafts or cortico-cancellous iliac crest grafts. k-wires the benefit of k-wire fixation after closed reduction is that there is relatively little surgical insult and exposure, and minimal soft tissue damage. this may reduce the risk of avascular necrosis.19,28 however, the thin cortices may not provide enough purchase for fixation, and loss of reduction may ensue.28 resch et al. describe a technique utilising the humerus block to provide lateral fixation and angular stability to the k-wires29 and it is felt the relative stability achieved may in fact be an advantage in osteoporotic bone where rigid implants can cut out, or promote non-union. this technique relies on soft tissue bridging between the fragments, and appears to be more suitable for valgus impaction fractures. resch himself reports good results in three-part fractures, but in four-part fractures this is a technically demanding technique and is not widely employed.19 plates since the introduction of locked plate technology (angular stable constructs) the rate of fixation of proximal humeral fractures has increased. although the majority (84%) of fractures are managed conservatively there has been a relative increase of 28.5% of fractures that underwent open reduction and internal fixation (orif) between 2004 and 2005 when compared to 1999–2000.30 it is worth noting that the rate of revision surgery has increased as well. this increase may not be related only to advances in technology, as other factors such as patient and surgeon expectations and the fracture patterns related to active lifestyles may also have contributed to this increasing surgical trend.28 fixed angle anatomic locking plates have become the most commonly utilised implants for fixation of proximal humerus fractures.20,31 the mode of failure of locked plates differs from conventional plates which will fail by the loosening of individual screws sequentially whereas locked plates will fail by simultaneous cut-out of multiple screws or by fracture of the bone at the stress riser at the end of the plate.32 it has been shown that good restoration of support to the inferomedial calcar is important in maintaining fracture reduction.33-35 early loss of reduction remains a problem and was noted in 22.5% of cases, with a strong correlation to the amount of impaction, female sex, and metaphyseal comminution. this highlights that surgical technique and implant placement are important. the screws should be placed in such a way so that they gain as much purchase as possible in subchondral bone. after reduction of the osteoporotic fracture, a residual cavity is often created. some authors advocate the use of adjuncts to fill this defect. calcium phosphate and bone graft (cancellous or fibula strut) have been used. attention to reduction technique may limit the size of the resultant bone defect.2 early good results with locked plates17 were tempered by studies reporting complication rates as high as 21%,18 and even as high as 37%,36 with a 20% re-operation rate. all the studies seem to report worse outcomes with four-part fractures, and it appears that two-part fractures tend to do well. the variation in indications for surgery and the type of fractures managed in most of these studies makes comparative interpretation of the reported results challenging. the proximal humerus plate has gone through a number of evolutionary changes in an attempt to improve the outcomes. the initial clover leaf plates did not have angular stability and have been replaced by fixed angle locking plates with divergent screws, low anatomic profiles, suture holes for the attachment of tension band sutures and rotator cuff sutures, and now variable angle locking screw options, medial calcar support screws and cannulated screws to allow delivery of cement into the fracture site. new technology continues to be introduced with the latest being investigation into the use of different materials such as peek (polyetheretherketone) plates. peek has a modulus of elasticity much closer to bone than titanium or stainless steel, and it is postulated that this material will allow the development of a plate with the benefits of angular stability for the screws, but reduced implant stiffness to reduce the stress riser affect and allow biological healing of the fracture.37 as an adjunct to fixation with plate or nails, tension band suture fixation of the rotator cuff and tuberosities has been shown to improve outcomes.38-40 nails in general, the surgical management of insufficiency fractures is best achieved by an implant that is load sharing. the intramedullary nail is such a load-sharing device. in addition, the more medial position of the implant, shorter lever arm in the humeral head, and better preservation of blood supply, soft tissue and periosteum would infer that this is the better implant to utilise. however, there are problems associated with its use in osteoporotic bone and insufficiency fractures because the fracture configuration is often complex and unstable with comminution of the lateral cortex, which may lead to secondary displacement and failure. post-fixation shoulder pain related to damage to the rotator cuff insertion and impingement remains an unsolved issue.9,41-43 a recent meta-analysis concluded that although satisfactory clinical results can be achieved utilising nails in twoand threepart fractures of the proximal humerus, re-operation rates were 15.8% and complication rates were as high as 42.5%, 28% of which were related to loss of reduction, screw perforation or malunion. in four-part fractures the re-operation rates were as high as 63.2%, and there were 29 complications in 33 patients they concluded that the use of intramedullary nails ‘for four-part fractures cannot be recommended’. in this meta-analysis, there was no study that included a non-operative control group and only 33 of a total of 448 patients had four-part fractures which were managed with intramedullary nails. this probably is a reflection that the general orthopaedic community is in agreement with their conclusions.44 good outcomes have been reported for fracture fixation with intramedullary nails but elderly patients tend to have poorer functional results and increased complications.45 nail design may impact on outcomes as straight nails have been shown to have better outcomes in terms of range of motion than curved nails, and the more medial insertion addresses the lateral cortex comminution better.46 there is, however, no statistical difference in the outcomes in a recent randomised controlled clinical trial comparing curved to straight nails.47 page 40 bernstein bp et al. sa orthop j 2019;18(2) the use of threaded bushings to minimise screw back-out and provide more angular stability in osteoporotic bone has been proposed.43 one of the most important goals of proximal humerus fracture fixation is to restore the medial calcar to prevent varus collapse. new generation nails are starting to incorporate more distal locking screws or a blade to support the medial calcar to prevent this mode of failure.1 the distal screw constructs may, however, put the axillary nerve at risk.48 the design of intramedullary proximal humeral nails has advanced a great deal recently in recent years. modifications have included: • straighter nails • nylon bushings and end caps to confer angular stability • more distal screws and blades angled superiorly • suture anchor points on the screw or blade heads • varied and divergent proximal screw placement.41 comparative studies of plate versus nail fixation have been performed. a recent study testing the biomechanics in sawbones shows higher stiffness and load to failure in nails over plates,43 but this does not take the soft tissue repair into account. clinical studies including large meta-analysis and cochrane reviews have found little to support one over the other, and both appear to be viable options in the twoand three-part fractures, although fourpart fractures may require a different approach.49 augmentation many different augments have been used in an effort to optimise the fracture stability, fill defects and promote anatomic healing. this is largely driven by the complications of implant failure and loss of reduction seen in all the surgical options. the most common augments utilised currently are fibula strut grafts, calcium phosphate and pmma (polymethyl methacrylate) cement. implants have been adapted and designed to accommodate these augments, such as the perforated cannulated screws and blades to allow for the delivery of cement to the screw tips and humeral head defects. anteromedial and anteroinferior screws have been shown to have the lowest breakaway torque and provide the greatest resistance to displacement when two of these screws are used for augmentation.50,51 biomechanical studies have shown that a corticocancellous bone block contributes to the stability of two-part fractures with a medial fracture gap by increasing the stiffness and load to failure.52 in-vitro studies have shown that filling the fracture void with calcium triphosphate cement using pmma augmentation with plates and nails decreases the risk of screw pull-out and loss of reduction.53-55 fibula struts show promise, although clinical studies in the current literature are of a small sample size.56,57 femoral head allograft augmentation has shown similar results in a group of ten patients, with an average post-op constant score of 72 at 28 months, and one non-union (10%).58 although clinical results are promising, these techniques are not without complications,59 and there are no studies with a control group to allow for comparison. this makes the interpretation of results difficult. concerns regarding late removal of implants following the use of augments such as bone cement appear unfounded.60 bone morphogenic proteins and biomaterials may become useful adjuncts as bmps are thought to be involved in the development of osteoporosis, but at this stage the literature is limited to preclinical trials.61 it seems that current opinion will concur that it does not matter what technique of fixation is employed, or which augmentation method utilised. good outcomes will still rely on anatomic reduction of the tuberosities and the humeral head. no amount of augmentation or implant evolution will compensate for poor surgical technique. the recommendation of the recent reviews is that medial support screws should be used in all cases as they seem to confer improved biomechanical stability by supporting the medial calcar and do not add to the surgical insult. with regard to augmentation, there is insufficient evidence to support their use, although they do appear to have a stabilising effect.62 soft tissue attention to the status of the soft tissue, and meticulous closure and dressing care in the elderly patient with thin skin is important, and the decision and timing of surgery must take this into account. arthroplasty a full discussion on the use of arthroplasty in the treatment of proximal humerus fractures is beyond the scope of the title of this article, but as this is a developing option a few points must be mentioned. there is a documented increase in the use of primary arthroplasty to manage the complex proximal humerus fracture and as with plate and nail fixation, good results have been shown to rely on healing of the tuberosities in an anatomical position. this is particularly relevant when it comes to the use of hemiarthroplasty. there has been a steadily increasing use of the reverse shoulder replacement in an attempt to bypass the requirements of tuberosity healing in fractures treated with hemiarthroplasty.30,63 as with the other treatment modalities the latest cochrane review does not find enough evidence to recommend the use of one modality over the other, nor is there enough evidence to advise arthroplasty over conservative treatment. our opinion and anecdotal findings are that patients often experience good early pain relief and mobility following reverse shoulder replacement, obviating the need for sling immobilisation and the complications associated with this in the elderly. the reverse shoulder replacement is also a useful salvage option in cases of failed fixation or hemiarthroplasty.64 there is little evidence to guide the timing of reverse shoulder arthroplasty, but one small retrospective study found that the use of the reverse shoulder arthroplasty as a primary procedure (rather than as revision for hemiarthroplasty or internal fixation) yielded better results. there was no significant difference in the outcomes if the reverse shoulder replacement was done for the acute fracture or for the treatment of a symptomatic malunion.65 conservative treatment this review would be incomplete if we did not report on the results of conservative treatment. a recent cochrane review concluded that ‘there is high or moderate quality evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures’. it is however ‘likely to result in greater need for subsequent surgery’! this finding was based on eight studies comparing outcomes between surgical and non-surgical groups but was dominated by the profher study. page 41bernstein bp et al. sa orthop j 2019;18(2) these findings excluded fractures as a result of high energy trauma, two-part fractures involving the tuberosities, fracture dislocations and head splitting fractures. it also found insufficient randomised control trials to support a particular choice between different non-surgical or, when indicated, surgical interventions.21 the profher study is a multicentre randomised clinical trial to assess the difference in outcomes between patients with proximal humerus fractures managed non-operatively and those managed surgically. patients included were those with proximal humerus fractures involving the surgical neck where the attending surgeon would have considered surgery. as mentioned, exclusions included, among others, fractures isolated to the tuberosities, head splitting fractures, fracture dislocations, and open fractures or fractures with severe soft tissue injury which would preclude operative treatment. patients with significant medical comorbidities who could not tolerate anaesthesia were also excluded.20 the results showed no difference in outcomes at six,12 or 24 months between the surgical and non-surgical groups, and in contrast to the cochrane review of 2012, there was also no difference in the complication rate and the number of patients requiring later surgical intervention or revision. there were relatively small numbers of four-part fractures in either group, which will make recommendations in this subgroup of patients difficult.20 will this change our treatment strategy? with the large variation in fracture types in this study there might well be subgroups that do clearly benefit from surgery, but these remain unidentified.66 conclusion there appears to be a growing body of evidence that these fractures can and often should be managed conservatively. two recent cochrane reviews and the profher randomised study found that surgical management did not confer better outcomes over conservative treatment. while this does not mean that surgery is contraindicated, it does make the patient selection for surgical intervention more difficult. to complicate matters further, there is little evidence to support one surgical modality over the other. this, combined with the number of new implants being developed and the industry-(market) driven pressures to use these implants (sometimes with little adequate clinical proof), makes decision making for the orthopaedic surgeon even more complex. there remains little compelling evidence to guide decision making for the complex proximal humeral fracture in the elderly, and the decision needs to be made on a case-by-case basis taking into account the patient’s comorbidities, the fracture pattern and characteristics, the attending surgeon’s skill sets, and the availability of equipment. it remains our opinion that too many of these fractures are undergoing surgical fixation unnecessarily. that said, many elderly patients will not tolerate conservative treatment and sling immobilisation, and many are presenting with fracture patterns resembling ‘young, high energy injuries’ due to increased activity and longevity. the decision to operate should then be made after discussing the pros and cons with the patient and their family. ethics statement this article does not contain any studies with human or animal subjects performed by any of the authors. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions it was a combined project, with each author providing literature review and equal input. orcid bp bernstein http://orcid.org/0000-0002-1859-4594 jp du plessis https://orcid.org/0000-0001-6469-7765 m laubscher http://orcid.org/0000-0002-5989-8383 references 1. hashmi f, mayr e. a new nail with a locking blade for complex proximal humeral fractures. eur. j. orthop. surg. 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[internet]. bone and joint research; 2016 [cited 2016 aug 23];5:178–84. available from: http://www.ncbi.nlm.nih.gov/ pubmed/27179004 _goback orthopaedics vol3 no4 sa orthopaedic journal spring 2015 | vol 14 • no 3 page 47 simple bilateral anterior shoulder dislocation: a case report and review of the literature n ali, ms senior resident a bhat, ms senior resident fa bangroo, ms senior resident ms dhanda, ms assistant professor sc sharma, ms, dnb professor and director all from the department of orthopaedics, shkm government medical college mewat, haryana, india corresponding author: dr nadeem ali email: drnadeeem@gmail.com cell: +919812962979 phone: + 9101942423211 introduction shoulder dislocation is the most common type of joint dislocation encountered in humans.1,2 anterior shoulder dislocation represents 95% of unilateral shoulder dislocations while unilateral posterior dislocation is far less common (4%).2,3 bilateral shoulder dislocations do occur and unlike unilateral dislocations they are most commonly of the posterior type.2,4 bilateral posterior dislocations are usually associated with seizures, electrocution and electroconvulsive therapy while bilateral anterior dislocations result from significant trauma.2,5,6 asymmetrical bilateral dislocations with one shoulder dislocated anterior and the other one posterior are extremely rare and have been reported in the literature.7,8 simple bilateral anterior shoulder dislocations without associated fracture are extremely rare. very few cases have been reported in the literature.4,9 we present a case of traumatic simple bilateral anterior shoulder dislocation and review the international literature on this rare type of injury. case history a young patient, 24 years of age, presented to our emergency department with complaints of pain and inability to move both his shoulders after he had suffered a backward fall from the edge of his bed. there was no history of alcohol intake, any medication or loss of consciousness. abstract bilateral shoulder dislocations are usually of the posterior type, which is commonly associated with seizures, electrocution or electroconvulsive therapy. bilateral anterior shoulder dislocations are very rare and usually result from significant trauma. simple bilateral anterior shoulder dislocations without associated fracture are much rarer and not many cases have been reported in the literature. we present a traumatic bilateral simple anterior shoulder dislocation in a 24-year-old male without any features of ligamentous laxity, and review the international literature on simple bilateral anterior shoulder dislocations. from the review we conclude that seizures are as important an aetiology of simple bilateral anterior shoulder dislocation as is trauma. moreover, this injury is not as rare as was considered in the past. key words: shoulder, dislocation, bilateral, seizures, glenoid, anterior dislocation http://dx.doi.org/10.17159/23098309/2015/v14n3a5 page 48 sa orthopaedic journal spring 2015 | vol 14 • no 3 there was no history suggestive of diabetes mellitus or seizure activity in the past. on examination the patient was conscious, cooperative and oriented. vitals were normal. the respiratory and cardiovascular system examination was unremarkable. both upper extremities were in the attitude of external rotation and abduction. shoulders were bilaterally symmetrical but appeared squared. laterally the sulcus sign was present together with the inability to palpate the greater tuberosity below the acromion on both sides. movements were painful and restricted on both sides. distally there was no motor, sensory or vascular deficit. there were no signs of generalised ligamentous laxity. antero-posterior radiographs of both shoulder joints had empty glenoid cavity with the humeral head lying below the coracoid process, without any associated fractures (figure 1). a diagnosis of traumatic simple bilateral anterior shoulder dislocation was made. after baseline investigations for general anaesthesia, dislocation was reduced by kocher’s manoeuvre, first on one side followed by the other, under sedation. reduction was secured in adduction and internal rotation by bilateral slings. post-reduction radiographs had concentric reduction of both shoulder joints (figure 2). the patient was discharged from the hospital with both shoulders immobilised in slings. intermittent pendulum movements of the upper extremities were started at two weeks and slings were discarded at four weeks after which full range of movement of shoulder joints was started. at eight weeks the patient gained full range of movement. at final follow-up of six months the patient had painless, full range of movement at the shoulder joints without any sign of shoulder instability (figure 3). discussion trauma is the most common mode of bilateral anterior shoulder dislocation.5,6,10 the mechanism is the same as that of unilateral dislocation but the traumatic force should be uniformly distributed between the two shoulder joints to dislocate both.2,5,11 when a person falls backwards as happened in our case, there is a reflex tendency to take the weight of the body on the hands by extending the elbow joints and abducting, externally rotating and extending the shoulder joints. the shoulder joint in the position of abduction, external rotation and extension will have greater tuberosity impinged on the posterior aspect of the acromion. figure 1. anterior dislocation of both shoulder joints without associated fracture figure 2. concentric reduction of both glenohumeral joints figure 3. range of motion of both shoulder joints at final follow-up of six months table i: published cases of simple bilateral anterior shoulder dislocation s. no. author (year) age (yr)/sex mode of trauma 1. jekic m (1973)31 ?/? fall 2. mcfie j (1976)20 31/f forward traction by motor bike 3. segal d(1979)21 60/m seizures 4. segal d (1979)21 19/m water skiing (forward traction) 5. onabowale bo (1979)28 62/m unknown (chronic at diagnosis) 6. sadhra k (1984)32 ?/f seizure (chronic at diagnosis) 7. brown rj (1984)33 60/m fall 8. brown rj (1984)33 65/m fall 9. brown rj (1984)33 31/m seizure (chronic at diagnosis) 10. hartney-velazco k (1984)37 22/f cocaine-induced seizure 11. sciammarella jc (1986)17 30/f seizure 12. jones m (1987)38 24/m weight lifting in bench press 13. litchfield jc (1988)39 21/m hypoglycaemia 14. mehta mp (1989)40 33/m fall over elbows 15. mathis rd (1990)23 23/m diving 16. maffulli n (1990)18 31/m pull over bench weight lifting 17. costigan ps (1990)29 74/f unknown (chronic at diagnosis)) 18. cresswell tr (1998)11 31/m weight lifting in bench press 19. esenkaya i (2000)19 ?/m weight lifting in sitting position 20. echarri sucunza a (2002)41 29/m seizure 21. singh s (2005)34 21/m trauma (sequential dislocation) 22. sreesobh kv (2005)9 32/m trauma (sequential dislocation) 23. ozcelik a (2006)42 20/m hypoglycaemia 24. ngim ne (2006)24 65/f domestic assault 25. o’connor-read l (2007)43 25/m seizure 26. bellazzini ma (2007)30 20/m unknown 27. de la fuente fa (2008)25 ?/? push-ups 28. turhan e (2008)22 ?/m fall from horse with sudden forward traction 29. abalo a (2008)44 ?/? fall 30. siwach r (2008)14 45/m sudden backward animal traction 31. galanakos s (2008)2 39/f fall 32. akdur o (2008)45 55/f road traffic accident with fall 33. kalkan t (2009)6 65/f fall with hanging from a bar 34. kalkan t (2009)6 64/f fall with hanging from a bar 35. felderman h (2009)26 44/f chin up workout 36. mofidi m (2010)46 ?/? seizures 37. botha ah (2010)8 27/m backward fall 38. rouhani a (2010)4 37/m seizure (delayed diagnosis by 2 weeks) 39. thakur a (2010)5 35/m backward fall against wall 40. silva lp (2011)12 82/f backward fall 41. tripathy sk (2011)47 32/m seizures 42. bilsel k (2012)16 66/f fall 43. dlimi f (2012)27 20/m backstroke swimming 44. ballesteros r (2013)35 74/f fall 45. ballesteros r (2013)35 17/m forward traction with sudden loss of resistance 46. yashavantha kc (2013)10 45/f fall on pointed elbows 47. present case (ali n) 24/m backward fall m: male f: female sa orthopaedic journal spring 2015 | vol 14 • no 3 page 49 once vertical force is transmitted along the humerus it tends to hyper-extend the shoulder joint, which is prevented by this impingement and rather acts as a lever to deliver the head anterior out of the glenoid.12 bilateral anterior shoulder dislocation is a rare injury and such an injury without an associated fracture is far rarer. dinopoulos et al.(1999) in their review of literature had 28 cases of bilateral anterior shoulder dislocation reported since 1966 out of which only 11 were simple dislocations without any associated fracture.13 siwach et al. (2008), in a similar type of literature review, reported only 14 cases of simple bilateral anterior dislocations.14 dodds et al. (2008) in their review of 1966 reported 24 cases of bilateral anterior shoulder dislocations of which 18 were simple dislocations.15 after an extensive search of international literature we found 41 published papers since 1973 with 46 cases of simple bilateral anterior shoulder dislocation, which is the first of its kind and largest review ever of this rare injury in the orthopaedic literature (table i). sreesobh et al. (2005),9 rouhani et al. (2010),4 bilsel et al. (2012)16 and yashavantha et al. (2013)10 in their reviews have mentioned, respectively, only two, four, eight and three cases of bilateral simple anterior shoulder dislocation being reported so far. our literature review refutes this injury being so rare. in our review of the case presented, fall on hands or elbows was the most common mode of injury (16 cases) followed by seizure activity, including hypoglycaemic seizures (12 cases). in seizures, anterior dislocation occurs by extension, abduction and external rotation of shoulder joint by direct or indirect trauma.14 weight-lifting in gymnasiums and during military drill is emerging as aetiology (four cases). our literature review refutes this injury being so rare page 50 sa orthopaedic journal spring 2015 | vol 14 • no 3 sudden exhaustion of shoulder muscles during work out can make the heavy weight push the shoulder joints in the position of instability and finally dislocation.11,17-19 both sudden forward traction to upper extremities in position of flexion, internal rotation and slight abduction (four cases) as well as sudden backward traction in position of extension, internal rotation and adduction (one case) can dislocate the shoulder joints anterior.14,20-22 fall with hands catching an overhead bar tends to dislocate the shoulder posteriorly but in the elderly population with age-related ligamentous laxity anterior shoulder dislocation is a possibility (two cases).6 diving (one case), backstroke swimming (one case), domestic assault (one case), push-ups (one case) and chin-ups (one case) were the other rare mode of injuries.23-27 in three cases of bilateral simple anterior shoulder dislocation aetiology was unknown.28-30 shoulder dislocation is said to be chronic when it remains unreduced beyond three weeks.31 four cases had chronic bilateral shoulder dislocation at the time of diagnosis among which two cases had seizures as the aetiology and in other two cases the cause was unknown.28,29,32,33 sequential bilateral anterior dislocations with one shoulder dislocating after the other have been reported in the literature and are extremely rare. there have been two cases of sequential simple bilateral anterior dislocation reported to date.9,34 bilateral anterior shoulder dislocation is managed on the same lines as unilateral dislocation.8 closed reduction followed by immobilisation for three weeks in bilateral sling is the standard protocol.12,35 but bilateral immobilisation of the upper extremities makes the patient dependent and his routine suffers. for this reason some authors recommend the use of upper extremities for personal hygiene and feeding purpose only during the period of immobilisation.8 others recommend early rehabilitation of the shoulder which is less painful, while continuing immobilisation of the more painful one.36 even early rehabilitation of both shoulders has been recommended especially in elderly patients.35 surgical intervention is rarely required in simple bilateral anterior dislocations as most of them are reduced closed. failure of closed reduction, and old missed or neglected dislocation, are indications for open reduction. all the requirements for internal fixation of proximal humerus as well as for shoulder prosthetic replacement should be available and on hand before attempting closed reduction under general anaesthesia as it carries a risk for fracture of the proximal humerus during manipulation, especially in elderly with osteoporosis.16 patients with old neglected dislocations can be managed by open reduction but the results are poor. in elderly patients with neglected dislocations who are at high risk during surgical intervention, a benign neglect strategy can be followed.35 conclusion final functional outcome of bilateral simple shoulder dislocations is the same as that of unilateral dislocations. trauma is the most common aetiology of simple bilateral anterior shoulder dislocation. seizure is nearly as common an aetiology as is trauma. dislocations that are chronic at diagnosis are usually associated with seizures. moreover, bilateral simple anterior shoulder dislocation is not as rare an injury as was previously thought. we declare that no benefits of any form have been received from a commercial party related directly or indirectly to the subject of this article. references 1. aronson pl,  mistry rd. intra-articular lidocaine for reduction of  shoulder dislocation. pediatr emerg care 2014;30(5):358-62. 2. galanakos s, christodoulou e, panayi c, papadakis as, nicolaides v, macheras ga. eexot 2008;59(4):252-56. 3. ngim ne,  udorroh eg,  udosen am. acute bilateral anterior shoulder dislocation following domestic assault – case report. west afr j med 2006;25(3):256-57. 4. rouhani a, zonooz ka, aghdam ha. an unusual cause of bilateral anterior shoulder dislocation. pak j med sci 2010;26(4):976-77. 5. thakur a, gupta r, kotwal v, arora d. a rare case of bilateral anterior dislocation of the shoulder. j clin diagn res 2010;4:3567-69. 6. kalkan t, demirkale i, ocguder a, unlu s, bozkurut m. bilateral anterior shoulder dislocation in two cases due to housework accidents. acta orthop traumatol turc 2009:43(3):260-63. 7. sandeep k, nema  dr, pai nks, krishna kg. a unique case of nontraumatic asymmetric shoulder dislocation with four-part fractures of proximal humeri following seizures. j emerg trauma shock 2013;6(3):231-23. 8. botha ah, du toit ab. bilateral anterior shoulder dislocation: a case report of this rare entity. sa orthop j 2010;9(4):68-70. 9. sreesobh kv, chacko b. an unusual case of bilateral anterior dislocation of the shoulder. j orthop 2005;2(4):e6. 10. yashavantha kc, nalini kb, maini l, nagaraj p. bilateral traumatic anterior dislocation of the shoulder – a rare entity. j orthop case reports 2013;3(1):23-25. 11. creswell tr, smith rb. bilateral anterior shoulder dislocations in bench pressing: an unusual cause. br j sports med 1998;32:71-72. 12. silva lp, sousa cv, rodrigues e, alpoim b, leal m. bilateral anterior glenohumeral dislocation: clinical case. res bras orthop 2011;46(3):318-20. 13. dinopoulos ht, giannoudis pv, smith rm, matthews sj. bilateral anterior shoulder fracture – dislocation. a case report and review of the literature. int orthop 1999;23(2):128-30. 14. siwach r, singh r, rohilla r, sangwan ss. bilateral anterior dislocation of the shoulder – a case report and review of the literature. injury extra 2008;39:394-97. sa orthopaedic journal spring 2015 | vol 14 • no 3 page 51 15. dodds sd, medvecky mj. chronic bilateral locked anterior shoulder fracture-dislocations. am j orthop 2008;37(7):364-68. 16. bilsel k, sayar s, ceylan hh, erdil m, elmadag m, tuncay i. bilateral traumatic anterior shoulder dislocation. j clin analytical med 2012;2012:385782. 17. sciammarella jc jr. bilateral shoulder dislocations. ann emerg med 1986;15(6):763. 18. maffulli n, mikhail hmt. bilateral anterior glenohumeral dislocation in a weightlifter. injury 1990;21(4):254-56. 19. esenkaya i, tuygun h, türkmen m. bilateral anterior shoulder dislocation in a weight lifter. an improperly performed military press put this patient at risk. phys sports med 2000;28(3):782. 20. mcfie j. bilateral anterior dislocation of the shoulder. injury 1976;8:67-9. 21. segal d, yablon ig, lynch jj, jones rp. acute bilateral anterior dislocation of the shoulders. clin orthop relat res 1979;140:21-22. 22. turhan e, demirel m. bilateral anterior glenohumeral dislocation in a horse rider: a case report and a review of the literature. arch orthop trauma surg 2008;128(1):79-82. 23. mathis rd. bilateral shoulder dislocation: an unusual occurrence. j emerg med 1990;8(1):41-43. 24. ngim ne,  udorroh eg, udosen am. acute bilateral anterior shoulder dislocation following domestic assault – case report. west afr j med 2006;25(3):256-57. 25. de la fuente fa,  hoyte c,  bryant sm. push-ups may be hazardous to your health: an atraumatic etiology for bilateral shoulder dislocation. am j emerg med 2008;26(1):116.e3-4. 26. felderman h, shih r, maroun v. chin-up-induced bilateral anterior shoulder dislocation: a case report. j emerg med 2009;37(4):400-402. 27. dlimi f, rhanim, lahlou a, kharmaz m, ouadghiri m, el bardouni a, berrada ms, mahfoud m, el yaacoubi m. bilateral anterior dislocation of the shoulders at the start of a backstroke competition. j orthop traumatol 2012;13:47-49. 28. onabowale bo, jaja mo. unreduced bilateral synchronous shoulder dislocations. a case report. niger med j 1979; 9(2):267-71. 29. costigan ps, binns ms, wallace wa. undiagnosed bilateral anterior dislocation of the shoulder. injury 1990;21(6):409. 30. bellazzini ma,  deming da. bilateral anterior shoulder dislocation in a young and healthy man without obvious cause. am j emerg med 2007;25(6):734.e1-3. 31. jekic m. der seltene fall beiderseitiger oberarmverrenkung. langenbecks arch chir 1973;334:331. 32. sadhra k. unusual dislocations associated with epileptic fits. br med j 1984;288(6418):681-82. 33. brown rj. bilateral dislocation of the shoulders. injury 1984;15:267-73. 34. singh s, kumar s. bilateral anterior shoulder dislocation: a case report. eur j emerg med 2005;12(1):33-35. 35. ballesteros r, benavente p, bonsfills n, chacón m, garcíalázaro fj. bilateral anterior dislocation of the shoulder: review of seventy cases and proposal of new etiologicalmechanical classification. j emerg med 2013;44(1):269-79. 36. dunlop ccr. bilateral anterior shoulder dislocation – a case report and review of the literature. acta orthop belg 2002;68(2):168-70. 37. hartney-velazco k, velazco a, fleming ll. bilateral anterior dislocation of the shoulder. south med j 1984;77:1340-41. 38. jones m. bilateral shoulder dislocation. br j sports med 1987:21:139. 39. litchfield jc, subhedar vy, beevers dg, patel ht. bilateral dislocation of the shoulders due to nocturnal hypoglycaemia. postgrad med j 1988;64(752):450-52. 40. mehta mp, kottamasu sr. anterior dislocation of the shoulders with bilateral brachial plexus injury. ann emerg med 1989;18(5):589-91. 41. echarri sucunza a,  santesteban echauri e,  irigoyen j,  aldaz berruezo j. anterior bilateral scapulohumeral luxation after convulsive crisis. aten primaria 2002;30(2):134. 42. ozcelik a,  dincer m,  cetinkanat h. recurrent bilateral dislocation of the shoulders due to nocturnal hypoglycemia: a case report. diabetes res clin pract 2006;71(3):353-55. 43. o’connor-read l,  bloch b,  brownlow h. a missed orthopaedic injury following a seizure: a case report. j med case rep 2007;1:20. 44. abalo a, dossim a, songne b, ayouba g. bilateral anterior dislocation of the shoulders. chir main 2008;27(2):118-21. 45. akdur o, ozkan s, durukan p, ikizceli a, avsarogullari l, vardar a, sozuer em. erciyes med j 2008;30(2):125-27. 46. mofidi m, kianmehr n, farsi d, yazdanpanah r, majidinezhad s, asadi p. an unusual case of bilateral anterior shoulder and mandible dislocations. am j emergmed 2010;28(6):745.e1-2. 47. tripathy sk, sen rk, aggarwal s, dhatt ss, tahasildar n. simultaneous bilateral anterior shoulder dislocation: report of the two cases and review of the literature. chin j traumatol 2011;14(5):312-15. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj orthopaedics vol3 no4 page 38 sa orthopaedic journal winter 2016 | vol 15 • no 2 radiation exposure to orthopaedic registrars in the pietermaritzburg metropolitan complex dr katherine troisi mbchb dr nando ferreira bsc, mbchb, fc orth(sa), mmed(orth), phd department of orthopaedic surgery, grey’s hospital, nelson r mandela school of medicine, university of kwazulu-natal correspondence: dr katherine troisi department of orthopaedic surgery grey’s hospital 3201 pietermaritzburg south africa tel: +27 33 897 3000 email: kdb082@hotmail.com introduction modern orthopaedic practice increasingly involves the use of fluoroscopic imaging during surgery. fluoroscopy is frequently used to facilitate surgical procedures including the reduction of long bone fractures and accurate placement of internal and external fixation devices. this has led to increased exposure to ionising radiation and is a potential occupational hazard to the orthopaedic registrar and accompanying theatre staff who are often under-educated and unaware of its dangers.1 radiation exposure is classified into public, medical and occupational.2 environmental radiation from cosmic rays, external sources and ingested radioactive materials constitute approximately 3 millisieverts (msv) per year.3 medical exposure constitutes the greatest source of artificial radiation; a cervical spine x-ray for example, is equivalent to 1.6 weeks of environmental radiation.4 occupational exposure constitutes radiation exposure at the workplace and for which workers should be registered. the whole body effective dose limit for radiation workers is 20 msv/year averaged over 5 years, whereas this limit for the general public is 1 msv/year.5 abstract introduction: modern orthopaedic surgery increasingly involves the use of fluoroscopic imaging in theatre. this has led to an increase in radiation exposure to the orthopaedic surgeon and other theatre staff. there is very little research as to which orthopaedic subspecialty may lead to higher exposures. this study aims to demonstrate whether radiation exposure levels in orthopaedic registrars in the pietermaritzburg complex are within safety limits and also to determine which subspecialty rotations lead to increased exposure levels. materials and methods: a retrospective quantitative observational study analysed the dosimeter readings of 20 registrars over a one-year period. dosimeter readings were also analysed per subspecialty rotation, namely orthopaedic trauma, spinal surgery, arthroplasty, ortho-paediatrics, upper limb surgery, and tumour sepsis and reconstruction. results: no registrar was found to have a dosimeter reading exceeding the international commission on radiological protection guidelines. rotations in which registrars received measureable readings were orthopaedic trauma, upper limb surgery, spinal surgery and arthroplasty. conclusion: trauma rotations appeared to produce to highest radiation exposure readings, although these were still within international safety limits. knowledge of radiation safety, staff education and safety measures to limit any unnecessary exposure should be employed. key words: radiation safety, registrar, orthopaedic training http://dx.doi.org/10.17159/2309-8309/2016/v15n2a6 sa orthopaedic journal winter 2016 | vol 15 • no 2 page 39 ionising radiation is energy transmitted via x-rays, gamma rays, beta particles (high speed electrons), alpha particles (the nucleus of the helium atom), neutrons, protons and other heavy ions such as the nuclei of nitrogen, carbon and other elements. x-rays and gamma rays are high-energy (high frequency) electromagnetic radiation. ultraviolet (uv) light is radiation of intermediate energy, which can damage cells (sunburn), but differs from electromagnetic radiation in that it does not cause ionisation (loss of an electron) of atoms or molecules, but rather excitation (change in energy level of an electron) of atoms. during ionisation the transferred energy is high enough to disrupt chemical bonds, which results in radical formation. radiation-induced ionisations may act directly on the cellular component molecules or indirectly on water molecules leading to the formation of hydrogen peroxide. the major effect on cells is damage to dna and can occur to either a single strand or to both strands. most single-strand breaks can be repaired as the undamaged strand of the double helix serves as a template. doublestrand breaks are more devastating, with poor repair resulting in mutations, chromosome aberrations and cell death. the biological effects of ionising radiation can be classified as either deterministic or stochastic. deterministic effects occur above a threshold exposure and vary with the radiation dose. above this threshold the damage increases with dose, e.g. cataracts and gonadal cell damage leading to infertility.6 stochastic effects are those for which there is a probability of the effect occurring. these effects have no threshold dose and the assumption is that the damage from radiation is cumulative over time. examples of stochastic effects are the induction of malignancy from irradiation of tissues such as the red bone marrow (leukaemia), bone, lungs, thyroid and breast. a study by volzke et al. concluded that there was a definite relationship between the occupational exposure to ionising radiation and autoimmune thyroid disease.7 according to a study by muller et al., the average registered radiation dose without a thyroid shield was approximately 70 times higher than with a lead shield.8 eighty-five per cent of papillary carcinomas of the thyroid are radiation-induced.9 an accumulated dose of as little as 65 µsv (which is frequently exceeded during procedures such as intramedullary nailing and pin and plate insertion), over multiple exposures can statistically increase the incidence of thyroid cancer many years later.9 there has also been concern over the potential hereditary effects to the offspring of male and female surgeons.10,11 numerous studies auditing orthopaedic trainees’ radiation exposure awareness, attitude and compliance to safety guidelines have demonstrated a lack of basic knowledge of radiation hazards, protective wear, pregnancy awareness and safe principles of radiation.12 studies also demonstrate a lack of compliance to safety guidelines.6 conflicting reports have been published regarding the effect that the presence of a consultant/senior surgeon has on image intensifier screening times; the assumption is that the presence of a senior member would result in decreased screening time and thus decreased overall exposure.6,13 a possible explanation for higher readings in some consultant-led cases could be due to the fact that cases requiring senior staff are often more complex and may require additional screening as a result.13 there is little research as to which orthopaedic subspecialty rotations might lead to higher exposure levels in registrars. if a particular rotation is identified to consistently result in higher readings for the registrar completing that block, it might prompt a more focused intervention, from education in c-arm positioning to increased senior/consultant presence in theatre to try and reduce fluoroscopic use. this study aimed to demonstrate whether radiation exposure readings among registrars in the pietermaritzburg complex were within safety limits and investigates whether any specific rotations might put registrars at increased risk. this study also highlights the dangers associated with increased radiation exposure and the importance of protective measures to limit exposure. methods such as personal protective equipment, the presence of an experienced surgeon or senior registrar during the trauma rotations, having a qualified radiographer in theatre and staff education are all modalities which are readily available in most institutions, and are a means of reducing x-ray screening time in theatre. materials and methods we conducted a blinded retrospective quantitative observational study of 20 orthopaedic registrars undergoing training in the pietermaritzburg metropolitan complex, between november 2012 and november 2013. orthopaedic surgeons at the pietermaritzburg metropolitan complex are encouraged to wear radiation dosimeters (badges) during all cases requiring fluoroscopy screening. these badges are worn on the outside of the protective lead aprons in theatre and it is the responsibility of the individual registrar to collect and wear this badge correctly. readings from these dosimeters are collected on a 4-weekly basis and evaluated offline to monitor radiation exposure. the reported readings were analysed. all radiation workers are assigned unique identity numbers to identify their individual badges. the investigator remained blinded to the wearer’s identity. dosimeter readings were then compared with registrar rotation timetables to determine the specific rotation a participant was in for each wearing period. all registrars’ dosimeter readings that were reported between november 2012 and november 2013 were included. readings from months during which registrars lost or damaged their badges, and any faulty dosimeter badge readings, were excluded. in keeping page 40 sa orthopaedic journal winter 2016 | vol 15 • no 2 with south african bureau of standards (sabs) guidelines, a faulty badge was defined as any badge showing evidence of being tampered with (broken plastic vacuum seal in which it was contained or loose dosimeter barcode sticker) as readings from these badges were deemed unreliable. results only seven of the 20 registrars in the study received a dosimeter reading greater than 0.00 msv. a single registrar received an isolated reading of 2.57 msv, which was the highest reading obtained in the group and well within the international commission on radiological protection (icrp) guidelines (figure 1). the rotations in which registrars received readings were orthopaedic trauma, upper limb surgery, spinal surgery and arthroplasty (figure 2). in the tumour sepsis and reconstruction (tsr) unit as well as ortho-paediatrics and icu rotation, registrars received no readings at all. apart from icu during which we would expect lower readings, the absence of readings in tsr and ortho-paediatrics may be due to the complex nature of these rotations and the need for specialist surgeons to perform most procedures. due to senior surgeon experience, it is possible that in these cases the surgeons required less fluoroscopic support; this would in turn account for the reduced screening time and reduced registrar (assistant in these cases) exposure readings. discussion the south african department of health has adopted the international commission on radiological protection (icrp) guidelines and safety limits and makes use of the radiation protection service (rps) to monitor this sector.14 the rps provides a national dosimetry service to all radiation workers in south africa.15 this service entails the issue, dispatch and monitoring of dosimeters used by radiation workers. the department of health recommends the following whole body limits for occupational exposure: • 20 msv/year over 5 years, with a maximum of 50 msv in 1 year • annual equivalent dose 150 msv (lens of eye), 500 msv (skin) and 500 msv (hands and feet) in cases of overexposure, the rps will notify the worker and his/her employer immediately so that action may be taken.15 although there are guidelines for radiation workers, no definitive protocol exists regarding overexposure readings of a member of the department of orthopaedic surgery in the pietermaritzburg metropolitan complex. it must be noted that registrar rotations include not only the subspecialty listed but also include after-hours work that mostly consists of trauma. thus radiation received while in a rotation does not only represent that rotation but includes on-call/after-hours trauma work. after-hours work is, however, evenly divided among the registrars on a month-to-month basis over their four-year period and can therefore be seen as a constant. trauma appears to be the rotation with the highest risk of radiation exposure, followed by upper limb surgery, spinal surgery and arthroplasty. the advent of minimally invasive percutaneous techniques, intramedullary nailing and the relative inexperience of junior staff, are all contributing factors to the high levels of radiation exposure during trauma rotations. upper limb surgery rotation readings may be explained by the high frequency of operative procedures in which surgeons are seated in very close proximity to the c arm. the spinal surgery rotation, although demonstrating very low screening times, may have readings due to registrars’ close proximity to the beam during screening. figure 1. cumulative readings 2.5 2 1.5 1 0.5 0 c u m u la ti v e re ad in g figure 2. dosimeter readings in the individual rotations. trauma divided among the three hospitals in which registrars train in pietermaritzburg – edh (edendale hospital), nd (northdale hospital) and grey’s (grey’s hospital) 0,09 0,0675 0,045 0,0225 0 h an d s t ra u m a e d h t ra u m a n d a rt h ro s p in es t ra u m a g re y s ic u p ae d s t s r n / a sa orthopaedic journal winter 2016 | vol 15 • no 2 page 41 the arthroplasty rotation in itself employs very little fluoroscopy; thus we can infer that most of these readings were incurred from after-hour trauma cases requiring fluoroscopy. it must also be noted that senior rotations are reserved for senior registrars; this may influence their readings due to the need to assist with more complex cases, which often require more screening. this research shows that registrars within the pietermaritzburg complex are exposed to occupational radiation that is within the icrp radiation safety limits. continued education and cognisance of radiation safety is important to maintain these standards and prevent the potential negative effects of ionising radiation. limitations of this research include the possibility that the registrars may not have worn their badges for every theatre case. dosimeter readings were also obtained for a period of only one year, and longer sampling periods may yield more data points that may alter the findings. guidelines the following guidelines should form part of staff dose management during fluoroscopy use in theatre: 1. always use a radiation protection apron that has at least 0.5 mm lead equivalence; 0.35mm may be acceptable if you can stand ± 2 m away during screening. openbacked aprons do not provide adequate protection and are not acceptable. 2. ensure the correct use and storage of radiation protection aprons to prevent them from being damaged. 3. thyroid shields are recommended for all procedures that require fluoroscopic use. 4. use lead glass eyewear if available. 5. keep hands out of the primary beam unless unavoidable. lead-impregnated gloves can reduce hand exposure by 15%–30% as long as the hands remain outside the primary beam. if lead-impregnated gloves are worn and the hand is in the primary beam, the automatic exposure control system will trigger an increase in exposure (kv), which will increase the dose to the hands. 6. knowledge of the available x-ray equipment – knowing how to adjust images (rotation, inversion, collimation, and contrast) and having a split monitor unit (which allows for last image hold and current image for comparison) will limit unnecessary screening. 7. stand in the correct place. move away from the x-ray tube where possible, and rather stand on the intensifier side of the machine. moving one step away from the machine can decrease the physician’s exposure by a factor of 4. dose rates can be reduced by a factor of 5 when the physician stands on the image intensifier side of the table during lateral projections. the highest absorbed radiation while in theatre is from scatter off the patient’s body on the side of the beam emission (the tube); thus the surgeon should stand on the intensifier side, to reduce radiation. 8. reduce screening time as follows: a. do not expose while not viewing the screen image. b. pre-plan images. ensure proper positioning to avoid ‘panning’. c. avoid redundant views. 9. keep you knowledge of radiation protection up to date. 10. always wear your personal radiation protectionmonitoring badge and know how to use it correctly. dosimeters should be worn outside of any protective equipment. 11. ensure that fluoroscopy equipment is functioning properly and periodically tested and maintained. 12. always ensure a qualified radiographer is present in theatre. this not only assists in positioning and optimising operative time, but also ensures the best image is taken in the least number of exposures due to the experience of the radiography staff. 13. should a complex case be encountered, try to have a senior staff member present. once again, experience and guidance will decrease unnecessary screening. conclusion radiation exposure of orthopaedic registrars in the pietermaritzburg metropolitan complex is within international safety limits. trauma rotations and after-hours trauma appear to pose the greatest risk of radiation exposure to the orthopaedic registrar. as the cumulative effect of ‘acceptable’ radiation exposure is still unknown, measures to limit radiation exposure should be emphasised and form a crucial part of daily practice. acknowledgment to sarah coleby (n dip rad), for her valued assistance in this study. compliance with ethics guidelines k troisi and n ferreira declare they have no conflict of interests, and no financial support was received for this study. the study was approved by an institutional ethics committee (be 007/14) and performed in accordance with the ethical standards of helsinki as revised in 2008. references 1. hynes de, conere t, mee mb, cashman wf. ionizing radiation and the orthopaedic surgeon. j bone joint surg br. 1992;74(3):332-34. 2. badman bl, rill l, butkovich b, arreola m, griend ra. radiation exposure with the use of the mini c arm for routine orthopaedic imaging procedures. j bone joint surg am. 2005;87(1):13-17. 3. singh pj, perera ns, dega r. measurement of the dose of radiation to the surgeon durung surgery to the foot and ankle. j bone joint surg br. 2007;89-b(8):1060-63. 4. louw du p df. radiation safety for orthopaedic surgeons. http://www.saoa.org.za/general/radiationsafety. (date last accessed july 2015) page 42 sa orthopaedic journal winter 2016 | vol 15 • no 2 5. van der merwe b. radiation dose to surgeons in theatre. sa j surg. 2012;50(2):26-29. 6. laird, mp. occupational exposure of orthopaedic trainees to radiation. j orthop. 2011;8(4):e6. 7. volzke h, werner a, wallaschofski h, friedrich n, robinson dm, kindler s, kraft m, john u, hoffmann w. occupational exposure to ionizing radiation is associated with autoimmune thyroid disease. j clin endocrinol metab. 2005;90(8):4587-92. 8. muller lp, suffner j, wenda k, mohr w, rommens pm. radiation exposure to the hands and thyroid of the surgeon during intramedullary nailing. injury. 1998;29(6):461-68. 9. devalia kl, peter vk, madanur ma, braithwaite ij. exposure of the thyroid to radiation during routine orthopaedic procedures. acta orthop belg. 2006;72(5):615620. 10. keene r, hillard-sembell d, robinson bs, novicoff wm, saleh kj. occupational hazards to the pregnant orthopaedic surgeon. j bone joint surg. 2011;93: e1411-15. 11. zadeh h, briggs tw. ionizing radiation: are orthopaedic surgeons’ offspring at risk. ann r coll surg engl. 1997;79(3):214-220. 12. khan fr, ul-abadin z, rauf s, javed a. awareness and attitudes among basic surgical trainees regarding radiation in orthopaedic trauma surgery. biomed imaging interv j. 2010;6(3):e25. 13. sutherland ag, finlayson df. screening times with image intensifier in orthopaedic trauma surgery. j r coll surg edinb. 1998;43(1):265-66. 14. valentin j. the 2007 recommendations of the international commission of radiological protection. http://www.icrp.org (date last accessed 24 july 2015) 15. no authors listed. http://www.health.gov.za/docs/ forms/2005/registration1a.pdf. (date last accessed may 2015) this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj 404 not found 404 not found firth gb et al. sa orthop j 2019;18(4) doi 10.17159/2309-8309/2019/v18n4a1 south african orthopaedic journal http://journal.saoa.org.za paediatric orthopaedics citation: rutarama a, firth gb. assessment of elbow functional outcome after closed reduction and percutaneous pinning of displaced supracondylar humerus fractures in children. sa orthop j 2019;18(4):14-19. http://dx.doi.org/10.17159/2309-8309/2019/v18n4a1 editor: prof j du toit, stellenbosch university, cape town, south africa received: january 2019 accepted: may 2019 published: november 2019 copyright: © 2019 rutarama a, firth gb. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: this study did not require any funding. conflict of interest: both authors declare having no conflict of interest with regard to this study. abstract background: the aim of the current study was to establish the functional outcome of gartland grade iii extension-type supracondylar fractures at 24 weeks after closed reduction and percutaneous pinning (crpp) without physiotherapy. the objectives of this study were 1) to measure the elbow range of motion (rom) at three, six, 12 and 24 weeks after crpp for grade iii supracondylar fractures; 2) to assess the functional outcome of the injured limb using the paediatric outcome data collection instrument (podci) score; 3) to compare elbow functional outcome of children less than 7 years old versus children more than 7 years old; and 4) to assess other risk factors or complications associated with poor outcomes after crpp (including age and associated soft tissue injury). patients and methods: a prospective cohort study was performed. the study included 38 children under the age of 14 years with grade iii extension-type supracondylar fractures who had manipulation under anaesthesia (mua) and crossed k-wire fixation. rom of the affected elbow (flexion, extension, pronation and supination) was measured at three, six, 12 and 24 weeks after crpp by the same author (ar) at each visit. the unaffected elbow was used as a control. the podci was also recorded. no physiotherapy was prescribed. results: thirty-eight children were included in the study. all components of elbow rom improved at 24 weeks (p<0.001). at 12 but not 24 weeks, the mean elbow extension was reduced in comparison with the controls (p=0.009). patients less than 7 years of age recovered extension more rapidly (p=0.001). seventy-six per cent of the children achieved satisfactory podci results at the 24-week final follow-up. nerve palsy (18.4%) and severe soft tissue injuries (7.9%) were the main contributory factors to a poor outcome on the podci assessment. conclusion: the majority of children with displaced supracondylar fractures recover full rom after crpp by 24 weeks without physiotherapy. older children, or those with associated neurovascular and soft tissue injuries had poor functional outcomes. further studies are needed to assess if these patients will benefit from physiotherapy. level of evidence: level 4 keywords: child, gartland grade iii supracondylar fracture, outcomes, closed reduction percutaneous k wires assessment of elbow functional outcome after closed reduction and percutaneous pinning of displaced supracondylar humerus fractures in children rutarama a1 , firth gb2 1 mbbch; registrar* 2 mbbch, fcs(orth), mmed(orth); consultant* *department of orthopaedic surgery, university of the witwatersrand, chris hani baragwanath academic hospital, johannesburg, south africa corresponding author: dr gb firth, faculty of health sciences, orthopaedic surgery division, university of the witwatersrand, private bag 3, wits 2050, south africa; tel: +27 (11) 717 2538; email: greg.firth@gmail.com https://orcid.org/0000-0002-8354-3371 https://orcid.org/0000-0002-1594-2290 page 15firth gb et al. sa orthop j 2019;18(4) introduction closed reduction and percutaneous pinning (crpp) of gartland grade iii supracondylar fractures in children has become the gold standard of care in the last 50 years in the global orthopaedic literature.1-4 this is known as the modern concept of skeletal stabilisation and soft tissue management in paediatric orthopaedic surgery. authors have cautioned against the open operative management of these fractures, and this has resulted in improved functional outcomes.4 many authors have also cautioned against physiotherapy in the management of uncomplicated children’s fractures.4 even though there may be a delay in recovery of elbow range of motion (rom), outcomes at one year have been shown to be equivalent (with or without physiotherapy) for gartland grade iii supracondylar fractures.5 there is paucity in the literature about the functional outcome after gartland grade iii supracondylar humerus fractures. pressure from parents and patients for early intervention and early rehabilitation for rapid and complete return to activity are an ever-increasing demand in today’s modern lifestyle. more recent evidence for physiotherapy after crpp for supracondylar fractures in children found no difference one year post treatment.6 keppler et al. showed a small benefit of physiotherapy at six weeks and no benefit at one year but schmale et al. showed no benefit at all.5,6 the outcome of grade iii supracondylar fractures in south africa has not been studied prospectively before. the aim of the current study was to establish the functional outcome of gartland grade iii extension-type supracondylar fractures at 24 weeks after crpp without physiotherapy. the objectives of this study were 1) to measure the elbow rom at three, six, 12 and 24 weeks after crpp for grade iii supracondylar fractures; 2) to assess the functional outcome of the injured limb using the paediatric outcome data collection instrument (podci) score; 3) to compare elbow functional outcome of children less than 7 years old versus children more than 7 years old; and 4) to assess other risk factors or complications associated with poor outcomes after crpp. materials and methods inclusion criteria included children under the age of 14 years with a unilateral extension-type grade iii supracondylar fracture requiring crpp. exclusion criteria included the presence of associated fractures on the ipsilateral or contralateral upper limb, children requiring open reduction, and children lost to follow-up. all children were treated with the following protocol: analgesia followed by a backslab in a comfortable position, usually at 90° of flexion. the child was taken to theatre as soon as possible – ideally the same night – for closed reduction and percutaneous cross k wires. the lateral wire was inserted first with the elbow flexed and then, to reduce the risk of ulnar nerve injury, the elbow was extended and the medial k wire inserted (figure 1). considering age as a risk factor for poor return of elbow extension, we compared two groups. the first group of children were younger than 7 years and the second group of children were aged 7 years or older. no physiotherapy was prescribed as standard practice. children were encouraged to return to normal activities as soon as the k wires were removed at three weeks, guided by the residual elbow pain. all associated soft tissue injuries and complications were assessed and recorded at each visit. control x-rays were taken at six weeks after crpp for every patient and at 24 weeks for those who still had residual impaired rom or any clinical suspicion of malunion (figure 1). at three weeks, rom measurements of the normal elbow were done with a goniometer (flexion, extension, pronation and supination) by the first author (ar) for the control; and baseline data on the affected elbow was also recorded. the rom on the affected side was then further recorded at six, 12 and 24 weeks. the podci is a questionnaire developed by the paediatric orthopaedic society of north america (posna) to measure functional outcomes after an orthopaedic intervention in children. it was validated and used in a wide array of musculoskeletal conditions including congenital, metabolic and traumatic. the versatility of the podci in using certain applicable parts makes it easier to use and more appropriate than just relying on physical findings. the use of podci after paediatric orthopaedic trauma is a good tool in assessing the function of these children. the current study used two of its five major components relevant to the upper limb: upper limb physical function (assesses basic activities of daily living such as combing hair, buttoning a shirt, eating with a spoon and carrying heavy books); and a general happiness score about the outcome of the intervention. the podci questionnaire was used at the final follow-up to look, in particular, at the patient’s upper extremity functional outcome scores as assessed by the figure 1. a) demonstration of the extension type gartland grade iii supracondylar fracture, b) crpp with cross pinning, and c) outcome at 24 weeks after crpp a b c a b c a b c a b c page 16 firth gb et al. sa orthop j 2019;18(4) parent, and the parent’s happiness about their child’s outcome after crpp. this evaluation aimed at gaining an understanding of clinical outcomes and perceptions from patients or parents about the outcome. scores for each of the answers were then calculated in terms of a percentage to assess how many were able or not able to perform basic activities of daily living as a result of the injury and its management. in the podci grading system for upper limb function, the parent/ caregiver reports as to whether their child could perform specific activities easily with no assistance (easy); with some difficulty but still able to perform them (little hard); and almost unable to perform task or performs it incompletely (very hard). overall outcome for the podci was assessed by the parent/ caregiver as either satisfactory (very or somewhat) or dissatisfactory (very or somewhat). raw data was entered into an excel spreadsheet, and statistical software (stata) was used to analyse the data. using the skewness kurtosis test for the normality of data, some of the data was not 160 140 120 100 80 60 40 20 0 -20 -40 d e g re e s flex pro sup 6 weeks 24 weeks control ext figure 2. a comparison of elbow rom (degrees) at 6 and 24 weeks after crpp versus control page 17firth gb et al. sa orthop j 2019;18(4) normally distributed and as a result, non-parametric data analysis was used. epidemiological data such as age, sex, affected upper extremity and podci were reported descriptively. rom measurements on the affected limb were compared with control measurements at six and 24 weeks. wilcoxon and mann-whitney u tests were used for the data that was skewed and compared with two age groups – those older than or equal to 7 years and those under 7 years of age. results were represented in ordinal tables as well as box plots and whisker tables and interpreted to assess the hypothesis. quantitative data of soft tissue injuries such as nerve and vascular injuries, compartment syndrome, pin-tract sepsis and podci scores were also reported descriptively. signed informed consent was completed by all parents and signed informed assent was obtained from all children who could understand the request. ethics approval was obtained from the university human research ethics committee. results this study was a prospective cohort study and included 53 children. fifteen children were lost to follow-up, leaving 38 children eligible for inclusion in the study. thirty out of the 38 children completed all four follow-up visits. six missed one and two missed two followup visits. the mean age at presentation was 7.5 years (sd 2.5). twenty-five (66%) patients were male and 29 (76%) patients injured the left side. range of movement twenty-nine (76%) of the children gained 90% of normal elbow rom at 24 weeks. a significant improvement in the elbow rom was noted between six and 24 weeks with a p-value of <0.001 using wilcoxon paired tests (figures 2a–d). elbow extension improved less compared to the other ranges in the elbow and forearm movement during the first 12 weeks. in addition, a statistically significant difference in loss of elbow extension was present in children 7 years of age or older. this was noted at six and 12 weeks with p-values of 0.001 and 0.009 respectively using the mann-whitney u test. at 24 weeks this difference was still observed although not statistically significant. there was no statistical difference in the rom at the final followup whether the patients had a complication or not (table i). outcomes the podci assessed the function of the child as reported by the parent/caregiver at final follow-up as well as the overall parent satisfaction regarding the child’s outcome. regarding the podci score of the upper limb physical function at final follow-up, 25 (66%) of the children easily performed basic functional activities; six (16%) found it a little hard and seven (18%) found it very hard and could not perform them at all. in the six patients who found it a little hard, four of them had sustained an iatrogenic ulnar nerve injury and two others were older than 7 years of age. the seven children who found it very hard to perform basic activities of daily living included two open injuries, two ulnar nerve injuries, one radial nerve injury (sustained at the time of the fracture), and two were older than 10 years of age (table ii). twenty-nine (76%) in the cohort attained 90% of the normal elbow rom at 24 weeks, but only 25 (66%) of the children could easily perform basic upper limb physical functional activities with parents being very satisfied about the outcome (table iii). in terms of podci scores that assessed happiness of the parent/caregiver about the outcome condition, 29 parents (77%) were either very or somewhat satisfied about the outcome of their child’s condition. six (16%) of the parents were somewhat or very dissatisfied about the outcome of their child’s condition at final follow-up (table iii). all six of the children whose parents were either somewhat or very dissatisfied had a reason for this – it was noted that two of these children had sustained open supracondylar fractures: one developed compartment syndrome, two missed two follow-up visits and one was 13 years old. four out of seven cases with neuropraxia had residual elbow dysfunction at 24 weeks and their parents were dissatisfied. associated injuries/complications all children with associated injuries (n=12) were included in the final outcome at 24 weeks but showed no statistical difference in the median rom when compared with children who had no complications (n=26) (table i). there were two cases with open supracondylar fractures in the study and both resulted in elbow fixed flexion deformities of more than 30° at the 24-week final follow-up. table i: summary comparing rom at final follow-up with presence or absence of complications final follow-up median flexion (iqr) median extension (iqr) median pronation (iqr) median supination (iqr) no complications (n=26) 145° (3°) -8° (7°) 90° (2°) 94° (8°) complications (n=12) 143° (6°) -6° (8°) 85° (4°) 98° (10°) iqr: inter-quartile range table ii: summary of paediatric outcome data collection instrument for upper limb function of the children as assessed by the parent easy (n=25, 66%) little hard (n=6, 16%) very hard (n=7, 18%) no complications 4 ulnar nerve palsies 2 open fractures 2 over 7 years of age 2 ulnar nerve palsies 1 radial nerve palsy 2 over 10 years of age parents reported whether their child could perform specific activities easily with no assistance (easy), with some difficulty but still able to perform them (a little hard) and almost unable to perform task or performs it incompletely (very hard). table iii: summary of paediatric outcome data collection instrument for parental satisfaction of their child’s outcome very satisfied somewhat satisfied neutral somewhat dissatisfied very dissatisfied 25 (66%) 4 (11%) 3 (8%) 3 (8%) 3 (8%) page 18 firth gb et al. sa orthop j 2019;18(4) associated soft tissue injuries included seven neuropraxias (18%) (six ulnar and one radial nerve). four of the six ulnar nerve injuries were iatrogenic and two were associated with the fracture pre-operatively. the seven children with nerve injuries had a mean age of 10 years. all but one of these nerve injuries progressively improved and fully recovered by the twelfth week. the child who developed compartment syndrome had a very slow and incomplete recovery of the radial nerve at the 24-week final follow-up. fasciotomy was done urgently after the crpp but resulted in a stiff elbow due to volkmann’s ischaemic contracture with an ffd of 38° by the 24-week follow-up. ulnar and radial nerve function was still affected by the end of the 24-week follow-up with nerve conductive studies indicating the injury to be a neuropraxia. discussion the current cohort (38 children) of grade iii supracondylar fractures was larger than other prospective studies noted in the literature.5-8 in the current study the male:female ratio was 1.5:1, half the 3:1 global figure given for these fractures. the current population has marginalised gender disparities in terms of activities performed by both sexes which differs from other studies on supracondylar fractures.4,7-14 in the current study, 29 (76%) had left-sided supracondylar fractures, in keeping with global literature in which the left side was predominantly affected.4-10,13-15 spencer et al. showed that there is rapid improvement in elbow rom in the first four weeks after removal of the cast followed by a slower increase in rom for up to one year. in their study, recovery of rom was slower in children older than five years and in those with severe injury patterns. they confirmed that recovery of full extension was slower in fractures with severe associated injuries around the elbow.7 this concurs with the current study results in which older children (over the age of 7 years) and those with associated injuries took longer to regain full rom but at the 24-week final follow-up had similar rom to those without complications. spencer et al.’s cohort achieved 95% of the normal elbow rom by 24 weeks. comparable results were noted by zionts et al. where 94% gained normal elbow rom at 26 weeks and 98% at 52 weeks after crpp.13 the podci has been used to measure outcome in children after many orthopaedic interventions.16 wang et al. also used podci to assess the functional outcome of gartland grade iii supracondylar fractures with early neurovascular compromise in children and showed it to have a high sensitivity and specificity compared with other outcome measures.11 these papers highlight that anatomical function (including anatomical reduction, alignment and full functional arc) does not always equate with good clinical outcome (such as pain scores and the ability to perform a task) – the 12 children (31%) in the current study who did not show satisfactory podci results either sustained associated soft tissue injuries (nerve injury, open fractures or compartment syndrome) or were older than 7 years of age, despite near normal rom at final follow-up (table ii). the benefit of podci is that it can add further information to the final assessment and outcome of these children by assessing more than just the rom and anatomical reduction (tables ii and iii). in the current study, the podci proved to be more sensitive to musculoskeletal changes after crpp than physical examination alone. lerman et al. observed that podci is an efficient instrument in the assessment of function after an orthopaedic intervention.16 the current study supports the findings of lerman et al. because restoration of anatomy does not always equate to function. up to a third of patients with full rom at the 24-week final follow-up could not perform basic upper limb physical functional activities easily and parents were not very satisfied about the outcome. in the current study, we have shown that supracondylar fractures can be a source of physical disability in those children with complications. children who sustained nerve injuries, open fractures, compartment syndrome, and those with age greater than 7 years had reduced elbow rom and podci results at the 24-week follow-up. spencer et al. showed similarly that in patients who were older than 5 years of age, the relative arc of motion was decreased by 3–9% compared with patients younger than 5 years of age.7 in the same study, it was noted that the more severe the injury, the slower the elbow motion recovery. this correlated with the findings of the current study where the children who sustained open fractures, compartment syndrome or nerve injuries had relatively poor elbow functional outcome at the 24-week follow-up. complications after supracondylar humerus fractures are not uncommon. acutely these include open soft tissue injuries, neurovascular injuries and compartment syndrome. some studies have shown incidence of vascular injuries of up to 20%.4,8,11,14,17 badkoobehi et al. noted that 20% of displaced supracondylar fractures have an associated vascular injury (ranging from vessel spasm to overt vessel damage).17 in the current study, only the case with compartment syndrome had vascular compromise due to spasm and kinking by the fracture fragment displacement compounded by subsequent compartment syndrome – flow was re-established after crpp and fasciotomy. in terms of nerve injuries associated with extension-type supracondylar fractures, the most commonly injured nerve is the radial nerve followed by the median nerve and ulnar nerve.3,4,14 in the current study the most commonly injured nerve was the ulnar nerve (excluding iatrogenic injuries) and then the radial nerve. the ulnar nerve injury is one of the most common iatrogenic complications recorded when using the crossed-pinning technique. pre-operative nerve injuries occur most commonly in older children.3,4,14 we observed an overall incidence of 18.4% (seven children) of nerve injuries and the mean age for these children was 10 years, which confirmed the findings in the literature. other studies in the literature have reported results within the same range.3,4,11,14 the children with associated nerve injuries all had reduced rom (especially extension) at final follow-up (p=0.009). in our study, there were six ulnar (16%) and one radial nerve injuries. four (10.5%) of the ulnar nerve injuries were iatrogenic, which was higher than other studies such as the one conducted by prashant et al. (6.5%).3 ongoing training of junior staff is essential but not the focus of this study – a safer alternative for junior staff may be two lateral k wires. the majority of patients who sustained an associated nerve injury/ open fracture were in the older group (over 7 years) and had poor outcomes compared with those without these associated injuries. one case developed compartment syndrome after crpp. fasciotomy was done urgently after crpp with subsequent volkmann’s ischaemic contracture, ulnar nerve neuropraxia and a fixed flexion deformity of 38° at 24 weeks. robertson et al. showed that neurovascular injuries and older age were both risk factors for developing compartment syndrome in children with grade iii supracondylar fractures, as in this case.18 sinikumpu et al. performed a population-based long-term followup study of 81 children with gartland i–iii fractures; of these, 25 were gartland iii fractures and they found that only 76% of these had a satisfactory outcome after closed or open reduction and percutaneous pinning according to flynn’s criteria.19 the current study was looking only at gartland iii fractures (38 cases) and also found that although most patients at 24 weeks had return of full rom, they had reduced scores using the podci in over 30% of cases. this and the current study highlight that these fractures often have mild symptoms and deformity at final follow-up, despite accurate reduction and fixation. both studies found that results were worse in older patients – sinikumpu et al. in children older than 10 years of age and the current study in children older than 7 years of age.19 page 19firth gb et al. sa orthop j 2019;18(4) tumomilehto et al. reviewed 264 children with gartland iii fractures and found that despite unsatisfactory pin fixation in a third of cases, significant malunion was rare at long-term follow-up.20 controversies exist on the effectiveness of physiotherapy in supracondylar fractures after crpp. sub-optimal limb function after an orthopaedic intervention due to poor or delayed rehabilitation may raise medico-legal issues. keppler et al.6 randomised two groups of children with supracondylar fractures (gartland grades ii and iii) for physiotherapy (21 children) and the other group without physiotherapy, looking at the effectiveness of physiotherapy in these children after open reduction and internal fixation. at 12 weeks they noticed a better return of elbow rom in the physiotherapy group but at one year the groups were the same. unlike the current study, none of these children had neurological injuries and they all had an open reduction which may have predisposed them to higher rates of elbow stiffness. if the neurological injuries were to be excluded from the current series, the results would be very similar. in contrast, schmale et al.5 demonstrated that there was no benefit of physiotherapy to children (n=61) with gartland grades i, ii and iii supracondylar fractures, managed by either casting or crpp. the inclusion of grades i–iii could have skewed the benefits of physiotherapy to a small subpopulation of this cohort with displaced supracondylar fractures. larger multi-centre randomised controlled trials (rcts) on the role of physiotherapy in displaced supracondylar fractures are needed. to our knowledge, this is the first prospective study in south africa focusing on the functional outcome of extension-type gartland grade iii supracondylar humerus fractures assessing both elbow rom and podci after crpp. although this study was prospective, there was a short period of data collection (24 weeks) and limited sample size. there was a large loss of patients (n=15, 26%) to follow-up due to loss or change of contact details, and the podci questionnaire was limited to only two items that were relevant to the study of the upper limb. conclusion this study has demonstrated that most children with gartland grade iii extension-type supracondylar fractures gain full elbow rom and have good functional outcome by 24 weeks after closed reduction and percutaneous cross k wires. further findings demonstrated that functional outcome does not necessarily equate to good or excellent clinical outcome with the use of the podci tool, especially in those children who were older than 7 years of age and those that sustained severe soft tissue injuries (open fractures, nerve injuries, compartment syndrome or internal degloving injuries). the value of a protocol-driven rehabilitation programme which may include physiotherapy for patients identified to be at risk of poor outcome (those over 7 years of age or with associated soft tissue injuries) requires further prospective study. ethics statement this study was approved by the human research ethics committee of the university of witwatersrand (clearance no. m150901) and consent was obtained from the ceo of chris hani baragwanath academic hospital. signed informed consent was completed by all parents and signed informed assent was obtained from all children who could understand the request. declarations the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ar conceived of the idea together with gbf and was the primary data collector in all cases. ar assisted with application to the departmental research committee and ethics board and wrote the initial manuscript. gbf conceived of the research idea and helped to develop the study protocol. gbf contributed to writing up the manuscript for submission and helped with revisions. orcid a rutarama https://orcid.org/0000-0002-8354-3371 gb firth https://orcid.org/0000-0002-1594-2290 references 1. zionts le, mckellop ha, hathaway r. torsional strength of pin configurations used to fix supracondylar fractures of the humerus in children. j bone joint surg am. 1994 feb;76(2):253-56. 2. howard a, mulpuri k, abel mf et al. the 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m, fong yj et al. prospective longitudinal evaluation of elbow motion following pediatric supracondylar humeral fractures. j bone joint surg am. 2010 apr;92(4):904-10. doi: 10.2106/jbjs.i.00736. 8. anvekar pm, nimbargi ss, akshay mk et al. a prospective study of surgical management of the displaced supracondylar fractures of humerus in children with k wire fixation. ijos 2017;3(3):176-81. 9. houshian s, mehdi b, larsen ms. the epidemiology of elbow fracture in children: analysis of 355 fractures, with special reference to supracondylar humerus fractures. j orthop sci. 2001;6(4):312-15. 10. abzug jm, herman mj. management of supracondylar humerus fractures in children: current concepts. j am acad orthop surg. 2012 feb;20(2):69-77. doi: 10.5435/jaaos-20-02-069. 11. wang si, kwon ty, hwang hp et al. functional outcomes of gartland iii supracondylar humerus fractures with early neurovascular complications in children. a retrospective observational study. medicine (baltimore). 2017 jun;96(25):e7148. doi: 10.1097/md.0000000000007148. 12. hasler cc. supracondylar fractures of the humerus in children. eur j trauma. 2001;27(1):1-15. 13. zionts le, woodson cj, manjra n et al. time of return of elbow motion after percutaneous pinning of pediatric supracondylar humerus fractures. clin orthop relat res. 2009 aug;467(8):200710. doi: 10.1007/s11999-009-0724-y. 14. rockwood ca, green dp, bucholz rw. rockwood and green’s fractures in adults. lippincott williams & wilkins; 2006. 15. hassan fo. hand dominance and gender in forearm fractures in children. strategies trauma limb reconstr. 2008 dec;3(3):101103. doi: 10.1007/s11751-008-0048-6. 16. lerman ja, sullivan e, barnes da et al. the pediatric outcomes data collection instrument (podci) and functional assessment of patients with unilateral upper extremity deficiencies. j pediatr orthop. 2005 may-jun;25(3):405-407. 17. badkoobehi h, choi pd, bae ds et al. management of the pulseless pediatric supracondylar humeral fracture. j bone joint surg am. 2015 jun 3;97(11):937-43. doi: 10.2106/jbjs.n.00983. review. 18. robertson ak, snow e, browne ts et al. who gets compartment syndrome? a retrospective analysis of the national and local incidence of compartment syndrome in patients with supracondylar humerus fractures. j pediatr orthop. 2018 may/ jun;38(5):e252-e256. doi: 10.1097/bpo.0000000000001144. 19. sinikumpu jj, victorzon s, pokka t et al. the long-term outcome of childhood supracondylar humeral fractures: a population-based follow up study with a minimum follow up of ten years and normal matched comparisons. bone joint j. 2016 oct;98-b(10):1410-17. 20. tuomilehto n, kvisaari r, sommarhem a et al. outcome after pin fixation of supracondylar humerus fractures in children: postoperative radiographic examinations are unnecessary. acta orthop. 2017 feb;88(1):109-15. doi: 10.1080/17453674.2016.1250058. https://orcid.org/0000-0002-8354-3371 https://orcid.org/0000-0002-8354-3371 https://orcid.org/0000-0002-1594-2290 https://orcid.org/0000-0002-1594-2290 _goback _hlk9344529 _hlk3401067 _hlk8194138 _hlk9344792 _hlk536177444 _hlk3618262 _goback _goback orthopaedics vol3 no4 page 52 sa orthopaedic journal winter 2015 | vol 14 • no 2 mycobacterium fortuitum as infectious agent in a septic total knee replacement: case study and literature review rg venter mbchb(stell) registrar, orthopaedics, tygerberg hospital, stellenbosch university c solomon mbchb(stell), fcs ortho orthopaedic surgeon, department of orthopaedic surgery, paarl hospital m baartman mbchb, fcs ortho head of department, department of orthopaedic surgery, paarl hospital corresponding author: dr rg venter 22 minaret close welgevonden estate stellenbosch 7600 email: rgventer@gmail.com case report we present a 70-year-old, caucasian, hiv-negative patient, from a rural district in the western cape, south africa. she presented to an outreach clinic with a 10-year history of left knee pain. clinically she had a 20 degrees valgus deformity (correctable) without fixed flexion. radiographically there was marked osteopaenia, cysts and degenerative changes. a clinico-radiological diagnosis of rheumatoid arthritis was made (figures 1 and 2). she had no previous medical history of note, and did not have any infiltrations or penetrating wounds of that knee. no other joints were affected. a total knee replacement was performed in april 2013 (triathlon®, stryker). the pre-operative blood investigations included a white cell count of 7.10 × 109 and rheumatoid factor of 198.3 iu/ml. the erythrocyte sedimentation rate was not requested. intra-operative findings included large cysts in the medial tibial plateau, medial femoral condyle and a large concavity of the lateral plateau requiring bone graft, as well as marked distal femoral erosion with minimal erosion of the posterior aspect of the lateral femoral condyle. this atypical pattern of joint erosion prompted us to sample synovial tissue. introduction infection of prosthetic joints with non-tuberculous mycobacteria (ntm) is rare. the rapidly growing mycobacteria (rgm) are a subgroup of ntm. they are not very virulent organisms, found ubiquitously in the environment, and most infections in humans are due to direct inoculation of the organism into a joint or soft tissue. we describe a 70-year-old patient, who developed an infection with mycobacterium fortuitum after primary knee arthroplasty, one of only a handful described in the literature. peri-prosthetic infections with rgm are a challenge because there is a lack of data guiding management, and because the diagnosis is often delayed. routine cultures of joint effusions or tissue are often discarded before the non-tuberculous mycobacteria have a chance to culture (in our case, 14 days). principles of treatment include: making a diagnosis from tissue culture, staged revision surgery with aggressive surgical debridement of the joint and high dosages antibiotics (for at least six weeks, treating empirically initially until a sensitivity profile for the organism is available). the second stage of the revision should be delayed by 3–6 months. in our case the removed implant was autoclaved and reimplanted loosely with antibiotic-loaded cement as part of the first-stage revision. key words: total knee replacement, peri-prosthetic joint infection, septic arthritis, rapidly growing mycobacteria, non-tuberculous mycobacteria, mycobacterium fortuitum, mycobacterium abcessus, mycobacterium chelonae, mycobacterium smegmatis, mycobacterium kansasii, mycobacterium goodii http://dx.doi.org/10.17159/2309-8309/2015/v14n2a8 saoj winter 2015_press_orthopaedics vol3 no4 2015/05/11 10:00 am page 52 sa orthopaedic journal winter 2015 | vol 14 • no 2 page 53 post-operatively she did very well, her early recovery and rehabilitation was uneventful, and she was discharged a week later in good health. the post-operative blood investigations also suggested a diagnosis of rheumatoid arthritis. anti-cyclic citrullinated peptide: more than 250 units, erythrocyte sedimentation rate: 85 mm/hr. histological investigation of the synovial biopsy showed proliferated synovial cell lining, infiltration of lymphocytes, plasma cells, but also neutrophils. the histology was therefore highly suggestive of rheumatoid arthritis, but the component of acute inflammation was unaccounted for. no microbiological examinations were ordered at the time. figures 3 and 4 show component placement post-operatively. intra-operative findings included large cysts in the medial tibial plateau, medial femoral condyle and a large concavity of the lateral plateau requiring bone graft, as well as marked distal femoral erosion with minimal erosion of the posterior aspect of the lateral femoral condyle figure 1. ap radiograph, pre-operative figure 2. lateral radiograph, pre-operative figure 3. ap radiograph, before revision figure 4. lateral radiograph before revision saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 53 page 54 sa orthopaedic journal winter 2015 | vol 14 • no 2 three weeks post-operatively she presented to her local district hospital with symptoms of knee pain and swelling, vomiting and dysuria. she was diagnosed with acute gastroenteritis and a urinary tract infection. however, her left knee pain and swelling was not addressed at the time. the patient became lost to arthroplasty follow-up and visits the clinic for the first time 2 months after the surgery. at this stage her knee was painful, tender and warm, and had developed two draining sinuses. the inflammatory markers were raised. white cell count: 10.8 × 109, erythrocyte sedimentation rate: 100 mm/hr, c-reactive protein: 82.3 mg/l. she underwent debridement of the knee as an emergency and tissue samples were taken for diagnostic purposes. intravenous ampicillin, 2 g, 6 hrly and cloxacillin 2 g, 6 hrly, was started empirically. routine cultures were negative; however, tb investigations were also ordered, and although direct microscopy was negative, the cultures revealed acid-fast bacilli at day five and day 12, respectively, but polymerase chain reaction test for mtb complex was negative. the organism was later identified as mycobacterium fortuitum. histological examination revealed features of acute and chronic inflammation, with granulation tissue, hemosiderophages, fibrosis and giant cell formation. we decided on empiric therapy of the rapidly growing mycobacteria based on available literature:1 meropenem, 1 g, 8 hrly, iv and ciprofloxacin, 750 mg 12 hrly, po. her second debridement took place three weeks after the first debridement. the implants and cement were removed completely. a radical synovectomy was performed. the removed femoral and tibial implants were cleaned and sterilised in an autoclave. the sterilised components were loosely re-implanted as a spacer with cement loaded with 5 g of vancomycin and 3.6 g of tobramycin per 40 g of simplex cement. a conventional uhmwpe spacer was also inserted. response to therapy was excellent – reduced pain and swelling and active flexion to 90° early post-operatively. the infection markers returned to almost normal levels within three weeks. white cell count: 7.0 × 109, erythrocyte sedimentation rate: 46 mm in 1hr and c-reactive protein: 11.8 mg/l. the patient remained in hospital for four weeks, receiving meropenem intravenously. the ciprofloxacin was stopped a week after the debridement, and replaced with amikacin, 600 mg dly and cefuroxime, 1.5 g, 6 hrly. at the end of four weeks of total intravenous therapy she was discharged home with a course of ciprofloxacin (500 mg, 12 hrly, orally) and cotrimoxazole (160/800 mg, 12 hrly, orally) for six weeks. the second stage revision of the joint three months after completion of the antibiotic course was planned if she remained clinically aseptic. at the most recent follow-up visit in january 2014 (9 months after the primary total knee replacement) she was very satisfied with regard to function and pain. she had a full range of motion of the left knee, was fully weightbearing and all the inflammatory markers were within normal limits. she refused the second stage of revision. figures 5 and 6 show the left knee at last followup visit. literature review a literature search revealed 22 previous cases of prosthetic knee joint infections with rapidly growing mycobacteria (rgm).2–15 infections of other prosthetic joints and infections where the infectious agent was one of the other non-tuberculous mycobacteria (ntm) were not included. the most prevalent organisms were m. fortuitum (11 patients), m. chelonae (four patients), and m. goodii (three patients). by far the most were immunocompetent and not receiving any immunosuppressive medication. the average time to onset of symptoms from prosthesis implantation was 136.6 weeks, in the 20 patients of whom this information was stated in the case reports. the shortest was 1 week,2 and the longest was 16 years.10 at presentation the mean erythrocyte sedimentation rate (esr) was 38.2 mm/hr (reported in eight patients), the highest measured was 96 mm/hr.3 the time for rgm to appear in culture was reported in seven patients and the average time was 6.8 days. the longest was 11 days.13 figures 5 and 6. the left knee at last follow-up. response to therapy was excellent – reduced pain and swelling and active flexion to 90° early post-operatively saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 54 sa orthopaedic journal winter 2015 | vol 14 • no 2 page 55 in most cases the patients received at least one debridement in theatre with removal of the implants and insertion of an antibiotic-loaded cement spacer. the average time to successful revision arthroplasty, from the removal of the implant, was 21.5 weeks (reported in 12 cases). the shortest time to successful re-implantation was 12 weeks.9 one case of relapse was reported in 1987, after the revision arthroplasty was performed only seven weeks after resection arthroplasty. the infection was treated with doxycycline as suppressive therapy, until a superinfection with yet another organism prompted resection and arthrodesis.6 in four cases, for various reasons, the prosthesis was retained and the infection controlled with long-term suppressive therapy. 2,10,15 table i summarises the sensitivity profiles for the reported cases. discussion infection of a prosthetic joint can be a potentially devastating complication following knee arthroplasty and a critical part of treatment is identification of the causative organism, the most common being staphylococcus.16 infections with rgm can be difficult to diagnose for a variety of reasons. they are rarely the causative organism and therefore not suspected. acid-fast staining is often not positive and although quicker than m. tuberculosis, they take longer to culture than other organisms (1–2 weeks in liquid cultures),17 and by that time routine cultures might have been discarded. the rgm are divided into three groups, based on differentiation according to antimicrobial susceptibility testing: fortuitum group, with wider antimicrobial sensitivity, chelonae/abcessus group and smegmatis group that incorporates m. goodii and m. woliskyi.18 these organisms are pervasive in the environment and have been isolated from water, soil, and in hospitals.19 infections in humans have been well described, and occur mostly secondary to direct inoculation20 or contaminations of wounds. in case reports these often occurred in clusters, and on more than one occasion contaminated hospital fresh water supply was suspected.21,22 cornelius et al. described a cluster of three m. fortuitum prosthetic joint infections (two knees and one hip), postulating intra-operative contamination.9 ahmad describes a case of peri-prosthetic infection, most probably acquired during physical therapy in a whirlpool bath.12 however, in most cases of peri-prosthetic infection with ntm the source of infection is never identified. predisposing factors have been proposed, like rheumatoid arthritis, other comorbidities and pre-operative intraarticular steroid depot injections.3 whether this implies a possible direct inoculation of the organisms into the joint or the immune depressing effects of the steroid is unclear. furthermore, ntm infection of native joints, even one without violation of the joint (in an hiv-positive patient), has been described, implying that purely haematogenous spread also occurs.23,24 infections with rgm can be difficult to diagnose mic, µg/ml patient organism amk tob cfx clr dox tmp-smx cip mox imp lnz 1 m. fortuitum 2 (s) 16 (r) 0.25 0.12 4 32 (r) 23 m. fortuitum 1 >128 (r) 0.5 0.5 >4 (r) >16 m. abcessus 0.5 >128 (r) >8 >16 0.25 311 m. fortuitum (s) (r) (s) (s) 45 m. fortuitum <0.5 32 (r) <0.25 <0.25 >8/125 (r) 2 4 52 m. chelonae 32 (i) 16 (r) >16 (r) 0.5 >128 (r) >2/38 (r) >2 (r) 16 (r) 62 m. chelonae 32 (i) >16 (r) 16 (s) >128 (r) .../>64 (r) >16 (r) 8 72 m. smegatis <2 <1 128 (r) >32 (r) <0.12 …/8 0.5 <0.12 2 <2 82 m. fortuitum <2 16 (r) 32 (i) 2 >64 (r) …/<4 <0.25 <0.12 1 <2 92 m. fortuitum <2 16 (r) 64 (i) 4 (i) >64 (r) …/8 <.25 0.5 4 8 102 m. chelonae 8 <1 256 (r) <0.25 (s) <0.25 …/32 (s) 2 (i) 4 32 (r) <2 (s) 112 m. abcessus 8 8 (i) 32 (i) <0.25 (s) >64 (r) …/>64 (r) >16 (r) 4 (s) 16 (i) 1214 m. woliskyi 16(s) >256 (r) 64 (r) 0.5 (s) 1 (s) <0.125 (s) >64 (r) 1312 m. goodii (s) (s) (s) (s) (s) (s) 1411 m. fortuitum (s) (r) (s) (s) (r) (s) (s) 1513 m. goodii <0.5 (s) 4 (s) 0.25 (s) 168 m. chelonae (s) (s) (s) (s) 177 m. fortuitum (s) note: amk, amikacin; cfx, cefoxitin; cip, ciprofloxacin; clr, clarithromycin; dox, doxycycline; imp, imipenem; lnz, lenezolid; mox, moxifloxacin; (i), intermediate; (s), sensitive; (r) resistant. table i: sensitivity profiles of organisms at initial culture saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 55 page 56 sa orthopaedic journal winter 2015 | vol 14 • no 2 this family of organisms grow in biofilm,25 possibly explaining why there is a delay in presentation, but more importantly, explaining why aggressive debridement, removal of the implants, and prolonged courses of antibiotics seem to offer the only hope of cure. conclusion prosthetic joint infection with non-tuberculous mycobacteria can be considered as rare. we report a case of a prosthetic knee infection with one of the rapidly growing mycobacteria, m. fortuitum and review the previous case reports in the literature. considering the outcomes of previously reported cases, delay in identification of the causative organism appears to be a significant cause of morbidity, emphasising the importance of a high index of suspicion, especially if initial microbial cultures are negative. the most effective way to treat these infections seems to be removal of the implant and debridement combined with antimicrobial therapy for at least six months, guided by sensitivity testing, before re-implantation is attempted. based on documented sensitivity profiles of previous cases, we recommend empiric meropenem, iv and ciprofloxacin, iv while sensitivity profiles are pending, and the use of antibiotic-impregnated cement. for patients that are poor candidates for surgery, however, chronic suppressive therapy in a poor surgical candidates has also been shown to be effective.2,10,15 the content of this article is the original work of the author. no benefits of any form have been or are to be received from a commercial party related directly or indirectly from this article. references 1. brown-elliott b a, nash k a, wallace rj. antimicrobial susceptibility testing, drug resistance mechanisms, and therapy of infections with nontuberculous mycobacteria. clin microbiol rev. 2012 jul;25(3):545–82. 2. eid a, berbari e. prosthetic joint infection due to rapidly growing mycobacteria: report of 8 cases and review of the literature. clin infect dis. 2007 sep 15;45(6):687–94. 3. wang s, yang c, chen y, lay c, tsai c. septic arthritis caused by mycobacterium fortuitum and mycobacterium abscessus in a prosthetic knee joint: case report and review of literature. intern med.2011;50(19):2227–32. 4. cheung i, wilson a. mycobacterium fortuitum infection following total knee arthroplasty: a case report and literature review. knee 2008 jan;15(1):61–63. 5. saccente m. mycobacterium fortuitum group periprosthetic joint infection. scand j infect dis. 2006 jan;38(8):737–39. 6. herold rc, lotke pa, macgregor rr. prosthetic joint infections secondary to rapidly growing mycobacterium fortuitum. clin orthop relat res. 1987 mar;(216):183–86. 7. booth j, jacobson j. infection of prosthetic arthroplasty by mycobacterium fortuitum. two case reports. j bone joint surg am.1979 mar;61(2):300-302. 8. pring m, eckhoff d. mycobacterium chelonae infection following a total knee arthroplasty. j arthroplasty. 1996;11(1):115–16. 9. cornelius l, reddix r, burchett c, bond g, fader r. cluster of mycobacterium fortuitum prosthetic joint infections. j surg orthop adv. 2007 jan;16(4):196–98. 10. porat m, austin m. bilateral knee periprosthetic infection with mycobacterium fortuitum. j arthroplasty. 2008 aug;23(5):787–89. 11. yung y, li p, lee q, wong y, wai y. treatment of mycobacterium fortuitum infection of total knee arthroplasty: a case report. j orthop. 2012 dec;16(2):82–85. 12. ahmad s, khakoo r a. left knee prosthesis-related mycobacterium goodii infection. int j infect dis. 2010 dec;14(12):e1115–16. 13. ferguson dd, gershman k, jensen b, arduino mj, yakrus m a, cooksey rc, et al. mycobacterium goodii infections associated with surgical implants at colorado hospital. emerg infect dis. 2004 oct;10(10):1868–71. 14. jeong jh, seo y-h, kim k-h, ahn j-y, park p-h, park y-k. mycobacterium wolinskyi infection confirmed by rpob gene sequencing. j clin lab anal. 2012 sep;26(5):325–27. 15. tompkins jc, harrison ms, witzig rs. mycobacterium goodii infection of a total knee prosthesis. infect med. 2008;25(11):522–25. 16. sia ig, berbari ef, karchmer aw. prosthetic joint infections. infect dis clin north am. 2005 dec;19(4):885–914. 17. brown-elliott b. antimicrobial susceptibility testing, drug resistance mechanisms, and therapy of infections with nontuberculous mycobacteria. clin microbiol. 2012 jul;25(3):545–82. 18. kothavade rj, dhurat rs, mishra sn, kothavade ur. clinical and laboratory aspects of the diagnosis and management of cutaneous and subcutaneous infections caused by rapidly growing mycobacteria. eur j clin microbiol infect dis. 2013 feb;32(2):161–88. 19. brown t. the rapidly growing mycobacteria: mycobacterium fortuitum and mycobacterium chelonei. infect control. 1985;6(7):283–88. 20. miron d, el a, zuker m. mycobacterium fortuitum osteomyelitis of the cuboid after nail puncture wound. pediatr. 2000;19(5):475–88. 21. hoffman p, fraser d. two outbreaks of sternal wound infections due to organisms of the mycobacterium fortuitum complex. j infect dis. 1981;143(4):533–42. 22. meyers h, brown-elliott b a, moore d, curry j, truong c, zhang y, et al. an outbreak of mycobacterium chelonae infection following liposuction. clin infect dis . 2002 jun 1;34(11):1500–507. 23. butt aa, janney a. arthritis due to mycobacterium fortuitum. scand j infect dis. 1998;30:525–27. 24. bernard l, vincent v, lortholary o, raskine l, vettier c, colaitis d, et al. mycobacterium kansasii septic arthritis: french retrospective study of 5 years and review. clin infect dis. 1999 dec;29(6):1455–60. 25. chen jm, german gj, alexander dc, ren h, tan t, liu j. roles of lsr2 in colony morphology and biofilm formation of mycobacterium smegmatis. j bacteriol. 2006;188(2):633–41. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 5 404 not found 404 not found 404 not found orthopaedics vol3 no4 page 62 sa orthopaedic journal summer 2015 | vol 14 • no 4 epithelioid haemangioendothelioma of the scapula in a child: a case report and review of the literature dr mn rasool mbchb, fcs orth(sa), phd(ukzn) consultant orthopaedic surgeon dr rf snyders mbchb registrar orthopaedics dr g bydawell mbchb, frcr (sa) consultant radiologist corresponding author: dr mn rasool department of orthopaedic surgery university of kwa-zulu natal nelson r mandela school of medicine private bag 7 congella, durban, 4001 tel: 031 260 4297 email: rasool@ukzn.ac.za introduction epithelioid haemangioendothelioma (ehe), a rare tumour of vascular endothelial origin, is one of the lesser-known tumours of bone. the tumour pursues a clinical course between that of a haemangioma and an angiosarcoma. it occurs mainly in soft tissues such as the skin, liver and lung, but rarely in bone. the osseous lesions may be solitary but the majority are multi-centric.1–5 the lower limbs are more commonly involved. the scapula is a very rare site of involvement and this tumour is uncommon in children. one report only, occurring in the scapula, has been described in a child as part of a multi-centric involvement.6 ehe can be misdiagnosed as a metastatic carcinoma or primary sarcoma in children. resection is still the primary modality of treatment. radiotherapy is useful for surgically inaccessible sites. profuse local bleeding at the time of biopsy or surgery has been reported.4,7,8 the aim of this report is to describe a rare site of involvement of ehe in the scapula, and the value of preoperative transarterial embolisation (tae) to decrease operative bleeding during scapulectomy. case report a 10-year-old girl was referred from a rural hospital for a slow-growing, enlarging mass, associated with pain over the right scapula. symptoms were present for 6 months. an open biopsy was done in the rural hospital. the report of the biopsy, which was done at the referral hospital, was inconclusive. the child was well, but slightly pale. the swelling was 20 cm × 15 cm × 12 cm fixed to the scapula and involving the supraand infraspinous fossae (figure 1). the skin was adherent to the tumour over the biopsy site only. multiple dilated veins were present. axillary and supraclavicular lymph nodes were not enlarged. abstract epithelioid haemangioendothelioma (ehe) is a vascular tumour which rarely affects bone. a 10-year-old girl presented with slow onset of swelling of the scapula for 6 months. radiology revealed a destructive lesion of the scapula. histology confirmed epithelioid haemangioendothelioma. pre-operative transarterial embolisation was performed to decrease the vascularity of the tumour. the tumour was completely resected with the entire scapula. post-operatively the child improved with useful function and a stable shoulder 13 months later. large, isolated ehe of the scapula has not been reported in children. key words: epithelioid haemangioendothelioma, scapula, transarterial embolisation, scapulectomy http://dx.doi.org/10.17159/2309-8309/2015/v14n4a9 saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 62 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 63 all shoulder movements were limited. there was no neurovascular involvement. the elbow and the hand function were good, though the arm muscles were wasted. plain radiographs of the right scapula showed a large tumour with destructive changes (figure 2). mri showed a multi-lobulated mass of heterogeneous signal intensity, with central necrosis but no calcification (figure 3). the neurovascular bundle was displaced anteriorly. there was no infiltration of the chest wall. a pathological fracture of the glenoid neck was present. the haemoglobin was 8 g/l and the esr was 15 mm/hr. staging investigations revealed that the lesion was confined to the scapula, with the bone scan showing no other areas of increased uptake. the tru-cut biopsy revealed haemangioendothelioma of bone on histology. using 300-500 and 500-700 micron particles, a transarterial embolisation was performed by an interventional radiologist. the tumour-feeding branches from the axillary artery was targeted, using a micro-catheter. this allowed a window period in which to surgically remove the tumour (figures 4a and 4b). figure 1. the clinical picture shows a large tumour over the scapula extending into the axilla. the biopsy was performed at the referral hospital. figure 2. the radiograph shows large soft tissue swelling, destructive lesion of scapula with pathological fracture of the glenoid neck. figure 3. the mri scan shows large multilobulated tumour of heterogeneous signal intensity. figure 4a and 4b. an arteriogram, pre-operatively, shows the vascularity of the tumour with several feeding vessels. the post-embolisation arteriogram shows a marked decrease in vascularity. a b saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 63 page 64 sa orthopaedic journal summer 2015 | vol 14 • no 4 a tumour resection was performed 6 days after the embolisation. the previous biopsy scar was excised and the incision was extended to the inferior angle of the scapula, and supero-laterally to the axilla. from inferomedially, the latissimus dorsi, rhomboids, levator scapulae and the trapezius were divided. the tumour was removed dividing the serratus anterior, reflecting the posterior deltoid from the acromion and dividing the rotator cuff. the lateral 2 cm of the acromion, together with the clavicle, remained after the resection of the entire scapula. the acromion was anchored posteriorly to the third rib with sutures to prevent drooping. bleeding was noted to be mild to moderate and the wound was closed over a suction drain. the tumour weighed 1.3 kg. histology confirmed a low grade ehe of bone with no signs of mitosis. the tumour was non-encapsulated and the soft tissue margin was free from tumour. post-operatively the child made good progress and was immobilised in a broad arm sling for 4 weeks. there were no neurovascular problems. at 13 months followup, the child gained weight, shoulder flexion and extension were 30° each, internal rotation was 40° and external rotation 15°, abduction reached 20°, and passively the limb could be elevated to above the head (figure 5). there was no recurrence, pain or instability of the joint (figure 6). discussion ehe of bone is rare. the incidence is between 0.1% to 1% of all malignant primary bone tumours. this tumour is usually seen in soft tissues such as the liver and lungs. bone lesions are usually multi-centric and have a predilection for long bones of the extremities, usually the lower limbs. lesions are often located in the diaphysis, but may occur in the metaphysis or meta-epiphysis. less frequently, this tumour is found in the vertebral column, the upper limbs, and flat bones.1–5,7,9,10 the age distribution ranges from 10–73 years (mean 30 years). ehe comprises two general groups, those of low grade malignancy, and those that are highly malignant and metastatic.4,7,8 clinically the tumour is slow growing, and the time from initial symptoms to presentation is reported as 7 months to 8 years.1 pathological fractures may be the presenting problem, but the major clinical manifestations of ehe of bone are pain and swelling. microangiopathic haemolytic anaemia, consumption coagulopathy and high output cardiac failure due to arterio-venous shunts have been reported.9,11 radiologically the lesions are osteolytic, expansile and multi-focal. reactive new bone formation is rare. the lesions may be in cancellous or cortical bone. occasionally, the radiological appearance is ‘honeycombed’ or may have ‘ballooning’ features with bulging of the thinned cortex.4-8 calcification is occasionally seen in large, deeply situated tumours.6 histology confirmed a low grade ehe of bone with no signs of mitosis. the tumour was non-encapsulated and the soft tissue margin was free from tumour figure 6. a radiograph shows the stable humeral head in the axilla. figure 5a and 5b. clinical pictures showing useful function of the shoulder b a saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 64 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 65 macroscopically the appearance of the tumour tissue is dark red or brownish. the consistency is soft but it may be firm if the cells are in dense collagen fibres. profuse bleeding may be encountered during surgery.4,8,9 microscopically, a rich network of anastomosing vessels, lined with atypical epithelial cells are seen, together with primitive vaso-formative features, and vascular channels showing various stages of angiogenesis. silver staining of the vascular reticulin sheath is useful in distinguishing ehe from haemangiopericytoma and other vascular tumours.5,7 deposits of haemosiderin may be noted. ultra-structurally the important feature is the presence of the vascular lumina showing various degrees of maturation. the endothelial nature of the tumour can be confirmed by the presence of weibel-palade bodies and factor viii related antigen in the vascular endothelial cells.5-7 tumours are graded i–iii, though histological grading can be difficult in gr ii and gr iii, and in the case of recurrence.4,5 high and low malignant areas may be present initially in the same tumour.5 the most important criterion for predicting the prognosis of ehe of the bone was visceral involvement.4,5 when metastasis occurs, it usually develops from the tumours with atypical features. mitosis (>1 per hp field), focal spindling or cell necrosis are features of a more aggressive course. metastases in regional nodes may occur in 30%. the overall survival for solitary ehe is 89% and 50% for those with multi-focal disease. ehe can be misdiagnosed as metastatic carcinoma, due to its growth pattern and low mitotic activity. in children, ewing’s sarcoma, rhabdomyosarcoma, osteolytic osteosarcoma and skeletal angiomatosis must also be considered.3–5,12 in accessible regions, radical excision is the treatment of choice.4-7 radiation treatment alone may be effective in some patients with multi-centric tumours. the potential for complications must be considered. the role of chemotherapy is not clear but it may be used to treat tumours involving multiple bones. limb-sparing resection of the scapula is rarely done in children. in an adult with sarcoma, villalobos et al.13 performed a resection of the scapula and reconstruction using a customised scapula endoprosthesis. this is a useful alternative to forequarter amputation. the result was satisfactory with good elbow and hand function, though overhead activity was limited. the child in this report was able to perform activities of daily living with limitation of overhead activities. cosmetically the outcome was more acceptable, and functionally superior to a forequarter amputation. trans-arterial embolisation (tae) is one of the more important treatment modalities being used in the treatment of primary and secondary bone tumours.14–16 it reduces vascularity and intra-operative blood loss thereby allowing for better definition of tissue planes, and assisting in complete excision during surgery. the principles of tae of bone tumours are the precise targeting of the occlusive embolic material to the tumour-feeding vessels. the aim is the occlusion of the tumour capillary bed, and not the major arterial feeders. embolic agents used are either liquid or particulate. occluding only the major vessels leads to vascularisation of the tumour via other vessels. tumour types treated include metastatic lesions, giant cell tumours, aneurysmal bone cysts, vertebral haemangiomas, osteosarcomas and arterio-venous malformations.16 lower operative blood loss and the decreased need for intra-operative transfusion were advantages in the excision of the tumour in this patient. in conclusion, ehe is rare in children. only one scapula lesion has been described in a child, as part of a multi-centric involvement.6 primary solitary scapula lesions have only been described in adults.4,13 the child in this study had a large primary tumour isolated to the scapula. the morbidity of a forequarter amputation was avoided and the child has useful upper limb function. no benefits of any form have been or are to be received from a commercial party related directly or indirectly to the subject of the article. references 1. weiss sw, ishak kg, dail dh, sweet de, enzinger fm. epithelioid hemangioendothelioma and related lesions. semin diagn pathol 1986;3:259-87. 2. stout ap. hemangio-endothelioma: a tumor of blood vessels featuring vascular endothelial cells. ann surg 1943;118:445-64. 3. weiss sw, goldblum jr epithelioid haemangioendothelioma: vascular tumours of intermediate malignancy. enzinger and weiss. soft tissue tumors 5th edition: 2008 chapter 23, pp 681-88. mosby elsevier. 4. kleer cc, unni kk, mcleod ra. epithelioid hemangioendothelioma of bone. am j surg pathol 1996;20:130111. 5. campanacci m, boriani s, giunti a. hemangioendothelioma of bone: a study of 29 cases. cancer 1980;46:804-14. 6. tsuneyoshi m, dorfman hd, bauer tw. epithelioid hemangioendothelioma of bone: a clinicopathologic, ultrastructural, and immunohistochemical study. am j surg pathol 1986;10:754-64. 7. garcia-moral ca. malignant hemangioendothelioma of bone. review of world literature and report of two cases. clin orthop 1972;82:70-79. in accessible regions, radical excision is the treatment of choice. radiation treatment alone may be effective in some patients with multi-centric tumours saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 65 page 66 sa orthopaedic journal summer 2015 | vol 14 • no 4 8. bundens wd, brighton ct. malignant hemangioendothelioma of bone: report of two cases and review of the literature. j bone joint surg (am)1965;47-a:762-72. 9. srinivasan ck, patel mr, pearlman hs, silver jw. malignant hemangioendothelioma of bone: review of the literature and report of two cases. j bone joint surg (am)1978;60-a:696-700. 10. sweterlitsch pr, torg js, watts h. malignant hemangioendothelioma of the cervical spine. a case report. j bone joint surg (am)1970;52-a:805-808. 11. lye dj. wepfer jf, haskell ds. low grade hemangioendothelioma of the clavicle and acromion. case report 458, skeletal radiology 1988;17:57-59. 12. volpe r, mazabraud a. hemangioendothelioma (angiosarcoma) of bone: a distinct pathologic entity with an unpredictable course. cancer 1982;49:727-36. 13. villalobos ce, hayden bl, silverman a, choi i, wittig jc. limb-sparing resection of the scapula and reconstruction with a constrained total scapula prosthesis: a case of multicentric epithelioid hemangioendothelioma involving the scapula and surrounding soft tissues. ann surg oncol 2009;16:2321-22. 14. gupta p, gamanagatti s. preoperative transarterial embolization in bone tumors. world j radiol 2012;4:18692. 15. ibrahim wh, safran za, hasan h, zeid wa. preoperative and therapeutic embolization of extremities of bone and soft tissue tumors. angiology 2013;64:151-56. 16. owen rj. embolization of musculoskeletal bone tumors. semin intervent radiol 2010;27:111-23. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 66 page 236 sa orthop j 2022;21(4) cpd questionnaire. november 2022 vol 21 no 4 access gate-related lower limb fractures in children and adolescents: a review of injury patterns and evaluation of associated injuries (phala mp, rachuene pa, socutshana b, bila ks) 1. which of the following statements is correct relative to access gate-related injuries in south africa? a. motorised gates account for the majority of the injuries a b. injuries are equally observed in both motorised and manually operated gates b c. gate falling onto the child is the most common mechanism of injury c d. a and c are correct d e. all of the above statements are correct e 2. which of the following statements correctly describes fracture distribution in victims of access gate injuries? a. femur fractures are commoner than the other lower limb fractures a b. tibia fractures are commoner than the other lower limb fractures b c. both the femur and the tibia are equally affected c d. the majority of the cases will present with multiple fractures d e. physeal injuries were observed to be occurring around the knee joint in this cohort e 3. which of the following statements correctly describes injury patterns in victims of access gate injuries? a. compound fractures were the most commonly found fracture patterns in these patients a b. the majority of the patients have associated head injury b c. head injuries were commonly seen in patients with open tibia fractures c d. head injuries were commonly seen in patients with femur fractures d e. open fractures more commonly involved the ankle joint e an audit on the accuracy of freehand acetabular cup positioning in total hip arthroplasty with the direct lateral approach at a tertiary institution over seven years (erasmus rd, fourie pj, janse van rensburg c, jacobs hw) 4. what was the initial safe zone described by lewinnek for acetabular cup placement? a. 20° ± 10° anteversion and 40° ± 10° inclination a b. 15° ± 10° anteversion and 30° ± 10° inclination b c. 15° ± 5° anteversion and 40° ± 10° inclination c d. 15° ± 10° anteversion and 40° ± 10° inclination d e. 20° ± 10° anteversion and 30° ± 10° inclination e 5. what was our freehand cup placement accuracy? a. 37% a b. 47% b c. 57% c d. 67% d e. 77% e 6. what was our dislocation rate? a. 5% a b. 4% b c. 3% c d. 2% d e. 1% e a retrospective comparative study of complications after total knee replacement in rheumatoid arthritis and osteoarthritis patients (nansook a, ryan p) 7. what is the overall complication rate in this article? a. 15% a b. 7% b c. 3% c d. 40% d e. 26% e 8. which of the following statements is true? a. the study showed a higher complication rate in the rheumatoid arthritis subgroup a b. there was a statistical significance in complication rates between the groups b c. hiv did not increase the overall risk of complications c d. most patients were male (87%) d e. no complications occurred in the osteoarthritis subgroup e 9. a local study by hodkinson et al. showed that: a. despite appropriate treatment, a large proportion of ra patients still develop significant functional impairment a b. hiv is the leading cause of postoperative complications b c. ra patients have low functional impairment c d. only a small portion of patients develop complications post tka d e. dvt is the most common complication e retrospective audit of serum vitamin d levels in patients who underwent latarjet procedure for anterior shoulder instability (rachuene ap, dey r, de villiers s, berry k, mulder m, du plessis j-p, roche s) 10. with reference to vitamin d deficiency in young patients, which of the following statements is correct? a. vitamin d deficiency in the young south african population is reported to be uncommon in the literature a b. vitamin d deficiency only affects elderly patients and children with rickets b c. vitamin d deficiency is reported to affect over 15% of south african children c d. people with dark skin pigment have increased vitamin d synthesis, and hypovitaminosis d is uncommon in this population group d e. all of the above statements are correct e 11. which of the following statements is correct regarding latarjet procedure? a. latarjet procedure is a successful procedure with minimal to no risk of complications a b. coracoid bone block has blood supply from the conjoint tendon, therefore non-union and resorption are not a concern b c. ct scan-based studies report over 90% bone block resorption rate following this procedure, with minimal clinical impact c d. ct scan-based studies report under 10% bone block resorption rate following this procedure, with great clinical impact d e. bone block will invariably cause recurrent instability e orthopaedic journal s o u t h a f r i c a n � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � contents � � � � � � � � � � t h e s o u t h a f r ic a n o r t h o pa e d ic a s s o c ia t io n page 238 sa orthop j 2022;21(4) 12. regarding hypovitaminosis d in patients undergoing latarjet procedure for anterior shoulder instability, which of the following statements is correct? a. in the study, hypovitaminosis d was directly correlated to poor bone block union rate a b. hypovitaminosis d is common in young patients undergoing latarjet procedure and supplementation should be considered in these patients b c. hypovitaminosis d was shown to be associated with increased risk of bone block fracture c d. vitamin d has no impact on bone healing; therefore, it should not be considered in patients undergoing latarjet procedure d e. the study found hypovitaminosis d to affect only female patients e the burden of road traffic accident-related trauma to orthopaedic healthcare and resource utilisation at a south african tertiary hospital: a cost analysis study (thikhathali nd, ngcelwane mv) 13. which statement is true with regard to road traffic accidents (rtas) in south africa? a. the most common cause of trauma in south africa is road traffic accident followed by interpersonal violence a b. rtas cause less trauma in south africa than interpersonal violence b c. the majority of rta trauma patients have polytrauma c d. b and c only d e. a, b and c e 14. regarding the burden of trauma for our institution: a. the management of trauma patients does not influence the management of the non-trauma elective patients a b. the biggest cost driver in this study was hospital stay b c. management of acute fractures with external fixators does not have a significant impact on the overall costs of implants c d. external fixators were the most utilised implants accounting for 40% of the implants utilised in this study d e. the average number of days spent in hospital for these patients was 18 days per patient admitted e 15. choose the correct statement from the options below: a. the causes of rta-related injuries are preventable, as putting preventative measures in place as well as applying punitive measures for the offenders will help minimise the rtas a b. the number of mortalities from rtas is only reflected by the number of in-hospital mortalities b c. in comparison to previous studies done in africa, the commonest mode of rta-related injuries for this study was pedestrian-vehicle accident c d. a and c only d e. a, b and c e the mechanical testing of a novel interlocking forearm nail (pretorius hs, burger mc, ferreira n) 16. the nail produced in the article is made from titanium because of its low modulus of elasticity close to that of the radius. what is the modulus of elasticity of the radius? a. 90–100 gpa a b. 67–87 gpa b c. 10–17 gpa c d. 10–28 gpa d e. 34–53 gpa e 17. which standardised tests are performed on the radius to evaluate the nail for strength and durability? a. four-point torsion test, static rotational test and bending test a b. four-point rotational test, static rotational test and bending test b c. four-point bending test, static rotational test and rotational fatigue test c d. four-point bending test, static rotational test and four-point fatigue test d e. four-point rotational test, static rotational test and bending fatigue test e 18. the use of a semi-logarithmic graph is used in testing for what reason? a. it is the only way to predict outcome in testing with these variables a b. it is the best way to represent graphs with vastly different x and y values b c. it is the best way to represent x and y values with equivalent values c d. it is the only way to represent x and y values with equivalent values d e. it is the best way to represent x and y values with extremely large values e truth or dair? a review of debridement, antibiotics and implant retention (blair nr, van der merwe jf, matshidza s) 19. a 72-year-old female underwent left total knee arthroplasty (tka) 9 months ago. she now has new onset pain, with decreased range of motion. pji is suspected. based on the on the musculoskeletal infection society (msis), which of the following, if present, can be used in isolation for the diagnosis of an infected tka? a. elevated synovial wbc count and pmns a b. crp of 55 mg/l b c. sinus tract communicating with the prosthesis c d. purulence in the knee joint d e. esr of 60 mm/h e 20. in reference to debridement, antibiotics and implant retention (dair), which of the following statements is incorrect? a. irrigation with normal saline with or without the addition of an antiseptic solution is strongly recommended a b. dair can be performed in patients with a previous megaprosthesis b c. the causative organism does not play a role in dair success rates c d. dair performed for pji after fracture arthroplasty shows an increased risk for failure compared to pji after primary joint arthroplasty d e. exchange of mobile components is an independent factor related to dair success e subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm. co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online. • complete the questionnaire and click on submit. • your points are automatically submitted to the relevant authority. • please call mpc helpdesk if you have any questions: 0861 111 335. medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 mdb015/137/01/2022 phonela smh et al. sa orthop j 2020;19(4) doi 10.17159/2309-8309/2020/v19n4a6 south african orthopaedic journal http://journal.saoa.org.za trauma introduction osteogenesis imperfecta (oi) is an inherited collagen type 1 disorder with varying clinical manifestations.1,2 hallmarks include bone fragility, blue sclera, impaired hearing, defective dentition and hyperlaxity.1,3 the diversity of age at presentation and bone fragility best demonstrate the broad clinical spectrum of this condition. the clinical presentation ranges from mild forms to severe and lethal forms. 1,2 milder forms generally present in later stages of life, often with long bone fractures after minor trauma while the more severe forms can present with marked skeletal dysplasias, delayed milestones and even perinatal or early childhood death.1,2 type 1 collagen, a major extracellular protein constituent of bone, dentin, sclera, skin, vessels and heart valves, plays a central role in the pathogenesis of oi. nearly 90% of patients have an identifiable mutation in genes encoding for either the type 1 collagen or those involved in its post-translational modification, resulting in qualitative and/or quantitative defects.1,4 the modes of inheritance range from autosomal dominant to autosomal recessive but may also frequently arise as a spontaneous de novo mutation.1 the autosomal dominant forms arise from defective genes directly involved in type 1 collagen synthesis, whereas the recessive forms arise from defects in genes encoding the proteins which play a role in the post-translational modification of type 1 collagen.1 the international nomenclature group for constitutional disorders of the skeleton (incds) has modified the sillence classification into five types, oi types i–v. this article aims to provide a broad overview of oi, including the medical and orthopaedic aspects of management. current concepts review citation: citation: phonela smh, goller r, karsas m. osteogenesis imperfecta: an overview. sa orthop j 2020;19(4):229-234. http://dx.doi.org/10.17159/2309-8309/2020/v19n4a6 editor: prof. leonard c marais, university of kwazulu-natal, durban, south africa received: august 2020 accepted: october 2020 published: november 2020 copyright: © 2020 phonela smh. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this research. conflict of interest: the authors declare no conflict of interest. abstract osteogenesis imperfecta (oi) is a metabolic bone disorder commonly encountered in orthopaedic practice within the context of a multidisciplinary team. although relatively rare, it is among the most researched of the skeletal dysplasias, making it challenging for the general orthopaedic surgeon to keep abreast with current evidence. the aim of this review article is to provide a comprehensive overview of oi for the general orthopaedic surgeon. it touches on the relevant epidemiology, pathology and clinical aspects of the condition. a discussion of the background and current topical issues surrounding the classification systems, and the medical and orthopaedic management aspects follows. the main focus of this review is on the peri-operative orthopaedic care of the appendicular musculoskeletal system. we trust it will equip the general orthopaedic surgeon with concise, up-to-date and relevant information to efficiently manage affected patients and caregivers in south africa. level of evidence: level 5 keywords: osteogenesis imperfecta, type 1 collagen, multidisciplinary management, bisphosphonates, fassier-duval rods osteogenesis imperfecta: an overview phonela smh1 , goller r2 , karsas m3 1 mbbch; registrar in the department of orthopaedics, steve biko academic hospital, university of pretoria, pretoria, south africa ² mbchb, fcs orth(sa), mmed(orth)(pret); department of orthopaedics, steve biko academic hospital, university of pretoria, pretoria, south africa ³ mbchb, fc paed(sa), mmed (paed)(up), fc paed cert endocrinology and metabolism (sa); department of paediatrics and child health, steve biko academic hospital, university of pretoria, pretoria, south africa corresponding author: dr sizwe phonela, postnet suite 053, private bag x20009, garsfontein, 0042; tel: 071 684 3067; email: drphonela@outlook. com https://orcid.org/0000-0001-5804-9294 https://orcid.org/0000-0002-2764-3087 page 230 phonela smh et al. sa orthop j 2020;19(4) epidemiology the subtypes of oi diverge in both their incidence and prevalence rates, with oi types i and iv comprising more than half of all total cases worldwide.5 the global incidence of oi is approximately one per 20 000 live births and the prevalence is about six to seven per 100 000.5 there is a relative paucity of literature on the incidence and prevalence of oi in south africa. beighton et al. found an estimated minimum population frequency of 0.6/100 000 for oi type iii in the black african population residing in the johannesburg region and 0.1/100 000 for oi type i in the same group.6 however, in the southern african indigenous population, oi type iii tends to occur with greater frequency compared to other geographical regions.7 pathogenesis genetic mutations involving the two genes (col1a1 and col1a2) encoding for the synthesis and/or post-translational modification of collagen type 1 have been implicated in about 90% of oi patients.1,5 col1a1, which encodes for the pro-α1 procollagen chain, is located on the long arm of chromosome 17, while col1a2, which encodes for the pro-α2 procollagen chain, is located on the long arm of chromosome 7.1 these two chains form the triple helix molecule that is type 1 collagen.1,5 a working knowledge of the normal collagen biosynthesis and the errors in the metabolic process seen in oi is essential for understanding both the pathophysiology and the wide variability of this disorder.1,5 pathology the principal defect in most oi cases is either a critical reduction in the amount of normal type 1 collagen or the production of a wholly ineffectual and inferior variant.8,9 histologically, these may manifest in more than one way depending on the type of oi.8,9 woven bone may be more prominent, particularly in the more severe phenotypes.8,9 in 2000, rauch et al. reported the finding of normal bone mineralisation but with significant reductions in cortical width, cancellous bone volume and trabecular number and width in 70 children with oi. they also noted an increased bone turnover in nearly all types of oi, approximately a 70% increase compared with age-matched controls.8,9 osteopaenia, hypoplasia and gross deformities characterise the involved bone in oi.1 these are particularly poignant as the severity tends to worsen.1 secondary skeletal deformities (e.g. asymmetric physeal growth disturbance and angular or torsional deformities) frequently develop, compounding an already untenable situation.1 compression fractures and wedging of the vertebral bodies may be accompanied by kypho-scoliosis.1 in the skull, multiple centres of ossification occur, particularly in the occipital region. wormian bones (accessory skull bones completely surrounded by a suture line) are a well-recognised radiological feature of oi.1 classification in 1979, sillence et al. described four distinct types of oi based on clinical features and patterns of inheritance.1,3 they described them as follows: type i (autosomal dominantly inherited oi with blue sclerae); type ii (lethal perinatal oi with radiographic features of crumpled femora and beaded ribs); type iii (progressively deforming oi); and type iv (dominantly inherited oi with normal sclerae).1,3 of note, the mode of inheritance for types ii and iii was not yet conclusively confirmed as being exclusively autosomally recessive in nature as only some, but not all, of their patients displayed this pattern.1,3 following the discovery of a genetic cause of oi type ii in 1983 by chu et al., col1a1/col1a2 genes were subsequently implicated in all oi types, but there still remained some without a genetic explanation.1,3,10 in 1984, sillence et al. subdivided oi type ii into oi type ii-a, b and c based on radiographic features.1 in 2004, rauch et al. further modified the sillence classification to add oi types v–vii where they presupposed an autosomal dominant for type v and an autosomal recessive mode of inheritance for types vi–vii.1,8,10-12 at present, there are over 19 oi types based on genetic and clinical features but with much overlap.5,10 orthopaedic surgeons may prefer a more pragmatic system such as the modified sillence according to the incds, as given in table i. clinical and radiographic features clinical manifestations vary widely depending on the severity. these are typified by bone fragility (brittle bones), short stature, scoliosis, basilar skull deformities, blue sclerae, presenile deafness, opalescent teeth, joint hyperlaxity, wormian bones and easy bruisability. bone fragility is the defining feature.10 significantly decreased mineral bone density has been identified in genetically confirmed cases of oi.10 increased bone turnover with net table i: incds modified sillence classification of oi type (sillence) oi syndrome name (incds) mode of inheritance clinical features severity prognosis i non-deforming oi with blue sclerae autosomal dominant blue-grey sclerae, variable bone fragility, presenile deafness, straight long bones subdivided into a (normal teeth) and b (dentinogenesis imperfecta) mild form survives to adulthood, ambulant ii perinatal lethal autosomal recessive blue sclerae, very severe bone fragility often with crumpled bones (accordion femora) and beaded ribs perinatal death poor iii progressively deforming autosomal recessive normal sclerae, dentinogenesis imperfecta, severe bone fragility, bowing of long bones, rib fractures, marked short stature severely deforming die at end of second decade without bisphosphonates iv common variable oi with normal sclerae autosomal dominant moderate bone fragility, bowing of long bones, vertebral crush fractures, short stature subdivided into a (normal teeth) and b (dentinogenesis imperfecta) moderately deforming fair v oi with calcification in interosseous membranes autosomal dominant moderate to severe bone fragility, hyperplastic callus formation, juxtaphyseal radiodense band moderately deforming fair adapted from van dijk and sillence10 page 231phonela smh et al. sa orthop j 2020;19(4) osteoclastogenic resorption combined with immobilisation also plays a role.8,10,11 in 2018, peddada et al. suggested that transverse humerus, olecranon and diaphyseal humerus fractures are most commonly associated with oi, whereas physeal and supracondylar humerus fractures were least likely to indicate oi.13 associated features include dentinogenesis imperfecta, which presents as a yellow or greyish hue of teeth with apparent translucency and are prone to early wear.14-16 some skeletal deformities, such as scoliosis and basilar impression, are considered as secondary deformities.15,16 other non-skeletal features include cardiovascular deformations such as valvular dysfunction and aortic root dilatation.15,16 for ease of use, the features have been grouped into categories of severity as defined by the incds in table ii. diagnosis the diagnosis of oi is based on the clinical features and is often straightforward in patients presenting with bone fragility and a positive family history or several extra-skeletal manifestations.1,15,16 however, in the absence of these features, diagnosis may be challenging. the diagnosis of oi relies heavily on clinical and radiographic features. under exceptional circumstances where the diagnosis is equivocal, the following investigations may be handy in assessing bone metabolism and in excluding other conditions.8,15-19 biochemical markers of increased bone turnover may be elevated, especially in the more severe phenotypes of oi.8,15-18 as such, elevated levels of c-telopeptide of type 1 collagen, serum alkaline phosphatase and hypercalciuria have been reported, while levels of c-terminal propeptide of type 1 procollagen may be lower.8,15-19 although there are no definitive laboratory tests, progress in molecular genetic testing holds promise of readily accessible tests in future.15,16 type 1 collagen can be assayed by performing gel electrophoresis of samples from cultured dermal fibroblasts.1,15,16 these can reveal a qualitative or quantitative defect.15,16 sequence analysis of the dermal fibroblasts or genomic dna testing of leukocytes for mutations in col1a1 and col1a2 is also available, but these carry a false negative rate of about 10%.1,15,16 in south africa, genetic testing for the fkbp10 gene is available. differential diagnosis common differentials include non-accidental injury and rickets. abused children can have multiple fractures in many stages of healing.15,16 they may also have metaphyseal, rib and skull fractures; however, oi is rarely the cause of such fractures.1 allegations of abuse in children with oi and, conversely, presumptions of oi in abused children, are known to occur.1,15,16 every child with suspicious fractures must be prudently evaluated to confirm or exclude oi. when typical features are present, the diagnosis is straightforward. however, in the absence of such, it is more cumbersome. it behoves the attending clinician to exclude oi, especially in the setting of table ii: key clinical features of oi prenatal findings (20 weeks gestation) postnatal findings dexa scan/ radiographic mild oi (usually type i or iv) no in-utero abnormalities rarely congenital fractures fully ambulant normal/near normal growth velocity and height minimal vertebral crush fractures minimal chronic pain pre-pubertal fracture rate >1 p/a pre-senile deafness l-spine z-score > –1.5 but < +1.5 moderate oi rarely long bone bowing/ fractures occasional congenital fractures decreased growth velocity and height bowing of long bones pre-pubertal fracture rate >1 p/a pre-senile deafness l-spine z-score > –2.5 but < –1.5 severe oi long bone shortening/bowing/ fractures under-remodelling some rib cage abnormalities congenital fractures non-ambulatory significantly decreased growth velocity and height bowing of long bones chronic bone pain pre-pubertal fracture rate >3 p/a l-spine z-score < –3.0 extremely severe oi (usually oi type ii) marked long bone shortening/ bowing/ fractures with severe under-remodelling and crumpling marked rib cage abnormalities decreased mineralisation thighs held in fixed abduction and external rotation restricted range of motion of most joints decreased mineralisation of most bones (flat and long) small thorax with hypoplastic femora and vertebrae severe chronic pain lethal perinatal course adapted from van dijk and sillence10 table iii: common differential diagnoses of oi condition clinical features non-accidental injury may be distinguished by metaphyseal, rib and skull fractures1,15,16 rickets distinguished by typical radiographic features1,15,16 congenital hypophosphatasia lethal, presents with diminished phosphatase levels and excessive excretion of phosphorylethanolamine in urine1,15,16 camptomelic dwarfism congenital bowing and angulation of long bones may be mistaken for oi but fractures not common1 achondroplasia rhizomelia with enlarged head; radiographs sufficient to differentiate1,15,16 idiopathic juvenile osteoporosis self-limiting disorder characterised by its pre-pubertal onset1 page 232 phonela smh et al. sa orthop j 2020;19(4) suspected non-accidental injury. because a specific diagnosis is clinically important, genetic testing may be required.1,15,16 rickets can mimic oi clinically, but radiographic features usually suffice to exclude oi.1,15,16 table iii outlines the key features of the common differential diagnoses. management the management should consist of a multidisciplinary team.1,20-22 moreover, bisphosphonate therapy should preferably be overseen by a paediatrician well versed in genetic bone diseases.20 it is recommended that a diagnosis of osteoporosis in children requires a dual energy x-ray absorptiometry (dexa) scan bone mineral density (bmd) z-score of less than -2.0 accompanied by recurrent (minimum two) low trauma long bone fractures.20 moreover, a diagnosis can be made in the presence of pathological vertebral compression fractures alone.20 bisphosphonates bisphosphonates, a class of pyrophosphate-derived drugs which inhibit osteoclastic bone resorption, form the keystone of medical management.20,22 while their use is associated with reduced bone resorption, bone growth and modelling continues unimpeded.20-22 this results in significant increases in bone mass and strength in the growing child.20,21 intravenous bisphosphonates should be considered for use in severe oi types.20 oral bisphosphonates should be considered for mild to moderate cases while severe oi cases should continue therapy on a long-term basis.20 the best agent, dose or bisphosphonate frequency is as yet undetermined. in current practice, pamidronate is used in children under two years while zoledronate is used for children older than two years.20,21 the dosage will be guided by the age-, sexand height-adjusted bmd z-scores. once a child with oi stops growing, it is recommended that therapy be suspended and the child monitored.20 the treatment recommendations from the consensus guidelines on the use of bisphosphonate therapy in children and adolescents have gained widespread use. routine biochemical testing, dental review and bmd are recommended for children on bisphosphonate treatment. short-term complications include transient fever, bone pain and hypocalcaemia and/or hypophosphataemia during iv bisphosphonate administration.20,21 administration of paracetamol, slowing the infusion, giving a first-ever reduced bisphosphonate dose, ensuring adequate calcium, phosphate and vitamin d levels prior to treatment initiation and provision of post-treatment calcium and vitamin d supplementation, can avert these complications.20,21 metaphyseal bands of increased density have been reported after long-term bisphosphonate therapy.21 long-term complications may include delayed healing following osteotomy (but not traumatic fracture), osteopetrosis, persistence of primary spongiosa and rarely osteonecrosis of the jaw.21 clearly, a more detailed understanding of the long-term biological activity of bisphosphonates treatment is warranted. orthopaedic intervention the aim of any orthopaedic intervention is to optimise function, avoid or remedy any deformity and to monitor for any potential complications of oi.23-25 care must be tailored to the individual patient. in milder forms, orthopaedic management rarely goes beyond conservative measures.23 furthermore, the orthopaedic surgeon is rarely, if ever, called to assist in oi type ii (perinatal death).1,23-26 it is the more moderate-to-severe phenotypes (oi types iii to v) that often require specialised orthopaedic care.23-25 most fractures heal spontaneously. recurrent fractures are common, and prolonged immobilisation worsens incipient osteopaenia.1,26 perinatal fractures may require external bracing only when the fracture is unstable or interferes with care.1 minimising immobilisation helps to avoid muscle deconditioning and disuse atrophy.1,26 caregiver counselling regarding handling is essential.26 fracture rates decline after puberty, but may recur in post-menopausal women and in men above the age of 60 years.26 prophylactic bracing is the mainstay of conservative orthopaedic management in oi.1 in infancy and childhood, physiotherapy and external orthoses may facilitate normal development of milestones.1,23-26 closed treatment techniques are the mainstay of fracture management.1,26 fractures heal with abundant callus but with incremental deformities predisposing to further fracturing.24,26 avoiding prolonged immobilisation and heavy splints is essential.1,26 early mobilisation is actively encouraged.1,23-26 surgical realignment and intramedullary rodding is reserved for recurrent fractures and severe long bone deformities in children who are attempting to stand.1,23-26 the lower limbs are typically more involved than the upper extremities.1,26 medical treatment alone will not decrease lower extremity fracture rates.24 the best timing for surgery is controversial and some authors discourage operative intervention prior to ambulation. recent studies have shown no advantage in delaying surgery; however, early operative intervention must balance the beneficial effects of improved milestone attainment against the possibility of early revision surgery.24,26 pre-operative work-up should include evaluation for craniocervical and coagulation abnormalities.24 the cervical spine must be carefully stabilised during intubation.24 intra-operatively, the anaesthetist should carefully observe for any hyperthermia, blood loss or metabolic derangements and avoid atropine use.24,26 sullivan et al. demonstrated the safety of non-invasive blood pressure (bp) cuffs and invasive bp monitoring devices as well as tourniquet use in their retrospective review.27 the entire operative team must be educated in the care and handling of these children, especially during patient positioning, to avoid iatrogenic fractures.24,27 postoperative pain management may also be challenging, as many of the children may have been exposed to analgesics throughout their lives.26 spasms are often a major component of post-operative discomfort and therefore short-term, low-dose diazepam may be beneficial.26 the goals of surgery are the attainment and maintenance of optimal alignment with total correction of the deformity using an intramedullary rod which will act as an internal splint.1,23-26 as intramedullary rods are load-sharing, their misuse can result in stress-shielding.24 general principles in the surgical management of oi include avoiding plate-and-screw fixation in favour of intramedullary fixation and the use of gentle techniques for muscle preservation and minimisation of soft-tissue bleeding.1,23-26 hancock et al. reported in their retrospective review, decreased blood loss with intraoperative tranexamic acid administration in a cohort of patients undergoing deformity alignment.28 fluoroscopic use is essential as the deformities are often three-dimensionally complex.26 with the sofield-millar technique, the individual fragments should be as long and as straight as possible.23 placement of osteotomies in diaphyseal regions enhances stability with intramedullary rods.24,26 some bone shortening may be necessary when there are severe deformities, as the taut soft-tissue structures on the concave side can be stretched excessively when a deformity is corrected.24 reaming may be necessary for rod placement.24 violation of the growth plate should be avoided. immobilisation until union is almost always necessary.1,23-26 page 233phonela smh et al. sa orthop j 2020;19(4) various techniques have been described for deformity correction, including closed reduction with traction followed by pneumatic splints (morel technique), closed reduction with percutaneous intramedullary nailing, multiple corrective osteotomies with both nontelescopic (sofield-millar technique) and telescopic intramedullary rods (bailey-dubow, sheffield, fassier-duval, etc.).24,26 with each of these having their own advantages and pitfalls, surgeon preference will guide decision-making.24,26 in 1959, sofield and millar described their technique of subperiosteal exposure and multiple osteotomies (fragmentation) of a long bone deformity within the diaphysis and affixing these fragments onto an intramedullary rod (shish-kebab).1,23-26 they used static intramedullary rods (rush rods, k-wires, etc.) which proved to be very successful. this revolutionised the operative management of these severely deformed long bones, improving the mechanical characteristics of the bone and helping prevent further deformity and decreasing the risk of refractures.1,23-26 however, the children outgrew their rods, and complications such as rod migration were common.1 a decade later, as a solution, new telescopic rods were designed.24,29 these rods had both proximal and distal fixation in the epiphyses of the long bones, and elongated as the child grew.24,29 one such design was the bailey and dubow rod. these telescopic rods decreased the number of reoperations required; however, they were plagued with high complication rates of proximal rod migration and disengagement of the epiphyseal t-piece.23-26 in the 1980s, the sheffield group improved this telescopic rod design with a fixed t-piece on either end that was rotated intra-operatively for better fixation within the epiphysis.24 they reported fewer implantrelated complications and a 20% reoperation rate, but the insertion technique of the two telescoping components still required a knee arthrotomy for femoral rod insertions and ankle arthrotomies for tibial rod insertions.1,23-26 in 2003, the fassier-duval telescopic rod was introduced as having the advantage of a single proximal entry point and improved ‘screw-in’ fixation in the epiphyses plus a revision rate of 14%.24 it is inserted through small incisions under fluoroscopic control in conjunction with percutaneous osteotomies, whenever possible.1,23-26 rigid post-operative immobilisation is unnecessary.24,26 the procedure requires meticulous technique and experience.24,26 moreover, multiple bones may be treated simultaneously, reducing the operative burden on patients.1,23-26 later in 2007, the interlocking intramedullary (im) rod was introduced, initially for use in tibial deformities but then later expanded for use in the femur.30 it has a single proximal entry and a distal interlocking telescopic rod.24,30 the reported revision rates are 9% at two years and 28% at three years.24,30 this device appears to have the same rates of revision surgery as the fassier-duval rod.30 revision surgery may be required for persistent pain, progression of deformity, progressive signs of stress reaction or if the child sustains a fracture.24,30 fractures commonly occur distal to the proximally migrating nail, or near the male/female nail interface.1,23-26 there is a paucity of strong evidence as to which method of fixation is best.1 spinal deformities in oi can be challenging to manage.1,26 truncal shortening of thoracolumbar spinal segments can occur secondary to collapse of osteopaenic vertebrae.1,26 if the patient is symptomatic, a soft spinal orthosis is helpful.26 scoliotic and kyphoscoliotic curves often progress rapidly.26 bracing is ineffectual in the setting of a severely deformed rib cage and truncal shortening.26 in milder forms of oi, bracing can be utilised for curves of between 20 to 40 degrees or kyphosis greater than 40 degrees.26 spinal fusion has been recommended for scoliotic curves greater than 45 degrees to halt progression.1,26 for patients with more severe involvement, fusion is recommended for curves over 35 degrees, as these curves are most often progressive and potentially severe.1,26 there is a high incidence of complications from spinal fusion in oi, because internal fixation is limited by poor bone quality, autogenous iliac-crest bone graft is limited, and patients have a propensity to bleed.1,26 however, further discussion of spine-related issues falls outside the scope of this paper. conclusion osteogenesis imperfecta is a broad condition, with varying clinical presentations. even though a rare disorder, it is one of the most common congenital bone disorders encountered by the orthopaedic surgeon. although precise epidemiological data is lacking for sub-saharan africa, there are major differences in terms of the patterns of the prevalence of certain sub-types. although the classification has significantly evolved since sillence’s original description, there is no universal consensus yet. sillence has lent his support for the revised classification system published by the international nomenclature group for constitutional disorders and its adoption is growing, especially in research communication. an understanding of the more subtle clinical and radiographic features of oi aids in differentiating it from other metabolic bone diseases and in its diagnosis, particularly in a resource-constrained setting such as ours. the orthopaedic surgeon well versed in the basic sciences underpinning this condition is better equipped to manage and avoid the devastating outcomes common to this condition. although newer medical, surgical and rehabilitative therapies hold much promise for the future, a multidisciplinary approach remains the bedrock of comprehensive and sustainable positive outcomes and is gaining traction within our setting. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions sp and rg performed the literature review, contributed to the conceptualisation, preparation and revision of the manuscript. mk contributed to the conceptualisation of the article and performed manuscript review. orcid phonela smh https://orcid.org/0000-0001-5804-9294 goller r https://orcid.org/0000-0002-2764-3087 references 1. kim hkw. metabolic and endocrine bone diseases. in: herring ja, editor. tachdjian’s pediatric orthopaedics. 5th ed. chap. 42. philadelphia: elsevier; 2014. p. 608-29. 2. palomo t, vilaca t, lazaretti-castro m. osteogenesis imperfecta: diagnosis and treatment. curr opin endocrinol diabetes obes. 2017;24:381-88. 3. sillence do, senn a, danks m. genetic heterogeneity in osteogenesis imperfecta. j med genet. 1979;16:101-16. 4. ahn j, carter e, raggio cl, green dw. acetabular protrusio in patients with osteogenesis imperfecta: risk factors and progression. j pediatr orthop. 2019;39(10): e750-54. 5. van dijk fs, cobben jm, kariminejad a, et al. osteogenesis imperfecta: a review with clinical examples. mol syndromol. 2011;2:1-20. 6. beighton p, versfeld ga. on the paradoxically high relative prevalence of osteogenesis imperfecta type iii in the black population of south africa. clin genet. 1985;27(4):398-401. https://orcid.org/0000-0001-5804-9294 https://orcid.org/0000-0002-2764-3087 page 234 phonela smh et al. sa orthop j 2020;19(4) 7. vorster a, beighton p, chetty m, et al. osteogenesis imperfecta type 3 in south africa: causative mutations in fkbp10. s afr med j. 2017;107(5):457-52. 8. glorieux fh, wart l, rauch f, et al. osteogenesis imperfecta type vi: a form of brittle bone disease with a mineralization defect. j bone miner res. 2002;17:30-38. 9. rauch f, travers r, parfitt am, glorieux fh. static and dynamic bone histomorphometry in children with osteogenesis imperfecta. bone. 2000;26:581. 10. van dijk fs, sillence do. osteogenesis imperfecta: clinical diagnosis, nomenclature and severity assessment. am j med genet. 2014;164a(6):1470-81. 11. glorieux fh, rauch f, plotkin h, et al. type v osteogenesis imperfecta: a new form of brittle bone disease. j bone miner res. 2000;15:1650-58. 12. ward l, rauch f, travers r, et al. osteogenesis imperfecta type vii: an autosomal recessive form of brittle bone disease. bone. 2002;31:12-18. 13. peddada kv, sullivan bt, margalit a, sponseller pd. fracture patterns differ between osteogenesis imperfecta and routine pediatric fractures. j pediatr orthop. 2018;38:207. 14. marini jc. osteogenesis imperfecta: comprehensive management. adv pediatr. 1988;35:391-426. 15. beary jf, chines aa. osteogenesis imperfecta: clinical features and diagnosis. [online] uptodate. 2019. available from: https:// www-uptodate-com.uplib.idm.oclc.org/contents/osteogenesisimperfecta-clinical-features-and-diagnosis [accessed 3 april 2020]. 16. beary jf, chines aa. osteogenesis imperfecta: management and prognosis. [online] uptodate. 2019. available from: https:// www-uptodate-com.uplib.idm.oclc.org/contents/osteogenesisimperfecta-management-and-prognosis [accessed 3 april 2020]. 17. chines a, petersen dj, schranck fw, whyte mp. hypercalciuria in children severely affected with osteogenesis imperfecta. j pediatr. 1991;119:51. 18. chines a, boniface a, mcalister w, whyte m. hypercalciuria in osteogenesis imperfecta: a follow-up study to assess renal effects. bone. 1995;16:333. 19. lund am, hansen m, kollerup g. collagen-derived markers of bone metabolism in osteogenesis imperfecta. acta paediatr. 1998;87:1131. 20. simm pj, biggin a, zacharin mr, rodda cp, tham e, siafarikas a, jefferies c, hofman pl, jensen de, woodhead h, brown j, wheeler bj, brookes d, lafferty a, munns cf, on behalf of the apeg bone mineral working group. consensus guidelines on the use of bisphosphonate therapy in children and adolescents. j paediatr child health. 2018;54:223-33. 21. morris cd, einhorn ta. bisphosphonates in orthopaedic surgery. j bone joint surg am. 2005;87(7):1609-18. 22. caird ms, kozloff km. bisphosphonate therapy in children. current orthopaedic practice. 2012;23(5):435-41. 23. sofield ha, millar ea. fragmentation, realignment, and intramedullary rod fixation of deformities of the long bones in children: a ten-year appraisal. j bone joint surg am. 1959;41(8):1371-91. 24. esposito p, plotkin h. surgical treatment of osteogenesis imperfecta: current concepts. curr opin pediatr. 2008;20:52-57. 25. birke o, davies n, latimer m, little dg, bellemore mi. experience with the fassier-duval telescopic rod: first 24 consecutive cases with a minimum of 1-year follow-up. j pediatr orthop. 2011;31:458-64. 26. kocher ms, shapiro f. osteogenesis imperfecta. j am acad orthop surg. 1998;6:225-36. 27. sullivan bt, margalit a, garg vs, njoku db, sponsellar pd. incidence of fractures from perioperative blood pressure cuff use, tourniquet use, and patient positioning in osteogenesis imperfecta. j pediatr orthop. 2019;39(1):e68-e70. 28. hancock ge, price kr, giles sn, fernandes ja. the effect of tranexamic acid on blood loss and transfusion requirement in intramedullary rodding for deformity correction in osteogenesis imperfecta. orthopaedic proceedings. 2015;97-b(supp 9):17-17. 29. landrum m, birch c, richards bs. challenges encountered using fassier-duval rods in osteogenesis imperfecta. curr orthop pract. 2019;30(4):318-22. 30. cho tg, choi ih, chung cy, et al. interlocking telescopic rod for patients with osteogenesis imperfecta. j bone joint surg am. 2007;89:1028-35. _hlk54777853 _hlk37169859 brown o et al. sa orthop j 2019;18(4) doi 10.17159/2309-8309/2019/v18n4a6 south african orthopaedic journal http://journal.saoa.org.za orthopaedic oncology and infections citation: brown o, goliath v, van rooyen rm, aldous c, marais lc. communicating about prognosis with regard to osteosarcoma in a south african cross-cultural clinical setting: strategies and challenges. sa orthop j 2019;18(4):46-51. http://dx.doi.org/10.17159/2309-8309/2019/v18n4a6 editor: prof tlb le roux, university of pretoria, south africa received: march 2019 accepted: april 2019 published: november 2019 copyright: © 2019 brown o, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: there are no funding sources to declare. conflict of interest: all authors confirm that there are no conflicts of interest to declare. abstract background: effective prognostic communication with patients is a prerequisite for treatment decision-making, yet it is a difficult task to manage with confidence. this paper explores the strategies used and challenges faced when communicating about prognosis in a cross-cultural clinical setting. patients and methods: we used a qualitative exploratory descriptive contextual design and gathered data using focus group interviews with healthcare professionals. twenty-three healthcare professionals participated in three focus groups. we analysed the data thematically. guba’s model of trustworthiness was used to ensure rigour. results: our findings revealed strategies for communicating about prognosis. assessing patient emotions and knowledge, and providing patients with clear prognostic information, emerged as prominent strategies. healthcare professionals proposed communicating frankly about the consequences of not treating osteosarcoma, treatment limitations, metastases and poor prognoses. they also suggested presenting prognostic information in a staged approach, normalising death, and not specifying life expectancy. in addition, informing patients that a palliative amputation would help with pain management emerged as a strategy for instilling hope. various patient, provider and disease factors were identified as challenges when discussing prognosis. conclusions: deviations from western research findings emphasised the need for studies exploring prognostic communication in cross-cultural encounters. our study highlighted the need for creative and thoughtful approaches to communicating sensitive information in cross-cultural clinical settings. level of evidence: level 5 keywords: prognosis, patient–provider communication, cancer, osteosarcoma, cross-cultural communicating about prognosis with regard to osteosarcoma in a south african cross-cultural clinical setting: strategies and challenges brown o¹ , goliath v² , van rooyen rm³ , aldous c4 , marais lc5 ¹ phd; clinical psychologist, school of clinical medicine, university of kwazulu-natal, south africa ² phd; associate professor, department of social development professions, nelson mandela university, south africa ³ mcur, phd; professor and deputy dean of the faculty of health sciences, school of clinical care sciences, nelson mandela university, south africa 4 phd; professor and health care scientist in the school of clinical medicine, university of kwazulu-natal, durban, south africa 5 mbchb, fc(orth)sa, mmed(ortho), cime, phd; professor and head of the department of orthopaedics, university of kwazulu-natal, durban, south africa corresponding author: dr ottilia brown, the lighthouse arabia, 821 al wasl road, al safa 2, dubai; tel: +971 50 4601346; email: ottiliabrown1978@gmail.com https://orcid.org/0000-0003-2862-1733 https://orcid.org/0000-0003-0044-8318 https://orcid.org/0000-0002-6019-6602 https://orcid.org/0000-0002-7199-9160 https://orcid.org/0000-0002-1120-8419 page 47brown o et al. sa orthop j 2019;18(4) introduction effective prognostic communication with patients is a prerequisite for treatment decision-making and future planning that is commensurate with patient preferences.1 however, communicating about prognosis is widely documented as a challenging task.2-5 patients typically have varied preferences regarding prognosis information6 that are sometimes complicated by cultural and family expectations and demands.5 in addition, the medical literature provides conflicting directives. some studies indicate that patients want and need detailed information, and other studies report that patients want to limit their discussions about poor prognoses.2 this study was conducted with healthcare professionals working in a cross-cultural clinical setting in kwazulu-natal, south africa. the study is part of a larger project aimed at developing an evidence-based practice guideline for communicating with zulu patients diagnosed with osteosarcoma. the zulu people are indigenous and place great value on traditional belief systems and often prefer a family-centred model of medical decisionmaking5 especially when the proposed surgical treatment option is amputation.7 a 2012 study revealed that 66.67% of the patients presenting at the study site with osteosarcoma between 2009 and 2011 already had metastatic disease.8 healthcare professionals (hcps) therefore find communicating prognosis to be especially challenging in this cross-cultural context as patients present late for treatment and tend to practise systems of healing and decisionmaking that are different from the western medical system. prognostic communication literature provides some guidelines for healthcare professionals. a patient-centred approach,9,10 a staged approach,11 respect for patients’ occasional preference to maintain some ambiguity about the future,6 and responding to varied prognostic information needs between individuals and for a given individual over time,5 are recommended strategies. further, a need for detailed information may still include negotiation regarding the extent, format and timing of the information received.3 given the late presentation of patients at the study site, these proposed strategies may not be tenable as hcps have to communicate diagnostic and treatment information urgently. the treatment options are closely related to patients’ understanding of their prognosis and the outcomes resulting from various approaches to treatment. this paper explores the strategies used and challenges faced when communicating about prognosis in this cross-cultural clinical setting. methods study setting this study was conducted at a tertiary hospital in the province of kwazulu-natal (kzn), south africa. the hospital forms part of the national public health system that serves more than 80% of the south african population. the majority of the patients receiving services at this hospital are of zulu origin. zulu patients speak isizulu, one of south africa’s 11 official languages, while healthcare professionals mostly speak english or afrikaans. the hospital’s tumour, sepsis and reconstruction unit (tsr), dedicated to the treatment of musculoskeletal tumours, is the only one of its kind in western kzn and services a population of 3.5 million people. research design and methods a qualitative exploratory descriptive contextual design was used. we gathered data from three separate focus group interviews with orthopaedic consultants and registrars; allied health professionals including dieticians, occupational therapists, physiotherapists, and a social worker; and nurses from the orthopaedic and oncology outpatient clinics and wards. the focus group interview schedule was piloted with a social work colleague who has experience with working with cancer patients in the study setting. questions explored how hcps discuss prognosis with patients and also investigated how hcps responded to questions from patients regarding prognosis if they chose not to discuss prognosis with patients. participants and sampling the tsr unit uses a multidisciplinary team (mdt) approach to managing patients diagnosed with osteosarcoma. the mdt comprises the orthopaedic consultants and registrars, the allied health professionals (physiotherapists, dieticians, occupational therapists, social workers, clinical psychologists) and orthopaedic and oncology nursing staff. we used census sampling and invited all these members of the mdt to participate in the focus groups. twenty-three hcps participated (see table i) and five were not available due to scheduling constraints. four zulu healthcare professionals participated in the study, thus emphasising the fact that medical encounters are largely culturally discordant at this tertiary hospital. table i: focus group demographic information (n=23) orthopaedic consultants and registrars n=9 registered nurses from orthopaedic wards, orthopaedic clinic, oncology clinic and pain service n=5 allied health professionals (physiotherapists, occupational therapists, dieticians, social worker) n=9 sex males females n=8 n=15 ethnic group (south africa) white indian african (zulu) coloured n=13 n=4 n=4 n=2 data collection, analysis and trustworthiness the second author, an independent researcher with qualitative expertise and with no prior knowledge of the participants, conducted the focus group interviews. the interviews’ duration ranged from 54 to 95 minutes and were audiotaped and transcribed verbatim. we used thematic analysis to analyse the data.12 the primary researcher and the focus group interviewer independently coded the data, and themes were then discussed and agreed upon. themes were further independently reviewed by two qualitative research experts and finalised following multiple discussions with all three qualitative experts. the data analysis process was an iterative one. guba’s model of trustworthiness was used to ensure the rigour of the data collection and analysis processes.13,14 ethical approval and considerations we obtained ethical approval for the study from the biomedical research ethics committee at the university of kwazulu-natal. participation was voluntary, and written informed consent was obtained from all participants. results the findings highlighted the specific strategies used and challenges encountered when discussing prognosis with zulu page 48 brown o et al. sa orthop j 2019;18(4) patients diagnosed with osteosarcoma. participants reflected on the transformative nature of the focus groups15 as it created an opportunity for reflection on practice, and co-construction of culturally relevant strategies for communicating prognosis. strategies for managing the prognostic discussion strategy 1: assess patient emotions and knowledge hcps indicated that they first enquired about patients’ thoughts, fears and impressions of the future. i try to first find out what are their thoughts, what are they scared about, what are they feeling is going to happen and patients do know, especially prognosis, they do know when the end is near … strategy 2: provide patients with realistic prognostic information the late presentation of patients and additional time required for cultural practices meant that hcps had to share prognostic information urgently in order to fast-track treatment decisionmaking. strategy 2.1: inform patients about the prognostic consequences of not treating osteosarcoma hcps informed patients that if left untreated, the cancer would metastasise, and the patient would not survive. patients requiring amputation typically requested to go home to consult traditionally and perform rituals if indicated, thus causing treatment delays. hcps were therefore especially direct with these patients. participants sometimes phrased this discussion by informing patients that if nothing was done it would be detrimental but if the amputation was done there was a chance of survival. i tell them that if left untreated it can spread and it will kill you. i am saying if we do nothing it’s bad, if you do something there is a chance of a good result. strategy 2.2: inform patients about treatment limitations participants informed patients about treatment limitations. they explained the nature of osteosarcoma to patients and informed patients that this type of cancer was not curable. participants cautioned against telling patients that amputation could cure due to the possibility of recurrence. and then i typically explain that this cancer is not curable … osteosarcoma … if you leave it untreated it will kill you … participants reported that they informed patients that even with surgery the cancer could recur. hcps reiterated that patients had to return within six months and then annually to check for cancer recurrence. … it might spread later, you know even if we take it out now and we do an amputation now it does not mean that the cancer can’t come back. strategy 2.3: inform patients that they have metastases when patients had metastases, hcps informed them that the condition was not curable, but that amputation could help with pain. patients were informed that limited intervention was possible due to the metastases. … if we know that it’s a metastatic disease and it is not curable to tell them that it has spread already, we can do something about the pain that they have in the leg and the amputation will help for that pain for example, but it has already spread and we can’t do much about that. strategy 2.4: inform patients about a poor prognosis hcps highlighted being honest with patients about the terminal nature of the disease if the osteosarcoma was reasonably expected to result in the death of the patient within a short period of time. the time period was not specified. i personally do tell people if they have a terminal disease that it’s so … strategy 3: use a staged approach some of the allied health participants indicated that they dealt with prognosis in stages because the condition entailed long-term treatment. they focused on immediate goals and if the disease progressed, goals were adjusted to maintenance or palliative care. i would deal with it in phases because as we said it is a longterm treatment and we are going to wait and see. for now, your issue is this, so our goals will be this. if it becomes worse, then we are going to change our goals to either maintenance or palliative care. strategy 4: normalise death participants approached talking to patients about dying by trying to normalise death as universal to everyone. participants indicated that they could not specify when the patient would die and sometimes stated that it could be a long time and that they could die from something else as well. … i can drive out of the hospital and you know get into an accident and die and you may still survive for quite a long time after that, so everyone is going to die … strategy 5: do not specify a time frame participants emphasised that patients should never be informed of their life expectancy. some participants indicated that they would not know how to respond to a question about life expectancy. i never tell them what the life expectancy is. challenges related to communicating about prognosis during the strategy discussion, hcps highlighted a number of challenges that they did not know how to resolve. these challenges are described in terms of patient, disease, healthcare provider and communication factors. patient factors hcps reported that patients’ emotional responses varied from being in denial to being overly optimistic. participants were also concerned that patients would view treatment as futile when they were informed of poor prognoses. they had experienced that informing a zulu patient about a poor prognosis often resulted in these patients not returning to the hospital. hcps hypothesised that this was possibly due to patients believing that they were going to page 49brown o et al. sa orthop j 2019;18(4) die regardless. participants also experienced that patients stopped listening when they were informed of poor prognoses. … of course some patients are in denial, some patients are overly optimistic … … once we start saying no you are going to die because of cancer then they are not going to come back to you. participants observed that patients did not ask about prognosis and indicated that some patients may not want prognostic information. participants also noted that they would want to know the odds of surviving but that zulu patients had never asked them about the odds of survival. … you know if someone tells me okay you have got cancer, it hasn’t spread, if we do an amputation that is potentially curative, my thing will be okay what’s the chances of that being curative? you know that would be my first question. so, what are my odds? no one has ever asked me that. healthcare provider factors competency concerns and lack of training regarding communicating about prognosis were reported. allied health professionals experienced that there was unclear communication of prognostic information. from a physio side it can be a bit difficult when patients ask you am i going to die from this … whereas not being fully medically trained in that aspect we can’t always answer those questions for patients. … the problem is nobody tells you, say this and then say that … certain role expectations emerged among the hcps with regard to who should communicate with patients regarding prognosis. nurses were of the opinion that it was ethical procedure for doctors to communicate the prognosis to patients. they indicated that they often interpreted prognostic information for doctors. … call the doctors and they would explain … … you always let the doctor tell the patient the prognosis but we’re always standing there … hcps had varied perspectives regarding discussing prognosis with patients. some were of the opinion that patients should determine how much they wanted to know. other participants were unsure of whether to disclose poor prognoses. they were concerned that informing patients accordingly could be adding to the bad news of the diagnosis and result in loss of hope. some hcps expressed discomfort about talking about prognosis whereas others felt that they would be withholding the truth if they did not inform patients about a poor prognosis. discussing prognosis was especially challenging when hcps had to inform patients requiring a palliative amputation as despite the amputation, they would still have limited life expectancy. they were guarded as they did not want to create false hope. i know there are some people that would say you mustn’t tell people if they are terminally ill, that they are going to die. i don’t feel comfortable talking about prognosis … i find prognosis being the most difficult one to deal with when they say for a palliative amputation … hcps reported struggling with the timing of the prognostic communication. zulu patients often insisted on going home to consult with the elders and perform rituals after being informed about treatment options, especially when this entailed amputation.7 participants were concerned that when patients went home, they would be preoccupied with being told about a poor prognosis instead of focusing on consulting the decision-makers regarding proposed treatment options. you know as soon as they get home they say, the doctor said i am going to die. and then eventually even if the decisionmaker at home or the family sits down and asks about the options, the (patient) keeps saying no, i am going to die … the doctor told me. (the patient) is now against whatever they (the family) are saying. disease factors allied health professionals reported on the unpredictable and aggressive nature of osteosarcoma and its progression, and the consequent challenges of discussing prognosis. they indicated that treatment could start with rehabilitation and dealing with functional issues which then progress to palliative care very quickly. in my view of prognosis … i don’t know that it can be discussed with the patient because it is an osteosarcoma, it can change from the one stage to the other very quickly … discussion the data revealed several strategies for managing the prognostic discussion with zulu patients and highlighted several challenges that hcps were not able to resolve. due to the late presentation of patients at the study site, hcps felt compelled to communicate the urgency of treatment with patients and this typically included communicating prognostic information. despite the uniqueness of the setting and participants’ competency and training concerns, all the proposed strategies have been supported in the literature. hcps recommended assessing patient emotions and knowledge by asking them open-ended questions.2 they then advocated that patients should receive realistic information about the prognostic consequences of not treating the osteosarcoma, treatment limitations, metastases, and poor prognoses. this strategy, referred to as realism, can facilitate sound medical decision-making for both patients and hcps.9 however, taking the realistic approach without structuring the conversation and demonstrating empathy can be perceived as being uncaring.9 participants reported that they attempted to phrase information positively. participants also proposed the strategy of normalising death. a willingness to talk about death and doing so in a skilful manner without fear has been emphasised.16,17 participants preferred not to communicate estimations of life expectancy, which is in line with general practice18 and clinical practice guidelines on communicating prognosis.19 the allied health professionals proposed a staged approach to communicating prognosis.9,11,19,20 the late presentation for treatment at this study site8 unfortunately presents hcps with the challenging task of communicating diagnosis, treatment and prognosis in close succession or simultaneously. a staged approach may be more useful for patients that present with localised or minimally metastasised disease. the strategy of instilling hope did not overtly emerge from the data. however, participants’ tendency to inform patients that a palliative amputation would help with pain management has been described as a means of instilling hope.21 patients have reported that when hcps emphasised what could be done, such as pain and symptom control, this fostered hope.21,22 hope, therefore, is not exclusively dependent on cure2 and should be offered at all stages of the disease.23,24 participants also reported experiencing challenges pertaining to the prognostic communication process. they highlighted zulu patients’ emotional responses, their beliefs that treatment would be futile and their tendency to withdraw when poor prognoses were communicated. these reported responses may be associated page 50 brown o et al. sa orthop j 2019;18(4) with zulu patients’ cultural and health beliefs regarding cancer. the isizulu word for cancer, umdlavuza, means something that destroys everything or something that cannot be stopped.25 participants further indicated that zulu patients never asked about prognosis or the odds of surviving. this is in contrast to western research which showed that most cancer patients wanted some degree of prognostic awareness,6 with metastatic cancer patients wanting detailed prognostic information.3 patients’ reported tendency to never ask about survival rates is also significantly different from western trends.3 however, most surveys regarding patient preferences for detailed prognostic information have been conducted on english-speaking patients. little is known about the prognostic communication preferences of ethnically diverse populations.26 the hcps identified a number of challenges that pertained specifically to them. they highlighted competency and training deficits5,27,28 and role expectations regarding who communicated prognosis.29 furthermore, hcps could not agree on whether patients should be given prognostic information.6 reasons for preferring non-disclosure centred on hcps’ discomfort regarding disclosing prognosis22,24,28,30 and concerns that prognostic disclosure would result in negative emotional outcomes for patients28,30 and would destroy hope.2,5,31 disclosing a palliative amputation was highlighted as a particular challenge. hcps preferring prognostic disclosure were concerned about withholding the truth from patients and argued that patients should be truthfully informed of their prognosis.17,28 being clear about the palliative or curative goals of treatment and specifying the outcomes that can be improved by the treatment have been recommended.19 there is a lack of evidence that prognostic disclosure resulted in negative emotional outcomes or made patients less hopeful.32 in fact, research showed that honesty about prognostic information maintained and sometimes increased hope, even in patients with advanced disease.30 hcps highlighted timing of prognostic information as a challenge given that zulu patients often went home to discuss treatment options with family decision-makers. hcps were concerned that they would fixate on the poor prognosis if they were given prognostic information before going home. prognostic information should, however, be provided when there are requests or expectations that are inconsistent with clinical judgement,19 as in this case when patients go home to consult with decision-makers and often delay returning to the hospital.7 furthermore, discussing prognosis facilitates treatment decision-making.19,33 patient knowledge of prognosis has been shown to play a significant role in making appropriate treatment choices.34 with regard to disease factors, allied health professionals reported that the unpredictable nature of osteosarcoma complicated the prognostic discussion. as the majority of patients presenting at the study site have metastatic disease,8 the progression-free survival rate for these patients is poor and the condition is usually incurable, requiring palliation.35 furthermore, in patients with localised disease, the five-year survival rate is 60–70%35 with a 30–35% chance of local or systemic recurrence.36 there are, therefore, survival and disease progression rates available which the allied health professional staff may not be aware of as they have not been medically trained. limitations of the study are that although all those that were eligible to participate were approached, some mdt members were not available at the time of data collection. secondly, disciplinespecific focus groups were conducted which may have limited interprofessional synergy and data outcomes. thirdly, the study was conducted in one hospital and focused on a specific cultural group and hence the findings should be seen in context. lastly, the use of other qualitative data-gathering may have enriched the data. the study findings provided information on what is said and why it is said; however, further investigation is required to explore how it is said. deviations from western research findings emphasised the need for studies exploring prognostic communication in crosscultural encounters. contextual research on patients’ preferences and suggestions on how to communicate about prognosis emerged as a prominent area for future research. research exploring patients’ experience of the proposed strategies would also assist in refining these strategies. conclusion this paper explored strategies used and challenges faced when communicating about prognosis in this cross-cultural clinical setting. patients at this study site present late for treatment, and therefore have to receive diagnostic, treatment and prognostic information in close succession or simultaneously. in addition, this cross-cultural clinical setting requires that hcps integrate cultural beliefs and practices into their management of patients. hcps proposed strategies for responding to these unique conditions, and they expressed concerns regarding cultural competency, and highlighted a lack of training regarding prognosis communication. however, they proposed strategies that are well documented in the literature. they chose to be innovative and relied on experiential knowledge. importantly, various patient, disease and healthcare provider factors that posed challenges to the prognostic communication process were also outlined. hcps did not necessarily have solutions to these challenges; however, some of the factors highlighted demonstrated participants’ sensitivity to cultural aspects of patient care. furthermore, zulu patients were reported to respond differently to prognostic information as compared to western findings. the strategies reported on in this paper will contribute to the evidence-based practice guideline for communicating with zulu patients diagnosed with osteosarcoma. our study highlighted the uniqueness of this cross-cultural setting and the need for creative and thoughtful approaches to communicating sensitive information in cross-cultural clinical settings. ethics statement prior to commencement of the study ethical approval was obtained from the biomedical research ethics committee at the university of kwazulu-natal, reference no: be051/15. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was obtained from all patients included in the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ob contributed to the conception and design of the work; the acquisition, analysis, and interpretation of data for the work; drafting the work; final approval of the version to be submitted to the journal. vg contributed to data collection; the analysis and interpretation of data for the work; revising the work critically for important intellectual content; final approval of the version to be published. rmvr contributed to the conception and design of the work; revising it critically for important intellectual content; final approval of the version to be published. ca contributed to the conception and design of the work; revising it critically for important intellectual content; final approval of the version to be published. lcm contributed to the conception and design of the work; revising it critically for important intellectual content; final approval of the version to be published. orcid brown o http://orcid.org/0000-0003-2862-1733 goliath v http://orcid.org/0000-0003-0044-8318 van rooyen rm http://orcid.org/0000-0002-6019-6602 aldous c http://orcid.org/0000-0002-7199-9160 marais lc http://orcid.org/0000-0002-1120-8419 http://orcid.org/0000-0003-2862-1733 http://orcid.org/0000-0003-2862-1733 http://orcid.org/0000-0003-0044-8318 http://orcid.org/0000-0003-0044-8318 http://orcid.org/0000-0002-6019-6602 http://orcid.org/0000-0002-6019-6602 http://orcid.org/0000-0002-7199-9160 http://orcid.org/0000-0002-7199-9160 http://orcid.org/0000-0002-1120-8419 http://orcid.org/0000-0002-1120-8419 page 51brown o et al. sa orthop j 2019;18(4) references 1. robinson tm, alexander sc, hays m, jeffreys mc, olson mk, rodrigues kl, et al. patient–oncologist communication in advanced cancer: predictors of patient perception of prognosis. support care cancer. 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2014;29(2):311-17. https://www.ncbi.nlm.nih.gov/ pubmed/24402976 34. weeks jc, cook ef, o’day sj, peterson lm, wenger n, reding d, et al. relationship between cancer patients’ predictions of prognosis and their treatment preferences. jama, 1998;279:170914. https://jamanetwork.com/journals/jama/fullarticle/187594 35. errani c, longhi a, rossi g, rimondi e, biazzo a, toscano a, et al. palliative therapy for osteosarcoma. expert rev anticancer ther. 2011;11:217-27. https://www.tandfonline.com/doi/abs/10.1586/ era.10.172 36. bacci g, briccoli a, longhi a, ferrari s, mercuri m, faggioli f, et al. treatment and outcome of recurrent osteosarcoma: experience at rizzoli in 235 patients initially treated with neoadjuvant chemotherapy. acta oncol. 2005;44(7):748-55. https://www. tandfonline.com/doi/full/10.1080/0284186050032750 https://www.ncbi.nlm.nih.gov/pubmed/?term=marr%20la%5bauthor%5d&cauthor=true&cauthor_uid=18798531 https://www.ncbi.nlm.nih.gov/pubmed/?term=wallace%20ja%5bauthor%5d&cauthor=true&cauthor_uid=18798531 https://www.ncbi.nlm.nih.gov/pubmed/?term=yang%20hb%5bauthor%5d&cauthor=true&cauthor_uid=18798531 https://www.ncbi.nlm.nih.gov/pubmed/?term=yang%20hb%5bauthor%5d&cauthor=true&cauthor_uid=18798531 https://www.ncbi.nlm.nih.gov/pubmed/?term=arnold%20rm%5bauthor%5d&cauthor=true&cauthor_uid=18798531 _goback dunn rn et al. sa orthop j 2019;18(2) doi 10.17159/2309-8309/2019/v18n2a1 south african orthopaedic journal http://journal.saoa.org.za spine citation: dunn rn, horn a. posterior based circumferential spinal cord decompression in paediatric patients with the vertebral column resection (vcr) technique spares the anterior approach in severe kyphosis. sa orthop j 2019;18(2):20-24. http://dx.doi.org/10.17159/2309-8309/2019/ v18n2a1 editor: prof lc marais, university of kwazulu-natal, durban, south africa received: september 2018 accepted: february 2019 published: may 2019 copyright: © 2019 dunn rn, horn a. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors have no conflicts of interest with respect to this study. abstract introduction: patients with kyphosis and myelopathy have traditionally been managed by combined anterior and posterior surgery with associated morbidity and long theatre episodes. the posterior vertebral column resection (pvcr) technique allows circumferential apical decompression with instrumented correction and stabilisation through a single extra-pulmonary approach. the objective of this study was to review the use of pvcr in the paediatric population as to feasibility, safety and effectiveness. methods: a retrospective review of prospectively maintained database was undertaken. twenty-six consecutive paediatric patients (18 females) were reviewed. the median age at surgery was 12.1 years (iqr 7.6–14.2, range 2.1–17.7). the underlying pathology was active tuberculosis in nine patients, healed tuberculosis in seven, congenital in seven, tumour in two and trauma in one. myelopathy was present in 17 and two had associated syringomyelia. the median surgical duration was 3.3 hours (iqr 3–5.0, range 1.9–6.5) with a blood loss of 20.8 ml/kg (iqr 12.5–38.1, range 6.3–67.6). results: the median percentage sagittal correction was 65% (iqr 44–79, range 21–100). the correction was best in the thoracolumbar spine at 75%. all non-ambulatory patients improved to an ambulatory status. there was one permanent and one transient neurological deterioration. all intact patients (asia e) remained so. one of the two patients that had associated syringomyelia had complete resolution of the syrinx with improved neurological function. there were no related pulmonary complications. one patient developed early (in-hospital) proximal junctional failure requiring revision. conclusion: posterior based circumferential decompression and corrective fusion using the pvcr technique is both feasible and effective in the paediatric population. it avoids the morbidity associated with the trans-thoracic approach and allows improvement both in neurological function and csf dynamics when they are compromised. it remains a technically challenging procedure both for the surgical and anaesthetic team and there needs to be a clear understanding of the risk–benefit relationship when deciding on its implementation. level of evidence: level 4 key words: vertebral column resection, vcr, myelopathy, kyphosis, paediatric posterior based circumferential spinal cord decompression in paediatric patients with the vertebral column resection (vcr) technique spares the anterior approach in severe kyphosis dunn rn¹ , horn a² 1 1bchb(uct), fcs(sa)orth, mmed (orth)(uct); consultant spine and orthopaedic surgeon, pieter moll and nuffield chair of orthopaedic surgery, department of orthopaedic surgery, university of cape town, south africa ² mbchb, fc orth (sa), mmed(orth)(uct); consultant, red cross children’s hospital, department of orthopaedic surgery, university of cape town, south africa corresponding author: prof rn dunn, dept of orthopaedic surgery, h49 old main building, groote schuur hospital, anzio road, observatory, cape town; cell: 021 404 5118; email: robert.dunn@uct.ac.za https://orcid.org/0000-0002-3689-0346 https://orcid.org/0000-0002-4159-6520 page 21dunn rn et al. sa orthop j 2019;18(2) introduction the management of paediatric patients with severe rigid spinal deformity, particularly with associated spinal cord compression and myelopathy, is extremely challenging due to the risk of neurological injury and the difficult internal fixation of their small, distorted spines. traditionally pre-operative traction has been employed to reduce the deformity, but due to their low body weight this is frequently ineffective. although anterior transthoracic release and decompression has been utilised, gaining access to the apex of the deformity to relieve cord compression can be technically difficult. typically partial deformity correction with anterior column strut grafts have been employed.1 a posterior approach allows the surgeon to place segmental instrumentation which is powerful enough to obtain and maintain correction, while fusion occurs. this is then combined with an anterior decompression/release, either simultaneously or in a staged fashion. this strategy’s dual surgical approach comes at the cost of time and large physiological insult. with the development of the posterior based circumferential vertebral column resection (pvcr), the deformity can be well visualised. rigid posterior fixation and visualisation of the thecal sac by laminectomy allows better orientation and more controlled removal of bone anterior to the cord than the anterior approach.2-4 we have increasingly employed the pvcr technique in our paediatric patients that present with severe rigid deformity with established or predicted myelopathy. we present our experience with this technique in the paediatric group in an effort to assess feasibility, safety and effectiveness. methods following institutional ethics approval, we identified 26 paediatric patients (≤18 years old) undergoing the pvcr procedure from january 2010 to april 2017 from a prospectively maintained database. a case note and imaging review were conducted with regard to demographics, surgical indications and complications. outcome was assessed radiographically in terms of deformity correction and clinically in terms of neurological status. data was captured and analysed on microsoft excel spreadsheets. due to the relatively small numbers, median and inter-quartile ranges (iqrs)were used to avoid the distortion effect of outliers on average and ranges. our cohort had a median age of 12.1 years (iqr 7.6–14.2, range 2.1–17.7). there was a female predominance of 18 to 8 (figure 1). the commonest underlying pathology was tuberculosis, both active (nine cases) and healed disease (seven) followed by congenital anomalies (seven) (table i) (figure 2). the indication for the procedure was kyphotic deformity, frequently associated with myelopathy. two cases had associated syringomyelia. the commonest site was the thoracic spine (14 patients) followed by thoracolumbar and lumbar spine (six patients each). the procedure patients were positioned prone under total intravenous anaesthesia when spinal cord monitoring (scm) was used. in the earlier part of the study scm was not available but later, when neurological status allowed, surgeon-operated transcranial motor-evoked monitoring was performed. this is now considered routine practice by the authors.5 the spine was exposed and segmental pedicle screw instrumentation placed. fixed head screws were usually used but in the smaller children an adult cervical instrumentation system with polyaxial screws was utilised. once the surgeon was satisfied that rigid fixation was achieved, the pvcr was commenced. the thecal sac was exposed with laminectomy of the planned pvcr site. bilateral costotransversectomies were performed, resecting as many ribs as required to access the anterior column. an upcut (typically 5 mm) was used to follow the rib down to the side of the vertebral body. this plane was developed with blunt dissection (cottonoid on a kocher clamp) to visualise the vertebral discs and bodies, placing a copper malleable retractor to maintain this space, typically clipped to the drapes. thoracic roots were sacrificed when access required it, often more on one side to allow subsequent graft placement. the roots were tied distal to the dorsal root ganglion with 2/0 vicryl and cut with a blade. the sutures were kept long and clipped to lift and retract the dural sac and allow access to the posterior body wall. the discs and vertebral bodies were resected with curettes, upcuts and bone-nibblers, preserving 12 10 8 6 4 2 0 <5 5-10 10-15 15-18 3 7 2 6 5 2 1 age and sex female male figure 1. patient age distribution with female predominance (blue) figure 2. pre-operative mris confirming congenital spine dislocation, active tuberculosis and aneurysmal bone cyst (l to r) as causes of kyphosis table i: underlying pathology congenital 7 failure of formation 4 dislocations 3 incomplete sci 1 tuberculosis 16 active 9 healed 7 tumour 2 page 22 dunn rn et al. sa orthop j 2019;18(2) the posterior body wall until late. a plane between the theca and posterior longitudinal ligament is developed before this posterior wall is finally broken into the cavity created. care should be taken to avoid an anterior durotomy as it can be challenging to repair. during this process a temporary rod was placed to stabilise the spine and prevent cord injury. once the circumferential decompression was complete, the screws holding the temporary rod were loosened allowing some in situ rod bending while avoiding distraction with increased cord tension as the rod could slide through the screw heads. an anterior strut graft was placed and definitive rods sequentially applied with further sagittal correction and compression across the graft. in cases, especially the earlier ones, when struts could not be placed or were deemed unnecessary, morcellised graft was placed anteriorly. the remaining allograft strut was cut into bone plates and placed from the remaining cephalad to the caudal laminas to cover the theca. they were usually sutured in through drill holes to avoid migration. the wound was closed over a drain. allograft fibula shafts were used in 19 cases, a prosthetic cage in one and morcellised graft in six. the median duration of surgery (skin to skin) was 3.3 hours (iqr 3–5.0, range 1.9–6.5). the median blood loss was 500 ml (iqr 400–1225, range 100–2500). this represents a median 20.8 ml/kg (iqr 12.5–38.1, range 6.3–67.6).) cell-saving was only used in the larger children. spinal cord monitoring was used in 13 cases, with three cases failing to obtain signals. in the ten cases monitored there were two alerts while correcting the deformity which required remedial action. the median follow-up was 16 months (iqr 10.5–33.9). results the median overall percentage sagittal correction was 65% (iqr 44–79, range 21–100). the correction was best in the thoracolumbar spine at 75%, followed by the lumbar spine (table ii). there was dramatic improvement in the neurological status as presented in table iii. all non-ambulatory patients (asia c) improved to an ambulatory status. of the asia ds (walking but not normal power) most were normal at follow-up, two were unchanged at short-term follow-up, and one deteriorated. all neurologically normal patients (asia e) remained so. there was one permanent neurological deterioration from asia d to a in a patient with a congenital l1/2 dislocation and tethered cord. a short instrumentation was done to minimise growth disturbance as she was only 2 years old. the patient returned 12 weeks post-operatively with fixation failure and catastrophic neurological deterioration. despite revision, she remained an asia a (figure 3). one patient had a transient neurological deterioration postoperatively. on re-mri, incomplete decompression was confirmed with ongoing cord compression from the postero-inferior edge of the superior vertebral body. this was revised a week later with subsequent neurological recovery. one of the two patients that had associated syringomyelia had complete resolution of the syrinx on follow-up mri with improved neurological function (figure 4). one patient developed early (in-hospital) proximal junctional failure. following an excellent correction, she developed a proximal facet dislocation requiring cephalad extension of her instrumentation. there were no neurological sequelae, however (figure 5). one case developed surgical site sepsis requiring washout and subsequent instrumentation removal. there were no pulmonary complications. figure 3. two-year-old patient with congenital spine dislocation who presented 12 weeks post-surgery with paraplegia and failed correction due to inadequate instrumentation – kept short to allow spine growth. despite revision she did not recover neurologically as despite lumbar, it was a cord level injury due to her tethered cord and low conus. figure 4. pre-operative syrinx totally resolved on follow-up scan after vcr table iii: neurological status last follow-up a d m is si o n a b c d e a 0 b 0 c 9 3 6 d 8 1 2 5 e 9 9 table ii: sagittal correction pre-op post-op change % change lumbar 35.5° iqr 26–40.5 16–47 6° iqr 1–17 0–34 18° iqr 9–37 2–47 66% iqr 44–100 6–100 thoracic 64° iqr 55–88 30–100 27° iqr 17–30 8–70 28° iqr 20-64 −12–71 55% iqr 40–73 −21–87 tl 90° iqr 77–96 46–99 22° iqr 19–46 0–65 49° iqr 44–62 30–80 73% iqr 51–80 32–100 page 23dunn rn et al. sa orthop j 2019;18(2) discussion the pvcr was originally described by suk et al. for correction of severe deformity in an adult population.3 their focus, as with other authors, was largely around deformity correction.4,6-8 with the risk of neurological deterioration we are hesitant to promote such aggressive methods for deformity alone, but feel it is indicated when cord compression is present with established or predicted myelopathy. south africa has the rare combination of developing world pathology of advanced disease processes and developed world care. this is apparent in our cohort where paediatric patients present late with severe kyphotic deformity, many with established or impending myelopathy. it is tempting to defer aggressive management until a significant neurological deficit is present to justify the risk of intervention, but the more advanced the myelopathy, the less recovery can be expected. this and dissatisfaction with traditional anterior and posterior surgery has led us to steadily increase our use of the pvcr in this group.1 although technically challenging, it allows circumferential decompression of the spinal cord with excellent visualisation and correction of angular deformity. in addition, it allows spinal column shortening, thereby reducing tension on the cord and the risk of neurological injury. our experience confirms that pvcr is technically possible in a paediatric population of all ages. we successfully decompressed all patients with neurological improvement in the vast majority. all patients went on to a stable fusion with no rod breakage. instrumentation failures were the result of including too few levels in the fusion, compromising stability to allow more spinal growth in the future. the worst complication was the result of a short fixation in a 2-year-old. the other was a proximal failure in a severe kyphosis with massive correction, requiring proximal extension of the construct. the circumferential approach allows control of the spine at all times as compared to the more traditional anterior decompression and posterior fusion where transthoracic decompression and strut placement was followed by re-positioning and posterior surgery with risk of graft displacement in the process. in addition, the correction is performed in a controlled manner with visualisation of the thecal sac where the tension can be confirmed and avoided. the procedure is demanding with prolonged operating times and large blood loss reported. suk reported an average of 4.5 hours operating time and 2 300 ml blood loss in adults. lenke in his series of 147 paediatric cases reported just under 10 hours operating time and 1 610 ml blood loss, representing 65% of blood volume. our series compares favourably at 3.3 hours and 500 ml representing 30% of blood volume. the case mix is somewhat different with ours being largely sagittal plane deformity as opposed to scoliosis. in addition, the senior author performed all the surgery in our cohort whereas the lenke series had seven surgeons. our use of freehand pedicle screw insertion with fluoroscopy only used to confirm the level may also contribute to reduced surgical duration. paradoxically, despite the complexity, the smaller the patient, the quicker the procedure as there is far less to resect. complication rates are high, with lenke reporting a 59% incidence. suk had two paraplegias in his 70 cases whereas lenke had 27% intra-operative scm events but no permanent paraplegia. in our series there was one transient deterioration and one catastrophic deterioration 3 months post-operatively related to instrumentation failure. we had a 20% scm alert incidence which allowed intra-operative intervention to relieve stress on the cord. this risk makes scm mandatory for this type of procedure. we achieved excellent sagittal correction with this technique, comparable with the literature.3,4,8 it was slightly less in the thoracic spine compared to the lumbar and thoracolumbar. this is probably due to the anterior tethering effect of the costosternal joint complex. one needs to be cognisant of the forces generated when correcting the deformity as our only proximal failure was in a massive correction in a very young patient. no pulmonary complications were encountered as the pleural cavity is not violated. the reduced pulmonary function following transthoracic approaches is well documented, and avoiding this with the pvcr technique may make it safer in these young children with chest deformity and probably reduced respiratory reserve.9 conclusion posterior based circumferential decompression and corrective fusion using the pvcr technique is both feasible and effective in the paediatric population. it avoids the morbidity associated with the trans-thoracic approach and provides improvement in kyphosis, neurological function and csf dynamics when they are compromised. it remains a technically challenging procedure both for the surgical and anaesthetic team and there needs to be a clear understanding of the risk–benefit relationship when deciding on its implementation. ethics statement all procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. following database interrogation all data was anonymised. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions rnd maintained the database, performed the surgery, assisted with preparation of the manuscript and performed the revision. ah collated the data, performed the primary analysis and assisted with preparation of the manuscript. figure 5. following excellent sagittal plane correction, this young child developed early proximal junctional failure while still in hospital requiring cephalad extension of the construct. there were no neurological sequelae, however. page 24 dunn rn et al. sa orthop j 2019;18(2) orcid rn dunn http://orcid.org/0000-0002-3689-0346 a horn http://orcid.org/0000-0002-4159-6520 references 1. dunn r, garrett b. surgery for myelopathy in spinal deformity. sa orthopaedic journal 2011;10(1):30-34. 2. abdullah m, enrico n, dunn r. posterior vertebral column resection for severe spinal deformities. sa orthopaedic journal 2012;11(4):21-25. 3. suk si, kim jh, kim wj, lee sm, chung er, nah kh. posterior vertebral column resection for severe spinal deformities. spine 2002;27(21):2374-82. 4. lenke lg, newton po, sucato dj, shufflebarger hl, emans jb, sponseller pd, et al. complications after 147 consecutive vertebral column resections for severe pediatric spinal deformity: a multicenter analysis. spine 2013;38(2):119-32. 5. dunn r. surgeon operated trans-cranial motor evoked potentials (tcmep) in spinal deformity surgery a viable option in resourced challenged environments? imast abstract 64 cape town 2017. p 84. 6. mattila m, jalanko t, helenius i. en bloc vertebral column derotation provides spinal derotation but no additional effect on thoracic rib hump correction as compared with no derotation in adolescents undergoing surgery for idiopathic scoliosis with total pedicle screw instrumentation. spine 2013;38(18):1576-83. 7. lu g, wang b, li y, li l, zhang h, cheng i. posterior vertebral column resection and intraoperative manual traction to correct severe post-tubercular rigid spinal deformities incurred during childhood: minimum 2-year follow-up. eur spine j 2015;24(3):586-93. 8. hamzaoglu a, alanay a, ozturk c, sarier m, karadereler s, ganiyusufoglu k. posterior vertebral column resection in severe spinal deformities: a total of 102 cases. spine 2011;36(5):e340-44. 9. redding gj. early onset scoliosis: a pulmonary perspective. spine deform 2014;2(6):425-29. http://orcid.org/0000-0002-3689-0346 http://orcid.org/0000-0002-3689-0346 http://orcid.org/0000-0002-4159-6520 http://orcid.org/0000-0002-4159-6520 _goback _goback page 4 south african orthopaedic journal http://journal.saoa.org.za page 4 south african orthopaedic journal http://journal.saoa.org.za conferences, courses & symposia sassh (sa society for surgery of the hand) refresher course 23-25 february 2018 pretoria 18th congress sa spine society 24-26 may 2018 elangeni hotel, durban 64th congress of the south african orthopaedic association 3-6 september 2018 csir, pretoria january 2018 2nd international consensus meeting on orthopaedic infections 25 january 2018 26 january 2018 philadelphia, united states focus on arthroplasty symposium: unicondylar knee replacement 26 january 2018 27 january 2018 frankfurt am main, germany 19th annual aaos/aana/aossm sports medicine course 31 january 2018 04 february 2018 park city, united states february 2018 bernese hip symposium 2018 01 february 2018 03 february 2018 bern, switzerland paris shoulder symposium 2018 01 february 2018 03 february 2018 paris, france scandinavian hand surgical dissection course 05 february 2018 06 february 2018 copenhagen, denmark endoprosthetics congress berlin 2018 22 february 2018 24 february 2018 berlin, germany march 2018 aaos 2018 annual meeting 06 march 2018 10 march 2018 new orleans, united states kiel arthroscopy course 2018 09 march 2018 10 march 2018 kiel, germany utrecht spine course: complex paediatric spine 09 march 2018 10 march 2018 utrecht, netherlands annual meeting of the orthopaedic research society – ors 2018 10 march 2018 13 march 2018 new orleans, united states 12th international congress of sports medicine society of greece / 12th hellenic-cypriot conference 16 march 2018 18 march 2018 thessaloniki, greece 12th international meeting of the austrian foot society 22 march 2018 24 march 2018 going am wilden kaiser, austria european pelvic course 2018 22 march 2018 24 march 2018 hamburg, germany local international conferences, courses & symposia local 19th congress of the south african spine society 30 may 2019 – 01 june 2019 csir international convention centre, pretoria congress organiser: hendrika van der merwe, tel: +27 (0)21 981 3081; website: congress@saspine.org combined 65th south african orthopaedic congress 2019 – ‘unity in diversity’ 02 september – 06 september 2019 icc durban includes the following sub-specialty groups: 1. sa arthroplasty society (saas) 2. sa knee society (saks) 3. sa shoulder and elbow surgeons (sases) 4. sa foot surgeons’ association (safsa) 5. sa orthopaedic trauma society (saots) 6. sa paediatric orthopaedic society (sapos) 7. sa society for hip arthroscopy (sasha) 8. launch and inaugural meeting of the sa orthopaedic oncology and limb preservation society (sols) contact: chairman of the saoa congress committee: dr ian stead, email: iwstead@gmail.com international april 2019 5th international knee update 04 april 2019 – 06 april 2019 davos, switzerland icjr 7th annual revision hip & knee course – rochester 2019 04 april 2019 – 06 april 2019 rochester, united states utrecht spine course spinal trauma 2019 12 april 2019 – 13 april 2019 utrecht, netherlands 2nd international conference on orthopedics, rheumatology and osteoporosis 15 april 2019 – 16 april 2019 milan, italy atlanta trauma symposium 2019 18 april 2019 – 20 april 2019 atlanta, united states may 2019 eurospine spring specialty meeting 2019 02 may 2019 – 03 may 2019 frankfurt am main, germany 32nd annual meeting of the european musculo skeletal oncology society – emsos florence 2019 15 may 2019 – 17 may 2019 florence, italy 35th annual meeting cervical spine research society – rome 2019 22 may 2019 – 24 may 2019 rome, italy iaces 2019 – madrid international advanced course on elbow surgery 23 may 2019 – 25 may 2019 madrid, spain june 2019 8th international congress of arthroplasty registries isar 2019 01 june 2019 – 03 june 2019 leiden, netherlands isar 2019 01 june 2019 – 03 june 2019 leiden, netherlands 29th conference of the european wound management association – ewma 2019 05 june 2019 – 07 june 2019 gothenburg, sweden 14th ifssh and 11th ifsht triennial congress berlin 2019 17 june 2019 – 21 june 2019 berlin, germany page 10 south african orthopaedic journal http://journal.saoa.org.za editorial the p-value was introduced by fisher as a method to perform null hypothesis testing and has since been used widely in science as an indicator of significance.1 it can be defined as a measure of strength of evidence against the null hypothesis.2 in other words, it is the probability of finding an effect at least as or more extreme than the observed findings if the null hypothesis is true. however, the p-value is unable to reliably perform this function if the statistical power is not very high. in other words, if the power of a study is low, a repeat study will likely yield a substantially different p-value. beta errors are common in orthopaedic literature, with up to 28% of randomised controlled trials erroneously failing to reject the null hypothesis.3 furthermore, the arbitrary cut-off of 0.05 has led to the scientifically unsound practice of regarding so-called ‘significant  findings’ as more valuable, reliable or reproducible.4 in fact, treating a p-value as a dichotomous variable is unfounded.2 more worrying is the fact that the use of p-values may have served as an incentive for the introduction of bias: a practice referred to as ‘p-hacking’. these factors have combined to create serious concerns regarding the validity of many published scientific research findings, culminating in the statement that ‘it can be proven that most claimed research findings are false’.5 p-hacking, also known as selective reporting or inflation bias, typically involves the misreporting of true effect sizes.3 it occurs, for example, when researchers selectively employ certain statistical methodologies and/or data eligibility criteria in order to obtain a significant result. aschwanden has eloquently illustrated, with the aid of an interactive infographic, how simple it can be to manipulate a p-value by simply changing a variable.6 ‘data dredging’ and the shotgun approach to data analysis involves bombarding data with statistical tests until something significant is found. the aim should rather be to adhere to a well-designed protocol with an astute research question. probability testing should be thought of as currency, which should only be used to answer your research question/s or test the hypothesis. while it would remain reasonable to apply statistical methods to illustrate the similarity or dissimilarity of the groups being compared in a cohort study, reporting a p-value for every data element in a study depreciates its overall ‘value’. aside from p-hacking, other problems, inherent to the nature of p-values, remain. hypothesis testing involves the calculation of a test statistic (e.g., chi square value) that reflects the magnitude of association and the resulting p-value reflecting the extent to which the null hypothesis is compatible with the observed findings (assuming that the test statistic follows a specific probability distribution). it is not, for example, the probability that the null hypothesis is true or that the result is due to chance.7 as pointed out by gagnier and morgenstern: ‘overreliance on significance tests to interpret statistical findings ignores the magnitude of the association, estimation of precision, the consistency and pattern of results, possible bias arising from several sources, previous research findings, and foundational knowledge of relevant biological and clinical phenomena.’7 in 2016 the american statistical association developed a statement that aimed to guide the use and interpretation of p-values. six important principles are highlighted: 7,8 1. ‘p-values can indicate how compatible the data are with the specified statistical model.’ the accuracy of the p-value is only as good as the underlying statistical model and the assumptions used to arrive at it. 2. ‘p-values do not measure the probability that the studied hypothesis is true, or the probability that the data were produced by random chance alone.’ the p-value is therefore ‘a statement about data in relation to a specified hypothetical explanation and is not a statement about the explanation itself’. thus, the p-value only informs us of whether the statistical model used to test our assumptions is compatible with the observed data. 3. ‘scientific conclusions should not be based only on whether a p-value passes a specific threshold.’ in other words, a p-value that exceeds some arbitrary threshold does not tell us anything about the clinical importance of the findings. 4. ‘proper inferences require full reporting and transparency.’ a nice way of asking us to please avoid p-hacking. 5. ‘… does not measure the size of the effect or the importance of a result.’ therefore, a smaller p-value does not imply a stronger association. 6. ‘by itself, a p-value does not provide a good measure of evidence regarding a model or hypothesis.’ there are numerous factors that can affect the p-value including the power of the study, the statistical model used and various sources of bias. gagnier and morgenstern describe the emphasis on p-values in orthopaedic literature as misguided and ask us to move away from the emphasis on p-values with statements such as ‘statistically significant’.7 instead, it is recommended that confidence intervals are reported for tested outcomes in order to convey some information about the magnitude, direction and precision of the association. in addition, interpretation of results requires cognisance of any relevant factor, including all possible confounders and sources of bias; possible measurement errors; the suitability of the statistical the p-value: p for problem leonard marais phd, editor-in-chief, south african orthopaedic journal page 12 south african orthopaedic journal http://journal.saoa.org.za model; and findings from previous studies. as researchers, we have to accept that statistics alone are insufficient to translate our study findings to clinical practice. finally, hypothesis testing should be employed judiciously in order to maintain the value of our findings. references 1. fisher ra. statistical methods for research workers. 1925, london: oliver & boyd. 2. halsey lg, curran-everett d, vowler sl, drummond gb. the fickle p value generates irreproducible results. nature 2015;12(3):179-85. 3. abdullah l, davies de, fabricant pd, baldwin k, namdari s. is there truly ‘no significant difference’. j bone joint surg 2015;97-a(24):2068-73. 4. head ml, holman l, lanfear r, kahn at, jennions md. the extent and consequences of p-hacking in science. plos biol 2105;13(3): e1002106.doi:10.1371/journal.pbio.1002106. 5. ioannidis jpa. why most published research findings are false. plos med 2015;2(8): e124. doi: 10.1371/journal.pmed.0020124. 6. aschwanden c. science isn’t broken. fivethirtyeight 2015. available from: https://fivethirtyeight.com/features/science-isntbroken/#part1 (last accessed: 15 february 2018). 7. gagnier jj, morgenstern h. misconceptions, misuses, and misinterpretations of p values and significance testing. j bone joint surg 2017;99-a(18):1598-603. 8. wasserstein rl, lazar na. the asa’s statement on p-values: context, process and purpose. am stat 2016;70(2):129-33. 404 not found kruger n et al. sa orthop j 2019;18(2) doi 10.17159/2309-8309/2019/v18n2a6 south african orthopaedic journal http://journal.saoa.org.za traumahand surgery citation: kruger n, de villiers a-l, mcguire dt, solomons mw. intraosseous terminal phalanx epidermoid inclusion cyst: a first case of late recurrence. sa orthop j 2019;18(2):49-52. http://dx.doi.org/10.17159/2309-8309/2019/v18n2a6 editor: dr a ikram, stellenbosch university, cape town, south africa received: november 2018 accepted: january 2019 published: may 2019 copyright: © 2019 kruger n, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: this research received no funding. conflict of interest: all authors state that they have no conflict of interest with respect to this study. abstract introduction: epidermoid inclusion cysts (eic) of the terminal phalanx are a rare but relevant cause of lytic lesions, particularly in the context of previous trauma to the finger. we report the first known case of late recurrence, occurring almost three decades after the incident surgery. methods: a 56-year-old female patient presented to us with what proved to be a histologically confirmed eic of the terminal phalanx of her ring finger, but mentioned that she was treated for the same problem some 29 years ago. medical archive reports and the histological slide from the incident surgery confirmed an initial eic diagnosis, for which she was treated with curettage and iliac crest autograft, recovering uneventfully. results: despite the ‘zero’ risk of recurrence, she elected to have ablative surgery through the distal interphalangeal joint and recovered well. conclusion: care should be taken when counselling patients about possible recurrence of an eic of the terminal phalanx, and that this recurrence may be many years after the index procedure. level of evidence: level 5 key words: intraosseous, epidermoid, inclusion cyst, enchondroma, phalanx tumour intraosseous terminal phalanx epidermoid inclusion cyst: a first case of late recurrence kruger n¹ , de villiers a-l², mcguire dt³ , solomons mw4 ¹ mbchb(uct), msc diag imaging (oxon), msc (res) orth (oxon), mmed orth (uct), fcs orth (sa); martin singer hand unit, groote schuur hospital, university of cape town, south africa ² mbchb, mmed anat path; umane pathology inc, cape town, south africa ³ mbbch(wits), mmed orth (uct), fcs orth (sa); martin singer hand unit, groote schuur hospital, university of cape town, south africa 4 mbchb(uct), fcs orth (sa); professor and hod, martin singer hand unit, groote schuur hospital, university of cape town, south africa corresponding author: dr neil kruger, martin singer hand unit, j60 outpatients building, groote schuur hospital, main rd, observatory, cape town, 7925; tel: 021 404 5309; mobile: 079 3782480; email: neilkruger6@gmail.com https://orcid.org/0000-0002-0929-2092 ttps://orcid.org/0000-0001-5149-8708 https://orcid.org/0000-0002-4642-3311 page 50 kruger n et al. sa orthop j 2019;18(2) introduction epidermoid inclusion cysts (eic) of the bone are a rare but recognised cause for lytic lesions involving the terminal phalanx, particularly in the context of previous digital trauma. we report the first known case of late recurrence of an eic in the terminal phalanx, occurring 29 years after initial curettage and iliac crest autograft. methods and result an otherwise fit and healthy 56-year-old female presented to our hand unit with spontaneous onset, increasing right ring finger pain and swelling over the distal phalanx for the past six months. notably, at age 3 years she had caught her finger in a door hinge and sustained a crush injury to the terminal phalanx. despite some very mild tip sensitivity following this, she had a completely normally functioning finger. in 1986, at age 27, she had first presented with a similar history and an x-ray that showed a lytic lesion of the terminal phalanx for which she underwent curettage and iliac crest autograft, recovering uneventfully. intra-operative findings noted ‘sebaceous type material and cyst lining removed’ (figure 1). histology later confirmed an epidermoid inclusion cyst. twenty-nine years following this, she then represented with a very similar history, however denying any intercurrent finger trauma. clinical exam revealed a mildly swollen terminal phalanx with increased sensitivity to touch. she had a normal range of motion of the distal interphalangeal joint. x-ray revealed an expansile lesion involving the whole of the distal phalanx, with multiple lytic areas throughout, breeching the cortex distally and radially. generalised cortical thinning and associated surrounding soft tissue swelling were also noted (figure 2). a discussion was had with the patient regarding revision curettage and grafting. she was adamant that even if the lesion was benign, the repeat hassle and cosmetic abnormality that the finger had brought her was an indication for terminalisation. if the histology came back as a malignancy (e.g. chondrosarcoma) she understood the need for a more proximal resection margin. she thus elected to have the terminal phalanx ablated, and recovered well. pathology showed areas of keratin-lined cyst with surrounding foreign body reaction which again confirmed the diagnosis of an eic (figure 3). figure 1. a photograph of the original microfilmed operative notes from 1986 figure 2. an anteroposterior and lateral x-ray showing the diffuse lytic lesion, noting the eic diagnosis and detailing the findings accompanied by cortical thinning and cortical breeches. note the absence of a periosteal reaction. figure 3. histological slides of the original lesion (a) from 1986, and the recurrent lesion (b) confirming the diagnosis of an intraosseous epidermoid inclusion cyst page 51kruger n et al. sa orthop j 2019;18(2) discussion the differential diagnosis for lytic lesions involving the distal phalanx is broad, and encompasses benign and malignant tumours, as well as tumour-like conditions and infection (table i). eics account for such a lytic radiographic appearance but are rare pseudotumours. jamshidi et al., at a tertiary referral centre, over a five-year period, reviewed 14 patients presenting with a lytic lesion of the terminal phalanx and found only one to be an intraosseous eic.1 they occur predominantly in middle-aged adults, and more in males than in females.2,3 they are also distinctively associated with previous trauma to the digit in almost half the cases4,5 and this most likely explains both the male preponderance and terminal phalanx as the most common site, it being the most frequently injured part of the finger. infrequently the cyst arises spontaneously, and this is thought to be from congenital intraosseous inclusion of epidermoid cells. the time from either post-traumatic or iatrogenic intraosseous epidermoid cell introduction to clinical presentation is from months to many years. to our knowledge only one case of recurrence has been reported,6 occurring one year after the initial surgery. this recurrence occurred 29 years later, and it remains uncertain as to why this variability exists or what inciting event induces the cellular proliferation to form mature keratin-producing cysts. clinically the patients usually present with gradually increasing pain and mild swelling, but may present more acutely post pathological fracture. there may be accompanying nail deformity with pseudoclubbing, or erythema.4 radiographically they resemble enchondromas in appearance, but may be differentiated from them by location, as enchondromas usually occur closer to the base of the phalanx, and often have intralesional calcification. typically they are expansile lytic lesions with cortical thinning and little to no trabecular pattern.7 an absence of periosteal reaction helps to differentiate from osteomyelitis. histology is needed for definitive diagnosis and may be obtained through needle aspiration if enough keratin or sebaceous material is present.8 more often definitive treatment and diagnosis are undertaken concurrently with excision biopsy through curettage, and bone grafting of the defect if indicated. conclusion significantly, to our knowledge, this is the first reported case of late recurrence of an eic of the distal phalanx in the literature. it recurred almost three decades after the initial surgery, and care should be taken in counselling patients about possible late recurrence. ethics statement all procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. verbal informed consent was obtained from the patient prior to undertaking the study and all data was anonymised. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. acknowledgements thanks to the patients for their assistance in providing detailed information and allowing access to records for manuscript preparation. author contributions nk collected the microfilm data, drafted and edited the manuscript. a-ldv provided the slides and interpretation thereof, and edited the manuscript. dtm assisted with data collection and edited the manuscript. mws provided the original study concept, assisted with data collection and edited the manuscript. orcid kruger n https://orcid.org/0000-0002-0929-2092 mcguire dt https://orcid.org/0000-0001-5149-8708 solomons mw https://orcid.org/0000-0002-4642-3311 references 1. jamshidi k, mazhar fn, jafari d. lytic lesion in the distal phalanx of the hand. shafa orthopaedic journal. 2015;2(1):e441. table i: a differential diagnosis of lytic lesions occurring in the distal phalanx differential diagnosis tumours benign enchondroma osteochondroma aneurysmal bone cyst giant cell tumour simple bone cyst osteoid osteoma malignant metastasis – squamous carcinoma of the lung ewing sarcoma tumour-like conditions glomus tumour intraosseous ganglion/synovial cyst epidermoid inclusion cyst giant cell tumour of tendon sheath giant call reparative granuloma infection osteomyelitis tuberculosis systemic manifestation of diseases sarcoidosis metabolic hyperparathyroidism tophaceous gout https://orcid.org/0000-0002-0929-2092 https://orcid.org/0000-0002-0929-2092 https://orcid.org/0000-0001-5149-8708 https://orcid.org/0000-0001-5149-8708 https://orcid.org/0000-0002-4642-3311 https://orcid.org/0000-0002-4642-3311 page 52 kruger n et al. sa orthop j 2019;18(2) 2. hamad at, kumar a, anand kumar c. intraosseous epidermoid cyst of the finger phalanx: a case report. j orthop surg (hong kong). 2006;14(3):340-42. 3. lerner mr, southwick wo. keratin cysts in phalangeal bones. report of an unusual case. j bone joint surg am. 1968;50(2):365-72. 4. kalsotra n, singh m, sharma s, singh d. intraosseous epidermoid cyst of the finger phalanx: a case report. orthopaedic research and reviews. 2010;2:71-73. 5. mcgraw p, bonvento b, moholkar k. phalangeal intraosseous epidermoid cyst. acta orthop belg. 2004;70(4):365-67. 6. kurosawa k, kobayashi r, takagishi k. distal phalangeal reconstruction for recurrent intraosseous epidermoid cyst of the finger a case report. hand surg. 2011;16(3):375-77. 7. ruchelsman de, laino dk, chhor ks, steiner gc, kenan s. digital intraosseous epidermoid inclusion cyst of the distal phalanx. j hand microsurg. 2010;2(1):24-27. 8. handa u, kumar s, mohan h. aspiration cytology of epidermoid cyst of terminal phalanx. diagn cytopathol. 2002;26(4):266-67. _goback _goback orthopaedics vol3 no4 sa orthopaedic journal winter 2015 | vol 14 • no 2 page 35 sonographic assessment of the shoulders in asymptomatic elderly diabetics in a nigerian population e uchendu mbbs senior registrar, radiology department oo ayoola mbchb, fmcr senior lecturer, radiology department va adetiloye mbbs, fwacs, fmcr professor, radiology department rt ikem bm bch, fmcp, face associate professor, endocrinology unit, department of internal medicine ic ikem bm bch, fmcs orthop, fwacs, fics associate professor, department of orthopaedics and traumatology obafemi awolowo university, ile-ife, osun state 230001, nigeria corresponding author: dr oo ayoola department of radiology obafemi awolowo university ile-ife, osun state 230001 nigeria e-mail: oluyoola@gmail.com abstract background: there is an increased risk of developing shoulder lesions in diabetics especially with increasing age. ultrasonography provides a low risk and cost effective method of evaluating shoulder disorders in the general population. methods: this is a study of 60 diabetic subjects and 60 controls that were asymptomatic of shoulder joint disease. an ultrasound examination of both shoulders was performed according to standard protocol. data were analysed using the spss data analysis software. results: of the 60 diabetic subjects, 32 were male and 28 were female, while there were 35 males and 25 females in the subject group. supraspinatus (sst) tendon thickness was greater in diabetics than in controls, (6.44 ± 1.00 mm vs 5.25 ± 0.87 mm, p = 0.000) and (6.02 ± 0.90 mm vs 5.06 ± 0.81 mm, p = 0.000) in the dominant and non-dominant shoulders respectively. biceps tendon (bt) thickness was also significantly greater in diabetics (4.16 ± 0.57 mm vs 3.20 ± 0.49 mm, p = 0.000), and (3.99 ± 0.48 mm vs 3.99 ± 0.48 mm, p = 0.000) in the dominant and non-dominant shoulders respectively. conclusion: there was an increase in asymptomatic shoulder pathology in diabetic patients that was associated with ageing. key words: diabetes mellitus, elderly, shoulder, sonography, asymptomatic http://dx.doi.org/10.17159/2309-8309/2015/v14n2a4 saoj winter 2015_press_orthopaedics vol3 no4 2015/05/11 9:59 am page 35 page 36 sa orthopaedic journal winter 2015 | vol 14 • no 2 introduction the upper limbs perform diverse functions related to activities of daily living, sports and labour. this occurs due to the considerable range of motion of the shoulder. the shoulder is a complex of muscles, tendons and bony articulations that allow greater mobility than in any other joint in the human body. however, this mobility is achieved at the cost of structural stability.1 diabetes mellitus is a chronic metabolic condition characterised by persistent hyperglycaemia with resultant morbidity and mortality related to its associated microvascular and macrovascular complications. this can affect the shoulder in several ways as part of its effect on the glycation of musculoskeletal system. this has made shoulder pathology more common with diabetics than the general population.2-4 the lesions identifiable around the shoulder on ultrasonography include rotator cuff and biceps muscle tears, subacromial/subdeltoid bursa (sad) and biceps tendon effusions along with tendon thickening or thinning.5,6 these findings are largely as a result of tendon degeneration which is due to tendon overload, leading to microscopic collagen fibre failure and a failed healing response. it should be noted that inflammation is not part of the pathologic process, because inflammatory cells are not seen in biopsies obtained at the time of surgery in the patients.7 imaging methods used for the assessment of the shoulder includes plain radiography, single or double contrast arthrography, sonography, magnetic resonance imaging (mri), magnetic resonance (mr) arthrography and ct arthrography. mri and ultrasound remain the preferred imaging modalities as they have better soft tissue resolution for the non-bony components of the shoulder and do not involve radiation. ultrasound is however less expensive and more accessible than mri, which is a very important factor to be considered in evaluation of patients especially against the background of living in a developing world, low-income country with limited resources. subjects and methods this is a prospective, non-randomised, cross-sectional case-controlled study which was carried out in a nigerian tertiary hospital between august 2011 and may 2012. the study population consisted of 60 diagnosed type ii diabetic subjects and 60 ageand sexmatched controls. approval for the study was obtained from and approved by the (local) oauthc ethical and research committee. all study subjects were 50 years and above, had no history of symptomatic shoulder disease either previously or currently, and confirmed having type ii dm by who criteria;8 they were recruited consecutively from the diabetic outpatient clinic. control subjects with no history of diabetes and normal fasting blood glucose levels were recruited from apparently healthy volunteers asymptomatic of shoulder disease. an informed consent was obtained from all study participants. the participants were verified to have healthy and normally functioning shoulders by physical examination in which range of movement of the shoulder in all directions was assessed to be normal and without pain. exclusion criteria were previous history of trauma or surgery to either of the shoulder joints, renal failure, and a history of steroid or chronic nsaid use. the age of onset of diabetes, hand dominance, previous occupation and hobbies were noted and documented. previous working activity was classified as either clerical which includes civil servants, teachers, typists (entailing more light work) or non-clerical which includes drivers, traders, light farmers (relatively heavy work). non-clerical workers were excluded from the study. real-time grey-scale ultrasound was performed using a mindray ultrasound scanner model dc-6 and a variable high-frequency linear array transducer (5 to 10 mhz). all study subjects had ultrasonography of both shoulders using standardised procedure.9-11 the examination was performed by a fourth-year radiology resident, who was blinded to the status of the subjects. measurements were carried out three times, and the mean values obtained were recorded for each patient. all sonographic images were recorded and copied for repeated reviews and re-evaluation to confirm documented findings. data were reported as mean and standard deviation (mean ± sd) for continuous variables, whereas categorical variables were reported as frequencies and percentages. the independent samples t-test was used to compare mean tendon thickness and mean age in diabetics with those of the controls. the chi-square test was used to evaluate associations between shoulder disease and sex, hand dominance and grouped duration of diabetes. the significance level was determined at p < 0.05. analyses were done using spss, version 16.0. the statistical analysis was done by a qualified statistician and checked by the first author. results the 60 study subjects along with their ageand sex-matched controls did not differ in age, gender and hand dominance for both the diabetic and non-diabetic groups as shown in table i. the median duration of diabetes among subjects was 5.00 years, ranging from 0.2 to 26 years. in the diabetic group, the mean duration of diabetes was 4.17 ± 2.57 years in the diabetics that had been diagnosed for less than ten years, while the mean duration was 15.79 ± 3.84 years in diabetics that had the disease for over ten years. mri and ultrasound remain the preferred imaging modalities as they have better soft tissue resolution for the non-bony components of the shoulder and do not involve radiation saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 3 sa orthopaedic journal winter 2015 | vol 14 • no 2 page 37 as shown in table ii, the thickness of the supraspinatus tendon (sst) was significantly greater in diabetics (6.44 ± 1.00 mm) compared to controls (5.25 ± 0.87 mm) in the dominant shoulder, (p = 0.000). for the nondominant shoulder sst, the thickness was 6.02 ± 0.90 mm in the diabetic subjects and 5.06 ± 0.81mm in the control group (p = 0.000). similarly, the tendon thickness of the dominant long head of the biceps tendon (bt) and that of the non-dominant were 4.16 ± 0.57 mm and 3.99 ± 0.48 mm in diabetics and 3.20 ± 0.49 mm and 3.13 ± 0.50 mm in the control group, respectively (p = 0.000). table i: characteristics of study subjects characteristic diabetics (n = 60) controls (n = 60) p value age in years (mean ± sd) 70.18 ± 11.97 69.55 ± 12.41 0.776 gender male (n,%) 32 (53.3%) 35 (58.3%) 0.713 female (n,%) 28 (46.7%) 25 (41.7%) hand dominance right (n,%) 58 (96.7%) 60 (100%) 0.476 left (n,%) 2 (3.3%) 0 (0%) table ii: shoulder findings by hand dominance limb tendon dm control p value dominant sst thickness (mm) 6.44 ± 1.00 5.25 ± 0.87 0.000 partial thickness tear(n) 10 (16.7%) 3 (5.0%) 0.040 full thickness tear(n) 2 (3.3%) 0 (0.0%) 0.154 bt thickness (mm) 4.16 ± 0.57 3.20 ± 0.49 0.000 partial thickness tear(n) 0 (0.0%) 0 (0.0%) n/a full thickness tear(n) 1 (1.7%) 0 (0.0%) 0.315 effusion sad (n) 9 (15%) 4 (6.7%) 0.142 biceps tendon (n) 25 (41.7%) 12 (20.0%) 0.010 non-dominant sst thickness (mm) 6.02 ± 0.90 5.06 ± 0.81 0.000 partial thickness tear(n) 2 (3.3%) 4 (6.7%) 0.402 full thickness tear(n) 0 (0.0%) 1 (1.7%) 0.315 bt thickness (mm) 3.99 ± 0.48 3.13 ± 0.50 0.000 partial thickness tear(n) 1 (1.7%) 0 (0.0%) 0.315 full thickness tear(n) 1 (1.7%) 0 (0.0%) 0.315 effusion sad (n) 4 (6.7%) 5 (8.3%) 0.792 biceps tendon (n) 25 (41.7%) 22 (36.7%) 0.575 both shoulders sst thickness (mm) partial thickness tear(n) 12 (20.0%) 7 (11.7%) 0.211 full thickness tear(n) 2 (3.3%) 1 (1.7%) 0.559 bt thickness (mm) partial thickness tear(n) 1 (1.7%) 0 (0.0%) 0.315 full thickness tear(n) 2 (3.3%) 0 (0.0%) 0.154 effusion sad (n) 10 (16.7%) 7 (11.7%) 0.432 biceps tendon (n) 35 (58.3%) 29 (48.3%) 0.272 comparison between the tendon thicknesses, measured in mm, in the two groups were done using t-test while the number of subjects with a particular sonographic feature was done using a chi-square test. saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 37 page 38 sa orthopaedic journal winter 2015 | vol 14 • no 2 with regard to the sonographic features indicating tendon degeneration, there were more partial thickness tears in the supraspinatus tendons (sst) compared to the long head of biceps tendons (bt) in both diabetics and controls (figure 1). also a greater proportion of diabetics, ten (16.7%) had a significant proportion of partial sst tears compared to controls, three (5.0%) in the dominant shoulder (table ii). all the partial thickness tears were less than 1 cm in size, and no tear of the infraspinatus tendon was observed. full thickness tears of the sst were demonstrated in two (3.3%) diabetics while full thickness bt tears were noted in one (1.7%) in the same group. no full thickness tear of both tendons was observed in the control group for the dominant shoulder (table ii). the dominant shoulder showed near similar pattern of lesions for both study groups, with bt effusion (41.7% vs 20%) as the commonest sonographic feature of tendon degeneration. in the non-dominant shoulder, the control subjects had bt effusion (36.7%) as the most frequent lesion followed by sad effusion. the infraspinatus tendon did not show any sonographic features of degeneration in either of the groups (table ii). more diabetics than controls had sad and biceps sheet effusion for both shoulders combined and was significant for dominant side bt effusion (figure 1, table ii). the sonographic features of tendon degeneration elicited in men were generally not different from women in terms of shoulder abnormalities in both study groups. the only significant difference was the higher prevalence of dominant sad effusion in female controls compared with male controls (16.0% vs 0.0%, p = 0.014) (table iii). subjects with more than ten years’ duration of diabetes, who were 19 in number, had significantly higher sst thickness than those with less than ten years, who were 41 in number (7.04 ± 0.71 vs 6.16 ± 1.00, p = 0.001) while bt thickness in diabetics was not significantly higher (4.35 ± 0.49 vs 4.07 ± 0.59, p = 0.083). the subjects who had diabetes greater than ten years also had higher prevalence of sad effusion compared to those with those that had the disease for less than ten years (31.6% [n = 6] vs 7.3% [n = 3], p = 0.014.) bt effusion between both groups were not significantly different but higher in those with diabetes for more than ten years (52.6% [n = 10] vs 36.6% [n = 15]). a positive correlation was also noted between the duration of diabetes and dominant limb tendon thickness with an r value of 0.481 (p = 0.000) for supraspinatus thickness and 0.317 (p = 0.01) for biceps tendon thickness. there was a positive correlation between the dominant and non-dominant sst thickness with increasing subjects age in the diabetics. the r values were 0.5 (p = 0.000) and 0.51 (p = 0.000) respectively. discussion rotator cuff disease is a group of diverse conditions with multiple causes and mechanisms of injury, some symptomatic and others non-symptomatic. theories postulated as to the cause of rotator cuff disease include impingement, normal ageing, avascularity of the tendon, trauma, and compression from narrowing of the acromial space. several studies have shown an increase in prevalence of shoulder disease, with or without symptoms, in elderly12-15 subjects and in diabetics.2-4,16 the dominant shoulder showed near similar pattern of lesions for both study groups, with bt effusion (41.7% vs 20%) as the commonest sonographic feature of tendon degeneration table iii: association between shoulder disease and gender subject category tendon male (n=32) female (n=28) p value diabetic thickness (mm) sst 6.34 ± 1.02 6.55 ± 0.99 0.417 bt 4.22 ± 0.61 4.09 ± 0.52 0.397 effusion sad 6 (18.8%) 3 (10.7%) 0.384 bt 12 (37.5%) 13 (46.4%) 0.484 control thickness (mm) sst 5.30 ± 0.72 5.18 ± 1.05 0.610 bt 3.16 ± 0.41 3.25 ± 0.59 0.473 effusion sad 0 (0.0%) 4 (16.0%) 0.014 bt 6 (17.1%) 6 (24.0%) 0.513 comparison between the tendon thicknesses, measured in mm, in the two groups were done using the t-test while the number of subjects with a particular sonographic feature was done using a chi-square test. figure 1: a bar chart showing the pattern of lesions in both shoulders of all subjects saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 38 sa orthopaedic journal winter 2015 | vol 14 • no 2 page 39 this study demonstrated that asymptomatic shoulder lesions were more common in the diabetic subjects than the non-diabetics; this is shown by the significantly greater tendon thickness for both the sst and bt in the dominant and non-dominant shoulders, higher prevalence of the sst partial thickness tears in the dominant shoulder, and the effusion in the bt sheet (table ii). these findings are in concordance with those of other studies.5,17 the significance of these findings is the clinical implications of symptom progression for asymptomatic shoulder lesions, especially rotator cuff tears with time as shown by other investigators.18,19 they observed the development of pains and a decrease in the ability to perform activities of daily living as the natural history of most asymptomatic tears. in one of the studies, 51% of the previously asymptomatic patients became symptomatic over a mean of 2.8 years.18 abate et al.5 recorded higher percentages of tears in both the sst and bt with associated higher percentages of effusion in the bt sheet and the sad when compared to this study. a possible explanation may be related to the difference in races of the subjects used in both studies, raising the possibility of this study group being more resilient to tears, which may agree with the works of tashjian20 and other investigators21 that showed a strong genetic predisposition for rotator cuff disease. the bt and sad effusions observed are strongly associated with tears and are said to be an expression of early reactive inflammation to minimal tendon tears, following minor and unrecognised trauma.22 a good correlation between diabetes and increased shoulder lesions was also emphasised by the demonstration of an increased prevalence of shoulder pathology with the duration of diabetes. this supports the studies which suggested diabetes as a major risk factor in rotator cuff disease.4 the study also showed that there was a positive correlation between age and shoulder pathology as demonstrated by the significant increase in the thickness of the sst in both the dominant and non-dominant shoulders of the diabetics. a strong suggestion from this study is that diabetes has an effect on the established age-related background tendon lesions as shown by the higher prevalence of tendon pathologies in the diabetics. this supports the studies which suggested diabetes as a major risk factor in rotator cuff disease.4,12 rotator cuff disease is multi-factored and has been attributed to both intrinsic and extrinsic factors. extrinsic factors contribute to compression of the rotator cuff tendons, impingement syndrome, while the intrinsic factors result in tendon degradation due to the natural process of ageing,13 poor vascularity,22 altered biology,23 and inferior mechanical properties resulting in damage with tensile or shear loads.24 an inherited predisposition for the development of rotator cuff disease has also been identified.20,21 ageing and diabetes have a common biochemical mechanism of tendon degeneration secondary to nonenzymatic glycosylation of collagen with formation of advanced glycation end products (ages). the ages crosslink formation in the collagen fibres affects their physical and chemical properties, reducing their solubility with a resultant tougher, stiffer, less elastic and a weaker matrix.25 diabetics show excessive glycosylation and cross-linking of the collagens25 and, added to the microvascular complications, may explain the higher prevalence of the rotator cuff and long head of biceps tendon lesions in this group of subjects. apart from the unexplained statistically significant higher prevalence of sad effusion in the female control group, no other significant correlation was observed with the subjects’ gender and shoulder pathology which also agrees with other investigators that found no gender difference in the shoulder lesions (table iii).5 this finding is not in keeping with the work of yamamoto and co-workers15 who established a male preponderance which may be due to the inclusion of both symptomatic and asymptomatic subjects, and the males are more likely to be engaged in heavy labour and have a history of trauma that could cause cuff disease than the females. limitations of study some limitations to this study must be acknowledged. assessment of absence of pain and functional impairment was mainly based on patients’ judgment making it wholly subjective, as active and passive range of shoulder motion was not objectively measured. secondly, the researcher was not blinded to the status of both subject groups which may increase the chance of bias. conclusion there is an increase in the prevalence of asymptomatic shoulder pathology in diabetics that is aggravated by ageing. real-time ultrasound with its high sensitivity and specificity, provides a well-tolerated, convenient and costeffective method of evaluating these shoulder lesions. references 1. schenkman m, de cartaya vr. kinesiology of the shoulder complex. j orthop sports phys ther. 1987;8:438-50. 2. aydeniz a, gursoy s, guney e. which musculoskeletal complications are most frequently seen in type 2 diabetes mellitus? j int med res. 2008;36(3):505-11. 3. viikari-juntura e, shiri r, solovieva s, karppinen j, leinoarjas p, et al. risk factors of atherosclerosis and shoulder pain–is there an association? a systematic review. eur j pain 2008;12(4):412-26. 4. cole a, gill tk, shanahan em, phillips p, taylor aw, et al. is diabetes associated with shoulder pain or stiffness? results from a population based study. j rheumatol 2009;36(2):371-77. saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 39 page 40 sa orthopaedic journal winter 2015 | vol 14 • no 2 5. abate m, schiavone c, salini v. sonographic evaluation of the shoulder in asymptomatic elderly subjects with diabetes. bmc musculoskeletal disorders 2010;11:278. 6. zanetti m, hodler j. imaging of degenerative and posttraumatic disease in the shoulder joint with ultrasound. eur j radiol. 2000;35:119-25. 7. mckee, jennie. rethinking tendinopathy treatments. aaos now, 2011;5:8. 8. world health organization. definition, diagnosis and classification of diabetes mellitus and its complications; part 1: diagnosis and classification of diabetes mellitus. department of noncommunicable disease surveillance, geneva, 1999. 9. american college of radiology. acr practice guideline for the performance of a shoulder ultrasound examination. acr practice guideline, 2006;867-70. 10. american institute of ultrasound in medicine. alum practice guideline for the performance of a shoulder ultrasound examination. j ultrasound med. 2003;22:113741. 11. papatheodorou a, ellinas p, takis f, tsanis a, maris i, et al. us of the shoulder: rotator cuff and non-rotator cuff disorders. radiographics 2006;26(1):e23. 12. northover jr, lunn p, clark di, phillipson m. risk factors for the development of rotator cuff disease. int j shoulder surg. 2007;1:82-86. 13. tempelhof s, rupp s, seil r. age-related prevalence of rotator cuff tears in asymptomatic shoulders. j shoulder elbow surg. 1999;8(4):296-99. 14. schibany n, zehetgruber h, kainberger f, wurnig c, bassalamah a, et al. rotator cuff tears in asymptomatic individuals: a clinical and ultrasonographic screening study. eur j radiol. 2004;51(3):263-68. 15. yamamoto a, takagishi k, osawa t, yanagawa t, nakajima d, et al. prevalence and risk factors of a rotator cuff tear in the general population. j shoulder elbow surg. 2010;19(1):116-20. 16. arkkila pe, kantola im, viikari js, ronnemaa t. shoulder capsulitis in type i and ii diabetic patients: association with diabetic complications and related diseases. ann rheum dis. 1996;55(12):907-14. 17. mujde a, selma k, mahmut k, osman m. thickness of the supraspinatus and biceps tendons in diabetic patients. exp clin endocrinol diabetes 2007;115:92-96. 18. yamaguchi k, tetro am, blam o, evanoff ba, teefey sa, et al. natural history of asymptomatic rotator cuff tears: a longitudinal analysis of asymptomatic tears detected sonographically. j shoulder elbow surg. 2001;10(3):199-203. 19. mall na, kim hm, keener jd, steger-may k, teefey sa, et al. symptomatic progression of asymptomatic rotator cuff tears: a prospective study of clinical and sonographic variables. j bone joint surg am. 2010;92:2623-33. 20. tashjian  rz, farnham jm,  albright fs, teerlink cc, cannon-albright la. evidence for an inherited predisposition contributing to the risk for rotator cuff disease. j bone joint surg am. 2009;91:1136-42. 21. harvie p, ostlere s, teh j, mcnally e, clipsham k, et al. genetic influences in the aetiology of tears of the rotator cuff. sibling risk of a full-thickness tear. j bone joint surg br. 2004;86:696-700. 22. rudzki jr, adler rs, warren rf, kadrmas wr, verma n, et al. contrast-enhanced ultrasound characterization of the vascularity of the rotator cuff tendon: ageand activity-related changes in the intact asymptomatic rotator cuff. j shoulder elbow surg. 2008;.7(1 suppl):96s100s. 23. kumagai j, sarkar k, uhthoff h. the collagen types in the attachment zone of rotator cuff tendons in the elderly: an immunohistochemical study. j rheumatol, 1994;21:2096100. 24. lake s, miller k, elliott d, soslowsky l. effect of fiber distribution and realignment on the nonlinear and inhomogeneous mechanical properties of human supraspinatus tendon under longitudinal tensile loading. j orthop res. 2009;27:1596-602. 25. paul rg, bailey aj. glycation of collagen: the basis of its central role in the late complications of ageing and diabetes. int j biochem cell biol. 1996;28:1297-310. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 40 dey r et al. sa orthop j 2020;19(4) doi 10.17159/2309-8309/2020/v19n4a3 south african orthopaedic journal http://journal.saoa.org.za knee citation: dey r, patnaik s, nair g, steiner s, sivarasu s. an intra-operative device for parallel drilling and femoral landmark estimation during medial patellofemoral ligament reconstructive surgery sa orthop j 2020;19(4):212-217. http://dx.doi.org/10.17159/2309-8309/2020/v19n4a3 editor: dr michael held, university of cape town, south africa received: may 2019 accepted: february 2020 published: november 2020 copyright: © 2020 dey r. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: this study was funded by the national research foundation (nrf) – nrf grant no: csur13082630873. the funding sources had no influence on the reported study and the decision to submit the study for publication. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: the aim of this study was to design and test a device to guide medial patellofemoral reconstruction surgeries. materials and methods: a three-dimensional (3d) printed, modular and cost-effective medial patellofemoral ligament (mpfl) reconstruction guide, pat-rig, was designed with parallel holes running in the medio-lateral direction. this device was manufactured using a commercial additive manufacturing facility, and bench tested using a custom-built test rig. ct scans of patella bones were reconstructed, and the device was tested on four 3d-printed patellas of various sizes. results: the device was successful in guiding the surgical drill into the patella to drill parallel holes adhering to the current surgical requirements and specifications. the device was augmented with an innovative radiopaque scale which can allow the surgeon to accurately predict the landmarks to drill and measure the drill depth of the tunnels. conclusion: there are no devices on the market that accurately predict the drill locations on the patella during mpfl reconstruction surgeries. the device, pat-rig, was found to overcome the current limitations of the mpfl surgeries and was able to provide satisfactory surgical guidance during the reconstruction. level of evidence: level 5 keywords: knee surgery, patella, orthopaedic, mpfl reconstruction, 3d-printed, novel surgical device an intra-operative device for parallel drilling and femoral landmark estimation during medial patellofemoral ligament reconstructive surgery dey r1 , patnaik s2, nair g3, steiner s4, sivarasu s5 1 phd; postdoctoral fellow, faculty of health sciences, university of cape town, south africa 2 md; senior consultant, sunshine hospital, department of arthroscopy and sport centre, bhubaneswar, odisha, india 3 msc; senior technical officer, department of human biology, university of cape town, south africa 4 ms; lecturer, department of human biology, university of cape town, south africa 5 phd; associate professor, department of human biology, university of cape town, south africa corresponding author: dr sudesh sivarasu, room 7.17, anatomy building, university of cape town medical campus, anzio road, observatory, cape town, 7925, south africa; tel: (021) 404 7613; email: sudesh.sivarasu@uct.ac.za https://orcid.org/0000-0002-3616-1995 https://orcid.org/0000-0002-0812-568x page 213dey r et al. sa orthop j 2020;19(4) introduction the current global trend towards becoming fit and healthy has led to an increase in the number of soft tissue injuries of the lower limbs due to the additional stress of the related activities. the medial patellofemoral ligament (mpfl) attaches the medial aspect of the patella to the medial epicondyle of the femur.1,2 patella dislocation is a common knee joint pathology. apart from active individuals, people having soft tissue defects since birth also suffer from patellar dislocations.3 as the mpfl plays a very important part in keeping the patella in its place, microscopic tears have been observed in the ligament, post-acute patellar dislocations.3,4 while the incidence rate of primary dislocation is relatively low (6 to 80 per 100 000 individuals), one in every two of these patients suffers from re-dislocation of patella and lives with their knee pain until they have their knee re-operated. repetitive patellar dislocations cause microscopic tears in the mpfl which results in complete mpfl rupture in 94% of patients.3-7 over 130 techniques exist to treat patella-femoral instability and none of these completely alleviates the post-surgical pain and trauma.8 mpfl reconstruction surgeries replace the anatomic ligament with a 0.18–0.2 m long ligament graft.9 there are two major surgical procedures that are performed to reinstate the mpfl in its anatomic position: a. the single-bundle procedure,10 and b. the double-bundle procedure.10,11 the double-bundle surgical procedure (figure 1) requires two holes to be drilled on the medial aspect of the patella with the knee in 30° of flexion. these holes house the patellar end of the graft and also allow the graft to have a converging fan-shaped structure, which closely mimics the original structure of the mpfl.12 the single-bundle technique requires drilling of one hole into the patella. studies have demonstrated that there is no significant difference in the forces acting on the patella, post a single-bundle or a double-bundle mpfl reconstruction surgery.10 for both the procedures, the graft is inserted into the lateral femoral condyle through a single hole.13-15 with the exact point of insertion into the femur under debate, studies have shown that current mpfl reconstruction surgeries have a radial error of 0.004 m.16 there are no existing methods for locating the anatomic insertion points of the mpfl graft into the medial patella. the current best practice involves taking intra-operative x-rays, from which the surgeon makes an estimate of the location for the drills. moreover, there are no means to ensure that the drilled holes are parallel to each other. non-parallel drills might exert unequal forces on the bone bridge between the drills, which can lead to fracture of the patella.17,18 pat-rig8,19-20 is a drill-guiding medical device, designed by the authors, which can assist the surgeon in accurately locating the graft insertion locations on the patella and guide the surgeon when drilling parallel holes into the bone. the device is designed for single use and is made from a three-dimensional (3d) printed component. it can be made available to the surgeon within a few hours, in case of emergency. the additive manufacturing technique also makes the device low cost compared to the available surgical guides on the market.20 this is a bench study describing the design and development of a low-cost mpfl reconstruction guiding device, not previously described. materials and methods design considerations for the patellar landmarks a pre-design study was conducted, which helped the authors to understand the clinician’s requirement for the mpfl reconstruction surgery. the study revealed that the location for the first drill point must, on average, be 0.01 m from the superior surface of the patella. furthermore, it was also realised that the second parallel drill should be at a distance of 0.01–0.015 m from the first drill point. the initial prototype (figure 2) included fixed drill holes on the medial and the lateral sides of the device, with the goal of providing the surgeon with a single device which can be used for both the left and the right knee. with the aim to accommodate patellas of different shapes and sizes, it was realised that the drill-guide system should be movable. to achieve that goal, a separate drill-guide housing was designed having two parallel 0.0045 m drill guides cut into it, at a distance of 0.015 m from each other. the design of the figure 1. schematic representation of the double-bundle mpfl reconstruction technique. currently, there are no reliable guidance devices available for the orthopaedic surgeon, which increases the graft insertion landmarking error on the patella and the femur. figure 2. initial iteration of the pat-rig. the parallel holes are to guide the surgeon to drill parallel holes on the medial aspect of the patellar bone. the design was created to accommodate different sizes of patella. (source: sivarasu s, patnaik s. accessory for conducting patella surgery [pat-rig]. british patent application no gb1511597.5, 2015) page 214 dey r et al. sa orthop j 2020;19(4) device was further altered to make it right or left knee specific. the final prototype was designed around a 3d reconstructed model of a 0.046 m × 0.049 m male patella, which is bigger than the average size of the bone.21 this enabled a new design for the device which could accommodate every size of patella. design considerations for the femoral landmarks the mpfl is a fan-shaped soft tissue attaching the medial patella to the medial femur.1,7,22 if the superior and inferior edges of the soft tissue are considered, then at 30° of knee flexion the superior landmark of the mpfl (mpflsup) has an average length of 0.0575 m, and the average length of the inferior landmark of the mpfl (mpflinf) measures to 0.0555 m. 23 past studies have shown that the length of the central aspect of the mpfl changes negligibly, when compared to the changes in mpflsup and mpflinf, during the flexion of the knee from 0° to 30°.23 to design the device, therefore, trigonometric principles were applied to establish the angle of attachment between the fan-shaped ligament and the patella at the superior and inferior edges (figure 3). the average length of the central landmark of the mpfl (mpflcntr) is 0.055 m during the first 30° of knee flexion.23 neglecting the angular change in length of the central aspect of the ligament, using the formulae shown below, it can be established that the angle suspension of the inferior edge of the mpfl is 8° and the superior edge is 17° when the femur is flexed at 30°. inferior attachment angle = cos-1(mpflinf/mpflcntr) (1) superior attachment angle = cos-1(mpflsup/mpflcntr) (2) the other design aspect of this device was the converging angle of the fan on the femur. to calculate the angle subtended by the superior and inferior borders of the mpfl, the law of cosines was applied, and the angle was established to be 15.1°. the equation applied for this calculation is as follows: convergence angle = cos-1(152 – mpflinf – mpflsup/2*mpflinf*mpflsup) (3) the design was made in such a way that it fits into the drill-guide housing of the pat-rig. this fits well with the surgical practice of the double-bundle procedure as the drill-guide housing will not be in use during the second part of the surgery where the surgeon drills the tunnel into the femoral landmark. design considerations for the radiopaque scale to provide the surgeon with an option to view the depth of the drill and the distance of the drill landmarks on the patella, a radiopaque scale was designed. the material of choice was transparent, and the scale had markings every 0.025 m for the surgeon’s reference. design of the test rig to test the functionality of pat-rig, a test rig was designed to hold the 3d-printed patella and the drill-guiding device in place. the test rig was developed to function as a substitute for the quadriceps tendon, which is generally intact and holds the patella in place during the mpfl reconstruction surgery. the test rig was designed around the dimensions of the pat-rig, except for the height. the rig enabled the authors to drill holes into the patella through the drillguiding device and thereby assess the functionality of the pat-rig. the device was also tested in silico on a 3d-reconstructed model of the patella using solidworks (dassault systemes, velizy, france). the test involved drilling parallel holes into the medial aspect of the figure 3. schematic representation of the positional change of the medial patellofemoral ligament from 0° to 30° of knee flexion. this position is an important design parameter for the femoral landmark prediction device as the mpfl reconstruction surgery requires the knee to be flexed at that angle. (source: dey r, patnaik s, sivarasu s. novel device to accurately locate femoral insertion landmark in medial patellofemoral ligament (mpfl) reconstruction. proceedings of the 2017 design of medical devices conference. 2017 design of medical devices conference. minneapolis, minnesota, usa. april 10–13, 2017. v001t11a019. asme. https://doi.org/10.1115/dmd2017-3500) figure 4. schematic representation of the final design of the pat-rig overlaid on the 3d-reconstructed patella and the femur. the radiopaque scale and the pat-rig were overlaid on the entire set-up. in silico tests were performed on this set-up and the graft insertion landmarks were accurately marked. (source: dey r, patnaik s, sivarasu s. novel device to accurately locate femoral insertion landmark in medial patellofemoral ligament (mpfl) reconstruction. proceedings of the 2017 design of medical devices conference. 2017 design of medical devices conference. minneapolis, minnesota, usa. april 10–13, 2017. v001t11a019. asme. https://doi.org/10.1115/dmd2017-3500) page 215dey r et al. sa orthop j 2020;19(4) patella. along with the drilling of parallel holes into the patella, the clearance distance, i.e. the distance between the outer edges of the patella and the inner edges of the device, was measured. results pat-rig: the novel drill-guide device the designed device (figure 4) was modular and had four detachable parts. the medial and the superior components were fused together. the medial component had an ellipsoid gap, 0.036 m long, to house the drill-guide component. the gap had teeth on the top to hold the drill guide in place during the drilling process. the device was designed such that the minimum distance between the superior component and the first drill-guide hole was 0.01 m. the distance between the two drill-guiding holes were kept constant at 0.015 m. the inferior component was made to curve outwards to accommodate the convex inferior apex of the patellar bone. if the surgeon chooses the option of inserting a guidewire into the patella, an optional 0.0025 m plug-in drill-guide hole was designed. this guide hole can be inserted into the existing 0.0045 m drill hole using the fan-blade shaped protrusion. to make the device modular, slots were created into the lateral, medial and superior components. the slots enabled the dimensions of the device to be altered from 0.54–0.48 m in the superior-inferior axis and 0.54–0.43 m in the anterior-posterior axis. to fasten the device to the patient’s knee, loop-and-hook fasteners (velcro®), were used. to attach the fasteners to the patrig, two protruding appendages were designed on the medial and lateral sides. a radiopaque scale was designed to mount onto the pat-rig. two upward-facing protrusions on the pat-rig were used to mount the scale on the top of the device. the purpose of the scale was to assist the surgeons with accurately locating the initial points for drilling onto the patella. the scale could also be used to measure the depth of the drill into the patella. it would be possible to sterilise the whole device by using a gas sterilisation process; however, the device was designed to be disposable in order to reduce the risks of inter-patient infection. the test rig for testing the novel device the designed test rig (figure 5) was divided into superior and inferior segments. the superior segments of the rig could be collapsed onto the inferior one with the help of long screws. a spring was introduced in between the compartments to make the collapsing mechanism easy. this enabled the test rig to accommodate patellas of different heights. normally, the anterior aspect of a patella has a convex shape; keeping that in mind, an elliptical groove was cut into the floor of the superior component. the respective roof and floor of the inferior and superior compartments were layered with a figure 5. schematic representation of the 3d-manufactured test rig for the pat-rig. the device and the 3d-printed patella were stuck together in place using silicone double-sided adhesive. a mechanical drill was used to drill into the patella through the device. a b figure 6. (a) x-ray images showing the parallel holes drilled into the 3d-printed patella during bench testing using the test rig. (b) the parallel holes were observed to lie at surgically acceptable distances from each other. (b) page 216 dey r et al. sa orthop j 2020;19(4) silicon anti-slip pad. these design features kept the pat-rig and the patella in their respective positions. the drills were made into the medial aspect of four 3d-printed patellas, using the pat-rig. the drilled holes were found to be in a straight line and parallel to each other (figure 6a) and about 0.015 m apart (figure 6b). the test rig was able to withstand the drilling force and keep the components of the drill-guiding device and the patella fixed in their respective places. the in silico tests provided the proof of concept for the device. the holes drilled on the medial aspect of the patella were straight and parallel to each other. the average measured clearance distances were 0.00132 m. this suggested that the device will be able to accommodate the soft tissues around the knee joint space. discussion the pat-rig was designed, manufactured and tested at the university of cape town. traditional mpfl reconstruction surgical guide tools cost thousands of dollars, whereas the pat-rig can be manufactured for the equivalent of less than $20. this significant decrease in the cost of the device gives it the edge over the available devices on the market. as the results show, the device decreases the chances of misaligning the parallel holes and assists the surgeon to accurately predict the two points of drill during the double-bundle mpfl reconstruction surgery. mpfl is one of the major ligaments that holds the patella in place, articulating the femur. a weak or torn mpfl can give rise to pain in the knee and/or can make the patella ‘wobble’ in the available joint space. the pat-rig enables the surgeon to accurately fix the mpfl into its anatomical orientation and restore patella-femoral biomechanics and range of motion. after the successful in silico and bench tests of the pat-rig, the device will be tested in a real surgical setting on cadavers. following the cadaver trials, a clinical trial with the device will be conducted. to make the device a complete stand-alone device for the mpfl reconstruction surgery, a scale will also be developed, which would help the surgeons to accurately locate the femoral landmark for the mpfl graft insertion. this study was limited to developing a low-cost device to improve transosseus patellar fixations. this would possibly reduce post-surgical complication rates for the mpfl double-bundle procedure. future research is needed to validate this device’s ability to accurately predict the femoral and the patellar insertion points using cadaver tests and further adapt the design of pat-rig for different variations of the mpfl reconstruction surgery. conclusion the current study describes the design and development of a 3d-printed surgical guide. this device, pat-rig, addresses one of the current limitations of the mpfl reconstruction surgery. locating graft insertion points on the patella and the femur was found to be more intuitive and efficient with pat-rig. due to its significantly low cost of production, this device fits into the surgical set-up of any developing country, such as south africa. acknowledgements the authors would like to acknowledge dr tinashe mutsvangwa, charles harris and ms leanne haworth for their assistance. the authors would also like to thank the national research foundation (nrf) for funding this study. nrf grant no: csur13082630873. ethics statement this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study ethical approval was obtained from the following ethical review board: human research ethics committee, hrec ref: 707/2016. this article does not contain any studies with human participants or animals performed by any of the authors. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions rd: study conceptualisation, data capture, data analysis, first draft preparation and manuscript revision. sp: co-inventor of the device, manuscript preparation and revision. gn: study design, design of testing set-up and manuscript preparation. sst: manuscript preparation and manuscript revision. ssiv: co-inventor of the device, study supervisor, manuscript preparation and manuscript revision. orcid dey r https://orcid.org/0000-0002-3616-1995 sivarasu s https://orcid.org/0000-0002-0812-568x references 1. laprade rf, engebresten ah, ly tv, et al. the anatomy of the medial part of the knee. jbjs. 2007;89-a(9):2000-10. https://doi. org/10.2106/jbjs.f.01176. 2. steensen rn, dopirak rm, william g. the anatomy and isometry of the medial patello femoral ligament. am j sports med. 2004;32(6):1509-13. https://doi.org/10.1177/0363546503261505. 3. trikha sp, acton d, o’reilly m, curtis 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https://doi. org/10.1177/0363546515611652. 17. elias jj, cosgarea aj. technical errors during medial patellofemoral ligament reconstruction could overload medial patellofemoral cartilage: a computational analysis. ajsm. 2006;34:1478-85. https://doi.org/10.1177/0363546506287486. 18. parikh sn, nathan st, wall ej, eismann ea. complications of medial patellofemoral ligament reconstruction in young patients. am j sports med. 2013;41(5):1030-38. https://doi.org/ 10.1177/0363546513482085. 19. sivarasu s, patnaik s. accessory for conducting patella surgery [pat-rig]. british patent application no gb1511597.5, 2015. 20. dey r, patnaik s, steiner s, sivarasu s. low-cost three-dimensional printed surgical drill-guiding device for mpfl reconstruction (pat-rig). j med device. 2016;10(2):020914-7. https://doi.org/ 10.1115/1.4033205. 21. baldwin jl, house ck. anatomic dimensions of the patella measured during total knee arthroplasty. j arthroplasty. 2005;20(2):250-57. pmid: 15902866. 22. smirk c, morris h. the anatomy and reconstruction of the medial patellofemoral ligament. knee. 2003;10:221-27. https://doi. org/10.1016/s0968-0160(03)00038-3. 23. victor j, wong p, witvrouw e, sloten jv, bellemans j. how isometric are the medial patellofemoral, superficial medial collateral and lateral collateral ligaments of the knee? am j sports med. 2009;37:2028. https://doi.org/10.1177/0363546509337407. greeff w et al. sa orthop j 2020;19(4) doi 10.17159/2309-8309/2020/v19n4a7 south african orthopaedic journal http://journal.saoa.org.za traumaarthroplasty citation: greeff w, greeff rdv, frey ct, singh v. fatigue failure of the femoral component of a total knee arthroplasty: a case report and review of the literature. sa orthop j 2020;19(4):235-238. http://dx.doi.org/10.17159/2309-8309/2020/v19n4a7 editor: dr chris snyckers, university of pretoria, pretoria, south africa received: june 2019 accepted: june 2020 published: november 2020 copyright: © 2020 ferreira n. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for the purposes of this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract introduction: reports of fatigue failure of the femoral component of a total knee arthroplasty (tka) is scanty in the literature. as a result, there are no clearly defined risk factors to aid us in predicting fatigue failure of an implant. furthermore, these patients may present with non-specific knee pain, which may or may not be well tolerated, depending on the stability of the implant. we report a case of fatigue failure of a poorly cemented femoral component of a tka in a 72-year-old female, approximately seven years after the initial surgery. case report: a 72-year-old female presented to our tertiary level arthroplasty unit with new-onset knee pain approximately seven years after undergoing a tka at our unit. she reported hearing a crack six months earlier, while standing up from a seated position. she had initially presented to her local clinic, but the pathology was missed. she received revision surgery at our institution and was doing well at early follow-up. discussion: we reviewed the literature on fatigue failure of femoral components in tka in an attempt to define risk factors. we also summarised all cases of femoral component fatigue failure in the english literature. conclusion: although femoral component fatigue failure in tka is rare, the majority of cases have attributed the failure to poor surgical technique. despite this, certain implants have been failing more often than others, and proposed mechanisms for this exist. orthopaedic surgeons need to be aware of which implant designs are prone to failure, as well as how meticulous surgical technique can reduce the chances of fatigue failure. level of evidence: level 5 keywords: femoral component, total knee arthroplasty, fatigue failure, stress fracture fatigue failure of the femoral component of a total knee arthroplasty: a case report and review of the literature greeff w¹ , greeff rdv² , frey ct³ , singh v4 1 mbchb(up), fc orth(sa); mmed(orth)(wits); consultant, arthroplasty unit, department of orthopaedic surgery, chris hani baragwanath academic hospital, soweto; university of the witwatersrand, johannesburg, south africa ² mbchb(up), fc orth(sa); consultant, arthroplasty unit, department of orthopaedic surgery, chris hani baragwanath academic hospital, soweto; university of the witwatersrand, johannesburg, south africa ³ md, fcs(orth)(sa); head of arthroplasty unit, department of orthopaedic surgery, chris hani baragwanath academic hospital, soweto; university of the witwatersrand, johannesburg, south africa 4 mbchb(uct), fc orth(sa), mmed(orth)(wits); consultant, arthroplasty unit, department of orthopaedic surgery, chris hani baragwanath academic hospital, soweto; university of the witwatersrand, johannesburg, south africa corresponding author: dr tin (w) greeff, department of orthopaedic surgery, university of the witwatersrand, 7 york road, parktown, johannesburg, 2193 ; tel: +27 (11) 717 2538; email: tingreeff@gmail.com https://orcid.org/0000-0002-5692-593x https://orcid.org/0000-0001-7691-5192 https://orcid.org/0000-003-1692-9749 https://orcid.org/0000-0002-7873-2493 page 236 greeff w et al. sa orthop j 2020;19(4) introduction reports of fatigue failure of the femoral component of a total knee arthroplasty (tka) are rare in the literature. while there are some instances where an implant may have an inherent or manufacturing defect, the majority of cases are due to poor surgical technique, resulting in a lack of bony incorporation. as with most implants in orthopaedics, the tka components are intended to lie on a stable base, be it cement, bone or an augment. failure in this regard causes the implant to be loaded unevenly, resulting in fatigue failure. patients with a broken tka component may present in a multitude of different ways. the presentation usually depends on the amount of implant that is still fixed to bone. patients with a well-fixed implant, in which only a small portion of the implant has broken off, may still be able to mobilise on the prosthesis, albeit with pain. if the fractured component ends up between the tibial tray and femoral component, the patient may present with locking of the joint. case report initial surgery our case is that of a 72-year-old female who presented with a painful knee approximately seven years after she underwent a tka for tri-compartmental osteoarthritis. her index total knee replacement was performed on 15 october 2011. the surgery was performed via a medial parapatellar approach. a size 3 cemented lcs femoral component (johnson & johnson depuy, raynham, ma, usa) was used, while the tibial implant was a cemented size 3 rp lcs tibial implant with a 10 mm rotating platform polyethylene insert. according to the patient, she did not experience any early post-operative complications. she mobilised well with crutches initially, progressing to full weight-bearing without any walking aids by six weeks. presentation the patient presented to our clinic with a history of knee pain and inability to weight bear. the pain started after she stood up from a seated position and heard a cracking sound six months prior to her visit to our clinic. this was followed by acute pain and swelling. she reported presenting to her local clinic, but no pathology was noted and she was treated conservatively with analgesia. due to the chronicity and progressive pain, she decided to come to our institution for a second opinion. she initially presented to the emergency department and was referred to our clinic after the diagnosis of a femoral component fracture was made. besides being a well-controlled hypertensive, having an increased body mass index and osteoarthritis, she reported no other chronic medical conditions. her weight and height respectively were 94 kg and 1.6 m, giving her a bmi of 36.72 kg/m2. at presentation to our institution she was unable to mobilise without a walking frame due to pain and instability. her anterior knee incision was healed with a mature scar. she had a partially correctable 20° varus deformity. her affected knee was swollen with marked medial-sided joint tenderness. she had an extension and flexion lag. her range of movement was 0°–5°–90° according to the neutral zero method. tibial and peroneal nerve function, as well as perfusion at the ankle, was intact. her pre-operative radiographs revealed a fractured femoral component with signs figure 1. x-rays on arrival showing a broken femoral component and loosening of both components figure 2. broken femoral component noted at operation page 237greeff w et al. sa orthop j 2020;19(4) of loosening of both the femoral and tibial components (figure 1). laboratory investigations were normal. white cell count (wcc) was 7.87×109/l; erythrocyte sedimentation rate (esr) was 12 mm/hr; and a c-reactive protein (crp) was 5 ml/l. her american knee society score1 was 14. she gave consent for a revision tka. revision surgery incision was done through the old scar, with a medial parapatellar approach. no clinical signs of infection were observed. intraarticular fluid was used for an alpha-defensin test, which was negative. the fractured femoral component was visualised, but the broken flange was only visualised after removal of the femoral implant (figure 2). both femoral and tibial components were found to be loose. both metal implants were successfully removed without further bone destruction. examination of the fractured medial posterior flange of the femoral component revealed no cement on the implant surface or on the medial posterior condyle. the lack of cement on the posterior condyle of the femur ruled out the possibility of cement debonding. the rest of the implant was well cemented (figure 3). the polyethylene insert had signs of advanced wear, especially over the medial aspect. a thorough debridement was performed. a revision total knee replacement was performed using both augments and stems. cultures taken intra-operatively were all negative. follow-up our patient had no post-operative complications and was discharged once the wound was settled and appropriate level of rehabilitation was achieved with physiotherapy. she was seen 15 days after surgery and had no early wound complications. at the six-week follow-up, she was walking with one crutch and her range of movement was 0°–0°–95°. she was still attending regular physiotherapy. repeat x-rays revealed no radiological signs of loosening (figure 4). discussion the first reported case of fatigue failure of the femoral component of a tka was described by cook in 1991.2 the majority of the cases reported in the english literature have occurred in the same implant, namely ortholoc ii (wright medical, memphis, tn, usa). this was attributed to a design flaw where the portion of the implant which overlies the posterior chamfer cut was too thin, particularly in smaller-sized components. four different authors described cases of fatigue failure of the ortholoc ii tka. whiteside et al. documented 32 cases of failure of the femoral component,3 while wada et al. described a further three cases of failure in smallsized components.4 swarts et al. presented a further six cases of uncemented femoral implant failures,5 while chun et al.6 described another two femoral component fractures in cemented implants of the same design. two femoral component fractures have been reported with the genesis ii (smith & nephew, memphis, tn, usa).7,8 in the genesis ii cases, one was cemented and the other was not. three femoral component fractures were reported with the pfc implant (johnson & johnson depuy, raynham, ma, usa). sarraf et al.9 published a case of a femoral component fracture in a cemented implant, while duffy et al.10 reported two cases of fracture in uncemented implants. park et al.11 reported a femoral component fracture in a cemented titanium implant, the b-p™ total knee system (endotec, orlando, fl). huang et al.12 reported a case of fracture of the femoral component of a rotating platform low contact stress (rp-lcs) prosthesis (johnson & johnson depuy, raynham, ma, usa), and lemaire et al. reported it in the meniscus bearing lcs system13 (johnson & johnson depuy, raynham, ma, usa). both these femoral implants were uncemented. han et al.14 reported a similar complication with a cemented anterior-posterior glide low contact stress (ap-glide lcs) (johnson & johnson depuy, raynham, ma, usa) prosthesis. it is theorised that uncemented femoral implants can undergo fatigue failure when there is uneven bony ingrowth or osteolysis, resulting in uneven load transmission through the prosthesis and therefore fatigue failure. in cemented implants, osteolysis has been proposed as a potential cause.8,12 the reported cases of cemented implant failures failed at a mean of 81.6 months. this is in keeping with a fatigue fracture occurring late after the initial surgery. in our case, the cause of failure is difficult to establish due to the delayed presentation. we postulate that it is likely due poor cementing technique. the retrieved implant revealed no cement on the broken posterior medial flange which could have contributed to the loosening and subsequent fatigue failure. the omission of cement on the broken posterior medial could have contributed to the aseptic loosening and abnormal load on the metal. osteolysis may also have caused the failure. our patient’s increased bmi could have contributed to the broken implant, but figure 3. broken femoral component and worn polyethylene insert after removal. note the lack of cement on the posterior medial flange of the femoral component figure 4. post-operative x-rays after the revision surgery page 238 greeff w et al. sa orthop j 2020;19(4) due to the rarity of the incidence of component fracture compared to the overall trend in obesity in arthroplasty, it is unlikely to be the only risk factor. vaninbroukx et al.15 investigated the optimal cementing technique for the femoral component and concluded that it included cementing of the posterior flanges. fracture of the femoral component remains rare, but loosening of the component and poor cementing technique can predispose certain implants to fail. unfortunately, the lack of post-operative x-rays from the initial knee replacement prevents us from drawing any definitive conclusions regarding malposition of the components. poor implant design, obesity, the use of uncemented femoral components and poor cementing technique appear to increase the risk of implant fatigue fracture. conclusion femoral component fractures following a tka are rare. it might be due in part to under-reporting or surgeons opting to revise the implant without adding the complication onto a database or registry. component fracture should be considered as a potential diagnosis in the total knee replacement patient complaining of acute onset knee pain. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions wg was responsible for study conceptualisation, literature review, first draft preparation and manuscript revision. rg contributed to the study conceptualisation, supervision of the study and assisted in first draft preparation. cf contributed to the study conceptualisation, supervision of the study and assisted in first draft preparation. vs contributed to the study conceptualisation, supervision of the study and assisted in first draft preparation and manuscript revision. orcid greeff w https://orcid.org/0000-0002-5692-593x greeff rdv https://orcid.org/0000-0001-7691-5192 frey ct https://orcid.org/0000-003-1692-9749 singh v https://orcid.org/0000-0002-7873-2493 references 1. insall jn, dorr ld, scott rd, scott wn. rationale of the knee society clinical rating system. clin orthop relat res. 1989;248:13-14. 2. cook sd, thomas ka. fatigue failure of noncemented porous-coated implants. a retrieval study. j bone joint surg (br). 1991;73(1):20-24. 3. whiteside la, fosco dr, brooks jg, jr. fracture of the femoral component in cementless total knee arthroplasty. clin orthop relat res. 1993;286:71-77. 4. wada m, imura s, bo a, baba h, miyazaki t. stress fracture of the femoral component in total knee replacement: a report of 3 cases. int orthop. 1997;21(1):54-55. 5. swarts e, miller sj, keogh cv, lim g, beaver rj. fractured whiteside ortholoc ii knee components. j arthroplasty. 2001;16(7):927-34. 6. chun ch, song ji, nam ks, lee js. fracture of the femoral component in total knee arthroplasty using whiteside ortholoc prosthesis with cement metallurgical study by sem and eds. j korean orthop assoc. 1998;33(3):688-95. 7. michos j, rallis j, fassoulas a. fracture of femoral component in a resurfacing total knee arthroplasty. j arthroplasty. 2006;21(7):1068-71. 8. luring c, perlick l, schubert t, tingart m. a rare cause for knee pain: fracture of the femoral component after tkr. a case report. knee surg sports traumatol, arthrosc. 2007;15(6):756-57. 9. sarraf km, wharton r, abdul-jabar hb, shah g, singer gc. fatigue fractures of total knee prostheses a cause of knee pain. bull hosp jt dis. 2014;72(3):242-46. 10. duffy gp, murray eb, baker vs, trousdale rt. femoral component failure in hybrid total knee arthroplasty at 17 years. j arthroplasty. 2006;21(2):309. 11. park sw, kim h, in y. fracture of titanium nitride-coated femoral component after total knee arthroplasty. knee. 2014;21(4):871-74. 12. huang ch, yang cy, cheng ck. fracture of the femoral component associated with polyethylene wear and osteolysis after total knee arthroplasty. j arthroplasty. 1999;14(3):375-79. 13. lemaire r. fatigue fracture of the femoral component in a mobile bearing knee prosthesis. acta orthopaedica belgica. 2010;76(2):274-81. 14. han cd, han cw, yang ih. femoral component fracture due to osteolysis after cemented mobile-bearing total knee arthroplasty. the journal of arthroplasty. 2009;24(2):323.e7-12. 15. vaninbroukx m, labey l, innocenti b, bellemans j. cementing the femoral component in total knee arthroplasty: which technique is the best? knee. 2009;16(4):265-68. table i: recorded uncemented femoral component fatigue failure in the english literature (excluding ortholoc ii) author and year published journal implant sex patient age (years) months from surgery to fracture michos 2006 journal of arthroplasty (joa) genesis ii f 72 36 duffy 2007 joa pfc (press fit condylar) m unknown unknown duffy 2007 joa pfc m unknown unknown huang 2007 joa lcs rp (low contact stress) m 63 42 lemaire 2010 acta orthopaedica belgica lcs men f 58 78 saito 2012 orthopaedics fnk (flexible nichidai knee) f 64 132 saito 2012 orthopaedics fnk f 64 132 table ii: recorded cemented femoral component fatigue failure in the english literature (excluding ortholoc ii) author and year published journal implant sex patient age (years) months from surgery to fracture luring 2007 the knee surgery, sports traumatology, arthroscopy genesis ii m 68 108 sarraf 2014 bulletin for hospital for joint disease pfc m 78 134 park 2014 knee pfc f 56 36 han 2009 joa apg-lcs (anterior posterior glide-low contact stress) m 58 43 https://orcid.org/0000-0002-5692-593x https://orcid.org/0000-0001-7691-5192 https://orcid.org/0000-003-1692-9749 https://orcid.org/0000-0002-7873-2493 _hlk51334487 noconjo l et al. sa orthop j 2020;19(3) doi 10.17159/2309-8309/2020/v19n3a6 south african orthopaedic journal http://journal.saoa.org.za arthroplasty citation: noconjo l, nortje mb. the short-term outcome of hip revision arthroplasty with trabecular metal™ components and augments. sa orthop j 2020;19(3):162-166. http://dx.doi.org/10.17159/2309-8309/2020/v19n3a6 editor: dr chris snyckers, university of pretoria, south africa received: october 2018 accepted: january 2020 published: august 2020 copyright: © 2020 noconjo l. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: highly porous trabecular metal™ acetabular components are increasingly being used in revision hip arthroplasty as they facilitate ingrowth, provide a useful mechanism to deal with bone loss and may decrease the risk of infection. the purpose of this audit was to describe: 1) the total number of hip arthroplasty surgeries over five years, the ratio of revision to primary hip arthroplasty and indications for revision; 2) the short-term outcomes of revision hip arthroplasty with trabecular metal™ components and augments. methods: a retrospective folder and radiograph review of all patients who had revision total hip arthroplasty (tha) at a tertiary level hospital from february 2012 to february 2017 was done. results: there were 979 thas performed over the period – 863 (87%) primary thas, and 116 (12%) hip revision cases performed in 107 patients. of the 116 (107 patients) hip revisions, there were seven (6%) re-revisions in five patients. the indications for revision were aseptic loosening 67 (59%), septic loosening 11 (10%), liner wear 18 (16%), periprosthetic fracture five (4%), other 15 (13%). trabecular metal™ was used for revision in 16 hips (14 patients), which is 14% of the total 116 revisions. there were ten females and four males with an average age of 61 years. the average duration of follow-up in this group was 18.5 months (1.5–39.2). in these 16 trabecular metal™ hips, there were three (19%) early failures of fixation due to technical errors. conclusion: in our institution, 12% of the arthroplasty is revision surgery. the indications for revision are similar to published literature. trabecular metal™ revisions had a 19% early failure rate due to technical error. level of evidence: level 4 keywords: trabecular metal™, augments, total hip arthroplasty, revision hip arthroplasty the short-term outcome of hip revision arthroplasty with trabecular metal™ components and augments noconjo l¹ , nortje mb2 1 b physio; mbchb(ukzn); registrar, department of orthopaedic surgery, university of cape town, groote schuur hospital, cape town, south africa 2 mbchb(uct), fc orth(sa); mmed(uct), consultant orthopaedic and arthroplasty surgeon, department of orthopaedic surgery, university of cape town, vincent pallotti and kingsbury hospitals, cape town, south africa corresponding author: dr l noconjo, department of orthopaedic surgery, groote schuur, observatory, cape town, 8000; tel: 021 404 5108; cell: 083 751 1356; email: lubabalonoconjo@gmail.com https://orcid.org/0000-0001-9411-9392 https://orcid.org/0000-0002-7737-409x page 163noconjo l et al. sa orthop j 2020;19(3) introduction total hip arthroplasty (tha) is reported as one of the most successful procedures to relieve pain and restore function. it has evolved from a salvage procedure with poor long-term outcomes reserved for the most infirm patients, to one of the most successful and frequently undertaken elective surgical procedures.1 indications for revision in a swedish registry were aseptic loosening 75%, deep joint infection 8%, dislocation 6%, fracture 5%, technical errors 3% and implant fracture 1%.2 aseptic loosening is a leading cause of failure in the intermediate and long-term postoperative period. it is hypothesised to be the result of a harmful combination of mechanical and biological events destroying the bond between the implant and the bone bed. to date, a variety of host, implant and surgery-related factors have been delineated to explain the development of aseptic loosening and osteolysis.3 periprosthetic joint infection (pji) is a devastating and costly complication of total joint arthroplasty. diagnosis is challenging and a mixture of multiple tests can reasonably increase the diagnostic accuracy. some criteria from the musculoskeletal infection society (msis), european bone and joint infection society (ebjis), and infection disease society of america (idsa) have been published.4 in our institution we prefer to use the msis criteria. dislocation is a complication occurring in approximately 0.3% to 10% of all primary procedures and up to 28% in revision surgery. it is a multifactorial problem caused by patient, implant and surgeon factors and can be reduced by thoughtful pre-operative planning and a careful surgical technique.5 periprosthetic fractures in hip arthroplasty can occur intraor post-operatively. intra-operative fractures are estimated to occur in 1% of cemented and in 5.4% of uncemented primary tha. in revision surgery, incidence is higher, reaching 3.6% in cemented and 20.9% during uncemented procedures. post-operatively, the incidence has been estimated to be less than 1% after tha and up to 4% following revision tha.6 technical errors are of greater concern. poor exposure, undersizing, malposition, intra-operative fractures and failure to achieve correct soft tissue tension can cause any implant to fail despite optimal design characteristics. lastly, implant fracture after tha is a relevant complication leading to technically demanding revision surgery, with an incidence of 304 fractures per 100 000 implants from a pooled worldwide arthroplasty registry dataset.7 osteolysis can lead to problematic bone loss. several classifications exist for acetabular bone loss in tha. the most commonly cited classification is that by paprosky.8 the porous metal tantalum (trabecular metal™ zimmer/implex, warsaw, in) has been in use since 1997. a rough surface micro texture provides a high coefficient of friction for increased initial stability. it has a lower modulus of elasticity than that of titanium which creates a potential for improved transfer of forces to the pelvis and reduced stress shielding. interestingly, equivalent or lower bacterial adherence to porous tantalum has been demonstrated when compared with traditional surfaces.9 in our study all trabecular metal™ (or tm) cups were tm revision cups and if augments were used with the tm cup, they were zimmer biomet trabecular metal™ augments. the purpose of this audit was to describe: 1. the total number of hip arthroplasty surgeries over five years, the ratio of revision to primary hip arthroplasty and the indications for revision. 2. the short-term outcome of revision hip arthroplasty with trabecular metal™ components and augments. materials and methods after receiving approval from the institutional ethics board, we performed a retrospective audit on the use of tm acetabular components and augments in revision hip arthroplasty at groote schuur hospital from february 2012 to february 2017. eligible patients were identified from a prospectively collected orthopaedic surgery database. clinical data including patient demographics, date of surgery, type of implant, indication for revision, complications and surgeon were recorded from patient folders. the pictorial archive communicating system (pacs) was used to access digital radiographic images. pre-operative pelvic anteroposterior and lateral x-rays were reviewed, and defects classified as per paprosky.8 initial post-operative and last follow-up x-rays were evaluated for signs of osseous integration using the method of moore et al.10 all radiographs were reviewed by the investigator (registrar) and supervisor (senior consultant); a ct scan was not routinely performed. patients with incomplete clinical and radiographic information, internal fixation revision to tha and revision for tumours were excluded from the study. descriptive statistical analysis was used to analyse the data. results there were 979 thas performed over the period: 863 (87%) primary thas, and 116 (12%) hip revision cases performed in 107 patients. figure 1 shows a breakdown of primary and revision tha procedures done per year. in the revision group there were 43 (40%) males and 64 (60%) females with an average age of 60.8 years (range 50–71). the average follow-up of the revisions was 15.9 months (4.7–25.8) the indications for revision were aseptic loosening 67 (59%), septic loosening 11 (10%), liner wear 18 (16%), periprosthetic fracture five (4%), cortical perforation four (3%), recurrent dislocation four (3%), early failure of fixation four (3%), broken stem two (2%) and ankylosis one (1%). the paprosky classification of the revision cases is shown in table i. 250 200 150 100 50 0 year 1 year 2 year 3 year 4 year 5 n o . o f p ro c e d u re s primary thr revision thr figure 1. summary of primary and revision thr procedures done during the five-year period table i: paprosky8 classification of the revision cases type non-tm revisions (n=100) trabecular metal™ revisions (n=16) 1 42 1 2a 13 3 2b 29 1 2c 8 3 3a 2 6 3b 6 2 page 164 noconjo l et al. sa orthop j 2020;19(3) of the 116 (107 patients) hip revisions, there were seven (6%) re-revisions. one of these seven re-revisions have not yet been performed due to medical reasons; the patient remains dislocated but is included in the numbers as a revision is indicated. the indications for re-revision and procedure summary for the remaining six re-revisions in five patients are shown in table ii. there were three females and two males, with an average age of 60.2 years (47–71). trabecular metal™ was used for revision in 16 hips (14 patients), which is 14% of the total 116 revisions. there were ten females and four males, with an average age of 61 years (38–86). the average duration of follow-up in this tm group was 18.5 months (1.8–39.2). three hips (19%) that were revised with tm failed to remain stable and were classified as early failure of fixation. patient number 2 in table ii was revised with a cup and augment for a paprosky 3a defect and had an excision arthroplasty when it failed. patient number 5 in table ii was revised with a tm cup and screws which failed and was re-revised with a cup and augment, which failed and then re-revised with a cup cage construct. this accounts for the 16 hips and 14 patients in the tm group during the five-year study period. for the purposes of the study, excision arthroplasty and implantation of an antibiotic-impregnated cement spacer followed by reimplantation of components in the same joint were considered as a single two-stage revision procedure. discussion total hip replacement is one of the most cost-effective procedures to relieve pain and improve function.1 the annual reports of the national arthroplasty registry of sweden, norway, finland, denmark, australia and new zealand show a mean of 1.29 revisions per 100 observed component years. this corresponds to a revision rate of 6.45% after five years and 12.9% after ten years.11 in our study 12% of the procedures were revisions, not necessarily from our unit as we are a tertiary referral centre. we found similar indications for revision to the published literature. aseptic loosening was the most common cause of revision surgery in our study. ulrich et al. evaluated the indications for revision hip arthroplasty and showed that 51% were revised for aseptic loosening.12 it is probably a combination of several events and there is growing evidence indicating that cyclic mechanical loading, production of prosthetic wear particles and ensuing adverse tissue response are important contributors to local osteolysis and bone resorption at the bone–prosthesis interface.13 in our study, liner wear was the second most common indication for revision. there are three fundamental mechanisms of wear: abrasive, adhesive and fatigue. abrasive wear constitutes the main wear type in hip arthroplasty. the criteria for revision surgery due to a worn polyethylene hip cup or liner have long been controversial. often there is a dilemma in choosing polyethylene exchange alone or revising the acetabular components. grobbelaar et al. reported a correlation between cup wear on the one hand, and pain, interface widening and osteolytic failure on the other.14 in our institution, if a cup is radiologically aligned and well fixed, we prefer to do polyethylene exchange alone. periprosthetic joint infection is a devastating complication for both patient and surgeon. sepsis was the cause of 10% of our revisions. this figure is higher than that reported by ulrich et al.,12 probably because our institution is a tertiary referral centre. we did not analyse reasons for infection. a periprosthetic fracture of the femur in association with tha is increasingly common and often difficult to treat. similar to our study, marsland et al. reported an overall incidence of 4% of periprosthetic femur fractures with higher rates for uncemented and revision tha.15 we started using trabecular metal™ after promising findings in a retrospective study of 966 patients (421 men, 545 women and 990 hips) on the use of tantalum (ta) acetabular components in revision of tha. tokarski et al. believe that the reason tantalum is more protective against infection is the higher potential of tantalum for osteointegration, thereby obliterating any dead space.16 the ability of osteoblasts to proliferate and integrate onto the surface of the uncemented component may then deprive infecting organisms’ access to the surface. the second reason may relate to the topographical three-dimensional structure of the surface of tantalum that may be difficult for organisms to access and colonise. furthermore, tantalum as an element may carry specific charge or have surface characteristics that are hostile to infecting organisms. finally, they showed encouraging findings in the use of tantalum components which may be protective against failure due to infection at least in patients who had undergone revision surgery for infection. a case series by malkani et al. showed that table ii: the indications for re-revision and procedure patient primary procedure revision 1 revision 2 revision 3 1 1980s uncemented stem and cemented cup 2012 aseptic loosening of cup paprosky 3b cemented cup to uncemented spiked cup 2013 failure of fixation of cup spiked cup to multi-hole cup with screws 2 2014 cemented stem and uncemented cup 2016 aseptic loosening of cup paprosky 3a uncemented cup to tm revision cup and augment 2017 failure of fixation of the cup excision arthroplasty 3 1990 cemented stem and cup 2004 long stem for periprosthetic fracture uncemented cup stable 2014 aseptic loosening and liner wear loose long stem exchanged and new liner, cup stable 2017 aseptic loosening cup paprosky 3b uncemented cup to custom acetabular component 4 1990s cemented stem and cup 2015 long stem for aseptic loosening of the femur cemented cup stable 2015 recurrent dislocations cemented cup to uncemented cup with screws 5 2001 uncemented stem and cup 2016 aseptic loosening of uncemented cup to tm cup and two screws 2017 failure of fixation paprosksy 3a tm cup to tm cup and augment 2018 failure of fixation tm cup and augment to tm cup cage construct page 165noconjo l et al. sa orthop j 2020;19(3) all 21 patients developed ingrowth along the tantalum surface despite compromised bone loss, and he concluded that porous tantalum appears to be a promising material to use in revision hip arthroplasty to facilitate biological ingrowth in patients with acetabular bone loss.17 in most cases of acetabular component revision, there will be some degree of bone loss.18 our usual management of paprosky type 3a and 3b includes the use of augments. our approach is similar to that described by abolghasemian et al. which suggests that type 1 and type 2 defects do not usually require the use of acetabular augments. in type 1, conventional cemented or cementless components can be used. type 2 defects are usually managed with morselised bone graft and normal uncemented acetabular cups. if there is less than 50% contact of the cup with viable host bone, the use of an ultra-porous acetabular component is recommended to ensure sufficient initial stability and potential for subsequent bone ingrowth. type 3 defects are mostly associated with the use of augments.19 porous acetabular components are manufactured by numerous implant companies; we have used different manufacturers in our series but are focusing on the tantalum tm revision™ components from zimmer biomet. in table ii, patient 1 had failure of an uncemented 62 mm spiked cup in a 3b defect and was revised successfully to a 64 mm multihole uncemented cup with screws. in the first case, augments were incorrectly not ordered, probably causing the early failure of fixation and in the second, the cup screw construct was deemed stable and therefore augments not used. patient 2 was revised to a trabecular metal™ cup and augment and the augment grew in, but the cup failed due to cement extravasation during liner insertion that prevented osseous integration, evident at excision arthroplasty a year later. the patient had comorbidities precluding further major surgery. patient 5 had posterior superior acetabular bone loss which occurred with acetabular preparation at the first revision (figure 2a). no augments had been ordered and the cup screw fixation failed in 3 months (figure 2b). the second revision included an augment (figure 2c) and the cup failed a year later (figure 2d). this was converted to a cup cage construct (figure 2e) and at revision the cup and augment were found to have no osseous integration. there was no sign of infection at any stage and the reason for early failure of fixation was thought to be instability of the construct. this patient continues to be monitored and there is no sign of loosening of the cup cage construct at final follow-up. the series of x-rays is shown in figure 2. our study is limited by short follow-up. this is due to only recently starting to use trabecular metal™ and the fact that patients are lost to follow-up due to social factors and geographic movement. this audit needs to be repeated with longer follow-up. our small numbers make statistical analysis difficult. conclusion in our institution, 12% of the arthroplasty performed is revision surgery. the indications for revision are similar to the published literature. trabecular metal™ was used in 13% of revisions. three hips (19%) failed to remain stable and were classified as early failure of fixation due to technical error. acknowledgement i would like to acknowledge the assistance of mr archibald mutsambiwa for information technology contributions. ethics statement this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore. for this study, formal consent was not required and approval was given by our institutional human research ethics committee (hrec ref:149/2017). a d b e c figure 2. x-ray series of patient 5 (a) a 63-year-old female underwent revision with tm cup with screws for aseptic loosening of acetabular component; (b) subsequent loosening showing a vertically positioned acetabular cup; (c) re-revision with tm augment secured with screws; (d) loose acetabular augment; (e) re-revision with a cup cage page 166 noconjo l et al. sa orthop j 2020;19(3) declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ln: primary author, responsible for study design, data collection, data analysis and manuscript preparation mn: conceptualisation, study design, manuscript preparation, supervision of the study orcid noconjo l https://orcid.org/0000-0001-9411-9392 nortje mb https://orcid.org/0000-0002-7737-409x references 1. pivec r, johnson aj, mears sc, et al. hip arthroplasty. lancet. 2012;380(9855):1768-77. https://doi.org/10.1016/ s0140-6736(12)60607-2. 2. kartz in, wright j, wright ea, et al. failures of total hip arthroplasty: a population-based perspective. orthop j harvard med sch. 2007;9:101-106. 3. gallo j, konttinen yt, goodman sb, et al. aseptic loosening of total hip arthroplasty as a result of local failure of tissue homeostasis. in: fokter s, editor. recent advances in arthroplasty. intech; 2012. available from: http://www.intechopen.com/books/ recent-advances-in-arthroplasty/aseptic-loosening-of-totalhiparthroplasty-as-a-result-of-local-failure-of-tissue-homeostasis. 4. goel r, tarabich m, azboy i, et al. management of periprosthetic joint infection. miner va or topedica e traumatologica 2017;68(4):207-15. https://doi.org/10.23736/ s0394-4210.17.03842-5. 5. brooks pj. dislocation following total hip replacement: causes and cures. bone joint j. 2013;95-b(11 suppl a):67-69. https://doi. org/10.1302/031-620x.95b11. 6. tsiridese e, pavlou g, venkatesh r, et al. periprosthetic femoral fracture around hip arthroplasty. current concepts in their management. hip int. 2009;19(2):75-86. https://doi. org/10.1177/112070000901900201. 7. sadoghi p, pawelka w. giebensteiner mc, et al. the incidence of implant fracture after total hip arthroplasty. int orthop. 2014;38:3946. https://doi.org/10.1007/s00264-013-2110-3. 8. telleria jm, gee ao. classification in brief: paprosky classification of acetabular bone loss. clin orthop relat res. 2013;471(11):3725-30. https://doi.org/10.1007/s11999 013-3264-4. 9. long wj, noiseux no, mabry tm, et al. uncemented porous tantalum acetabular components: early follow-up and failures in 599 total hip arthroplasties. iowa orthop j. 2015;35:108-13. 10. moore ms, mcauley jp, young am, et al. radiographic signs of osteointegration in porous-coated acetabular components. clin ortho relat res. 2006;444:176-83. https://doi.org/10.1097/01. blo.0000201149.14078.50. 11. labek g, thaler m, janda w, et al. revision rates after total joint replacement: cumulative results from worldwide joint register datasets. j bone joint surg [br]. 2011;93(3):293-97.  https://doi. org/10.1302/0301-620x.93b3.25467. 12. ulrich sd, seyler tm, benett d, et al. total hip arthroplasty: what are the reasons for revision? int orthop. 2008;32:597-604. https:// doi.org/10.1007/s00264-007-0364-3. 13. hukkanen m, corbett sa, batten j, et al. aseptic loosening of total hip replacement. macrophage expression of inducible nitric oxide synthase and cyclo-oxygenase-2, together with peroxynitrite formation, as a possible mechanism for early prosthesis failure. j bone joint surg [br]. 1997;79-b:467-74. 14. grobbelaar cj, du plessis ta, van der linder mj, et al. long term evaluation of polyethylene wear in total hip arthroplasty. a statistical analysis of the association between the degree of wear versus pain, interface change, osteolysis and implant failure. sa orthop j. 2011;10(1):49-56. 15. marsland d, mears sc. a review of periprosthetic femoral fractures associated with total hip arthroplasty. geriatr orthop surg rehabil. 2012;3(3):107-20. https://doi.org/10.1177/ 2151458512462870. 16. tokarski at, novack ta, parvizi j. is tantalum protective against infection in revision total hip arthroplasty? bone joint j. 2015;97b45-9. https://doi.org/10.1302/0301-620x.97b1.34236. 17. malkani al, prince mr, crawford ch, et al. acetabular component revision using a porous tantalum biomaterial: a case series. j arthroplasty. 2009;24(7):1068-73. https://doi.org/10.1016/j. arth.2008.07.008. 18. reid c, grobler gp, dower bj, et al. revision total hip arthroplasty: addressing acetabular bone loss. sa orthop j. 2012;11(3):34-46. 19. abolghasemian m, tangsataporn s, sternheim a, et al. porous metal augments: big hope for big holes. bone joint j. 2013;95-b(suppl a):103-108. https://doi.org/10.3928/ 01477447-20100722-29. https://orcid.org/0000-0001-9411-9392 https://orcid.org/0000-0002-7737-409x https://www.ncbi.nlm.nih.gov/pubmed/23021846 https://doi.org/10.1097/01.blo.0000201149.14078.50 https://doi.org/10.1097/01.blo.0000201149.14078.50 https://doi.org/10.1007/s00264-007-0364-3 naidoo t et al. sa orthop j 2018;17(3) doi 10.17159/2309-8309/2018/v17n3a4 south african orthopaedic journal http://journal.saoa.org.za traumatrauma citation: naidoo t, govender s. fixation of extra-articular distal humerus fractures with a single posterolateral plate. sa orthop j 2018;17(3):35-40. http://dx.doi.org/10.17159/2309-8309/2018/v17n3a4 editor: prof lc marais, university of kwazulu-natal, durban received: february 2018 accepted: may 2018 published: august 2018 copyright: © 2018 naidoo t. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: this study required no funding. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: our study aimed to establish that use of a single posterolateral plate for the open reduction and internal fixation of extraarticular metaphyseal humerus fractures resulted in consistent fracture healing, good functional outcomes and low complication rates. methods: a retrospective study was conducted at the department of orthopaedics, northdale hospital, pietermaritzburg. a review of case x-rays and patient files from 1 january 2015 to 30 november 2017 of all patients who underwent operative intervention for extra-articular metaphyseal distal humeral fractures was undertaken. standardised radiographs, functional assessment criteria (quick disabilities of the arm, shoulder and hand score – quickdash score) and post-operative complications recorded in the patients’ charts were analysed. results: fifteen patients were included in the study. ten male patients and five female patient’s charts were analysed. the mean age of the participants was 33.13 years. all 15 patients showed adequate fracture healing on x-ray involving three or four cortices of the fracture site. there was no post-operative loss of fracture fixation. the mean humeral metaphyseal–diaphyseal angle was 84°, mean humeral–ulnar angle was 18°, mean shaft condylar angle was 40.4°, and the mean percentage of the capitellum anterior to the anterior humeral line was 49.3 per cent. the mean duration of surgery was 95.4 minutes. the mean quickdash score was 19.39. conclusion: the use of a single posterolateral plating system for the fixation of extra-articular distal humeral fractures provides a viable alternative to dual plating. this method of fixation provided adequate stability of fracture fixation, good functional outcomes, low complication rates, shorter surgical times and less soft tissue dissection. this study supports current published evidence in this regard. level of evidence: level 4 key words: distal, humerus, fracture, extra-articular, posterolateral plate fixation of extra-articular distal humerus fractures with a single posterolateral plate naidoo t¹, govender s² ¹ mbchb, fcortho, hdip(ortho), bmed sci(hons); orthopaedic surgeon, department of orthopaedics, northdale hospital, nelson r mandela school of medicine, university of kwazulu-natal, south africa ² mbbs, md, frcs, fc(orth)pr; professor and orthopaedic surgeon, spinal unit, king dinuzulu hospital, durban, south africa corresponding author: dr thivani naidoo, private bag x9006, pietermaritzburg, 3200; tel 033 387 9000; email: thivaninaidoo@gmail.com page 36 naidoo t et al. sa orthop j 2018;17(3) background south africa has a unique socio-economic background that presents significant challenges for healthcare provision. there is a high burden of injuries related to violence and road traffic accidents.1 eastwood noted that fractures of the distal humerus account for 2% of all fractures in the body.2 ten per cent of distal humerus fractures in adults are extra-articular supracondylar humerus fractures.3 the elbow joint has a highly functional articulation, required for activities of daily living. it is a constrained hinge joint, allowing the ulna to rotate around the axis of the trochlea.4 it forms part of a single synovial joint that encompasses three separate articulations: ulnar-humeral, proximal radio-ulnar and radio-capitellar.5 elbow joint articulations include flexion–extension, pronation– supination and limited varus–valgus. anatomical restoration of these articulations should allow loads of 0.3 to 0.5 times the body weight. the distal humerus is considered a two-column structure supporting the articular segment. the distal portion of the lateral column (capitellum) projects anteriorly approximately 35° to 45°. the medial column terminates at the medial epicondyle which does not curve anteriorly. the lateral column shares 60% of the load and the medial column 40%. pseudoarthrosis of the distal humerus usually occurs in the region of the metaphyseal and supracondylar level of radial columns due to varus stresses.6-8 involvement of the radial nerve in these injuries plays a significant role in complications for both operative and nonoperative management. the injury may arise following the initial trauma or during surgical intervention.9,10 the radial nerve courses in a caudal and lateral orientation around the posterior humerus in the spiral groove.11 the path of the radial nerve distally increases the risk of injury for this subset of fractures.12 treatment options for these fractures remain a challenge. functional bracing versus operative fixation are the two options available. jawa et al. found that operative treatment achieves more predictable alignment and potentially earlier return of function than functional bracing. there was a risk however, of iatrogenic nerve injury, infection and re-operation.13 stability following internal fixation is technically demanding in the face of complex fracture patterns and osteoporosis. non-operative management using functional bracing can be cumbersome and difficult for patients initially and has been associated with both skin problems and mal-alignment.4 sarmiento et al. found that functional bracing in comminuted extra-articular distal humerus fractures resulted in a varus deformity averaging 9° in 81% of patients with minimal loss of movement and good functional outcomes. shoulder abduction and external rotation were commenced only when radiological and clinical evidence of fracture healing was detected.14 the objective of operative management of extra-articular metaphyseal humeral fractures is to achieve stable fixation and enable early range of movement at the elbow joint. fracture fixation is difficult due to the restricted space for instrumentation at the distal fragment. also, there is a need to maintain repair integrity under a large range of motion and low-to-moderate loading. it is essential to avoid impingement at the olecranon fossa. internal fixation with dual plating systems is the gold standard for fixation.15 the majority of non-unions in extra-articular humerus fractures occur at the supracondylar level while healing of the articular components may occur in their reduced positions. stability of the construct requires adequate bony contact with interfragmentary compression. maximising stability between the distal fragments and the shaft of the humerus should be the focus of the fixation strategy. open reconstruction of extra-articular distal humerus fractures has traditionally been performed with the use of orthogonal plating.16 meloy et al. state that implant-related complications associated with dual plating such as ulna neuritis occur in upwards of 51% of patients. comparison of patients with ao/ ota 13a2 and ao/ota 13a3 (ao/ota – arbeitsgemeinschaft fur ostesynthesefragen/orthopaedic trauma association) type fractures operated with a dual plating technique versus a single posterolateral contoured plate, showed comparable union rates were achieved in both groups. the single plating group had an overall better range of movement than the dual plating group, and the overall complication rate was significantly greater in the latter.17 the objective of this study was to establish by radiological and patient record analysis that the use of a single posterolateral plate for open reduction and internal fixation of extra-articular figure 1. i) anterior humeral line transecting capitellum; ii) a: metaphyseal–diaphyseal angle, b: humero-ulnar angle; iii) c: shaft–condylar angle page 37naidoo t et al. sa orthop j 2018;17(3) metaphyseal distal humerus fractures resulted in adequate fracture healing, good functional outcomes and low complication rates. methods a retrospective case review of patient records and x-rays for all patients undergoing operative intervention of extra-articular metaphyseal distal humerus fractures from 1 january 2015 to 30 november 2017 was conducted. this data was analysed using specific functional assessment criteria (quickdash score), standardised radiological criteria (figure 1) as well as listed postoperative complications as recorded in the patient’s hospital records. other parameters assessed included demographic data, data related specifically to the injury and theatre data. patients fifteen patients with extra-articular metaphyseal distal humerus fractures, ao/ota type 13a2 and ao/ota type 13a3 were managed surgically with a single posterolateral distal humerus locking plate. the period from 1 january 2015 to 30 november 2017 was analysed. patient records were sourced using the inpatient numbers from the hospital registry and archives. the outpatient files were used to trace x-ray films which included the pre-operative x-ray (figure 2) and post-operative x-rays (figures 3 and 4). surgical technique the operations were performed under general anaesthesia with the patient positioned prone with the affected arm placed over an arm support. a tourniquet was not used. a midline, posterior triceps splitting technique was used. the radial nerve was identified figure 4. a) lateral view and b) ap view at 12 weeks after posterolateral platingfigure 2. pre-operative fracture x-ray figure 3. a) lateral view and b) antero-posterior view (ap) at 6 weeks after posterolateral plating page 38 naidoo t et al. sa orthop j 2018;17(3) and protected. fracture fragments were manipulated and reduced under direct visualisation and temporarily fixed with k-wires. interfragmentary screws were applied as required, following which a stryker variax (michigan, usa) posterolateral distal humerus locking compression plate was used to fix the fracture (figure 5). the plate used in all fracture fixation cases had five distal locking holes which were filled. depending on the fracture configuration and the presence of interfragmentary screws, the metaphyseal and diaphyseal plate holes were filled accordingly. the absence of olecranon impingement was determined intra-operatively. surgical time was documented from the time of skin incision to completion of skin closure. post-operative care an above-elbow backslab and a collar and cuff were used postoperatively for 48 hours. wound review was at 48 hours; the backslab was removed and the patient encouraged to perform active range of movement exercises. the patient was discharged home with only a collar and cuff, which the patient discarded before the next follow-up. all patients were directed to follow a home-exercise programme with physiotherapy appointments as available. most patients had limited physiotherapy due to large patient volumes at the physiotherapy department. skin staples were removed at 10 days post operation. x-rays were done at 6 weeks and 12 weeks post-op. x-ray films were assessed by an independent reviewer, using the following parameters:17-19 1. callus formation on three out of four cortices on anteroposterior and lateral radiographs taken 12 weeks post-operatively 2. post-operative loss of fixation of the fracture 3. metaphyseal–diaphyseal angle 4. humeral–ulnar angle 5. shaft–condylar angle 6. percentage of the capitellum anterior to the anterior humeral line functional post-operative outcomes were assessed utilising a quickdash score calculation that was recorded in the patient’s outpatient folder. complications encountered were recorded as per post-operative record in the outpatient folder. data analysis the data was analysed using the spss version 24 by a statistician. descriptive statistics such as percentages were used to summarise categorical data. measures of mean and of dispersion such as standard deviation and interquartile range were calculated for numerical variables. results demographics fifteen patients were included in the study – ten males and five females. the mean age of the participants was 33.13 years (range 18–52 years). fourteen of the patients were right-hand dominant and one patient was left-hand dominant. injuries occurred on the left side in nine cases and on the right in six cases. mechanisms of injury included eight patients (53.3%) involved in a motor vehicle accident (mva), two patients who sustained gunshot wounds to the distal humerus (13.3%), one patient with a previous distal humerus fracture non-union from a humeral nail (6.7%), two patients who were assaulted (13.3%) and two patients who sustained their injury after a fall (13.3%). functional scoring the mean quickdash score was 19.2 (range 11.4–59). the score is interpreted as 0 points for no disability and 100 points for complete disability. a quickdash score in a normal arm has been shown to be 7–9 points.17 this can be interpreted as minimal impairment. fracture union and alignment fracture union was obtained in all 15 patients, with 73.33% of cases having four cortices with callus formation. table i outlines the radiographic analysis. surgical data the mean time to theatre was nine days (range 1–20 days) and the mean duration of surgery was 95.4 minutes (range 50–150 minutes) with a standard deviation of 27.8 minutes. two patients had prolonged surgical time due to removal of metalware (patient with previous non-union and patient with a humeral nail periprosthetic fracture). complications one patient developed a radial nerve palsy post-operatively with partial recovery at 12 weeks follow-up. this patient had a 10-day pre-admission delay and a 17-day inpatient delay that resulted in partial entrapment of the radial nerve in callus. figure 5. intra-operative view of posterolateral plate; white arrow shows radial nerve overlying plate page 39naidoo t et al. sa orthop j 2018;17(3) discussion the use of a single posterolateral locking plate for extra-articular metaphyseal distal humerus fractures resulted in adequate fracture healing, good functional outcomes and low complication rates. the treatment of these fractures is complicated by elbow stiffness, pain and limitation of function. prolonged sick leave or incapacity leave has a negative impact on the already strained economy. in addition, it may have detrimental effects for a patient socially, psychologically and at the workplace. sarmiento’s work favoured functional bracing of distal third humerus fractures. however, holstein and lewis, reudi et al., horne as well as aitken and rorabeck suggest surgical management of distal third humerus fractures as a preferable option.14 this preference followed the belief that distal humerus fractures were difficult to reduce, difficult to maintain in position, and also due to initial radial nerve palsy. jawa et al. found that patients undergoing operative treatment fared better when compared to patients who underwent bracing.13 the objective of any treatment regimen would be to minimise the time that the patient is incapacitated with optimal stability of fracture fixation, to decrease surgical times with minimal soft tissue damage, allow early range of movement while ensuring fracture healing and low complication rates. the use of a single posterolateral locking plate is beneficial as it matches the contour of the distal humerus, does not impinge on the olecranon fossa, has increased distal fixation and it allows for a locking construct.11 o’driscoll suggested that distal humerus fracture fixation failure begins in the lateral column.16 this is linked to the higher loading capacity of the lateral column and pseudoarthrosis usually occurring at the metaphyseal/supracondylar lateral column.6-8 the force of gravity acting on the long lever arm (the forearm), while the elbow is flexed and extended during apparently minimal use activities leads to repetitive varus stresses across the elbow. the varus torque across the elbow results in distraction of the lateral column away from the fixation placed along the posterior surface. in the presence of cubitus varus, the mechanical axis, olecranon and the triceps line of pull are all displaced medially. the resultant repetitive external rotation torque on the ulna can stretch the lateral collateral ligament complex and lead to posterolateral rotatory instability.20 sabalic et al. stated that distal humeral fractures have different biomechanical demands than intra-articular fractures of the distal humerus.15 hence plates that are longer in the radial, more loaded column could at least be of equal strength to two plates. our study supports the available literature in this regard that a single posterolateral plate provides an adequately stable construct to allow for bony union while allowing for early range of movement. the findings of this study are similar to meloy et al. in that their study supported the use of a single plating system, quoting improved elbow function and fewer surgical complications compared to dual plating.17 jawa et al. found a 5% prevalence of loosening of fixation, up to 5% prevalence of infection and up to 6% prevalence of non-union that can be expected in some operatively managed patients. radial nerve injury has a prevalence of 3%.13 there was no loss of fixation post-operatively in our study, with no cases of infection or non-union. the average duration of surgery for single plating with a locking compression technique in 47 patients assessed by chavan et al. was 94±10 min.21 reising et al. quote the mean time of operation for fractures with articular involvement as 215 minutes (range: 77–405 minutes) with soon et al. quoting a mean value of 150.3 minutes (range: 70–240 minutes).22,23 a shortened duration of surgery combined with less soft tissue dissection during the procedure would theoretically decrease the number of implantrelated problems post-operatively.16 this study fulfils both these objectives. there is a significantly higher density of vessels in cancellous bone of the epicondylar area than in the watershed table i: radiographic analysis, functional assessment and complications of cases p at ie nt no of cortices with callus formation loss of fixation metaphyseal– diaphyseal angle normal: 82°– 84° humero-ulnar angle normal: 17.8° valgus shaft– condylar angle normal: 40° percentage capitellum anterior to anterior humeral line normal mid-1/3 quick dash score duration of surgery complications 1 4 no 82 18 35 45% 11.4 90 min nil 2 3 no 83 18 40 50% 22.7 147 min nil 3 4 no 82 17 41 50% 29.5 75 min nil 4 3 no 87 19 36 55% 11.4 94 min nil 5 4 no 84 19 42 50% 59 75 min pre-op radial nerve injury recovered fully 6 4 no 81 16 40 45% 13.6 80 min nil 7 4 no 87 19 40 50% 11.4 125 min nil 8 4 no 85 19 42 50% 13.6 95 min nil 9 4 no 83 17 40 50% 18.2 87 min nil 10 3 no 84 19 43 50% 11.4 65 min nil 11 4 no 86 18 40 45% 18.2 100 min nil 12 4 no 84 18 42 50% 31.8 150 min intra-op radial nerve injury partial recovery 13 4 no 85 18 45 50% 11.4 91 min nil 14 4 no 83 17 39 50% 9 50 min nil 15 3 no 86 18 42 50% 18.2 107 min nil page 40 naidoo t et al. sa orthop j 2018;17(3) area (trochlear, olecranon fossa and coronoid fossa).24 the use of a single posterolateral plate respects this finding as it minimises soft tissue stripping and hence the blood supply in the epicondylar area in comparison to the dual plating technique. in a biomechanical comparison of three standard fixation constructs, scolaro et al. compared a single posterolateral plate, 3.5 mm locking compression plate (lcp) and dual plating for extra-articular distal humerus fractures conducted on saw bones.11 they found that the single posterolateral plating fixation had significantly greater bending stiffness, torsional stiffness and yield strength than a single non-contoured lcp construct in more proximal fractures. in more distal fractures dual plating was biomechanically superior. limitations of this comparison is that the study was conducted on saw bones and not cadaveric bones, and the fracture configuration may not be the same as in a clinical setting. overall more comparative studies are needed to validate this finding. there are limitations to this study. in this retrospective analysis, the total patient number is small. due to the rare occurrence of this particular subset of fractures it would take a prolonged period to obtain a larger patient number. a direct comparison of operating times, functional outcomes, radiographic outcomes and complications in patients with this group of fractures with dual plating versus single posterolateral plating would be preferable. conclusion stabilisation and fixation of extra-articular articular distal humerus fractures have been traditionally conducted with dual plating techniques with a sizeable post-operative complication rate, extensive soft tissue dissection and varying functional outcomes. our study reveals that the use of a single posterolateral plate provides adequate stability of fracture fixation, good functional outcomes and low complication rates. with shorter surgical time duration and less soft tissue dissection, this type of fixation provides a valid alternative to the previous dual plating techniques. the study supports current literature validating the use of a single posterolateral plating system in this subset of fractures. however, future studies that compare dual plating directly to single posterolateral plating for these fractures would provide further insight. ethics statement institutional review board (irb) ethical approval was obtained from the university of kwazulu-natal biomedical research ethics committee via an expedited application referenced as: be587/17 prior to commencement of the study. the study was conducted according to the ethical principles for medical research on human subjects as defined by the world medical association declaration of helsinki (amended at the ma general assembly, seoul, oct 2008). for this study, formal consent was not required due to the study design being a retrospective chart review. references 1. norman r, matzopoulos r, groenewald p, bradshaw d. the high burden of injuries in south africa. bulletin of the world 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journal of elbow and joint surgery. 2005;14(1). supp: s186-s194. 17. meloy gm, mormino ma, siska pa, tarkin is. a paradigm shift in the surgical reconstruction of extra-articular distal humeral fractures: single column plating. injury. 2013;44:1620-24. 18. capo t, debkowska mp, liporace f, beutel bg, melamed e. outcomes of distal humerus diaphyseal injuries fixed with a single column anatomic plate. international orthopaedics (sicot). 2014;38:1037-43. 19. yang q, et al. surgical treatment of adult extra-articular distal humeral diaphyseal fractures using an oblique metaphyseal locking compression plate via a posterior approach. medical principles and practice, 2012;32:40-45. doi: 10.1159/000331791 20. o’driscoll sw, spinner rj, mckee md. tardy posterolateral rotatory instability of the elbow due to cubitus varus. 2001. j bone joint surg am. 2001 sep;83-a(9):1358-69. 21. chavan uc, mahesh sg, gudda ln, qureshi f. treatment of distal humerus fractures with extra-articular locking compression plate technique. international journal of surgery and medicine. 2017;3(2):103-106. 22. reising k, hauschild o, strohm pc, suedkamp np. stabilization of articular fractures of the distal humerus: early experience with a novel perpendicular plate system. injury. 2009;40:611-17. doi :10.1016/j.injury.2008.12.018 23. soon jl, chan bk, low co. surgical fixation of intra-articular fractures of the distal humerus in adults. injury. 2004;35:44-54. 24. wegmann k, burkhart kj, koslowsky tc, koebke j, weiss wf, muller lp. arterial supply of the distal humerus. surg radiol anat. 2014 sept;36(7):705-11. orthopaedics vol3 no4 page 14 sa orthopaedic journal winter 2015 | vol 14 • no 2 e d i t o r i a l arecent article published in aaos now dealt with burnout as a result of stress in the work place inamerican orthopaedic surgeons. it prompted me to ponder on the weight of responsibility we carry on a day-to-day basis. unless you are unrealistically detached, every surgeon has experienced that chilling feeling you get when things have not gone according to plan. a finger remains ivory white after a dupuytren’s contracture release, or the foot suffers a similar fate after tourniquet release, or perhaps the postoperative radiograph looks alarmingly unlike what had been intended by the procedure. these events produce laser-like burns to the brain, etching out indelible monuments like grave stones, until the graveyard is full. these events age us. they burn us out. our concern and involvement in our patients’ well-being is what makes us the professionals that patients expect us to be. while it can be detrimental, paralysing even, to the health caregiver to be too involved in patients’ outcomes, it is critical that we remain responsive to and responsible for providing holistic and empathic care throughout the cycle of treatment for any patient. the responsibility of clinical practice from the patient’s point of view, there is an expectation that once you have embarked on a course of action, you will provide continuous service until completion. their commitment to, and dependence on, the chosen practitioner is complete. the nature of clinical practice is such that patients more often than not transfer the decision-making role to the treating doctor. after all, ‘doctor knows best’! this is particularly pertinent in the case of surgery. despite the laborious and hugely flawed process of informed consent, and despite the good intentions of the ethicists to get this right, the process of giving consent for interventions relies heavily on trust and in many ways remains paternalistic. under current circumstances in south africa, and many other parts of the world, the complexities of medicine are too great for patients to achieve a meaningful grasp of the issues at stake when the two parties exchange information. considerable responsibility is thus placed on the doctor to act with integrity and in the best interests of the patient. we have been taught that whenever a doctor assumes the role of caregiver, that doctor will be responsible for whatever happens, until such time that the patient’s care has been transferred to the care of another doctor. the term responsibility as used here implies accountability rather than blame. in earlier years when the fragmentation of medical knowledge had not yet yielded the technical super-specialists of today, the continuity of overall care seldom broke down. today however, care of patients may fall between two stools, with each doctor dealing with a specific area of expertise in isolation. it may happen that no one in a multidisciplinary team views themselves as the primary caregiver, or being capable of giving advice or treatment in an area not deemed their own. this classically happens with patients in an icu. is it the physician or the surgeon? who do the patient’s relatives turn to for advice and information? who is correct when different opinions are expressed? it’s so easy to claim ‘beyond my scope of practice’ as a ‘defence’! our concern and involvement in our patients’ well-being is what makes us the professionals that patients expect us to be. it is critical that we remain responsive to and responsible for providing holistic and empathic care throughout the cycle of treatment for any patient saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 14 sa orthopaedic journal winter 2015 | vol 14 • no 2 page 15 the practice of medicine and acting as the caregiver can be compared to an athletics relay race. the medical intervention is the race and the surgeon is the runner who carries a baton of responsibility for the patient’s care. during the race, somebody and only one body, holds the baton at any given time. the doctor who ‘holds the baton’ is responsible and answerable for all the decisions, deliberations and communications until such time as the patient is formally referred on or handed over to the care of a different physician. the passing of the baton involves two hands, the passer and the receiver. there is an equally strong responsibility on the receiver. whoever receives a patient must know from whom and where and why the patient came, and must acknowledge the receipt of the patient, when not referred in person, from the previous caregiver. this analogy is useful and adequately addresses the ‘legal’ and ethical requirements of the practitioner; it does not, however, address the loss and disconnection experienced by the patient when being referred on to another practitioner. the relationship of trust established between patient and doctor will easily suffer when, in midstream, the patient is handed over for further treatment, especially of a complication, to another caregiver. not that this should not happen, as surely it may be in the best interests of the patient, but great care must be taken to ensure that the patient and family, often at a time of greatest need, do not feel they have been ‘left in the lurch’. it is frequently this perception of abandonment when a problem occurs that fosters the kind of resentment which culminates in a telephone call to the offices of the medical protection society. don’t walk away, remain concerned and involved. advances in medical practice have compartmentalised us to the extent that it is tempting if not ‘legitimising’ us to act as technicians. we are not technicians. we have to maintain knowledge in areas of clinical practice not our own. we need to retain a broad base of knowledge so that we can fulfil the role as professionals entrusted to us by our patients. we are professionals who have an understanding of suffering and have been afforded the privilege of providing appropriate support, whatever that may be, to others. key words: ethics, responsibility, professionalism, patient relationships johan walters department of orthopaedic surgery university of cape town the relationship of trust established between patient and doctor will easily suffer when, in midstream, the patient is handed over for further treatment, especially of a complication, to another caregiver saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 15 south african orthopaedic journal knee doi 10.17159/2309-8309/2022/v21n2a7le roux j et al. sa orthop j 2022;21(2) citation: le roux j, von bormann r, braun s, imhoff ab, held m. mega-oats of the knee without specialised instrumentation: a low-cost option for large cartilage defects in a resource-restrained environment. sa orthop j. 2022;21(2):106-110. http://dx.doi. org/10.17159/2309-8309/2022/ v21n2a7 editor: dr chris snyckers, eugene marais hospital, pretoria, south africa received: august 2020 accepted: july 2021 published: may 2022 copyright: © 2022 le roux j. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background a 26-year-old patient presented to a specialised knee clinic in a public hospital with ongoing pain after having sustained a soccer injury six years prior. a large osteochondral defect of the distal medial femoral condyle was diagnosed. due to resource limitations, fresh allograft or a large osteochondral autograft transplantation system (mega-oats) workbench was unavailable. case report a mega-oats cartilage transplantation was done, using the patient’s posteromedial femoral condyle as donor tissue, and transplanted to the defect in the distal femoral condyle, a technique that has been well documented and followed up. at six weeks postoperatively, an mri showed early incorporation of the graft tissue. clinical outcomes were excellent at one year follow-up with the eq-5d 5l score 11111, the knee injury and osteoarthritis outcome score (koos-ps) 100%, and the lysholm score also 100%. radiographs at one year confirmed an unchanged graft position and showed no signs of osteoarthritis. discussion large osteochondral lesions in the knee (> 4 cm2) are challenging to treat, and the most commonly used modalities are fresh osteochondral allograft (oca) or autologous chondrocyte implantation (aci). mega-oats of the knee has previously been described but is not commonly used due to the requirement of a specialised and expensive workbench, and fear of morbidity at the donor site. conclusion mega-oats of the knee is possible without a specialised workbench or tools and had good clinical outcomes at two-year follow-up of the patient. level of evidence: level 5 keywords: mega-oats, osteochondral lesion knee, osteochondral autograft, resource restraint mega-oats of the knee without specialised instrumentation: a low-cost option for large cartilage defects in a resource-restrained environment johan le roux,¹ richard von bormann,² sepp braun,³ andreas b imhoff,⁴ michael held¹* ¹ department of surgery, division of orthopaedic surgery, university of cape town, groote schuur hospital, cape town, south africa ² netcare christiaan barnard hospital, cape town, south africa ³ gelenkpunkt umit, research unit for orthopedic sports medicine and injury prevention, innsbruck, austria ⁴ department of orthopaedic sports medicine, technical university of munich, munich, germany *corresponding author: email.held@gmail.com introduction osteochondral lesions present a challenge in young patients when arthroplasty is not considered a reasonable treatment option.1 most joint-preserving treatment modalities for large cartilage defects are associated with considerable cost and often require intricate supply chains, subspecialist surgical skill sets, and an advanced theatre setup. therefore, complex cartilage surgery is often not feasible with limited resources.2 the use of autologous chondrocyte implantation (aci) is limited due to the high cost, and osteochondral allograft (oca) depends on a reliable tissue bank that can guarantee good quality and infection-free fresh allograft. these techniques are therefore unavailable in a limited-resource environment.3 an option that is available is a large osteochondral autograft transplantation system (mega-oats) where an ipsilateral posterior femoral condyle is harvested and transplanted. it must be highlighted that this is a salvage procedure and should not be used as a first-line option for all cases. this technique has been well described and excellent outcomes have been shown up to 5.5 years postoperatively.4-7 mega-oats relies on autograft, and therefore does not require access to chondrocyte culture or a tissue bank. however, in the described techniques, an expensive workstation to handle and shape the autograft is needed. the novelty and objective of our case report is the description of the https://orcid.org/0000-0002-5658-6827 https://orcid.org/0000-0002-0671-0439 page 107le roux j et al. sa orthop j 2022;21(2) mega-oats procedure with non-specialised instrumentation suitable for a limited-resource setup. case report history and clinical findings a 26-year-old healthy male presented to a subspecialist knee clinic of a large sub-saharan academic hospital complaining of medialsided left knee pain after a sports injury six years prior. the patient walked with an antalgic limp, had an effusion, and limited active range of motion of 0–90° and a passive range of motion (prom) of 0–130°. no pathology was noted regarding menisci and ligaments. diagnostic studies and workup radiographs revealed a large osteochondral lesion in the distal medial condyle (figure 1). magnetic resonance imaging (mri) demonstrated a high-grade 1.4 × 2.5 cm chondral lesion in the weight-bearing area, with loose intra-articular fragments (figure 2). the posterior condyles were unaffected and no secondary osteoarthritis was noted with intact menisci and ligaments. the mechanical axis was neutral on long limb views. planning of procedure due to graft handling challenges, a specialised mega-oats workstation has been developed which can be purchased directly from arthrex™ (naples, fl) for r531 065 ($38 085). no loan sets are available in south africa which therefore prevents local surgeons to follow the published techniques. after detailed discussion with international experts and the patient, it was decided to perform the mega-oats using only store-bought equipment to the value of r112 or $8. to allow for various defect sizes, a 20 mm, 25 mm and 30 mm flat drill bit with corresponding washers for templating were bought. surgical treatment we followed the previously described mega-oats technique, but without using the workstation.6,7 a midline longitudinal incision with a medial parapatellar approach was used, and the defect confirmed clinically (figure 3). the posteromedial femoral condyle was harvested with an osteotome in line with the posterior femoral cortex. hohman retractors were used to protect the medial collateral ligament and posterior cruciate ligament. the most dorsal cortex was carefully separated to avoid vascular damage. the osteochondral lesion measured 20 × 30 mm in size, and a 25 mm flat stainless steel drill bit obtained from the local hardware shop figure 1. anterior-posterior radiographs of the knee before surgery and at one year postoperatively figure 2. mri images of the knee: a) sagittal views preoperatively and b) at six weeks postoperatively; c) coronal views of the knee preoperatively, and d) at six weeks postoperatively figure 3. intraoperative view of the defect in the distal medial femoral condyle page 108 le roux j et al. sa orthop j 2022;21(2) was used to overdrill the osteochondral defect into a round shape and to a depth of 10 mm (figure 4). a marker pen was used to draw a circle with a 25 mm diameter onto the graft. a kirschner wire drilled through the graft from side to side and bent on both ends was used to handle the slippery graft without a specialised workstation. a rongeur was used to shape the autograft for press-fit grafting (figure 4). no additional hardware was necessary. after infiltration with local anaesthetic, the wound was closed with multiple layers of absorbable sutures. the surgical time for the procedure was 1 hour 37 minutes. the patient was discharged one day after the operation. postoperative rehabilitation consisted of non-weight-bearing for six weeks, after which closed chain exercises were started. weightbearing was started after confirming early integration of the graft with mri scan six weeks after the procedure (figure 2). already at the six-month follow-up, the patient showed marked improvement of pain and function, reporting of only mild start-up pain after sitting for a prolonged time. at two-year follow-up the patient reported no pain in the left knee, and good stair climbing or squatting without pain. the range of motion in the left knee was 0–130°, with no laxity or instability in the coronal or sagittal plane (figure 5). the eq-5d 5l score was 11111, the knee injury and osteoarthritis outcome score (koos-ps) 100%, and the lysholm score also 100%. radiographs at one year confirmed an unchanged graft position and showed no signs of osteoarthritis (figure 1). discussion cartilage defects are a common cause of painful knees and are most frequent in the medial femoral condyle in the young male patient.8,9 treatment options depend on the size of the defect. in lesions figure 4. clinical pictures of the knee: a) after over-drilling of the osteochondral defect and harvesting of the posteromedial condyle, and b) after implantation of the shaped autograft with a press-fit technique figure 5. clinical pictures of knee range of motion at one year postoperatively page 109le roux j et al. sa orthop j 2022;21(2) less than 2 cm2, microfracture and oats are recommended. with microfracture, treatment failure can be expected after five years postoperatively, whereas oats has shown better intermediate and long-term outcomes.10,11 in intermediate size lesions between 2 and 4 cm2 oats, microfracture and aci (autologous chondrocyte implantation) is commonly performed, and in large lesions > 4 cm2 treatment options are aci and oca (osteochondral allograft).1,3,12 gudas et al. showed that the patient-reported outcome measures (proms) after treatment for larger sized cartilage lesions with a mean of 2.8 cm2 is similar when comparing microfracture to oats at ten years postoperatively. however, 75% of patients returned to their pre-injury level of activity after oats compared to only 37% after microfracture. younger patients (< 25 years) showed significantly better proms with oats than older patients and remained higher at ten years after the procedure.13 in a randomised control trial, knutsen et al. noted that patients older than 30 years of age had worse outcomes than younger patients who were treated with microfracture and oats. there was no difference between the two treatment modalities at five years postoperatively.14 although oats does achieve restoration of organised hyaline cartilage, the limited amount of expendable donor cartilage limits this option to smaller lesions. for large lesions, imhoff et al. presented a mega-oats case series using the posterior femoral condyle as autograft.6 a concern with this technique may be that of morbidity at the donor site; however, the defect of the donor site had no clinical impact in follow-up and, in some cases, was found to be replaced by white fibrous tissue.6 although we had excellent results in one case, this should not be generalised and a larger series is needed to evaluate the outcomes when using the low-cost tools. promising results have been described in a 5.5-year followup of 33 patients using a mega-oats workstation which showed a highly significant median increase in the lysholm score from 49.0 preoperatively to 86.0 points.6 twenty-seven patients returned to recreational sports, and x-rays showed partial remodelling of the posterior condyle in 24 patients. like imhoff et al., we also noted marked improvement and no major deficit in knee function of the patient due to the harvest of the posterior condyle. imhoff used specialised equipment, such as a recipient and donor harvester, dilators, tamps and a workbench. however, the need for this instrumentation, and the complex surgical technique is known as a barrier to the use of mega-oats.2 although oats is frequently performed at our institution, the size of the defect in this patient required a mega-oats. as previously mentioned, the loan sets are not available in our country and a purchase price of $38 095 (r531 065) prevented its use. we, therefore, acquired a set of stainless-steel flat drill bits from 20 mm to 30 mm in 5 mm increments, priced at a total of $8 (r112) (figure 6). the most important limitation of this technique remains the possible morbidity at the donor site, despite previously, and in this case, being reported as minimal to none.6 we therefore do not advise this technique as a standard treatment option, but rather as one that should be approached with caution by an experienced knee surgeon in a very select patient combined with a resourcelimited environment, as highlighted above. the main advantage of using the described low-cost technique is that the instrumentation is freely available and very costeffective. yet, there are important problems and pitfalls to take into consideration when considering this option. the main technical disadvantage of this technique was the difficulty of handling the slippery osteochondral autograft and preventing it from falling on the floor. the mega-oats workbench has six holding screws that tighten around the graft, securing it in place. we solved the problem by drilling a k-wire through the graft from side to side, not damaging the chondral surface, and using it as handles. the precision of the graft shaping is also limited without a core reamer, but only a rongeur. this can be overcome by using circular templates (i.e., a 20 mm washer bought at the local hardware store). also, no jig was available to ensure perpendicular orientation of the reamer to the cartilage level. we used a store-bought 25 mm flat drill bit for this. there was also no depth gauge available to confirm depth of the donor site. here we used a ruler at 12, 3, 6, and 9 o’clock and correlated this with the graft thickness. also, careful placement of the reamer and frequent checks while reaming are of paramount importance. another technical consideration must be that a fixation system for the graft (i.e., headless screws) should be available in case press-fit fixation fails. it is a potential medico-legal challenge to use equipment not designed for clinical use. this needs to be highlighted to the patient, hospital and theatre staff beforehand and written consent for it must be obtained. a limitation of the study is the short radiological follow-up of six weeks (mri) and one year (x-rays). although we can report that the procedure is safe and carries no objective morbidity within two years postoperatively, longer follow-up will need to be done to screen for the development of osteoarthritis and other complications. conclusion the mega-oats was successfully performed in this patient with a new low-cost technique, without complications and excellent outcome. it could therefore be used as a safe salvage procedure and may be a viable low-cost alternative for young patients with large osteochondral defects in the knee. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, ethics approval was obtained from the university of cape town human research ethics committee no. 144/3030. informed consent was obtained from the patient. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. figure 6. the flat drill bits obtained from a hardware store page 110 le roux j et al. sa orthop j 2022;21(2) author contributions jlr: data analysis, first draft preparation, manuscript preparation, manuscript revision, submission, primary author rvb: study conceptualisation, manuscript revision sb: study conceptualisation, manuscript revision abi: study conceptualisation, manuscript revision mh: study conceptualisation, data capture, first draft preparation, manuscript revision, study design orcid le roux j https://orcid.org/0000-0002-5658-6827 von bormann r https://orcid.org/0000-0002-4546-3143 braun s https://orcid.org/0000-0002-8865-2606 imhoff ab https://orcid.org/0000-0001-5085-6446 held m https://orcid.org/0000-0002-0671-0439 references 1. karataglis d, learmonth dja. management of big osteochondral defects of the knee using osteochondral allografts with the mega-oats technique. knee. 2005;12(5):389-93. https:// doi.org/10.1016/j.knee.2004.12.008. 2. bugbee wd, pallante-kichura al, görtz s, amiel d, sah r. osteochondral allograft transplantation in cartilage repair: graft storage paradigm, translational models, and clinical applications. j orthop res. 2016;34(1):31-38. https://doi.org/10.1002/jor.22998. 3. richter dl, schenck rc, wascher dc, treme g. knee articular cartilage repair and restoration techniques: a review of the literature. sports health. 2016;8(2):153-60. https:// doi.org/10.1177/1941738115611350. 4. braun s, minzlaff p, hollweck r, wörtler k, imhoff ab. the 5.5-year results of mega-oats – autologous transfer of the posterior femoral condyle: a case-series study. arthritis res ther. 2008;10(3):1-14. https://doi.org/10.1186/ar2439. 5. minzlaff p, braun s, haller b, wörtler k, imhoff ab. der autologe transfer der posterioren femurkondyle bei ausgedehnten osteochondralen schäden des knies : 5-jahresergebnisse der mega-oats-technik. orthopade. 2010;39(6):631-36. https://doi. org/10.1007/s00132-010-1608-2. 6. agneskirchner jd, brucker p, burkart a, imhoff ab. large osteochondral defects of the femoral condyle: press-fit transplantation of the posterior femoral condyle (mega-oats). knee surg sport traumatol arthrosc. 2002;10(3):160-68. https://doi.org/10.1007/ s00167-001-0259-6. 7. brucker pu, paul j, imhoff ab. mega-oats technik und ergebnisse. unfallchirurg. 2002;105(5):443-49. https://doi.org/10.1016/b978-1-4377-0878-3.10009-9. 8. hjelle k, solheim e, strand t, muri r, brittberg m. articular cartilage defects in 1,000 knee arthroscopies. arthroscopy. 2002;18(7):730-34. https://doi.org/10.1053/jars.2002.32839. 9. pareek a, sanders tl, wu it, larson dr, saris dbf, krych aj. incidence of symptomatic osteochondritis dissecans lesions of the knee: a population-based study in olmsted county. osteoarthr cartil. 2017;25(10):1663-71. https://doi.org/10.1016/j.joca.2017.07.005. 10. hangody l, füles p. autologous osteochondral mosaicplasty for the treatment of full-thickness defects of weight-bearing joints: ten years of experimental and clinical experience. j bone joint surg. 2003;85(suppl 2):25-32. https://doi. org/10.2106/00004623-200300002-00004. 11. goyal d, keyhani s, lee eh, hui jhp. evidence-based status of microfracture technique: a systematic review of level i and ii studies. arthroscopy. 2013;29(9):1579-88. https://doi. org/10.1016/j.arthro.2013.05.027. 12. hohmann e, tetsworth k. large osteochondral lesions of the femoral condyles: treatment with fresh frozen and irradiated allograft using the mega oats technique. knee. 2016;23(3):436-41. https://doi.org/10.1016/j.knee.2016.01.020. 13. gudas r, gudaite a, pocius a, et al. ten-year follow-up of a prospective, randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint of athletes. am j sports med. 2012;40(11):2499-508. https://doi.org/10.1177/0363546512458763. 14. knutsen g, drogset jo, engebretsen l, et al. a randomized trial comparing autologous chondrocyte implantation with microfracture: findings at five years. j bone joint surg. 2007;89(10):2105-12. https://doi.org/10.2106/jbjs.g.00003. https://orcid.org/0000-0002-5658-6827 https://orcid.org/0000-0002-4546-3143 https://orcid.org/0000-0002-8865-2606 https://orcid.org/0000-0001-5085-6446 https://orcid.org/0000-0002-0671-0439 layout 1 south african orthopaedic journal immelman rj et al. sa orthop j 2018;17(1) http://journal.saoa.org.za doi 10.17159/2309-8309/2018/v17n1a1 arthroplasty comparing outcomes between enhanced recovery after surgery and traditional protocols in total hip arthroplasty: a retrospective cohort study immelman rj1, de vos jn2, venter jh3 1 mbchb(pret), registrar in orthopaedic surgery, university of pretoria 2 mbchb(pret) mmed orth(pret), orthopaedic surgeon, wilgers hospital, pretoria 3 mbchb(pret) mmed int(pret), specialist physician, wilgers hospital, pretoria project completed at life wilgers hospital, pretoria corresponding author: dr rj immelman, 408 berea street, muckleneuk, 0002; cell: 0833763848; email: rjimmelman@gmail.com abstract background: traditionally, hip replacement surgery was associated with prolonged recovery and rehabilitation in a hospital setting. prolonged stay is causing growing concern internationally, where there is an increased drive to cost-effective practice and a realisation that prolonged hospitalisation is not required and may be detrimental. enhanced recovery after surgery (eras) protocols address this problem by advocating evidence-based multidisciplinary peri-operative management pathways associated with rapid recovery, without compromising safety. despite proven efficacy, these protocols are not being implemented in most south african orthopaedic practices. methods: data from two cohorts (80 patients) undergoing elective primary total hip arthroplasty were included. one group was rehabilitated according to a prolonged stay protocol and the other according to eras. cohorts were matched according to demographics and comorbidities. the functional outcome was compared using the oxford hip score. the 30-day readmission rate was compared to assess the safety of early discharge, and the length of stay of patients was compared. results: the readmission rate and oxford hip scores showed no clinically significant difference between the cohorts. the length of stay was markedly decreased in the eras group. conclusion: eras protocols can decrease the length of stay in elective total hip replacement without compromising patient safety or functional outcome. level of evidence: level 4 key words: eras, enhanced recovery, rapid recovery, total hip replacement, arthroplasty citation: immelman rj, de vos jn, venter jh. comparing outcomes between enhanced recovery after surgery and traditional protocols in total hip arthroplasty: a retrospective cohort study. sa orthop j 2018;17(1):11-16. http://dx.doi.org/10.17159/2309-8309/2018/v17n1a1 editor: prof anton schepers, university of the witwatersrand received: may 2017 accepted: september 2017 published: march 2018 copyright: © 2018 immelman rj, de vos jn, venter jh. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: the cost of completing this research was covered in whole by the authors, and no external funding was received. conflict of interest: none of the authors have any conflict of interest with regard to the content of this article. page 12 immelman rj et al. sa orthop j 2018;17(1) introduction osteoarthritis is a chronic progressive and debilitating disease caused by articular cartilage wear and destruction. total hip arthroplasty has proved to be a reliable, effective, reproducible and sustainable method of treatment for this disease process. health-related quality of life assessments have shown that return to function after arthroplasty, and especially after primary total hip arthroplasty, is excellent and that the money spent on these procedures is justified. with the incidence of arthritis on the rise, it is expected that the incidence of total hip replacements will also rise by 174% by 2030, putting these surgeries and the approach towards them in the spotlight.1-3 length of stay after total hip arthroplasty varies drastically across the literature, ranging between one and 21 days. the trend is that of a decreasing length of stay. traditionally, in south africa, the teaching and protocols followed were that of a longer length of stay ranging between four and seven days, with delayed and prolonged hospital mobilisation and rehabilitation. while this is still an accepted method of treatment with excellent outcomes, very little attention is given to new or alternative protocols.2 enhanced recovery after surgery (eras) is a concept popularised in the early 2000s by henrik kehlet from denmark. eras is an evidence-based peri-operative care pathway that emphasises and advocates pre-, intraand post-operative interventions that are associated with enhanced recovery and decreased length of stay without compromising patient care. these protocols were originally developed specifically for gastroenterology but have been modified and tailored by the original task team, as well as multiple other authors, to be applied to other surgical procedures. in and around 2010, eras found its way into arthroplasty surgery with many european and american centres applying these protocols with success. results by multiple authors have shown a significant decrease in length of stay without compromising outcome and patient safety. outcomes with post-operative hip scores were equal and, in certain cases, showed improvement, with readmission rates decreasing in the rapid recovery pathways.4-6 when assessing a new rehabilitation protocol, there has to be certainty that the change does not negatively affect the quality of care and outcome. this implies that the minimal acceptable results are at least equivalent to the results of the previous method. when assessing outcome in joint replacement, one has to compare functional outcome and assess complication rate. in arthroplasty, functional outcome is measured by various scoring systems, with the harris and oxford hip scores being the most commonly used, validated scoring systems.7 readmission rate is the accepted way of determining relevant complications requiring intervention. as a result of the early discharge of these patients, this is the most reliable way of determining complications that require intervention, and these can be considered more significant complications. a concern of the eras protocol is that patients are rehabilitated and discharged too early, and therefore many complications that could have been prevented, or diagnosed earlier, are now only presenting later with a worse prognosis and unnecessary readmission.1,6,8,9 the aim of this study is to show that an eras protocol can be implemented so as to decrease length of stay without compromising on patient outcome or safety. materials and methods this study was conducted retrospectively in the form of a cohort study, at the practice of the senior author. the institution is a private healthcare hospital setting, situated in pretoria. this hospital draws many patients from rural mpumalanga, as well as surrounding pretoria. files were reviewed assessing various patient demographics, comorbidity profile and surgical factors in view of comparing cohorts. the main outcomes, readmission rate and post-operative oxford hip scores, were also collected and compared. the oxford hip scores (ohs) were calculated at least six months post-operatively in all patients. all patients undergoing primary elective total hip replacement were included in this study. the senior author changed practice during this time to an eras pathway. consequently, all patients after the change were assigned to the eras group without selection. all patients before the change were assigned to the traditional group, also without selection. the only exclusion criteria were an incomplete file and less than six months’ postoperative follow-up. a total number of 80 patients were included for analysis and divided into two cohorts, consisting of 40 patients each. data collection for the eras group was conducted in a retrospective manner starting on 1 may 2015. this coincided with the senior author changing to an eras protocol. at this stage, all patients without any selection, were treated with the eras protocol. on consultation with statisticians, the size of the cohorts was determined to be 40 patients in each cohort to achieve statistical significance. the first 40 patients being treated with an eras protocol and having at least six months’ follow-up were included. subsequently, the last 40 patients before the change in protocol were included in the traditional group. the data collection period was from 13 october 2014 to 12 march 2016. all patients were followed up for 30 days post-operatively for readmissions, and ohs was done at least six months post-operatively. all patients had identical surgical treatment. this consisted of a primary total hip replacement done in the lateral decubitus position. the same surgical approach, hardinge direct lateral, was used. all patients were treated with prostheses, with the same design and from the same manufacturer. this included an uncemented press fit stem and cup. the difference in approach to these cohorts was the clinical pathway used in each group. as mentioned, eras contained pre-, intraand post-operative components (table i). pre-operative changes included allowing clear fluids up to two hours pre-op, omission of sedative premedication, prophylactic antiemetic (odansetron) and multimodal non-opioid analgesia. analgesia premedication included two days of oral pregabalin and intravenous ketorolac and paracetamol two hours preoperatively. the patients also received a crystalloid fluid bolus. intra-operatively, changes were mainly pharmaceutical and type of anaesthetic. all patients received spinal anaesthetic. only if this failed, general anaesthetic was utilised. opioids were avoided both intravenously and within the spinal block. patients received conscious sedation and benzodiazepines were replaced by a low dose propofol infusion. bladder catheterisation was avoided if possible. this unfortunately was necessary at times, but the catheter was removed in theatre post-op or on arrival in the ward. during wound closure, local infiltrative anaesthesia was utilised. post-operatively, the patients were not sent to high care, which was previously the case for 1–2 days. patients were allowed a normal diet directly post-operatively. previously only clear fluids were administered on day 0, fluids on day 1 and then a normal diet on day 2. the patients received no parenteral opioids, and surgical drains were removed within 12 hours of surgery. patients were mobilised within 2–4 hours post-op, this included getting out of bed, and mobilising in the ward and out of the room – all under physiotherapy supervision. day 1 mobilisation included mobilising out of the ward and stair climbing, again with physiotherapy supervision. ice packs were used over the dressing to minimise swelling. mobilisation in the traditional cohort was delayed and less aggressive (table i). immelman rj et al. sa orthop j 2018;17(1) page 13 discharge criteria were similar with the two groups. the only difference was that there was less reliance placed on blood results in the eras group. daily bloods were done to monitor renal functions, haemoglobin and inflammatory markers in the traditional group. patients were only discharged once the crp was on a downward trend. this was usually only noted on day 4 to 5. except for the medical reason stated above, surgical and physiotherapy or mobilisation criteria were identical in both groups. the patient was required to be able to mobilise and cope with their outside environment; pain should be controlled; there should be no medical reasons against discharge; and the wounds and swelling were to be judged as adequate by the surgeon. prior to commencing data collection, ethical approval was obtained from the university of pretoria’s research ethics department. results the results were analysed by the department of statistics at the medical research council. the two cohorts were well matched according to demographics and comorbidity profiles (table ii). only three variables, namely, the type of anaesthetic, body mass index (bmi) and age stood out and reflected a difference. with regard to the type of anaesthetic table i: differences between traditional and eras pathways intervention traditional eras pre-operative informed consent informed consent education session pre-operative fasting npo for 8 hours pre-op clear fluids up to 2 hours pre-op pre-operative medication benzodiazepine sedative stat medication • ketorolac ivi • ondansetron ivi • paracetamol ivi • decadron ivi pre-admission • pregabalin 2 days post-operative ward high care 1–2 days standard ward post-operative diet day 0 clear fluids day 1 full fluids day 2 full diet full diet from day 0 anaesthetic general preferred opioids benzodiazepine less emphasis on restoring fluid lost during fasting spinal no opioids no benzodiazepine preand intra-operative fluid status nb mobilisation day 0 – nil day 1 – bed programme, to chair day 2 – in room day 3 – out of room day 4 – stairs day 0 – out of room day 1 – stairs medication opioid containing in hospital and upon discharge non-opioid containing* local infiltrative anaesthetic** *opioid containing analgesia given after discharge on prn basis **intra-operatively other drain catheter surgical drain prn catheter prn *drain and catheter removed before mobilisation on day 0 table ii: patient matching pre-eras eras gender 55% male, 45% female 50% male, 50% female smoking 15% 10% hypercholesterolaemia 33% 40% hypertension 62% 62% diabetes mellitus 10% 10% renal impairment 0 12% copd 8% 3% ischaemic heart disease 15% 13% hepatic impairment 0 0 type of anaesthesia general-83%, spinal-17% general-40%, spinal-60% age 59.2(sd-14.8) 64.2(sd-15) bmi 28(sd-4.7) 30(sd-5) page 14 immelman rj et al. sa orthop j 2018;17(1) in the traditional group, general anaesthetic was favoured, and in eras, spinal anaesthetic was preferred. this is in keeping with the eras protocol that favours regional anaesthetic. the mean age of the eras group was also five years older at 64.2 years (sd 14.8), compared to 59.2 (sd 15). lastly, the eras group had a mean bmi of 30 (sd 5) kg/m2 which was 2 kg/m2 higher than the traditional group at 28 (sd 4.7) kg/m2. with regard to readmission rate, the eras group had a lower readmission rate than the traditional group; however, this was not statistically significant (p-value 0.75). the reasons for readmission were subsequently evaluated (table iii) and divided into major and minor according to the american college of surgeons’ national surgical quality improvement program (nsqip). the nsqip is a database validated in orthopaedic surgery and has been in existence for more than 30 years.10 major complications encountered are generally complications requiring return to the operating room (periprosthetic infections and fractures) or more serious or lifethreatening medical complications such as myocardial infarct, organ failure, stroke and pulmonary embolism. major complications are associated with prolonged hospital stay and major increases in cost. major complications encountered in our study included deep surgical site infection, periprosthetic fracture requiring surgery, and seroma requiring drainage in theatre. minor complications include complications that generally do not markedly add to morbidity or return to the operating theatre; these include urinary tract infection, superficial surgical site infection, dvt, blood loss requiring transfusion, and pneumonia.10,11,17 once the severity of the complications was determined, the eras group’s major readmission equated to one readmission and the traditional group five. there were three readmissions for pain during early implementation of eras. there were no mortalities in either cohort. the modified oxford hip scores (out of 60) showed no statistically significant difference. all patients in both groups had an excellent outcome7 with scores ranging between 58 and 60. the mean score in the traditional group was 60 (range 59–60) and the eras group 59.7 (range 58–60). of note is that the traditional group’s scores were taken on average 9–12 months after surgery and the eras group 6 months. this is due to the timeline of data collection where the traditional cohort had longer follow-up. length of stay (los) was compared and showed a statistically significant decrease in the eras group (p-value 0.0011). the mean los was 6.95 (3–59) days in the traditional group, compared to 1.85 (1–7) days in the eras group. two patients in the traditional group had exceptionally long stays, 59 and 24 days, for prosthetic joint infection and pneumonia respectively. if these patients were removed from the cohort, the los mean in this group decreased to 5.13 days. discussion clinical pathways or rehabilitation protocols lack a definition in orthopaedic literature but can be described as a set of orders or interventions determined to standardise the treatment of patients and which aim to optimise a positive outcome. comparing these protocols with one another is exceedingly difficult, as they consist of multiple interventions which function as cogs in a machine. isolating and determining the weight each component contributes to outcome, is currently not possible, and further research into the topic is required.12 eras is one such pathway. the difference in philosophy between eras and other pathways is not major, but definitely significant. first, in eras the emphasis placed on the multidisciplinary approach is fundamentally different from other protocols. in eras, each member is tasked with periodically reviewing the best available and up-to-date literature and formulating a plan to implement this. each member of the team also contributes to the education of patients and the team. secondly, outcomes criteria are mandated by eras. these outcomes should be prospectively defined and collected; they should be comprehensive and used to regularly evaluate and improve care. lastly, eras requires a regular audit of outcomes. this audit process should involve all practitioners and should be critical concerning shortcomings. during audit, the team should reevaluate interventions and review literature to ascertain if the current approach is still up to date with trends. this process in effect ensures that the eras pathway is not a static pathway, but rather constantly evolving towards the newest and highest level of evidence.12,13 the effects of this audit process are evident when considering results in our eras cohort. in the eras cohort, during the early phase of implementation, three patients (7.5%) of the cohort were readmitted due to pain. one of these patients was admitted in another hospital in the periphery and transferred, the other two at the treating institution. all three patients were not assessed or discussed with an orthopaedic surgeon prior to admission. sibia et al. showed that pain or swelling was the most common reason for re-presentation to hospital within 30 days in their 655 patients.16 in their study, they divided hospital returns into readmissions and emergency department visits. emergency department visits were 75% more common than readmissions. as a result of uncertainty regarding the treatment course of patients after total joint arthroplasty (tja), and possibly due to the litigious nature of the current healthcare system, these patients are often readmitted by general practitioners or casualty officers. this trend was noted, and preoperative education and discharge medications were adjusted in an attempt to avoid this situation and improve on post-discharge pain management. this has resulted in no further readmissions for pain in 91 consecutive total hip arthroplasties (thas) up to the time of the writing of this article. changes in education included emphasis on post-operative pain and asking patients to call the surgeon’s room if pain is not bearable after discharge. the discharge analgesia also included stronger opioid-containing medication to be taken on a pro re nata (prn) basis. the study presented similar results when compared to many other studies and showed that eras or rapid recovery protocols can be safely implemented and do not compromise outcome. although this was the aim of the study, several other findings were made. first is the concept of patients at risk, or specific characteristics associated with prolonged stay. it was clear in our study that patients with a length of stay exceeding two days presented common characteristics. these included advanced age (>75 years), high bmi (>30 kg/m2) and comorbidity profile, which was especially relevant if los was three or more days (table iv). this correlated well with a review by kehlet et al., that certain characteristics are associated with prolonged stay in eras. table iii: reasons for readmission reason for readmission traditional eras surgical site infection 3 (2 deep, 1 superficial) 2 (superficial) periprosthetic fracture 2 pain 3 seroma for drainage 1 major readmissions 5 1 minor readmissions 1 4 immelman rj et al. sa orthop j 2018;17(1) page 15 of note is that kehlet’s review shows that these patients, with more comorbidities, a higher age and bmi are predominantly the patients who benefit most from eras. their los, morbidity and mortality rates as a group, show the greatest improvement when eras is applied compared to prolonged stay. it is thus imperative to understand that eras does not equate to early discharge, but rather earlier and safer discharge for a specific patient profile without compromising clinical outcome.6,9,12,13,15 discharge criteria are becoming more important to ensure safety, minimise readmission and maximise outcome. discharge criteria are of pivotal importance in recognising complications and preventing unsafe discharge. hospital-acquired conditions (hac) is a term described by medicaid in the usa as a condition or complication acquired in hospital, specifically due to admission or interventions that are potentially avoidable. the most common hacs in arthroplasty are, in order of frequency, urinary tract infection, surgical site infection, venous thromboembolism and pneumonia. the presence of a hac is the strongest predictor of early readmission following arthroplasty. recognition of these hacs is the responsibility of the surgeon via set criteria and, if recognised prior to discharge, can decrease readmission rate four-fold.16 avoiding readmission is key as up to 39% of patients readmitted after tha require surgical intervention.14 the discharge approach followed in this study is congruent with eras philosophy and includes a team approach. this concept is not new but emphasises input from all team members in assessing readiness for discharge. both medical and surgical parameters are assessed by the main role players, namely the surgeon, physician, physiotherapist and nursing staff, with the anaesthetist being the only part of the team not involved in discharge. our approach simplified, included that there should be no surgical or medical reason not to discharge the patients, and the patients should be able to mobilise unaided out of bed and on stairs, and be able to dress and take care of basic personal hygiene. traditionally, length of stay after tja ranges between four and seven days. this los was often required to achieve adequate mobility and due to concerns about high rates of complications in the post-operative period. parvizi stated that the vast majority of complications in tja are recorded within the first four days, prompting many surgeons to monitor patients for longer in hospital.18 what should be taken cognisance of is that parvizi’s cohort included both knee and hip primary and revision surgery as well as bilateral surgeries. the vast majority of complications were noted in the revision arthroplasties and knee arthroplasties and not in primary hip arthroplasties. recent literature, including new literature by parvizi, indicates that these complications are not easily preventable, and that shorter hospital los may be protective against readmission and some of these complications, or at the least give equivalent results to longer stay.19,20 the effect of early mobilisation, regional anaesthetic and multimodal, non-opioid analgesia has in turn played a major role in decreasing los without increasing morbidity.21 limitations in this study include the retrospective nature and limited number of patients. prospective matching of cohorts was thus not done, although the groups happened to be well matched in most aspects due to the specific patient profile undergoing arthroplasty. treatment of the two cohorts did not run concurrently; this could have had an effect due to possible changes in unknown factors such as hospital and supporting staff caring and managing patients. conclusion implementation of evidence-based eras pathways that are diligently monitored will lead to safe discharge without compromising clinical outcome. in south african healthcare systems, which are hampered by many constraints, implementation of these protocols can go a long way towards improved service delivery by improving turnaround time and saving costs. ethics statement prior to commencing data collection, ethical approval was obtained from the university of pretoria’s research ethics department. references 1. berry dj, lieberman j. surgery of the hip. elsevier health sciences; 2012. 2. michaud cm, mckenna mt, begg s, tomijima n, majmudar m, bulzacchelli mt, et al. the burden of disease and injury in the united states 1996. population health metrics 2006;4(1):1. 3. ethgen o, bruyere o, richy f, dardennes c, reginster jy. health-related quality of life in total hip and total knee arthroplasty. a qualitative and systematic review of the literature. j bone joint surg am 2004 may;86-a(5):963-74. 4. kehlet h, dahl jb. anaesthesia, surgery, and challenges in postoperative recovery. the lancet 2003;362(9399):1921-28. 5. kurtz s, ong k, lau e, mowat f, halpern m. projections of primary and revision hip and knee arthroplasty in the united states from 2005 to 2030. j bone joint surg am 2007 apr;89(4):780-85. 6. callaghan jj, pugely a, liu s, noiseux n, willenborg m, peck d. measuring rapid recovery program outcomes: are all patients candidates for rapid recovery. j arthroplasty 2015;30(4):531-32. 7. halawi mj. outcome measures in total joint arthroplasty: current status, challenges, and future directions. orthopedics 2015;38(8):e685-e689. 8. dawson-bowling sj, jha s, chettiar kk, east dj, gould gc, apthorp hd. a multidisciplinary enhanced recovery programme allows discharge within two days of total hip replacement; threeto five-year results of 100 patients. hip international 2014;24(2). 9. jorgensen cc, kehlet h, lundbeck foundation centre for fasttrack hip and knee replacement collaborative group. role of patient characteristics for fast-track hip and knee arthroplasty. br j anaesth 2013 jun;110(6):972-80. 10. pugely aj, callaghan jj, martin ct, cram p, gao y. incidence of and risk factors for 30-day readmission following elective primary total joint arthroplasty: analysis from the acs-nsqip. j arthroplasty 2013;28(9):1499-504. 11. ingraham am, richards ke, hall bl, ko cy. quality improvement in surgery: the american college of surgeons national surgical quality improvement program approach. adv surg 2010;44: 251-67. 12. soffin e, yadeau j. enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence. br j anaesth 2016;117(suppl 3):iii62-iii72. table iv: patient profile associated with prolonged stay vs early discharge stay >3 days stay 2 days or less bmi 30.8 29.8 age 74 61.6 comorbidity (number per patient) 2.25 1.14 page 16 immelman rj et al. sa orthop j 2018;17(1) 13. scott nb, mcdonald d, campbell j, smith rd, carey ak, johnston ig, et al. the use of enhanced recovery after surgery (eras) principles in scottish orthopaedic units—an implementation and follow-up at 1 year, 2010–2011: a report from the musculoskeletal audit, scotland. arch orthop trauma surg 2013;133(1):117-24. 14. sibia us, mandelblatt ae, callanan ma, macdonald jh, king pj. incidence, risk factors, and costs for hospital returns after total joint arthroplasties. j arthroplasty 2017;32(2):381-85. 15. stambough jb, nunley rm, curry mc, steger-may k, clohisy jc. rapid recovery protocols for primary total hip arthroplasty can safely reduce length of stay without increasing readmissions. j arthroplasty 2015;30(4):521-26. 16. raines bt, ponce ba, reed rd, richman js, hawn mt. hospital acquired conditions are the strongest predictor for early readmission: an analysis of 26,710 arthroplasties. j arthroplasty 2015;30(8):1299-307. 17. molina cs, thakore rv, blumer a, obremskey wt, sethi mk. use of the national surgical quality improvement program in orthopaedic surgery. clinical orthopaedics and related research® 2015;473(5):1574-81. 18. pulido l, parvizi j, macgibeny m, sharkey pf, purtill jj, rothman rh, et al. in hospital complications after total joint arthroplasty. j arthroplasty 2008;23(6):139-45. 19. sutton jc,3rd, antoniou j, epure lm, huk ol, zukor dj, bergeron sg. hospital discharge within 2 days following total hip or knee arthroplasty does not increase major-complication and readmission rates. j bone joint surg am 2016 sep 7;98(17):1419-28. 20. rozell jc, courtney pm, dattilo jr, wu ch, lee gc. late complications following elective primary total hip and knee arthroplasty: who, when, and how? j arthroplasty 2017;32(3):719-23. 21. zmistowski b, restrepo c, hess j, adibi d, cangoz s, parvizi j. unplanned readmission after total joint arthroplasty: rates, reasons, and risk factors. j bone joint surg am 2013 oct 16;95(20):1869-76. south african orthopaedic journal editorial doi 10.17159/2309-8309/2022/v21n4a0magobotha sk sa orthop j 2022;21(4) where are they now? sebastian k magobotha* professor and head of clinical unit sport and general, deputy head orthopaedic surgery chris hani baragwanath academic hospital, head research directorate department of orthopaedic surgery, university of the witwatersrand, johannesburg, south africa *corresponding author: sebastianmagobotha22@gmail.com introduction we held interviews for medical officers in orthopaedic surgery at the university of the witwatersrand (wits). this process takes place twice a year, during april/may and october/november. what is striking is the number of applicants vying for only a few posts – in this instance, only seven posts. the question is: what happens to the rest of the candidates who are not successful in getting a post on the teaching/training circuit? in other words: ‘where are they now?’ cluster hospitals the university of the witwatersrand has three teaching hospitals, namely chris hani baragwanath academic hospital, charlotte maxeke johannesburg academic hospital and helen joseph hospital. there are a number of level 2 hospitals in the cluster, namely sebokeng, klerksdorp, leratong, thambo memorial hospital, pholosong, far east rand, edenvale and thelle mogoerane hospitals. each of these hospitals offers orthopaedic services and has one or two orthopaedic specialists and a number of medical officers or career orthopaedic medical officers. this scenario is true for the hospitals under the university of pretoria and that of sefako makgatho health science university in gauteng. in the johannesburg metro, ekurhuleni and mogale city, there are 171 orthopaedic doctors in public service. this number comprises 51 specialists, 52 registrars and 58 medical officers. the population of this area is 11 679 659.1 therefore, the ratio is 1:68 302 (1.4 per 100 000). a 2018 study aimed at determining the orthopaedic surgeon density in south africa showed 1.63 orthopaedic surgeons per 100 000 population.1 we do not know what a healthy population ratio of an orthopaedic doctor to the general population is, but we do have figures from other countries like australia and canada (4 per 100 000). within the usa and uk, it is 7.5 per 100 000. in scandinavia, it is 20 per 100 000.2 according to sava and the registrar of the hpcsa, there is an average of 650 active orthopaedic surgeons in sa. currently, the sa population is 60.6 million.3 this represents a ratio of 1:10 154 000. from the statistics, it is clear that we need more doctors. i am aware of an editorial by prof. r dunn (2015) where he was concerned that we might be producing too many specialists or rather specialists without a bright future.4 however, i am looking at the medical officers and what is happening to them. realising that more doctors are needed, we embarked on a drive/exercise to increase the number of training posts at wits. we applied for more training post numbers early this year and were successful. an additional 30 training posts were granted by wits, ten for each teaching hospital. sadly, these posts cannot be filled because there is no funded post from the gauteng department of health. posts have been frozen and we have no idea when the sanction will be lifted for posts to become available. for now, these posts can only be filled by supernumerary doctors who get their salary from their respective government. after completion of their training, they are expected to return to their home country. this means the ratio of orthopaedic doctors to the population remains unchanged despite the greater number of trainees in our institution. the process of creating a funded medical officer’s post is difficult, tedious, political and centrally driven. recommendation is made by the hospital after a request from the orthopaedic department. all this depends on budget allocation and treasury, and very little attention is given to statistics such as the impact on service delivery and quality thereof due to the dangerously low doctor:patient ratio. it is clear that no new posts will be created. the only way in which posts become available is by someone vacating such a post, namely: 1. a consultant leaving either for private practice or retiring thereby making way for a qualified registrar to move into that post. 2. a registrar moving out after completing their contract. 3. a medical officer moving into a registrar training post. there are on average around seven registrar posts opening as these doctors qualify and vacate their posts. that means an average of seven medical officers can apply to fill these registrar posts, and consequently, seven medical officers’ posts open up. there were 49 applications for these seven medical officer posts. what happened to the rest? a snap telephone survey was conducted with candidates who were unsuccessful applicants asking them what they are doing now and where they are. some of the responses were: 1. applied elsewhere as an orthopaedic medical officer and still waiting 2. working at a forensic mortuary 3. career orthopaedic medical officer 4. gone to private practice as a general practitioner 5. registrar post elsewhere 6. not working – still looking for a post as i read through the cvs of some of the applicants, i realise how much they love orthopaedic surgery and how passionate they are about becoming orthopaedic surgeons, if given a chance, to make a change to the orthopaedic landscape of this country. i shudder page 194 magobotha sk sa orthop j 2022;21(4) when i see the large pile of cvs with the z83 application form, knowing very well that only seven will be successful this year. for the rest, i do believe their dreams for a future career in orthopaedics are shattered. i find myself asking the question, ‘where are they now?’ references 1. dell aj, gray sc, fraser r, held m, dunn r. orthopaedic surgeon density in south africa. world j surg. 2018;42(4):3849-55. 2. dunn rn. orthopaedic surgical career path – where’s the plan? sa orthop j. 2022;21(1):9-10. 3. stats sa. available from: https://www.statssa.gov.za/?p=15601. accessed 14 september 2022. 4. dunn r. are we oversupplying the orthopaedic surgical market? sa orthop j. 2015 mar;14(1):16-17. 404 not found august 2002 education, training and accreditation i , i i i i l am most appreciative of the opportunity given me by professor grabe to contributethese few words about the accreditation of orthopaedic education. in 1989 at the meeting of the south mrican orthopaedic association i was honoured to present the francois p. fouche lecture titled "the training of orthopaedic surgeons".! that lecture included some material on the accreditation of orthopaedic residency programmes in the united states. i will enlarge on that subject in the following dissertation. in the united states the accreditation of orthopaedic residency programmes is only one step in the overall educational process. medical schools are accredited by the liaison committee on medical education. residency programmes are accredited by the specialty residency review committees (rrc) under the accreditation council for graduate medical education (acgme). certification of the individual orthopaedic surgeon is done by the american board of orthopaedic surgery (abos). licensure to practise medicine in the united states is a function of the medical licensure board of each state. privileges, what the individual orthopaedic surgeon can do in a hospital, are the decision of each individual hospital medical board. the accreditation council for graduate medical education (acgme) has overall responsibility for the accreditation of all graduate medical education. the acgme has representatives from the american board of medical specialties, american hospital association, american medical association, association of american medical colleges and the council of medical specialty societies. the duties of institutions and residency programmes are described in the graduate medical education directory 2002-2003 published by the american medical association.' the following two paragraphs are from that publication. "the single most important responsibility of a sponsoring institution of gme (graduate medical education) is to ensure the provision of organised educational programs with guidance and supervision of the resident, facilitating the resident's professional and personal development while ensuring safe and appropriate care for patients. a resident takes on progressively greater responsibility throughout the course of a residency, consistent with individual growth in clinical experience, knowledge, and skill. the education of resident physicians relies on an integration of didactic activity in a structured curriculum with diagnosis and management of patients under appropriate levels of supervision and scholarly activity aimed at developing and maintaining life-long leaming skills. the quality of this experience is directly related to the quality of patient care, which is always the highest priority".2 the acgme accredits institutions to be certain they meet the requirements for resident educational programmes. this covers those things which are common to all residency education. residency programmes are accredited by residency review committees (rrc) which are specialty specific. the rrcs do the accreditation under authority and periodic review by the acgme. in a somewhat simplistic approach i look on the role of the acgme and rrc as assuring an orthopaedic resident that the residency programme offers him/her the opportunity of a quality education in orthopaedic surgery. education, training and accreditation whether the resident gets the education is then up to the resident and whether they learned what they needed is determined by the abos. the american board of orthopaedic surgery "exists to serve the best interests of the public and of the medical profession by establishing education standards for orthopaedic residents and by evaluating the initial and continuing qualifications and competence of orthopaedic surgeons".3 the requirements for programme accreditation and the educational requirements for certification of the resident must be and are compatible. in this manner both organisations, the acgme / rrc and abos, complement each other in the education of orthopaedic surgery residents. the rrc for orthopaedic surgery is composed of nine orthopaedic surgeons, three appointed by the american board of orthopaedic surgery, three by the american academy of orthopaedic surgeons and three by the american medical association, and one orthopaedic surgery resident who is selected by the rrc from those recommended by the programme chairmen. the orthopaedic surgeon members have a six-year appointment and the resident member has a twoyear term. support staff for the rrc are members of the acgme staff. scheduling of site visits, collection of fees for the site visits and disbursing funds are done through the acgme. all ten members of the rrc have equal votes on actions by the rrc. in addition the executive director of the american board of orthopaedic surgery is ex-officio to the rrc without vote. historical perspective in orthopaedic surgery, approval of residency programmes began informally soon after the incorporation of the american board of orthopaedic surgery: after the second world war the american medical association (ama) which was also accrediting programmes and the american board of orthopaedic surgery (abos) began working together. about 1952 there was a more formal residency review committee formed with orthopaedic surgeon representatives from the ama and the abos. the american academy of orthopaedic surgeons joined the rrc with three appointments in 1972. this brought the number of members to nine. in the 1980s the acgme was formed to oversee the rrcs and assure appropriate uniformity in the accreditation of all specialty education and institutional responsibility. a resident member was added to the rrc about four years ago to obtain direct input from the residents' viewpoint. orthopaedic surgery residency programmes must meet a set of special requirements which originate with the rrc but require acgme approval. these requirements include the following areas. all programmes are now for five years, of which four must be in orthopaedic surgery; however, one year, if in accredited resident position, may be spent in orthopaedic research. this is rarely done as most programmes want to use all four orthopaedic years in clinical residency. the first year must now be under the direction of the director of the orthopaedic surgery residency programme and must contain six months of structured education in surgery which includes vascular surgery, plastic / bum, surgical intensive care and multi-system trauma; three one month rotations selected from emergency medicine, medical/cardiac intensive care, internal medicine, neurology, neurological surgery, paediatric surgery or paediatrics, rheumatology, anaesthesiology, musculoskeletal imaging and rehabilitation. no more than three months may be spent on orthopaedic surgery. barrier ... ensuring a safe and aseptic operating environment for the patient, theatre staff and surgeon. prevents the dispersal of airborne and fluid-borne contaminants. barrier® single use surgical drapes and gowns ... manufactured to fail-safe standards, in a comprehensive range covering every surgical requirement. the barrier® range ...only from nampak tissue healthcare division. call 0860 67 33 77 for purchasing and product information the remaining four years are spent on orthopaedic rotations. the duration of the various clinical areas and subspecialty rotations are prescribed by the educational requirements of the american board of orthopaedic surgery. these include a minimum of six months of paediatric orthopaedics, 12 months of adult reconstruction and 12 months of orthopaedic trauma. most programmes include subspecialty rotations in these areas including total joints, sports medicine, hand and upper extremity surgery, orthopaedic oncology, spine surgery and foot/ankle surgery. the sponsoring institution must be the primary site where the residents have extensive experience in patient care. it is also the primary site for didactic and clinical conferences including the basic sciences. the governing body of the sponsoring institution must provide support for the programme director in meeting his duties. when other institutions are used for resident education as part of the programme there must be affiliation agreements which spell out their contribution and obligation to the programme. service is not considered a reason for a residency programme or a clinical rotation. the programme director is responsible for the content and organisation of the programme; for recruiting faculty; for obtaining adequate teaching and patient care facilities; for selecting residents; for monitoring residents' progress including support and / or disciplinary actions if needed; regular evaluation of residents' progress and informing them of their progress; and supervision of the residents. the programme director must have the authority to control the residents' educational experience in the affiliated hospitals. resident supervision and education is also a function of the attending staff. the attending staff must maintain their own academic interests, have a strong interest in teaching residents and devote adequate time to these areas. there must be at least three faculties who devote at least 20 hours a week to the programme. there must be at least one full time equivalent (45 hours per week) faculty member for every four residents in the programme. the programme must have the other professional, technical and clerical personnel to support the educational mission of the programme. ~11lnllcal aspects the clinical problems seen by the residents and available for resident education must be of sufficient variety and volume to support the educational programme. these problems must include both nonoperative and operative cases including outpatient and inpatient experience. the clinical problems must "include adult orthopaedics, including joint reconstruction; paediatric orthopaedics, including paediatric trauma; trauma, including multiple system trauma; surgery of the spine, including disk surgery, spinal trauma, and spinal deformities; hand surgery; foot surgery in adults and children; athletic injuries, including arthroscopy; metastatic disease; and orthopaedic rehabilitation, including amputations and post-amputation care"? residents must be able to demonstrate "compassionate, appropriate and effective'" patient care including preventive care. "residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices".' in the course of meeting this requirement the residents must be taught to utilise scientific studies and methods. residents must be able to demonstrate effective communication skills with patients and with professional associates. "residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population".' the residents must be able to respond and utilise the medical system in an effective manner for patient care. "resident education must include orthopaedic oncology, rehabilitation of neurologic injury and disease, spinal cord injury rehabilitation, orthotics and prosthetics, and the ethics of medical practice".' the educational programme must be such that the residents have the opportunity to take part in providing continuity of patient care. orthopaedic education must include non-operative outpatient care of appropriate orthopaedic problems. in the course of the residents' education they must be given increasing responsibility, under supervision, for patient care in keeping with their knowledge and abilities. it is important to emphasise that the patients seek an orthopaedic surgeon because they have a problem and not as cases for resident education. staff supervision is therefore a necessity to assure appropriate and quality patient care. the residency programme must have at least four hours a week of formal teaching conferences and seminars. these must be regularly scheduled and held with faculty as either presenter or discusser. these conferences should include clinical indications and treatment, outcome evaluations and basic sciences. the basic sciences must include anatomy taught with dissection and lectures; orthopaedic pathology which includes correlative pathology; biomechanics in seminars and conferences; and, organised teaching in imaging techniques and indications. the basic sciences must be integrated into the daily discussions of appropriate patient problems. the residents must have instruction in basic motor skills including the use of appropriate instruments. this instruction also includes arthroscopy. graduate medical education must take place in an environment of inquiry and scholarship. residents and the clinical staff must take part in journal clubs, clinical discussions and critical consideration of scientific articles. instruction must include experimental design, hypothesis testing and current research methods. space and support personnel for investigative studies must be provided by the programme. a list of resident and faculty research projects must be kept and be available for review. there must be library facilities with appropriate texts and journals, electronic retrieval and availability of appropriate library material at all times. evaluation the residents must be evaluated by the teaching faculty on a regular basis and the results of the evaluations must be discussed with each resident at least twice a year. the faculty should evaluate the programme including the affiliated hospitals at least annually and this should include input from resident evaluations of the programme. in this regard each programme should have written goals for the programme by year of training and by rotations including affiliated hospital rotations. the programme should use resident performance results such as the orthopaedic in-training examination (oite) and abos certifying examinations in the evaluation of the programme. each residency programme is evaluated by the rrc at least every five years and more often if the programme has difficulties, is on probation or has a change of programme director. dates for review and site visitors are determined by the rrc. the office of the secretary of the rrc for orthopaedic surgery notifies the programme to be reviewed of the date and the site visitor. the programme must complete a document giving information about the programme (programme information form pif) which includes the institutions in the programme; director and staff at each institution including the contribution from that institution and the curriculum vitae of the staff; a narrative description of the clinical programme, basic science lectures, clinical sessions, and research staff and projects; a diagram of the resident's rotations for the five years of training which includes the institution, the duration of the rotations and the clinical area; a list of the residents in the programme by year of training; the pass / fail record of the previous five years' residents on the certification examination by the american board of orthopaedic surgery; and, a list of the rotations and operative cases for the previous year's finishing residents. a copy of the programme information form is sent to the site visitor at least two weeks before the scheduled visit. the site visitor's function is to verify the information provided by the programme, address the status of previous deficiencies and clarify any parts of the pif which are unclear. the site visitor also lists any areas which he/she believes warrant special attention by the rrc. the site visitor follows a specified format called the specialist site visit report (ssvr). after the site visit three copies of the pif and the ssvr are sent to the rrc. two members of the rrc review these reports before the semi-annual meetings of the rrc and report to the full committee. these two reviewers do make recommendations for action the basis of which is deviation form the special requirements fo; residency programmes in orthopaedic surgery and from the institutional requirements. the committee may raise further questions for the programme director. the committee makes the accreditation, including the time for subsequent review and the number of residents per year and total number of residents in the programme. in 1985-1986 the rrcs for orthopaedic surgery, general surgery and plastic surgery developed special requirements for post-residency training (fellowships) in surgery of the hand. concurrent with this the respective certifying boards jointly developed an examination for added qualifications for surgery of the hand. this certifying examination like that for the american board of orthopaedic surgery is time-limited to ten years. following the accreditation of hand surgery fellowships the acgme approved the rrc for orthopaedic surgery's request to develop special requirements for fellowships in adult reconstruction, spine, paediatric orthopaedics, musculoskeletal oncology, sports medicine, foot/ankle and orthopaedic trauma. as with the accreditation of residency programmes the accreditation of fellowships gives assurance to those taking the fellowships that there is an opportunity for a quality education experience. at this time the american board of orthopaedic surgery does not offer certification examinations in any of these other fellowship areas. it is apparent from this presentation that accreditation of residency programmes in the united states is a detailed and formal process. this is necessary because of the large number of residency programmes and the diversity of sponsoring institutions, i.e. university, private hospital, county hospital and military. other countries with fewer residency programmes use different methods of accreditation and certification of orthopaedic surgeons. in 1995 i was permitted by professor einhard erken and professor roelie grabe to do a site visit very much along the lines used in the united states at the university of the witwatersrand and the university of pretoria, respectiv~ly. at that time the structure of those programmes differed from each other and to varying degrees from those in the united states. i know several south african orthopaedic surgeons and am familiar with the practice of orthopaedic surgery in south africa so i know that your system produces excellent orthopaedic surgeons. in canada all of the orthopaedic residency programmes are university-based and are accredited at the same time the university medical school is accredited. s in belgium the system is again different with the number of residents determined nationally and entrance and continuation in orthopaedic surgery dependent on examinations. the last examination at the end of the six years of residency also accredits them to practise. 6 again i know these systems produce excellent orthopaedic surgeons. in summary i have presented the accreditation of residency programmes in the united states which is a system developed to ensure the opportunity for a quality education in orthopaedic surgery. other systems in other countries also produce excellent orthopaedic surgeons. those items which are common to all residency programmes in orthopaedic surgery include dedicated programme directors and attending staff (faculty), an organised educational programme, patient care problems of sufficient number and variety, and often some research experience. the one thing that we must not forget in the increasing technology of orthopaedic surgery and the pressures for "production of orthopaedic care" is that our primary goal was and must be providing competent, compassionate and ethical care for our patients. 1. kette1kamp db. the training of orthopaedic surgeons. transactions of the college of medicine of south africa, janjun 1990;34(1):25-29. 2. graduate medical education directory, 2002-2003. american medical association, 515 n state street, chicago, il 60610. 3. 2002 rules and procedures for residency education, part i and part ii examinations. american board of orthopaedic surgery, 400 silver cedar court, chapel hill, nc 27514. 4. wickstrom, jk. history of the american board of orthopaedic surgery. 1934-1984. 5. nestler s. secretary, rrc for orthopaedic surgery, acgme, chicago, il. personal communication. 6. verdonk r. orthopaedic surgery, university hospital, gent, belgium. personal communication. pages from kettelkamp_10cropped.pdf pages from kettelkamp_11cropped pages from kettelkamp_12 pages from kettelkamp_13 wiese kr et al. sa orthop j 2020;19(1) doi 10.17159/2309-8309/2020/v19n1a4 south african orthopaedic journal http://journal.saoa.org.za arthroplasty citation: wiese kr, kock fw, blake ca, franken t, jordaan jd. the accuracy of pre-operative digital templating in total hip arthroplasty performed in a low-volume, resource-constrained orthopaedic unit. sa orthop j 2020;19(1):28-32. http://dx.doi.org/10.17159/2309-8309/2020/v19n1a4 editor: dr m held, university of cape town, cape town, south africa received: september 2018 accepted: august 2019 published: march 2020 copyright: © 2020 wiese kr, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no external funding received. conflict of interest: all authors declare there are no conflicts of interest with regard to this study. abstract aims: total hip arthroplasty (tha) is considered one of the most successful surgical procedures in modern medicine. the success of tha is well documented, and includes high patient satisfaction rates, low morbidity rates and cost-effective surgery. most publications come from tha performed in high-volume arthroplasty units, done in high-income countries. limited data is available on tha performed in low-volume, low-income countries. the aim of this study was to evaluate the accuracy of digital templating in a low-volume, resource-constrained orthopaedic unit from 2016 to 2017. we introduced a standardised hip radiography programme, followed by a stepwise pre-operative templating method. we compared the implant sizes inserted during tha with the templated sizes determined pre-operatively. this was to deduct whether digital templating in a low-volume arthroplasty unit is accurate and of the same value as digital templating done in a high-volume unit. methods: a descriptive retrospective study was conducted on all patients who received elective primary uncemented tha in a low-volume, resource-constrained orthopaedic unit. pre-operative radiographs were done according to guidelines published by scheerlinck followed by pre-operative templating using the impax orthopaedic tools® software and a stepwise technique described by bono. implanted prosthesis sizes, as recorded in operation notes, were retrospectively compared to pre-operative templating. results: a total of 56 participants were included (30 females, 26 males), with a mean age of 55.5 (32–78) years. on the acetabular side, in 71% (n=40; p<0.001) there was a cumulative difference of one implant size between the templated cup size and the actual cup size used. on the femoral side, in 79% (n=44; p<0.001) there was a cumulative difference of one implant size between the templated stem size and the actual stem size used. oversizing of the implants was more prevalent, with 20% (n=11) of the acetabular components oversized by two or more sizes and 13% (n=7) of the femoral components oversized by two or more sizes. conclusion: with the introduction of a standardised radiology programme and a stepwise templating technique, the benefits and accuracy of pre-operative templating done in a low-volume, resource-constrained orthopaedic unit is comparable to published data done in high-volume arthroplasty units. level of evidence: level 4 keywords: arthroplasty, templating, calibration, radiographs, implant, acetabulum the accuracy of pre-operative digital templating in total hip arthroplasty performed in a low-volume, resource-constrained orthopaedic unit wiese kr1 , kock fw2 , blake ca3 , franken t4 , jordaan jd5 1 mbchb; registrar, division of orthopaedic surgery, stellenbosch university, south africa ² mbchb; registrar, division of orthopaedic surgery, stellenbosch university, south africa ³ mbchb, mmed(orth); consultant, department of orthopaedic surgery, university of the free state, bloemfontein, south africa 4 mbchb, mmed(orth); consultant, department of orthopaedic surgery, worcester provincial hospital; division of orthopaedic surgery, stellenbosch university, south africa 5 mbchb, h dip orth(sa), fc orth(sa); orthopaedic surgeon, division of orthopaedic surgery, stellenbosch university, south africa corresponding author: dr karin rae wiese, division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, south africa; tel: 021 938 4911; email: karinraewiese@gmail.com http://orcid.org/0000-0003-1764-8500 https://orcid.org/0000-0003-3943-1994 https://orcid.org/0000-0002-3592-4823 https://orcid.org/0000-0003-0033-8303 https://orcid.org/0000-0002-6150-9463 page 29wiese kr et al. sa orthop j 2020;19(1) introduction total hip arthroplasty (tha) is considered one of the most successful surgical procedures in modern medicine.1 treatment goals include pain relief, restoration of normal hip biomechanics and improvement in function.1 the success of tha is well documented, with high patient satisfaction rates, low morbidity rates and cost-effective surgery.2 most of these publications come from tha performed in high-volume arthroplasty units, done in high-income countries. limited data is available on tha performed in low-volume, low-income countries. pre-operative templating for tha is considered an essential part of planning prior to performing hip arthroplasty. pre-operative templating is highly beneficial to both the surgeon and ultimately the patient as it alerts the surgeon to the need for unusual sized components or additional instruments and therefore allows for a smooth and well-planned surgery.3,4 pre-operative templating also reduces the intra-operative stress experienced by the surgeon and aids the surgeon to ensure correction of hip biomechanics. failure to obtain adequate femoroacetabular offset or the correction of limb length discrepancy following tha results in altered hip biomechanics, and thus influences the patient’s functional outcome and the longevity of the implant.3,4 both charnley and müller advocated for the use of pre-operative templating as it encourages the surgeon to think three-dimensionally, improve the precision of the surgery, reduce the length of the procedure and reduce the incidence of post-operative complications.5 digital radiography has replaced traditional radiography in most healthcare facilities worldwide.6 this led to the development and use of computer-based templating programmes instead of standard onlay templating techniques. these templating programmes rely on a calibration device in order to template accurately. for example, the use of a 20 mm radiographic marker such as a metal ball bearing, placed in a clear plastic tube, positioned at the same depth as the greater trochanter has proven to be a cost-effective, accurate and repeatable method of calibrating the size of digital radiographs.7,8 the contralateral hip is often used for templating as it is often less affected by a pathological process and offers a mirror image of the planned surgical field.7 it is thus essential to be able to see both hips on the ap pelvis radiograph. due to high costs, digital templating software is not readily available in units that perform tha in low-income countries. currently, we were unable to find any studies that analyse the accuracy of pre-operative templating in a low-volume, low-income country where tha is performed in a resource-constrained orthopaedic unit. the exact number to define the term ‘highand/or low-volume arthroplasty unit’ is not well defined in the literature. the most accepted number for a high-volume arthroplasty unit, as described by katz et al. of >100 procedures per year was used in our study.9 the surgical technique and intra-operative considerations are different for cemented and uncemented tha. in uncemented tha, the accuracy of the exact implant size is very important, either to prevent peri-operative fractures from oversized implants or subsidence from undersized implants. in cemented tha, the cement and cement mantle allow for a more forgiving implant size selection.3,4 for this reason, we specifically studied the data for uncemented implants. the aim of this study was to evaluate the accuracy of digital templating in a low-volume, resource-constrained orthopaedic unit from 2016 to 2017. we introduced a standardised hip radiography programme, followed by a stepwise pre-operative templating method. we compared the actual implant sizes, cup and stem, inserted during tha with the templated implant sizes determined pre-operatively. this was to deduce whether digital templating in a low-volume arthroplasty unit is accurate and of the same value as digital templating done in a high-volume unit. materials and methods a descriptive retrospective review was performed from 1 january 2016 to 31 december 2017 on all patients who underwent elective uncemented tha at a low-volume, secondary-level provincial hospital in south africa that has significant resource constraints. exclusion criteria included traumatic neck of femur fractures requiring tha, cemented total hip arthroplasty and hybrid systems. a total of 109 tha surgeries were performed during the two-year review period, thus on average <100 surgeries per year. of the 109 tha performed, 53 cases were excluded for neck of femur fracture cases, including cemented or hybrid tha procedures. a total of 56 elective primary uncemented total hip arthroplasties were performed during this time period. medical records, including admission notes, operation reports and radiographs were retrospectively reviewed. pre-operative radiographs were done according to guidelines published by scheerlinck.10 this included standard anteroposterior (ap) view radiographs of the pelvis and proximal femurs as well as a lateral view of the affected hip. on the radiographs, visualisation of the proximal one-third of the femur on the ap pelvis view facilitated templating of the femoral component. pre-operative templating was done by the primary surgeon, or the assisting medical officer, using the impax orthopaedic tools® software. during the pre-operative planning ward round, the templating was reviewed and the final decision was saved in the patient records. all thas were performed by a senior orthopaedic surgeon through a standard anterolateral approach. dupuy synthes® uncemented implants, the pinnacle cup and summit stem (le locle, switzerland) were used for all cases. during surgery the surgeon had access to both the electronic recording of the pre-operative templating as well as the documented implant sizes. the final implant sizes were chosen based on clinical operative feedback by the surgeon. the final implant sizes were then recorded in the operative notes. this data was analysed retrospectively and compared to the pre-operative templated size. standardised radiograph technique pre-operative radiographs were standardised according to the technique described by scheerlinck.10 this included a standing ap pelvis and lateral hip radiograph. the ap pelvis radiograph is taken in the standing position with both feet internally rotated 15 degrees. both iliac spines are placed at the same distance from the film to standardise the radiographs and ensure adequate visualisation of the femoral neck length. the radiograph beam is centred on the symphysis pubis rather than the sacrum and this is to ensure inclusion of the proximal third of the femur, which is required to perform templating of the femoral stem component. all of the pre-operative radiographs were obtained with a standardised 100 cm distance from the radiograph tube to the radiograph plate. this resulted in an average magnification of 20%±6%.6,10 in the event that the radiograph was deemed to be of poor quality, the patient was sent for repeat radiographs. although we utilise both ap and lateral radiographs as part of our radiographic workup, for the purpose of this study, we only templated from the ap radiograph. pre-operative templating the stepwise approach to digital pre-operative templating was utilised as described by bono.11 step 1 includes determining the magnification of the radiograph. this is achieved with the use of a 20 mm ball bearing marker page 30 wiese kr et al. sa orthop j 2020;19(1) inside a plastic tube (figure 1). the marker is placed between the patient’s legs, at the same depth as the greater trochanters for all pre-operative radiographs. the calibration software, impax orthopaedic tools planning module hip, uses this marker to calibrate the radiograph for templating (figure 2). step 2 consists of determining the pelvic axis. this is achieved with the ap pelvis radiograph and the templating software, which utilises the acetabular teardrop as a landmark. a line connecting the left and right acetabular teardrops serves as a reference for pelvic orientation and from this reference point, left and right limb length corrections are then accomplished. the pelvic axis also determines the appropriate abduction or inclination angle of the acetabular component ensuring that the prosthesis is placed in the correct position relative to the pelvis. step 3 involves determining whether a limb length discrepancy is present. this is accomplished by a measurement from the tip of the lesser trochanter perpendicular to the pelvic axis as determined in step 2. step 4 is to determine the centre of rotation of the hip joint. the software achieves this by importing a digital acetabular template within the osseous confines of the acetabulum. it is important to ensure that the cup is imported centrally at a 45 degree angle to the pelvic axis. step 5 is to determine the size of the femoral component. this is done by measuring the width of the medullary canal within the proximal femoral diaphysis as well as at the metaphyseal flare. with the aid of the calibration software an appropriately sized femoral stem is then selected. during step 6 the appropriately sized digital femoral component is placed within the femur in such a position as to reproduce the existing limb length or to correct for any limb length discrepancy. the combination of acetabular and femoral implants should reproduce the appropriate femoral offset of the hip with the ability to fine-tune this utilising different head length sizes. templating was routinely done during the pre-operative arthroplasty ward round by the planning surgeon. this was supervised and confirmed by the orthopaedic consultant after which it was saved on impax orthopaedic tools for later use during surgery. intra-operative decision-making intra-operatively, the surgeon had access to the pre-operative templating. the final decision on sizing was however made on clinical grounds using standard operating techniques. at the time of the surgery, the surgeons were not aware of this retrospective study that followed later. statistical analysis basic descriptive statistics were reported including differences in implants (cup and stems) between pre-operative templating and intra-operative decision-making. information such as age and sex was also recorded for basic demographic data. a chi-square test was used to detect differences between the number of participants where less than or equal to one change in template size was required compared to those who required a change of more than one size. data was analysed using excel and statistica v13. results the mean age of all participants (n=56) was 55.5 (32–78) years. of these, 54% (n=36) of the participants were female and 46% (n=20) were male. acetabular components the median difference between implant size templated and actual implant size used was 1 (interquartile range 0–2, range 0–3). the exact acetabular cup size was predicted in 30% of cases (n=17) (table i). cumulatively, in 71% of cases (n=40), the implant inserted was within one implant size (above, equal or below) of the templated acetabular cup size. in 29% of cases (n=16), the implanted cup was more than one size above the templated size (p<0.001). cumulatively in 98% (n=55) of the hips, acetabular components were within two sizes (4 mm) smaller, equal or larger than the templated size (table i). femoral stem component differences the median difference between implant size templated and actual implant size used was 1 (interquartile range 0–1, range -4–3). the exact femoral stem size was also predicted in 30% (n=17) of cases (table i). cumulatively, in 79% of cases (n=44), the implant inserted was within one implant size (above, equal or below) of the templated stem size. in 21% (n=12) the implanted stem was more than one size above or below the templated size (p<0.001). cumulatively, in 96% (n=54) of the hips, the femoral stem components were within two implant sizes of the templated size (smaller, equal to or larger) (table i). figure 1. ball bearing inside a clear plastic tube used as a marker for calibration of the radiograph figure 2. ap pelvis radiograph showing impax orthopaedic tools planning module hip calibration and templating software page 31wiese kr et al. sa orthop j 2020;19(1) outliers in our study we found that we tend to oversize both the acetabular and femoral components during pre-operative digital templating. twenty per cent (n=11) of the acetabular components were oversized by two or more sizes, and 13% (n=7) of the femoral components were oversized by two or more sizes. nine per cent (n=5) of the acetabular and femoral components were undersized by two or more sizes, respectively. males were templated more accurately than females, with 17% (n=9) of males compared to 32% (n=19) of females having an acetabular cup and femoral stem size differentiation of two or more between templated and implanted implant sizes. discussion during the last decade, the indications for tha have broadened with an increase in patients’ expectations in functional outcome and implant longevity. improvements in technology have addressed both fixation and wear issues.10 the development of pre-operative templating has allowed surgeons to focus more attention on the optimisation of hip biomechanics and to anticipate the correct implant sizing, positioning, as well as potential difficulties prior to surgery.10 the majority of studies on tha, including pre-operative templating, are conducted in high-volume arthroplasty units. katz et al. defined a high-volume arthroplasty unit as one in which >100 procedures are performed annually.9 these studies showed a significant reduction in complications following tha in higher volume units. this was due to pre-operative planning and surgeons being more comfortable and familiar with the procedure.12 we could find no publication on pre-operative templating and its benefits in a low-volume arthroplasty unit. the opinion of the senior authors was that the benefits of pre-operative templating would be equal, if not better, to the surgeons who do not perform this procedure as regularly as high-volume surgeons. the use of a stepwise approach to digital templating, such as that described by bono, ensures a repeatable and reliable method.11 pre-operative templating alerts the surgeon in difficult cases, where restoration of normal hip anatomy is not possible with standard implants, to request extended selections of implants to be available in theatre. this is important in low-volume units that do not carry a large in-hospital consignment of the full range of implants and/or revision implants.10 anyaehie et al.’s study which focused on total knee arthroplasty in a resource-constrained environment, similar to that of the public health sector of south africa, showed that the absence of ideal infrastructure and equipment alongside deficient surgical expertise are some of the reasons why many hospitals in resourceconstrained areas do not offer arthroplasty services.13 patients in these environments were also shown to present much later for joint arthroplasty. reasons for this included a preference for traditional healers; patients have easier access to their services compared to utilising hospital services with long waiting lists. further contributing to delayed presentation are cultural beliefs, together with the health-seeking behaviour of patients who accept pain and disability until they become immobile before seeking arthroplasty services. these factors lead to complex pathology with severe joint degeneration on presentation, resulting in conservative treatment no longer being an option, with arthroplasty the only solution to improve pain and function.13 the recent increased use of collared implants may be a solution to this problem, with collared uncemented stems showing improved axial and rotational stability. this prevents subsidence and aids the stem to remain in its intra-operative position.10 several studies have been published that aim to evaluate the accuracy and reliability of pre-operative templating, with results being favourable towards templating as shown by knight and atwater. implants inserted during uncemented tha within one size above or below what was templated were deemed to be adequate.14 the use of pre-operative templating encourages the surgeon to think three-dimensionally and greatly improves the precision of the surgery. this results in a potential reduction of surgical time, which has significant cost implications for all parties involved.7 the south african public health sector faces multiple challenges. it has long arthroplasty waiting lists as a result of surgical skill shortages and severe financial resource constraints. the value of having a tool like pre-operative templating available, which reduces surgical time and increases theatre efficiency while saving on long-term costs, is significant (figure 3). our results were comparable to that of gamble et al.6 who, with the use of digital pre-operative templating, showed an accurate figure 3. ap pelvis radiograph showing a recruited patient with the implant inserted on the right without the use of pre-operative templating, and the implant on the left with the use of pre-operative templating. the right hip implant is undersized, which could have significant long-term implications. table i: overview of templating size differences compared to in-situ implant sizes used component size difference count (n) per cent femoral -4 1 1.8 -3 1 1.8 -2 2 3.6 -1 11 19.6 0 17 30.4 1 16 28.6 2 8 14.3 acetabular -3 1 1.8 -2 10 17.9 -1 14 25 0 17 30.4 1 9 16.1   2 5 8.9 page 32 wiese kr et al. sa orthop j 2020;19(1) prediction in 38% of cases in terms of acetabular cup sizing (29% in our study), and 35% of cases in terms of femoral stem component sizing (30% in our study). accuracy improved dramatically to 80% (71% in our study) for acetabular cup sizing and 85% (79% in our study) for femoral stem sizing, when cases within one implant size above or below what was templated were included. considering that their study was conducted in a high-income, high-volume arthroplasty unit, our study shows that pre-operative digital templating in a low-volume, resource-constrained unit can be just as accurate and valuable. reasons for templating implant outliers (implant size bigger or smaller than two sizes from the templated size) in our dataset may have been due to human error in the templating process during the initiating stage of implementing pre-operative digital templating. surgeon experience in a low-volume unit that uses the digital templating software may also have an effect on the accuracy and reliability of templating. even with the technique being carefully applied, patient body habitus, anatomical variability, and radiograph quality may become sources of error in pre-operative templating.15,16 body mass index (bmi) was not measured as part of this study. in south africa we have the second largest female population in africa.17 a high bmi may contribute to a bigger margin of error in digital templating. this may have been the possible reason for the female predominance in our outlier group. our study has a few limitations. firstly, this study was conducted in a low-volume arthroplasty unit with only one or two elective tha cases being performed per week. these cases were not necessarily done uncemented, thus the numbers were small over the review period. reasons for outliers could be due to templating errors possibly as a result of implementation of digital templating, combined with inexperience of junior orthopaedic staff. intra and inter-observer reliability and professional experience were not specifically analysed during the templating process, and leg length discrepancy correction was not quantified preand postoperatively. conclusion the benefits of pre-operative templating have been shown in numerous studies conducted in high-volume arthroplasty units in high-income countries. the results of this study, conducted in a lowvolume, resource-constrained orthopaedic unit, are promising and comparable in accuracy to other published literature. this study confirms the multiple advantages of having digital pre-operative templating available for any orthopaedic unit that preforms tha and we strongly advocate the use of digital pre-operative templating, done in a stepwise technique, for any surgeon that performs tha currently. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study ethical approval was obtained from the following ethical review board: stellenbosch university health research ethics committee (hrec) reference number: #6534. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was not obtained from all patients for being included in the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions krw contributed to the conception and design of the work; the acquisition, analysis and interpretation of data for the work; drafting the work and final approval of the version to be submitted to the journal. fwk contributed to the acquisition, analysis and interpretation of data for the work and assisted with drafting the work. cab contributed to the conception and design of the work. tf contributed to the final approval of the version to be submitted to the journal. jdj contributed to drafting the work, revising it critically for important intellectual content, and final approval of the version to be submitted to the journal. orcid wiese kr http://orcid.org/0000-0003-1764-8500 kock fw http://orcid.org/0000-0003-3943-1994 blake ca http://orcid.org/0000-0002-3592-4823 franken t http://orcid.org/0000-0003-0033-8303 jordaan jd http://orcid.org/0000-0002-6150-9463 references 1. kahlenberg c, nwachukwu bu, schairer ww, steinhaus me, cross mb. patient satisfaction reporting after total hip arthroplasty: a systematic review. orthopedics. 2017;40(3):e400-e404. doi:10.3928/01477447-20170120-04. 2. davies p, graham s, maqungo s, harrison w. total joint replacement in sub-saharan africa: a systematic review.  tropical doctor. 2019;49(2):120-28. doi: 10.1177/0049475518822239. 3. unnanuntana a, wagner d, goodman sb. the accuracy of preoperative templating in cementless total hip arthroplasty. j arthroplasty. 2009;24(2):180-86. doi:10.1016/j.arth.2007.10.032. 4. tripuraneni kr, archibeck mj, junick dw, carothers jt, white re. common errors in the execution of preoperative templating for primary total hip arthroplasty. j arthroplasty. 2010;25(8):1235-39. doi:10.1016/j.arth.2009.10.004. 5. müller m. lessons of 30 years of total hip arthroplasty. clin orthop relat res. 1992 jan;274:12-21. 6. gamble p, de beer j, petruccelli d, winemaker m. the accuracy of digital templating in uncemented total hip arthroplasty. j arthroplasty. 2010;25(4):529-32. doi:10.1016/j.arth.2009.04.011. 7. blake c, van der merwe j, raubenheimer j. a practical way to calibrate digital radiographs in hip arthroplasty. sa orthop j. 2013;12(4):33-37. 8. sinclair vf, wilson j, jain npm, knowles d. assessment of accuracy of marker ball placement in pre-operative templating for total hip arthroplasty. j arthroplasty. 2014;29(8):1658-60. doi:10.1016/j.arth.2014.03.013. 9. katz j, et al. association of hospital and surgeon volume of total hip replacement with functional status and satisfaction three years following surgery. arthritis rheum. 2003;48:560-68. doi:10.1002/ art.10754. 10. scheerlinck t. primary hip arthroplasty templating on standaard radiographs. a stepwise approach. acta orthop belg. 2010;76:432-42. 11. bono j. digital templating in total hip arthroplasty. j bone joint surg. 2004;86:118-22. doi: 10.2106/00004623-200412002-00016. 12. laucis n, chowdhury m, dasgupta a, bhattacharyya t. trend toward high-volume hospitals and the influence on complications in knee and hip arthroplasty. j bone joint surg. 2016;98:707-12. doi:10.2106/jbjs.15.00399. 13. anyaehie u, eyichukwu g, nwadinigwe c. total knee replacement in a resource constrained environment: a preliminary report. niger j clin pract. 2017;20:369-75. doi:10.4103/1119-3077.196117. 14. knight j, atwater r. preoperative planning for total hip arthroplasty. quantitating its utility and precision. j arthroplasty. 1992;7(supp):403-409. 15. hamilton wg. the rationale for a collared titanium stem in primary total hip arthroplasty. depuy synthes, 2017. 16. mclawhorn a, nam d, mcarthur b, cross m, su e. preoperative templating and its intraoperative applications for hip resurfacing arthroplasty. am j orthop. 2012;41:e157-62. 17. puoane t, steyn k, bradshaw d, laubscher r, fourie j, lambert v, mbananga n. obesity in south africa: the south african demographic and health survey. obesity research. 2002;10:1038-48. doi:10.1038/oby.2002.141 http://orcid.org/0000-0003-1764-8500 http://orcid.org/0000-0003-3943-1994 http://orcid.org/0000-0002-3592-4823 http://orcid.org/0000-0003-0033-8303 http://orcid.org/0000-0002-6150-9463 _goback _hlk26962178 _goback south african orthopaedic journal general orthopaedics doi 10.17159/2309-8309/2022/v21n1a3dunn c et al. sa orthop j 2022;21(1) citation: dunn c, held m, laubscher m, nortje m, roche s, dunn r. orthopaedic surgical training exposure at a south african academic hospital – is the experience diverse and in depth? sa orthop j 2022;21(1):22-28. http://dx.doi.org/10.17159/23098309/2022/v21n1a3 editor: prof. leonard c marais, university of kwazulu-natal, durban, south africa received: april 2021 accepted: august 2021 published: march 2022 copyright: © 2022 dunn c. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background with increasing pressure on our training hospitals, we undertook to ascertain whether our clinical orthopaedic surgery training platform is providing adequate surgical exposure, both in diversity and the level of trainee participation. methods the orthopaedic surgery database was interrogated for theatre procedures logged for the 12-month period 1 january to 31 december 2018. each theatre case was assessed as to the level of trainee participation, whether it was performed during or after hours, and categorised as being elective or trauma in nature, as well as the orthopaedic subdiscipline. results a total of 3 147 orthopaedic surgical procedures were logged with an even split of elective (51.1%) and trauma (49.9%) cases. adults predominated in the trauma group while the paediatric service contributed most to the elective cases, followed by arthroplasty and spine. overall, 25.5% of procedures were performed by consultants and 74.5% by registrars. registrars were more frequently the primary surgeon in trauma cases (90%) compared to elective procedures (59%) (p < 0.001). of the elective cases, 37% were performed by registrars as supervised unscrubbed and 22% as supervised scrubbed operations. in total, 17.5% of cases were performed after hours, with 31.7% of trauma surgeries and only 2.9% of elective surgeries occurring after hours. registrars were the primary surgeon in 98.7% of after-hours trauma cases and 58% of afterhours elective cases under unscrubbed supervision. conclusion our study presents the surgical experience and level of participation available to orthopaedic surgical trainees in a south african training hospital where their exposure was an equal number of elective and trauma cases. the vast majority of the cases were performed by the registrars in their supervised unscrubbed capacity although the more complex, elective cases were performed by consultants. almost all after-hours trauma cases were performed by registrars. this suggests the platform allows for a high level of registrar surgical participation and training despite the challenges. further review is required to assess achievement of trainee competency and whether in fact the current experience is adequate. level of evidence: level 4 keywords: orthopaedic registrar surgical experience, south african orthopaedic training exposure, orthopaedic case exposure orthopaedic surgical training exposure at a south african academic hospital – is the experience diverse and in depth? cara dunn,1 michael held,2,3 maritz laubscher,2,3 marc nortje,2,3 stephen roche,2,3 robert dunn2,3* 1 mbchb student, university of cape town, cape town, south africa ² division of orthopaedic surgery, groote schuur hospital, university of cape town, cape town, south africa ³ orthopaedic research unit, university of cape town, cape town, south africa *corresponding author: robert.dunn@uct.ac.za introduction the practice of surgery encompasses both technical skills and an academic knowledge base which, traditionally, was transferred from teacher to student in an apprenticeship fashion. the concept of a more structured registrar training programme was initiated in 1880 in germany to be followed by the united states (us) in 1889.1 today there are many variations globally with different entry levels, durations, experience and assessment processes.2 however, this fundamental mentorship of a trainee, transforming them from a novice to specialist and ready for independent practice, is challenged both by the sheer volume and diversity of modern orthopaedic surgical practice. in addition, there is increasing concern around reduced contact time by work hour reduction particularly in the us and united kingdom (uk.)3,4 there is also a loss of trainee autonomy with more consultant-performed surgery, possibly due to financial arrangements and medicolegal risk.5 locally there are different challenges imposed by underresourced, overburdened teaching hospitals. service demands influence the spectrum of pathology managed with a bias towards trauma, risking an incomplete training. the pressure of limited theatre access time risks reducing trainee participation in elective surgery and paradoxical inadequate supervision while they perform complex trauma cases at night.6-8 https://orcid.org/0000-0002-3689-0346 page 23dunn c et al. sa orthop j 2022;21(1) as most examination processes are academic, success in this area does not necessarily confirm well-trained, safe surgeons. we attempt to ascertain whether our clinical training platform is providing adequate surgical exposure, both in diversity as well as the level of trainee participation. methods the training programme the registrar rotation entry criterion at our institution is the college of medicine of south africa (cmsa) 1b intermediate examination. this exam requires a minimum of one year of orthopaedic surgery, three months general surgery and three months accredited intensive care (icu) experience with single best answer exams on orthopaedic principles and the care of the surgical patient. we run a pre-registrar medical officer training programme at our surrounding level 2 hospitals where these junior doctors work while obtaining the required qualification. by the time they join the registrar rotation, they are generally competent in limb fracture management, able to plate and nail fractures independently, and ready for more complex work. due to the competitive nature of the rotation, they usually have more than the minimum experience. the registrar rotation once on the programme, the trainee will spend 18–21 months in the trauma firms (three months being paediatric), six months hand unit, six months paediatric unit, six months spine/foot and ankle, six months upper limb, six months lower limb/oncology, and invariably three months on a relief slot. sixteen funded and five self-funded registrars are on the programme supported by 11 fulltime and three sessional consultants. surgical exposure in each block, trainees will work with the consultant/fellow team predominantly in their discipline but on occasion with some involvement in other clinics and calls. based on the consultant’s assessment of the trainee’s competence, they will be allowed to observe, assist or perform the procedure under supervision. database all surgical cases are captured on a bespoke orthopaedic research electronic data capture (redcap) based database.9,10 redcap is a secure, web-based software platform designed to support data capture for research studies. it provides an intuitive interface for validated data capture, audit trails for tracking data manipulation and export procedures, automated export procedures for seamless data downloads to common statistical packages and procedures for data integration and interoperability with external sources. the software is provided to our institution at no cost. we have customised it to facilitate our departmental requirements and have institutional ethics approval to use it for research purposes (r039/2013). redcap was queried to identify all orthopaedic surgical procedures performed at groote schuur hospital (gsh), red cross children’s hospital (rxh) and maitland cottage home (mch) for the year 1 january to 31 december 2018. this included all trauma and elective procedures except hand surgery, which unfortunately was not yet logged during this period. the following data fields were exported to a microsoft excel spreadsheet: date, hospital, procedure start time, firm, hospital folder number, primary surgeon, assistant surgeon, status of surgery (with regard to registrar role), category of surgery, anatomical site of surgery, and description of surgery. using a list of consultants’ and registrars’ names, each surgery was determined to have been performed by either a consultant or registrar, and the level of supervision from a trainee perspective was noted. therefore, consultant surgeries were labelled ‘assisting’; registrar surgeries with a consultant scrubbed in were labelled ‘supervised scrubbed’; and surgeries where the registrar was the primary surgeon but the consultant was not present in theatre were classified as ‘supervised unscrubbed’. despite the physical absence of the consultant, prior discussion and planning of the surgery takes place with the registrar, and the consultant is available by telephone; therefore, no surgeries were classified as ‘not supervised’. procedures were classified as ‘after hours’ if outside 07h30 and 17h00 or saturday/sunday. elective procedures with a missing procedure start time but occurring on a weekday were assumed to elective – paediatric non-trauma 15% elective – spine 8% elective – oncology 3% elective – arthroplasty 7% elective – foot/ankle 5% elective – knee 5% elective – upper limb 6% trauma – asci 1% trauma – paediatric 6% trauma – a-f 41% elective – limb reconstruction unit 3% figure 1. pie chart of the distribution of total surgeries occurring at gsh, rxh and mch in 2018 across firms page 24 dunn c et al. sa orthop j 2022;21(1) be ‘work hours’. trauma procedures without procedure start time were omitted from this part of the analysis. elective surgeries were divided into the respective firms: limb reconstruction, upper limb, spine, knee, arthroplasty, oncology, foot/ankle and paediatric non-trauma. trauma surgeries were divided into the general four firms, the acute spinal cord injury (asci) unit and paediatric trauma. procedures were divided into categories as per the database options of amputation, arthroplasty, arthroscopy, arthrotomy, closed reduction percutaneous pinning (crpp), external fixator (ex-fix), manipulation under anaesthetic (mua), open reduction internal fixation (orif) nail, orif plate, orif other (including titanium elastic nail system [tens] nail, cannulated screws, k-wires, dynamic hip screws), osteotomy, spinal, soft tissue – botox, soft tissue – lengthening, soft tissue – biopsy, soft tissue – arthrodesis, soft tissue – removal of hardware, and soft tissue – other. these categories were further divided into anatomical sites. these were all analysed in terms of the registrar participation, namely, assist, supervised scrubbed and supervised unscrubbed. microsoft excel was used to produce graphical representations of the data. quantitative analysis was done, and fisher’s exact test used for the categorical data. results during the 2018 year, 3 147 orthopaedic surgical procedures were logged. they were evenly split with 50.1% elective (n = 1 603) and 49.9% trauma (n = 1 544). this excludes hand surgeries, which were not logged. figure 1 represents the overall distribution where adult trauma represented 41%, paediatric trauma 6% and acute spine 1%. the paediatric service contributed the biggest proportion of elective cases, followed by spine, arthroplasty and upper limb firms. surgeon and level of supervision overall, 25.5% of surgeries were primarily performed by consultants and 74.5% were primarily performed by registrars. registrars were more frequently the primary surgeon in trauma cases (90%) compared to elective procedures (59%) (p < 0.001). largely, registrars were supervised unscrubbed in 60.3% of cases and supervised scrubbed in 14.1% of cases. this was more skewed in trauma surgery where registrars performed 90% of the cases, with 84% supervised unscrubbed and only 6% supervised scrubbed (figure 2). more than 50% of trauma cases in all categories of surgery were performed by registrars supervised unscrubbed except for arthroplasty procedures where of the 80 cases, 24 were performed by consultants, 34 by registrars supervised unscrubbed and 22 cases by registrars supervised scrubbed. the only trauma surgery that had significantly more consultant cases than registrar cases was pelvic orif-plating (23/31 cases by consultant). of the elective cases, 37% were performed by registrars as supervised unscrubbed and 22% supervised scrubbed. consultants performed more than 50% of elective cases in each of the categories of shoulder arthroplasty (14/25), ankle arthroplasty (100%, 5/5), knee arthroscopy (56/78), elbow ex-fix (100%), orifnail lower leg (8/12), orif-plate upper arm (6/9), orif-plate ankle (8/12), osteotomy upper leg (11/17), spinal thoracolumbar (27/34), and soft tissue lengthening (16/20). registrars performed more than 65% of elective cases in each of the categories of amputation, arthrotomy, crpp, mua, biopsy, and removal of hardware, with more than 50% of the surgeries in each category performed supervised unscrubbed. surgery after hours generally, 17.5% of cases were performed after hours, with 31.7% of trauma surgeries occurring after hours compared to only 2.9% of elective surgeries (p < 0.001). orif-plate, orif-nail and soft tissue procedures predominated (figure 3). registrars were the primary surgeon in 98.7% of after-hour trauma cases and 58% of after-hour elective cases as supervised unscrubbed. no cases were supervised scrubbed, with the balance being performed by consultants. categories of surgery and general anatomical site exposure trauma surgeries consisted of three main categories of surgery in terms of frequency, namely, orif-plate (25%), soft tissue procedures (including general soft tissue procedures, biopsy and 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% p er ce nt ag e of s ur ge rie s elective reg. supervised unscrubbed reg. supervised scrubbed consultant 596 1 303 88 153 1 899 444 804 356 651 trauma type of surgery total figure 2. a stacked bar chart showing proportions of surgeries performed by either consultant or registrar (reg.) with their level of supervision for elective and trauma surgeries at gsh, rxh and mch in 2018 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% p er ce nt ag e of s ur ge rie s elective reg. supervised unscrubbed reg. supervised scrubbed consultant trauma type of after-hours surgery figure 3. a stacked bar chart representing the proportion of afterhours trauma and elective surgeries performed by either consultants or registrars, with the relevant level of supervision at gsh, rxh and mch in 2018 page 25dunn c et al. sa orthop j 2022;21(1) removal of hardware) (25%), and orif-nail (22%). osteotomy, closed reduction/percutaneous pinning and arthroscopy trauma cases were very infrequent (figure 4). the three main categories of elective surgeries were soft tissue combined (botox, lengthening, biopsy, arthrodesis, removal of hardware, general procedures; 30%), arthroplasty (22%), spinal surgery (16%). overall, trauma surgeries predominate categories of ex-fix, mua and orif surgeries, whereas elective surgeries are predominant in all other categories of surgeries except for amputation and soft tissue general which have a more even distribution of trauma and elective cases as shown in tables i and ii. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% p er ce nt ag e of s ur ge rie s elective spine lower limb upper limb trauma type of surgery performed by registrar total figure 4. a stacked bar chart showing the proportions of logged cases to the broad anatomical sites in elective and trauma surgeries occurring at gsh, rxh and mch in 2018 table i: trauma surgeries and the level of the primary surgeon reg. supervised scrubbed reg. supervised unscrubbed consultant total ex-fix ex-fix upper leg (incl. knee, pelvis) 0 16 0 16 ex-fix lower leg (incl. ankle, foot) 1 50 2 53 ex-fix arm (upper, lower, wrist, elbow) 0 13 0 13 1 79 2 82 mua elbow 0 47 0 47 lower arm (incl. wrist) 0 20 0 20 upper arm (incl. shoulder) 1 3 0 4 upper leg (incl. hip, knee) 0 12 1 13 lower leg (incl. foot, ankle) 0 16 0 16 1 98 1 100 orif – nail hip 1 17 1 19 upper leg (incl. knee) 6 153 3 162 lower leg (incl. foot, ankle) 4 118 12 134 upper arm (incl. shoulder) 1 11 2 14 lower arm (incl. elbow) 0 14 1 15 12 313 19 344 orif – plate upper arm 10 44 2 56 lower arm 4 36 0 40 upper leg 4 31 0 35 lower leg 1 24 5 30 shoulder 3 7 2 12 elbow 1 25 3 29 wrist 0 16 2 18 pelvis 4 4 23 31 hip 1 37 6 44 knee 6 9 0 15 ankle & foot 6 50 16 72 40 283 59 382 amputation upper leg (incl. knee) 1 7 0 8 lower leg (incl. foot) 0 6 0 6 upper arm 0 2 0 2 1 15 0 16 arthroplasty upper leg (incl. pelvis) 1 4 1 6 hip 21 29 22 72 arm (incl. shoulder, elbow) 0 1 1 2 22 34 24 80 arthroscopy 0 2 1 3 arthrotomy 0 18 1 19 osteotomy 2 2 1 5 soft tissue – remove hardware 0 15 5 20 soft tissue – biopsy 0 12 2 14 soft tissue chest/spine/head 0 4 0 4 upper arm 0 17 1 18 lower arm 0 16 1 17 upper leg 2 26 3 31 lower leg 1 111 4 116 shoulder 0 13 0 13 elbow 0 11 0 11 wrist 1 0 0 1 pelvis 0 10 3 13 hip 0 15 2 17 knee 3 31 0 34 ankle & foot 1 64 5 70 8 314 19 345 spine cervical 0 18 4 22 continued on next page page 26 dunn c et al. sa orthop j 2022;21(1) table i continued cervicothoracic 0 2 0 2 thoracic 1 12 1 14 thoracolumbar 0 6 0 6 lumbar 0 6 4 10 chest 0 1 0 1 wound washout/biopsy 0 2 0 2 1 47 9 57 crpp 0 2 3 5 orif – other head 0 1 0 1 upper arm (incl. shoulder) 0 4 0 4 lower arm (incl. elbow, wrist) 0 22 0 22 hip 0 8 1 9 upper leg (pelvis, knee) 0 19 3 22 lower leg (foot, ankle) 0 11 3 14 0 65 7 72 table ii: elective surgeries and the level of the primary surgeon reg. supervised scrubbed reg. supervised unscrubbed consultant total amputation leg (upper, lower, hip, knee) 3 10 8 21 foot 3 2 0 5 arm (lower, upper) 0 1 2 3 6 13 10 29 arthroplasty shoulder 7 4 14 25 elbow 2 3 5 10 hip & pelvis 66 43 57 166 knee 41 46 66 153 ankle 0 0 5 5 116 96 147 359 arthroscopy shoulder 31 12 26 69 hip 1 1 2 4 knee 9 13 56 78 ankle 0 2 3 5 elbow/foot 0 1 1 2 41 29 88 158 arthrotomy 0 14 0 14 crpp hip 2 6 1 9 leg (foot, knee, lower, upper) 1 3 1 5 3 9 2 14 ex-fix upper leg (knee) 2 1 2 5 lower leg 7 13 14 34 elbow 0 0 3 3 9 14 19 42 mua hip & pelvis 4 5 1 10 upper leg (knee) 0 9 5 14 lower leg (foot) 1 3 1 5 arm (upper, lower, elbow) 0 8 3 11 5 25 10 40 orif – nail arm (upper, lower) 0 2 0 2 hip & upper leg 6 3 4 13 lower leg 4 0 8 12 10 5 12 27 orif – plate shoulder 3 1 3 7 upper arm 2 1 6 9 elbow 1 3 2 6 hip, pelvis, upper leg 3 2 3 8 knee 3 4 2 9 lower leg 1 2 0 3 ankle 0 4 8 12 foot 3 1 4 8 16 18 28 62 orif – other arm (incl. elbow, shoulder) 0 2 4 6 hip & upper leg 2 5 2 9 lower leg 1 2 3 6 foot 2 0 1 3 5 9 10 24 osteotomy full leg 2 1 2 5 hip & pelvis 3 3 6 12 upper leg 5 1 11 17 knee 2 1 2 5 lower leg 5 10 8 23 ankle &foot 12 4 9 25 shoulder 2 0 3 5 arm (elbow, lower, wrist) 3 3 0 6 34 23 41 98 spinal cervical 4 31 16 51 cervicothoracic 0 3 2 5 thoracic 1 22 11 34 thoracolumbar 0 7 27 34 lumbar 5 30 19 54 lumbosacral 1 10 11 22 chest 0 2 1 3 revision 0 8 4 12 washout/biopsy/removal of hardware 1 30 3 34 12 143 94 249 continued on next page page 27dunn c et al. sa orthop j 2022;21(1) discussion this is the first south african paper to attempt to quantify the orthopaedic surgical exposure available to trainees and their level of participation in the surgery. data collection is a ubiquitous problem with hospital systems seldom capturing useful enough clinical information and it largely being inaccessible to analyse. our orthopaedic department has maintained some individual unit databases since 2001, but a universal collection database was only instituted in 2011. this was maintained physically on the main theatre computer which created access problems and risk of data loss. in 2017 we converted to redcap which is cloud-based and accessible via the internet. this allows trainees to enter data from any internet-connected device, which has markedly increased compliance. as it is now used for mortality and morbidity meetings and career progression logbooks, the compliance is much higher. with a recent ‘white listing’ of the redcap site, meaning it is accessible on any hospital pc irrespective of internet access status, compliance is further improved as all hospital intranet pcs can be used. as always this requires buy-in. at the time of this review, our hand unit had their reservations due to high-volume, shortduration procedures. their non-compliance led to no day case hand data being captured. they have subsequently seen the value of database contribution. from our m&m data (personal data of senior author), the hand unit processes around an additional 2 600 outpatient surgeries a year with about a third for sepsis, a third trauma and a third elective cases, where the bulk of the electives are carpal tunnel and trigger releases. the vast majority of these cases follow the above trauma surgery trend of registrar surgery supervised unscrubbed. our data highlights the high proportion of trauma cases. this is often a criticism of our training as there is less elective training occurring. lawrence compared the south african (sa) trauma load to the uk and found a more varied profile and higher case load in sa.11 our data is a snapshot of a year’s cases, and not a registrar’s total experience. as registrars will spend more time rotating through the elective firms than in trauma, the total experience will be more balanced. greensmith et al. compared the uk and sa general surgical logbooks in two six-month windows during 1992–3 and 2009–12. they found that due to reduced uk work hours, the south african trainee completed 15% more hours per week in 2009–10. while elective cases predominated in the uk, the rsa trauma cases were substantial at 21–26%. the uk trainee was reduced from 72% to 30% as primary operator in the latter period, with the sa trainee consistent at 80%.3 the emphasis of different areas of training is a vexing issue often driven more by local personalities than science. this is really dictated by what product is desired at the end of training. in sa this is complicated by public practice being largely trauma and emergency driven with private practice requiring the trauma skills when starting out but usually maturing to management of elective pathologies. the requirements have not been formally defined locally. kohring et al. compared the us early career profile with training case load by comparing 4 329 561 registrar cpt codes and 413 370 procedures performed by board-registered surgeons in the three-year period following registration. they generally correlated well other than spine instrumentation which was done less once in practice. of course, the training may well influence case load choice.12 the milieu is constantly changing with the junior doctor experience at risk. rashid assessed uk junior doctor experience in trauma and orthopaedic surgery during their core surgical training before the start of higher surgical training in their chosen speciality. they reviewed the clinical duties of 935 doctors over a five-day period. only 8.5% of their time was spent in theatre with 35% in the ward and 21% off duty post call. only 5% of these junior surgical trainees met their minimal clinical exposure standards where two trauma operation sessions, one elective surgery session and one fracture clinic is expected. they also did not meet the required five consultant supervised sessions a week.5 registrars may well enter the training programmes with a lower level of skills than before, placing more emphasis on acquiring experience during their rotation. this development is further challenged by the loss of surgical autonomy of the trainee where ‘see one, do one, teach one’ is no longer acceptable to many. with higher productivity demands by institutions, theatre time at a premium, increased supervision requirements and patient safety concerns, the consultants tend to operate rather than assist.13 this is less of an issue locally, and especially in trauma where the trainees perform the bulk of the surgery. in fact, in our department, if it were not for the bulk of the straightforward trauma being processed after hours, little elective work would be possible. this leads to the number of cases required for competence to be discussed with little science and often unrealistic expectations. stotts et al. surveyed us programme directors and early practice surgeons as regards the commonest procedures. recently qualified surgeons consistently reported higher numbers required table ii continued soft tissue – botox leg (full, upper, lower) 9 9 17 35 arm (upper, lower, wrist) 1 2 3 6 both (u/l limb) 0 4 6 10 10 15 26 51 soft tissue – lengthening 1 3 16 20 soft tissue – biopsy upper leg 1 8 3 12 lower leg 1 6 3 10 hip & pelvis 2 3 1 6 knee 0 6 1 7 ankle & foot 1 2 1 4 upper arm & shoulder 0 2 3 5 5 27 12 44 soft tissue – arthrodesis 3 3 9 15 soft tissue – removal of hardware 14 21 13 48 soft tissue – other shoulder 5 3 9 17 upper arm 1 1 3 5 elbow 2 3 5 10 lower arm 1 0 4 5 wrist 0 5 1 6 hip & pelvis 3 16 6 25 upper leg 1 8 7 16 knee 6 22 7 35 lower leg 13 22 28 63 ankle 25 26 16 51 foot 9 21 24 70 full leg 0 1 3 4 u/l limb 0 1 1 2 66 129 114 309 page 28 dunn c et al. sa orthop j 2022;21(1) for training than programme directors and both exceeded the national accreditation minimum numbers set. although most adult procedural experience was recommended in the 20–30 range, directors suggested 36 knee arthroplasties and recently qualified surgeons 50. likewise, 40 and 50 cases respectively for total hip replacement and 10 and 20 for shoulder arthroplasty were suggested.14 with the explosion of orthopaedic-associated technology and procedures this is clearly not attainable in a reasonable training period. this does not account for the translational skills where operative learning in high volume trauma procedures is carried across to other lower volume elective procedures in well-trained hands supported by academic knowledge and the ability to think. this all begs for evolution of teaching methods. there is an increased interest in simulation training. simulation ranges from simple knot-tying practice to complex it virtual reality assisted tasks.1,15 newer technology provides haptic feedback where the sense of touch, motion and proprioceptive feedback can be delivered, allowing the requisite skills to be developed. strom et al. confirmed better performance after a period of abdominal diathermy haptic training.16 these technologies are expensive and not readily available locally; however, cadaver-based courses are. our department runs monthly workshops for our trainees to perform procedures on cadavers. these have to be well structured to maximise the learning outcomes.17 simulation can never replace the real thing but may prepare the surgeon to maximally benefit from less live surgery training, making the process safer and more efficient. there is no doubt that surgery is not only a technical exercise but also an emotional challenge with a need to learn to override one’s anxiety and deal with trouble when it occurs. unlike simulation, where you can simply restart, surgeons have to complete whatever they are faced with in the real patient with all the fears and inadequacies they have. this ability to ‘cope’ is just as important to learn and practise as is the technical execution.4,18 conclusion our study presents the surgical experience and level of participation available to orthopaedic surgical trainees in a south african training hospital where their experience is an equal number of elective and trauma cases. most of the cases were performed by the registrars in the supervised unscrubbed capacity although the more complex, elective cases were performed by consultants. almost all afterhour trauma cases were performed by registrars. this suggests the platform allows for a high level of registrar surgical participation and training despite the challenges. further review is required to assess achievement of trainee competency and whether in fact the current experience is adequate. ethics statement all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, ethical approval was obtained from the following ethical review board: university of cape town human research ethics committee (r039/2013). declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions cd: data collection, initial analysis and first draft preparation mh, ml: data capture, study design, supervision of data collection, manuscript review and revision mn, sr: data capture, study design, manuscript review and revision rd: study conceptualisation, study design, supervision of data collection, data analysis, manuscript revision, submission orcid held m https://orcid.org/0000-0002-0671-0439 laubscher m https://orcid.org/0000-0002-5989-8383 nortje m https://orcid.org/0000-0002-7737-409x roche s https://orcid.org/0000-0002-5695-2751 dunn r https://orcid.org/0000-0002-3689-0346 references 1. fritz t, stachel n, braun bj. evidence in surgical training a review. innov surg sci. 2019;4(1):7-13. https://doi.org/10.1515/iss-2018-0026. 2. marais lc, dunn r. teaching and training in orthopaedics. sa orthop j. 2017;16(4).15-19 3. greensmith m, cho j, hargest r. changes in surgical training opportunities in britain and south africa. int j surg. 2016;25:76-81. https://doi.org/10.1016/j.ijsu.2015.11.052. 4. kalun p, wagner n, yan j, et al. surgical simulation training in orthopedics: current insights. adv med educ pract. 2018;9:125-31. https://doi.org/10.2147/amep.s138758. 5. bota collaborators, rashid ms. an audit of clinical training exposure among junior doctors working in trauma & orthopaedic surgery in 101 hospitals in the united kingdom. bmc med educ. 2018;18(1):1. https://doi.org/10.1186/s12909-017-1038-5. 6. kruger d, veller mg. exposure to key surgical procedures during specialist general surgical training in south africa : general surgery. s afr j surg. 2014;52(4):96-100. https://doi. org/10.7196/sajs.2162. 7. norman r, matzopoulos r, groenewald p, bradshaw d. the high burden of injuries in south africa. bull world health organ. 2007;85(9):695-702. https://doi.org/10.2471/blt.06.037184. 8. seedat m, van niekerk a, jewkes r, et al. violence and injuries in south africa: prioritising an agenda for prevention. lancet. 2009;374(9694):1011-22. https://doi.org/10.1016/ s0140-6736(09)60948-x. 9. harris pa, taylor r, minor bl, et al. the redcap consortium: building an international community of software platform partners. j biomed inform. 2019;95:103208. https://doi. org/10.1016/j.jbi.2019.103208. 10. harris pa, taylor r, thielke r, et al. research electronic data capture (redcap)--a metadata-driven methodology and workflow process for providing translational research informatics support. j biomed inform. 2009;42(2):377-81. https://doi.org/10.1016/j. jbi.2008.08.010. 11. lawrence je, khanduja v. from cape town to cambridge: orthopaedic trauma in contrasting environments. world j orthop. 2016;7(5):308-14. https://doi.org/10.5312/wjo. v7.i5.308. 12. kohring jm, bishop mo, presson ap, et al. operative experience during orthopaedic residency compared with early practice in the u.s. j bone joint surg am. 2018;100(7):60516. https://doi.org/10.2106/jbjs.17.01115. 13. dougherty pj, cannada lk, murray p, osborn pm. progressive autonomy in the era of increased supervision: aoa critical issues. j bone joint surg am. 2018;100(18):e122. https://doi.org/10.2106/jbjs.17.01515. 14. stotts ak, kohring jm, presson ap, et al. perceptions of the recommended resident experience with common orthopaedic procedures: a survey of program directors and early practice surgeons. j bone joint surg am. 2019;101(113):e63. https://doi.org/10.2106/ jbjs.18.00149. 15. atesok k, macdonald p, leiter j, et al. orthopaedic education in the era of surgical simulation: still at the crawling stage. world j orthop. 2017;8(4):290-94. https://doi. org/10.5312/wjo.v8.i4.290. 16. strom p, hedman l, särnå l, et al. early exposure to haptic feedback enhances performance in surgical simulator training: a prospective randomized crossover study in surgical residents. surg endosc. 2006;20(9):1383-88. https://doi.org/10.1007/ s00464-005-0545-3. 17. klima s, cornwall j, kieser d, hammer n. the utility and benefit of a newly established postgraduate training course in surgical exposures for orthopedic and trauma surgery. arch orthop trauma surg. 2019;139(12):1673-80. https://doi.org/10.1007/s00402-019-03189-5. 18. kneebone r, aggarwal r. surgical training using simulation. bmj. 2009;338:b1001. https:// doi.org/10.1136/bmj.b1001. https://orcid.org/0000-0002-0671-0439 https://orcid.org/0000-0002-5989-8383 https://orcid.org/0000-0002-7737-409x https://orcid.org/0000-0002-5695-2751 https://orcid.org/0000-0002-3689-0346 https://doi.org/10.1515/iss-2018-0026 https://doi.org/10.1016/j.ijsu.2015.11.052 https://doi.org/10.2147/amep.s138758 https://doi.org/10.1186/s12909-017-1038-5 https://doi.org/10.7196/sajs.2162 https://doi.org/10.7196/sajs.2162 https://doi.org/10.2471/blt.06.037184 https://doi.org/10.1016/s0140-6736(09)60948-x https://doi.org/10.1016/s0140-6736(09)60948-x https://doi.org/10.1016/j.jbi.2019.103208 https://doi.org/10.1016/j.jbi.2019.103208 https://doi.org/10.1016/j.jbi.2008.08.010 https://doi.org/10.1016/j.jbi.2008.08.010 https://doi.org/10.5312/wjo.v7.i5.308 https://doi.org/10.5312/wjo.v7.i5.308 https://doi.org/10.2106/jbjs.17.01115 https://doi.org/10.2106/jbjs.17.01515 https://doi.org/10.2106/jbjs.18.00149 https://doi.org/10.2106/jbjs.18.00149 https://doi.org/10.5312/wjo.v8.i4.290 https://doi.org/10.5312/wjo.v8.i4.290 https://doi.org/10.1007/s00464-005-0545-3 https://doi.org/10.1007/s00464-005-0545-3 https://doi.org/10.1007/s00402-019-03189-5 https://doi.org/10.1136/bmj.b1001 https://doi.org/10.1136/bmj.b1001 _hlk68704858 404 not found 404 not found hilton tl et al. sa orthop j 2019;18(2) doi 10.17159/2309-8309/2019/v18n2a5 south african orthopaedic journal http://journal.saoa.org.za orthopaedic oncology citation: hilton tl, wiese kr, hosking kv, hoffman eb. proximal fibular resections for primary bone tumours: oncological and functional results of a case series. sa orthop j 2019;18(2):44-48. http://dx.doi.org/10.17159/2309-8309/2019/v18n2a5 editor: prof tlb le roux, university of pretoria, south africa received: october 2018 accepted: march 2019 published: may 2019 copyright: © 2019 hilton tl, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no external funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: resection of aggressive benign or malignant tumours of the proximal fibula are difficult due to the high number of surrounding anatomical compartments and close association with many important neurovascular and functional structures. for the same reasons malignant tumours behave differently in this area. before the 1980s results were poor. with the introduction of neoadjuvant chemotherapy and limb salvage surgery, malawer described a technique of local en bloc resection. this study presents the oncological and functional results of a case series using this technique. patients and methods: a retrospective folder review of 14 patients was done. six patients with a large active, an aggressive benign or a low-grade malignant tumour had a malawer type i marginal resection, and eight patients with a stage iib malignant sarcoma had a malawer type ii wide intracompartmental resection sacrificing the common peroneal nerve. the follow-up at a median of 38 months included the imaging, histology and a functional msts score. results: the median age of the type i resections was 42.5 years; giant cell tumour was the commonest tumour (50%); and the median functional msts score at follow-up was 29. the median age of the type ii resections was 12 years; osteoblastic osteosarcoma was the commonest tumour (75%); and the median functional msts score was 26. all type ii resections achieved clear margins at the initial surgery and there were no recurrences or metastases in either group. there were no wound complications and no vascular complications in spite of sacrificing the tibialis anterior artery in some type i and all type ii resections, and the peroneal artery in type ii resections. no patient complained of knee instability. the main functional impairment was due to loss of common peroneal function which required an afo in some patients and a tibialis posterior tendon transfer in one patient. conclusions: resection of benign and malignant tumours of the proximal fibula achieved good cure rates and functional results, despite the sacrifice of the common peroneal nerve. level of evidence: level 4 key words: benign aggressive and malignant primary bone tumours, proximal fibula, malawer procedure proximal fibular resections for primary bone tumours: oncological and functional results of a case series hilton tl¹ , wiese kr² , hosking kv³ , hoffman eb4 ¹ mbchb(uct), da(sa), dippec(sa), fcorth(sa), mmed(uct); orthopaedic consultant, groote schuur & vincent pallotti hospitals, cape town, university of cape town, south africa 2 mbchb (uct), orthopaedic registrar, division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, south africa 3 mbchb(uct), fcorth(sa), orthopaedic consultant, vincent pallotti life orthopaedic hospital, cape town, university of cape town, south africa 4 mbchb(us), fcs orth(sa), emeritus associate professor, university of cape town, south africa corresponding author: dr tl hilton, 11 clive street, vredehoek, cape town, 8000; email: tlhilton@hotmail.com; cell phone: 0027 (82) 796 7608 https://orcid.org/0000-0002-6178-5062 https://orcid.org/0000-0003-1764-8500 https://orcid.org/0000-0002-3557-0252 https://orcid.org/0000-0001-5954-0069 page 45hilton tl et al. sa orthop j 2019;18(2) introduction primary bone tumours of the proximal fibula are rare, comprising only 2.5% of bone tumours.1 approximately half of these tumours are malignant.1 abdel et al.2 found an incidence of malignant tumours of the proximal fibula of 1.2 per year (112 tumours at the mayo clinic from 1910 to 2007). although uncommon, the treatment has large functional and oncological implications for the patient. half of the tumours of the proximal fibula are malignant and require wide local excision. the proximal fibula is in close proximity to many important neurovascular and musculoskeletal compartments. malawer3 hypothesised that because of the anatomical peculiarities of the proximal fibula, tumours behave differently in this area. the proximal fibula, with multiple muscle attachments and thin cortices, allows early cortical extension and direct invasion of surrounding structures, rather than the usual pushing growth and respect of fascial boundaries of sarcomas in other areas of the body. the results of resection in the past were poor, showing high rates of re-operation for contaminated margins, and local recurrence, poor prognosis and functional results. as a result many centres advised amputation for malignant lesions of the proximal fibula.4 the concept of performing limb salvage surgery was revisited in the 1980s and was pioneered by pritchard et al.,5,6 rosen et al.,7 bacci and campanacci et al.,8 and malawer and zaleskie.9 all showed good functional outcomes and equivalent cure rates using newer limb salvage techniques. malawer in 19843 described the specific approach and technique for resection of tumours of the proximal tibia. this paper presents the curative and functional results of our series of malawer-type i marginal resections for large active or aggressive benign tumours and low-grade sarcomas, and malawer type ii wide intra-compartmental resections for high-grade bone sarcomas. methods and materials a retrospective folder review was performed from january 1995 to january 2017. fourteen patients who underwent limb salvage for a proximal fibula neoplasm were included. this group was then subdivided into those who had a type i malawer resection for a large active or aggressive benign tumour or low-grade malignant bone sarcoma, and those who received a type ii resection for a stage iib or higher10 primary bone sarcoma (figure 1). exclusion criteria included incomplete records and patients who were lost to follow-up. two patients were excluded. mri (figure 2) or ct was used to assess the lesion, patency of the relevant vasculature and position of the common peroneal nerve. ct angiography was used in selected cases if assessment of the vasculature was equivocal or inadequate on the mri. diagnosis was confirmed with open or 14-gauge needle biopsy in the operative theatre. for the stage iib type ii resections, patients received neo-adjuvant chemotherapy and no pre-operative radiotherapy. adjuvant chemotherapy was commenced three to six weeks post-operatively.7 the patients who had type i resections received neither chemotherapy nor radiotherapy. follow-up was performed by the oncologists for the highgrade malignant lesions and included a chest x-ray and clinical examination every three months for the first two years, six monthly for years 2–5 and annually for years 5–10, at which point the patient was discharged. the patients with aggressive benign lesions or lowgrade malignant sarcomas were followed up by the orthopaedic surgeons with clinical examination and x-ray of the lesion every six months until discharge at two years. a musculoskeletal tumour society (msts) score11 was performed at final follow-up. at a median follow-up of 38 (6–123) months the clinical notes including the msts score, imaging and histology were reviewed. descriptive statistical methods are used to present our findings. no further statistical methods were deemed necessary as no comparisons are being made and patient numbers are small. figure 1. antero-posterior x-ray of the proximal lower leg of a 12-year-old female patient with an osteoblastic osteosarcoma of the proximal fibula after neoadjuvant chemotherapy figure 2. t2-weighted mri pictures, coronal (a), sagittal (b) and axial (c), with a proximal fibula high-grade sarcoma figure 3. illustration showing patient positioning and utilitarian incision with biopsy scar included for both type i and ii resections 1 2a 2b 2c page 46 hilton tl et al. sa orthop j 2019;18(2) surgical technique the surgical technique for en bloc resection of the proximal fibula was performed as described by malawer in 1984.3 a marginal excision of the proximal fibula is described as a type i and a wide intra-compartmental resection as a type ii resection. the patient is placed in a semi-supine position, with a sandbag under the ipsilateral buttock. this allows access to the anterior and lateral compartments, the popliteal space and the posterior compartment when the knee is flexed.3 it is prudent to prepare the limb for an above-knee amputation in the event that resection is not possible with a large and aggressive lesion. a single utilitarian anterolateral incision is used which includes the biopsy site and tract with an ellipse of surrounding skin. placement of the biopsy site is therefore crucial (figure 3). type i resections include the proximal fibula with 2–3 cm of normal diaphysis and a thin cuff of muscle in all dimensions (figure 4 – red marker). the peroneal nerve and motor branches are preserved. the anterior tibial artery is sacrificed if necessitated by tumour extent. the artery is sacrificed in type ii resections, but may be preserved in type i resections. the tibiofibular joint is excised intraarticularly. reconstruction of the lateral collateral ligament (lcl) and biceps femoris tendon (bt) is to the proximal tibia, remaining soft tissue or anterolateral capsule, with the knee flexed at 30°. this may be achieved either with drill holes or the use of a bone anchor. type ii resections (figure 4 – yellow marker) include the proximal fibula and 6–7 cm of normal diaphysis, the proximal anterior and lateral muscle compartments, the proximal flexor hallucis longus (fhl) and tibialis posterior (tp) muscles, the anterior tibial artery, the peroneal nerve, and if required, the peroneal artery. the tibiofibular joint is resected extra-articularly with resection of the lateral tibial cortex and a variable portion of its metaphysis. soft tissue reconstruction involves fixing the lcl and bt to the proximal tibia. the lateral gastrocnemius muscle is rotated to cover the surgical defect and exposed tibia. the muscle is released from the medial belly in the midline and distally as it joins the soleus. post-operative rehabilitation included three weeks of immobilisation at 30° of flexion. full weight bearing was allowed as tolerated. an ankle–foot orthosis was prescribed for type ii resections if required. some authors2,12 use a knee immobiliser for six weeks, during which motion exercises are started in the last two weeks. results six patients had a type i resection and eight a type ii resection. the median follow-up period was 38 (6–123) months overall. the median follow-up for type i resections was 20 months and for type ii was 47.5 months. both groups had no recurrences or metastases. there were no wound or vascular complications. the characteristics of the patients and the msts score at follow-up are shown in tables i and ii. figure 4. axial mri (t1-weighted) depicting the difference between type i (red) and type ii (yellow) resections. note type i resections include preservation of peroneal nerve, anterior, lateral and deep posterior muscular compartments with resection through the tibio-fibular joint. type ii resections sacrifice the anterior tibial artery, proximal portions of tibialis anterior, extensor hallucis longus, extensor digitorum longus, the peroneii muscles, fhl and tp muscles and include a shark-bite resection of the lateral cortex of the proximal tibia. the peroneal artery and nerve are resected as required. table i: patients with type i resection patient sex age at time of surgery (years) histology msts score 1 male 32 chondroblastoma 29 2 female 53 chondrosarcoma 30 3 female 60 gct 29 4 male 53 gct 15 5 male 17 gct 30 6 female 14 osteochondroma 28 table ii: patients with type ii resection patient sex age at time of surgery (years) histology huvos score msts score 1 female 13 osteoblastic osteosarcoma 90% 25 2 male 10 osteoblastic osteosarcoma 100% 24 3 male 6 ewing’s sarcoma 100% 26 4 male 18 osteoblastic osteosarcoma 25% 26 5 female 83 leiomyosarcoma 60% 24 6 female 11 osteoblastic osteosarcoma 0% 30 7 male 11 osteoblastic osteosarcoma 95% 27 8 male 18 osteoblastic osteosarcoma 95% 27 page 47hilton tl et al. sa orthop j 2019;18(2) type i the median age for type i resections was 42.5 (14–60) years. the commonest tumour was giant cell tumour (gct) in three patients (50%) and one each of an osteochondroma, chondrosarcoma and chondroblastoma. the median msts functional score was 29 (15–30). no patients in the type i resection group required further surgical intervention. type ii the median age for type ii resections was 12 (6–83) years, with seven of the eight patients being under 20 years of age at presentation. all the tumours were stage iib. osteoblastic osteosarcoma was the most common tumour (75%). the remaining two patients were ewing’s sarcoma and leiomyosarcoma. the median huvos score was 92.5% (0–100%). five patients achieved ≥90% necrosis of the resected tumour after neo-adjuvant chemotherapy, two of which demonstrated 100% necrosis. the remaining three patients were alive without disease at their last follow-up (range 35–96 months). all patients achieved clear margins at initial surgery, and none required a secondary oncological procedure. all patients reported good msts functional scores despite resection of the common peroneal nerve in all patients. the median score was 26 (24–30). one patient required a tibialis posterior tendon transfer (tptt) for the management of an equinovarus foot following resection. his msts score post-tptt was 26. of the remaining seven patients, six required an afo. discussion the more common enneking sub-types of neoplasms found in this location include benign aggressive and malignant stage iib lesions. dahlin13 noted that the most common tumours in this location include gct, osteogenic osteosarcoma and ewing’s sarcoma. in our study, similar to that of abdel et al.2 and dahlin,13 gct was the commonest tumour (50%) and osteogenic osteosarcoma the commonest tumour (75%) undergoing type i and ii resections respectively. for this reason and due to the crowded anatomy of the region, above-knee amputations were advised as the best oncological surgical option before 1980.4 however, with the onset of limb-sparing surgery the anatomy and resection techniques were revisited.3,5-9 the main concerns associated with proximal fibula resections are recurrence, post-operative knee instability, peroneal nerve palsy, and vascular insufficiency.2 the most important prerequisite of limb salvage is that the patient must be left with a limb of better or equal function than that of an amputation.14 in resections of the proximal fibula, ligation of two of the three major vessels, which is required in a type ii resection, is compatible with a functional extremity, even in elderly patients with peripheral vascular disease.3,15 previously biplanar angiography was recommended by hudson et al.16, and marcove and jensen.17 mri is currently used to identify the involvement, location of displaced vessels and the aberrant lack of the posterior tibial artery, which can occur in approximately 5% of cases.3 in the scenario of an absent posterior tibial artery, an above-knee amputation would be indicated. other contra-indications to limb salvage include extension of the tumour intra-articularly into the knee and direct tibial involvement. we had no vascular complications. this may be because only one of our patients was over 20 years of age (83 years). limb salvage must not compromise oncological outcome, as margins are all important for prognosis in high-grade malignant sarcomas of bone. an involved margin at resection increases the morbidity for the patient necessitating re-excision, possible amputation or post-operative radiotherapy. the attainment of a clear margin in resections of the proximal fibula is not straightforward. malawer3 describes the direct invasion and serpiginous spread of stage iib tumours along the multiple musculotendinous junctions of the surrounding muscles that originate off the fibular head and proximal shaft. this is in contrast to the pushing border that is more commonly seen with iib tumours in other sites of the body. this may be due to the lack of fascial containment in this area and the relatively thin cortex of the fibula. the close proximity of the tibiofibular joint to the origin of these tumours leads to invasion of the tibiofibular joint by the aggressive sarcomas. this joint, along with its capsule and adjacent tibial cortex, must be included in the type ii resections to attain a wide margin. in the study by abdel et al.2 local recurrence occurred in three of 24 patients (13%) who had a type ii resection and the postoperative rate of metastases was 50% for all 112 patients. our study had a 100% negative margin rate in all high-grade tumours with no recurrences. we attribute this oncological success to ensuring adequate margins and by not attempting to preserve the common peroneal nerve where margins are doubtful. abdel et al.2 also report a high local recurrence rate in six of 29 (21%) patients who had a type i resection for malignant tumours, especially osteosarcoma and chondrosarcoma. although they do not note the enneking staging10 for each tumour type, they recommend a type ii resection for osteosarcoma and chondrosarcoma. we agree that a high-grade sarcoma with an extraosseous component warrants a type ii resection, but for a low-grade intra-osseous chondrosarcoma, a type i resection is adequate. in benign aggressive tumours intralesional curettage has a recurrence rate of 50–100%,12,18 which supports a type i resection for these tumours. this differs from enneking10,11 who advises intralesional curettage with an adjuvant with or without bone graft. the better results with a type i resection may be due to the unique anatomy of this area. the huvos scoring system evaluates the histology of the tumour post resection by grading the extent of necrosis relative to the percentage of residual viable tumour. the scoring system has been shown to be useful in prognosis and in the adjuvant chemotherapeutic management of both osteogenic osteosarcoma and ewing’s sarcoma.7 in our series of type ii resections, 62.5% (n=5) of the patients achieved more than 90% necrosis, which, together with negative margins, contributed to their good outcomes. the remaining three patients in this group were alive without disease at their last follow-up. their follow-up periods were 35, 47 and 96 months respectively. despite the sacrifice of the common peroneal nerve, all the patients who underwent type ii resection reported a good functional outcome. inatani et al.18 reiterate this with their report of a mean msts score of 20 (65%) with sacrifice of the common peroneal nerve. in our series of type ii resections the median msts score was 26. naturally in our type i resections, where a wide margin can be taken safely with preservation of the nerve, the median functional score improves to 29. only one patient required a tptt for the management of an equinovarus foot. the patient had a good functional outcome with a msts score of 27. none of the other type ii resection patients underwent this procedure and had equivalent scores, although six of the seven patients required an ankle–foot orthosis (afo). peroneal nerve palsy has been described as a complication despite attempts at nerve preservation. in the paper by abdel et al.2, two of 29 (7%) patients suffered a palsy where the peroneal nerve was spared during a type i resection. the incidence in the literature varies between 20% and 57%.3,7,14 type i and type ii resections include sacrificing adjacent knee page 48 hilton tl et al. sa orthop j 2019;18(2) stabilising structures. unlike traumatic disruption of the lateral ligamentous structures, their reconstruction is controversial. reconstruction of the biceps femoris tendon (bt) and lateral collateral ligament (lcl) is performed by some authors; however, einoder et al.19 believe that the reconstruction of the transected tendon and ligament is unnecessary as the integrity of the posterior capsule and other supporting structures such as the cruciate ligaments still remains. in their study however, the patients remained in a hinged knee brace for three months. other authors2,12,18 advised bt and lcl reconstruction. in two of these studies,2,12 83 knees were examined with a varus stress test at 30° of knee flexion. no patient had more than grade 2 instability. we did not examine our patients formally with a varus stress test but no patient subjectively complained of instability. there were no wound complications found in this study. wound dehiscence, haematoma and flap necrosis can be prevented with a primary lateral gastrocnemius flap in type ii resections. the rotated gastrocnemius belly also fills the defect created by resection of the proximal anterolateral muscles and fibula, and results in a more cosmetically acceptable shaped leg. unfortunately, this causes delay in post-operative adjuvant oncological treatment, as the surgical wound requires time to heal before treatment is given. synovial fistula was not seen in our study and was seen in only one of ten patients in malawer’s3 original study. this complication can be prevented by meticulous closure of the posterior capsule and immobilising the knee in 30° of flexion for three weeks. this study is subject to the bias of a retrospective study. we had small numbers. it must be noted that this is a rare group of tumours and a smaller subset has been selected. even in abdel’s paper2, which spanned 97 years, they amassed only 112 patients with malignant tumours, of whom less than half (n=53) underwent limb-sparing surgery and even fewer (n=24) type ii resections. we did not assess knee instability formally. conclusions to achieve a favourable outcome, the biopsy technique is important and must be carried out to involve only one compartment; usually anterolaterally within the utilitarian incision to allow a 2–3 cm ellipse of skin with its tract to be included in the excision. close but safe margins are achievable with the correct technique, and vital structures are retained as much as possible. our recommendations when faced with a lesion in the proximal fibula would depend on its histological diagnosis and enneking staging.10 benign latent lesions should be managed conservatively with observation, while benign active lesions should be addressed with intra-lesional resection. a very large active lesion, such as the osteochondroma in our study, may require a type i malawer resection. benign aggressive lesions, such as gcts, and malignant tumours without extra-osseous spread, such as the chondrosarcoma in our study, should be excised en bloc using the type i malawer resection. all malignant stage iib tumours, i.e. with extra-osseous extension, should be treated with a type ii malawer resection with no attempt to spare the common peroneal nerve. this is to ensure a good oncological result with a functionally acceptable limb. resection of malignant and benign tumours of the proximal fibula in this series achieved good cure rates and functional results, with or without the aid of an orthosis, despite the sacrifice of the common peroneal nerve in type ii resections. ethics statement this study was subject to an institutional review by the human research ethics committee number 807/2017. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions tlh – ethics, data collection, analysis, write up; kw – write up, analysis; kvh – proposal, data collection; ebh – data collection, final write up. orcid hilton tl https://orcid.org/0000-0002-6178-5062 wiese kr https://orcid.org/0000-0003-1764-8500 hosking kv https://orcid.org/0000-0002-3557-0252 hoffman eb https://orcid.org/0000-0001-5954-0069 references 1. unni kk. dahlin’s bone tumors: general aspects and data on 11,087 cases. philadelphia: lippincott williams & wilkins, 1996. 1-9 2. abdel mp, papagelopoulos p, morrey me, inwards cy, wenger de, rose de, sim fh. malignant proximal fibular tumors: surgical management of 112 cases. j bone joint surg am, 2012;94(22):165. 3. malawer mm. surgical management of aggressive and malignant tumors of the proximal fibula. clin orthop relat res, 1984(186):172-81. 4. malawer m, sugarbaker ph. fibular resection. in: musculoskeletal cancer surgery treatment of sarcomas and allied diseases. kluwer academic publishers, 2001. 503-16. 5. pritchard dj, dahlin dc, dauphine rt, taylor wf, beabout jw. ewing’s sarcoma. a clinicopathological and statistical analysis of patients surviving five years or longer. j bone joint surg am, 1975;57(1):10-16. 6. pritchard d. ewing’s sarcoma. presented to the musculoskeletal tumour society, new york, april 1982. 7. rosen g, caparros g, nirenberg a, ralph c, marcove md, huvos ag, et al. ewing’s sarcoma: ten-year experience with adjuvant chemotherapy. cancer, 1981;47(9):2204-13. 8. bacci g, picci p, gitelis s, borghi a, campanacci m. the treatment of localized ewing’s sarcoma: the experience at the istituto ortopedico rizzoli in 163 cases treated with and without adjuvant chemotherapy. cancer, 1982;49(8):1561-70. 9. malawer mm, zaleskie t. giant cell tumour of bone: en-bloc resection and cryosurgery: evaluation, indications and recommendations for treatment. orthop trans, 1982;6:91. 10. enneking wf, spanier ss, goodman ma. a system for the surgical staging of musculoskeletal sarcoma. clin orthop relat res, 1980;153:106-20. 11. enneking wf, a system of staging musculoskeletal neoplasms. clin orthop relat res, 1986;204:9-24. 12. abdel mp, papagelopoulos pj, morrey me, wenger de, rose ps, sim fh. surgical management of 121 benign proximal fibula tumors. clin orthop relat res, 2010;468(11):3056-62. 13. dahlin dc. bone tumours, general aspects and data on 6,221 cases. springfield, 1978. 11-12. 14. dicaprio mr, friedlaender ge. malignant bone tumors: limb sparing versus amputation. j am acad orthop surg, 2003;11(1):25-37. 15. imparato am, roses df, francis kc, lewis mm. major vascular reconstruction for limb salvage in patients with soft tissue and skeletal sarcomas of the extremities. surg gynecol obstet, 1978;147(6):891-96. 16. hudson tm, haas g, enneking wf, hawkins if. angiography in the management of musculoskeletal tumors. surg gynecol obstet, 1975;141(1):11-21. 17. marcove rc, jensen mj. radical resection for osteogenic sarcoma of fibula with preservation of the limb. clin orthop relat res, 1977;125:173-76. 18. inatani h, yamamoto n, hayashi k, kimura h, takeuchi a, miwa s, et al. surgical management of proximal fibular tumors: a report of 12 cases. j bone oncol, 2016;5(4):163-66. 19. einoder pa, choong pf. tumors of the head of the fibula: good function after resection without ligament reconstruction in 6 patients. acta orthop scand, 2002;73(6):663-66. https://orcid.org/0000-0002-6178-5062 https://orcid.org/0000-0002-6178-5062 https://orcid.org/0000-0003-1764-8500 https://orcid.org/0000-0003-1764-8500 https://orcid.org/0000-0002-3557-0252 https://orcid.org/0000-0002-3557-0252 https://orcid.org/0000-0001-5954-0069 https://orcid.org/0000-0001-5954-0069 _goback _hlk508782556 _goback _hlk511815082 _goback orthopaedics vol3 no4 page 58 sa orthopaedic journal winter 2015 | vol 14 • no 2 expert opinion on published articles orthopaedic surgery has undergone a gradual evolution toward sub-specialisation over the last 30 years. the american academy of orthopaedic surgeons currently recognises 22 orthopaedic speciality societies. one of the more recent subspecialties to emerge has been limb lengthening and reconstruction surgery. this area of orthopaedics is undergoing rapid growth across the world and south africa is no exception, with increasing numbers of surgeons attracted to this field. despite increased awareness and practice of this subspecialty, early enthusiasm for this service has often been met with reluctance to establish dedicated limb reconstruction units in academic institutions. this has frequently resulted in complex reconstructions being undertaken by relatively inexperienced surgeons with suboptimal outcomes. this should motivate academic departments to establish dedicated units where cases can be concentrated and expertise developed. in the current review, rozbruch et al. shares their experience of developing such a dedicated limb lengthening and complex reconstruction service (llcrs) over a nine-year period at the hospital for special surgery, cornell university. the authors provide some background to their orthopaedic services and how the llcrs is situated in their department. a review of their outpatient and surgical load showed a significant year-on-year increase in volume since the inception of the llcrs in 2005. noteworthy was the fact that 56% of patients in the unit were referred from orthopaedic surgeons, showing the need for such a highly specialised service that general orthopaedic surgeons can access when they are faced with complex cases that they themselves are either unwilling or unable to manage. a further 25% of cases tended to be self-referrals of patients following internet searches, indicating frustration with traditional orthopaedic service avenues that were unable to address their reconstructive needs. the authors further provide a breakdown of the types of cases their unit managed over a one year period, including foot and ankle, adult deformity, trauma reconstruction, arthroplasty, paediatric, limb salvage, tumour and upper extremity. the techniques that were used also varied considerably, including circular fixators, monolateral fixators, intramedullary nails, internal lengthening nails, plates and arthroplasty. this emphasises the in-depth knowledge of reconstructive techniques and recent advances in the field that reconstructive surgeons require. as an academic field, limb reconstruction is evolving rapidly, with more and more research emerging, and even journals dedicated to this field of orthopaedics appearing. with a dedicated service, this academic advance can be more focussed and productive. the llcrs, during the period of review produced 49 peer-reviewed articles, 23 book chapters, review articles, and web based publications focused on limb deformity topics. we have had a similar experience with developing the tumour, sepsis and reconstruction unit in pietermaritzburg. since the establishment of our unit in 2009, there has been an exponential year-on-year increase in referrals to our unit. the unit also had a significant contribution to the academic output of our department, with 30 research articles produced, nine masters degrees completed or underway and two doctoral degrees currently underway. the research underlines the importance of a dedicated limb reconstruction service that general orthopaedic surgeons and patients can access when they are faced with complex cases requiring reconstruction. i concur with the findings of the authors and agree that the ideal setting for such a service to be the academic institutions in south africa. the authors conclude by stating: ‘with establishment of a dedicated service comes focus and resources that establish an environment for growth in volume, and purposeful research and education.’ what is the utility of a limb lengthening and reconstruction service in an academic department of orthopaedic surgery? rozbruch sr, rozbruch es, zonshayn s, borst ew, fragomen at clin orthop relat res doi 10.1007/s11999-015-4267-9 reviewer: dr n ferreira tumour, sepsis and reconstruction unit department of orthopaedic surgery university of kwazulu-natal grey’s hospital pietermaritzburg tel: +27 033 897 3299 nando.ferreira@kznhealth.gov.za this should motivate academic departments to establish dedicated units where cases can be concentrated and expertise developed the techniques varied considerably, including circular fixators, monolateral fixators, intramedullary nails, internal lengthening nails, plates and arthroplasty saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 58 page 60 sa orthopaedic journal winter 2015 | vol 14 • no 2 introduction in this update, the authors state that whether or not the contralateral hip should undergo prophylactic fixation is still a matter of controversy. the aim of the paper was not to discuss whether or not prophylactic fixation of the contralateral hip should be performed routinely in all patients with unilateral slips at primary diagnosis, rather to discuss those important matters that need to be taken into account when deciding on how to manage the slipped upper femoral epiphysis (sufe). the incidence of the subsequent slip of the contralateral side is reported to be up to 63% (jerre et al.). the risk of contralateral slip hagglund et al. found that in 260 patients with a unilateral sufe the incidence of slipping of the contralateral side was 61%. jerre et al. reviewed 61 patients with unilateral sufe at primary diagnosis and found a 63% incidence of subsequent slipping of the contralateral side. patients at risk of contralateral slip risk factors have been used at the primary diagnosis of patients with unilateral slips in order to help identify those who will develop a contralateral slip to try and avoid unnecessary fixation of the contralateral hip. these risk factors include: a. young age at primary diagnosis b. skeletal maturity c. female gender d. endocrine disorders such as adiposogenital dystrophy e. the angle of the slip at primary diagnosis f. the slope of angle of the physis g. an open triradiate cartilage. at present the authors would consider prophylactic fixation of the contralateral hip in children with adiposogenital dystrophy, nonspecific obesity, those cases in which there is a long delay between onset of symptoms of the slip at the initial consultation and children who are being treated with growth hormone. finally in those cases where for social reasons or geographical reasons the patient cannot be expected to comply with a protocol of continued regular clinical and radiological observation. stabilisation or closure of the physis the femoral neck grows at an estimated rate of 4 mm/year according to menelaus. in patients where there is significant remaining femoral neck growth premature of closure of the physis will lead to a short femoral neck, producing a short lever arm for the abductors. the fixation method should therefore stabilise the epiphysis and not fuse the physis when pinning the contralateral hip. using smooth pins will avoid fusing the physis. threaded pins should be avoided when fusing the contralateral hip. non-operative management if this route is chosen, the authors recommend regular radiographs of the contralateral hip be obtained every 3 months until complete fusion of the physis has occurred. billing and severin believed that complete fusion of the triradiate cartilage ruled out subsequent slip of the femoral epiphysis. for detection of the contralateral slip, lateral radiographs of the hip are the most commonly used methods. the method described by billing in 1954 is the most accurate method of obtaining the lateral view of the hip. the hip is positioned in 25° of flexion and 90° external rotation using an external support device. a slipping angle is then measured which should be less than 7°, it indicates a definite slip if it is more than 13°. conclusion in this update, it has been shown that pining of the contralateral hip in sufe is still controversial. recommendations have therefore been suggested for pinning the contralateral hip and for observing it. the authors recommend that 3 monthly radiographs should be done if the contralateral hip is observed, a single lateral view as described by billing should be done to avoid over-radiation exposure. they argued that modern radiological equipment has low radiation exposure. when the contralateral hip is pinned, a single smooth pin should be used to avoid closure of the capital femoral physis, multiple pins should be avoided. reviewer: dr s sombili consultant orthopaedic surgeon steve biko academic hospital university of pretoria tel: 012 354 2851 specialty update: hip management of the contralateral hip in patients with unilateral slipped upper femoral epiphysis to fix or not to fix – consequences of two strategies g hansson and j narthorst-west journal of bone and joint surgery: british. may 2012;94-b:596–602 saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 0 biopsy is a critical step in the diagnosis of bone and softtissue sarcomas. current literature has not clarified the optimal biopsy technique of these tumours. while incisional biopsy (ib) is still considered the gold standard, recent literature suggests that fine needle aspiration (fna) and core needle biopsy (cnb) may have a comparable diagnostic yield. in this current concepts review, from the aaos exhibition selection, the authors from the istituti ortopedici rizzoli explores the existing literature on the topic and proposes guidelines for biopsy of bone and soft tissue tumours. the potential advantages of percutaneous techniques noted in the article, include: decreased cost and theatre usage, low risk of adjacent tissue contamination and lower risk of complications due to its minimal invasive nature (0 to 10% compared to up to 16% for incisional biopsy). it is however agreed that incisional biopsy will not cause metastatic dissemination and that ib is still indicated when the diagnosis following a percutaneous biopsy is inconclusive or does not correspond to the clinical and radiographic findings. the authors recommend ultrasound-guided cnb and ctguided cnb as first line biopsy techniques in soft tissue and bone tumours, respectively. while these guidelines appear reasonable, the evidence for preference of one technique over another (in my opinion) remains weak. of the 21 studies included in the review only one compared the diagnostic yield of incisional and percutaneous techniques on the same tumours, finding 100% accuracy for ib, 45% for cnb and 33% for fna in terms of the specific histological diagnosis. in addition the authors state that many of studies reviewed excluded non-diagnostic samples, which falsely elevated the accuracy rate. while we have increased the usage of cnb in our unit, ib is still preferred in many cases. furthermore, the diagnostic accuracy of percutaneous techniques is a function of the expertise of histologists evaluating the case and we have found that as our unit’s experience has grown the diagnostic yield has improved. it is essential, though, to emphasise that all the standard biopsy principles apply for percutaneous techniques. as stated by the authors the biopsy should be planned carefully on the basis of the location of the intended definitive surgery following mri and should be performed by an experienced orthopaedic surgeon. a common error involves sampling of non-representative or necrotic areas. if not done correctly a biopsy can complicate patient care and sometimes even eliminate certain treatment options. while the extraosseous extension of a malignant bone tumour is considered to be as representative of the tumour as the osseous component is, the shortest route to the lesion is not necessarily the optimal one. in addition the surgeon should not open any compartmental barrier, anatomic plane, joint space, or tissue area around a neurovascular bundle and should avoid creating a hematoma. i consider this an excellent current concepts review on the topic. i have to agree with the authors’ concluding sentiments: incisional biopsy appears to be the most accurate modality, the evidence is not strong enough to recommend one biopsy technique over another and that further research is required to determine the diagnostic accuracy of the various biopsy techniques. page 62 sa orthopaedic journal winter 2015 | vol 14 • no 2 current concepts in the biopsy of musculoskeletal tumors traina f, errani c, toscano a, pungetti c, fabbri d, mazzotti a, donati d, faldini c. j bone joint surg am 2015;97(2):e7(1–6) reviewer: dr lc marais tumour, sepsis and reconstruction unit department of orthopaedic surgery university of kwazulu-natal grey’s hospital pietermaritzburg tel: 033 897 3424 leonard.marais@kznhealth.gov.za • saoj saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 2 workman mi et al. sa orthop j 2019;18(2) doi 10.17159/2309-8309/2019/v18n2a2 south african orthopaedic journal http://journal.saoa.org.za traumaspine citation: workman mi and kruger n. a survey of the use of traction for the reduction of cervical dislocations. sa orthop j 2019;18(2):25-30. http://dx.doi.org/10.17159/2309-8309/2019/v18n2a2 editor: prof rn dunn, university of cape town, south africa received: june 2018 accepted: november 2018 published: may 2019 copyright: © 2019 workman mi, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: this research received no funding. conflict of interest: both authors have no conflicts of interest to declare. abstract background: literature supports early decompression of low energy cervical spine dislocations. closed reduction can safely and rapidly achieve this; however, its use and acceptance among specialists is poorly described. this study aimed to assess the training, experience and decision-making of trainees and surgeons who manage cervical spine dislocations with the goal of reinforcing educational programmes as necessary. the objective was to assess the need to implement further training for trainees and specialists involved in the management of cervical spine dislocations. methods: orthopaedic and neurosurgery registrars and specialists in south africa were emailed a questionnaire consisting of 13 questions related to their training, experience and management of cervical dislocations. results: seventy-nine per cent (n=62) of surgeons were taught closed reduction during specialist training. ninety-two per cent (n=12) of neurosurgeons covered spine trauma compared to 66% (n=42) of orthopaedic surgeons. of surgeons covering trauma, 21% (n=16) would refer the patient on, accepting a 2-hour delay in treatment. forty-two per cent (n=5) of neurosurgeons vs <2% (n=1) of orthopaedic surgeons preferred mri before closed reduction. fifty-six per cent (n=40) of surgeons thought that the risk of worsening neurology during traction was up to 25%. sixty-nine per cent (n=54) of surgeons felt emergency room (er) doctors could safely perform closed cervical reduction with training. fifty-one per cent of surgeons do not think cervical reduction is routinely possible in under 4 hours. conclusion: the public and specialists have misconceptions around cervical traction which may affect best clinical practice and optimum management. cervical traction does not require prior mri and carries a very low risk of worsening a patient’s condition. closed cervical traction reduction is the most rapid, safe mechanism to reduce cervical dislocations and requires specific education of undergraduates, emergency doctors, and specialists to increase awareness of the reduction process. level of evidence: level 4 key words: cervical spine dislocation, closed reduction of cervical spine dislocation, unifacet dislocation, bifacet dislocation a survey of the use of traction for the reduction of cervical dislocations workman mi¹ , kruger n² 1 bsc physio, mbbch; registrar, department of orthopaedic surgery, university of cape town, south africa ² bsc, mbchb, frcs, fcorthsa; consultant, department of orthopaedics, groote schuur hospital, university of cape town, south africa corresponding author: dr mi workman, department of orthopaedics, old main building, groote schuur hospital, anzio road, observatory 7925, cape town, south africa; email: matthew.workman1@gmail.com; tel: +27 83 297 5059 https://orcid.org/0000-0002-7999-9069 page 26 workman mi et al. sa orthop j 2019;18(2) introduction cervical spinal cord injuries (sci) are a relatively common problem, not only in the western cape, but worldwide accounting for 3–6% of all trauma cases.1 they are potentially devastating with high morbidity and poor prognosis if not managed promptly and appropriately.1-5 the major demographic involved in cervical spine dislocations are young male adults.2-5 in south africa, violence and motor vehicle accidents (mvas) are the main causes of traumatic spinal cord injury.2,6 vasiliadis reports that 25% of traumatic sci are cervical.6 in our institution, bifacet and unifacet dislocations are the most common cause of a cervical sci,2 and occur most commonly at c5 neurological level. cervical dislocations carry a high incidence of devastating neurological injury. animal models and class iii medical evidence support early reduction to improve neurological outcomes. cervical reduction restores bony canal dimensions and indirectly decompresses the cord. anecdotally, our experience is that the relatively simple procedure of cervical traction is perceived as a specialist-only procedure that is potentially risky and that specialists have little practice in reductions. in many hospitals, spinal injuries are managed by general orthopaedic or neurosurgeons who are uncomfortable with the procedure, and delays in reduction are common. in addition to these concerns, a 2015 south african constitutional court judgement ruled that all low energy cervical dislocations should be reduced within 4 hours. this has put the spotlight on the emergency management of cervical dislocations, from first emergency response to definitive specialist management. this study aimed to determine the training, experience and decision-making of orthopaedic and neurosurgical trainees and specialists in the closed reduction of low energy cervical spine injuries. the subject group would also comment on the feasibility of the 4-hour judgement ruling in the south african context. as noted, this information is instrumental in addressing any undergraduate or postgraduate educational needs relevant to cervical reductions as well as highlighting the skill requirements for specialists who provide emergency cover. methods a questionnaire consisting of 13 questions relating to the field of specialisation, training, decision-making and management of cervical dislocations was constructed (see appendix 1). the hypothetical clinical scenario presented was: a rugby player referred by the emergency room (er) 2 hours post injury with a c5/6 bifacet cervical dislocation on x-ray and motor complete (asia a) neurological injury. qualified specialists and registrars in orthopaedics and neurosurgery in south africa were identified using their respective professional member listings and university registrations. email databases from the south african orthopaedic association, the society of neurosurgeons of south africa and the south african spine society were used. the study outline and an online questionnaire link were emailed to all of the above registered specialists and trainees in south africa. voluntary participation was requested, and non-responders were sent a single email reminder before closure of the survey. incomplete survey responses were excluded. no tracking of survey responses was used, and it was completed anonymously. data was collected on excel sheets. a biostatistician was consulted for data analysis. results table i: respondents speciality number of responses orthopaedics consultant 44 (56%) registrar 22(28%) neurosurgery consultant 9 (12%) registrar 3 (4%) total n=78 a total of 78 responses were recorded (table i) from 420 emailed questionnaires (18.6% response rate). these were predominantly from orthopaedic registrars and consultants (84%, n=64). the majority (79%, n=62) of respondents were taught closed reduction during specialist training with the remainder having training during internship or medical officer posts. ninety-two per cent (n=12) of neurosurgeons cover emergency spine conditions compared to 66% (n=42) of orthopaedic surgeons. sixty-two per cent (n=47) of respondents had performed or supervised closed cervical spine reduction within the last year. of clinicians covering spinal emergencies, 64% (n=52) would confidently perform closed reduction. twenty-one per cent (n=16) of respondents, however, when presented with a patient with deteriorating neurological deficit, would prefer to refer the patient on and accept a 2-hour delay in reduction. fifty-six per cent (n=40) thought that the risk of worsening neurology with closed reduction was between 1% and 25% or greater. forty-two per cent (n=5) of neurosurgeons and <2% (n=1) of orthopaedic surgeons would require an mri prior to performing closed cervical spine reduction even though this resulted in a 2-hour delay in treatment. if presented with an mri showing a herniated cervical disc (disc at risk),7 39% (n=21) of respondents would take the patient urgently to theatre rather than attempt closed reduction. eighty-one per cent (n=42) of respondents covering spinal emergencies considered that open reduction in theatre in under 4 hours was unachievable, but 48% (n=37) thought closed cervical reduction was feasible in under 4 hours. sixty-nine per cent (n=54) of respondents felt er doctors could perform closed cervical reduction if properly trained. discussion the literature shows closed reduction to be safe and effective in 80% of patients. an overall permanent neurological complication rate of 1% is reported.8 numerous studies favour early reduction to maximise the chance of neurological recovery. on admission to hospital the standard of care for cervical dislocations is urgent closed reduction with skeletal traction. surgical stabilisation can then occur at the next theatre opportunity without it having to be an emergency procedure. emergency reduction restores bony canal alignment and offers indirect decompression to the compressed spinal cord.9 this has been shown to have improved outcomes and is supported by animal models and case series of dislocation injuries with class iii medical evidence.10-14 this standard of care of urgent closed reduction relates to district hospitals as well as tertiary centres. not all hospitals have the skills or resources to perform spinal surgery. where a cervical dislocation presents at a district hospital, the cervical reduction can be performed with minimal equipment and resources. once reduced, the patient can be transferred to the regional spinal centre where surgical stabilisation and definitive treatment15-21 can take place non-emergently. page 27workman mi et al. sa orthop j 2019;18(2) the recent south african constitutional court ruling (oppelt vs department of health provincial administration: western cape) on 14 october 2015, found that the department of health was negligent in not performing cervical reduction within 4 hours of the injury.22 this conclusion was based on a single publication from the conradie hospital experience of rugby injuries involving 57 players with cervical dislocations. the primary author, dr newton, claimed that patients with bilateral cervical facet dislocation sustained in low velocity impact have a 64% chance of a complete recovery if the dislocation was decompressed within 4 hours of the injury. in their conclusions, the authors recommended that cervical dislocations should probably be reduced within 4 hours of injury.23 these findings are controversial especially relating to the 4-hour deadline; however, there are no studies giving contrary evidence and most of the available literature supports early as possible reduction. the 4-hour theory was accepted by the court. this ruling is particularly important since the constitutional court is the highest court in the land and the judgement would be extremely difficult, if not impossible, to overturn. this has farreaching ramifications involving emergency transport from the accident scene, triage and primary er management. subsequent treatment by clinicians including er doctors and specialists is directly affected by the 4-hour ruling. these issues apply equally to state and private hospitals. the lay public and courts assume that all specialists covering spinal injuries are competent and skilled in cervical closed reduction. this is incorrect. of concern is that 21% of specialists in this study had no formal training in cervical reductions at postgraduate level. undergraduate education was poor with only 2% having had training. only 62% had performed or supervised a reduction in the past year, which reinforces our view that the procedure is very infrequently performed outside tertiary referral hospitals. in practice, especially in the private sector, many specialists are orthopaedic or neurosurgical generalists and do not have a specific interest in spinal surgery. they cover emergencies and minor acute spinal conditions such as back pain and sciatica, but certainly would not be comfortable performing cervical reduction. this is borne out by the 21%, who in the clinical case scenario, preferred to refer the patient elsewhere. non-spinal surgeons do not carry medicolegal specific spinal cover due to the high costs of insurance and there may be concerns that their indemnity would not extend to the management of a cervical dislocation. in communication with insurers (dr gr howarth, medical protection society; and jp ellis, ethiqal medical risk protection, pers. comm.), there was written confirmation that cervical closed reductions are considered nonsurgical emergency procedures and would be indemnified even where spinal work is broadly excluded from the orthopaedic surgeon’s policy schedule. this indemnification extends to any clinician performing an emergency non-surgical cervical reduction if they have the appropriate training and skill. in the western cape, the average time from injury to er is 3 hours.24 under the court ruling that low energy cervical dislocations need to be reduced within 4 hours, the 21% of specialists choosing to refer a patient on (accepting a 2-hour delay in treatment) are putting themselves at risk for medico-legal challenges. we feel it is unacceptable for a specialist entrusted with covering spinal emergencies to be unable to perform closed cervical reduction. a further concern was the relatively high percentage of surgeons who would request an mri prior to closed reduction (predominantly neurosurgeons 42% vs orthopaedic 1%). the literature clearly does not support the routine use of pre-reduction mri. in a qualitative medical evidence-based review published in neurosurgery 2013,9 the authors concluded that the use of pre-reduction mri did not improve the safety or efficacy of closed traction–reduction of patients with acute dislocations. there were concerns that an mri would unnecessarily delay treatment and was not without further risk to the patient. a significant finding from this study was how the mri changed surgeon behaviour. when given the scenario of a disc-at-risk on mri, the percentage of closed reducers declined from 67% to 42%. of those declining closed reduction, 28% would perform emergent open reduction and 30% would prefer to refer the case on and accept a 2-hour delay in treatment. this is particularly worrying since numerous large clinical series have failed to establish a relationship between pre-reduction disk herniation and subsequent neurological deterioration during closed traction–reduction.25 what is evident, however, is that obtaining an mri causes delay in treatment, in some instances hours to days.26,27 mri is not without risk to the patient, who needs to be transferred off the spinal stretcher into and out of the scanner. treatment is delayed with little useful information being obtained by the mri. to comply with best clinical practice, an mri should not be routinely performed pre-reduction. twenty-eight per cent of surgeons would perform emergency surgery with a pre-reduction mri demonstrating a disc at risk. the procedure of choice would be anterior cervical decompression, removal of the disc, and open reduction of the dislocation. most acute dislocations are able to be safely reduced in this manner. our concern is that the surgical time taken to perform open reduction would be in excess of 4 hours. if one considers time taken to arrange the mri, source staff, prepare sets, anaesthetise the patient, drape and proceed ( assuming there is an available theatre waiting), most surgeons would be hard pressed to achieve reduction within 4 hours of injury. from this survey, 54% of surgeons did not think open reduction was feasible within the timeframe. there was a perception that the risks of worsening neurological status during closed reduction were high. fifty-one per cent thought the risks could be as high as 25%. less than half of the respondents (44%) recognised that closed awake cervical reduction carries a very low risk of worsening neurological status (<1%). many junior doctors feel cervical reduction is only the domain of specialists. however, in this survey, 69% of respondents felt that an adequately trained er doctor could perform closed cervical spine reductions. most specialists do not stay on site when covering emergencies and often need to travel a distance to the hospital. this is problematic when a cervical dislocation requires urgent management in a very small timeframe. one solution would be to train er doctors to perform or at least initiate cervical reduction. at the university of cape town, our position is that cervical reduction is a cord-saving procedure. it is no less an essential skill than cardiopulmonary resuscitation, intercostal drain insertion and intubation. these skills are taught to every medical doctor as part of the mbchb curriculum. the uct orthopaedic department includes cervical traction reduction as standard teaching to all medical students. the constitutional court judgement is controversial among specialists. many consider it to be based on weak evidence and impractical to implement. most ers, especially in state hospitals, are inundated with severe life-threatening injuries, and many patients need to wait several hours for management. with the court judgement, there is now increased pressure to prioritise cervical dislocations ahead of other critically injured patients, presenting an ethical dilemma to clinicians. we are unaware of any other court judgement worldwide where a specific timeline has been applied to the reduction of low energy cervical dislocations. in this survey, 78% of specialists did not agree with the judgement ruling. of concern, was that 19% were unaware of the ruling. this is staggering, given the constitutional court’s enormous award of r19  000  000 damages to the plaintiff for delayed reduction. it would be anticipated that the various hospital groups would align page 28 workman mi et al. sa orthop j 2019;18(2) their management of cervical dislocations to the time limitations, set up protocols, educate staff and acquire the relevant low-cost equipment. to our knowledge this has only happened in the state sector in the western cape, where policy changes and educational programmes have been put in place. in its judgement media summary, the minority judgement acknowledged that dr newton’s 4-hour theory was new, unpublished, and unknown at the time of the plaintiff’s injury in 2002.22 that is no longer the case and the enormous implications of this ruling should be clearly understood by every hospital manager, emergency response services and medical staff dealing with these injuries. this study primarily aimed to identify what percentage of orthopaedic and neurosurgery specialists and registrars would be able to reduce a cervical spine dislocation within 4 hours of referral, with the aim of implementing further training for both specialists and er doctors. as depicted in figure 1, only 49% of respondents envisage achieving this end point, highlighting the necessity for education, training and establishment of protocols. this survey targeted all specialists managing cervical spine trauma. as noted above, the response was poor from both neurosurgical specialists and registrars (16% of the sample size despite channelling their surveys through the spinal society, neurosurgical society and medical schools), which may have biased the results in terms of a smaller sample size from this group. this is particularly disappointing considering that in south africa, a greater proportion of neurosurgeons practise spinal surgery than orthopaedic surgeons, and cervical dislocation management is very relevant to them. a strong response was, however, recorded from orthopaedic specialists and registrars, with comparable answers indicating a similar approach to the management of this condition. there may have been bias with a higher response rate from the authors’ institution (university of cape town) respondents, who would naturally align themselves with the authors’ teaching and viewpoints. this may explain the relatively high reported rate of cervical reductions (60% reductions in previous year) which does not match our anecdotal observations of the cervical reduction rates outside of the teaching hospitals. this bias effect may have increased the pro-reduction percentage and the proportion who would not perform mri scan. unfortunately, being an anonymous survey, we were not permitted to track where respondents practised or trained, nor could we establish the percentage response from different universities. thus, it is important to note that there may well be a much higher percentage of clinicians who are not comfortable with cervical spine reduction, who think an mri pre-reduction is indicated and who are not aware of the court’s 4-hour ruling. in this survey, 69% supported closed reduction by trained er personnel. this is an important component of acute care since er doctors are on-site and in the event of a patient presenting with a cervical dislocation, they can immediately commence calliper application and initiation of the reduction process. since time is of critical importance, delays for off-site specialists are avoided. it follows from the above that education of medical personnel in the emergent closed reduction of cervical spine dislocations is vital. this is already part of the undergraduate curriculum at the university of cape town as we consider this to be a generalist essential skill. er doctors should have competency in cervical spine assessment and reductions. specialists covering spinal emergencies need to be comfortable performing reductions. hospital managers have a burden of responsibility to provide protocols for cervical reductions, have reduction equipment sets readily available, and ensure all staff are knowledgeable about the time constraints. conclusion this survey demonstrates misconceptions around cervical traction which may compromise optimum management. only 67% of specialists would perform urgent reduction in the most urgent of case scenarios. mri in acute facet dislocation is still being employed against recommendations. surgeons are less inclined to perform closed reduction after mri and in this survey, a significant proportion would not primarily manage the patient, thus incurring a further 2-hour delay. most surgeons are comfortable with er doctors managing cervical reductions and do not agree with the constitutional court ruling. in the western cape, with an average travel time of 3 hours to er, there are unreasonable time constraints placed by the court ruling and unfair priority given to cervical dislocations over other critically injured patients. for the present however, a legal requirement remains around the management of low energy cervical dislocations and clinicians need to adhere to best clinical practice. cervical spine dislocation q: would you be able to reduce within 4 hours? (sample: orthopaedic and neurosurgical registrars and specialists) 18% – no, i do not treat spinal emergencies 1% – yes, would do an open reduction 33% – no, the time frame is too short 49% would achieve cervical spine reduction within 4 hours 48% – yes, would do a closed reduction figure 1. responses to the question: would you be able to reduce in 4 hours? page 29workman mi et al. sa orthop j 2019;18(2) ethics statement this research was approved by the university of cape town department of surgery research committee (2016/024) and the university of cape town faculty of health sciences ethics committee (hrec/ref:310/2016). the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. acknowledgements mr michael mccaul, biostatistician, department of biostatistics, stellenbosch university, south africa. author contributions mw contributed to proposal write-up, data collection and analysis, and final write-up of manuscript. nk contributed to original study concept and conceptualisation, design, data collection and analysis, and write-up of final manuscript. orcid mi workman https://orcid.org/0000-0002-7999-9069 appendix 1 survey questionnaire skeletal traction for cervical dislocations: perceptions and use among specialists in south africa dear colleague, as you may be aware, the recent constitutional court of south africa has placed a 4-hour timeframe on the reduction of low energy cervical reductions with huge medico-legal ramifications. this study is an effort to measure the training, perceptions and experience of the specialists and registrars who are tasked with these reductions. thank you for taking your valuable time to complete this survey of 13 questions which should take 5 minutes to complete. 1. what is your registered speciality? orthopaedic surgeon neurosurgeon orthopaedic registrar neurosurgery registrar 2. describe your formal training in the use of cervical traction: none undergraduate training internship or medical officer level during specialist orthopaedic or neurosurgical training refresher course or lectures post specialisation 3. describe your practice: registrar state employed specialist state/private practice private practice 4. categorise your practice: do not do emergency cover cover emergency general orthopaedics/neurosurgery and spinal conditions cover emergency general orthopaedics/neurosurgery but not spinal conditions 5. after hours: if presented with an acute cervical dislocation from the emergency room, choose the most applicable option: i treat spine emergencies and would manage a cervical dislocation with closed traction myself i treat spine emergencies but would rather refer the patient to a colleague for closed reduction i don’t treat any spine emergencies and would refer the patient to a colleague for treatment 6. give an indication of your medico-legal insurance status: i have spine cover and would perform cervical reduction in an emergency i have no spine cover and would perform cervical reduction in an emergency i have spine cover and would not perform cervical reduction in an emergency i have no spine cover and would not perform cervical reduction in an emergency 7. how many closed cervical reductions did you perform or supervise in the last year? 0 <5 >5 i do not treat emergency spine conditions and would refer to a colleague 8. a rugby player is referred by your emergency room 2 hours after injury with a c5/6 bifacet cervical dislocation diagnosed on x-rays, motor complete (frankel a). your immediate management is: closed cervical skeletal traction reduction mri before closed reduction urgent theatre without mri urgent theatre after mri refer to a specialist who covers spine conditions accepting that is will involve a further 2-hour delay 9. the same rugby player who presented within 2 hours of a c5/6 bifacet cervical dislocation diagnosed on x-rays, motor complete (frankel a), has an mri pre-reduction which shows an uncontained herniated cervical disc (disk at risk). your management is: closed reduction urgent theatre refer to a specialist who covers spine conditions accepting that is will involve a further 2-hour delay https://orcid.org/0000-0002-7999-9069 https://orcid.org/0000-0002-7999-9069 page 30 workman mi et al. sa orthop j 2019;18(2) 10. what is the shortest time you envisage you would be able to surgically open reduce a dislocated cervical spine after receiving the telephone call from the emergency room? consider pre-operative imaging, arranging theatre and an anaesthetist, requesting sets, travel time, set-up in theatre and scrubbing etc? < 4 hours >4 hours non-spinal surgeon 11. in a cervical dislocation with normal or partial neurology, what do you feel is the risk of causing the neurological level to deteriorate during closed cervical traction reduction? >50% 25–50% 1–25% <1% 12. do you feel an adequately trained emergency room doctor is competent to perform a closed cervical skeletal traction reduction if indicated? yes – with proper training no – it is only a specialist procedure 13. in your practice, would you be able to reduce a cervical spine dislocation within 4 hours of referral? no – i do not treat emergency spine conditions no – this time frame is too short yes – by performing closed cervical skeletal traction yes – by performing surgical open reduction references 1. ghafoor au, martin tw, gopalakrishnan s, viswamitra. caring for the patients with cervical spine injuries: what have we learned? journal of clinical anaesthesia jan 2006;17(8):640-49. 2. fielingsdorf k, dunn rn. cervical spine injury outcome – a review of 101 cases treated in a tertiary referral unit. samj mar 2007;97(3):203-207. 3. frankel hi, coll jr, charlifue sw et al. long-term survival in spinal cord injury: a fifty-year investigation. spinal cord 1998;36:247-56. 4. gerhart ka. spinal cord injury outcomes in a population-based sample. j trauma 1991;31:1529-35. 5. vaccaro ar, daugherty rj, sheehan tp, et al. neurologic outcome of early versus late surgery for cervical spinal cord injury. spine 1997;22:2609-13. 6. vasiliadis av. epidemiology map of traumatic spinal cord injuries: a global overview. international journal of caring sciences. sept 2012;5(3):335-47. 7. fleming ma, westgarth-taylor t, candy s, dunn r. how does pre-reduction mri affect surgeons’ behaviour when reducing distraction-flexion (dislocation) injuries of the cervical spine? saoj 2015;14:42-46. 8. initial closed reduction of cervical spine fracture-dislocation injuries. in: guidelines for the management of acute cervical spine and spinal cord injuries. neurosurgery 2002 mar;50:s44-50. 9. gelb de, hadley, mn, dhall ss, hurlbert rj, rozzelle cj, ryken tc, theodore n, walters bc. initial closed reduction of cervical spine fracture-dislocation injuries. neurosurgery 2013;72:73-83. 10. ackland h. the alfred spinal clearance management protocol. the alfred national trauma research institute, melbourne. updated june 2006. 11. hadley mn, walters bc, et al. guidelines for the management of acute cervical spine and spinal cord injuries. section on disorders of the spine and peripheral nerves of the american association of neurological surgeons and the congress of neurological surgeons 2013. 12. rathore fa. spinal cord injuries in the developing world. international encyclopedia of rehabilitation. 2013 – centre for international rehabilitation research information and exchange (cirrie). 13. como jj, diaz jj, dunham m, chiu wc, duane tm, et al. practice management guidelines for identification of cervical spine injuries following trauma: update from the eastern association for the surgery of trauma practice management guidelines committee. j trauma 2009;67:651-59. 14. pimentel l, diegelmann l. evaluation and management of acute cervical spine trauma. emerg med clin n am 2010;28:719-38. 15. hagen em, rekand t, gilhus ne, grunning m. traumatic spinal cord injuriesincidence, mechanisms and course. tidsskr nor legeforen 2012;132(3):831-37. 16. cervical traction. department of orthopaedic surgery – university of stellenbosch, south africa. website: www0.sun.ac.za/ortho/ webct-ortho/general/trac/trac-3.html accessed on 1 july 2013. 17. miller md, thompson sr, hart j. review of orthopaedics, 6th edition. elsevier philadelphia 2012. 18. flyn jm. orthopaedic knowledge update 10. american academy of orthopaedic surgeons 2011 rosemont il. 19. kleyn pj. dislocation of the cervical spine: closed reduction under anaesthesia. paraplegia 1984;22:271-81. 20. cotler hb, miller ls, delucia fa, cotler jm, davne sh. closed reduction of cervical spine dislocations. clin orthop relat res 1987 jan;214:185-99. 21. papadopoulos sm, selden nr, quint dj, patel n, gillespie b, grube s. immediate spinal cord decompression for cervical spinal cord injury: feasibility and outcome. journal of trauma and acute care surgery 2002 feb;52(2):323-32. 22. constitutional court of south africa case cct 185/14 in the matter between: charles oppeld applicant and head: health, department of health provincial administration western cape. 23. newton d, england m, doll h, gardner bp. the case for early treatment of dislocations of the cervical spine with cord involvement sustained playing rugby. j bone joint surg br. 2011 dec;93(12):1646-52. 24. potgieter msw, davis j. a review of the success of reduction of cervical facet dislocation in tygerberg hospital. presented comoc 2016, cape town, south africa. currently submitted for publication. 25. vaccaro ar, falatyn sp, flanders ae, balderston ra, northrup be, cotler jm. magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. spine 1999;24(12):1210-17. 26. tomycz nd, chew bg, chang yf, darby jm, gunn sr, nicholas dh, ochoa jb, peitzman ab, schwartz e, pape hc, spiro rm, okonkwo do. mri is unnecessary to clear the cervical spine in obtunded/comatose trauma patients: the four-year experience of a level i trauma center. j trauma. 2008;64:1258-63.  27. battistuzzo cr, armstrong a, clark j, worley l, sharwood l, lin p et al. early decompression following cervical cord injury: examining the process of care from accident scene to surgery. journal of neurotrauma 2016 jun 15;33(12):1161-69. _goback _goback ole_link2 ole_link3 ole_link4 ole_link5 ole_link6 ole_link7 ole_link8 ole_link1 404 not found 404 not found 404 not found page 116 sa orthop j 2020;19(3) congress news saoa 2020 congress postponed to november the world has been brought to its knees by a single strand of rna surrounded by four proteins. we have been forced into a new digital age of virtual meetings, webinars and even virtual consultations. almost all conferences planned for 2020 have been cancelled or hosted on a virtual platform. these platforms are improving all the time but cannot replicate face-to-face meetings and the ability to catch up with old friends at social events. in south africa, we are still only reaching the peak of the surge and this will continue at least until september. after this we will all need some time to catch up procedures that have been delayed due to the pandemic. it is for this reason that south african orthopaedic association has decided to postpone this year’s annual congress until november 2020. we are trying our best to host a hybrid congress with the host venue in cape town and virtual access for those that cannot travel to the venue. we hope that travel will be allowed at this stage and that we will be allowed reasonable face-to-face interaction. we will reassess the regulations closer to the time. as usual we will have a combination of scientific papers with instructional courses, breakaway sessions for specialty groups and new technology provided by the trade. the theme of the congress will remain as ‘together into the future’ and will feature new advances such as virtual surgery and the use of artificial intelligence to improve outcomes of surgery. we promise you an all-new experience not to be missed. please submit abstracts to us as soon as possible for the scientific programme. we are also including a session on new concepts or research that have not necessarily been scientifically validated, the aim of which is to stimulate debate. one of the key concepts of the congress will be artificial intelligence in orthopaedic surgery. phillip webster president: south african orthopaedic association president@saoa.org.za miseer s et al. sa orthop j 2019;18(1) doi 10.17159/2309-8309/2019/v18n1a4 south african orthopaedic journal http://journal.saoa.org.za traumaspine citation: miseer s, mann t, davis jh. burden and profile of spinal pathology at a major tertiary hospital in the western cape, south africa. sa orthop j 2019;18(1):33-39. http://dx.doi.org/10.17159/2309-8309/2019/v18n1a4 editor: prof rn dunn, university of cape town, south africa received: may 2018 accepted: august 2018 published: march 2019 copyright: © 2019 miseer s. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: spinal pathology in the western cape is managed at three tertiary level hospitals, including tygerberg hospital. the tygerberg hospital orthopaedic spinal unit is responsible for the management of spinal pathology for the 3.4 million people in the hospital’s catchment area. however, the unit’s overall burden of disease and associated resource use is currently unclear. aim: the first aim was to investigate the overall burden and clinical profile of spinal pathology presenting to the tygerberg hospital spinal unit over a one-year period. the second aim was to determine resource use associated with spine pathology admissions. methods: overall burden was investigated by performing a retrospective review of all patients admitted to the spine unit between 1 october 2016 and 30 september 2017. demographic and clinical data was collected, and patients were assigned to one of five spinal pathology sub-groups. resource use was determined by length of hospital stay, waiting times, advanced imaging and theatre usage. results: overall burden comprised 349 individual patients and 376 admissions, including readmissions. trauma (51%) and infection (24%) accounted for the majority of admitted pathology with degenerative (10%), deformity (7%) and malignancy (7%) representing fewer admissions. motor vehicle accidents were the primary mechanism of injury, accounting for 48% of spine trauma. tuberculosis was the causative organism in 87% of spinal infections with 44% hiv co-infection. hospital resource use was considerable with 92% of spine patients requiring advanced imaging, a median operating time of 3 h 36 min and a median hospital stay of 19 days. infection and malignancy sub-groups had the longest waiting times for advanced imaging and theatre with a median wait of 14–16 days, accounting for approximately 62% of the typical total hospital stay. conclusions: the spine unit experienced a substantial patient burden requiring significant hospital resources. reduced in-patient waiting times and upskilling of orthopaedic services at secondary hospitals represent key areas for health system strengthening. however, multi-sectoral strategies would be required to effectively address our high burden of largely preventable spinal pathology. level of evidence: level 4 key words: spinal pathology epidemiology, spinal trauma, spinal tuberculosis, spinal surgery burden and profile of spinal pathology at a major tertiary hospital in the western cape, south africa miseer s¹ , mann t² , davis jh³ 1 mbchb, fc orth (sa); division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, tygerberg hospital, cape town, south africa ² phd; division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa ³ mbchb, mmed(ortho), fc orth (sa); division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa corresponding author: dr sanesh miseer, tygerberg hospital, francie van zijl drive, cape town, 7500, south africa; tygerberg hospital, private bag x3 tygerberg, 7505; tel: 021 938 4911; email: saneshmsr@gmail.com https://orcid.org/0000-0003-0478-0668 https://orcid.org/0000-0002-9750-5106 https://orcid.org/0000-0002-1909-7629 page 34 miseer s et al. sa orthop j 2019;18(1) introduction spinal pathology represents a wide spectrum of disease involving components of the functional spinal unit and contents of the spinal canal.1 typical spinal orthopaedic presentations can be broadly classified into trauma, infection, malignancy, degenerative and deformity subgroups, each of which involve a distinct diagnostic and management approach. nevertheless, all types of spinal pathology can have major implications for functional ability and quality of life, hence access to appropriate treatment is of high importance.2,3 in the western cape, specialist spinal services are only available at three tertiary level hospitals, including tygerberg hospital. officially opened in 1976, tygerberg hospital is the largest tertiary hospital in the province and the second largest in the country with 1 384 active beds and an annual budget of r2.6 billion.4 tygerberg hospital’s orthopaedic spinal unit is responsible for the management of all spinal column pathology, including acute, nonpenetrating spinal cord injuries, for a population of 3.4 million within the hospital’s catchment area. however, the unit is staffed by only one permanent and one sessional consultant, a long-term fellow and two orthopaedic registrars. anecdotal evidence suggests that the spine unit manages a significant volume of patients, many of whom require advanced imaging, considerable theatre time and a lengthy hospital stay. however, this has not been formally investigated, with previous burden of disease studies focusing on specific conditions such as spinal cord injury and spinal tuberculosis (tb).5-7 it follows that the overall profile of spinal pathology presenting to a tertiary institution in south africa and the associated burden on health system resources is currently unclear. with this in mind, the first aim of the current study was to investigate the overall burden and clinical profile of spinal pathology presenting to the tygerberg hospital spinal unit over a one-year period, including patient demographics and human immunodeficiency virus (hiv) prevalence within each pathology subgroup. the second aim of the study was to determine the resource use associated with spinal pathology admissions, including the length of hospital stay, use of advanced radiological modalities and theatre time. it is envisaged that increased insight into the volume, distribution and resource costs of spinal pathology within our setting will help to identify areas for health system strengthening, including accurate and adequate resource allocation. materials and methods overall burden a retrospective review was performed of all patients admitted to the spine unit at tygerberg hospital during the period 1 october 2016 to 31 september 2017. patients were initially identified from the admission files of the unit’s primary admitting wards, after which this list was cross-referenced with the principal investigator’s personal surgical logbook to ensure that no surgical cases were unaccounted for. all duplicate cases were identified and removed. demographic and clinical characteristics patient case records, radiological and biochemical investigations were reviewed, and clinical and demographic information collected for each patient included age, sex, residential area, region of pathology and hiv status. patients were also assigned to one of five spinal pathology subgroups based on clinical notes: trauma, deformity, degenerative disease, infection and malignancy. further information pertaining to the two most prevalent subgroups, trauma and infection, was also collected. trauma data included the mechanism of injury (moi), presence of polytrauma, and american spinal injury association (asia) score on admission. among patients with infection, the causative organisms were categorised as tb or ‘other’ and frankel grade on admission was recorded. resource use to determine the resource use per patient, the length of hospital stay, use of advanced radiological investigations, total theatre time, and waiting times for surgery and for advanced imaging were recorded. theatre time was obtained from intra-operative records of the anaesthetic start and end times as recorded by a member of the nursing team. total admissions n=376 individual patients n=349 repeat admissions n=27 transferred pre-diagnosis n=3 trauma n=180 motor va n=87 pedestrian va n=22 ipv n=15 fall n=46 other n=9 primary n=9 tuberculosis n=72 metastatic n=15 other n=10 deformity n=23 degenerative n=36 infection# n=83 malignancy n=24 figure 1. absolute burden of patients admitted to tygerberg hospital spinal unit within a one-year period, in total and by pathology. va = vehicle accident, ipv = inter-personal violence. *mechanism of trauma, missing data (n=1), #infection causative organism unknown (n=1) page 35miseer s et al. sa orthop j 2019;18(1) data analysis categorical data was presented as counts and percentages whereas continuous data was tested for normal distribution and presented as mean ± standard deviation (sd) or median and interquartile range (iqr) as appropriate. when continuous data was normally distributed within some pathology groups but not others, median (iqr) was presented for all groups. statistical analysis was conducted using microsoft excel 2013 (© 2012 microsoft corporation, impressa systems, santa rosa, california) and graphpad prism (graphpad prism version 6.00, graphpad software, la jolla, california). ethical considerations the study was approved by the human research ethics committee of stellenbosch university and by the management of tygerberg hospital. results overall burden and clinical profile a total of 349 individual patients were admitted to the spine unit over the one-year study period (figure 1). in addition to the initial admission, 21 (6%) patients required one re-admission and three (<1%) patients required two re-admissions, amounting to 376 admissions in total. trauma and infection made up the majority of admitted pathology, accounting for 75% of the overall burden (figures 1 and 2). among trauma admissions, a motor vehicle accident (mva) was the primary moi, accounting for 48% of spinal trauma, with falls contributing a further 26%. polytrauma was noted in 39% of trauma patients with an mva or pedestrian vehicle accident (pva) recorded as the moi in 65% and 24% of polytrauma cases, respectively. tb was the dominant causative organism among patients with infection, accounting for 87% of admissions in this subgroup. demographic and clinical characteristics patient clinical and demographic characteristics are shown in table i. overall, patients with spine pathology ranged from 1 to 80 years of age, including 29 children ≤14 years old. age distribution was distinctive within each subgroup, with the trauma and infection pathologies affecting a particularly wide range of ages (figure 3). although most pathology subgroups showed an approximately equal distribution of males and females, the trauma subgroup showed a notably higher proportion of male patients (67%) (table i). overall, most spine patients were from the cape metro (65%) or the cape winelands (18%) with a much smaller contribution from the hospital’s other referral districts. while 17% of all spine patients were confirmed hiv positive, a further 58% had an unknown hiv status. nevertheless, there was some variation in hiv testing between subgroups with hiv status known in 86% of the infection subgroup and only 17–46% of the other subgroups. of the 72 patients with spinal tb, 32 (44%) were hiv positive, 33 (46%) hiv negative and seven (10%) of unknown status. neurology was intact in 74% and 61% of spine trauma and infection patients, respectively, with only 4–5% presenting with complete paralysis. notably, the majority (45 of 68) of patients with polytrauma presented as asia e. figure 2. distribution of pathology among tygerberg hospital spinal unit patients t r a u m a d e f o r m ity d e g e n e r a t iv e in fe c t io n m a l ig n a n c y t o ta l 0 1 2 3 4 5 6 7 8 9 1 0 o p e ra ti n g t im e ( h o u rs ) figure 4. operating time within pathology type. error bars indicate median and iqr available operating times: trauma (n=70), deformity (n=19), degenerative (n=17), infection (n=60), malignancy (n=6), total (n=172) t r a u m a d e f o r m ity d e g e n e r a t iv e in fe c t io n m a l ig n a n c y x 0 1 0 2 0 3 0 4 0 5 0 6 0 7 0 8 0 9 0 a g e ( y e a rs ) c h ild r e n a d u lt s figure 3. age distribution within pathology type. error bars indicate median and iqr page 36 miseer s et al. sa orthop j 2019;18(1) resource use hospital resource use associated with each initial spine unit admission is shown in table ii. overall, 92% of spine patients required some form of advanced imaging, with 26% receiving both a computed tomography (ct) and a magnetic resonance imaging (mri) scan. in contrast to other subgroups, trauma patients were most likely to have an isolated ct scan (53%) and accounted for 94% of patients receiving a ct scan only. the majority of patients in the deformity, degenerative and infection subgroups received an mri scan only (57–82%), whereas patients with malignancy required both ct and mri imaging in 54% of cases. overall, 52% of spine patients received operative management, with the trauma and infection subgroups requiring surgery in 41% and 78% of patients, respectively (table ii). although patients with malignancy utilised the largest percentage of combined imaging out of any subgroup while admitted to the unit, only 25% underwent surgery. of the 346 patients for whom operative data was available, the median (iqr) operating time was 3 h 36 min (1 h 48 min to 5 h 27 min). however operative time varied by subgroup with the shortest median (iqr) operative times recorded for malignancy (1 h 33 min, 1 h 09 min to 2 h 05 min) and infection (1 h 43 min, 1 h 20 min to 3 h 17 min), and the longest for deformity (7 h 06 min, 6 h 18 min to 8h 18 min) (figure 4). median hospital stay varied by pathology, with the degenerative subgroup showing the shortest median stay (eight days) and the deformity subgroup the longest (38 days). among patients with infection and malignancy, there was a median 14–16 day waiting time between admission and surgery, of which a median of 8–10 days was spent waiting for an mri scan. it follows that waiting time for mri and surgery typically accounted for more than 50% of the median total hospital stay of 23–25 days for these subgroups. while the majority of patients from other subgroups were discharged home, 79% of patients with malignancy were transferred to another department within tygerberg hospital. furthermore 17% of patient with infection were discharged to the western cape rehabilitation centre (wcrc), representing the most common discharge pathway for tb spine patients with neurological fallout. only 3% of patients required referral to the acute spinal cord injury (asci) unit at groote schuur hospital with a further 3% recorded as ‘other’ discharge pathways such as deaths, patient refusal of hospital treatment and absconsions. discussion burden and clinical profile the first finding of the study was that the orthopaedic spinal unit at tygerberg hospital experienced a substantial patient burden over the one-year study period, including 349 individual patients and 376 separate admissions. the clinical profile of spine patients was dominated by trauma and infection, with these subgroups accounting for 51% and 24% of all spine pathology, respectively. spinal orthopaedic surgery is a highly specialised branch of orthopaedics and its scope of practice in our centre is not limited table i: demographic and clinical characteristics of tygerberg hospital spinal unit patients trauma (n=180) deformity (n=23) degenerative (n=36) infection (n=83) malignancy (n=24) total (n=346) demographics age, median (iqr) 36 (26–49) 15 (11–21) 59 (54–68) 41 (21–54) 60 (40–67) 41 (26–56) male sex, n (%) 121 (67) 10 (43) 20 (56) 40 (48) 12 (50) 203 (59) district, n (%) city of cape town 108 (60) 14 (61) 26 (72) 64 (77) 12 (50) 224 (65) cape winelands 34 (19) 6 (26) 6 (17) 13 (16) 5 (21) 64 (18) overberg 16 (9) 1 (4) 6 (7) 5 (21) 28 (8) west coast 20 (11) 1 (4) 4 (11) 2 (8) 27 (8) other 2 (1) 1 (4) 3 (1) hiv status, n (%)* positive 19 (11) 1 (3) 35 (42) 4 (17) 59 (17) negative 31 (17) 4 (17) 6 (17) 36 (43) 7 (29) 84 (24) unknown 129 (72) 19 (83) 28 (80) 12 (14) 13 (54) 201 (58) vertebrae affected, n (%) cervical 85 (47) 2 (9) 11 (31) 1 (1) 3 (13) 102 (29) thoracic 20 (11) 12 (53) 4 (11) 34 (41) 2 (8) 72 (21) thoracolumbar 41 (23) 4 (17) 12 (14) 2 (8) 59 (17) lumbar 14 (8) 2 (9) 11 (31) 24 (29) 2 (8) 53 (15) lumbosacral 5 (3) 3 (13) 7 (19) 4 (5) 4 (17) 23 (7) non-contiguous 15 (8) 3 (8) 8 (10) 11 (46) 37 (11) asia/frankel grade, n (%)† a 9 (5) n/a n/a 3 (4) n/a 12 (5) b 2 (1) n/a n/a 2 (3) n/a 4 (2) c 15 (9) n/a n/a 15 (20) n/a 30 (12) d 18 (10) n/a n/a 9 (12) n/a 27 (11) e 128 (74) n/a n/a 46 (61) n/a 174 (70) *hiv status missing data, trauma (n=1), degenerative (n=1), †asia/frankel grade missing data, trauma (n=8), infection (n=8) page 37miseer s et al. sa orthop j 2019;18(1) by age or pathology type. our varied clinical profile supports this, especially if one considers the admission of 29 paediatric patients which in itself is a significant burden given the added demands of this population group. the discipline is also predominantly consultant-driven with regard to decision-making and surgical management and includes the teaching of registrars and medical students. the high burden of spinal pathology in the state sector lacks adequate specialist cover and this is made even more apparent when compared to the private healthcare sector; a total of 26 private spinal orthopaedic surgeons currently listed on the south african spine society webpage8 for a population of 1.3 million medical aid members in the western cape,9 versus 1.5 surgeons for 3.4 million people. to our knowledge, the current study was the first to report the clinical profile of spinal pathology presenting at a tertiary hospital in south africa, including the major contribution of spinal trauma. nevertheless, the high volume of trauma admissions is in keeping with the overall high trauma burden seen in south africa. for example, there were over 50 000 trauma-related deaths reported countrywide in 201510 and injuries were purported to account for 20% of male deaths in the cape town metro between 2010 and 2015.11 the majority (60.5%) of spine trauma was caused by road traffic collisions, with 80% due to mvas and the remainder to pvas. the majority of mva-related trauma illustrates the highenergy, acceleration/deceleration mechanisms required for spinal pathology. in contrast, a previous multicentre study assessing the burden of spine fractures in india reported that falls were the primary cause of injury in 72% of the patient group. furthermore, traffic accidents accounted for only 23% of all spine fractures despite india having twice as many reported non-fatal road traffic injuries as south africa.12,13 this contrast suggests that mvas within our setting are particularly severe, a premise supported by a 2016 report ranking the western cape as the province with the third highest road traffic collision fatalities.14 of concern is that causal analysis of fatal crashes shows that 74% are due to human factors, meaning that this massive burden is largely preventable.15 while the second largest subgroup of spinal pathology was broadly described as infection, 87% of these patients were individuals with spinal tb. it is well established that the western cape has one of the highest burdens of tb worldwide, with a reported incidence of 681 cases per 100 00016 and a true incidence that is almost certainly higher. within the western cape, the cape metro is the district with the highest absolute burden of tb,16 and this was also the district from which the majority (77%) of our spinal infection patients presented. a higher burden of spinal tb in urban areas is in keeping with previous findings from kwazulu-natal7 and is likely explained by adverse living conditions. another well-known risk factor for tb is hiv infection and in the current study, 44% of patients with spinal tb were hiv-infected with a further 10% of unknown hiv status. this hiv prevalence is approximately twice as high as the 20% hiv prevalence reported among patients with spinal tb treated at groote schuur hospital, a discrepancy that could possibly be explained by an increase in hiv prevalence in the western cape between the study periods (2013–2014 vs 2016–2017),17 more areas with high hiv prevalence within the tygerberg catchment area,18 and differences in the number of individuals with unknown status (10% vs 16%). more importantly, the current hiv prevalence was approximately four times the estimated national hiv prevalence of 12.6% and almost table ii: imaging, treatment, hospital stay and discharge pathway for tygerberg hospital spinal unit patients trauma (n=180) deformity (n=23) degenerative (n=36) infection (n=83) malignancy (n=24) total (n=346) advanced imaging, n (%) no advanced imaging 15 (8) 1 (4) 4 (11) 6 (7) 1 (4) 27 (8) ct only 95 (53) 1 (3) 1 (1) 4 (17) 101 (29) mri only 13 (7) 13 (57) 27 (75) 68 (82) 6 (25) 127 (37) ct and mri 57 (32) 9 (39) 4 (11) 8 (10) 13 (54) 91 (26) treatment, n (%) non-operative 107 (59) 4 (17) 18 (50) 18 (22) 18 (75) 165 (48) operative 73 (41) 19 (83) 18 (50) 65 (78) 6 (25) 181 (52) waiting time and hospital stay, days median (iqr) admission to mri* 2 (1–10) 8 (1–24) 2 (1–9) 8 (3–12) 10 (5–14) 6 (1–12) admission to surgery 6 (3–11) 3 (3–17) 3 (3–8) 14 (9–22) 16 (8–23) 8 (3–17) total hospital days 15 (9–27) 38 (18–60) 8 (4–16) 25 (19–36) 23 (18–30) 19 (10–31) discharge pathway, n (%) discharged home 114 (63) 19 (83) 32 (89) 43 (52) 3 (13) 211 (61) discharged to wcrc 15 (8) 3 (13) 14 (17) 32 (9) transferred to asci 11 (6) 11 (3) transferred to another tbh department 11 (6) 1 (4) 3 (8) 7 (8) 19 (79) 41 (12) transferred to another hospital 26 (14) 15 (18) 1 (4) 42 (12) other 3 (2) 1 (3) 4 (5) 1 (4) 9 (3) ct = computed tomography, mri = magnetic resonance imaging, wcrc = western cape rehabilitation centre, asci = acute spinal cord injury unit (groote schuur hospital), tbh = tygerberg hospital. *data available for patients receiving in-patient mris: trauma (n=64), deformity (n=7), degenerative (n=9), infection (n=65), malignancy (n=17), total (n=162) page 38 miseer s et al. sa orthop j 2019;18(1) seven times the hiv prevalence in the western cape.19 while this appears to suggest an association between hiv-infection and spinal tb, evidence from prospective studies is required to confirm this link. when considering that trauma and infection account for 75% of the burden on spine services at tygerberg hospital, it is pertinent to note that these pathology types are to some extent preventable. for example, stricter road traffic laws and harsher penalties for infringements may help to reduce the incidence of high velocity mvas in the province, and ongoing efforts to reduce tb transmission may reduce the incidence of spinal tb. when excluding spine pathology due to mvas, pvas, inter-personal violence and spinal tb, the current patient burden is reduced by 56% from 349 to 153 patients – highlighting the extent of the preventable burden. while such drastic reductions are unrealistic, the current study could serve as a useful baseline with which to audit relevant societal interventions in the future. resource use the second finding of the current study was that spine pathology was a significant consumer of hospital resources with 92% of patients requiring advanced imaging, a median operating time of 3 h 36 min and a median hospital stay of 19 days. while relatively high resource consumption for managing spine pathology may be well known anecdotally, to our knowledge the current study is one of the first to formally quantify this. high utilisation of key resources such as scanners, operating theatres and hospital beds has implications not only for hospital services but also on the expenses incurred. for example, according to current cash prices in the private sector, the average cost of a regional spinal ct and mri is r3 600 and r6 400, respectively. using the aforementioned estimates, the total cost of diagnostic imaging for isolated cts in 53% of the trauma subgroup was r342 000. the infection subgroup required the greatest number of isolated mris due to the modality’s value with management, and incurred a total cost of r1  305 600 for 24% of all spine patients. exact costing for imaging modalities in the state sector was difficult to obtain and while the cost analysis of the different subgroups is crude, it does provide insight into the significant potential expenditure. a further key expense associated with managing spinal pathologies is theatre time. theatre time is one of the most valuable resources in the health system and is estimated to cost r10 300 per hour.20 spinal surgery is generally lengthier given the complexities of both anaesthesia and surgery and is best reflected in our deformity cases which averaged just over seven hours at a cost of roughly r72 000 per case for theatre time alone. our biggest burdens of trauma and infection averaged a total theatre cost of r35 000 and r15 000, respectively. the relatively short theatre usage for the infection subgroup demonstrates the large number of pedicle biopsies performed in order to establish a tissue diagnosis.21,22 overall, only 52% of spine patients received operative management, indicating the unit’s appreciation for its resourcelimited environment and ability to appropriately treat certain pathologies non-operatively. nevertheless, further cost-saving could be achieved by appointing a dedicated, experienced spinal anaesthetic team to lower anaesthetic time and thus overall surgical time. furthermore, improved provision of basic spinal surgical services at district level would allow for simpler procedures, such as biopsy-taking, to be conducted in secondary hospitals where theatre time is cheaper.23 while advanced imaging and frequent operative treatment are implicit in managing spinal pathology, the high associated costs are compounded by inpatient waiting times for these modalities. due to the severity of pathology referred to the spine unit, the opportunities for outpatient advanced imaging are rare with the majority of patients either draining directly to tygerberg hospital with no secondary holding facility or requiring the immediate care and expertise of a specialised unit. outpatient mri waiting times are also longer as priority is given to inpatients, and very often admitting patients is the most efficient way of providing timely treatment. although trauma waiting times were impressive considering the overall burden of trauma presenting to tygerberg hospital, typical waiting time from admission to surgery was approximately two weeks in the infection and malignancy subgroups. as a result, waiting times contributed substantially to the longer total hospital stay of 23–25 days in the infection and malignancy subgroups. the average cost of a tertiary level general ward hospital stay is r1 640 per day for the facility alone,23 resulting in a total cost of r31 160 for the average spine patient, with the longer hospital stays averaging r62 320. when one considers the average waiting time of 14 days from admission to surgery for the infection patient, a total facility cost of r22 960 is incurred per patient purely from ‘waiting’ for advanced imaging and theatre. this is more expensive than a whole spine mri and stresses the need for not only increased, but efficient mri and surgical theatre services to meet this enormous burden. just as most of the burden of spine pathology seen at the tygerberg hospital spinal unit is preventable, so too could the high costs of treating these preventable conditions be theoretically averted. with a minimum total cost for a surgically treated trauma or infective patient ranging from r62 000 to r68 000, it is clear that both policymakers and society need to be held more accountable before the monetary impact of the disease burden becomes unbearable. while long-term goals of reduced trauma and infection will require time and multi-sector cooperation to achieve, shortand mediumterm goals for saving costs and strengthening health systems could include innovative strategies to reduce the cost of inpatient waiting times at tertiary level and upskilling of basic spinal services at the district level. given the consultant-driven nature of spinal surgery, it is inferred that further training and employment of sub-specialists will improve service delivery and lower overall costs, especially when faced with the high burden of spinal pathology demonstrated in our study. conclusion our study is the first to describe admissions to a tertiary spinal unit in the south african setting and demonstrated a large patient burden and a clinical profile dominated by preventable pathologies such as mvas and spinal tb. the study was also one of the first to quantify resource use between spine pathologies and to confirm the high resource cost of spine pathology management. the high burden of preventable, costly spine pathology within our resource-limited environment highlights a need for urgent, multisectoral interventions. however, health system interventions such as reduced inpatient waiting time and upskilling of orthopaedic services at secondary hospitals would also be very beneficial. future research could focus on the effectiveness of such strategies on the burden, clinical profile and resource use associated with spinal pathology. ethics statement the study was approved by the human research ethics committee of stellenbosch university and by the management of tygerberg hospital. all procedures were in accordance with the ethical standards of the institutional and/ or national research committee and with the 1964 helsinki declaration and its later page 39miseer s et al. sa orthop j 2019;18(1) amendments or comparable ethical standards. a waiver of informed consent was granted for this retrospective review. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. acknowledgements the authors would like to thank mr danie krynauw for his valuable contribution to data collection for the study. author contributions sm contributed to the original study concept, proposal write-up, data collection and analysis, and final article write-up. tm contributed to the original study concept, data analysis, and assisted with the article and proposal write-up. jd contributed to the study design, layout and final article concepts. orcid miseer s http://orcid.org/0000-0003-0478-0668 mann t https://orcid.org/0000-0002-9750-5106 davis jh http://orcid.org/0000-0002-1909-7629 references 1. white and m. panjabi a. clinical biomechanics of the spine, 2nd ed. philadelphia: lippincott 1990;2:18-20. 2. mancuso ca, stal m, duculan r, girardi fp. physical and psychological comorbidity independently associated with spine-related disability. spine (phila. pa. 1976). 2014;39:1969-74. 3. otani k, kikuchi s, yabuki s, igarashi t, nikaido t, watanabe k, et al. lumbar spinal stenosis has a negative impact on quality of life compared with other comorbidities: an epidemiological cross-sectional study of 1862 community-dwelling individuals. sci. world j. 2013;2013. 4. western cape government. tygerberg hospital facts and figures. tygerb. hosp. inf. pam. 2016;6-7. available from: https://www. westerncape.gov.za/your_gov/153 5. joseph c, delcarme a, vlok i, wahman k, phillips j, nilsson wikmar l. incidence and aetiology of traumatic spinal cord injury in cape town, south africa: a prospective, population-based study. spinal cord 2015;53:692-96. available from: http://dx.doi. org/10.1038/sc.2015.51 6. held mfg, hoppe s, laubscher m, mears s, dix-peek s, zar hj, et al. epidemiology of musculoskeletal tuberculosis in an area with high disease prevalence. asian spine j. 2017;11:405-11. 7. godlwana l, gounden p, ngubo p, nsibande t, nyawo k, puckree t. incidence and profile of spinal tuberculosis in patients at the only public hospital admitting such patients in kwazulu-natal. spinal cord 2008;46:372-74. 8. the south african spine society. no title. available from: http:// www.saspine.org/ 9. barron p, padarath a. south african health review 2017. 2017. available from: url: http://www.hst.org.za/publications/ south-african-health-review-2017 10. statistics south africa. mortality and causes of death in south africa, 2015: findings from death notification. stat. release p0309.3 2016;1–127. available from: http://www.statssa.gov.za/ publications/p03093/p030932015.pdf%0ahttp://www.statssa.gov. za/publications/p03093/p030932010.pdf%5cnhttp://www.statssa. gov.za/publications/p03093/p030932009.pdf 11. massyn n, padarath a, peer n dc. district health barometer 2016/2017. durban: health systems trust; 2017. 12. aleem is, demarco d, drew b, sancheti p, shetty v, dhillon m, et al. the burden of spine fractures in india: a prospective multicenter study. glob. spine j. 2017;7:325-33. 13. toroyan t. global status report on road safety. world health organization. 2009;15:286-86. 14. gainewe m. road traffic manag. corp. 2016 calendar year rep. available from: http://www.rtmc.co.za/images/doc/calender/ calender2016/calendar 2016 report 15. republic of south africa. national road safety strategy 2016–2030. 2016;51. available from: https://www.westerncape. gov.za/assets/departments/transport-public-works/documents/ 2017_05_18_strategic_plans_national_road_safety_strategy_2016_ to_2030_approved.pdf 16. massyn n, peer n, padarath a, barron p, day c, trust hs, et al. district health barometer 2015/16. 2016. 17. johnson lf, dorrington re, moolla h. hiv epidemic drivers in south africa: a model-based evaluation of factors accounting for inter-provincial differences in hiv prevalence and incidence trends. south. afr. j. hiv med. 2017;18:1-9. available from: http:// www.sajhivmed.org.za/index.php/hivmed/article/view/695 18. thom a. w cape plots hiv rates by district. the south african health news service 2004 oct;1-2. 19. poolman m, van der walt n, luwaca b. western cape prov aids council. west. cape gov. 2017. available from: http://sanac.org.za/ wp-content/uploads/2017/06/western-cape.pdf 20. netcare group. netcare private hospitals netcare day clinics. 2016;available from: http://www.netcarehospitals.co.za/portals/3/ images/content-images/pdf/final-netcare-rsa-ind-priv-payingpatients.pdf 21. dunn r, zondagh i. spinal tuberculosis: diagnostic biopsy is mandatory. south african med. j. 2008;98:360-66. 22. watt jp, davis jh. percutaneous core needle biopsies: the yield in spinal tuberculosis. south african med. j. 2014;104:29-32. 23. western cape government. upfs billing proced. sched. full-paying patients.available from: https://www.westerncape. gov.za/general-publication/western-cape-government-hospital -tariffs-overview _goback _hlk511594352 south african orthopaedic journal trauma and general orthopaedics doi 10.17159/2309-8309/2023/v22n2a2laney w et al. sa orthop j 2023;22(2) citation: laney w, naicker d, milner b, omar s. analysis of orthopaedic injuries in ct pan scans of polytrauma patients at a quaternary academic hospital. sa orthop j. 2023;22(2):76-81. http:// dx.doi.org/10.17159/2309-8309/2023/ v22n2a2 editor: prof. sithombo maqungo, university of cape town, cape town, south africa received: july 2022 accepted: january 2023 published: may 2023 copyright: © 2023 laney w. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background in south africa, doctors commonly treat patients suffering major trauma, often with multiple injuries, which necessitates the demand for a rapid diagnostic assessment. whole body computed tomography (ct pan scan) allows for a rapid multisystem injury diagnosis. there is a scarcity of literature evaluating the extent of orthopaedic injuries in ct pan scan of polytrauma patients. the aim of the study was to evaluate the local epidemiology of orthopaedic injuries in polytrauma patients who underwent a ct pan scan. methods a retrospective, observational analysis, based at an academic hospital, was done of polytrauma patients who underwent a ct pan scan during a two-year period. a database was compiled by accessing the picture archiving and communication system. results a total of 296 polytrauma patients had a reported ct pan scan; 85% were male and 15% were female with a median age of 33 years. the most common mechanism of injury was motor vehicle accidents (33.1%). a total of 1 012 injuries were identified; 196 were spinal fractures (mostly cervical), 137 were pelvic/sacral fractures, and 101 were long bone fractures of the upper and lower limbs. the most frequent non-orthopaedic injury sustained was a chest injury. in a pedestrian-vehicle accident, the most common combination of injuries was a chest injury with an associated pelvic/sacral injury. interpersonal and intentional injuries were significantly associated with a higher risk of thoracic spine fractures (relative risk [rr] 1.8, ci 1.1–2.9), whereas road traffic accidents were significantly associated with a higher risk of scapula/clavicula fractures (rr 2.0, ci 1.2–3.5) and a higher risk of tibia/fibula fractures (rr 3.5, ci 1.2–10.3). conclusion the majority of polytrauma patients were young males involved in road traffic accidents. a patient involved in a road traffic accident is 3.5 times more likely to sustain a tibia/fibula fracture as opposed to any other fracture. one in four patients who sustained a chest injury had an associated cervical spine injury, and one in three patients had a pelvic/sacral injury, and similarly with head injuries. the findings of this study highlight injury patterns that should be anticipated in polytrauma patients. level of evidence: level 3 keywords: ct pan scan, orthopaedic injuries, polytrauma, whole body computed tomography analysis of orthopaedic injuries in ct pan scans of polytrauma patients at a quaternary academic hospital wezley laney,¹* dharshen naicker,² brenda milner,² shahed omar³ ¹ department of orthopaedic surgery, charlotte maxeke johannesburg academic hospital, university of the witwatersrand, johannesburg, south africa ² university of the witwatersrand, johannesburg, south africa ³ main intensive care, chris hani baragwanath academic hospital, school of clinical medicine, university of the witwatersrand, johannesburg, south africa *corresponding author: wezleylaney@gmail.com introduction traumatic injuries account for ten per cent of the global burden of disease.1 the proportion of traumatic injuries is greater in low-to-middle-income societies, with 90% of all global cases of trauma-related mortality occurring in these countries.2 south africa represents one of these countries, being a middle-income country, with the reported rate of trauma-related mortality being six times higher than the global rate.2 in south africa, we frequently see patients who have sustained major trauma, suffering from multiple injuries. these patients are often described as polytrauma patients, which is defined as a combination of two or more severe injuries occurring in two or more anatomical areas; rarely, two or more severe injuries in one region where one injury is life-threatening.3 this significant burden of trauma necessitates the demand for a rapid diagnostic assessment of injuries for appropriate therapeutic intervention. the introduction and popularisation of whole body computed tomography (ct pan scan) allows for a rapid multisystem injury diagnosis of trauma patients. the definition of a pan scan is a ct scan of the head/brain, spine, chest, abdomen, pelvis and extremities that occurs in a single series at the scanner. the administration of contrast is given as per the protocols.4 https://orcid.org/0000-0002-0663-6531 page 77laney w et al. sa orthop j 2023;22(2) the use of a ct pan scan has a unique role in the polytraumatised patient, as it is more sensitive for the detection of head, spinal, thoracic, abdominal and pelvic injuries compared to conventional radiography.4 in addition, a ct pan scan has been shown to be associated with a reduction in mortality rates, and has a proven benefit over targeted ct examination.5 despite the benefit of a ct pan scan in the assessment of polytrauma patients, there is no international consensus or validated clinical criteria for the selection of trauma patients who should undergo this scan. rather, as highlighted by gunn et al., the decision to do a ct pan scan is based on one of three indications, these being: the mechanism of injury (moi), the location of injury or the physical examination correlating to the injury severity score.4,6 even with the widespread acceptance of the use of a ct pan scan in the assessment of polytrauma patients, there is a scarcity of literature evaluating the extent of orthopaedic injuries in polytrauma patients. therefore, the aim of the study is to evaluate the local epidemiology of orthopaedic injuries in polytrauma patients who have undergone a ct pan scan. the objectives of the study are: • to determine the prevalence of orthopaedic injuries in polytrauma patients • to identify the orthopaedic injuries sustained in polytrauma patients who underwent a ct pan scan • to evaluate the relationship between orthopaedic injuries, nonorthopaedic injuries sustained and other contributing factors (epidemiological data and mechanisms of injury) methods this study was based at a quaternary level state hospital in johannesburg, south africa. a retrospective, observational analysis of patients who underwent a ct pan scan was done over a two-year period from 1 january 2018 to 31 december 2019. polytrauma patients aged 18 years and older who presented to the trauma unit and required a ct pan scan were included in the study. for this study, the polytrauma patients included had a combination of injuries in two or more anatomical areas. patients who had no reported injuries, an isolated system injury or no orthopaedic injuries were excluded from the study. a database was compiled for the evaluation period 1 january 2018 to 31 december 2019. the data were retrieved from the picture archiving and communication system (pacs) by selecting ‘ct’ as the modality of investigation, followed by using the descriptive term ‘ct pan scan’. statistical analysis statistical analysis was performed using statistica, version 13.3. non-normal data were described using medians and interquartile ranges (iqrs). the qualitative data were reported using frequencies and percentages. categorical variables were analysed using the chi-squared test (or fisher’s exact test). category a injuries included interpersonal and intentional injuries: assault, gunshot wound (gsw), injury from a heavy object, and unintentional injuries, such as fall from a height (ffh). category b injuries included road traffic accidents: motor vehicle accident (mva), pedestrian-vehicle accident (pva), and train accidents, respectively. all unknown mechanisms of injury were excluded from these categories. results over the two-year study period, a total of 21 466 patients attended the trauma casualty. of these patients, a total of 4 856 patients were deemed priority resuscitation patients. a total of 954 ct pan scans were found on pacs when the previously mentioned parameters were used. of these, 64 ct pan scans were eliminated (figure 1). after exclusions were applied, there were 296 polytrauma patients that had a reported ct pan scan. therefore, the incidence of polytrauma patients identified by ct pan scan is 1%. nevertheless, one-third (33%) of the trauma ct pan scans performed diagnosed patients with polytrauma injuries. of the 296 ct-reported polytrauma patients included, 85% were male (n = 252) and 15% were female (n = 44) with a male to female ratio of 5.6:1.0. the median age of the patients was 33 pacs search: 954 ct pan scans performed 890 reported trauma ct pan scans 472 non-orthopaedic injuries 540 orthopaedic injuries 296 ct pan scans reported polytrauma patients eliminated scans (64): • 3 medical scans • 12 no report • 32 no scan loaded to pacs • 12 descriptively mislabelled • 4 duplicated • 1 scan post-surgical intervention excluded scans (594): • 39 under 18 years old • 1 no age of patient recorded • 170 no injury reported • 384 with no orthopaedic injury figure 1. ct pan scan search flow chart 18 –2 3 24 –2 8 29 –3 3 34 –3 8 39 –4 3 44 –4 8 49 –5 3 54 –5 8 59 –6 3 64 –6 8 > 69 age category (years) sa m pl e si ze (n ) 80 70 60 50 40 30 20 10 0 figure 2. age distribution of polytrauma patients (n = 296) page 78 laney w et al. sa orthop j 2023;22(2) years (interquartile range of 28–42 years). the male age range was 18–79 years whereas the female age range was 18–68 years. figure 2 shows the age distribution of the study population. the five most common moi were: mva (33%), pva (31%), ffh (22%), assault (4%) and unknown moi (3%). figure 3 shows the moi frequencies based on sex. there were 1 012 injuries found among the 296 patients included in the study. there was a total of 472 (47%) non-orthopaedic injuries and 540 orthopaedic injuries reported in this sample. the prevalence of orthopaedic injuries in polytrauma patients was 53% (95% ci 51.7–54.9%). fractures accounted for 94% (n = 508) of all orthopaedic injuries while joint injuries accounted for the remaining 6% (n = 32) of orthopaedic injuries. figure 4 shows the frequency of each injury reported. one hundred and ninety-six (196) spinal fractures were detected in 152 of the 296 patients on whom a ct pan scan was performed. the relative frequency of the different spinal fractures and combinations of injuries sustained is shown in figure 5. there was a total of 137 pelvic/sacral fractures reported on ct pan scan. forty-five of these were acetabular fractures and two had associated posterior hip dislocations. there were 29 sacral fractures, including sacral alar fractures and sacroiliac joint diastasis injuries. the remaining injuries included pubic rami or iliac blade fractures. of the 296 patients included in the study, a total of 101 long bone fractures were sustained in 85 patients. the majority of long bone fractures involved the lower limbs (75%), while 25% were upper limb fractures. of all long bone fractures, 78% were isolated long bone fractures while 22% were multiple long bone fractures. the relative frequency of the different long bone fractures and combinations of fractures is shown in figure 6. the upper limb joints (shoulder and elbow) only represented 29% of joint injuries. the knee and ankle joint injuries represented 56% and 15%, respectively. g s w h ea vy o bj ec t tr ai n u nk no w n a ss au lt ff h p va m va 100 90 80 70 60 50 40 30 20 10 0 mechanism of injury n um be r o f p at ie nt s males females figure 3. moi based on sex va sc ul ar in ju ry h an d/ fo ot # in tra pe lv ic in ju ry u pp er li m b# jo in t i nj ur y s ca pu la r/c la vi cl e# lo w er li m b# a bd om in al in ju ry p el vi c# h ea d in ju ry s pi na l# c he st in ju ry category of injury n um be r o f i nj ur ie s 250 200 150 100 50 0 3 9 12 25 32 65 76 79 137 169 196 209 figure 4. frequency of all injuries sustained in polytrauma patients #: fractures c er vi ca l lu m ba r th or ac ic c er vi ca l + th or ac ic th or ac ic + lu m ba r c er vi ca l + lu m ba r c er vi ca l + th or ac ic + lu m ba r spinal injury category pe rc en ta ge o f i nj ur ie s (% ) 30 25 20 15 10 5 0 28.9 28.3 15.1 10.5 9.2 6.6 1.3 figure 5. spinal injuries h um er us r ad iu s/ ul na h um er us + ra di us /u ln a fe m ur ti bi a/ fe m ur fe m ur + ti bi a/ fib ul a category of long bone fracture pe rc en ta ge o f t ot al in ju rie s (% ) 45 40 35 30 25 20 15 10 5 0 21.2 3.5 2.4 41.2 15.3 16.5 figure 6. relative frequency of long bone fractures page 79laney w et al. sa orthop j 2023;22(2) there were only three reported vascular injuries among the 296 patients included. these were a thoracic aortic pseudoaneurysm, a descending aorta intimal flap and a popliteal vessel injury after sustaining a shatzker-6 tibial plateau fracture. in our sample, 48% (n = 142) of patients had sustained multiple fractures. there were 19 patients with two or more long bone fractures; of these, 13 patients had a combination of femur and tibia/fibula fractures. in addition, there were 25 patients that had sustained pelvic/sacral fractures with an associated long bone fracture. furthermore, 18 patients with spinal fractures had also sustained long bone fractures. interestingly, 34% (48/142) of patients with multiple orthopaedic injuries had a scapula/clavicle fracture. the most common orthopaedic injury in this group were pelvic/sacral fractures, and 32% of these patients had an associated lumbar spine fracture. the most common non-orthopaedic injury sustained was a chest injury with 209 injuries reported. table i shows the percentage of head and chest injuries with various orthopaedic injuries sustained. the most common combination of orthopaedic and nonorthopaedic injuries identified in the study was a chest injury with an associated pelvic/sacral fracture secondary to a pva. the most common orthopaedic injury associated with either a head injury or chest injury or abdominal injury was a pelvic/sacral fracture. table i: percentage of head and chest injuries associated with orthopaedic injuries cervical spine injury pelvic/ sacral injury upper limb injury lower limb injury head injury 27% 34% 7% 26% chest injury 25% 33% 8% 22% category a (interpersonal and intentional injuries) mechanisms included: assault, fall from a height, a gunshot wound and injury from a heavy object. category a mechanisms were significantly associated with a higher risk of thoracic spine fractures (relative risk [rr] 1.8, ci 1.1–2.9). none of the assaulted patients, that were ct pan scanned, suffered a lower limb long bone fracture (femur or tibia/fibula). category b (road traffic accidents) injuries included: mvas, pvas and train injuries. category b mechanisms were significantly associated with a higher risk of scapula/clavicula fractures (rr 2.0, ci 1.2–3.5) and a higher risk of tibia/fibula fractures (rr 3.5, ci 1.2–10.3). discussion the aim of the study was to describe the orthopaedic injuries sustained in polytrauma patients that underwent a ct pan scan. with a paucity of studies looking specifically at this subject, we compared the data obtained from the current study to the findings reported in similar studies that reported on polytrauma injuries, not only identified on ct pan scan. in the current study, we had a predominance of males (85%). this is similar to the 83% male predominance reported by donovan et al. at tertiary level grey’s hospital, and the 80% male predominance described by dhaffala et al. from the mthatha hospital complex, both located in south africa.7,8 however, when compared to the international burden of disease as reported in spain by barrera et al., they found a 75% male majority in their polytrauma patients.9 the median age of the population studied was 33 years. this is comparable to studies from chris hani baragwanath academic hospital (chbah), botswana and india reporting mean ages of 33.0, 33.5 and 35.2 years, respectively.3,10,11 in comparison to a local and an international study, the mean ages reported were 44.4 and 43.9 years, respectively.8,12 the iqr of 28–42 years found in the current study is in keeping with the age ranges of polytrauma patients reported at an indian tertiary care centre where 57.7% of their trauma patients were aged 21–40 years old and similarly at grey’s hospital where 60.3% of their patients were aged 20–39 years old.7,13 the mechanism of injury is an important aspect of trauma and orthopaedics, which relates to the severity of an injury and the number of injuries sustained. the most common moi to cause polytrauma in patients seen is either high velocity injuries (mva/ pva) or high energy trauma (ffh). table ii highlights and compares the five most common mois observed in the current study, as well as those reported in five other studies. of note, road traffic accidents are the most significant mechanism of injury in our study (64%). this is a similar trend reported by other similar studies, and highlights the deficiency in road safety awareness and practices among pedestrians, passengers and drivers. this finding highlights the need for improved road safety education, as well as improvements to public transport infrastructure to possibly reduce the number of traffic-related accidents. falls from a height represented the second largest mechanism of injury in our study (22%). this is in stark contrast to local studies, with chbah reporting only 6% injuries due to fall from a height. a possible explanation for this finding is that the study hospital is located in close proximity to the johannesburg central business district, with a large number of residents living in highrise buildings. thus, the large number of high-rise buildings is expected to be a significant contributor to the trauma burden due table ii: a comparison of mois reported in various studies reference current study leshoele11 kalsotra et al.13 donovan et al.7 manwana et al.10 jarman et al. 14 n 296 289 258 8 722 372 815 298 % % % % % % road traffic accident 64 86.9 76.4 28.17 25.5 29.2 motor vehicle accident 33 54.7 51 18.48 pedestrian-vehicle accident 31 32.2 25.4 9.69 fall from height 22 6.0 10.5 2.42 39 47.9 assault 4 4.5 10.9 18.06 15.3 7.2 unknown 3 <1 1.63 11.6 gunshot wounds 32 1.1 1.2 miscellaneous 2.2 5.1 page 80 laney w et al. sa orthop j 2023;22(2) to falls from a height, unlike chbah where there are virtually no high-rise buildings. in comparison to two international studies by jarman et al. and manwana et al., the authors reported that falls were the most common moi; however, these studies included all types of falls in this category, i.e., falls from a height and falls of the elderly.10,14 in 2017, pelonomi hospital in bloemfontein, south africa, reported that 50.6% of all hospital visits were due to interpersonal and intentional violence.15 in this study, only 4% of polytrauma injuries were due to interpersonal and intentional violence. however, upon review of the casualty statistics, it shows that 43.5% of patients seen at the trauma unit was because of interpersonal and intentional violence. similar trends were seen in the western cape, with groote schuur hospital reporting 38% of patients seen due to assault.16 this highlights that the prevalence rates of interpersonal violence are similar across south africa, but that the patients seen are less likely to be polytrauma patients. the burden of violence in south africa is emphasised by the crime rate of 77.3%, which is the third highest crime rate in the world.17 in the analysis of spinal fractures (196/1012), these accounted for most of the orthopaedic injuries reported on a ct pan scan. the only other study to have also shown this was published by shannon et al.5 the authors also used ct pan scans which were compared to clinically suspected injuries. table iii compares the number of injuries observed in the current study compared to those reported in other studies. the most common spinal fracture was a cervical spine fracture (72/196) which had concomitant thoracic spine injuries 11% of the time. this is comparable to nelson et al. who reported a 9% noncontiguous cervicothoracic vertebral fracture rate.18 thus, a high index of suspicion for thoracic spine trauma is required when a cervical spine fracture is identified in a polytrauma patient. when analysing the number of pelvic/sacral fractures, these represented 25% of the orthopaedic injuries sustained in the sample size. pelvic/sacral fractures showed a proportionally higher prevalence in the study population when compared to other studies. however, the global prevalence of pelvic fractures is estimated at 2–8%, but in polytrauma patients this is reported to increase to 20–25%, which is comparable to our study.20 a reason for the high number of pelvic/sacral fractures seen in the study is based on the moi (road traffic accidents and ffh), which tend to be high velocity and high energy injuries leading to increased incidence of pelvic fractures. in addition, the quaternary hospital receives more complex trauma cases that may have been transferred to this hospital for further management. the prevalence of long bone fractures is predominantly lower limb fractures, and this is comparable to the other studies cited in table iii. however, it is believed that the ct pan scans performed on the study population has under-reported on the total number of lower limb fractures due to where the scan sequence was terminated. many of the scans were performed to the level of the proximal femora which may result in injuries being missed distal to the point of termination. it is important to note that an extended scan should be requested if there is an index of suspicion for injury to the lower limb (vascular or fractures that would require a ct scan).21 the reported number of upper limb fractures in comparison to other studies is markedly lower, and this also raises the suspicion for under-reporting in the study population. the upper limbs are notorious for not being included in the ct field based on the position of the upper limb.12 chest injuries are the most common non-orthopaedic injury, comprising rib fractures, lung contusions and haemopneumothoraxes as the most common injuries reported. this is a similar finding to those reported in other studies (table iii) which is to be expected since the chest is one of the largest body cavities that is often involved in both blunt and penetrating trauma.22 from table i, the polytrauma patients that present with chest injuries also have a high incidence of orthopaedic injuries, similarly with head injuries. it is important to identify combined injuries, especially with chest and head injuries, as these are critical factors in determining whether a patient requires early total care or damage control orthopaedics. based on the results obtained from this study, should a patient be involved in a road traffic accident, they are 3.5 times more likely to sustain a tibia/fibula fracture as opposed to any other fracture. these road traffic accident patients are also twice as likely to sustain scapula or clavicle fractures compared to the other mois. the study is based on a large sample size for a select group of patients, over a two-year period. thus, we have established a significant data bank on which further studies can be conducted. table iii: a comparison of the number of injuries reported in various studies reference current study sampson et al.19 shannon et al.5 kalsotra et al.13 banerjee et al.12 n 296 255 588 285 14 583 investigation ct pan scan ct pan scan pan scan x rays + ct x rays + ct orthopaedic injuries spinal fractures c spine 72 26 62 22t spine 55 48 85 l spine 69 55 long bone fractures upper limb 25 174 3 266 lower limb 76 461 5 381 pelvic/sacral 137 67 60 30 hand/foot 9 163 1 487 scapula/clavicle 65 27 2 640 trauma injuries head injury 169 127 158 153 7 277 chest injury 209 311 399 81 9 319 abdominopelvic injury 91 89 78 89 3 281 page 81laney w et al. sa orthop j 2023;22(2) the study encompasses a wide spectrum of orthopaedic and non-orthopaedic injuries, identified and confirmed objectively by a consultant radiologist. a limitation of the study was its retrospective nature and there was no follow-up on the patient outcomes of the identified injuries. with regard to spinal fractures, there was no collection of data regarding the presence or absence of neurological dysfunction, which may be a consideration for further research. the ct pan scan protocol includes patients who are deemed clinically stable to undergo a ct pan scan; thus those patients who were deemed to be too unstable were not pan scanned and thus may not reflect the injury patterns of these unstable polytrauma patients. there is no set protocol as to the level of termination of the ct pan scan and this could lead to injuries being missed on the ct pan scan. in south africa, there are periods of power outages during which ct scans are performed offline. the ct scan images and reports are not transferred to the pacs once the servers are back online. conclusion the majority of polytrauma patients seen are young males who sustained injuries during road traffic accidents. the most common orthopaedic injury detected in our cohort, overall, was a spine fracture, most commonly involving the cervical spine. a patient involved in a road traffic accident is 3.5 times more likely to sustain a tibia/fibula fracture as opposed to any other fracture. the most common non-orthopaedic injury sustained is a chest injury; importantly, one in four of these patients sustained an associated cervical spine injury and one in three a pelvic injury, three similarly with head injuries. the most common combinations of injuries were a chest injury with an associated pelvic/sacral fracture secondary to a pva. the findings highlight the significant burden of orthopaedic injuries in polytrauma patients. in addition, the findings of this study highlight injury patterns that could be anticipated in polytrauma patients. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. approval to conduct the study was obtained from the human research ethics committee (medical) of the university of the witwatersrand (clearance number: m201131), as well as the hospital research committee and management. informed consent was waived by the ethics committee due to the retrospective nature of the study and lack of identifying data. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions wl: report design, data collection, literature review and analysis, article drafting, final approval and submission dn: report design, literature review and analysis, article drafting and final approval bm: report design, literature review and analysis, article drafting, final approval and submission so: data analysis, article drafting, article review and final approval orcid laney w https://orcid.org/0000-0002-0663-6531 naicker d https://orcid.org/0000-0001-9617-1063 omar s https://orcid.org/0000-0001-8494-1518 references 1. haagsma ja, graetz n, 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2020;23(3):125-38. https://doi.org/10.1016/j. cjtee.2020.04.003 https://orcid.org/0000-0002-0663-6531 https://orcid.org/0000-0001-9617-1063 https://orcid.org/0000-0001-8494-1518 orthopaedics vol3 no4 page 50 sa orthopaedic journal summer 2014 | vol 13 • no 4 expert opinion on published articles what are the functional outcomes of endoprosthetic reconstructions after tumor resection? nm bernthal, m greenberg, k heberer, jj eckart clin orthop relat res 2014;doi 10.1007/s11999-014-3655-1 the diagnosis of a primary bone sarcoma has historically meant extremely poor survival, and surgical procedures limited to amputations. with advances in medical and surgical treatment of these cancers, patient survival has improved tremendously. this increased life expectancy has resulted in a higher demand for limb salvage. it should however still be emphasised that the primary aim in tumour surgery is to save a life, secondarily to save a limb and lastly to restore function beyond routine daily living activities. where limb salvage can be performed without jeopardising patient survival, it is imperative to discuss expected outcomes with patients and their families. objective data regarding implant longevity and functional results can assist the orthopaedic oncological surgeon in generating reasonable expectations of life after limb salvage and provide the patient with a realistic look into the future. bernthal et al. invited 69 eligible patients to participate in a study evaluating the functional outcome of endoprosthetic reconstructions after tumour resections. the authors aimed to answer three questions: 1) what is the efficiency of gait? 2) what is the knee strength compared to the contralateral side? and 3) how active are patients at home and in the community? twenty-four patients (seven proximal femur, nine distal femur and eight proximal tibia replacements) at a mean of 13.2 years (2.5–28.2) from endoprosthetic reconstruction responded to the invitations. all respondents underwent evaluation in a gait laboratory to ascertain 02 cost of walking and walking speed. isokinetic strength testing of knee extension and flexion was measured and all patients were asked to wear a stepwatch activity monitor to measure their total number of strides per day. the results were compared with a control group of eight healthy individuals. there was no statistical difference for median 02 cost during gait between any of the groups (proximal femur, distal femur and proximal tibia replacements) and controls. median walking speed between the groups and control also showed no statistical significant difference. all reconstructions showed decreased strength in knee extension and flexion compared to the contralateral side with the proximal tibial reconstruction group showing the greatest deficit. there was no statistical significant difference in the number of steps taken at home or in the community among the different reconstruction groups. objective functional outcomes after tumour resection and endoprosthesis reconstruction are necessary to generate reasonable expectations for surgeons and patients undergoing limb salvage. the current study reports excellent functional results over long follow-up times. it is however important to note that only about a third of the eligible patients responded to the invitation for functional evaluation. this obviously has the potential for a significant observational bias, as patients with poorer outcomes might not be willing to participate in the physical activities required for the evaluation. i would caution against generating expectations of functional outcomes reported in this paper with all patients about to undergo tumour resection and megaprosthesis reconstruction. this study does, however, propose good objective measures to evaluate functional outcomes after tumour resection and endoprosthetic reconstruction. these measures can potentially be used to objectively evaluate different surgical reconstruction techniques and implant designs in future. reviewer: dr n ferreira tumour, sepsis and reconstruction unit department of orthopaedic surgery university of kwazulu-natal grey’s hospital pietermaritzburg tel: +27 033 897 3299 nando.ferreira@kznhealth.gov.za the current study reports excellent functional results over long follow-up times giant cell tumour of the middle finger bone saoj summer 2014_orthopaedics vol3 no4 2014/11/05 12:07 pm page 50 page 52 sa orthopaedic journal summer 2014 | vol 13 • no 4 ‘warning signs’ of primary immunodeficiency among patients with periprosthetic joint infection claudio diaz-ledezma, jennifer baker, javad parvizi j appl biomater funct mater 2014;12(2):65-69. doi: 10.5301/jabfm.5000207 periprosthetic joint infection (pji) is a devastating complication following hip and knee arthroplasty. the role of the host in the development of pji is well recognised and several scoring systems have been devised in an attempt to identify high-risk patients. these scoring systems have, however, focused on factors known to be associated with secondary immunodeficiency. in this article the authors investigate the potential role of primary immunodeficiency (pid) in the development of pji. primary immunodeficiency encompasses a wide spectrum of genetic disorders which result in a reduction in the competency of a patient’s immune response, placing them at risk of multiple infections. more than 180 such disorders have been identified and it is estimated that 1 in 1 200 people in the united states may be afflicted with pid. these disorders have been classified into eight broad categories consisting of combined immunodeficiencies, antibody deficiencies, immune dysregulation, phagocyte abnormalities, innate immunity dysfunction, autoinflammatory disorders and complement deficiencies. one of the more common disorders presenting in adulthood is common variable immunodeficiency (cvid), which is characterised by varying degrees of hypogammaglobulinaemia. clinically these disorders may be difficult to detect, and researchers have developed a list of ten ‘warning signs’ which may point towards the possible presence of a pid. these warning signs consist of the following: 1. two or more new ear infections within one year 2. two or more new sinus infections within one year, in the absence of allergy 3. one pneumonia per year for more than one year 4. chronic diarrhoea with weight loss 5. recurrent viral infections (colds, herpes, warts, condyloma) 6. recurrent need for intravenous antibiotics to clear infections 7. recurrent, deep abscesses of the skin or internal organs 8. persistent thrush or fungal infections on skin or elsewhere 9. infection with normally harmless tuberculosis-like bacteria 10. a family history of primary immunodeficiency in the study by diaz-ledezma et al., 14% of the 185 patients with pji included in the study had one or more of these ‘warning signs’. only a small number of cases, though, had no additional comorbidities (which could have caused a secondary immunodeficiency). the potential prevalence of pid was therefore estimated to be in the region of 1.6%. the limitations of this study were, however, acknowledged by the authors. only patients with more than 15 medical consults at the institution’s facilities, prior to the diagnosis of pji, were included in the study. this means that 587 patients on their pji database were excluded and the sample size was considerably reduced. the second limitation is the retrospective nature of the analysis. the prevalence can only be inferred, as routine testing for pid was not performed. the final shortcoming relates to the ten ‘warning signs’ themselves. these have been criticised in several other publications because of their lack in accuracy. while the article under scrutiny does not necessarily provide the answers, it raises important questions. what percentage of patients with implant-related infections has an underlying primary immunodeficiency? a well-designed prospective study will be required to answer this question. common variable immunodeficiency, for example, can be treated through immunoglobulin replacement therapy. should we, therefore, be screening patients for the presence of a pid prior to elective arthroplasty? the authors of this study concluded that administration of these ‘warning sign’ questions to patients with multiple infections may lead to identification of a primary immunodeficiency status which may in turn influence the outcome of elective arthroplasty. in my limited experience, the management of patients with pid has been particularly challenging and requires a multidisciplinary approach. it may, therefore, be advisable to screen patients with an unexplainable infection for the presence of an underlying immunodeficiency. reviewer: dr lc marais tumour, sepsis and reconstruction unit department of orthopaedic surgery university of kwazulu-natal grey’s hospital pietermaritzburg tel: (033) 897 3424 leonard.marais@kznhealth.gov.za saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:57 pm page 52 page 54 sa orthopaedic journal summer 2014 | vol 13 • no 4 management after failed treatment of ankle fracture john a scolaro, david p zamorano current orthopaedic practice 2014;25(3):221-26 failed treatment of ankle fractures can result in ankle instability and joint surface incongruity. biomechanical studies have shown that lateral talar shift of more than 1 mm causes a loss of over 40% of the tibiotalar contact area. this leads to pain, loss of function and early post-traumatic degenerative changes. the aim of treatment should be to identify the reason for failure, and anatomically reduce and restore the tibiotalar joint with stable fixation. the ideal time for reconstruction is not known; the literature supports a few months to years. evaluation should include a complete clinical and radiological evaluation. the radiological investigation includes xrays (three views), anteroposterior, mortis (20° internal rotation) and a lateral view. a ct scan can be helpful to evaluate the syndesmosis, fracture reduction, bony fragments, debris and articular surface. lateral malleolus restore fibular length and rotation. visualisation of the distal tibiofibular joint is essential to ensure correct reduction of the lateral malleolus within the incisura of the distal tibia. transverse, step and oblique fibular osteotomies have been described to restore length and rotation. if the osteotomy exceeds 3 mm, autologous bone graft should be used. medial malleolus osteotomy or debridement of non-healing bone surfaces. the anterior medial edge of the tibial plafond should be exposed to ensure chondral reduction of the medial malleolus. fixation can be done with screws, tension band construct or a plate fixation. fragment excision can be performed if the fragment removal does not result in ankle instability. the deltoid ligament can be advanced and secured to bone with anchors or bone tunnels. posterior malleolus isolated malunion or non-union of the posterior malleolus is rare. if posterolateral subluxation of the talus occurs, a corrective osteotomy and revision fixation should be done. syndesmosis revision fixation should be performed with an open technique. visualise the distal tibiofibular joint and debride the incisura. conclusion ankle fractures are commonly treated orthopaedic injuries; the goal should be to achieve a well-aligned stable ankle joint. this article summarises the treatment options for the failed treatment of ankle fractures, and is a good read for all registrars. reviewer: dr p greyling department of orthopaedic surgery steve biko academic hospital tel: 012 354 2851 the aim of treatment should be to identify the reason for failure, and anatomically reduce and restore the tibiotalar joint with stable fixation saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:57 pm page 54 page 56 sa orthopaedic journal summer 2014 | vol 13 • no 4 external fixation is increasingly used for the treatment of complex trauma, trauma sequelae and congenital conditions. the weak point of any external fixator is the pin–bone interface, as this is where the fixation of the external fixator to the bone takes place. compromise of this interface through pin track infection can lead to catastrophic failure of the external fixator device. in these two excellent articles from two prominent local limb reconstruction surgeons, they first discuss a scientific approach to pin track care, followed by a critical look at hiv as a risk factor for pin track sepsis. in the first article, the principles of proper pin track care are systematically and clearly discussed with good reference to the available literature. an important message is that pin track care commences during the intra-operative phase, as proper pin and wire insertion are essential in preventing later pin track problems. the authors then guide the reader through a scientific postoperative pin track protocol through the early and late postoperative periods. they also discuss the management of pin track problems after frame removal. treatment of established pin track sepsis is also discussed in some detail. this article is a seminal work in the field of external fixator surgery and makes essential reading for anyone who uses external fixation, even occasionally. the second article explores whether hiv should be seen as a significant risk factor for pin track infection. this article represents the biggest single study where pin track sepsis rates were evaluated and compared between hiv positive and negative patients. it also seems to be the only one focusing on circular external fixation. a meticulous retrospective analysis of a single centre’s results was performed and all the patients were treated with a strict pin care protocol. it was shown clearly that hiv positivity and indeed cd4 count showed no correlation to the presence or severity of pin track sepsis. this means that the dogma that circular fixation is not appropriate for hiv-positive patients is refuted. in this regard, this paper will become one of the benchmark papers in the field of external fixation. these two papers, read together, illustrate the importance of meticulous pin track care, which can give excellent results despite factors like immunocompromise. acceptably low infection rates can be achieved, thereby making external fixation a more attractive option in the treatment of complex orthopaedic pathology. prevention and management of external fixator pin track sepsis n ferreira, lc marais strategies in trauma and limb reconstruction 2012;7:67-72 the effect of hiv infection on the incidence and severity of circular external fixator pin track sepsis: a retrospective comparative study of 229 patients n ferreira, lc marais strategies in trauma and limb reconstruction 2014;9:111-15 reviewer: dr ff birkholtz unitas hospital lifestyle management park suite 8c lyttleton 012 644-2641 • saoj saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:57 pm page 56 orthopaedics vol3 no4 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 67 rosai-dorfman disease of the distal radius in a child: a case report and review of the literature dr mn rasool mbchb, fcs orth(sa), phd(ukzn) consultant orthopaedic surgeon dr v genzengane mbchb registrar orthopaedics corresponding author: dr mn rasool department of orthopaedic surgery university of kwazulu-natal nelson r mandela school of medicine private bag 7 congella, durban, 4001 tel: 031-2604297 email: rasool@ukzn.ac.za introduction rosai–dorfman disease (rdd) is a non-neoplastic, selflimiting disease of bone marrow stem cell origin. it is characterised by bilateral painless cervical lymphadenopathy accompanied by fever, leucocytosis, elevated esr and hypergammaglobulinaemia.1 the disease has a predilection for the head and neck including the nasal, oral cavities and paranasal sinuses.2 although extranodal involvement can occur, primary osseous lesions without lymphadenopathy are rare, <2%. it typically affects young adults and adolescents and has a high incidence in people of african descent.2 rdd is also known as sinus histiocytosis with massive lymphadenopathy (shml). clinically and radiologically the condition can mimic various solitary bone lesions including tumours and infection.3,4 a primary lesion in the right distal radius in a 15-month-old child is reported. case report a 15-month-old girl presented with pain and swelling of the distal forearm of 3 months’ duration. clinical examination revealed bony swelling of the distal radius (figure 1). there was no fluctuance, slight tenderness on palpation and no cervical or axillary nodes. radiologically a well-defined lucent intramedullary lesion, slightly expansile adjacent to the physis, 5 cm × 3 cm, was seen with slight periosteal reaction. the radial margin was sclerosed and ulna margin eroded (figure 2). the hb was 9 g/dl, wcc 13.0 × 109/l, esr 20 mm/hr and crp <5. the differential count and protein electrophoresis were normal. the mantoux test was negative. ct scan showed a lucent lesion with scalloping and a thin rim. there was no calcification or fluid in the matrix (figure 3). abstract rosai–dorfman disease (rdd) is a non-neoplastic self-limiting disease of bone marrow stem cell origin characterised by cervical lymphadenopathy. primary osseous lesions are rare and the condition can mimic various solitary bone lesions radiologically. a 15-month-old child presented with an isolated, well-defined, lucent lesion of the distal radius. histology demonstrated numerous large histiocytes with intracytoplasmic lymphocytes, plasma cells and neutrophils. immunohistochemistry showed cd 68 immunopositivity, confirming rdd. healing of the lesion was seen 6 months post-operatively following curettage. isolated extranodal osseous lesions are very rare in children and can mimic several osseous conditions. key words: rosai–dorfman disease, distal radius, emperipolesis http://dx.doi.org/10.17159/2309-8309/2015/v14n410 it typically affects young adults and adolescents and has a high incidence in people of african descent saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 67 page 68 sa orthopaedic journal summer 2015 | vol 14 • no 4 surgical exploration from a dorsal approach revealed a cavity filled with tissue resembling a caseating granulomatous lesion similar to tuberculosis, extending into the volar aspect of the radius. the cavity was well demarcated; the ulna border was deficient. histology demonstrated granulomatous tissue with a mixed inflammatory cell infiltrate composed of plasma cells, lymphocytes, neutrophils and numerous large histiocytes which demonstrated ‘emperipolesis’ (intracytoplasmic lymphocytes, plasma cells and neutrophils). the histiocytes showed s-100 and cd-68 immunopositivity. no evidence of tuberculosis or malignancy was seen. cultures for pyogenic infection were negative. the features were consistent with rosai–dorfman disease. post-operatively the patient recovered well. at 6-months’ follow-up, radiographs showed healing of the cavity (figure 4). discussion the histiocytoses are a group of haematologic disorders defined by the pathologic infiltration of normal tissues by cells of the mononuclear phagocytic system. the pathogenic cells central to the development of the histiocytosis arise from a common haematopoetic progenitor. the central cell of this system, the mononuclear phagocyte or histiocyte, represents a group of cells arising from a common precursor, the haematopoetic stem cell. figure 1. clinical picture showing diffuse swelling of dorsal forearm figure 4. radiographs showing healing with sclerosis at 6-months’ follow-up figure 2. radiographs showing radiolucent expansile lesion in the distal radius, adjacent to the physis, some sclerosis of the radial border and deficiency of the ulnar border. slight periosteal reaction is seen. surgical exploration from a dorsal approach revealed a cavity filled with tissue resembling a caseating granulomatous lesion similar to tuberculosis figure 3. ct sections confirming a radiolucent lesion in the radius with deficiency of ulnar border. there is no calcification or trabeculation in the cavity. saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 6 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 69 mononuclear phagocytes can be divided into two major classes, macrophages and dendritic cells. the world health organisation classified histiocytic disorders into three classes based on pathologic cells present within the lesions namely, dendritic cell histiocytoses, nondendritic cell histiocytoses and malignant histiocytoses (table i). langerhans cell histiocytosis (lch) is the most common of the dendritic cell-related histiocytic disorders. lch includes the previously identified disorders known as eosinophilic granuloma, letterer–siwe disease and hand–schuller–christian disease. sinus histiocytosis with massive lymphadenopathy (shml) also known as rosai–dorfman disease (rdd), is the most common type in the class ii group. it is characterised by a lymphohistiocytic accumulation in the sinuses of the lymph nodes.5 rosai–dorfman disease is a benign disorder of histiocytic proliferation of unknown cause, initially described by rosai and dorfman in 1969.1 it is a non-neoplastic systemic disease of bone marrow stem cell origin which commonly presents with bilateral, non-tender, painless cervical lymphadenopathy which may be accompanied by fever, raised esr, weight loss, leucocytosis, anaemia and hypergammaglobulinaemia. other nodes are less frequently involved.1-3 extranodal rdd involving the bone poses a clinical and radiological challenge. primary osseous lesions are rarely reported in children. sundaram reviewed the literature and found seven cases of primary osseous involvement in children <17 years of age. the lesions were mainly lytic or cystic in appearance with cortical erosions. periosteal reaction was uncommon. extranodal rdd occurs in 43% of patients with 23% experiencing isolated extranodal disease, commonly involving the head and trunk.2-4 osseous involvement with nodal disease is rare <8%; most of these consist of multiple lesions involving the same bone. primary solitary osseous manifestation without lymphadenopathy is even more rare accounting for <2% of all reported cases.6-8 the aetiology of rdd is unknown. it is thought to be genetic or an immunological disorder, postulated to be a response to an infectious agent with subsequent lymph node proliferation.2,8 this in turn leads to an immunosuppressed state as proliferates of histiocytes phagocytose active lymphocytes. it has also been documented with immune disorders.2 other infectious agents such as herpes virus, epstein–barr virus and cytomegalovirus have also been implicated to be associated with rdd.2 the mean age of onset is usually about 20 years.2 in isolated osseous involvement the location of the lesions was mainly in the lower limbs (tibia and femur). lesions in the hand, spine, facial and skull bones have been reported. in children distal radius involvement has been reported on two occasions only.6,9 pain and swelling were the main features. the lesions were part of a multifocal involvement. radiographs commonly show a lytic medullary lesion with a sclerotic border. there may be cortical erosion and periosteal reaction.5 a bone scan is useful to show other areas of increased uptake. ct and mri scans may help with evaluation of the extent of the lesion, the contents of the lesion and any fluid levels in the cystic cavities. the radiological and clinical features of rdd can mimic various common osseous lesions and the diagnosis can be delayed. simple and aneurysmal bone cysts, tuberculosis, subacute osteomyelitis, langerhan’s cell histiocytosis (lch), chondroblastoma, non-ossifying fibroma, monostotic fibrous dysplasia, lymphoma, leukaemia and metastases have been considered by some authors in children.3,7-11 all these conditions have variable presentations clinically and radiologically which makes the diagnosis more difficult. in the literature langerhans cell histiocytosis (lch) is the most closely related condition to rdd based on radiological findings. however lch differs from rdd based on histological presentation. lch usually exhibits many eosinophils and histiocytes. immuno-histochemical staining is always cd1a positive in lch. eosinophils are absent in rdd and cd-68 immunopositivity is the distinguishing feature. table i: who classification of histiocytic disorders class i: dendritic cell histiocytoses • langerhans cell histiocytosis • secondary dendritic cell processes • juvenile xanthogranuloma and related disorders • erdheim–chester disease • solitary histiocytomas of various dendritic cell phenotypes class ii: non-dendritic cell histiocytoses • primary haemophagocytic lymphohistiocytosis • familial haemophagocytic lymphohistiocytosis • secondary haemophagocytic lymphohistiocytosis • infection-associated • malignancy-associated • rosai–dorfman disease (sinus histiocytosis with massive lymphadenopathy) • solitary histiocytoma with macrophage phenotype class iii: malignant histiocytoses • monocyte-related • leukaemias (fab and revised fab classification) • monocytic leukaemiam5a and m5b • acute myelomonocytic leukaemias m4 • chronic myelomonocytic leukaemias • extramedullary monocytic tumour or sarcoma • dendritic cell-related histiocytic sarcoma • macrophage-related histiocytic sarcoma fab: french-american-british radiographs commonly show a lytic medullary lesion with a sclerotic border. there may be cortical erosion and periosteal reaction saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 69 page 70 sa orthopaedic journal summer 2015 | vol 14 • no 4 the diagnosis is confirmed on characteristic histological features of ‘emperipolesis’, i.e. histiocytic phagocytosis, which is characterised by intact inflammatory cells in the cytoplasm of large histiocytes in rdd. this is an important clue in the pathological diagnosis. although the typically described intracytoplasmic inflammatory cells are lymphocytes, other cells such as plasma cells, erythrocytes and polymorphonuclear leucocytes can be present. in our environment cystic tuberculosis, subacute osteomyelitis and fungal infections are more common conditions that can resemble rdd.7 primary lymphoma of bone can present with destructive bone lesions, typically b cell non-hodgkin’s variety. this tumour is becoming more prevalent in our environment due to hiv infection.12 nephroblastoma is the commonest primary tumour with metastases to bone. the clinical course of rdd is typically self-limiting. greater than 70% have spontaneous resolution.1,2,10,11 a small subset relapse. the prognosis is worse with disseminated involvement of nodal sites. no malignant transformations have been reported. studies that have focused on skeletal manifestations have documented success with curettage or surgical resection.13 bone graft was used to fill defects of the talus in one report.3 steroid administration induces the disappearance of fever and reduction of lymph node size in patients with soft tissue involvement.14 there is no information on its use in preventing osseous disease. extraosseous and intraosseous lesions can develop after a disease-free interval.1,8 although response to chemotherapy has been documented, including a combination of alkylating agents with vincristine and steroids and the combination of methotrexate and vincristine, chemotherapy has been shown to be ineffective.15 radiotherapy has limited efficacy, but occasional response may occur.15 further data on the use of interferon is needed to define the role of immunomodulators in rdd. in conclusion, extranodal primary osseous presentation of rdd may present a diagnostic challenge. the condition must be included in the differential diagnosis of lytic or lucent lesions of the skeleton. no benefits of any form have been or are to be received from a commercial party related directly or indirectly to the subject of the article references 1. rosai j, dorfman rf. sinus histiocytosis with massive lymphadenopathy a newly recognized benign clinicopathological entity. arch pathol. 1969;87:63–70. 2. foucar e, rosai j, dorfman rf. sinus histiocytosis with massive lymphadenopathy (rosai-dorfman disease): review of the entity. semin diagn pathol. 1990;7:19–73. 3. allegranza a, barbareschi m, solero cl, et al. primary lymphohistiocytic tumour of bone: a primary osseous localization of rosai-dorfman disease. histopathology. 1991;18:83–86. 4. walker pd, rosai j, dorfman rf. the osseous manifestations of sinus histiocytosis with massive lymphadenopathy. am j clin pathol. 1981;75:131-39. 5. shahlaee ah, arceci rj. histiocytic disorders. in arceci rj, hann im, smith op (eds). paediatric haematology (3rd edition). massachusetts: blackwell publishing; 2006:693-723. 6. sundaram c, uppin sg, chandrashekar p, et al. multifocal osseous involvement as the sole manifestation of rosaidorfman disease. skeletal radiol. 2005;34:658–64. 7. rasool mn, ramdial pk. osseous localization of rosaidorfman disease. j hand surg (br.) 1996;21:349–50. 8. kang rw, mcgill kc, lin j, gitelis s. chronic ankle pain and swelling in a 25 year old woman. clin orthop relat res. 2011;469:1517–21 9. rodriguez-galindo c, helton kj, sanchez nd, et al. extranodal rosai-dorfman disease in children. j pediatr hematol oncol. 2004;26:19–24. 10. dean em, wittig jc, vilalobos c, garcia ra. a 16 year old boy with multifocal, painless osseous lesions. clin ortho rel res. 2012;470:2640-45. 11. loh sy, tan kb, wong ys, et al. rosai-dorfman disease of the triquetrum without lymphadenopathy. a case report. j bone joint + surg. 2004;86-a:595–98. 12. opie j. haematological complications of hiv infection. s afr med j 2012;102:465–68. 13. walczak be, halperin dm, bdeir rw and irwin rb. a 50year-old woman with persistent knee pain. clin orthop rel res. 2011;469:3527–32. 14. oka m, kamo t, goto n, et al. successful treatment of rosai–dorfman disease with low-dose oral corticosteroid. j dermatol. 2009;36:237–40. 15. pulsoni a, anghel g, falcucci p, et al. treatment of sinus histiocytosis with massive lymphadenopathy (rosai–dorfman disease): report of a case and literature review. am j hematol. 2002;69:67–71. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 70 south african orthopaedic journal message from the president page 6 vrettos b sa orthop j 2023;22(1) communicate, collaborate and document: the pillars to avoid and manage complaints basil vrettos president 2022/2023 south african orthopaedic association it is an unfortunate sign of the times that complaints and litigation against the medical profession are increasing, even going as far as doctors being accused of assault and culpable homicide. orthopaedic surgery is not exempt from this, and the saoa has received a number of complaints from patients over the last year regarding surgeons. in other cases, patients have gone directly down the legal route and/or to the hpcsa. complaints can result in extreme stress, affecting the mental health of the surgeon, and cases can take years to resolve. an example is a case in the last few years which went to court 11 years after the initial complaint. the surgeon endured extreme stress for all those years and in the end, the case was dismissed in court. the reasons for increasing complaints include commercialisation of medical practice, patients being more aware of their rights, the emergence of legal firms targeting the medical profession (with some openly offering litigation services against the medical profession), and the existence of expert witnesses acting as ‘hired guns’ for the litigation attorneys. it is very unfortunate that there are colleagues who, as expert witnesses, act as advocates for the plaintiff and the litigation attorneys. an expert witness ‘should be of high standing in the medical profession, be an expert in their field of medicine, and have a reputation for being independent and unbiased in their views’.1 an expert witness is appointed to be impartial. medical indemnifiers will appoint a medical expert whose role is not to defend the case but rather to do an assessment and to judge whether the surgeon acted ‘as what would be expected of the reasonable orthopaedic surgeon’. in other countries, court rulings have redefined the court’s role in ensuring the quality of expert witnesses and some require expert witness to have training and accreditation.2 an expert witness appointed by the indemnifier, may find that the surgeon had acted in an unreasonable way and find the surgeon at fault. in such a case the surgeon’s indemnifier will settle the case without going through an extensive legal process, thereby preventing a prolonged dispute. no offence should be taken when the expert finds the surgeon at fault in such a case as they have acted independently and impartially. although we are fortunate to have indemnity insurance, it is preferable to prevent or to avoid such situations. there are three pillars that will help to protect against complaints: • communication • collaboration • documentation communication communication is the hallmark of preventing complaints. it has been shown that a happy and satisfied patient is far less likely to make a complaint even where there has been a complication. complications themselves are not necessarily due to negligence, and are part and parcel of surgical practice. it is the manner in which surgeons deal with the patient who has a complication which is crucial. communication starts with the initial assessment of the patient. patients often just want to be heard, and allowing them time to explain their condition will often result in revealing the diagnosis, revealing the patient’s character, and establishing a rapport and relationship with the patient. there is an inverse correlation between time spent with the patient and the likelihood of being sued.3 even though it may not be necessary to examine the patient fully, it is always good practice to do an examination, even if this just involves checking the neurovascular status in a patient who has a fracture. this simple ‘laying of hands’ establishes a contact between surgeon and patient and enhances the relationship and rapport between them. too often a patient will state that the surgeon did not even examine them but just looked at the x-ray. a clear explanation to the patient of their condition in layman’s terms will again reassure the patient of the doctor’s attention and care. the simple tasks of taking a history and giving the patient time, examination and clear explanation will go a long way towards ensuring a happy patient.4 if the patient has a complication, it is important to keep a clear line of communication, communicating regularly and explaining the situation clearly. one must not try to avoid the patient or avoid discussing the complication. regularly seeing the patient will make the patient feel that their surgeon is concerned and that they are being looked after. consent communication involves consent, and under south african law, it is a requirement to take informed consent (national health act 61 of 2003).5 there seem to be differing opinions on what this entails and who is required to take the consent. there are guidelines for informed consent laid down by the hpcsa.6 to make sure that you protect yourself, you as the surgeon should take the consent and the patient should be informed of all the major complications, alternative treatments, and consequences of the complications. this should be well documented. the mediclinic group has their own consent form which surgeons themselves are required to complete, and the patient is not allowed to go to theatre unless this consent form has been completed. in the event of a complication described in the consent form, this goes a long way towards negating an issue. the saoa does have a prescribed consent form, but surgeons can also make their own specific consent forms. consent regarding the financial aspects in the practice is essential. a number of complaints arise because of misor non-communication regarding the fees and how they page 8 vrettos b sa orthop j 2023;22(1) relate to reimbursement by the medical aid. one should have in place details of the charges for consultations, with explanation that this will not necessarily be covered by the medical aid and it is the patient’s responsibility. this is particularly important when it comes to surgery, and it should be made clear prior to the surgery that even if authorisation is obtained, the medical aid may not honour the fees and the shortfall will be the responsibility of the patient. consent to use patient’s notes, radiographs and intraoperative pictures for teaching, research and presentations should be obtained. this should be on your agreement with the patient when they attend for consultation and should be on the operation consent form. colleagues communication with colleagues is important. if one sees a patient for a second opinion, it is courtesy to send a letter to the first surgeon unless the patient specifically requests that you do not, in which case this should be recorded in the notes. one should be very cautious when seeing a patient for a second opinion to not pass comments or judgements on the first surgeon’s treatment. it is unfortunate that comments made by the second opinion surgeon may be construed as criticism and this has resulted in patients pursuing a legal case against the primary surgeon. patients who are unhappy with the initial treating surgeon may be very quick to pounce on a comment which may be made innocently regarding the initial treatment and construe this as criticism, using it to make a case against the initial doctor. red flags should be raised when patients seek opinions from multiple surgeons and are critical of the previous surgeons. we all have cases in which we have made an error of judgement. we would certainly not like a surgeon who sees the patient for a second opinion to criticise us and potentially put us in a precarious legal position. as the saying goes, ‘do unto others as you would have them do unto you’. collaboration ‘no man is an island’ (john donne: dean of st. paul’s cathedral, 17th century). get advice and assistance. when faced with a difficult condition or operation, it is wise to consult other surgeons. in this age of technology, communication is very easy and a colleague or group of colleagues is available for consultation (e.g. shoulder society whatsapp group). when one is faced with either a difficult condition, a difficult patient or a postoperative complication, bringing such a patient to a meeting for advice will often defuse a potentially litigious situation. patients often appreciate surgeons who get a second opinion from colleagues. it is wise to nurture relationships with other surgeons and work in collaboration. when faced with an operation with which you may not be totally familiar, it is wise to seek the assistance of another orthopaedic surgeon. even experienced surgeons will obtain the assistance of another specialist for difficult cases. this provides shared responsibility and reassurance that one is making correct decisions, and is often very much appreciated by the patient. documentation in cases in which complaints have been made, documentation is often very poor. this not only reflects poorly on the surgeon, but means that the surgeon’s side of the story cannot be totally substantiated. a clinical note will be accepted as clear evidence in these situations. in this age of technology, clinical notes should be made in digital form. although it is acceptable to have written notes, these are often illegible and have to be deciphered when there is a query. digital notes provide clear evidence of what has been said and done. one should make an effort to record everything that is discussed, including phone calls. this will go a long way towards protecting the surgeon if a complaint is made. patients will often not hear or remember what the surgeon has told them, and will dispute that the surgeon informed them of the facts. if the surgeon has documented the details of the consultation, this provides clear evidence. the operation notes should be comprehensive. photography photographic and video footage of surgical procedures is the norm in arthroscopic surgery. this provides evidence in cases of complaints. in one such case, this showed clearly what the surgeon had seen and done, although the patient disputed this. it is prudent to take photographs in open surgery so that one can show evidence of what was done. in cases in which a nerve has been released, it is good practice to take a photograph or a video showing that the nerve is intact at the end of the surgery. this gives peace of mind to the surgeon if the patient has a neurapraxia following surgery, and the patient can be reassured that the nerve was intact. confidentiality it goes without saying that confidentiality is of utmost importance, and in south africa it is legislated by the popi act.7 summary communicating well with patients, collaborating with colleagues and being meticulous with documentation are essential to good practice and an effective means of mitigating complaints. references 1. grobler s. the role of the expert witness. the south african gastroenterology review. march 2007:11-14. 2. vinen j. negligence of medical experts. mbj. 2005;330:1027. 3. hickson gb, federspiel cf, pichert jw, et al. patient complaints and malpractice risk. jama. 2002;287:2951-57. 4. oyebode f. clinical errors and negligence. med princ pract. 2013;22:323-33. 5. national health act 61 of 2003, south african government. 6. hpcsa: guidelines for good practice in the health care professions seeking patients’ informed consent: the ethical considerations; booklet 4. pretoria. september 2016. 7. protection of personal information act, no 4 of 2013. south african government. 404 not found page 17south african orthopaedic journal http://journal.saoa.org.za south african orthopaedic association it was a great privilege to experience the american–british– canadian (abc) fellowship during the 2018 tour through north america (figure 1, table i). the following passages will introduce the fellowship and its history, and provide feedback relevant to orthopaedic practice in south africa. table i: institutions visited and hosts institution city hosts university of new mexico albuquerque robert schenck, daniel wascher university of arizona, core institute phoenix jason scalise, mike mckey university of california la (ucla) los angeles nick bernthal university of california san francisco san francisco sigurd berven scripps clinic medical group san diego michael thompson university of utah salt lake city robert tashjian university of colorado denver robert d’ambrosia, evalina burger, bennie lindeque university of alberta edmonton edward masson, david sheps university of manitoba winnipeg peter macdonald the abc fellowship was created by professor harris, chief of orthopaedics in toronto and president of the american orthopedic association who organised the first tour in 1948 (figure 2). its purpose was to continue the collaboration and knowledge exchange in orthopaedic surgery which emerged between the allied forces caring for casualties during the second world war. since then, a group of british surgeons visited north america on even years, and on odd years a canadian–american group made the reverse trip. from 1982 onwards, australia, new zealand and south africa each sent a fellow every two years to north america alongside four uk fellows. and so, over the last 70 years, the abc fellowship has supported many promising surgeons to make a significant impact on orthopaedic surgery (www.aoassn.org, link, for previous south african abc fellows, see table ii). the most suitable meaning of ‘fellowship’ for the purpose of this tour was ‘camaraderie, friendship, mutual support and respect’. now, as then, the emphasis of it is to enter the international orthopaedic family, fostering networks and collaborations to create value among the fellows and for our colleagues and patients at home. it allows the exchange of new approaches, the south african take on the america–british–canadian fellowship held m¹, walmsley p², baker p³, ramasamy a4, sandiford a5, johnson l6, rosenfeldt m7 1 md, phd fc orth(sa); consultant orthopaedic surgeon; knee unit, groote schuur hospital and orthopaedic research unit, university of cape town, south africa ² md, ffsted, frcs(tr&orth); consultant orthopaedic surgeon and honorary senior lecturer; trauma and orthopaedic department, victoria hospital, hayfield road, kirkcaldy and university of st andrews, united kingdom 3 msc, md, dipstat, frcs(tr&orth); consultant orthopaedic surgeon; south tees hospital nhs foundation trust and the university of york, united kingdom 4 ma, phd, frcs(tr&orth); ramc consultant orthopaedic surgeon and senior lecturer; the royal british legion centre for blast injuries studies, imperial college london, south kensington, united kingdom 5 msc, frcs(tr&orth); consultant orthopaedic surgeon; st george’s university hospital, london, united kingdom 6 bsc, fracs(ortho), faortha; consultant orthopaedic surgeon; south australia bone tumour unit, flinders university and flinders centre for innovation in cancer, australia 7 bhb, fracs; consultant orthopaedic surgeon; unisports sports medicine clinic and counties manukau dhb, auckland, new zealand figure 1. abc tour 2018 figure 2. the first abc tour aboard queen victoria to visit north america in 1948 http://www.aoassn.org https://www.aoassn.org/aoaimis/aoanew/fellowships%20and%20awards/abc_alumni.aspx page 18 south african orthopaedic journal http://journal.saoa.org.za leadership styles and exploration of different health systems, but most importantly, it enables conversations around the mandate, vision, and future of our profession. during our tour we saw that we all have similar challenges but tackle them in different ways in terms of clinical care, administration, funding and research. the us spends 17% of the gdp on health care which is not centrally funded. strategies of us orthopaedic surgeons are based on individualism and creativity, promoting their techniques, services and outcomes to increase or defend market share and to stand out in a competitive health care system. in their hospitals, orthopaedic surgeons are seen as income generators, are given resources, posts and space, as long as this generates more productivity and income. as such, departments we visited have created biotechnology or implant design companies, massive data management hubs and hospital management consulting companies, one-stop holistic sport injury assessment and treatment centres, arthroplasty centre turned insurance company, medical tourism hotspots, and much more. often, financial incentives are built into these systems to offset a high work load but the risk of burnout in this system is increasingly recognised and addressed. you can (and might have to) always do more! most of this system is mainly accessible for patients with private health care although patients with no or a lower paying health insurance are cross-subsidised, up to a certain point. what happens beyond this point is not uniformly organised or addressed. many of the programmes we visited therefore incorporated non-for-profit organisations or projects into their departments, which attempt to look beyond short-term financial capital, including social, human and intellectual capital. this american way of orthopaedic surgery stood in contrast to the centralisation and standardisation of the state-funded canadian health care system. built on egalitarian and socialistic principles it makes essential health care accessible and affordable to all. currently canada spends about 10% of its gdp on health care. centralised intake clinics, standardised referral pathways, pre-operative optimisation algorithms, countrywide registries, and enforced national protocols for treatment have grown in the effort to allow equal access to high quality orthopaedic surgery. hospitals are publicly funded and the amalgamation of hospitals has reduced competition which has increased regional and national collaborations in care, research and training. these hospitals, by law, are obliged to stay within their budget, therefore costs are cut wherever possible. often orthopaedic departments are regarded as money spenders and are scrutinised to reduce costs by limiting procedures, implants and equipment or human resources. as a result, many trainees are unable to find posts and increasingly have to pursue double fellowships and higher research degrees to stay competitive or look for job opportunities in the us. another drawback of this system is the increased waiting periods, namely up to two years for joint replacements. as a result, programmes have been established to increase the efficiency of doctor–patient communication, allow screening and centralised intake, which aim to decrease unnecessary care, ultimately cutting wait times. but cross-border medical tourism to the us has increased, especially for non-essential surgery and the upper class. with these vast differences there were similarities which stood out. these will be discussed in the next section and related to our practice in south africa. although there are major differences in the american and canadian system, both attempt to ensure delivery of high quality care for the populations of patients they serve, and to keep costs as constrained as possible. to achieve this, an overarching focus in both systems was to measure and analyse outcome. this was seen as key to improve access and quality of care, drive innovation, evaluate and allocate resources, and to highlight the impact and need of orthopaedic surgery. besides this, almost all research units we visited in the us and canada started their programme with outcome research, through which they were able to build a track record, increase funding, and assess the clinical impact of their lab-based basic science research. and so, for orthopaedic surgery in south africa, measuring outcome might be the single most important step to adjust our practice to resource pressures and future system changes, both in the private as well as the public sector. there is much discussion on the national health insurance (nhi), to increase equity to health care, especially for lower-income households. most of our health expenditure (8% of the country’s gdp) is spent in the private sector in which 80% of approximately 900 of our orthopaedic surgeons work. to adjust this, the nhi plans to cap doctors’ fees and link them to outcome. without our own data we won’t be able to back up our arguments in upcoming negotiations, both in the public and private sectors. one quote that figure 3. in phoenix we were hosted by jason scalise and cliff jones at the core institute. here we got to know their world-renowned programme for standardised outcome-based orthopaedic care. figure 4. mike mckey recently transferred from the university of toronto to the university of arizona and shared is insights of the very different health care systems in canada and the us. table ii: previous south african abc fellows before 2000 2000–2018 1959 – m lunz 1964 – c malkin 1970 – je handelsman 1974 – r pillemer 1978 – rb snowdowne 1982 – id learmonth 1984 – jb craig 1986 – ja shipley 1988 – mm (thys) malan 1990 – ja (koos) louw 1992 – bgp lindeque 1994 – m lukhele 1996 – rk fraser 1998 – bc vrettos 2000 – el burger 2002 – p makan 2004 – rn dunn 2006 – mt mariba 2008 – ad barrow 2010 – s dix-peek 2012 – ch snyckers 2014 – gb firth 2016 – c anley 2018 – m held page 19south african orthopaedic journal http://journal.saoa.org.za came up again and again was: ‘any system will need to be paid for, either with money, waiting time or clinician hours.’ during these times, our leadership will be tested to adjust to the change of our environment. on our tour we met incredible leaders of our profession who mainly measured their success by the progress of people they supported. to see how these departments held their junior staff in the centre of their organisation and celebrated their success was one of the most powerful memories of this trip. we often saw senior consultants and heads of departments helping out in various clinics, assisting registrars in surgery, teaching medical students, taking time to engage with sisters in the wards, visiting research support staff in their labs, and being involved in their community. this people-centred approach created an inclusive, supportive, authentic and transparent culture in their department, and the saying ‘culture eats strategy for breakfast’ was echoed and lived by many. but most importantly it made departments dynamic and resilient to challenges. this type of leadership and culture is also practised by many orthopaedic surgeons in south africa and might be the greatest positive effect on the future of our profession. this trip was an unforgettable experience, exploring the perspectives and solutions but also the countries and cultures of our orthopaedic sister associations. it brought us closer as a group of fellows and hosts, and our shared insights triggered reflections to improve our practice at home. i am humbled to have been given this great opportunity and the support from my department in cape town, the saoa and our british, american and canadian sister associations, as well as the bone and joint journal. this fellowship is one of the best ways to get to know the ‘behind the scenes’ of orthopaedic surgery and create the future leaders of our profession through camaraderie, friendship, and mutual support. mayet z et al. sa orthop j 2019;18(3) doi 10.17159/2309-8309/2019/v18n3a4 south african orthopaedic journal http://journal.saoa.org.za traumafoot and ankle citation: mayet z, ferrao pnf, saragas np. cross-screw technique for the modified lapidus procedure using headless compression screws. sa orthop j 2019;18(3):41-46. http://dx.doi.org/10.17159/2309-8309/2019/v18n3a4 editor: dr g mccollum, university of cape town, cape town, south africa received: january 2019 accepted: may 2019 published: august 2019 copyright: © 2019 mayet z, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: none. conflict of interest: none of the authors have any conflict of interest to declare. no benefits of any kind have been or are to be received from a commercial party related directly or indirectly to the subject of this article. abstract aims: the aim was to evaluate union rates using two cross headless compression screws for the modified lapidus procedure. this was compared to conventional fixation using solid ao screws and plates, as recorded in the published literature. patients and methods: this is a retrospective study of the modified lapidus procedure performed in patients with a moderate to severe hallux valgus deformity. union time and patient demographics were retrieved from medical records. patient demographics included age, sex, smoking habits and other comorbidities. the union rate was compared to the literature using the two-population probability test, with p<0.05 being significant. results: sixty-nine feet in 56 patients were assessed for radiographic union. there were three delayed unions and two non-unions. the union rate of 97% was not statistically different when compared to studies using conventional solid ao screws. conclusion: the use of headless compression screws in the fixation of the first tarsometatarsal joint and early mobilisation was found to be comparable to conventional solid ao screws with regard to union rates. the cannulated design enhances ease of insertion and, being headless, minimises the risk of intra-operative fracture and hardware prominence requiring subsequent removal. level of evidence: level 4 key words: modified lapidus, cross-screw technique, headless compression screw, hallux valgus, first ray instability cross-screw technique for the modified lapidus procedure using headless compression screws mayet z1 , ferrao pnf2 , saragas np3 1 bsc(wits), mbchb(medunsa), fc orth (sa), mmed(orth)(wits); the orthopaedic foot and ankle unit, netcare linksfield hospital, johannesburg; consultant, chris hani baragwanath academic hospital and university of the witwatersrand, johannesburg, south africa ² mbchb(pret), fcs(sa)ortho; the orthopaedic foot and ankle unit, netcare linksfield hospital, johannesburg; consultant, university of the witwatersrand, johannesburg, south africa ³ mbbch(wits), fcs(sa)ortho, mmed(ortho surg)(wits); the orthopaedic foot and ankle unit, netcare linksfield hospital, johannesburg; professor, university of the witwatersrand, johannesburg, south africa corresponding author: dr ziyaad mayet, po box 901177, bertsham, 2013; tel: 011 4339522; fax: 0866013108; email: bonedoc.zm@gmail.com https://orcid.org/0000-0002-7340-3148 https://orcid.org/0000-0003-4639-0326 https://orcid.org/0000-0002-5566-7588 page 42 mayet z et al. sa orthop j 2019;18(3) introduction in 1934 lapidus described a method of fusing the first tarsometatarsal joint for the treatment of hallux valgus. after preparation of the first tarsometatarsal and intermetatarsal joints, fixation was achieved by suturing the capsule with chromic catgut.1 a prolonged period of immobilisation followed. lapidus reported non-union as one of his main complications. theories regarding the cause of hallux valgus has evolved in recent years, and the concept of first ray instability has become more important.2-9 currently, the modified lapidus procedure is seen as a very powerful procedure with the ability to correct deformities in three different planes simultaneously.2-9 the hallux valgus and metatarsus primus varus are corrected in the coronal plane; plantar angulation can be increased in the sagittal plane; and the pronation deformity is corrected in the axial plane. by correcting it at the source, the true cause of a hallux valgus deformity is therefore addressed.9 added to this, by arthrodesing the first tarsometatarsal joint, the likelihood of recurrence is reduced. however, coetzee et al. have emphasised the need for proper surgical technique and attention to detail to minimise complications.10 the lapidus procedure, over the years, has been criticised for several reasons. most notable of these is a high non-union rate and prolonged post-operative immobilisation.2,4,9 the technical difficulty of the procedure is one factor that contributes to this nonunion rate. recent advances in fixation have resulted in an increase in the popularity of the procedure. numerous reports have been published recently using solid screws or locking plates for fixation. modern reviews quote the non-union rate at 2–10%.3 however, a recent article reports it at 0–2.5%.2 added to this, these publications also claim reduced times to weight bearing. we present a technique for the modified lapidus procedure using two 4.7 mm cannulated headless compression screws for fixation, as well as a retrospective review of our cases. the purpose of this retrospective review was to evaluate union rates using a cross-screw technique with two cannulated headless compression screws for fixation, and to compare this to union rates using other fixation techniques. materials and methods study population and design a retrospective review was carried out of all patients that had undergone a modified lapidus procedure using the cross-screw technique with two headless compression screws. the operations were performed by the senior authors (nps and pnf) between february 2014 and march 2015. exclusion criteria included: patients younger than 18 years, and absent data regarding status of bony union. patient demographics included age, sex, smoking status and comorbidities. the indications for performing the modified lapidus procedure included hypermobility of the first ray, severe hallux valgus deformities and recurrent hallux valgus deformities. severity of the deformity was recorded as mild, moderate or severe. this was based on the hallux valgus (hv) angle and intermetatarsal (im) angle, as shown in table i. the data recorded from the operative notes included the side of operation, the addition of any other procedures to the hallux or the lesser toes, the use of bone graft and any complications intra-operatively or post-operatively. lastly, the time to union was recorded. follow-ups were done at one, two and four weeks for wound check and taping, and then at six weeks an x-ray was taken to assess for union. union was defined as bridging of bone across three cortices, and non-union was defined as the lack of union at six months as described by de vries et al.11 delayed union was defined as any fusion that took place between six weeks and six months. patients were then assessed at 12 weeks, as a final follow-up. further assessments were scheduled as needed, especially in the cases of complications or non-unions. operative technique a distal soft tissue release is performed first through a dorsal incision in the first web space. this includes sequential release of the adductor hallucis tendon, sesamoid suspensory ligament and the lateral capsule. this is followed by a bunionectomy through a medial skin incision and an l-shaped capsulotomy. the modified lapidus procedure is then performed through a 3–4 cm incision dorsally over the first tarsometatarsal joint. the extensor hallucis longus tendon is retracted medially. a capsular incision is made, and the joint is carefully exposed. the proximal metatarsal articular surface is cut with an oscillating saw blade at the level of the subchondral plate. the orientation of the first metatarsal cut is perpendicular to the long axis of the first metatarsal in all planes. the medial cuneiform articular surface is then resected perpendicular to the long axis of the second metatarsal in the frontal and sagittal planes. by doing this the first metatarsal will be almost parallel to the second metatarsal once the fusion site is reduced, thus correcting the im angle. a lamina spreader is very helpful in debriding the plantar surface and removing any remaining bony fragments. figure 1 shows the skin marking over the long axis of the second metatarsal, as well as the perpendicular osteotomy made in the medial cuneiform. both joint surfaces are then fenestrated using a 2.5 mm drill bit to allow for the access of marrow elements into the fusion site. the two joint surfaces are reduced, allowing for correction in all planes, with abduction and supination of the metatarsal. this is done while dorsiflexing the hallux, to ensure plantarflexion of the first metatarsal. the reduction is then secured with guide wires. the first guide wire is placed dorsolateral running from the medial cuneiform to the table i: classification of severity hallux valgus angle intermetatarsal angle number of feet (n) (%) mild 15–30° 9–15° 3 4 moderate 31–40° 16–20° 38 55 severe above 40° above 20° 19 28 not classified 4 6 revisions 5 7 hypermobility 44 64 figure 1. completed osteotomies with second metatarsal orientation marking page 43mayet z et al. sa orthop j 2019;18(3) plantar-lateral cortex of the first metatarsal. the second guide wire is placed dorsomedial on the first metatarsal running to the plantarmedial cortex of the medial cuneiform. adequate correction of the im angle and positioning of the guide wires is confirmed under image intensification. figure 2 shows the placement of these wires, and figure 3 shows their position under the image intensifier. the fusion site is then compressed and fixed using two 4.7 mm headless compression screws (acutrak® acumed, usa) (figure 4). a distal medial closing wedge chevron osteotomy (mcwc) and akin osteotomy are added when indicated. the mcwc is performed in cases with a high distal metatarsal articular angle (dmaa), which increases when doing a modified lapidus (rotational correction). the akin osteotomy is performed for correction of hallux valgus interphalangeus and pronation of the hallux. the capsule is repaired using vicryl and the wound is closed in layers. the patient is placed in a heel-wedge shoe day 1 post surgery and taught to mobilise in it by the physiotherapist. the patient is advised to keep the foot elevated in the first two weeks. they can bear weight as tolerated in the heel-wedge shoe for the first six weeks. at six weeks the foot is x-rayed, and the patient can transition into supportive shoe wear if radiographic union is present. the patient is referred to physiotherapy for rehabilitation. statistics the rate of union in our series was compared to similar studies in the published literature using the two-population probability test, or z-test. 2,4,11-19 to allow for the use of the two-population probability test, only case series were used where the total number of feet and non-unions were reported. the significance level was set at p<0.05. results population demographics between february 2014 and march 2015, 56 patients had undergone a modified lapidus procedure to correct a hallux valgus deformity. there were no exclusions from this group. fifty patients were female and six were male. the average age was 51 years (20–72 years). the average time of follow-up at the time of data collection was 15 months (4–25 months). three of the patients were smokers. a complete list of comorbidities is presented in table ii. thirteen patients had bilateral procedures, 16 patients were operated on the right foot and 27 patients were operated on the left. this gave a total of 69 feet for analysis. of these, three were classified as mild, 38 as moderate and 19 as severe. four feet (6%) were not classified according severity as no preoperative measurements were available. five patients (7%) had the modified lapidus done as revision surgery for recurrence of the deformity subsequent to previous corrective surgery. one of these patients had a previous modified lapidus with plate fixation which went onto non-union; this was revised using this crossscrew fixation technique. the other four patients had previous corrective metatarsal osteotomies. instability of the first ray, as determined clinically by the surgeon according to the method described by myerson and badekas,20 was the primary indication for the modified lapidus procedure in 44 feet (64%). moderate and severe deformities accounted for 83% of the cases. table i shows the percentages in each of these groups. no patients had arthritis of the first tarsometatarsal joint (tmtj). figure 2. placement of k-wires figure 4. compression across arthrodesis site after screw placement figure 3. image intensifier ap and lateral views confirming reduction and wire placement page 44 mayet z et al. sa orthop j 2019;18(3) additional procedures removal of hardware was necessary in three of the revision cases (4%). mcwc osteotomies were performed in 21 feet (30%) and akin osteotomies in 38 feet (55%). one revision case, with a non-union from a previous modified lapidus procedure using plate fixation, required bone grafting (1%). no other case required bone grafting. arthrodesis of the second tmtj was performed in three cases (4%) with associated degenerative changes of that joint. the 1–2 intermetatarsal joints were not included in the fusion, thus not making this a true lapidus procedure. lesser toe surgery was performed in 25 feet (36%). these are listed in table iii. complications complications are listed in table iv. two feet had a mild residual valgus deformity. one foot developed a hyperextension deformity, and one foot developed a 5° hallux varus deformity. these patients were happy with their results and no further surgery was required. no wound complications were reported. one patient described a burning pain after a fall. no fractures were noted, and the pain settled. one patient described intermittent discomfort, which settled after three months. union rates there were three delayed unions, with incomplete fusion at six weeks. by 12 weeks these three feet had united. two feet had non-unions that failed to unite within six months. neither patient required further surgery as the patients became asymptomatic. one of the non-unions occurred in a revision case. the union rate was therefore 97%. figure 5 shows x-rays demonstrating union. table v lists the z scores and p values calculated using the z test to compare union rates between our study and similar studies in the recent literature.2,4,10-19 all the other studies reported union rates between 90 and 100%. no study showed a statistically significant difference to our union rate at a significance level of p<0.05. furthermore, no difference was found when the tests were repeated at a significance level of p<0.01. fixation in these studies were mainly solid ao screws, or locked plates with or without lag screws.2,4,10-19 discussion the lapidus procedure has been commonly used for the correction of hallux valgus deformities since being described in 1934. with the ability to correct the deformity in three planes, it a very powerful procedure.4,8,9 indications for its use include hypermobility, generalised ligamentous laxity, and moderate to severe deformities. its use has been cautioned in smokers and individuals with a shortened first ray.3 previous reports have shown good results with this technique. kopp et al. reported an improvement of the visual analogue score from 7.2 to 2.3.4 a successful fusion has also been shown to have a low recurrence rate.10 the lapidus procedure is known to be technically demanding, with its long lever arm. it is this long lever arm that makes the lapidus a powerful procedure. however, the combination of a long lever arm and a small fusion surface means that it is prone to over and under correction, as well as developing non-unions.3 metaanalysis currently reports non-union rates between 2 and 10%.3 in the 14 series that we reviewed, the non-union rate was between 0 and 10%. we had a non-union rate of 3%, which was not found to be statistically different to any of the other 14 studies with the available numbers. cadaver studies have shown increased rigidity of lock plate constructs as compared to crossed screws.21-23 this has however not translated to superior results in clinical studies, and no good prospective randomised controlled studies exist to validate the superior stability of any of the constructs.2 most studies are retrospective, and the prospective studies have small numbers. table ii: comorbidities comorbidity number of patients number of feet general conditions smokers 3 4 rheumatoid arthritis 1 1 scleroderma 2 1 overweight 1 2 gout 3 3 hypothyroid 1 1 hypertension 2 2 hypoglycaemia 1 1 foot conditions cavus foot 1 1 flatfoot 2 2 previous foot surgery (excluding hallux valgus surgery) 1 1 previous failed hallux valgus surgery (osteotomies) 4 5 table iii: additional procedures performed procedure number of feet  hallux procedures  bunionectomy 64  removal of hardware from previous correction  3  mcwc* osteotomy  21  distal soft tissue release  66  akin osteotomy  38  bone graft  1  lesser toe procedures  second tmtj** arthrodesis  3  deformity corrections or neuroma excisions  25  *mcwc: medial closing wedge chevron  **tmtj: tarsometatarsal joint  table iv: complications complication number of feet (n) (%) osseous delayed union 3 4 non-union 2 3 deformity recurrence 1 1 mild residual deformity 2 3 hyperextension 1 1 hallux varus (5°) 1 1 general pulmonary embolus 1 1 burning pain 1 1 intermittent discomfort 1 1 page 45mayet z et al. sa orthop j 2019;18(3) preparation of the fusion surfaces varied among the different studies. some authors preferred removal of the subchondral plate,10,15,16 whereas others preferred cartilage removal and fenestration of the subchondral plate.7,11,18 ray et al. in a cadaver study showed decreased movement of the screws across the fusion site if the subchondral plate was left intact.24 the other area of variability was fixation. besides various plate constructs, there were also differences in the number of screws (two or three screws) used and the screw configurations with screw fixation techniques. in the two screw fixations, there was a lot of variability in the configuration in which the screws were placed. coetzee et al. and sangeorzan et al. placed their screws so as to engage the intermetatarsal joint as well.10,16 some authors using cross-screw configurations, similar to ours, added a third screw to secure the intermetatarsal joint if they felt there was intermetatarsal or intercuneiform instability. all these authors used solid ao 3.0 or 3.5 mm screws. in our study, we removed the subchondral plate, and used two 4.7 mm cannulated headless compression screws. we did not find it necessary to include the intermetatarsal or intercuneiform joint in the fusion. the union rates were not found to be statistically different to other studies published in recent literature. however, the cannulated screw system allows for easier placement of screws. the guidewires also help maintain the tmtj in a reduced position so that adequate correction can be confirmed on imaging prior to definitive fixation. solid ao screws have a head which can result in hardware prominence requiring a subsequent procedure to remove the hardware. some surgeons avoid this by countersinking the head of the screw. this can sometimes compromise the dorsal cortex when tightening the screw to compress the joint, by cracking the dorsal rim, thereby losing stability and even reduction. the screws we use are headless, thus avoiding these complications. king et al. suggested that a non-weight-bearing status postoperatively is a risk for non-union and early pedal loading reduces disuse osteopaenia, limits muscle atrophy and facilitates rehabilitation.2 the trend in the recent literature is towards early weight bearing post-operatively. our patients were encouraged to start weight bearing immediately in heel wedge shoes, as tolerated. interestingly, we had one patient who complained of intermittent discomfort, despite having united. the only other publication table v: comparisons of union rates study no. of feet (n) no. of unions union (%) fixation used bone grafting z score p value current series 69 67 97 crossed screws (4.7 mm acutrak®) one case (revision) – – king et al.2 136 133 97 crossed screws (ao) (ima screw added if needed) none -0.3038 0.76418 kopp et al.4 38 38 100 crossed screws (ao) all cases -1.0594 0.28914 de vries et al.11 96 88 92 crossed ao screws (ima screw added as needed) dbmb or bmac 1.4432 0.14986 de vries et al.11 47 46 98 lock plate (lag screw as needed) dbmb or bmac -0.2568 0.79486 gutteck et al.12 17 17 100 dorsomedial plate none -0.7103 0.4777 gutteck et al.12 17 17 100 plantar plate none -0.7103 0.4777 thompson et al.13 201 193 96 crossed ao screws all cases 0.4105 0.6818 popelka et al.14 143 136 95 variable-in ra none 0.6756 0.4965 saxena et al.15 40 39 98 plate or two distal ao screws not mentioned -0.1226 0.90448 sangeorzan et al.16 40 36 90 two distal cross ao screws 3.5 mm in revision cases 1.5668 0.11642 mallette et al.17 36 33 92 staples none 1.2413 0.21498 coetzee et al.10 105 98 93 t-configuration screws (ao) 3.5 mm none 1.0979 0.27134 klos et al.18 59 58 98 plantar plate + lag screw none  -0.4487 0.65272 ellington et al.19 25 24 96 crossed screws (ao) five cases 0.2684 0.78716 aim: intermetatarsal, bdbm: demineralised bone matrix, cbma: bone marrow aspirate figure 5. x-rays showing union page 46 mayet z et al. sa orthop j 2019;18(3) to report this was kopp et al.4 they reported 24% midfoot and 34% forefoot discomfort after the lapidus procedure. no further intervention was needed for these patients. limitations of this study is that it was performed retrospectively and lacks outcome measurements for patient satisfaction and postoperative corrections achieved. this should be added in any future prospective studies. conclusion the modified lapidus procedure is a powerful procedure for the correction of hallux valgus. however, it is technically demanding and prone to developing non-unions. attention to detail is imperative to prevent this. we present a technique where meticulous joint preparation and fixation with two 4.7 mm headless compression cross-screws has given a 97% union rate. this was not statistically different from published data where a locking plate or solid screws were used. being headless they minimise hardware prominence and intra-operative fractures. early weight bearing is possible and beneficial with this technique. ethics statement this was a retrospective study. formal consent was not required for the study. all procedures performed in this study were in accordance with the ethical standards of the institution and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions zm contributed to study idea and design, data collection and processing, and write-up of proposal and study at all stages. pf contributed to the study design, and write-up of the study at all stages. ns contributed to the study idea and design, and write-up of the study. orcid z mayet http://orcid.org/0000-0002-7340-3148 pnf ferrao http://orcid.org/0000-0003-4639-0326 np saragas http://orcid.org/0000-0002-5566-7588 references 1. lapidus pw. operative correction of the metatarsus varus primus in hallux valgus. surg gynecol obstet. 1934;58:183-91. 2. king cm, richey j, patel s, collman dr. modified lapidus with crossed screw fixation: early weightbearing in 136 patients. j foot ankle surg 2015;54:69-75. 3. schmid t, krause f. the modified lapidus procedure. foot ankle clin 2014;19:223-33. 4. kopp fj, patel mm, levine ds, deland jt. the modified lapidus procedure for hallux valgus: a clinical and radiographic analysis. foot ankle int 2005;26(11):913-17. 5. bednarz pa, manoli a. modified lapidus for the treatment of hypermobile hallux valgus. foot ankle int 2000;21(10):816-21. 6. taylor gn, metcalfe sa. a review of surgical outcomes of the lapidus procedure for the treatment of hallux abductovalgus and degenerative joint disease of the first mcj. foot 2008;18:206-10. 7. ellington jk, myerson ms, coetzee jc, stone rm. the use of the lapidus procedure for recurrent hallux valgus. foot ankle int 2011;32(7):674-80. 8. toolan bc. surgical strategies: the lapidus procedure. foot ankle int 2007;28(10):1108-14. 9. baravarian b, ben-ad r. contemporary approaches and advancements to the lapidus procedure. clin podiatr med surg 2014;31:299-308. 10. coetzee jc, wickum d. the lapidus procedure: a prospective cohort outcome study. foot ankle int 2004;25(8):526-31. 11. de vries jg, granata jd, hyer cf. fixation of the first tarsometatarsal arthrodesis: a retrospective comparative cohort of two techniques. foot ankle int 2011;32(2):158-62. 12. gutteck n, wohlrab d, zeh a, radetzki f, delank k-s, lebek s. comparative study of lapidus bunionectomy using different osteosynthesis methods. foot ankle surg 2013;19:218-21. 13. thompson im, bohay dr, anderson jg. fusion rate of first tarsometatarsal arthrodesis in the modified lapidus procedure and flatfoot reconstruction. foot ankle int 2005;26(9):698-703. 14. popelka s, hromảdka r, vavřik p, bartảk v, popelka s jr., sosna a. hypermobility of the first metatarsal bone in patients with rheumatoid arthritis treated by lapidus procedure. bmc musculoskelet disord 2012;13:148-55. 15. saxena a, nguyen a, nelsen e. lapidus bunionectomy: early evaluation of crossed lag screws versus locking plate with plantar lag screw. j foot ankle surg 2009;48(2):170-79. 16. sangeorzan b, hansen st jr. modified lapidus procedure for hallux valgus. foot ankle int 1989;9(6):262-66. 17. mallete jp, glenn cl, glod dj. the incidence of non-union after lapidus arthrodesis using staple fixation. j foot ankle surg 2014;53:303-306. 18. klos tk, wilde ch, lange a, wagner a, gras f, skulev hk, muckley t, simons p. modified lapidus arthrodesis with plantar plate and compression screw for treatment of hallux valgus with hypermobility of the first ray: a preliminary report. foot ankle surg 2013;19:239-44. 19. ellington jk, myerson ms, coetzee jc, stone rm. the use of the lapidus procedure for recurrent hallux valgus. foot ankle int 2011;32(7):674-80. 20. myerson ms, badekas a. hypermobility of the first ray. foot ankle clin 2000;5(3):469-84. 21. young nj, zelen cm. new fixation techniques and alternative fixation for the lapidus arthrodesis. clin podiatr med surg 2013;304:23-434. 22. scranton pe, coetzee jc, carreira d. arthrodesis of the first metatarsocuneiform joint: a comparative study of fixation methods. foot ankle int 2009;30(4):341-45. 23. klos k, gueorguiev b, mückley t, fröber r, hofmann go, schwieger k, windolf m. stability of medial locking plate and compression screw versus two crossed screws for lapidus arthrodesis. foot ankle int 2010;31(2):158-63. 24. ray rg, ching rp, christensen jc, hansen st jr. biomechanical analysis of the first metatarsocuneiform arthrodesis. j foot ankle surg 1998;37(5):376-85. http://orcid.org/0000-0002-7340-3148 http://orcid.org/0000-0002-7340-3148 http://orcid.org/0000-0003-4639-0326 http://orcid.org/0000-0003-4639-0326 http://orcid.org/0000-0002-5566-7588 http://orcid.org/0000-0002-5566-7588 _goback _hlk505415573 _hlk504725230 _hlk507922944 _hlk504726760 _hlk530524896 page 18 sa orthopaedic journal august 2002 education, training and accreditation education, training and accreditation orthopaedic surgery fellowships profngj maritz head: department of orthopaedic surgery, university of pretoria o rthopaedic fellowships are becoming more and more popular. the author discusses the advantages and dis-advantages of further training once qualified as an orthopaedic surgeon. fellowships were started in the usa in the mid-eighties and were accredited much later. they have now become very popular and of the 630 new orthopaedic surgery residency graduates per year in the united states, more than 60% will take a fellowship of at least one year. in south africa there are a few fellowships available, which are run fairly informally with no accreditation as such. the question is: how do we see the road ahead? must we continue and structure it better and start an accreditation programme? to answer this question we have to look at the pros and cons of orthopaedic fellowships. for the registrars these are the reasons to take a fellowship: • extra training in an area of special interest • another year's experience to gain confidence • to add to one's cv for the institutions, fellowships have the following benefits: • teaching: because they have fewer extraneous commitments, fellows are more available and better positioned to teach registrars and medical students • patient care: fellows are able to help with the high volume of patients • research: they are ideally situated to do the necessary research • they boost the number of physicians in academic medicine at a time when academic institutions are under great stress the disadvantages of sub-speciality fellowships include: • they may interfere with the registrars' training who may then have less opportunity to gain clinical and surgical experience • sub-specialisation may lead to fragmentation of the orthopaedic association. examples of this are the hand society and now the spine society • sub-specialisation may lead to regulations that exclude the treatment of certain conditions from the domain of the general orthopaedic surgeon. it may also have certain medico-legal consequences if you do not have a fellowship in a certain field, it may be seen that you are inadequately trained to do certain procedures i believe fellowships are here to stay, because a sub-specialist who has additional education and experience and who sees many similar cases, best serves patients with complex orthopaedic conditions. this may well represent the most cost-effective type of care. however, fellowships should be better structured with a clear goal. the sub-speciality group in the orthopaedic association should most likely, also accredit it. business should be involved in the financing of fellowships! oj bibliography simon ma. evolution of the present status of orthopaedic surgery fellowships. jbjs dec 1998;80(12):1826-1850. 404 not found 404 not found south african orthopaedic journal arthroplasty doi 10.17159/2309-8309/2021/v20n1a1khan s et al. sa orthop j 2021;20(1) citation: khan s, wadee n, burger m, ferreira n, jordaan k. prevalence of pathological neck of femur fractures in patients undergoing arthroplasty at a tertiary referral hospital. sa orthop j 2021;20(1):16-20. http://dx.doi.org/10.17159/23098309/2021/v20n1a1 editor: dr david north, paarl hospital, western cape, south africa received: august 2020 accepted: october 2020 published: march 2021 copyright: © 2021 khan s. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was secured for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background this study aimed to determine the prevalence of pathological neck of femur (nof) fractures at a tertiary referral hospital through histological examination of specimens in all nof fracture patients undergoing hip arthroplasty. a secondary aim was to determine whether the current practice of sending all femoral heads for histological evaluation, to avoid missing unsuspected malignancies, is financially warranted. methods a retrospective folder review of patients who underwent arthroplasty for nof fractures was conducted. patients with suspected pathological fractures were managed by the divisional bone tumour unit while fragility traumatic fractures were managed by the arthroplasty unit. all femoral heads were sent for histological analysis regardless of suspicion of pathological fracture. quotes from the public and private sector were sought to determine cost implications of sending femoral head specimens for histology results a total of 311 patients were included. of these, 11 patients (4%) had suspected pathological fractures, with fragility/traumatic fractures being diagnosed in the remaining 300 patients (97%). histology results were available for 195 patients (63%), including all the patients with suspected pathological fractures. no unexpected malignant histological results were observed, while nine of the suspected pathological fracture group had pathological fractures, confirmed with histology. conclusion pathological lesions were identified in 3% of patients undergoing arthroplasty for nof fractures in our population, which is higher than other reports in the literature. routine histological screening of femoral heads to exclude pathological fracture might not be necessary and cost effective, as pathological lesions can accurately be identified by clinical and radiographic evaluation. level of evidence: level 4 keywords: femoral head histology, pathological fracture, neck of femur fracture, metastases, hip arthroplasty prevalence of pathological neck of femur fractures in patients undergoing arthroplasty at a tertiary referral hospital suhayl khan , naweed wadee , marilize burger , nando ferreira* , jacobus jordaan division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa *corresponding author: nferreira@sun.ac.za introduction femoral neck fractures pose a significant burden to the healthcare system in developed and developing countries, with the annual incidence expected to increase in the coming years.1 the reason for this increase is suggested to be decreasing global mortality rates and the ageing populations’ subsequent risk for osteoporosis.2 over 84% of elderly patients with femoral neck fractures are reported to have underlying osteoporosis.3 osteoporotic or fragility femoral neck fractures result in significant morbidity and mortality. most patients never achieve pre-fracture functional status after surgical intervention,4 and up to 33% die within the first 12 months post-operatively.5 a small minority of patients sustain femoral neck fractures because of underlying pathological lesions.6 pathological fractures may be caused by any bone lesion (benign, primary malignant or metastatic), but metastatic bone tumours and multiple myeloma are far more prevalent than other primary bony malignancies in the elderly population.7 the american cancer association expects around 1.8 million new cancer cases to be diagnosed in 2020.8 there is also a steady decrease in mortality rate of 1.5% per year in patients with cancer and, as the population’s life expectancy increases, there is an increased prevalence of bony metastases with subsequent risk of pathological fractures.9 breast, thyroid, kidney, lung and prostate primary malignancies have a predilection for bony metastases, though any primary malignancy can metastasise to bone.10 the vertebral column is most commonly affected by bony metastases while the proximal femur is the most common site for metastases to the appendicular skeleton.11 this, along with the strong deforming forces across http://dx.doi.org/10.17159/2309-8309/2021/v20n1a1 http://dx.doi.org/10.17159/2309-8309/2021/v20n1a1 https://orcid.org/0000-0002-5664-6658 https://orcid.org/0000-0002-4204-6686 https://orcid.org/0000-0003-2831-4960 https://orcid.org/0000-0002-0567-3373 https://orcid.org/0000-0002-6150-9463 page 17khan s et al. sa orthop j 2021;20(1) the hip joint, disproportionately predisposes the proximal femur to pathological fractures. fifty per cent of pathological fractures occur at the femoral neck, 20% at the intertrochanteric area, and the remaining 30% in the rest of the femur.11 there are two studies in the english literature documenting the prevalence of pathological neck of femur (nof) fractures. ramisetty et al., in their review of 2 223 consecutive nof fractures, conducted in birmingham, england, reported ten patients (0.004%) with pathological fractures.6 this figure, however, does not represent true prevalence as only 90 of the 2 223 patients in their cohort had histological evaluation. davis et al. in their retrospective review at a level 1 trauma centre in california, united states of america, evaluated 850 consecutive femoral neck fracture patients, and found no unexpected malignancy in any of the 466 (54.8%) specimens which were sent for histological evaluation.12 similarly, true prevalence of pathological fractures in this study cannot be deduced as 45.2% of femoral heads were not sent for histological analysis, and hence missed pathological fractures cannot be definitively excluded. true incidence of pathological femoral neck lesions in patients undergoing elective arthroplasty of the hip, in stark contrast, has been extensively researched.13-16 however, there is no clear consensus on whether it is necessary from an economic standpoint to send all resected specimens for histological examination in these patients.15,16 the aim of this study was to determine the prevalence of pathological nof fractures at a tertiary referral hospital between 2014 and 2016 through histological specimens in all nof fracture patients presenting for hip arthroplasty. the secondary aim was to determine if the current practice of sending all femoral heads for histological evaluation, to avoid missing unsuspected malignancies, is warranted, and to explore the financial cost involved. methods a retrospective, observational review of case notes, imaging studies and histological results of all patients who underwent arthroplasty for nof fractures between january 2014 and december 2016 was conducted. as per institutional protocol, on admission all patients were divided into two groups depending on suspicion of pathological or fragility/ traumatic nof fractures according to clinical and radiographic findings. patients with suspected pathological fractures were subsequently managed by the divisional bone tumour unit while fragility and traumatic nof fractures were managed by the arthroplasty unit (figure 1). clinical features raising concern of possible pathological fractures included: i) antecedent hip pain, ii) atraumatic mechanism of injury and iii) a history of malignancy. radiological features suggestive of pathological fractures included atypical fracture patterns (e.g. transverse fractures with minimal trauma) or any bony lesions (e.g. lytic, permeative, moth-eaten lesions) at the fracture site or any other bone on the radiograph. patients were identified from records from both units. all patients that underwent a head-sacrificing procedure were included in the study while patients who received arthroplasty for reasons other than nof fractures and patients treated with internal fixation were excluded. there was no exclusion for age. all resected femoral heads were sent for histology regardless if malignancy was suspected or not (figure 1) as per our current standard of care for these fractures. for the fragility/traumatic fracture group, the type of hip reconstruction following head resection was selected on an individualised approach but was based on the national institute of health and care excellence (nice) guidelines. cognitively sound community ambulators who are anaesthetically medically fit are offered total hip arthroplasty over hemiarthroplasty.17 patients who presented with a suspicious fracture without a known primary malignant lesion were investigated in order to find the primary lesion and exclude a primary malignancy of bone and were then offered surgery. patients with known metastasis (and those where the primary malignant lesion causing metastasis was found) were offered bipolar hemiarthroplasty with long cemented stems to prevent periprosthetic fracture. primary implants used for fragility/traumatic group fractures were the depuy johnson & johnson corail pinnacle system. primary implants used for figure 1. flow diagram of patients presenting with neck of femur fractures patients presenting with femur neck fracture histologybone tumour unit arthroplasty unit suspected pathological fracture suspected fragility/traumatic fracture clinical evaluation • history of malignancy or metastases • constitutional symptoms • atraumatic mechanism of injury • antecedent hip pain radiological evaluation radiological features of pathological/fragility fracture page 18 khan s et al. sa orthop j 2021;20(1) pathological fractures were stryker exeter v40 long femoral stems with bipolar hemi-arthroplasty heads. to determine the financial implications of sending femoral heads for pathological examination, the national laboratory health service, which provides histopathological examination for specimens in the state sector, as well as pathcare, which services the private sector, provided quotes in november 2019 of routine processing of these specimens. data was analysed using statistica v13. continuous demographic data (age) is reported as a mean and standard deviation together with 95% confidence intervals (ci). categorical data is described as frequencies and/or counts. results a total of 311 patients who underwent arthroplasty for nof fractures were included in this study. the cohort comprised 215 women (69%) and 96 men (31%) with a mean age of 73.4 years ± 12.6 (95% ci 72–74.). a total of 11 of 311 patients (4%) were admitted with suspected pathological fractures, based on clinical and/or radiological suspicion with fragility/traumatic fractures being diagnosed in the remaining 300 patients (97%). histology results were available for 195 patients (63%) including all of the patients with suspected pathological fractures, and 184 of the suspected traumatic/fragility fractures. nine of the suspected 11 patients were histologically confirmed to have a malignancy (table i), all of which were secondary to metastatic disease or multiple myeloma, with no primary sarcomas diagnosed. of these, four out of nine (44%) patients presented with an unknown primary malignancy and required a thorough clinical examination and basic haematological (tumour markers, myeloma workup) and radiological (ct chest/abdomen/pelvis) investigations to identify the primary malignancy prior to surgery. the histology from the resected femoral specimens for these patients confirmed the respective primary malignancy after initial workup. breast and lung carcinoma were the most common source of the primary malignancies, accounting for six of the nine pathological fractures (three each). multiple myeloma, renal and prostate carcinoma accounted for the other three patients (table i, figure 2). the first of the two suspected pathological fracture patients who did not have a pathological lesion on histology was a 68-yearold male known with prostate cancer and who had a suspicious femoral neck lytic lesion on radiographs, not in keeping with the blastic metastasis usually associated with prostate cancer. after mri (hip), ct (chest, abdomen and pelvis) and bone scan were non-contributory, the lytic lesion was biopsied to exclude a primary bony sarcoma or second primary malignancy. the biopsy showed no signs of pathological fracture and he subsequently received a total hip replacement. histological evaluation of the resected femoral head confirmed the absence of any pathological lesions. the second patient was a 47-year-old hiv-positive female with a large breast mass with skin involvement. this was her index presentation to any healthcare facility for the breast mass. radiographs revealed a subcapital nof fracture and suspicious per trochanteric lytic lesion. she was assumed to have a pathological fracture secondary to metastasis from breast cancer and hence received a long-cemented stem bipolar hemiarthroplasty. biopsy of the breast mass was done concurrently, and she was subsequently discharged to the care of the breast surgical oncology unit for further management. the breast biopsy confirmed malignancy (invasive carcinoma); however, histology of the femoral head did not show any pathology. three of the nine (33%) patients with pathological fractures presented with antecedent hip pain, five (56%) with a known primary malignancy, three (33%) with known metastatic disease, and two (22%) with an atraumatic mechanism of injury. all nine patients had radiographic features of pathological fractures (figure 3). histological results were available for 184 (of 300) patients in the fragility/trauma group. there were no unexpected malignant histological results found in this group. in 116 patients no table i: patients with pathological findings on histology age (years) sex known primary known metastases x-ray features of malignancy atraumatic mechanism of injury antecedent hip pain histology results 65 female no no lytic no no metastatic lung carcinoma 67 female no no sclerotic yes no metastatic lung carcinoma 75 female yes yes permeative no no metastatic breast carcinoma 54 female yes yes lytic no yes metastatic breast carcinoma 51 female no no permeative no yes metastatic lung carcinoma 87 male yes no sclerotic no no metastatic prostate carcinoma 54 female no no lytic no no multiple myeloma 72 female yes yes lytic no no metastatic renal carcinoma 54 female yes no lytic yes yes metastatic breast carcinoma figure 2. percentage of primary malignancies responsible for metastatic lesions breast 33% lung 33% renal 11% prostate 11% myeloma 11% page 19khan s et al. sa orthop j 2021;20(1) histological results could be found. the reason these 116 excised femoral heads were not histologically analysed as per institutional protocol was difficult to define retrospectively. lost specimens, problems with transport of specimens from theatre to the pathology lab, human error, resulting in the specimens not being ordered are all considerations. all but one of the patients with pathological fractures were treated with a long-cemented stem bipolar hemiarthroplasty. this patient returned two weeks post-surgery with a periprosthetic fracture below the implant that required revision. there was no major intraoperative or immediate post-operative morbidity or mortality related to cementation in patients who received long cemented stems for pathological fractures. the approximate cost of a single femoral head histological examination in the private healthcare sector and the state healthcare system was zar 1 956 (us$ 134) and zar 540 (us$ 37) respectively. discussion the aim of the study was to establish the prevalence of pathological fractures at our institution and to determine the financial implications of sending all femoral heads for histological examination. the first main finding of this study was that all pathological femoral neck fractures were secondary to metastatic disease and represented 3% of patients in the total cohort (9 of 311), or 5% (9 of 195) of those with confirmed histology findings. this is considerably higher than that reported by davis et al. (0.9%)12 and ramisetty et al. (0.45%).6 no conclusive reason can be given for this disparity in prevalence without further comparative studies. it could be explained by the lower number of femoral heads sent for histological examination (52% and 4% respectively), perhaps resulting in missed pathological fractures. more likely, it represents the delayed presentation due to health-seeking behaviour18 and lack of comprehensive screening programmes for cancer;19 hence the delay in treatment, increasing the prevalence of metastatic disease in the south african context. the patients with pathological fractures presented at a younger age (mean 63 years) than those with fragility fractures (mean 73 years), and this should be considered when treating these patients. in view of the fact that there were no missed pathological fractures, and that nine of 11 patients with pathological lesions were correctly identified on clinical features and radiographic findings in our series, sending all femoral heads routinely seems unnecessary. almost half of the pathological fractures in the current series presented without a known primary malignancy, and in all these cases the primary was preliminarily identified using rougraff et al.’s20 rudimentary diagnostic approach comprising basic blood tests and a computed tomography scan of the chest, abdomen and pelvis. three of the four unknown primary tumours were of lung origin, in keeping with the nature of bronchogenic malignancies as they have few clinical symptoms initially and metastasise early, with metastatic lesions often the first manifestation of the disease.21 there were no pathological fractures due to bony sarcomas consistent with the rarity of primary malignant bony lesions in elderly patients.22 all four patients who presented with metastases of an ‘unknown primary’ had a first histological diagnosis made on their femoral head specimens, as this preceded biopsy from the area of primary malignancy. this highlights the importance of pathological examination of the femoral heads from suspected lesions. there is controversy in the literature regarding the use of short uncemented or longer cemented stems for patients with pathological fractures. short uncemented stems weigh the risk of prosthetic loosening or periprosthetic fracture in the future, with the immediate risk of intra-operative haemodynamic instability or death with bone cement implantation syndrome associated with longer cemented stems.11,22 in the current series we did not experience any cementation-related complications in patients who received long cemented stems for pathological fractures. a secondary aim was to determine the cost implications of sending all femoral heads for histological evaluation. in this study, femoral head histology (n=195) amounted to between zar 105 300 (us$ 7 274) and zar 381 420 (us$ 26 322) over the three-year period. as we were able to accurately exclude malignancy using clinical and radiographic criteria, sending only the suspicious femoral heads (n=11) for histological examination would have resulted in a reduced cost of between zar 99 360 (us$ 6 864) and zar 359 904 (us$ 24 838). as femoral neck fracture incidence is increasing globally,1 and considering financial constraints on the healthcare system, judicious use of resources is imperative. subsequently, the findings of this study confirm the recommendation that clinicians should consider sending only the suspected pathological fractures for histological evaluation. the limitations of this study include its retrospective nature and the fact that not all femoral heads were sent for pathological examination. we are therefore not able to definitively exclude pathological fractures for all patients, although we report a higher percentage than previous studies. figure 3. anteroposterior radiographs of patients from our study presenting with pathological fractures with the source of the primary malignancy denoted below each image page 20 khan s et al. sa orthop j 2021;20(1) conclusion pathological lesions were identified only in a small percentage of patients undergoing arthroplasty for nof fractures in our population, albeit higher than other studies in the literature. routine histological screening of femoral heads to exclude pathological fracture might not be necessary, as pathological lesions can accurately be identified by clinical and radiographic evaluation. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study ethical approval was obtained from the following ethical review board: health research ethics committee, stellenbosch university, project id 8744 and ethics reference number s18/10/264. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was not obtained from all patients for being included in the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions sk: data capture, manuscript preparation nw: data capture, manuscript preparation mb: data analysis, manuscript revision nf: study conceptualisation, data capturing, study design, manuscript revision kj: study conceptualisation, data capturing, study design, manuscript revision references 1. johnell o, kanis j. epidemiology of osteoporotic fractures. osteoporos int. 2005;16(suppl. 2):6-10. https://doi.org/10.1007/s00198-004-1702-6. 2. thorngren kg, hommel a, norrman po, thorngren j, wingstrand h. epidemiology of femoral neck fractures. injury. 2002;33(suppl 3):c1-7. http:// www.ncbi.nlm.nih.gov/pubmed/12423584. 3. cummings sr, browner w, cummings sr, et al. bone density at various sites for prediction of hip fractures. lancet. 1993;341(8837):72-75. https://doi. org/10.1016/0140-6736(93)92555-8. 4. compston je, mcclung mr, leslie wd. osteoporosis. lancet. 2019;393(10169):364-76. https://doi.org/10.1016/s0140-6736(18)32112-3. 5. guzon-illescas o, perez fernandez e, crespí villarias n, et al. mortality after osteoporotic hip fracture: incidence, trends, and associated factors. j orthop surg res. 2019;14(1):1-9. https://doi.org/10.1186/s13018-019-1226-6. 6. ramisetty nm, pynsent pb, abudu a. fracture of the femoral neck, the risk of serious underlying pathology. injury. 2005;36(5):622-26. https://doi. org/10.1016/j.injury.2004.08.034. 7. torbert jt, lackman rd. chapter 2 pathological fractures. in: pignolo rj, keenan ma, hebela nm, editors. fractures in the elderly. aging medicine. springer science+business media; 2011. p. 43-54. https://doi. org/10.1007/978-1-60327-467-8. 8. siegel rl, miller kd, jemal a. cancer statistics, 2020. ca cancer j clin. 2020;70(1):7-30. https://doi.org/10.3322/caac.21590. 9. siegel rl, miller kd, jemal a. cancer statistics, 2018. ca cancer j clin. 2018;68(1):7-30 https://doi.org/10.3322/caac.21442. 10. damron ta, sim fh. surgical treatment for metastatic disease of the pelvis and the proximal end of the femur. j bone jt surg am. 2000;49:461-70. http:// www.ncbi.nlm.nih.gov/pubmed/10829199. 11. swanson kc, pritchard dj, sim fh. abstract. the surgical treatment of metastatic disease of the femur. j am acad orthop surg. 2000;56(3):335-39. http://www.ncbi.nlm.nih.gov/pubmed/10974383. 12. davis ja, rohlfing g, sagouspe k, brambila m. assessing the value of routine pathologic examination of resected femoral head specimens after femoral neck fracture. j am acad orthop surg. 2019;27(14):e664-8. https://doi.org/10.5435/ jaaos-d-17-00901. 13. fornasier vl, battaglia dm. finding the unexpected: pathological examination of surgically resected femoral heads. skeletal radiol. 2005;34(6):321-28. https://doi.org/10.1007/s00256-004-0820-8. 14. lin mm, goldsmith jd, resch sc, deangelis jp, ramappa aj. histologic examinations of arthroplasty specimens are not cost-effective: a retrospective cohort study. clin orthop relat res. 2012;470(5):1452-60. https://doi. org/10.1007/s11999-011-2149-7. 15. liow mhl, agrawal k, anderson dw, et al. unsuspected malignancies in routine femoral head histopathologic examination during primary total hip arthroplasty: cost-effectiveness analysis. j arthroplasty. 2017;32(3):735-42. https://doi.org/10.1016/j.arth.2016.08.017 16. rubin g, krasnyansky s, gavish i, et al. meta-analysis of unexpected findings in routine histopathology during total joint replacement. isr med assoc j. 2011;13(2):80-83. 17. national institute of health and care excellence. hip fracture: management. bmj. 2011;342:d2108. https://doi.org/10.1136/bmj.d2108. 18. moodley j, cairncross l, naiker t, momberg m. understanding pathways to breast cancer diagnosis among women in the western cape province, south africa: a qualitative study. bmj open. 2016;6(1):1-7. https://doi.org/10.1136/ bmjopen-2015-009905. 19. rayne s, schnippel k, kruger d, benn ca, firnhaber c. delay to diagnosis and breast cancer stage in an urban south african breast clinic. south african med j. 2019;109(3):159-63. https://doi.org/10.7196/samj.2019.v109i3.13283. 20. rougraff bt, kneisl js, simon ma. skeletal metastases of unknown origin. a prospective study of a diagnostic strategy. j bone jt surg. 1993;75(9):1276-81. https://doi.org/10.2106/00004623-199309000-00003. 21. li j, zhu h, sun l, xu w, wang x. prognostic value of site-specific metastases in lung cancer: a population based study. j cancer. 2019;10(14):3079-86. https://doi.org/10.7150/jca.30463. 22. takagi t, katagiri h, kim y, et al. skeletal metastasis of unknown primary origin at the initial visit: a retrospective analysis of 286 cases. plos one. 2015;10(6):1-18. https://doi.org/10.1371/journal.pone.0129428. _hlk33642667 layout 1 south african orthopaedic journal marais lc et al. sa orthop j 2018;17(1) http://journal.saoa.org.za doi 10.17159/2309-8309/2018/v17n1a5 trauma circular external fixation in the management of tibial plateau fractures in patients over the age of 55 years marais lc1, ferreira n2 1 phd; department of orthopaedics, grey’s hospital, school of clinical medicine, university of kwazulu-natal, pietermaritzburg, 3201, south africa 2 phd; department of orthopaedics, tygerberg hospital, university of stellenbosch, cape town, 7505, south africa corresponding author: dr leonard c marais, department of orthopaedics, school of clinical medicine, grey’s hospital, pietermaritzburg, south africa; email: maraisl@ukzn.ac.za; tel: +2733 897 34 abstract introduction: tibial plateau fractures in the elderly pose significant treatment challenges because of coexisting medical problems, pre-existing degenerative joint disease and osteoporosis. while several studies have reported promising results with the use of circular external fixation, little data is available on its use in older patients. this study aims to compare the complications and union rate of circular external fixation in patients over the age of 55 years with that achieved in younger patients. materials and methods: we retrospectively reviewed all patients treated with circular external fixation over a six-year period. patients were divided in two groups: group 1 consisted of patients under the age of 55 years and group 2 of patients 55 years and older. group 1 consisted of 63 cases (mean age 37.2 ± 9.1 years and group 2 of 16 cases (mean age 60.2 ± 5.8 years). apart from the patient age, there was no significant difference between the two groups in terms of demographics, mechanism of injury (p-value = 0.9) or the prevalence of polytrauma (p=1.0). results: at a mean follow-up of 19 ± 6.2 months all but two of the fractures had united. the mean overall duration of external fixation was 20.2 ± 8.2 weeks, with a slightly longer mean time-in-frame in group 1 (20.9 ± 1.1 weeks) in comparison to group 2 (17.8 ± 1.4 weeks, p=0.1). complications occurred more frequently in patients over the age of 55 years (56% vs 37%, p-value = 0.2). loss of reduction also occurred more frequently in patients over 55 years (19%), compared to patients younger than 55 years (6%) (p=0.1). conclusion: circular external fixation may be a viable treatment option in patients over the age 55 years who sustain highenergy tibial plateau fractures associated with significant soft tissue compromise. no significant difference was found in terms of the union rate or the development of complications when compared to younger patients. level of evidence: level 3 key words: tibial plateau, fracture, circular fixator, external fixation, ilizarov, osteoporosis, geriatric, elderly citation: marais lc, ferreira n. circular external fixation in the management of tibial plateau fractures in patients over the age of 55 years. sa orthop j 2018;17(1):35-40. http://dx.doi.org/10.17159/2309-8309/2018/v17n1a5 editor: prof anton schepers, university of the witwatersrand received: november 2016 accepted: march 2017 published: march 2018 copyright: © 2018 marais lc, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. page 36 marais lc et al. sa orthop j 2018;17(1) introduction tibial plateau fractures are complex injuries that affect a major weight-bearing joint and are frequently associated with significant compromise of the surrounding soft tissue.1 at time of injury a large amount of energy is transferred to the thin layer of soft tissue overlying the proximal tibia. as a result, this soft tissue envelope is often intolerant of extensive dissection and this has significant implications for the surgical management of the underlying bony injury.2 the management of tibial plateau fractures is difficult and may be associated with complications such as knee stiffness, deep infection, post-traumatic arthritis, malunion and non-union.3 treatment options include circular or hybrid external fixation and internal fixation, with either a single lateral locking plate or dual medial and lateral plates. while open reduction and internal fixation of tibial plateau remains a popular treatment option, it carries the risk of wound complications which can lead to deep sepsis and chronic osteomyelitis in approximately 10–20% of cases.4-6 heightened awareness of the importance of soft tissue management has led to the development of percutaneous reduction techniques and minimally invasive plate osteosynthesis (mipo), which aims to minimise these risks.7 circular fixation has also emerged as a useful treatment option in high-energy injuries where the injured soft tissue envelope often precludes open reduction and internal fixation.8 tibial plateau fractures in the elderly poses some additional challenges because of coexisting medical problems, pre-existing degenerative joint disease and osteoporosis.9 bone mineral density (bmd) is significantly decreased after the age of 60 years in female patients.10 quantitative computed tomography analysis has revealed that the bmd of the tibial plateau is lowest in the central and antero-medial regions and highest in the postero-medial or postero-lateral regions.10 this reduction in bmd results in an increased risk of re-displacement of fractures, which may be as high as 79% in patients over the age of 60.11 while several studies have reported promising results with the use of circular external fixation, little data is available on its use in the elderly.1,2,8 in the elderly hybrid external fixation has been reported to deliver inferior results in comparison to internal fixation.9 this study aims to compare the complication and union rate of conventional circular external fixation in patients over the age of 55 years with that achieved in younger patients. ethical approval was obtained from our institution’s ethics review board prior to commencement of the study. patients and methods we retrospectively reviewed all patients with tibial plateau fractures treated with circular external fixation at our institution between june 2009 and june 2015. eligible patients were identified from a prospectively gathered database. all patients treated with circular external fixation for a tibial plateau fracture were included in the study. patients treated with different fixation techniques, pathological fractures and follow-up of less than 12 months were excluded. for the purposes of this study patients were divided in two groups: group 1 consisted of patients under the age of 55 years and group 2 of patients 55 years and older. the subjects’ charts were reviewed and data extracted in order to describe the patient demographics, number and nature of surgical procedures performed, time to union and, finally, the complications that occurred. classification of the fracture and soft tissue injury, time to union, complications and range of knee motion were also documented. isolated tibial plateau fractures were classified according to the schatzker classification system.12 fracture dislocation involving the tibial plateau were classified according to the hohl and moore classification system.13 soft tissue injury was classified as described by oestern and tscherne.14 pin site infections were graded according to the checketts and otterburn classification.15 the definitive surgical procedure was performed once ct imaging was completed. the condition of the soft tissue envelope did not influence the timing of definitive surgery. the surgical technique included closed or limited open, indirect reduction through a 2 cm midline incision. after joint line alignment was achieved, a single 6.5 mm cannulated screw was inserted from lateral, into the subchondral bone (figure 1). no bone graft was used. fixation was completed with application of a four-ring circular external fixator. both ilizarov (smith & nephew, memphis, tn) and truelok (orthofix, verona, italy) fixators were used. frame design and fixation followed the technique previously described.2 post-operative rehabilitation commenced on day 1 after definitive fixation. early knee range of motion exercises was followed by weight bearing as pain allowed. pin site dressings were left undisturbed for the first seven days following the procedure. after this period, the dressings were removed and twice daily pin site cleaning, with chlorhexidine-alcohol solution, were commenced. initially all patients were followed up at twoweekly intervals at our outpatient department. the intervals were extended to four-weekly once a robust rehabilitation programme and pin tract care regimen was established. particular attention was paid to weight bearing mobilisation, functional rehabilitation and normalisation of gait pattern in order to promote recovery and bony union. follow-up radiographs, the progress with rehabilitation and the occurrence of any complications were documented at each clinic visit. figure 1. clinical and x-ray images of a 62-year-old female patient with a schatzker vi tibial plateau fracture. pre-operative x-rays show highly comminuted fracture (a). fracture fixation with a 6.5 mm cannulated screw and fine-wire circular fixator (b, c). x-ray following removal of external fixation (d). a b c d marais lc et al. sa orthop j 2018;17(1) page 37 union was considered as the presence of combination of fracture consolidation in at least three cortices and painless weight bearing. malunion was defined as radiographic angulation of more than 10 degrees in any plane. statistical analysis was performed using stata 13.0 (statacorp. college station, texas). continuous variables were reported as mean (± sd) or median (with interquartile range) and categorical variables as number and percentages, unless otherwise stated. differences in continuous variables were compared with the use of the unpaired t-test. the chi-square test was used for categorical data. all tests were two-sided, and the level of significance was set at p<0.05. for the purposes of optimal sample size calculation, a power of 80% was selected. results we identified 84 fractures, in 80 patients, that were treated by circular external fixation from the prospectively kept database. five patients were excluded from the study. four cases had less than 12 months’ follow-up and one patient was lost to followup (figure 2). seventy-nine patients, with a mean follow-up of 19.4 ± 6.2 months, were included in the analysis. the mean age was 41.8 years (range 21–73 years). the demographic and clinical characteristics of the two groups are provided in table i. group 1 consisted of 63 cases below the age of 55 years (mean age 37.2 ± 9.1 years) and group 2 of 16 cases that were 55 years or older (mean age 60.2 ± 5.8 years). apart from the patient age, there was no significant difference between the two groups in term of demographics, mechanism of injury (p-value = 0.9) or the prevalence of polytrauma (p=1.0). the majority of fractures (58%) were sustained in road traffic accidents and 29% of all patients sustained multiple injuries. notably, 18 patients were found to be hiv positive (group 1=17 and group 2=1, p=0.1) with a mean cd4 count of 389 cells/mm3. figure 2. flow chart of patient population cohort n=84 patients aged <55 years n=67 (3 bilateral cases) patients aged ≥55 years n=17 (1 bilateral case) group 1 (age <55 years) n=63 group 2 (age ≥55 years) n=16 excluded (<12 months follow-up) n=4 lost to follow-up n=1 excluded (<12 months follow-up) n=1 table i: demographic and baseline clinical characteristics of the cohort subdivided into group 1 (cases under the age of 55 years) and group 2 (over the age of 55 years) overall (n=79) group 1 age <55 years (n=63) group 2 age ≥55 years (n=16) p-valueb agea 41.8 ± 12.5 37.2 ± 9.1 60.2 ± 5.8 <0.001 male sex (%) 52 (66) 41 (65) 11 (69) 1.00 diabetes (%) 3 (4) 1 (2) 2 (13) 0.1 smoking (%) 14 (18) 14 (22) 0 (0) 0.06 hiv (%) 18 (23) 17 (27) 1 (6) 0.1 mechanism of injury 0.9 mvac (%) 26 (33) 21 (33) 5 (31) pvad (%) 20 (25) 15 (24) 5 (31) motorcycle accident (%) 5 (6) 5 (8) 0 (0) fall (%) 23 (29) 17 (27) 6 (38) assault (%) 2 (3) 2 (3) 0 (0) sport (%) 2 (3) 2 (3) 0 (0) bilateral fractures (%) 8 (10 6 (10) 2 (13) 0.6 segmental fracturese (%) 5 (6) 4 (6) 1 (6) 1.0 open fractures (%) 11 (14) 10 (16) 1 (6) 0.4 polytrauma (%) 23 (29) 18 (29) 5 (31) 1.0 fracture classificationf 0.4 schatzker ii (%) 2 (3) 1 (2) 1 (6) schatzker iv (%) 3 (6) 3 (5) 0 (0) schatzker v (%) 12 (15) 11 (17) 1 (6) schatzker vi (%) 58 (73) 44 (70) 14 (88) fracture-dislocation (%) 4 (5) 4 (6) 0 (0) soft tissue classification 0.5 tscherne 0 (%) 2 (3) 2 (3) 0 (0) tscherne 1 (%) 9 (11) 7 (11) 2 (13) tscherne 2 (%) 26 (33) 18 (29) 8 (50) tscherne 3 (%) 29 (37) 25 (40) 6 (37) a mean ± standard deviation [sd]; b statistical comparison of group 1 and 2; c motor vehicle accident; d pedestrian vehicle accident; e plateau fracture in combination with ipsilateral tibial shaft or plafond fracture; f schatzker classification system page 38 marais lc et al. sa orthop j 2018;17(1) furthermore, 22% of patients in group 1 were cigarette smokers compared to none in group 2 (p-value = 0.06). overall, 88% of fractures were classified as bicondylar in nature (schatzker v or vi) and there was no significant difference in the classification of the fracture type between the two groups (p=0.4). the majority of fractures, 70% in group 1 and 88% in group 2, were classified as schatzker type vi fractures. few fractures were unicondylar in nature, 7% and 6% in group 1 and 2 respectively. significant soft tissue injury (tscherne class ≥ 2) was present in the 69% of cases in group 1 and 87% of cases in group 2 (p-value = 0.5). fourteen per cent of all fractures were classified as open (group 1=16% and group 2=6%, p=0.4). at a mean follow-up of 19 months (standard deviation [sd] = 6.2) all but two of the fractures had united. the mean overall duration of external fixation was 20.2 ± 8.2 weeks, with a slighter longer mean time-in-frame in group 1 (20.9 ± 1.1 weeks) in comparison to group 2 (17.8 ± 1.4 weeks, p=0.1). there was no significant difference in the type of fixator used (p=0.2), the addition of cannulated screw fixation (p=0.7) or the need for cross-knee extension of the external fixator (p=0.5) (table ii). three patients in group 1, compared to none in group 2, required an additional surgical procedure. in one patient, with a delayed union, a fibula osteotomy was performed which resulted in successful union. bone graft and locked plate fixation was performed in the second patient for a non-union of a highly comminuted fracture. an iliac crest bone graft procedure was performed in the final patient who sustained a gustilo-anderson grade iiib open fracture. despite the autogenous bone graft a non-union occurred, at the metadiaphyseal component of the fracture, in this patient. complications occurred more frequently in patients over the age of 55 years (56% vs 37%, p-value = 0.2). overall, pin-tract sepsis was the most common complication encountered (18%) and there was no significant difference between the two groups (p=0.5). loss of reduction occurred more frequently in patients over 55 years (19%), compared to patients younger than 55 years (6%) (p=0.1). malunion occurred in 13% of patient in group 2 compared to 8% in group 1 (p=0.6). joint contracture, non-union and prominent hardware occurred infrequently, and only in patients under the age of 55 years. none of the patients required total knee replacement during the follow-up period. discussion there are several unique characteristics of tibial plateau fractures in the elderly. the most common fracture pattern is schatzker type ii fractures, followed by bicondylar fractures (schatzker type v and vi).16,17 the schatzker classification is, however, not necessarily predictive of the clinical outcome in patients over the age of 55 years.9 furthermore, there appears to be no correlation between the radiological and clinical outcome of treatment.9,12 while radiographic progression of osteoarthrosis occurs in up to 60% of patients, less than 10% of patients go on to require total knee replacement.9 su et al. found that the need for arthroplasty becomes evident relatively early and total knee replacements were performed at an average of one year after the injury.9 finally, the incidence of associated knee ligament injuries is also lower in the elderly, approximately 3%, compared to 20–25% in younger patients.16,18 in comparison to younger patients, the outcome of tibial plateau fractures in patients over the age of 40 years is associated with poorer standardised health and disability ratings.19 schwartsman and co-workers drew attention to the problems related to patient self-assessment of treatment outcome and concluded that tibial plateau fractures in patients over the age of 50 years is likely to have an unsatisfactory objective outcome, even in the hands of experienced surgeons, regardless of the treatment method.20 several treatment options have been explored in older patients, including plating, nailing, minimally invasive osteosynthesis and total knee arthroplasty. satisfactory clinical outcomes have been reported in 70–90% of elderly patients treated with internal fixation using non-locking plates (table iii).9,16,17,21 while the results of standard plating appears uniformly good, the majority of fractures in these studies were simple fracture patterns with relatively few schatzker type vi fractures. frattini et al. found that satisfactory results were obtained in only 53% of patients with complex fracture patterns, compared to 90% in the simple fracture pattern group.17 furthermore satisfactory radiological results were achieved in only 32% of complex fractures. locking plates offer several potential advantages; however, limited data is available on their use in elderly patients alone. shimizu et al. reported satisfactory results in 85% of patients over the age of 65 years, table ii: treatment and complications of the cohort subdivided into group 1 (cases under the age of 55 years) and group 2 (over the age of 55 years) overall (n=79) group 1 age <55 years (n=63) group 2 age ≥55 years (n=16) p-valueb treatment truelok circular fixator 36 28 8 0.2 ilizarov circular fixator 39 33 6 taylor spatial frame 3 2 1 tlhex fixator 1 0 1 cannulated screw 64 50 14 0.7 cross-knee extension 14 10 4 0.5 additional surgery 2 2 0 1.0 follow-upa (months) 19.4±6.2 19.5±0.8 18.6±1.5 0.5 time in frame (weeks) 20.2±8.2 20.9±1.1 17.8±1.4 0.1 complications (%) 22 (41) 23 (37) 9 (56) 0.2 pin-tract sepsis (%) 14 (18) 10 (16) 4 (25) 0.5 loss of reduction (%) 7 (9) 4 (6) 3 (19) 0.1 malunion (%) 7 (9) 5 (8) 2 (13) 0.6 joint contracture 2 (3) 2 (3) 0 (0) 1.0 non-union 2 (3) 2 (3) 0 (0) 1.0 prominent hardware 1 (1) 1 (2) 0 (0) 1.0 a mean ± standard deviation (sd); b statistical comparison of group 1 and 2 marais lc et al. sa orthop j 2018;17(1) page 39 although their series included only three schatzker type vi fractures.22 novel treatment options have also been explored. roerdink and co-workers reported good to excellent results in 30 fractures (only one of which was a schatzker vi) in patients older than 55 treated by arthroscopically assisted minimal osteosynthesis, despite recurrence of displacement in 30% of cases.23 pizanis et al. utilised balloon tibiaplasty to good effect in five patients aged 44–88 years with schatzker type ii or iii fractures.24 intramedullary nailing in conjunction with inter-fragmentary screw fixation has recently been shown to be a viable option for certain selected cases without significant impaction.25 internal fixation combined with primary arthroplasty has been described as technically challenging, but may be an option in certain complex cases with severe fracture comminution, osteoporosis or pre-existing osteoarthritis.26,27 following some initial enthusiasm for hybrid external fixation in the management of peri-articular fractures, the use of these devices has significantly decreased. hybrid fixators combine beam loading through tensioned fine wires on a single ring that is attached to a canter-level loading monolateral fixator. the resultant fixator exhibited decreased stiffness at higher loads and less axial and bending stiffness when compared to traditional ilizarov circular external fixators.28,29 this led to unwanted motion and the fracture site with resultant loss of reduction, non-union and increased pin-site infection rates.30-34 conventional circular external fixation, however, has recently emerged as a viable treatment alternative for bicondylar plateau fractures.8 these fixators use beam loading through the entire span of the fixator that results in symmetrical loading of the fracture site.35 multiple pretensioned wires on the proximal ring can be configured to provide uniform support for the tibial plateau articular surface in a custom raft-construct that is tailored to each individual fracture pattern. biomechanical analysis also demonstrated that the use of four tensioned olive wires combined with a single lag screw provided adequate stability when compared to dual plating.28 the aim of this study was to compare the complication and union rate of tibial plateau fractures treated by circular external fixation in patients older than 55 years with that achieved in younger patients. while we would like to believe that a 55-year-old person should not be classified as elderly, we used this figure as it is in line with previously published reports.9,20 no significant difference was found in terms of the union rate or the development of complications. the duration of external fixation was marginally shorter in patients over the age of 55 years. while loss of reduction and malunion was encountered more frequently in patients over the age of 55 years, the difference was not statistically significant. it should however be noted that the cohort comprised mainly cases with high-energy fracture patterns and/or a compromised soft-tissue envelope. in fact, 88% of patients older than 55 years had schatzker type iv fractures. these results should therefore not be extrapolated to tibial plateau fractures in general. there are several shortcomings to this study. first, the number of cases in group 2 is small and the event rate was low. thus, the study was not sufficiently powered to find actual equivalence between the two groups. secondly, the presence of osteoporosis of the tibial plateau was not objectively quantified. thirdly, the addition of a control group involving internal fixation would have been of value. a prospectively designed study comparing internal and circular external fixation of tibial plateau fractures in the elderly could possibly shed further light on the role of circular external fixation in these challenging fractures. ta b le i ii : s u m m ar is ed r es u lts f ro m s tu d ie s o f o p er at iv e tr ea tm en t o f tib ia l p la te au f ra ct u re s in o ld er p at ie n ts a u th o rs s a m p le s iz e m e a n a g e (y e a rs ) f o llo w -u p (y e a rs ) s c h a tz k e r v i fr a c tu re s f ix a ti o n t e c h n iq u e b o n e g ra ft i s a ti s fa c to ry o u tc o m e ii c o m p lic a ti o n s l o s s o f re d u c ti o n p ro g re s s io n o f o s te o a rt h ri ti s iii c o n ve rs io n to t k r b iy an i e t al .1 6 3 2 7 1 3 .7 1 6 % n o n -l o ck ed p la te 9 4 % 7 2 % 6 % d v t iv n /r v 1 6 % 0 s u e t al .9 5 9 6 6 2 .5 2 8 % n o n -l o ck ed p la te 4 8 % 8 7 % 8 % in fe ct io n vi 5 % d v t n /r v 6 0 % 8 % h su e t al .2 1 2 2 6 6 4 .1 9 % n o n -l o ck ed p la te 5 5 % 9 0 % 5 % in fe ct io n vi 3 0 % 5 % 0 f ra tin n i e t al .1 7 4 9 7 2 4 .2 1 8 % n o n -l o ck ed p la te 7 % 7 5 % 4 % in fe ct io n vi 0 n /r v 4 % s h im iz u e t al .2 2 2 1 7 0 4 1 4 % l o ck in g p la te 7 6 % 8 5 % 0 1 0 % n /r v 0 r o er d in k et a l.2 3 3 0 7 2 3 3 % a rt h ro sc o p ic a ss is te d m in im al o st eo sy n th es is 4 0 % 8 0 % 0 3 0 % 2 7 % 3 % g ar n av o s et a l.2 5 8 6 7 2 6 2 % n ai l p lu s sc re w s 0 % n /r v 0 0 n /r v 0 a li et a l.3 4 1 1 7 2 3 .2 1 0 0 % h yb rid e xt er n al f ix at io n 9 % 8 2 % 2 7 % m al u n io n 4 5 % p in t ra ct s ep si s 2 7 % n /r v 9 % i b o n e g ra ft o r b o n e g ra ft s u b st itu te ; ii g o o d t o e xc el le n t cl in ic al o u tc o m e ac co rd in g t o t h e r as m u ss en c rit er ia ; iii o n e o r m o re g ra d es o n t h e r es n ic k sc al e; iv d ee p v ei n t h ro m b o si s; v n o t re p o rt ed ; vi d ee p in fe ct io n . page 40 marais lc et al. sa orthop j 2018;17(1) conclusion circular external fixation may be a viable treatment option in patients over the age 55 years who sustain high-energy tibial plateau fractures associated with significant soft tissue compromise. no significant difference was found in the union rate or the development of complications when compared to younger patients. ethical statement all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. prior to commencement of the study ethical approval was obtained from relevant ethical review board. due to the retrospective nature of the analysis informed written consent was not required. references 1. narayan b, harris c, nayagam s. treatment of high-energy tibial plateau fractures. strat traum limb recon 2006;1:18-28. 2. ferreira n, marais lc. bicondylar tibial plateau fractures treated with fine wire circular external fixation. strat traum limb recon 2014:9: 25-32. 3. papagelopoulos pj, partsinevelos aa, themistocleous gs, mavrogenis af, korres ds, soucacos pn. complications after tibial plateau fracture surgery. injury, int j care injured 2006;37:475-84. 4. barei dp, nork se, mills wj, bradford henley m, benirschke sk. complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique. j orthop trauma 2004;18:649-57. 5. zura rd, browne ja, black md, olsen sa. current management of high-energy tibial plateau fractures. current orthopaedics 2007;21:229-35. 6. musahl v, tarkin i, kobbe p, tzioupis c, siska pa, pape h-c. new trends and techniques in open reduction and internal fixation of fractures of the tibial plateau. j bone joint surg [br] 2009;91-b: 426-33. 7. colligne c, sanders r, dipasquale t. treatment of complex periarticular fractures using percutaneous techniques. clin orthop relat res 2000;375:69-77. 8. the canadian orthopaedic trauma society. open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures. results of a multicenter, prospective, randomized clinical trial. j bone joint surg 2006;88:2613-23. 9. su ep, westrich gh, rana aj, kapoor k, helfet dl. operative treatment of tibial plateau fractures in patients older than 55 years. clin orthop relat res 2004;421:240-48. 10. khodadadyan-klostermann c, von seebach m, taylor wr, duda gn, haas np. distribution of bone mineral density with age and gender in the proximal tibia. clinical biomechanics 2004;19:370-76. 11. ali am, el-shafie m, willet km. failure of fixation of tibial plateau fractures. j orthop trauma 2002;16(5):323-29. 12. schatzker j, mcbroom r, bruce d. the tibial plateau fracture. the toronto experience 1968–1975. clin orthop 1979;139:94-104. 13. hohl m, moore tm. articular fractures of the proximal tibia. in evarts cm, editor. surgery of the musculoskeletal system. 2nd ed. new york: churchill livingstone; 1990. 14. oestern hj, tscherne h. physiopathology and classification of soft tissue lesion. hefte unfallheilkd 1983;162:1-10. 15. checketts rg, maceachern ag, otterburn m. pin track infection and the principles of pin site care. in de bastiani a, graham apley a, goldberg a, editors. orthofix external fixation in trauma and orthopeadics. berlin heidelberg new york: springer; 2000. 16. biyani a, reddy ns, chaudhury j, simison ajm, klenerman l. the result of surgical management of displaced tibial plateau fractures in elderly. injury 1995;26(5): 291-97. 17. frattini m, vaienti e, soncini g, pogliacomi f. tibial plateau fractures in elderly patients. musculoskelet surg 2009;93:109-14. 18. delamarter r, hohl m and hopp jr e. ligament injuries associated with tibial plateau fractures. clin orthop rel res1990;250:226. 19. stevens dg, beharry r, mckee md, et al. the long-term functional outcome of operatively treated tibial plateau fractures. j orthop trauma 2001;15:312-20. 20. schwartsman r, brinker mr, beaver r, et al. patient self assessment of tibial plateau fractures in 40 older adults. am j orthop 1998;27: 512-19. 21. hsu c, chang w, wong c. surgical treatment of tibial plateau fracture in elderly patients. arch othop traum surg 2001;121:67-70. 22. shimizu t, sawaguchi t, skagoshi d, goshima k, shigemoto k, hatsuchi y. geriatric tibial plateau fractures: clinical features and surgical outcomes. j orthop science 2016;21:68-73. 23. roerdink wh, oskam j, vierhout pam. arthroscopically assisted osteosynthesis of tibial plateau fractures in patients older than 55 years. arthroscopy 2001;17(8):826-31. 24. pizanis a, garcia p, pohleman t, burkhardt m. balloon tibioplasty: a useful tool for reduction of tibial plateau depression fractures. j orthop trauma 2012;26:e88-e93. 25. garnavos c, nikolaos g, lasanianos g. the management of complex fractures of the proximal tibia with minimal intra-articular impaction in fragility patients using intramedullary nailing and compression bolts. injury 2011;42:1066-72. 26. vermiere j, scheelinck t. early primary total knee replacement for complex proximal tibia fracturesin elderly and osteoarthritic patients. acta orthop belg 2010;76:785-93. 27. hsu je, pappas n, lee g-c. a systematic approach to simultaneous periarticular fracture fixation and primary non-hinged knee replacement in patients with comminuted periarticular fractures about the knee. curr orthop prac 2011;22(6):567-72. 28. watson ma, mathias kj, maffulli n. external ring fixators: an overview. proc instn mech engrs 2011;214:459-70. 29. erhan y, oktay b, lokman k, nurettin a, erhan s. mechanical performance of hybrid ilizarov external fixator in comparison with ilizarov circular external fixator. clin biomech 2003;18:518-22. 30. pugh kj, wolinsky pr, dawson jm, stahlman gc. the biomechanics of hybrid external fixation. j orthop trauma 1999;13:20-26. 31. khalily c, voor mj, seligson d. fracture site motion with ilizarov and ‘hybrid’ external fixation. j orthop trauma 1998;12:21-26. 32. parameswaran ad, roberts cs, seligson d, voor m. pin track infection with contemporary external fixation: how much of a problem? j orthop trauma 2003;17:503-507 33. marsh jl, smith st, do tt. external fixation and limited internal fixation for complex fractures of the tibial plateau. j bone joint surg am 1995;77(5):661-73. 34. ali am, burton m, hashmi m, saleh m. treatment of displaced bicondylar tibial plateau fractures (ota-41c2&3) in patients older than 60 years of age. j orthop trauma 2003;17(5):346-52. 35. fragomen at, rozbruch sr. the mechanics of external fixation. hss j. 2007;3(1):13-29. orthopaedics vol3 no4 page 32 sa orthopaedic journal summer 2014 | vol 13 • no 4 the shelf life of sterile medical devices ta du plessis, msc(physics), dsc(chem) gammatron (pty) ltd, modimolle, limpopo reprint requests: dr ta du plessis po box 1271 kokanje 0515 email: gammatron@mweb.co.za introduction manufacturers of sterile medical devices often give an expiry (‘use by’) date on the package, generally five years from the date of sterilisation. the question arises as to what limits the duration of the sterility of such devices? why is the shelf life limited by manufacturers, and if so, why specifically five years and not three or ten years – probably relating to the accelerated or real-time testing of the packaging material? this becomes particularly relevant in the case of medical implants such as prostheses. if the implant is specified by the manufacturer to have a shelf life of five years prior to implantation, how does this relate to the in vivo performance of the device? it should be clearly pointed out that in this discussion the emphasis is put on the sterility of the implant and not on the mechano-clinical performance of such a device. in order to get perspective on this issue, it is necessary that we clearly understand the underlying principles of the particular sterilisation technique and the associated packaging of sterile medical devices. the concepts of sterile, sterilisation and sterility assurance levels in many authoritative books in the field of sterilisation, the concept sterile is referred to as a state completely free of any viable microorganisms, and sterilisation is defined as the process which will destroy all viable microorganisms.1-3 these concepts are thus used in the absolute sense where no viable microorganisms exist. however, an inherent problem is that it is impossible in practice to prove either the complete absence or the destruction of these microorganisms.4 this will be discussed in more detail later. the fact that the destruction of microorganisms through physical (radiation and steam) and chemical (ethylene oxide) sterilisation methods shows an exponential dependence on the various process parameters, clearly implies that the absence of microorganisms on a medical device following a properly validated sterilisation process can only be described in terms of a probability function.4-5 this exponential nature of sterilisation means that, although the probability may reach a very low value, it can never be lowered to a zero level in the absolute sense of the word.5-7 this probabilistic approach to sterility leads to the concept of sterility levels – a view which no doubt may have little room in the ‘classical’ approach to sterility. such a probabilistic approach also implies the existence of certain ‘sterility assurance levels’ (sals) – a concept that plays an important role in this field and is being used to quantify the level or probability of sterility achieved through a certain sterilisation process.8 abstract the issues of the shelf life of sterile medical devices and the concept of end-product sterility testing of a sample of devices to prove the sterility of a batch of sterile devices are discussed against the background of the probabilistic approach to sterility and sterilisation. the particular role that the sterilisation technique and the packaging materials used play in maintaining sterility are discussed against the background that sterility and the maintenance thereof is eventand not time-related, and the implications thereof on the shelf life of sterile medical devices. key words: sterile medical devices, sterility maintenance, shelf life what limits the duration of the sterility of sterile medical devices? saoj summer 2014_orthopaedics vol3 no4 2014/11/05 11:58 am page 32 sa orthopaedic journal summer 2014 | vol 13 • no 4 page 33 the sal indicates the expected probability of finding a viable microorganism on a medical device after subjecting such a device to an acceptable and properly validated sterilisation process in which all process specifications are strictly adhered to, and is usually expressed as an exponential function – 10-n.6 the use of sals improves the understanding of the efficacy of a sterilisation process and its practical significance. field of application as a determinant of the required sterility assurance level (sal) the association for the advancement of medical instrumentation (aami) in the usa in the early seventies recognised that different sals can be specified for medical devices, depending on the locality of their application.9 in the iso codes on sterilisation a similar distinction is made between two different medical device categories, depending on the intended field of application of such a device: with this approach, the contamination risk to the patient is the determining factor in selecting an sal for a particular device. those devices that are of an invasive nature will require a lower sal than those that are non-invasive. both categories will still be considered and classified as ‘sterile’ and appropriately labelled as such. end-product sterility testing the probabilistic approach to sterility and sterilisation has led to the concept and common practice of end-product sterility testing as proof of efficiency of a sterilisation process after completion. however, sterilisation is internationally recognised as an example of a process for which the efficacy cannot be verified by retrospective inspection and testing of the end product.6 this implies that sterility testing of the end product cannot be applied to verify a sal of smaller than about 10-2, because the number of devices required as a representative sample for the sterility testing becomes both impractical and uneconomical. to perform end product sterility testing to uniquely ‘prove’ an sal of 10-6 will require the sterility testing of one million devices. to further complicate matters, it is accepted that the inherent limitations of sterility testing typically leads to ‘false positives’ at a level of about 10-3, which prevents end-product sterility testing to low sal values.10-11 it clearly follows that end-product sterility testing of a few medical devices following sterilisation to ‘demonstrate’ or ‘prove’ that the entire batch is sterile, without a proper prior process validation, is without scientific foundation and can lead to erroneous conclusions with regard to the sterility of the batch as a whole. however, it should be pointed out that the use of dosimeters (radiation) or biological indicators (steam and ethylene oxide) with a known accuracy and properly calibrated to monitor a properly validated sterilisation process, is completely acceptable and indeed essential, but they are employed to monitor the process parameters and not to prove the sterility of the resulting product. the impact of sterilisation technique and packaging on the maintenance of sterility based on the basics of sterility and sterilisation, we return to our initial question on the shelf life of sterile medical devices – thus the maintenance of sterility prior to implantation. the sterilisation technique employed obviously plays a very important role on the nature and type of packaging that can be used.12,13 in the case of ethylene oxide gas sterilisation (eto), the packaging material for both the primary and secondary packaging has to be selected to permit penetration by the sterilising gas to sterilise the devices, and its later removal at the end of the cycle. for this reason the polymer laminate packaging commonly used for radiation sterilisation cannot be used for gas sterilisation. in the case of radiation sterilisation the device is hermetically sealed in double laminate pouches (polyethylene/polyester) – in general with a double seal and in the case of polymeric orthopaedic prostheses blanketed under ultra-pure nitrogen gas – the latter to protect the device or its polymeric components from radiation oxidative degradation during the radiation sterilisation cycle and subsequent storage. radiation sterilisation has the advantage that the packaging integrity of these laminate pouches is particularly high and the author is not aware of any of such laminate pouches having failed during storage prior to use. sal 10-6: surgically implanted devices sterile fluid paths other products transgressing natural tissue barriers; implying that not more than one device in a million shall be non-sterile. sal 10-3: topical products mucosal devices non-fluid path surfaces of sterile devices; implying that not more than one device in a thousand shall be non-sterile. radiation sterilisation has the advantage that the packaging integrity of these laminate pouches is particularly high saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 33 page 34 sa orthopaedic journal summer 2014 | vol 13 • no 4 provided a properly validated sterilisation process is used, and the integrity of the packaging is maintained, there is no reason to limit the shelf life of a sterile medical device – especially so in the case of radiation sterilisation. this clearly underlines the concept that sterility as a property of a medical device is recognised as event-related and not time-related. should the packaging of a sterile medical device be compromised, it could lose its sterility directly after sterilisation. similarly, if the packaging integrity is not compromised, the device will remain sterile. the entire concept of the shelf life of medical devices is clearly still a topic that is hotly debated as follows from the international literature on the internet, with the role of the packaging materials and the sterilisation techniques employed being the major points of discussion. accelerated ageing of the packaging materials and seals that are generally used by manufacturers to set the shelf life are topics with their own inherent uncertainties. no benefits of any form have been received from a commercial party related directly or indirectly to the subject of this article. references 1. medical microbiology, ed. r cruickshank, p 680, e&s livingstone limited, london, 1968. 2. dorland’s illustrated medical dictionary, 24th edition, p 1440, wb saunders company, london, 1965. 3. sykes g. disinfection and sterilization, second edition, p 6, e and f n spon limited, london, 1967. 4. whitby jl. resistance of microorganisms to radiation and experience with dose setting, in sterilization of medical products, volume 5, p 346, polyscience publications inc., canada, 1991. 5. medical devices – validation and routine control of ethylene oxide sterilization, draft international standard iso/dis 11135, p 2, international organization for standardization, 1992. 6. sterilization of health care products – methods for validation and routine control gamma and electron beam radiation sterilization. iso/tc 198 wg 2 n16, pp 1 and 5, international organization for standardization, 1991. 7. tallentire a, khann aa. the sub process in defining the degree of sterility assurance, in sterilization by ionizing radiation, volume 2, pp 65 66, multiscience publications limited, montreal, 1978. 8. ibid, p 5. 9. masefield j, et al. a north american viewpoint on selection of radiation sterilization dose, in sterilization by ionizing radiation, volume 2, pp 322-325, multiscience publications limited, montreal, 1978. 10. sterilization of health care products – methods for validation and routine control gamma and electron beam radiation sterilization. iso/tc 198 wg 2 n16, p 99, international organization for standardization, 1991. 11. iso 11137-1: sterilization of health care products – radiation – part 1: requirements for development, validation and routine control of a sterilization process for medical devices (2006). 12. iso 11607-1: packaging for terminally sterilized medical devices – part 1: requirements for materials, sterile barrier systems and packaging systems (2007). 13. iso 11607-2: packaging for terminally sterilized medical devices – part 2: validation requirements for forming, sealing and assembly processes (2007). this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. sterility as a property of a medical device is recognised as event-related and not time-related • saoj saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 34 koch o et al. sa orthop j 2019;18(4) doi 10.17159/2309-8309/2019/v18n4a5 south african orthopaedic journal http://journal.saoa.org.za traumahand surgery citation: koch o, alexander an, olorunju s, mcloughlin ha, le roux tl. grip strength following total wrist arthrodesis using the same hand as reference: a prospective study. sa orthop j 2019;18(4):41-45. http://dx.doi.org/10.17159/2309-8309/2019/v18n4a5 editor: dr a ikram, stellenbosch university, cape town, south africa received: february 2019 accepted: may 2019 published: november 2019 copyright: © 2019 koch o, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: the authors confirm that no benefits of any form have been received from any party related directly or indirectly to the subject of this article. conflict of interest: the authors, their immediate family, and any research foundation with which they are affiliated did not receive any financial payments or other benefits from any commercial entity related to the subject of the article. abstract introduction: many patients suffer from a decrease in grip strength due to various conditions of the wrist, including osteoarthritis. a stable painless wrist is essential for normal function of the hand. many patients are offered a total wrist fusion to alleviate their pain and increase their grip. there is a dearth of literature investigating the effect of total wrist arthrodesis on grip strength utilising the same side as a reference. methods: a prospective study was done to determine change in grip strength and patient-reported outcome measurements postoperatively as compared to same-side pre-operative values in subjects undergoing total wrist arthrodesis with a minimum follow-up of one year. grip strength was measured pre-operatively and at least one year post-operatively using the jamar® (patterson medical) dynamometer in the standardised method as part of set protocol. functional outcomes were assessed by the patients completing disabilities of arm, shoulder and hand (dash) scores, pre-operatively and at one-year follow-up. the differences in measures were assessed using a paired samples t-test, as well as percentage changes between measurements. results: twenty-two patients were evaluated, with a mean age of 49.6 years (range 19–85). the mean follow-up was 27 months (12–52 months). the grip strength in the affected hand improved on average by 12.6 kg (p<0.001; ci 95% [7.7, 17.3]). the grip in the affected hand was 84.5% compared to the pre-operative value of the unaffected side (32.8 kg vs 38.8 kg; p<0.001). the dash score improved by 27.8 points (p=0.1). conclusion: total wrist fusion remains a reliable procedure to restore a power grip at the expense of wrist movement. it is a suitable option for a high-demand patient with an isolated wrist problem. level of evidence: level 3 keywords: wrist, fusion, grip strength, arthritis grip strength following total wrist arthrodesis using the same hand as reference: a prospective study koch o1 , alexander an2, olorunju s3 , mcloughlin ha4, le roux tl5 1 mbchb(up), mmed(orth)up, fc orth sa; 1 military hospital, department of orthopaedic surgery, university of pretoria; pretoria east hospital suite m33 ² mbchb(up), fc orth sa; kalafong hospital, department of orthopaedic surgery, university of pretoria ³ phd; biostatistics unit, south african medical research council 4 d litt et phil; pretoria east hospital suite m33 5 mbchb(up), mmed(orth)up fcs ort sa; 1 military hospital, department of orthopaedic surgery, university of pretoria; pretoria east hospital suite m33 corresponding author: dr odette koch, department of orthopaedic surgery, 1 military hospital, hospital road, pretoria, 0187, south africa; 289 thatchers fields, lynnwood, 0081; cell: 0723145566; tel: 0129984203; email: okoch@okoch.co.za https://orcid.org/0000-0003-1871-9569 https://orcid.org/0000-0002-5598-8090 page 42 koch o et al. sa orthop j 2019;18(4) introduction a stable painless wrist is essential for normal function of the hand. many patients suffer from a decrease in grip strength due to various conditions of the wrist, including osteoarthritis. highdemand patients are often offered a total wrist fusion as a possible solution to their pain and grip strength deficits. various studies have compared post-operative grip strength as a value of the contralateral side or as a comparison to the normative values for age and sex.1 a limited number of studies have quantified the gain in grip strength of the affected hand before surgery and after successful fusion. rauhaniemi et al.2 published research where post-operative grip strength was measured as a percentage of the pre-operative value in 115 patients with rheumatoid arthritis following a total wrist arthrodesis. this study used the mannerfelt technique.3 right-hand grip strength was 24% stronger after one year, and 20% stronger if surgery was on the left hand. this is the most extensive series reported in the literature. a study similar to the current paper retrospectively reviewed the gain in grip strength in 39 cases and reported the pre-operative grip in the affected hand as 21 kg on average and 31 kg post-operatively (meads et al.4). an ao plate and iliac crest autograft were used in this series by meads. the study objectives were to determine: 1. the gain in grip strength in the same hand as a percentage of the value pre-operatively 2. grip strength after the successful fusion of the wrist as a percentage of the pre-operative value of the contralateral side 3. grip strength as a percentage of the normative value (mathiowetz1) 4. the improvement in the disability of arm, shoulder and hand (dash)5 score from baseline values. patients and methods a prospective observational study was performed at our institution. twenty-five participants undergoing a total wrist fusion for osteoarthritic-related conditions from august 2013 to the current date were eligible for the study provided they could comply with a one-year minimum follow-up post-operatively. twenty-two participants completed the study as required. one participant terminated employment and could not be reached for follow-up. two participants voluntarily withdrew from the study before the final assessment. thirteen males and nine females underwent surgery. the mean age of the study population was 49.6 years (range 19–85). in 13 cases, the participant’s dominant wrist was operated. the mean follow-up was 27 months (12–52 months). each participant completed the dash questionnaire before surgery and at final follow-up. the participants did not have access to their personal pre-operative dash form at follow-up. a jamar dynamometer was used to measure the grip strength before surgery in all cases. all measurements were taken in a standardised position with the participant sitting with their arm held abducted next to the body and the elbow in 90° flexion with the forearm in the neutral position.6 the jamar was set on the second handle position for all participants. the average of three trials was used while allowing enough time for recovery in-between efforts to prevent fatigue. the dynamometer was calibrated according to manufacturer guidelines.7 the measurement was repeated at three-monthly intervals and finally at a minimum of 12 months after surgery. participants with known rheumatoid or seronegative arthritis, any neuromuscular disorders or tendon-related problems were excluded. the surgery was performed by two surgeons (ok and tlb). the patient was positioned supine on the operating table with the arm positioned on a hand table. an above-elbow tourniquet was used in all cases. the skin incision was dorsal from the middle of the middle finger metacarpal and extended 5–7 cm proximal to the dorsal wrist crease. through a dorsal approach between the third and fourth extensor compartments, the extensor pollicus longus muscle was identified and retracted radially. transverse incisions were made at the proximal and distal end of the extensor retinaculum, and this structure was reflected ulnarly, underneath the tendons of the fourth compartment. the extensor retinaculum was reattached at the end of the procedure between the plate and the muscle to prevent tendon attrition. the distal part of the posterior interosseous nerve was resected, the lister’s tubercle was removed, and the cartilage on the articular surface between the radius and lunate, and lunate and capitate, was fishscaled. though the third carpometacarpal joint was spanned, no particular attention was paid to the joint between the base of the middle finger and the capitate. bone graft was done in all cases, with an allograft bone graft used in 17 of the cases. in five of the cases, a partial or complete resection of the distal ulna was done in combination with the wrist fusion due to arthritis at the distal radioulnar joint. in these cases, the resected bone was used as an autograft. a depuy synthes® wrist arthrodesis plate was used in all cases. the plate was placed from the third metacarpal to the distal radius. the implant was used in compression mode for all procedures. with the plate in position, the wrist is in 10° of wrist extension and positioned in neutral deviation. post-operative management included a volar splint for two weeks followed by a circular cast for another four weeks. radiographs were repeated at the six-week follow-up visit. a hand therapist instructed the patients on the correct hand and finger movement while in the splint on the day of the surgery. the participants received a home programme on discharge and routinely attended hand therapy. the surgeons evaluated the participants’ wrists at two and six weeks. an individualised follow-up regimen was followed up to one-year post-operatively. all of the participants were followed up by the principal investigators. the participants included in the study can receive medical care only at our institution. the hospital provides healthcare service to members of the military and their dependents in kwazulu-natal, mpumalanga, north west, limpopo and gauteng (provinces in south africa). this accounts for a third of the country. the referring units provide transport to and from the facility. all post-operative care and complications related to the wrist are treated at one hospital. statistical analysis the data analyses were done in collaboration with the biostatistics unit of the medical research council. the following aspects of the analyses are of importance: • the improvement in grip strength in the same hand as a percentage of the value pre-operatively, as a percentage of the contralateral side and as a percentage of the normative value • the improvement in dash scores • descriptive statistics (summary statistics, i.e. mean, variance) • confidence intervals (ci) • the paired t-test was used to compare the parameters of interest page 43koch o et al. sa orthop j 2019;18(4) the test was applied between preand post-test scores for each of the parameters for individual patients, and served as his/her control. furthermore, the change between preand post-test scores was tested using the one-sample t-test. results scaphoid non-union advanced collapse (snac) (5/22) and scapholunate advanced collapse (slac) (8/22) (figure 1) accounted for 59% of the operative indications (table i). the grip strength in the affected hand improved on average by 12.6 kg (p<0.001; ci 95% [7.7, 17.3]) from 20.2 kg (14.03, 26.6) to 32.8 kg (27.2, 38.32). the grip strength in the affected hand was 84.5% compared to the pre-operative value of the unaffected side (32.8 kg vs 38.8 kg; p<0.001). in comparison to the normative values as defined by mathiowetz,1 the post-operative grip in the operated wrist was 85.4% (p<0.001) (table ii). the dash score improved by 27.8 points from 52.0 preoperatively to 24.2 post-operatively, although this improvement was not statistically significant (p=0.1). eleven participants had undergone previous surgery to the same wrist preceding the total wrist fusion. five had associated ulnar-sided surgery at the same setting (three matched distal ulnar resections and two darrach procedures). four participants required follow-up surgery. one participant was scheduled for carpal tunnel surgery and requested removal of the hardware during the same procedure (table iii). one patient developed a non-union and needed four subsequent operations before union was achieved. he initially had a high-velocity distal radius fracture on the non-dominant hand and had undergone multiple surgeries before the wrist fusion. this participant worked as a maintenance and recovery official at his unit and continued with his manual labour after successful fusion. the current study populations’ job requirements are unique because of the need to handle a rifle and do physical training. the permanent force military members all returned to work with duty restrictions within six weeks following the surgery. one participant changed his dominance. he was ambidextrous and continued to play action cricket at a provincial level after the wrist fusion. three participants required reclassification with duty restrictions because they could not handle a rifle with the affected wrist and could not do push-ups. they were, however, able to handle a handheld weapon. one participant was reskilled, and one participant changed her occupation, but this was unrelated to the wrist fusion. all of the pensioners in the study went back to their hobbies but made adjustments. specific actions like turning a doorknob and opening a tight jar were difficult. participants reported improvement of pain after the wrist fusion. question number 24 of the dash score was evaluated. preoperatively, the participants scored their pain as follows: 21% extreme, 63% severe, 10% moderate and 5% mild. post-operatively, the score improved to 21% moderate, 42% mild and 36% no pain. the radiological union was not evaluated by a radiologist as the hospital does not routinely receive radiology reports. the x-rays were, however, assessed by the attending physician and correlated clinically with the appearance of the wrist, amount of pain, and swelling in the region of the implant (figure 2). discussion reliable evaluation of grip strength is essential to evaluate the effectiveness of the different surgical options in the management of arthritic conditions of the wrist.8 theoretically, loss of grip strength is a consequence of total wrist arthrodesis. the patients who suffer from arthritis in the wrist due to various reasons are in good health generally, but have an isolated problem in the wrist, which results in disability. weak grip strength is already present in the affected wrist due to the underlying condition. improvement in the power of the grip leads to improvement of this isolated impairment. various authors have found the loss of grip strength to range from 57% to 78%2,4,9-11 compared to the unaffected side. the current study examined the grip strength in the affected hand preoperatively as a value of the grip strength after successful fusion. in the population studied, the manual labourer runs the risk of losing their job if they are not able to comply with work requirements. these requirements often include a power grip. this study has shown that grip strength improved by 62.3% from the starting value and this is 84.5% of the value of the contralateral side. the significant gain in grip strength compared to the other authors might be attributed to the prolonged follow-up. figure 1. (left) pre-operative radiograph of a slac wrist with age-related atherosclerosis figure 2. (below) post-operative radiograph 12 months after wrist arthrodesis table i: indications for surgery wrist condition total percentage snac 5 23 slac 8 36 primary osteoarthrosis 5 23 post-traumatic conditions 3 14 secondary osteoarthrosis due to sepsis 1 4 total 22 100 snac: scaphoid non-union advanced collapse; slac: scapholunate advanced collapse page 44 koch o et al. sa orthop j 2019;18(4) in a recent review article by wei and feldon12 major complications were described as wrists requiring follow-up surgery, and minor complications as those not requiring any follow-up surgery. in the 45 studies included, reporting on 1 782 wrists, the major complication rate was 19% and the minor complication rate 10%. the advances in implants have successfully decreased the complications reported in total wrist fusion surgery. a 1996 study reported a 51% complication rate with a high re-operation rate, mostly due to tendon-related issues.13 the major complication rate in the current study was 18.2%. adey et al.14 reported 14 out of 22 patients still experienced pain after successful fusion. they speculate the sources of pain to be implant-related or due to neuroma formation. the results of the current population are similar, with 13 participants reporting mild to moderate pain at final follow-up. a benefit of the procedure is subjective improvement of pain.15 although the pain experienced at the last follow-up was less than initially, only seven participants reported complete alleviation of pain. total pain relief after wrist fusion is infrequent, and sources of pain remain debatable. the optimal position of the fused wrist remains controversial. grip strength is optimal with the wrist in 45° of extension16 and the inability to restore grip to normative value might be due to suboptimal wrist positioning. extreme extension of the wrist in a fused position might cause median nerve-related problems, and is cosmetically less acceptable. field et al.17 concluded that the most suitable position for the wrist remains uncertain. the ao plate incorporates 10° of extension and neutral deviation. when a patient has a deficient grip and discomfort, it causes disability in upper limb function. a total wrist fusion is considered a salvage operation, with the prerequisite that it improve persistent wrist pain.17 because of the limitations after a wrist fusion, the procedure is often postponed, while several other motionpreserving operations are offered. meads4 states that a wrist fusion should be recommended earlier, limiting the number of operations before the wrist fusion, but the patient should be warned about the limitations after the fusion. we support meads’ opinion that a wrist fusion should be offered sooner, as 11 participants had a total of 23 procedures to the wrist preceding the fusion. although barbieri et al.10 reported controversies regarding the patients’ subjective perception of overall upper limb function after total wrist fusion, 65.7% of their study population with low-demand work requirements went back to the same occupation after the surgery. in a study reporting on bilateral wrist fusions, most patients adapted to their limited wrist motion and were satisfied with their functionality.18 in another study, hastings et al.13 reported a 64.5% return to the same work activities performed pre-operatively. three participants with ultra-high demand occupations needed permanent duty restrictions and one participant was retrained. the remainder of the participants returned to the same occupation or hobbies. conclusion total wrist fusion remains a reliable procedure to restore a power grip and provide pain relief at the expense of wrist movement. it is a suitable option for a high-demand patient with an isolated wrist problem and should remain in the skill set of the orthopaedic surgeon. ethics statement this study was approved by 1 military hospital research ethics committee adhering to good clinical practice/international conference on harmonisation and south african clinical trial guidelines. ethics approval number: 1mh/302/6. informed consent was obtained from all participants before surgery. the anonymous datasheets and dash questionnaires were numbered in sequential order to protect the participants’ confidentiality. declarations the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. table ii: summary statistics sex summary statistics age (yrs) dash pre dash post grip pre grip post contra normative affected normative contra female n=9 mean 54.8 60.7 31.1 12.9 21.9 26.7 24.9 25.4 min 29.0 17.9 7.1 0.7 9.3 14.7 18.6 17.0 max 85.0 88.3 63.8 23.7 31.3 43.7 35.7 32.0 median 61.0 56.0 31.0 14.3 20.3 24.7 20.7 25.0 male n=13 mean 46.1 46.0 19.5 25.3 40.3 47.2 47.8 45.8 min 19.0 20.8 5.0 5.0 22.3 20.7 29.4 34.2 max 70.0 67.5 55.8 56.7 62.3 78.0 55.2 54.9 median 52.0 47.5 19.0 22.7 41.0 45.7 50.1 47.4 total n=22 mean 49.6 52.0 24.2 20.2 32.8 38.8 38.4 37.5 min 19.0 17.9 5.0 0.7 9.3 14.7 18.6 17.0 max 85.0 88.3 63.8 56.7 62.3 78.0 55.2 54.9 median 52.5 51.8 20.6 16.8 34.8 43.2 41.0 34.8 table iii: wrists requiring follow-up surgery non-union 1 carpal tunnel syndrome 1 removal of hardware 2 persistent ulnar-sided wrist pain requiring ulnar-sided surgery 1 total 18.2% page 45koch o et al. sa orthop j 2019;18(4) author contributions ok and tlr conceived of the research idea and were the primary surgeons in all cases. ok further assisted with application to the departmental research committee and ethics board; developed the study protocol and gathered patient data; contributed to writing up the manuscript for submission. ana developed the study protocol and gathered patient data. so contributed to writing up the manuscript for submission. ham assisted with application to the departmental research committee and ethics board; contributed to writing up the manuscript for submission. orcid o koch https://orcid.org/0000-0003-1871-9569 s olorunju https://orcid.org/0000-0002-5598-8090 references 1. mathiowetz v, kashman n, volland g, weber k, dowe m, rogers s. grip and pinch strength: normative data for adults. arch phys med rehabil 1985;66(2):69-74. doi:https://www.ncbi.nlm.nih.gov/ pubmed/3970660 2. rauhaniemi j, tiusanen h, sipola e. total wrist fusion: a study of 115 patients. the journal of hand surgery: british & european volume 2005;30(2):217-19. doi:10.1016/j.jhsb.2004.11.008 3. mannerfelt l, malmsten m. ar throdesis of the wrist in rheumatoid ar thritis. a technique without external fixation. scand j plast reconstr surg 1971;5(2):124-30. doi:10.3109/02844317109042952 4. meads bm, scougall pj, hargreaves ic. wrist arthrodesis using a synthes wrist fusion plate. the journal of hand surgery: british & european volume 2003;28(6):571-74. doi:10.1016/ s0266-7681(03)00146-3 5. hudak pl, amadio pc, bombardier c. development of an upper extremity outcome measure: the dash (disabilities of the arm, shoulder and hand) [corrected]. the upper extremity collaborative group (uecg). am j ind med 1996;29(6):602-608. doi:10.1002/ (sici)1097-0274(199606)29:6<602::aid-ajim4>3.0.co;2-l 6. mathiowetz v, weber k, volland g, kashman n. reliability and validity of grip and pinch strength evaluations. the journal of hand surgery 1984;9(2):222-26. doi:10.1016/s0363-5023(84)80146-x 7. fess ee. a method for checking jamar dynamometer calibration. journal of hand therapy 1987;1(1):28-32. doi:10.1016/ s0894-1130(87)80009-1 8. fong pw, ng gy. effect of wrist positioning on the repeatability and strength of power grip. am j occup ther 2001;55(2):212-16. doi:10.5014/ajot.55.2.212 9. de smet l, truyen j. arthrodesis of the wrist for osteoarthritis: outcome with a minimum follow-up of 4 years. journal of hand surgery (british and european volume) 2003;28(6):575-77. doi:10.1016/s0266-7681(03)00208-0 10. barbieri ch, mazzer n, elui vmc, fonseca mcr. resultados funcionais da artrodese do punho (functional results of wrist arthrodesis). acta ortopédica brasileira 2002;10(1):17-24. doi:10.1590/s1413-78522002000100003  11. leighton rk, petrie d. arthrodesis of the wrist. canadian journal of surgery. journal canadien de chirurgie 1987;30(2):115-16. 12. wei dh, feldon p. total wrist arthrodesis indications and clinical outcomes. j am acad orthop surg 2017;25(1):3-11. doi:10.5435/ jaaos-d-15-00424 13. hastings h 2nd, weiss ap, quenzer d, wiedeman gp, hanington kr, strickland jw. arthrodesis of the wrist for post-traumatic disorders. the journal of bone and joint surgery. american volume 1996;78(6):897-902. doi:10.1007/s00238-011-0556-3 14. adey l, ring d, jupiter, jesse b. harvard medical school, boston, ma. health status after total wrist arthrodesis for posttraumatic arthritis. j hand surg. 2005;30(5):932-36. doi:10.1016/j. jhsa.2005.06.004 15. birch a, nuttall d, stanley jk, trail ia. the outcome of wrist surgery: what factors are important and how should they be reported? the journal of hand surgery, european volume 2011;36(4):308-14. doi:10.1177/1753193410396647 16. bhardwaj p, nayak ss, kiswar am, sabapathy sr. effect of static wrist position on grip strength. indian journal of plastic surgery 2011;44(1):55-58. doi:10.4103/0970-0358.81440 17. field j, herbert tj, prosser r. total wrist fusion: a functional assessment. the journal of hand surgery: british & european volume 1996;21(4):429-33. doi:10.1016/s0266-7681(96)80039-8 18. wagner er, elhassan bt, kakar, sanjeev department of orthopedic surgery, division of hand surgery, mayo clinic, rochester, mn. long-term functional outcomes after bilateral total wrist arthrodesis. j hand surg 2015;40(2):224-28. doi:10.1016/j. jhsa.2014.10.032 https://orcid.org/0000-0003-1871-9569 https://orcid.org/0000-0003-1871-9569 https://orcid.org/0000-0002-5598-8090 https://orcid.org/0000-0002-5598-8090 _goback _hlk9323403 _hlk17279523 _goback 404 not found 404 not found page 117sa orthop j 2021;20(2) cpd questionnaire. may 2021 vol 20 no 2 treatment outcomes of civilian gunshot tibia fractures at a major trauma centre (gerafa m, jakoet s, van heukelum m, le roux n, van der merwe s, makhubalo o, du preez g, burger m, ferreira n) 1. choose the correct statement regarding the management of civilian gunshot-induced tibia fractures: a. no association was found between clinical outcome and hiv status a b. a staged approach is preferred over single-stage surgery b c. delay to surgery did not affect outcome in terms of union and infection c d. intramedullary fixation showed poor outcomes with union rates below 20% d e. external fixation produced the best outcome in terms of union and infection e 2. which fractures are most frequently identified in civilian gunshot-induced fractures involving tibial fractures in young males? a. articular injuries to the knee a b. articular injuries to the ankle b c. diaphyseal injuries c d. proximal metaphyseal injuries d e. distal metaphyseal injuries e 3. what is the most common complication in civilian gunshot-induced tibia fracture? a. malunion a b. compartment syndrome b c. fracture-related infection c d. nonunion d e. fat embolism syndrome e the association between hiv infection and periprosthetic joint infection following total hip replacement in young adults (ngwazi m, ryan p, goga i, marais lc) 4. with regard to the use of cemented implant in the hiv-positive patient, the correct statement is: a. always use cemented implants to prevent infection a b. there is no risk involved and it is acceptable to use uncemented implants b c. the results are the same with cemented and uncemented implants c d. there is an increased rate of stem subsidence with uncemented implants d e. cementation has shown an increase in wear in the shortto mid-term e 5. with regard to joint arthroplasty: a. there is evidence to show that the use of prolonged antibiotic prophylaxis will reduce infection a b. the use of cemented implants helps in the prevention of infection post-joint arthroplasty b c. well-optimised patients with regard to cd4/viral load and comorbidities will have same outcomes as hiv-negative patients c d. we should avoid arthroplasty in hiv-positive patients as it is associated with increased complication rates d e. arthroplasty should only be reserved for elderly hiv-positive patients with well-controlled comorbidities e adherence to a standard operating procedure for patients with acute cervical spine dislocations: review of a tertiary, referral, academic hospital in south africa (ayik gdd, mukabeta tdm, nyandoro g, osborne c, kruger na) 6. according to this article, what is the most common mechanism of injury of cervical dislocations associated with high-risk catastrophic long-term disabilities if not treated and addressed well? a. mva only a b. fall only b c. mva and fall c d. diving injuries d e. violent assault e 7. groote schuur hospital introduced the standard operating procedure protocol in 2016 for early reduction of acute cervical dislocation injuries. according to this protocol, reduction should be done within how many hours? a. 3 a b. 4 b c. 5 c d. 1 d e. 6 e 8. to reduce the potential risk of acute cervical dislocation injuries as stated in this article, what is the best intervention? a. anterior cervical decompression and fusion a b. posterior cervical decompression and fusion b c. early reduction using skeletal traction to realign the vertebrae c d. both a and b d e. no intervention is needed, only conservative management e growth modulation may decrease recurrence when used as an adjunct to osteotomy in infantile blount’s disease (maré ph, thompson dm, marais lc) 9. the approximate recurrence rate after proximal tibial osteotomy and acute realignment in infantile blount’s disease is: a. 100% a b. 80–100% b c. 60–80% c d. 40–70% d e. 0–20% e 10. which of the following factors are associated with recurrent deformity after proximal tibial osteotomy and acute realignment in infantile blount’s disease? a. age at osteotomy greater than 4 to 5 years a b. langenskiöld stage ≥4 b c. medial physeal slope ≥60° c d. lamont stage ≥c d e. all of the above e south african orthopaedic journal page 118 sa orthop j 2021;20(2) 11. which of the following strategies to decrease the recurrence rate after proximal tibial osteotomy and acute realignment in infantile blount’s disease have been investigated? a. overcorrection to 5°–10° mechanical valgus alignment a b. lateral proximal tibial epiphysiolysis b c. postoperative ambulatory medial unloader knee bracing c d. medial proximal tibial epiphysiodesis d e. bisphosphonate therapy e polio-like deformity: a diagnostic dilemma (ben salem ka, maré ph, goodier m, marais lc, thompson dm) 12. relating to polio vaccination, which statement(s) is/are true? a. vaccination has eradicated polio worldwide a b. opv cannot cause vaccination-associated paralytic poliomyelitis (vapp) b c. ipv has been associated with vapp c d. all of the above d e. none of the above e 13. clinical features of poliomyelitis include: a. over 90% are associated with acute flaccid paralysis a b. symmetrical lower motor neuron paralysis b c. tibialis anterior muscle is commonly involved c d. all of the above d e. none of the above e culturally competent patient–provider communication with zulu patients diagnosed with osteosarcoma: an evidence-based practice guideline (brown o, van rooyen drm, aldous c, marais lc) 14. cultural competence requires the application of: a. self-reflection skills for managing cultural differences a b. awareness, attitudes, knowledge and skills about cultural differences b c. knowledge of others’ prejudice and awareness of patients’ prejudice c d. expert care and detailed knowledge of the medical condition d e. communication skills that demonstrate knowledge of cultural bias e 15. when delivering prognostic information, it is recommended that: a. patients are informed regarding treatment limitations and poor prognoses a b. mortality timelines are specifically and clearly communicated b c. patients are not burdened with metastatic information c d. treatment limitations are not specified so that patients don’t lose hope d e. healthcare providers do not talk about death e 16. it is recommended that healthcare professionals demonstrate an understanding of patients’ cultural beliefs by: a. acknowledging patients’ need to discuss treatment with their family a b. encouraging patients to engage in their cultural traditions and rituals b c. encouraging patients to combine western and traditional approaches c d. respecting patients’ cultural health beliefs and their desire to consult a traditional healer d e. all of the above e chronic lateral ankle instability: a current concepts review (mayet z, ferrao pnf, saragas np, paterson r, magobotha skm, alexander a, eshragi h, ettehadi h, khademi ma, mehtar m, tladi mj, strydom a, workman m) 17. which statement regarding lateral ankle ligament injuries is incorrect? a. this accounts for 85% of all ankle sprains a b. acute injuries are best managed conservatively b c. this injury occurs when the foot is forced into inversion while the ankle is dorsiflexed c d. up to 20% of acute injuries can progress to chronic instability d e. chronic instability can be either mechanical or functional e 18. which statement regarding functional instability is incorrect? a. the patients complain of a perceived sense of instability a b. these patients may have weak peroneal muscles b c. these patients have decreased postural control c d. these patients have a positive anterior drawer stress radiograph d e. this can be caused by disruption of capsular mechanoreceptors e mycobacterium xenopi osteomyelitis of the spine: a case report (ukunda fun) 19. which one of the statements is correct with regard to typical radiological spinal tb manifestations? a. two adjacent vertebrae irregularities or collapse on x-rays a b. double heart-shadow or ‘heart within a heart’ sign on thoracic spine is seen on lateral view x-rays b c. mri scan is mandatory in all spinal tb cases c d. the disc is first to be affected in spinal m. tuberculosis infection d e. only follow-up x-rays are required in assessing disease progression and response to tb treatment e 20. regarding m. xenopi, which one of the following statements is correct? a. it is a rapid-growing, nonchromogenic or scotochromogenic nontuberculous mycobacterium (ntm) a b. increasingly, rrna nucleic acid probe testing for m. xenopi is performed to confirm the diagnosis b c. the microbiologic criterion for ntm of bones requires a positive culture from at least two separate tissue samples c d. in hiv-reactive patients, low cd4 counts has no role to play d e. a positive culture for m. xenopi cannot be a contaminant e subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm.co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online • once you have completed the answers, go back to the top of the page next to the registration option. there is another icon “find my cpd certificate”. (you will have to answer the two questions regarding your internship and last cpd audit once you have completed a questionnaire and want to retrieve your certificate). • if you click on that icon it will open your certificate which you can print or save on your system. • please call mpc helpdesk if you have any questions: 0861 111 335. medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 page 4 south african orthopaedic journal http://journal.saoa.org.za page 4 south african orthopaedic journal http://journal.saoa.org.za conferences, courses & symposia sassh (sa society for surgery of the hand) refresher course 23-25 february 2018 pretoria 18th congress sa spine society 24-26 may 2018 elangeni hotel, durban 64th congress of the south african orthopaedic association 3-6 september 2018 csir, pretoria january 2018 2nd international consensus meeting on orthopaedic infections 25 january 2018 26 january 2018 philadelphia, united states focus on arthroplasty symposium: unicondylar knee replacement 26 january 2018 27 january 2018 frankfurt am main, germany 19th annual aaos/aana/aossm sports medicine course 31 january 2018 04 february 2018 park city, united states february 2018 bernese hip symposium 2018 01 february 2018 03 february 2018 bern, switzerland paris shoulder symposium 2018 01 february 2018 03 february 2018 paris, france scandinavian hand surgical dissection course 05 february 2018 06 february 2018 copenhagen, denmark endoprosthetics congress berlin 2018 22 february 2018 24 february 2018 berlin, germany march 2018 aaos 2018 annual meeting 06 march 2018 10 march 2018 new orleans, united states kiel arthroscopy course 2018 09 march 2018 10 march 2018 kiel, germany utrecht spine course: complex paediatric spine 09 march 2018 10 march 2018 utrecht, netherlands annual meeting of the orthopaedic research society – ors 2018 10 march 2018 13 march 2018 new orleans, united states 12th international congress of sports medicine society of greece / 12th hellenic-cypriot conference 16 march 2018 18 march 2018 thessaloniki, greece 12th international meeting of the austrian foot society 22 march 2018 24 march 2018 going am wilden kaiser, austria european pelvic course 2018 22 march 2018 24 march 2018 hamburg, germany local international conferences, courses & symposia local 18th congress sa spine society 24 may 2018 26 may 2018 elangeni hotel, durban sassh (sa society for surgery of the hand) annual congress 31 august 2018 – 2 september 2018 csir, pretoria 64th congress of the south african orthopaedic association 3 september 2018 6 september 2018 csir, pretoria international july 2018 8th world congress of biomechanics dublin 2018 08 july 2018 12 july 2018 leinster dublin, ireland 11th world congress on orthopaedics, rheumatology & sports medicine 18 july 2018 19 july 2018 sidney, australia august 2018 10th orthopedics & rheumatology annual meeting & expo 30 august 2018 31 august 2018 toronto, canada 5th qatar orthopedic review course 31 august 2018 06 september 2018 september 2018 73rd annual meeting of the american society for surgery of the hand assh 2018 13 september 2018 15 september 2018 boston, united states eurospine barcelona 2018 19 september 2018 21 september 2018 barcelona, spain 13th congress of the european hip society ehs2017 20 september 2018 22 september 2018 the hague, netherlands 13th ehs congress 2018 20 september 2018 22 september 2018 the hague, netherlands 11th international conference on arthroplasty 24 september 2018 25 september 2018 london, united kingdom 7th annual direct anterior approach hip course – houston 2018 27 september 2018 29 september 2018 houston, united states kgoedi mn et al. sa orthop j 2019;18(1) doi 10.17159/2309-8309/2019/v18n1a1 south african orthopaedic journal http://journal.saoa.org.za traumapaediatric orthopaedics citation: kgoedi mn, rischbieter p, goller r. body mass index and blount’s disease: a single academic hospital experience. sa orthop j 2019;18(1):15-20. http://dx.doi.org/10.17159/2309-8309/2019/v18n1a1 editor: prof jacques du toit, stellenbosch university, south africa received: march 2018 accepted: september 2018 published: march 2019 copyright: © 2019 kgoedi mn. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received with respect to research and preparation of this article. conflict of interest: the authors declare no potential conflict of interest with respect to research, authorship and publication of this study. abstract background: blount’s disease is a developmental disorder of the proximal tibia with progressive varus, flexion and internal rotation deformity. it is often seen in overweight children and strongly associated with obesity. as the prevalence of childhood obesity is increasing worldwide, the incidence of blount’s disease has been noted to be on the increase as well. in the south african population, most children are malnourished with high levels of undernutrition compared to other middle-income countries. we hypothesised that in our institution, patients with blount’s disease have a body mass index (bmi) lower than reported in studies from mainly developed countries. the aim of the study was to investigate the relationship between bmi and blount’s disease in a south african academic institution. methods: all clinical and radiological records of patients with blount’s disease at a tertiary hospital in south africa over a six-year period were retrospectively reviewed. five patients did not meet inclusion criteria and were excluded from the study. data collected included patients’ demographics, weight, height and radiological investigations. a control group of randomly selected paediatric orthopaedic patients was studied. results: a total of 39 blount’s patients (19 females, 20 male) were studied. all the blount’s patients were of black ethnicity. there were nine patients with early-onset and 30 patients with late-onset blount’s disease. the mean bmis for blount’s disease and control groups were 26 kg/m² and 20 kg/m² respectively (p<0.001). there was no statistical difference in sex, laterality, bmi and bmi-percentiles (bmi%) between early-onset and late-onset blount’s disease. there was no relationship between bmi and severity of blount’s disease deformities. conclusion: high bmi is associated with blount’s disease in the cohort studied. there was no relationship between increasing bmi and severity of blount’s deformities. no relationship was found between sex, onset or laterality and blount’s disease in our study. level of evidence: level 4 key words: blount’s disease, body mass index, childhood obesity, metaphyseal–diaphyseal angle, tibio-femoral shaft angle body mass index and blount’s disease: a single academic hospital experience kgoedi mn¹ , rischbieter p², goller r³ 1 mbchb(ufs); registrar orthopaedic surgery, university of pretoria, pretoria, south africa ² mbchb(up); registrar radiology, university of pretoria, pretoria, south africa ³ mbchb, fcs ortho(sa), mmed(ortho); specialist orthopaedic surgeon, department of orthopaedic surgery, university of pretoria, pretoria, south africa corresponding author: dr mn kgoedi, orthopaedic department level 7, steve biko academic hospital, cnr steve biko road and savage street, gezina, pretoria, 0001; email: nelsonkgoedi@gmail.com; tel: +27 12 354 2851 https://orcid.org/0000-0002-5749-9960 page 16 kgoedi mn et al. sa orthop j 2019;18(1) introduction blount’s disease is a developmental condition characterised by disordered endochondral ossification of the medial part of the proximal tibial growth plate resulting in multi-planar deformities of the lower limb.1,2 secondary to the asymmetrical growth with relative inhibition of the posteromedial portion of the proximal tibial growth plate, a three-dimensional deformity of the tibia develops with varus, procurvatum (apex anterior), and internal rotation along with possible limb shortening in unilateral cases.1,2 this entity can lead to a progressive deformity with gait abnormalities, limblength discrepancy, and premature arthritis of the knee.1,2 blount’s disease is classified into early-onset (infantile) and late-onset based on whether the limb deformity develops before or after the age of four years.2-4 it is classified radiologically by langenskiold into six progressive stages per severity of the deformity to help in prognosticating patients’ outcome.4-7 the incidence of blount’s disease in south africa was estimated to be 0.03% three decades ago.8 the aetiology of blount’s disease remains unknown, though multifactorial origin is proposed with genetic and mechanical components contributing to its development.3 there is a predisposition of black children to develop blount’s disease compared to other racial groups.3 blount’s disease has been linked to increasing weight and vitamin d deficiency.1,2,9,10 a number of studies show a strong correlation between blount’s disease and obesity.3,10-14 lisenda et al. found no independent association between vitamin d deficiency and blount’s disease in their study in south african children.15 obesity has been shown to greatly increase the medial compartment pressure and contribute to the development of blount’s disease by the heuter-volkmann principle.16 limited research is inconclusive on the relationship between increasing body mass index (bmi) and the severity of blount’s disease deformity.11,13 a strong correlation has been found only between morbid obesity and radiological deformities of earlyonset blount’s disease.13 as the prevalence of childhood obesity is increasing worldwide, blount’s disease has been noted to be on the increase as well.1,16 in a retrospective study of 44 blount’s disease patients by sabharwal et al., the average bmi was 35.6, with the average bmi of 29.2 for early-onset and 39.7 for late-onset blount’s disease.13 childhood obesity has doubled in the past three decades. the percentage of children aged 6–11 years who were obese increased from 7% in 1980 to nearly 18% in 2012 in the united states.17 similarly, the percentage of adolescents aged 12–19 years who were obese increased from 5% to nearly 21% over the same period.17 in 2012, more than one-third of children and adolescents were either overweight or obese.17 it has been estimated that over 22 million children under the age of 5 years are obese worldwide.18 the prevalence of being overweight in africa and asia averages below 10% while in america and europe it averages above 20%.18 in the south african population, many children are malnourished compared to other middle-income countries.19-23 micronutrient malnutrition is regarded as a public health problem of considerable significance in south africa.19,22,23 south african children aged 1 to 9 years have an intake of less than 67% of the recommended dietary allowances (rdas) for energy, calcium, vitamin d and other micronutrients.19,22,23 in a national study conducted in 2004, 10% of children were classified as overweight and 4% as obese in south africa.22 the health of the nation study, estimated an increase in overweight from 1.2% to 13% and in obesity from 0.2% to 3.3% over the period from 1994 to 2004, and more recent studies showed a mean prevalence of just over 15% for overweight and obesity combined.24 the purpose of this study was to investigate the bmi profile and demographics of patients with blount’s disease in the south african context and determine the relationship between body weight and blount’s disease and the severity of angular deformities. we hypothesised that in our institution, patients with blount’s disease have a higher bmi than the general paediatric population, but still lower than reported studies from mainly developed countries. the second hypothesis was that increasing bmi is associated with worsening angular deformities. material and methods a retrospective review of clinical and radiological records was conducted of all patients with blount’s disease that attended the paediatric orthopaedic unit from 1 january 2011 to 31 december 2016. patients’ details were obtained from the surgical database and outpatient records. patients’ folders were retrieved from the records department. radiological images of all patients were available from the hospital’s picture archiving and communication system (pacs). all patients diagnosed with blount’s disease were included in the study. patients were grouped into four ethnicities, i.e. black, white, coloured and indian. incomplete clinical records, other congenital abnormalities and patients over 20 years of age were excluded from the study. a randomised control group of 100 paediatric orthopaedic patients was included in the study to achieve a ratio of at least 2:1 for statistical analysis. this included patients that were treated for injuries with clinical records of weight and height. patients with other congenital abnormalities/deformities and patients over 20 years of age were excluded from the control group. a simple randomisation method was utilised to obtain a representative sample of the control group from 1 january 2016 to 31 december 2016. the control group consisted of patients seen in 2016, grouped by sex. each was allocated a number and a random number generator was utilised to obtain a sample of 50 patients for each sex. bmis were calculated from the patients’ weight and height records. the bmis were interpreted as follows: <18.5 kg/m2 as underweight, 18.6–24.9 kg/m2 as normal, 25–30 kg/m2 as overweight and >30 kg/m2 as obese.9 bmi percentiles (bmi%) were plotted using the 2000 centre for disease control and prevention ageand sexspecific charts for every patient. patients’ radiological images were studied for classification of blount’s disease using the langenskiold classification system. this is a staging system of blount’s disease according to the degree of metaphyseal–epiphyseal changes seen on radiographs used to prognosticate outcomes.2,4,5 stage i is defined as presence of medial epiphyseal beaking; stage ii is described as a saucershaped defect of medial metaphysis; stage iii is when the saucer defect deepens into a step; stage iv is when the epiphysis is bent down over the medial beak; stage v when there is the presence of a double epiphysis; and stage vi when there is development of a medial physeal bony bar.2,4,5 these were further categorised as low grade (langenskiold stages i–iv) and high grade (langenskiold stages v–vi) blount’s disease.7,25 tibio-femoral angles (tfa) were calculated on the pacs images and recorded for each patient. x-rays were full weightbearing with the patella facing forward. all data collected was recorded onto microsoft excel spreadsheet for analysis. ethics approval was obtained prior to commencement of the study. statistical methods the descriptive statistics were used with the assistance of a statistician. standard deviation and ranges, with 95% confidence intervals for body mass indices in children with blount’s disease and page 17kgoedi mn et al. sa orthop j 2019;18(1) the control group were calculated. the t-test and wilcoxon ranksum (mann-whitney) test were used to determine differences in bmi between early-onset and late-onset blount’s disease children. cross-tabulations of categorical variables with fisher’s exact and chi-squared tests were done to assess for associations. the frequency distributions in terms of bmi and bmi% of early-onset and late-onset blount’s disease were compared using the chisquared test. the two-sample wilcoxon rank-sum (mann-whitney) test was used to determine statistically significant differences in bmi between the blount’s disease group and the control group, controlling for age. pearson’s correlations were used to assess the relationship between bmi and angular deformity (tfa), and a univariate logistic regression model using bmi to predict the langenskiold classification for severity was assessed. significance was determined at p-value <0.05 for all statistical analyses. statistical analysis was done using stata 14 (statacorp, 4905 lakeway drive, college station, texas, usa). results forty-four blount’s disease patients were identified. five patients were excluded from the study (three had no weight and height records and two had no radiographs on pacs). records and radiographs of 39 patients were retrospectively analysed. there were 20 male patients and 19 female patients with a mean age of 7.5 years (range: 1–15). a summary of the patient data is given in table i. there was no difference in sex distribution of both earlyonset (infantile) and late-onset (juvenile and adolescent) blount’s disease patients. the mean age was 3 years (range: 2–4) for earlyonset blount’s disease and 10 years (range: 5–17) for late-onset blount’s disease patients. all blount’s disease patients were of black ethnicity. a total of 100 control patients were studied. the control group had 50 male and 50 female patients with a mean age of 8.4 years (range: 2–17). the mean bmi for blount’s disease patients was 26.5 kg/m2 (range: 12–44) with early-onset blount’s patients having a mean of 24.2 kg/m2 (range: 12–44) and 27.7 kg/m2 (range: 12–43) for lateonset blount’s patients (table ii). there was no statistical difference between the mean bmi of early-onset and late-onset blount’s disease patients (p=0.3944), although the late-onset group had a slightly higher mean bmi. the mean bmis of male and female patients with blount’s disease were 27.7 kg/m2 and 25.3 kg/m2 respectively (p=0.4489). there was no association between laterality and onset of blount’s disease (early vs late) with pearson chi-squared = 0.22 with p-value = 0.64 and fisher’s exact = 0.72. there was a statistically significant difference between the mean bmi of patients with unilateral disease 23.2 kg/m2 (range: 12–40) and bilateral disease 29.9 kg/m2 (range 13–44) with p-value = 0.0275). the mean bmi for the control group was 20.2 kg/m2 (range: 12–36). there was a statistically significant difference between the mean bmi of blount’s disease patients and the control group (p-value = 0.0005). table iii presents a comparison of bmi% between blount’s disease patients and the control group based on the cdc criteria for children (fisher’s exact = 0.002). five (56%) of nine children with early-onset blount’s disease and 18 (60%) of 30 patients with late-onset blount’s disease were classified as obese (fisher’s exact = 0.459). five (17%) of the 30 patients with late-onset blount’s disease and none of nine patients with early-onset blount’s disease were classified as overweight. using bmi values to interpret categories without controlling for age and sex shows that 31% of blount’s patients are underweight (figure 1). this was disproved by using bmi-for-age percentiles, highlighting the importance of using the ageand sex-adjusted percentiles (cdc 2000 charts) to interpret bmi values in children. table i: summary of blount’s patients’ demographic data early late total number of patients 9 30 39 sex male 4 16 20 female 5 14 19 laterality unilateral 4 16 20 bilateral 5 14 19 langenskiold classification stage i 2 0 2 stage ii 9 7 15 stage iii 6 1 7 stage iv 0 11 11 stage v 1 14 15 stage vi 0 8 8 table ii: mean bmi values of the subgroups of blount’s disease patients mean bmi p-value onset early 24.2 0.459 late 27.7 sex male 27.7 0.4489 female 25.3 laterality unilateral 23.2 0.0275 bilateral 29.9 table iii: classification of blount’s patients and the control group based on bmi percentile ranges (cdc 2000 percentile chart) percentile blount’s control total <5th (underweight) 13% (5) 3% 5.76% 5th to 85th (normal) 15% (6) 46% 37.4% 85th to 95th (overweight) 13% (5) 11% 11.51% >95th (obese) 59% (23) 40% 45.32% fisher’s exact = 0.002 page 18 kgoedi mn et al. sa orthop j 2019;18(1) figure 1. body mass index categories of blount’s disease patients and the control group [celeste please delete the text at the top of the figure] 31 13 23 33 45 38 14 3 0 5 10 15 20 25 30 35 40 45 50 underweight normal overweight obese p e rc e n ta g e o f p a ti e n ts ( % ) bmi category blount's control figure 1. body mass index categories of blount’s disease patients and the control group figure 2. radiograph of a 3-year-old child with bilateral limb involvement, early-onset blount’s disease figure 3. standing antero-posterior (ap) radiograph of a 9-year-old female patient with langenskiold stage vi late-onset blount’s disease of the right limb page 19kgoedi mn et al. sa orthop j 2019;18(1) a total of 58 knees were studied radiologically (19 bilateral, 20 unilateral disease). examples of the cases are illustrated in figures 2 and 3. using the pearson correlations, no relationship was found between bmi and tfa (r=0.0342, p=0.8364). using bmi to predict the langenskiold classification for severity by the univariate logistic regression model, no association was found between bmi and langenskiold classification (p=0.453). the mean tfa was 26.88° (range: 12–50) for early-onset disease and 27.4° (range: 4–54) for late-onset disease. using cross-tabulation and fisher’s exact test to assess for an association between onset and langenskiold classification, eight of nine patients with early-onset blount’s had low-grade (i–iv) blount’s disease (88.9%) whereas 56.7% of patients with late-onset blount’s disease had high-grade (v–vi) blount’s disease. this was statistically significant with p=0.023. discussion the results our cohort show that patients with blount’s disease have a higher bmi compared to the general paediatric population. these results are comparable to studies reported in developed and other developing countries. however, the mean bmi for blount’s disease patients was significantly lower than in the existing literature.13 sex in our study population, blount’s disease affected both sexes equally with a comparable number of unilateral and bilateral cases. similarly, there was an equal presentation of both sexes in early-onset and late-onset blount’s disease groups. a recent meta-analysis by rivero et al. found that patients with early-onset blount’s disease were more likely to be females than males (61% vs 39%; p=0.01).3 inaba et al. in a multi-centre study in japan found that there were more females in both early-onset and lateonset blount’s disease.26 on the contrary, montgomery et al. found that blount’s disease had a statistically significant positive association with patient’s sex, with males 8.16 times more likely to have blount’s disease compared with females.10 sabharwal et al. in their study of 51 blount’s disease patients also found more males affected than females (32 males vs 19 females).27 our study found that male patients had a higher mean bmi value than their female counterparts. sabharwal et al. also found a higher bmi in males than females (38.2 vs 32.1 p=0.07) in his study of 45 patients with blount’s disease.13 on the contrary, pirpiris et al. found no statistical difference in bmi between males and females, with females having slightly higher bmi values than males (24.6 kg/m2 in males vs 26.1 kg/m2 in females, p=0.10).11 laterality our study found that patients with bilateral disease had significantly higher bmis compared to patients with unilateral disease. sabharwal et al. also found that patients with unilateral blount’s disease have a lower mean bmi than patients with bilateral blount’s disease (34.7 kg/m2 and 36.8 kg/m2 respectively, p=0.53).13 there was no relationship between the onset of blount’s disease and laterality, with equal numbers of unilateral and bilateral cases found in each group. this contrasts with the meta-analysis by rivero et al. which found more bilateral cases in early-onset blount’s disease patients and a high incidence of unilateral cases in late-onset (adolescent) blount’s disease patients.3 our limited number of early-onset blount’s disease rendered comparison inconclusive. body mass index the mean bmi values of our study population are significantly lower than those reported in the literature. a retrospective study of 45 blount’s disease patients by sabharwal et al. found a mean bmi of 35.6 kg/m2 with mean bmi of 29.2 kg/m2 for early-onset blount’s disease and 39.7 kg/m2 for late-onset blount’s disease.13 in our study, the mean bmi was 26.5 kg/m2 with a mean bmi of 24.2 kg/m2 for early-onset and 27.2 kg/m2 for late-onset blount’s disease. malnutrition and environmental effects may have contributed to the difference.15,21-23 race our study population with blount’s disease consisted only of the black race. although a conclusion cannot be reached, there seems to be a high predisposition of blount’s disease in black children. rivero et al. found a greater prevalence of blount’s disease among black children, although this predisposition was stronger in lateonset blount’s disease.3 a recent study by lisenda et al. from south africa also found all the patients in their study to be of black race.15 this forms a strong basis to suggest the relationship between black race and blount’s disease. onset our study had only nine (23%) early-onset blount’s patients compared to 30 (77%) late-onset blount’s disease patients. although late-onset blount’s patients had a higher mean bmi compared to early-onset blount’s disease, this was not found to be statistically significant. these results are similar to a study by sabharwal et al. which found that early-onset blount’s disease patients have lower bmi values than late-onset blount’s disease patients.13 severity our study found no statistical difference in severity of angular deformity using tfa in both the early-onset and late-onset diseases and no association with bmi. dietz et al. have investigated the relationship between obesity and angular deformities in 15 children diagnosed with blount’s disease and found a strong relationship between body weight, tfa and varus deformities.13 in a study by sabharwal et al., a linear correlation was found between obesity and radiographic changes in children with early-onset blount’s disease (r=0.74, p < 0.0001) and children with bmi values greater than 40 kg/m2 who have late-onset blount’s disease. no relationship was found in late-onset blount’s disease patients with bmi <40 kg/m2.13 langenskiold classification our study found that patients with early-onset disease had lowgrade blount’s disease (i.e. langenskiold i–iv) and more than 50% of patients with late-onset blount’s disease had high-grade disease (i.e. langenskiold v–vi). this finding was expected as langenskiold staging is associated with patient age.2,4-5 there was no relationship found between bmi and the langenskiold classification system. to our knowledge, no study was done to assess the effect of bmi on the langenskiold classification, but several studies were conducted to assess the relationship between bmi and severity of angular deformity using tfa angles. the study limitations include the retrospective nature of the study and the limited number of patients due to the low incidence of this condition. the study had a small group of patients with early-onset blount’s disease, thus conclusions between the two groups could page 20 kgoedi mn et al. sa orthop j 2019;18(1) not be reached. although increased bmi has a strong association with blount’s disease and probably influences the severity of angular deformities, other factors that may contribute to these changes were not assessed, i.e. vitamin d deficiencies and early walking age although vitamin d deficiency was not found to be associated with blount’s disease in a recent study.15 conclusion our study demonstrates that our cohort with blount’s disease has a higher bmi than the control population at our institution. contrary to existing literature, no relationship was found between sex, onset or laterality and blount’s disease in our study. there was also no significant difference in bmis between early-onset and late-onset blount’s disease patients or the severity of the deformities. although our study only had black patients, a larger multi-centre study is required in the south african population to assess the relationship between race and blount’s disease and to assess the genetic aetiology that may be responsible for the black racial predilection. our findings support the association between bmi and blount’s disease in children. measures aimed at decreasing weight and thus childhood obesity may have some effect on the number of children with this condition. ethics statement the study was conducted after written approval from the academic hospital management. approval from the university mmed committee was obtained. the faculty of health science’s ethics committee approval was obtained (protocol number: 5/2017) prior to the commencement of the study. all patients’ records were assigned a study number and no patient details were divulged in order to protect their confidentiality. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. acknowledgements we wish to thank the staff at paediatric orthopaedic unit, for their continuous dedication and management of these patients with blount’s disease. author contributions kgoedi mn – main author, study conceptualisation, protocol preparation, collection and interpretation of data and preparation of the manuscript rischbieter p – contributed to study conceptualisation, preparation of the protocol and collection of data goller r – study supervisor from study conceptualisation, review of protocol, preparation and revisions of the manuscript orcid kgoedi mn http://orcid.org/0000-0002-5749-9960 references 1. sabharwal s. blount’s disease. j bone joint surg am. 2009 jul;91(7):1758-76. 2. birch jg. blount’s disease. j am acad orthop surg. 2013 jul;21(7):408-18. 3. rivero sm, zhao c, sabharwal s. are patient demographics different for earlyand late-onset blount’s disease? results based on meta-analysis. journal of pediatric orthopaedics b. 2015 november;24(6):515-20. 4. langenskiold a. tibia vara. a critical review. clin orthop relat res. 1989 sep;246:195-207. 5. catonne y, pacault c, azaloux h, tire j, ridarch a, blanchard p. radiological appearances in blount’s disease. j radiol. 1980 mar;61(3):171-76. 6. laville jm, chau e, willemen l, kohler r, garin c. blount’s disease: classification and treatment. j pediatr orthop b. 1999 jan;8(1):19-25. 7. khanfour aa. does langenskiold staging have a good prognostic value in late onset tibia vara? j orthop surg res. 2012 jun 7:23. 8. bathfield ca, beighton ph. blount’s disease. a review of etiological factors in 110 patients. clin orthop relat res. 1978 sep;135:29-33. 9. gettys fk, jackson jb, frick sl. obesity in pediatric orthopaedics. orthop clin north am. 2011 jan;42(1):95,105, vii. 10. montgomery co, young kl, austen m, jo ch, blasier rd, ilyas m. increased risk of blount’s disease in obese children and adolescents with vitamin d deficiency. j pediatr orthop. 2010 dec;30(8):879-82. 11. pirpiris m, jackson kr, farng e, bowen re, otsuka ny. body mass index and blount’s disease. j pediatr orthop. 2006 sep-oct;26(5):659-63. 12. chan g, chen ct. musculoskeletal effects of obesity. curr opin pediatr. 2009 feb;21(1):65-70. 13. sabharwal s, zhao c, mcclemens e. correlation of body mass index and radiographic deformities in children with blount’s disease. j bone joint surg am. 2007 jun;89(6):1275-83. 14. scott ac, kelly ch, sullivan e. body mass index as a prognostic factor in development of infantile blount’s disease. j pediatr orthop. 2007 dec;27(8):921-25. 15. lisenda l, simmons d, firth gb, ramguthy y, kebashni t, robertson aj. vitamin d status in blount’s disease. j pediatr orthop. 2016 jul-aug;36(5):e59-62. 16. guven a, hancili s, kuru li. obesity and increasing rate of infantile blount’s disease. clin pediatr (phila). 2014 jun;53(6):539-43. 17. ogden cl, carroll md, kit bk, flegal km. prevalence of childhood and adult obesity in the united states, 2011-2012. jama. 2014 feb 26;311(8):806-14. 18. kosti ri, panagiotakos db. the epidemic of obesity in children and adolescents in the world. cent eur j public health. 2006 dec;14(4):151-59. 19. nutrition and south africa’s children [homepage on the internet]. 2003 [cited 24 june 2016]. available from: www.soulcity.org.za/ projects/soul-buddyz/soul-buddyz.../nutrition-literature-review. 20. 2000 cdc growth charts for the united states: methods and development [homepage on the internet]. hyattsville, maryland: dhhs publication no. (phs) 2002-1696 may 2002 [cited 04 june 2016]. available from: www.cdc.gov/growthcharts/cdc_charts.htm. 21. overview: child and maternal health [homepage on the internet]. south africa: unicef south africa 2013 [cited 24 june 2016]. available from: http://www.unicef.org/southafrica/survival_ devlop_343.htm. 22. labadarios d, swart r, maunder emw, kruger hs, gericke gj, kuzwayo pmn. executive summary of the national food consumption survey fortification baseline south africa, 2005. the south african journal of clinical nutrition. 2008;21(3):245-300. 23. labadarios d, steyn np, maunder e, macintryre u, gericke g, swart r, et al. the national food consumption survey (nfcs): south africa, 1999. public health nutr. 2005 aug;8(5):533-43. 24. hermanus a. rossouw, catharina c. grant, margaretha viljoen. overweight and obesity in children and adolescents: the south african problem. j afr j sci. 2012;108(5). 25. wendee morgan. blount’s disease. [cited 03 august 2017] available from: https://pdfs.semanticscholar.org/1c0a/553d1876c6 bf6c69735f5b02b7d1dec68635.pdf 26. inaba y, saito t, takamura k. multicenter study of blount’s disease in japan by the japanese pediatric orthopaedic association. j orthop sci. 2014 jan;19(1):132-40. 27. sabharwal s, zhao c, sakamoto sm, mcclemens e. do children with blount’s disease have lower body mass index after lower limb realignment? j pediatr orthop. 2014 mar;34(2):213-18. _goback _hlk531873592 _goback 404 not found orthopaedics vol3 no4 page 56 sa orthopaedic journal autumn 2015 | vol 14 • no 1 perspectives on legg-calvé-perthes disease colin moseley md, cm, frcs clinical professor of orthopaedics, university of california at los angeles emeritus chief of staff, shriners hospitals for children, los angeles correspondence: prof c moseley 4865 glencairn rd los angeles usa 90027 email: colinmoseley@mac.com based on a presentation to the south african paediatric orthopaedic society in april, 2014 evidence it is worth considering why we do not have stronger evidence about a disease that is fairly common, and has been the subject of countless papers, very few of which have resulted in strong evidence or useful guidelines. herring conducted a review of the literature and concluded that the literature is not very helpful.1 he initiated a rigorous and well-managed multi-centred study in 1984 to examine several surgical and non-surgical treatments.2 after 30 years of collecting data, and with a 20-year follow-up the difference in the results of these several treatment modalities were not obvious. he found that young patients did not all do well, and that patients over 8 years of age with moderate femoral head deformity might benefit from surgery. why has strong evidence been so hard to come by? one of the difficulties stems from the fact that we do not have an objective and reliable classification to use in grading the severity of this condition. the salter-thompson classification is reputed to give an early indication of the severity in terms of the extent of epiphyseal involvement, but the sub-chondral fracture they describe is only visible in the early stages, and in less than half of those cases.3 catterall’s classification with the ‘head at risk’ signs is, unfortunately, a staging classification since the classification can change during the course of the disease as the apparent extent of involvement of the epiphysis increases.4 herring’s ‘lateral pillar’ classification,5 which has become widely accepted, is likewise a staging, not a grading, classification. the categories in the original classification were difficult to assign, requiring the addition of the ‘b/c’ class to accommodate those cases that could not be clearly assigned to either the b or c categories. at the other end of the disease we have a similar problem with respect to defining outcomes. outcomes are played out over the lives of our young patients, but no prospective long-term studies have been reported. retrospective studies of late outcomes are difficult to perform, and weinstein’s study6 is one of the few good ones available, showing that about 50% of all lcp patients go on to need total hip arthroplasty. introduction the world of legg-calvé-perthes disease (lcp) has been full of activity but there has been little progress made. we are as unsure of the indications for treatment now as we were half a century ago and, in fact, the evidence that any treatment is effective is weak. our understanding of the disease is incomplete; nevertheless each of us, as a surgeon, must develop a working approach to the problem in order to deal with the patients who present with this condition. this article, therefore, will not attempt to provide recommendations for management, but will present ideas and a framework that might help orthopaedic surgeons to gather their thoughts about this condition, and to develop their own working approach. key words: paediatric, hip, femoral head, legg, perthes we do not have an objective and reliable classification to use in grading the severity of this condition saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:57 pm page 56 sa orthopaedic journal autumn 2015 | vol 14 • no 1 page 57 because of the difficulty in following patients over the long term we have resorted to intermediate, or proxy, outcomes that we can determine at skeletal maturity. the stulberg classification7 is used most commonly but is not completely adequate because it uses some imprecise terminology and is difficult to apply. in addition, it is not completely clear how the stulberg classes relate to the development of osteoarthritis and later difficulties. it seems clear, then, that as long as we have difficulty classifying the patients as they enter our studies, and have difficulty assessing their outcomes, we will have difficulty gathering evidence and reaching strong conclusions about the management of this condition. two diseases i have found it helpful in thinking and teaching about this condition to consider it as two diseases that are marching hand-in-hand. the first is a biologic disease that is described in biologic terms as shown in figure 1. the consequence of the biologic disease is that the femoral epiphysis goes through a period of softness. the second is a mechanical disease that is described using the mechanical terms in the same figure. the mechanical disease takes advantage of the softness with the consequence that the femoral epiphysis loses its sphericity. as orthopaedic surgeons we are limited to altering structure and mechanics in the hope of ameliorating the mechanical disease, but have been powerless in affecting the biologic disease. a possible exception to this is the claim by joseph8 that early surgery can speed up the natural history and perhaps skip stages. until now all of our treatments of lcp have been based on the principle of containment. it is important to stress that ‘containment’ is a word used only in lcp, and is different from ‘coverage’ which is measured by the centre-edge angle. containment reflects the proportion of the articular surface of the femoral epiphysis that is apposed to the acetabular surface. it makes sense to think that increased containment minimises the loss of sphericity that results from variable pressure on the soft femoral epiphysis. the analogy of a scoop of ice cream on a cone may be illustrative. ice cream a scoop of ice cream that is placed on a cone is perfectly round because it has been formed by the round scoop. it is rigid enough to maintain its round shape against gravity, but if you push on it with your thumb you will form a depression and the ice cream will extrude in other areas of lesser pressure with a consequent loss of sphericity. similarly, if you push on it with the round scoop it will extrude in areas outside the margin of the scoop even though the part within the scoop will remain perfectly round. if, however, the entire scoop of ice cream is ‘contained’ within the scoop, it will maintain its sphericity no matter how soft it is and no matter the pressure because there is no route for it to extrude. it is, in other words, perfectly contained. containment perfect containment of the proximal femoral epiphysis cannot be achieved. the fact that the hip can move means that even if perfect containment can be achieved in one position it will compromised when the hip moves to a different position. it is reasonable, however, to adopt a surgical goal of maximally containing the epiphysis in the weight-bearing standing position when maximum joint reaction forces occur. the articular surface of the femoral head is part of a spherical surface that includes not only the epiphysis, but also the physis and part of the metaphysis. the articular surface of the head is larger than the acetabulum with the result that part of the head is always outside the acetabular articular surface. in the context of lcp however, we are concerned with the epiphysis, not the head. the epiphysis occupies about 50% of the head and, since the normal acetabulum is about half of a sphere, it corresponds well to the epiphysis. there is, therefore, some position of the hip in which the epiphysis is fully contained within the acetabulum. the goal of containment treatment is to ensure that this position corresponds to the standing weight-bearing position of the hip. in the standing position the lateral part of the epiphysis is usually not contained and achieving containment involves changing the relationship of the femoral head to the acetabulum. it is worth noting that, in the normal hip, it is the lateral part of the epiphysis that is uncovered, and that this is the part of the head most consistently involved in lcp.6 containment of this part of the epiphysis can, theoretically at least, be accomplished by changing the attitude of the acetabulum (by redirectional pelvic osteotomy), the shape of the proximal femur (by proximal femoral varus osteotomy), or the position of the femur (by casting or bracing). perfect containment of the proximal femoral epiphysis cannot be achieved figure 1. lcp can be thought of as two diseases marching hand-in-hand: a biological disease, and a mechanical disease, each with its own terminology biological perthes • vascular compromise • cell death • bone resorption • vascular ingrowth • bone formation mechanical perthes • subchondral fracture • softening • collapse • extrusion • loss of sphericity • lateral hinging • containment saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:57 pm page 57 page 58 sa orthopaedic journal autumn 2015 | vol 14 • no 1 containment and the lateral pillar herring,5 in coining the term and stressing the importance of the ‘lateral pillar’, is usually given credit for bringing the importance of the lateral part of the epiphysis in lcp to our attention but somerville expressed this concept many years before.9 in his important article in 1971 he made the point that ‘when part of the ossific nucleus only is affected it is almost invariably the antero-lateral part’, and went on to state that: ‘…provided the head of the femur is well contained in an undeformed acetabulum it will develop normally even though the ossific nucleus may be in part or in whole ischaemic. …the aim of treatment must be to see that the mould in which the head is shaped is the right shape when ossification occurs.’ he used the term ‘subluxation’ to mean much the same as we would use the term ‘uncontained’ today. we can give herring credit for pulling these concepts together in the concept of the lateral pillar.5 the future we have good evidence that surgical treatment can be of benefit in certain patients. we cannot help but suspect that the benefit to other groups is masked by the difficulty in assessing their disease. we must hope that new techniques to evaluate the circulation in the femoral head will improve our classification of this disease in its early stages and facilitate meaningful studies and strong evidence for indications for treatment. multi-centre international registries that follow patients into their adult lives will provide functional and radiologic information by which to assess outcomes. we must do what we can to encourage the development of such registries. attention is being devoted to the possibility of modifying the biological disease with medications such as the bisphosphonates. it is hopeful that such treatment will help to maintain the strength of the bone and minimise extrusion and deformity. references 1. herring ja. legg-calvé-perthes disease at 100: a review of evidence-based treatment. j pediatr orthop. 2011;31 (2 suppl):137-40. 2. larson an, sucato dj, herring ja et al. a prospective multicenter study of legg-calvé-perthes disease: functional and radiographic outcomes of nonoperative treatment at a mean follow-up of twenty years. j bone joint surg am. 2012;94(7):584-92. 3. salter rb, thompson gh. legg-calvé-perthes disease. the prognostic significance of the subchondral fracture and a two-group classification of the femoral head involvement. j bone joint surg am. 1984;66(4):479-89. 4. catterall a. natural history, classification, and x-ray signs in legg-calvé-perthes disease. acta orthop belg. 1980; 46(4):346-51. 5. herring ja, neustadt jb, williams jj. the lateral pillar classification of legg-calvé-perthes disease. j pediatr orthop. 1992;12(2):143-50. 6. mcandrew mp, weinstein sl. a long-term follow-up of legg-calvé-perthes disease. j bone joint surg am. 1984;66(6):860-69. 7. neyt jg, weinstein sl, spratt kf et al. stulberg classification system for evaluation of legg-calvé-perthes disease: intra-rater and inter-rater reliability. j bone joint surg am. 1999;81(9):1209-16. 8. joseph b. natural history of early onset and late-onset legg-calve-perthes disease. j pediatr orthop. 2011;31 (2 suppl):152-55. 9. somerville ew. perthes’ disease of the hip. j bone joint surg br. 1971;53(4):639-49. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:57 pm page 58 404 not found south african orthopaedic journal research doi 10.17159/2309-8309/2022/v21n2a4 sibindi c et al. sa orthop j 2022;21(2) citation: sibindi c, mageza a, socci a. orthopaedic research in zimbabwe: a seminal bibliometric analysis. sa orthop j. 2022;21(2):89-94. http://dx.doi. org/10.17159/2309-8309/2022/ v21n2a4 editor: dr marilize burger, stellenbosch university, cape town, south africa received: may 2021 accepted: october 2021 published: may 2022 copyright: © 2022 sibindi c. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: this study was funded in part by the yale school of medicine medical student research fellowship. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background to provide a bibliometric analysis of published orthopaedic research in the form of peer-reviewed articles as well as non-indexed articles from zimbabwe in the past six decades. methods we carried out a literature search of the ‘clarivariate analytics’ web of science database, specific journals not included in the database and the university of zimbabwe repository. we then selected articles focused on research in orthopaedic pathology in zimbabwe. these articles were then classified by year of publication; focus of research; first and last author country of origin; collaboration type between high-, middleand low-income countries; journal title; journal country; methodology; and level of evidence. results a total of 27 articles published from 1965 to 2020 were found in the search with 26 having a single focus of research and one multiple foci. the highest focus of research was osteoporosis with six articles (22%), while trauma was second with five articles (19%). a majority, 19/27 (70%), of studies had a first author from zimbabwe, while a plurality, 10/27 (37%), had a zimbabwean last author. most collaborations, 12/27 (44%), were high-income–low-income countries, with most studies being concomitantly published in the united states, 13/27 (48%). cross-sectional descriptive studies represented the most common methodology with 13/27 articles carried out in this method (48%). the majority of these articles, 14/27 (52%), represented a low level of evidence at level 4, while 11/27 articles (41%) of articles were of a high level of evidence (levels 1 or 2). conclusion there is a limited amount of published orthopaedic surgery research work from zimbabwe, highlighting the need for more and higher quality research from zimbabwe. among different models, partnerships between zimbabwean researchers and researchers from other international institutions appear to be the most productive in terms of research output and hence should be replicated more broadly. level of evidence: level 4 keywords: orthopaedic surgery research, bibliometric analysis, research collaborations, zimbabwe, africa orthopaedic research in zimbabwe: a seminal bibliometric analysis cosmas sibindi,¹* akimu mageza,² adrienne socci³ ¹ medical student, yale school of medicine, new haven, connecticut, united states of america ² parirenyatwa group of hospitals and university of zimbabwe, harare, zimbabwe ³ department of orthopaedics, yale school of medicine, new haven, connecticut, united states of america *corresponding author: cosmas.sibindi@yale.edu introduction musculoskeletal pathology accounts for an increasing proportion of deaths in sub-saharan lowand middle-income countries (lmics) as other leading causes of death such as communicable diseases have been effectively targeted.1,2 musculoskeletal pathology, specifically due to road traffic injuries (high-energy trauma), has also experienced an absolute increase in incidence due to increased motorised vehicle use in an environment of limited infrastructure and lax traffic law enforcement.3,4 trauma and other musculoskeletal pathology, which require orthopaedic surgery for definitive management, are particularly concerning as already limited surgical capacity has not grown at the same rate to face the increased incidence of the orthopaedic trauma.4 murray et al. projected in 1997 that by 2020, up to seven out of ten deaths would be due to non-communicable diseases (ncds), with motor vehicle accidents accounting for a significant portion in lmics, a fact already seen in individual country studies.2,5,6 zimbabwe is one such country facing a trauma epidemic in sub-saharan africa. while increasing surgical capacity represents the most salient aspect of addressing this orthopaedic trauma epidemic, training programmes and associated orthopaedic research in these programmes complement this effort.7 training provides for the next generation of surgeons.7,8 research, on the other hand, allows for stakeholders to craft better-aligned local solutions as well as guide policy decision making. for instance, trauma registries and protocols as well as resource allocation guidelines developed in high-income countries may not be applicable to a local zimbabwean https://orcid.org/0000-0003-2424-2904 page 90 sibindi c et al. sa orthop j 2022;21(2) environment.7 as such, orthopaedic surgery research in zimbabwe can be expected to generate output with immediate relevance to zimbabwean surgeons and other clinicians. according to hedt-gauthier et al., orthopaedic surgery research in lmics can proceed in three main partnerships: local research only, lmic–lmic partnership or high-income country to lowand middle-income country collaboration (hic–lmic).9 all models are utilised in most countries as they allow for knowledge sharing in complex projects via hic–lic collaboration and increased independence of local researchers in lmic–lmic partnerships. in the most recent survey of orthopaedic surgery research using web of science, graham et al. found only four peer-reviewed papers from zimbabwe.10 the nature of the collaborations involved was not explored. with such limited research, a bibliometric analysis of existing literature provides a deeper view of the orthopaedic research work from the country showing specific numbers in areas of active research and potential collaboration, current partnership trends and providing guidance for research questions.7 to our knowledge, there has been no bibliometric analysis work looking at research work on musculoskeletal disease and specifically orthopaedic surgery only from zimbabwe. with the increasing rates of musculoskeletal disease and orthopaedic trauma; increased resources dedicated to the same; increased training of zimbabwean clinicians into orthopaedic specialist surgeons through the college of east, central and southern african surgeons association (cosecsa); and the increased likelihood of a postgraduate training programme being established in zimbabwe, there is a clear need for a review of the current state of orthopaedic research in zimbabwe. this paper aims to provide a bibliometric analysis of published orthopaedic research in the form of peer-reviewed articles as well as non-indexed articles from zimbabwe in the past six decades. it explores the numbers, author origins, nature of partnerships and orthopaedic subspecialties for this research work. it then discusses areas of current collaboration as well as areas that are in urgent need of increased research. we hypothesise that there will be a small body of orthopaedic surgery work following research trends seen in other lics along the metrics such as author origins, research focus and methodology. methods and materials we carried out a literature search of the ‘clarivariate analytics’ web of science database for indexed studies published in all years up to and including in 2020. we also searched journals which are not included in the web of science website, specifically tropical doctor, and the east and central african journal of surgery, where articles may have been published. we also searched the university of zimbabwe online academic repository for thesis articles as it was the only institution with a medical school until 2009, the only one with an accessible online portal and also the one with the most developed surgery faculty. we searched in english using the terms: orthopaedics or orthopedics or musculoskeletal or trauma or surgery or bone or spine or hip or knee or neck or shoulder or pelvis. we then filtered by the research material country of origin for zimbabwe as well as selected for medical categories excluding non-medical categories. we included articles whose area of research work was zimbabwe regardless of author origin. in spite of this, all the articles we found had at least one author from zimbabwe. this process is shown in the flow chart in figure 1. although vosviewer software was utilised to visualise data networks, the number of included papers was too limited to contribute any value to the analysis.11 as such, we read the articles individually to determine their relevance to orthopaedic surgery versus other medical areas. this was carried out initially by a medical student and then by two orthopaedic surgeons with a broad focus on articles examining orthopaedic pathology and orthopaedic surgery. these were then reviewed identifying for each article, the title, year of publication, first and last author country of origin, collaboration type as between high-income countries (hic), middleincome countries (mic) or low-income countries (lic), journal title, journal country of publication, focus of research, methodology and level of evidence.12 the foci of research were based mainly on orthopaedic subspecialities: trauma, spine, paediatrics, sports medicine, foot and ankle, hand surgery and limb reconstruction. we also had a distinct field titled hiv-related pathology which combined research on osteoporosis, bone mineral density and monoarticular arthritis as these distinct orthopaedic topics were all researched and related to hiv/aids infection. paediatrics was labelled as ‘paediatric-clubfoot’ specifically as it reflects all but one article in the field of paediatric orthopaedics in zimbabwe. the authors’ country of origin was established by looking at the primary affiliation of the author’s location. country income status was determined using world bank classifications as of 2020 with income less than $1 035 representing low-income status, $1 035 to $12 535 middle income and above $12 535 representing highincome status.13 results quantity and foci of research twenty-seven articles were identified which had research focused on orthopaedic surgery research in zimbabwe. twenty-four articles search web of science, non-listed journals and academic repository for orthopaedic surgery articles filter by zimbabwe as country of origin or include zimbabwe in search terms exclude non-medical categories review articles for relevance to orthopaedic surgery analyse articles according to set criteria figure 1. flow chart showing search bibliometric analysis strategy n um be r o f a rti cl es decade 1960–69 1970–79 1980–89 1990–99 2000–09 2010–20 20 18 16 14 12 10 8 6 4 2 0 figure 2. articles published over the years 1 1 7 18 page 91sibindi c et al. sa orthop j 2022;21(2) were from indexed journals, two from non-indexed journals and one identified as a thesis. they ranged in years from 1965–2020. the highest decade of research productivity was 2010–2020, with 18 articles published, while the period 1970–1989 had no indexed articles. there was a significant drop from seven articles in 1990–1999 to only one article in 2000–2009 (figure 2). notably, there was an oxford–university of zimbabwe clubfoot research collaboration to introduce the ponseti method led by professor christopher lavy and graduate students at the time, that led to a total of three out of the four articles within paediatric orthopaedics. twenty-seven papers had a singular focus under orthopaedic surgery, while one had multiple foci. the highest focus of research was hiv-related pathology with eight articles while trauma was second with five articles (figure 3). levels of evidence and methodology there was a broad distribution of articles by levels of evidence. the majority of articles were of a lower level of evidence (levels 4 and 5). most articles showed level 4 evidence, while there were four level 1 articles (figure 4). most papers (14/27) relied on cross-sectional descriptive methodology, with prospective cohort studies representing the secondlargest proportion at 7/27 articles. there were no randomised clinical trials identified (table i). author origins the majority of papers (19/27) were first authored by zimbabwean authors with six papers from the united kingdom (uk) and one each from uganda and south africa. there was a zimbabwean last author for a plurality of articles (10/26). south africa and the uk each had six last authors, with the united states (us) having three and malawi one. there were only 26 papers under the last author designation as one of the papers had only one author (figures 5 and 6). we also found the countries that collaborated the most with zimbabwean authors on orthopaedic research articles aligned directly with the last author origin for the articles, for example, if the last author was from south africa, then the article country of collaboration would be south africa. partnerships and collaborations there were 12 collaborations between zimbabwean authors and hics and five with mics. while there were no lic–lic n um be r o f a rti cl es focus of research 9 8 7 6 5 4 3 2 1 0 h iv -r el at ed p at ho lo gy tr au m a p ae di at ric -c lu bf oo t s pi ne s po rts m ed ic in e m ul tip le fo cu s fo ot a nd a nk le h an d su rg er y li m b re co ns tru ct io n figure 3. number of articles by research label foci 15 10 5 0 n um be r o f a rti cl es level of evidence i ii iii iv v 4 7 14 2 figure 4. number of articles by levels of evidence figure 5. pie chart showing percentages of first author origin 70% 22% 4% 4% zimbabwe ugandaunited kingdom south africa figure 6. pie chart showing percentages of last author origin 4% 38% 23% 23% 12% zimbabwe south africa united kingdom united states malawi page 92 sibindi c et al. sa orthop j 2022;21(2) collaborations, there were 10/27 papers authored solely by zimbabwean authors. these articles were published in 23 different journals, with the highest number (3/27) being at the university of zimbabwe-based central african journal of medicine. the joint highest numbers beyond zimbabwe were at the archives of osteoporosis and bme musculoskeletal disorders (2/27). in terms of country income status, most articles (13/27) were published in us-based journals and uk-based journals (8/27), both hics, with only three articles published in an lic-based journal, zimbabwe. discussion we provide here a seminal bibliometric analysis on orthopaedic surgery research work from zimbabwe. as hypothesised, the overall orthopaedic research output represents a low number of publications researched using lower levels of evidence methodologies. due to this limited number of publications, classic bibliometric analysis techniques had significantly limited applicability. broadly, the research work has been appropriately dominated by work focused on hiv/aids and antiretroviral therapyrelated orthopaedic pathology (figure 3). beyond this, there is no commensurate increase in other research foci, specifically trauma, in recent years to address the growing trauma epidemic. while zimbabwe had a higher proportion of both zimbabwean first-authored articles as well as zimbabwean published articles compared to lmic average proportions, according to graham et al.,10 the overwhelming majority of articles were still published in hic-based journals (table ii). however, the authorship proportion drops significantly when looking at last author origin suggesting the prevalence of zimbabwe–hic collaborations as being the backbone of most publications. in this light, south africa and the uk are clearly the most frequent collaborators, although there are a growing number of collaborations from other english-speaking nations such as the us and canada. the limited number of orthopaedic publications was the most salient finding in this study. according to the latest world bank data, zimbabwe has only 0.2 doctors per 1 000 people, while hics like the us have an over ten-fold higher rate, at 2.74 doctors per 1 000 people.14 this ratio places pressure on surgeons and trainees to be more focused on clinical work.15 this, paired with the fact that zimbabwe did not have an orthopaedic training programme until cosecsa inaugurated its training programme in 1999, is the likely explanation for the significantly limited quantity and quality of research articles and, more generally, academic research productivity.7,16,17 in terms of research foci, hiv-related pathology is appropriately the highest focus as a consequence of zimbabwe and the southern african region having a high hiv/aids prevalence rate. accounting for this, trauma being the second-highest focus of research is consistent with other lmics as found by graham et al. as well as other studies.10,18 the other trends in research work such as levels of evidence, methodology and authorship also followed a pattern similar to that seen in other lmics.18 regardless of the limited body of work, the distribution across foci was similar to other lmics suggesting that the research output needs to increase across all foci rather than particular ones.10 the noted longitudinal oxford–university of zimbabwe clubfoot collaboration which generated both improved clinical benefit for patients as well as research output on clubfoot can be considered a model to undertake such increases.19 indeed, such longitudinal academic collaborations have been identified by the lancet global surgery and other systematic reviews as some models to boost both the clinical and research capacity of lics such as zimbabwe.7,20 it can be expected that adoption of this model across more fields by hics considering work in zimbabwe as well as zimbabwean researchers looking to partner with hic partners would lead to increased research output. with regard to partners, south africa and the uk were zimbabwe’s largest collaborators as represented in authorship, most likely because of the strong academic ties between these countries as a consequence of geographic and colonial relationships, respectively.21,22 south africa has historically aided with zimbabwean academic development due to the geographical and political proximity of the two countries as members of the southern african development community (sadc).23 the partnership with the uk is consistent with trends seen in other countries such as kenya which were colonised by the uk and is similarly seen in francophone countries, with france.22 such ties need to be nurtured, especially if they remain equitable and build zimbabwean research capacity while maintaining a clinical impact such as the clubfoot programme. in line with these trends, and looking at evidence from multiple studies, zimbabwean researchers should continue pursuing collaborations with other english-speaking countries as the shared language and background enhances collaboration productivity.24,25 table i: distribution of articles according to methodology methodology number of articles (%) cross-sectional descriptive study 13 (48) prospective cohort study 7 (26) case series 3 (11) retrospective cohort study 2 (7) case control 1 (4) expert review 1 (4) total 27 (100) table ii: distribution of articles according to country of publication ranked from highest to lowest country (income status) number of articles (%) united states (hic) 13 (48) united kingdom (hic) 8 (29) zimbabwe (lic) 3 (11) france (hic) 1 (4) germany (hic) 1 (4) italy (hic) 1 (4) hic: high-income country; lic: low-income country table iii: distribution of articles according to country income status collaboration ranked from highest to lowest partnership/collaboration countries’ income status number of articles (%) hic–lic 12 (44) mic–lic 5 (19) lic–lic 0 (0) zimbabwe only 10 (37) page 93sibindi c et al. sa orthop j 2022;21(2) the nature of research methodology with cross-sectional descriptive studies (table i) of a lower level of evidence being the most common is consistent with trends in other lmics.10,20,26 this is likely to be due to a number of factors common to lmics. for instance, like most lmics, zimbabwe has only just begun implementing a national electronic medical record.27 this paired with the absence of a dedicated orthopaedic faculty as well as a complement of experienced research staff hinders longitudinal research, favouring cross-sectional or retrospective studies. the two longitudinal prospective cohort studies that were carried out corroborate these explanations as they were carried out under wellfunded and staffed hiv-research programmes looking into hivrelated orthopaedic pathology or the oxford–clubfoot longitudinal collaboration (hic–lic).19,28 it can be hoped that infrastructure and lessons related to hiv/aids-related research could be utilised in the future for other fields of research in zimbabwe, including orthopaedics. on the other hand, hic–lic partnerships were found by wu et al.26 to be associated with higher quality and quantity of output providing more support for their promise in increasing orthopaedic research methodology and level of evidence quality in zimbabwe. with literature showing that the majority of funding hic–lic collaborations comes from hics, the significant drop in the proportion of authorships when considering the first author versus the last author can be better understood.29,30 the last author is normally a senior author leading the team with funding and intellectual contributions while the first author carries out most of the day-to-day research.31 as such, the funding from hic leads to more last authors from hics. outside of funding, the absence of a dedicated orthopaedic faculty in zimbabwe also leads to the absence of local mentors for trainees, leading to more international mentors and hence international last authors.7 it is hoped that these first authors, mostly trainees, will one day become faculty and provide local zimbabwe-based mentorship, growing the local orthopaedic research ecosystem and increasing last name authorship. more support can be provided to these early career researchers with a view to increase research productivity in the long run. over a third of articles were authored by zimbabwe-based authors only (table iii). these proportions are also consistent with those found by graham et al. for lmics globally.10 however, this trend in articles by zimbabwean-only authors drops precipitously with zimbabwean economic output which dropped in the 2000–2009 decade (figure 2). additionally, most of these exclusively zimbabwean papers were from the decades earlier than 2000 when the country had a higher gdp per capita.32 this suggests that there has been some local funding for research work, most likely through governmental sources or better economic prosperity driving some zimbabwean-based privatefunded research work. this scenario suggests the need for the development of robust local research funding systems which can be more insulated from economic shocks allowing zimbabwean orthopaedic research to consistently flourish. while our findings results are based on zimbabwe, it can expected that similar findings would be seen in countries of similar lic profile. as wu et al.26 have found, successful models for academic productivity are similar, mainly centred on hic– lic partnerships. we also speculate that reasons proffered for research constraints would be applicable to other such nations. while it is clear from this study that there is an aggregate need for increased research across all fields in zimbabwe, limited resources constrain this. given this constraint, an area of future work could ascertain prioritisation of the fields within orthopaedic surgery for research, likely through interviews with orthopaedic surgeons and other stakeholders supported by more data on zimbabwe’s needs. our study was limited by a few factors. first, since our search was carried out using the web of science portal with articles filtered by geographic origin of zimbabwe, we may have missed articles published on zimbabwe but not tagged on the geographic origin. in a similar vein, we could also have missed articles published in other languages and not translated into english. second, while we were able to access the repository for the university of zimbabwe theses, the sole medical school in the country until 2009, we were not able to find any papers. it is possible that we missed some theses which have not been digitised or were stored in other ways. third, in conversations with local orthopaedic surgeons, we also learnt about a number of projects which are not published in peer-reviewed journals or repositories but were presented at local meetings. these unpublished works also represent a limitation to developing an accurate picture of orthopaedic projects carried out in zimbabwe. lastly, we utilised liberal criteria to classify articles as being related to orthopaedic surgery centred on their examination of orthopaedic pathology versus strictly surgical work. this liberal classification may lead to differences in results with other articles examining orthopaedic work but we felt such liberal criteria were key for a seminal work on which more studies can then be built. conclusion to our knowledge, this is the first bibliometric analysis of orthopaedic surgery research from zimbabwe. our analysis shows that there is a limited amount of published orthopaedic surgery research work from zimbabwe, highlighting the need for more and higher quality research from zimbabwe across all foci of research. among different models, partnerships between zimbabwean researchers and researchers from other international institutions appear to be the most productive in terms of research output and hence should be replicated more broadly. lastly, while there are many first authors who are zimbabwe-based, there is also a need for an increased proportion of zimbabwe-based last authors, suggesting a need for more locally devised work and sustainable ways of supporting such research. acknowledgements we thank the yale school of medicine medical student research fellowship for funding part of this study. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. no ethical review was required for this bibliometric analysis of existing published literature, with no human subjects involved. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions cs: study conceptualisation, design, data analysis and manuscript preparation am: study conceptualisation, design, data analysis and manuscript preparation as: study conceptualisation, design, data analysis and manuscript preparation orcid sibindi c https://orcid.org/0000-0003-2424-2904 mageza a https://orcid.org/0000-0002-1505-586x socci a https://orcid.org/0000-0001-9935-6928 references 1. abegunde do, mathers 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2018;19(1):450. https://doi.org/10.1186/ s12891-018-2365-3. 20. franzen sr, chandler c, lang t. health research capacity development in low and middle income countries: reality or rhetoric? a systematic meta-narrative review of the qualitative literature. bmj open. 2017;7(1):e012332. https://doi.org/10.1136/bmjopen-2016-012332. 21. eichbaum qg, adams lv, evert j, ho mj, semali ia, van schalkwyk sc. decolonizing global health education: rethinking institutional partnerships and approaches. acad med. 2021;96(3):329-35. https://doi.org/10.1097/acm.0000000000003473. 22. boshoff n. neo-colonialism and research collaboration in central africa. scientometrics. 2009;81:413. 23. mhlanga s, matope s, mugwagwa l, phuthi n, moyo vs. academic staff development strategies in engineering fields of study: case study of zimbabwe. 2013. proceedings of the 2nd biennial conference of the south african society for engineering education, cape town. 24. hoekman j, frenken k, tijssen rj. research collaboration at a distance: changing spatial patterns of scientific collaboration within europe. res policy. 2010;39:662-73. 25. hou l, pan y, zhu jj. impact of scientific, economic, geopolitical, and cultural factors on international research collaboration. j informetr. 2021;15:101194. 26. wu hh, liu m, patel kr, turner w, baltus l, caldwell am, hahn jc, coughlin rr, morshed s, miclau t, shearer dw. impact of academic collaboration and quality of clinical orthopaedic research conducted in lowand middle-income countries. sicot j. 2017;3:6. https://doi.org/10.1051/sicotj/2016042. 27. ministry of health and child welfare. zimbabwe electronic health records. february 2016. available from: https://apps.mohcc.gov.zw/mrs-docs/. accessed 28 march 2022. 28. rukuni r, gregson c, kahari c, kowo f, mchugh g, munyati s, mujuru h, ward k, filteau s, rehman am, ferrand r. the impact of vertical hiv infection on child and adolescent skeletal development in harare, zimbabwe (imvask study): a protocol for a prospective cohort study. bmj open. 2020;10(2):e031792. https://doi.org/10.1136/ bmjopen-2019-031792. 29. rees ca, lukolyo h, keating em, dearden ka, luboga sa, schutze ge, kazembe pn. authorship in paediatric research conducted in low‐and middle‐income countries: parity or parasitism? trop med int health. 2017;22(11):1362-70. https://doi.org/10.1111/tmi.12966. 30. kelaher m, ng l, knight k, rahadi a. equity in global health research in the new millennium: trends in first-authorship for randomized controlled trials among lowand middle-income country researchers 1990-2013. int j epidemiol. 2017;45(6):2174-83. https://doi. org/10.1093/ije/dyw313. 31. tscharntke t, hochberg me, rand ta, resh vh, krauss j. author sequence and credit for contributions in multiauthored publications. plos biol. 2007;5(1):e18. https://doi. org/10.1371/journal.pbio.0050018. 32. trading economics. 7 december 2020. zimbabwe gdp per capita. available from: https:// tradingeconomics.com/zimbabwe/gdp-per-capita. _hlk99356795 noconjo l et al. sa orthop j 2020;19(1) doi 10.17159/2309-8309/2020/v19n1a2 south african orthopaedic journal http://journal.saoa.org.za spine citation: noconjo l, horn a. an epidemiology of paediatric cervical spine injuries at the red cross war memorial children’s hospital over a ten-year period. sa orthop j 2020;19(1):18-22. http://dx.doi.org/10.17159/2309-8309/2020/v19n1a2 editor: dr j davis, stellenbosch university, cape town, south africa received: june 2019 accepted: september 2019 published: march 2020 copyright: © 2020 noconjo l. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors have no conflicts of interest to declare. abstract background: paediatric cervical spine injury (csi) is rare compared to adult csi. very little has been published regarding the epidemiology and outcome of csi in children in south africa. the objective of this retrospective study is to characterise the epidemiology and report on the outcome of csi in children <13 years at a tertiary referral centre for paediatric trauma. methods: we performed a retrospective study of csi at our hospital over a ten-year period. the picture archiving and communication system (pacs) of our institution was searched for patients with csis. search terms included: cervical spine fracture, subluxation, dislocation, contusion, sciwora (spinal cord injury without radiographic abnormality) and retroclival haematoma. demographic and clinical data were obtained from hospital records. injury-related variables were compared for children ≤8 and >8 years due to anatomical and biomechanical differences observed. outcome was assessed using the frankel grading. results: sixty-six children were identified with a cumulative incidence of 0.1%. the median age was 7 years (inter-quartile range 4–8.8) and 65% were male. all injuries were caused by blunt trauma. passenger motor vehicle injury (mva) accounted for 52% of injuries. injuries due to physical abuse, and recreational and sporting activities did not occur. children ≤8 years of age incurred more injuries than those >8 years (74.2% vs 25.8%). ninety-eight per cent of injuries occurred in the upper cervical spine (c1–c4) of children ≤8 years. of the 13 (19.6%) children with neurologic injury, five (7.5%) had complete spinal cord injury, four (6%) had incomplete neurology, and three (4.5%) died. sciwora occurred in six (9%) children with variable outcome. seven patients (10.6%) were operated for instability. an injury severity score (iss) of 25 (13–34) was associated with poor outcome. the mortality rate was 4.5% and all children who died were ≤8 years with upper csis and closed head injuries (chis) related to mva. conclusion: csi occurred in 0.1% of patients evaluated following trauma. mvas, either pedestrian or passenger, were responsible for the majority of these injuries. children ≤8 years were more frequently injured and sustained injuries to the upper cervical spine. the majority of paediatric csis are stable injuries that can be managed conservatively; however, urgent surgical stabilisation is indicated for unstable injuries. csi with associated chi caused by mvas in young children is associated with death. even though our patients are referred from high violence communities, no csis were attributed to physical abuse or penetrating injury. level of evidence: level 4 keywords: cervical spine injury, motor vehicle accident, frankel grade, head injury an epidemiology of paediatric cervical spine injuries at the red cross war memorial children’s hospital over a ten-year period noconjo l¹ , horn a² 1 b physio, mbchb(ukzn); registrar, orthopaedic surgery (uct) ² mbchb(pret), fc orth(sa), mmed(uct)ortho; consultant orthopaedic surgeon department of orthopaedic surgery, faculty of health sciences, groote schuur hospital and university of cape town, south africa corresponding author: dr l noconjo, department of orthopaedic surgery, faculty of health sciences, room 49 h floor, old main building, groote schuur hospital, 7701; tel: 0837511356: email: lubabalonoconjo@gmail.com https://orcid.org/0000-0001-9411-9392 https://orcid.org/0000-0002-4159-6520 page 19noconjo l et al. sa orthop j 2020;19(1) introduction paediatric cervical spine (c-spine) injury (csi) is serious yet relatively uncommon, occurring in less than 1% of all children evaluated following blunt trauma.1 in the paediatric population as a whole, spinal cord injuries occur far less frequently than in adults.2 csis account for 30–40% of spinal trauma in adults, but in children 80% of vertebral injuries occur in the c-spine.3 the anatomy of the immature c-spine predisposes it to injuries which do not occur in the adult population. the paediatric spine is characterised by increased elasticity of the interspinous ligaments, posterior joint capsule and cartilaginous end plates. wedgeshaped vertebral bodies and the horizontal orientation of the facet joints may predispose children to upper csis.3 children ≤8 years have relatively larger and heavier heads in relation to the body, which shifts the fulcrum of movement to the upper c-spine with the maximum movement at c2/c3. this explains the epidemiological finding that most of the spinal injuries occur between c0 and c2 in young children whereas older children, like adults, more commonly sustain injuries in the sub-axial c-spine.4 by the age of 8 years, the c-spine is nearing maturity and the injury profile is similar to that of an adult. in this study, we take anatomical and biomechanical differences into account and have divided children into young (0–8 years) and older (8–12 years) groups. most paediatric csis are as a result of blunt trauma. in south africa the road traffic mortality rate overall in 2011 was 33.2 per 100 000 population. road traffic accidents are one of the leading causes of child injury deaths in south africa, and in cape town road traffic injuries are the leading cause of death in children aged 5–14 years, significantly above the hiv/aids mortality rate.5 our institution’s trauma unit processes approximately 1 200 victims of road traffic injuries per year, yet little is known about the true incidence and severity of csi in children. other common mechanisms of injury include falls from a height and contact sports. in the international literature, sporting injuries are the second most common reported mechanisms of injury, although these studies usually include patients up to 18 years of age.6 we conducted an epidemiological study in order to characterise csi at a tertiary referral centre for paediatric trauma, and to report on the incidence, nature and outcome of csi in paediatric patients in the south african population. methods we performed a retrospective study of paediatric csis treated at our institution from 2008 to 2017. approval of the study was obtained from the institution’s human research ethics committee. all records and radiological investigations of patients seen from 2008 to 2017 with csi, including isolated cord injuries and intra-spinal haematomas, were reviewed. patients with inadequate medical or radiological records were excluded, as were those patients with non-traumatic causes for spinal cord compromise. the picture archiving and communication system (pacs) of our institution’s radiological services was searched for patients with csis as the diagnosis is invariably confirmed by radiology. search terms included: cervical spine fracture, subluxation, dislocation, contusion, sciwora (spinal cord injury without radiographic abnormality) and haematoma. patient demographics, date and cause of injury, type and level of injury and outcome data were obtained from hospital records. outcomes were defined by the frankel grading system.7 patients were divided into those ≤8 years and those >8 years of age, based on anatomical and biomechanical differences in the cervical spine.8 our institution accepts patients up to the age of 13 years from the local community, public and private hospitals that are within its drainage area, and any other child deemed to require subspecialist polytrauma management or neurosurgical intervention. the severity of associated injuries was categorised according to the paediatric injury severity score (iss) which predicts the morbidity and mortality risk. iss was calculated from a combination of the abbreviated injury score (ais). the body was divided into six areas: head or neck, face, thorax, abdomen, extremities and external. every injury was identified and the most severe in each of the areas was identified. iss is the sum of the squares of these injuries ranging from 1–75. by convention, a score of 1–8 is considered minor, 9–16 moderate and >16 severe. an iss of >41 indicates a very severe injury with significant risk of mortality. data was analysed using microsoft excel for office 365. descriptive statistics were reported using standard nomenclature for non-parametric data. results we identified 74 patients that had a radiologically confirmed csi during the study period. eight patients were excluded due to inadequate records being available. our study is based on the remaining 66 patients. the median age of our patients was 7 years (iqr 4–8.8) (figure i); 43 (65%) of the patients were males with a male to female ratio of 2:1. all injuries were caused by blunt trauma. the most common mechanism of injury (moi) was passenger (n=34 [52%]) and figure 1. age distribution of children with csis by sex [celeste, please delete heading inside graphic] 3 3 6 2 6 8 5 1 1 55 1 3 3 4 3 4 2 1 0% 2% 4% 6% 8% 10% 12% 14% 0 1 2 3 4 5 6 7 8 9 10 11 12 f re q u e n c y o f c h il d re n age (years) males females figure 1. age distribution of children with csis by sex page 20 noconjo l et al. sa orthop j 2020;19(1) pedestrian (n=26 [39%]) mvas. falls from a height (4 [6%]) and other, unspecified causes (2 [3%]) accounted for the rest. there was no information available on the usage of restraining safety mechanisms. none of the injuries reported were a result of physical abuse, or recreational or sporting activities (figure 2). various patterns of injuries occurred mostly in young patients, with fracture without spinal cord injury (sci) being the most common injury. the distribution of these injuries for two age groups is depicted in table i. of the 17 patients with retroclival haematoma, 16 had no associated ligament injury. one patient had superior tectorial membrane injury; however, subsequent flexion–extension x-rays did not demonstrate cervical instability. most injuries occurred in the upper c-spine of the younger group. there was only one patient in this cohort who sustained an injury to the lower c-spine (table ii). fifty-seven patients (77.3%) had associated closed head injuries (chi). the next most common injuries were long bone fractures (34.8%), blunt chest trauma (27.7%) and blunt abdominal trauma 15 (22.7%). the median iss was 25 (iqr 13–34) and 8 (iqr 1–16) for children that sustained fatal injuries and for those who survived, respectively. patients with stable csis were treated conservatively with immobilisation: 56 (85%) in a soft collar and three (4.5%) with a hard collar. seven patients (10.6%) with unstable csis required operative intervention in the form of open reduction and internal fixation. these were all younger children with upper csis. one patient underwent anterior fusion and six patients had posterior fusion. the indications for and outcome of surgery are listed in table iii. there was no deterioration of neurological status following surgery in any patient. patients with sciwora showed variable neurology (one frankel a; four frankel c and one frankel c improved to e). four patients had residual neurological deficit but were associated with significant chi. quadriparesis (frankel a) occurred in four other patients. three of the four patients had associated c-spine instability with subsequent surgical stabilisation. one patient with cervical spinal cord transection at c7/t1 (frankel a) had a stable c-spine and was treated conservatively with a soft collar. the overall mortality rate was 4.5%. the three patients who died were admitted following mvas (two passengers and one pedestrian). they were between the ages of 3 and 5 years. two patients sustained cervical spinal cord transection at c0/c1 and c1/2 respectively and all had associated severe chi. discussion the cumulative incidence of csi in our patients was 0.1%. this is less than the published incidence of 1–2.2% following blunt trauma.1,6 forty-nine patients (66%) in our cohort were under the age of 8 years, and there was male preponderance with a male to female ratio of 2:1. in contrast to this, brown et al. in their review, figure 2. mechanism of injury according to age group [celeste: please remove heading inside graphic that is repeated as the caption. also change the symbol for the blue blocks to ≤8 years; close gap to make red code ˃8 years; lower case a for accident at base of first column] 20 25 3 1 6 9 1 1 0% 5% 10% 15% 20% 25% 30% 35% 40% pedestrian vehicle accident passenger vehicle accident fall from height other f re q u e n c y o f c h il d re n mechanism of injury < 8 years > 8 years figure 2. mechanism of injury according to age group table i: types of injury and age type of injury all <8 years >8 years n (%) n (%) n (%) fracture without sci 18 (27) 11 (17) 7 (11) retroclival haematoma 17 (26) 11 (17) 6 (9) ligamentous injury 10 (15) 9 (14) 1 (2) atlanto-occipital dissociation 9 (14) 8 (12) 1 (1) sciwora 6 (9) 6 (9) 0 (0) subluxation 5 (8) 4 (5) 1 (2) fracture with sci 1 (1) 0 (0) 1 (1) total 66 49 17 sci: spinal cord injury table ii: level of spinal cord injury level of c-spine injuries all ages 0–8 years 8–12 years n (%) n (%) n (%) upper c-spine c1–c4 65 (98) 48 (73) 17 (26) lower c-spine c5–c7 1 (2) 1 (1) 0 (0) total 66 (100) 49 (74) 17 (26) ≤8 years >8 years page 21noconjo l et al. sa orthop j 2020;19(1) found that 66% of their patients were between 9 and 19 years of age. they had a male to female ratio of 1.6:1.6 this difference can be explained by the fact that our institution only treats patents up to the age of 13 years, as opposed to 18 years. mvas, which account for 48–61% of all injuries, are the most common mechanism of injury in children both older and younger than 8 years.9 patel et al. showed that 61% of injuries resulted from mvas and occupants were found to be unrestrained in 61% of cases.10 in our study, passenger mvas were responsible for 52% and 26% of injuries in the younger and older age groups respectively. information on the usage of seat belts/child safety seats was not available for our study. the literature clearly documents the effectiveness of safety belts and child safety seats in reducing csis in children involved in mvas.11 in the pedestrian subgroup, the majority (73.5%) of patients were ≤8 years and had a male preponderance. this could be explained by the fact that boys are naturally more risk-seeking than girls, yet the lack of supervision while children are on the street is alarming. falls occurred in only four patients (6%) and were associated with less serious injuries and no neurological sequelae. all these children either fell from caregivers’ arms or from a bed, and they were <1 year of age. in the published literature, falls account for 11–18% of csis,6,10 which is higher than in our population. this may be due to our only including patients with radiologically confirmed csis. although not classically associated with child abuse, csi may occur and should not be overlooked. it has been estimated that 1% of children who suffer non-accidental head injuries also have co-existing spinal trauma.12 rooks et al. reported two cases of child abuse with csis and classical radiographic evidence of abuse at multiple sites in the axial and appendicular skeleton.13 it is worth noting that in our series there were no csis that resulted from physical abuse. sporting injuries account for up to 27% of paediatric csis in other published series,1,6,14 although this is mostly in the pre-adolescent and adolescent population. in our population, 98% of injuries occurred in the upper c-spine. this is consistent with other published series. mccall et al. reported that children under 9 years of age usually have upper csis whereas older children, whose biomechanics more closely resemble those of adults, are prone to lower csis.8 kokoska et al. in a retrospective study of 408 children who suffered blunt trauma, found that younger (≤10 years of age) children sustained high (c1–c4) injuries as compared to their older counterparts who sustained low (c5–c7) csi (85.3% versus 56.9%).15 fractures, with or without sci were the most frequently observed injury pattern in both age groups, accounting for 31% of all injuries. this is similar to the reported incidence of 28–54%.6 subluxation or dissociation and fractures involving c1–c2 were observed more frequently in the younger group. leonard et al. reported that in children aged 2–7 years, 78% of csis occurred in the axial region; atlanto-axial rotatory subluxation (aars) and atlanto-occipital dislocation were the most common injuries.14  retroclival haematoma in children may occur in three compartments: epidural, subdural and subarachnoid. retroclival epidural haematoma may be associated with ligamentous injury, which may further result in instability at the cranio-cervical junction.16 in our study there was only one patient who had a documented ligamentous injury associated with a retroclival haematoma (superior tectorial membrane), and this did not result in cervical instability. sciwora describes an acute sci that results in sensory and/ or motor deficit without radiographic evidence of vertebral fracture or bony misalignment on plain x-rays or computed tomography (ct) scan. ninety per cent of sciwora occurs in the paediatric population aged on average from 7 to 8 years.17 our study confirms this finding with all children that had sciwora being 8 years and younger. neurological deficit following sciwora can range from transient paresis to complete and permanent paralysis.18 our patients similarly demonstrated variable neurological outcomes. associated injuries are common due to high velocity forces that usually cause scis. in this study chi was the most commonly associated injury. the median iss of patients that sustained fatal injuries was 25, which is in accordance with the findings of brown et al.6 who also report a mean iss of 25 in patients with fatal injuries. in their series, as in ours, most fatal injuries were attributed to mvas. in an audit of 22 acute injuries by watson et al., the only child who died had an associated severe head injury.19 the mortality rate in our study was 4.5%, which is much lower than in other published series.6,19 all children who died were between the ages of 3 and 5 years and had severe chis. in our study only seven patients (10%) were treated with open reduction and internal fixation. the remainder of patients had stable injuries that healed well with simple immobilisation. recognising unstable injury patterns is therefore essential to provide stability, but also to avoid overtreatment of stable injuries.14 the management of unstable injuries in children is the same as for the adult population, though admittedly technically more challenging due to the small size of the child’s vertebrae. there are several limitations in this study. it is a retrospective study and therefore it is possible that our population does not completely represent all csis in children. our method of identifying patients also excluded those patients with transient neurological deficit but no objective evidence of csi. our cohort does not include children older than 13 years and we can therefore not comment on injury patterns and outcomes in the older paediatric population. conclusion our study provides insight into the epidemiology of csis in children <13 years within the south african context. csis are rare and only occurred in 0.1% of all patients assessed at our institution following trauma. csi should be excluded in all patients who sustained high velocity injuries such as mvas. this is especially true for children table iii: details of surgical intervention patient injury type type of surgery outcome 1 atlanto-occipital dissociation c0–c2 posterior fusion quadriplegia 2 atlanto-occipital subluxation c0–c2 posterior fusion quadriplegia 3 atlanto-axial dissociation c0–c2 posterior fusion no neurology 4 c2/3 fracture subluxation c2–c4 anterior fusion no neurology 5 c3/4 unifacet dislocation c3–c4 posterior fusion hemiparesis 6 dens fracture type 2 + transverse ligament injury c1–c2 posterior fusion no neurology 7 dens fracture type 2 + transverse ligament injury c1–c2 posterior fusion no neurology page 22 noconjo l et al. sa orthop j 2020;19(1) under the age of 8 years and those with associated head injuries. the majority of paediatric csi are stable injuries that can be managed conservatively; however, urgent surgical stabilisation is indicated for unstable ligamentous disruptions and fractures. chis caused by mvas in young children are associated with increased mortality. even though our patients are referred from high violence communities, no csis were attributed to physical abuse or penetrating injury. ethics statement this was a retrospective study and formal consent was not required. the ethical approval was obtained from the university of cape town research committee (hrec ref: 832/2017) prior to commencement of data collection. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ln: literature review, data collection, data interpretation and primary author. an: study idea and design, supervision, editing and final approval of work. orcid noconjo l http://orcid.org/0000-0001-9411-9392 horn a http://orcid.org/0000-0002-4159-6520 references 1. leonard cj. cervical spine injury. pediatr clin n am. 2013;60:1123-37. https:// doi.org/10.1016/j.pcl.2013.06.015. 2. hart c, williams e. epidemiology of spinal cord injuries: a reflection of change in south african society. paraplegia. 1994;32(11):709-14. 3. jones tm, anderson pa, noonan kj. pediatric cervical spine trauma. j am acad orthop surg. 2011;19:600-611. 4. basu s. spinal injuries in children. front neurol 2012;3:96. https:// doi.org/10.3389/fneur.2012.00096 5. isaac kn, van niekerk a, van as ab. child road traffic crash at the red cross war memorial children’s hospital in cape town, south 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neuro-imaging findings of retroclival hemorrhage in children; a diagnostic conundrum. childs nerv syst. 2014;30(5):835-39. https://doi.org/10.1007/ s00381-014-2369-8. 17. kreykes ns, letton rw, et al. current issues in the diagnosis of pediatric cervical spine injury. semin pediatr surg. 2010;19(4):257-64. https://doi.org/10.1053/j.sempedsurg.2010. 06.002. 18. horn a, workman mi, dix-peek s, et al. ligamentous integrity in spinal cord injury without radiographic abnormality (sciwora): a case series. sa orthop j. 2017;16(2):32-38. https://doi. org/17159/2309-8309/2017/v16n2a3. 19. watson g, upadhyay v. paediatric cervical spine injuries: an audit of 22 acute injuries and literature review. injury extra 2005;36(11);469-74. https://doi.org/10.1016/j.injury.2005.03.024. http://orcid.org/0000-0001-9411-9392 http://orcid.org/0000-0002-4159-6520 https://doi.org/10.1053/jpsu.2001.20720 _goback _hlk27029352 _hlk508841616 _hlk508841726 _hlk508842039 _hlk508842247 _hlk2465196 _goback _goback orthopaedics vol3 no4 sa orthopaedic journal winter 2015 | vol 14 • no 2 page 43 dysplasia epiphysealis hemimelica: an interesting case report involving the talus and literature review n kruger, mbchb(uct), msc diagnostic imaging (oxon), msc orth (oxon) orthopaedic registrar, university of kwazulu-natal, pietermaritzburg hospital complex d thompson, mbchb(uct), frcs(glas) principal specialist in paediatric orthopaedics, university of kwazulu-natal, grey’s hospital, pietermaritzburg corresponding author: dr neil kruger 162 waltdorf complex 771 townbush road montrose 3201 pietermaritzburg email: neilkruger6@gmail.com tel (w): 033 897 3000 tel (h): 033 347 0979 introduction affecting approximately only one in 1 million patients, dysplasia epiphysealis hemimelica (deh), or trevor disease, is a rare developmental disorder of the evolving skeleton resulting in asymmetric overgrowth of epiphyseal cartilage. mouchet and belot initially termed it ‘tarsomegalie’, referencing the tarsus as a common site of its occurrence. trevor then later described ‘tarsoepiphyseal aclasis’ when referring to this osteochondromatous lesion of the epiphysis.1 both these names ultimately fell out of favour due to the much broader distribution of deh, and fairbank was credited with coining the current term in 1956.2 we present a case of deh of the talus causing fixed hindfoot valgus deformity and describe the condition and its current treatment strategies. case report an 11-year-old girl presented with a painful left medial ankle mass. it was first noticed as a painless growth two years prior and had since slowly enlarged. there was no history of trauma or family history of similar growths, bone dysplasias or metabolic bone diseases. the child was fully immunised, had no significant childhood illnesses and was hiv-negative. no other joints were involved. clinically pathology was confined to the left ankle, with a tender bony growth just inferior to the medial malleolus. the lesion measured approximately 6 cm × 4 cm, with bruising visible over and just inferior to the medial malleolus. the hindfoot was held in fixed valgus of 20° and could not correct to neutral. dorsiflexion was limited by 10° but there was no inhibition of plantar flexion (figure 1). abstract dysplasia epiphysealis hemimelica (deh) is a rare osteochondromatous condition arising unilaterally from an epiphysis in the developing skeleton. unhindered, this osseocartilaginous lesion continues to grow until skeletal maturity. characteristic radiographic features are usually sufficient to make the diagnosis. one common site of occurrence is the talus, which has the potential to cause pain, joint deformity or limit range of motion. we report a case of deh of the talus causing fixed hindfoot valgus deformity, successfully treated with surgery, and review the literature on deh and its current treatment strategies. key words: valgus hindfoot, dysplasia epiphysealis hemimelica, trevor disease, talus, bone dysplasia http://dx.doi.org/10.17159/2309-8309/2015/v14n2a6 saoj winter 2015_press_orthopaedics vol3 no4 2015/05/11 10:00 am page 43 page 44 sa orthopaedic journal winter 2015 | vol 14 • no 2 the tendons of tibialis posterior, flexor digitorum longus and flexor hallucis longus were all mildly tender to palpation but no neurovascular fallout was noted. routine blood work-up was normal. routine ankle x-rays revealed a bony exostosis that appeared to be originating from the talus and extending medial and cephalad to abut the medial malleolus (figure 2). ct and 3d-ct were done to delineate the exact origin and extent of the mass, and to define the osseous from the cartilaginous component. it identified a pedunculated mass arising from the anteromedial border of the talus and extending inferiorly to involve the subtalar joint. this confirmed a diagnosis of deh (figures 3 and 4). surgery and outcome surgical excision was undertaken for pain and fixed valgus hindfoot deformity. we carried out a formal excisional biopsy through a submalleolar c-shaped skin incision. the deltoid ligament was reflected from its tibial insertion, leaving a cuff of tissue for repair. the lesion was macroscopically excised completely and sent for histology. although this looked pedunculated on the ct scan, it appeared sessile at surgery with no clear demarcation of normal from abnormal bone. this made confident complete excision difficult, and she is at risk for recurrence (figure 5). following excision, the ankle and sub-talar joints had full range of movement. post-operatively a below-knee cast was applied to protect the deltoid ligament, and changed to a walking cast at 2 weeks for another 4 weeks. figure 1. medial and anterior projection photographs of the left ankle showing the medial ankle mass and bruising it identified a pedunculated mass arising from the anteromedial border of the talus and extending inferiorly to involve the subtalar joint figure 2. anteroposterior and lateral left ankle x-rays showing the osseocartilaginous mass arising from the talus figure 3. select anteroposterior, lateral and axial ct cuts showing the medial talar origin of the mass and extension into the subtalar joint saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 44 sa orthopaedic journal winter 2015 | vol 14 • no 2 page 45 the child regained full movement within weeks, and has maintained this with no sign of recurrence at 1 year. annual follow-up is recommended to monitor for recurrence. discussion background deh occurs peri-articularly, with the ankle being involved approximately a third of the time.3 the other common site is around the knee, with cases involving the upper limbs being significantly less frequent. the disease is overwhelmingly hemimelic, normally confined to the medial or lateral half of the epiphysis in a single limb.4 the medial epiphysis is twice as commonly affected as the lateral,5 and predominantly only a single epiphysis within a limb is affected. it may however occur in multiple epiphyses within the same limb, and rare cases of bilateral disease have been reported.6,7 unhindered, deh’s natural course is to enlarge until closure of the physes. the usual age of manifestation is between two and 14 years8 and, in contrast to our case, males are affected three times more commonly than females.9 presentation is usually that of a slow-growing painless mass either on the medial or lateral side of the ankle or knee. in the ankle, the lesion most commonly originates from the talus. subsequent extension into the subtalar joint or progressive medial growth impinging on the medial malleolus either limits range of motion or produces progressively worsening joint deformity. its aetiology remains elusive. older theories have included dysregulation of cartilage proliferation,10 or fairbank’s original preor post-axial apical limb bud disturbance in utero.2 however, more recently published data suggests dysregulation of resident chondroprogenitor cells11 to be the cause, and lends weight to connor et al.’s dysregulation of cartilage proliferation theory.10 figure 4. anterior, medial and posterior views of the 3d-ct reconstruction showing the mass. the posterior view best illustrates the forced valgus hindfoot position figure 5. intra-operative photographs showing the medial approach through the deltoid ligament and mass excision saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 45 page 46 sa orthopaedic journal winter 2015 | vol 14 • no 2 classification deh has been classified by azouz et al. into three main forms:5 1. a localised form affecting only one epiphysis 2. a classic form, affecting more than one epiphysis in the same limb 3. a generalised form in which the entire limb is affected. more recent authors have concentrated on identifying whether or not the lesion is intraor extra-articular.12 rosero et al. however emphasise that, as most lesions are intracapsular, the terms ‘articular’ and ‘juxta-articular’ are more appropriate in defining their exact location as this has relevance to the joint-deforming potential of the growth.3 extracapsular lesions are by definition extraarticular. diagnosis besides the clinical features highlighted above, the diagnosis ultimately relies on typical radiographic characteristics. x-ray usually shows an irregular ossified mass protruding from the epiphyseal cartilage. initially this mass is cartilaginous, but multiple ossification centres then develop and become confluent with the underlying bone.3 ct is useful in differentiating the cartilaginous component from its bone origin, but this has largely been replaced by mri as the investigation of choice for defining the extent of the lesion, condition of the articular cartilage and any existing joint deformity. bone scintigraphy has also shown increased uptake in the cartilage mass and has been proposed as a useful screening investigation to determine whether localised or polyostotic.13 histology confirmed the diagnosis showing features of an osteochondroma originating from the epiphysis. management individualised treatment strategies need to be instituted on a case-by-case basis, depending on the location, extent and specific presenting problem. in patients where there is no articular involvement or pain, observation of the lesion is recommended.4 patient understanding of their pathology is paramount, as early surgical excision for cosmesis carries both surgical risk and that of recurrence. it is preferable to delay surgery to as near skeletal maturity as possible. judicious longitudinal follow-up is also safe, as no cases of malignant transformation have been reported.4 if articular problems and pain are prominent, surgery is indicated. initially, surgical treatment favoured extensive resection, with removal of the cartilaginous articular surface in older patients whose secondary ossification centres had fused with the epiphyses.14 this is in contrast to present practice, where preservation of as much normal articular cartilage is desired, in order to avoid early osteoarthritis or even subsequent arthrodesis.3,9 specific to deh of the talus with extension into the subtalar joint, excisional objectives should be the restoration of normal ankle and subtalar joint congruity, with maximum preservation of articular cartilage and removal of all mass inhibiting the range of motion. both surgeon and patient need to be aware that the operation may need to be repeated prior to skeletal maturity, ultimately attempting to avoid irreversible joint degeneration. bakerman et al. even recommend annual ankle mri to identify developing joint incongruity and surgically correct it prior to ‘secondary adaptive changes’ within the joint.9 excision of talar deh provides improved subjective and functional outcome in ankle function,9 but any articular component excision carries the risk of early osteoarthritis. smaller and juxtaarticular lesions have better outcomes and hence early presentation is desirable. in select cases of advanced disease with severe joint destruction, early primary arthrodesis may be the treatment of choice. conclusion dysplasia epiphysealis hemimelica of the talus is a typical site of occurrence, but extension into the subtalar joint uncommon and disabling. intra-articular extension causing pain, joint destruction or reduced mobility mandates surgical excision while attempting to preserve all normal articular cartilage. subsequent risk of recurrence is significant, with accurate delineation between normal and abnormal cartilage difficult. judicious follow-up until skeletal maturity is recommended. informed signed consent was obtained from the mother of the patient for publication of this work. all figures and investigative procedures have been anonymised and patient records are kept on site at the hospital as per hospital data access restrictions. the content of this article is the original work of the authors. no commercial or other benefits have been or are to be received directly or indirectly related to the publication of this work. references 1. trevor d. tarso-epiphysial aclasis. j bone joint surg (uk) 1950;32b-2:204-13. 2. fairbank t. dysplasia epiphysealis hemimelica. j bone joint surg (uk) 1956;38b-1:237-57. 3. rosero v, kiss s, terebessy t, köllö k, szöke g. dysplasia the diagnosis ultimately relies on typical radiographic characteristics. x-ray usually shows an irregular ossified mass protruding from the epiphyseal cartilage saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 4 sa orthopaedic journal winter 2015 | vol 14 • no 2 page 47 epiphysealis hemimelica (trevor's disease): 7 of our own cases and a review of the literature. acta orthopaedica 2007;78-6:856-61. 4. azzoni r. dysplasia epiphysealis hemimelica of the talus. j orthopaed traumatol 2009;10-1:43-46. 5. azouz e, slomic a, marton d, rigault p, finidori g. the variable manifestations of dysplasia epiphysealis hemimelica. paediatric radiology 1985;15-1:44-49. 6. merzoug v, wicard p, dubousset j, kalifa g. bilateral dysplasia epiphysealis hemimelica: report of two cases. paediatric radiology 2002;32-6:431-34. 7. takegami y, nogami h. a case of bilateral dysplasia epiphysealis hemimelica associated with polydactyly and syndactyly. clin orthop relat res 1993;296:307-309. 8. silveira r, lopes f, reis a, granzotto e, oliveira a. dysplasia epiphysealis hemimelica (trevor-fairbank disease): case report. radiologia brasileira 2013;46(1):59-60. 9. bakerman k, letts m, lawton l. dysplasia epiphysealis hemimelica of the ankle in children. canadian journal of surgery 2005;48(1):66-68. 10. connor j, horan f, beighton p. dysplasia epiphysialis hemimelica. a clinical and genetic study. j bone joint surg (uk) 1983;65b-3:350-54. 11. perl m, brenner r, lippacher s, nelitz m. case report: dysplasia epiphysealis hemimelica: a case report with novel pathophysiologic aspects. clin orthop relat res 2009;467(9):2472-78. 12. acquaviva a, municchi g, marconcini s, mazzarella f, occhini r, toti p, mazzei m, volterrani l. dysplasia epiphysealis hemimelica in a young girl: role of mri in the diagnosis and follow-up. joint bone spine 2005;72(2):18386. 13. teixeira a et al. scintigraphic findings of dysplasia epiphysealis hemimelica: a case report. clin nucl med 2001;26(2):162. 14. fasting o, bjerkreim i. dysplasia epiphysealis hemimelica. acta orthopaedica scand 1976;47:217-25. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj winter 2015_press_orthopaedics vol3 no4 2015/05/07 7:59 pm page 47 404 not found orthopaedics vol3 no4 page 50 sa orthopaedic journal winter 2017 | vol 16 • no 2 incidence of dupuytren’s disease in africans: a report of 48 new cases and a literature review ti sefeane bsc(lesotho), mbbch(wits), mmed(ortho)wits, fc(ortho)sa consultant orthopaedic surgeon and head of the hand unit, chris hani baragwanath hospital, department of orthopaedics, university of the witwatersrand, johannesburg pn mwangi mbchb(nairobi), mmed(ortho)moi university fellow at the hand unit chris hani baragwanath hospital; consultant orthopaedic surgeon and surgery specialist, moi teaching and referral hospital, eldoret, kenya corresponding author: dr ti sefeane hand unit chris hani baragwanath hospital tel: 083 291 8648 email: tatolos@me.com; tatolos@webmail.co.za; sefeane67@gmail.com introduction when mennen and grabe1 accurately reported on the discovery of a patient of pure african descent with dupuytren’s disease in 1979, little was known of the disease ever affecting other ethnic groups, especially africans. this condition was first described by the french surgeon guillaume dupuytren in 1834 and it has largely been believed to occur in males of northern european descent, and that migratory patterns of society distributed this condition to other parts of the world.2 since the first initial report of a black patient with the disease,3 a few more cases have been reported in black african patients4-20 and other ethnic groups.21,22 we have seen an increasing number of patients of pure african descent that have undergone surgery at our institution in recent years. we conducted an audit of our theatre records to identify black african patients with dupuytren’s contracture who underwent surgery in a referral-based patient population. we also undertook a literature search of all reported cases of the condition in patients of african descent to try and determine the true incidence and prevalence in this population group. abstract background: dupuytren’s disease is rare in the black population. it was initially believed it occurred only in males of north european origin and since the initial confirmed report of a male of african descent with the disease only a few other africans have been reported with the condition in the literature. we wanted to conduct a literature search for all reports of patients of african descent with the disease and to report on our own numbers in our institution. methods: we searched our theatre records for all surgeries for dupuytren’s disease from 1997 to 2015 and identified all those that are of pure african descent. a comprehensive literature search in pub med, google scholar and clinical key was then done to identify all reported cases to date. results: from our records a total of 48 patients were identified. of them, 43 were male and five were female with an average age of 58.7 years (29 to 75). from the literature, only 462 patients were ever reported with the condition to date. one paper which constituted the majority of these cases was treated with caution as there were questions of reliability about the true ethnicity of the patients, leaving only 50 cases ever reported to date prior to our 48. conclusion: the true incidence of dupuytren’s disease in africans cannot be accurately determined but it is an extremely rare condition. population studies should be encouraged so as to come up with an accurate incidence and disease burden. key words: dupuytren’s disease, contracture, black population, africans http://dx.doi.org/10.17159/2309-8309/2017/v16n2a6 sa orthopaedic journal winter 2017 | vol 16 • no 2 page 51 methods we searched our hand unit database for all patients who underwent dupuytren’s disease contracture surgery between 1997 and 2015. we then determined the number of these patients who were african by way of surnames and their location (black townships), which is a useful method in south africa. our hospital is situated in soweto which is a black township with an estimated population of about 6 million. we then compared this number to the number of total surgeries performed in the unit during the same period and worked out our local prevalence. the number of these patients were compared year on year and charted to determine any possible trends (figure 1). the two authors independently undertook a literature search of all reports of patients of african descent having been diagnosed with dupuytren’s disease using the search words dupuytren’s, disease, contracture, blacks, africans in pubmed, google scholar and clinical key in order to find the numbers of patients that were ever reported. the search included all kinds of studies (prospective, retrospective, case reports, letters and communications). included were all studies or reports of patients of african descent with the disease, and excluded were those studies that reported on non-african patients. we selected all relevant abstracts and among those selected, the most relevant were identified and the full articles and reports thereof then fully reviewed. the authors then looked at any possible bias (about the true ethnicity of these patients) in these articles and extensively reviewed those that could be potentially controversial or misleading. results from our theatre records we were able to document 70 patients who underwent 73 surgeries for dupuytren’s disease from 1999 to 2015 by different surgeons in our hand unit. there were 65 males and five females with an average age of 58.7 years (29 to 75). out of this group, 48 were identified as pure africans as per our criteria; one had bilateral disease; and fasciectomies were done in different settings (figures 2 and 3). in this period a total of 22 468 patients were operated for various conditions in our operating rooms. this would then mean that 0.2% of these patients were black patients who presented with dupuytren’s disease and underwent surgery. we also found that there has been an increasing number of african patients year on year since 1999 (figure 1). figure 2. left hand of an african patient with bilateral dupuytren’s disease figure 1. numbers of african patients with dupuytren’s disease in our institution1 19 97 9 8 7 6 5 4 3 2 1 0 n u m b er s 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 years figure 3. right hand of the same patient as in figure 2 during the second operation page 52 sa orthopaedic journal winter 2017 | vol 16 • no 2 from the literature search in pubmed, google scholar and clinical key using our key words, there were initially 873 articles to consider. sixty-six of these articles were deemed relevant and their abstracts were reviewed. sixteen of these abstracts were selected as relevant and their full articles were comprehensively reviewed and analysed. from these 16 articles dating from 1974 to present, 462 patients of african descent have been reported with dupuytren’s disease worldwide. adding our 48 cases to this total would bring the total to 510 african patients ever reported with the disease worldwide to date. discussion hindocha et al.23 described the prevalence of dupuytren’s disease in northern europe as between 18 and 39%, north america 4 to 26%, oceania 23% and japan 19% in an epidemiology evaluation of the disease in 49 papers from across the globe.23 africa and the rest of asia had only sporadic cases in this report. in a japanese study, egawa et al.21 suggested that the incidence of dupuytren’s disease in japan differs little from that in northern europe. in their series of 1 154 individuals over 60 years of age, 19.7% of the men and 9% of the women were found to have the disease. there have not been any specific epidemiological studies of the incidence and prevalence of the disease in africans, and indeed most papers reviewed in our report were case reports. the question of dupuytren’s disease occurring in black patients of pure african descent was settled by mennen and grabe by way of genotyping in 1979. since then other authors have gone to great lengths to try to prove the bona fides of the ethnicity of these patients.11,13,14,19,20 it has been asserted that the disease is rare in non-white races but there are no population studies to support this. most population studies are from northern europe and australia where the disease is prevalent. a ten-year retrospective study of the department of veteran affairs records showed that there are similarities in the characteristics of the disease in black and white races.18 in both groups the disease has a late onset and affects predominantly the ulna digits. unlike the disease in whites, it is rarely bilateral in blacks and it is rarely reported. mitra and goldstein12 reported on eight patients in whom the disease is often bilateral and associated with manual labour. the differential prevalence among the racial groups, geographic distribution pattern and familial predilection suggests a genetic component to the pathogenesis of the disease.18 it has been suggested that you may inherit the genetic predisposition but certain environmental factors are also required to induce the genetic expression of the disease. the largest series of people of african descent with dupuytren’s disease that has ever been reported was from the american department of veteran affairs of 412 patients.18 in scrutinising this article, a lot of potential conflicting factors about the purity of the ethnicity is found; in addition, the report was not a clinical report but a data base search. in the 2000 paper describing the database search at the us department of veteran affairs, 412 black patients were identified who presented to various centres with dupuytren’s contractures. of those, full details of only 136 were obtained. from the search, all these patients were self-declared as black, and considering american history and society, it might be problematic to assess the bona fides and legitimacy of these claims. in their own admission, they also declare that there were no standardised criteria to make the diagnosis and all the doctors that made the diagnosis were not hand surgeons. this is contrary to all the other reports in the literature where the diagnosis was clinical and made by hand surgery units. in the light of these remarks, we believe that these 412 cases cannot accurately be relied upon as being people of pure african descent with dupuytren’s disease. if these 412 patients are not considered, the final reliable number of reported cases of dupuytren’s disease in africans in the literature is 50 to date. if we include ours, the total is then only 98. conclusion considering the literature, it is evident that the disease is extremely rare in people of african descent though the presentation and associations do not differ much among different population groups. the literature also suggests that the true incidence and prevalence of dupuytren’s disease in africans cannot be accurately determined. from our own records, the number of new cases is steadily increasing in recent years. the limitations of this study are that our hospital is the largest in the southern hemisphere and a major referral centre in southern africa hence not a true reflection of the population. secondly, theatre records give only the name, age, sex, diagnosis and its laterality and surgery done. there are no details on racial descent, disease presentation or risk factors, and often some details are missing or not correctly entered. finally, purity of race can only be determined genetically and there is a need for population studies that sample the general population to identify subtle disease not just those with severe disease that present to hospital. compliance with ethics guidelines the authors declare that this is an original work undertaken by them and there are no potential conflicts of interest with respect to the research, authorship and declaration of conflicting interests. the authors received no financial support for the research, authorship and publication of this article. sa orthopaedic journal winter 2017 | vol 16 • no 2 page 53 references 1. mennen u, grabe rp. dupuytren’s contracture in a negro: a case report. j hand surg am. 1979 sep;4(5):451-53. 2. flatt ae. the vikings and baron dupuytren’s disease. proc (bayl univ med cent). 2001 oct;14(4):378-84. 3. yost j, winters t, fett hc. dupuytren’s contracture: a statistical study. am j surg. 1955 oct;90(4):568-71. 4. adu ej. management of contractures: a five-year experience at komfo anokye teaching hospital in kumasi. ghana med j. 2011 jun;45(2):66-72. 5. aladin a. dupuytren’s contracture in a black patient. int j clin pract. 2001 nov;55(9):641-42. 6. furnas dw. dupuytren’s contractures in a black patient in east africa. plast reconstr surg. 1979 aug;64(2):250-51. 7. gonzalez mh, sobeski j, grindel s, chunprapaph b, and weinzweig n. dupuytren’s disease in africanamericans. j hand surg br. 1998 jun;23(3):306-307. 8. haeseker b. dupuytren’s disease and the sickle-cell trait in a female black patient. br j plast surg. 1981 oct;34(4):438-40. 9. leflore i, antoine ga. dupuytren’s contracture and gouty tophi in a black patient. j natl med assoc. 1991 jan;83(1):78-80. 10. makhlouf mv, cabbabe eb, shively re. dupuytren’s disease in blacks. ann plast surg. 1987 oct;19(4):334-36. 11. mennen u. dupuytren’s contracture in the negro. j hand surg br. 1986 feb;11(1):61-64. 12. mitra a, goldstein ry. dupuytren’s contracture in the black population: a review. ann plast surg. 1994 jun;32(6):619-22. 13. muguti g, appelt b. dupuytren’s contracture in black zimbabweans. cent afr j med. 1993 jun;39(6):129-32. 14. plasse js. dupuytren’s contracture in a black patient (letter). plast reconstr surg. 1979 aug;64(2):250. 15. richard-kadio m, guedegbe f, dick r, et al. dupuytren’s contracture: review of the literature. case report of a black african med trop (mars). 1990 julsep;50(3):311-13. 16. richard-kadio m, yeo s, kossoko h et al. [dupuytren’s contracture. a report of three cases in black africans]. chir main. 2008 feb; 27(1):40-2. epub 2007 nov 26. 17. rosenfeld n, mavor e, wise l. dupuytren’s contracture in a black female child. hand. 1983 feb;15(1):82-84. 18. saboeiro ap, porkorny j, shehadi si, et al. racial distribution of dupuytren’s disease in department of veterans affairs patients. plast reconstr surg 2000;106:71-75. 19. sladicka ms, benfanti p, raab m, becton j. dupuytren’s contracture in the black population: a case report and review of the literature. j hand surg am. 1996 sep;21(5):898-99. 20. zaworski re, mann rj. dupuytren’s contracture in a black patient. plast reconstr surg. 1979 jan;63(1):122-24. 21. egawa t, horiki a, senrui h. dupuytren’s contracture in japan. in j. hueston and r tubiana (eds), dupuytren’s disease, 2nd ed. edinburgh churchill livingston, 1985. 22. srivastava s, nancarrow jd, cort df. dupuytren’s disease in patients from the indian sub-continent. report of ten cases. j hand surg br. 1989 feb;14(1):3234. 23. hindocha s, mcgrouther d, bayat a. epidemiological evaluation of dupuytren’s disease incidence and prevalence rates in relation to etiology. hand (n y). 2009 sep;4(3):256-69. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj orthopaedics vol3 no4 page 34 sa orthopaedic journal autumn 2015 | vol 14 • no 1 gunshot face as a cause of hyperextension central cord syndrome in a young patient l bomela mbchb(uct), fcorth(sa) spine fellow: spine surgery unit, groote schuur hospital rn dunn mbchb(uct), mmed(uct)ortho, fcorth(sa) consultant spine and orthopaedic surgeon professor and head of the department of orthopaedics, university of cape town head: orthopaedic spinal services, groote schuur hospital spine deformity service, red cross children’s hospital from groote schuur hospital and the department of orthopaedics, university of cape town, south africa correspondence prof robert dunn email: robert.dunn@uct.ac.za introduction acute central cervical cord syndrome is commonly seen in elderly patients with underlying cervical spine stenosis following a fall and subjected to a hyperextension force.1 patients present with an incomplete spinal cord injury with predominantly upper limb weakness and relatively spared lower limbs.2 we present an unusual case of a young man who was subjected to an acute hyperextension force during a gunshot to the face. in addition to the infrequently encountered aetiology, the management challenges will be discussed. case report a 43-year-old male was admitted to our tertiary hospital trauma unit after having sustained a gunshot injury to the face. he was fully conscious with features of neurogenic shock (bp 93/50 and heart rate 86). anal tone was present but decreased. the bullet had entered through the philtrum and exited above the right maxillary sinus. these facial injuries were cleaned and sutured. his neurological examination confirmed a c4 incomplete lesion with motor weakness but sensory preservation. there was reduced anal tone and he required a urinary catheter due to retention. on arrival at the trauma unit he was screened by lowdose digital x-ray whole body scan (lodox) which excluded a skull fracture and confirmed that the bullet had not been retained. no cervical spine pathology was identified although these images were of poor quality. computerised tomography (ct) scan illustrated a linear undisplaced fracture of the anterior wall of the right maxillary antrum with extension into the alveolar process. there was haemorrhage into the right maxillary sinus. magnetic resonance imaging (mri) demonstrated mild retrolisthesis of c3/c4 with increased signal in the prevertebral tissue as well as interspinous ligaments. disc osteophyte complexes were present at c3/4 and c4/5 in a congenitally narrowed canal. there was cord compression and contusion from c3–c5 as evidenced by hyperintense cord signal on the t2 mri sequence as revealed by high signal foci within the cord (figures 1 and 2). abstract central cord syndrome (ccs) is a syndrome where the patient’s upper limbs are more severely affected than the lower limbs in terms of neurological deficit. this is typically found in an elderly patient with pre-existing spondylosis and a minor hyperextension injury. this case report highlights an unusual cause of ccs in a young patient with pre-existing congenital cervical canal stenosis and acute hyperextension induced by a facial gunshot. the aetiology and management dilemmas are discussed. key words: central cord syndrome, gunshot, hyperextension, spinal cord injury his neurological examination confirmed a c4 incomplete lesion with motor weakness but sensory preservation saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 34 sa orthopaedic journal autumn 2015 | vol 14 • no 1 page 35 the patient was stabilised physiologically and referred to the acute spinal cord injury (asci) unit for supportive ventilation and treatment of atelectasis, bronchopneumonia and shock. the patient was stabilised with regard to the neurogenic shock, and the bronchopneumonia treated with broadspectrum antibiotics. supportive ventilation was required. the neck was initially managed in a philadelphia collar. based on the extensive nature of cord compression from c3–c5, and underlying congenital stenosis, a posteriorbased procedure was chosen. a laminoplasty was performed rather than a laminectomy due to his young age. however, despite an adequate canal enlargement intraoperatively, the patient had no neurological recovery in the subsequent two weeks. thus a second stage anterior c3/4 disc osteophyte complex decompression was performed via a smith-robinson approach (figure 3). following this anterior procedure there was an immediate neurological gain of at least an mrc grade, more so in the lower than upper limbs. three weeks later the patient was transferred to the spinal rehabilitation centre. figure 1. pre-operative sagittal mri demonstrating multilevel stenosis and c3/4 disc protrusion figure 2. pre-operative axial mri confirming c3/4 disc protrusion figure 3. post-operative x-rays with laminoplasty plates and anterior crevical plate present saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 35 page 36 sa orthopaedic journal autumn 2015 | vol 14 • no 1 at the six-month post-operative visit, his lower limbs had improved from 1/5 to 3 and 4s but due to the severe spasticity he remained non-ambulatory, thus asia b to c. his upper limbs remained at 2/5 power. a follow-up mri confirmed adequate canal decompression with myelomalacia of the cord (figure 4). discussion acute traumatic central cervical cord syndrome was defined by schneider in 1954 as an incomplete spinal cord injury with the upper extremities illustrating a significantly greater motor impairment than the lower extremities with variable bladder dysfunction and sensory abnormality below the affected level.2 however, sir thornburn was the first to describe cervical cord syndrome in literature in 1887 as ‘a case of concussion of the spine’.3 it is caused by a variety of mechanisms but the most common is a hyperextension force resulting in cord compression and injury to the central part of the spinal cord with some sparing of the peripheral pathways.2,4 three main mechanisms have been postulated: 1. young patients sustaining a high velocity injury, e.g. motor vehicle accident, diving accident or fall from height 2. older patients (>50 years) due to a hyperextension force in an already degenerate spine 3. low velocity trauma in a patient with an acute central disc herniation4-9 hyperextension of the cervical spine can cause damage to the spinal cord via buckling of the ligamentum flavum or impaction of the posterior elements with rupture of the posterior longitudinal ligament.2,4,8-10 hyperextension can be caused by a contact or non-contact force. direct frontal impact to the head can also cause anterior distraction and posterior compression of the spinal cord, a mechanism reported with the deployment of airbags.11,12 in this case, the young patient had underlying stenosis due to premature c3/4 degenerative stenosis. despite the bullet not contacting the spine, it is likely to have induced an acute hyperextension force due to its trajectory across the face in an inferior-to-superior direction. in order for the patient to be classified as a traumatic ccs, pouw et al.13 recommended that the upper limb asia motor score should be a minimum of 10 points lower than the lower limbs.13,14 in our case the differential was 30 points with an initial asia b improving to a c. radiological features of ccs vary. x-rays may be normal if there is no pre-existing pathology. underlying congenital narrowing can be assessed with the pavlov or torg ratio. this is a ratio of canal size to anterior-to-posterior vertebral body dimension on the lateral x-ray. this should be >0.82 but in our patient was 0.5–0.7 from c3–c5.15 these patients are best investigated with an mri where disc and ligament disruption, spinal canal compromise and degree of spinal cord injury can be assessed. the mri may indicate cord oedema, cyst formation or, on rare occasions, a haematomyelia.2,16-19 with regard to the case study, the mri was an essential tool in identifying the multilevel cord compression and preexisting spondylosis. the treatment of ccs is controversial. aarabi et al.20 state that management recommendations in an extensive literature review (1966–2011) is limited to class iii medical evidence. he separates the treatment of all acute central ccs according to the presenting pathology: 1. patients with mri evidence of spinal cord signal change but no radiological abnormality can be treated medically. 2. patients with skeletal pathology such as fracture must undergo surgery for stabilisation and decompression. 3. patients with no bony abnormality but who have concomitant spinal stenosis have the option of either surgical or medical treatment.20 timing of surgery in ccs remains controversial. the question remains as to whether there is a role for urgent decompression in order to enhance neurological recovery in patients with no instability. a systemic review by lenehan et al.21 reviewed whether there was a need to urgently decompress patients within 24 hours or stage the surgery. direct frontal impact to the head can also cause anterior distraction and posterior compression of the spinal cord figure 4. post-operative mri confirming capacious canal and myelomalacia saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 36 sa orthopaedic journal autumn 2015 | vol 14 • no 1 page 37 the conclusion was that patients who had asia c and below and persistent cord compression benefited from early intervention, but those with asia d deficit could be observed and potentially treated surgically later if there was no improvement.21 other studies have supported the notion that surgically treated patients for acute cervical syndrome have better outcomes neurologically compared to those receiving only medical treatment.22-25 a trend towards decreased length of hospital stay and fewer complications has been illustrated in patients who are treated surgically compared to nonsurgical groups.26-35 there is class iii evidence to support improved patient outcome in acute ccs by aggressive medical support to allow perfusion of the spinal cord.19,31,36,37 conservative treatment of patients with acute traumatic cervical spine syndrome may predispose the patient to persistent neuropathic pain and spasticity. the spasticity can be so severe as to hinder recovery, decrease the functional motor grade, prevent a patient from achieving potential ambulation and be the main cause of patient dissatisfaction. physiotherapy and certain drugs such as baclofen, dantrolene and gabapentin may assist in the reduction of these symptoms.19,32,38-41 in this case study the patient was unable to achieve full ambulation due to the severe spasticity he developed. he underwent physical therapy and medical treatment to control the spasticity, to no avail. surgical options vary with regard to the pathology. most patients present with multilevel pathology due to preexisting spinal stenosis. anterior decompression is favoured for focal pathology. this may include discectomy or corpectomy. zhu et al.42 performed metaanalysis comparing the anterior versus posterior approach for multilevel cervical spondylotic myelopathy. they found that anterior surgery provided better short-term neurological outcome but higher complication and reoperation rates compared with posterior surgery.42 posterior surgery includes laminectomy, laminoplasty, foraminectomy and posterior cervical fusion. posterior surgery has been associated with increased neck pain and disability,43,44 but this was disputed by a study by seng et al.45 whereby in a two-year follow-up the study showed no increased neck instability or neck pain post laminoplasty in 52 patients. to date there is no proven superior approach with regard to treating multilevel disease.42,46,47 our case highlights the dilemma of both pre-existing multilevel stenosis due to congenital narrow canal and premature spondylosis with a focal disc extrusion. to address this all anteriorly would necessitate multilevel corpectomies with prolonged theatre time and approachrelated risks. posterior decompression allows technically easier multilevel decompression with the laminectomy technique or slightly more demanding laminoplasty. as long as there is lordosis, the thecal sac will migrate posteriorly.19,48,49 however, this posterior migration is kept in check by the nerve roots which run antero-laterally. thus large anterior compression such as the c3/4 disc in this case may cause ongoing compression.50 therefore an additional focal anterior decompression was performed when there was no initial neurological improvement. of course, it will never be known whether the subsequent neurological recovery was directly due to the anterior approach or coincidental with delayed recovery from the posterior decompression. conclusion this case reports an unusual cause of ccs in a young patient, via facial gunshot-induced hyperextension with indirect injury to the spinal cord. the management dilemma of anterior focal versus posterior multilevel decompression remains, and the decision is left to the surgeon on a case-by-case basis. in retrospect, with significant disc extrusion, an initial anterior decompression and fusion procedure is probably indicated. the content of the article is the sole work of the authors. no benefits of any form have been or are to be received from a commercial party related directly or indirectly to the subject of the article. as this is a case report, our ethics committee does not require 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49. kim sw, hai dm, sundaram s, kim yc, park ms, paik sh et al. is cervical lordosis relevant in laminoplasty? the spine journal 2013;13:914-21. 50. hirai t, okawa a, arai y, takahashi m, kawabata s,kato t et al. middle-erm results of a prospective comparative study of anterior decompression with fusion and posterior decompression with laminoplasty for the treatment of cervical spondylotic myelopathy. spine (phila pa 1976) nov 2011;36(23):1940-47. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 39 swan ak et al. sa orthop j 2019;18(4) doi 10.17159/2309-8309/2019/v18n4a3 south african orthopaedic journal http://journal.saoa.org.za spinal surgery citation: swan ak, dunn rn. ‘out with the old and in with the new’ – a retrospective review of paediatric craniocervical junction fixation: indications, techniques and outcomes. sa orthop j 2019;18(4):28-34. http://dx.doi.org/10.17159/2309-8309/2019/v18n4a3 editor: dr j davis, stellenbosch university, cape town, south africa received: march 2019 accepted: may 2019 published: november 2019 copyright: © 2019 swan ak, dunn rn. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no external funding was applied for nor obtained for this study. conflict of interest: neither of the authors have any conflict of interest to declare related directly or indirectly to the research. abstract background: the paediatric craniocervical junction has anatomical, physiological and biomechanical properties that make this region unique from that of the adult spine, vulnerable to injury, and contribute to the complexity of management. traditionally, onlay fusion with external halo immobilisation has been used. instrumented fusion offers intra-operative reduction and immediate stability. methods: a retrospective review of a single surgeon’s prospectively maintained database was conducted for all cases of paediatric patients that had undergone a fusion involving the occipito-atlanto-axial region. case notes were reviewed and a radiological analysis was done. results: sixteen patients were managed with onlay fusion and external immobilisation, and 27 patients were managed with internal fixation using screw-rod constructs. the fusion rates were 80% and 90.5% respectively. allograft bone grafting was found to be a significant risk factor for non-union. conclusion: the screws can be safely and predictably placed as confirmed on radiological follow-up with a high fusion rate and an acceptable complication rate. uninstrumented onlay fusion with halo immobilisation remains an acceptable alternative. allograft in the form of bone croutons or demineralised bone matrix is a significant risk factor for non-union, and posterior iliac crest graft should be used preferentially. level of evidence: level 4 keywords: paediatric, craniocervical junction, occipito-atlanto-axial, harms ‘out with the old and in with the new’ – a retrospective review of paediatric craniocervical junction fixation: indications, techniques and outcomes swan ak¹ , dunn rn² 1 mbchb(uct), fc orth(sa); spine fellow, department of orthopaedic surgery, university of cape town, groote schuur hospital, cape town, south africa ² mbchb(uct), mmed orth(uct), fc orth(sa); hod/pieter moll and nuffield chair of orthopaedic surgery, university of cape town, groote schuur hospital and red cross children’s hospital, cape town, south africa corresponding author: prof rn dunn, h49 old main building groote schuur hospital, main road, observatory, cape town, south africa, 7925; tel: +27 (0)21 404 5108; fax: +27 (0)21 447 2709; email: robert.dunn@uct.ac.za https://orcid.org/0000-0003-2940-5928 https://orcid.org/0000-0002-3689-0346 page 29swan ak et al. sa orthop j 2019;18(4) introduction and aim craniocervical junction (ccj) instability is caused by traumatic and atraumatic aetiologies with underlying pathology of congenital, syndromic, autoimmune, inflammatory, infectious or neoplastic aetiologies.1,2 ccj instability may require surgical stabilisation from the pathology itself or for iatrogenic instability from decompressive surgery. a successful ccj fusion requires re-creation of a stable biomechanical environment and bony preparation for biological bony on-growth. secondary goals include decompression and protection of neurological structures, restoration and maintenance of alignment, motion segment preservation, limitation of morbidity (including that of bone graft harvest), pain control, and the facilitation of nursing care.2-5 consideration should be given to the benefits, risks and cost-effectiveness of the chosen method of stabilisation.3,5 a variety of techniques are available for stabilisation and fusion of the ccj in paediatric patients: onlay fusion with external halo immobilisation, wiring techniques, and screw/screw-rod instrumented techniques with or without adjuvant wiring and external immobilisation. in children younger than 8 years, the relatively large head, small occipital condyles, horizontally oriented atlanto-occipital and facet joints as well as capsular and ligamentous laxity make the ccj the most significant transitional zone.3,6-8 this unique anatomy of the ccj in children complicates the interpretation of biomechanical studies that are largely done in adult cadaveric specimens. anatomic size constraints, craniovertebral anomalies associated with congenital and syndromic conditions, immature ossification, as well as future growth potential, further complicate the decisionmaking process.3,9-11 consequently, surgeons have until recently avoided instrumentation in the paediatric population. having evolved from traditional onlay fusion with external halo immobilisation to internal fixation of the ccj in paediatric patients with predominantly the harms technique, we present our institutional experience and radiological outcomes. methods a retrospective review of a single surgeon’s prospectively maintained database was conducted for all cases of paediatric patients that had undergone a fusion involving the occipito-atlantoaxial region during the period 1 january 2002 to 31 august 2018. baseline demographic data, underlying pathology, indication for surgery, surgical technique, surgical parameters and intraoperative complications were assessed. preand post-operative radiology was used to assess implant placement and union. ct and mri scanning were used at the discretion of the lead surgeon on a per case basis. fusion was assessed on antero-posterior and lateral radiographs as either cross trabeculation of fusion mass (figure 1); or the absence of peri-screw lucency, absence of instrumentation failure and stability on flexion/extension views when adequate visualisation of the fusion mass was not possible.12 typically, concealment of the fusion mass is due to the instrumentation (figure 2). case notes were reviewed for any complications and progress during the follow-up period. figure 1. lateral cervical spine x-ray demonstrating c1–c2 fusion achieved with an uninstrumented fusion technique with halo external immobilisation figure 2. lateral cervical spine x-ray demonstrating partial concealment of the fusion mass due to screw-rod instrumentation. this was accepted as fused as there is no implant loosening or failure and no motion demonstrated on flexion-extension views. page 30 swan ak et al. sa orthop j 2019;18(4) surgical technique halo external immobilisation the patient is positioned supine. between four and eight pins are placed with between 40 and 60 pounds per square inch and attached to the halo ring. reduction of the deformity is confirmed on lateral imaging and the halo is secured to the jacket. screw-rod the patient is positioned prone on either a relton hall or montreal mattress and the skull is held with a mayfield clamp (figure 3). the patient’s neck is positioned in the ‘military chin-tuck position’ and slight flexion to improve access, and attempted reduction of the c0–c1–c2 joints is done when possible. a midline skin incision is used in all cases here, with subperiosteal exposure of the intended fusion levels. a watson-cheyne dissector is placed into the c1–c2 joint to retract the c2 root inferiorly and gain access to the c1 lateral mass entry point. a burr is used to create a cortical breach in the lateral mass as it joins the c1 arch. a 2.7 mm drill bit is used in oscillating mode and drilled with 10–15° convergence and parallel to the arch under lateral imaging. during c2 pedicle screw insertion, the c2–c3 facet joint is identified but not exposed. the starting point is created using a burr in the infero-lateral quadrant of the c2 lateral mass to optimise screw length. the medial border of the c2 pedicle is identified by palpation using a blunt hook or watson-cheyne and is drilled using oscillating mode with approximately 20° convergence and parallel to the c2 pedicle as visualised on lateral imaging. all drill holes are probed to exclude cortical breech and to confirm screw length prior to screw placement. a standard cervical set with 3.5 mm screws is used for all cases reported here. the intended fusion levels are decorticated and, in most cases, cortico-cancellous strips harvested from the posterior iliac crest are packed underneath the screw-rod construct and occasionally secured with an absorbable suture when deemed necessary. when allograft is used, it is in the form of sa bone croutons or demineralised bone matrix (dbm). a soft collar is used post-operatively for a period of six weeks. statistical analysis analysis was performed using the r language and environment for statistical computing (version 3.5.2) (r foundation for statistical computing, vienna, austria). results forty-three consecutive paediatric patients underwent a fusion involving the occipito-atlanto-axial region during the study period. sixteen consecutive patients with a mean age of 7.5 years (range 3.8–13.8 years) had uninstrumented onlay fusion with halo immobilisation. pre-operative ct scan was done for two patients and pre-operative mri for one patient. fifteen of these patients had adequate radiological follow-up for analysis. twenty-seven consecutive patients with a mean age of 9.8 years (range 2.2–16.7 years) had instrumented internal fixation. preoperative ct scan was done for 16 patients and pre-operative mri for 15 patients. twenty-one of these patients had adequate radiological follow-up for analysis. the most common underlying diagnoses were trauma and os odontoideum. indications for surgery included non-traumatic instability (17 patients), traumatic instability (13 patients) and instability with myelopathy (eight patients). a breakdown of the underlying diagnosis and indication for surgery are given in tables i and ii. figure 3. the patient is positioned prone on a montreal mattress and positioned in the ‘military chin-tuck position’. the patient is draped for posterior iliac crest autograft harvest. page 31swan ak et al. sa orthop j 2019;18(4) the screw configuration for the 27 instrumented fusion group included 13 skull plates, 16 bilateral c1 lateral mass screws, 23 bilateral c2 pedicle screws, three bilateral c2 translaminar screws and one patient with unilateral c2 and c3 translaminar screws. the median operative time for uninstrumented fusion was 45 minutes (interquartile range 44–61 min), and 100 minutes (interquartile range 80–120 min) for instrumented fusion. operative time was found to be significantly different between the two groups (p<0.01). the median blood loss for uninstrumented fusion was 100 ml (interquartile range 50–100 ml), and 150 ml (interquartile range 100–250 ml) for instrumented fusion. blood loss was found to be significantly different between the two groups (p=0.01). fifteen of the 16 patients managed with uninstrumented onlay fusion were followed up for a median period of 19.5 months (interquartile range 11–27 months) and had adequate radiological follow-up for analysis. the union rate for this group was 80% at a median period of two months (interquartile range 2–8 months), with two patients achieving a stable pseudarthrosis and one patient who represented with a non-union and a myelopathy following a subtle injury six years later. a successful union was achieved in this patient with instrumented fusion and autograft. twenty-one of the 27 patients managed with instrumented fusion were followed up for a median period of 22 months (interquartile range 11–37 months), and had adequate radiological follow-up for analysis. unfortunately, as many of these patients were treated as out-patients and often followed up at institutions near their homes, x-rays were not available as frequently. a union rate of 90.5% was observed for this group in a mean period of 4 months (interquartile range 3–12 months). one patient achieved a stable pseudarthrosis and another managed initially with allograft had hardware failure but was successfully revised and achieved union with autograft. autograft harvested from the posterior iliac crest was used for all but two patients in the halo group and three patients in the instrumented group, where allograft in the form of bone croutons or dbm was used. when comparing graft type across both groups, allograft use was found to be a significant risk factor for non-union (p=0.01). in isolation, allograft was found to be a significant risk factor for non-union in the uninstrumented group (p=0.03), but not for the instrumented group (p=0.27). including patients who failed to achieve bony union, there was a 25% complication rate for the halo group. one patient developed pin-site infection which was successfully treated with antibiotics, and another with a non-union who presented myelopathic following a subtle injury at six years post attempted fusion. the instrumented fusion group had a complication rate of 21%. one patient developed a wound infection requiring operative washout, two durotomies during dissection were repaired without incident, and one presumed vertebral artery (va) injury during dissection was controlled and resulted in no adverse outcome. no malposition of screws was noted on any of the post-operative radiological imaging. discussion wiring techniques are biomechanically inferior to screw and screwrod constructs and show a significant decrease in stability when physiological loading is applied.13-15 this necessitates supplemental external immobilisation and frequently the incorporation of subaxial levels to improve stability.1,16,17 in patients younger than 2 years, the soft cartilaginous bone may not withstand the tensile load from wiring.6 congenital, dysplastic or absent posterior elements, or in cases when posterior decompression is required, limitation of fixation points, may preclude the use of wiring techniques or require the inclusion of additional subaxial levels.18 complications of wiring techniques include compression or injury to dura and neurological structures during sublaminar passage of wires especially with inadequate reduction, wire cut-out or loosening, and suboptimal non-union rates as high as 30%.1,5,13,16,17,19 a case control study of 27 adults comparing c1–c2 transarticular screw fixation (tasf) with collar and posterior wiring with halo, showed a significant 21 times improvement in union rate with tasf.20 tasf is frequently augmented with posterior wiring techniques compounding the risks of the procedure. halo immobilisation is cumbersome, poorly suited to polytrauma patients who require stability to aid nursing care, and not without complications. halo management can be labour-intensive, often requiring inpatient care for pin-site hygiene and regular tightening. biomechanically in adults, halos have been shown to have less ability to reduce sagittal plane motion at the atlantoaxial complex (by 71%) than a philadelphia collar.21 pin-tract loosening and infection, dural puncture and neurological complications are all associated with halo use, and the overall complication rate is as high as 53–68%.16,22-25 we achieved an 80% union rate and had a 25% complication rate using this method. screw and screw-rod constructs have gained popularity for the improved stability, fusion rates and shorter duration to fusion.1,5,14,18,26 a variety of fixation points are available: c1–c2 transarticular screw fixation; c1 lateral mass or pedicle screw; c2 pedicle, pars or translaminar screws; and subaxial translaminar or lateral mass screws.27 recently, c1 pedicle screws have been advocated to reduce venous plexus bleeding, c2 nerve root injury, and reliance on fluoroscopy during insertion.11 table i. underlying diagnosis diagnosis number trauma 13 os odontoideum 13 atlantoaxial rotatory subluxation 4 morquio syndrome 4 basilar invagination 3 trisomy 21 2 conradi–hunermann syndrome 2 tuberculosis 2 table ii. indications for surgery indication for surgery number instability 30 instability: non-trauma (17) instability: trauma (13) instability with myelopathy 8 myelopathy 4 instability with radiculopathy 1 page 32 swan ak et al. sa orthop j 2019;18(4) when interpreting biomechanical studies comparing the various fusion techniques, consideration should be given to the fact that the primary motion at the occipitocervical (oc) joint is in the sagittal plane, while primary motion at the atlantoaxial joint is axial rotation and anterior/posterior translation in pathological states.28 results of various adult cadaveric biomechanical studies vary slightly when comparing tasf and the harms technique, with some showing no difference15 and others showing a trend to improved stability with either the harms technique1,29,30 or tasf.31 both the harms technique and tasf have improved stability over translaminar screw techniques.30,31 a tomographic analysis of children aged 2–6 years concluded that midline occipital plates could be used in 100% of cases; standard 3.5 mm screws could be used in 100% of c1 lateral mass screws, 74% of c2 pedicle screws, and 98% of bilateral c2 translaminar screws, yet only 4% were deemed suitable for tasf.32 another study done in 94 paediatric patients 6 years and older found that 3.2% were unsuitable for tasf bilaterally, 18% unsuitable for unilateral tasf and 5.3% feasible but risky. it was suggested that careful scrutiny of ct scans be done for the course of the va and pre-operative planning.33 analysis of 69 patients younger than 16 years found only 30.4% of c2 suitable to accept bilateral translaminar screws.34 it has been suggested that screws with a larger diameter than the cortex may be accommodated by the viscoelastic properties of bone in children.11 c1–c2 tasf popularised by margel for the longer screw length and purchase of at least three cortical surfaces may be precluded by anatomic variability in 20% of cases.1,27 this technique requires reduction of the c1–c2 facet joint prior to screw placement, and as the variable location of the transverse foramen and the medial trajectory of the screw increases the risk of va injury, pre-operative ct planning is strongly advocated.1,3,4,9,16,26,35-38 other difficulties with tasf are the acute angle of screw placement in cases of kyphosis, obesity or barrel chest; and the additional risk during supplemental wire fixation, which is frequently done.4,10,26,29,35,36,38,39 the major benefit of screw-rod constructs are the versatility of fixation options and constructs. the construct can be used as a means of intra-operative reduction through compression, distraction or cantilever techniques; it is better able to conform to, and contour the individual anatomy; and can be used in congenital or decompressive cases with hypoplasia or absence of posterior elements.4,18,26,37,39,40 the morbidity of transoral decompression may be avoided by the indirect decompression gained by reducing the deformity using screw-rod techniques, and the direct posterior decompression of lamina or foramen magnum that this technique allows.41-43 the trajectory of the c1 lateral mass screw may make vertebral artery injury less likely than that of tasf, reducing the dependence on pre-operative ct scanning.1,4,29 a retrospective review of 191 adults managed with tasf showed that 92% of sides were suitable for tasf with a 1.4% chance of va injury per screw placed. the overall complication rate was 16.7%.44 a retrospective review by the lead author (rd) of 19 adult patients who successfully underwent tasf had a 21% complication rate including one va injury without consequence. union was achieved in all patients.45 several retrospective reviews of tasf in paediatric patients, most augmented with posterior wiring and autograft, had a union rate of 94–100% at a mean period of 4–7 months. the complication rate for the procedure varied from 11.8–25% with the risk of va injury between 1.6–2.9% per screw placed. all had preoperative ct planning and 89–95% of sides were deemed suitable for transarticular screw placement.35,38,46-48 a meta-analysis of mostly level 3 evidence of screw-rod fixation in patients over 18 years included 1 073 patients across 24 studies. the overall union rate was 97.5% and complications directly attributable to surgery were 0.2%. the overall va injury rate was 0.6% with 0.4% occurring during dissection, and 0.1% for c1 and c2 screw placement. mention is made of exercising caution during dissection over the lateral aspect of the posterior arch of c1. screw malposition requiring revision for c1 lateral mass (lm) was 0.3% and 0.1% for c2 pars/pedicle screws. the overall minor complication rate was 9.1% with 7.7% related to c2 root morbidity.49 less data is available for union rate, period to union and complication rate for screw-rod constructs in paediatric patients than for tasf. retrospective reviews of screw-rod fixation with mainly c1 lateral mass and c2 pedicle or pars screws indicate a 93–100% union rate with a mean time to fusion of between 4.1 and 7.3 months. the minor complication rate varies between 7 and 33% if smaller case series are included.4,9,11,40,50,51 only one va injury was seen in a small retrospective review of four cases.9 we achieved an acceptable union rate of 90.5% with a 21% complication rate (7.4% re-operation rate). mixed adult and paediatric retrospective reviews suggest a low risk of va injury of up to 1.3% per side.41,52,53 screwrod fixation using c2 translaminar screws has also been used with a low complication and high union rate.54-56 retrospective reviews comparing adult and paediatric patients undergoing fusion with either harms or tasf showed no difference in union rate, operative time or risk of va injury.8,39 blood loss has been shown to be significantly higher for the harms technique.39 in paediatric patients, hardware failure is associated with skeletal dysplasia or congenital spine anomalies and not the fixation method. deep wound infection is a risk factor for requiring surgical revision of instrumentation or graft.37 dunn et al. in a retrospective series of 42 adults undergoing tasf or harms found no difference in surgical time; however, blood loss and cost of implants was higher for harms technique. the va injury rate was 14.8% for tasf and 6.7% for harms. the higher overall va injury rate may reflect the lack of ct scan availability at the time of the study.57 in the paediatric population undergoing c1–c2 screw-rod fixation, the mean operative time varies from 109 to 138 min and the mean blood loss varies from 68 to 155 ml, with lower operative times and blood loss generally seen when allograft is used.11,40,50 this is comparative with our experience. while it is widely accepted that autograft is the gold standard for achieving fusion, harvesting from the iliac crest is associated with increased blood loss, operative time and donor site morbidity.50,58,59 open posterior cervical surgery creates a large potential ‘dead space’, allowing the graft to drift back when the patient is positioned supine post-operatively. it is suspected that this is a reason for the reduced fusion rate seen with the use of allograft croutons in this series. structural graft that is secured to the fusion site is therefore favoured. there has been success in paediatric patients with the use of structural allograft placed under compression at the c1–c2 fusion site with fusion rates of 97–100%.50,59 however, time to fusion may be significantly less than with autograft use.50 the retrospective nature of the study is an inherent limitation. other limitations include concealment of the fusion mass on the x-ray by the screw-rod constructs which can make interpretation of union difficult; and patient fallout due local follow-up, resulting in infrequent radiological follow-up, and thus determining the period to union is inaccurate, particularly in the instrumented fusion group. conclusion instrumentation of the paediatric cervical spine is both possible and safe, despite the anatomical size constraints. instrumented fusion of the paediatric craniocervical junction using screw-rod constructs offers versatility, is useful as an intra-operative reduction aid, and allows immediate stabilisation following decompressive procedures. the immediate stability creates a biomechanical environment with a high fusion rate and an acceptable complication rate. page 33swan ak et al. sa orthop j 2019;18(4) uninstrumented onlay fusion with halo immobilisation remains an acceptable alternative despite the challenges of intensive outpatient care. allograft in the form of bone croutons or dbm is a significant risk factor for non-union and should not be used. ethics statement the author/s declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study ethical approval was obtained from the university of cape town human research ethics committee (hrec 051/2019). declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions rd was responsible for the conceptualisation, and contributed to the design, data collection, manuscript preparation and final write-up. as was responsible for the design, data collection, manuscript preparation and final write-up. orcid ak swan https://orcid.org/0000-0003-2940-5928 rn dunn https://orcid.org/0000-0002-3689-0346 references 1. inamasu j, 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47. brockmeyer dl, apfelbaum ri. a new occipitocervical fusion construct in pediatric patients with occipitocervical instability. journal of neurosurgery: spine. 1999;90(2):271-75. 48. brockmeyer dl, york je, apfelbaum ri. anatomical suitability of c1–2 transarticular screw placement in pediatric patients. journal of neurosurgery: spine. 2000;92(1):7-11. 49. elliott re, tanweer o, boah a, morsi a, ma t, smith ml, et al. atlantoaxial fusion with screw-rod constructs: meta-analysis and review of literature. world neurosurgery. 2014;81(2):411-21. 50. zhang y-h, shen l, shao j, chou d, song j, zhang j. structural allograft versus autograft for instrumented atlantoaxial fusions in pediatric patients: radiologic and clinical outcomes in series of 32 patients. world neurosurgery. 2017;105:549-56. 51. kosnik-infinger l, glazier ss, frankel bm. occipital condyle to cervical spine fixation in the pediatric population. j neurosurg pediatr. 2014;13(1):45-53. 52. goel a, desai ki, muzumdar dp. atlantoaxial fixation using plate and screw method: a report of 160 treated patients. neurosurgery. 2002;51(6):1351-57. 53. harms j, melcher rp. posterior c1–c2 fusion with polyaxial screw and rod fixation. spine. 2001;26(22):2467-71. 54. chamoun rb, relyea km, johnson kk, whitehead we, curry dj, luerssen tg, et al. use of axial and subaxial translaminar screw fixation in the management of upper cervical spinal instability in a series of 7 children. neurosurgery. 2009;64(4):734-39. 55. haque a, price av, sklar fh, swift dm, weprin be, sacco dj. screw fixation of the upper cervical spine in the pediatric population. clinical article. j neurosurg pediatr. 2009;3(6):529-33. 56. leonard jr, wright nm. pediatric atlantoaxial fixation with bilateral, crossing c-2 translaminar screws. journal of neurosurgery: pediatrics. 2006;104(1):59-63. 57. dunn r, stander h. atlanto-axial fusion: magerl transarticular versus harms instrumentation techniques. sa orthopaedic journal. 2014;13(2):31-34. 58. huang d-g, zhang x-l, hao d-j, yu c-c, mi b-b, yuan q-l, et al. posterior atlantoaxial fusion with a screw-rod system: allograft versus iliac crest autograft. clinical neurology and neurosurgery. 2017;162:95-100. 59. iyer rr, tuite gf, meoded a, carey cc, rodriguez lf. a modified technique for occipitocervical fusion using compressed iliac crest allograft results in a high rate of fusion in the pediatric population. world neurosurgery. 2017;107:342-50. _goback _goback _goback 404 not found siyo z et al. sa orthop j 2019;18(1) doi 10.17159/2309-8309/2019/v18n1a2 south african orthopaedic journal http://journal.saoa.org.za traumatumours and infections citation: siyo z, marais lc. reactivation of chronic haematogenous osteomyelitis in hiv-infected patients. sa orthop j 2019;18(1):21-25. http://dx.doi.org/10.17159/2309-8309/2019/v18n1a2 editor: prof tlb le roux, university of pretoria, pretoria, south africa received: december 2017 accepted: april 2018 published: march 2019 copyright: © 2019 siyo z. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for the purposes of performing this study. conflict of interest: the authors have no conflict of interest to declare. abstract background: the aim of the study is to determine the prevalence of hiv infection among adult patients with reactivation of haematogenous chronic osteomyelitis. methods: a retrospective analysis of prospectively collected data from 143 adult patients with chronic osteomyelitis. results: a total of 143 patients were included in the study group, with a mean age of 38 years (range 14–78 years). twenty-two per cent (n=31) of patients were diagnosed with reactivation of chronic haematogenous osteomyelitis, while 78% of patients had contiguous chronic osteomyelitis (29% [n=42] post-operative and 49% [n=70] post-traumatic, respectively). forty (28%) patients were found to be hiv positive with a mean cd4 count of 414 cells/mm³ (range 13–1 034 cells/mm³). twenty-four (60%) of patients with hiv were on antiretroviral therapy at time of diagnosis. the prevalence of hiv infection among patients with contiguous (post-operative or post-traumatic) infections was 32%, in comparison to 13% in the group with reactivation of chronic haematogenous infections (p=0.04; or 3.2; 95% ci 1.0–9.8). conclusion: the prevalence of hiv infection among patients with reactivation of chronic haematogenous osteomyelitis appeared to be lower than that seen in patients with chronic osteomyelitis from other causes and lower than that seen in the general population in south africa. level of evidence: level 4 key words: haematogenous, osteomyelitis, hiv, aids reactivation of chronic haematogenous osteomyelitis in hiv-infected patients siyo z¹ , marais lc² 1 mbchb, fc orth sa; department of orthopaedics, school of clinical medicine, university of kwazulu-natal, pietermaritzburg, south africa ² mbchb, fc orth sa, mmed ortho, phd; department of orthopaedics, school of clinical medicine, university of kwazulu-natal, pietermaritzburg, south africa corresponding author: dr z siyo, department of orthopaedic surgery, school of clinical medicine, university of kwazulu-natal, grey’s hospital, pietermaritzburg, 3200, south africa; email: zukosiyo@gmail.com https://orcid.org/0000-0002-8420-9244 https://orcid.org/0000-0002-1120-8419 page 22 siyo z et al. sa orthop j 2019;18(1) introduction the total number of people living with human immunodeficiency virus (hiv) in south africa is currently estimated at approximately 7.06 million. in the age group 15–49 years, the national prevalence is estimated at 16.8%.1 the prevalence in kwazulu-natal, the second largest province in south africa with a population of approximately 11.1 million people, is currently estimated at 21.5%.2 hiv infection results in a combination of immune suppression and chronic inflammation through the mechanisms of immune exhaustion with effector t-cell dysfunction and immune senescence with premature aging of the immune system.3 the resulting neutrophil, monocyte and b-lymphocyte abnormalities lead to a decreased capacity for bacterial phagocytosis and an increased rate of bacterial infections. methicillin-resistant staphylococcus aureus infection is, for example, 6–18 times more common in hiv patients than in the general population.4 hiv co-infection is presumed to be among the major contributing factors to the pathogenesis of bone infection. chronic osteomyelitis can be defined as a biofilm-based infection where the majority of pathogens are sessile-based and are resiliently attached to the nidus of infection.5 in the case of chronic haematogenous osteomyelitis, the nidus of infection is typically a sequestrum that is formed following acute osteomyelitis in childhood. the appropriate treatment of acute haematogenous osteomyelitis has resulted in a drastic decrease in the incidence of chronic osteomyelitis of haematogenous origin in the developed world; however, it remains fairly common in the developing world.6 owing to the unique characteristics of the causative organisms, reactivation of chronic osteomyelitis may occur as much as 65 years following the initial infection.7,8 these characteristics include the internalisation of bacteria by osteoblasts which is mediated by the sigma b regulon in the case of staphylococcus aureus.9 the exact cause of the reactivation of infection has, however, not been clearly defined but it is believed to be associated with a decrease in local or systemic immune protection. jellis reported a possible increase in haematogenous osteomyelitis in patients with hiv infection. this was however only a comment and further data on the topic was not provided.10 to the best of our knowledge, there is currently no data on the reactivation of chronic haematogenous osteomyelitis in hiv patients. the aim of the study is to determine the prevalence of hiv infection among adult patients with reactivation of haematogenous chronic osteomyelitis. materials and methods a retrospective descriptive study was performed on prospectively collected data from consecutive patients seen at a tertiary-level tumour and sepsis unit with chronic osteomyelitis. all adult patients over the age of 14 years assessed from january 2011 to december 2014 were included in the study. patients excluded from the study were those with atypical infections including fungal, parasitic and tuberculosis, acute post-operative infection, periprosthetic joint infection or hand sepsis. following ethical approval from the relevant biomedical ethics review board, data were collected with respect to patient age, cause of osteomyelitis (haematogenous or contiguous), physiological host stage and anatomic nature of the disease according to the cierny and mader classification system, hiv status, cd4 count and the presence of antiretroviral therapy. for the purposes of this study chronic osteomyelitis was defined as an infection involving bone, with a duration of at least ten days, where the causative organisms were thought to have persisted either intracellularly or in interactive biofilm-based colonies. haematogenous chronic osteomyelitis was defined as the reactivation of chronic osteomyelitis resulting from a previous episode of acute osteomyelitis of haematogenous origin. contiguous chronic osteomyelitis was defined as chronic osteomyelitis resulting from a prior open fracture (post-traumatic) or operative intervention (post-operative). all patients were screened for hiv infection. following clinical, radiological and biochemical evaluation, patients were classified according to a modified version of the original cierny and mader classification system (table i).11 in terms of the physiological status of the host, the cierny and mader classification system was modified in order to provide a more pragmatic and objective definition of a c host. a patient was classified as a c host if one major or more than two minor risk factors were present (table ii). in order to remove any ambiguity during classification of the anatomical nature of the disease, this was performed prior to, rather than following, the debridement. statistical analysis was performed using stata 13.0 (statacorp. college station, texas). continuous variables were reported as mean (± sd) or median (with interquartile range) and categorical variables as numbers and percentages, unless otherwise stated. categorical data were compared using the fisher’s exact test or the chi-square test. all tests were two-sided, and the level of significance was set at p<0.05. table i: modified version of the original cierny and mader classification system that served to guide treatment strategy selection11 classification characteristic physiological type a host no risk factors type b host fewer than three minor risk factors type c host one major and/or three or more minor risk factors pathoanatomy i – medullary no cortical sequestration ii – cortical direct contiguous involvement of cortex only iii – combined (stable) both cortex and medullary regions involved iv – combined (unstable) as for iii plus unstable prior to debridement nidus sequestrum cortical sequestrum present implant biofilm-based infection in presence of implant no identifiable nidus minimal necrosis osteomyelitis impairment minimal patient able to perform adl (activities of daily living) severe unable to perform adl page 23siyo z et al. sa orthop j 2019;18(1) results a total of 149 patients met the inclusion criteria. four patients with early post-operative infection and two patients with fungal osteomyelitis were excluded, leaving a total of 143 patients in the study group. the mean age of patients was 38 years (range 14–78; standard deviation [sd] 15.5 years). twenty-eight per cent (n=40) of patients were found to be hiv positive with a mean cd4 count of 414 cells/mm3 (range 13–1 034; sd 132 cells/mm3). sixty per cent (n=24) of patients with hiv were on antiretroviral therapy at time of diagnosis. twenty-two per cent (n=31) of patients were diagnosed with reactivation of chronic haematogenous osteomyelitis, while 78% of patients had contiguous chronic osteomyelitis (29% [n=42] post-operative and 49% [n=70] post-traumatic, respectively). the location of the infection was the tibia in 52% of cases (n=75), femur in 27% (n=39), humerus, pelvis or foot in 5% (n=7), fibula or radius/ ulna in 3% (n=5) and clavicle in 1% of cases. overall, 15% (n=21) of patients were classified as a hosts, 41% (n=59) were b hosts and 44% (n=63) c hosts. of the b hosts, nine patients were hiv-positive with a mean cd4 of 627 cells/mm3. thirty-one (49%) of c hosts were hiv-positive, mean cd4 352 cells/mm3. the prevalence of hiv infection among patients with contiguous (post-operative or post-traumatic) infections was 32%, in comparison to 13% in the group with reactivation of chronic haematogenous infections (p=0.04; or 3.2; 95% ci 1.0–9.8) (table iii). in addition, there was a significant difference between the two groups in terms of the site of infection, the physiological stage of the host and the anatomic nature of the disease (table iii). two of the four hiv patients in the haematogenous group (mean cd4 487 cells/mm3) were on antiretroviral medication compared to 12 of the 28 patients in the contiguous group (mean cd4 405 cells/mm3). discussion considerable controversy remains regarding the association of hiv infection and the development of bone infections. in the 1990s, jellis and hoekman independently reported an infection rate of operatively treated fractures of 24% and 33% in symptomatic hiv patients.10,12 in contrast, a study by harrison et al., in 2002, showed that the risk of post-operative infection is dependent on wound contamination. hiv status was not found to be a risk factor for wound infection following operative management of closed fractures.13 the study reinforced earlier findings that asymptomatic hiv-positive patients with high energy open injuries were prone to infection compared to hiv negative.14 in contrast to this, howard et al. showed that hiv does not necessarily increase early infection in open fractures.15 these findings were echoed by niewoudt et al., who noted that hiv did not appear to be associated with an increased risk of deep infection or non-union in grade iii open tibia fractures treated with circular external fixation.16 the influence of cd4 count on the development of infection also remains unclear. guild et al., showed an increased infection rate in patients with a cd4 count below 300.17 all of the above-mentioned studies, however, focused on contiguous (post-operative or post-traumatic) infections. limited data is available on the impact of hiv on haematogenous osteomyelitis. lavy and co-workers noted a three-fold increase in the number of septic cases treated in malawi and speculated that this may, at least in part, have been the result of an increased seroprevalence of hiv.18 while osteomyelitis was mentioned in this report, haematogenous osteomyelitis was not specifically looked at. in 1996 jellis reported an increase in the incidence of adult long-bone haematogenous osteomyelitis in patients with hiv and further stated that it was a common orthopaedic presentation of adults with advanced hiv disease.10 the aim of this study was to determine the prevalence of hiv infection among adult patients presenting with chronic haematogenous osteomyelitis in an attempt to investigate the possible association between hiv infection and adult chronic osteomyelitis. intuitively, it seems reasonable to expect that an immune-compromising disease like hiv/aids might cause an increase in the incidence of reactivation of quiescent adult osteomyelitis, especially in patients with very low cd4 counts. somewhat surprisingly we found a lower prevalence of hiv infection among adult patients presenting with chronic haematogenous osteomyelitis in comparison to adult osteomyelitis from other causes (13% vs 32%, p=0.04). the prevalence of hiv infection in the contiguous group of patients was comparable to that seen in the general population of the region where the study was performed; however, in the haematogenous group it was considerably lower. in addition, the hiv-positive patient who did present with haematogenous osteomyelitis did not have table ii: risk factors used to stratify the physiological status of the host11 major risk factors minor systemic risk factors minor local risk factors cd4 count <350 cells/mm³ hiv infection poor soft tissues requiring flap albumin <30 g/l anaemia chronic venous insufficiency hba1c >8% smoking peripheral vascular disease cellulitis or abscess diabetes mellitus previous radiation therapy malignancy at site of infection rheumatoid arthritis surgery will result in instability pathological fracture chronic lung disease adjacent joint stiff/arthritic chronic cardiac failure heterotopic ossification paraplegia/quadriplegia failed reconstruction elsewhere drug or substance abuse foot involvement chronic corticosteroid use pelvic involvement active tuberculosis adjacent joint involved ischaemic heart disease segmental resection of >6 cm required to achieve cure cerebrovascular disease compliance and motivation age >65 years common variable immune deficiency page 24 siyo z et al. sa orthop j 2019;18(1) exceptionally low cd4 counts. while this study by no means provides the definitive answer, it appears that hiv infection may not necessarily be associated with the reactivation of quiescent haematogenous osteomyelitis in adults, as was initially thought. this study has several shortcomings. due to the retrospective nature of the study it was not possible to determine how many patients with haematogenous osteomyelitis remained asymptomatic. thus, we were unable to compare the true prevalence of reactivation in hiv-positive and -negative patients. a long-term prospective follow-up of patients with haematogenous osteomyelitis will be required for this purpose. a further limitation is the small sample size, especially in the haematogenous group. the question therefore remains unanswered and further research in the field is warranted. conclusion the prevalence of hiv infection among patients with reactivation of chronic haematogenous osteomyelitis appeared to be lower than that seen in patients with chronic osteomyelitis from other causes, and lower than that seen in the general population in south africa. this appears to be in contradiction to previous reports stating that hiv infection may be associated with adult chronic haematogenous osteomyelitis. ethics statement prior to commencement of the study ethical approval was obtained from the following ethical review boards: 1. kwazulu-natal department of health (kz_2016rp44_836) 2. biomedical research ethics committee (brec 204/16) all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was not obtained from all patients included in the study. declarations the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. acknowledgements none author contributions zs: literature review conceptualisation, design, data collection and analysis, manuscript. lcm: conceptualisation, design, data collection and analysis, manuscript. orcid siyo z http://orcid.org/0000-0002-8420-9244 marais lc http://orcid.org/0000-0002-1120-8419 references 1. statistics sa. mid-year population estimates 2017. http://www. statssa.gov.za/publications/p0302/p03022017.pdf (date last accessed 30 november 2017). 2. welz t, hosegood v, jaffar s, batzing-feigenbaum j, herbst k, newell m. continued very high prevalence of hiv infection in rural kwazulu-natal, south africa: a population-based longitudinal study. aids 2007;21:1467-72. 3. mohan t, bhatnagar s, gupta dl, rao dn. current understanding of hiv-1 and t‐cell adaptive immunity: progress to date. microb pathogen 2014;73:60-69. 4. hidron ai, kemper r, moanna a, rimland d. methicillin-resistant staphylococcus aureus in hiv-infected patients. inf drug resist 2010;3:73-86. 5. cierny g. surgical treatment of osteomyelitis. plast reconstr surg 2011;127(suppl 1):s190-94. 6. walter g, kemmerer m, kappler c, hoffmann r. treatment algorithms for chronic osteomyelitis. dtsch arztebl int 2012;109(14):257-64. table iii: comparative statistics of patients with reactivation of chronic haematogenous osteomyelitis and contiguous osteomyelitis haematogenous chronic osteomyelitis (n=31) contiguous chronic osteomyelitis (n=112) p-value site 0.01iii tibia 12 (39%)i 63 (56%) femur 15 (48%) 24 (21%) humerus 7 (6%) other 4 (13%) 18 (16%) host staging12 <0.01iii a-host 13 (42%) 8 (7%) b-host 10 (32%) 49 (44%) c-host 8 (26%) 55 (49%) anatomic classification12 <0.01iii type 1 3 (3%) type 2 2 (2%) type 3 26 (84%) 44 (39%) type 4 5 (16%) 63 (56%) hiv status 0.04iv positive 4 (13%) 36 (32%) negative 27 (87%) 76 (68%) cd4 count vi 487 (360–646)ii 405 (13–1 034) 0.47v (i) n (%); (ii) mean (range); (iii) chi-square test; (iv) fisher’s exact test (v) t-test; (vi) cd4 count of hiv-positive patients in each group https://orcid.org/0000-0002-8420-9244 http://orcid.org/0000-0002-8420-9244 https://orcid.org/0000-0002-1120-8419 http://orcid.org/0000-0002-1120-8419 page 25siyo z et al. sa orthop j 2019;18(1) 7. al-maiyah m, hemmady mv, shoaib a, morgan-jones rl. recurrence of chronic osteomyelitis in a regenerated fibula after 65 years. orthopedics 2007;30:403-404. 8. donati l, quadri p, reiner m. reactivation of osteomyelitis caused by staphylococcus aureus after 50 years. j am geriatr soc 1999;47:1035-37. 9. nair sp, bischoff m, senn mm, et al. the sigma b regulon influences internalization of staphylococcus aureus by osteoblasts. infect immun 2003;71:4167-70. 10. jellis je. orthopaedic surgery and hiv disease in africa. int orthop 1996;20:253-56. 11. marais lc, ferriera n, aldous c, le roux tlb. the outcome of treatment of chronic osteomyelitis following an integrated approach. strat traum limb recon 2016;11(2):135-42. 12. hoekman p, van den perre p, nellisen j, kwisanga b, bogaerts j, kanyangabo f. increased frequency of infection after open reduction of fractures in patient who are seropositive for human immunodeficiency virus. j bone joint surg am 1991;73‐a(5):675-79. 13. harrison wj, lavy cbd, lewis cp. one-year follow-up of orthopaedic implants in hiv-positive patients. int orthop 2004;28:329-32. 14. paiement gd, hymes ra, la douceur ms, gosselin ra, green hd. postoperative infections in asymptomatic hiv-seropositive orthopedic trauma patients. j trauma 1994;37(4):545-50. 15. howard ne, phaff m, aird j, wicks l, rollinson p. does human immunodeficiency virus status affect early wound healing in open surgically stabilized tibial fractures? bone joint j 2013;95-b:1703-707. 16. niewoudt l, ferreira n, marais lc. short term results of grade iii open tibia fractures treated with circular fixators. s afr orthop j 2016;15(3):20-26. 17. goerge n, guild md, thomas j, moore md, whitney barnes mph, christopher bs. cd4 count is associated with postoperative infection in patients with orthopaedic trauma who are hiv positive. clin orthop relat res 2012;470:1507-12. 18. lavy c, schmidt c, kalua e, phuka j. the resistable rise of surgical sepsis in malawi. malawi med j 2001;13(1):35-36. _goback _hlk500598290 asmall t et al. sa orthop j 2020;19(1) doi 10.17159/2309-8309/2020/v19n1a5 south african orthopaedic journal http://journal.saoa.org.za traumaarthroplasty citation: asmall t, gunston g, venter r, henry bm, keet k. surgical anatomy of the sciatic nerve and its relationship to the piriformis muscle with a description of a rare variant. sa orthop j 2020;19(1):33-39. http://dx.doi.org/10.17159/2309-8309/2020/v19n1a5 editor: dr c snyckers, university of pretoria, pretoria, south africa received: may 2019 accepted: september 2019 published: march 2020 copyright: © 2020 asmall t, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: this work was supported by the university of cape town and royal rice, who were not involved with the study design or outcomes. conflict of interest: the authors have no conflicts of interest to declare. abstract aims: variation of the sciatic nerve may increase the risk of iatrogenic injury during total hip arthroplasty or arthroscopy, result in failure of peripheral blocks, or be associated with piriformis syndrome. studies from africa are scarce, with none to date from south africa. thus, the aims were to document the relationship between the sciatic nerve and piriformis muscle, variation in the bifurcation level and in the length of the nerve. any significant differences between sexes and sides were also investigated. methods: the lower limbs of 42 cadavers (84 limbs) were dissected and the relationship between the sciatic nerve and piriformis classified according to the patterns described by beaton and anson. the region of sciatic nerve bifurcation was documented, and the length of the nerve was measured in individuals with bifurcation in the thigh. results: the normal relationship between the sciatic nerve and piriformis muscle was present in 64 limbs (76.2%). the bifurcation level of the nerve was variable in more than half the sample. no significant differences occurred in any of the variant patterns or bifurcation regions between side or sex; however, variations were more common in females than in males. the mean length of the sciatic nerve was 133.30±19.33 mm, with no differences in length between sex or side. conclusion: variations in the anatomy of the sciatic nerve occurred in up to half of the sample, which may have implications for increased risk of iatrogenic injury in total hip arthroplasty and arthroscopy, piriformis syndrome or sciatic block failure. level of evidence: level 4 keywords: anatomical variation, piriformis muscle, piriformis syndrome, sciatic nerve, total hip arthroplasty surgical anatomy of the sciatic nerve and its relationship to the piriformis muscle with a description of a rare variant asmall t1 , gunston g2 , venter r3 , henry bm4 , keet k5 1 bsc(hons); post-graduate student, division of clinical anatomy and biological anthropology, department of human biology, faculty of health sciences, university of cape town, south africa ² mbchb, mphil ed; senior lecturer, division of clinical anatomy and biological anthropology, department of human biology, faculty of health sciences, university of cape town, south africa 3 mbchb, fc orth, mmed; orthopaedic surgeon, division of clinical anatomy, department of biomedical sciences, faculty of medicine and health sciences, stellenbosch university, south africa and division of orthopaedic surgery, department of surgical sciences, tygerberg hospital, south africa 4 md; coordinator, the heart institute, cincinnati children’s hospital medical center, cincinnati, ohio, united states of america 5 msc; lecturer, division of clinical anatomy, department of biomedical sciences, faculty of medicine and health sciences, stellenbosch university, south africa corresponding author: ms kerri keet, f103, fisan building, faculty of medicine and health sciences, francie van zyl drive, tygerberg hospital, cape town, south africa, 7505; tel: +27279389754; email: keetkerri@gmail.com https://orcid.org/0000-0002-6839-6836 https://orcid.org/0000-0002-0780-0364 https://orcid.org/0000-0003-0022-6969 https://orcid.org/0000-0002-8047-338x https://orcid.org/0000-0003-3513-9232 page 34 asmall t et al. sa orthop j 2020;19(1) introduction the sciatic nerve (sn) is formed in the pelvis from the ventral roots l4–s3 of the lumbosacral plexus.1 the nerve emerges from the greater sciatic foramen, and enters the gluteal region, inferior to the piriformis muscle (pm). it courses over the superior gemellus, tendon of obturator internus, inferior gemellus and quadratus femoris muscles and descends to the ischial tuberosity, passing deep to the gluteus maximus and the long head of the biceps femoris.2 the nerve then enters the posterior thigh and usually divides here into the tibial nerve (tn) and common fibular nerve (cfn). division typically occurs in the lower third of the thigh, near the apex of the popliteal fossa.3 however, this bifurcation level is variable.4 although it passes through the gluteal region, the sn does not give off any branches here. instead it continues inferiorly to supply motor and sensory innervation to the posterior compartment of the thigh and all compartments of the leg (including all lower limb joints) via its branches.1,5 in 1937, beaton and anson were the first to categorise variations in the relationship between the sn and pm (types a-g).6 the normal type, type a, is where the sn emerges as a single trunk below the pm.7 the pooled prevalence of type a has been reported as 85.2%.1 the course of the sn is of clinical importance in the surgical treatment of hip disorders using arthroscopy or open surgical approaches. posterior surgical approaches to the hip include the moore or southern approach, used mostly for hip arthroplasty procedures, and the kocher-langenbeck approach, typically used to visualise the posterior acetabulum.8,9 in arthroscopy, the joint is visualised with an arthroscope and instruments are introduced from one of several portals or standardised points of access to avoid critical structures.10 one of these portals, the postero-lateral portal, lies 2 cm posterior to the tip of the greater trochanter and has been associated with occasional injury to the sn, especially if the limb is positioned in external rotation.11 an abnormal course of the sn in relation to the pm may cause entrapment and compression, resulting in piriformis syndrome (ps), an extra-spinal cause of sciatic nerve pain.12 high bifurcation of the sn in the gluteal or thigh regions may result in inadequate analgesia during popliteal blocks as only one of its branches may be successfully anaesthetised.13 variations in the formation and bifurcation level of the sn indicate that a range of lengths are present in the population. a meta-analysis by tomaszewski et al. identified differences in the prevalence of variation between studies from different geographic regions, with a significant lack of studies from africa, potentially resulting in an increased risk of sciatic nerve pathologies (sciatica) and preventable iatrogenic nerve injuries.1 as such, the aim of this study was to determine a) the prevalence of the relationship types present between the sn and pm, b) the bifurcation level of the sn, and c) the length of the sn in a south african sample. any differences in the outcomes between side and sex were also investigated. materials and methods study design a cross-sectional observational study of 43 embalmed, formalinfixed adult cadavers was conducted at our institution between april and november 2017. the sample included both lower limbs from all cadavers that were dissected by second-year medical students in that year. exclusion criteria included cadavers in whom the relationship between the sn and pm could not be determined due to previous dissection, trauma or pathology. dissection the gluteal, posterior thigh and popliteal regions were dissected for both the left and right lower limbs of each cadaver. the skin, fat and connective tissues were removed using a standard dissection kit and technique. the body was placed in the prone position and a midline skin incision was made with a scalpel (size 10 blade), extending from the sacrum to the coccyx, progressing laterally beneath the fold of each buttock. the skin of the thigh and popliteal fossa were also removed by means of a vertical midline incision from the fold of each buttock to the popliteal fossa. the skin was reflected to either side and the fat and fascia were removed. next, the gluteus maximus was exposed and reflected laterally by cutting the muscle at the point of its origin from the iliac crest, posterolateral aspect of the sacrum and the sacrotuberous ligament. the gluteus medius was exposed and reflected inferiorly by means of an incision through its origin, on the lateral surface of the ilium. gluteus minimus, the pm and the sn were cleared of fascia and exposed. the course of the sn was followed between the hamstring muscles of the posterior thigh and the popliteal fossa, until its bifurcation into the cfn and tn. data collection the primary outcomes investigated in this study were a) the relationship types between the sn and pm, b) the region of bifurcation of the sn, and c) the mean length of the sn. secondary outcomes included determining any significant differences in the primary outcomes between males and females, and between left and right sides. the relationship between the sn and pm in each lower limb was classified into types described by beaton and anson6 (1937) and updated by tomaszewski et al.1 (2016). figure 1. the different types (a–g) of relationships between the sciatic nerve and piriformis muscle (figure reproduced with permission from tomaszewski et al.1) sn: sciatic nerve; pm: piriformis muscle; tn: tibial nerve; cfn: common fibular nerve page 35asmall t et al. sa orthop j 2020;19(1) the description of each type of relationship between the sn and pm is as follows: type a: the sn passes undivided below the pm (normal relationship) (figure 1a). type b: the sn divides in the pelvis, with the cfn piercing the pm and the tn emerging below the muscle (figure 1b). type c: the sn divides in the pelvis, with the cfn emerging superior to the pm and the tn emerging below the muscle (figure 1c). type d: the sn passes undivided through the belly of the pm (figure 1d). type e: the sn divides in the pelvis, with the cfn emerging superior to the pm and the tn piercing the muscle (figure 1e). type f: the sn emerges undivided superior to the pm and courses over the muscle (figure 1f). type g: the sn divides in the pelvis, with both the cfn and tn emerging below the pm (figure 1g). the types were recorded for both the left and right legs of each individual in a tabular format in microsoft excel, and photographs were taken with a huawei p8 smartphone (13 megapixels). two independent reviewers (anatomists) confirmed the pattern type for each limb to reduce the risk of observer bias. next, the region in which the sn bifurcated into the cfn and tn was documented. division of the nerve in the area between the sacrum and the superior border of the quadratus femoris muscle was classified as a gluteal division; bifurcation between the inferior border of quadratus femoris and the apex of the popliteal fossa a thigh division; and division within the popliteal fossa was classified as a popliteal fossa division. the regions of bifurcation were confirmed by a second observer. for cadavers in which division occurred in the thigh, the sn was measured in situ from the midpoint of the inferior border of the quadratus femoris muscle to its bifurcation point. the inferior border of quadratus femoris was used as a reference point as it is a consistent and easily identified landmark in all individuals. standard measuring equipment (an edo shatter-resistant ruler, yarn and pins) were utilised and the measurements were recorded in millimetres in microsoft excel. each measurement was taken three times, and the average of the three was used in the statistical analysis. intra-observer bias was assessed by the principal researcher repeating the measurements after a period of one month. these measurements were then compared with the first set of measurements. two independent reviewers, who were blinded to the study outcomes, measured the length of the sn in the assessment of inter-observer bias. information about height of the cadavers or limb length was not available, thus we were unable to correct for differences in length of the sn resulting from height variations. statistical analysis all statistical analyses were performed in ibm spss® version 24.0 (armonk, new york, united states). categorical data was represented as number (n) and percentage (%). for numerical data, summary statistics for variables were reported as mean±standard deviation (sd) for normally distributed data, or median and interquartile range for non-normally distributed data. normal distribution of the numerical data was determined with the shapiro-wilk test. intraand inter-observer variability of numerical data was assessed using bland-altman plots and anova tests. significant differences in the prevalence of pattern types and bifurcation level were investigated between right and left sides and between males and females using chi-square or fisher’s exact tests. differences in the length of the sn between the sex and side were investigated by means of unpaired student’s t-tests. for all statistical analyses, a p-value <0.05 was considered significant. results subject characteristics initially, 43 embalmed cadavers were included in the study. however, one male cadaver was excluded as the relationship between the sn and pm could not be determined due to previous dissection. this resulted in a final sample size of 42 cadavers (84 lower limbs), with 24 (57.1%) males and 18 (42.9%) females between the ages of 22 and 99 years. the cause of death in all individuals was natural. prevalence of the types of relationships present between the sn and pm type a was the most common pattern in 76.2%, followed by type g in 15.5% and lastly, type b in 7.1% (figures 2–4). the other types (c, d, e, f) were not observed. an unclassified pattern was observed in one right lower limb (1.2%) of a female cadaver, in which the sn emerged as two separate branches, with the cfn passing beneath the pm, while the tn coursed beneath the inferior gemellus muscle (figure 5). there were no significant differences in prevalence of types between sides (p=0.50) and sex (p=0.08). the above-mentioned data is summarised in table i. figure 2. type a in which the sciatic nerve (sn) emerged undivided below the piriformis muscle (pm). in this individual, the sciatic nerve divided into tibial (t) and common fibular (cf) nerves in the thigh. page 36 asmall t et al. sa orthop j 2020;19(1) of the 42 cadavers studied, 31 (73.8%) showed symmetry in the pattern types. type a was the most common pattern observed bilaterally (table ii). no significant differences were observed between males and females (p=0.927) with respect to symmetry of types. region of bifurcation of the sciatic nerve the sciatic nerve bifurcated in the gluteal, thigh and popliteal regions (table iii). significant differences were observed between males and females (p=0.02) in the region of sn bifurcation. bifurcation in the gluteal or thigh regions was 27.8% higher in males than in females, while bifurcation in the popliteal region was 27.7% more common in females than in males (table iii). no significant differences were observed between left and right sides (p=0.73). of the 42 cadavers, 30 (71.4%) displayed symmetrical division, with unilateral division present in 12 (28.6%). length of the sciatic nerve the length of the sn was measured for limbs in which the sn bifurcated in the thigh region. two limbs were excluded as the sn figure 3. type b in which the sciatic nerve emerged as two separate branches, with the common fibular nerve (cf) piercing the piriformis muscle (pm), while the tibial nerve (t) emerged below the muscle figure 4. type g in which the tibial nerve (t) and common fibular nerve (cf) emerged separately below the piriformis muscle (pm) figure 5. unclassified type in which the common fibular nerve (cf) emerged below the piriformis muscle (pm), and the tibial nerve (t) coursed below the inferior gemellus (ig) table i: the prevalence of sciatic nerve variation types with respect to sex and side total n (%) males n (%) females n (%) right n (%) left n (%) type a 64 (76.2) 35 (73) 29 (81) 32 (76.2) 32 (76.2) type b 6 (7.1) 2 (4.2) 4 (11.1) 4 (9.5) 2 (4.8) type g 13 (15.5) 11 (23) 2 (5.6) 5 (11.9) 8 (19) unclassified 1 (1.2) 0 (0) 1 (2.8) 1 (2.4) 0 (0) total 84 48 36 42 42 types c, d, e and f were not observed in this study. page 37asmall t et al. sa orthop j 2020;19(1) bifurcated at the lower border of quadratus femoris, resulting in 33 limbs being measured. of these, 17 were from the right side and 16 from the left; 20 were from males and 13 from females. the data were normally distributed (p>0.05). bland-altman and anova tests revealed good interand intra-observer reliability (p=0.99). the average length of the nerve was 133.30 mm±19.33 mm, with no significant differences between side (p=0.89) or sex (p=0.90). the mean±sd and range of the measurements are shown in table iv. independent t-tests revealed no significant differences between left and right (p=0.89) or between males and females (p=0.90). discussion the sn was first described in detail by ambroise par’e in the 16th century, and in the 19th century, cruveither observed variation in the bifurcation level.14 variant types include the sn passing through the belly of the pm, or the high bifurcation of the sn into the tn and cfn in the gluteal region, with one of these branches possibly coursing through the pm.6,7 in this study, variation was observed in the position of the sn relative to the pm, the bifurcation level of the nerve, and the length of the nerve. type a was the most common pattern in 76.2%, which is lower than the pooled prevalence of 85.2% (95% ci: 78.4–87.0) reported by tomaszewski et al.1 (table v). this suggests that variation in the relationship between the sn and pm may be more prevalent in south africans. when compared with the prevalence of type a determined for other african samples (85.9%), namely ethiopian, kenyan and ugandan, variation was still more common in this study.1,4,12,15 type g was the second most common pattern in 15.5%, which is significantly higher than the pooled prevalence worldwide (0.6%) and other african studies (3.8%).1 type b was observed in 7.1%, which, although higher than the prevalence for other african studies (2.2%), was similar to that reported for european studies (7.4%).1 types c, d, e and f although not present in our study, have been observed in other african studies with a prevalence of 2.6%, 0.4% 0.4% and 0.4% respectively.1 an unclassified type was observed unilaterally in one cadaver. similar patterns have been described by sabnis, where the tn was observed coursing beneath the inferior gemellus muscle.16 although not significantly different, type b was more common in females (11.1%) than in males (4.2%), similar to the findings by tomaszewski et al., who reported a prevalence of 20.1% and 11.7% respectively.1 these authors suggest that sex differences in the anatomy of the pelvic organs could predispose females to developing a type b pattern. this in turn, may increase the risk of ps in females, although the link between variant anatomy and ps is controversial.17-20 risk of iatrogenic sn injury during tha is, however, reported to be higher in females than in males, with suggested explanations related to the smaller size of the hip and associated muscles in females.21 variations in the course of the sn have also been implicated in iatrogenic nerve injury during certain procedures, such as total hip arthroplasty and arthroscopy.11,22 the moore/southern and kocherlengenbeck approaches utilise the same inter-muscular planes. from a lateral incision, the gluteus maximus is split, in line with the muscle fibres, in the interval between the anterior third and the posterior two-thirds of the muscle, revealing the posterior edge of the greater trochanter and the short external rotators: piriformis, gemelli and obturator internus. the piriformis and the rest of the external rotators are then tagged with a suture, for re-attachment later, and cut 1.5 cm from the insertion on the greater trochanter. retracting the external rotators posteriorly away from the trochanter effectively creates a sling that also pulls the sn out of the operating field.8,9 the incidence of sn palsy following tha ranges from 0.05% table iii: the region of sciatic nerve bifurcation with respect to sex and side total n (%) male n (%) female n (%) right n (%) left n (%) thigh 35 (41.7) 22 (45.8) 13 (36.1) 19 (45.2) 16 (38.1) gluteal 25 (29.8) 18 (37.5) 7 (19.4) 11 (26.2) 14 (33.3) popliteal 24 (28.6) 8 (16.7) 16 (44.4) 12 (28.6) 12 (28.6) total 84 48 36 42 42 table iv: length of the sciatic nerve total (n=33) males (n=20) females (n=13) right (n=17) left (n=16) mean±sd (mm) 131.0±54.4 137.1±64.1 121.7±35.1 132.4±46.4 129.6±63.4 range (mm) 7–250 7–250 60–194 34–240 7–250 table v: comparison of the prevalence of pattern types observed in the present study with those reported by tomaszewski et al. in a meta-analysis published in 20161 sample type a (%) (95% ci) type b (%) (95% ci) type c (%) (95% ci) type d (%) (95% ci) type e (%) (95% ci) type f (%) (95% ci) type g (%) (95% ci) present study 76.2 (66.4–84.0) 7.1 (2.9–12.9) 0 (0.0–0.0) 0 (0.0–0.0) 0 (0.0–0.0) 0 (0.0–0.0) 15.5 (9.4–24.7) total 85.2 (78.4–87.0) 9.8 (6.5–13.2) 1.9 (0.6–3.8) 0.8 (0.0–2.2) 0.5 (0.0–1.5) 0.4 (0.0–1.4) 0.6 (0.0–1.9) africa 85.9 (78.4–87.0) 2.2 (0.0–16.5) 2.6 (0.0–17.7) 0.4 (0.0–9.7) 0.4 (0.0–9.7) 0.4 (0.0–9.7) 3.8 (0.0–20.8) europe 87.7 (81.0–91.2) 7.4 (3.8–11.6) 2.0 (0.4–4.7) 0.9 (0.0–3.0) 0.3 (0.0–1.4) 0.2 (0.0–1.2) 1.1 (0.0–3.3) asia 77.2 (69.0–82.9) 17.0 (11.1–23.4) 2.2 (0.3–5.4) 1.2 (0.0–3.3) 0.9 (0.0–2.8) 0.6 (0.0–2.1) 0.4 (0.0–1.7) north america 92.6 (77.9–99.4) 2.8 (0.0–10.4) 0.6 (0.0–5.0) 0.3 (0.0–4.1) 0.2 (0.0–3.5) 0.2 (0.0–3.5) 0.2 (0.0–3.5) south america 85.0 (76.4–92.8) 9.8 (3.9–18.0) 1.4 (0.0–4.8) 0.8 (0.0–3.6) 0.5 (0.0–2.8) 1.4 (0.0–4.8) 0.5 (0.0–2.8) table ii: the prevalence of sciatic nerve variation types with respect to symmetry total n (%) males n (%) females n (%) bilateral (type a) 28 (66.7) 15 (35.7) 13 (31) bilateral (variant types*) 3 (7.1) 2 (4.8) 1 (2.4) unilateral (type a and variant type) 8 (19) 5 (11.9) 3 (7.1) unilateral (variant types*) 3 (7.1) 2 (4.8) 1 (2.4) total 42 24 18 *variant types included types b, g and the unclassified type page 38 asmall t et al. sa orthop j 2020;19(1) to 1.9%.21 during tha, the disruption of the insertion of the pm may predispose the sn to stretching, particularly in cases where a variant relationship exists.17 in addition, tha has been associated with limb lengthening, which places the sn under tension.23,24 in arthroscopy of the hip, certain variant positions result in the sn being situated closer to the placement of the posterolateral portal than the usual ±3 cm, increasing the risk of iatrogenic injury.10,11 awareness of the position of the sn and careful positioning of the lower limb during procedures have been shown to decrease the incidence of iatrogenic injury by up to 50%.25 piriformis syndrome (ps), although difficult to diagnose, is characterised by the following main symptoms: buttock pain that is aggravated during sitting, and external tenderness near the greater sciatic notch.26 in patients presenting with lower back or leg pain, the incidence of ps is around 5–6%.27 it has been suggested that variation in the relationship between the sn and pm is associated with ps. however, there is some debate as to the extent of this association, as not all individuals with ps have variant anatomy and vice versa.17-20 type b and other variants in which the sn, cfn or tn pass through the pm, causing possible nerve impingement, have been linked with ps. inflammation of the pm as a consequence of trauma may also result in ps, as inflammatory mediators released by the muscle irritate the sn.27 variation in the bifurcation point of the sn may result in the decreased effectiveness of popliteal blocks, as both the tn and cfn may not be anaesthetised if the nerve has divided in the gluteal region or superior thigh.4 in this study, variation was observed in the sn bifurcation level, with division in the thigh in 41.7%, followed by the gluteal and popliteal regions in 29.8% and 28.6%, respectively. this contradicts ogeng’o et al.’s findings, in which the sn divided in the gluteal region in 2.4%, in the thigh in 10.4%, while 67.1% divided in the popliteal fossa, in a total of 82 cadavers.4 interestingly, in 20.1% of cases, the nerve divided proximal to the pm. kukiriza et al. reported variation in the bifurcation level in a ugandan study, with no association between variation and the height of individuals.15 patients considered for popliteal blocks should have the sn bifurcation point visualised with ultrasound prior to the procedure to ensure adequate anaesthesia of the leg and foot. the length of the sn has been reported with little consistency with regard to any reference points. in this study, the inferior border of quadratus femoris was used, while other studies have measured the distance from the popliteal fossa to the bifurcation point (mean 65.43 mm).1 tomaszewski et al. proposed the distance from the transverse subcondylar plane be used, as it is a constant landmark.1 depending on the formation of the sn and its bifurcation level, the length of the nerve is highly variable between individuals, with a range of 7–250 mm (133.30 mm±19.33 mm) recorded in our study. there are limitations to this study. the length of the sn was measured from the inferior border of quadratus femoris, thus not reflecting the full length of the nerve from its formation in the pelvis. no biometric data (height or weight) was available for the cadavers, and limb length was not able to be measured, as medical students had already dissected the soft tissue structures. thus, we were not able to consider the effect of height or limb length on the length of the nerve. there was no medical history available for the cadavers, and it was not known whether any of the individuals suffered from ps during their lifetimes. therefore, we were unable to determine whether any of the variant types were associated with ps in our study. future morphometric studies of the sn should take the height, weight and body mass index of the sample into account. conclusion variation in the relationship between the sciatic nerve and piriformis muscle was observed, namely types a, b, g and a rare, unclassified pattern. type b, possibly associated with piriformis syndrome, was more common in females than in males, while no differences were observed between left and right sides. the bifurcation level of the sn was variable, which may have implications for successful popliteal blocks. bifurcation in the gluteal region was present in almost one-third of the sample. awareness of the position of the nerve during surgical procedures around the hip and the variability that has been described may reduce the risk of iatrogenic injury. as the sciatic nerve is highly variable in its course and bifurcation, ultrasound should be used to identify the position of the nerve and its bifurcation point prior to nerve blocks. the use of ultrasound may increase the success rate and reduce complications associated with sciatic or popliteal blocks. ethics statement all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. written consent was obtained from the body donors, while consent for indigent individuals was obtained by the department of health, south africa. the body donation programme at our institution complies with the international federation of associations of anatomists (ifaa)’s ‘recommendations of good practice for the donation and study of human bodies and tissues for anatomical examination’. in accordance with the policies of the institution’s review board, it was not necessary to seek ethical approval as written informed consent was obtained from body donors for teaching and research purposes. consent for the use of unclaimed bodies in this study was granted by the country’s government health department. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ta contributed to the acquisition, analysis and interpretation of data for the work; drafting of the work; and final approval of the version to be submitted to the journal. gg contributed to the conception and design of the work, revising it critically for important intellectual content; and final approval of the version to be published. rv contributed to revising the work critically for important intellectual content; and final approval of the version to be published. bh contributed to revising the work critically for important intellectual content; and final approval of the version to be published. kk contributed to the conception and design of the work; drafting the work, revising it critically for important intellectual content; and final approval of the version to be published. orcid asmall t http://orcid.org/0000-0002-6839-6836 gunston g http://orcid.org/0000-0002-0780-0364 venter r http://orcid.org/0000-0003-0022-6969 henry bm http://orcid.org/0000-0002-8047-338x keet k http://orcid.org/0000-0003-3513-9232 references 1. tomaszewski ka, graves mj, henry bm, 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eggli s, hankemayer s, muller me. nerve palsy after leg lengthening in total replacement arthroplasty for developmental dysplasia of the hip. j bone joint surg br. 1999;81(5):843-45. 25. navarro ra, schmalzried tp, amstutz hc, dorey fj. surgical approach and nerve palsy in total hip arthroplasty. j arthroplasty. 1995;10(1):1-5. 26. hopayian k, danielyan a. four symptoms define the piriformis syndrome: an updated systematic review of its clinical features. eur j orthop surg traumatol. 2018;28:155-64. doi: 10.1007/ s00590-017-2031-8. 27. benzon ht, katz ja, benzon ha, iqbal ms. piriformis syndrome: anatomic considerations, a new injection technique, and a review of the literature. anesthesiology. 2003;98:1442-48. https://doi.org/10.1007/s00276-006-0169-x https://doi.org/10.1007/s00276-005-0056-x https://doi.org/10.1007/s00590-017-2031-8 https://doi.org/10.1007/s00590-017-2031-8 _goback swanepoel s et al. sa orthop j 2018;17(3) doi 10.17159/2309-8309/2018/v17n3a2 south african orthopaedic journal http://journal.saoa.org.za traumaeducation citation: swanepoel s, dunn r, klopper j, held m. the fc orth(sa) final examination: how effective is the written component? sa orthop j 2018;17(3):25-29. http://dx.doi.org/10.17159/2309-8309/2018/v17n3a2 editor: prof lc marais, university of kwazulu-natal, durban received: december 2017 accepted: february 2018 published: august 2018 copyright: © 2018 swanepoel s. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: the authors declare they received no funding for this research. conflict of interest: the authors declare that they have no conflicts of interest that are directly or indirectly related to the research. abstract background: to determine the pass rate of the final exit examination of the college of orthopaedic surgeons of south africa [fc orth(sa)] and to assess the correlation between the written component with the clinical and oral component. methods: results of candidates who participated in the fc orth(sa) final examination during a 12-year period from march 2005 through to november 2016 were assessed retrospectively. pass rates and component averages were analysed using descriptive and inferential statistics. spearman’s rho test was used to determine the correlation between the components. results: a total of 399 candidates made 541 attempts at the written component of the examination; 71.5% of attempts were successful and 387 candidates were invited to the clinical and oral component, of which 341 (88%) candidates were certified. the second-attempt pass rate for those candidates who wrote the written component again was 42%. the average annual increase in the number of certified candidates was 8.5%. the overall certifying rate increased by 1.5% for this period. invited candidates who scored less than 54% for the written component were at significant risk of failing the clinical and oral component. the written component showed weak correlation with the clinical and oral component (r=0.48). conclusion: while the written component was found to be an effective gatekeeper, as evidenced by a high eventual certifying rate, the results of this component of the fc orth(sa) final examination did not correlate strongly with the performance in the clinical and oral component. this finding confirms the value of the written component as part of a comprehensive assessment for the quality of orthopaedic surgeons. level of evidence: level 4 key words: certification examinations, postgraduate training, orthopaedic surgery the fc orth(sa) final examination: how effective is the written component? swanepoel s¹, dunn r², klopper j³, held m⁴ ¹ mbchb(up), registrar, department of orthopaedic surgery, faculty of health sciences, university of cape town, south africa ² mbchb(uct), mmed(orth), fc orth (sa); professor and head of department of orthopaedic surgery, faculty of health sciences, university of cape town, south africa ³ mbchb, fcs(sa); department of surgery, faculty of health sciences, university of cape town, south africa ⁴ md, phd(orth), fc orth(sa), department of orthopaedic surgery, faculty of health sciences, university of cape town, south africa corresponding author: dr s swanepoel, department of orthopaedic surgery, groote schuur hospital, observatory, cape town 8000; email: swanepoeles@gmail.com; cell: 083 227 8594; work: 021 404 5108 page 26 swanepoel s et al. sa orthop j 2018;17(3) introduction and background the urgent need to produce well-trained surgeons in low-middle income countries (lmic) has recently been highlighted by the lancet commission on global surgery.1 a crucial requisite to evaluate the quality of surgeons produced is a comprehensive specialist exit examination which confirms a candidate is fit to practice. in south africa, orthopaedic surgical training is under the supervision of eight academic institutions. the health professions council of south africa (hpcsa) has appointed the colleges of medicine of south africa as the designated unitary examination body to evaluate and certify successful candidates of the college of orthopaedic surgeons of south africa [fc orth(sa)] final examination. candidates need to complete training time, produce a dissertation and pass the final composite examination to become a specialist. although this format seems well suited to assess the complexity of surgical competence, there is limited evidence in the surgical domain regarding the description of the examination processes with the majority of literature devoted to the psychometric adequacy of various assessment methods.2,3 furthermore, the composite examination format is a labourand resource-intensive undertaking and depends to a great degree on the feasibility regarding high cost, examiners’ time, facilities and funds, especially for lmics.4,5 with resource limitations in sub-saharan africa a reality, the focus is to minimise the administrative burden for examination bodies and therefore constantly re-evaluate and choose appropriate examination components which can still deliver the desired quality in selecting our surgeons. the overall aim of this study was therefore to analyse and describe the results of the fc orth(sa) final examination. specific objectives were to assess the correlation between the written component with the clinical and oral components of the examination as well as to determine the overall certifying rate of those candidates who passed the written component. the written component functions as a gatekeeper, preventing candidates who fail this component from progressing to the clinical and oral component. in addition, the written component measures higher order cognitive skills which is different from the more clinical skills required in the oral and clinical components.6 methods a retrospective review of the fc orth(sa) final examination results was conducted and all test results of this specialist examination from march 2005 through to november 2016 were included. no demographic data was available and the results of all candidates who were admitted to the written component were included in the analysis. examination structure the fc orth(sa) use a composite test format to assess candidates’ knowledge and clinical skills. this examination comprises written papers, clinical cases and oral examinations (figure 1). during the period of this review, the written component consisted of three 3-hour papers with shortand essay-style questions. the clinical component was composed of a long case with 30 minutes to interview and examine a non-standardised patient. the candidate then presented the case in 15 minutes to the examiners with an additional 15 minutes allocated for discussion around the case. these questions were not standardised. furthermore, candidates were to examine two sets of short clinical cases, pathological cases as well as radiological material. the oral examination consisted of three 30-minute examinations. each candidate was assessed separately by three teams of two examiners each. they covered orthopaedic trauma, reconstructive orthopaedic surgery and orthopaedic pathology. the overall mark for each component reflected a score made up of marks from the three sub-components. all scores were expressed on a percentage scale. the set pass mark for the written examination was 50% and subsequently allowed for entry into the clinical and oral examination. the weighing of these two components were equal. candidates were unsuccessful if they failed two or more sub-components or if their combined mark for the clinical and oral examination was less than 50%. statistical analysis descriptive and inferential statistics were performed using the wolfram programming lab (wolfram research, inc. champaign, illinois) to analyse the data. the shapiro-wilk test was used to determine the data distribution for the three components of the examination. non-parametric tests were used to analyse and describe the various results of the examination components as the data was not normally distributed. continuous variables were analysed using the mann-whitney test (when two sets of data were compared) or kruskal-wallis test (when more than two sets of data were compared). spearman’s rank correlation was used to describe the relationship between the different components of the examination. a p-value of <0.05 was accepted as statistically significant. results during the 12-year period, a total of 399 candidates made 541 attempts at the written part of the examination. at this written component, 71.5% of attempts were successful and 387 candidates were invited to the clinical and oral component, of which 341 (88%) candidates were certified. figure 2 gives details of the number of candidates admitted to the written component, invited candidates to the clinical and oral component, and number of certified candidates. an average annual increase of 8.5% was observed in the number of successful candidates during this period. figure 3 shows the pass rates of the three components and the overall certifying rate for each year. the overall certifying rate increased by 1.5% during the period of this study. eighty-six candidates made 141 repeat attempts at the written component. sixty-six candidates eventually passed the examination at an fc orth(sa) final examination written component > 50% pass > 50% clinical component oral component figure 1. flow chart illustrating the sequence of events in the examination process page 27swanepoel s et al. sa orthop j 2018;17(3) average of 2.5 attempts. the second-attempt pass rate for those candidates who attempted the written component again was 42%. figure 4 shows the breakdown of the annual number of first and second-attempt candidates who were successful in the fc orth(sa) final examination. the marks allocated for each component (written, clinical and oral) were analysed separately. table i compares the average percentage scores of the sub-components. the average mark for the final examination was 60.1% (iqr 56–64%). there was a statistically significant difference when comparing the averages of the written, clinical and oral components, the three written papers, as well as the three clinical sub-components (p<0.05). the averages for the three sub-components of the oral examination were similar (p=0.97). furthermore, the annual averages of the written, clinical and oral components showed marked variance (p<0.5). candidates who passed the clinical and oral component scored significantly higher marks in the written component compared to candidates who were unsuccessful in the oral or clinical component. the average marks were 59.6% (iqr 56–63.5%) compared to 54.1% (iqr 51–57%) respectively in the written component (p<0.05). sixty-nine per cent of candidates who were unsuccessful in the clinical and oral component failed due to poor performance in the clinical component of the examination. the components correlated poorly with each other (p<0.05). the highest correlation coefficient was between the written and oral component (r=0.49). the written component correlated poorly with the clinical component (r=0.33) and showed a weak correlation with the combined clinical and oral mark (r=0.48). discussion this is the first reported study evaluating the outcomes of an orthopaedic surgery specialist examination in an lmic. the present study shows that the results of the written component did figure 2. line graph showing the annual volume of candidates admitted to the written examination, candidates invited to the clinical and oral component, and overall successful candidates 0 10 20 30 40 50 60 70 80 1 3 4 5 6 7 8 9 1 0 1 1 n um be r of c an di da te s year written attempts written passed successful candidates figure 3. line graph showing the annual pass rates of candidates admitted to the written examination, candidates invited to the clinical and oral component, and overall certifying rate 0 10 20 30 40 50 60 70 80 90 100 1 2 3 4 5 6 7 8 9 10 pe rc en ta ge year clinical and oral written overall figure 2. line graph showing the annual volume of candidates admitted to the written examination, candidates invited to the clinical and oral component, and overall successful candidates figure 3. line graph showing the annual pass rates of candidates admitted to the written examination, candidates invited to the clinical and oral component, and overall certifying rate page 28 swanepoel s et al. sa orthop j 2018;17(3) not correlate with the clinical and oral components; however, the written component was an effective gatekeeper as evidenced by the high certifying rate for candidates who passed this component. this finding confirms that the written component is an essential part of the composite examination process. the poor correlation between the components likely indicates that the components are testing different aspects of competency. the essay-style questions in the written component were aimed at testing candidates’ knowledge base and higher order cognitive processes when dealing with common orthopaedic problems.6 the longand short-case clinical component aims to assess candidates’ competency holistically by examining real patients with actual problems.7 this format requires candidates to display their knowledge, skills and judgement in a given sub-discipline. a possible explanation could be that the knowledge base tested in the written component has little relation to the more clinically based skills required by candidates for performance in the clinical and oral component of the examination. deterioration of clinical examination skills among medical practitioners has been attributed to improvements in technology and a lack of time to properly examine patients.8,9 however, especially in resourcerestricted countries, a thorough clinical examination remains an important skill in the armamentarium of healthcare professionals. it is postulated that the clinical examination component of an examination allows for evaluation of the effectiveness of a training programme and acts as a screening device to identify inadequately trained candidates.7 in this study, 69% of candidates who were unsuccessful in the clinical and oral component of the examination failed due to poor performance in the clinical component of the examination. this finding might point out inefficiencies in the training programme and poor candidate preparation. the fc orth(sa) final examination uses the traditional pass mark of 50% for the written component. this pass mark appears to be generous given that candidates who scored less than 54% for this component were at significant risk of failing the clinical and oral component of this examination. this finding should be interpreted with caution due to the weak positive correlation found between the first and second parts of the examination. the significant variation observed in the annual average mark of the written component suggests differences in the cognitive ability levels between the groups of candidates for each examination sitting or could indicate the lack of standardisation of the examination between different hosting centres. the process of determining an appropriate pass mark to separate the competent candidate from those who do not perform well enough is called standard setting. in the absence of formal standard setting methods to improve the fairness of the set pass mark, variations in the level of difficulty of each examination could potentially lead to the misclassification of candidates. the ideal pass mark is the one in which unsuccessful candidates are truly incompetent and successful candidates are truly competent. for this reason the medical education literature strongly recommends formal standard setting procedures to improve the quality of high stakes certifying examinations and to ensure that the pass mark is robust and defensible especially in an era of increased litigation.10 there is limited literature on specialist certification processes and objective measures to improve it.11 historically assessment mainly focused on knowledge and know-how and less on skills and competencies. as the findings of our study were evident to the examination board, recent changes include the addition of an objective structured clinical examination (osce), multiple-choice questions (mcq) with single best answers and extended matching questions. the introduction of an osce to the clinical component follows the international trend towards a more competencybased certification process.12 to our knowledge this will be the first postgraduate orthopaedic surgery exit examination in africa to include an osce as part of the certifying process. currently the essay-style questions are in a process of being phased out of the written component of the fc (orth)sa final examination and have been replaced by the more reliable and reproducible mcq format.6 the mcq assessment format is well known for its superior objectivity and allows for a wider sampling of a subject, which results in a more reproducible assessment and reduces the perception of examiner bias. these changes also served to improve the cost-effectiveness of the written component given the superior efficiency of their marking. the introduction of formal standard setting methods in the written and clinical components has also improved the credibility of pass/fail decisions. more research is required to guide evaluation bodies in resourceconstrained environments to ensure that their examination processes are evidence-based in order to provide a credible and defensible certifying examination.11 the cost of the two-day assessment in the second part of the fc orth(sa) examination is figure 4. breakdown of first-attempt candidates and repeat-attempt candidates who were successful in the fc orth(sa) final examination per annum 0 10 20 30 40 50 60 70 80 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 n um be r o f c an di da te s year repeat-attempt candidates first-attempt candidates figure 4. breakdown of first-attempt candidates and repeat-attempt candidates who were successful in the fc orth(sa) final examination per annum table i: comparing the average mark of the sub-components of the written, clinical and oral examinations 1 2 3 p-value written papers (iqr) 55 (48–62) 55 (48–62) 57 (51–64) <0.05 clinical cases (iqr) 60 (55–70) 57 (50–65) 59 (54–65) <0.05 oral examination (iqr) 60 (55–70) 60 (55–70) 60 (55–70) 0.97 page 29swanepoel s et al. sa orthop j 2018;17(3) enormous for the examination body and the candidates, and more research is required that will lead to cost-effective and goal-directed changes in the clinical and oral component. the limitations of this study include the lack of additional objective variables that may predict candidate performance in the fc orth(sa) examination and future research could potentially include the appraisal of surgical logbooks, primary and intermediate examination results as well as annual in-training examination results. these predictors could potentially lead to the identification of inadequately trained candidates prior to the final examinations and the initiation of appropriate remedial action to improve their success rates. conclusion this study confirms that the results of the written component did not correlate with performance in the clinical and oral component. this finding highlights the importance of the various components of this examination. the written component was found to be an effective gatekeeper, as evidenced by a high eventual certifying rate for candidates who passed this component. this study adds a contribution to the medical education literature describing the value of the written component in the composite examination format of a high-stakes postgraduate certification examination. ethics statement ethical approval was obtained from the institution’s human research ethics committee. references 1. meara jg, greenberg slm. the lancet commission on global surgery global surgery 2030 : evidence and solutions for achieving health , welfare and economic development. surgery. 2014;157(5):834-35. doi:10.1016/j.surg.2015.02.009 2. chou s, lockyer j, cole g, et al. assessing postgraduate trainees in canada : are we achieving diversity in methods. medical teacher. 2016 (oct);31:2, e58-e63. doi:10.1080/01421590802512938 3. hutchinson l, aitken p, hayes t. are medical postgraduate certification processes valid ? a systematic review of the published evidence. med educ 2002;36:73-91. doi:10.1046/j.1365-2923.2002.01120.x 4. rahman g. appropriateness of using oral examination as an assessment method in medical or dental education. med educ 2011;1(2). doi:10.4103/0974-7761.103674 5. turner jl, dankoski me. objective structured clinical exams : a critical review. fam med 2008;40(8):574-78. 6. hift rj. should essays and other open-ended -type questions retain a place in written summative assessment in clinical medicine? bmc medical education 2014;14:249. doi:10.1186/ s12909-014-0249-2 7. ponnamperuma gg, karunathilake im, mcaleer s, davis mh. medical education in review. the long case and its modifications : a literature review. med educ 2009:936-41. doi:10.1111/j.1365-2923.2009.03448.x. 8. feddock ca. the lost art of clinical skills. am j med 2007. doi:10.1016/j.amjmed.2007.01.023 9. asif t, mohiuddin a, hasan b, pauly rr. importance of thorough physical examination : a lost art. cureus 2017 (may);9(5):e1212. doi 10.7759/cureus 10. goldenberg mg, garbens a, szasz p, hauer t, grantcharov tp. systematic review to establish absolute standards for technical performance in surgery. br j surg 2017:13-21. doi:10.1002/ bjs.10313 11. burch vc, norman gr, schmidt hg, van der vleuten cpm. are specialist certification examinations a reliable measure of physician competence? adv in health sci educ 2008:521-33. doi:10.1007/s10459-007-9063-5 12. jonker g, manders la, marty ap, et al. variations in assessment and certification in postgraduate anaesthesia training: a european survey. br j anaesth. 2017 (sept):1-6. doi:10.1093/bja/ aex196 page 28 sa orthopaedic journal autumn 2017 | vol 16 • no 1 calcific myonecrosis following snakebite n ferreira bsc, mbchb, fc orth(sa), mmed(orth), phd department of orthopaedic surgery, tygerberg hospital, stellenbosch university, cape town, south africa lc marais mbchb, fcs orth(sa), mmed(ortho), phd department of orthopaedic surgery, grey’s hospital, nelson r mandela school of medicine, university of kwazulu-natal, pietermaritzburg, south africa corresponding author: dr nando ferreira department of orthopaedic surgery tygerberg hospital stellenbosch university 7505 cape town south africa tel: +27 21 938 4911 email: nferreira@sun.ac.za introduction calcific myonecrosis is a rare condition and less than 50 cases have been reported in the english literature. it was first described by gallie and thompson in 1960 as a late sequela of compartment syndrome.1 although a hypothesis for the development of this complication was proposed by janzen et al. in 1993 and o’keefe et al. in 1995, the exact physiological mechanism is not fully understood.2,3 the condition is characterised by muscle necrosis of an entire osteofacial compartment with central liquefaction and peripheral calcification. the clinical and radiographic findings can be misdiagnosed as a soft tissue sarcoma.4-6 differential diagnosis includes synovial sarcoma and soft tissue osteosarcoma as well as benign conditions like myositis ossificans, dermatomyositis, tumoral calcinosis and calcific tenosynovitis (table i).5 we report two similar cases of calcific myonecrosis of the anterior compartment of the lower leg following snakebites and review the available literature on this rare condition. case report two similar cases were managed at our unit during the same year. these cases involved female patients aged 62 and 81 years respectively, who both reported a painless, progressively enlarging mass in the anterolateral aspect of abstract calcific myonecrosis is a rare condition and is believed to be a late sequela of untreated compartment syndrome. patients usually present with a progressively enlarging mass, years after the initial injury, that can be misdiagnosed as a soft tissue sarcoma. calcific myonecrosis following snakebite is extremely rare. the anterior compartment of the leg is most frequently involved and appears to be especially vulnerable to developing this complication. conservative management should be considered in asymptomatic patients but spontaneous soft tissue breakdown with sinus formation may develop and prolonged surveillance is advised. we report two similar cases of calcific myonecrosis of the anterior compartment of the lower leg that developed decades following snakebite. key words: calcific myonecrosis, compartment syndrome, soft tissue calcification, snakebite http://dx.doi.org/10.17159/2309-8309/2017/v16n1a3 table i: differential diagnosis of calcified soft tissue lesions malignant conditions benign conditions synovial sarcoma heterotypic ossification/myositisossificans epithelioid sarcoma dystrophic soft tissue calcification soft tissue osteosarcoma dermatomyositis/polymyositis soft tissue mesenchymal ondrosarcoma tumoral calcinosis diabetic myonecrosis calcific tenosynovitis saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/02/27 7:42 pm page 28 saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/02/27 7:42 pm page 29 page 30 sa orthopaedic journal autumn 2017 | vol 16 • no 1 only two reports of calcific myonecrosis following snakebites have been reported in the english literature and these cases are almost identical to the cases presented here. yuenyongviwat et al. reported a case of a 66-year-old thai woman who presented with calcific myonecrosis 52 years after being bitten by a malayan pit viper (calloselasma rhodostoma).18 the anterior compartment of the leg was affected and after a four-year period of conservative management, soft tissue breakdown necessitated surgical intervention in the form of mass resection and primary closure with vacuum drainage. chun et al. also reported a case of calcific myonecrosis following a snakebite. their case presented 44 years after being bitten, again involved the anterior compartment of the leg and was treated by mass resection.19 although neither of our patients could recall the species of snake, a member of the viperidae family was probably involved. three viper species are frequently encountered in kwazulu-natal, including the puff adder (bitis arietans), berg adder (bitis atropos) and night adder (causus rhombeatus).15 the puff adder specifically, is one of the most common venomous snakes in south africa and is responsible for more fatal bites than any other snake. if not fatal, puff adder bites frequently result in extensive necrosis that may require amputation of the affected limb.20 a bite from one of these snakes is consistent with previous reports of compartment syndrome7,13,14,21 and calcific myonecrosis18,19 following viper bites. interestingly, venom from the saw-scaled viper (which contains ecarin that activates prothrombin) has also been associated with renal cortical necrosis followed by calcification.16 acute anterior compartment syndrome involves the isolated anterior compartment of the lower leg and usually follows trauma.22 wood et al. reported that approximately 9% of patients with rapid progressive swelling (rps) after serious snakebites develop compartment syndrome.23 in the acute setting, management involves release of this compartment through a fasciotomy. compartment syndrome as a result of snakebite frequently involves the anterior compartment in isolation and may be the result of envenomation of this compartment and the specific anatomical characteristics of the anterior compartment of the lower leg. the sequelae of untreated compartment syndrome include rhabdomyolysis, permanent nerve damage, contracture and loss of function, infection and even amputation. calcific myonecrosis is believed to be a rare complication of untreated compartment syndrome and follows several years to decades after the trauma. conservative management of calcific myonecrosis is advised in asymptomatic patients. some authors even propose that calcific myonecrosis be considered as ‘don’t-touch’ lesions due to the high risk of infection following surgical intervention.24-27 a conservative approach does not, however, preclude infective complications. affected patients may present with soft tissue breakdown as the mass enlarges and de novo infection has also been reported.5 spontaneous soft tissue breakdown with sinus formation was seen in one of our cases and in the case reported by yuenyongviwat et al.18 patients with calcific myonecrosis should be followed closely so that early intervention can be initiated once soft tissue breakdown occurs. the theory that calcific myonecrosis develops after compartment syndrome suggests that a treatable cause for this complication exists. patients who present with snakebites to the lower limb should be carefully evaluated for compartment syndrome and the appropriate treatment instituted. conclusion calcific myonecrosis is a rare complication following snakebites. the anterior compartment of the leg is most frequently involved and appears especially vulnerable to developing this complication. conservative management should be considered in asymptomatic patients but spontaneous soft tissue breakdown with sinus formation may develop, and prolonged surveillance is advised. compliance with ethics guidelines written consent was obtained from both patients for publication of this report and any accompanying images. a copy of the written consent is available for review by the editor-in-chief of this journal. the content of this article in the sole work of the authors. no benefits of any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. references 1. gallie we, thomson s. volkmann’s ischaemic contracture: two case reports with identical late sequelae. can j surg. 1960;3:164-66. 2. janzen dl, connell dg, vaisler bj. calcific myonecrosis of the calf manifesting as an enlarging soft-tissue mass: imaging features. ajr am j roentgenol. 1993;160(5):107274. 3. o’keefe rj, o’connell jx, temple ht, scully sp, kattapuram sv, springfield ds, et al. calcific myonecrosis. a late sequela to compartment syndrome of the leg. clin orthop relat res. 1995;318:205-13. 4. wang jw, chen wj. calcific myonecrosis of the leg: a case report and review of the literature. clin orthop relat res. 2001;389:185-90. 5. holobinko jn, damron ta, scerpella pr, hojnowski l. calcific myonecrosis: keys to early recognition. skeletal radiol. 2003;32(1):35-40. 6. portabella f, narvaez ja, llatjos r, cabo j, maireles m, serrano c, et al. [calcific myonecrosis of the leg]. rev esp cir ortop traumatol. 2012;56(1):46-50. saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/02/27 7:42 pm page 30 sa orthopaedic journal autumn 2017 | vol 16 • no 1 page 31 7. evers lh, bartscher t, lange t, mailander p. adder bite: an uncommon cause of compartment syndrome in northern hemisphere. scand j trauma resusc emerg med. 2010;18:50. 8. reading cj. incidence, pathology, and treatment of adder (vipera berus l.) bites in man. j accid emerg med. 1996;13(5):346-51. 9. cawrse nh, inglefield cj, hayes c, palmer jh. a snake in the clinical grass: late compartment syndrome in a child bitten by an adder. brit j plast surg. 2002;55(5):43435. 10. tucker sc, josty i. compartment syndrome in the hand following an adder bite. j hand surg br. 2005;30(4):434-35. 11. karlson-stiber c, salmonson h, persson h. a nationwide study of vipera berus bites during one year-epidemiology and morbidity of 231 cases. clin toxicol. 2006;44(1):25-30. 12. anz aw, schweppe m, halvorson j, bushnell b, sternberg m, andrew koman l. management of venomous snakebite injury to the extremities. j am acad orthop surg. 2010;18(12):749-59. 13. hamdi mf, baccari s, daghfous m, tarhouni l. upper limb compartment syndrome after an adder bite: a case report. chin j traumatol. 2010;13(2):117-19. 14. dhar d. compartment syndrome following snake bite. oman med j. 2015. 15. wood d, sartorius b, hift r. ultrasound findings in 42 patients with cytotoxic tissue damage following bites by south african snakes. emerg med j. 2016 16. gopalakrishnakone p, faiz m, fernando r, gnanathasan c, habib a, yang c, editors. clinical toxicology in asia pacific and africa. netherlands: springer netherlands; 2015. 17. braud s, bon c, wisner a. snake venom proteins acting on hemostasis. biochimie. 2000;82(9-10):851-9. 18. yuenyongviwat v, laohawiriyakamol t, suwanno p, kanjanapradit k, tanutit p. calcific myonecrosis following snake bite: a case report and review of the literature. j med case rep. 2014;8:193. 19. chun ys, shim hs. calcific myonecrosis of the antetibial area. clin orthop surg. 2010;2:191-94. 20. blaylock r. epidemiology of snakebite in eshowe, kwazulu-natal, south africa. toxicon. 2004;43(2):159-66. 21. kincaid r, ruppert s. rattlesnake envenomation and compartment syndrome: a case study. j adv nurs. 2009;11(1):1-7. 22. leach re, hammond g, stryker ws. anterior tibial compartment syndrome. acute and chronic. j bone joint surg [am]. 1967;49(3):451-62. 23. wood d, webb c, demeyer j. severe snakebites in northern kwazulu-natal: treatment modalities and outcomes. s afr med j. 2009;99(11):814-18. 24. malisano lp, hunter ga. liquefaction and calcification of a chronic compartment syndrome of the lower limb. j orthop trauma. 1992;6(2):245-47. 25. early js, ricketts ds, hansen st. treatment of compartmental liquefaction as a late sequelae of a lower limb compartment syndrome. j orthop trauma. 1994;8(5):445-48. 26. tuncay ic, demirors h, isiklar zu, agildere m, demirhan b, tandogan rn. calcific myonecrosis. int orthop. 1999;23(1):68-70. 27. o’dwyer hm, al-nakshabandi na, al-muzahmi k, ryan a, o’connell jx, munk pl. calcific myonecrosis: keys to recognition and management. ajr am j roentgenol. 2006;187(1):w67-76. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/02/27 7:42 pm page 31 404 not found layout 1 south african orthopaedic journal kruger n et al. sa orthop j 2018;17(1) http://journal.saoa.org.za doi 10.17159/2309-8309/2018/v17n1a2 shoulder the oxford shoulder score: cross-cultural adaptation and translational validation into afrikaans kruger n1, stander l2, maqungo s3, roche s4, held m5 1 mbchb(uct), msc (t) diag imaging (oxon), msc (res) orth (oxon); orthopaedic research unit, department of orthopaedics, university of cape town 2 bsc(hons)(stel)anatomy, bsc anatomy(stel), btech(hons)(cput); division of anatomy and histology, faculty of medicine and health sciences, stellenbosch university, tygerberg, cape town 3 mbchb, fc orth(sa), mmed; professor and head: orthopaedic trauma service, orthopaedic research unit, department of orthopaedics, university of cape town 4 mbchb, fc orth(sa); professor and head: shoulder and elbow unit, orthopaedic research unit, department of orthopaedics, university of cape town 5 md, phd(uct), fc orth(sa), orthopaedic research unit, department of orthopaedics, university of cape town corresponding author: dr neil kruger, orthopaedic research unit, department of orthopaedics, university of cape town, h49, old main building, groote schuur hospital, observatory, cape town, 7937; email: neilkruger6@gmail.com; cell: 0027 793782480; tel: 0027 214045108 abstract purpose: the oxford shoulder score (oss) is a robust and universally utilised shoulder score that has been translated for use in western and asian countries. this study aimed to translate, cross-culturally adapt and psychometrically validate the afrikaans version of the oss for use in africa. methods: translation and cross-cultural adaptation was performed in accordance with guidelines in the literature. onehundred-and-eight consecutive patients with either degenerative or inflammatory pain of the shoulder were prospectively enrolled. patients were evaluated by completing the afrikaans oss, constant-murley, quickdash, and the subjective shoulder value (ssv) scores. comprehensibility and acceptance, as well as any floor or ceiling effects, were calculated. reliability was assessed through reproducibility. internal consistency was assessed using cronbach’s alpha. validity was determined using a pearson correlation coefficient between the afrikaans oss and the other validated shoulder scores. results: comprehensibility and acceptance were excellent, and no floor or ceiling effects were observed. reproducibility (r=0.99) and internal consistency (cronbach’s alpha = 0.93) were both excellent. correlation of the afrikaans oss with the constant-murley and quickdash was excellent (r=0.84; r=0.81 respectively), and very good with the ssv and visual analogue scale (vas) pain score (r=0.73; r=0.66). conclusion: the afrikaans oss proved understandable, acceptable, reliable and valid. it is an appropriate instrument for use in afrikaans-speaking patients with shoulder pain from degenerative or inflammatory origin. level of evidence: level 3 key words: patient reported outcome measure (prom); oxford shoulder score (oss); shoulder pain; afrikaans; questionnaire; cross-cultural; quality of life; psychometrics; rotator cuff disease citation: kruger n, stander l, maqungo s, roche s, held m. the oxford shoulder score: cross-cultural adaptation and translational validation into afrikaans. sa orthop j 2018;17(1):17-23. http://dx.doi.org/10.17159/2309-8309/2018/v17n1a2 editor: prof anton schepers, university of the witwatersrand received: november 2016 accepted: february 2017 published: march 2018 copyright: © 2018 kruger n, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: this study did not require funding. conflict of interest: the authors declare they have no conflicts of interest. page 18 kruger n et al. sa orthop j 2018;17(1) introduction shoulder pain from inflammatory or arthritic disease is a disabling condition, with an incidence of 7% in the general population rising to about 20% in the elderly.1,2 most studies on shoulder pain have been conducted in developed countries,3 but the burden of musculoskeletal disease does not escape low-to-middle income countries.4 in these regions, manual labour consists commonly of high-risk work for shoulder pathology such as repetitive work, working with hands above shoulder height, carrying heavy loads, and operating vibrating tools.4-7 with specific reference to shoulder pain, the oxford shoulder score (oss) is a joint-specific patient-reported outcome measure (prom) to assess patient perception about their shoulder pain and its effect on their quality of life. it has been translated into and validated in numerous european and asian languages,5,6,8-13 reflecting its robustness and universal acceptability. it is yet to be translated into and validated in any african language. afrikaans is the most spoken language in the western half of south africa, with 50% of the western cape population speaking it as a first language, and the total number speaking it totalling almost seven million people.14,15 with increased emphasis on randomised controlled trials to provide adequate answers to clinical questions,16 and the difficulty in acquiring sufficient patient numbers without multicentre international collaboration,17 the aim of this study was to translate and crossculturally validate the oss into afrikaans to enable appropriate assessment of our patient populations’ shoulder pain, and increase its universal applicability. methods the study was conducted in three distinct phases. the first phase involved the translation of the oss, followed by a pilot study, run to assess comprehension and suitability of the translated questionnaire. lastly a definitive prospective trial was undertaken. translation translation was performed in accordance with guidelines in the literature.16,18,19 due to the wide variety of dialects spoken among the various ethnic groups, emphasis on understanding and simplicity of concept over grammatical correctness was requested. three bilingual speakers independently translated the oss into afrikaans. each person had a medical background and at least a university level degree of education. a single translated version was then agreed upon by consensus decision. three different translators then back translated this version into english. following this, a final version was agreed upon, again at consensus, which matched the original version of the oss (appendix see end of article). the translated oss was piloted on ten consecutive bilingual patients presenting to the upper limb outpatient clinic with shoulder pain. comprehension of 11 of the 12 questions was perfect. one question required adjustment of one word to a more colloquial form to facilitate easier understanding. all patients completed the questionnaire in less than six minutes and none described the test as difficult or onerous. validation study a total of 108 consecutive patients were prospectively recruited via the upper limb outpatient clinic of a tertiary care hospital in cape town, from july to november 2015. patients were included if they were over 18 years of age; were able to read, write and speak both english and afrikaans; and had shoulder pain arising from inflammatory, degenerative or post-traumatic causes. patients with shoulder pain from instability, as well as literacy and language difficulties, were excluded. each patient first completed the translated oss, followed by the quickdash20 (which had a visual analogue scale [vas] pain score included), subjective shoulder value (ssv)21 and constant-murley shoulder assessment.22 the clinical assessment of the constant-murley score was administered by a single researcher, under the guidance of and following a training session with the head of the shoulder unit. patient-specific outcome scores oxford shoulder score the oss is a shoulder-specific prom devised for use in patients with degenerative or inflammatory conditions thereof. it elucidates both the degree and frequency of pain, and its impact on shoulder-related activities of daily living (adls). there are 12 questions, graded in the original paper on a likert scale from 1 to 5, with a range of 60 (worst) to 12 (best) score.2 this was later revised to a more intuitive 0 to 4 scale, with a range from 0 (worst) to 48 (best).23 it is simple to administer, validated, consistent,24 sensitive to clinical changes, and reliable.2,23,25 quickdash -11 score the quickdash score consists of 11 questions, each graded 1 to 5. for each question one selection is made, representing the score as felt by the patient over the last week. the scores are then summed, and mathematically manipulated to a score out of 100.20 this abbreviated version of the more comprehensive dash score is reliable, valid and responsive to change.26,27 a vas score, rating pain level with activity, but not specifying the duration, was also recorded with the quickdash. the scale was from 0 (no pain) to 10 (worst pain). subjective shoulder value the subjective shoulder value (ssv) is a patient estimation of the function in their afflicted shoulder, relative to their completely normal shoulder, expressed as a percentage.21 constant-murley score this shoulder scoring system is a combination of subjective (patient-reported – three questions) and objective (clinicianbased – five measurements) assessment, adding to a total out of 100. of the subjective questions, one examines the pain severity and two determine the effect on adls (maximum 35 points). the objective measurements involve four questions assessing range of shoulder motion (maximum 40 points), and a last question evaluating abduction force as measured in pounds by a spring scale.22 statistical analysis sample size calculation an a priori power calculation, setting alpha at 0.05 and the power at 80%, defined a need for at least 44 patients. this assumed a population mean of 24.9 for the oss (sd 9.0),23 a minimal clinically important difference of half the standard deviation,28 and a postulate sample mean to be within 2 points of the population mean. despite an acceptable power with only kruger n et al. sa orthop j 2018;17(1) page 19 44 patients, most other studies, in accordance with terwee et al.’s recommendations,25 included more than 100 patients when translating and validating the oss into their native language.5,8-10 comprehensibility, acceptance and time comprehensibility and acceptance were assessed by compliance via the number of questions answered or omitted. no more than two questions may be omitted for the questionnaire to be valid, and if any single question had two or more answers, we adhered to the convention of adopting the worse score for recording.23 the time taken for the patient to complete the oss was recorded. floor and ceiling effects floor and ceiling effects were also determined to assess whether there was any bias introduced at the extremes of the scores.19 if more than 15% of the respondents achieve either the highest or lowest score, these effects are present.29 this limits content validity, as discrimination is lost at the limits of the scale. reliability reliability is a measure of stability8 of a test. it consists of a measure of both reproducibility and internal consistency. the american society for testing and materials (astm) recommends both a qualitative statement of the test set-up and a quantitative statement of precision, when assessing the reliability of a measurement tool where the accepted reference values are not known or exactingly defined for the population.30,31 this precision in questionnaires involves test–retest reproducibility. it was measured by contacting the first 40 patients telephonically between 24 and 48 hours of their consult, to again complete the afrikaans oss. a pearson correlation coefficient (r) was used to determine the correlation between these overall test scores. pearson correlation coefficients may range from −1 (inverse correlation) to 1 (perfect correlation), with values nearing 0 indicating very poor correlation.9,10 further, a bland altman plot was calculated to determine the test–retest score consistency relative to the overall mean, across the range of scores.32 internal consistency was determined by calculating cronbach’s alpha. it defines the correlation between all the items within a scale.8 values may range from 0 to 1, with 0.90–0.95 optimal for clinical application.33 values above 0.95 indicate items are too similar and may be redundant. validity validity is a qualitative characteristic that may be described according to face, content, criterion and construct.34 validity of face exists in that the oss is ostensibly a questionnaire developed to assess patients’ perceptions about their shoulder problems. content validity was established in the original derivation of the oss through exploratory interviews with patients’, without ‘imposing clinical assumptions’ and ensuring complete understanding prior to questionnaire finalisation.2 criterion validity cannot truly be determined as there is no universally accepted benchmark prom for shoulder pain. validity of construct was assessed by calculating the pearson correlation between the afrikaans oss and the quickdash, the vas pain score, the ssv and the constant-murley score. the correlation was interpreted as poor, fair, moderate, very good and excellent when r=|0.00–0.20|, r=|0.21–0.40|, r=|0.41–0.60|, r=|0.61–0.80| and r=|0.80–1.00|, respectively.35 ethics statement the institutional human research ethics council gave approval for the study (hrec reference number 457/2014) and it was conducted in accordance with principles in the declaration of helsinki (2013). each patient gave written, informed consent prior to being enrolled. results translation no major discrepancies were noted between translators in either the forward or backward translation of the oss. consensus agreement was reached easily. patient and questionnaire characteristics all 108 patients who met the inclusion criteria participated and completed the questionnaires. demographic data and pathology were recorded and are outlined in table i. thirty-nine patients were pending planned surgery, 40 patients post-surgery (not within six weeks post-operatively) and 29 patients were being managed conservatively with no scheduled surgery. table i: demographic data and diagnosis for the study population patients (n) 108 mean age years (±sd) 55 (13) age range years 18–84 male:female 49:59 right – left handed 105–3 right left shoulder 69–39 dominant shoulder 70 diagnoses (%) n (%) impingement syndrome with rotator cuff tear 27 (25) impingement syndrome without rotator cuff tear 17 (15.7) primary or secondary oa (glenohumeral or acromioclavicular) 33 (30.6) adhesive capsulitis 13 (12) calcified deposits in rotator cuff 3 (2.8) other diagnoses 15 (13.9) proximal humerus fracture or non-union 3 (2.8) chronic elbow dislocation with shoulder pain 3 (2.8) acute r/c tear and clavicle fracture 2 (1.9) traumatic suprascapular nerve palsy 2 (1.9) acj dislocation with pain 1 (0.9) tuberculosis of the shoulder 1 (0.9) no diagnosis 3 (2.8) table ii: mean ± sd and ranges for the scores of all the outcomes measures used scores mean ± sd range oss 18.03±11.99 0–48 quickdash 65.00±23.85 0–100 quickdash pain vas 7.03±2.39 0–10 constant-murley 35.26±21.48 0–96 ssv (%) 41.29±23.34 2–95 page 20 kruger n et al. sa orthop j 2018;17(1) comprehensibility, acceptance and time no patients reported any difficulty with comprehension. acceptance was excellent with all patients answering all the questions for the oss, and only one patient omitting one question for the quickdash. the mean time (min:sec) to complete the oss was 4:09 (standard deviation [sd] ± 1:12). overall absolute values, mean scores and the ranges are given in table ii. floor and ceiling effects in the oss dataset, the lowest possible score is 0 and the highest possible score is 48. seven respondents achieved the lowest and only one achieved the highest, totalling 7.4% of all respondents. no floor or ceiling effects were thus present. reliability the test–retest reproducibility for the 40 patients was very high (r=0.99). the mean difference between the questionnaires was 0.2 points (95% ci −0.31 to 0.43). the internal consistency was also high (cronbach’s alpha=0.93). single question elimination did not drop the value significantly, with all items correlating (item total correlation ≥ 0.65) (table iii). a bland altman plot was calculated to indicate the differences between the test–retest scores, as plotted against the overall mean and across the range of scores (figure 1). validity pearson correlation coefficients calculated between the afrikaans oss, the constant-murley, and the quickdash were excellent (r=0.84 and 0.81 respectively), and very good for the ssv and the vas pain score (0.73 and 0.66 respectively). discussion afrikaans was originally derived from dutch and is now the first language for approximately seven million people in southern africa.15 it is a diverse language with multiple dialects and expressions within each dialect, which creates the potential for misunderstanding of questions. this was borne out in our study in the pilot phase, with one question requiring revision of a word ‘kruideniersware’ meaning ‘groceries’, to the more colloquial and direct translation of ‘huishoudelike inkopies’, meaning ‘household shopping’. this was rectified for the definitive study, and the results indicate excellent acceptance and understanding, for all patients answered all questions, skipping none. this overall response rate of 100% was similarly high in comparison to other studies.8-12 the mean age of 55 years was approximately the same as that reported for other oss translation study populations.8-12 there was a slight female preponderance in our study (male:female, 49:59), which was similar to the turkish11 and chinese12 findings. the dutch5 and german8 population had approximately equal numbers, with the italian9 and korean10 population having a strong male prevalence. this probably reflects the heterogeneity of shoulder pain from inflammatory or degenerative disease, without a specific sex-associated risk.36,37 the mean time taken to complete the oss (4 min 9 sec) was slightly longer than in other translations.8-10,12 this may reflect the patient population that we serve, for although the inclusion criteria mandated that patients were bilingual in both afrikaans and english, many have only had access to a basic education possibly resulting in more time to read and complete the questionnaire. the psychometric properties of the afrikaans oss were excellent across all measurements and compared favourably with other validation studies. the test–retest reproducibility was very high (r=0.99), and the internal consistency was excellent (cronbach’s alpha=0.93), indicating the translated oss is reliable (table iv). by correlating the translated oss with the constant-murley, the quickdash, the ssv and a vas pain score, construct validity was determined. all the comparative outcome scores are reliable and widely accepted outcome scores, and correlations between each were either ‘very good’ or ‘excellent’, demonstrating good construct validity. the bland altman plot of the differences against their means indicated no systematic bias across the range of scores. the english (data from original paper), german, italian, dutch and korean translations used the older oss scoring system, while the chinese and turkish have adopted the newer, more intuitive scoring system. absolute values for the scores give an indication of the severity of the patient’s perception of their shoulder problem. with simple mathematical conversion, the standardised scores for comparison are given in table v. the mean score for the afrikaans patients is at least 4.6 points below the mean of the lowest scoring population group compared. this is equal to a minimal clinically important difference for the oss.23 reasons for this difference are likely to be due to access and our patient population. low-income populations generally have inferior access to healthcare services. figure 1. a bland altman plot of the differences between the 40 test–retest scores, plotted against the overall mean, across the range of scores achieved 6 5 4 3 2 1 0 -1 -2 -3 0 10 20 30 40 50 0.34 mean 2.44 -1.76 -1.96 sd +1.96 sd table iii: mean scores and sds for each question of the afrikaans oss, along with each item total correlation and measure of internal consistency question mean score (±sd) item total correlation cronbach’s alpha (one item removed) 1 1.036±0.976 0.678 0.924 2 1.772±1.359 0.777 0.920 3 2.455±1.418 0.700 0.924 4 2.200±1.543 0.770 0.921 5 1.682±1.433 0.771 0.921 6 1.818±1.546 0.676 0.926 7 1.364±1.393 0.793 0.919 8 1.255±1.112 0.760 0.921 9 1.200±1.387 0.800 0.919 10 1.536±1.488 0.851 0.916 11 1.091±1.130 0.784 0.920 12 0.836±1.129 0.646 0.926 kruger n et al. sa orthop j 2018;17(1) page 21 patients often only seek help when it is direly needed due to prohibitive transport costs and long waiting times. this may result in perceived and ‘real’ differences in their shoulder pain, both from patient desperation for assistance with their shoulder and disease progression. there are some limitations that merit discussion. our patient cohort is only from a single centre. although our drainage area is broad and encompasses a wide spectrum of afrikaans dialects, it will not have included them all. secondly, unlike many other studies that translated the oss into their native languages,5,8,9,11,12 we chose not to use a generalised health assessment questionnaire when assessing construct validity. although shoulder-specific pathology may not necessarily have direct impact on overall patient function and wellness,5,10 this would not reflect in our study. lastly, we did not include a measure of sensitivity to change within the questionnaire, which would have aided assessment of responsiveness. conclusion the oxford shoulder score has been translated, cross-culturally adapted and validated into afrikaans in this study. the questionnaire was easily comprehended and completed by all patients. measures of stability and validity were robust in statistical analysis, with excellent internal consistency and construct validity in comparison to other shoulder outcome scores. acknowledgments the authors wish to thank karin wiese, francois meyer, toni kriel, narette botha, jani ferreira and theodi albrecht for their assistance with the forward and back translation of the questionnaire. compliance with ethical standards ethical approval: the human research ethics committee (hrec) of the university of cape town approved the study prior to its implementation: hrec number 457/2014. a copy thereof is available from the corresponding author if required. all procedures performed in this study were in accordance with the ethical standards of the 1964 helsinki declaration and its later amendments. informed consent: informed consent was obtained from all individual participants included in the study. table iv: overall mean values and standard deviations of the oss for different translation studies2,5,8-12 afrikaans (n=108) chinese (n=121) english (n=111) dutch (n=103) german (n=102) italian (n=140) turkish (n=84) korean (n=105) oss (mean & sd) 18.03±11.99 not stated 36.3 32.5±9.5 27.34±10.42 36.05±13.95 22.58±9.88 25.6±7.3 reliability cronbach’s alpha 0.93 0.92 0.89–0.92 0.92 0.94 0.95 0.92 0.91 icc (95% ci)/pearson’s correlation coefficient 0.99 0.97 (0.94–0.98 n/a 0.98 0.98 0.97 0.99 0.95 (0.91–0.98) construct validity constant-murley 0.84 0.66 0.74 0.64 0.60 0.73 n/a 0.3<r<0.6 quickdash/dash 0.81 n/a n/a n/a n/a n/a n/a >0.6 vas (pain activity) 0.66 0.70 n/a n/a n/a n/a n/a 0.34–0.45 table v: standardised mean scores for the oss for each language (range 0–48) afrikaans (n=108) chinese (n=121) english (n=111) dutch (n=103) german (n=102) italian (n=140) turkish (n=84) korean (n=105) oss (mean) 18.0 not stated 23.7 27.5 32.7 24.0 22.6 34.4 page 22 kruger n et al. sa orthop j 2018;17(1) references 1. chard md, hazleman r, hazleman bl, king rh, reiss bb. shoulder disorders in the elderly: a community survey. 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gedurende die afgelope 4 weke... was dit moontlik om u hare te kam/borsel met die seer arm? geen gering matig erg onuithoudbaar8. gedurende die afgelope 4 weke... hoe sal u die pyn wat u gewoonlik in u skouer ervaar het, beskryf? ja, maklik met bietjie moeite met moeite met baie moeite nee, onmoontlik 9. gedurende die afgelope 4 weke... was dit moontlik vir u om u klere in die kas op te hang met die seer skouer/arm? ja, maklik met bietjie moeite met moeite met baie moeite nee, onmoontlik10. gedurende die afgelope 4 weke... was dit vir u moontlik om onder albei arms te was en af te droog? glad nie klein bietjie matig grootliks heeltemal11. gedurende die afgelope 4 weke... tot watter mate het u skouer pyn/ongemak met u daaglikse werk (insluitend tuiswerk) u ingekort? nee, geen aande slegs een of twee aande sommige aande meeste aande elke aand12. gedurende die afgelope 4 weke... pla u skouerpyn u snags as u slaap? kruger n et al. sa orthop j 2018;17(1) page 23 10. roh yh, noh jh, kim w, 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for assessing the reliability of a measurement tool: a survival guide for orthopaedic surgeons. bone and joint journal, 2016;98-b(2):166-72. 31. authors not listed. american society for testing and materials (astm): standard practice for use of the terms precision and bias in astm test methods. 2013. west conshohocken: astm international. 32. bland jm, altman dg. statistical methods for assessing agreement between two methods of clinical measurement. lancet, 1986;1(8476):307-310. 33. bland jm, altman dg. cronbach’s alpha. british medical journal, 1997;314(7080):572. 34. mcgovern dpb, valori rm, summerskill wsm, levi m. key topics in evidence-based medicine (key topics series). 2001. oxford: bios scientific publishers ltd. 35. feise rj, michael menke j. functional rating index: a new valid and reliable instrument to measure the magnitude of clinical change in spinal conditions. spine (phila pa 1976), 2001;26(1): 78-86; discussion 87. 36. oh jh, chung sw, oh ch, kim sh, park sj, kim kw, park jh, lee sb, lee jj. the prevalence of shoulder osteoarthritis in the elderly korean population: association with risk factors and function. journal of shoulder and elbow surgery, 2011;20(5): 756-63. 37. yamamoto a, takagishi k, osawa t, yanagawa t, nakajima d, shitara h, kobayashi t. prevalence and risk factors of a rotator cuff tear in the general population. journal of shoulder and elbow surgery, 2010;19(1):116-20. 404 not found hitge c et al. sa orthop j 2019;18(3) doi 10.17159/2309-8309/2019/v18n3a7 south african orthopaedic journal http://journal.saoa.org.za general citation: hitge c, pietrzak jrt, de buys bm, van der jagt dr, ramokgopa m, mokete l. publication rates of podium presentations at the annual south african orthopaedic association congress from 2010 to 2015. sa orthop j 2019;18(3):58-62. http://dx.doi.org/10.17159/2309-8309/2019/v18n3a7 editor: prof lc marais, university of kwazulu-natal, durban, south africa received: february 2018 accepted: may 2019 published: august 2019 copyright: © 2019 hitge c, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was required in the preparation of this paper. conflict of interest: all authors declare that there are no conflicts of interest regarding this research. abstract background: international literature shows a discrepancy between presentations at annual general orthopaedic meetings and subsequent publication. the aim of this study was to determine the publication rate of manuscripts presented as podium presentations at the south african orthopaedic congress (saoc) from 2010 to 2015. materials and methods: all abstracts accepted as podium presentations at the saoc from years 2010 to 2015 were identified from the archives of the south african orthopaedic society (saoa). abstract titles and authors were searched using search engines looking for all published manuscripts. the presentations were cross-referenced with publications and the conversion ratio from presentation to publication was compared to international results. sub-analyses included orthopaedic subspecialty performance and publication rates and the types of research conducted. record was also made of each publication’s journal impact factor and date of publication. results: a total of 445 abstracts were accepted for podium presentation by the saoc from 2010 to 2015. of these, 70 (15.7%) were published in peer-reviewed journals. the mean time from presentation to publication was 16 months with an average journal impact factor of 1.29. orthopaedic trauma (21.67%) and foot and ankle surgery subspecialties (21%) were responsible for the most publications in general. the south african orthopaedic journal (44.29%), strategies in trauma and limb reconstruction (6.7%) and the injury journal (6.7%) were the three most common publishing journals. conclusion: a lower conversion rate from podium presentation at saoc to publication exists compared to similar published international findings. a poor publication rate was highlighted across all orthopaedic subdisciplines. half of the publications appeared only in local journals, with just over 8% of presentations reaching international publication. the results suggest there is a need to identify barriers to publication among south african orthopaedic surgeons. level of evidence: level 4 key words: publication rate, south african orthopaedic association, south african orthopaedic congress publication rates of podium presentations at the annual south african orthopaedic association congress from 2010 to 2015 hitge c¹ , pietrzak jrt² , de buys bm³ , van der jagt dr4 , ramokgopa m5, mokete l6 1 mbbch(wits), bsc(wits); registrar, department of orthopaedic surgery, university of the witwatersrand, johannesburg ² fc orth(sa), mbbch(wits); consultant, arthroplasty unit, department of orthopaedic surgery, university of the witwatersrand, charlotte maxeke johannesburg academic hospital ³ mbbch(wits), bsc(med)(hons); registrar, department of orthopaedic surgery, university of the witwatersrand 4 fc orth(sa), mbbch(wits); professor, university of the witwatersrand, charlotte maxeke johannesburg academic hospital 5 fcs(orth)sa, mbchb(ukzn); head of orthopaedic department, university of the witwatersrand, chris hani baragwanath academic hospital 6 frcs(edin), frcs(eng), fc orth(sa), mbchb(uct); senior consultant, department of orthopaedic surgery, university of the witwatersrand, charlotte maxeke johannesburg academic hospital corresponding author: dr curran hitge, department of orthopaedic surgery, charlotte maxeke johannesburg academic hospital, university of the witwatersrand, jubilee road, parktown, johannesburg, 2196, south africa; tel: +2720714006969, email: cuz.hitge@gmail.com https://orcid.org/0000-0002-9290-436x http://orcid.org/0000-0001-5694-0016 https://orcid.org/0000-0002-8780-433x https://orcid.org/0000-0002-3301-9459 http://orcid.org/0000-0001-9227-0515 page 59hitge c et al. sa orthop j 2019;18(3) introduction the various medical disciplines globally have annual association meetings which represent an anticipated event in the academic calendar. these meetings generally consist of a programme that includes lectures or instructional courses, as well as presentations of the latest research and clinical evidence from a given field. it has been summated that the quality of a presentation and by extension the quality of an orthopaedic meeting in general, can partly be determined by the quality of research presented at these meetings.1-3 research at annual general meetings is typically presented in two main formats: podium or poster presentations. several studies have attempted to assess the quality of research produced at annual meetings.1-5 podium presentations have been shown to be more than two or three times more likely to be published than poster presentations.1,5,6 quality of presentations may be evaluated by determining the subsequent publication rate in peer-reviewed journals.4 the american academy of orthopaedic surgeons’ annual general meeting is widely recognised as the gold standard in terms of quality of meeting with 58% of presentations at this congress proceeding to publication.2,7 developed countries, especially those from north america and the european union, have been shown to produce the most literature in any given medical field.8 this is believed to be due to more access to appropriate funding for research projects, more competition within the field, and improved proficiency in the english language.8 as such, research coming out of these unions is more likely to go on to publication than any other centre around the world.3 in addition, it has been shown that most presentations are published within four years of presentation, and the mean time to publication has been shown to be 15–25 months.1,4,9 the aim of this study was to assess the conversion rate from all abstracts accepted for podium presentations between 2010 and 2015 at the south african orthopaedic association (saoa) annual congress into subsequent manuscripts and then on to full publication. moreover, the study looked at each orthopaedic subdiscipline and assessed the rate of publication of each following podium presentation. the study also aimed to evaluate the type of journals that published the articles, the impact factor of these journals and, by inference, the quality of research. methodology the saoa was contacted directly and the release of the congress brochures for the saoa meetings from 2010 to 2015 were requested. only podium presentations were captured, and all poster and instructional course presentations were excluded. a six-year time frame was chosen to collect an adequate sample size, as well as to allow sufficient time for publication, in accordance with published literature.1,4,9 abstract titles of the presentations were entered into different search engines to evaluate if the presentation had subsequently been converted into a formal manuscript and gone on to publication in a peer-reviewed journal. search engines included pubmed, google scholar, google, scielo and embase. if no matches were found, the authorship as well as title key words were used as search inputs in an attempt to find a different link to the title of the publication. if the author in question was responsible for other research publications, an attempt was made to enter in key words to filter through other publications to find relevant matches. if no hits were achieved after four pubmed searches, assumption of non-publication was made, an assumption that is supported by schoenfeld et al.10 if a hit was achieved on one platform, the process was still repeated on all other platforms to ensure all journal publications were found. all journal publications were recorded and tallied to establish which journals were most popular. successful publications were divided into international and local south african journal publications. the presentation-to-publication conversion rate was compared to international experience. the abstract titles were divided into subspecialties by assessing the title as well as the authors involved. the division into eight subspecialties was made based on recognised subspecialties in the south african context and included arthroplasty, upper limb and hands, trauma, paediatrics, spine, foot and ankle, tumour and sepsis, and sports and knee. the subspecialties were analysed both in terms of the quantity of research presented as well as the quality, determined by assessing their subsequent publication rates. furthermore, presentations were separated into three categories of research as done by marsland et al.2 these included: clinical studies or case series; basic science or biomechanical; and audit, miscellaneous or educational.2 the number of publications in each category were recorded and results compared to literature. for each presentation, the time of presentation from the date of the congress was recorded. if the presentation went on to publication, the month and year of publication was recorded. the date of publication was used rather than the date of journal acceptance.4 this ultimately provided a time taken to publication for each presentation. articles that were published prior to the year of presentation were excluded from the calculation of time to presentation but publications from earlier in the year of presentation were still included. each journal was evaluated for its 2018 recorded impact factor score as provided by the researchgate web portal. this is a marker of the scientific influence of a journal. a score of zero was allocated to the journal if no impact factor score was found. local journals were excluded from the calculation to avoid skewing of the results as the south african orthopaedic journal (saoj) did not feature on the portal used. results a total of 445 podium presentations were presented at the annual saoa congress between 2010 and 2015 (figure 1) with a total of 70 (15.7%) podium presentations going on to publication in peerreviewed journals. 8% 7% 85% international journals local journals not published figure 1. comparison between total number of podium presentations and those that went on to international or local publication (2010–2015) page 60 hitge c et al. sa orthop j 2019;18(3) of these, 37 (8.31%) presentations were published in international journals and 33 (7.42%) were published in local south african journals (figures 1 and 2). analysing each subspecialty showed that arthroplasty had the most podium presentations at 115 (25.84%) and from this eight (7%) international publications and four (3.5%) local publications were derived. orthopaedic trauma and foot and ankle were the subspecialties with the highest publication rates at 21.67% and 21% respectively (figure 3). the most internationally published subspecialty was foot and ankle at 14% followed by tumour and sepsis with 13% and then upper limb and hands with 12%. there were 27 podium presentations that did not fit an individual specialty, of which one (3.7%) was published in an international journal and five (18.52%) were published in local journals. there was a total of 25 journals that published manuscripts from the podium presentations examined in this study. the saoj was the most common journal wherein presentations were published, with 31 (44.29%) of the publications. the most common international peer-reviewed journals that received podium presentation publications were injury and strategies in trauma and limb reconstruction, with four (6.67%) entries each. there were also three (5%) publications in the journal of hand surgery and the journal of bone and joint surgery (jbjs). of the 445 podium presentations, 165 were based on clinical studies or case series, 140 had a basic science or biomechanical base and 140 were audits, educational or miscellaneous. forty-one per cent of publications were clinical studies or case series, while 27% were basic science. 63 72 86 77 98 49 2 9 10 6 6 44 3 4 7 7 8 0 20 40 60 80 100 120 2010 2011 2012 2013 2014 2015 total presented international journal local journals figure 2. comparison between number of total podium presentations (dark blue) and the subsequent number of international (blue) and local journal publications (light blue) in each year of study 115 43 65 77 72 14 27 23 98 5 5 7 6 2 1 3 04 0 9 6 7 1 5 1 0 0 20 40 60 80 100 120 140 a rth ro p la sty u p p e r lim b & h a n d s t ra u m a p a e d ia tric s s p in e f o o t & a n kle g e n e ra l t u m o u r & s e p sis s p o rts figure 3. subspecialty comparison looking at the number of total podium presentations (dark blue) and subsequent international (blue) and local (light blue) publications (2010–2015) page 61hitge c et al. sa orthop j 2019;18(3) the mean time from presentation to publication was 16 months (range from six months prior to presentation to seven years post presentation). there were seven presentations that were excluded due to publication occurring prior to the year of saoc presentation. the impact factors as determined by the researchgate ranged from 0.25 to 3.06 with an average of 1.29. discussion it was found that 15.7% of podium presentations at the saoc between 2010 and 2015 went on to publication. of this, 7.4% of the presentations were published locally in south african journals with 8.3% of presentations being published in international journals. these findings correlate unfavourably with international experience where publication rates range from 26.6 to 59% (figure 4).1,4 this highlights a significant lack of progression to publication and raises a number of important questions about barriers to publication for research in south africa. the results above suggest that there is a lack of progression to publication of research that is conducted within the south african orthopaedic circuit. investigation into the possible sources of this shortfall may provide valuable insight and ultimately create solutions to the poor publication rates in south africa. peerreviewed journals have rigorous criteria to meet in order to qualify for publication; these criteria are largely more stringent than that required for podium presentations at general meetings and as such research presented at the saoc may not be accepted for publication.1,4 further barriers to publication have also been cited and include the following: • lack of time for authors to write up their research • poor communication between authors and co-authors • deficiency of senior mentorship in preparation of a manuscript • deficit of support from the institution, financially and logistically.2,4,11 it has also been hypothesised that because presentations at the saoc is a requirement for most orthopaedic surgeons in training, there is an initial drive to start research in order to write an abstract that would qualify for a general meeting. once the abstract is accepted however, the motivation to complete the research in the form of a journal submission may be lost. furthermore, it may be worth assessing how many presentations have gained ethical clearance prior to presentation, as this would later be required for publication in an accredited journal. the level of experience of the author may also have a significant impact on the publication rate. experienced authors with a history of achieving publications will have a clearer idea of requirements for publication and therefore have directed research aims. on 1 january 2011, a compulsory masters in medicine (mmed) was introduced to all specialist training programmes in south africa by the health professions council of south africa. this was done in an attempt to enhance the quality of specialists in the respective fields and expose students to research.11 this mmed programme may therefore play a role in increasing subsequent publication rates of papers presented at the annual general meetings in future and will ensure that all candidates are exposed to research and research methodology. chan et al. revealed that students not allocated a research block reported publication rates of 8%. this was in comparison with 29% publication rates from students who were given dedicated research leave.11 it can be postulated that sufficient support and opportunity afforded to training students may enhance subsequent research output. the low conversion rates may be a reflection of the scientific quality of the saoc. high quality meetings may be defined as those from which a large proportion of presented research has gone on to publication,4 whereas a lower publication rate may represent deficiencies in the quality of the meeting. subspecialty performance review shows a general lack of conversion of presentations to publication; publication rates ranging from 0 to 23% of presentations at the saoc between the subspecialties were documented. arthroplasty has been the most active subspecialty in terms of overall research presentation comprising approximately 25% of all presentations at the saoa congresses over the defined period. despite this, only 7% of those presentations went on to international publication and 3% converted to local publications. internationally, it has been shown that the discipline least likely to achieve publication from presentations in general meetings is trauma.1 in this series, trauma was found to be the best performing subspecialty in terms of local publication with a 14% publication rate. trauma also had a further 8% international publication conversion rate. investigation of publication rates arising from subspecialtyspecific meetings in south africa will provide important insight. research presented at these meetings may be of a higher standard and have higher subsequent publication rates. this study showed that presentations in the clinical studies or case series category had a higher conversion rate to publication than did publications in the basic science or biomechanical base or audits, educational or miscellaneous categories. these results are in contrast to those published by marsland et al. who noted that 59 58.1 36.3 34.9 32.5 31 29.5 28.2 26.6 15.7 0 10 20 30 40 50 60 70 somos aaos boa gsots ioa aoa totc soa cbot saoa figure 4. comparison of overall documented publication rates (in %) from presentations at different international conferences american academy of orthopaedic surgeons (aaos); australian orthopaedic association (aoa); british orthopaedic association (boa); congresso brasileiro de ortopedia (cbot); german society of orthopaedics and traumatology congress (gsots); irish orthopaedic association (ioa); south african orthopaedic association (saoa) and singapore orthopaedic association (soa); society of military orthopaedic surgeons (somos); turkish orthopaedics and traumatology congress (totc) page 62 hitge c et al. sa orthop j 2019;18(3) basic sciences were more likely to progress to full publication than clinical studies.2 there were 25 journals that published presentations from the saoa congress. these reflected a mean average journal impact factor of 1.29. several of these journals scored low on the researchgate website. this compared slightly better than daruwalla et al. from singapore who achieved an average of 0.96 but was far lower than that found by orr et al. from the annual general meeting for the society of military orthopaedic surgeons (somos) of 2.6.1,4 there is a paucity of literature showing journal impact factors in relation to publication rates. it can be deduced however that the higher the impact factor of the journal, the greater the quality of research.3 this was the first study on record to look into publication rates of podium presentations at the saoc. there have been several international studies in this field, and these provide a good platform from which to compare the performance of the soac. it also may help to outline areas of weakness that can be targeted to improve the standard of future saoa orthopaedic meetings. this paper highlights the need for further interrogation and investigation into the various barriers to research leading to the poor rate of publication in south africa. future research needs to be conducted to identify specific barriers to publication, especially looking at each facet of the publication process. this will include analysing the perceived barriers as suggested above. this study is not without limitations. only presentations that went on to full peer-reviewed journal publication were considered. our finding of a period of 16 months between presentation and publication is in keeping with and at the lower end of the mean time to publication of 15–25 months noted in the literature.1,4,9 however, as presentations from 2014 and 2015 were only given three and two years respectively to allow for subsequent publication, there may be under-reporting of publications. it has been shown that publication rates peak at four years post presentation and some studies take up to ten years to reach publication.1 future research into this field is required to establish whether time to publication in south africa is similar to the international time periods presented above, and therefore further studies looking at publication rates need to allow for an adequate time period from presentation. as marsland shows, search engines may not yield all presentations that have successfully gone on to publication.2 direct contact with each author responsible for the presentations at the annual meetings would likely yield a higher rate of publication. however, this study was modelled on research conducted in other unions in order to draw comparisons between south africa and other influential orthopaedic communities. marsland et al. have also shown that several abstracts are not completed at the time of presentation, and as such, by the time they are ready for publication, the title, authorship or abstract may have required alteration.2 it has been shown that 25–30% of presentations have been altered prior to publication, and as such may not be found in the various search engines and strategies highlighted above.12 this too may have led to an underestimate of the true number of presentations that have ultimately gone on to publication. conclusion there is a low conversion rate from research presented at the annual south african orthopaedic congress into subsequent manuscripts and eventual publication in peer-reviewed journals. further investigations exploring the specific barriers to publication in south africa and comparisons of performance of the annual meeting with subspecialty meetings within the south african orthopaedic association will identify specific factors leading to poor publication rates and as such may provide a means for improvement. in conclusion, this paper highlights the need for increased emphasis on publication of literature presented and support provided to facilitate publication. ethics statement the study is a retrospective data analysis with no patient records analysed directly and as such no ethical clearance was needed. declarations the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ch: data collection, analysis and write up; jrtp: supervisor; bmdb: data collection, analysis, submission process; drvdj: supervisor; mr: supervisor; lm: supervisor orcid hitge c https://orcid.org/0000-0002-9290-436x pietrzak jrt http://orcid.org/0000-0001-5694-0016 de buys bm https://orcid.org/0000-0002-8780-433x van der jagt dr https://orcid.org/0000-0002-3301-9459 mokete l http://orcid.org/0000-0001-9227-0515 references 1. daruwalla zj, sumon sh, keng lw, pei yn, diarmuid pm. ‘publish or perish’presentations at annual national orthopaedic meetings and their correlation with subsequent publication, journal of orthopaedic surgery and research. 2015;10(58). 2. marsland d, mumith a, taylor hp. full text publication rates of papers presented at the british foot and ankle society. foot and ankle surgery. 2018;24(6):525-29. 3. abzug jm, osterman m, rivlin m, paryavi e, osterman al. current rates of publication for podium and poster presentations at the american society for surgery of the hand annual meetings. archives of bone and joint surgery. 2014;2(3):199-202. 4. orr j, dunn jc, kusnevov n, fares ab, waterman br, garcia e, pallis m. publication rate and impact factor for society of military orthopaedic surgeons. annual meeting presentations, 2009–2013. military medicine 2017;182:e1992-e1996. 5. ejnisman gs, de oliviera gr, malavolta ea, gobbi rg, de camargo, p. publication rates of papers presented at the brazilian orthopaedic meeting. acta ortopedia brasilia. 2013;21(5):285-87. 6. yalcinkaya m, bagatur e. fate of abstracts presented at a national turkish orthopedics and traumatology congress: publication rates and consistency of abstracts compared with their subsequent full-text publications. acta orthopaedica et traumatologica turcica. 2013;47(4):223-30.. 7. voleti pb, donegan dj, kim tw, lee gc. level of evidence: does it change the rate of publication and time to publication of american academy of orthopaedic surgeons presentations? journal of bone and joint surgery (am). 2013;95(1):e2. 8. choudhari p, agrawal u, shaikh t. trends in scientific publications of indian arthroplasty surgeons over 15 years (2001–2015). journal of arthroscopy and joint surgery. 2017. e. pp. 94-99. 9. donegan dj, kim tw, lee gc. publication rates of presentations at an annual meeting of the american academy of orthopaedic surgery. clinical or thopaedics and related research. 2010;468(5):1428-35. 10. schoenfeld aj, carey pa, frye bd. publication rate of presentations at an annual military orthopaedic meeting. journal surgery and orthopaedic advances. 2012;21(4):204-209. 11. chan rkw, lockyer j, hutchison c. block to succeed: the canadian orthopaedic resident research experience. canadian journal of surgery. 2009;52(3):187-95. 12. bhandari m, devereaux pj, guyatt gh, swiontkowski mf, sprague s, schemitsch eh. an observational study of orthopaedic abstracts and subsequent full text publications. journal of bone and joint surgery (am). 2002;84(a):615-21. https://orcid.org/0000-0002-9290-436x https://orcid.org/0000-0002-9290-436x http://orcid.org/0000-0001-5694-0016 http://orcid.org/0000-0001-5694-0016 https://orcid.org/0000-0002-8780-433x https://orcid.org/0000-0002-8780-433x https://orcid.org/0000-0002-3301-9459 https://orcid.org/0000-0002-3301-9459 http://orcid.org/0000-0001-9227-0515 http://orcid.org/0000-0001-9227-0515 _goback engelmann ewm et al. sa orthop j 2019;18(2) doi 10.17159/2309-8309/2019/v18n2a3 south african orthopaedic journal http://journal.saoa.org.za traumatrauma citation: engelmann ewm, maqungo s, laubscher m, hoppe s, roche s, nicol a, navsaria p, held m. epidemiology and injury severity of 294 extremity gunshot wounds in ten months: a report from the cape town trauma registry. sa orthop j 2019;18(2):31-36. http://dx.doi.org/10.17159/2309-8309/2019/v18n2a3 editor: dr franz birkholtz, walk-a-mile centre for advanced orthopaedics, pretoria, south africa received: june 2018 accepted: march 2019 published: may 2019 copyright: © 2019 engelmann ewm, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract aims: to describe the epidemiology and injury severity of patients with extremity gunshot injuries in an area with a high rate of interpersonal violence. patients and methods: this is a prospective cohort study of patients who presented with an extremity gunshot injury and were recorded as part of a trauma registry at a large tertiary care hospital in cape town, south africa, between june 2015 and april 2016. patient demographics, injury severity scores, injury patterns and referral pathways were evaluated. results: of 1 123 gunshot trauma admissions in ten months, 290 (25.8%) patients (91.5% males, n=269) with a median age of 26 years (iqr 13.0) presented with extremity injuries. median injury severity score (iss) was 4.0 (iqr 8.0). only one-fifth of patients had an iss of 15 or more (n=50, 17%). upper extremity injuries were associated with a higher risk of fractures (rr 2.15, p=0.05), higher number of nerve injuries (p=0.01), and a two times higher mean iss (p=0.01). admissions between 7pm and 7am with limited staffing at the emergency department were twice as high as the day admissions (n=169, 57.5% versus n=79, 26.9%). conclusion: there is a high trauma load on the emergency department and orthopaedic service due to extremity gunshot injuries. although upper extremity gunshot wounds constituted a red flag for higher injury severity, the overall injury severity was low. inadequate timing and selection of emergency referrals of patients with low iss are avoidable aggravators of this burden and should be targeted to increase efficiencies in the care of these patients. level of evidence: level 4 key words: gunshot, trauma, upper extremity, lower extremity, epidemiology epidemiology and injury severity of 294 extremity gunshot wounds in ten months: a report from the cape town trauma registry engelmann ewm¹ , maqungo s², laubscher m³ , hoppe s4, roche s5, nicol a6, navsaria p7 , held m8 1 md, msc, llm; department of orthopaedic surgery, groote schuur hospital, university of cape town, south africa 2 md, fc ortho; associate professor, department of orthopaedic surgery, groote schuur hospital, university of cape town, south africa 3 mbchb, dip pec, fc orth (sa), mmed ortho (uct); department of orthopaedic surgery, groote schuur hospital, university of cape town, south africa 4 md, phd; department of orthopaedic surgery, groote schuur hospital, university of cape town, south africa; and department of orthopaedic surgery, division of spine surgery, inselspital bern, switzerland 5 mbchb, fcs orth (sa); associate professor, department of orthopaedic surgery, groote schuur hospital, university of cape town, south africa 6 md; professor, department of traumatology, groote schuur hospital, university of cape town, south africa 7 mbchb, mmed, fcs, facs, trauma surgery; professor, department of traumatology, groote schuur hospital, university of cape town, south africa 8 md, phd, fc ortho; associate professor, department of orthopaedic surgery, groote schuur hospital, university of cape town, south africa corresponding author: dr ewm engelmann, 8 james road, observatory, 7925, cape town, south africa; email: esmee.engelmann@gmail.com; tel: +31 620377825 https://orcid.org/0000-0002-7685-4024 https://orcid.org/0000-0002-5989-8383 https://orcid.org/0000-0002-5152-3317 https://orcid.org/0000-0002-0671-0439 page 32 engelmann ewm et al. sa orthop j 2019;18(2) introduction armed violence constitutes one of the greatest global health challenges, especially in certain parts of africa.1-6 south africa’s lethal violence rates are close to those of countries at war and cape town specifically is one of the most violent cities in the world regarding homicides.4,7 in recent years a high rate of interpersonal violence combined with gun trafficking and use of guns as main weapon in gang wars has caused a surge of gun-related injuries (figure 1). this causes an extreme burden to the health care system in costs as well as hospital stay.7 reports on the epidemiology of civilian gunshot injuries and orthopaedic injury patterns are limited.8,9 most evidence and guidelines are based on small american and european retrospective case series or military experience with high-velocity injuries.1,3,6,9-11 civilian gunshot trauma is associated with low-velocity injuries in more focal patterns. it is difficult to translate the available literature to civilian gunshot trauma due to distinct injury characteristics and potential of the firearms and bullets.8 moreover, little is known about the trauma burden and injury profile in civilian low-velocity gunshot injuries in low-income countries. vast differences in injury pattern, associated injuries, system-related resources and the accessibility to health care limit the use of external evidence in the local management of gun-related injuries in these countries. to date, there are no studies which examine the injury pattern in patients with extremity gunshot injuries in africa or other lowincome regions. we therefore aimed to describe the demographics, epidemiology and injury pattern of extremity gunshot wounds in a large hospital in cape town with the secondary aim to determine factors influencing injury severity. methods study design and setting the prospectively collected electronic trauma registry of groote schuur hospital, a large tertiary care facility with a level i trauma unit in cape town, south africa was used to extrapolate all patients with gunshot injuries to extremities.12 this is an observational study that adheres to the strobe guidelines for research and was approved by the hrec. patients all patients with orthopaedic ballistic injuries to the extremities, who presented to the trauma unit in a ten-month period from june 2015 to april 2016 were included. orthopaedic injuries were defined as an acute fracture, dislocation, or fracture dislocation, as well soft tissue, nerve and arterial injuries of the lower and upper extremities. lower extremity fractures included fractures of the foot, tibia, fibula, patella, femur and acetabulum. upper extremity fractures were defined as fractures to the hand, ulna, radius, humerus, scapula and clavicle. patients with incomplete fractures or isolated fractures of the pelvic girdle, spine, skull, face and ribs were excluded. approval for the prospective collection of data for this registry and the analysis of the collected data was obtained from the human research ethics council at the university of cape town. variables, outcome measures, data sources and bias patient demographics, such as age, sex, as well as illicit drug intoxication were recorded. data on the incident included injury date and time, arrival date and time, type of violence and perpetrator, geolocation, and transport mode to the hospital. children were defined as patients under 19 years of age. this hospital does not admit children under 13 years of age as these patients are treated at a specific children’s hospital. injuries were classified according to triage code (1 = green, standard; 2 = yellow, urgent; 3 = red, very urgent), anatomical site, injury type, abbreviated injury scale (ais), injury severity score (iss), glasgow coma scale (gcs) and revised trauma score (rts). the type of injury was described as fracture, abrasion, contusion, haematoma, or superficial laceration. associated injuries were defined as injury to an anatomical structure other than the upper and lower extremity. statistical analysis, study size demographic and clinical data were compared using bivariate analysis. the p-values were determined by the chi-squared or two-sided fisher’s exact test for categorical variables, and by the student’s t test or the mann-whitney u test for continuous variables. differences in two population proportions or means were calculated using oneor two-tailed z tests. one-way anova was used to determine differences between the means of two or more independent groups. risk factors identified by bivariate analysis at p<0.1 were put into a logistic regression model to test for association with injury severity. significant confounders (p<0.05) between the compared groups were identified using multivariate analysis. univariate and multivariate analyses were performed to investigate associations between demographical characteristics, anatomic site of injury and injury severity. values are reported as percentages for categorical variables and mean + sd for continuous variables. p-values lower than 0.05 were regarded significant. analyses were figure 1. lodox image (ap view) as part of primary assessment of a patient with multiple upper extremity gunshot injuries at groote schuur hospital trauma unit figure 2. age–sex distribution of patients (n=290) 0 10 20 30 40 50 60 70 0 -4 5 -9 1 0 -1 4 1 5 -1 9 2 0 -2 4 2 5 -2 9 3 0 -3 4 3 5 -3 9 4 0 -4 4 4 5 -4 9 5 0 -5 4 5 5 -5 9 6 0 -6 4 6 5 -6 9 7 0 -7 4 7 5 + n u m b e r o f p a ti e n ts p e r c a te g o ry ( n ) age categories (yrs) female male figure 2. age–sex distribution of patients (n=290) page 33engelmann ewm et al. sa orthop j 2019;18(2) performed using statistica 13 (dell software, california) and spss version 23 (statistical package for the social sciences, ibm company, new york). results demographics and epidemiology a total of 294 of 1123 (26.2%) cases (269 male, 90.1%) had extremity injuries (figure 2). four patients were readmitted for a repeat gunshot injury during the study period (1.4%) resulting in a total of 294 cases in 290 patients. the demographic data is shown in table i. there were 243 adults (82.7%) and 47 children (16.2%). of the 230 patients who were tested for intoxications, 32 were positive for alcohol (13.9%), 39 for illegal drugs (17.0%), and 18 for both alcohol and illegal drugs (7.8%). the average age was 28.1 years (median 26.1; iqr=13.0, figure 2). most injuries were the result of intentional violence (n=265; 90.1%). gang-related violence accounted for 37.1% (n=109) of injuries. while 181 victims were shot on the streets (61.6%), 44 were shot at home (15%). a peak incidence was observed in the summer months from september to january with more than 35 admissions per month compared to 20 admissions per month during the rest of the year. one-third of admissions occurred on weekends (n=98; 33.3%) compared to two-thirds during the five weekdays (n=196; 66.7%). most patients were shot on sunday (n=59; 20.1%). factors affecting injury severity the mean iss was 7.7+9.4 with a median of 4 ranging from 0 to 75 (iqr=8.0). fifty patients (17%) had an iss of >15, suggestive of major trauma.13 the average rts was 6.9 + 0.3 ranging from 4 to 7. detailed clinical characteristics are presented in table ii and iii. further pre-hospital characteristics of this severely injured group are displayed in table iv. in analysis of time to admission and mean iss, patients admitted two hours or more after injury were found to have a significantly lower mean iss (p=0.03) (figure 3). compared to the lower limb, upper extremity gunshot wounds increased the risk of a fracture 2.15 times (95% ci 1.07–3.07; p=0.02); had a higher number of nerve injuries; a greater risk of associated abdominal or thoracic injuries with a risk ratio of 2.42 (95% ci 1.74–3.37); a higher number of triage code red patients (p=0.002); a higher mean iss (p=0.008; t=-2.679; 95% ci -5.55 to -0.85); and greater number of patients with an iss>15 (p=0.03) (table v). arterial injuries were reported more frequently in the lower extremity group (p=0.1). table i: demographics and admission data variables patients (n; %) patients (n) age (yrs) mean ± sd median range sex male female type of conflict intentional non-intentional perpetrator stranger family/friends/acquaintance police/legal intervention unknown transport ambulance vehicle walked unknown transfer direct from scene inter-facility transfer unknown time of arrival 7am–7pm 7pm–7am unknown time injury to admission 0 to 1 hour 1 to 2 hours 2 to 3 hours more than 3 hours unknown 294 28.1±10.1 26.1 0.8–74.7 269 (91.5%) 25 (8.5%) 265 (90.1%) 29 (9.9%) 124 (42.2%) 25 (8.5%) 4 (1.4%) 141 (48.0%) 256 (87.1%) 18 (6.1%) 3 (1.0%) 17 (5.8%) 108 (36.7%) 137 (46.6%) 49 (16.7%) 79 (26.9%) 169 (57.5%) 46 (15.6%) 32 (10.9%) 52 (17.7%) 29 (9.9%) 72 (24.5%) 109 (37.1%) table ii: clinical details variables patients (n; %) patients (n) triage 1 2 3 iss mean ± sd median range >15 orthopaedic injuries upper extremity lower extremity both other injuries abdomen chest head/neck urogenital 294 107 (35.4%) 149 (50.7%) 38 (12.9%) 7.7±9.4 4 0–75 50 (17.0%) 90 (30.6%) 186 (63.3%) 18 (6.1%) 49 (16.7%) 26 (8.8%) 10 (3.4%) 13 (4.4%) table iii: anatomical distribution of fractures bone fractures n=70 tibia/fibula femur foot acetabulum patella 28 (42.4%) 27 (38.6%) 11 (15.7%) 2 (2.9%) 2 (2.9%) bone fractures n=72 radius/ulna humerus clavicle scapula hand 26 (39.3%) 18 (27.2%) 4 (6.1%) 9 (13.6%) 19 (28.8%) table iv: clinical characteristics of major trauma patients iss>15 (n=50) intentional gang-related 7pm–7am intoxication multiple gsw fractures neurovascular injuries 90% (45) 34% (17) 68% (34) 38% (19) 90% (45) 66% (33) 10% (5) page 34 engelmann ewm et al. sa orthop j 2019;18(2) referral patterns most patients were brought in by ambulance (n=256; 87.1%). onethird (n=108; 36.7%) presented directly from the scene; almost half of the patients (n=137, 46.6%) had an interfacility transfer prior to admission to our hospital. in 49 patients (16.7%) no transfer data was available. most patients were transferred within two hours of injury. injury severity did not have a significant influence on transport and transfer. a map of cape town and its surrounding areas is provided in figure 4, depicting the assigned referral areas for regional public hospitals. only 43 patients (14.6%) came from the specific referral area (figure 4, area c) of the facility. most patients were injured in the townships (area e) and informal settlements in the cape flats (n=131, 44.6%). compared to other areas, fewer patients in these townships came directly from the scene (n=37; 28.2%) as most patients had an inter-facility transfer. admissions between 7pm and 7am were twice as high as the day admissions (n=169, 57.5% and n=79, 26.9%, respectively). discussion this study shows a very high burden of extremity gunshot injuries to the emergency and orthopaedic trauma service of a large tertiary care facility in cape town. this was aggravated by inadequate emergency referrals of patients, regarding low iss, timing of the transfer at night time, and referrals from areas outside the referral area. although the lower extremity was shot more frequently, upper extremity gunshot injuries are associated with a higher rate of fractures, nerve injuries, and iss and constitute a red flag. alarming was the high rate of children (16%) among the victims. most patients were young males intentionally shot by strangers. the age and sex distribution were similar to those in the literature, with a lower median age of patients involved in gang violence.1,3,11,14 the high rate of alcohol or drug abuse of those tested was consistent with other studies.15,16 most injuries occurred on the streets in the cape flats township area, known for a high rate of gang-related violence.17,18 we also noticed a high rate of underage victims in cape town, which shows the effect of armed violence on an extremely vulnerable group.19,20 most patients were admitted to our hospital after an inter-hospital transfer, although 83% were not severely injured (iss lower than 15) and were inadequate referrals for tertiary emergency care. trauma overload at local township hospitals, resource restrictions or an initial overestimation of injury severity might be reasons for this. only 20% of the patients came from the actual drainage area (figure 4).21 access to our tertiary care hospital for these patients was acceptable with an average delay from injury to admission of two hours. the time to admission was shorter in patients with a higher iss compared to patients with a lower iss, suggesting that figure 3. box-plot of mean iss and 95% confidence interval against time to admission figure 4. geographic distribution of admissions table v: comparison of injuries in the upper and lower extremity upper extremity lower extremity both patients (n) triage 1 2 3 iss mean ± sd median range >15 fractures none one two three and more associated injuries nerve arterial other injuries abdomen chest head/neck urogenital 90 42 (46.7%) 30 (33.3%) 18 (20.0%) 9.4±9.9 9 0–59 21 (23.3%) 40 (44.4%) 36 (40.0%) 12 (13.2%) 2 (2.2%) 9 (10.0%) 6 (6.7%) 23 (25.6%) 17 (18.9%) 6 (6.7%) 2 (2.2%) 186 51 (27.4%) 115 (61.8%) 20 (10.8%) 6.2±9.0 4 0–75 24 (12.9%) 138 (74.2%) 35 (18.8%) 10 (5.4%) 3 (1.6%) 3 (1.6%) 24 (12.9%) 20 (10.8%) 6 (3.2%) 4 (2.2%) 11 (5.9%) 18 14 (77.8%) 4 (22.2%) 0 (0%) 14.1±7.7 13 1–29 5 (27.8%) 5 (27.8%) 6 (33.3%) 4 (22.2%) 3 (16.7%) 0 (0%) 2 (11.1%) 6 (33.3%) 3 (16.7%) 0 (0%) 1 (5.6%) page 35engelmann ewm et al. sa orthop j 2019;18(2) the pre-hospital triage and referral system adequately prioritises more severely injured patients. most of the patients with low iss were brought to the emergency department during the night, which poses an additional burden on the trauma services often with minimal staffing during this time. a similar finding was reported previously in another area of high gang violence.11 this shows the need for support in the decision-making for referrals of extremity gunshot injuries to tertiary care emergency facilities in our area which should be reserved for patients who require specialised clinical resources and expertise.22 a better understanding of factors influencing injury severity could help to guide this process. patients with upper extremity injuries had a higher median iss and a higher risk of associated and other injuries compared to patients with lower extremity injuries; this is most likely due to the proximity to the head, as well as thoracic and abdominal vital organs. lichte et al. described high rates of mortality in civialin gunshot injuries to the torso.8 however, the injury profile of orthopaedic injuries has not been studied before. based on our novel findings, upper extremity injuries should therefore be regarded as a red flag in the primary survey of orthopaedic ballistic trauma patients. a limitation to this study is that the trauma registry is maintained by treating clinicians, and the high trauma burden might have led to a lower quality of data collection. however, previous assessment of this clinician-driven data collection proved to be feasible and this is the first registry of its kind in africa and provides important insight on patient demographics, injuries, and the local trauma health care system.12 another limitation was that data assessing the burden of gunshot-related injuries in our referring hospitals was not included in this study, which might have provided better insight into the patient flow into our hospital. currently there are no databases available in the township hospitals. we also did not classify the fractures according to their severity which might have triggered referral to our tertiary care orthopaedic service. yet, most patients with low injury severity should have been referred to orthopaedic clinics without overloading the emergency intake of our trauma unit. conclusions this is the first large prospective registry-based study on the epidemiology, injury severity and admission data of civilian gunshot injuries in a low-income setting. our findings are key to better understanding the effects of the extremely high burden of gunshot injuries in (south) africa and to find possible indigenous solutions. although most gunshot injuries to the extremities were not lifethreatening, upper extremity gunshot wounds constituted a red flag for higher injury severity. inadequate timing and selection of emergency referrals of patients with low iss are avoidable aggravators of this burden and should be targeted to increase efficiency in the care of these patients. suggestions for clinical practice include the need for more physicians and other staff at night, as well as increased awareness regarding the involvement of underaged patients. future research should assess criteria for referral, admission and surgical intervention for these injuries and evaluate treatment algorithms with least burden on the health care system and best possible outcomes with available resources.22 ethics statement all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. given the observational character and retrospective analysis, formal consent was not required for this study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. acknowledgements we thank dr richard spence for his support in management of the ethr database. author contributions ee conducted the study, data analysis and wrote the manuscript. sm, ml and sr managed the patients and contributed to the final write-up of the manuscript. an and pd contributed to the data collection, managed the database, and contributed to the final manuscript. sh assisted with the protocol and data analysis, and contributed to the protocol and final manuscript. mh supervised the study, contributed to the original study concept, data analysis and manuscript of the study. orcid ewm engelmann http://orcid.org/0000-0002-7685-4024 m laubscher http://orcid.org/0000-0002-5989-8383 p navsaria http://orcid.org/0000-0002-5152-3317 m held http://orcid.org/0000-0002-0671-0439 references 1. brown td, michas p, williams re, dawson g, whitecloud ts, barrack rl. the impact of gunshot wounds on an orthopaedic surgical service in an urban trauma center. journal of orthopaedic trauma. 1997;11(3):149-53. 2. geneva declaration secretariat. global burden of armed violence 2015. geneva, 2015. 3. persad ij, reddy rs, saunders ma, patel j. gunshot injuries to the extremities: experience of a uk trauma centre. injury. 2005;36(3):407-11. 4. united nations office on drugs and crime. global study on homicide. homicide statistics 2013; homicide counts and rates, time series 2000-2012. 2013. 5. united nations general assembly. report of the panel of governmental experts on small arms. general and complete disarmament: small arms. new york, 1997. 6. volgas da, stannard jp, alonso je. current orthopedic treatment of ballistic injuries. injury. 2005;36(3):380-86. 7. martin c, thiart g, mccollum g, roche s, maqungo s. the burden of gunshot injuries on orthopaedic healthcare resources in south africa. s afr med journal, 2017;107(7):626-30. 8. lichte p, oberbeck r, binnebosel m, wildenauer r, pape hc, kobbe p. a civilian perspective on ballistic trauma and gunshot injuries. scand j trauma resusc emerg med, 2010;18(35). 9. held m, engelmann e, dunn r, ahmad s, laubscher m, keel m. gunshot induced injuries in orthopaedic trauma research. a bibliometric analysis of the most influential literature. orthopaedics & traumatology: surgery & research. 2017;103(5):801-807. 10. gunst m, ghaemmaghami v, gruszecki a, urban j, frankel h, shafi s. changing epidemiology of trauma deaths lead to a bimodal distribution. proceedings (baylor university medical center). 2010;23(4):349-54. 11. song dh, naude gp, gilmore da, bongard f. gang warfare: the medical repercussions. journal of trauma injury infection and critical care. 1996;40(5):810-15. 12. zargaran e, schuurman n, nicol aj, matzopoulos r, cinnamon j, taula t, ricker b, ross garbutt brown d, navsaria p, morad hameed s. the electronic trauma health record: design and usability of a novel tablet-based tool for trauma care and injury evaluation of 294 patients at a level i trauma centre in south africa 17 surveillance in low resource settings. journal of the american college of surgeons. 2014;218(1):41-50. 13. butcher n, balogh z. update on the definition of polytrauma. european journal of trauma and emergency surgery. 2014;40(2):107-11. 14. woloszyn jt, uitvlugt gm, castle me. management of civilian gunshot fractures of the extremities. clinical orthopaedics and related research. 1988;226:247-51. http://orcid.org/0000-0002-7685-4024 http://orcid.org/0000-0002-7685-4024 http://orcid.org/0000-0002-5989-8383 http://orcid.org/0000-0002-5989-8383 http://orcid.org/0000-0002-5152-3317 http://orcid.org/0000-0002-5152-3317 http://orcid.org/0000-0002-0671-0439 http://orcid.org/0000-0002-0671-0439 page 36 engelmann ewm et al. sa orthop j 2019;18(2) 15. black m, ricardo i. drug use, drug trafficking, and weapon carrying among low-income, african-american, early adolescent boys. paediatrics. 1994;72:1065. 16. cherpitel c. alcohol and casualties: a comparison of emergency room and coroner data. alcohol and alcoholism. 1994;29:211. 17. jensen s. gangs, politics and dignity in cape town. the university of chicago press books; 2008. 18. petrus t. enemies of the ‘state’: vigilantism and the street gang as symbols of resistance in south africa. aggressive violent behavior. 2015;22:26-32. 19. campbell n, colville j, van der heyde y, van as a. firearm injuries to children in cape town, south africa: impact of the 2004 firearms control act. s afr j surg 2014;51(3):92-96. 20. wesson h, bachani a, mtambeka p, schulman d, mavengere c, ward millar a, hyder a, van as a. changing state of pediatric injuries in south africa: an analysis of surveillance data from a pediatric emergency department from 2007–2011. surgery 2017;162(6s):s4-s11. 21. government western cape. map of referral and support areas for public hospitals in the western cape. cape town, 2015. 22. meara jg, leather ajm, hagander l, alkire bc, alonso n, ameh ea, bickler sw, conteh l, dare aj. global surgery 2030: evidence and solutions for achieving health, welfare and economic development. the lancet. 2015;386(9993):569-624. _goback _goback _goback _goback _goback 404 not found orthopaedics vol3 no4 sa orthopaedic journal winter 2017 | vol 16 • no 2 page 63 additive manufacturing in orthopaedics: clinical implications tl hilton mbchb(uct), da(sa), dippec(sa), fcorth(sa), mmed(uct) orthopaedic consultant, groote schuur & vincent pallotti hospitals, cape town. affiliated to the university of cape town n campbell msc(med) biomedical engineering (uct) managing director, lrs implants, cape town k hosking mbchb(uct), fcorth(sa) orthopaedic consultant, groote schuur & vincent pallotti hospitals, cape town. affiliated to the university of cape town corresponding author: dr tl hilton 11 clive street vredehoek 8000 cape town western cape, south africa email: tlhilton@hotmail.com cell: 0027 (82) 796 7608 introduction the reconstruction of complex pelvic trauma or developmental bone deformities is problematic with little in the literature by way of guidance.1,2 the primary goals of achieving a long-term, functioning and pain-free hip joint after pelvic reconstruction are to recreate the integrity and symmetry of the bony pelvic ring and to balance the soft tissues carefully.3 pre-operative planning is essential in order to achieve these goals and must be based on a precise understanding of the deformity. two-dimensional imaging often falls short in conveying enough information about the complex threedimensional (3d) anatomy of the pelvis. the 3d capabilities of computed tomography (ct) and magnetic resonance imaging (mri) can expand these capabilities significantly.4,5 however, proprietary hardware, software and services are known to be extremely costly when customised reconstructions are required.3 this case report demonstrates that the use of 3d printing and rapid prototyping can provide affordable and personalised templates and implants, which abstract background: the reconstruction of complex pelvic trauma or developmental bone abnormalities is challenging as it involves in-depth understanding of a complex three-dimensional structure. advances in medical imaging and rapid prototyping allow for detailed pre-operative planning and manufacture of planning models, custom jigs and prostheses to make this type of surgery manageable with good results. methods: we report the reconstruction of a hip and proximal femur using planning models, jigs and custom prostheses produced by rapid prototyping methods. these tools helped to solve a complex problem and produced a good functional result for the patient. results: in this case report the patient underwent the reconstruction of her right hip joint. she was unable to mobilise well independently prior to the surgery. the surgery provided her with a stable and functional hip joint. this allows her to mobilise independently with an external prosthesis. one year down the line she has a fair msts score (14 of 30). conclusion: advances in medical imagining and rapid prototyping have produced planning and operative tools with which surgeons are able to solve complex problems safely and with good result. this technology has widespread use not only in orthopaedics but other surgical disciplines, and with increasing availability and improved cost effectiveness will be used more frequently in the future. level of evidence: level v (case report) key words: pelvic reconstruction, proximal femoral focal deficiency, 3d printing, rapid prototyping http://dx.doi.org/10.17159/2309-8309/2017/v16n2a9 page 64 sa orthopaedic journal winter 2017 | vol 16 • no 2 are useful in planning and performing these technically difficult surgeries.6 we describe below an example where this technology was used to assist in the reconstruction of a severely dysplastic acetabulum. table i defines the terms used. case report a 53-year-old woman was referred to our unit for management of her right leg problem. she was born with an aitken type c proximal focal femoral deficiency (pffd). as a child she underwent a stump plasty, which included the fusion of her knee joint and a transtibial amputation. however, she developed a fixed flexion contracture of her right hip, which, together with an unstable hip joint, made prosthetic use and mobilisation impossible. on examination, she was assessed as having a telescoping right hip joint that was painful on weightbearing and a fixed flexion contracture of 40 degrees. she was otherwise well (figures 1a, b, c). her plain film x-rays showed her prior knee fusion and stump plasty with a dislocated and severely dysplastic hip joint (figures 2a and b). the goals for her management were to provide her with a stable hip joint with adequate range of movement to allow functional mobility. it was decided that a customised proximal femoral replacement would be the most suitable option for the patient in view of these issues and her skeletal abnormality. the problems identified included the position and secure placement of the cup into a dysplastic acetabulum, and performing adequate contracture release while maintaining sufficient soft tissue balance to prevent hip dislocation and to provide motor function. work-up included a ct scan of the pelvis and right acetabulum in 1 mm axial slices (figure 3). the postimaging processing could be used to provide more information on bone defects and stock. the ct dicom data was then converted into stereolithography (.stl) file format and imported into solidworks 3d computer aided design (cad) software (dassault systemes). the resultant bone models were then used to design a suitable prosthesis, as well as the templates and jigs table i: definition of terms 3d printing a process for making a physical object from a three-dimensional digital model, typically by laying down many successive thin layers of a material additive manufacturing the process of joining materials to make objects from 3d model data, usually layer upon layer, as opposed to subtractive manufacturing methodologies rapid prototyping a group of techniques used to quickly fabricate a scale model of a physical part or assembly using three-dimensional computer aided design (cad) data. construction of the part or assembly is usually done using 3d printing or ‘additive layer manufacturing’ technology. figures 1a, b and c. clinical pictures of fixed flexion deformity, adduction and abduction range 1a 1b 1c figures 2a and b. pre-operative x-rays showing the patient’s prior knee fusion, and stump plasty with telescoping hip joint and a fitted external prosthesis 2a 2b figure 3. ct scan of the patient’s pelvis showing an axial cut at the level of the hip joint. of note is the severe dysplasia of her right acetabulum with a dislocated femoral head. sa orthopaedic journal winter 2017 | vol 16 • no 2 page 65 required for the insertion of the implant (lrs implants, cape town). plastic models of the pelvis and the implant were printed for final approval by the surgeon (figures 4a and b). once approval was given, the custom acetabular component was manufactured from ti6al4v powder using electron beam melting (ebm, pro-fit, germany). the use of ebm, which is a form of additive manufacturing (3d printing), facilitated rapid, costeffective manufacture of the customised component that would not have been possible using conventional machining techniques. the proximal femoral component was produced using a combination of conventional milling and turning processes (figures 5a and b). the customised acetabular component was designed to have both superior and inferior screw fixation into the pelvis. it was engineered to facilitate the cementation of a dual mobility cup (zimmer-biomet avantage) into the acetabular component. trabecular ti6al4v surfaces were incorporated onto the backside of the acetabular component to encourage bone in-growth for superior fixation. custom-made jigs were used to ensure the correct reaming position of the new acetabulum and placement of the screws (figures 6a and b). the surgery was performed with the patient bolstered in the lateral position and a lateral approach was used to gain access to the hip joint. after removal of existing hardware and the proximal femur, the novel acetabulum was created using the premade reaming jigs. the acetabular component was fitted into this structure using screws accurately placed by the customised drill guide (figures 7a and b, and figure 8). an avantage dual-mobility cup was cemented into the acetabular component and a proximal femur replacement (lrs implants, cape town) was performed with repair of the soft tissues.7 we followed up on this patient one year after the operation. she scored a fair score (14/30) on her musculoskeletal society tumour score (msts) patient-related outcome measure (prom) and showed good range of movement at the hip joint with values of: flexion 90°; extension 10°; abduction 45°; adduction 15°; internal rotation 20°; external rotation 20°. she presented with no fixed flexion deformity of the hip joint. she did not complain of pain at her hip joint or surgical site but was not happy with her prosthesis, which caused her a moderate degree of pain. she was happy with the appearance of her leg. discussion the combination of improved imaging and computer software in medicine together with advances in rapid prototyping has facilitated the development of customised implants to solve complex surgical problems.4,8,9 the many uses of this technology include surgical planning, implantand tissue-designing, medical research, and medical education and training.4 revision surgery and limb-reconstruction surgery are technically demanding.1,10-12 there are many problems such as distorted soft tissue and bony anatomy, variable bone stock and quality, and prosthetic placement. all of these difficulties were present in this case. performing a complex joint reconstruction under these circumstances requires careful pre-operative planning in order to achieve accurate bony cuts and correct implant positioning and fixation. figures 4a and b. 3d reconstructed renderings of the pelvis and the printed prosthesis 4a 4b figure 5a. cad image illustrating how the computer design enables accurate planning of screw fixation of the definitive prosthesis figure 5b. image of the definitive prosthesis applied to the printed model of the pelvis after simulated reaming of the new acetabulum. this allows the screw position to be checked prior to surgery. page 66 sa orthopaedic journal winter 2017 | vol 16 • no 2 the precise extent of bone deformity is difficult to assess from conventional imaging, especially in a complex structure such as the pelvis, and standard prostheses may often be inadequate to allow proper placement and stable fixation.2,13,14 in response to these two problems, customised implants with the addition of plates, shaped specifically for the altered anatomy, and jigs to aid in the accurate placement of screws, have been developed.2,12 in the case report described above the goals of the surgery were to provide a pain-free, stable hip joint with an improved range of motion to allow for prosthetic use. the problems faced included the patient’s dysplastic acetabulum and soft tissue contracture. the instruments required to perform this surgery together with the overall planning of the optimal surgical approach demand precise knowledge of bony dimensions and local variations in shape.1 the utilisation of ct scan data and the 3d printing of the bony anatomy provides the surgeon with an accurate representation of what is present and establishes a good basis for planning the surgery. the initial planning phase (figure 4) involved producing models of the pelvis in its current form. this was to assess the amount and position of available bone stock in order to plan the position of the acetabular cup and screws. not only are these models able to supply quantitative and qualitative data on the acetabular defect but they also allow for a surgical rehearsal.2 the rehearsal allows for simulating all the complicated surgical steps in advance and can help the surgeon to anticipate possible intra-operative complications.4 this will help to reduce theatre time and allow for a smoother procedure. the second phase (figures 5 and 6) concerned the method with which to effect the surgery simply and accurately. a jig was printed using a 3d printer that would fit onto the contour of the native acetabulum and guide the reaming of the novel hip joint. the acetabular implant is fitted into this reamed cavity. into this would fit a second jig which would act as a drill guide for the predetermined placement of screws through the prosthesis and into good pelvic bone. further advantages of this type of planning reduces the amount of backup equipment and implant options often required for the complex cases.12 furthermore, with a better appreciation of the location of bone stock and defects, maximal host-bone contact is achieved without the use of structural allografts.2 disadvantages of this method include the increased cost of the ct scan and printed models. however, these costs can be offset with reduced theatre time and allograft use, smaller inventory of implants, and a decreased revision rate.2 this process enabled a difficult surgery to be transformed into a manageable one by using accurate and well-fixed components with confidence. the surgery was performed a year ago and the patient has been fitted with an external prosthesis which allows independent pain-free functioning to date. this software and technology is used extensively in orthopaedic oncology. it has many other potential uses, ranging from primary arthroplasty to complex trauma such as pelvic fractures.4 as the availability of this method of performing surgery increases, its use will become more frequent. the rapid prototyping technique figures 6a and b. 3d printed jigs to guide acetabular reaming and screw placement. the jigs were printed with a 3d printer and are used to simulate the steps that would be taken intra-operatively. figure 6a would simulate the application of the definitive acetabular component (green) into which the screw guide (white) would be placed to guide the drilling of the screw holes. these two simulations would aid the surgeon in familiarising himself with the processes that would take place and ensure the jigs were correct in the placement of the acetabular component and screw placement. 6a 6b figures 7a and b. post-operative x-rays showing final implant. of note is the accurate placement of screws into the superior pubic ramus and ilium as well as the correct placement and fixation of the acetabular component. the figures also illustrate the proximal femoral replacement cemented into the cut end of the original knee arthrodesis. it also shows the attachments for the iliopsoas and abductor complexes to the proximal femoral replacement. 7a 7b figure 8. post-operative clinical picture to show resolution of fixed flexion deformity sa orthopaedic journal winter 2017 | vol 16 • no 2 page 67 is beneficial not only for bone reconstructions but also for replacing soft tissues such as an auricular prosthesis. future applications may include the production of soft tissue scaffolds for cellular growth or even entire artificial organs adapted to the anatomy and needs of individual patients.4 compliance with ethics guidelines conflict of interest statement each author certifies that he or she has no commercial associations that might pose a conflict of interest in connection with the submitted article. ethics review committee statement none required. email consent was obtained from the patient for the case report. work for the article was performed at groote schuur hospital and vincent pallotti life orthopaedic hospital. disclosure dr keith hosking is a medical advisor to lrs implants, cape town but receives no financial compensation from the company. mr neil campbell is the biomedical engineer for lrs implants, cape town. references 1. potamianos p, et al. rapid prototyping for orthopaedic surgery. proc inst mech eng h, 1998;212(5):383-93. 2. john jf, talbert rf, taylor jk, bargar wl. use of acetabular models in planning complex acetabular reconstructions. j. arthroplasty, october 1995;10(5):661-66. 3. wu xb, et al. printed three-dimensional anatomic templates for virtual preoperative planning before reconstruction of old pelvic injuries: initial results. chin med j (engl), 2015;128(4):477-82. 4. rengier f, et al. 3d printing based on imaging data: review of medical applications. int j comput assist radiol surg, 2010;5(4):335-41. 5. gouin f, et al. computer-assisted planning and patientspecific instruments for bone tumor resection within the pelvis: a series of 11 patients. sarcoma, 2014;2014:842709. 6. truscott m, de beer dj, vicatos g, hosking k, barnard l, booysen g, campbell ri. using rp to promote collaborative design of customised medical implants. rapid prototyping journal, 2007;13(2):107-14. 7. fresard pl, et al. seven-year results of a press-fit, hydroxyapatite-coated double mobility acetabular component in patients aged 65 years or older. eur j orthop surg traumatol, 2013;23(4):425-29. 8. d’urso ps, et al. custom cranioplasty using stereolithography and acrylic. br j plast surg, 2000;53(3):200-204. 9. kim ms, hansgen ar, carroll jd. use of rapid prototyping in the care of patients with structural heart disease. trends cardiovasc med, 2008;18(6):210-16. 10. morrey bf, bryan rs. the elbow/revision. joint replacement arthroplasty, 1991; ch. 25, pp. 345-60. 11. morrey bf, kavanagh bf. complications with revision of the femoral component of total hip arthroplasty. comparison between cemented and uncemented techniques. j arthroplasty, 1992;7(1):71-79. 12. baauw m, et al. the accuracy of positioning of a custommade implant within a large acetabular defect at revision arthroplasty of the hip. bone joint j, 2015;97-b(6):780-85. 13. tanzer m, et al. revision of the acetabular component with an uncemented harris-galante porous-coated prosthesis. j bone joint surg am, 1992;74(7):987-94. 14. mcgurk m, et al. rapid prototyping techniques for anatomical modelling in medicine. ann r coll surg engl, 1997;79(3):169-74.. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj south african orthopaedic journal editorial doi 10.17159/2309-8309/2021/v20n2a0sa orthop j 2021;20(2) here we go again: is this our new normal? lipalo mokete orthopaedic surgeon and lecturer incoming president of the south african arthroplasty society corresponding author: lipalo@hotmail.com as i write this piece, we are in the throes of working through the logistical consequences of cancelling the 2021 biennial south african arthroplasty society (saas) conference. in may last year, even as the first wave of covid-19 engulfed south africa, we were confident of holding a successful congress in 2021. september came, covid-19 cases receded, elective surgery resumed, and our lives started to take on a semblance of normality. this state of affairs lulled us into believing that we were on track to a relatively covid-19-free 2021. the 2021 conference would be one way of reclaiming normality in our orthopaedic lives. however, we have now had to make the painful but inevitable decision to postpone the saas conference to 2022 as the covid-19 pandemic has continued to be the chief disruptor in our lives for the second year running. george bernard shaw is credited with the saying ‘if history repeats itself, and the unexpected always happens, how incapable must man be of learning from experience’. a quick google search of the word ‘pandemic’ brings up the 1918 influenza pandemic which was the most widespread lethal pandemic in recent memory. according to the centers for disease control and prevention (cdc) in the us, an estimated 500 million people or one-third of the world’s population became infected with the 1918 strain of the flu virus, and 50 million people succumbed.1 the 1918 pandemic had multiple waves, with the second wave being much more deadly than the first and third waves. one hundred years later and just over a year since the declaration of sars-cov-2 as a pandemic, we have been transported back in time. as implausible as it may seem given the significant advances in medicine and technology that we have witnessed in the last 100 years, ‘we are much more vulnerable today to a catastrophic influenza pandemic than we were in 1918’.2 these are the words dr osterholm (director of the center for infectious disease research and policy at the university of minnesota) intimated during the centennial of the 1918 flu epidemic in 2018, a full two years before the current pandemic. as we slowly get to grips with a new normal following the recent second covid-19 wave, we should heed the warnings from the experts and prepare for a third wave. vaccines offer a welcome respite from the misery we have endured but they have been late in coming to south africa and they are unlikely to substantially change our course towards the inevitable third covid-19 wave. the social cost of the pandemic has been immense. there is not a single orthopaedic surgeon in south africa who has not been affected by the pandemic. we bear deep personal scars having lost family members and colleagues to the pandemic. the effect on orthopaedic private practices has been brutal, with elective orthopaedics bearing the brunt. elective joint arthroplasty has arguably suffered the most of all orthopaedic disciplines. we observed with trepidation as the first reports of the impact of the pandemic on elective orthopaedics started emerging from the northern hemisphere. governments rightfully mandated the complete cessation of elective surgical operations.3 and soon we were living the same shared reality. fortunately, the south african covid-19 surges and peaks have lagged the northern hemisphere and we can take valuable lessons from their experience. during the aftermath of the first wave in europe, oussedik et al. suggested reinstating elective orthopaedic surgery by operating on patients with a low risk of morbidity from covid-19 with short duration of surgery first then progressing to include low-risk patients with longer duration of surgery or hospital stay.4 the vast majority of lower limb arthroplasty patients are at high risk for covid-19 because of their advanced age and comorbidities. furthermore, their surgery is high risk because of prolonged theatre time and hospital stay. chang et al. showed that elective orthopaedic surgery could be done safely with a designated covid-19-free pathway.5 as we emerged from the first wave, into an unfamiliar new normal, we recognised that there would likely be pent-up demand for elective joint arthroplasty and many of us armed with fresh covid-19-safe treatment protocols started making plans accordingly. private hospitals quickly ramped up capacity to handle elective surgery to make up for lost revenue. but patients have not returned in anticipated numbers. the green shoots that we experienced towards the end of 2020 were soon quashed by the advent of the second wave. patients remain concerned and fearful of contracting covid-19 in hospital settings. our experience is certainly not unique as it mirrors that of other countries where arthroplasty surgical and outpatient volumes have failed to recover to pre-pandemic levels.6 the south african orthopaedic association has been supportive in mitigating the financial pain, but now more than ever, efforts need to be intensified to ensure the survival of orthopaedic private practices. established practices will likely weather the storm because of their financial reserves; however, new practices will battle to survive the pandemic. the young, recently qualified orthopaedic surgeon, without the financial security of a government job, is facing a precarious financial future, certainly in the short term. special efforts should be devoted to ensuring the survival of our young colleagues as south africa can ill afford to lose orthopaedic surgeons. admittedly, there is no financial blueprint regarding how to survive this once-in-a-lifetime event. there are a lot of knowledgeable individuals, but no experts! page 64 sa orthop j 2021;20(2) as orthopaedic surgeons we need the collective wisdom and fraternity of our peers to navigate these unprecedented times. our representative bodies have to be more aligned towards alleviating our common plight and serving our interests. as individuals we must keep adapting and learn to embrace the ever-evolving new normal. references 1. centers for disease control and prevention [internet]. 1918 pandemic (h1n1 virus). available from: https://www.cdc.gov/flu/pandemic-resources/1918pandemic-h1n1.html. [accessed 03 march 2021]. 2. voelker r. vulnerability to the flu pandemic could be greater today than a century ago. jama. 2018;320(16):1523-25. 3. remuzzi a, remuzzi g. covid-19 and italy: what next? lancet. 2020;395(10231):1225-28. 4. oussedik s, zagra l, shin gy, d’apolito r, haddad fs. reinstating elective orthopaedic surgery in the age of covid-19. bone joint j. 2020;102-b(7):807-10. 5. chang js, wignadasan w, pradhan r, et al. elective orthopaedic surgery with a designated covid-19-free pathway results in low perioperative viral transmission rates. bone joint open. 2020;1-9:562-67. 6. tan yn, vandekerckhove pj, verdonk p. the long road to recovery: at six months since the first covid-19 wave, elective orthopedic care has not fully recovered in belgium. j exp orthop. 2020;7:99. https://doi.org/10.1186/ s40634-020-00316-9. 404 not found orthopaedics vol3 no4 sa orthopaedic journal summer 2014 | vol 13 • no 4 page 35 hepatitis c virus and the risk to the healthcare worker p greyling mbchb(pret), mmed(orth)(pret), fcs(orth)sa consultant, orthopaedic surgery, steve biko academic hospital prof tlb le roux mbchb(pret), mmed(orth)(pret), fcs(orth)sa head of department orthopaedic surgery, 1 military hospital, department of orthopaedic surgery, steve biko academic hospital, university of pretoria, faculty of health sciences l botha mbchb(pret) orthopaedic registrar, 1 military hospital correspondence: dr p greyling department of orthopaedic surgery steve biko academic hospital pretoria south africa tel: 012 354 2851 email: pgrey@live.com introduction south african surgeons need to familiarise themselves with the risk of acquiring hepatitis c virus (hcv) via sharps injury (si). any of the 60 blood-borne pathogens (bbp) may be transferred by si, the three foremost being the human immunodeficiency virus (hiv), hepatitis b virus (hbv) and hcv.1 in south africa (sa) there is little prevalence of hbv (5–7%) and the greatest risk is from hiv (17.9%) for which there are documented protocols and insurance cover.2,3 little has been written of hcv risk to sa surgeons; there is no protocol in place for hcv exposure, little guidance for surgeons, and insurance companies do not cover hcv exposure claims. a canadian surgeon recently acquired hcv from an si and was banned from practice for 6 months – testimony of the importance of hcv as a disease risk to surgeons.4 this paper outlines the prevalence of hcv in sa, the incubation and outcomes of hcv infection, the tests and medications available, and the protective strategies available to minimise hcv exposure. epidemiology hepatitis c virus was discovered in 1989; it is a small 50 nm, single-stranded rna virus that belongs to the flaviviridae family.5,6 there are six major hcv genotypes, with five more having recently been added (7–11), and more than 50 subtypes have been described. genotype 5 is predominantly found in sa (40% of all hcv genotypes).7,8 the virus is able to mutate which results in changes that allow the virus to replicate and escape immune surveillance. the result is that hcv infecting humans are remarkably heterogeneous, with only a 70% similarity among all known isolates.9 abstract the risk of hepatitis c virus (hcv) transmission is six times higher per needle-stick exposure than is the risk of hiv infection (1.8% vs 0.3%). the prevalence of hcv in south africa is not known but estimated to be between 0.1 and 0.7%. genotype 5 is predominantly found in south africa. currently there is no protocol in place for hcv exposure. the treatment cost of hcv is expensive. currently none of the insurance companies covers post-hcv exposure. key words: hepatitis c virus, transmission risk, post-exposure protocol saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 35 page 36 sa orthopaedic journal summer 2014 | vol 13 • no 4 prevalence and risk of hcv transmission (figures 1–3) the prevalence of hcv in sa is not known but estimated to be between 0.1 and 0.7% (who up to 10% in some areas).2,7 three per cent of the world’s population is estimated to be infected with hcv (130–170 million people).2,10 the world health organisation (who) has calculated that unsafe medical devices account for 2.3 million new hcv infections per year and 200  000 premature hcv-related deaths. the risk of hcv transmission is six times higher per needle-stick exposure than is the risk of hiv infection (1.8% vs 0.3%).5,11 burden of disease hcv is responsible for more than 350 000 deaths annually. unsafe injections in healthcare settings result in 2 million new hcv infections yearly. up to 30% of people infected with hiv are also infected with hcv. unless the disease is contained, the death rate from hcv will rise to a level greater than that of aids.10,15 the cost of treating hcv is enormous. a 24-week treatment course is estimated at $10  200, but if either telaprevir or boceprevir is added, costs can go up to $70 000.4,17 hepatitis c specific diagnostic tests diagnostic tests can be divided into two general categories:5,7,9,18 1. serological assays: detect antibodies to hcv and are used as screening tests for prior exposure to hcv. 2. molecular assays: detect, quantify, and or characterise hcv rna genomes within an infected patient. categorised as: • qualitative • quantitative (quantitative pcr and branched dna assay) • genotyping molecular test is necessary to confirm the diagnosis. treatment of acute hepatitis c early treatment of acute hcv improves rates of viral clearance. treatment should be started within 3 months after testing positive for hcv.7 the current suggested treatment regimen consists of a combination of chemotherapy drugs for all types of hepatitis c:1,7,11,19,20,21 • interferon alpha (pegingerferon alpha-2a) – 180 μg per week subcutaneously • ribavirin – 800 mg per day • boceprevir and telaprevir are recommended by the national institute for health and clinical excellence (nice) as an option for the treatment of people with genotype 1. interferon alpha and ribavirin are on the south african national essential medicines list for the treatment of hcv; however, there are no guidelines available suggesting who is eligible for treatment.2 duration of treatment depends on the genotype. in patients with genotype 2 or 3, a 24-week course is effective, while a 48-week course is suggested for genotype 1. genotype 5 responds similarly to type 2 and 3, and a 24-week course is recommended.5,7,16,21 if no response (drop in viral load) is noted within 24 weeks of combination therapy, treatment should be stopped as no benefit has been proven with continued treatment.7,16 follow-up monitoring after completion of treatment should include serum aminotransferase levels and testing for hcv rna at 6 months. interferon alpha and ribavirin are on the south african national essential medicines list for the treatment of hcv; however, there are no guidelines available suggesting who is eligible for treatment figure 1. incidence of occupational percutaneous injuries to hcv12,13 needles 51% blood sugar test 6% intravenous catheter 7% suture needles 12% blade 4% operation device 6% other 14% figure 2. hcv prevalence rate in sub-saharan africa14 hcv prevalence rate in subsaharan africa 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% central africa west africa southern and east africa 6.0% 2.4% 1.6% saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 36 sa orthopaedic journal summer 2014 | vol 13 • no 4 page 37 prevention of hepatitis c hepatitis c vaccination there is no reliable vaccine due to the unique characteristics of hcv, which include high replication rate and multiple mutation possibilities. neutralising antibodies emerge too late to prevent chronic infection.16,22 refer to figure 4 for the suggested post-exposure protocol. should hcv positive surgeons refrain from operating? (surgeon risk to patient) current guidelines allow surgeons who are antibodypositive for hcv to continue performing procedures. if however it has been shown that they have transmitted hcv to a patient they are not allowed to continue operating.6,11,24 currently in south africa there are no guidelines advising infected surgeons on the reporting, assessment, and management of any incidents in which patients appear to have been exposed to a healthcare worker’s blood.23 there is controversy in identifying infected healthcare workers. at present there is no legislation on this subject.25 risk to surgeon healthcare workers sustain 0.5–4.7 sharps-related injuries per year. the risk of virus transmission after percutaneous exposure is 1.8% (six times higher than the risk for hiv).11,23 perception of surgeons regarding hepatitis c in a questionnaire survey by the royal college of surgeons of england it was reported that 67% of orthopaedic surgeons do not routinely report sharps injuries or eye contamination. the reason given is the complex process for reporting an injury on duty.3 medical insurance and post-exposure hepatitis c the treatment cost of hepatitis c is expensive. currently none of the insurance companies covers post-hcv exposure for healthcare workers. should hcv not be receiving the same insurance coverage as hiv? figure 3. natural history of hepatitis c5,9,15,16 symptomatic hepatitis (10 15%) • malaise • weakness • fatigue • right upper quadrant pain • nausea or vomiting • jaundice non-symptomatic infection (85 90%) spontaneous clearance (10 15%) spontaneous clearance (25 52%) chronic hepatitis (symptomatic group 48 75%, non-symptomatic group 85 90%) defined as: • hcv rna qualitative or quantitive > 6 months • persistent elevated alanine aminotransferase levelsrisk factors for progression of chronic hepatitis: • alcohol use • male gender • > 40 years at time of infection • advanced histology at the time of diagnosis • co-infection hiv/hep 8 progression of chronic hepatitis c • hepatic cirrhosis (1.7% per year) • hepatocellular carcinoma (1 4% per year) hepatitis c exposure incubation period 6 7 weeks (2 26 weeks) healthcare workers sustain 0.5–4.7 sharps-related injuries per year. the risk of virus transmission after percutaneous exposure is 1.8% (six times higher than the risk for hiv) saoj summer 2014_orthopaedics vol3 no4 2014/11/05 11:59 am page 37 page 38 sa orthopaedic journal summer 2014 | vol 13 • no 4 conclusion there is no cure for hepatitis c at the present, and no postexposure prophylaxis is recommended. immunoglobulins are not effective, interferon-alpha does not prevent transmission, antiviral agents have not been adequately assessed and there is no vaccine.22,25 although surgeons fear transmission of hiv, it is hepatitis c which poses the greater risk.26 we would like to acknowledge the positive information and advice from terry grimmond from hamilton new zealand. the content of the article is the sole work of the authors. no benefits of any form have been or are to be received from a commercial party related directly or indirectly to the subject of the article references 1. waljee jf, malay s, chung kc. sharps injuries: the risks and relevance to plastic surgeons. prsj 2013;131:784-91. 2. lazarus jv, safreed-harmon k, sperle i. global policy report on the prevention and control of viral hepatitis in who member states. who report 21 may 2012:1-220. 3. global aids response progress report 2012. 4. jeanes d. the butterfly effect how a needle-stick grew into a big deal. coa bulletin aco. summer 2012:11-13. 5. maheshwari a, ray s, thuluvath p. acute hepatitis c. lancet 2008;372:321-32. 6. stevens ab, coyle pv. hepatitis c virus: an important occupational hazard. occup. med. 2000;50:377-82. 7. botha jf, kassianides c, schneider hr, song e, spearman w, van der merwe sw. south african hepatitis c management guidelines 2012. the south african gastroenterology review 2010:20-25. 8. abuelhassan w. hepatitis c virus infection in 2012 and beyond. south afr j epidemiol infect 2012;27(3):93-97. 9. bonkovsky hl, metha s. hepatitis c: a review and update. j am acad dermatol 2001:159-79. 10. averhoff fm, glass n, holtzman d. global burden of hepatitis g: considerations for health providers in the united states. cid2012;55(suppl 1):s10-s15. 11. asthana s, kneteman n. operating on a patient with hepatitis c. can j surg 2009;52:337-42. 12. ryoo sm, kim wy, kim w, lim ks, lee cc, woo jh. transmission of hepatitis c virus by occupational percutaneous injuries in south korea. jfma 2012;111:113-17. 13. adams d. needlestick and sharps injuries: practice update. nursing standard 2012;26:49-57. 14. madhava v, burgess c, drucker e. epidemiology of chronic hepatitis c virus infection in sub-saharan africa. the lancet infectious diseases 2002;2:293-302. 15. rhoads j. natural history and epidemiology of hepatitis c. janac 2003;14:18s-25s. 16. liang, tj, rehermann b, seeff lb, hoofnagle jh. pathogenesis, natural history, treatment, and prevention of hepatitis c. annal of internal medicine 200;132:296-305. 17. holmberg sd, spradling pr, moorman ac, denniston mm. hepatitis c in the united states. n engl j med 2013;368:1859-61. 18. gretch dr. diagnostic tests for hepatitis c. hepatology 1997;26:43s47s. 19. mchutchison jg, gordon sc, schiff er, shiffman ml, lee wm, rustgi vk, goodman zd, ling m-h, cort s, albrechgt jk. interferon alfa-2b alone or in combination with ribavirin as initial treatment for chronic hepatitis c. n engl j med 1998;339:1485-92. 20. nih. national institutes of health consensus development conference panel statement: management of hepatitis c. hepatology 1997;26:2s-10s. 21. qureshi h, agha f. should hbv or hcv positive surgeons refrain from operating? j pak med assoc 2011;61:843-45. 22. jawaid a, khuwaja ak. treatment and vaccination for hepatitis c: present and future. j ayub med coll abbottabad 2008;20:129-33. 23. ramsay me. guidance on the investigation and management of occupational exposure to hepatitis c. communicable disease and public health 1999;2:258-62. 24. crockcroft a. surgeons who test positive for hepatitis c should not be transferred to low risk duties. rev med virol 2000;10:79-82. 25. viral hepatitis prevention board. viral hepatitis. vhpb 2005;14:1-16. 26. wallis gc, kim wy, chaudhary br, henderson jj. perceptions of orthopaedic surgeons regarding hepatitis c viral transmission: a questionnaire survey. ann r coll surg engl 2007;89:276-80. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj figure 4. suggested post‐exposure protocol6,11,23 wound management: • clean with soap and running water • mucous membranes wash with water assess infection risk: type of exposure: • percutaneous • mucous membrane • non-intact skin body substance: • blood • tissue • potential infected fluid base line testing: patient (source): • anti-hcv (antibody to hcv) healthcare worker (exposed): • anti-hcv • liver function (aminotransferase) • pcr • eia • liver function • eia at six months repeat monthly for first three months when to initiate treatment: • two sequential anti-hcv positive tests • hcv-rna positive status fails to clear after 3 months suggested treatment: • interferon alpha • ribavirin saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 3 page 19south african orthopaedic journal http://journal.saoa.org.za editorial racial categories are widely used in medical scientific research both in south africa and in other countries around the world. different categorisations of race are used in different contexts and when i encounter these references in articles i read or review, i am often struck by how the use of race, as a category, somehow escapes the normal scientific rigour we use to define any other category. race is used in various ways in medical research: studies looking at the impact of socioeconomic factors on health; the effect of culture on medical compliance and understanding; the impact of language and, in some cases, a link is made between the race of participants and a perceived common or unusual clinical outcome or clinical pathway. it is contemporary knowledge and widely accepted that there is no scientific basis for race. race is a socio-political entity. this is not to say that racism does not exist. race is often used as a social and political means of justifying and reinforcing oppression of one group of people by another. as ta-nehisi coates so eloquently states in his book, between the world and me: ‘but race is the child of racism, not the father’. looking into the history of race-based medical research is a sobering exercise. dr samuel morton is known as the father of scientific racism. he was a prominent scientist that lived in the usa in the 19th century. in his widely published craniometry experiments, he stuffed various skulls with pepper seeds which he then decanted to determine the volume of the braincase. his conclusion was that there were five races in the world and they all originated from separate acts of creation (polygenism). caucasians were at the top of the pile and represented the most intelligent of races. blacks were at the bottom. his ideas were soon endorsed and popularised by the defenders of slavery. sadly, from these humble beginnings, the science of race was born, and very infrequently reexamined. it just became gospel. importantly, dr samuel morton worked before dna was discovered. the use of racial categorisation in medical literature is not always benign; it can carry motives of oppression or perpetuating stereotypes. when morton died, in 1851, the  charleston medical journal  in south carolina praised him for ‘giving to the negro his true position as an inferior race’. and just recently, a 2019 study from stellenbosch university on intellectual capabilities of coloured women concluded that coloured women were cognitively inferior. after a massive outcry, and rightly so, this article has been withdrawn. it is a sad testimony to the unexamined hegemony of race in our consciousness and our research that such a study was approved by the ethics committee and passed a rigorous peerreview process. elizabeth kolbert writes that race as a scientific entity does not exist. she further expands that it is a made-up label that has been used to define and separate people for millennia. but the concept of race is not grounded in genetics. many of the differences we see are based on skin pigmentation, culture and language, which when combined are often referred to as race. skin pigmentation simply reflects how our ancestors used melanin to deal with sun exposure, and not much else. heather norton, a molecular anthropologist at the university of cincinnati who studies pigmentation, remarks that ‘we often have this idea that if i know your skin colour, i know x, y, and z about you’. all scientific categories we use in our research are subjected to the rigours of clear definition, yet race is often used with no attempt to define what it is. we are all just expected to know. human diversity includes skin colour, hair, facial features and all other physical attributes that make us different. these differences are not easily categorised into groups but rather are a complex and beautiful continuum. creating race from this converts the richness of this continuous variable into a falsely simplistic and reductionist categorical one in a process that defies any attempts at rational or objective methodology. many articles in our own south african orthopaedic journal still include racial categorisation. writing in 1986, cooper and david conclude that ‘the pragmatism of medicine and its isolation from social science may account for much of this backwardness’. it has been 33 years since this article was published acknowledging the flaws of racial classification in medical science, but we do not seem to have taken heed of this and moved on. even when some studies are not race-related, the demographics section will often include race when defining the cohort almost as a default. whenever i have asked a speaker or researcher ‘how did you decide who was coloured and who was white or black?’, i am always met with shock, awkward silence, rolled eyes and shoulder shrugging, but i have never been given a satisfactory answer. i am just expected to know. often the response is ‘we asked the patients to classify themselves’. using the self-classification quick-fix card is simply an abdication of scientific responsibility and conflates social identity with race biology. the fact that senior and experienced researchers still do this, and ethics committees approve it and reviewers accept it, does not make the category any more scientific. in conclusion, aside from the significant issues around race as a social and political vehicle for oppression of one group by another, the inability to define race as a scientific category should make any serious researcher pause. using race as a proxy for any variable in medical research is at best lazy research. using race as a biological variable is deeply flawed. my plea to you, fellow academics, scientists and researchers, is to refrain from using racial categories in our research. the fact that most people do it must not be a reason to continue with this practice. further reading 1. coates, ta-nehisi. between the world and me. 2015. new york: spiegel & grau. 2. kolbert, eilzabeth. there’s no scientific basis for race – it’s a made-up label. national geographic. the race issue. april 2018. 3. cooper r, david r. the biological concept of race and its application to public health and epidemiology. j health polit policy law 1986;11(1):97-116. the use of racial classification in medical research sithombo maqungo mbchb, fc ortho, mmed, pg dip hpe associate professor and head of clinical unit: orthopaedic trauma service groote schuur hospital and university of cape town sithombo@msn.con _goback orthopaedics vol3 no4 page 52 sa orthopaedic journal spring 2015 | vol 14 • no 3 prevention of periprosthetic joint infection: pre-, intra-, and post-operative strategies a shahi md j parvizi md, frcs rothman institute at thomas jefferson university, philadelphia, pa corresponding author: javad parvizi md, frcs 125 s 9th street philadelphia, pa 19107 tel: (267) 339-3605 fax: (215) 503-5651 email: parvj@aol.com introduction total joint arthroplasty (tja) is the ultimate treatment for degenerative joint disease. it restores function in the majority of patients and improves quality of life. it is projected that by the year 2030 the total number of primary total knee arthroplasty (tka) procedures in the united states will reach 3.48 million per year, a 673% increase in comparison with the number of procedures in 2005. furthermore, the demand for total hip arthroplasty (tha) is projected to grow by 174%, which would be 572 000 procedures per year. that is about 4 million tjas per year.1 similar to all medical interventions, tja is accompanied by some complications, the most challenging of which is periprosthetic joint infection (pji). infection is the leading cause of revision after tka and the third most common reason for revision tha in the medicare population.2-5 pji can occur any time after the surgery, and there is no ‘gold standard’ for diagnosis.6-8 pji has a huge financial impact on the healthcare system. revision due to infection cost about $320 million in 2001, increased to $566 million in 2009, and is projected to exceed $1.62 billion by 2020 in the united states.9 prevention of pji is therefore imperative. definition of pji until recently there was no unified definition for pji. in 2011, in an effort to standardise the definition of pji, a list of criteria was provided by the musculoskeletal infection society (msis).10 in addition, in august 2013, the international consensus meeting (icm) on pji was held in philadelphia. more than 400 experts from 52 countries and representatives from over 130 societies convened. the icm supported the msis definition of pji and modified it by adding a minor criterion (leukocyte esterase test) and determining the threshold for lab results.11 according to the modified definition, a definite pji is present when: • there is a sinus tract communicating with the prosthesis, or • a phenotypically identical pathogen is isolated by culture from two or more separate tissue or fluid samples obtained from the affected prosthetic joint, or abstract prosthetic joint infection (pji) is a calamitous complication with high morbidity and substantial cost. the reported incidence is low but it is probably underestimated due to the difficulty in diagnosis. pji has challenged the orthopaedic community for several years and despite all the advances in this field, it is still a real concern with immense impact on patients and the healthcare system. numerous factors can predispose patients to pji. in this review we have summarised the effective prevention strategies along with the recommendations of a recent international consensus meeting on surgical site and periprosthetic joint infection. key words: pji, prevention, infection, total hip replacement, total knee replacement, total joint arthroplasty http://dx.doi.org/10.17159/23098309/2015/v14n3a6 infection is the leading cause of revision after tka and the third most common reason for revision tha sa orthopaedic journal spring 2015 | vol 14 • no 3 page 53 • when three of the following five criteria exist: 1. elevated serum erythrocyte sedimentation rate and serum c-reactive protein concentration 2. elevated synovial white blood cell count, or ++ change on leukocyte esterase test strip 3. elevated synovial polymorphonuclear percentage 4. positive histological analysis of periprosthetic tissue 5. a single positive culture. note that pji can exist regardless of the absence of these criteria in some cases, such as low-virulence microorganisms like propionibacterium acnes. classifications of pji based on the pathogenesis or the timing of the clinical manifestation, different classifications are suggested for pji. as far as pathogenesis is concerned, pji is either exogenous or haematogenous.12 pji can occur any time post-operatively. based on the time interval between the surgery and the onset of the clinical manifestations, pji can be divided into four different stages:12-14 1. stage one/early: symptoms start within the first 4 to 8 weeks post-operatively. 2. stage two/delayed: presents 3 to 24 months after the surgery. 3. stage three/late onset: usually occurs after 2 years postoperatively. 4. stage four/silent pji: a condition in which a positive culture is captured at the time of revision in a patient with no symptom of infection. early, delayed and silent infections are often exogenous. early pji is usually caused by virulent organisms such as s. aureus. late pji has an acute clinical manifestation and is usually haematogenous. silent pji is mostly caused by lowvirulence microorganisms such as coagulase-negative staphylococci or propionbacterium acnes.14,15 the most common sources of contamination are the patient’s skin and soft tissue. nevertheless, some studies reported seeding from the respiratory, urinary and gastrointestinal tracts, and dental infections.16 sendi et al.17 reported that in 57.5% of haematogenous pji, there was no sign of primary bacteraemia or infection during the clinical manifestation; therefore, it is usually difficult to identify the source of infection. prevention of pji many different factors are involved in the development of pji. these elements concern both the host and the environment. conditions that can increase the risk of infection include (but are not limited to): uncontrolled diabetes, rheumatoid arthritis, renal failure, congestive heart failure, hypercholesterolaemia, malnutrition, pulmonary disease, valvular heart disease, pre-operative anaemia, venous thromboembolism, peripheral vascular disease, metastatic tumour, psychosis, alcohol abuse and depression.3,18–20 patients who undergo elective arthroplasty are typically in suboptimal health. additionally, the impact of various risk factors is cumulative.21,22 therefore, it is imperative to identify the risk factors and address them pre-operatively to reduce the risk of pji and other post-operative complications. generally strategies to prevent pji are categorised as preoperative, intra-operative and post-operative. pre-operative period medical optimisation of host all modifiable conditions should be optimised prior to an elective tja. studies have shown that the patient’s general health has a direct link with post-operative complications. an american society of anesthesiologists score of greater than 2, uncontrolled diabetes, and rheumatoid arthritis, for example, can significantly increase the risk of pji.18,20,23–25 furthermore, any other comorbidity accompanied by diabetes is shown to place patients at a cumulatively higher risk for infection.21,26 merchant et al.27 reported that patients with a higher level of haemoglobin a1c are at a higher risk of pji, with an odds ratio of 2.31. additionally, not only is the pre-operative glucose level an important factor, but mraovic et al.28 demonstrated that the post-operative blood glucose level also plays an important role as far as the risk for pji is concerned. the authors stated that patients with sugar levels of greater than 200 mg/dl on post-operative day 1 were twice more likely to develop pji. therefore, evaluating patients in a multidisciplinary clinic prior to performing tja is crucial in order to identify comorbidities and manage them, if required. these assessments significantly reduce post-operative mortality and pre-admission costs in complex orthopaedic surgeries, including tja.29 the icm comment the icm workgroup stated that certain conditions such as history of previous surgery, uncontrolled diabetes mellitus (glucose levels > 200 mg/l or hba1c > 7%), malnutrition, morbid obesity (body mass index > 40 kg/m2), chronic renal disease, active liver disease, excessive smoking (> one pack per day), exorbitant alcohol use (> 40 units per week), intravenous drug abuse, extended stay in a rehabilitation facility, recent hospitalisation, post-traumatic arthritis, inflammatory arthropathy, previous surgical procedure in the affected joint, male gender, and severe immunodeficiency can increase the risk of developing pji.30 bacterial decolonisation (pre-operative skin cleansing) prevention guidelines regarding surgical site infections (ssi) published by the centers for disease control (cdc) recommended patients take a bath with an antiseptic agent at least once on the night before the operation to reduce the load of bacteria.31 page 54 sa orthopaedic journal spring 2015 | vol 14 • no 3 many reports have shown that a whole-body bath with an antiseptic agent reduces the bacterial load in the skin and lowers the risk of developing ssi.32-35 according to the cdc, ssis are the second most common cause of nosocomial infections and are responsible for more than 25% of hospital-related infections in the united states.36,27 there is still a debate on how to achieve entire-body coverage and maintain adequate concentrations of the solution for effective results. another issue is the patient’s compliance with these protocols.38 the icm comment the icm group suggests that a whole-body skin cleansing regimen with chlorhexidine gluconate (chg) should begin at least one night before the surgery. in case of sensitivity to chg or when it is not available, antiseptic soap can also be used.39 prophylactic antibiotics it is believed that prophylactic antibiotics are one of the most important factors in preventing pji.40-43 one of the sentinel studies in the field of orthopaedic surgery is that of fogelberg et al.40, in 1970. they compared two groups of patients; one group was given prophylactic penicillin preoperatively, intra-operatively, and up to 5 days postoperatively; and the other group was not given any antibiotics. the incidence of infection was 1.7% the group receiving antibiotics versus 8.9% in the group that did not receive antibiotics. the study also demonstrated that methicillin-resistant staphylococcus aureus (mrsa) infections were increased in the antibiotic group, demonstrating the fine balance between appropriate use of antibiotics and its overuse. the american association of orthopaedic surgeons (aaos) published a guideline discussing the choice and dosing of prophylactic antibiotics.22 the optimum time for prophylactic antibiotic administration is within an hour prior to the surgery, in order to reach the minimal inhibitory concentration in the end organs during the operation.44 in certain conditions such as prolonged surgical duration beyond the half-life of the antibiotic or when excessive blood loss occurs during the surgery, a second dose of antibiotic is required. indications for vancomycin first-generation cephalosporins are adequate for the majority of patients undergoing elective tja. in some circumstances, however, administration of vancomycin or a teicoplanin is also indicated. currently the use of vancomycin or teicoplanin is deemed to be appropriate in: • patients who are carriers of mrsa • patients from dialysis units or centres with an outbreak of mrsa • healthcare workers • patients who are allergic to penicillin. the icm comment a firstor second-generation cephalosporin (cefazolin or cefuroxime) is suggested as routine pre-operative surgical prophylaxis, administered within an hour prior to the surgical incision. the timing can be extended up to two hours for vancomycin and fluoroquinolones. no special considerations are required for patients with pre-existing prostheses such as heart valves, and the same antibiotics can be used.45 intra-operative hair removal hair removal at the incision site has become a part of the routine patient preparation for surgery. interestingly, there is no evidence to support the role of hair removal in reducing the risk of ssi. a review article by the cochrane group stated that there is no statistical difference in the incidence of ssi when hair, at the surgical site, is removed versus when it is not. the article mentioned that patients whose hair was removed using a razor had even higher rates of infection compared to those on whom clippers were used.46 the icm comment the consensus group suggested the hair removal be attempted as close to surgery as possible and done with the use of clippers. the icm group had no comment on the use of depilatory cream for hair removal.39 pre-operative skin preparation patients one of the most common causes of ssi are the native microorganisms of the skin.47,48 in a study by von eiff et al.49 it was shown that in more than 80% of nosocomial infections with staphylococcus aureus, the source of the infection was endogenous, based on the genotyping evaluations. according to the cdc’s estimation, ssi is the second major cause for nosocomial infections, and is responsible for more than one-fourth of the hospital-related infections in the united states.37 hence, despite new advances in prophylactic antibiotics, skin-decolonising agents still have crucial importance. various antiseptic agents are available for surgical skin preparation. the most common ones are: chg, alcohol-based solutions, and povidone-iodine, all of which have advantages and disadvantages. chg, for instance, is very popular due to its long-lasting and cumulative effect against gram-positive and gram-negative bacteria. povidone-iodine is very effective on skin flora; however, it becomes relatively ineffective upon contact with blood and has a shorter duration of activity in comparison with chg.36 skin-decolonising agents have crucial importance sa orthopaedic journal spring 2015 | vol 14 • no 3 page 55 alcohol is a very good antimicrobial agent but the flammability and discontinued effect after drying are the downsides. a meta-analysis by the cochrane group in 2004 stated that there was no significant difference in the rate of ssi in clean surgeries carried out using different antiseptic agents.50 recent studies mentioned that alcohol and chg combination is more successful than alcohol and povidoneiodine in reducing the bacterial load of the skin; however, the rate of ssi was not significantly different.51-53 the icm comment the icm workgroup stated that there is no superiority of one skin preparation agent over another. there is some evidence that combinations of antiseptic agents with alcohol may be helpful for skin antisepsis.39 surgeons antiseptic hand preparation agents are categorised into two main groups: hand scrub and hand rub agents. hand scrubs are usually solutions of chg or povidone-iodine and hand rubs are mostly alcohol-based solutions. most studies reported equivalent efficacy in decreasing bacterial colony units when comparing povidone-iodine with chg. furthermore, the incidence of ssi is not different using either hand scrub solutions or hand rubs.54,55 however, hand rubs require less water consumption and have better surgeon compliance.54 the icm comment the surgeon and other operating room (or) personnel should wash their hands with an antiseptic agent for at least two minutes prior to the first case. the icm group stated no preference for one antiseptic agent over others.39 draping there is a strong support in the literature for the use of plastic adhesive tapes for draping the surgical site. numerous studies have shown that the rate of ssi is significantly increased when traditional cloth drapes were used.56-60 in one study, plastic adhesive drapes were compared with cloth, and deep wound contamination rates were compared. cultures were collected right before closing and the result showed 60% of contamination when cloth drapes were used versus 6% with plastic adhesive drapes.57 ritter et al.61 presented that iodophor-incorporated drapes can reduce wound contamination but do not decrease the wound infection rate after tja. plastic adhesive drapes are effective when skin preparation is performed using alcohol-based solutions. duraprep (3m company, st. paul, mn) is believed to improve the adhesion properties of the drapes.62 however, there are controversies about the effectiveness of adhesive incise drapes for the prevention of bacterial contamination. in 2007 the cochrane group reviewed about 3 000 patients in five different studies and concluded that there is no evidence to support that the use of adhesive incise drapes (plain or infused with antimicrobials) can reduce the rate of ssi.63 the icm comment the icm group identified studies that demonstrated iodineimpregnated skin incise drapes can decrease skin bacterial loads. however, they found no study that would be able to demonstrate a correlation between the use of iodine-impregnated drapes and the incidence of ssi. the icm has no comment on the use of skin barriers and recommends further studies.64 surgical gloves sterile surgical gloves are dual protection barriers; on one side the glove protects the patient from residual bacteria on the surgeon’s hands, and on the other side it protects the surgeon from the patient’s body fluids. double gloving reduces the risk of glove perforation; and in procedures such as orthopaedic surgeries, where sharp edges could be encountered easily, following double gloving protocols is highly recommended.65-67 however, with a double gloving protocol, the inner glove could still be perforated and become contaminated during the course of the procedure. therefore, some studies have shown that in procedures such as implantation, triple gloving is the protocol of choice.68,69 sutton et al.70 introduced the triple gloving protocol in 1998. the authors used two latex gloves with a cut-resistant layer between them. results showed a significant decrease in perforation compared with the double-gloving protocol. in a study by pieper et al.71 different protocols of triple gloving were compared to double gloving in maxillofacial surgeries. the authors presented that various techniques of triple gloving are superior to double gloving in terms of protecting the inner glove from perforation. however, triple gloving has some disadvantages, such as decreased tactile sensation and surgeon dexterity. the icm comment the icm group suggested the use of double gloving. however, they recognised the theoretical advantages of triple gloving.64 antibiotics in cement there are many reports stating that adding antibiotics to cement can decrease the risk of pji in tha.72,73 however, there is no consensus on the fact that it is an effective strategy for tka or not.74,75 the icm comment the icm group believes that antibiotic-impregnated polymethylmethacrylate cement can reduce the risk of pji development and should be considered in patients at high risk for pji following elective arthroplasty.76 following double gloving protocols is highly recommended page 56 sa orthopaedic journal spring 2015 | vol 14 • no 3 blood conservation allogeneic blood transfusion is an independent predictor for pji, and the number of transfused units has a direct link with the likelihood of developing pji.77 the latter statement can be justified with the modulating effects of transfusion on the immune system.78 this fact endorses the importance of pre-operative patient optimisation. correction of preexisting anaemia is one of the best ways to minimise the amount of intra-operative transfusion.79 other preventive strategies include meticulous haemostasis to minimise blood loss, neuraxial anaesthesia, and the use of tranexamic acid.80,81 the icm comment the icm group believes that allogeneic blood transfusion can increase the risk of developing ssi and/or pji. furthermore, management of pre-operative anaemia with iron, with or without erythropoietin, can decrease the risk of intra-operative transfusion. the icm group endorses neuraxial anaesthesia to reduce the amount of blood loss during tka and tha.82 the or environment laminar airflow the ultimate goal of or design is to diminish the patient’s exposure to the infecting organisms throughout the procedure. to pursue this aim, laminar airflow was introduced in 1964. however, there are controversies on the efficacy of laminar flow in reducing ssis. some studies stated that laminar flow could even increase the risk of ssis.83 the cdc has no comment regarding the use of laminar airflow in reducing ssi. nevertheless, the cdc has released a guideline for the proper use of laminar airflow. the icm comment the icm group believes that arthroplasty may be performed in ors that are not equipped with laminar flows. the icm has no comment in favour or against the use of laminar flows and recommends further studies.64 duration of the operation the risk of pji has a direct link with the duration of the operation.84,85 furthermore, the surgeon’s surgical volume also has a potential effect on the rate of ssi; surgeons with lower number of surgeries tend to have higher rates of infection.86 the icm comment the icm workgroup believes that the rate of ssi has a direct link with the duration of the surgery. they recommend that a coordinated effort must be made to minimise the surgical duration without compromising the procedure.64 or traffic the incidence of ssi is directly related to the or traffic. or traffic can increase the load of airborne microorganisms. furthermore, more door openings due to higher traffic can interfere with laminar airflow, which can itself increase the rate of ssi.87-89 the icm comment the icm recommended that or traffic should be kept at a minimum.64 medical equipment several studies have demonstrated that equipment contamination can occur during surgery.90-94 givissis et al.91 investigated the contamination rate of suction tips and tried to correlate it with the development of subsequent deep wound infection. the authors reported a 54% rate of contamination in the suction tips. one of the cases developed deep ssi with the same organism that was isolated from the suction tip. the authors concluded that the contamination rate has a direct link with operation time. therefore, they recommended that the suction tip should be changed every hour in long orthopaedic procedures. davis et al.90 determined the contamination rates of glove tips (28.7%), syringe bags (20.0%), gown swabs (17.0%), base of light handles (14.5%), body of light handles (14.5%), sieve swabs (13.5), suction tips (11.4%), needles for deep closure (10.1%), skin blades (9.4%), and inside blades (3.2%). beldame et al.95 reported significantly higher rates of contamination in gloves prior to prosthesis implantation and advised changing gloves before this step. the icm comment the icm workgroup recommended changing suction tips every 60 minutes. suction tips can be inserted into the femoral canal to evacuate fluid but should not be left there, where significant amounts of ambient air and particles are circulated that can potentially contaminate the case. furthermore, the workgroup encourages surgeons to change their gloves at least every 90 minutes and after cementation. the icm recommended further study on electrocautery devices and had no specific comment on their use.64 post-operative prevention of late pji pji may occur any time after the surgery. episodic bacteraemia can be a potential risk for pji development. certain medical procedures are more likely to cause bacteraemia. in 2012, the aaos released a new guideline on ‘the prevention of orthopaedic implant infections in patients undergoing dental procedures’. sa orthopaedic journal spring 2015 | vol 14 • no 3 page 57 the guideline is a collaboration between the aaos and the american dental association. it has three main recommendations:96 1. ‘the practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee prosthetic joint implants undergoing dental procedures. 2. we are unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other orthopaedic implants undergoing dental procedures. 3. in the absence of reliable evidence linking poor oral health to pji, it is the opinion of the workgroup that patients with prosthetic joint implants or other orthopaedic implants maintain appropriate oral hygiene.’ the icm comment the icm workgroup concluded that the use of prophylactic antibiotics prior to dental procedures in patients who have tja in place should be based on the individual’s risk factors and the complexity of the dental procedure. furthermore, in cases of viral infection, there is no role for oral antibiotics, even for patients at higher risk. the workgroup also concluded that for other minor surgical procedures such as endoscopy and colonoscopy, transient bacteraemia could be minimised by administration of prophylactic antibiotics, especially in high-risk patients.97 conclusion pji is a serious complication with a significant morbidity and mortality. several factors in the pre-, intra-, and postoperative periods are involved that can predispose a patient to develop pji. prevention is always better than treatment. one of the most important pre-operative factors to reduce the risk of pji is to optimise the patient’s general health prior to elective arthroplasty. evaluation of all patients in pre-assessment clinics prior to elective tja is recommended. pre-operative prophylactic antibiotic administration should always be considered. implementation of a surgical safety checklist can significantly reduce the incidence of ssi and subsequent pji. it is imperative to follow the recommendations of the cdc and the aaos to minimise the risk of infection intraoperatively. finally, patients who undergo tja are always at risk of developing infection; therefore, it is essential to administer appropriate prophylactic antibiotics prior to certain medical procedures. medical science is fluid in nature. further research and developments may provide better insights for prevention of infection after orthopaedic procedures. references 1. kurtz s, ong k, lau e, mowat f, halpern m. projections of primary and revision hip and knee arthroplasty in the united states from 2005 to 2030. j bone joint surg am 2007;89:780–5. doi:10.2106/jbjs.f.00222. 2. bozic kj, kurtz sm, lau e, ong k, chiu v, vail tp, et al. the epidemiology of revision total knee arthroplasty in the united states. clin orthop 2010;468:45–51. doi:10.1007/ s11999-009-0945-0. 3. bozic kj, kurtz sm, lau e, ong k, vail tp, berry dj. the epidemiology of revision total hip arthroplasty in the united states. j bone joint surg am 2009;91:128–33. 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haas jp, hutzler l, slover j, phillips m, et al. surgical site infection prevention initiative patient attitude and compliance. bull nyu hosp jt dis 2011;69:312–5. 39. tokarski at, blaha d, mont ma, sancheti p, cardona l, cotacio gl, et al. perioperative skin preparation. j arthroplasty 2014;29:26–8. doi:10.1016/j.arth.2013.09.029. 40. fogelberg ev, zitzmann ek, stinchfield fe. prophylactic penicillin in orthopaedic surgery. j bone joint surg am 1970;52:95–8. 41. pavel a, smith rl, ballard a, larsen ij. prophylactic antibiotics in clean orthopaedic surgery. j bone joint surg am 1974;56:777–82. 42. meehan j, jamali aa, nguyen h. prophylactic antibiotics in hip and knee arthroplasty. j bone joint surg am 2009;91:2480–90. doi:10.2106/jbjs.h.01219. 43. mauerhan dr, nelson cl, smith dl, fitzgerald rh jr, slama tg, petty rw, et al. prophylaxis against infection in total joint arthroplasty. one day of cefuroxime compared with three days of cefazolin. j bone joint surg am 1994;76:39–45. sa orthopaedic journal spring 2015 | vol 14 • no 3 page 59 44. van kasteren mee, manniën j, ott a, kullberg b-j, de boer as, gyssens ic. antibiotic prophylaxis and the risk of surgical site infections following total hip arthroplasty: timely administration is the most important factor. clin infect dis off publ infect dis soc am 2007;44:921–7. doi:10.1086/512192. 45. hansen e, belden k, silibovsky r, vogt m, arnold wv, bicanic g, et al. perioperative antibiotics. j arthroplasty 2014;29:29–48. doi:10.1016/j.arth.2013.09.030. 46. tanner j, norrie p, melen k. preoperative hair removal to reduce surgical site infection. cochrane database syst rev 2011:cd004122. doi:10.1002/14651858.cd004122.pub4. 47. lee j, singletary r, schmader k, anderson dj, bolognesi m, kaye ks. surgical site infection in the elderly following orthopaedic surgery. risk factors and outcomes. j bone joint surg am 2006;88:1705–12. doi:10.2106/jbjs.e.01156. 48. prokuski l. prophylactic antibiotics in orthopaedic surgery. j am acad orthop surg 2008;16:283–93. 49. von eiff c, becker k, machka k, stammer h, peters g. nasal carriage as a source of staphylococcus aureus bacteremia. study group. n engl j med 2001;344:11–6. doi:10.1056/nejm200101043440102. 50. edwards ps, lipp a, holmes a. preoperative skin antiseptics for preventing surgical wound infections after clean surgery. cochrane database syst rev 2004:cd003949. doi:10.1002/14651858.cd003949.pub2. 51. ostrander rv, brage me, botte mj. bacterial skin contamination after surgical preparation in foot and ankle surgery. clin orthop 2003:246–52. doi:10.1097/01.blo.0000030176. 56585.d3. 52. keblish dj, zurakowski d, wilson mg, chiodo cp. preoperative skin preparation of the foot and ankle: bristles and alcohol are better. j bone joint surg am 2005;87:986–92. doi:10.2106/jbjs.d.02695. 53. ostrander rv, botte mj, brage me. efficacy of surgical preparation solutions in foot and ankle surgery. j bone joint surg am 2005;87:980–5. doi:10.2106/jbjs.d.01977. 54. tanner 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et al. prevention of wound contamination using duraprep solution plus ioban 2 drapes. clin orthop 2005;439:32–7. 63. webster j, alghamdi aa. use of plastic adhesive drapes during surgery for preventing surgical site infection. cochrane database syst rev 2007:cd006353. doi:10.1002/14651858.cd006353.pub2. 64. alijanipour p, karam j, llinás a, vince kg, zalavras c, austin m, et al. operative environment. j orthop res off publ orthop res soc 2014;32 suppl 1:s60–80. doi:10.1002/ jor.22550. 65. guo yp, wong pm, li y, or ppl. is double-gloving really protective? a comparison between the glove perforation rate among perioperative nurses with single and double gloves during surgery. am j surg 2012;204:210–5. doi:10.1016/j.amjsurg.2011.08.017. 66. tanner j, parkinson h. double gloving to reduce surgical cross-infection. cochrane database syst rev 2006:cd003087. doi:10.1002/14651858.cd003087.pub2. 67. ersozlu s, sahin o, ozgur af, akkaya t, tuncay c. glove punctures in major and minor orthopaedic surgery with double gloving. acta orthop belg 2007;73:760–4. 68. carter ah, casper ds, parvizi j, austin ms. a prospective analysis of glove perforation in primary and revision total hip and total knee arthroplasty. j arthroplasty 2012;27:1271–5. doi:10.1016/j.arth.2012.01.021. 69. demircay e, unay k, bilgili mg, alataca g. glove perforation in hip and knee arthroplasty. j orthop sci off j jpn orthop assoc 2010;15:790–4. doi:10.1007/s00776-010-1547-0. 70. sutton pm, greene t, howell fr. the protective effect of a cut-resistant glove liner: a prospective, randomised trial. j bone joint surg br 1998;80-b:411–3. 71. pieper sp, schimmele sr, johnson ja, harper jl. a prospective study of the efficacy of various gloving techniques in the application of erich arch bars. j oral maxillofac surg off j am assoc oral maxillofac surg 1995;53:1174–1176; discussion 1177. 72. parvizi j, saleh kj, ragland ps, pour ae, mont ma. efficacy of antibiotic-impregnated cement in total hip replacement. acta orthop 2008;79:335–41. doi:10.1080/ 17453670710015229. 73. engesaeter lb, lie sa, espehaug b, furnes o, vollset se, havelin li. antibiotic prophylaxis in total hip arthroplasty: effects of antibiotic prophylaxis systemically and in bone cement on the revision rate of 22,170 primary hip replacements followed 0-14 years in the norwegian arthroplasty register. acta orthop scand 2003;74:644–51. doi:10.1080/ 00016470310018135. 74. bohm e, zhu n, gu j, de guia n, linton c, anderson t, et al. does adding antibiotics to cement reduce the need for early revision in total knee arthroplasty? clin orthop 2014;472:162–8. doi:10.1007/s11999-013-3186-1. 75. namba rs, inacio mcs, paxton ew. risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. j bone joint surg am 2013;95:775–82. doi:10.2106/jbjs.l.00211. page 60 sa orthopaedic journal spring 2015 | vol 14 • no 3 76. citak m, argenson j-n, masri b, kendoff d, springer b, alt v, et al. spacers. j arthroplasty 2014;29:93–9. doi:10.1016/j.arth.2013.09.042. 77. koval kj, rosenberg ad, zuckerman jd, aharonoff gb, skovron ml, bernstein rl, et al. does blood transfusion increase the risk of infection after hip fracture? j orthop trauma 1997;11:260–265; discussion 265–266. 78. innerhofer p, klingler a, klimmer c, fries d, nussbaumer w. risk for postoperative infection after transfusion of white blood cell-filtered allogeneic or autologous blood components in orthopedic patients undergoing primary arthroplasty. transfusion (paris) 2005;45:103–10. doi:10.1111/j.1537-2995.2005.04149.x. 79. spahn dr. anemia and patient blood management in hip and knee surgery: a systematic review of the literature. anesthesiology 2010;113:482–95. doi:10.1097/ aln.0b013e3181e08e97. 80. alshryda s, sarda p, sukeik m, nargol a, blenkinsopp j, mason jm. tranexamic acid in total knee replacement: a systematic review and meta-analysis. j bone joint surg br 2011;93:1577–85. doi:10.1302/0301-620x.93b12.26989. 81. yang z-g, chen w-p, wu l-d. effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: a meta-analysis. j bone joint surg am 2012;94:1153–9. doi:10.2106/jbjs.k.00873. 82. rasouli mr, gomes lsm, parsley b, barsoum w, bezwada h, cashman j, et al. blood conservation. j arthroplasty 2014;29:65–70. doi:10.1016/j.arth.2013.09.032. 83. gastmeier p, breier a-c, brandt c. influence of laminar airflow on prosthetic joint infections: a systematic review. j hosp infect 2012;81:73–8. doi:10.1016/j.jhin.2012.04.008. 84. ong kl, lau e, manley m, kurtz sm. effect of procedure duration on total hip arthroplasty and total knee arthroplasty survivorship in the united states medicare population. j arthroplasty 2008;23:127–32. doi:10.1016/ j.arth.2008.04.022. 85. urquhart dm, hanna fs, brennan sl, wluka ae, leder k, cameron pa, et al. incidence and risk factors for deep surgical site infection after primary total hip arthroplasty: a systematic review. j arthroplasty 2010;25:1216–1222.e1–3. doi:10.1016/j.arth.2009.08.011. 86. muilwijk j, van den hof s, wille jc. associations between surgical site infection risk and hospital operation volume and surgeon operation volume among hospitals in the dutch nosocomial infection surveillance network. infect control hosp epidemiol off j soc hosp epidemiol am 2007;28:557–63. doi:10.1086/513613. 87. andersson ae, bergh i, karlsson j, eriksson bi, nilsson k. traffic flow in the operating room: an explorative and descriptive study on air quality during orthopedic trauma implant surgery. am j infect control 2012;40:750–5. doi:10.1016/j.ajic.2011.09.015. 88. salvati ea, robinson rp, zeno sm, koslin bl, brause bd, wilson pd jr. infection rates after 3175 total hip and total knee replacements performed with and without a horizontal unidirectional filtered air-flow system. j bone joint surg am 1982;64:525–35. 89. young rs, o’regan dj. cardiac surgical theatre traffic: time for traffic calming measures? interact cardiovasc thorac surg 2010;10:526–9. doi:10.1510/icvts.2009.227116. 90. davis n, curry a, gambhir ak, panigrahi h, walker cr, wilkins eg, et al. intraoperative bacterial contamination in operations for joint replacement. j bone joint surg br 1999;81:886–9. 91. givissis p, karataglis d, antonarakos p, symeonidis p, christodoulou a. suction during orthopaedic surgery. how safe is the suction tip? acta orthopædica belg 2008;74:531–3. 92. greenough cg. an investigation into contamination of operative suction. j bone joint surg br 1986;68:151–3. 93. insull pj, hudson j. suction tip: a potential source of infection in clean orthopaedic procedures. anz j surg 2012;82:185–6. doi:10.1111/j.1445-2197.2011.05949.x. 94. mulcahy dm, mccormack d, mcelwain jp. intraoperative suction catheter tip contamination. j r coll surg edinb 1994;39:371–3. 95. beldame j, lagrave b, lievain l, lefebvre b, frebourg n, dujardin f. surgical glove bacterial contamination and perforation during total hip arthroplasty implantation: when gloves should be changed. orthop traumatol surg res otsr 2012;98:432–40. doi:10.1016/j.otsr.2011.10.015. 96. american academy of orthopedic surgeons. aaos clinical practice guideline: prevention of orthopaedic implant infection in patients undergoing dental procedures n.d. 97. chen a, haddad f, lachiewicz p, bolognesi m, cortes le, franceschini m, et al. prevention of late pji. j arthroplasty 2014;29:119–28. doi:10.1016/j.arth.2013.09.051. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj page 64 sa orthopaedic journal spring 2014 | vol 13 • no 3 effect of additional ultrasound therapy to analgesics in treatment of acute low back pain a randomised control trial conducted at the aga khan university hospital, nairobi (akuh, n) dr s mohammedali* mbchb, mmed(surg) dr sk mutiso** bsc mbchb dr p oroko* mbchb, mmed(surg), frcs(ed), frcs(tr&orth) dr b ombachi* mbchb, mmed, ao spine fellow dr h saidi*� bsc, mbchb, mmed(surg), fcs(ecsa), facs *department of surgery, aga khan university hospital, nairobi, kenya **medical officer at the tigoni hospital, limuru, kenya � department of human anatomy, university of nairobi, kenya correspondence: dr s mohammedali department of surgery aga khan university hospital nairobi, kenya po box 030270-00100 nairobi, kenya tel: +254711092115 fax: +254203743935 email: shamshuza@yahoo.com abstract background: acute low back pain (lbp) is a common condition that is encountered by many physicians with varied treatments instituted in its management. ultrasound physiotherapy is a common modality used in its management, although its effectiveness and its role in management of acute lbp is not well known. methods: a randomised controlled trial was conducted to compare the effect of the addition of ultrasound therapy to a defined analgesia protocol in patients presenting with acute lbp at the aga khan university hospital, nairobi. the main outcomes were reduction in disability and pain which were evaluated using the mean change in oswestry disability index (odi) and visual analogue scale (vas) score for pain, respectively. patients were followed up for a minimum of four weeks with assessment using the odi and vas at weekly clinic visits. results: seventy-four patients were included in the study. thirty-six patients were allocated to the analgesia with additional ultrasound group and 38 to the analgesia alone group. the minimal clinically important difference (mcid) of 10% points at four weeks after initiation of treatment was achieved in the ultrasound group but not in the analgesia only group. this difference was not statistically significant though, 10.35% vs 8.44%; p=0.36. there was no difference in the mean change in the odi score between the two groups at any of the four follow-up visits after initiation of treatment. mean difference in change of odi (95% confidence interval) was −3.2(−7.0 to 0.6) after the first week, 2.96(−1.3 to 7.2) after the second and 1.90(−2.3 to 6.1) after the third week, p=0.36, 0.17 and 0.096 respectively. there was also no difference detected in the mean change of vas score between the two groups at the first and fourth visit. mean difference in vas between the first and fourth weeks was 0.2 with a 95% confidence of −0.85 to 1.2 (p=0.72). conclusion: the addition of ultrasound therapy to the treatment of acute lbp improved patient outcomes as assessed by an mcid of a disability index, but which was not statistically significant. no outcome difference was noted in the two groups using the vas pain score. key words: acute low back pain, analgesia, ultrasound therapy saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 3:04 pm page 64 sa orthopaedic journal spring 2014 | vol 13 • no 3 page 65 introduction low back pain (lbp) is a common condition worldwide with associated significant disability and economic implications.1,2 the lifetime prevalence of lbp is over 70% in industrialised countries with peak prevalence occurring between ages 35 and 55 years.3 it is the second most common reason for absence from work in adults aged <55 years, with work-related lbp estimated to cause 818 000 disability-adjusted life years lost annually.4,5 in african countries, a lifetime prevalence of 62% among adults has been reported and this was associated with significant disability, loss of productivity and working man hours.6 most patients with lbp have no serious pathologic aetiology, with most having their lbp attributed to an unidentified cause, either due to mechanical strain or related to work/posture.7-9 the natural history of acute lbp is resolution of symptoms in the majority of patients by the fourth week of onset with 90% returning to work within three months.10-12 with minimal intervention such as analgesia and minimising activity to tolerable levels only, most patients improve in the first few weeks.13,14 analgesic therapy alone without additional treatment has been shown to be effective in terms of pain control and reduction of disability.15 the use of paracetamol, ibuprofen and mefenamic acid has been recommended, with opiates and muscle relaxants being disapproved due to their sedative effects, drug dependence and lack of additional benefit.12,16,17 interventions such as physiotherapy, bed rest and back exercises that are frequently used in clinical practice, have no strong evidence to support their routine use.12,14 moreover, massage and transcutaneous electrical nerve stimulation (tens) therapy are not recommended as modalities of therapy because of a lack of proven clinical benefit.12 ultrasound waves are often used as an adjunct to medical therapy for their thermal effect.18,19 however, although its use is expensive to the patient there is no proven clear benefit in the management of acute lbp.20-22 there is no published randomised trial to assess this. the present study aimed to assess the effectiveness of ultrasound in addition to analgesia as compared to analgesia alone as interventions to reduce the morbidity of lbp with regard to pain control and disability. methods trial design the study was a randomised, controlled trial of patients with acute lbp comparing an intervention group, who received the standard analgesia protocol and ultrasound therapy, with a control group, who received only the standard analgesia protocol (figure 1). participants patients presenting with acute lbp, as defined in the inclusion and exclusion criteria, aged 18–60 years. the patients were all seen at the aga khan university hospital, nairobi (akuh, n), kenya. the inclusion criteria constituted: patients aged 18–60 years with acute onset lbp. an acute episode of pain was defined as pain that lasts for more than 24 hours but less than six weeks. moreover, the pain had to be in an area bounded superiorly by t12 and inferiorly by the buttock crease. the exclusion criteria constituted the following: • patients with indicators of serious pathology from history and examination findings, also referred to as ‘red flags’.12 patients with red flags were further investigated with imaging and referred for further management. • patients who were vomiting – we wished to administer the analgesic prescription by the oral route. • patients who were already on other forms of analgesia, e.g. opioids and muscle relaxants. • patients with contraindications to ultrasound treatment such as skin allergies, dermatitis or a skin haematoma, and those already on other forms of physiotherapy. interventions study protocol a study guideline and unbiased randomisation was adhered to. this guideline was circulated and a copy for reference was available at all study recruitment sites. informed consent was obtained by the treating physician after discussing the study with patients. training was held for the doctors and physiotherapists who were involved in patient recruitment and to maximise protocol adherence. the odi was given to the patients and was reported by patient self-response on study entry and at intervals of 1, 2 and 3 weeks after initiation of therapy. following an initial visit, they were provided with a mobile phone contact for reporting non-improvement of their pain and instructions for escalation of pain management were given as per the protocol. treatment protocol control arm: patients were commenced on 1 g of paracetamol by mouth stat, then 1 g 6 hourly for seven days. all patients were managed as outpatients unless they had severe pain, i.e. odi score of 50% or more or a vas score of more than 8/10; were not ambulatory due to pain; requested to be managed as an inpatient; fulfilled the three criteria above and could afford the admission fee or opted to go to another hospital. intervention arm: patients were commenced on 1 g of paracetamol by mouth stat, then 6 hourly for seven days. concurrent physiotherapy (ultrasound only) was commenced with the first session starting the same day of recruitment unless they presented after midnight, in which case it was commenced on the earliest available session. pulsed ultrasound therapy was administered with a total of three sessions in a week for two weeks (a total of six sessions). all patients were managed as outpatients unless they met the criteria stated above. with minimal intervention such as analgesia and minimising activity to tolerable levels only, most patients improve in the first few weeks saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 3:04 pm page 65 page 66 sa orthopaedic journal spring 2014 | vol 13 • no 3 follow-up: in both arms, patients managed on an in/outpatient basis were reviewed at intervals of 1, 2, and 3 weeks with the odi administered at every contact. if at subsequent review the reported pain was persistent or had increased, the treating physician was to add a non-steroidal antiinflammatory drug, i.e. ibuprofen 400 mg twice daily for seven days.17,21,23 all patients had access to a central help line number for enquiries or to report any problems during their management. direct questioning about medication compliance was used to confirm patient compliance with the protocol. outcome oswestry disability index (odi) outcomes were measured using a patient-administered questionnaire, the oswestry disability index (odi). the odi is a validated and widely used tool for assessing disability from back pain. it is a ten-question, self-administered questionnaire that is convenient to use. it has been translated for use into various languages around the world, and has been shown to be indicative of the respondent’s disability from lbp. we used the english version to assess disability from acute back pain in this study.23,24 the minimal clinically important difference (mcid) for the odi in the present study was taken to be 10 percentage points.23 sample size determination malimvaara and colleagues14 showed that at three weeks, the mean odi index for patients who were randomised to exercise as compared to no treatment, was significantly different (mean difference=6.6) to that for patients on bed rest (mean difference=3.9). in the same study at 12 weeks, the mean odi index was about 6 for all treatments. in a meta-analysis of acute lbp treatment, machado and colleagues compared the analgesic effects of treatments for non-specific lbp using a 100-point scale and reported that analgesics had a moderately significant treatment effect (10–20 points) when compared to placebo, unlike exercise, radiotherapy, traction, physiotherapy or prolotherapy, which showed a minor treatment benefit (<10 points).24 the estimated pooled standard deviation (sd) of the odi for the bed rest-control and exercise-control comparisons was 10.5 and 11.71 at three weeks, and 9.44 and 10.07 at 12 weeks, respectively. using a level of significance of 5% and 80% power, the study needed 37 patients in each study arm assuming a clinically meaningful difference (δ) in the odi index of 10, an observed difference (δ) between the control and treatment arm of 3.5 and a standard deviation of 10. the formula for calculating the sample size in the control and treatment group for a comparative study is given by: figure 1. study flow chart pain improved pain persistent/ worsened pain improved pain persistent/ worsened administer odi at 1, 2 and 3weeks add ibuprofen 400mg bd x 7days administer odi at 1, 2 and 3weeks add ibuprofen 400mg bd x 7days paracetamol 1gm po qds x 7days paracetamol 1gm po qds x 7days + ultrasound therapy improved not improved administer odi at 1, 2 and 3 weeks exclude, start opioid improved not improved administer odi at 1, 2 and 3 weeks exclude, start opioid acute low back pain saoj spring 2014_orthopaedics vol3 no4 2014/08/06 11:36 am page 66 sa orthopaedic journal spring 2014 | vol 13 • no 3 page 67 where: z1-a and z1-b are the critical values from standard normal tables associated with type i and ii errors as a and b respectively, δ = μe – �μc (difference in treatment effect) s is the standard deviation showing variation in the odi index in each group. it was hypothesised that at three weeks the absolute difference in the mean odi in the control arm (μc) and the mean of the index from the other arm (μe) is not clinically important. thus the hypotheses to be tested are: h0: | μe – μc | ≥d� ha: | μe – μc | <d� (not equivalent) (equivalent) where d quantifies a clinically important difference in the odi index. therefore: n= 2(0.84+1.96) (0.84+1.96) =37.11 (3.5–10/10) (3.5–10/10) i.e. 37 patients in each arm adjusting for 10% loss to follow-up then a total of 82 patients were to be recruited in the study. randomisation the recruited patients were randomised by the choosing of sealed envelopes with written prescription for paracetamol alone (38 patients) and paracetamol with the ultrasound therapy regimen (36 patients). the envelopes were opened at the accident and emergency department and pharmacy, and the doctor/pharmacist administered the prescription drug and directed the patient to the physiotherapy department depending on the treatment allocation. recruited patients were randomised with each arm having the odi administered, and treatment commenced immediately according to protocol. statistical methods each recruited patient’s odi was recorded in their file and retrieved after three weeks for analysis. the mean change in odi and vas score was calculated using the spss-version 17(spss inc., chicago, illinois) and stata-10 software for analysing the trends and assessing statistical difference between the groups. comparisons among the treatment groups was done using t-tests for normally distributed continuous variables such as age of patients and mean change in scores, while the mannwhitney non-parametric test was used for non-normally distributed continuous outcomes, for example, the individual odi scores of each patient. linear mixed-effect models were used for multivariate analysis to determine factors that may be associated with the rate of change of the odi index over time. ethical considerations ethical approval was obtained from the akuh, n research committee ethics board. all information was confidential and used for the sole purpose of the study. in all participants, the following guidelines were observed: all patients received the current standard of care with regard to pain management, i.e. pain control according to the prior stated protocol. if for any reason their pain was not controlled according to the protocol, they were given opioid analgesia and excluded from the study with an ‘intention to treat’ analysis being performed. all adverse events were reported and recorded. patients who reported severe adverse events related to the treatment or non-improvement in back pain were excluded, with the protocol being discontinued, reassessed and referred to the orthopaedic clinic for further treatment. informed consent was obtained from all participants by the treating physician at the first contact. the patient was at liberty to withdraw from the study at any time he/she wished. results a total of 108 patients were screened of which 14 patients declined participation and 94 patients were recruited. of the recruited patients, 20 were excluded for the following reasons: ten patients had already been started on alternative analgesic agents that differed from our analgesic protocol and had used muscle relaxants; five had chronic back pain; and five patients had started other forms of physiotherapy. patient demographics seventy-four patients met the eligibility criteria and were randomised to receive analgesia with ultrasound (ultrasound group n=36), or analgesics alone (no-ultrasound group n=38). there were 39 (52.7%) male patients and 35 (47.3%) female patients. the participants had a mean age of 44 years in the ultrasound group and 38 years in the noultrasound group (table i). primary outcome change in odi score the median odi score was higher on the first visit in the ultrasound group but the rate and trend of odi score change at any point over the four visits was not different from the final visit odi score (figure 2 and table ii). the score was 3 in the ultrasound group and 1 in the no-ultrasound group (p=0.23). there was no difference in the mean change of the odi score between the first and fourth, first and third and first and second visits. that is, none of the groups were improving faster on follow-up with regard to the change in odi score over subsequent visits (table iii). ultrasound group analgesics alone no. of patients 36 38 mean age (years) 44 38 table i: patient general characteristics the oswestry disability index (odi) is a validated and widely used tool for assessing disability from back pain saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 3:05 pm page 67 page 68 sa orthopaedic journal spring 2014 | vol 13 • no 3 it is also important to note that the mcid (minimal clinically important difference) of 10 percentage points at four weeks after initiation of treatment was achieved in the ultrasound group but not in the analgesia-only group. this difference was however not statistically significant: 10.35% vs 8.44%; p=0.36 (table iii). change in visual analog score (vas) both groups had similar pain scores in terms of the vas at the initial and final visits. there was no difference between the groups at the first and fourth visit; p=0.48 and p=0.8 respectively (table iv). also, no difference was detected in the mean change of the vas over the first and fourth visits between the two groups (p=0.73). two of the 74 patients (one from each group) had persistent pain at the end of four weeks and went on to have a magnetic resonance imaging (mri) assessment of the lumbo-sacral spine and orthopaedic referral. one patient had inter-vertebral disc extrusion of l4/5 that necessitated lumbar discectomy. the other had mild disc dehydration and disc bulge at l3/4 and l4/5 and is currently on follow-up for the same. discussion lbp is of high prevalence worldwide with significant varied disability and economic implications.1,3 however, the efficacy of ultrasound therapy in addition to analgesia in its treatment is not well known. consequently, the present study set out to determine the effect of additional ultrasound therapy to analgesia in the management of lbp. at presentation, patients who were randomised to receive ultrasound had a higher odi score but went on to improve in a similar manner as the no-ultrasound group by the fourth visit. two of the 74 patients (one from each group) had persistent pain at the end of four weeks and went on to have an mri assessment of the lumbo-sacral spine and orthopaedic referral. none of the patients had plain radiographs performed. this was in keeping with recommendations from other published literature as this practice has not been shown to add any value in the diagnosis or management of patients with acute lbp.25,26 figure 2. change in odi scores medians over the four visits ultrasound median no ultrasound median visit 1 visit 2 visit 3 visit 4 14 12 10 8 6 4 2 0 o d i s co re s ultrasound median (min, max) no ultrasound median (min, max) *p-value odi – visit 1 13 (3, 40) 8.5 (3, 32) 0.03 odi – visit 2 7 (0, 39) 7 (0, 32) 0.87 odi – visit 3 3 (0, 36) 4.5 (0, 19) 0.97 odi – visit 4 3 (0, 18) 1 (0, 26) 0.23 table ii: odi score for both groups over the follow-up period ultrasound median (min, max) no ultrasound median (min, max) *p-value vas 1 5 (0, 9) 4.5 (0, 8) 0.48 vas 4 0 (0,5) 0 (0, 8) 0.88 table iv: comparison of the median vas score of the two groups on the first (vas 1) and fourth visit (vas 4) ultrasound mean (sd) no ultrasound mean (sd) difference (95%ci) *p-value difference in odi (1–4) 10.35 (9.8) 8.44 (8.1) 1.90 (−2.3 to 6.1) 0.36 difference in odi (1–3) 8.51 (10.6) 5.55 (7.9) 2.96 (−1.3 to 7.2) 0.17 difference in odi (1–2) 5.97 (9.61) −2.76 (6.45) −3.2 (−7.0 to 0.6) 0.096 table iii: difference in mean odi change at different intervals between first and fourth, first and third, and first and second visits saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 3:05 pm page 68 sa orthopaedic journal spring 2014 | vol 13 • no 3 page 69 most of the patients improved by the fourth week of treatment in both arms, as expected in the natural course of acute lbp.3,27 for analysis, the individual median odi score was used as the measure of central tendency as opposed to the means because the data was distributed in a non-parametric fashion, whereas the changes in the scores over time were normally distributed; therefore the difference in the mean change of the odi score was analysed for significance. no statistically significant difference was observed to provide benefit with the addition of ultrasound in terms of odi or vas score change. one must take note that the micd at 90% confidence is 10 percentage points. that means at least a 10%  change is required to be clinically meaningful and a change of less than this may be attributable to an error in the measurement.23 in our study the micd for the odi at four weeks after initiation of treatment was achieved in the ultrasound group but not in the analgesia only group. this difference, however, was not statistically significant. this creates grounds for further investigating the clinical effectiveness of analgesia alone in the treatment of lbp when evaluated with the odi. acute lbp can result from a variety of sites also known as ‘pain generators’ such as the facet joint, fascia, sacroiliac joint and inter-vertebral disc.28,29 the episodes of acute pain are usually self-limiting but cause significant absenteeism from work, affect productivity and loss of man hours.30 the rationale for additional therapeutic modalities for back pain should be guided by evidence of improvement in this disability. the most commonly used dosage of ultrasound was employed in this study.20 ultrasound waves used at this frequency achieve tissue penetration transdermally and are postulated to confer analgesic effect by improving the elasticity of collagencontaining tissues.21 apart from the ‘thermal theory’ of the mechanism of action of ultrasound,20,21 it is also thought that ultrasound promotes healing by increasing blood supply, hence increasing oxygen delivery, nutrients and white blood cells at the site of application.31,32 almost immediately after injury to tissues, mast cells release histamine into the bloodstream, causing localised arteriolar vasodilatation and a consequential increase in blood flow.33,34 dyson and hasson and colleagues suggest that, if damaged tissues are exposed to ultrasound during the inflammatory phase of the healing process, blood flow may further increase. whether this is attributable to a rise in temperature or to the release of histamine via nonthermal mechanisms remains unclear.35,36 we can therefore conclude that the use of additional ultrasound treatment resulted in a clinical difference in the disability index but did not statistically reduce pain or disability as compared to analgesia alone. most of our patients had back pain that was adequately managed with analgesic therapy alone although this was not clinically detectable as per the odi. we therefore recommend the use of paracetamol alone as first line therapy and adding an nsaid for those whose pain persists, with appropriate follow-up for gastritis when indicated. since the use of additional physiotherapy in the form of single modalities or multimodal therapy is quite common, a study to address the effects of other therapies with a standard analgesic protocol and/or ultrasound therapy is indicated. also, as the evidence for use of combination analgesics with muscle relaxants is weak and there are no clear guidelines for their use, future research is needed to investigate their usefulness in reducing pain and disability in this patient population. limitations the present study had a couple of limitations: first, absence from work or loss of man hours were not recorded because of the concern for validity due to recall basis as this data could only be collected after the fourth visit on completion of therapy. secondly, due to limited funds available our desire to have a sham therapy arm, i.e. allocation of patients to receive analgesics with the ultrasound probe being applied on the back but no delivery of the waves could not be executed. references 1. mounce k. back pain. rheumatology (oxford). 2002;41:1–5. 2. maetzel a, li l. the economic burden of low back pain: a review of studies published between 1996 and 2001. best practice & research clinical rheumatology, jan 2002;16(1):23-30. 3. andersson gbj. the epidemiology of spinal disorders. in: frymoyer jw, ed. the adult spine: principles and practice. 2nd ed. new york: raven press, 1997;93-141. 4. hadler nm. workers with disabling back pain. n engl j med 1997;337:341–43. 5. punette m, et al. estimating the global burden of low back pain attributable to combined occupational exposures. am j of ind med 2005;48:459–69. 6. louw qa, et al. the prevalence of low back pain in africa. bmc musculoskeletal disord. 2007;8:105. 7. croft pr, papageorgiou ac, ferry s, et al. psychologic distress and low back pain. evidence from a prospective study in the general population. spine 1995;20(24):2731-37. 8. katz jn, et al. lumbar disc disorders and low-back pain: socioeconomic factors and consequences. bone joint surg am. 2006;88 suppl 2:21-24. 9. macfarlane gj, thomas e, papageorgiou ac, croft pr, jayson mi, silman aj. employment and physical work activities as predictors of future low back pain. spine 1997;22(10):1143-45. 10. croft pr, et al. outcome of low back pain in general practice: a prospective study. bmj 1998;316:1356-57. 11. roland m, et al. spine (phila pa 1976). 1983;8(2):145-50. 12. van tulder m, et al. european guidelines for the management of acute nonspecific low back pain in primary care. eur spine j 2006;15 (suppl. 2):s169–s191. 13. andersson gb, svensson ho, oden a. the intensity of work recovery in low back pain. spine 1983;8:880-84. 14. malimvaara a, et al. the treatment of acute low back pain – bed rest, exercise or ordinary activity? n engl j med 1995;332:351-55. 15. koes bw, scholten rjpm, mens jma, bouter lm. efficacy of non-steroidal anti-inflammatory drugs for low back pain: a systematic review of randomised clinical trials. ann rheum dis 1997;56:214-23. 16. van tulder m, et al. european guidelines for the management of acute nonspecific low back pain in primary care. eur spine j 2006;15 (suppl. 2):s169–s191; recommendation t5. we can conclude that the use of additional ultrasound treatment resulted in a clinical difference in the disability index but did not statistically reduce pain or disability as compared to analgesia alone saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 3:05 pm page 69 page 70 sa orthopaedic journal spring 2014 | vol 13 • no 3 17. roelofs pd, deyo ra, koes bw, scholten rj, van tulder mw. non-steroidal anti-inflammatory drugs for low back pain. cochrane database of systematic reviews 2008; issue 1. art. no.:cd000396. 18. philadelphia panel. philadelphia panel evidence-based clinical practice guidelines on selected interventions for low back pain. physther 2001;81(10):1641-74. 19. maher cg, et al. effective physical treatment for chronic low back pain. orthop clin n am 2004;35:57-64. 20. coakley, s. biophysical effects of ultrasound at therapeutic intensities. physiotherapy 1978;64(4):169. 21. dyson, m. sucking stimulation of tissue repair by ultrasound. physiotherapy 1978:64(4):105. 22. university of manchester. backache beaten by good vibrations? science daily, 3 november 2006. http://www. sciencedaily.com . [last accessed 10th january 2010]. 23. fairbank jc, pynsent pb. the oswestry disability index. spine 2000;25(22):2940-52. 24. the italian version of the oswestry disability index. spine (phila pa 1976). 2009;34(19):2090-95. 25. van tulder mw, assendelft wj, koes bw, bouter lm. spinal radiographic findings and nonspecific low back pain. a systematic review of observational studies. spine (phila pa 1976). 1997;22(4):427-34. 26. van den bosch maaj, hollingworth w, kinmonth al, dixon ak. evidence against the use of lumbar spineradiography for low back pain. clinical radiology 2004;59:69-76. 27. pengel lhm, herbert rd, maher cg, refshauge km. acute low back pain: systematic review of its prognosis bmj 2003;327:323-25. 28. carragee ej, barcohana b, alamin t, van den haak e. prospective controlled study of the development of lower back pain in previously asymptomatic subjects undergoing experimental discography. spine 2004;29(10):1112-17. 29. rives pa, douglass ab. evaluation and treatment of low back pain in family practice. j am board fam pract 2004;17:s23–31. 30. national institute of neurological disorders and stroke (ninds). low back pain fact sheet. bethesda, md: national institute of neurological disorders and stroke; 2003. 31. baker rj, bell gw. the effect of therapeutic modalities on blood flow in the human calf. j orthopaedic and sports physical therapy 1991;13:23-27. 32. houghton pe. effects of therapeutic modalities on wound healing: a conservative approach to the management of chronic wounds. physical therapy reviews 1999;4:167-82. 33. maxwell l. therapeutic us: its effects on the cellular and molecular mechanisms of inflammation and repair. physiotherapy 1992;78:421-26. 34. sherwood l. human physiology: from cells to systems 4th ed. new york: brooks/cole publishing, 2001. 35. dyson m. mechanisms involved in therapeutic us. physiotherapy 1987;73:116-20. 36. hasson s, mundorf r, barnes w, williams j, fujii m. effect of pulsed us versus placebo on muscle soreness perception and muscular performance. scand j rehabilitation medicine 1990;22:199-205.) this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj spring 2014_orthopaedics vol3 no4 2014/08/06 11:38 am page 70 page 56 south african orthopaedic journal http://journal.saoa.org.za conferences, courses and symposia local august 2020 66th south african orthopaedic association (saoa) congress 31 august 2020 – 4 september 2020 venue: cticc 2 (cape town international convention centre 2), cape town, western cape, south africa organiser: south african orthopaedic association (saoa) theme: ‘together into the future’, with an emphasis on advances made in the delivery of orthopaedic care academic programme: the academic programme includes all the saoa-affiliated specialty groups with both local and invited international guest speakers. topics will cover 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endoprosthetics congress berlin 2018 22 february 2018 24 february 2018 berlin, germany march 2018 aaos 2018 annual meeting 06 march 2018 10 march 2018 new orleans, united states kiel arthroscopy course 2018 09 march 2018 10 march 2018 kiel, germany utrecht spine course: complex paediatric spine 09 march 2018 10 march 2018 utrecht, netherlands annual meeting of the orthopaedic research society – ors 2018 10 march 2018 13 march 2018 new orleans, united states 12th international congress of sports medicine society of greece / 12th hellenic-cypriot conference 16 march 2018 18 march 2018 thessaloniki, greece 12th international meeting of the austrian foot society 22 march 2018 24 march 2018 going am wilden kaiser, austria european pelvic course 2018 22 march 2018 24 march 2018 hamburg, germany local international south african orthopaedic journal orthopaedic oncology and infections doi 10.17159/2309-8309/2021/v20n3a3 saini ak et al. sa orthop j 2021;20(3) citation: saini ak, ferreira n. the surgical management of metastatic lesions of the femur. sa orthop j 2021;20(3):151-156. http://dx.doi.org/10.17159/23098309/2021/v20n3a3 editor: dr thomas hilton, university of cape town, cape town, south africa received: august 2020 accepted: january 2021 published: august 2021 copyright: © 2021 saini ak. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background malignant tumours commonly metastasise to bone. when this occurs in the femur, surgical intervention is required to reduce pain and restore mobility post fracture, or as a prophylactic measure when fracture is anticipated. this is typically in the form of replacement with hemior total arthroplasty or stabilisation with an intramedullary device. the indications for one modality over the other are debatable and the reported outcomes and complications are varied. the purpose of this study is to assess the management algorithm for bony metastasis of the femur at a tertiary bone tumour unit, and the outcomes of the surgical strategies employed. methods a retrospective cohort study was performed of all patients presenting to our institution with femoral metastasis, both with and without pathological fracture, who were managed surgically from april 2016 to february 2020. fractures of the femoral neck were managed with cemented arthroplasty. all other fractures were managed with intramedullary nailing, as were all lesions requiring prophylactic stabilisation. data was recorded regarding demographics, primary pathology, location of lesion, type of surgery, and implant used. the incidence of complications including radiological failure of fixation, infection, thromboembolic phenomena, re-operation and mortality were recorded. results eighty-five femurs in 77 patients were included (mean age 61 years, range 20–90). lesions were located in the femoral neck (19/85, 22%), intertrochanteric (20/85, 24%), subtrochanteric (40/85, 47%), diaphyseal (2/85, 2%) and metaphyseal/per-condylar (4/85, 5%) regions of the femur. a total of 64/85 (753%) procedures were performed for fractures and 21/85 (25%) prophylactically. eighteen of the 85 (21%) underwent long-stemmed cemented bipolar hemiarthroplasty, 1/85 (1%) long-stemmed cemented total hip replacement (thr), 62/85 (73%) cephalomedullary nailing, and 4/85 (5%) retrograde femoral intramedullary nailing. mean follow-up was eight months (range 1–36). there were no dislocations or periprosthetic fractures in the arthroplasty group. one failure (1/66, 2%) of fixation occurred in the intramedullary nailing group. six deaths occurred in the arthroplasty group (6/64, 9%) and 24 in the nailing group (24/66, 36%) during the study period. four patients suffered from thromboembolic phenomena (4/77, 5%). of the 13 patients who sustained a pathological fracture and were managed with intramedullary nailing and followed up for at least one year, all had achieved clinical and radiological union. conclusion femoral metastasis can be appropriately managed with intramedullary nailing, both prophylactically and in the event of fracture, with a low rate of implant failure and an expectation that healing will occur once stabilised. intracapsular fractures can be managed with long-stemmed cemented arthroplasty with a low risk of subsequent fracture or dislocation. level of evidence: level 4 keywords: bone metastasis, femur, pathological fracture the surgical management of metastatic lesions of the femur aaron k saini, nando ferreira* division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa *corresponding author: nferreira@sun.ac.za https://orcid.org/0000-0002-2661-8445 https://orcid.org/0000-0002-0567-3373 page 152 saini ak et al. sa orthop j 2021;20(3) introduction bone is the third most common destination for metastatic disease following the lung and liver.1 the occurrence of bone metastasis is associated with a poor prognosis, with five-year survival shown to be between 1% and 13% depending on the primary tumour type.2 the femur is the most common skeletal site after the ribs and sternum, spine and pelvis, and is the commonest long bone affected.3 surgical intervention may be indicated prophylactically when fracture is anticipated, or after fracture has occurred, to reduce pain and restore function. solitary bone metastasis may be amenable to resection with reconstruction. this may offer a chance of cure with complete remission should the primary tumour also be treatable, singularly or through a combination of resection, chemotherapy and radiotherapy. the mirels’ score is commonly used to estimate the risk of fracture for a given lesion, and can be used in conjunction with clinical assessment, general patient condition, and to guide the surgical intervention.4 post fracture, surgery is typically in the form of stabilisation with an intramedullary device, or replacement with hemior total arthroplasty. the indications for one modality over the other are debatable, with a varying range of outcomes shown for each.5-8 the purpose of this study is to assess the management algorithm for bony metastasis of the femur at a tertiary bone tumour unit, and the outcomes of the surgical strategies employed. methods after obtaining health research and ethics committee approval, we performed a retrospective folder review of all patients presenting to our institution with femoral metastasis, both with and without pathological fracture, who were managed surgically from april 2016 to february 2020 using the algorithm described below. patients presenting with lesions without fracture were assessed clinically and radiologically, including a calculation of the mirels’ score, and proceeded to surgical intervention if both patient and surgeon were in agreement. these patients were treated with prophylactic cephalomedullary nail (figure 1) (intertantm, smith & nephew, london, united kingdom). patients presenting with fractures of the femoral neck were managed with cemented long-stem exetertm v40tm (stryker, michigan, usa) bipolar hemiarthroplasty (figure 1) or total hip replacement (thr) if significant acetabular disease was identified. all inter/subtrochanteric (figure 2) and diaphyseal fractures (figure 3) were managed with cephalomedullary nail (intertantm smith & nephew), and metaphyseal/per-condylar fractures with the metatantm retrograde femoral nail (smith & nephew). post surgery, patients received bisphosphonates, and once all wounds had healed, all patients received radiotherapy. chemo/ hormonal therapy was instituted by the medical oncology team if indicated. this varied depending on primary, subtype, and patient appropriateness, including comorbidities and prognosis. figure 1. a 62-year-old patient with metastatic breast cancer who sustained a left femoral neck fracture managed with long-stemmed cemented hemiarthroplasty. the patient subsequently underwent right prophylactic cephalomedullary nailing. radiographs preand post-hemiarthroplasty and cephalomedullary nailing figure 2. an 83-year-old patient with metastatic breast cancer who sustained a left intertrochanteric femoral fracture. radiographs preand one-year postcephalomedullary nailing page 153saini ak et al. sa orthop j 2021;20(3) data was recorded regarding demographics, primary pathology, location of lesion, type of surgery and implant used. the incidence of complications including radiological failure of fixation, infection, thromboembolic phenomena, re-operation, and mortality were recorded. mortality was considered perioperative if within 48 hours of the procedure, early postoperative if within one month, or late if after one month. patients with incomplete records were excluded. results the final cohort consisted of 58 female patients (75%) and 19 male patients (25%) with a mean age of 61.6 years, (range 20–90) (table i). mean follow-up was 8.3±8.52 sd months (range 1–36). a total of 85 femurs in 77 patients underwent surgical management (tables ii and iii). no dislocations or periprosthetic fractures were seen in patients who received arthroplasty. one failure of fixation occurred in the retrograde intramedullary group (1/4, 25%) two months post procedure. the patient was deemed to be medically unfit for revision surgery and died two months post failure. there were no failures in the cephalomedullary group, giving an overall failure rate for the nailing group of 1/66 (2%). six patients who underwent an arthroplasty procedure demised during the study period (6/19, 32%); one early postoperative and five deemed late, at a mean of four months post procedure. the early death occurred in a patient who was readmitted 13 days post procedure with respiratory compromise and a pericardial effusion. cardiac arrest and death occurred within 24 hours of readmission. among patients who underwent intramedullary nail fixation, 24 deaths (24/66, 36%) occurred during the study period: one perioperative, one early postoperative, and 22 late, at a mean of 9.3 months post surgery. the single perioperative mortality occurred in a patient who underwent sequential humeral followed by femoral intramedullary nailing during a single sitting and subsequently suffered on-table cardiac arrest. the patient was resuscitated but died 24 hours thereafter. post-mortem examination was unable to provide a definite cause of death, but note was made of bone marrow emboli within the lungs. the early postoperative death occurred in a patient who was readmitted 14 days post procedure with a superficial wound infection. after consultation with the anaesthetic team, the patient was felt to be inappropriate for further surgical intervention and was managed with systemic antibiotics. the patient developed an acute abdomen 22 days following surgery but the general surgical team felt surgical intervention to be inappropriate. the patient died 23 days post surgery. four patients suffered thromboembolic phenomena in the early postoperative period (4/77, 5%). all had been receiving weightadjusted chemical thromboprophylaxis in the form of low molecular weight heparin (lmwh). one patient in the arthroplasty group developed a proximal deep vein thrombosis (dvt). in the nailing group, two patients developed pulmonary emboli, and one patient a proximal dvt. all were anti-coagulated initially with treatmentdose lmwh followed by warfarin. of the patients who sustained a pathological fracture managed with intramedullary nailing, 13 were followed up for at least one year. all 13 of these had achieved clinical and radiological bony union at the one-year mark. discussion the management of metastatic disease of the femur remains controversial in terms of implant choice in relation to the location and extent of the lesion. the aim of this study was to review our current management algorithm for femoral metastatic lesions. cephalomedullary fixation is generally performed for extracapsular proximal femur lesions, either prophylactically or post fracture. variation exists in the outcomes and recommendations in the literature. wedin and bauer9 suggested that for fractures of the proximal third of the femur, endoprosthetic replacement was preferable to reconstruction nailing due to lower implant failure rates (8.3% vs 13.6% respectively). a large study of 228 implanted nails10 recorded an implant failure rate of 8%, with those implanted for fracture failing at a higher rate than those inserted prophylactically (hazard risk 3.61). we did not observe any instances of implant failure in our series. another study reported a ‘loss of implant stability in 19 of 199 (10%)’ of peritrochanteric lesions treated with cephalomedullary nails.11 nails were inserted both prophylactically and for the treatment of fractures, although the proportions performed for each was not stated. the reasons for the loss of stability included fracture, disease progression, non-union and implant failure. fifty-one per cent of the procedures included curettage of the metastatic deposit with cement augmentation. no cement augmentation was used in our series as we encountered no cases where it was deemed necessary. our single loss of fixation occurred in a patient who underwent retrograde nailing for a very distal metaphyseal fracture. traditional teaching has often suggested that pathological fractures secondary to malignancy have variable potential to heal. of our patient cohort who were reviewed clinically and figure 3. a 68-year-old patient with metastatic breast cancer who sustained a left diaphyseal femoral fracture. radiographs preand postcephalomedullary nailing table i: general characteristics of included participants n=77 age (mean±sd, years) 61.6±12.32 (77) sex female male 75.3% (58) 24.7% (19) side left right bilateral 48.1% (37) 41.6% (32) 10.4% (8) follow-up (months) 8.3±8.52 sd (77) data is presented as mean±standard deviation and frequencies, with the number of participants in parentheses. page 154 saini ak et al. sa orthop j 2021;20(3) radiologically at one year, while small at 13 patients, all achieved union. gainor and buchert12 showed an overall union rate of 35% in 129 patients with fractures (not confined to the femur), although wide variation existed depending on the primary type, method of stabilisation, subsequent lifespan of the patient, and the dose of postoperative radiotherapy applied. our high rate of union would suggest that despite the bone being pathological, it retains healing potential when provided with stability and an appropriate mechanical environment. surgery of the lower limbs and malignancy are independent risk factors for thromboembolic phenomenon. venous thromboembolism is six times more prevalent in cancer patients and is the second largest cause of death in this patient group.13 aneja et al.14 suggested that femoral metastases treated prophylactically were more likely than those treated post fracture to develop pulmonary emboli and dvt (odds ratio 2.1 and 1.5 respectively). we did not find such a disparity, with thromboembolic phenomena seen in 4.8% of the prophylactic group vs 5.4% of those treated post fracture. our overall rate of 5% was slightly lower than that of other studies of surgically managed long-bone metastasis which found rates between 6% and 10%.15-17 it is worth noting that the patients in each of these study groups received varying levels of perioperative chemo-thromboprophylaxis. the four cases of thromboembolism in our series were observed in patients who had been receiving weight-adjusted chemical thromboprophylaxis in the form of lmwh, as did our entire cohort. long-stemmed cemented arthroplasty has an established role in complex primary and revision arthroplasty. its use in the context of femoral metastatic disease has a hypothetical but logical benefit over shorter stems in terms of protecting a longer segment of femur. this is from the possibility of future periprosthetic fracture of known, occult or new femoral metastatic deposits. good results were reported by peterson et al.18 in their series of 21 patents who underwent cemented long-stem hemiarthroplasty for metastatic disease with either impending or fractured proximal lesions; one periprosthetic fracture occurred three months post procedure, with no dislocations or infections. similarly, randall et al.19 reported one periprosthetic fracture in 27 patients, one haematoma requiring evacuation, but no dislocations or infections. we did not observe any periprosthetic fractures, dislocations or infections in the current series. bone cement implantation syndrome is a recognised phenomenon occurring in cemented hemiand total arthroplasty of the hip. there is wide variation in the precise definition, incidence and effect on intraand perioperative mortality.20-22 risk stratification is generally described based on the american society of anesthesiologist’s physical status classification (asa-ps). metastatic disease has a wide variation in associated functional and physiological impairment, and as a diagnosis in itself does not relate to a patient’s asa-ps. however, herrenbruk et al.23 showed a statically significant increase in the risk of cement-associated complications in patients with metastatic disease undergoing long-stem cemented hemiarthroplasty when compared with those that did not. randall et al.19 described their strategy of reducing cement-related complications, including aggressive medullary lavage, canal suctioning, the use of early low-viscosity cement and slow, controlled insertion of the long stem. cement-related hypotension occurred in 14% of their series, with no cardiac events or deaths. petersen et al.18 in their series of 21 patents recorded no cemented-related complications; this was also the case in our series. mega-prosthetic replacement has an established role in the management of metastatic bone lesions. this is usually reserved for cases where reconstruction post fracture, or for prophylaxis, using intramedullary nails or conventional arthroplasty is felt unlikely to succeed given the location and extent of a metastatic lesion. we agree with their use in specific cases but did not encounter any we felt required this in our series. simultaneous nailing of long bones in the context of metastatic disease has a significant mortality. ristevski et al.24 reported 3/18 (17%) of patients in their series of simultaneous bilateral femoral nailing died intraoperatively. moon el al.25 in their series of simultaneous nailing which included combinations of femurs, humeri and a tibia, reported two mortalities in their series of 16 patients as a direct result of acute pulmonary complications secondary to simultaneous nailing. one of these occurred intraoperatively. our only on-table cardiac arrest occurred in the only patient in our series undergoing sequential nailing of two long table ii: summary of primary pathology and treatment % (n) primary pathology (n=77) breast lung prostate haematological renal gastric rectal 58 (45) 16 (12) 10 (8) 9 (7) 4 (3) 1 (1) 1 (1) anatomical location of lesion (n=85) femur neck intertrochanteric subtrochanteric diaphyseal distal metaphysis 22 (19) 24 (20) 47 (40) 2 (2) 5 (4) surgical procedures fracture fixation prophylactic fixation arthroplasty 53% (45) 25% (21) 22% (19) data is presented as frequencies, with the number of participants in parentheses. table iii: summary of treatment complications locale of lesion (n) procedure complications femur neck (19) cemented bipolar hemiarthroplasty (18) cemented total hip arthroplasty (1) none none intertrochanteric (20) cephalomedullary nail (20) (fracture 13, prophylactic 7) none subtrochanteric (40) cephalomedullary nail (40) (fracture 26, prophylactic 14) none diaphyseal (2) cephalomedullary nail (2) (both for fracture) none distal metaphysis (4) retrograde femur nail (4) (all for fracture) fixation failure (1) data is presented as the number of participants in parentheses. page 155saini ak et al. sa orthop j 2021;20(3) bones (a femur and humerus) in one session, with death occurring within 24 hours. this supports the need for the staging of the required procedures when prophylactic, which we now perform at our institution at an interval of four to six weeks. our management algorithm for the surgical management of femoral metastasis consisting of cemented long-stemmed arthroplasty for neck fractures, and intramedullary nailing for all other fractures and prophylaxis, leads to favourable outcomes. we observed no periprosthetic fractures, dislocations, bone cement reactions or infections in the arthroplasty group. in the nailing group, we saw no implant failures and a single loss of fixation. thromboembolic phenomena occurred at a rate slightly lower than the published literature in the context of all of our patients receiving chemical prophylaxis. caution should remain regarding sequential nailing of long bones; the only perioperative death occurred after this was performed on a patient’s femur and humerus. the main limitation in our series is that of frequency and duration of follow-up. the cause of this can be attributed to two factors. first, the position of our service as a tertiary referral centre for an entire province means that patients are often faced with extended journeys from rural areas. this may include journeys to regional hospitals followed by overnight transfer to our centre, meaning that patients will often only attend when in difficulty. the second factor is the poor prognosis of the cohort, namely patients with bone metastasis from disseminated malignancy. one-year survivorship for patients with metastatic lesions of the femur treated surgically has been reported at between 14% and 35%.11,26 this high mortality unavoidably reduces the duration and number of patients that can be followed up. conclusion femoral metastasis can be managed with intramedullary nailing, both prophylactically and in the event of fracture, with an expectation that healing will occur once stabilised. intracapsular fractures can be managed with long-stemmed cemented hemiarthroplasty with a low risk of subsequent fracture or dislocation. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethical approval for this study was obtained prior to commencement of data collection: health research ethics committee, stellenbosch university, ethics reference number n20/04/042. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions aks: study conceptualisation, acquisition, analysis and interpretation of data, first draft preparation, revision and submission of the final manuscript nf: study conceptualisation, acquisition, analysis and interpretation of data, revision of manuscript and approval of final draft orcid saini ak https://orcid.org/0000-0002-2661-8445 ferreira n https://orcid.org/0000-0002-0567-3373 references 1. macedo f, ladeira k, pinho f, et al. bone metastases: an overview. oncol rev. 2017;11(1):321. https://doi.org/10.4081/oncol.2017.321. 2. svensson e, christiansen cf, ulrichsen sp, et al. survival after bone metastasis by primary cancer type: a danish population-based cohort study. bmj open. 2017 sep 11;7(9):e016022. 3. kakhki vr, anvari k, sadeghi r, et al. pattern and distribution of bone metastases in common malignant tumors. nucl med rev cent east eur. 2013;16(2):66-69. https://doi.org/10.5603/nmr.2013.0037. 4. mirels h. metastatic disease in long bones. a proposed scoring system for diagnosing impending pathologic fractures. clin orthop relat res [internet]. 1989;249:256-64. available from: https://www.ncbi.nlm.nih.gov/ pubmed/2684463. 5. siegel gw, biermann js, calinescu aa, et al. surgical approach to bone metastases. curr osteoporos rep. 2018;16(4):512-18. https://doi.org/10.1007/ s11914-018-0463-7. 6. soeharno h, povegliano l, choong pf. multimodal treatment of bone metastasis-a surgical perspective. front endocrinol. 2018;9:518. https://doi. org/10.3389/fendo.2018.00518. 7. damron ta, sim fh. surgical treatment for metastatic disease of the pelvis and the proximal end of the femur. instr course lect [internet]. 2000;49:46170. available from: https://www.ncbi.nlm.nih.gov/pubmed/10829199. 8. jonas sc, mehendale sm, bick sm, baker rp. current orthopaedic management of bony metastases in the proximal third of the femur. hip int. 2017;27(1):1-7. https://doi.org/10.5301%2fhipint.5000497. 9. wedin r, bauer hc. surgical treatment of skeletal metastatic lesions of the proximal femur: endoprosthesis or reconstruction nail? j bone jt surg br. 2005;87(12):1653-57. https://doi.org/10.1302/0301-620x.87b12.16629. 10. willeumier jj, kaynak m, van der zwaal p, et al. what factors are associated with implant breakage and revision after intramedullary nailing for femoral metastases? clin orthop relat res. 2018;476(9):1823-33. https://doi. org/10.1007/s11999.0000000000000201. 11. chafey dh, lewis vo, satcher rl, moon bs, lin pp. is a cephalomedullary nail durable treatment for patients with metastatic peritrochanteric disease? clin orthop relat res. 2018;476(12):2392-401. https://doi.org/10.1097/ corr.0000000000000523. 12. gainor bj, buchert p. fracture healing in metastatic bone disease. clin orthop relat res [internet]. 1983;178:297-302. available from: https://www.ncbi.nlm. nih.gov/pubmed/6883864. 13. donnellan e, khorana aa. cancer and venous thromboembolic disease: a review. oncologist. 2017;22(2):199-207. https://doi.org/10.1634/ theoncologist.2016-0214. 14. aneja a, jiang jj, cohen-rosenblum a, et al. thromboembolic disease in patients with metastatic femoral lesions: a comparison between prophylactic fixation and fracture fixation. j bone jt surg am. 2017;99(4):315-23. https://doi. org/10.2106/jbjs.16.00023. 15. groot oq, ogink pt, janssen sj, et al. high risk of venous thromboembolism after surgery for long bone metastases: a retrospective study of 682 patients. clin orthop relat res. 2018;476(10):2052-61. https://doi.org/10.1097/corr.00 00000000000463. 16. ratasvuori m, lassila r, laitinen m. venous thromboembolism after surgical treatment of non-spinal skeletal metastases an underdiagnosed complication. thromb res. 2016;141:124-28. https://doi.org/10.1016/j.thromres.2016.03.013. 17. shallop b, starks a, greenbaum s, et al. thromboembolism after intramedullary nailing for metastatic bone lesions. j bone jt surg am. 2015;97(18):1503-11. https://doi.org/10.2106/jbjs.n.01067. 18. peterson jr, decilveo ap, o’connor it, et al. what are the functional results and complications with long stem hemiarthroplasty in patients with metastases to the proximal femur? clin orthop relat res. 2017;475(3):745-56. https://doi. org/10.1007/s11999-016-4810-7. 19. randall rl, aoki sk, olson pr, bott si. complications of cemented long-stem hip arthroplasties in metastatic bone disease. clin orthop relat res. 2006;443: 287-95. https://doi.org/10.1097/01.blo.0000191270.50033.3a. 20. costa ml, griffin xl, pendleton n, pearson m, parsons n. does cementing the femoral component increase the risk of peri-operative mortality for patients having replacement surgery for a fracture of the neck of femur? data from the national hip fracture database. j bone jt surg br. 2011;93(10):1405-10. https://doi.org/10.1302/0301-620x.93b10.26690. 21. donaldson aj, thomson he, harper nj, kenny nw. bone cement implantation syndrome. br j anaesth. 2009;102(1):12-22. https://doi.org/10.1093/bja/aen3 28. 22. talsnes o, vinje t, gjertsen je, et al. perioperative mortality in hip fracture patients treated with cemented and uncemented hemiprosthesis: a register study of 11,210 patients. int orthop. 2013;37(6):1135-40. https://doi.org/10.100 7%2fs00264-013-1851-3. 23. herrenbruck t, erickson ew, damron ta, heiner j. adverse clinical events during cemented long-stem femoral arthroplasty. clin orthop relat res. 2002;(395):154-63. https://doi.org/10.1097/00003086-200202000-00017. 24. ristevski b, jenkinson rj, stephen dj, et al. mortality and complications following stabilization of femoral metastatic lesions: a population-based study ttps://orcid.org/0000-0002-2661-8445 https://orcid.org/0000-0002-0567-3373 page 156 saini ak et al. sa orthop j 2021;20(3) of regional variation and outcome. can j surg [internet]. 2009;52(4):302-308. available from: https://www.ncbi.nlm.nih.gov/pubmed/19680515. 25. moon b, lin p, satcher r, lewis v. simultaneous nailing of skeletal metastases: is the mortality really that high? clin orthop relat res . 2011;469(8):2367-70. https://doi.org/10.1007/s11999-011-1814-1. 26. sarahrudi k, hora k, heinz t, et al. treatment results of pathological fractures of the long bones: a retrospective analysis of 88 patients. int orthop. 2006;30(6):519-24. https://doi.org/10.1007/s00264-006-0205-9. _hlk68842322 404 not found orthopaedics vol3 no4 sa orthopaedic journal summer 2014 | vol 13 • no 4 page 39 imaging diagnosis of muscle herniation of the forearm dr yacoob omar carrim1 mbchb(up), bcom(hons)dsm dr rene truter2 mbchb, mmed(rad)(d) stell dr farhana suleman1 fcrad(d)(sa), mmed(rad)(d) medunsa prof savvas andronikou2,3 mbbch(wits), fcrad(diag)(sa), frcr(lond), phd(uct) 1department of radiology, university of pretoria, pretoria, south africa 2drs schnettler, corbett and partners, cape town, south africa 3department of radiology, faculty of health sciences, university of the witwatersrand, johannesburg, south africa correspondence: dr yo carrim department diagnostic radiology university of pretoria po box 14336 laudium 0037 south africa email: ycarrim@gmail.com tel: +2712 354 2406 introduction muscle herniation is defined as protrusion of muscle through an acquired or congenital defect of enclosing fascia.1 fascial defects may be described as traumatic or constitutional. traumatic causes may result from direct or indirect trauma1 and fascial tears are caused by direct penetrating wounds or fascial ruptures produced by blunt trauma on a contracted muscle.2,3 constitutional causes of fascial defects may be due to exertional fatigue2 or may be secondary to vigorous exercise followed by hypertrophy and elevation of intracompartmental pressure.1 we present the role of imaging for the rare situation where a factory worker developed a forearm muscle hernia, spontaneously, while lifting a heavy weight, and without having sustained any preceding injury. abstract muscle herniation is defined as a protrusion of muscle through an acquired or congenital defect of enclosing fascia. there have been 19 cases of symptomatic forearm muscle herniation reported in the literature. in this article we present a case of a 26-year-old factory worker who developed a traumatic forearm muscle herniation diagnosed on ultrasound and mri, and we review the imaging of muscle hernias. key words: forearm, muscle herniation, ultrasound, mri the ultrasonographic findings were confirmed by mri, using fast spin echo (fse) images in the axial, coronal and sagittal planes before and after muscle contraction saoj summer 2014_orthopaedics vol3 no4 2014/11/05 12:03 pm page 39 page 40 sa orthopaedic journal summer 2014 | vol 13 • no 4 case report a 26-year-old male factory worker felt a lump in the right elbow region, near the common extensor compartment, after the strenuous task of lifting a heavy weight. he presented to his physician with a non-tender soft tissue mass, measuring 3 cm over the medial left forearm. the patient showed full range of motion for the wrist and hand. a facial defect with muscle herniation was noted using dynamic sonographic examination (figures 1a and b). colour doppler sonogram also showed prominent vessels traversing the fascia at the site of the hernia. no ultrasound features of chronic exertional compartment syndrome were present. the ultrasonographic findings were confirmed by mri, using fast spin echo (fse) images in the axial, coronal and sagittal planes before and after muscle contraction. mri demonstrated the size of the muscle herniation and the extent of the fascial defect while the forearm was contracted (figure 2). again no features of chronic exertional compartment syndrome were present. the patient was advised of the diagnosis and referred to the orthopaedic department. discussion symptomatic muscle herniations in the lower extremities are much more common than in the upper limb, with the anterior compartment of the lower leg being the most common site.4 symptomatic forearm muscle herniation is a rare entity1 with only 19 cases described in the literature. most are caused by trauma and only four reported cases were caused by strenuous exercise.4 the aetiology of muscle herniation is thought to occur secondary to muscle hypertrophy and increase in intracompartment pressure from forced exertion of strenuous activity. the muscle usually herniates in areas of weakness, where the neurovascular bundles penetrate the deep fascia. muscle herniation usually occurs secondary to trauma and rarely from strenuous exercise.4 figure 1 a and b. ultrasound of the extensor region of the right forearm in a 26-year-old factory worker demonstrating muscle herniation a. grey-scale high-resolution transverse ultrasound using a linear probe demonstrates a discontinuity in the muscle fascia (arrows) with projection of muscle through the space to lie external to the fascia in the subcutaneous fat space b. colour flow demonstrates continuity of blood flow in vessels across the fascial defect figure 2. axial t1-weighted mri of the right forearm confirms the defect in the muscle fascia, with muscle extending through the defect to lie in the subcutaneous fat space (immediately deep to the mri oil marker) saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 40 sa orthopaedic journal summer 2014 | vol 13 • no 4 page 41 patients usually complain of pain or discomfort with pronation or supination of the hand1 secondary to forced exertion or strenuous activity or following trauma. on physical examination a soft tissue swelling over the ventral forearm, which becomes prominent following the making of a fist, is characteristic.1 the muscle bulge, usually located in the middle of the forearm,5 becomes tense after contraction in the area of the muscle defect1,6 and is effaced or shrinks when the muscle is relaxed.6 most hernias are located in the mid-forearm and not the distal forearm.5 proximal mid-forearm fascial defects overlie muscle that may protrude, causing a bulge with local muscle contraction. distal fascial defects do not overlie muscle bellies and do not cause muscle hernia when there is a fascial defect and therefore do not cause a bulge.5 pain is due to muscle protrusion as the hernia courses against the proximal fascial edge of the defect.5 the diagnosis of muscle herniation can be suspected clinically but radiological evaluation is useful for definitive diagnosis, especially in the cases with associated soft tissue oedema and/or hypertrophy of subcutaneous fat.1,7 radiographs reveal a focal soft tissue mass over the ventral medial forearm that becomes prominent with making a fist.1 plain films and ct may detect calcification and allow assessment of adjacent bony structures but, unlike ultrasound and mri, do not offer much in the way of tissue characterisation.5 ultrasound is performed using a high frequency linear transducer in the longitudinal and transverse planes and includes both static and dynamic examination of the forearm. dynamic imaging involves rest, isotonic muscle contraction, and compression of the herniation for reduction.1 the skin should be marked because the mass may be difficult to feel during sonographic examination.6 coupling gel should be applied liberally, gain focus should be set to optimise the near field and the transducer should be applied lightly to avoid effacing the hernia.6 the contralateral forearm may also be examined.1 sonographic evaluation demonstrates the normal muscle fascia as a continuous hyperechoic linear structure with a mean thickness of 1 mm. fascial defects and the muscle herniation can be demonstrated directly with dynamic sonographic examination.1 longitudinal sonogram shows the fascia is thinned and elevated by a small bulge.6 colour doppler sonogram shows prominent vessels traversing fascia at the site of the hernia.6 the advantage of ultrasound is its relative ease of application, relative increased access to all the muscle groups, low cost and reduced time required to make a diagnosis.2,8 sonographic features of muscle herniation are characteristic and exclude alternative clinical diagnosis such as tumours.6,8 dynamic ultrasonography can successfully reduce the hernia during the examination by compression of the transducer over the tissue mass.1-3 sonography can also determine the size of the hernia and the extent of the fascial defect. however, ultrasonography remains a user-dependent investigation. ultrasonography post-exertional depth perception may also be useful as a non-invasive investigation complementing direct intramuscular depth perception to diagnose chronic exertional compartment syndrome.9 there have been limited reports of mri for muscle herniation.1,5 dynamic mri may be useful for surgical planning. mri is not operator-dependent, and its findings are reproducible. mri may help in the evaluation of the amount of soft tissue oedema and the identification of the specific muscles and structures involved. mri of a muscle hernia is a visualised local defect, with measurable size and extent of the fascial defect.2 mri of chronic exertional compartment syndrome may be noted as either a focal area of signal change or as an area of diffuse signal change within an osteofascial plane. in asymptomatic patients with forearm muscle herniation, surgical options are best considered only after a trial of conservative management.10 patients that present with symptomatic pain on extremity exertion or an unaesthetic bulge are candidates for surgery.5 surgical management is by fascial repair, fasciotomy or anatomical repair of the fascial defect. fascial repair, particularly in patients with lower limb muscle herniation, has been associated with chronic compartment syndrome.10,11 fasciotomy may reduce the risk of compartment syndrome, but may leave an unappealing forearm deformity, and there have been reports of incomplete resolution of pain on extremity exertion. anatomical repair with autologous inlay graphs and mesh have also been used in the management of forearm muscle herniation,7 but morbidity at the donor site is a drawback.3 polypropylene mesh may allow early return to activities without undue concern for herniation.2 conclusion forearm muscle herniation is a rare entity. when forearm muscle herniation is symptomatic, radiology through dynamic ultrasound and dynamic mri, as in our patient, can make a definitive diagnosis and assist in surgical planning and management. no funding or grants were used in the preparation of this manuscript. the diagnosis of muscle herniation can be suspected clinically but radiological evaluation is useful for definitive diagnosis ultrasound is performed using a high frequency linear transducer in the longitudinal and transverse planes and includes both static and dynamic examination of the forearm saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 41 page 42 sa orthopaedic journal summer 2014 | vol 13 • no 4 references 1. kendi tk, altinok d, erdal hh, kara s. imaging in the diagnosis of symptomatic forearm muscle herniation. skeletal radiol. 2003;32:364-66. 2. bruce j, robertson, sanders bs. treatment of a symptomatic forearm muscle herniation with a mesh graft. sports health: a multidisciplinary approach 2011;3:179-81. 3. roberts jo, regan pj, dickinson jc, bailey bn. forearm muscle herniae and their treatment. j hand surg br. 1989;14:319-21. 4. khalid  ka, mah et. case report treatment of a symptomatic forearm muscle herniation with a wrap-around fascia lata graft. journal of hand and microsurgery 2009;1:54-59. 5. olch cl, watson hk. symptomatic forearm fascial hernia. j hand surg am. 1996;21:693-95. 6. beggs i. sonography of muscle hernias. ajr  am j roentgenol 2003;180:395-99. 7. golshani sd, lee c, sydorak r. symptomatic forearm muscle hernia: repair by autologous fascia lata inlay. ann plast surg. 1999;43:204-206. 8. king tw, lerman oz, carter jj, warren sm. extertional compartment syndrome of the thigh: a rare diagnosis and literature review. j emer med; 2010;39:e93-99. 9. wassermann d, oschmann z. role of ultrasound as a noninvasive method of diagnosis of chronic exertional compartment syndrome. sa orthop j. 2011;10(4):59-65. 10. miniaci a, rorabeck ch.  compartment syndrome as a complication of repair of a hernia of the tibialis anterior: a case report. j bone joint surg am. 1986;68:1444-45. 11. wolfort fg, molvang lc, piltzer hs.  anterior tibial compartment syndrome following muscle hernia repair. arch surg. 1973;106:97-99. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 42 404 not found workman mi et al. sa orthop j 2019;18(3) doi 10.17159/2309-8309/2019/v18n3a3 south african orthopaedic journal http://journal.saoa.org.za trauma citation: workman mi, wever gs, mccollum ga. a survey of the management of posterior malleolar ankle fractures in south africa. sa orthop j 2019;18(3):36-40. http://dx.doi.org/10.17159/2309-8309/2019/v18n3a3 editor: prof np saragas, university of the witwatersrand, johannesburg, south africa received: october 2018 accepted: april 2019 published: august 2019 copyright: © 2019 workman mi, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: none. conflict of interest: none of the authors have any conflict of interest to declare with respect to this research. abstract background: posterior malleolus fractures are associated with poorer functional outcomes compared to simpler malleolar fractures. traditional teaching states that if a posterior malleolus fracture involves less than 25% of the distal tibia, it can be managed without fixation. current literature has shown that fixation should not be based on the size of the posterior fragment but rather on the fracture pattern, instability and awareness that reduction and fixation is biomechanically advantageous. we hypothesised that current management of ankle fractures with posterior malleolus involvement in south africa is not evidence-based and is suboptimal. we sought to assess the training, experience and decision-making of surgeons and trainees who are involved in the management of ankle fractures. another aim was to develop evidence-based algorithms for the management of posterior malleolus and complex ankle fractures. methods: an email survey consisting of questions related to the management of ankle fractures was sent to specialists, registrars and medical officers who voluntarily completed an online survey. results: a total of 103 out of 456 emails sent drew responses to the survey. responses included 28% from consultants, 54% from registrars and 18% from medical officers. forty-six per cent of responders believed that posterior malleolus fractures can be managed non-operatively if less than 20% of the tibial plafond is involved. only 49% would ct scan a posterior malleolus prior to operating. thirty-eight per cent of the responders were not familiar or comfortable with the posterior-lateral approach used for fixation of the posterior malleolus directly. conclusion: understanding of ankle fractures has progressed. a significant proportion of responders to the survey are not following best practice and current literature. posterior malleolus fractures are not benign and have poorer outcomes compared to bi-malleolar or lateral malleolus ankle fractures. all patients with posterior malleolus fractures should receive pre-operative ct scan. all posterior malleolar fractures that can be held with a plate or screws should be fixed. level of evidence: level 5 key words: trimalleolar ankle fracture, open reduction of posterior malleolus, syndesmosis injury, haraguchi classification, ct scan of ankle fractures a survey of the management of posterior malleolar ankle fractures in south africa workman mi¹ , wever gs² , mccollum ga³ 1 bsc physio, mbbch; registrar* ² mbbch; registrar* ³ mbchb, mmed(uct), fc orth sa; consultant* *department of orthopaedics, groote schuur hospital, university of cape town, cape town, south africa corresponding author: dr mi workman, department of orthopaedics, old main building, groote schuur hospital, anzio road, observatory 7925, cape town, south africa; email: matthew.workman1@gmail.com; tel: +27 83 297 5059 https://orcid.org/0000-0002-7999-9069 https://orcid.org/0000-0001-7072-1565 page 37workman mi et al. sa orthop j 2019;18(3) introduction the incidence of ankle fractures is approximately 187 per 100 000 people per year. two-thirds of these are isolated malleolar fractures, with bimalleolar fractures occurring in one-fourth and trimalleolar fractures making up the remainder. risk factors for ankle fractures include increased body mass index and the elderly. open fractures are rare.1 management of ankle fractures ranges from non-operative treatment to surgery and prolonged non-weight-bearing. the consequences of inadequate treatment can lead to a poor outcome and further reconstructive surgery. missed or insufficient syndesmotic injury management is associated with ankle joint failure. the presence of a posterior malleolus fracture is associated with poorer functional outcomes compared to more simple fractures.2 fractures involving the posterior malleolus frequently include damage to the articular cartilage which is likely to contribute significantly to rapid onset of severe arthritis.3 these injuries occur secondary to a pronation–external rotation type force and result in a weber b or c type pattern of injury to the distal fibula with or without a medial injury.4 depending on the degree of force imparted to the ankle at the time of injury, progressive failure of the syndesmotic ligaments occurs, from the anterior inferior tibia fibular ligament (aitfl) anteriorly, through the interosseous ligament (iol) and the posterior inferior tibial fibular ligament (pitfl) posteriorly. when a posterior fragment is visualised on radiographic imaging, this indicates that the pitfl has avulsed the volkmann’s fragment, completely destabilising the syndesmosis.5-7 traditional teaching states that, if a posterior malleolus fracture involves less than 25% of the distal tibia, it can be managed without fixation. reducing and fixing the medial and lateral malleolar fractures and inserting a syndesmotic screw became the accepted treatment.5,8,9 rigid fixation of the syndesmosis with a syndesmotic screw has, however, been associated with inhibition of the normal motion at the tibia–fibula syndesmosis, sometimes resulting in pain and/or failure of the screw.10 the likelihood of malreduction at this joint is also significant. current understanding and emerging evidence is that fixation should not be based on the size of the posterior fragment but rather on the awareness that reduction and fixation is biomechanically advantageous and may have fewer adverse sequelae. fixation stabilises the pitfl of the syndesmosis, potentially negating the need for a syndesmotic fixation.11 beumer et al. suggest that syndesmotic screw fixation does not adequately stabilise the syndesmosis with early weight-bearing.12 the technical requirement of approaching the posterior malleolus may discourage surgeons unfamiliar with the posterolateral approach. as opposed to the traditional direct lateral approach to the subcutaneous fibula, the postero-lateral approach requires dissection through the flexor mass and protection of neurovascular structures. the patient also needs to be positioned either in the lateral position or prone. once mastered, however, this is a relatively simple approach that provides excellent exposure for reduction and fixation of posterior and lateral malleolus fractures.13 considering the above, it is hypothesised that current management of ankle fractures is suboptimal. the indications for non-operative management may be based on outdated evidence and posterior malleolus fractures may not be reduced and fixed. this study aimed to assess the training, experience and decisionmaking of the surgeons who are involved in the management of ankle fractures with the aim of implementing a technical update or training as necessary. methods this was a descriptive cross-sectional survey analysis. qualified specialists, registrars and medical officers in orthopaedics in south africa were identified using their respective professional member listings and university registrations. email databases from the south african orthopaedic society were used to email a questionnaire using the google forms platform. this consisted of questions related to the management of ankle fractures (see appendix). these questions were based on questions from the consensus of the 7th round table held in cardiff in september 2017. these are the thoughts and opinions, with consensus where possible, of 30 orthopaedic foot and ankle consultant surgeons gathered from across europe and the united kingdom.14 the specialists, registrars and medical officers voluntarily completed an online survey regarding ankle fractures with respect to experience, training and decision-making. this was a single email survey. non-responders were sent a reminder after one week. our data management plan entailed analysis of google forms responses in excel. we used simple descriptive statistics to analyse the data. we reported categorical data in tables with frequencies and percentages. we tested normality of the data qualitatively. a sample size of 100 was required to estimate a hypothesised sample point of 50% for the primary outcome (‘are ankle syndesmosis injuries treated non-operatively when they should be operatively fixated?’) with a 10% error either side of the mean. this is a qualitative questionnaire. validity was determined by face, content and construct validity. reliability was enhanced by targeting responses from a large population group. responses were analysed according to current accepted standards of care. results one hundred and three out of 456 emails sent drew responses to the survey (22.6% response rate). of these, 28% (n=29) were from consultants; 54% (n=52) from registrars; and 18% (n=19) from medical officers. most those who responded (49%, n=50) had between five and ten years of experience in orthopaedics; 38% (n=40) had less than five years of orthopaedic experience; and 13% (n=13) of responders had more than ten years of experience. thirty-two per cent (n=33) of responders would treat an undisplaced weber a type fracture with weight-bearing as tolerated in a boot. fifty-six per cent (n=58) would manage this fracture nonweight-bearing in a moulded cast while the remainder (12%, n=12) would perform reduction and internal fixation with a syndesmosis fixation in 2.8% (n=3). forty-nine per cent (n=50) would treat a displaced weber b type fracture with mortice shift and deltoid ligament avulsion with reduction and fixation and no syndesmotic fixation. twenty-seven per cent (n=28) would use open reduction internal fixation (orif) with syndesmosis fixation. twenty-four per cent (n=25) would manage in a moulded cast. eighty-one per cent (n=83) of responders would reduce and fixate the syndesmosis for a weber c type fracture. nine per cent (n=9) would not use syndesmosis fixation (but open reduce and fixate), and the remainder would treat in moulded plaster or a boot (10%, n=10). with regard to a trimalleolar fracture shown on x-ray, 49% (n=50) would ct scan and then plan to open reduce and fixate the posterior malleolar fragment. thirteen per cent (n=13) would proceed to surgery of the posterior malleolus without a ct scan. twelve per cent (n=12) would orif with syndesmotic fixation (no ct scan), and 26% (n=27) would manage it in a moulded plaster, non-weight-bearing for six weeks (figure 1). page 38 workman mi et al. sa orthop j 2019;18(3) forty-six per cent (n=47) of respondents would not fix a posterior malleolar fragment that was <20% of the total joint surface area. fifty-one per cent (n=53) would not ct scan a posterior malleolar fracture identified on x-ray prior to surgery. sixty-two per cent (n=64) of respondents feel comfortable performing the posterior approach to fix a posterior malleolar fracture (figure 2). sixty-five per cent (n=67) fix syndesmotic injuries with a screw, 25% (n=26) use a combination of screw-and-tightrope type device and 10% use only a tightrope type device. eighty-five per cent (n=88) do not routinely offer removal of syndesmosis fixation. discussion by the nature of this study being a survey, a low response rate is to be expected. questions were validated, but some of the questions can be perceived to be leading due to the accompanying x-ray images. this study clearly highlighted the differing opinions on the management of ankle fractures by orthopaedic surgeons in south africa. although this study aimed primarily to assess current practice with regard to the management of posterior malleolar fractures, it also questioned the management of weber a, b and c type fractures. of note here is that the understanding of a stable fracture (one with no syndesmotic disruption) versus those requiring that the syndesmosis be addressed to avoid ankle joint failure, appears to be deficient. this may be related to responses from junior surgeons but is of concern as ankle fractures are frequently left to the junior team members to perform. correct understanding is therefore critical. unfortunately, not tracking responses for confidentiality reasons meant that this could not be investigated further. stable fractures such as weber a type may be managed with early weight-bearing. clinical examination and further investigations should aim to elicit any evidence of syndesmosis injury, which should prompt fixation. current literature refutes the long-held belief that posterior malleolus fractures constituting less than 25% of the total joint surface area do not need to be fixed.15 rather, sufficient imaging in the form of a ct scan should be obtained routinely. this allows the heterogeneous nature of these fracture patterns to be optimally appreciated. the functional outcome does not correlate with the size of the fragment. without a ct scan, the size of the fragment is often underestimated as the fracture line may run in oblique planes to the standard ap and lateral radiographs. meijer et al. showed that it is impossible to quantify the size of a posterior malleolar fracture on x-ray. this makes application of the ‘rule of 25s’ impossible. a ct scan is therefore always required to quantify the fragment morphology.16 additionally, a flipped fragment of articular surface is often encountered once the posterior malleolus fragment is mobilised and needs to be reduced to correctly reduce and recreate the joint surface. this is visualised on ct scan as shown in figure 3. the haraguchi classification of posterior malleolar fractures (figure 4) describes the fracture pattern but does not address the mechanism of injury. mason et al. have suggested a classification system of posterior malleolar fractures that progresses in severity, indicating the pathomechanics of the fracture and then guides surgical fixation.17 attempting to address the syndesmosis without reduction and stabilisation of the posterior malleolus often results in malreduction of the syndesmosis. gardner et al., in a cadaveric model, demonstrated that fixation of the posterior malleolus restored about 70% of syndesmosis stability compared to 40% after syndesmotic screw fixation.18 reduction was found to be more accurate when the posterior malleolus was fixed.19 there is also evidence to suggest that midterm functional outcomes were equivalent to what might be expected with a unimalleolar ankle fracture.20 orif with syndesmotic fixation 12 cr, moulded plaster and nwb for 6 weeks 26 orif of posterior malleolus 13 ct scan then orif posterior malleolus 49 figure 1. treatment of posterior malleolus fracture no 38% yes 62% are you comfortable with the posterior approach for fixation of haraguchi-type fractures? figure 2. respondents’ comfort level with respect to the posterior approach for fixation of haraguchi-type fractures figure 3. ct scan to quantify the fragment morphology page 39workman mi et al. sa orthop j 2019;18(3) conclusion the understanding of ankle fractures has progressed. we have shown that a significant proportion of responders to the survey are not following best practice and current literature. posterior malleolus fractures, particularly, are not benign and have poorer outcomes compared to bi-malleolar or lateral malleolus ankle fractures. size is not in itself an indicator for fixation. for surgeons to optimally manage posterior malleolus fractures, a pre-operative ct scan should be performed on all patients. they need to familiarise themselves with the surgical management of posterior malleolus fractures and with this, the postero-lateral approach to the ankle. current literature supports the fixation of posterior malleolar fractures. there is certainly further to go regarding the understanding and treatment of these injuries. ethics statement this research was approved by the university of cape town department of surgery research committee (2018/023) and the university of cape town faculty of health sciences ethics committee (hrec/ref: 314/2018). the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. informed consent was obtained. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. acknowledgement dr christof marias, foot and ankle surgeon, netcare blouberg hospital, cape town, south africa. author contributions mw contributed to the original study concept, proposal write-up, data collection and analysis, and final article write-up; gw assisted with the article and proposal write-up and final article additions; gm contributed to the study design, data analysis and final article concepts. orcid mi workman http://orcid.org/0000-0002-7999-9069 gs wever http://orcid.org/0000-0001-7072-1565 references 1. egol k, koval k, zuckerman j. handbook of fractures 4th ed. philadelphia, pa: wolters kluwer health/lippincot williams and wilkins, 2010. 2. velleman j, nijs s, hoekstra h. operative management of ao type 44 ankle fractures: determinants of outcome. jfas, dec 2017. 3. lauge -hansen n. fractures of the ankle i. combined experimentalsurgical and experimental-roentgenologic investigations. arch surg 1950;60:957-85. 4. reudi tp, murphy wm. ao principles of fracture management. stuttgart, germany: thieme. 2000. 5. burns wc ii, prakash k, adelaar r, beaudoin a, krause w. tibiotalar joint dynamics: indications for the syndesmotic screw: a cadaver study. foot & ankle 1993;14:153-58. 6. close jr. some applications of the functional anatomy of the ankle joint. jbjs 1956;38:761-81. 7. scheidt kb, stiehl jb, skrade da, barnhardt t. posterior malleolar ankle fractures: an in vitro biomechanical analysis of stability in the loaded and unloaded states. j orthop trauma 1992;6:96-101. 8. phillips wa, schwartz hs, keller cs, woodward hr, rudd ws, spiegel pg, laros gs. a prospective, randomized study of the management of severe ankle fractures. jbjs 1985;67:67-78. 9. mast jw, teipner wa. a reproducible approach to the internal fixation of adult ankle fractures: rationale, technique, and early results. orthop clin north am. 1980;11:661-79. 10. needleman rl, skrade da, stiehl jb. effect of the syndesmotic screw on ankle motion. foot & ankle 1989;10:17-24. 11. van den bekerom mp, haverkamp d, kloen p.  biomechanical and clinical evaluation of posterior malleolar fractures: a systematic review of the literature. j trauma 2009;66:279-84. 12. beumer a, campo mm, niesing r, day j, kleinrensink gj, swierstra ba. screw fixation of the syndesmosis: a cadaver model comparing stainless steel and titanium screws and three and four cortical fixation. injury 2005;36:60-64. 13. tornetta p 3rd, ricci w, nork s, collinge c, steen b.  the posterolateral approach to the tibia for displaced posterior malleolar injuries. j orthop trauma 2011;25:123-26. 14. malhotra k, wright s, jeyaseelan l, singh d. consensus of the 7th round table, aspects of foot and ankle surgery. cardiff, september 2017. 15. drifthout van hooff cc, verhage sm, hoogendoorn, jm. influence of fragment size and postoperative joint congruency on long-term outcome of posterior malleolar fractures. foot & ankle int. feb 2015;36(6):673-78. 16. meijer dt, doornberg jn, sierevelt in, et al. guesstimation of posterior malleolar fractures on lateral plain radiographs. injury 2015 oct;46(10):2024-29. 17. mason lw, marlow wj, widnall j, molloly ap. pathoanatomy and associated injuries of posterior malleolus fracture of the ankle. foot and ankle int. 2017 nov;38(11):1229-35. 18. gardner mj, brodsky a, briggs sm, nielson jh, lorich dg. fixation of posterior malleolus fractures provides greater syndesmotic stability. clin orthop rel res. 2006;447:165-71. 19. miller an, corroll ea, parker rj, boraiah s, helfet dl, lorich dg. direct visualisation for syndesmotic stabilization of ankle fractures. foot & ankle int. 2009;30(5):419-26. 20. robert v, mason lw, harrison e, molloy a, mangwani j. mid-term functional outcomes of reduced and malreduced fractures in two university teaching hosptials. bone & joint journal. 2016;98b(supp 19):16. figure 4. the haraguchi classification of posterior malleolar fractures http://orcid.org/0000-0002-7999-9069 http://orcid.org/0000-0002-7999-9069 http://orcid.org/0000-0001-7072-1565 http://orcid.org/0000-0001-7072-1565 page 40 workman mi et al. sa orthop j 2019;18(3) appendix a survey of the management of ankle fractures in south africa dear colleague thank you for taking your valuable time to complete these 10 questions on how you manage minimally displaced ankle fractures. this should take 3 minutes. 1. what is your current position? a: medical officer b: registrar c: specialist 2. years of experience in orthopaedics? a: less than 5 b: 5–10 c: more than 10 3. how would you treat the fracture below? a: weight-bearing (wb) as tolerated in boot b: closed reduction (cr), moulded plaster, non-weight-bearing (nwb) for 6 weeks c: open reduction internal fixation (orif) with no syndesmotic fixation d: orif with syndesmotic fixation 4. how would you treat the injury below? a: wb as tolerated in boot b: cr, moulded plaster and nwb for 6 weeks c: orif without syndesmotic fixation d: orif with syndesmotic fixation 5. how would you treat the injury below? a: wb as tolerated in boot b: cr, moulded plaster and nwb for 6 weeks c: orif without syndesmotic fixation d: orif with syndesmotic fixation 6. how would you treat the injury below? a: cr, moulded plaster and nwb for 6 weeks b: orif with syndesmotic fixation c: orif of posterior malleolus d: ct scan then orif posterior malleolus 7. would you fix a posterior malleolus fracture of <20% total joint surface area? a: yes b: no 8. are you comfortable with the posterior approach for fixation of haraguchi-type fractures? a: yes b: no 9. how do you fixate syndesmotic injuries? a: screw c: tightrope d: combination 10. do you offer routine screw removal? a: yes b: no _goback _hlk9077484 _hlk9075470 pretorius hs et al. sa orthop j 2019;18(4) doi 10.17159/2309-8309/2019/v18n4a4 south african orthopaedic journal http://journal.saoa.org.za traumatrauma and general orthopaedics citation: pretorius hs, strauss k, ferreira n, lamberts rp. circular frames of the humerus: salvage surgery case series. sa orthop j 2019;18(4):3540. http://dx.doi.org/10.17159/2309-8309/2019/v18n4a4 editor: dr f birkholtz, university of pretoria, pretoria, south africa received: march 2019 accepted: june 2019 published: november 2019 copyright: © 2019 pretorius hs. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: the authors declare that they have no conflict of interest. conflict of interest: no benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. abstract introduction: high energy fractures like gunshot-related injuries or high velocity road traffic accidents are often complex to treat and have been associated with a higher non-union rate, especially when there is extensive bone loss. fractures with severe comminution may not heal due to bone loss and an inability to achieve adequate fracture stability. treatment of fractures that are not amenable to plating or nailing may lead to non-unions, septic or aseptic, that need repeat surgeries. stabilisation with external fixation is a reliable option to maintain stability and provide a suitable environment for union. materials and methods: this retrospective study used medical records of all patients with complex mid-shaft humerus fractures, as well as their complications, that were treated with hexapod circular external fixation between january 2009 and september 2015. all the patients in this case series presented with severe humerus fractures or complications thereof which were not amenable to conventional therapy. results: union was achieved in ten out of the 12 cases (83.3%). union was achieved without bone graft or any other interventions at the fracture site except implant removal where indicated. the median time in external fixation was 196 days (interquartile range: 112–228). the most common complication encountered in this series was pin-site infection. fixation points were noted to be infected in 33% of cases at some time during the treatment period. conclusion: this study suggests that humeral non-unions and complex humerus fractures that are not amenable to conventional fixation methods, such as intramedullary nails and plates, can successfully achieve union when treated with a hexapod circular external fixator. level of evidence: level 4 keywords: taylor spatial frame, complex humerus fractures, non-union, septic non-unions circular frames of the humerus: salvage surgery case series pretorius hs¹ , strauss k², ferreira n³ , lamberts rp4 1 bsc, mbchb, mmed(orth)(stell); senior specialist* ² mbchb, fcorth, mmed(orth)(sa); registrar* ³ bsc, mbchb, fcorth, mmed(orth)(sa); associate professor* 4 msc (med hms), phd (exer physiol), fecss; professor and head of research* * division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, tygerberg, south africa corresponding author: dr hs pretorius, division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, tygerberg campus, tygerberg, south africa; po box 19063, tygerberg, 7505; tel +27 21 938 9266; email: hsp359@sun.ac.za https://orcid.org/0000-0002-7419-0885 https://orcid.org/0000-0002-0567-3373 https://orcid.org/0000-0003-1112-2604 page 36 pretorius hs et al. sa orthop j 2019;18(4) introduction high energy fractures like gunshot-related injuries (figure 1) or high velocity motor vehicle accidents (mvas) are often complex to treat and have been associated with a higher non-union rate, especially when there is extensive bone loss.1 conventional management of these fractures would include an intramedullary nail or plate fixation to span the fracture while maintaining stability. fractures with severe comminution may not heal due to bone loss and an inability to achieve adequate fracture stability. when the fixation fails due to non-union or infection, the use of external fixation is often required and may even be required as the initial fracture management due to severe soft tissue defects.1-3 in 2007, tomic used ilizarov circular external fixation to treat 28 non-unions of the humerus and achieved 100% union in all 28 cases in an average period of 4.1 months (range: 3.5–5.7 months).4 in 2016, ferreira et al. used circular external fixation to treat septic non-unions in eight cases and achieved 100% union rates with a mean fixator time of 29 weeks.5 a vital procedural step performed in this study was the radical debridement of devascularised bone ends and excision of the interposed fibrous tissue, which meant exposing the fracture site. the purpose of this study was to present our experience with the use of hexapod circular external fixation of the humerus for a variety of indications. materials and methods this retrospective study used medical records of all patients with complex mid-shaft humerus fractures, as well as their complications, that were treated with hexapod circular external fixation between january 2009 and september 2015. all the patients in this case series presented with a severe humerus fracture or a complication thereof which was not amenable to convention therapy. an external fixator was the only viable option for management. all patients between the ages of 18 and 75 years were eligible for inclusion. all patients were treated by the method of circular external fixator application to the humerus, using the taylor spatial frame (tsf) (smith & nephew, memphis, tn). some cases required the removal of metal prior to fixator application, and intra-operative tissue samples were taken for microscopy, culture and sensitivity via the same approach used for the index procedures in the case of plate removal. no bone grafting was done for any of the fractures. suppressive antibiotics were given in all septic cases. a single stack tsf (5/8th ring proximal, and 5/8th ring distal) with six variable length struts was the standard configuration used. rings were fixed with the open side of the proximal ring facing medial and the open side of the distal ring facing dorsal to allow elbow movement (figures 2 and 3). fixation points varied according to the regional anatomy and wounds, but a minimum of two hydroxyapatite (ha)-coated half pins were inserted in the proximal segment. distal fixation consisted of two to three fixation points as a combination of fine wires and ha pins. all fixation points adhered to described safe zones.6 meticulous attention to the orthogonal mounting of the fixator as well as the correct pin insertion technique, with the avoidance of thermal necrosis by constant cooling with water while drilling, was performed as standard practice. after frame application the fracture was aligned as well possible in the coronal and sagittal planes under fluoroscopy, after which the fast-fix struts were locked. pin sites were cleaned, and gauze swabs impregnated with chlorhexidine and alcohol were applied. all patients received three doses of post-operative antibiotic prophylaxis and pin-site care was commenced on day 3 post-operatively in the ward. wound dressings were exchanged for clean ones on day 3 and radiographs were obtained to determine the quality of the reduction. patients who required adjustments were kept as inpatients until completion of the reduction. patients were taught how to perform pin-site care by trained ward staff, and materials for this (chlorhexidine and gauze swabs) were dispensed on discharge. the first follow-up appointment was booked at the outpatient department no later than two weeks from the surgery date. figure 1. x-ray to illustrate the comminuted humerus fracture due to a gunshot wound that confirms the difficulty of conventional management figure 2. intra-operative photograph taken after circular external fixator application, demonstrating full extension without tethering of soft tissues figure 3. intra-operative photograph of the same patient as in figures 1 and 2, illustrating correct frame positioning and full flexion possible page 37pretorius hs et al. sa orthop j 2019;18(4) radiological assessment standard radiographs consisted of two orthogonal views, namely antero-posterior and lateral views, at each follow-up consultation. additional radiographs were performed in select cases where residual deformity required further corrections. these consisted of radiographs centred on the specified reference ring. prior to removal of the fixator, the radiographs were scrutinised to assess union. in two cases the plain films were ambiguous in demonstrating union, and computerised tomography (ct) scans were performed in order to assess union. two weeks following frame removal, all patients were followed up at the clinic where radiographs would be repeated and assessed for residual deformity. functional assessment a functional assessment in the form of a disabilities of the arm, shoulder and hand (dash) score was performed on all patients as part of their first follow-up visit following frame removal. statistical analysis all data was captured from the patient medical records and entered into a microsoft excel spreadsheet. data analyses were performed with statistica 12.0 (statsoft inc. tulsa, ok, usa). due to the lack of homogeneity, descriptive statistics are expressed as median and interquartile ranges. due to the descriptive nature of this case series, no inferential statistical analyses could be performed. table i: summary of characteristics of each patient in the series patient fracture mechanism of injury* previous implants specific treatment aetiology 1 open mva nail implant removed and fracture not opened or biopsy done septic non-union 2 open mva none trauma 3 open assault nail implant removed and fracture not opened or biopsy done atrophic non-union 4 closed foosh none atrophic non-union 5 closed foosh nail implant removed and fracture not opened or biopsy done septic non-union 6 open gsw none trauma 7 open gsw none trauma 8 open gsw none trauma 9 open mva nail implant removed and fracture not opened or biopsy done septic non-union 10 closed mva plate implant removed and fracture opened and biopsy done atrophic non-union 11 open mva nail implant removed and fracture not opened or biopsy done septic non-union 12 open foosh plate implant removed and fracture opened and biopsy done atrophic non-union  *mva: motor vehicle accident; gsw: gunshot wound; foosh: fallen on outstretched hand foosh: 2 assault: 2 gunshot wounds: 3 motor vehicle accidents: 5 figure 4. an overview of the mechanism of injury which caused the complex humerus fracture table ii: summary of injury characteristics, previous treatments and aetiology of each patient in the series patient fracture mechanism of injury* previous implants aetiology 1 open mva nail septic non-union 2 open mva none trauma 3 open assault nail atrophic non-union 4 closed foosh none atrophic non-union 5 closed foosh nail septic non-union 6 open gsw none trauma 7 open gsw none trauma 8 open gsw none trauma 9 open mva nail septic non-union 10 closed mva plate atrophic non-union 11 open mva nail septic non-union 12 open foosh plate atrophic non-union  *mva: motor vehicle accident; gsw: gunshot wound; foosh: fallen on outstretched hand page 38 pretorius hs et al. sa orthop j 2019;18(4) results the final cohort consisted of 12 patients with a median age of 53 years (interquartile range or iqr: 44–59). all the patients were right-hand dominant, and eight of the 12 had sustained a rightsided humerus fracture while the remaining four had a left-sided humerus fracture (table i). the mechanism of injuries for the patient varied from mvas and gunshot wounds to mechanical falls and assaults (figure 4). nine fractures were open injuries while the remaining three were closed (table ii). seven of the 12 (58%) cases had previously been treated with internal fixation; of these, five patients had intramedullary nails while the remaining two had plates and screws. a total of four acute fractures and eight non-unions were treated in this series. union was achieved in ten out of the 12 cases (83.3%). union was achieved without bone graft or any other interventions at the fracture site except implant removal where indicated, and only in the plate cases were the fractures opened. the median time in external fixation was 196 days (iqr: 112–228). the overall limb length showed a maximum shortening of 4 mm (iqr: 1–3) in the operated humerus and a mean varus angulation of 3° (iqr: 2–9). the bone contact and alignment were achieved intra-operatively with the frame (figure 5). two cases failed to unite (figures 6 and 7). in both of these cases the patients requested frame removal prior to completion of treatment. against recommendations, the frames were removed. custom-made thermoplastic splints were provided for these patients and chronic suppressive antibiotic therapy was prescribed for the one case that had chronic osteomyelitis. both cases had been referred to internal medicine to assist with the optimisation of the comorbidities at the outset of treatment, and appropriate medical therapies were instituted. in retrospect, both these cases probably represent failure on our part in terms of patient selection with regard to their comorbidities (table iii). the median dash scores at the first follow-up visit following fixator removal, was 70 (iqr: 41–76). according to the dash score work module, seven of the 12 patients were employed prior to circular fixator treatment, three worked as manual labourers, while the remaining four performed sedentary work not requiring physical tasks. three of these seven patients (42.8%) returned to sedentary work within six weeks from the date of fixator application. of the remaining four patients, a further two returned to work within three months. one patient changed occupation at the completion of treatment as he lost his job due to prolonged absence. one patient was unable to return to work in his former capacity. figure 5. the x-ray on the left shows previous instrumentation in-situ, with evidence of sepsis and peri-implant osteolysis, in keeping with a diagnosis of septic non-union. the nail was removed and the fracture was not opened. the x-ray on the right of the same patient after circular external fixator had been removed, showing union figure 6. the x-ray on the left shows the frame collapse and failure due to loose pins. the x-ray on the right of the same patient shortly after frame removal, with u-slab applied. note the erosive bone loss at each of the fixation points. figure 7. x-rays show the stabilised fracture in a reasonable position in a frame and severe bone destruction and fracture non-union after frame removal. note the complete loss of the distal fragment. table iii. summary of patient characteristics that may have contributed to a poor outcome in failed cases age (years) site previous implants aetiology risk factors duration in frame (days) outcome 58 right humerus none atrophic non-union smoking, etoh, rheumatoid arthritis, diabetes 200 non-union 50 left humerus none septic non-union (trauma) smoking, hiv+ve (cd4 <350) 184 non-union + chronic osteomyelitis page 39pretorius hs et al. sa orthop j 2019;18(4) regarding the sports/performing arts module of the dash score, there were four sportsmen among this group. three had returned to their respective sporting activities and one had given up all sporting activities at the completion of treatment. the most common complication that was encountered in this series was pin-site infection. fixation points were noted to be infected in 33% at some time during the treatment period (a total 20 out of 59 fixation points used). the majority of these complications (16 out of 20, 80%) were encountered at the proximal pins while only four out of 20 (20%) of the distal fixation points became infected. in a single case, a septic proximal pin site was identified and treated at the first follow-up visit following frame application, but among the rest of the group there were no reports of pin-site problems in the first two months. pin-site infections were graded using the checketts and otterburn classification,7 and found to be grade 2 or less in all but one case. this isolated case proved to be a significant challenge in management due to ongoing chronic osteomyelitis, and eventually resulted in a failure to unite. local sepsis control was not successful in this case despite removal of the offending pin. all other episodes of pin-site infection were managed successfully with a short course of oral antibiotics where indicated, local pin-site care and patient education. discussion the aim of this study was to present our experience with the treatment of complex high energy humerus fractures and their associated complications, managed with hexapod circular external fixation. although this treatment modality is very seldom needed for humerus fractures, a small subgroup of injuries remains difficult to treat by conventional means. in our case series a union rate of 83.3% was achieved. this is similar to the expected outcome of the gold standard in treating humeral non-unions, namely autogenous iliac crest bone grafting and plating,4,8 without the need to expose the fracture/non-union site as in the study by tomic et al.4 sadiq, in 2002, reported a 91% union rate of aseptic non-unions with compression plating and bone grafts, which is comparable to union results.8 the union rate of 83.3% achieved in this series supports the findings of mcfayden et al. who successfully treated two humeral non-unions with tsfs.9 the aim of the treatment in the septic cases was to provide stability for the fracture: nails were removed without opening the fracture; and in the cases with a plate, the plate was removed and a biopsy done. the other aspect of this type of limb reconstruction is the length of the limb after the treatment has been completed. in our series we did not find it necessary to actively shorten the humerus in any of these cases, which results in a more favourable residual deformity. the use of internal fixation for the treatment of septic non-unions has not been reported in recent literature. several articles report external fixation as the preferred method of fixation with or without debridement and secondary bone grafting for aseptic non-unions. this is an obvious advantage which would favour the use of the circular external fixator over internal fixation in the presence of sepsis.5,10-13 the complications encountered in this study offered some key learning points. the pin-site infection rate in this study was 33%, which is significantly higher than the 17.9% incidence of pin-site sepsis found by ferreira et al. in their study involving tibias,12 but also lower than the 41.6% pin-site sepsis rate quoted by al-sayyad in his study of tsfs of the upper limb in a paediatric population.13 the majority (80%) of the problematic pin sites were related to the proximal pins, presumably as they traverse a thicker soft-tissue envelope than the distal pins. in our series, all patients were righthand dominant, and right-sided humerus fractures were twice as common as on the left, which meant that 66% of these patients had to perform pin-site hygiene with their non-dominant hand. for these reasons, we would recommend teaching a family member to assist the patient with pin-site care as this may lower infection rates and possibly the need for premature removal of pins. the case series comprised an inhomogeneous group of patients which makes the results difficult to interpret. the sample size of 12 cases would appear to fall short when compared to studies of a similar nature conducted on tibias;14 however, it must be remembered that the underlying event rate of complex humeral fractures and non-unions is significantly lower than for the same pathology seen in tibias.14 witness to this fact is the sum total of 12 cases collected in a time span of six years. when compared to studies involving circular external fixators of the upper limbs, however, this study is the largest of its kind according to our knowledge. the functional assessment of these cases is based on the dash score. however, we interpret these scores with caution as they were recorded at the first follow-up appointment following frame removal. unfortunately, no follow-up dash scores were available for comparison, and even though they are likely to show improvement over time, this is recognised as a limitation of this study. conclusions in conclusion, this study suggests that complex humerus fractures that are not amenable to conventional fixation methods such as intramedullary nails and plates, as well as those cases that have failed to unite using these methods, can successfully achieve union when treated with a hexapod circular external fixator. an overall success rate of 83% was found, without the need for bone grafting or the excision of any bone that would lead to significant shortening. all the treatment failures occurred in non-union cases. despite a limited functional capacity of the affected limb, the majority of patients were able to return to their previous level of function regarding work and even sporting activities. this treatment modality can, however, have a long duration, and is not without complications. ethics statement the author/s declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study ethical approval was obtained from the following ethical review board: stellenbosch university health research ethics committee, s15/09/208). declarations the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions hsp (primary surgeon, contributed to the original study concept, primary author) and nf (contributed to the final manuscript) are orthopaedic surgeons with extensive clinical expertise in using taylor spatial frames. rpl (contributed to the original study concept, data collection and analysis, contributed to the final manuscript) is an expert in the field of conducting orthopaedic research. ks (contributed to data collection analysis and managed the database, collation and contributed to the final manuscript) was a registrar at the time of the study. orcid hs pretorius http://orcid.org/0000-0002-7419-0885 n ferreira http://orcid.org/0000-0002-0567-3373 rp lamberts http://orcid.org/0000-0003-1112-2604 http://orcid.org/0000-0002-7419-0885 http://orcid.org/0000-0002-0567-3373 http://orcid.org/0000-0003-1112-2604 page 40 pretorius hs et al. sa orthop j 2019;18(4) references 1. keller a. the management of gunshot fractures of the humerus. injury,1995;26(2):93-96. 2. hsu tl, chiu fy, chen cm, chen th. treatment of non-union of humeral shaft fracture with dynamic compression plate and cancellous bone graft. j chin med assoc. 2005;68:73-76. 3. march jl, mahoney d, steinbronn d. external fixation of open humerus fractures. iowa orthop j. 1999;19:35-42. 4. tomić s, bumbasirević m, lesić a, mitković m, atkinson hd. lizarov frame fixation without bone graft for atrophic humeral shaft nonunion: 28 patients with a minimum 2-year follow up. j orthop trauma, 2007;21(8):549-56. 5. ferreira n, charles l, serfontein c. two stage reconstruction of septic non-union of the humerus with the use of circular external fixation. injury, 2016;47(8):1713-18. 6. nayagam s. safe corridors in external fixation: the lower leg (tibia, fibula, hindfoot and forefoot). strategies in trauma and limb reconstruction. 2007;2(2-3):105-10. 7. checketts rg, otterburn m, maceachern ag. pin track infection: definition, incidence and prevention. int j orthop trauma. 1993;3:16-18. 8. sadiq sa. non-union of the humeral shaft treated by internal fixation. international orthopaedics, 2002;26(4):214-16. 9. mcfayden i ar. the taylor spatial frame in trauma and limb reconstruction surgery: report of 100 cases. j bone jt surg br. 2006;88:158-64. 10. mostafavi hr, tornetta p. open fractures of the humerus treated with external fixation. clin orthop rel res. 1997;337:187-97. 11. struijs pa, poolman rw, bhandari m. infected nonunion of the long bones. j orthop trauma. 2007;21(7):507-11. 12. ferreira n, marais lc. management of tibial non-unions: prospective evaluation of a comprehensive treatment algorithm. sa orthop j. 2016;1:60-66. 13. al-sayyad mj. taylor spatial frame in the treatment of upper extremity conditions. j pediatr orthop. 2012;32:169-78. 14. ferreira n, aldous c. the pathogenesis of tibial non-union. sa orthop j. 2016;15(1):51-59. _goback south african orthopaedic journal trauma and general orthopaedics doi 10.17159/2309-8309/2021/v20n4a4 de wet jj et al. sa orthop j 2021;20(4) citation: de wet jj, dey r, vrettos b, du plessis jp, anley c, rachuene pa, haworth lc, yimam hm, sivarasu s, roche sjl. do anatomical contoured plates address scapula body, neck and glenoid fractures? a multi-observer consensus study. sa orthop j 2021;20(4):213-218. http://dx.doi.org/10.17159/23098309/2021/v20n4a4 editor: dr frans birkholtz, walk-a-mile centre for advanced orthopaedics, pretoria, south africa received: september 2020 accepted: january 2021 published: november 2021 copyright: © 2021 de wet jj. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background the surgical management of scapula body, neck and glenoid fractures remains a challenge. this study focuses on templating an available anatomical pre-contoured plating system using three-dimensional (3d)-printed scapulae to assess the ability of these plates to address the aforementioned fractures and to determine consensus on classifying scapula body, neck and glenoid fractures. methods we used a cohort of 22 3d-printed scapulae prototypes and an available anatomical precontoured plating system to determine anatomical congruency and fit. nine investigators templated the scapulae using four pre-contoured plates, and the investigators classified the 22 scapulae using the ideberg and ao/ota classification systems. results eleven out of 22 fractures were found to be fixable using the plates under study. the long lateral plate addressed 83% of fractures involving the lateral border, while the glenoid plate was unable to adequately address any glenoid fractures. we observed good to excellent (p ≤ 0.001) interobserver reliability for three of the four plates. the interobserver reliability was moderate (icc = 0.74) for the ao/ota classification and good (icc = 0.88) for the ideberg classification. conclusion we believe that the anatomical pre-contoured plating system does not address all the fracture patterns encountered in clinical practice and further development in plate design is required. there is good to moderate interobserver reliability using the ideberg fracture classification for intra-articular fractures and the ao/ota classification for extra-articular fractures involving the body. level of evidence: level 3 keywords: scapula fracture, open reduction and internal fixation (orif), south africa, scapula plate analysis, 3d printing, fracture classification do anatomical contoured plates address scapula body, neck and glenoid fractures? a multi-observer consensus study japie j de wet,1 roopam dey,1,2 basil vrettos,3 jean-pierre du plessis,1,4 cameron anley,5 pududu a rachuene,6 leanne c haworth,2 habtamu m yimam,2 sudesh sivarasu,2 stephen jl roche3* 1 division of orthopaedic surgery, faculty of health sciences, university of cape town, cape town, south africa 2 division of biomedical engineering, department of human biology, faculty of health sciences, university of cape town, cape town, south africa 3 shoulder and elbow unit, groote schuur hospital, university of cape town, cape town, south africa 4 orthopaedic research unit 5 shoulder and elbow unit, tygerberg hospital, division of orthopaedics, stellenbosch university, stellenbosch, south africa 6 dr george mukhari academic hospital, sefako makgatho health sciences university, pretoria, south africa *corresponding author: stephen.roche@uct.ac.za introduction isolated scapula fractures are rare, accounting for 3–5% of upper limb fractures and 0.7% of all fractures.1-3 they commonly occur in the polytraumatised patient and are generally associated with significant trauma. low energy scapula fragility fractures sustained after falls may be found in the geriatric population.4 the scapula plays a pivotal role in maintaining the resting position of the shoulder girdle and, together with the clavicle, provides the anchor for the upper limb to the thorax.3 the rotator cuff muscles originate from the scapula and function not only as a dynamic glenohumeral stabiliser, but also in the initiation of glenohumeral motion. loss of motion at the glenohumeral joint is well tolerated through increased scapulothoracic movement, and displaced fractures may affect this movement. the aim of scapula fracture management should be to restore shoulder function by correcting alterations in anatomy that cannot be compensated for.3 non-surgical management of minimally to moderately displaced scapula body and neck fractures has rendered clinically acceptable and favourable long-term outcomes. however, the displaced https://orcid.org/0000-0001-5464-749x https://orcid.org/0000-0002-5695-2751 page 214 de wet jj et al. sa orthop j 2021;20(4) and intra-articular fractures types still pose a clinical dilemma due to a lack of comparative literature and well-defined surgical indications.2,3,5 displaced and malunited intra-articular fractures lead to glenohumeral joint incongruency and increased degeneration, resulting in early onset (accelerated) arthrosis of the glenohumeral joint.1-3,6,7 shoulder deformity with chronic pain, and stiffness, are frequently encountered in malunited scapula fractures.8,9 rotator cuff weakness and dysfunction with impingement have also been described.3,4,9 the surgical management of scapula fractures can be difficult and challenging. adequate fixation options are limited not only by the osseous anatomy and anatomical variability of the scapula, but also by zones of poor bone stock and the lack of bone thickness.1 the complexity of fracture patterns, challenging surgical approaches and implant limitations may lead to hesitancy from surgeons to perform open reduction and internal fixation (orif).1,10 limited implant options and pre-contoured plating systems have often led surgeons to use alternate fixation systems intended for other bones to fix scapular fractures.11,12 historically, several classification systems were proposed, attempting to guide the surgeon in decision-making and fracture management. the most used classification system was developed by the ota classification committee in 1996 and revised ten years later.13 to address the limitations of the existing classification systems, the ota classification committee and the ao classification advisory group (cag) collaborated to development a new validated classification system.14,15 although validated and reproducible, the ao/ota classification system does not determine surgical indications, operative approaches or implant choice.14 the primary aim of this study was to quantify anatomical congruence and fit of the only available plating system in the country and to determine its fracture fixation capability. the secondary aim of the study was to determine the interobserver reliability of scapula fracture classifications and consensus among the investigators using 3d-printed scapulae. methods recruitment and enrolment ethical approval was obtained from the host institute’s hrec (human research ethical committee). the philips electronics isite electronic radiology system database was used to search for all shoulder ct scans performed from 1 january 2016 to 31 january 2018. twenty-six patients with closed scapula body, neck and glenoid fractures were identified. the inclusion criterion was closed scapula body, neck and glenoid fractures. the exclusion criteria were any patient younger than 18 years, penetrating gunshot wounds, isolated acromion and/or coracoid fractures. twenty-two closed scapula body, neck and glenoid fractures met the inclusion criteria, while four scapula fractures were excluded as they were isolated acromion fractures. the mean age of the cohort was 46.6 years (range 26–71), with a male predominance. research procedure the digital imaging and communication in medicine (dicom) files of the 22 fractures were used to create three-dimensional (3d) models (figure 1) using materialise mimics® (leuven, belgium), and then printed using the additive manufacturing process. each fracture fragment was anatomically reduced and glued in place to maintain the reduction. the 3d models were used to template and determine the anatomical congruency of the available pre-contoured anatomical plating system. templating was performed with the only locally available plating system16 from acumed® (hillsboro, or, usa). the pre-contoured anatomical plating system has four plates designed to address the different anatomical locations of the scapula. the plate options were a long and a short medial plate for the medial scapula border, a long lateral plate and short lateral (glenoid) plate for the lateral border and the glenoid respectively. all four plates were templated on appropriate anatomical locations, determined by the fracture propagation through the scapula anatomy, to attain the best anatomical fixation (figure 2). data collection nine investigators (five surgeons and four engineers) templated four plates on 22 scapulae on two separate occasions, one month apart. a scoring system, similar to our previous study,17 was applied to this study where plates were defined in an ordinal scale of fit or no-fit depending on their ability to adhere around the fractured region (table i). templating of the plates around fracture regions was performed in a similar way to malhas et al.18 the scoring system considered three factors: 1. plate overhang: defined as plate overhang on either the medial or lateral border of the scapula, preventing the placement of a screw figure 1. 3d reconstructed scapula (figure created by the authors) figure 2. templating reconstruction plates (figure created by the authors) table i: the scoring system classification definition ordinal score fit the plate fitted around the fracture within surgical limits and there was no plate overhang observed 1 no-fit the gap between the plate and the fracture line was above acceptable surgical limits and there was plate overhang 0 page 215de wet jj et al. sa orthop j 2021;20(4) 2. plate offset: defined as the distance (in millimetres) from the inferior border of the plate from the bone 3. adequate fixation: defined as the ability of the plate to allow for placement of three screws proximal and three screws distal to the fracture line as advocated by the ao society fracture fixation guidelines19 each plate was scored and subdivided into a fit or no-fit group: 1. fit: defined as plate offset of less than 3 mm with no plate overhang and adequate fixation (six cortices) proximal and distal to the fracture line 2. no-fit: defined as plate offset of more than or equal to 3 mm with plate overhang (as defined by the aforementioned definition) and/or inadequate fixation (less than six cortices) either proximal or distal to the fracture line the surgeons (six) classified each scapula fracture pattern using the ideberg classification for the glenoid fractures and the ao/ ota classification for the body and neck fractures.20,21 five senior shoulder and elbow surgeons and one trainee registrar classified the fracture patterns of the 22 scapulae at a single sitting. data analysis to determine the dependency of plate types and their ability to fit the fracture pattern, the chi-squared test was performed. intraclass correlation coefficients (icc) were calculated (model: two-way mixed; type: absolute agreement) to measure the inter-rater variability among the nine observers performing the quantitativefit analysis of the 22 scapulae. the icc was also calculated for a fixability rating provided by the surgeons as a binary score (1: fixable; 0: not fixable). the fracture was categorised as fixable when it was rated 1 by at least 80% of the surgeons. the classifications provided by the group of surgeons were also compared using the icc and chi-squared tests. we reported the icc values according to the categories specified by koo and li.22 the cut-off for statistical significance was kept at p < 0.05. the statistical analyses were performed in ibm spss v.26 (ibm co., armonk, ny, usa). results twenty-seven per cent of fractures were found to propagate through the lateral border, scapula body and the medial border. of the fractures, 18% involved the lateral border and the scapula body. other fracture combinations can be seen in figure 3. seventy-seven per cent of the fractures involved the scapula body, 54% involved the lateral border, 45% involved the medial body, and only 36% of fractures involved the glenoid. only body only lateral body only glenoid lateral border + body glenoid + body lateral border + median border + body medial border + body medial border + glenoid glenoid + lateral border + medial border + body figure 3. fracture pattern figure 4. flexibility potential mapped according to fracture locations lateral border involved glenoid involved b od y in vo lv ed m edial border involved total fractures fixable fractures not fixable fractures figure 5. involvement of the plates in scapula fracture fixation lateral border involved glenoid involved total fractures long lateral plate glenoid plate long medial plate short medial plate m edial border involved b od y in vo lv ed page 216 de wet jj et al. sa orthop j 2021;20(4) the involvement of different anatomical regions of the scapula anatomy influenced the fixability potential of the available plates (p ≤ 0.001). good inter-rater reliability (icc = 0.844, 95% ci = 0.712–0.927; p ≤ 0.001) was found for the fixability categorisation of the fractures. overall, 11 out of the 22 fractured scapulae were found to be fixable using the pre-contoured plating system. none of the glenoid fractures were found to be fixable. potential fixation could be achieved in nine (out of 17) body fractures, ten (out of 12) fractures involving the lateral border, and nine (out of 12) fractures involving the medial border (figure 4). when a fracture was deemed fixable, a combination of a long lateral plate and at least one of the medial plates was used for six (out of 11) fractures. the rest of the fractures could be fixed using only the long lateral plate (figure 5). due to the consensus that the glenoid plate was unable to fit the fracture patterns included in this study (figure 5), we excluded the observations for the glenoid plates from the icc calculations. for the remaining plates we observed good to excellent (p ≤ 0.001) interobserver reliability (table ii). interobserver reliability was moderate (icc = 0.842; 95% ci = 0.387–0.921; p = 0.001) for the ao/ota classification (table iii) and good (icc = 0.883; 95% ci = 0.073–0.964; p ≤ 0.001) for the ideberg classification (table iv). the chi-square test suggested that the surgeon’s ability to classify scapula fractures was dependent on the fracture classification being used (p ≤ 0.001). discussion to our knowledge this is the first study done on three-dimensional (3d)-printed scapulae and scapula fracture fixation using an anatomical contoured plating system. nguyen et al. conducted a similar study but used computerised 3d reconstructions of scapulae and digital templating, using the same plating system.23 however, the authors used healthy cadaver scapulae, and the templating was done by digitally superimposing the plates onto the scapulae.23 in another study, the authors physically templated anatomical plates on healthy adult museum scapula specimens.17 despite the difference in methodologies, comparable results were table ii: the intraclass correlation coefficient (icc) and the corresponding 95% confidence interval (ci) calculated for the two observation sessions presented for each plate plates first observations second observations icc 95% ci icc 95% ci long lateral 0.894 0.813–0.949 0.916 0.852–0.960 long medial 0.742 0.545–0.876 0.818 0.678–0.913 short medial 0.821 0.685–0.914 0.839 0.697–0.917 table iii: the surgeons’ observations of the scapula with isolated body fractures classified using ao/ota classification ao/ota surgeon 1 surgeon 2 surgeon 3 surgeon 4 surgeon 5 surgeon 6 scapula 1 14b2 14b2 14b2 14b1p1 14b2 14b2 scapula 6 14b1p1 14b1p1 14b1 14bp1 14b1 14b1 scapula 7 14b2 14b2 14b1 14b1 14b1 14b1 scapula 9 14b2p1 14b2 14a3 14b2 14b2f 14b2 scapula 10 14b1 14b2 14b1 14b1 14b2f 14b2 scapula 12 14b1 14b2 14b2 14b2 14b1 14b1 scapula 13 14b2 14b2 14b1 14b1 14b2 14b2 scapula 14 14b1 14b1 14b2 14b2 14b2 14b2 scapula 16 14b1 14b1 14b1 14b1 14b1 14b1 scapula 20 14b2 14b2 14b2 14b2 14b2 14b2 scapula 22 14b1 14b1 14b1 14b1 14b1 14b1 table iv: surgeons’ classification of isolated glenoid fractures using ideberg classification system ideberg surgeon 1 surgeon 2 surgeon 3 surgeon 4 surgeon 5 surgeon 6 scapula 2 id3 id3 id3 unclassified id6 id2 scapula 3 id2 id2 id4 id2 id3 id2 scapula 4 id3 id3 id3 id3 id3 id3 scapula 5 id3 id3 id3 id3 id3 id2 scapula 8 id3 id3 id4 id3 id3 id2 scapula 11 id5a id5b id5b id5a id4 id3 scapula 15 id3 id3 id3 id3 id3 id3 scapula 17 unclassified unclassified unclassified unclassified id3 unclassified scapula 18 id5a id5a id5a id5a id4 id2 scapula 19 unclassified id3 id2 id5b id3 id2 scapula 21 id3 unclassified id3 id3 id3 id3 page 217de wet jj et al. sa orthop j 2021;20(4) obtained in our study and the previous ones. the results from the studies showed that the long lateral plate achieved a good fit along the fractures of the lateral border of the scapula. this can be attributed to the thicker geometry of the lateral border offering better screw purchase and the linear design pattern of the plate which makes it congruent to the anatomy of the region. dugarte et al. conducted a 2d versus 3d scapula fracture mapping study using computerised tomography (ct) reconstructions and found the majority of fracture lines involved the base of the spine and lateral border, just inferior to the glenoid.24 the fracture lines were least likely to involve the inferior lateral border. armitage et al. reported similar results on 2d images of scapulae.25 we found the long lateral plate successfully addressed all fractures exiting at the subglenoid, middle and distal thirds of the lateral border. the medial border of the scapula, compared to the lateral border, is much thinner and offers poor to no screw purchase.10 the short medial plate performed marginally better than the long medial plate. of all four plates, the medial plates measured the greatest plate offset and overhang. this might have been due to the angle between its superior and inferior limbs not being acute enough and causing the plate to extend off the medial border. the medial plate, as with the lateral plate, offers no variable angle screw placement option and no proximal or distal locking options for smaller diameter locking screws.26,27 the glenoid plate had the worst score for anatomical fit compared to the other three plates. it proved challenging to place the short triangular-shaped glenoid plate onto the spinoglenoid notch and posterior glenoid. the glenoid plate was not successful in addressing any glenoid fractures. these observations are in line with our previous findings.17 the ideberg type 3, 4 and 6 fractures pose the greatest challenge to the treating surgeon and in our study, as we observed that the glenoid plate offered limited screw options to adequately fix these fractures. when the fracture propagated, inferior to the spine, towards the medial border, the glenoid plate was found to be inadequate to address the fracture. when addressing intra-articular glenoid fractures and the associated glenoid rim and/or neck fractures, we prefer cannulated screws as first-line of treatment for these fractures. a variety of fixation techniques, such as cannulated screws, buttressing plates, bone grafting (coracoid/iliac crest), cerclage wiring, suture anchors or a combination of these, have been described in the literature.28,29 the fixation of scapula fractures is not limited to the anatomical pre-contoured system. the use of alternative fixation is well described in the literature with good to excellent results.11,12,30 non-anatomical plates, with or without k-wire/screw fixation and even plates designed to address a completely different fracture pattern at different anatomical sites, have been used to fix scapula fractures. utilising different fixation techniques, as outlined in the literature, corroborates our observation that the current precontoured anatomical scapula plates might not be suitable to fit around all types of scapula fractures. future developments should focus on introducing design changes to the existing designs to make them fit more fracture patterns. the secondary aim of the study was to determine consensus on two available scapula fracture classifications. we used the ao/ota and ideberg classification systems to classify the different types of fractures – scapula body and neck fractures were classified using the ao/ota classification system, and glenoid fractures were classified using the ideberg classification system. we found that the consensus remains less than perfect. the ao/ota and ideberg classification systems are well described and often referred to in the literature. although newer classification systems have been proposed, all the investigators unanimously decided on the ao/ota and ideberg classification systems. in a previous study, armitage et al. stated that many classification systems lack clinical correlation compared to actual fracture patterns.25 in another study, bartoníček et al. reported that the available classifications are purely descriptive and have neither therapeutic nor prognostic implications.21 recently, two new scapula fracture classifications systems were proposed which are yet to be adapted in our clinical facility, namely the more comprehensive ao/ota classification, and the new international classification for scapula fractures (nicsf).13,14 neuhaus et al. compared the validity of the ao/ota and the nicsf and concluded the nicsf system is validated and more reliable than the ao/ota.15 another study by harvey et al. confirmed that the inter-rater reliability increased when ct images were used in scapula fracture classifications.13 in both the classification systems, glenoid fractures were observed to have had the best agreement among the observers. in our study, using 3d-printed fractured scapula models, we observed better consensus among the surgeons when describing glenoid fractures using the ideberg classification compared to fracture classifications using the ao/ota classification system. implementing 3d prototypes in practice has its limitations. the benefit of 3d printing is not limited to templating only as 3d-printed scapula prototypes have been used as an adjunct to radiographs in detailed preoperative planning and teaching.31-33 the authors caution readers that the cost and time spent on 3d prototyping process may not be feasible in all orthopaedic institutions. with the machinery and expertise needed, institutions embarking on such research need to consider the volume of complicated fracture patterns encountered in an orthopaedic practice, in order to justify the cost-benefit. the primary limitation of this study was the small sample size of the fractured scapulae used in the study. the secondary limitation of the study was that only one anatomical plating system was used in the study as it is also the only commercially available plating system in south africa. the ability to address the fracture with non-anatomical plates has been well documented. the study did not use plate bending or other methods to improve plate shape to improve fit and fixation that would be possible in the clinical setting. for future studies, the authors would recommend that other available plating systems, including those not necessarily designed for scapula fractures, and different fracture fixation techniques, be compared on a larger sample size of fractured scapula. conclusion the long lateral plate had the best ability to fit scapula body fractures, followed by a combination of the long lateral plate and one of the medial plates, while the glenoid plate was found to be an unsatisfactory solution for addressing scapula body and glenoid fractures. further emphasis on improving the scapula plate design is recommended. classifying scapula fractures using existing scapula fracture classifications remains an underlying challenge among the shoulder surgeons in our part of the world. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, ethical approval was obtained from the following ethical review board: university of cape town hrec ref no: 311/2019. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. page 218 de wet jj et al. sa orthop j 2021;20(4) author contributions jjdw: study conceptualisation, data collection, preparation of the first draft rd: data analysis, data representation, manuscript review and re-writing bv: study conceptualisation, manuscript review and re-writing jpdp: study conceptualisation, manuscript review and re-writing ca: study conceptualisation, manuscript review and re-writing par: study conceptualisation, manuscript review and re-writing lch: data collection hmy: data collection ss: study conceptualisation, manuscript review and re-writing sjlr: study conceptualisation, manuscript review and re-writing orcid de wet jj https://orcid.org/0000-0001-5464-749x dey r https://orcid.org/0000-0002-3616-1995 du plessis jp https://orcid.org/0000-0001-6469-7765 anley c https://orcid.org/0000-0002-5983-3520 yimam hm https://orcid.org/0000-0002-7929-2231 sivarasu s https://orcid.org/0000-0002-0812-568x roche sjl https://orcid.org/0000-0002-5695-2751 references 1. cole pa, gauger em, schroder lk. management of scapular fractures. j am acad orthop surg. 2012;20:130-41. 2. bi as, kane lt, butler ba, et al. outcomes following extra-articular fractures of the scapula: a systematic review. injury. 2020;51:602-10. 3. aldridge s, gray m. fractures of the scapula. orthop trauma. 2019;33:308-14. 4. schroder lk, gauger em, gilbertson ja, et al. functional outcomes after operative management of extra-articular glenoid neck and scapular body fractures. j bone jt surg . 2016;98:1623-30. 5. tatro jm, schroder lk, molitor ba, et al. injury mechanism, epidemiology, and hospital trends of scapula fractures: a 10-year retrospective study of the national trauma data bank. injury. 2019;50:376-81. 6. zlowodzki m, bhandari m, zelle ba, kregor pj, cole pa. treatment of scapula fractures: systematic review of 520 fractures in 22 case series. j orthop trauma. 2006;20:230-33. 7. chadwick ekj, van noort a, van der helm fct. biomechanical analysis of scapular neck malunion a simulation study. clin biomech. 2004;19:906-12. 8. hobbs h, garrett b, sanchez p, et al. open reduction and internal fixation of scapula fractures. sa orthop j. 2008;7:8-13. 9. noguchi t, mautner jf, duncan sfm. dorsal plate fixation of scapular fracture. j hand surg am. 2017;42:843.e1-843.e5. 10. burke cs, roberts cs, nyland ja, et al. scapular thickness-implications for fracture fixation. j shoulder elb surg. 2006;15:645-48. 11. panigrahi r, madharia d, das ds, et al. outcome analysis of intra-articular scapula fracture fixation with distal radius plate: a multicenter prospective study. arch trauma res. 2016;5:36406. 12. hu y, shi h, wang f, et al. functional outcomes of extra-articular scapula fracture fixation with distal humeral y-type locking plate: a retrospective study. j orthop surg res. 2019;14:176. https://doi.org/10.1186/s13018-019-1205-y. 13. harvey e, audigé l, herscovici d, et al. development and validation of the new international classification for scapula fractures. j orthop trauma. 2012;26:364-69. 14. audigé l, kellam jf, lambert s, et al. the ao foundation and orthopaedic trauma association (ao/ota) scapula fracture classification system: focus on body involvement. j shoulder elb surg. 2014;23:189-96. 15. neuhaus v, bot agj, guitton tg, et al. scapula fractures: interobserver reliability of classification and treatment. j orthop trauma. 2014;28:124-29. 16. acumed llc. scapula plating system brochure. hillsboro. available from: https://www. acumed.net/wp-content/uploads/2017/12/scapula-plating-system-brochure.pdf. accessed 14 august 2020. 17. dey r, sivarasu s, charilaou j, et al. evaluating the fit of current anatomical scapula reconstruction plates: a study using fifty scapulae. in: proceedings of the 2020 design of medical devices conference. 2020 design of medical devices conference. minneapolis, minnesota, usa. april 6–9, 2020. v001t03a007. asme. minneapolis, minnesota, usa: american society of mechanical engineers digital collection. epub ahead of print 27 july 2020. https://doi.org/10.3109/17453679508995571. 18. malhas am, skarparis yg, sripada s, et al. how well do contoured superior midshaft clavicle plates fit the clavicle? a cadaveric study. j shoulder elb surg. 2016;25:954-59. 19. andermahr j, mckee m, nam d. orif plate fixation for glenoid fossa, extraarticular, simple. available from: https://surgeryreference.aofoundation.org/orthopedic-trauma/ adult-trauma/scapula/glenoid-fossa-extraarticular-simple/orif-plate-fixation. accessed 20 august 2020. 20. ideberg r, grevsten s, larsson s. epidemiology of scapular fractures incidence and classification of 338 fractures. acta orthop scand. 1995;66:395-97. 21. bartoníček j, tuček m, klika d, et al. pathoanatomy and computed tomography classification of glenoid fossa fractures based on ninety patients. int orthop. 2016;40:2383-92. 22. koo tk, li my. a guideline of selecting and reporting intraclass correlation coefficients for reliability research. j chiropr med. 2016;15:155-63. 23. nguyen tqd, park ay, distefano jg, et al. congruency of scapula locking plates: implications for implant design. asme 2010 summer bioeng conf sbc 2010. 2010;501-502. 24. dugarte aj, tkany l, schroder lk, et al. comparison of 2 versus 3 dimensional fracture mapping strategies for 3 dimensional computerized tomography reconstructions of scapula neck and body fractures. j orthop res. 2017;36:265-71. 25. armitage bm, wijdicks ca, tarkin is, et al. mapping of scapular fractures with three-dimensional computed tomography. j bone jt surg ser a. 2009;91:2222-28. 26. acumed llc. surgical technique locking clavicle plating system. hillsboro. available from: https://www.acumed.net/wp-content/uploads/2018/03/acumed-surgical-technique-enlocking-clavicle-plating-shd10-05-b.pdf. accessed 16 july 2019. 27. acumed llc. acu-loc® 2 wrist plating system product overview. hillsboro. available from: https://www.acumed.net/wp-content/uploads/2016/01/acumed-brochure-en-acu-loc-2hnw40-09-c.pdf. accessed 14 august 2020. 28. van oostveen dph, temmerman opp, burger bj, et al. glenoid fractures: a review of pathology, classification, treatment and results. acta orthop belg. 2014;80:88-98. 29. theivendran k, mcbryde cw, massoud sn. scapula fractures: a review. trauma. 2008;10:25-33. 30. cole pa, gauger em, herrera da, et al. radiographic follow-up of 84 operatively treated scapula neck and body fractures. injury. 2012;43:327-33. 31. rengier f, mehndiratta a, von tengg-kobligk h, et al. 3d printing based on imaging data: review of medical applications. int j comput assist radiol surg. 2010;5:335-41. 32. martelli n, serrano c, van den brink h, et al. advantages and disadvantages of 3-dimensional printing in surgery: a systematic review. surg. 2016;159:1485-500. 33. bizzotto n, sandri a, regis d, et al. three-dimensional printing of bone fractures: a new tangible realistic way for preoperative planning and education. surg innov. 2015;22:548-51. https://orcid.org/0000-0001-5464-749x https://orcid.org/0000-0002-3616-1995 https://orcid.org/0000-0001-6469-7765 https://orcid.org/0000-0002-5983-3520 https://orcid.org/0000-0002-7929-2231 https://orcid.org/0000-0002-0812-568x https://orcid.org/0000-0002-5695-2751 https://doi.org/10.1186/s13018-019-1205-y https://www.acumed.net/wp-content/uploads/2017/12/scapula-plating-system-brochure.pdf https://www.acumed.net/wp-content/uploads/2017/12/scapula-plating-system-brochure.pdf https://doi.org/10.3109/17453679508995571 https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/scapula/glenoid-fossa-extraarticular-simple/orif-plate-fixation https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/scapula/glenoid-fossa-extraarticular-simple/orif-plate-fixation https://www.acumed.net/wp-content/uploads/2018/03/acumed-surgical-technique-en-locking-clavicle-plating-shd10-05-b.pdf https://www.acumed.net/wp-content/uploads/2018/03/acumed-surgical-technique-en-locking-clavicle-plating-shd10-05-b.pdf https://www.acumed.net/wp-content/uploads/2016/01/acumed-brochure-en-acu-loc-2-hnw40-09-c.pdf https://www.acumed.net/wp-content/uploads/2016/01/acumed-brochure-en-acu-loc-2-hnw40-09-c.pdf _hlk82007189 page 72 south african orthopaedic journal http://journal.saoa.org.za saoj south african orthopaedic journal. cpd questionnaire. august 2019 vol 18 no 3 complications following acute severe haematogenous osteomyelitis of the long bones in children (horn a, wever s, hoffman eb) 1. in a recent study on osteoarticular infections in children, which causative organism was associated with co-infection with hiv? a. pseudomonas aeruginosa a b. klebsiella pneumonia b c. streptococcus pneumonia c d. staphylococcus epidermidis d e. staphylococcus aureus e 2. which of the following factors are commonly associated with the development of complications following acute haematogenous osteomyelitis? a. raised esr at presentation a b. male sex b c. history of trauma c d. raised crp at presentation d e. raised temperature at presentation e 3. in this study, there was an association between: a. delay in presentation and the development of complications a b. the development of complications and a prolonged hospital stay b c. the need for repeat surgery during the index admission and duration of antibiotic treatment c d. raised crp at presentation and the development of a pathological fracture d e. infection with mrsa and the development of complications e 4. the main radiological finding in this study was that: a. bony changes in more than 45% of the diaphysis on x-rays taken at 6 weeks were significantly associated with the development of complications a b. bony changes in more than 66.1% of the diaphysis on x-rays taken at 6 weeks were significantly associated with the development of complications b c. x-rays taken at presentation are usually normal c d. mri should be performed in all cases of suspected osteomyelitis d e. x-rays taken at presentation usually show early periosteal reaction which is associated with the development of complications e profile of patients with blount’s disease at an academic hospital (mehtar m, ramguthy y, firth gb) 5. the deformities of blount’s disease develop secondary to relative inhibition of the: a. posterolateral aspect of the proximal tibial growth plate a b. anteromedial aspect of the proximal tibial growth plate b c. posterior aspect of the proximal tibial growth plate c d. posteromedial aspect of the proximal tibial growth plate d e. anterolateral aspect of the proximal tibial growth plate e 6. regarding the classification of blount’s disease as described by thompson and carter, which statement is correct? a. juvenile blount’s onset is after the age of 10 years a b. adolescent blount’s onset is after the age of 15 years b c. juvenile blount’s onset is at age 4 to 10 years c d. infantile blount’s occurs under the age of 5 years d e. infantile blount’s occurs under the age of 3 years e 7. in our study, the percentage of patients with blount’s disease classified as obese was: a. highest in the infantile group a b. highest in the adolescent group b c. highest in the juvenile group c d. equal in all the groups d e. lowest in the juvenile group e 8. according to the series of blount’s patients at chris hani baragwanath academic hospital: a. unilateral involvement occurred more frequently compared to bilateral disease a b. there is an increased occurrence of obesity in female children with blount’s b c. the majority of patients in the adolescent group were female c d. blount’s disease is associated with an early walking age d e. blount’s disease is not associated with an early walking age e cross-screw technique for the modified lapidus procedure using headless compression screws (mayet z, ferrao pnf, saragas np) 9. choose the incorrect statement regarding the modified lapidus procedure: a. the lapidus procedure is used to treat hallux valgus a b. it is a powerful procedure b c. correction is possible in two planes c d. correction is possible in three planes d e. it has a long lever arm for correction e page 74 south african orthopaedic journal http://journal.saoa.org.za subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm.co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online • once you have completed the answers, go back to the top of the page next to the registration option. there is another icon “find my cpd certificate”. (you will have to answer the two questions regarding your internship and last cpd audit once you have completed a questionnaire and want to retrieve your certificate). • if you click on that icon it will open your certificate which you can print or save on your system. • please call mpc helpdesk if you have any questions: 0861 111 335. 10. in the preparation of the joint for the modified lapidus fusion: a. the plantar side of the joint should be neglected a b. joint surfaces are never fenestrated b c. the intercuneiform joint should always be included c d. the medial cuneiform articular surface is resected perpendicular to the long axis of the second metatarsal d e. all of the above e 11. fixation options for the modified lapidus procedure does not include: a. solid 3.5 mm ao screws a b. chromic sutures b c. cannulated screws c d. a lag screw with a plate d e. headless compression screws e 12. regarding complications of the lapidus procedure, select the correct answer: a. attention to detail and meticulous surgical technique minimises complications a b. non-union is a minor complication b c. transfer metatarsalgia is not a concern c d. the distal metatarsal articular angle is not affected d e. none of the above e unrepaired rotator cuff tears following acromioplasty (chivers d, lambrechts a, vrettos b, dachs r, roche s) 13. melis et al.’s research into the progression of fatty infiltration and atrophy in tears of supraspinatus stated that: a. traumatic tears do not progress to fatty atrophy and infiltration a b. traumatic tears progress faster than atraumatic tears b c. muscle atrophy was present in all tear types at 6 years c d. tears progressed to stage 2 fatty infiltration at 6 years d e. traumatic tears can heal without intervention e 14. the aetiology of atraumatic rotator cuff tears: a. is only due to intrinsic causes a b. is mainly due to genetic influence b c. is attributed to genetic, intrinsic and extrinsic causes c d. is such that acromial morphology does not play a role d e. is such that acromial morphology is the only extrinsic cause e 15. evidence to support intrinsic theories for rotator cuff tears include: a. bursal-sided tears are more common than articular-sided tears a b. cuff tears and acromial degeneration both progress with age b c. open acromioplasty prevents cuff tear progression c d. there is a zone of hypovascularity and hypoxia which results in cuff degeneration d e. acromial morphology is directly related to cuff tear progression e 16. in the rotator cable theory as described by burkhart: a. three distinct areas with different load characteristics are described a b. the rotator cable is relatively thicker and supports more load b c. there is progressive thickening of the crescent area with age c d. kim et al. have not been able to support burkhart’s theory d e. degenerative tears occur in a more anterior position e anthropometric differences in the tibial tuberosity to trochlear groove measurement in an african population (rankin m, mohideen mah) 17. the tibial tuberosity trochlear groove (tttg) measurement is clinically relevant for which diagnosis? a. osteoarthritis a b. anterior cruciate ligament laxity b c. patella instability c d. medial co-lateral laxity d e. blount’s disease e 18. the tttg measurement predominantly utilised with which imaging modality? a. ultrasonography a b. x-ray b c. ct scan c d. mri d e. radionuclide scan e 19. regarding the tttg measurement: a. tttg measurement decreases at terminal extension due to the ‘screw-home’ mechanism a b. tttg measurement increases at terminal extension due to the ‘femoral roll-back’ mechanism b c. tttg measurement decreases at terminal extension due to the ‘femoral roll-back’ mechanism c d. tttg measurement increases at terminal extension due to the ‘screw-home’ mechanism d e. tttg measurement is unaffected by range of motion of the knee e 20. according to current literature, a medialising osteotomy of the tibial tuberosity should be considered when the tttg is: a. >20 mm a b. >15 mm b c. >12 mm c d. <20 mm d e. not a consideration e medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 south african orthopaedic journal current concepts review doi 10.17159/2309-8309/2021/v20n2a7mayet z et al. sa orthop j 2021;20(2) citation: mayet z, ferrao pnf, saragas np, paterson r, magobotha skm, alexander a, eshragi h, ittehadi h, khademi ma, mehtar m, tladi mj, strydom a, workman m. chronic lateral ankle instability: a current concepts review. sa orthop j 2021;20(2):106-113. http://dx.doi. org/10.17159/2309-8309/2021/ v20n2a7 editor: prof. leonard c marais received: august 2020 accepted: january 2021 published: may 2021 copyright: © 2021 mayet z. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest to declare that are directly or indirectly related to the research. abstract injuries to the lateral ankle ligaments are quite common, with a reported incidence of up to 22% of all sports injuries, and 85% of all ankle sprains. most of these are effectively managed using nonoperative measures in the acute setting. approximately 20% of patients will, however, develop chronic lateral ankle instability (clai). although the anatomy and biomechanics are well documented, more recently, the concepts of the lateral talofibular calcaneal ligament (ltfcl) and microinstability have been described. for those who develop clai, a full assessment is mandatory to not only search for correctable risk factors (malalignment), but also to differentiate between functional and mechanical instability. associated injuries need to be excluded, such as osteochondral lesions of the talus. rotational ankle instability is a new concept that needs to be considered. patients who present with clai are initially managed conservatively in the form of functional rehabilitation. this management is especially effective in patients with functional instability. surgery is generally indicated after failed conservative management in patients with objective mechanical instability. the elite athlete is a relative indication to performing surgery early. the choice of surgical procedure is made on an individualised basis, although open anatomical procedures remain the gold standard. non-anatomical procedures are no longer recommended. newer minimally invasive and endoscopic techniques show promise in experienced hands but there is only limited evidence to support its use at present. the use of a suture tape as an augment is reserved for specific indications and should not be used routinely. level of evidence: level 5 keywords: chronic lateral ankle instability, atfl, cfl, functional rehabilitation, broström, surgical procedures for lateral ankle ligaments chronic lateral ankle instability: a current concepts review ziyaad mayet,¹* paulo nf ferrao,¹ nikiforos p saragas,¹ richard paterson,¹ sebastian km magobotha,² alwich alexander,¹ hooman eshragi,¹ hossein ittehadi,¹ mohammed a khademi,¹ mohammed mehtar,¹ makgabo j tladi,¹ andrew strydom,¹ matthew workman¹ ¹ linksfield foot and ankle fellowship programme; division of orthopaedics, university of the witwatersrand, johannesburg, south africa ² division of orthopaedics, university of the witwatersrand, johannesburg, south africa *corresponding author: bonedoc.zm@gmail.com introduction ligamentous injuries of the ankle, commonly called ankle sprains, are very common. there is a reported incidence of up to 22% of all sports injuries. an injury of the lateral ligamentous complex from an inversion sprain accounts for 85% of ankle sprains. this injury occurs when the foot is forced into inversion while the ankle is plantarflexed. most of these injuries will present to casualty or primary healthcare settings for evaluation.1-3 most acute injuries, if treated appropriately with conservative management, will recover.4 there are, however, those that do go on to have chronic problems. residual pain and instability are the most common complaints as confirmed in a cohort of athletes by yeung et al.5 the incidence was 30.2% and 20.4% respectively. the authors also reported that as the number of recurrent sprains increased, so did the frequency of residual symptoms.1,5 approximately 20% of patients can proceed to develop chronic instability. recommended management for chronic lateral ankle instability (clai) is conservative, with operative treatment being indicated for failed conservative management. recent literature reported poor response to conservative management in patients with mechanical instability, unlike functional instability.5-9 there is much renewed interest in the surgical management of clai. this is partly due to the recent advances in minimally invasive and arthroscopic surgery. this was described as ‘a big wave is coming’ by authors of a recent editorial.10 anatomy the ankle joint is stabilised by a combination of the bony mortice and the supporting soft tissue. this creates a hinge-like joint with the talus gliding in the mortise where the wedge shape of the trochlea https://orcid.org/0000-0002-7340-3148 page 107mayet z et al. sa orthop j 2021;20(2) of the talus allows the talus to internally rotate and supinate as the ankle plantar flexes. this sets up a complex mechanical interaction between bones, ligaments and tendons.7,11 soft tissue stability is also provided by three ligamentous complexes: the deltoid, the syndesmosis and the lateral collateral ligament complex. the lateral complex is made up of three ligaments: the anterior talofibular ligament (atfl), calcaneofibular ligament (cfl) and posterior talofibular ligament (ptfl) (figure 1). the atfl is the weakest of the three with a tensile strength of about 140 n. it lies almost horizontal, with the ankle in a neutral position, as it runs from the anterior part of the lateral malleolus to the talar neck. as the ankle moves into plantarflexion the atfl tightens and comes to lie almost vertical. in this position it is vulnerable to injury under excessive internal rotation stress or inversion and is the first of the ligaments injured in a sprain. the cfl runs from the tip of the lateral malleolus to the calcaneus in a slightly posterior oblique direction forming an angle of approximately 105° to the atfl.12 progression of the injury leads to cfl injury in about 20% of cases. injury to the cfl has also been implicated in subtalar instability.13 the atfl is intracapsular while the cfl is extracapsular. the ptfl is injured in less than 10% of cases.11 besides these static structures, the tendons around the ankle also aid in the stability of the ankle and are the focus in conservative management.7 with the advent of minimally invasive surgery, there has been a renewed interest in the anatomy of the ligamentous complex by various authors. matsui et al., in a meta-analysis of cadaver studies, looked at anatomical features for the development of endoscopic and minimally invasive reconstructions. the atfl was found to have one bundle in 61.6% of specimens, two bundles in 35.7% and three bundles in 2.7%. the fibular origin was on the inferior part of the anterior border of the fibula, approximately 50% between the anterior tubercle and inferior tip. the obscure tubercle, or anteroinferior tubercle of the fibula, may be used as a landmark for this point. the talar insertion is anterior to the lateral articular surface. the fibular origin of the cfl is just distal to that of the atfl, with both ligaments sharing a single confluent footprint on the anterior border of the fibula. the cfl runs from the tip of the fibula, under the peroneal tendons, and attaches to the lateral surface of the calcaneus.13 vega et al. described the anatomy of the atfl and cfl in 32 cadaveric specimens. all specimens showed the atfl to have two fascicles, superior and inferior. the superior fascicle was shown to be a distinct anatomical structure that tightened in plantarflexion. the inferior fascicle was shown to be isometric with the cfl and did not change in length with plantarflexion. furthermore, the inferior fascicle is joined to the cfl by arciform fibres. the authors stated that this was one structure and called it the lateral talofibular calcaneal ligament (ltfcl). the superior fascicle was found to be intracapsular and therefore thought to have poor healing potential after a rupture. the inferior fascicle and cfl are extracapsular. the authors hypothesised that a tear of the ltfcl causes classic instability while an isolated tear of the superior fascicle results in microinstability. this theory is based on the supposition that the superior fascicle, being intra-articular, will probably not heal. the authors also suggested that the lftcl complex explains why an isolated atfl repair gives good results despite there being involvement of both atfl and cfl.14 pathomechanics sprains of the lateral ligaments have varying degrees of injury. acutely this is graded as stretching, partial tear or complete tear of the ligament.2 acute sprains do not only cause injury to the ligaments, but also disrupt normal neural processes. this is caused by disruption of capsular mechanoreceptors that can lead to the loss of afferent nerve function and ankle motor coordination. these disrupted neural processes can result in functional clai.15,16 clai can result from functional or mechanical causes. functional instability is present in patients complaining of the ankle giving way but have no clinical and radiographic evidence of instability. these patients therefore have a perceived sense of instability with no anatomical deficit. factors leading to this may include impaired proprioception, diminished neuromuscular control, compromised strength, decreased postural control, tight achilles tendon and weak peroneal muscles. in contrast, with mechanical instability there is clinical evidence of instability which is due to the lateral ligaments being incompetent or stretched out. these patients will have positive stress tests on clinical examination and obvious instability on radiography due to the incompetent anatomical structures. surgical management is not indicated for isolated functional instability, and this is treated with nonoperative measures, including proprioceptive rehabilitation.4 however, in reality, clai tends to be due to a combination of both mechanical and functional instability.4,7 this supports the concept of initial conservative management and surgery being reserved for failed conservative management.17 the concept of rotational ankle instability (rai) has been described by buchhorn et al. and vega et al. as a combination of lesions in the medial (anterior deltoid ligament) and lateral ligament complex. the condition is defined as an abnormal increase of talar rotation within the tibiofibular mortise due to an injury in the most anterior component of the deltoid ligament secondary to a chronic deficiency of the lateral collateral ligaments. this is observed during arthroscopy as a deltoid ‘open book’ tear of the most anterior component of the deltoid ligament as it separates from the medial malleolus while proximal attachments remain intact, when applying passive internal rotation of the tibio-talar joint.18,19 a limited number of patients with clai may have a partial deltoid injury; the authors highlight the high index of suspicion in recognising this injury. it is often difficult to assess clinically especially in the absence of medial symptoms, only to become apparent once isolated repair of the lateral ligament is performed. there is no specific clinical test to diagnose rai. an mri is imperative when rai is suspected in patients with clai and arthroscopic evaluation of the deltoid ligament is advisable prior to treating the torn lateral ligament. the benefit of repairing both ligaments is emphasised in studies by buchhorn et al. and vega et al.18,19 ankle sprains may be associated with several other pathologies. there is an overall incidence of 93% of associated injuries.4 digiovanni et al., in a retrospective review of 61 patients with clai, found that no patient had isolated ligament injuries. peroneal tendon and retinacular pathologies, and anterolateral impingement figure 1. lateral collateral ligament complex (artwork courtesy of prof. np saragas) page 108 mayet z et al. sa orthop j 2021;20(2) occurred most often. their findings are summarised in table i. of note is a 23% incidence of osteochondral lesions of the talus (olt).20 the incidence of olt has been reported as high as 98%.21 table i: associated injuries20 injury incidence peroneal tenosynovitis 77% attenuated peroneal retinaculum 54% peroneus brevis tear 25% anterolateral impingement lesion 67% ankle synovitis 49% intra-articular loose body 26% talar osteochondral lesions 23% medial ankle tendon tenosynovitis 5% clinical evaluation history patients usually present with a history of giving way or rolling of the ankle. there is often a preceding history of trauma. important questions in the history that need to be asked are related to the chronology of the sprains and the frequency of recurrent sprains, as well as inciting events like sport or uneven surfaces. associated symptoms may include swelling, pain and sometimes locking of the ankle especially if there is an associated osteochondral lesion. a past medical history and family history of neuromuscular and ligamentous problems is important. footwear and orthotics should not be forgotten. lastly, a history of previous treatment modalities or interventions should be asked about, as well as any problems with the opposite ankle. an occupational and sporting history is mandatory.6 examination gait is usually normal but may be antalgic if a recent sprain has occurred. in this case there will be associated swelling around the lateral malleolus but may extend along the joint line of the ankle. assess for hindfoot varus malalignment. this deformity may be subtle, and the presence of a ‘peek-a-boo’ sign (figure 2) and lateral foot callosities should be checked for. the coleman block test is important to assess for the forefoot-driven cavovarus foot. it is very important that a varus malalignment is adequately corrected when associated with clai.22 tenderness is usually present around the anatomical areas of the ligaments but should also be checked for along the ankle joint line, medial malleolus, syndesmosis and base of fifth metatarsal. range of motion, assessing for any tendinopathy, strength in the muscle groups around the foot and ankle and, most importantly, a neurovascular assessment needs to be performed. the lateral ligaments are tested for stability using the anterior drawer and varus stress tests (figure 3). the anterior drawer test (assess atfl integrity) is performed by stabilising the tibia with one hand and holding the calcaneus with the other while pulling the foot forward. the varus stress test (assess cfl integrity) is performed by inverting the talus relative to the tibia while maintaining the ankle in neutral. the degree of movement and the quality of the endpoint should be assessed and compared to the opposite side. these tests are thought to be reasonably accurate for diagnosing ligament injury. the sensitivity of the anterior drawer test is reported at 58% to 84% and specificity at 96% to 100%. sensitivity of the varus stress test is 50% and specificity 88%.23,24 they are, however, unable to objectively quantify the severity of the instability.6 investigations x-rays in the acute sprain, ankle views should be used to exclude fractures according to the ottawa rules. for clai, stress radiography is figure 2. the ‘peek-a-boo’ sign for hindfoot varus figure 3. clinical stress tests. a – anterior drawer test; b – varus stress test page 109mayet z et al. sa orthop j 2021;20(2) done which includes anterior talar displacement (drawer) view and varus talar tilt view (figure 4). stress may be applied manually or with stress devices like the telos se 2000® (telos gmbh, marburg, germany). some authors have questioned the usefulness of the stress x-rays stating that there is not much more that can be gained from them as compared to clinical assessment.6,7 despite this, stress radiography is the ‘gold standard’ for diagnosing mechanical instability. karlsson et al. have been quoted as defining an anterior translation of 10 mm or a talar tilt of 9° as diagnostic.7 furthermore, a draw of 3 mm or a tilt of 3° greater than the opposite side is significant.7 other authors have defined instability as 2 mm translation on the anterior drawer view, and 10° degrees of tilting or 5° greater than the opposite side on the varus tilt view.25 malliaropoulos et al. also added stress radiography to their staging to cater for an unstable injury.2 instability on the talar tilt test has been shown to correlate with changes on the mri. this suggested that the talar tilt test is a useful screening tool for the status of the ligament and the decision of a reconstruction versus a repair.26 the authors recommend stress radiography as a diagnostic tool. however, it needs to be done correctly, and preferably by the attending orthopaedic surgeon. ultrasound ultrasound is a cheap, effective way to assess tears as well as the quality of the ligaments, with the benefit of being a dynamic assessment. ultrasound is operator-dependent and a musculoskeletal-trained ultrasonographer is preferred. in experienced hands, accuracy ranges between 85 and 95%.6 the quality of ligaments can be assessed to help decide between performing a reconstruction or repair.27 mri mri can be used to assess for ruptures and quality of the ligaments. morphology of the lateral ligaments has been described in various papers as absent, thin, hypertrophied or thickened, and wavy or irregular. ligaments can also be assessed for continuity by the presence of an intraligamentous signal.26,28 normal thickness is defined between 1 and 3.2 mm. this can assist in preoperative decision-making as to whether ligaments are reparable or if a reconstruction is required. reconstruction would be needed if ligaments are thin (<1 mm thickness) or absent. the intraobserver reliability is around 80% (77.3–81.8) and interobserver reliability is between 68.2% and 90.9%.6,26,28 the decision-making based on mri findings, however, is not well set out or validated yet, and the final decision is dictated by the surgeon’s experience and findings at the time of surgery. besides assessment of the ligaments, associated pathologies like olts and anterolateral impingement can also be identified. a drawback of mri is that it gives a static assessment of the quality of the ligaments with no direct assessment of its mechanical properties.6,26,28 management nonoperative management nonoperative management is the mainstay for management of lai in the acute setting.29-31 broström stated that primary surgical repair should not be the routine in acute injuries.29 surgical repair has only been recommended in patients undergoing surgery for an associated injury or fracture, in the acute setting. surgery may also be considered in elite athletes but this is controversial.30,31 therefore, acute lateral ligament injuries should be managed conservatively. management and rehabilitation protocols follow a stepwise regimen that follows the phases of ligament healing. initially, management of the inflammation is focused on reduction of swelling and pain. most will tend to follow the rice protocol. this involves rest, ice, compression and elevation. protection and immobilisation in the form of a cast or moonboot may be used for a short period, noting that prolonged immobilisation is not recommended. immobilisation is known to cause loss of ligament strength and muscle mass and should not be continued beyond two weeks. braces, strapping and orthotics have also been used. inflammation commonly lasts about ten days.7,30 the next phase of healing is proliferation. rehabilitation generally focuses on motion, strengthening, coordination and proprioception. this can last up to eight weeks. this usually involves the use of eversion strengthening and inclines. the evertors have been shown to be an excellent dynamic splint to inversion.7,30 lastly, during remodelling, the emphasis turns to endurance and balance. this can be achieved with trampolines, balance boards and wobble boards. aerobic fitness is maintained with crosstraining.7,17,30 activity-specific exercises with progression from low level to full activity specific exercises are started from week 10.29 in the chronic setting, the emphasis has been on initial nonoperative management, with most studies stating that patients receive full conservative management before surgery is considered. this is especially important for cases of functional clai. karlsson et al. have been quoted as reporting improvement in 50% of patients with clai using a structured rehabilitation programme, with the emphasis on functional rehabilitation.7 peroneal reaction times were found to be longer in patients with clai and needed to be addressed, as were proprioception and coordination. patients with functional instability benefit more than those with mechanical instability from nonoperative treatment. a delay in surgery for clai has not been shown to adversely affect outcomes.7,17,31 operative management operative management of clai is indicated for obvious mechanical instability and failed conservative management4 (figure 5). the patient must have both symptoms and objective findings of figure 4. radiological stress views comparing both ankles. a – anterior talar displacement (drawer) view; b – varus talar tilt view page 110 mayet z et al. sa orthop j 2021;20(2) instability. many procedures have been described. the procedures can be divided up into anatomical and non-anatomical, depending on whether they restore or replicate normal anatomy or not. further subdivisions can be made regarding repair versus reconstructions, and recently, open versus percutaneous or arthroscopic procedures.4,12,32 management of clai is incomplete without addressing varus malalignment of the tibia or hindfoot. failure to address this will lead to excessive stress on the repair and will lead to failure. associated pathologies need to be treated at the same time. it is imperative that these problems are addressed for a successful outcome.33 contraindications to clai surgery include neuroarthropathy, spasticity, peripheral vascular disease and a noncompliant patient. open techniques anatomical this group of procedures either repair the native atfl and cfl or use a tendon graft reconstruction to restore the normal anatomical configuration of the ligaments. by restoring the normal anatomy, it allows for normal ankle and subtalar joint kinematics to be maintained. the broström procedure, which was described in 1966, is arguably the most reported procedure for the management of clai and has been the basis of many of the procedures used today. it is a suture repair of primarily the atfl but can include the cfl if it is also involved (figure 6). broström himself reported good results with the procedure. many, however, felt the need to augment the repair and protect it. this resulted in what is today the gold standard in surgical repair of clai, known as the broström–gould procedure. the broström repair is augmented with the inferior extensor retinaculum which is pulled up over the repair in a pantsover-vest fashion; this is known as the gould modification. the gould modification has been shown to increase the biomechanical strength of the repair by 60% and more closely restore ankle joint contact pressures. since the inferior retinaculum attaches to the calcaneus distally, by advancing it onto the fibula, the subtalar joint is also stabilised.17,33,34 over the years, many modifications have been made to the broström technique and many different augments have also been used. one of the more recently described is the internal brace® (arthrex, naples, fl). the internal brace® is a suture tape that is placed extracapsularly to protect the ligament repairs by acting as a check-rein (figure 7). biomechanical studies have shown increased ultimate load to failure as compared to isolated repairs. cho et al. have reported improved isokinetic peroneal strength clai functional instability/ microinstability functional rehabilitation 3–6 months failed conservative management open anatomical repair broström–gould augmentation elite athlete high bmi ligamentous laxity arthroscopic anatomical repair experienced arthroscopist attenuated/stretched ligament deficient/absent ligament allograft/autograft anatomical reconstruction percutaneousopen ankle arthroscopy if intra-articular pathology or rai suspected symptomatic mechanical instability figure 5. management algorithm for clai figure 6. broström procedure figure 7. internal brace® page 111mayet z et al. sa orthop j 2021;20(2) and postural control when a suturetape is added to the repair. these augments have resulted in significant improvements in outcome scores as well as decreased talar tilt and anterior translation.35,36 these studies were not comparative studies. these results have to be tempered against the potential for surgical complications and long-term effects of this foreign body. appropriate indications for using the internal brace® include hyperlaxity and revision cases.4,30 the internal brace® must be used judiciously and not as a matter of routine. there must be decent quality ligament available for repair as these artificial augments are not a replacement for absent soft tissue. in certain cases, repair of the ligaments is just not possible. the quality of the tissue may be too poor for an adequate repair, or the ligaments may be completely absent. this is likely to be the case in patients with long-standing instability with many recurrent sprains, or those with failed previous surgery. in these cases, a reconstruction is needed. this can be achieved with a tendon autograft or allograft, (figure 8) placed anatomically at the footprints, to replicate the normal anatomy of the native ligaments.12,30 as a group, anatomical repairs and reconstructions have shown high satisfaction and function rates by li et al. in a 5–10 year follow-up study.37 in a systematic review, brambilla et al. have shown no evidence of superiority of either autograft and allograft, but noted a lack of good quality studies.38 non-anatomical non-anatomical procedures do not re-create the normal anatomy of the ligaments. most procedures use the peroneus brevis as a transfer. it is interesting to note that these procedures pre-date the broström procedure and were the first procedures described for clai. the most reported on non-anatomical procedures include the watson–jones and chrisman–snook. they were thought to be more useful in patients with hyperlaxity or obesity and revision cases.12,31 as a group they alter kinematics in the ankle and subtalar joints and have shown to produce stiffness resulting in unsatisfactory long-term results.36 as a result, these procedures have fallen out of favour in preference to anatomical procedures.39 minimally invasive minimally invasive surgery (mis) has become the latest buzz word in foot and ankle surgery. with regard to clai, this is no different. this phenomenon has been described as a new wave in the treatment of clai10 and part of the natural progression in surgical management of clai. arthroscopic techniques have the advantage of dealing with other associated pathologies like olts through the same approach.40 there is a lot of hype around these techniques currently, with many articles being published regarding mis for clai. potential advantages are shorter rehabilitation times and smaller incisions. development of these techniques has rejuvenated the interest in basic anatomy and biomechanics to help refine and develop these techniques.13,14,41-43 minimally invasive procedures can be separated into arthroscopic and percutaneous. the arthroscopic procedures include repairs and reconstructions, while the percutaneous group includes only reconstructions. the repairs are essentially arthroscopic modifications of the broström. one of the techniques even bears the name arthroscopic broström.44 the procedures can be divided into three categories, namely, arthroscopically assisted, allinside and inside-out techniques. reconstructions can be done arthroscopically or percutaneously, using either allografts or autografts. the percutaneous techniques are thought to be easier than their arthroscopic counterparts, with the disadvantage of not being able to manage associated intra-articular pathologies without the addition of an arthroscopy prior to doing the reconstruction. arthroscopy or fluoroscopy is used to find the relevant footprints for graft placement in these minimally invasive techniques. these techniques show a lot of promise.38,45-47 most papers, however, are low level studies, or papers written by the developers of these techniques. we found no level 1 studies to promote these techniques over open procedures.16,22,33,39,40,43,48-52 a systematic review has also borne this out and concluded that there was no clinical evidence to support the advantages of arthroscopic techniques. added to this, a higher complication rate was reported as compared to open broström–gould procedures (11.5% compared to 5.4%). the most commonly reported complication was superficial peroneal nerve injury (4%), which included neuritis, damage and numbness.53 evidence supporting the use of arthroscopic procedures is limited at present.36 matsui et al. also concluded that there is limited and poorquality evidence which is insufficient to allow a high grade of recommendation to support the use of mis in treating clai. of 33 studies which met their inclusion criteria, most of them were level 4 and 5 evidence, with only two being level 3.54 arthroscopy is advisable prior to the ligament repair. it must definitely be considered in patients complaining of a dull deep ankle pain, the mri reporting intra-articular pathology and to assess for rai if suspected. a note of caution when considering a scope followed by an open procedure; the extravasation of fluid may waterlog the tissue and distort the anatomy. the elite athlete up to 40% of all athletics-related injuries involve the lateral ankle ligaments and are commonly seen in sports such as football, basketball, running and dance activities.21,52,55 as with most sports injuries, most studies regarding ankle ligament injuries are reported on the athletic population resulting in most of the advances in management. the demanding nature of professional sport, the fact that the athletes are extremely motivated and have access to excellent rehabilitation teams, results in the boundaries being pushed and necessitating more innovative strategies and research. unfortunately, this puts immense pressure on the treating physician. the need to return to play as figure 8. allograft reconstruction page 112 mayet z et al. sa orthop j 2021;20(2) soon as possible is enormous and the danger of ending a career is always present. controversies centre around management of acute sprains, particularly grade iii injuries. indications for surgery in this group include the ability to deal with associated injuries and shortened time for return to play. there is controversy around timing of surgery and the extent to which nonoperative management should be pursued prior to doing surgery.21,56,57 in the elite athlete the mainstay of treatment, as in the general population, is functional treatment/exercise training with additional mechanical bracing. up to 30% of patients sustaining a grade iii injury to the lateral collateral ligament complex can experience ongoing symptoms namely, pain, swelling and instability. in attempting to avoid these complications, early surgical treatment of these high-grade injuries is considered in the athlete.21,58 this, however, needs to be balanced against the potential risks of surgery.58,59 most treating physicians agree that in grade i and ii injuries in the elite athlete, a trial of nonoperative treatment should be initiated due to ease of implementation, lower cost, and avoidance of surgical complications. in the elite athlete with a grade iii injury, early surgery to allow faster return to play can be considered on a case-by-case basis.56,58 identifying which athletes will do better with acute surgical intervention as opposed to a trial of nonoperative management is difficult. the decision eventually boils down to imaging results, the athlete’s symptoms and the clinician’s experience that the healing response would be inadequate for that athlete.55,56,58 lateral ankle ligament repair has been reported to be safe and effective for grade iii injuries in the elite athlete.31,58,60 it provides a stable ankle, with level 3 studies showing a return to sport at approximately three months. where surgery gave longer return times than functional rehabilitation in the past, they are now comparable. these studies are, however, done in high-volume centres with experienced surgeons, highly motivated patients, and accelerated rehabilitation protocols. it should also be kept in mind that even though it is attractive to surgically address acute injuries in the elite athlete, there is no medical urgency as the results of delayed repair or reconstruction are comparable and satisfactory.31,58,60 conclusion injuries to the lateral ankle ligaments are common. most of these are effectively treated by nonoperative measures in the acute setting. the few that do develop clai should first undergo a full assessment to differentiate between functional and mechanical instability. patients with functional instability are best managed with functional rehabilitation. patients with objective mechanical instability are managed surgically. the exact procedure should be decided on an individualised basis. an anatomical repair such as the broström–gould is still the gold standard; however, newer minimally invasive techniques show promise in surgeons experienced with arthroscopic techniques. if poor or inadequate tissue is available to repair, an anatomical reconstruction using a tendon graft is advised. the elite athlete may benefit from early surgical intervention for acute grade iii injuries. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethical approval was not obtained (review article). declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions zm was the main author responsible for drafting of the article, and was assisted by pnff, nps and rp. zm, nps and pnff were responsible for article design. pnff and nps were responsible for editing, critical review, and final approval of the published version. all authors contributed to conception and literature review on the topic. these include zm, pnff, nps, rp, skmm, aa, he, he, mak, mm, mjt, as and mw. orcid mayet z https://orcid.org/0000-0002-7340-3148 ferrao pnf https://orcid.org/0000-0003-4639-0326 saragas np https://orcid.org/0000-0002-5566-7588 paterson r https://orcid.org/0000-0002-2956-4374 magobotha skm https://orcid.org/0000-0003-4774-0420 alexander a https://orcid.org/0000-0002-4023-7550 eshragi h https://orcid.org/0000-0002-6714-6691 ittehadi h https://orcid.org/0000-0002-0556-3553 khademi ma https://orcid.org/0000-0003-3167-7797 mehtar m https://orcid.org/0000-0002-8372-0446 tladi mj https://orcid.org/0000-0003-4997-3009 strydom a https://orcid.org/0000-0002-4915-8816 workman m https://orcid.org/0000-0002-7999-9069 references 1. ferran na, maffulli n. epidemiology of sprains of the lateral ankle ligament complex. foot ankle clin. 2006;11(3):659-62. https://doi.org/10.1016/j. fcl.2006.07.002. 2. malliaropoulos n, papacostas e, papalada a, maffulli n. acute lateral ankle sprains in track and field athletes: an expanded classification. foot ankle clin. 2006;11(3):497-507. https://doi.org/10.1016/j.fcl.2006.05.004. 3. ajis a, younger ase, maffulli n. anatomic repair for chronic lateral ankle instability. foot ankle clin. 2006;11(3):539-45. https://doi.org/10.1016/j. 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https://doi.org/10.1177/1071100718820341. 34. zeng g, hu x, liu w, et al. open broström-gould repair vs arthroscopic anatomical repair of the anterior talofibular ligament for chronic lateral ankle instability. foot ankle int. 2020;41(1):44-49. https://doi. org/10.1177/1071100719875964. 35. cho bk, hong sh, jeon jh. effect of lateral ligament augmentation using suture-tape on functional ankle instability. foot ankle int. 2019;40(4):447456. https://doi.org/10.1177/1071100718818554. 36. yasui y, shimozono y, kennedy jg. surgical procedures for chronic lateral ankle instability. j am acad orthop surg. 2018;26(7):223-30. https://doi. org/10.5435/jaaos-d-16-00623. 37. li h, hua y, li h, chen s. anatomical reconstruction produced similarly favorable outcomes as repair procedures for the treatment of chronic lateral ankle instability at long-term follow-up. knee surgery, sport traumatol arthrosc. 2020:28:3324-29. https://doi.org/10.1007/s00167-018-5176-z. 38. brambilla l, bianchi a, malerba f, loppini m, martinelli n. lateral ankle ligament anatomic reconstruction for chronic ankle instability: allograft or autograft? a systematic review. foot ankle surg. 2020;26(1):85-93. https://doi. org/10.1016/j.fas.2018.11.014. 39. cordier g, ovigue j, dalmau-pastor m, michels f. endoscopic anatomic ligament reconstruction is a reliable option to treat chronic lateral ankle instability. knee surgery, sport traumatol arthrosc. 2020;28(1):86-92. https:// doi.org/10.1007/s00167-019-05793-9. 40. teixeira j, guillo s. arthroscopic treatment of ankle instability allograft/ autograft reconstruction. foot ankle clin. 2018;23(4):571-79. https://doi. org/10.1016/j.fcl.2018.07.004. 41. acevedo ji, ortiz c, golano p, nery c. arthrobroström lateral ankle stabilization technique. am j sports med. 2015;43(10):2564-71. https://doi. org/10.1177/0363546515597464. 42. crombé a, borghol s, guillo s, pesquer l, dallaudiere b. arthroscopic reconstruction of the lateral ankle ligaments: radiological evaluation and short-term clinical outcome. diagn interv imaging. 2019;100(2):117-25. https:// doi.org/10.1016/j.diii.2018.09.002. 43. cordier g, lebecque j, vega j, dalmau-pastor m. arthroscopic ankle lateral ligament repair with biological augmentation gives excellent results in case of chronic ankle instability. knee surgery, sport traumatol arthrosc. 2020;28(1):108-15. https://doi.org/10.1007/s00167-019-05650-9. 44. acevedo ji, mangone p. arthroscopic brostrom technique. foot ankle int. 201536(4):465-73. https://doi.org/10.1177/1071100715576107 45. glazebrook m, stone j, matsui k, et al. percutaneous ankle reconstruction of lateral ligaments (perc-anti roll). foot ankle int. 2016;37(6):659-64. https:// doi.org/10.1177/1071100716633648. 46. takao m, matsui k, stone jw, et al. arthroscopic anterior talofibular ligament repair for lateral instability of the ankle. knee surgery, sport traumatol arthrosc. 2016;24(4):1003-1006. https://doi.org/10.1007/s00167-015-3638-0 47. glazebrook m, eid m, alhadhoud m, et al. percutaneous ankle reconstruction of lateral ligaments. foot ankle clin. 2018;23(4):581-92. https://doi. org/10.1016/j.fcl.2018.07.013. 48. vega j, guelfi m, malagelada f, peña f, dalmau-pastor m. arthroscopic all-inside anterior talofibular ligament repair through a three-portal and no-ankle-distraction technique. jbjs essent surg tech. 2018;8(3):e25. 49. vega j, malagelada f, dalmau m. arthroscopic all‑inside atfl and cfl repair is feasible and provides excellent results in patients with chronic ankle instability. knee surgery, sport traumatol arthrosc. 2020;28(1):116-23. https:// doi.org/10.1007/s00167-019-05676-z. 50. takao m, glazebrook m, stone j, et al. ankle arthroscopic reconstruction of lateral ligaments (ankle anti-roll). arthrosc tech. 2015;4(5):e595-e600. https://doi.org/10.1016/j.eats.2015.06.008. 51. glazebrook m, eid m, alhadhoud m, et al. percutaneous ankle reconstruction of lateral ligaments. foot ankle clin. 2018;23(4):581-92. https://doi. org/10.1016/j.fcl.2018.07.013. 52. batista jp, javier del vecchio j, patthauer l, ocampo m. arthroscopic lateral ligament repair through two portals in chronic ankle instability. open orthop j. 2017;11(1):617-32. https://doi.org/10.2174/1874325001711010617. 53. brown aj, shimozono y, hurley et, kennedy jg. arthroscopic repair of lateral ankle ligament for chronic lateral ankle instability: a systematic review. arthrosc j arthrosc relat surg. 2018;34(8):2497-503. https://doi.org/10.1016/j. arthro.2018.02.034. 54. matsui k, burgesson b, takao m, et al. minimally invasive surgical treatment for chronic ankle instability: a systematic review. knee surgery, sport traumatol arthrosc. 2016;24(4):1040-48. https://doi.org/10.1007/ s00167-016-4041-1. 55. thompson jy, byrne c, williams ma, et al. prognostic factors for recovery following acute lateral ankle ligament sprain: a systematic review. bmc musculoskelet disord. 2017;18(1):1-14. https://doi.org/10.1186/ s12891-017-1777-9. 56. slater k. acute lateral ankle instability. foot ankle clin. 2018;23(4):523-37. https://doi.org/10.1016/j.fcl.2018.07.001. 57. wei s, liu s, han f, xu f, cai x. clinical outcomes of a modified all-inside arthroscopic repair of anterior talofibular ligament for chronic ankle instability: a preliminary report. med (united states). 2019;98(36):1-7. https://doi. org/10.1097/md.0000000000016734. 58. kerkhoffs gmmj, van dijk cn. acute lateral ankle ligament ruptures in the athlete: the role of surgery. foot ankle clin. 2013;18(2):215-18. https://doi. org/10.1016/j.fcl.2013.02.003. 59. hunt kj, mangone p, cooper mt, brigido sa. update on lateral ankle instability. foot ankle spec. 2018;11(1):67-71. https://doi. org/10.1177/1938640017753170. 60. white wj, mccollum ga, calder jdf. return to sport following acute lateral ligament repair of the ankle in professional athletes. knee surgery, sport traumatol arthrosc. 2016;24(4):1124-29. https://doi.org/10.1007/ s00167-015-3815-1. _hlk49462556 _hlk49238793 _hlk56933800 _hlk56933841 _hlk49646077 _hlk49646146 _hlk67859138 _hlk67605004 _hlk49260440 _hlk49354764 _hlk49647245 _hlk56935286 _hlk49459552 _hlk49710292 _hlk68845080 _hlk68848714 layout 1 solomons m and isaacs s. saoj 2017;16(3) south african orthopaedic journal doi 10.17159/2309-8309/2017/v16n3a10 http://journal.saoa.org.za upper limb intraosseous suture technique with k-wire stabilisation for fixation of mallet fracture with dipj volar subluxation m solomons,2 s isaacs2 1 mbchb(uct) fcs (ortho), professor, consultant and head of unit, martin singer hand surgery unit, department of orthopaedic surgery, groote schuur hospital, cape town 2 mbchb(uct), specialty registrar: dept. of plastic and reconstructive surgery, west wing, john radcliffe hospital, oxford university hospitals nhs foundation trust, headley way, headington, oxford corresponding author: prof michael solomons, consultant and head of unit, martin singer hand surgery unit, department of orthopaedic surgery, groote schuur hospital, observatory, cape town 8000, email: docsol@absamail.co.za abstract background: mallet fracture with distal interphalangeal joint (dipj) subluxation remains a challenging problem, with numerous techniques proposed for repair of this fracture. methods: the authors present a modified approach to mallet fractures with volar subluxed dipj by k-wire fixation and intraosseus suture of the avulsed extensor tendon. results: the described technique resulted in successful clinical management of 12 patients with isolated mallet fractures with volar subluxation with 1/12 patients having a complication of stable non-union. conclusions: the intraosseous suture technique with k-wire stabilisation offers a simple and reproducible technique of fracture reduction and stabilisation of volar subluxed dipj mallet fractures. key words: mallet fractures, dipj volar subluxation, surgical technique, mallet injury, k-wire stabilisation citation: solomons m, isaacs s. intra-osseous suture technique with k-wire stabilisation for fixation of mallet fracture with dipj volar subluxation. saoj 2017;16(3):70-73. doi 10.17159/2309-8309/2017/v16n3a10 editor: prof anton schepers, university of the witwatersrand received: august 2016 accepted: december 2016 published: august 2017 copyright: © 2017 solomons m, isaacs s. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: the authors have no sources of funding to declare. conflict of interest: the authors have no conflicts of interest to declare. introduction the size of the fracture fragment, the percentage of joint surface involvement and the association with joint subluxation have all been offered as indications for operative intervention in mallet finger fracture.1-6 there still remains no clear consensus regarding the indications for operative intervention in the literature. once a decision to intervene surgically has been made, the surgeon is confronted with a litany of options.4,6-18 the commonly utilised surgical technique of extension blocking wire only serves to reduce the displaced fractures but struggles to contain the volar subluxation of the distal phalanx.1,19-21 furthermore, as these wires are passed percutaneously into the distal interphalangeal joint (dipj), the risk of intra-articular sepsis is not inconsequential. some surgeons prefer passing a small screw into the fragment but this carries the serious potential risk of splitting an already small bone fragment and substantially increasing the complexity of the surgery.22 saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:02 pm page 70 solomons m and isaacs s. saoj 2017;16(3) page 71 below, we present a modified approach which resulted in successful clinical management of isolated mallet fractures with volar subluxation in a series of patients. indications/contraindications all patients presenting to our hand unit with a mallet fracture associated with volar subluxation were included in the study. we enrolled 12 patients with mallet finger injuries over an 18-month period. the average age of the patients was 29.2 years with an age range of 15 to 56 years. the average interval from injury to surgery was 26 days with a range of 5 to 49 days. ethics committee approval for this retrospective study was obtained. informed consent was obtained from all patients and clinical notes and radiological material were reviewed. post-operative assessment included measurement of fixed flexion deformity, extensor lag and end range flexion. surgical technique the surgical procedure is performed either under general anaesthetic or regional anaesthetic (biers block). the patient lies supine with the arm placed outstretched on a hand operating table. a bloodless field is created with the use of a tourniquet. a dorsal y-shaped (mercedes benz) incision is utilised (figure 1). full thickness skin flaps are elevated with careful protection of the germinal matrix. at this stage, care needs to be taken to elevate the fracture from distal to proximal. clearly, it would be a gross surgical error to attempt to create a dissection plane between the fracture and the extensor tendon. the fracture is carefully elevated from the fracture bed and reflected proximally. the dipj, including the fractured terminal phalanx, can be seen in a volar subluxed position. careful curettage of the fracture bed should remove most of the haematoma and/or early soft callus. usually the terminal phalanx can be reduced from the volar subluxed position but in the case of a substantial delay, it might be necessary to perform a limited release of the collateral ligaments. at this stage, the very small fragment is stabilised in an adsons forceps. a 23-gauge needle is then chosen as a drilling device. the hub needs to be removed and the needle placed into a wire driver. two holes are drilled parallel starting from the raw fracture surface and exiting on the dorsal base at the insertion of the extensor tendon (figure 2). subsequently, two 23-gauge needles are inserted from dorsal to volar through the small fragment. they are passed through until the tips of the bevel are visible in the fracture site. it is important now to reduce the dislocation and to reduce the fracture as well as possible. using a finger drilling technique on the 23-gauge needles, holes are drilled through the volar component of the terminal phalanx. this ensures that the sequential holes in the two separate fragments are continuous. if this were not the case, displacement is likely to occur as the suture is tightened. once the starter holes are made in the fracture bed of the terminal phalanx, then the fracture fragment can be removed and the rest of the procedure performed by passing needles freehand through the terminal phalanx using the starter holes as a positioning guide. the two needles are passed through the volar cortex and delivered into a second separate longitudinal volar incision at the base of the terminal pulp. it is important to get the dissection all the way down to the flexor insertion at the level of the periosteum. it is mandatory that no soft tissue gets trapped by the suture material (figure 3). a prolene suture is pretensioned and the needle is removed. the two ends are passed through the bevels of the 23-gauge needles to exit dorsally through the fracture site. the needles are removed and the two ends are pulled so that the sutures lie snug against the volar periosteum, with no evidence of any soft tissue impingement and most importantly no neurovascular compromise (figure 4). figure 1. dorsal y-shaped (mercedes benz) incision. figure 2. two holes are drilled parallel starting from the raw fracture surface and exiting on the dorsal base at the insertion of the extensor tendon. figure 3. the two needles are passed through the volar cortex and delivered into a second separate longitudinal volar incision at the base of the terminal pulp. it is important to get the dissection all the way down to the flexor insertion at the level of the periosteum. it is mandatory that no soft tissue gets trapped by the suture material. saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:02 pm page 71 page 72 solomons m and isaacs s. saoj 2017;16(3) the next stage involves reducing the joint and passing a k-wire in a pro-grade and then retrograde direction. it is desirable to try and pass the k-wire through the intact volar cartilage. failing this, one runs the risk of blocking the reduction of the fracture due to the k-wire transgressing the fracture site. if this is not possible then it is necessary to pass the k-wire through the fracture site and withdraw it so that there is no k-wire evident when the fracture is reduced (figure 5). on reducing the fracture, one can then pass the k-wire carefully across the dipj in a retrograde manner. our choice is for a .035 k-wire (mm). using two separate needles through the dorsal fracture figure 4. using two separate needles through the dorsal fracture fragment, the same two ends of the prolene are now passed from volar to dorsal through the fracture fragment. figure 5. k-wire through the fracture site. figure 6. an image intensifier is used to confirm perfect reduction. figure 7. once the reduction is confirmed the k-wire is driven across the fragment and the suture is carefully tied. figure 8. an illustration of the final result. saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:02 pm page 72 solomons m and isaacs s. saoj 2017;16(3) page 73 fragment, the same two ends of the prolene are now passed from volar to dorsal through the fracture fragment (figure 4). it is now time to reduce the fracture. the fracture is reduced and held. an image intensifier is used to confirm perfect reduction (figure 6). once the reduction is confirmed the k-wire is driven across the fragment and the suture is carefully tied (figure 7).the final result of this is illustrated in figure 8. haemostasis is achieved and the wound is closed with interrupted 5-0 nylon. due to the fact that there is a k-wire across the joint, no external splint is necessary. a bulky dressing is applied, with removal of sutures at ten days. the wire is normally kept in position for a minimum of four weeks and then the patient is carefully mobilised with a removable thermoplastic splint. active motion only is allowed for the first two weeks, with gentle passive motion starting at six weeks. results all patients were reviewed at three months post-surgery by the senior author. nine of the operated patients had crawford classification graded as excellent. two patients were classified as good and one (20-degree extension lag) patient as fair. eleven out of the 12 patients all had complete bone union. there was one incident of non-union of the fracture site. this patient had a fair result. she did not want further surgery and the non-union remained stable. there were no incidents of fracture fragmentation. with regard to soft tissue complications there were no sutures or wound dehisced. there was one superficial wound infection of the operated digit, which was managed conservatively with systemic antibiotics and this resolved clinically. there were no nail abnormalities or injuries. there were two patients who accidentally caught the wires on stationary objects and they were pulled out but with no instability of the joint. there were no wound breakdowns and no swan-neck deformities. there were no dorsal bumps. discussion lange and engber, in 1983, alerted the literature to the concept of the hyperextension mallet.1 it is the senior author’s opinion that most mallet fractures that result in volar subluxation are the consequence of the hyperextension mallet. this was not specifically looked at in the study. the indication for surgery in mallet fractures aside, the management can be extremely frustrating. most surgeons would agree that trying to insert any form of hardware is frustrated by the comminution of these fragments. this substantially complicates the options available. surgeons have utilised various techniques including internal fixation,5,6,8,9,11-14,18-24 external fixation25 and various suture techniques.6,13,26 even suture anchors have been used. the technique that comes closest to ours is that is used by ulusoy et al.13 bauze and bain have also used a technique of a suture; their suture is also trans-osseous but goes around the extensor insertion to act more like a tension band concept.6 we utilise a full interosseous suture technique with the ability to get a perfect reduction and a stable fixation. the operation is simple, reliable and replicable. in our hands, this remains our technique of choice. compliance with ethics guidelines ethics committee approval for this retrospective study was obtained. informed consent was obtained from all patients and clinical notes and radiological material were reviewed. references 1. lange rh, engber wd. hyperextension mallet finger. orthopedics. 1983;6(11):1426-31. 2. wehbe ma, schneider lh. mallet fractures. j bone joint surg am. 1984;66(5):658-69. 3. schneider lh. fractures of the distal interphalangeal joint. hand clin. 1994;10(2):277-85. 4. damron ta, engber wd. surgical treatment of mallet finger fractures by tension band technique. clin orthop relat res. 1994(300):133-40. 5. darder-prats a, fernandez-garcia e, fernandez-gabarda r, dardergarcia a. treatment of mallet finger fractures by the extension-block k-wire technique. j hand surg br. 1998;23(6):802-805. 6. bauze a, bain gi. internal suture for mallet finger fracture. j hand surg br. 1999;24(6):688-92. 7. stark hh, boyes jh, wilson jn. mallet finger. j bone joint surg am. 1962;44-a:1061-68. 8. abouna jm, brown h. the treatment of mallet finger. the results in a series of 148 consecutive cases and a review of the literature. br j surg. 1968;55(9):653-67. 9. jupiter jb, sheppard je. tension wire fixation of avulsion fractures in the hand. clin orthop relat res. 1987(214):113-20. 10. badia a, riano f. a simple fixation method for unstable bony mallet finger. j hand surg am. 2004;29(6):1051-55. 11. fritz d, lutz m, arora r, gabl m, wambacher m, pechlaner s. delayed single kirschner wire compression technique for mallet fracture. j hand surg br. 2005;30(2):180-84. 12. rocchi l, genitiempo m, fanfani f. percutaneous fixation of mallet fractures by the ‘umbrella handle’ technique. j hand surg br. 2006;31(4):407-12. 13. ulusoy mg, karalezli n, kocer u, uysal a, karaaslan o, kankaya y, et al. pull-in suture technique for the treatment of mallet finger. plast reconstr surg. 2006;118(3):696-702. 14. nelis r, wouters db. is the use of biodegradable devices in the operative treatment of avulsion fractures of fingers, the so-called mallet finger advantageous? a feasibility study with meniscus arrows. open orthop j. 2008;2:151-54. 15. lee sk, kim kj, yang ds, moon kh, choy ws. modified extensionblock k-wire fixation technique for the treatment of bony mallet finger. orthopedics. 2010;33(10):728. 16. zhang x, meng h, shao x, wen s, zhu h, mi x. pull-out wire fixation for acute mallet finger fractures with k-wire stabilization of the distal interphalangeal joint. j hand surg am. 2010;35(11):1864-69. 17. miura t. extension block pinning using a small external fixator for mallet finger fractures. j hand surg am. 2013;38(12):2348-52. 18. aarts fl, derks r, wouters db. the meniscus arrow(r) as a fixation device for the treatment of mallet fractures: results of 50 cases. hand (n y). 2014;9(4):499-503. 19. mazurek mt, hofmeister ep, shin ay, bishop at. extension-block pinning for treatment of displaced mallet fractures. am j orthop (belle mead nj). 2002;31(11):652-54. 20. hofmeister ep, mazurek mt, shin ay, bishop at. extension block pinning for large mallet fractures. j hand surg am. 2003;28(3):453-59. 21. pegoli l, toh s, arai k, fukuda a, nishikawa s, vallejo ig. the ishiguro extension block technique for the treatment of mallet finger fracture: indications and clinical results. j hand surg br. 2003;28(1):15-17. 22. kronlage sc, faust d. open reduction and screw fixation of mallet fractures. j hand surg br. 2004;29(2):135-38. 23. damron ta, engber wd, lange rh, mccabe r, damron la, ulm m, et al. biomechanical analysis of mallet finger fracture fixation techniques. j hand surg am. 1993;18(4):600-607; discussion 8. 24. theivendran k, mahon a, rajaratnam v. a novel hook plate fixation technique for the treatment of mallet fractures. ann plast surg. 2007;58(1):112-15. 25. kaleli t, ozturk c, ersozlu s. external fixation for surgical treatment of a mallet finger. j hand surg br. 2003;28(3):228-30. 26. cheon sj, lim jm, cha sh. treatment of bony mallet finger using a modified pull-out wire suture technique. j hand surg eur vol. 2011;36(3):247-49. saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:02 pm page 73 page 20 south african orthopaedic journal http://journal.saoa.org.za a historic perspective having been fortunate enough to be selected as a 2019 smith & nephew travelling fellow, i decided to look into the history of this prestigious programme. the fellowship was established in 1981 after numerous discussions within the south african orthopaedic association during the late 1970s.1 the first fellow, dr daneel heyns, was selected by prof roelie grabe of pretoria. since that momentous day, a total of 92 orthopaedic consultants and registrars have completed the fellowship. the list of past travelling fellows includes four past south african orthopaedic association presidents (table i), three current heads of south african orthopaedic departments and numerous past heads of south african orthopaedic departments. despite being a costly endeavour, smith & nephew have proven their commitment to keep this illustrious fellowship running every year. in 2014, mike woods (senior director orthopaedic trauma and asd state sector, smith & nephew, africa region) reiterated their commitment through the following statement: ‘it is very satisfying to reflect on the calibre and achievements of the orthopaedic travelling fellows. smith & nephew has the privilege of facilitating training which is geared to meet skill gaps in the industry, build expertise and help healthcare professionals to use our products safely and effectively. this is about more than just financial results. it is also about our commitment to ethical and responsible behaviour in everything that we seek to deliver.’2 true to those words, smith & nephew have kept the fellowship going at a consistent pace. a tour to remember before embarking on the fellowship, i decided to speak to a few past fellows to see what lay in store for me. experiences ranged from ‘a terrifying ordeal’ to ‘an opportunity to socialise with colleagues at every academic institution in the country’. of course, the former was uttered by a colleague who went on the fellowship prior to his final fc orth(sa) exams while the latter came from a colleague who embarked on the travelling fellowship after graduating. fortunately, i fell in the same group as the latter. despite those polar opinions, one thing was certain: the true challenge of the fellowship would be to maintain my body weight after being bombarded with delicious (albeit not always healthy) meals at every stop. armed with those pearls of wisdom, my presentations, clothing for almost five weeks, and finally a copy of my department’s 2018 consolidated statistics (expecting to be quizzed on the burden of disease seen at chris hani baragwanath academic hospital, ‘bara’) i boarded the flight from johannesburg to cape town. the first stop was tygerberg hospital. i was warmly received by prof j du toit who immediately proceeded to impress me with a tour of his advanced orthopaedic training centre. true to its name, this ‘advanced centre’ consists of two separate 3d printers which the department uses to fabricate 3d models of everything from complex acetabular deficiencies to tibias with bone defects. being at the forefront of total hip arthroplasties via the direct anterior approach in the state sector, dr koos jordaan set up a cadaver workshop for me to try out this novel approach. throughout the rest of the stellenbosch leg of the trip, i attended multiple academic seminars and had the opportunity to reacquaint myself with colleagues i had previously met at congresses. many of the discussions revolved around the spectrum of cases and treatment protocols at bara hospital. upon arriving at groote schuur hospital, prof r dunn gave me an opportunity to present one of my talks: ‘hip attack: the bara perspective’. the discussion then evolved into a question-andanswer session about working at bara as well as my experience at tygerberg hospital in the days preceding. it was at this moment that i realised i was expected to carry knowledge and experiences from one institution to the next – an act most aptly described in gary nabhan’s book cross-pollinations where he says that we ‘dissolve the boundaries and blend disciplines to reveal a world rich in possibility, one where unthinkable solutions emerge’.3 i was happy to impart all i had observed at tygerberg while simultaneously taking in the common and conflicting practices at groote schuur. an objective analysis to increase the accuracy of my information-gathering, i decided to find a system to analyse the factors that result in a sustainable south african orthopaedic association the smith & nephew orthopaedic travelling fellowship: a cross-pollination of knowledge singh v mbchb(uct), fc orth(sa), mmed(orth)(wits) consultant and arthroplasty fellow, chris hani baragwanath academic hospital, soweto corresponding author: dr virsen singh, department of orthopaedic surgery, university of the witwatersrand, johannesburg; tel: +2711 717 2538; email: virsensingh@live.com table i: smith & nephew travelling fellows who went on to become president of the saoa name year travelling fellow saoa president prof m ngcelwane 1987 2010–2011 dr j de vos 1991 2013–2014 prof t le roux 1993 2011–2012 dr p makan 1994 2017–2018 page 21south african orthopaedic journal http://journal.saoa.org.za department. i came across the concept of the ‘three pillars of sustainability’ which was developed by barbier in 1987.4 since then, the model has been used by local and international institutions to guide resource allocation in order to ensure a sustainable workplace. for my purposes, i equated the pillars to the more recognisable arenas of a south african academic hospital. i used the social pillar to look at the human resource element of the departments; the environmental pillar to look at the infrastructure, and finally the economic pillar to look at the innovation and advances within the department (figure 1). using this adapted model, i decided to analyse and compare these aspects within each department along the way. with this newfound approach to the travelling fellowship, my next stop was frere hospital in east london. dr n gibson commenced my visit in true small-town style with a barefoot walk on the beach. i was informed that my tie and coat were not welcome on this leg of the tour and we proceeded to the hospital where even my smart pants were a far reach from the daily dress code. a casual discussion then ensued regarding my experiences at bara as well as my exposure to the systems in groote schuur and tygerberg. with frere hospital being vastly different from the western cape hospitals in regard to staff and infrastructure constraints, my stories of highly progressive academic units were not comforting. nonetheless, i was able to equate the worn infrastructure of frere hospital to what i experience on a daily basis in bara hospital. next on the itinerary was durban. upon presenting my boarding pass at the airport gate in east london, i quickly realised that the propeller engine plane on the runway was to be my means of travel. having never been on such a small aircraft before, images of the late hansie cronje and jfk jr flashed through my mind. a swift google search then revealed that propeller-driven planes were in fact at a higher risk of crashing than larger aircraft – a fact that failed to comfort me. having started my orthopaedic career in kwazulu-natal, fresh out of community service, i was keen to go back to see the system and my old colleagues. prof len marais (who was one of the first faces i had encountered as a junior medical officer in orthopaedics) welcomed me and allowed me an opportunity to present one of my talks. the highlight of my kzn visit was spending a day with one of the giants of orthopaedic surgery in south africa, prof s govender. i was humbled to meet a man whose work i had quoted countless times throughout my orthopaedic training (figure 2). after that short stint at the durban coast, i was bloemfontein bound. dr s matshidza’s department at the university of the free state had a mandate to show me that despite being small, they had a rich academic and extra-curricular programme. they did not fail to deliver. activities and meals were planned at every juncture and i was truly impressed by their welcoming nature. their unique approach to orthopaedics was epitomised by the fact that their paediatric orthopaedic unit consultant not only single-handedly runs the unit, but also takes regular drives to neighbouring provinces to provide specialised care. a truly impressive feat! in the hallways of their department, i came across a photo of dr cj joubert, one of the first smith & nephew travelling fellows (figure 3). with the welcome prospect of a few days in a familiar setting ahead, i boarded a flight to johannesburg to spend a few days at my own department in wits university under the auspices of prof mt ramokgopa. being familiar with all the hospitals on my figure 1. an adapted version of barbier’s ‘pillars of sustainability’ (1987) figure 2. i was humbled by my encounter with prof s govender of ukzn figure 3. a picture of one of the first smith & nephew travelling fellows (1983), dr cj joubert, found in the department at the university of the free state page 22 south african orthopaedic journal http://journal.saoa.org.za home orthopaedic circuit, i took advantage of my time as a guest by allowing my colleagues to drive me around and take me out in the evenings, as they had done with fellows from other departments in the past. i presented a provisional report of the travelling fellowship thus far, and my colleagues were comforted to see that we were not the only ones struggling with resource-related issues when it came to service delivery. of course, the talk also motivated a number of junior colleagues to express their passion to pursue the travelling fellowship in the future. my final two visits were also within my home province of gauteng. at the university of pretoria, prof mv ngcelwane took me around his department personally. from academic meetings to scrubbing in theatre, he made sure to expose me to all aspects of his department. one of the awe-inspiring aspects of his department was a wall dedicated to the history of orthopaedic surgery in south africa. an impressive collection of photos paints the picture of the formation of the south african orthopaedic association in two phases: ‘the planning phase’ and ‘the growth phase’. one truly incredible photo within the collage shows hrh queen elizabeth ii bestowing honours upon professor gt du toit in 1952. sefako makgatho university was to be my final stop. a few kilograms heavier, and longing to go home, i took a drive on some very small roads en route to dr george mukhari hospital. prof ss golele was quick to impress me with a visit to his department of hand and microsurgery. i had the opportunity to watch a live procedure where a 1 mm diameter artery in a rat was cut and then repaired using a microscope. the former head of their orthopaedic department, prof rg golele, also took me on tour of his paediatric ward. to my amazement, he showed me the list of orthopaedic surgeons that had qualified under him. the list, which he proudly pointed out, included four heads of orthopaedic departments in south africa. throughout my visits to the eight academic institutions, i found that every department was increasingly curious to find out the occurrences at the previously visited departments. discussions often revolved around issues like staffing, number of calls, spectrum of cases seen, working conditions, and data collection systems. the information imparted was received with a wide range of reactions. those in resource-constrained environments were comforted to know that they were not alone, while simultaneously expressing frustration at the overburdened healthcare system throughout the country. nonetheless, despite individual challenges, each department still emphasised their commitment to provide the best possible holistic patient care. i thoroughly enjoyed talking to previous smith & nephew travelling fellows. i particularly enjoyed the debate that often ensued between those who had done the fellowship before and after exams. a final reflection the smith & nephew travelling fellowship was indeed an eye-opening experience. it showed me that the south african orthopaedic community is a closely knit one, with familiar faces being seen at every visit. although we frequently see our colleagues from neighbouring institutions presenting their work at congresses, it is often a biased picture as they usually present their successes and achievements. visiting these departments in person allowed me to be more intimately acquainted with them, seeing both their strengths and shortcomings. the biggest lesson for me was to see the prevalence of difficulties in every department. be it infrastructure or staffing-related, no department is immune to resource constraints. despite this, every single orthopaedic department showed me that they always strove to improve. whether their passion to enhance themselves results from a need to provide the best possible treatment, or simply to outdo their colleagues at other departments, every department inspired me with their pursuit of perfection. references 1. no authors listed. south african orthopaedic association website. https://saoa.org.za/history/smith-nephew-orthopaedic-travellingfellowship (date last accessed 07 february 2019) 2. no authors listed. smith & nephew website. http://www. smith-nephew.com/south-africa -old/education/or thopaedictravelling-fellows/fellows-inducted-since-1981 (date last accessed 07 february 2019) 3. nabhan gp. cross-pollinations. 1st ed. minneapolis: milkweed editions; 2004. isbn 978-1571312709 4. barbier eb. the concept of sustainable economic development. environ conserv 1987;14:101. https://saoa.org.za/history/smith-nephew-orthopaedic-travelling-fellowship https://saoa.org.za/history/smith-nephew-orthopaedic-travelling-fellowship _goback _hlk8816185 layout 1 south african orthopaedic journal bakkai a et al. saoj 2017;16(3) http://journal.saoa.org.za doi10.17159/2309-8309/2017/v16n3a2 hip tapered uncemented ha-coated femoral stems: a radiological study a bakkai,1 p ryan,2 ie goga3 1 mbchb, hdip orth(sa), fc orth(sa), orthopaedic surgeon, university of kwazulu-natal 2 mbchb(uct), hdip(orth), mmed(orth), fc orth(sa), consultant orthopaedic surgeon 3 md, frcs(edin), fcs orth(sa), professor and head of department: orthopaedic surgery, inkosi albert luthuli central hospital, durban, kwazulu-natal, south africa corresponding author: prof ie goga, po box 65167, reservoir hills, durban, 4090, south africa, tel: 031 240 2160, email: goga@icon.co.za abstract introduction: numerous national joint registries demonstrate a trend towards the use of uncemented femoral components in total hip arthroplasty. while the results of first-generation uncemented, and some of the second-generation uncemented implants have been unacceptably poor, others, including the fully hydroxyapatite (ha) coated femoral stems, have been excellent with survival rates of greater than 95% at 20 years. component longevity is largely related to robust stem fixation to native bone. adequate stem fixation to the native bone can be determined by clinical assessment and radiological signs of osteointegration. the absence of these radiological signs might be an indication of early loosening. with this in mind, we performed a radiological analysis of the osteointegration of uncemented fully ha-coated femoral stems inserted at our arthroplasty unit. materials and methods: we performed a retrospective chart and radiological review of patients who had undergone total hip replacement with an uncemented fully ha-coated femoral component over a five-year period. between march 2003 and march 2008, 80 patients met the criteria used, and radiological changes around the femoral stem were analysed. the mean patient age at the time of surgery was 59 years, and the most common presenting pathology was avascular necrosis (43%). the immediate post-operative, six-week, six-month, one-year and five-year radiographs were evaluated. results: there were no revisions for stem-related complications. the earliest radiological signs of osteointegration, which included remodelling and trabecular bone formation, were noticed as early as six weeks post-operatively in 4%. at six months and one year, these had increased to 63% and 100% respectively. thereafter, the radiographs demonstrated minimal change and maintained so-called ‘radiological silence’. conclusion: osteointegration of fully ha-coated stems occurs in a predictable manner, and is noted in radiographs as early as the six-week follow-up period. signs of osteointegration can be used as reliable indicators of solid femoral stem fixation after total hip replacement. key words: total hip replacement, hydroxyapatite, corail, osteointegration citation: bakkai a, ryan p, goga ie. tapered uncemented ha-coated femoral stems: a radiological study. saoj 2017;16(3):27-30. doi 10.17159/2309-8309/2017/v16n3a2 editor: prof anton schepers, university of the witwatersrand received: december 2014 accepted: october 2016 published: august 2017 copyright: © 2017 bakkai a et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no benefit of any form has been received from any commercial party related directly or indirectly to the subject of this article. conflict of interest: the authors have no conflict of interest in the writing of this study. the content of this paper is the original work of the authors. introduction total hip replacement is an effective treatment for hip pathology, proven to eliminate pain and restore function in the affected joint. advances in design of both cemented and uncemented hip prostheses, and improvements in bearing surfaces, have resulted in implants that are durable, with excellent long-term survival.1-3 numerous national joint registries demonstrate a trend towards the use of uncemented femoral components in total hip arthroplasty. while the results of first-generation uncemented, and some of the second-generation uncemented implants have been unacceptably poor, others, including the tapered fully hydroxyapatite (ha) coated femoral stems, have been excellent, with survival rates exceeding 96.8% at 20 years.4,5 saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:01 pm page 27 page 28 bakkai a et al. saoj 2017;16(3) the longevity of uncemented stems relies on initial mechanical stability and thereafter on biological fixation or osteointegration.4,6 the radiographic appearance of stability and osteointegration seen in uncemented stems has been described by numerous authors.4,6,10 more specifically, the radiographic osteointegration of fully ha-coated stems has been extensively described by chatelet,7 who separated the changes seen into three stages: the insertion stage, followed by the osteointegration stage, and then the period of periprosthetic bone remodelling. the purpose of our study is to describe the radiographic changes seen around tapered titanium, fully ha-coated femoral stems. recognition of these manifestations should aid in the understanding of the bone remodelling that occurs about well-fixed ha-coated femoral implants. material and methods we retrospectively reviewed the charts and radiographs of patients who had undergone primary uncemented total hip replacement with a fully ha-coated stem (corail, depuy) during a five-year period, and who had a minimum of five years’ radiographic follow-up. notes were canvassed for demographic and surgical data as well as further interventions or revision. radiographs were then evaluated as set out below. between march 2003 and march 2008, 257 patients had undergone total hip replacement with a fully ha-coated stem (corail, depuy). eighty patients, and 112 hips, met the criteria which included: same surgeon, same surgical approach and regular completed radiological follow-up. the mean patient age at the time of surgery was 59 years (range 31 to 88 years). there were 44 females and 36 males. the surgery was performed on the right hip in 26 patients, on the left in 20, and bilaterally in 33. the aetiology of the hip disease was avascular necrosis in 34 patients (42%), osteoarthritis in 31 (38%), rheumatoid arthritis in nine (11%), systemic lupus erythematosus in three (4%), and other diagnoses in three (4%) (figure i). the aetiology of a vascular necrosis was as follows: 29% due to steroid use, 26% due to alcohol, 26% due to smoking, 11% posttraumatic, and 8% due to old perthe’s disease. we acknowledge that there was no documentation of hiv status, as it was not tested routinely at that time. however, currently, we encourage all patients to be tested. all patients were operated by the senior author using the same surgical approach (lateral approach a modification of the stracathro method using a single osteo-periosteal sleeve).8 the surgical technique for stem insertion was as described by the design surgeon especially with regard to cancellous bone preservation.7 the femoral prosthesis utilised in all was the collarless, fully ha-coated, press-fit stem (corail, depuy international ltd). the femoral stem sizes ranged from 8 to 13. the acetabular components were pinnacle in all patients, head size was 28 and 36, bearing surface was metal-on-metal in 24; the rest of patients were ceramic and metal-on-polyethylene. patients were mobilised on day one or two post-operatively, with weight bearing allowed as tolerated. the immediate post-operative x-ray was anteroposterior of the pelvis, centred on the pubis, showing the entire prosthesis. the subsequent films included the same anteroposterior view, as well as a lateral view, which included the acetabular component and the most distal aspect of the femoral component. radiological changes were reviewed at six weeks, six months, one year, and five years, looking for the following: • femoral component alignment (valgus, neutral or varus) • femoral subsidence (defined as an increase in prosthesis-greater trochanter distance >3 mm)9 • analysis of the 14 femoral component zones (as described by gruen and johnston)10,11 looking for any lucencies, osteolysis, or reactive bony changes (endosteal remodelling, cortical thickening, stress shielding) results in this series, there were no revisions for stem-related complications. one hip was revised for a large pseudo-tumour, associated with a metal-on-metal bearing surface. at the time of revision, the stem was found to be well fixed and did not require removal. other complications not related to the femoral stems were: residual sciatic nerve palsy in one patient; iatrogenic fracture of acetabulum treated conservatively and healed during follow-up; periprosthetic fracture; vancouver type c managed with open reduction and internal fixation using plate and circulage with retention of the stem. radiographic analysis showed the component orientation was neutral in 89, varus in 10, and valgus in 13 patients. there were no cases of subsidence or loosening. on zonal analysis (table i), there were no progressive lucencies or osteolytic defects. the earliest bony changes were noted at the six-week follow-up in three hips (4%). this manifested as an increase in the endosteal density, and bridging of bone trabeculae (figure 2). the peri-prosthetic osteogenesis, in the area between the prosthesis and the inner cortex, was noted in 50 hips (63%) at six months, and in all hips (100%) at one year. comparison of one-year and five-year follow-up films showed no alteration of the endosteal changes (so-called silent or mute x-rays) (figures 3a and b). the endosteal remodelling was most commonly seen in zones 3 and 5 (87% and 94% respectively) on the anteroposterior radiograph, and in zone 12 (55%) on the lateral film (figures 4a and b). figure 1. aetiology of hip disease 40 35 30 25 20 15 10 5 0 avn oa rh arthritis sle others table i: summary of radiographic findings radiology 6 weeks 6 months 1 year 5 years endosteak remodelling 3 (4%) 50 (63%) 80 (100%) 80 radiolucent lines 0 0 0 0 reactive lines 0 0 0 3 pedestal formation 0 0 0 0 cortical hypertrophy 0 3 3 17 calcar remodelling 0 4 4 41 subsidence 0 0 0 0 stress shielding 0 0 0 0 osteolysis 0 0 0 1 saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:01 pm page 28 bakkai a et al. saoj 2017;16(3) page 29 parallel bridging bone trabeculae were seen in zone 1 (figure 5a), cortical hypertrophy was seen in 17 (figure 5b), and calcar rounding was seen in 41 (figure 5c). there was no evidence of proximal stress shielding. tip on-growth was differentiated from pedestal by the formation of dense oblique trabeculae between the surface of the implant and closest endosteum, while in the pedestal, it was seen as divergent radio-opaque lines separated from the tip of the implant. discussion longevity of uncemented components in total hip arthroplasty relies on robust fixation of the implant to the host bone.4,12 osteointegration may be confirmed by the presence of bridging bone formation between the endosteum and the prosthesis.4,7,9,13 long-term remodelling of this peri-prosthetic bone is vital for component survival.4,13 the surface finish of the implant plays a vital role in the host bone/component reaction, and different surface finishes have been employed with varying success.13 archibeck et al. reported excellent results with the use of second-generation uncemented implants, with 100% stem survival at ten years. they attributed this to improved bone ingrowth around porous-coated stems.14 the classic description of the radiological signs of uncemented hips described by engh et al.9 relates to the radiological findings in cylindrical medullary locking stems. the distinction between this description and that of the changes seen in ha-coated stems is considered to be extremely important. ha coatings are known to encourage bone formation around implanted components, and this may be seen as early as three weeks post-operatively on microscopic sections.15 this phenomenon is due to the similarity in mineral content of ha to native bone,4,16 and this osteointegration results in excellent long-term fixation to host bone, and subsequently to implant survival.4,17 radiological stages jean-christophe chatelet7 extensively described the radiological stages of osseointegration of fully ha-coated tapered stems, as follows: figure 2. endosteal changes noted at six weeks post-operatively figure 3a and b. x-rays at one and five years demonstrating ‘radiological silence’ figure 4a and b. distribution of endosteal remodelling noted in ap and lateral views figure 5a, b and c. radiographs demonstrating parallel bone trabeculae; zone 1 (a), cortical hypertrophy (b), and calcar rounding (c) a bc a b a b saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:01 pm page 29 page 30 bakkai a et al. saoj 2017;16(3) 1. insertion stage: the immediate post-operative x-ray depends on the thickness of cancellous tissue and its compaction strength, the thickness of cortices and the implant size. 2. osteointegration stage: this includes the first six weeks post surgery in which secondary osteointegration phenomena occur, leading to definitive stem fixation to the host bone. 3. remodelling stage: this is the stage of bone adaptation to the implant. it begins at six months and includes the phenomenon of endosteal remodelling and other bony changes. bone adaptation is an ongoing dynamic process affected by the patient’s age, activity levels and bone quality, including osteoporosis. endosteal remodelling refers to the bony bridges from the inner cortex towards the stem, which differ according to gruen zones. it is important to assess not only the presence of these trabecular lines but also the direction of these trabecular lines. as described by vidalain,4,7 in zone 1, the trabecular lines run from the greater trochanter towards the stem (tensile forces); in zones 2 to 6, in the presence of true compressive forces, the lines run oblique toward the stem; and in zone 7, the calcar remains blunt and rounded. other radiological findings with regard to other radiological findings, first, the absence of pedestal formation indicates stem fixation distally to cortical bone. secondly, stress shielding is not usually seen in corail stems, and this is attributed to the young’s modulus of titanium being more similar to bone, and to the mechanical effects of the triple taper design. thirdly, osteolysis, if it occurs, will be limited to the proximal femur, because of the bone-implant barrier; and lastly, stem malpositioning leads to a hemi-circumferential or hemi-ogival reaction, manifesting as cortical hypertrophy. in the current study, we note similar radiographic findings. we confirm the positive radiographic signs of endosteal remodelling, calcar rounding, bridging bone trabeculae and cortical hypertrophy, while there were no cases of negative radiological signs (subsidence, stress shielding, osteolysis). the limitations of our study include the small sample size and the fact that the investigating doctor was not blinded regarding the dates of post-operative x-rays assessed. the radiographic signs studied relate to a specific implant (corail) without comparison to other uncemented fully ha-coated stems. conclusion this study evaluated the radiographic signs of osteointegration in a consecutive cohort of primary total hip replacements using an uncemented, triple tapered, fully hacoated femoral stem (corail, depuy). osteointegration of fully ha-coated stems occurs in a predictable manner, and is noted in radiographs as early as the six-week follow-up period. signs of osteointegration can be used as reliable indicators of solid femoral stem fixation after total hip replacement. the results of this study are comparable to other reported series using the same prosthesis. references 1. cheung kw, chiu kh, chung ky. long-term result of cementless femoral stem in avascular necrosis of the hip. hip international: the journal of clinical and experimental research on hip pathology and therapy. 2014. 2. prins w, meijer r, kollen bj, verheyen cc, ettema hb. excellent results with the cemented lubinus sp ii 130-mm femoral stem at 10 years of follow-up: 932 hips followed for 5-15 years. acta oothopaedica. 2014;85(3):276-79. 3. molloy d, jack c, esposito c, walter wl. a mid-term analysis suggests ceramic on ceramic hip arthroplasty is durable with minimal wear and low risk of squeak. hss journal: the musculoskeletal journal of hospital for special surgery. 2012;8(3):291-94. 4. vidalain jp. twenty-year results of the cementless corail stem. international orthopaedics. 2011;35(2):189-94. 5. ferrell ms, browne ja, attarian de, cook c, bolognesi mp. cementless porous-coated anatomic total hip arthroplasty at duke: 18to 24-year follow-up. journal of surgical orthopaedic advances. 2009;18(3): 150-54. 6. epinette ja, manley mt. uncemented stems in hip replacement – hydroxyapatite or plain porous: does it matter? based on a prospective study of ha omnifit stems at 15-years minimum follow-up. hip international: the journal of clinical and experimental research on hip pathology and therapy. 2008;18(2):69-74. 7. chatelet jc. the radiology of the bone/stem interface: a time-tested couple. the corail hip system – a practical approach based on 25 years experience. heidelberg dordrecht london new york: springer; 2011. pp.106-107. 8. mclaughlin j. the stracathro approach to the hip. journal of bone and joint surgery (br) 1984;66(1):30-31. 9. engh ca, massin p, suthers ke. roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. clinical orthopaedics and related research. 1990(257):107-28. 10. gruen ta, mcneice gm, amstutz hc. ‘modes of failure’ of cemented stem-type femoral components: a radiographic analysis of loosening. clinical orthopaedics and related research. 1979(141):17-27. 11. johnston rc, fitzgerald rh, jr, harris wh, poss r, muller me, sledge cb. clinical and radiographic evaluation of total hip replacement. a standard system of terminology for reporting results. journal of arthroplasty 2007;22(4 suppl. 1):71-74 12. chambers b, st clair sf, froimson mi. hydroxyapatite-coated tapered cementless femoral components in total hip arthroplasty. the journal of arthroplasty. 2007;22(4 suppl 1):71-4. 13. coathup mj, blunn gw, flynn n, williams c, thomas np. a comparison of bone remodelling around hydroxyapatite-coated, porous-coated and grit-blasted hip replacements retrieved at post-mortem. the journal of bone and joint surgery (brit). 2001;83(1):118-23. 14. archibeck mj, berger ra, jacobs jj, quigley lr, gitelis s, rosenberg ag, et al. second-generation cementless total hip arthroplasty. eight to eleven-year results. the journal of bone and joint surgery (am). 2001;83-a(11):1666-73. 15. kusakabe h, sakamaki t, nihei k, oyama y, yanagimoto s, ichimiya m, et al. osseointegration of a hydroxyapatite-coated multilayered mesh stem. biomaterials. 2004;25(15):2957-69. 16. ergun c, liu h, webster tj, olcay e, yilmaz s, sahin fc. increased osteoblast adhesion on nanoparticulate calcium phosphates with higher ca/p ratios. journal of biomedical materials research part a. 2008;85(1):236-41. 17. tanzer m, kantor s, rosenthall l, bobyn jd. femoral remodeling after porous-coated total hip arthroplasty with and without hydroxyapatitetricalcium phosphate coating: a prospective randomized trial. the journal of arthroplasty. 2001;16(5):552-58. saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:01 pm page 30 page 110 south african orthopaedic journal http://journal.saoa.org.za saoj south african orthopaedic journal cpd questionnaire. may/june 2020 vol 19 no 2 short-term results following two-stage revision for periprosthetic joint infection (du plessis j, greeff r, singh v, fang n, frey ct) 1. according to the host classification by mcpherson, which of the following scenarios represent a type c host? a. a 73-year-old male with hypertension and gout, presenting with a draining sinus two months after total hip arthroplasty a b. an 84-year-old female with diabetes and chronic obstructive pulmonary disease presents with an active draining sinus for four months following total knee arthroplasty b c. a 54-year-old male with hiv infection for the last two years and on antiretrovirals. his cd4 count is 300 and viral load undetectable. he presents three weeks following total hip arthroplasty with pain and erythema c d. a 74-year-old female with previous bicolumnar plating of a tibial plateau fracture through two incisions presents with wound breakdown following total knee arthroplasty two weeks ago d e. a 62-year-old male with chronic alcoholism develops a draining sinus four weeks following total hip arthroplasty for avascular necrosis e 2. which of the following do not represent an increased risk of reinfection following a two-stage revision at one year? a. type c host a b. pus found at reimplantation stage b c. positive frozen section at time of reimplantation c d. positive alpha defensin at reimplantation d e. limited debridement e 3. the current gold standard for the management of tsukayama 4 periprosthetic joint infection includes: a. two-stage revision with explant and antibiotic cement spacer, six weeks targeted antibiotics, two weeks antibiotic-free period and reimplantation when no signs of infection a b. single stage revision with thorough debridement and empiric antibiotics for six weeks b c. thorough debridement with antibiotics and implant retention (dair) followed by six weeks of antibiotics c d. wound debridement followed by six weeks of targeted antibiotics d e. explant and debridement followed by arthrodesis e low dislocation rates achieved when using dual mobility cup hip implants for femur neck fractures (erasmus lj, fourie ff, van der merwe jf) 4. which of the following is not a risk factor for hip dislocation after total hip arthroplasty? a. dementia a b. alcohol abuse b c. age older than 60 years c d. psychiatric disorders d e. neuromuscular disorders e 5. which of the following is true regarding dual mobility cups: a. has three articulations a b. has two articulations b c. only available in cemented options c d. only available in non-cemented options d e. none of the above e 6. the study in this journal looking at dual mobility cups used for femur neck fractures found (at one year after surgery) a dislocation rate of: a. 0% a b. 1.3% b c. 2.2% c d. 4.3% d e. 8.5% e percutaneous intra-articular tranexamic acid following total knee arthroplasty without drainage to reduce blood loss (gericke e, de beer j, deacon m, marais lc) 7. which of the following methods of administrating tranexamic acid are preferred, considering outcome and possible side effects? a. intravenous a b. intra-articular b c. oral c d. topical d e. inconclusive e 8. blood loss is a common and challenging complication in total knee replacement and has been reported to range from: a. <300 ml a b. 300–500 ml b c. 500–700 ml c d. 700–1 700 ml d e. >1 700 ml e 9. regarding the biomechanical effect of tranexamic acid reducing blood loss, which is the most appropriate statement? a. clot formation at the surgical site is promoted due to prevention of the formation of plasmin by blocking the conversion of plasminogen to plasmin a b. tranexamic acid is a synthetic antifibrinolytic, blocking plasminogin directly b c. fibrin degradation and breakdown of clots are prevented due to prevention of the formation of plasmin by blocking the conversion of plasminogen to plasmin c d. tranexamic acid has a higher coagulation effect given intravenously d e. tranexamic acid potency to reduce blood loss is due to the high concentration that is achieved at the target location e the use of three-dimensional models in tibial plateau fractures (joubert ja) 10. according to the author, can we improve the reliability of tibial plateau fracture classification by utilising a 3d printed model (in addition to 3d ct scans)? a. yes, for both the hohl and moore and the schatzker classification systems a b. no, 3d printed models do not improve the reliability of fracture classification b c. yes, but only when using the schatzker classification c d. yes, but only when using the hohl and moore classification d e. no, except for the ao classification system e page 112 south african orthopaedic journal http://journal.saoa.org.za subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm.co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online • once you have completed the answers, go back to the top of the page next to the registration option. there is another icon “find my cpd certificate”. (you will have to answer the two questions regarding your internship and last cpd audit once you have completed a questionnaire and want to retrieve your certificate). • if you click on that icon it will open your certificate which you can print or save on your system. • please call mpc helpdesk if you have any questions: 0861 111 335. 11. taking into consideration that this is a level 4 study, are 3d printed models useful when managing tibial plateau fractures? a. yes, because the reliability of classification is improved a b. yes, the use of 3d models resulted in decreased length of hospital stay and less surgical blood loss b c. no, 3d printed model manufacturing only contributes to patient radiation exposure c d. yes, observers found 3d models superior to 3d ct in terms of spatial awareness and one’s ability to estimate how much bone graft is required d e. no, 3d printed model use resulted in more patients theoretically receiving surgical management than needed e correlation of soft tissue projection in injured necks (cspine): prevertebral soft tissue measurement in paediatric cervical spine trauma (mccaul j, horn a, mccaul m, dix-peek s) 12. a 10-year-old female falls off her bunk bed and presents to your emergency department with a distal radius fracture. which statement is correct? a. c-spine injuries are common in the paediatric population and therefore this patient should definitely have a full c-spine x-ray series a b. intubation will significantly increase the appearance of the soft tissue shadow on the upper part of the c-spine on lateral x-ray b c. in children, the lower c-spine is much more likely to be injured than the upper c-spine c d. soft tissue swelling on lateral c-spine x-ray correlates well with bony injury d e. soft tissue swelling on lateral c-spine x-ray cannot be measured as a ratio of vertebral body width e 13. in this patient, you suspect that the prevertebral soft tissue is swollen by its appearance on the lateral c-spine x-ray. which of the following measurements would alert you to the possibility of injury and prompt further investigation (e.g. ct scan or mri)? a. the soft tissue in front of the c6 vertebral body is 65% of the width of the c7 vertebral body a b. the soft tissue in front of c2 is more than 20% of the c3 vertebral body b c. the soft tissue in front of the c6 vertebral body is more than 55% of the width of the c7 vertebral body c d. the soft tissue in front of the c2 vertebral body is 38% of the width of the c7 vertebral body d e. the soft tissue in front of the c2 vertebral body is more than 55% of the width of the c7 vertebral body e 14. you apply the cspine rule to interpret her x-ray. this rule has a sensitivity of about 33–45% and a specificity of around 82–93%. this means: a. it is a good screening tool a b. it will have a good positive predictive value as c-spine injury has a high prevalence b c. it is useful to rule in the chance of cervical spine injury c d. it has a low false negative rate d e. it is useful to rule out the chance of cervical spine injury e epidemiology of paediatric and adolescent fractures admitted to a south african provincial hospital (strydom s, hattingh c, ngcelwane m, ngcoya n) 15. which of the following is not a risk factor to identify child abuse? a. unplanned pregnancy a b. children less than 5 years of age b c. unemployed parents c d. femur fracture in children less than 1 year of age d e. multiple fractures in different stages of healing e 16. which of the following strategies may best decrease the number of children admitted with fractures? a. better gun control a b. improved playground supervision at school b c. build pedestrian sidewalks in communities c d. home traction treatment of femur fractures d e. enforce the use of child seats in cars e 17. regarding pvas in children, which of the following statements is true? a. most fractures occur in the upper limbs a b. educational programmes have not been proven to reduce the incidence b c. most accidents occur at night c d. the majority occur in pre-school children d e. these children tend to suffer more severe injuries e the risk of early complications in patients with hand infections (verhoef h, marais lc, ryan pv, rollinson pd) 18. the following are all independent risk factors for development of early complications in hand infections, except: a. polymicrobial infections a b. human bites b c. diabetes mellitus with hba1c 7.8% c d. hiv infection with cd4 count 180 cells/mm3 d e. diabetes mellitus with hba1c 10.1% e 19. regarding the bacteriology of hand infections, which one of the following statements is correct? a. polymicrobial infections are found more frequently than isolated s. aureus infections in hiv-positive patients a b. polymicrobial infections are found more frequently than isolated s. aureus infections in diabetic patients b c. s. epidermidis is the most frequently isolated organism c d. eikenella corrodens is the most frequently isolated organism in hiv-positive patients d e. hiv-positive patients and poorly controlled diabetic patients are more likely to be affected by polymicrobial infections than patients who are hiv negative and non-diabetic e management of femur neck fractures in young adults under the age of 60 years (blake ca, van staden gf, van der merwe jf, matshidza s) 20. the most important aspect of hip-preserving surgery in young adults under the age of 60 years with femur neck fractures is: a. capsulotomy a b. surgical timing b c. open reduction c d. quality of reduction and fixation d e. choice of internal fixation e 21. which surgical implant should be avoided in pauwels type 3 fractures? a. cannulated screws a b. proximal femoral locking plate b c. dynamic hip screw c d. cephalomedullary device d e. hybrid plate e medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 404 not found page 12 sa orthopaedic journal summer 2016 | vol 15 • no 4 primary malignant bone tumours: epidemiological data from an orthopaedic oncology unit in south africa dr y pillay mbchb, fc orth(sa) dr n ferreira bsc, mbchb, fc orth(sa), mmed(orth), phd dr lc marais mbchb, fcs orth(sa), mmed(ortho), cime, phd tumour sepsis and reconstruction unit, department of orthopaedic surgery, grey’s hospital, nelson r mandela school of medicine, university of kwazulu-natal corresponding author: dr yogesh pillay tumour, sepsis and reconstruction unit department of orthopaedic surgery grey’s hospital nelson r mandela school of medicine university of kwazulu-natal 3201 pietermaritzburg, south africa tel: +27 33 897 3000 email: yogeshpillay@icloud.com abstract introduction: limited data is available with regard to the epidemiology of primary malignant orthopaedic tumours in the south african clinical setting. as a result, orthopaedic surgeons have to rely on data from other countries when formulating differential diagnoses for malignant bone lesions. existing data, however, demonstrates variance in the incidence between different geographic regions. by analysing the tumour epidemiology at our centre and comparing it to published data from other parts of the world, we aim to better define the local prevalence of primary malignant bone tumours. materials and methods: a retrospective review of all patients with biopsy confirmed malignant primary bone tumours that presented between january 2008 and june 2015 were conducted. patients with multiple myeloma and lymphoma were excluded. epidemiological data pertaining to patient demographics, tumour location and histological diagnosis were recorded and analysed. results: included for review were 117 patients with biopsy-confirmed primary malignant bone tumours. tumours involving the proximal humerus, distal femur, proximal tibia and pelvis accounted for 80% of all tumours. osteosarcoma was the most common histological diagnosis (72.6%) and higher than reported figures from any other country. it was followed by chondrosarcoma (11.4%), ewing’s sarcoma (9.4%), spindle cell sarcoma (4.2%) and malignant giant cell tumour (gct) (1.7%). a single patient was diagnosed with adamantinoma. hiv infection had no significant association with primary bone tumour incidence. conclusion: epidemiological data from this review reflect small but significant differences compared to international literature. the incidence of osteosarcoma appeared to be higher than in previous reports from other regions. future study in this area may identify a reason for this difference, socio-economic reasons may be responsible. key words: primary bone malignancies, osteosarcoma, epidemiology http://dx.doi.org/10.17159/2309-8309/2016/v15n4a1 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 12 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 13 introduction primary malignant bone tumours are defined as tumours originating in bone. these malignancies are rare, and account for only 0.2% of all cancers.1 by comparison, breast cancer is the most common malignancy in women, accounting for 25% of all cancers.2,3 despite the rarity, the consequences of malignant primary bone tumours are grave and they are typically associated with high morbidity and mortality.4 the scarcity of these tumours combined with the lack of a national database contributes to the lack of south african epidemiological data regarding primary malignant bone tumours. the national health laboratory services has published tumour data based on histological diagnosis. the latest tumour statistics are from 2010 and broadly group all tumours under the heading ‘bone’. the lab processed 177 samples during 2010 of which 96 were male and 81 female. unlike our study, this includes haematological tumours affecting bone including myeloma and lymphoma.5 orthopaedic oncology surgeons in south africa currently rely on international epidemiological data concerning tumour epidemiology, and statistics from north america and the united kingdom are frequently referenced.1,6 data from the american cancer society suggest that chondrosarcoma is the most common primary malignant bone tumour affecting adults (40%). osteosarcoma, chordoma, ewing’s sarcoma and fibrosarcoma follow at 28%, 10%, 8% and 4% respectively.1 reports from the united kingdom quote osteosarcoma as the most frequently encountered tumour (34.2%) followed by chondrosarcoma and ewing’s sarcoma at 27.2% and 19.3% respectively.6 epidemiological data from nigeria report osteosarcoma as their most common malignancy (58.9%), followed by chondrosarcoma (21.4%), fibrosarcoma (8.9%) and ewing’s sarcoma (7.2%).7 the above data clearly demonstrates variance in tumour incidence between geographic regions. the aim of this study was to determine the relative incidence and describe the demographics of primary malignant bone tumours diagnosed at a south african tumour unit. this retrospective review aims to establish demographic data for primary malignant bone tumours in south africa. materials and methods we retrospectively reviewed all patients diagnosed with malignant primary bone tumours at our institution from january 2008 and june 2015. ethical approval was obtained from our institution’s ethics review board prior to commencement of the study. eligible patients were identified from a prospectively gathered database. patients were included if they had a biopsy-confirmed diagnosis of primary malignant bone tumour. patients with multiple myeloma and lymphoma were excluded. all patients were admitted for local and systemic staging, which was followed by an incisional biopsy. local staging consisted of radiographs and a magnetic resonance imaging (mri) scan. systemic staging included workup for medical co-morbidities, laboratory investigations, computerised tomography (ct) scan and bone scintigraphy. histology was obtained by formal incisional biopsy in all cases. diagnosis was subsequently confirmed by combined radiological and histological evaluation. patient charts were reviewed and data extracted pertaining to patient demographics, tumour location and histological diagnosis. statistical analysis was performed using stata 13.0 (statacorp. college station, texas). continuous variables were reported as mean (± sd) or mean (with interquartile range) and categorical variables as numbers and percentages, unless otherwise stated. categorical data was compared using the fisher’s exact test. all tests were twosided and the level of significance was set at p < 0.05. results one-hundred-and-seventeen patients met the inclusion criteria. eighteen patients with multiple myeloma and seven patients with lymphoma were excluded. figure 1. primary malignant bone tumour anatomical distribution saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 13 page 14 sa orthopaedic journal summer 2016 | vol 15 • no 4 the final cohort consisted of 64 men and 53 women with a mean age of 23.8 years (range 5 to 69). eighteen patients (15.4%) were confirmed to be hiv positive, 95 patients were negative, and the hiv status of four patients was unknown. the majority of tumours (88.9%) were located in the pelvis and lower limbs, and 80% of all tumours were confined to four anatomical areas, namely the distal femur, proximal tibia, proximal humerus and pelvis (figure 1). osteosarcoma was diagnosed in 85 patients, followed by chondrosarcoma (n=13), ewing’s sarcoma (n=11), fibrosarcoma (n=5), malignant giant cell tumour (n=2) and adamantinoma (n=1) (table i). osteosarcoma osteosarcoma was the most common primary malignant bone tumour and accounted for 72.6% of all cases. there was a slight male predominance with a male-to-female ratio of 1.1:1. mean age at diagnosis was 21 years (range 6–56). the incidence failed to show a bimodal age distribution and only had a single peak during adolescence (15–19 years) (figure 2). the majority of osteosarcomas (78.8%) arose around the knee with 38 out of 85 (44.7%) involving the distal femur and 29 out of 85 (34.2%) involving the proximal tibia (figure 3). histological variants consisted of 73 (85.8%) high grade intra-medullary (conventional), four periosteal (4.7%), four telangiectatic (4.7%), three high grade surface (3.9%) and one parosteal (1.4%) osteosarcoma (table ii). conventional osteosarcomas were histologically further subdivided into 55 (75.3%) osteoblastic, 15 (20.5%) chondroblastic and three (4.1%) fibroblastic variants. juxta-cortical lesions were the most common osteosarcoma variant. periosteal osteosarcomas were diagnosed in two women and two men and accounted for 4.7% of all osteosarcomas. median age at presentation was 18 years (range 8– 30). all four tumours arose from the proximal tibia. high grade surface lesions were diagnosed in three patients (3.9%). all three patients were women with a median age of 33 years (range 23–40). two patients were hiv positive. all three tumours were located around the knee with two arising from the distal femur and one from the proximal tibia. a single (1.4%) parosteal osteosarcoma was diagnosed in the distal femur of a 24-year-old hiv-positive man. telangiectatic osteosarcoma was seen in four (4.7%) patients. these included two men and two women. median age was 26 years (range 14–40). two lesions were located in the distal femur and two in the proximal humerus. our data failed to show any significant association between hiv infection and conventional osteosarcoma (p=0.268), juxta-cortical lesions (p=0.086), high grade surface lesions (p=0.342) or telangiectatic osteosarcoma (p=0.068). when patients whose hiv status was not known were excluded, however, a significant association between hiv infection and high-grade surface osteosarcomas was observed (p=0.050). table i: relative percentages of primary bone tumours, excluding haematopoietic tumours grey’s hospital usa china uk nigeria osteosarcoma 72.6% 39.5% 59.8% 34% 58.9% chondrosarcoma 11.1% 28.6% 16.3% 27% 21.4% ewing’s sarcoma 9.4% 11.9% 4.4% 19% 7.2% fibrosarcoma 4.2% 5.5% 0.8% 8.9% chordoma 0% 8.5% 4.2% malignant gct 1.7% 0.7% 1.4% adamantinoma 0.9% 0.7% 0.5% figure 3. osteosarcoma anatomical locations figure 2. osteosarcoma age distribution table ii: osteosarcoma subtypes grey’s hospital usa china conventional osteosarcoma 86.8% 78.4% 90% telangiectatic osteosarcoma 3.9% 3.6% 1.1% small cell osteosarcoma 0% na 0.9% low-grade central osteosarcoma 0% 1.1% 0.7% secondary osteosarcoma 0% 10.3% 0.6% parosteal osteosarcoma 1.4% 4.1% 5.1% periosteal osteosarcoma 3.9% 1.7% 0.9% high-grade surface osteosarcoma 3.9% 0.7% 0.8% abbreviations: na, data not available saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 14 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 15 chondrosarcoma thirteen patients (11.1%) were diagnosed with chondrosarcoma. these tumours were more common in men with a male-to-female ratio of 1.6:1 and exhibited a trend of increased incidence with advancing age (mean 39.2 years, range 15–65) (figure 4). the most common location was the lower limb (tibia, femur, fibula), accounting for 53.8% of cases followed by three tumours in the upper limb (humerus, radius) and three in the pelvis (figure 5). the majority of chrondrosarcomas (84.6%) were classified as low and intermediate grade (grade i and ii), with only two cases (15.4%) being classified as high grade (grade iii). ewing’s sarcoma ewing’s sarcoma was diagnosed in 11 patients (9.4%). these tumours occurred exclusively during the first two decades of life with a mean age of 13.2 years (range 5–20) at time of diagnosis (figure 6). there was a male predominance with a male-to-female ratio of 1.75:1. the most common primary site was the lower limb (90.1%), with the tibia being involved in five cases, femur in four cases and foot in one case. the remaining case involved the radius (figure 7). spindle cell sarcoma spindle cell sarcoma was diagnosed in five patients (4.2%). this group was composed of three fibrosarcomas and two undifferentiated sarcomas of bone. three men and two women with a median age of 46 years (range 9–63) were affected. the lower limb (tibia, femur, foot) was most commonly involved (80%) followed by a single occurrence in the humerus. malignant giant cell tumour of bone (gct) malignant gct of bone was diagnosed in two patients (1.7%). these tumours occurred in a 36-year-old man and 63-year-old women and involved the proximal tibia and distal ulna respectively. adamantinoma a single patient was diagnosed with an adamantinoma. this tumour was located in the midshaft of the tibia of a 34-year-old hiv-positive woman. our data failed to show any significant association between hiv infection and the incidence of any primary malignant bone tumours (p=0.698). discussion this retrospective review represents novel demographic data for primary malignant bone tumours from a developing region in south africa. while overall tumour statistics grossly mirror international data, significant differences were observed. osteosarcoma was the most frequently diagnosed tumour, in keeping with international statistics. the relative incidence of osteosarcoma compared to other primary malignant bone tumours, however, was higher than in previous reports. osteosarcoma made up 73% of all tumours compared to 40%, 34%, 60% and 59% in the us, uk, china and nigeria respectively.8,9 the incidence of osteosarcoma in our cohort was more than double that of the uk. it is notable that the incidence of osteosarcoma is higher in developing countries than their developed counterparts. figure 4. chondrosarcoma age distribution figure 5. chondrosarcoma anatomical locations figure 6. ewing’s sarcoma age distribution figure 7. ewing’s sarcoma anatomical locations saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 15 • saoj page 16 sa orthopaedic journal summer 2016 | vol 15 • no 4 a possible explanation for this discrepancy is the younger average age of the population in those countries. the average age of the populations in nigeria and south africa are 18 years and 25 years respectively, compared to 36 years and 40 years in the us and uk.10 a higher incidence of hiv infection in south africa compared to these other countries might also influence the incidence of osteosarcoma but further research into this association is required.11 the lower average population age could also explain why our data failed to show a bimodal age distribution, with only a single peak identified in adolescence.12 this difference in relative incidence is worth further investigation. if the difference cannot be explained on the basis of population age difference alone, it could imply that certain socio-economic factors contribute to the development of osteosarcoma. chondrosarcoma represented the second most common tumour at our institution. this tendency was also reflected in the literature from the us, uk, china and nigeria. the incidence in our cohort, however, was significantly lower than in other geographic regions, with chondrosarcoma accounting for 29%, 27%, 16% and 21% of primary malignant bone tumours in the us, uk, china and nigeria9 respectively. the discrepancy in observed incidence may again be a reflection of the relative age differences of the reported populations as chondrosarcoma typically affect older patients. a trend of increased incidence of chondrosarcoma with advancing age was also demonstrated in our data. international literature reports a high incidence of chondrosarcoma located in the pelvis; however, in our study this was less frequent than in the tibia. the incidence of ewing’s sarcoma varies significantly in published literature. the highest incidence was reported from the uk (19%), compared to only 4% from china. our results fall within this range and accounted for 9% of all primary malignant bone tumours diagnosed. ewing’s sarcoma’s predilection for the long bones of the lower limb was mirrored in this series. tumour location also differed from published data. the top anatomical locations in our data was the distal femur (33%), proximal tibia (24%), humerus (7%) and pelvis (6%). by comparison, data from the mayo clinic and jst hospital (china) revealed the distal femur (25% and 42.3%), tibia (9.6% and 19.6%) and pelvis (14% and 11%) as the top three anatomical locations. several limitations are identified in our study including its retrospective design and single centre cohort. the vast majority of our patients were of african descent and this might skew the findings. this study presents novel data from south africa but the sample size is relatively small compared to similar series from the us, europe and china. although the associations between hiv infection and sarcomas were reported, this study was not specifically designed to identify these associations. we hope that this research stimulates other similar studies elsewhere in the country, eventually yielding a sample size as large as other centres. conclusion differences in the relative incidence of certain malignant primary bone tumours, in comparison with european, american, nigerian and chinese populations, were identified. an especially high incidence of osteosarcoma and correspondingly low incidence of chondrosarcoma was noted in our patient cohort. more research into the possible reasons for the apparent increase in the relative incidence of osteosarcoma is warranted. compliance with ethics guidelines ethical approval was obtained from our institution’s biomedical research ethics committee prior to commencement of the study. drs pillay, ferreira and marais declare that the content of this article is their original work. no benefits of any form have or will be received from any commercial party related directly or indirectly to the subject of this article. references 1. american cancer society [internet]. available from: http:// www.cancer.org/cancer/bonecancer/detailedguid/bone-cancerkey-statistics 2. jensen a, jacobsen jb, norgaard m, yong m, fryzek jp, sorensen ht. incidence of bone metastases and skeletal-related events in breast cancer patients: a population-based cohort study in denmark. bmc cancer. 2011;11:29. 3. wcrf.org. world cancer research fund international [internet]. 2016 [cited 19 january 2016]. available from: http://www.wcrf.org. 4. bramer jam, somford mp. the epidemiology of primary skeletal malignancy. orthopaedics and trauma 2010;24(4);247-51. 5. national health laboratory service. tumours diagnosed by histology [internet]. 2010 [cited 19 january 2016]. available from: http://www.nioh.ac.za/assets/files/ncr_final_ 2010_tables(1).pdf 6. arora rs, alston rd, eden tob, geraci m, birch jm. the contrasting age-incidence patterns of bone tumours in teenagers and young adults: implications for aetiology. int. j. cancer. 2012;131:1678-85. doi:10.1002/ijc.27402. 7. daw nc, billups ca, rodriguez-galindo c, mccarville mb, rao bn, cain am, jenkins jj, neel md, meyer wh. metastatic osteosarcoma. cancer. 2006;106:403-12. doi: 10.1002/cncr.21626 8. obalam dc, giwa so, banjo af, akinsulire at. primary bone tumours in a tertiary hospital in nigeria: 25-year review. niger j clin pract. 2009;12(2)169-72. 9. niu x, xu h, inwards c, li y, ding y, letson g et al. primary bone tumors: epidemiologic comparison of 9200 patients treated at beijing ji shui tan hospital, beijing, china, with 10 165 patients at mayo clinic, rochester, minnesota. archives of pathology & laboratory medicine. 2015;139(9):1149-55. 10. cia.gov. the world factbook [internet]. 2016 [cited 19 january 2016]. available from: https://www.cia.gov/library/publications/ resources/the-world-factbook/ 11. marais lc, ferreira n. osteosarcoma in patients living with hiv/aids. isrn oncology. 2013;1-6. doi:10.1155/ 2013/219369. 12. ottaviani g, jaffe n. the epidemiology of osteosarcoma. cancer treat res. 2009;152:3-13. doi:10.1007/ 978-1-4419-0284-9_1. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/26 10:35 page 16 orthopaedics vol3 no4 page 60 sa orthopaedic journal autumn 2015 | vol 14 • no 1 expert opinion on published articles the importance of blood conservation in orthopaedic surgery is beyond discussion. blood transfusion adds cost to the procedure and risk to the patient. the risks include, but are not limited to, periprosthetic joint infection, allergic reaction and viral transmission. an estimated 800–1 800 ml of blood is lost during and shortly after a total knee arthroplasty (tka). previous studies showed that 11–67% of tka patients require a blood transfusion. tranexamic acid (txa) stabilises blood clots by preventing fibrinolysis, thereby reducing bleeding. txa is a synthetic derivative of the amino acid lysine. txa competes with lysine to bind with the plasminogen molecule, preventing transformation of plasminogen to plasmin, which is necessary in the fibrinolysis cascade. the antifibrinolytic agent txa is very popular due to ease of administration, minimal impact on the flow of the surgical procedure and cost-effectiveness. but there is no consensus regarding dosage, timing, frequency and route for administration. the safety parameters for intravenous and intra-articular use have not being determined. although none of the studies have shown an increase in thromboembolic events, it still is a concern. after intravenous administration txa diffuses into the synovial membranes and fluid. within a short time the concentration of the txa in synovial fluid is the same as that of the serum. its biological half-life in the joint is about 3 hours. it is eliminated via the kidney, with excretion being about 30% at 1 hour, 55% at 3 hours and 90% at 4 hours after an intravenous dose of 10 mg txa/kg. there seems to be a marked increase in local fibrinolysis after the release of the tourniquet. this led to the assumption that topical or intra-articular txa should be able to inhibit local fibrinolysis more effectively than intravenous administration. it is not advisable to use intravenous txa in some preexisting medical conditions, i.e. renal insufficiency, previous thromboembolic disease, cerebrovascular disease and cardiac disease. the question is rightly asked, whether the same applies to the topical use of txa? perhaps the contraindications are not so pertinent as wong et al. found plasma levels of txa after topical application about 70% less than an equivalent dose of iv administration. in the study the authors compared the efficacy and safety of one intravenous administration (10 mg/kg) versus topical application (2.0 gm in 100 ml saline) of txa. this is a therapeutic level 1 study in 89 patients. the patients were demographically matched. the study proved no inferiority regarding efficacy of topical versus intravenous administration of txa. the strengths of the study are: • prospective randomised study • blinded nature of the follow-up • statistically adequately powered the shortfalls or limitations of the study are: • haemoglobin levels and transfusion rates rather than functional outcomes were used as end-points. • the follow-up period of 18.3 weeks is rather short, especially if outcomes were to be compared. • the incidence of thromboembolic conditions in the study is probably lower than the true incidence, because only clinical suspicion was used as a trigger point for further investigation. • plasma levels of txa were not evaluated and compared. • the dosage of txa used was not the same. message: there does not seem to be a downside to using txa. the efficacy of intra-articular application and intravenous administration appears to be the same. comparison of intravenous versus topical tranexamic acid in total knee arthroplasty: a prospective randomized study jay n. patel, jonathan m. spanyer, langan s. smith, jiapeng huang, madhusudhan r. yakkanti, arthur l. malkani the journal of arthroplasty 2014;29(8):1528–31 reviewer: dr jan de vos private practice, wilgers hospital, pretoria tel: +27 (0) 82777 4058 jndevos@mweb.co.za saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:57 pm page 60 page 62 sa orthopaedic journal autumn 2015 | vol 14 • no 1 surgical management of lumbar degenerative spondylolisthesis frank j. eismont, robert p. norton, brandon p. hirsch journal of the american academy of orthopaedic surgeons, april 2014;22(4):203–13 the authors emphasise that surgical management is to be considered in patients whose symptoms are debilitating and recalcitrant to non-surgical management. the most appropriate indications for surgery are radicular pain, neurogenic claudication as well as patients with a bowel or bladder dysfunction with progressive weakness. various surgical options are reviewed: 1. decompression without fusion the authors indicate satisfactory outcome in 69% of patients in a meta-analysis in 1994, and furthermore mention two further studies, in 2002 as well as 1998, with good to excellent outcomes in 82% and 73.5% of patients respectively. this might well be an option for an elderly patient with stable degenerative spondylolisthesis. 2. decompression with non-instrumented fusion a small series is mentioned: 50 patients in 1991 who underwent this procedure with autogenous iliac crest bone graft with follow-up for 3 years. although pseudoarthrosis occurred in 36% of cases, this did not appear to affect the clinical outcome. a further study in 2007 confirmed the beneficial role of non-instrumented fusion in managing degenerative spondylolisthesis. 3. decompression with instrumented postero-lateral fusion the authors indicate that this should be considered as the standard of care in 2014. data indicates improved fusion rates with the use of instrumentation. a prospective randomised study in 1997, comparing decompression laminectomy and arthrodesis, with and without spinal instrumentation, indicated that at 2-year follow-up, the instrumented group had significantly higher fusion rates, although there was no statistical significant difference in clinical outcome. a follow-up study of 47 patients however indicated significantly better outcomes if a solid fusion was obtained. 4. degenerative spondylolisthesis and the sport perspective a total of 303 patients were enrolled in this study in 2007. a high rate of crossover between patients assigned to surgery and patients assigned to non-surgical management complicated analysis of data. however, authors were able to demonstrate substantially greater improvement in pain and function in the surgical group, at 2-year follow-up, which was maintained at 4-year follow-up. a further subgroup analysis of 380 patients indicates that 80 patients had postero-lateral in situ fusion, 213 had postero-lateral instrumented fusion, 63 had 360° fusion and 23 had decompression alone without fusion. in this study in 2009, at 4-year follow-up, no consistent difference in clinical outcomes were found between these fusion methods. also, the type of bone graft did not make a difference, including morcellised allograft. 5. interbody fusion anterior lumbar interbody fusion, posterior lumbar interbody fusion and trans-foraminal lumbar interbody fusion are discussed under this heading. posterior lumbar interbody fusion and trans-foraminal lumbar interbody fusion avoid the morbidity associated with an anterior approach, and less theatre time is needed. the authors mention that the addition of interbody fusion should be considered in patients who are at risk of non-union, e.g. presence of local kyphosis, high grade slip, symptomatic instability with sagittally oriented facet joints, joint effusion on mri and a tall intervertebral disc, emphasising load sharing in the setting of an insufficient anterior column. 6. minimally invasive decompression in this group, authors mention that increase in slippage was a problem and emphasise that decompression without concomitant fusion should be reserved for patients with a stable degenerative spondylolisthesis and primarily radicular symptoms. a learning curve is to be kept in mind with these kinds of procedures, although cost effectiveness is a consideration, i.e. a shorter stay in hospital. 7. minimally invasive decompression and fusion in a 2010 study, 85 patients were randomly assigned to minimally invasive trans-foraminal lumbar interbody fusion and open trans-foraminal lumbar interbody fusion. the minimally invasive group had greater x-ray exposure, but less blood loss, shorter hospital stay and less post-operative back pain. patients were followed up for a minimum period of 5 years with an overall patient satisfaction rate of 80%. the authors conclude that minimally invasive trans-foraminal lumbar interbody fusion is a safe and effective surgical technique at 5-year follow-up. 8. dynamic stabilisation twenty-six patients were evaluated in a study in 2008: at 4 years the authors concluded that dynamic stabilisation could maintain clinical improvement and radiologically stability. however, this procedure did not prevent the development of adjacent segment degeneration. reviewer: dr pr engelbrecht orthopaedic surgeon wilgers consulting rooms tel: 012 807 1298/9 fax: 012 807 2639 surgical management is to be considered in patients whose symptoms are debilitating and recalcitrant to non-surgical management saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:57 pm page 62 page 64 sa orthopaedic journal autumn 2015 | vol 14 • no 1 9. lumbar interspinous spacers clinical studies are not conclusive and long-term outcomes of these devices are not known. 10. degenerative spondylolisthesis and the elderly the authors note that satisfactory clinical and radiographic success with relatively low complication rates were reported in elderly patients treated with traditional decompression and instrumented posterior fusion. age alone should not be a contra-indication to surgical intervention. this article provides an overview of surgical options available to the treating surgeon. laminectomy and posterior instrumented spinal fusion is the current standard of care and most commonly performed surgical procedure for degenerative spondylolisthesis. however, laminectomy alone, if the degenerative spondylolisthesis is stiff, should be kept in mind that the more technical the procedure becomes, the more of a learning curve there is. the authors quite correctly mention that, when deciding on appropriate treatment, the surgeon should always consider his or her familiarity with a specific technique, potential risks and benefits, consider the total expense of implants, surgical time, patient’s length of stay in hospital and time away from work. the south korean authors reported on 16 cases where cement (with or without antibiotic loading) was used as a primary salvage procedure to treat ankle joint destruction. cases included three tumours of the talus, six failed ankle arthrodeses, five failed total ankle replacements, talus fracture and infected charcot joint. nine cases had prior infection. comorbidities included diabetics, rheumatoid arthritis, renal failure and multiple open fractures. at operation devitalised infected and/or tumour tissue was removed until healthy bone was reached. concave surfaces were created proximally and distally. alignment and length was optimally maintained while the space was filled with cement. in six of the 16 patients screws were used to increase stability at the bone-cement junction. post-operatively a short cast was used for 4 weeks after which full weight bearing was allowed. in follow-up (14–100 months; mean 39 months) patients reported aofas score improvement from 39 (11–71) pre operation to 70(47–88) post operation.  at final follow-up nine of the 16 patients did not need walking aids, three used a walking cane and one a wheel chair. nine patients could walk continuously and four participated in recreational activities. comorbidities were the main factor in the less active patients. only one patient had a failed cement arthroplasty.  the authors conclude that cement arthroplasty is a relatively easy option for ankle joint destruction in less active patients. the longevity in young patients is unknown at this stage. this article highlights a valuable addition to possible procedures for a severely compromised ankle joint. cement arthroplasty for ankle joint destruction ho-seong lee, md, ji-yong ahn, md, jong-seok lee, md, jin-young lee, md, phd, jae-jing jeong, md, and yoing rak choi, md, phd investigation performed at the department orthopeadic surgery, asan medical centre, university of ulsan, college of medicine, seoul, south korea j bone joint surg am. 2014 sep 3;96(17):1468-75 reviewer: dr mm malan mediclinic c5 joubertstreet vereeniging tel: 016 422 2378 saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:57 pm page 64 page 66 sa orthopaedic journal autumn 2015 | vol 14 • no 1 delayed debridement of severe open fractures is associated with a higher rate of infection pd hull, sc johnson, djg stephen, hj kreder, rj jenkinson the bone & joint journal 2014;96-b:379–84 the adage ‘all open fractures need to be debrided within six hours’ was taught to all of us, but how true is it? this is one of many recent studies1,2 that have examined and challenged this rule. this study performed in the health sciences centre toronto, canada was done on 459 open fractures seen at this level 1 trauma centre. the authors found that while lower grade open fractures showed little increase in deep sepsis when debridement was delayed, gustilo and anderson grades ii and iii showed a 3% linear increase in deep sepsis per hour of delay. despite the traditional teaching that all open fractures should be debrided within six hours, this time constraint has never been established (or quantified) by the orthopaedic literature. this study tries to address this deficit. this retrospective study looks at all patients presenting between 2003 and 2007 with open fractures. patients who died or had amputations were excluded, resulting in 403 patients with 459 open fractures. the authors administered antibiotics on presentation and until 24 hours post-operatively. cefuroxime was the standard antibiotic given. with severely contaminated wounds gentamycin and metronidazole and penicillin were added. clindamycin was the alternative to penicillin in allergic individuals. debridement was done as soon as possible, but delays over six hours were often encountered. the timing of wound closure as well as the method of fixation was at the discretion of the treating surgeon. failure of treatment was defined as deep infection which resulted in an unplanned repeat operation for bone infection. results the mean time to starting with antibiotics was 2.4 hours, and to performing the debridement was 10.6 hours. infection was seen in 10% of cases. no grade i fractures became septic, and as a result the authors excluded these from their analysis. grade 2 fractures resulted in a 6.9% sepsis rate. this increased to 20% deep sepsis with grade iiib and c fractures. high grade fractures (>iiia) had twice the rate of becoming infected than low grade (<iiia) fractures. tibial fractures had a much higher chance of becoming infected than any other site (odds ratio of 2.44 compared to other non-tibial sites). when analysing their results the authors conclude that delay to surgery increases the risk of deep sepsis by 3% per hour. discussion the ‘six hour rule’ (time to debridement) is more an adage than a proven fact. this study shows that higher-grade open tibial fractures (gustilo and anderson 3b and c) show a much increased risk of infection. the authors claim that they can predict a non-tibial fracture would have a 2.4 per cent chance of infection, if debrided within four hours. this risk increases to 2.9% if surgery was to be delayed another six hours. in contrast, a high grade open tibial fracture, delayed for a similar period, would be predicted to experience a significantly higher infection rate. in this case, the predicted chance of the limb developing sepsis will increase from 35.6% to 43.4%! this is a higher figure than the actual 20% sepsis for high-grade fractures the authors experienced in their study, because the ‘predicted probability’ was derived by extrapolation using the more abundant data from the lowergrade open fractures. in this model only severely contaminated wounds were considered, but the debridement periods were similar. effect of delay is less significant than some other factors, such as which bone is affected. some studies have failed to show that early vs. delayed debridement make any difference.1 this study shows that that the tibia has a 2.5 times higher chance of developing deep sepsis after an open fracture compared to other bones. what are the hazards of late night surgery? the authors point out the well documented effect of surgeon exhaustion. operating on an open tibia is not particularly demanding, but this may change if plastic surgical procedures need to be done. if these types of skills are required, low grade open fractures, with minimal infection risk, may well be deferred to daylight hours the conclusion is that the tibia needs priority over other bones especially if it has suffered a high grade open fracture. lower grade open fractures, especially if they need complex plastic surgical procedures may have delayed surgery with low risk of deep infection. reviewer’s commentary any level 1 study on the question of the permissible time delay to debridement of open fractures will be unlikely to achieve ethical approval. the type of retrospective study done by hull et al. is what the orthopaedic surgeon requires for practicing evidence based medicine. this study does highlight the vast differences in infection risk between the tibia and other open fractures, and the low risk type i and ii pose regarding deep infection. although the last word regarding the six-hour rule has not been written, this study emphasises the need to prioritise high grade tibial fractures. decision makers controlling emergency list allocation can safely delay lower grade open fractures, particularly if they are non tibial fractures. in contrast, high grade open fractures need to be given highest priority and pushed onto the emergency list above all other orthopaedic casualties. references: 1. schenker m, yannscoli s, baldwin k, ahn j, mehta s. does timing to operative active debridement affect infectious complications in open long-bone fractures? a systematic review. j bone joint surg [am] 2012;94a:1057-64. 2. pollak an, jones a, castillo rc, bosse mj, mackenzie ej. the relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma. the journal of bone & joint surgery 2010;92:7-15. reviewer: dr icm robertson dept of orthopaedics tygerberg hospital private bag x3 tygerberg, cape town tel: 021 938 5458 saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:57 pm page 66 page 68 sa orthopaedic journal autumn 2015 | vol 14 • no 1 reproducible fixation with a tapered, fluted, modular, titanium stem in revision hip arthroplasty at 8–15 years follow-up jose a rodriguez md, ajit j deshmukh, jonathan robinson md, charles n cornell, vijay j rasquinha md, amar s ranawat and chitranjan s ranawat md j of arthroplasty 2014 (sept) 29, suppl 2, pp.214-18 this retrospective study assesses the midand long-term results of titanium tapered, fluted, modular (tfmt) stems in revision hip surgery. seventy-one hips were followed up over an average of 10 years. seventy-nine per cent of the femurs had paprosky 3a or more bone loss. there were a total of eight re-operations: three for instability, two for periprostetic fractures, one for acetabular loosening, one for infection and one for a stem fracture at the modular junction. all of the stems showed distal osteo-integration, 68% showed proximal bony reconstitution, two stems subsided >5 mm and the average harris hip score improvement were 37 points with 73% of patients ambulating without a walking aid after surgery. the need for revision hip arthroplasty is ever increasing and high mechanical failure rates with cylindrical, fully porous coated cocr stems led surgeons to favour tfmt stems. this study is the longest average follow-up of these stems published to date. some reasons for re-operations: • 4.2% instability: this is comparable to other literature and all three hips had severe abductor deficiency. none of the unstable hips subsided. • there were two intra-operative fractures which were treated with cabling and re-implantation with no problems afterwards. • one implant fracture 3 years post-operatively: the fracture site was just proximal to the most proximal area of distal osteo-integration and below the modular junction. this was one of the 38% with radiolucent lines around the proximal body which implies no osteointegration around the body. it also happened to be in the widest area of the stem. tips when using tfmt stems: • pre-op planning to determine the optimal site of bone fixation and estimate implant dimensions is pivotal • prophylactic cerclage cable around the most proximal circumferentially intact bone. if an eto was done, this should be below the most distal eto site. it serves to prevent fracture propagation and iatrogenic fractures during reaming and implant placement. • c-arm guidance during reaming to asses endosteal contact, bypass of stress risers and anterior cortical perforation. • ream by hand and not with power • you need at least 6 cm of stem distal to your prophylactic cerclage cable. • determine the 6 cm mark on the reamer and then increase in diameter. don’t go deeper as you need to ream a cone for the stem to seat in. • choose the thickest implant possible in high bmi patients and where proximal osteo-integration is unlikely. • the study is limited by its retrospective, nonrandomised and uncontrolled nature, but it still supports the use of tfmt stems with reliable distal fixation in patients with femoral bone loss. reviewer: dr beyers oosthuizen suite 8c unitas hospital tel: 012 664 4600 high mechanical failure rates with cylindrical, fully porous coated cocr stems led surgeons to favour tfmt stems this is going to become one of the seminal articles about the anatomy of the toes. the authors, all from spain and including the late prof pau golanό, have written a very extensive review of the anatomy of the lesser toes with regard to the muscles and tendons, to give an insight as to why certain toes are more prone to certain problems. they draw attention to the fact that there have been very few well-researched reviews of this anatomy. mostly the hand anatomy has been copied to the foot. it is interesting that they do an extensive literature search and find that the best previous work on this subject was written by sarrafian in 1969. the article is richly illustrated and well and clearly written so that one can read it and understand what is going on and why certain structures are more important than others. this is not an article that can be summarised as a quick abstract, as they carefully look at the anatomical structure and highlight previously inaccurate descriptions which have crept into the literature and into text books. this is an article to be read by all registrars and should be re-read by all consultants who really want to understand foot and ankle anatomy and pathology. reviewer: jj van niekerk po box 650819 benmore 2010 tel: 011 883 1719 fax: 011 884 2349 extensor apparatus of the lesser toes: anatomy with clinical implications – topical review miquel dalmau-pastor, betlem fargues, enric alcolea, nerea martínez-franco, patricia ruiz-escobar, jordi vega, pau golanó, jordi vega foot & ankle international 2014;35(10):597–969 saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:57 pm page 68 this is a summary of an excellent review article in which 24 prospective randomised studies in b&j journal, jbjs, and j of arthroplasty from the previous year were selected. implant choice numerous studies, breeman et al., nutton et al., pijls et al. have demonstrated no difference between mobile-bearing and fixed-bearing knee implants. ‘although mobile-bearing knees have several potential theoretical advantages, the randomised controlled trials continue to demonstrate no significant differences with regard to outcome, function or survivorship due to this technology’ kim et al. compared oxidised zirconium femoral components with conventional components and found no difference in all measured outcomes and concluded that the oxidised zirconium femoral components provide no benefit and they question the additional expense of these components. jensen et al. looked at the use of trabecular metal tibial cones in revision knee replacements and concluded in their small study that these components demonstrated a trend towards improved implant stability. alignment recent debate has questioned the long standing belief that neutral mechanical alignment improves longevity of knee replacements. this is of special importance for the proponents of computer navigation. kim et al. showed navigation does not improve alignment or clinical outcome. in contrast, huang et al. saw improved neutral mechanical alignment with navigation. yim et al., however, saw no difference between navigated vs non-navigated knees. patient specific cutting guides: chareancholvanich et al. saw no specific improvement with regard to limb or implant alignment when using this technology. there is also no significant difference in the numbers of outliers, raising considerable doubt regarding the clinical relevance of this technology. intra-operative products no difference in sepsis rates between plain and antibioticloaded cement in a study of 2 948 patients, according to hinarejos et al. jules-elysee et al. demonstrated lower pain scores when intravenous hydrocortisone was given peri-operatively without increase of pain or wound healing. as only 17 patients in each arm of the study were presented the authors concluded that ‘caution should be taken until larger studies reveal that the infection rate does not rise in patients receiving perioperative hydrocortisone’. intra-operative techniques minimal invasive surgery (mis) – the overwhelming majority of studies over the last decade have failed to show significant clinical advantage in these mis techniques but did find increased rates of complications. peripatellar electrocautery – baliga et al. have shown that this technique has no benefit. tourniquet use or not – tai et al. showed significant less blood loss with tourniquet use. the inflammatory markers, crp and creatine phosphokinase were also higher in the non-tourniquet group demonstration greater injury and inflammation without a tourniquet. pain was higher, although not statistically significant when a tourniquet was used. ‘although some surgeons may feel strongly about the use or avoidance of tourniquets, it appears that these prospective randomised studies do not reveal an obvious recommendation’. pain control multimodal protocols that pre-empt pain and nausea that encourage early mobilisation have led to dramatic changes patients experience following knee replacements. periarticular infiltration of local anaesthetic has become the norm as part of pain control strategy. chia et al., studied the efficacy of additional corticosteroid infiltrations with the local anaesthetics. they saw no advantage in the group that had additional corticosteroid periarticular injections. page 70 sa orthopaedic journal autumn 2015 | vol 14 • no 1 what’s new in adult reconstructive knee surgery carl deirmengian, md; jess h. lonner, md j bone joint surg am. 2014 jan 21;97(2):169-74 reviewer: dr allan van zyl po box 28772 danhof bloemfontein tel: 051 448 3051 • saoj saoj 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(page 66) saoj (page 68) saoj (page 69) saoj (page 70) saoj (page 72) page 1sa orthop j 2019;18(1) congress proceedings 64th south african orthopaedic congress 2018 3-6 september 2018 pretoria, south africa abstracts paper 2 orthopaedic surgeon density in south africa aj dell, s gray, r fraser, m held, r dunn background:  in the era of global surgery, there are limited data regarding the available surgical workforce in south africa. methods: this aim of this study was to determine the orthopaedic surgeon density in south africa. this involved a quantitative descriptive analysis of all registered specialist orthopaedic surgeons in south africa. results:  the results showed 1.63 orthopaedic surgeons per 100 000 population. the vast majority were male (95%) with under two-thirds (65%) being under the age of 55 years. the majority of the orthopaedic surgeons were found in gauteng, followed by the western cape and kwa-zulu natal. the majority of specialists reportedly worked either full or part-time in the private sector (95%) and the orthopaedic surgeon density per uninsured population (0.36) was far below that of the private sector (8.3). conclusion:  interprovincial differences as well as intersectoral differences were marked indicating geographic and socioeconomic maldistribution of orthopaedic surgeons. this parallels previous studies which looked at other surgical sub-disciplines in south africa. addressing this maldistribution requires concerted efforts to expand public sector specialist posts as well as quantifying the burden of orthopaedic disease in both private and public sectors before recommendations can be made regarding workforce allocation in the future. paper 5 assessment of the reliability and reproducibility of the langenskiöld classification in blount’s disease j du plessis, g firth background: the langenskiöld classification is the most commonly utilised classification system for the radiological features of blount’s disease. although there is only a single study on the inter-observer variability and none found on the intra-observer variability, it is commonly used for prognostication and guiding management decisions. the aim of this study was to determine the reliability and reproducibility of the langenskiöld classification. methods:  a retrospective review of radiographs was done of patients treated for infantile and juvenile blount’s disease at chris hani baragwanath academic hospital from 2006 to 2016. there were 70 radiographs of acceptable quality which were reviewed and staged on two occasions according to the langenskiöld classification by three orthopaedic surgery consultants and three orthopaedic surgery senior registrars. pearson correlation coefficients, percentage agreements and kappa statistics were used to evaluate both the reliability and reproducibility. results: of the 70 images staged only two (2.9%) were staged the same by all six observers, and 20 (28.6%) images differed by a single stage. the consultants had 17 (24.3%) images staged the same whereas the registrars had 12 (17.1%) images staged the same. the overall kappa (κ) for all six observers showed a fair agreement at κ-value 0.24. again the consultants had a higher κ-value compared to registrars at 0.25 to 0.24 respectively. the pearson correlation showed higher agreement of 0.54 indicating a moderate agreement. the reproducibility amongst all observers was also fair with a κ-value of 0.38 overall, again with the consultants higher than the registrars at 0.48 compared to 0.26. conclusion: there was only a fair overall reliability and reproducibility amongst the six observers, with the consultants consistently more reliable and with higher reproducibility than the registrars. we recommend the langenskiöld classification be used with caution when being used for prognostication and management planning as well as when interpreting any research relying on this classification. page 2 sa orthop j 2019;18(1) paper 6 the accuracy of pre-operative digital templating in uncemented total hip arthroplasty: a single-centre retrospective review kr wiese, fw kock, ca blake, t franken background: total hip arthroplasty (tha) is considered one of the most successful surgical procedures in modern medicine. goals include pain relief, functional improvement, and restoration of normal hip biomechanics. pre-operative templating is a useful tool to aid surgeons in theatre in the choice and size of implant to use so that adequate restoration of hip biomechanics occurs. the study aims to compare the implant sizes inserted during uncemented total hip arthroplasty done at a district orthopaedic unit from 2016 to 2017 with the computer-based templated sizes determined pre-operatively. methods: a descriptive retrospective study was conducted on all patients who received elective uncemented tha. operation reports and radiographs were reviewed. standard anteroposterior (ap) view of the pelvis and proximal femur were taken pre-operatively and used for templating. the medical officer or consultant who was responsible for the patient carried out templating during the preoperative ward round. the intra-operative cup and stem size was noted and compared to the pre-operative templated radiographs saved on impax orthopaedic tools. the regional university granted ethics approval. results: 56 participants were included (30 females, 26 males), with a mean age of 55,5 years.  in 71,4% (n=40; p<0.001) there was a difference  ±1 implant size between the templated cup size and the actual cup size used. in 78,6% (n=44; p<0.001) there was a difference ±1 implant size between the templated stem size and the actual stem size used. conclusion: the results of the study are promising with over 70% of the participants having a cup or stem size inserted that was ±1 implant size templated. templating is an accurate tool to guide inexperienced surgeons with implant sizing. we hope to progress to a stage that only the required sized implants need to be ordered, resulting in lower transport and admin costs. paper 9 efficacy of periarticular local anaesthetic blocks in total knee arthroplastya move towards the simplification and standardization of peri-articular infiltration m van heukelum, c blake, g gobetz, t franken, n ferreira, m burger background: peri-articular injections (pai) in total knee arthroplasty offer affective analgesia, are cost effective, safe and easy to perform. currently there is no prescribed technique in performing the infiltration; this is highlighted by the significant heterogeneity in the literature surrounding pai.this study aims to investigate the effectiveness of the technique and contribute towards the simplification and standardization of pai. methods: a double blind randomized control trial compared the effectiveness of pai with a simple anaesthetic solution (bupivacaine and adrenalin) to a normal saline control group. infiltration volumes were calculated at 1ml/kg and the infiltration technique followed a specific protocol. post-operative outcomes included visual analogue scores, ambulation scores, morphine use, knee range of motion and time to discharge. results: two comparable groups of 26 patients each were included (intervention: 80.7% female, mean age 64.73 ± 8.80 years vs control: 65.38% female, mean age 67.03 ± 7.60 years). no difference of vas scores was noted at 24 and 72 hours. mean vas scores at 48 hours were significantly lower in the intervention group. (vas score 3.0 ± 1.60 vs 4.14 ± 1.23, p=0.013). the other parameters measured strongly favoured the intervention group but did not prove to be significant. conclusions: a simplified dose per kilogram peri-articular injection protocol provides a significant reduction in vas scores at 48h hours after total knee arthroplasty. this study contributes towards the simplification and standardization of the peri-articular infiltration technique paper 11 partial versus total knee replacement for isolated patello-femoral arthritis: no functional difference at a minimum 8 years follow up rj immelman, nd clement, t howard, d macdonald, jt patton, g lawson, r burnett background: the primary aim of this study was to compare the midterm knee specific functional outcome of partial compared with total knee replacement (tkr) for the management of patellofemoral osteoarthritis. the secondary aims were to compare length of stay (los), general physical and mental health improvement, patient satisfaction and implant survival between partial compared with tkr. patients and methods: fifty-four consecutive patients undergoing an avon patellofemoral replacement were identified retrospectively from an arthroplasty register held at the study centre. propensity score matching for age, gender, comorbidity and pre-operative function was performed to match a cohort of 54 patients undergoing a tkr for patellofemoral osteoarthritis. los was recorded prospectively in the database. the oxford knee score (oks) and the short form (sf-) 12 were collected for all patients pre-operative, one year and final follow up (mean 9.2 years). patient satisfaction was assessed at one year and final follow up. survival of the implant was assessed, which was defined by revision or intension to revise. results: there was no significant difference in the oxford knee scores (p>0.60) or sf-12 scores (p>0.28) between the groups at page 3sa orthop j 2019;18(1) one year or at final follow up. at one year there was a trend towards a higher rate of satisfaction for the avon group (88.9% versus 81.5%, p=0.21), however at final follow up the tkr group was significantly less likely to be satisfied with their knee (95.1% versus 78.3, odds ratio 0.18, p=0.03). length of stay was significantly (p=0.008) shorter for the avon group when compared to the tkr group (difference 1.8, 95% confidence intervals 0.4 to 3.2 days). there were five revised prostheses in the avon group and one in the tkr group. the 5 and 10 year survival for the avon group was 94.2% (95% ci 90.6 to 97.9) and 92.3% (95% ci 87.1 to 97.5) and for the tkr group was 100% (95% ci 95.6 to 100) and 100% (95% ci 93.8 to 100), respectively. there was no statistical difference in the survival rate between the groups (log rank p=0.10). conclusions: the avon patellofemoral replacement for the management of end stage osteoarthritis has a functional outcome equal to that of tkr and in addition is associated with a greater rate satisfaction and a shorter length of stay. however the benefits of the avon need to be balanced against the increased rate of revision at 10 years when compared to tkr. paper 12 optimising perioperative care for hip and knee arthroplasty in south africa: a delphi consensus study mb nortje, u plenge, lc marais, kd jordaan, r parker, n van der westhuizen, jf van der merwe, j marais, wv daniels, gl davies, t pretorius, c solomon, p ryan, am torborg, z farina, r smith, c cairns, h shan background:  a structured approach to perioperative patient management based on an enhanced recovery pathway protocol facilitates early recovery and reduces morbidity in high income countries. however, in low and middle income countries (lmics), the feasibility of implementing enhanced recovery pathways and its influence on patient outcomes is scarcely investigated. to inform similar practice in lmics for total hip and knee arthroplasty, it is necessary to identify potential factors for inclusion in such a programme, appropriate for lmics. methods:  applying a delphi method, 33 stakeholders (13 arthroplasty surgeons, 12 anaesthetists and 8 physiotherapists) from 10 state hospitals representing 4 south african provinces identified and prioritised i) risk factors associated with poor outcomes, ii) perioperative interventions to improve outcomes and iii) patient and clinical outcomes necessary to benchmark practice for patients scheduled for primary elective unilateral total hip and knee arthroplasty. results: 30 of the 33 stakeholders completed the 3 months delphi study. the first round yielded i) 36 suggestions to preoperative risk factors, ii) 14 (preoperative), 18 (intraoperative) and 23 (postoperative) suggestions to best practices for perioperative interventions to improve outcomes and iii) 25 suggestions to important postsurgical outcomes. these items were prioritised by the group in the consecutive rounds and consensus was reached for the top ten priorities for each category.   conclusion:  the consensus derived risk factors, perioperative interventions and important outcomes will inform the development of a structured, perioperative multidisciplinary enhanced patient care protocol for total hip and knee arthroplasty. it is anticipated that this study will provide the construct necessary for developing pragmatic enhanced care pathways aimed at improving patient outcomes after arthroplasty in lmics. paper 13 unstable ankle fractures is there a difference between using a locked intramedullary fixation compared to anatomically contoured plating dlrhs badenhorst, ips terblanche, m burger background: ankle fractures represents a major proportion of orthopaedic trauma workload. the gold standard treatment is open-reduction-internal-fixation with plate-and-screws but skin complications are reported to be as high as 30%. fibular nails are a potential alternative technique for fixation of the lateral malleolus. the aim of the study was to evaluate whether the fibula nail can be used to effectively maintain reduction of an unstable weber b and c ankle fracture and cause less soft tissue complications.  methods: all ankle fractures presenting to a tertiary referral centre were randomised into two groups: i) patients receiving plate-andscrew fixation (pg, n=26) or ii) patients receiving intramedullary nail fixation (ng, n=37). post-operatively, patients were followedup at 2-weeks, 6-weeks, 3-months, 6-months and 1-year recording measurements and functional scores. (sun hrec s13/10/202) results: general characteristics between groups were similar (p>0.05).the pg consisted of 84.6% (52.4% unstable syndesmosis) weber b and 7.7% (4% unstable) weber c vs the ng which had 56.8% (52.4% unstable) weber b and 37.8% (81.8% unstable) weber c fractures. the posterior malleolus were involved in 76.6% of the pg and 75.7% of the ng. the scar sizes of the pg and ng were 10cm and 1.5cm whilst operating time was 51.7 ± 9.2 min and 46.8 ± 14.3 min, respectively. screening time for pg and ng 0.4min and 0.6min, respectively. a single deep infection required plate removal after union in the pg. using the olarud-molander scoring system, a significant difference (p<0.001) at 6-months post-operative with the ng having increased range-of-motion was observed.  conclusion: there was an improved cosmetic outcome when comparing plating and nailing. additionally, at 6-months postoperatively the functional outcome of the ng was significantly better than the pg. the nail proved to reduce and maintain unstable ankle fractures as well as plating does with minimal risk of post-operative infection. page 4 sa orthop j 2019;18(1) paper 14 lost to follow-up: challenges to conducting orthopaedic research in south africa dlrhs badenhorst, m burger, n ferreira background: loss-to-follow-up presents a major concern for treating physicians and researchers. the aim of this study was to describe potential factors contributing to the loss-to-follow-up experienced in orthopaedic patients attending the sole public orthopaedic service provider within the northern cape province in south africa. methods: patients who underwent ankle fracture surgery at kimberly provincial hospital were included in this study. demographic information of all patients that were admitted for ankle fracture surgery between january 2012 and july 2013 were captured and reviewed. (ecufs nr 50/2012) results: two-hundred-and-sixty-eight patients (male: n=112 (42%); female: n=156 (58%)) were included in this study between january 2012 and july 2013 after admission to kimberly provincial hospital for surgical intervention. the mean age was 42.3 ± 13.8 (95% ci 40.6 – 43.9, n=266) years and the mean bmi was 28.0 ± 6.5 (95% ci 27.2 – 28.8, n=251) with the bmi of females being 30.2 ± 6.1 (95% ci 29.3 – 31.2, n=152) compared to the 24.6 ± 5.7 (95% ci 23.4 – 25.7, n=99) of male patients. excluding the local patients residing in kimberly (n=77) within 5km travel distance, the mean travel distance increased to 460km, ranging from 10 –  910km. significantly associations between the number of follow-up visits attended and i) travel distance (irr 0.999 (95% ci 0.999 – 1.000), p=0.030), ii) bmi (irr 0.980 (95% ci 0.966 – 0.994), p=0.004) and iii) hiv status (irr 0.841 (95% ci 0.725 – 0.975), p=0.022) were observed. conclusion: research in the south african setting is hindered by loss to follow up in the public setting. increased travel distance, financial constraints and lifestyle habits contribute to the complexities of follow-up. a future, multi-center approach could potentially provide an improved strategy in protocol planning to accommodate for these factors to improve our patient follow-up and related research quality. paper 15 an epidemiology of paediatric cervical spine injuries in red cross war memorial children hospital over a 10-year period l noconjo, a horn background: to characterise cervical spine injuries at level one referral centre for paediatric trauma and to report on outcome of cervical spine injuries (csi) in paediatric patients. methods: we performed a retrospective study of cervical spine injuries in red cross war memorial children’s hospital over a 10-year period. picture archiving and communication system (pacs) of our institution’s radiological services was searched for patients with c-spine injuries as the diagnosis is invariably radiologically confirmed. search terms included: c-spine fracture, subluxation, dislocation, contusion, sciwora. patient demographics, date and cause of injuries, management, level of injury and outcome data was obtained from hospital records. these variables were compared for children less than 8 and more than 8 years due to anatomical, biomechanical difference. results: there were 66 children identified with csi, overall incidence was 0.1%. the mean age of the study group was 7 (4-8.8) and 65% were females. all injuries were caused by blunt trauma and passenger mva (52%) was the most common cause. injuries due to physical child abuse, recreational or sporting activities did not occur. children under 8 years of age incurred more injuries than children who were more than 8 years (74.2%, age <8; 25.7%, age >8). majority of injuries occurred in the upper c-spine of children <8 years (98%). of the 23 (35%) children with neurologic injury, 8 (12.1%) children had complete spinal cord injury and 3(4.5%) died. sciwora occurred in 6 (9%) children with variable outcome. due to instability 10.6% children were surgically managed. an injury severity score (iss) of 25 (13-34) was associated with poor outcome. there was a mortality rate of 4.5% and all children who died were below 8 years with injuries in upper cervical spine (c1c4). conclusion: the majority paediatric csi occur in upper cervical spine of children younger than 8 years. the aetiology and injury pattern are similar to reported literature. upper cervical spine injury with closed head injury was associated with poor outcome paper 16 talus replacement case series dma abramson, g mcollom, t hilton, m abramson background: there are currently no internationally accepted surgical options for complex talus trauma or tumours that offer good long term outcomes. tibiotalar or tibiocalcaneus arthrodesis, considered the gold standard, has a reported high incidence of non-union and poor patient satisfaction. alternative options have been explored, including the total talus replacement.  reports in the literature have been limited to two single case reports. both cases demonstrated encouraging early results, but due to the lack of any larger studies, it is considered a novel operation. we wish to present the medium term results of a case series of patients who have undergone a total talus replacement. methods: we performed a retrospective review of a case series of patients that underwent total talus replacement.  cases were included with a minimum of 6 months follow up.  we used the american society of foot and ankle score (aofas) and the short form health survey (sf-36) scoring systems as our outcome measures.  we also recorded complications.  we  used descriptive statistics to analyse our results. results: eight cases were included with a minimum of 6 months follow up.  median follow up was 6-36 months.  no cases were excluded.  indications included complex trauma in 2, post traumatic complications in 5 and an infiltrative tumour in 1. no talus page 5sa orthop j 2019;18(1) replacement was revised during the study period.  patient reported outcome measures showed good return to function and foot and ankle scores with a low complication rate. conclusion: total talus replacement shows encouraging medium term results in a variety of indications with an acceptable rate of complications. longevity and long term function is yet to be established. paper 17 prevalence of a post-operative troponin leak in patients with cardiac risk factors undergoing knee and hip arthroplasty in a south african population rd van zyl, mc burger, jd jordaan background: determining the prevalence of a post-operative troponin leak in patients with different cardiac risk factors undergoing hipor knee arthroplasty and investigating differences in troponin t levels between co-morbidities and different types of arthroplasty i.e. total hip replacement (thr), total knee replacement (tkr), and neck of femur fracture hip replacement (nofhr) methods: a prospective, cross-sectional study of patients with ≥1 cardiac risk factor, undergoing replacement surgery and treated at a tertiary academic hospital in south africa from october 2017 – april 2018 conducted. troponin t levels of all included patients were recorded on day one and three post-surgery using a highly sensitive cardiac troponin t assay (ctnt-hs). a level of > 15ng/l is considered abnormal and termed a positive troponin leak and >100ng/l is suspected in acute coronary syndrome (a.c.s.) (sun hrec s17/02/042) results: one-hundred-and-sixty-two patients (n=68 thr; n=55 nofhr; n=39 tkr) were included.  sixty-eight patients (42%) recorded a positive troponin leak of which six cases had a suspected a.c.s. the highest prevalence was recorded in nofhr (62%) followed by tkr (46%) and thr (24%) conclusion: many patients undergoing arthroplasty surgery have multiple co-morbidities putting them at risk for myocardial injury after non-cardiac surgery (mins). mins is often a silent event estimated at 40% internationally which, with a 4-times raised morbidity and mortality risk, carries a poor prognosis at 30-days, 6-months and 1-year post-surgery. post-operative troponin testing, a cost effective measure, is imperative to diagnose mins, subsequently increasing early detection, medical optimisation, referral and prevention strategies. there is currently no published data on mins prevalence in orthopaedic specific patients in south africa. our finding of 42% positive troponin leaks raises awareness and we recommend routine post-operative troponin t testing for arthroplasty units in south africa. paper 18 outcomes of open reduction internal fixation of femoral neck fractures: a three-year audit at central academic hospital g pienaar, k jordaan, m burger background: femoral neck fractures, resulting from low or highenergy trauma, are common in patients of all ages. open reduction and internal fixation (orif) is the treatment of choice for younger patients. in elderly patients, orif is only considered in stable fracture patterns. the primary purpose of our audit is to evaluate the cohort of femoral neck fractures treated with an orif at our hospital and compare our outcomes and complications with what is available in the literature. methods: a retrospective audit was done of all adult patients with femoral neck fractures treated with an orif at a single academic hospital from january 2015 to december 2017. data captured was: demographics, mechanism of injury, time to admission and surgery, type of fixation constructs, complications and re-operation rate. ethics reference #: n18/03/029 results: a total of 108 patients (69 males and 39 females), with a mean age of 53 years (range 19–95) were included. of these, 45 patients (42%) sustained a high velocity injury, with 63 (58%) sustaining low velocity injuries. average time from injury to admission was 58 hours, with average time to surgery being 81 hours. cannulated hip screws were used in 41 patients (38%), with dynamic hip screws in 65 patients (60%) and 2 (2%) cephalomedullary nails. a total of 56 patients (52%) achieved union, 17 patients (16%) complicated by failure and 35patients (32%) were lost to follow up. conclusion: there are no published studies describing the burden of femoral neck fractures and the outcomes of treatment in south africa. multiple surgical fixation techniques were used to treat different age group patients and pathology and subsequently, treatment protocols and modalities varies substantially. we report a high rate of complications in our patients, but it remains comparable with international data. paper 19 proximal fibular resections for primary bone tumours: functional results of a case series kr wiese, v boskovic, k hosking, t hilton background: resection of aggressive benign or malignant tumours of the proximal fibula are difficult due the high number of surrounding anatomical compartments and close association with many important neurovascular and functional structures. for the same reasons malignant tumours behave differently in this area. before the 1980’s results were poor. with the introduction of neo-adjuvant chemotherapy and limb salvage surgery, malawer described a technique of local en bloc resection. this study presents the oncological and functional results of a case series using this technique. page 6 sa orthop j 2019;18(1) methods: a retrospective folder review of fourteen patients was done. six patients with a large active, an aggressive benign or a low grade malignant tumour had a malawer type i marginal resection and eight patients with a stage iib malignant sarcoma had a malawer type ii wide intracompartmental resection sacrificing the common peroneal nerve. the follow-up at a mean of 48 months included the imaging, histology and a functional msts score. results: the median age of the type i resections was 42 years, giant cell tumour was the commonest tumour (50%) and the median functional msts score at follow-up was 29. the median age of the type ii resections was 12 years, osteoblastic osteosarcoma was the commonest tumour (75%) and the median functional msts score was 26.  all type ii resections achieved clear margins at the initial surgery and there were no recurrences or metastases in both groups. there were no wound complications and no vascular complications in spite of sacrificing the tibialis anterior artery in some type i and all type ii resections and the peroneal artery in type ii resections. no patient complained of knee instability. the main functional impairment was due to loss of common peroneal function which required an afo in some patients and a tibialis tendon transfer in one patient. conclusions: resection of benign and malignant tumours of the proximal fibula achieved good cure rates and functional results, despite the sacrifice of the common peroneal nerve. paper 20 wear patterns of medial and lateral compartments in the knee cr oosthuizen background: the degenerative knee presents to the clinician at a specific stage with pain, deformity and loss of function being the dominant symptoms and signs. the stage varies in any patient cohort and thus the need to evaluate the constitutional degenerative wear pattern and stage of wear to consider the treatment modality. various authors researching the partial knee replacement evaluated the tibia wear pattern. this was necessary to determine whether the knee suitable for unicompartmental knee arthroplasty (uka) presents with a focal or a pre-determined tri-compartmental progressive disease. the research concluded that the constitutional wear pattern will continue after the definitive arthroplasty as the erosion repeated itself when the fixed bearing wear surfaces were compared with the initial wear erosion. constitutional alignment or misalignment can impact on progression of osteoarthritis (oa) if a moderate kellgren & lawrence grade iii wear is evident as this increases the loading force on damaged areas. aims and objectives: to assess the wear patterns found on the tibia resection in pka. methods: the resected tibial specimens of 1597 partial knees were evaluated when harvested from unicompartmental knee operations. the specimens were photographed by the pathologist and filed. 1366 medial and 231 lateral plateaus. the tibial plateau surface was divided in three sections and the dominant wear area assessed and charted. the medial partial knee wear patterns were then compared with the lateral wear patterns. results: the medial wear area is predominantly anterior and central (92%) with 5.7% incidence of posterior wear. the lateral wear area is predominantly central and posterior (93.1%) with 5.6% incidence of anterior wear. conclusion: the anterior-medial wear pattern is the inverse of the posterior-lateral wear pattern. posterior wear was found with an intact acl. paper 21 the results of anterior cruciate ligament (acl) reconstruction and unicompartmental knee arthroplasty (uka) cr oosthuizen background: a comparison of uka without acl reconstruction, uka with acl reconstruction and bicondylar uka according to the oxford knee scoring method methods: the study reviewed a total of 1629 uka cases over 217 months (2000-2018). uka with acl reconstruction accounted for 1.7% (n=28) over a period of 141 months and bicondylar uka with/without acl reconstruction accounted for 0.37% (n=6) over 35 months. results: 1595 uka cases with average age of 65 at the time of the operation. majority of 51.7% females (n=825) at average age 65 and 48.3% males (n=770) at average age of 65. the average oxford knee score increased from 21 at pre-operation to 40 after 4 months post-operative. 28 acl reconstruction cases with average age of 56 at the time of the operation. majority 85.7% males (n=24) at average age 56 and 14.3% females (n=4) at average age of 55. the average oxford knee score increased from 28 at pre-operation to 41 after 4 months post-operative. 4 bicondylar uka cases with acl reconstruction with average age of 53 at the time of the operation, consisted of only males. 2 bicondylar uka cases without acl reconstruction with average age of 58 at the time of the operation also consisted of only males. the average oxford knee score increased from 26 at pre-operation to 40 after 4 months post-operative. conclusion: the oxford knee scoring for acl reconstruction as well as bicondylar arthroplasty with/without acl reconstruction had similar improvement from pre-operation to post-operative than the uka as indicated above. page 7sa orthop j 2019;18(1) paper 22 validation of kogs (knee osteoarthritis grading system) cr oosthuizen background: the knee osteoarthritis grading system (kogs) is a newly developed x-ray based tool to evaluate the knee for specific arthroplasty surgery. the presented x-ray assessment is to improve the decision when arthroplasty is considered and distinguish between the need for partial knee arthroplasty (pka) or total knee arthroplasty (tka). objectives: to classify and differentiate knee degeneration suitable for arthroplasty. to determine the efficacy of the newly developed x-ray based tool. methods: the efficacy of kogs was validated by independent practitioners. a cohort of complete pre-operative x-ray sequences of postsurgical knees was compiled. cases where desired sequences of x-rays were not available were not included. x-ray sequence method based on standard pre-operative x-rays (6 views): ap and lateral knee views and 30o  skyline patella view, 15o  (medial oa) and 45o (lateral oa) rosenberg/lyon views and stress views in 20o  of flexion. the x-ray sequences were produced as routine requirement at a single radiological facility with no involvement by clinician. the set of x-rays per case were anonymised and presented to selected orthopaedic surgeons to assess (evaluate). results: the evaluator’s kogs assessment is compared to the actual arthroplasty performed by the clinician. conclusion: the comparison establishes the validity of kogs and whether kogs as a grading system can suggest the suitable arthroplasty. paper 23 management of acetabular bone loss following infected osteosynthesis i swart, j van der merwe background: deep infection following orif of an acetabular fracture is a rare but devastating complication. aggressive debridement of dead bone and removal of infected hardware is the best treatment option and can lead to extensive peri-articular bone loss. methods: a retrospective descriptive study was done to describe five such patients, successfully treated with a two-stage procedure. the final reconstruction made use of the tmars (trabecular metal acetabular revision system) (zimmer biomed) for the acetabular reconstruction part of the total hip replacement. results: there were 3 males and 2 females treated from 2011 – 2016. all five patients presented with extensive posterior segmental acetabular defects (paprosky type 3a) and required the use of augment buttress plates screwed onto the ilium and tmt revision shell. follow up period is 6 months to 6 years. preoperative harris hip score showed an average of 39.1 compared to 74.3 at the follow up. no further clinical, biochemistry or x ray evidence was found to indicate recurrent infection or loosening.  conclusion: although this is a small series of patients, it is unique in the literature and describes a successful treatment option for such a complex problem. paper 24 the reuse of circular external fixator components: an assessment of safety and potential savings ss swanepoel, m held, m laubscher background: to determine the cost saving and mechanical failure associated with the reuse of circular external fixation components. methods: a retrospective review of a prospectively collected database was undertaken to identify all adult patients treated with ring fixators between january and december 2017.  the indications for and average duration of external fixation was determined for each patient.   the cost of each frame was calculated from the company invoice for the new components used.  cost saving was calculated as the difference between the price for a complete new frame and the amount invoiced for the new components only in a re-used frame.  we also determined mechanical failure events associated with the reuse of these components. results:  a total of 34 lower extremity circular frames were applied during the study period.  the average duration of external fixation was 36 weeks.  the cost of an all new component external fixator frame was r56 000 during the study period.   using re-used components led to a significant cost saving of r34 000 per case.  no mechanical failure of any of the re-used components occurred during this study. conclusion:   the majority of circular external fixators are used for an extended period of time. given the considerable expense associated with new external fixation frame components, the practice of reusing external fixators components is safe and resulted in significant cost saving to our institution and should be supported. page 8 sa orthop j 2019;18(1) paper 25 water wise hand preparation: the true impact of our practice msw potgieter, m burger, a ikram, a faisal background: the western cape is experiencing the worst drought in decades. considering the low dam levels and little rain fall, every possible method of water saving must be applied. we investigated water usage during scrubbing for surgical procedures and possible interventions to reduce water consumption. aim:  determine water consumption during scrubbing procedures and the effect of easy-to-implement, cost effective yet efficient ways to reduce water usage during scrubbing. secondary aims include: gaining insight into the surgeons’ knowledge of water use/ saving methods and their experience of water saving strategies. methods: a two-phase observational study was performed on orthopaedic theatre personnel scrubbing for theatre cases at our institution.  phase one evaluated standard practice to establish a control group. phase two implemented three water reducing strategies. group a) adjusted tap levers to improve tap control; group b) an assistant to open and close tap during preparation; and group c) alcohol-only-preparation. total water usage and time at basin was recorded for each scrub. participants completed a questionnaire to establish their experience of the various preparation techniques. approval was obtained from our hospital and ethical board. results:  the control group used a mean 5,64 l/scrub (n=36; sd=1.79) at a mean flow rate of 2.19ltr/min(sd=0.89). significantly lower water usage per scrub(p=0.00015) and lower flow rates (p=0.000158) were recorded for group a(n=12;1.93ltrs@ 0.73l/min) and group b(n=13;2.29ltr@1.36l/min). the lowest total water consumption recorded in group c (n=18; < 2.9ltr per case). eight(8/10) participants claimed to be aware of who guidelines for hand preparation in water scares environments, yet only one(1/10) routinely used an alcohol-only hand preparation technique conclusion:  water use for surgical hand preparation can be significantly reduced by implementing simple cost effective measures. this study strongly recommends intermittent tap closure or alcohol based scrubs for hand preparation. paper 26 the relationship of the radial line to the capitellum in normal paediatric elbows f omojowo, a robertson, d simmons background: the radiocapitellar line (rcl) is a vital tool routinely used in the evaluation of the elbow, however the line has never been validated in young children. aim: to establish the relationship of the radial line to the capitellum in normal paediatric elbows and to determine if the rcl can be reliably applied in the paediatric population. methods: the radial line was drawn through the neck and shaft of the radius on ap and lateral x-rays of normal paediatric elbows. the x-rays were assessed in two age groups; group 1 (two to six years) and group 2 ( seven to fourteen years). the capitellum was divided into the middle third, outer two-thirds and outside the capitellum. the part of the capitellum intersected  by the rcl was documented. results: x-rays of 122 patients were assessed with 61 in group 1 and 61 in group 2 .of the total population, 277 of 488 rcls (57%) bisected the middle third of the capitellum, with no statistical difference in the number of rcls bisecting the middle third in both age groups (p=1.00). the radial neck line on the lateral view showed the most consistency. in group 1, the radial neck line on the lateral x-ray was the most accurate with 77% bisecting the middle third. in group 2, the radial neck line was the most accurate on lateral neck x-ray with 98.4% bisecting the middle third. conclusion: there is no difference in the accuracy of lines between the two age subgroups with the radial neck line being more accurate than the radial shaft line. the results suggest that the line is reliable in children but both the ap and lateral view must be assessed. paper 27 the outcome of first metatarsophalangeal joint arthrodesis using a locking plate: a retrospective clinical audit at a private orthopaedic practice in pretoria jg meijer, p greyling, c gräbe background:  arthrodesis of the first metatarsophalangeal joint is a relatively common and frequently performed procedure in the practice of foot and ankle surgery and has a multitude of indications. the preferred surgical technique has constantly changed in the past and is currently still evolving. one of the surgical techniques described to fuse the first metatarsophalangeal joint includes the use of a dorsal locking plate. the aim of this study was to assess the outcome of arthrodesis of the first metatarsophalangeal joint using a dorsal locking plate system. methods: we performed a retrospective clinical audit at a private orthopaedic practice in pretoria. all patients who had a first metatarsophalangeal joint arthrodesis with an acumed® locking plate system between 2010 and 2016 were identified. hallux valgus and dorsiflexion angles were measured on standing antero-posterior and lateral x-rays of the foot before surgery and compared to measurements taken on x-rays done 6 weeks after surgery. x-rays taken 6 months after surgery were assessed for any radiological evidence of non-union. an american orthopaedic foot and ankle society (aofas) score was calculated for each patient before surgery and 1 year after surgery. results:  we identified 115 patients (133 feet) who underwent arthrodesis of the first metatarsophalangeal joint with a locking plate. an observed rate of non-union of less than 2% at 6 months after surgery was recorded. the hallux valgus and dorsiflexion angles as well as the aofas score also showed statistically significant improvement after this procedure. conclusion:  the results of this retrospective study suggest that an overall positive outcome can be expected when fusing the first metatarsophalangeal joint with the use of a locking plate system. page 9sa orthop j 2019;18(1) paper 31 the use of tourniquets during total knee replacements. a review of the literature d van der jagt, r immelman background: the use of tourniquets during total knee replacements remains controversial. we reviewed the literature to determine whether it is advantageous or not to use a tourniquet during a knee replacement. methods: we searched the pubmed, medline and cochrane databases for appropriate articles. the prisma guidelines were followed to ensure only high quality studies were included. results: we determined that there was no difference in transfusion rates if a tourniquet was used or not. there is a higher rate of deep venous thrombosis with the use of tourniquets. tourniquet use may lead to a very transient muscle damage which recovers within hours. koos scores and rom were significantly better for 8 weeks post-operatively when tourniquets were not used, and patients where tourniquets were used required more analgesics. this may benefit programs with rapid discharge protocols. several studies questioned the accepted benefit of better visualization and improved cement interdigitation when a tourniquet is used. conclusion: we concluded that the current literature does not favour the use or not of tourniquets in tka’s. the use of tourniquets is safe, but there does seem to be some short-term benefits to not using tourniquets in tka’s. paper 32 intramedullary nailing of tibial non-unions not previously treated with a nail using the suprapatellar approach nhs botma, m held, s graham, m laubscher background: the incidence of tibial non-unions had been reported to be between 4-48% following tibial shaft fractures.   various treatment options are available for the treatment of non-unions.  for non-unions with a tibial nail in situ, an exchange nail is the treatment of choice if not septic.  for non-unions following other treatment modalities, the current treatment trend includes an application of a ring fixator with or without bone grafting and a fibula osteotomy.  although very good results have been achieved with the application of ring fixators, it is not always well tolerated by the patient. the suprapatellar approach is a recent variation of the traditional infra-patellar approach for the insertion of a tibial nail. it allows insertion of the nail with the leg held in extension.  this enables easier correction of malalignment in the sagittal and coronal planes. methods: we retrospectively reviewed all cases of non-union of the tibial shaft treated between may 2016 and january 2018.  cases were included that were managed with a suprapatellar tibial nail, not previously managed with a nail and without active sepsis at time of intervention.  cases were followed up to assess rate and time to union and the incidence of complications. results: twelve cases were included.  no cases were lost to follow up.  we achieved a high rate of union.  two patients developed complications, although the treatment aim (union) was still achieved.  all cases were performed close, without opening of the non-union site.  conclusion: a tibial nail, inserted using the suprapatellar approach, is an acceptable management option for tibial non-unions, not previously managed with a nail. paper 34 incidence of spinal deformity, level of pain and physical status in adults with cerebral palsy and spastic diplegia e britz, rp lamberts, si dix-peek, ag fieggen, ng langerak background: the aim of this study was to determine the incidence of spinal deformities (scoliosis, hyperkyphosis, hyperlordosis and spondylolisthesis), pain (location, frequency and influence on daily life) and the physical status of the lower extremities in adults with spastic diplegic cerebral palsy (cp), who had multiple orthopaedic surgeries, with the first surgery more than 15 years before. methods: thirty adults (18 females) with spastic diplegic cp were recruited for this study (hrec no: n10/05/181). all participants were assessed by an orthopaedic surgeon (sd) and a physiotherapist (nl). in addition to the consult and physical exam, spinal x-rays were taken and participants completed the oswestry disability index (odi) questionnaire. results: the median time after the first orthopaedic intervention was 27 years (iqr: 21-33years). x-rays revealed that 31% (28% mild; 3% severe) of the participants had a scoliosis, 7% had a thoracic hyperkyphosis, 17% had a lumbar hyperlordosis, while in 3% of the patients a spondylolisthesis was found. three-quarters of the patients reported back pain, however, based on the odi, 77% indicated that this led to only ‘minimal disability’, while  6% reported ‘moderate disability’ and 3% ‘severe disability’. the physical examination showed limited range of motion in mainly hip and knee extension and dorsal flexion of the foot. strength was most commonly reduced in hip abduction (in 60% of participants), hip and knee flexion (43% and 48% respectively). increased muscle tone was mainly seen in knee extension (83%), while selectivity overall was pretty good. conclusion: a relatively high number of adults with cp have spinal deformities with mild scoliosis being the most common. although this and the fact that most adults reported some level of back pain, did not lead to moderate or severe disability in most participants.   page 10 sa orthop j 2019;18(1) paper 35 “out with the old and in with the new” paediatric atlanto-axial fusion evolution of technique ak swan, r dunn background: a number of techniques are available for stabilization of the occipito-atlanto-axial spine from traditional uninstrumented fusions requiring halo immobilization to instrumented techniques. in the paediatric group surgeons have avoided instrumentation due to safety concerns. aims: to review our experience of paediatric occipito-atlanto-axial fusions in terms of indications, surgical technique and outcomes.  methods: a retrospective review of a single surgeons’ prospectively maintained database identified 43 consecutively managed paediatric patients undergoing atlanto-axial fusion with some extended to the occiput. baseline demographic data, underlying pathology, indications for surgery, surgical technique, surgical parameters and intraoperative complications were collated. preand post-operative radiology was used to assess implant placement and union.  case notes were reviewed for any post-operative complications. results: the most common indications for surgery were trauma (16 patients), os odontoidium (11 patients), and atlantoaxial rotatory subluxation (6 patients). of the 43 patients, 15 with a mean age of 7.5 years (range 3.8-13.8 years) were managed with uninstrumented fusion and halo immobilization. twenty-eight patients with a mean age of 9.9 years (range 2.2-17.8 years) were managed with rigid internal fixation using a combination of harms technique, occipital skull plate, c1 lateral mass screws, c2 pedicle screws or c2 translaminar screws. the implant group demonstrated the ability to reduce the atlanto-axial joint and c0-c1 deformity when required. in both groups there was one stable fibrous fibrous non-union and one non-union. conclusions: uninstrumented fusion remains an option, but the extensive external immobilization can be safely obviated with spinal instrumentation, allowing immediate mobilization and low nonunion rate. despite the paediatric anatomy, the c1 and c2 screws can be safely and predictably placed. paper 36 low dislocation rates achieved with dual mobility cup as treatment for neck of femur fractures lj erasmus, fj van der merwe, ff fourie background: total hip replacement (tha) for intracapsular neck of femur fractures (nof) have a 9% dislocation rate, and a five times higher risk for dislocation compared to patients with osteoarthritis. using a dual mobility cup (dmc) has been shown effective in negating this problem. the study aimed to determine the dislocation rate of the dmc for this patient group. methods: a retrospective study was done on 124 patients treated with dmc-tha for an intracapsular nof from 2006 until 2016. a minimum one year follow up period was required for inclusion into the study. the number of dislocations were noted. in cases where dislocation occurred, additional data was collected to determine the cause of dislocation. results: 113 patients with a mean age of 63 years were included (64 females and 49 males). all patients were operated via the posterior approach. in total there were there were 2 posterior dislocations (1,77%). both patients had additional patient as well as surgical risk factors for dislocation. conclusion: low dislocation rates (1,777%) can be achieved using dmc-tha in the management of intracapsular nof fractures. this compares favourably to conventional tha with a dislocation rate of 9%. paper 37 patient factors affecting outcome following morton’s neuroma excision: a prospective study v bucknall, d rutherford, d macdonald, h shalaby, j mckinley, sj breusch background: patient reported outcomes and satisfaction scores following excision of interdigital morton’s neuroma have been recently established. however, little is known regarding what patient factors affect these outcomes. this is the first and largest prospective study to determine which patient factors influence surgical outcome following morton’s neuroma excision. methods: over a seven-year period, 99 consecutive patients (112 feet) undergoing surgical excision of morton’s neuroma were prospectively studied. 78 patients were female with a mean age at operation of 56 years. patient recorded outcomes and satisfaction were measured using the manchester-oxford foot questionnaire (moxfq), short form-12 (sf12) and a supplementary patient satisfaction survey three months pre and six months postoperatively. patient demographics were recorded in addition to comorbidities, deprivation, associated neuroma excision and other forefoot surgery. results: obesity, deprivation and revision surgery proved to statistically worsen moxfq outcomes post-operatively (p=0.005, p=0.002 and p=0.004 respectively). deprivation significantly worsened the mental component of the sf12 (p=0.043) and depression the physical component (p=0.026). no difference in outcome was identified for age, sex, time from diagnosis to surgery, multiple neuroma excision and other forefoot surgeries. 23.5% of deprived patients were dissatisfied with their surgery compared to 7% of the remaining cohort. conclusions: patient reported outcomes following resection of symptomatic morton’s neuroma are shown to be less favourable in those patients who display characteristics of obesity, depression, deprivation and in those who undertake revision neuroma resection. surgery can be safely delayed, as time to surgery from diagnosis bears no impact on clinical outcome.  page 11sa orthop j 2019;18(1) paper 43 septic sequelae in total knee replacements after anterior cruciate ligament reconstructions: a case series and a review of the literature d van der jagt, k sikhauli, r kgabo, kr van der jagt, jrt pietrzak, lmokete background: we report a series of cases of septic knee replacements after previous anterior cruciate reconstruction surgery. the purpose of this study was to identify common factors leading to the septic sequelae and suggest methods to prevent them. methods: we reviewed the clinical records of the patients. results: the interval between index acl surgery and the tka ranged from 10 to 32 years. there was no correlation between the method of acl reconstruction and the subsequent septic sequelae at the time of the tka. in all cases there were no positive haematological markers suggestive of underlying infection prior to the tka. there was no consistency with regards to the infective bacteriology.a review of the literature was done revealing a paucity of reports on the subject. this though revealed that there is a significantly higher incidence of septic sequelae with knee replacements after a previous acl reconstruction. we also report on three cases who had had a previous acl reconstruction, where targeted investigations prior to a tka were done. conclusion: findings from the septic knee replacements together with those from the targeted investigations have led to the development of protocols to reduce the incidence of septic tka’s after previous acl reconstructions. paper 44 surgeon operated spinal cord monitoring in spinal deformity surgery: a review of transcranial motor evoked potentials monitoring rs magampa, r dunn background: spinal deformity surgery carries a risk of neurological injury. neurophysiological monitoring allows early identification of intraoperative cord injury and early intervention.  although multimodal monitoring is ideal, resource constraints make surgeon operated monitoring a useful compromise. we present our experience of transcranial motor evoked potential (tcmep) monitoring in spinal deformity surgery. methods: a retrospective review of a single surgeon series of 305 consecutive cases between 2010 and 2017 where tcmep monitoring was utilised.  a simple control was used by comparing upper and lower limbs.  a positive alert was defined as a 50% or more loss of amplitude with maintained upper limb signals. results: of the 305 cases, we were unable to achieve traces in 6 and proceeded with surgery without.  52 (17%) cases had globally decreased amplitudes due to anaesthetic and physiological factors (hypotension, hypothermia, anaesthetic agents) but maintained throughout the procedure. there were 24 (7.9%) alerts where 20 had complete incongruent trace signal loss, and 4 had diminished signal present. the alert group surgical indications were for progressive severe scoliosis -17, myelopathy -3, chin on chest deformity -2, rigid scoliosis and instability.  after the alert the suspected offending action (i.e. instrumentation and deformity correction) was reversed and trace amplitudes improved and or returned to base line. two patients had recurrent signal loss on re-insertion of removed rods and were left with screws in situ but uncorrected, i.e. no rod.  they woke with mild transient lower limb neurological deficit.  they were taken back to theatre 2 weeks later where moderate correction was performed without incident. no patient with normal intra-operative traces had post-operative neurological deficit. conclusion: tcmep has a 100% negative predictive value. tcmep intra-operative monitoring allows early identification of physiological cord distress and immediate intervention to minimise clinical sequelae of neurological deficit. paper 45 anatomical study of the intramedullary canal of the distal fibula: implications for treating fractures e joubert, h muller, ips terblanche, rp lamberts background: detailed anatomical descriptions of the ankle joint and more specifically the distal fibula is lacking. insight into this anatomy can help to further improve the treatment of ankle fractures and design of ankle fixation methods and devices especially intramedullary nails for the fibula. therefore the aim of this study was to determine the anatomical variability in the intramedullary measurements of the distal part of the fibula. methods:  a total of 158 patients (113 male) who received a computed tomography (ct) scan of their lower limbs at tygerberg hospital were included in the study (hrec no. s13/10/224). the anatomical profile of the distal 50mm of the lateral malleolus was studied. measurements of the intramedullary diameters in the antero-posterior and medial-lateral plane were taken. the thickness of the anterior, posterior, medial, and lateral cortex were also captured. results:  two hundred and ninety-two ankle joint computed tomography (ct) scans were studied. no anatomical differences were found between the right and left fibula measurements. average thickness medially (1.1 to 2.0 mm), laterally (1.1 to 2.0 mm) and posteriorly (1.0 2.0 mm) tended to become more with moving more distally. the average medial-lateral intramedullary diameter ranged from 6.2 to 15.5 mm, while the antero-posterior intramedullary diameter ranged from 11.0 to 22.8 mm. no correlations were found between the measurements and the age or gender of the patients. page 12 sa orthop j 2019;18(1) conclusion: no differences in cortical thickness and intramedullary diameters were found between gender, side and age. the reported anatomical variation provides important clinical insight. the distal fibula is well suited to accept the intramedullary fibula nails that are commercially available. these results can assist medical companies to further improve fibula intramedullary fixation devices. paper 46 treating unstable weber c ankle fractures in young adults with a locked intramedullary fibula nail e joubert, ips terblanche, rp lamberts background: the accepted gold standard treatment of unstable weber c   ankle fractures in adults is an open reduction and internal fixation by means of plate and screw fixation. however, this approach has also been associated with a 31% incidence of significant hardware-related pain, which will impair  most physically active young adults. therefore, the aim of this study was to determine if unstable weber c ankle fractures in young adults can also be treated with a locked intramedullary  fibula nail. methods: fourteen patients (34 ± 19 yrs) were treated with a plate and screw fixation (synthes lc-dcp), while twenty patients (29 ± 10 years) were treated with an intramedullary fibula nail (acumed) (hrec no. s12/11/270). as part of the clinical follow-up visits, x-rays were taken to assess the adequacy of reduction of the fractures, while the functional assessment of the ankle was done using the olerud and molander functional score. results: at twelve weeks post-operatively, similar reduction rates were found in the plating and nailing group. functional assessment scores in the nailing group {85 (70-93)} were significantly better than in the plating group {70 (55-75)} (p = 0.01). in line with this, lower pain scores (p=0.04), earlier return to running (p=0.03) as well as earlier return to activities of daily living (p<0.01), were seen in the nailing group. conclusion: treating unstable weber c ankle fractures in young adults with an intramedullary fibula nail seems to be a viable alternative. the finding of this study even suggests that better functionality might be achieved earlier with the intramedullary fibula nail. future research needs to establish the long-term effect of this treatment regime and establish the complication rate of both fixation methods. paper 47 results on assessment of elbow functional outcome after closed reduction and percutaneous pinning of gartland grade iii supracondylar humerus fractures in children a rutarama, gb firth background: the purpose of this study was to assess elbow functional outcome of closed reduction and percutaneous pinning of gartland grade iii supracondylar humerus fractures in children. methods: prospective cohort study with patient follow up period of 24 weeks. all patients between 5-14 years with isolated displaced supracondylar humerus fracture who presented to cmjah and chbah between the 31st april 2016 to the 31st july 2016 were included. flexion, extension, pronation and supination of the affected elbow was measured at three, six, 12 and 24 weeks after crpp using a goniometer. similar measurements on unaffected elbow were recorded to be used as a control. paediatric outcome data collection instrument (podci) was also recorded at the end of 24 weeks as an outcome instrument. results: thirty eight children were included in the study at final follow up. elbow flexion, extension, pronation and supination significantly improved (p<0.0001) by 24 weeks. at 24 weeks however, the mean elbow extension was significantly reduced in comparison with the controls (p<0.0094). patients less than seven years recovered all rom including extension more rapidly (p<0.0011) than patients older than  seven years. 80% of children achieved satisfactory podci results at 24 weeks of follow up. nerve palsy (18.4%) and severe soft tissue injuries (7.9) were the main contributory factors to poor elbow functional outcomes which largely contributed to the 20% of the children who had unsatisfactory podci results. conclusion: children with seven years and younger gained full rom and excellent functional outcome at 24 weeks after crpp. podci tool demonstrated that  functional outcome doesn’t necessarily equate to good clinical outcome. soft tissue injuries translates into poor functional and podci outcomes. protocol driven rehabilitation may be of valuve to older children with severe injuries. paper 50 open or arthroscopic lateral clavicle resection for the treatment of acromioclavicular joint arthritis? a systematic review and metaanalysis of prospective level i and ii studies e hohmann, k tetsworth, v glatt background: the purpose of this study was to perform a metaanalysis comparing open and arthroscopic surgical techniques for distal clavicle resection. methods: a systematic review of medline, embase, scopus, and google scholar identified relevant publications in the english and german literature between 1997 and 2017. all included studies were level i to iv, describing both treatments, with a minimum of 12 months follow-up, had at least one validated outcome score and documented patient recruitment, study design, demographic details, and surgical technique. studies were excluded if they were only abstracts or conference proceedings, involved revision procedures, or the loss to follow-up exceeded 20%. publication bias and risk of bias was assessed using the cochrane collaboration tools, and heterogeneity was assessed using the i2statistic. page 13sa orthop j 2019;18(1) results: four studies (n=319 patients) met the criteria for inclusion. the pooled estimate for clinical outcomes (constant, ases) demonstrated no significant differences (smd 0.323, i2= 0%, p=0.065) between open and arthroscopic resection, although the analysis favored open resection. the pooled estimate for clinical outcomes (sst) also demonstrated no significant differences (smd 0.744, i2= 49.82%, p=0.144) between open and arthroscopic resection, but the analysis again favored open resection. the pooled estimate for vas assessment of pain demonstrated no differences (smd 0.217, i2= 58.96%; p=0.404) between open and arthroscopic resection.  conclusion: the results of this study suggest that similar functional and clinical outcomes can be achieved with either open or arthroscopic distal clavicle resection. the observed trend that open resection may have a more favorable outcome warrants further investigation. paper 51 expert consensus statement on degenerative meniscal lesions using the modified delphi technique e hohmann, k shea, b arciero, r laprade, m miller, b mandelbaum, j farr, a bedi, b cole, a imhoff, n sgaglione, s rodeo, b gelbhard, j monllau, f noyes, d shelbourne, j feller, s yoshiya, d parker, a gomoll, b bach, v glatt, k tetswor background: the treatment of degenerative meniscal lesions has recently attracted substantial media attention. despite the lack of strong evidence to support operative management of these lesions, both medical journals and the lay press now generally recommend exclusively non-operative treatment. the purpose of this study was to use the modified delphi technique to produce a consensus statement on the diagnosis and treatment of degenerative meniscus lesions. methods: twenty international leading knee surgeon were asked to answer 10 open ended questions to define degenerative meniscus lesions, suggest treatment, specify the role of surgery and the anticipated outcomes of both conservative and operative interventions. the responses were further defined in round 2 and specific likert style questions were used on the responses of the two previous rounds to reach consensus. results: consensus was achieved for the following items: tears are a physiological part of aging; the onset is insidious; they occur mainly in zone 2 and 3. they are not always symptomatic and the onset is rather gradual. weight-bearing radiographs are recommended. the initial treatment should always be conservative but true mechanical symptoms may benefit from early arthroscopy. in general biologics and steroids are not helpful. chondral defects should not be ignored but microfracturing is not a good option. the outcomes with surgery vary but are poor with obesity and substantial malalignment. the majority of the panel agrees that the current evidence is poor and should be viewed cautiously. surgery may not be cost-effective but must be compared to the outcomes of conservative treatment. conclusions: the results of this delphi consensus statement suggest that there is consensus for diagnosis and treatment of degenerative meniscus lesions. paper 52 fellowship exit examination in orthopaedic surgery in the commonwealth countries of australia, united kingdom, south africa and canada. are they comparable and equivalent? e hohmann, k tetsworth, v glatt background: international migration of health care professionals has increased substantially in recent decades. in order to practice medicine in the recipient country, international medical graduates (img) are required to fulfil the requirements of their new countries medical registration authorities. the purpose of this project was to compare the final fellowship exit examination in orthopaedic surgery for the united kingdom, australia, canada, and south africa.  methods: the curriculum of the australian orthopaedic association (set) was selected as a baseline reference. the competencies and technical modules specified in the training syllabus, as well as the specifics of the final fellowship examination as outlined in set, were then compared between countries. results: of the nine competencies outlined in set, only the curriculum of the uk and south africa were compatible with the australian syllabus, and covered 97.7% and 86% respectively of all competencies and sub-items; canada mentioned 79.1% of all items.  the final fellowship examinations of australia, south africa and the uk were all highly similar in format and content. the examination in canada was substantially different, and had two written sessions but combined the oral and clinical component into a structured osce using standardized patients and the component included unmanned stations. there were no significant differences for completion certificate of training and/or board certification observed between these countries. conclusions: the results of this study strongly suggest that the final fellowship examination in orthopaedic surgery in australia, south africa and the united kingdom are compatible. between country reciprocal recognition of these fellowship examinations should not only be considered by the relevant colleges, but should also be regulated by the individual countries health practitioner registration boards and governing bodies. page 14 sa orthop j 2019;18(1) paper 53 the hamstring/quadriceps ratio is an indicator of function in acl-deficient but not in aclreconstructed knees e hohmann, k tetsworth, v glatt background: the purpose of this study was to investigate isokinetic, eccentric and isometric hamstring/quadriceps (hq) ratios in patients before and after acl reconstruction (aclr) using bonepatella-tendon grafts and to establish the relationships between hq ratio and knee function. methods: forty-four patients (mean age of 26.6 years) underwent isokinetic testing of quadriceps and hamstring muscles before and after aclr and hq ratios were calculated. lysholm, ikdc  and cincinnati scores were used to assess function. isokinetic concentric and eccentric peak torque (nm/kg) was measured at three different speeds: 60, 120 and 180 deg/sec.  isometric strength  was tested at 30 and 60 degrees of knee flexion.  results: for the isometric tests, the hq ratio between the involved and non-involved limb was not different for the acld knee (p=0.28) at 30 degree knee flexion but significant at the 60 degree flexion angle (p=0.02)  and for the aclr knees at 30 and 60 degrees (p=0.02). for the isokinetic tests, the ratio between involved and non-involved limb was significant for acl-deficient knees at both  60 (p=0.039) and 120 deg/sec ( p=0.05). there were significant differences between limbs for all speeds in aclr knees (p=0.00030.01). for the eccentric tests, the hq ratio between the involved and non-involved limbs were not significant for both the acld (p=0.19) and aclr knees (p=0.29) at the speed of 60 deg/sec. at 120 and 180 deg/sec there were significant differences between limbs for both the acld (p=0.02) and aclr knees (p=0.003). linear regression did not reveal significant relationships between cincinnati, lysholm, and ikdc scores and hq ratios in the acld (r2=  0.35, p=0.58; r2=0.34, p=0.63; r2=0.38, p=0.49). in contrast, there were significant correlations between the lysholm and ikdc scores and hq ratios in the aclr knees (r2=0.84, p=0.002; r2=0.86, p=0.001). conclusions: the findings of this study suggest that the hq ratio in acld patients was not a predictor but an indicator of patient perceived knee function following aclr. paper 54 case-match controlled comparison of minimally invasive plate osteosynthesis and open reduction internal fixation for the stabilization of humeral shaft fractures e hohmann, k tetsworth, v glatt aims and objective: to compare minimally invasive plate osteosynthesis (mipo) to standard open reduction and internal fixation (orif) for humeral shaft fractures, to determine which technique minimized complications while optimizing clinical outcomes. design: case-match controlled cohort. setting: metropolitan tertiary referral public hospital and trauma centre. patients/participants: all patients with humeral shaft fractures between april 2010 and september 2015 were identified retrospectively, and of these 31 were treated by mipo and 54 by orif. a case-matched cohort was assembled according to fracture pattern, gender, age, and comorbidities, with a total of 56 patients (28 patients in each group). outcome measurements: the complication rate was the primary outcome measure (radial nerve injury, non-union, infection, prominent implants, and re-operation). radiographic alignment and the disabilities of the arm, shoulder and hand (dash) score were secondary outcome measures. results: the cumulative complication rate was 3.6% following mipo, and 42.9% following orif (p=0.0004). the mipo group reported an average dash score of 17.0, with a mean residual deformity of 1.8 degrees in the coronal plane, and 3.0 degrees in the sagittal plane. the orif group reported an average dash score of 24.9, with a mean residual deformity of 1.0 degrees in the coronal plane, and 1.0 degree in the sagittal plane. conclusions: minimally invasive plating of the humeral shaft achieves nearly equivalent radiographic alignment, while the overall complication rate following orif was 12 times greater. compared to orif, in this cohort mipo achieved highly comparable clinical results with a dramatically lower risk of post-operative complications. paper 55 arthroscopic partial meniscectomy versus physical therapy for degenerative meniscus lesions. how robust is the current evidence? a critical systematic review and qualitative synthesis e hohmann, k tetsworth, v glatt, m cote background: the purpose of this systematic review was to investigate study quality and risk of bias for randomised trials comparing partial meniscectomy versus physical therapy in middle-aged patients with degenerative meniscus tears. methods: a systematic review of medline, embase, scopus, and google scholar was performed from 1990 through 2017.  the inclusion criteria were: at least one validated outcome score, and middle-aged patients (40 years and older) with a degenerative meniscus tear. studies with a sham arm, acute and concomitant injuries were excluded. risk of bias was assessed with the cochrane risk of bias tool. the quality of studies was assessed with the cochrane grade tool and quality assessment tool (ephpp). page 15sa orthop j 2019;18(1) publication bias was assessed by funnel plot and egger’s test. the i2 statistics was calculated a measure of statistical heterogeneity. results: six studies were included and all were assessed as having a high risk of bias. there was no publication bias (p=0.23). all studies were downgraded (low, n=5; very low, n=1). ephpp assessed one study as strong, two as moderate, and three as weak. the overall results demonstrated moderate to low quality of the included studies. the i2 statistic was 96.2%, demonstrating substantial heterogeneity between studies. conclusion: the results of this systematic review strongly suggest there is currently no compelling evidence to support arthroscopic partial meniscectomy versus physical therapy. the studies evaluated here exhibited a high risk of bias, and the weak to moderate quality of the available studies, the small sample sizes, and the diverse study characteristics do not allow any meaningful conclusions to be drawn. therefore, the validity of the results and conclusions of prior systematic reviews and meta-analyses must be viewed with extreme caution. the quality of the available published literature is not robust enough at this time to support allegations of superiority for either alternative, and both arthroscopic partial meniscectomy or physical therapy could be considered reasonable treatment options for this condition. paper 56 multiligament knee injuries in cape town medium term outcomes of delayed ligament reconstruction and conservative management m held, t makubeta, h hobbs, r von bormann background: the current recommendations for the management of multiligament knee injuries (mlki) are early, single stage ligament reconstruction with auto – or allograft, but this is not always possible in a low-resource setting. this study aimed to describe the management and evaluate the outcomes of multiligament knee injuries at groote schuur hospital in cape town, south africa.  methods: a prospectively collected database was interrogated which included all mlkis in patients managed at the knee unit at groote schuur hospital in cape town during a 12-month period, starting january 2017. patients’ folders, mri scans, and operative notes were reviewed. demographic data, information on ligamentous and associated injuries, as well as outcomes in form of range of motion and laxity were analysed. results: 35 mlkis of 33 patients (19 male, 58%) with a median age of 35 years (iqr 15) were included. 22 patients were involved in a motor vehicle accident. six patients presented with ipsilateral fractures, five patients had periarticular open wounds, 7 had an associated popliteal artery injury. a total of 28 knees were reconstructed, 16 acutely and 12 after a median delay of 12 weeks (iqr 8.5) for various reasons. in seven patients an initial planned delayed reconstruction was not done due to acceptable function and stability confirmed with stress radiographs. overall, there was no difference in range of motion, or laxity in acute or delayed reconstructions at a median follow-up of 6 months (iqr 3.3). conclusion: timing, approaches and graft choices for ligament surgery in mlkis varied widely. a planned knee ligament reconstruction was delayed in more than half of cases of which 40% (20% of all mlki) were treated non-operatively with acceptable results. a more conservative approach for mlkis could therefore be justified in our setting but needs to be tested in a larger prospective trial. paper 57 a surgical informed consent knowledge study (sicks) of surgical staff in pretoria tertiary centres mo mudau, a vlok background: informed consent is a prerequisite for all surgical and some medical procedures. it is defined as the process whereby the practitioner informs a patient about the details of a procedure considering preconditions of the patient. consent form only serves as an evidence that such conversation has taken place. methods: a survey was done amongst doctors and professional nurses working in orthopaedic, general and neurosurgery. as self-administered questionnaire was used for the research, as validated by our institutional committees. the questionnaire included information about participant’s hospital of employment, designation, years of experience and if participant ever signed or witnessed a surgical informed consent. participants were asked to list five elements of surgical informed consent, choose legal age for signing medical and surgical consent as stipulated in national health act 61 of 2003, how they deal with language and time perceived as adequate for obtaining a consent. academic meetings were used to conduct a research on doctors and handover meetings were used to conduct research on professional nurses. inclusion criteria was all doctors and professional nurses working in these 3 surgical departments. exclusion criteria was refusal to participate. results: eighty participants were involved, including professional nurses and medical doctors of all grades in orthopaedic, general and neurosurgery. seventy four percent of participants were medical doctors and twenty six percent were professional nurses. seventy percent mentioned less than three elements of consent, majority mentioned information (76%). sixty percent of participants didn’t know the correct age to sign a medical consent and 89% of participants didn’t know the legal age to sign a surgical consent. conclusion: medical professionals are not informed with regards to the medical laws of this country. more medical law education is needed at the post graduate level to empower specialists trainees and protect the patients. page 16 sa orthop j 2019;18(1) paper 58 attitudes of south african orthopaedic surgery registrars to the research based masters of medicine degree (mmed): is a paradigm shift needed? a sekeitto, m bhamjee, n patel, mt ramokgopa background:  the health professions council of south africa in 2010 incorporated the completion of a research project as a requirement for medical specialist registration. objective: to explore the attitudes and requirements of orthopaedic surgery trainees regarding the compulsory research component of their specialist training. patients and methods:  human research ethics clearance was obtained prior to study commencement. a descriptive questionnaire based study that assesses  registrar demographics,  prior involvement in research, present   research participation and  reasons for performing research, perceptions regarding   the importance of research, deterrents to research, and suggested resolutions to obstacles to research was distributed to orthopaedic surgery registrars. all responses were confidential and voluntary.  descriptive statistics were generated with ms excel. results.  six of the eight orthopaedic surgery training centres in south africa (sa) were sampled, and 46.4 % (91/196) of orthopaedic registrars completed the questionnaire. respondents identified insufficient time (80/91, 88%), deficient basic research methodology training (31/91, 34%), supervision inadequacy (31/91, 34%), lack of ongoing research within their departments (30/91, 33%), and inadequate financial resources (27/91, 30%) as significant obstacles to research. half of all respondents (50.3%, 46/91) indicated that they only performed research as a requirement of registration.  the majority of respondents (91.2%, 83/91) proposed a dedicated research rotation to facilitate the completion of the research component of specialist training. additional proposals included the mandatory completion of a postgraduate research methodology course (62/91, 68%), research supervisors with an mmed or higher postgraduate degree (59/91, 65%), and greater undergraduate research exposure (36/91, 40%). conclusion. registrars identified a lack of time, inadequate training in research and insufficient research supervision as the greatest obstacles to research. dedicated time for research, adequate training in research and upskilling of research supervisors are recommended as potential solutions to the problems encountered. paper 59 burden and profile of spinal pathology at a major tertiary hospital in the western cape, south africa s miseer, t mann, jh davis background: spinal pathology in the western cape is managed at three tertiary level hospitals, including tygerberg hospital. the tygerberg hospital orthopaedic spinal unit is responsible for the management of spinal pathology for the 3.4 million people in the hospital’s catchment area. however, the unit’s overall burden of disease and associated resource use is currently unclear. aim: the first aim was to investigate the overall burden and clinical profile of spinal pathology presenting to the tygerberg hospital spine unit over a one-year period. the second aim was to determine resource use associated with spine pathology admissions. methods: overall burden was investigated by performing a retrospective review of all patients admitted to the spine unit between 1st october 2016 and 30th september 2017. demographic and clinical data was collected and patients were assigned to one of five spinal pathology sub-groups. resource use was determined by length of hospital stay, waiting times and advanced imaging and theatre usage.the study was approved by the human research ethics committee of stellenbosch university and by the management of tygerberg hospital. hrec #/: n17/10/105 results: overall burden was comprised of 349 individual patients and 376 admissions, including readmissions. trauma (51%) and infection (24%) accounted for the majority of admitted pathology with degenerative (10%), deformity (7%) and malignancy (7%) representing fewer admissions. motor vehicle accidents (mva’s) were the primary mechanism of injury accounting for 48% of spine trauma. tuberculosis (tb) was the causative organism in 87% of spinal infections with 44% hiv co-infection.hospital resource use was considerable with 92% of spine patients requiring advanced imaging, a median operating time of 3h 36min and a median hospital stay of 19 days. infection and malignancy sub-groups had the longest waiting times for advanced imaging and theatre with a median wait of 14-16 days, accounting for approximately 62% of the typical total hospital stay. conclusions: the spine unit experienced a substantial patient burden requiring significant hospital resources. reduced in-patient waiting times and upskilling of orthopaedic services at secondary hospitals represent key areas for health system strengthening. however, multi-sectoral strategies would be required to effectively address our high burden of largely preventable spinal pathology. paper 60 one versus two adjacent interdigital neuroma excision a patient outcome study kb mogami, np saragas, pnf ferrao, a strydom background:  interdigital neuroma is a benign condition of the interdigital plantar nerve. clinically, patients present with pain in the forefoot, typically radiating into the toes and aggravated by wearing tight shoes. diagnosis is mainly clinical, however there is some utility for investigations such as magnetic resonance and ultrasonography in unclear or recurrent cases. surgery is reserved for patients with intractable symptoms despite conservative therapy. page 17sa orthop j 2019;18(1) aim: to report on patient satisfaction on two cohorts of patients who underwent surgical neuroma excision, those with a single webspace neuroma compared to those with adjacent web space neuromas. methods:  we retrospectively reviewed the data of patients treated operatively between 2003 and 2016. we interviewed and administered the self reported foot and ankle scores questionnaire by telephone. patient scores were then analyzed categorically and variation between groups analyzed. results:  sixty-two patients were available for questionnaire administration. 31 patients had a single interdigital neuroma while another 31 had adjacent interdigital neuromas. twenty-seven of the 31 (90%) patients with a single neuroma had good or excellent results while 23 (74.2%) of those with adjacent neuromas had similar outcomes.  one patient with a single neuroma had a poor score while four with adjacent neuromas had poor scores. the average score for patients with a single interdigital neuroma was 41 (excellent) while the average  for those with adjacent neuromas was 37 (good) (p=0.473). the majority of patients in both groups would undergo the surgery again. conclusion:  based on our results, we have found no significant difference in outcomes of patients who undergo surgery for either a single or adjacent interdigital neuromas. general patient satisfaction is good and/or excellent. paper 62 the reliability of physical examination per anatomic area to detect vascular injury in penetrating trauma to extremities ja le roux, mc burger, n ferreira, g du preez background: the purpose of this study was to determine the specificity and sensitivity of physical examination alone in detecting arterial injury in penetrating injuries to extremities (pte), versus ct angiography (cta). secondary aims were to determine whether the result is similar across all anatomic regions, and with different types of penetrating trauma. methods: a retrospective review included 353 extremity cta’s performed between 1-june-2016 to 30-june-2017. presence of arterial injuries were noted, together with the specific anatomic area injured: upper arm, cubital fossa, forearm, thigh, popliteal fossa, lower leg, or multiple zones. medical notes were reviewed to screen whether pulse deficit/hard signs of arterial bleeding were reported upon admission. (hrec #s16/07/119) results: a total of 352 ct angiograms were included: 326 (92.4%) male,27 (7.6%) female. of these, 220 were lower limbs and 133 upper limbs. the mean age of included patients were 28.9 years (range: 11 68 years). the sensitivity of physical examination in detecting an arterial injury when considering all patients, compared to the gold standard cta, was 92.1% (95% ci 84.5 96.8%) with the specificity 93.5% (89.9 96.2%).    the thigh had the highest specificity of 96.38% (91.75–98.81%), followed by lower leg:  91.75% (78.09-98.3%), upper arm: 89.23% (79.06-95.56%) and forearm: 77.78% (39.9997.19%). when considering gunshots the specificity was 91.49% (79.62–97.63%) whilst for stab wounds the specificity was 86.79% (74.66-94.52%).  the numbers for the other subgroups were too small to interpret.   conclusion: this study is in agreement with the literature which indicates that physical examination has a high specificity in detecting arterial injury in the setting of penetrating trauma of the extremities (pte). it does however show that the specificity is not equal for all anatomic regions or mechanisms of injury. this new finding should be considered individually for patients presenting pte. paper 63 do we have a common approach to common orthopaedic trauma problems? a survey of senior orthopaedic registrars and surgeons sj van deventer, jrt pietrzak, i egbunike, a robertson background: although surgical management of orthopaedic trauma in south africa is common, much controversy still exists surrounding optimal management of a number of surgical entities. each year, an academic meeting is held with senior registrars and consultants from each university in south africa. the aim of this study was to determine the extent of agreement of treatment of common orthopaedic trauma in training institutions in south africa. methods: an anonymous questionnaire was completed by 47 of 55 attendees (85.45%) of the 2018 south african registrar congress. the questionnaire included four randomly selected clinical scenarios: ankle syndesmotic injury, an intertrochanteric femur fracture, an extra articular distal radius fragility fracture and a neck of femur fracture. the responses were assessed results: the reduction technique for isolated syndesmotic injuries showed the most disagreement with 25 respondents (53.2%) choosing closed reduction while 22 (46.85) deciding to perform an open reduction. intertrochanteric femur fractures would be stabilized with a cephallomedullary nail (cmn) in 85% of respondents. a short cmn was selected by 57.4% if the patient was 50 years old as opposed to 78.7% if the patient was >80 years. 18 (38%) of respondents would manage an extra-articular distal radius fracture in a 50 year old female non-operatively whereas 29 (62%) would perform a volar orif. in a displaced neck of femur fracture in a 50 year old, 30 (64%) would do a reduction and cannulated screw fixation, while 17 (36%) would immediately do a total hip arthroplasty (tha). disagreement in treatment was seen according to the university attended (p<0.005). conclusion: there is a lack of consensus among attendees of the saoa registrar congress with regards to certain treatment aspects of 4 common orthopaedic trauma conditions. page 18 sa orthop j 2019;18(1) paper 67 a survey of the management of ankle fractures in south africa mi workman, gs wever, g mccollum background: inadequate treatment of ankle fractures can lead to poor outcomes and further reconstructive surgery. the presence of a posterior malleolus fracture is associated with poorer functional outcomes compared to simpler malleolar fractures. traditional teaching, based on historic literature, states that if a posterior malleolus fracture involves less than 25% of the distal tibia, it can be managed without fixation.  current literature has shown that fixation should not be based on the size of the posterior fragment but rather on the fracture pattern, instability and awareness that reduction and fixation is biomechanically advantageous.  fixation may also stabilise the syndesmosis. we hypothesised that current management of ankle fractures with posterior malleolus involvement in south africa is not evidence based and suboptimal. aim:  we sought to assess the training, experience and decisionmaking of surgeons and trainees who are involved in the management of ankle fractures. another aim was to develop evidence-based algorithms for the management of posterior malleolus and complex ankle fractures. methods: an email survey consisting of questions related to the management of ankle fractures was sent to specialists, registrars and medical officers who voluntarily completed an online survey regarding ankle fractures with respect to experience, training and decision making. results: 103 out of 456 emails sent drew responses to the survey. 30% of these were from consultants, 52% from registrars and 18% from medical officers. 40% of responders believe that posterior malleolus fractures can be managed non-operatively if less than 20% of the tibial plafond is involved. only 10% would ct scan a posterior malleolus prior to operating. 30% of the responders are not familiar or comfortable with the posterior-lateral approach used for fixation of the posterior malleolus directly.  conclusion: understanding of ankle fractures has progressed. posterior malleolus fractures are not benign and have poorer outcomes compared to bi-malleolar or lateral malleolus ankle fractures. we have shown that a significant proportion of responders to the survey are not following best practice and current literature. paper 71 type 5 acromioclavicular dislocations: surgical management in acute cases np bhagwan background: to evaluate the clinical and radiological outcomes after surgical treatment of acute high grade ac joint injuries using an endobutton technique. methods: retrospective case study following 33 patients treated between 2011 and 2016. all patients were reviewed for at least 12 months. the constant score, acromioclavicular instability score and subjective shoulder value were assessed at the final clinical follow up. radiographs were also available. results: most patients remained very satisfied or satisfied with the procedure outcome. all scores improved significantly when compared with baseline. there was one major complication and 5 minor complications. conclusion: arthroscopic stabilisation of high grade dislocations is a safe and effective method leading to good and excellent clinical and radiological results after a follow-up of at least one year. paper 75 the prevalence of self-reported depression rates in total hip arthroplasty (tha) at an academic hospital and the subsequent impact on functioning and satisfaction rates jrt pietrzak, a asare-bediako, e van greunen, k sikhauli, l mokete, dr van der jagt background: postoperative outcomes and satisfaction rates are affected by depression. the aim of our study was to determine the prevalence of self-reported depression in patients undergoing total hip arthroplasty (tha) in a johannesburg academic hospital. a secondary objective was to determine the impact of depression on patient functional outcomes and satisfaction rates after tha. material and methods: we retrospectively reviewed 195 patients undergoing tha from 2015-2016 at a single academic institution. 157 (80.5%) of patients were followed up at a minimum of 2 years. patients pre-operative depression and functional status was compared with that at 2 years follow-up. satisfaction rates and 30 and 90-day readmission rates were correlated with pre-operative depression. results: overall, according to the zung self-rating depression scale 82 patients (42%) were classified as moderately depressed and 37 (18.97%) were severely depressed. females, hiv-infected and morbidly obese patients were more likely to be depressed. no patients were on anti-depressive medication. the mean preoperative harris hip score (hhs) was 35.95 (24-66) and oxford hip score (ohs) 17.11 (0-48). the 30-day readmission rate was 2% and all these patients were pre-operatively severely depressed. at a minimum of 2 years, the post-operative hhs was 81.1. overall, there was an improvement in zung self-rating depression scale and phq-9 scores. this improvement may reflect a lower pain load post-operatively.  the least improvement was in the severely depressed group (p<0.05). the overall satisfaction rate was 89.7% with the only 70.27% of the severely depressed group satisfied post-operatively. age (>70) and bmi >40 also correlated with dissatisfaction (p<0.05). conclusion: there is a high prevalence of depression in tha. incorporation of psychological management strategies may improve satisfaction rates and functional outcomes post-tha. pain relief may also lead to decreased depression scores. page 19sa orthop j 2019;18(1) paper 76 discharge within 24 hours post total hip arthroplasty with a minimally-invasive direct anterior hip approach is safe and effective jrt pietrzak, j botha background: the introduction of joint care programs and fasttrack protocols have reduced the length of stay (los) for total hip arthroplasty (tha) worldwide. length of stay after tha has become a surrogate marker of the effectiveness and quality of peri-operative surgical care. the aim of this study was to determine the prevalence of discharge within 24 hours post-tha. we also examined the early operative outcomes for these patients regarding the amount of perioperative and postoperative complications, readmissions and reoperations. methods: a retrospective single-surgeon review of 205 patients undergoing unilateral minimally-invasive direct anterior approach (daa) tha was performed. all patients were included in a fast-track surgery protocol between january 2016 and december 2017. no patients were excluded irrespective of age, medical co-morbidities, bmi, pre-operative diagnosis and pre-operative functioning. the complication rate was 6.8% and was not related to discharge within 24 hours. results: 53% of all patients were discharged within 24 hours posttha. the average length of stay was 1.83 days (1-18 days). only 4 patients (1.98%) required a post-operative blood transfusion. males were more likely than females to be discharged after an overnight stay only (p<0.005). age less than 70 years and body mass index (bmi) less than 30 were also more likely to be discharged early. the peri-operative complication rate was 6.8%. the 30-day readmission rate and 90-day readmission rate was 3.4% and 1% respectively. complication and readmission rates were independent of early discharge (p=1.00). there were 3 (1,5%) early reoperations. conclusion: a fast-track program for most patients undergoing tha can safely result in a length of stay of 24 hours with few complications, re-admissions and reoperations. paper 78 reduction in air contamination levels during total joint arthroplasty with a continuous ultraviolet filtration system (uvc) jrt pietrzak, m tlhabane, s van deventer, k sikhauli, l mokete, dr van der jagt background:  air contamination in the operating theatre has been associated with surgical site infections (ssi). a linear relationship exists between a high air particle count and subsequent contamination of the surgical site. the aim of this study was to determine whether air contamination in an orthopaedic operating theatre could be reduced by ultraviolet air filtration.  methods: air contamination levels were assessed in 2 laminar flow theatres in a johannesburg academic hospital. 190 air particle readings were obtained in 19 randomly selected control procedures {10 primary total hip replacements (tha), 9 primary total knee replacements (tka)} and in 19 randomly selected procedures (12 tha, 7 tka) in which   continuous ultraviolet filtration air treatment (uvc) (aerobiotix, usa) was performed. this system includes hepa (high-efficiency particulate air) filtration and ultraviolet radiation of theatre air during procedures. in each group, readings of 0.3μm, 1.0μm and 5μm particles were obtained for a total of 380 readings. all readings were performed with a laser particle sensor in the region of the instrument table, surgical field, anaesthetic trolley and main door. results: there was a 46.8% reduction in overall air contamination from a mean of 5106 particles/m3  to 2701 particles/m3  with uvc air filtration (p=0.043). the reduction of 0.3μm, 1μm and 5μm was 57.9%, 47.9% and 30.8% respectively. particulate counts were decreased throughout the theatre. bovie smoke was correlated with higher particle readings. there were no incidences of ssi or 30-day readmissions in all 38 cases. conclusion:  air contamination in the operating theatre can be effectively reduced by ultraviolet filtration, and may be considered as an adjuvant method to potentially reduce the risk of ssi. paper 80 proposal and validation of a novel, descriptive classification system for hip pathology in hivinfected patients jrt pietrzak, tc nell, r rajcoomar, k sikhauli, r kgabo, l mokete, dr van der jagt background: improved life expectancy in patients with human immunodeficiency virus (hiv) results in an increased possibility of developing chronic degenerative and hiv-associated joint disease. subsequently, more patients will present with hip-related problems. the aim of this paper was to propose and validate a descriptive hip-specific radiological classification system for hiv-associated hip pathology. methods: we retrospectively reviewed pelvic and lateral hip radiographs of 69 consecutive hiv-infected patients and 108 hips with hip pathology necessitating consultation at an arthroplasty unit in a johannesburg academic hospital. each hip was classified as type 1 if avascular necrosis of the femoral head was evident; type 2 if a neck of femur (nof) fracture was present and type 3 if the pathology was unrelated to hiv (osteodegenerative or inflammatory arthritic changes).  type 1 hips were subclassified according to the acetabular changes and subsequent change in position of the centre of rotation (cor) of the necrotic femoral head. consequently, type 1a had normally contained femoral heads, type 1b had proximal or dome erosion of the acetabulum, type 1c had supero-lateral migration of the cor and type 1d had medial migration of the cor and acetabuli protrusio. interand intra-observer reliability was evaluated by 6 independent reviewers. results: 72 hips (67%) were type 1 (with evidence of avn). the majority, 34 patients (47%), were type 1a (well contained) while 12 (16.6%) showed proximal migration and superior acetabular page 20 sa orthop j 2019;18(1) erosion (type 1b) and 15 (20.8%) had acetabuli protrusion (type 1d). there were 24 (22.2%) who were type 2 with 16 with tonnis 2 and 3 oa and 6 with radiological inflammatory arthritis. there were 12 (11%) with nof fracture (type 3) of which 5 had coxa vara. there was osteopaenia in 50 (72.4%). there was both excellent interand intra-observer reliability (kappa-value 0.95). conclusion: we propose and have validated a descriptive classification system for hiv-associated hip pathology in patients awaiting tha. paper 82 the seroprevalence of hiv in patients undergoing total joint arthroplasty in a single south african academic institution jrt pietrzak, z maharaj, k sikhauli, n khoza, s jooma, l mokete, dr van der jagt background: the prevalence of immunocompromised patients undergoing total joint arthroplasty (tja) is increasing worldwide as a consequence of advances in treatment. hiv is presenting in an older population group and concerns of higher rates of infection, early failures and dangers posed to healthcare workers exist. methods: the aim of this study was to determine the seroprevalence of hiv in non-haemophilic patients undergoing total hip arthroplasty (tha) and total knee arthroplasty (tka) at a single sub-saharan urban academic institution. the prevalence of patients undergoing tja (tha and tka) was prospectively evaluated. all patients undergoing tja from january 2016 – march 2018 were counseled and offered hiv testing pre-operatively. the cd4+ count and viral load was measured for all hiv-infected patients.   results: 38 patients (15.8%) of 252 patients undergoing tha were hiv-infected. the seroprevalence of 224 patients undergoing tka was 4.46%. only 1(0.21%) of the 476 patients undergoing tja was newly diagnosed for hiv-infection. all other patients were already on anti-retroviral therapy. the average cd4+ counts for tha and tka was 286 (56-854) and 326 (185-1000) respectively. of the hiv-infected patients presenting for tha, 27 (71%) had evidence of avascular necrosis (avn) and 4 (10.5%) with a neck of femur fracture. no hiv-infected patients presenting for tka had evidence of avn of the knee. conclusion: the seroprevalence of hiv in patients undergoing tha is higher than those undergoing tka and the reported average in the general population. this may reflect the high association between both hiv and haart and avn of the hip. our findings  predict a significant burden on arthroplasty services in the future. routine testing may, however, allow earlier initiation of arv therapy paper 83 are total joint arthroplasty surgeons waterwise? simple water conservation techniques result in significant water saving jrt pietrzak, ts masango, s van deventer, k sikhauli, dr van der jagt, l mokete background: south africa is a water scarce country and the western cape is currently in the throes of a drought. the aim of this study was to determine the water consumption for primary total joint arthroplasty (tja). thereafter, we determined if it was possible to reduce water consumption with simple and practical water conserving interventions. methods: we conducted a prospective analysis of total water consumption in 15 consecutive tjas (9 tha, 6 tka). this included water used for pre-operative scrubbing, intra-operative surgical site irrigation and post-operative instrument cleaning. we subsequently introduced simple water saving techniques for the next 15 tjas (8 tha, 7 tka). this consisted of the fitting of water flow regulators into taps used for pre-operative scrubbing, a timer limiting preoperative scrubbing to 5 minutes for the first case of the day and 2 minutes for subsequent cases and a tap on/off scrubbing technique in which the taps were switched off in between rinsing. results: an average of 282.36 litres/case (226l -307l) was used per case without any water conservation measures. pre-operative scrubbing by the surgeons was responsible for 91% of water consumption. the pre-operative scrubbing time was inconsistent and was shortest amongst consultants (average time: 235 secs) and longest in junior registrars (average time: 323 secs). the introduction of flow regulators decreased water flow from taps from 15.3 l/min to 4.8 l/min. water conservation techniques decreased the average water use to 72.7 l/case (68.4l – 74.4l) which is a 793% decrease in water use. there were no incidences of surgical site infections or 30or 60-day readmissions in both groups. conclusion: immediate water savings measures are possible with simple easily adoptable conservation techniques with the main focus being on pre-operative surgical scrubbing.  significant environmental and economic benefits can be derived from this water-wise approach without compromising patient care paper 84 publication rates of podium presentations at the annual south african orthopaedic association congress from 2010 to 2015 c hitge, jrt pietrzak, bm de buys, l mokete, dr van der jagt background: presentation of research at annual national orthopaedic congresses provides an opportunity for the communication of current and relevant knowledge. the publication rate of presentations may provide a barometer of the quality of research work and the reputation of a scientific meeting. the aim of this study was to determine the publication rate of abstracts presented as podium presentations at the south african orthopaedic congress  (saoc) from 2010 to 2015. a comparison with other national orthopaedic meetings including the united kingdom, ireland, australia, germany, turkey, singapore and brazil was also performed. page 21sa orthop j 2019;18(1) methods: all abstracts accepted as podium presentations were scrutinized by 2 independent observers. google scholar, pubmed, embase was used to search for titles and authors for all published manuscripts. sub-analyses included publication rates of types of research and sub-speciality. data including the journal the paper was published in, time to publication and level of evidence was recorded. results: a total of 445 abstracts were accepted for presentation from 2010 to 2015.  a total of 60 (13.4%) were published in peerreviewed journals. the mean time from presentation to publication was 27 months. arthroplasty (33.3%) and trauma (30%) were responsible for the most number of publications. the south african orthopaedic journal (51.67%) and the injury journal (6.7%) were the most common journals published in. the publication rates from other countries was 26,6% to 58.1%. conclusion: a low conversion rate from podium presentation to publication existed in work presented at the saoc between 2010 to 2015. this recognition may subsequently promote higher quality research or stimulate identification of barriers to publication amongst south african orthopaedic surgeons. paper 85 total knee arthroplasty in a low-income country sm graham, c moffat, n lubega, n mkandawire, d burgess, wj harrison background: we describe our 10-year experience with total knee arthroplasty in patients who are included in the malawi national joint registry. methods: a total of 127 patients underwent 153 total knee arthroplasties (tkas) between 2005 and 2015. the mean duration of follow-up was 4 years and 3 months (range, 6 months to 10 years and 6 months). the study group included 98 women and 29 men with a mean age of 65.3 years (range, 24 to 84 years). nine patients were human immunodeficiency virus (hiv)-positive. results: the primary indication for surgery was osteoarthritis (150 knees), and the mean preoperative and postoperative oxford knee scores were 16.81 (range, 4 to 36) and 45.61 (range, 29 to 48), respectively. four knees (2.6%) were revised because of early periprosthetic joint infection (1 knee), aseptic loosening (1 knee), and late periprosthetic  joint infection (2 knees). there were no perioperative deaths. in the group of 9 patients who were hiv-positive, there were no early or late complications and the mean oxford knee score was 47 (range, 42 to 48) at the time of the latest follow-up. conclusions: this study demonstrated good short-term results following 153 primary tkas performed in a low-income country. paper 87 orthopaedic research in low-income countries: a bibliometric analysis of the current literature k berry, c brennan, sm graham, m laubscher, s maqungo, n ferreira, wj harrison background: more than 90% of global mortality from trauma and injuries occurs in lowand middle-income countries. however, only a small amount of published, peer-reviewed orthopaedic research appears to originate from these settings. the aim of this study is to quantify the amount of orthopaedic literature published from low and lower-middle income countries. methods: the web of science database was utilised to identify all indexed orthopaedic journals. all articles published in the 76 journals over the last 10 years were reviewed, to determine their geographic origin. those articles that had been published from lowand lower-middle-income countries were identified and included in the analysis. results:  a total of 131,454 articles were published across 76 orthopaedic journals over the last 10 years. of these, 132 (0.1%) were published from low-income countries and 3515 (2.7%) were published from lower-middle-income countries. the study suggests that 85.7% (n=112,716) of published orthopaedic research is being carried out in a high-income setting. conclusions:there is a stark mismatch between the publication of scientific reports on orthopaedic research and the geographical areas of greatest clinical need. these results show that there is a need for more orthopaedic research to be carried out in lowand lower-middle-income countries, potentially in collaboration with high-income partners to increase the output. paper 88 retention versus removal of the posterior cruciate ligament in total knee arthroplasty j wessels, r greeff, ct frey background: there is no consensus as to whether to use the posterior cruciate ligament retaining or sacrificing designs in total knee arthroplasty. the objective of the study was to establish any clinical or functional difference in these two designs.  methods: in this single surgeon case series we compared one implant that is available in two designs cruciate retaining (cr) and posterior stabilised (ps). we compared two cohort groups with each 20 consecutive primary tka done at our institution. all the patients are from one hospital and matched for age, gender and primary diagnosis. we excluded patients that had previous knee surgery and an absent posterior cruciate (pcl). we followed up the patients for at 6 months. as outcome measures we used american knee society score (kss), range of movement, stability and subjective improved function of the patient.  page 22 sa orthop j 2019;18(1) results: the outcome scores were comparable. there were no statistically significant differences in the knee scores and range of motion of the 2 groups.  in all cases the knee scores improved from poor (average 38 points) to good (average 87 points). all knees were stable. five patients had partial intra-operative iatrogenic damage of the pcl.  conclusion: from the literature it is difficult to find any concrete difference in the clinical outcome when these 2 different knee replacement designs are compared. even though the follow up in our cohorts were short our results between the two groups were similar. we however found there was a learning curve and initially not all the posterior ligaments in the ps group were retained successfully. these patients didn’t have adverse clinical outcome.  paper 89 early hip dislocation after primary total hip arthroplasty j wessels, f garcez, ct frey background: adverse events after primary arthroplasty surgery are worrying. mal-positioning of the acetabular components is a factor in early postoperative dislocation after total hip arthroplasty (tha). we used the “safe zone” as described by levinnek as post surgery quality control. methods: we analysed 395 consecutive primary tka done at our institution. we included confounding factors that we assumed as additional risk for early post operative dislocation: age, gender, body mass index, co-morbidities, american society of anaesthesiologists (asa) physical status classification and dementia. all dislocation up to 6 months after surgery were included. we excluded patients that had previous hip surgery, revision hips, dysplastic hips and patients that were referred to us with dislocations. forty-nine were excluded due to incomplete data. institutional ethical approval was obtained.  results: out of the 346 primary hips we had eight early dislocation. six underwent closed reduction one patient twice. two required revision surgery. of the 8 dislocations 7 were male one female. average age was 66 years (range 54 to 81). three patients has an anterior-lateral approach and a 5 posterior approach to the hip. bmi ranged from 23 to 39 with an average of 29. admission diagnosis for surgery was in 4 cases degenerative arthritis, 2 osteonecrosis of the femoral head, 1 inflammatory arthritis and one neck of femur fracture. physical status classification according to asa, five patients had a score of 2, two a score of 3 and one patient had a score of 4. average cup inclination was 37 degree (range 4 to 52 degree) and average cup ante version 18,5 degree (range 11 to 20 degree).  conclusion: early hip dislocations are an unpleasant adverse event for the patient as for the surgeon. cup positioning is combined with the version of the stem and not a good predictor for dislocation. in addition we found that levinnek’s safe zone is too wide. we found chronic personality changes and impaired reasoning as a predisposing factor. paper 90 uni-compartmental knee arthroplasty feasibility at a state hospital j wessels, e thwala, ct frey, r greeff background: uni-compartmental knee arthroplasty (uka) has become more popular in recent years. one of the reasons is that the indications for surgery have changed. the new indication criteria moved away from the fact that a uka could only be done for anterior-medial wear in an otherwise normal knee.  the advantages of a uka are better proprioception and feel, better range of movement that is not hampered by a post, less “noise” and bone preserving surgery that a uka could be revised to a primary total knee replacement.  methods: we were wondering why we were not doing more uka. we used the oxford criteria as well as the criteria published by dr oosthuizen for uka and retrospectively analysed 150 consecutive knees done at our institution if they were feasible for uka. ethics approval was obtained.  results: none of our patients was at the time of surgery suitable for a uka. we analysed the knees of 52 male and 98 female patients. mean age was 62 years (range 52 to 78). the bmi was increased in all patients, especially females. all but 3 had co-morbidities. the american society of anesthesiologists (asa) physical status classification was 2 and 3 in most cases. the average bmi was increased to 37,2 for female patients and 34,2 for male patients. the average american knee society score was 38 pre operative. the average oxford knee score was 11,6 (range 7 to 24). twenty eight patient fulfilled partially some criteria but not all. most common exclusion criteria were advanced tri-compartmental arthritis, increased bmi and instability.  conclusion: at the time of surgery we did not find patients that would have been feasible for a uni-compartmental knee arthroplasty at our institution. the reason is most likely our rather long waiting list. at first presentation the patient might very well be a candidate for uni-compartmental knee arthroplasty. unfortunately by the time of surgery the disease has rapid progressed. paper 92 survival and functional outcome of roof graft for severe acetabular dysplasia with cemented socket fixation: 12 to 22 year follow up rj immelman, nd clement, d macdonald, sj breusch, cr howie background: the long-term survival and functional outcome of autologous structural grafts to reconstruct acetabular defects in patients with developmental dysplasia in combination with a cemented socket as part of a total hip arthroplasty (tha) is not known.  purpose: the primary aim of the study was to describe the survival of a cemented socket with autologous roof graft at a minimum of 12 years follow up. the secondary aims were to assess functional outcome, patient satisfaction, radiographic loosening and outcome of revision surgery (was the roof graft incorporated). page 23sa orthop j 2019;18(1) patients and methods: we reviewed 62 patients (74 hips) who had undergone cemented tha with an autologous acetabular roofgraft with a median follow-up of 16.6 (range 12-23) years. mean age at surgery was 45 years (range, 19–71 years). patients note and radiographs were reviewed retrospectively for revision and lysis (delee and charnley). functional outcome was assessed using the oxford hip score (ohs), short form (sf-) 12 and forgotten joint score (fjs).  results: six hips were revised for aseptic loosening of the socket. all roof grafts had fully incorporated at time of revision. one patient at time of revision had marked lysis of the socket with erosion of the roof graft. the 10 year  survival was 98.6% (95% confidence intervals (ci) 92.5 to 100) and at 15 years was 95.3% (95% ci 88.1 to 100).  the functional outcome and radiographic assessment will be presented.   conclusions: autologous roof graft with cemented socket as part of tha for patients with acetabular dysplasia offers excellent survival in the mid term. incorporation of the roof graft facilitates revision of the socket. paper 93 access to health care for osteoporotic hip fracture patients in south africa part of the frax multicenter study k jordaan, s dela, m lukhele, f paruk, a kalla, m conradie, b cassim purpose of the study: the larger study aim is to determine the ethnic and gender specific incidence of hip fractures in south africa (sa) and to understand the burden of the disease in our multi-ethnic population.  the specific purpose of this study was to document the access to health care for this specific population group and to document time between injury, admission and surgical treatment. methods: a prospective multi-center observational study was conducted in gauteng, kwazulu-natal (kzn) and the western cape (wc).  all patients ≥40 years presenting with an osteoporotic hip fracture to both public and private sector hospitals within the defined geographic areas were capture by trained fieldworkers.  traumatic and pathological fractures were excluded. data were recorded from april 2017 – december 2017.  additional data captured include time of fall, time of admission and time of surgery. (sun hrec n15/09/085) results: a total of 2115 patients (n=682 male; n=1433 female) were included.  kzn n=826, gauteng n=426 and wc n=863 patients.  of these, 1412 (66.7%) were treated in public hospitals and 701 (33.2%) in private hospitals. the median time from fall to admission to hospital was 15 h, whilst the median time from admission to surgery was 95.4 h (nearly 4 days). finally, the median time from fall to surgery was 124 h (>5 days).  these times were significantly longer in the public sector compared to private hospitals. conclusion: morbidity and mortality for osteoporotic hip fractures are known to be very high and international data suggests the biggest modifiable risk factor to reduce this morbidity and mortality to be the time between fractures to surgery. public health care hospitals have different barriers to surgery then private health care hospitals in sa to address the delays but this study nonetheless highlights areas to be improved. this is the largest and most representative data on incidence of osteoporotic hip fractures in sa. paper 94 perthes disease – valgizing osteotomy a naidoo, mn rasool background: the main aim of operative treatment in perthes disease is containment of the femoral head and preventing further deformation. for advanced perthes, or a noncontainable head, salvage procedures involving osteotomies of the pelvis or proximal femur have been described. within this noncontainable group is a subset of patients who present with hinge abduction, and a large flattened head which is laterally subluxed. in this group of 18 patients we evaluate the use of a valgizing osteotomy stabilised with an intermediate pin and plate, and the radiological and clinical outcomes. methods: eighteen patients with perthes disease were included in this study. they all presented with a painful short limb gait, a fixed flexion deformity of the hip and hinge abduction. they were treated between 2007 and 2017 by adductor tenotomy, a closing wedge valgizing osteotomy, derotation to neutral was perfomed to correct any external rotation deformity, and extension to correct flexion deformity  a pin and plate was applied. strict non weightbearing post op was enforced by a uslab spica, or in an older child by a period of skin traction followed by non weightbearing with crutches. results:  there were 13 boys and 5 girls. hinge abduction was not present post osteotomy on the table. the leg length discrepancy improved by 1,52cm in all patients, with a gradual improvement of hip range of movement. two patients also had a shelf osteotomy to improve containment of the head.  radiographs show improved remodelling of the femoral head with an increase in the neck shaft angle. the pin and plate was removed at one year. conclusion: the valgizing osteotomy is a useful salvage procedure to improve outcomes in perthes disease. paper 95 the effect of lateralisation on reverse shoulder arthroplasty outcomes a biomechanical study jg glenday, s roche, t rosch, s sivarasu background: it has been suggested that lateralisation can improve the functional outcomes of reverse shoulder arthroplasty. this study makes use of a biomechanical shoulder model to investigate the changes to the reverse shoulder through lateralisation of the glenosphere and humerus. page 24 sa orthop j 2019;18(1) methods:  the reconstructed scapula and humerus from 15 ct scans were used to customise a 3d biomechanical model of the shoulder. each model underwent a virtual surgery using the delta xtend, which was 3d reconstructed from an explant. 3 configurations were tested: the default location with no offset and 2 offset locations (10 mm of glenosphere lateralisation and 5 mm of humeral lateralisation, which was achieved via medialisation of the humeral tray). impingement-free range of motion (ifrom) and mean deltoid muscle force were measured during abduction and forward flexion. results: during both motions, glenosphere lateralisation increased both outcome measures. during abduction, ifrom increased by 50.3° (95%ci: 41.8, 58.9) and mean deltoid muscle force increased by 16.6 n (95%ci: 41.8, 58.9). during forward flexion, ifrom increased by 27.1° (95%ci: 20.9, 33.4) and mean deltoid muscle force increased by 11.4 n (95%ci: 8.7, 14.1). humeral lateralisation had no effect on ifrom and decreased mean deltoid muscle force during both motions. mean deltoid muscle force decreased by 17.1 n (95%ci: -20.3, -14.0) and -1.7 n (95%ci: -2.5, -0.9) for abduction and forward flexion, respectively. conclusion: this study has highlighted that glenosphere lateralisation can improve ifrom at the expense of increased effort required by the patient. whereas, humeral lateralisation can decrease the effort required by the patient and has no effect on ifrom. these results provide insight into the functional changes due to lateralisation of the prosthesis. paper 96 ethnic and gender specific incidence rates for hip fractures in south africa a multicentre study k jordaan, s dela, f paruk, m lukhele, a kalla, m conradie, b cassim background: to determine ethnic and gender specific incidence rates of hip fractures in south africa (sa) and to understand the burden of the disease in our multi-ethnic population.  the secondary purpose is to develop a frax® base model for sa. methods: a prospective, multi-centre, observational study was conducted in gauteng, kwazulu-natal and the western cape.  all patients ≥40 years presenting with an osteoporotic hip fracture to both public and private sector hospitals within the defined geographic areas were captured between april 2017 – december 2017 by trained fieldworkers.  traumatic and pathological fractures were excluded.  (hrec n15/09/085) results: a total of 2115 patients (n=682 male; n=1433 female) were included of african (n=563, 26.6%); coloured (n=384, 18.2%); indian (n=284, 13.4%) and white (n=882, 41.7%) ethnicity. women were significantly older than men in the total and each ethnic group (p<0.001) additionally, white subjects were significantly older (p<0.001) and africans significantly younger (p<0.001) than other groups.differences in the genderand ethnic-specific, ageadjusted incidence rates were observed: in women, the highest incidence rate was noted in whites (164.8 per 100 000), followed by indians (128.7 per 100 000) with the lowest rates in coloured and african women (61 and 36.7 per 100 000, respectively). a similar pattern was seen in men albeit at lower rates, with the highest rate in white men (73.1 per 100 000). an increase in the relative risk with increased age in the i) total cohort, ii) in women, and iii) in white, indian and coloured women was observed. conclusion: hip fractures occur in all ethnic groups at higher rates than previously thought.  differences in the ethnic specific incidence rates suggest that ethnic specific frax® models are required for south africa. paper 97 optimisation of reverse shoulder arthroplasty through the combination of prosthesis placement modifications a biomechanical study jd glenday, s roche, t rosch, s sivarasu background: it is hypothesised that an optimised placement of the reverse shoulder prosthesis can be obtained. this study makes use of a biomechanical shoulder model to investigate the changes to the reverse shoulder through the combination of glenosphere eccentric placement, humeral tray placement, humeral tray depth decreases and augmentation of the greater tuberosity (which increased its effective radius). methods:  the reconstructed scapula and humerus from 15 ct scans were used to customise a 3d biomechanical model of the shoulder. each model underwent a virtual surgery using the delta xtend, which was 3d reconstructed from an explant. 144 configurations were tested in each model: the default location with no offsets and 143 offset locations that systematically combined the 4 types of modifications and their associated altered placements. impingement-free range of motion (ifrom), mean deltoid muscle force and glenohumeral joint stability were measured during abduction and forward flexion. a score between -1 to 1 was assigned to each combination of offset configuration and outcome measure, for a given motion. this score was based on the offset configuration’s effect relative to the default and, consequently, a maximum score of 6 was obtainable. results: the range of scores achieved was 0 to 4.5. the maximum score was achieved by combining a 5 mm inferior glenosphere translation, a 2.5 mm medial humeral tray translation and a 5 mm augmentation to the greater tuberosity. it was also observed that this result was not sensitive to decreases in humeral tray depth. conclusion: this study has demonstrated that placement of the reverse shoulder prosthesis can be modified to optimise functional outcomes. that being said, the optimal configuration was unable to maximise all 6 outcome measures and obtained an overall score of 4.5 (75%). page 25sa orthop j 2019;18(1) paper 98 a clinical audit of ankle fractures presenting to an academic hospital and its subsequent burden of care f ahmed, jrt piertzak, s van de venter, f ahmed background: ankle fractures are one of the most common fractures presenting to accident and emergency units in south africa. the aim of the study was to retrospectively analyse the epidemiology of patients presenting to a tertiary level academic hospital and its subsequent burden of care. this included determining basic demographic data, length of hospital stay, mechanisms of injury, implants used, 30 day readmission rate and the overall cost of an admission of an ankle fracture to both the hospital and the patient. results: there were 104 patients presenting between october 2017 and march 2018. of these, 51 were female and 53 were male patients. the average age of patients sustaining ankle fractures was 53 years. each fracture was classified according to the danis weber classification and the hersovici classification if the posterior malleolus was involved. of the 104 patients admitted 18 were classified as danis weber a, 60 were classified as danis weber b and 26 were classified as weber c. the mechanisms of injury included fall from height, pedestrian vehicle accidents, motor vehicle accidents, sports related accidents as well as simple falls. the average time to surgery was 9.5 days. 44 percent of patients was operated on an emergency list after hours and 15 percent were operated during working hours. 6 percent of patients  was operated on by consultants during elective list surgery. the implants used to maintain reduction included 64 precontoured locking plates, 8 semitubular plates and 32 dcp plates.  the average length of hospital stay was 10.2 days.  6 patients were readmitted within 30 days of admission, all for wound related complications. conclusion: ankle fractures present a significant burden on orthopaedic health care provision at tertiary level academic hospitals. a definite trend is emerging for the use of locked precontoured plates which as dramatically increased the financial burden.  better health care policies may alleviate this burden whilst still insuring proper care of ankle fractures. paper 101 correlation between acute pain relief and platelet counts of intra-articular platelet injections for osteoarthritis of the knee aw maina, br gelbart, p firer background:  intra-articular administration of platelet rich plasma (prp) for pain management has been described for the management of osteoarthritis of the knee (oak).  there are several techniques employed to prepare prp, resulting in varying platelet concentrations. pain relief from prp administration has also been variable. as there is no local anaesthetic or immune modulatory mechanism employed, patients often enquire about the impact of prp on their pain. we evaluated the acute effect on pain and the relation to platelet count. hypothesis: prp injections provide acute pain relief in oak. there is a relationship is between pain relief and prp platelet count. study design: prospective cohort study methods:  outpatients with oak, received three prp injections, a week apart. pain was quantified at baseline, and a week following every injection for each knee using the visual analog scale (vas). whole blood platelet counts (wbpc) and prp platelet counts were done prior to and post processing of the patients blood. results: forty six patients (63 knees) with an average age of 66.43 ± 14.27 years participated. 73% of knees had oak kellgren and lawrence grade (klg) 3 or worse in one or more compartments. mean baseline vas was 6.5 ± 3.24 and significantly abated with a mean decrease of 3.31 ± 2.94 cm over the course of treatment in all participants (p<0.05). a minimal clinically important difference of ≥ 15mm was observed in 75% of the patients at the last visit (range: -80mm – 25mm). platelet counts of 260.18 ± 72.35 (wbpc) and 366.11 ± 130.49 (prp) were observed, with a percentage change of 36.41% (range: -31% 113%). improvement in pain was no related to change in platelet count. conclusion: prp injections improve pain in the first two weeks of treatment. the improvement is not related to platelet count. paper 102 the influence of shortening on clinical outcome in healed, displaced, midshaft clavicle fractures after nonoperative treatment e goudie, nd clement, ir murray, m wilson, cm robinson background: the association between clavicular shortening and shoulder function following displaced midshaft clavicle fractures remains controversial. this study evaluates the effect of clavicular shortening, measured by three-dimensional ct, on functional outcomes and patient satisfaction following nonoperative treatment of displaced midshaft clavicle fractures up to one year following injury. methods: the data used in this study were collected as part of a multicentre prospective randomised control trial comparing open reduction and plate fixation with nonoperative treatment for displaced midshaft clavicle factures. patients randomised to nonoperative treatment and who healed by one year were included in the present study. clavicle shortening relative to the contralateral uninjured clavicle was measured using three-dimensional ct. outcome analysis was conducted at six weeks, three months, six months and one year following injury and included the dash, constant and sf-12 scores, and patient satisfaction. results: the mean shortening of injured clavicles, relative to the contralateral side, was 11mm (+/7.6mm) with a mean proportional shortening of 8%. proportional shortening of the clavicle did not page 26 sa orthop j 2019;18(1) significantly (p=0.84) correlate with any functional outcome score at any follow-up time point. assessment of satisfaction at one year also failed to demonstrate a significant difference in clavicle shortening between satisfied and unsatisfied patients. conclusion: this study has shown no association between shortening and functional outcome or satisfaction in patients with healed displaced midshaft clavicle fractures. caution should be exercised in using shortening to inform treatment decisions to avoid exposing large numbers of patients who would otherwise regain good shoulder function without intervention to potential surgical complications. paper 108 the timing of arthroplasty for femoral neck fractures: a three-year audit at central academic hospital fc conradie, g pienaar, k jordaan, m burger background: displaced femoral neck fractures are frequent, represent a great health care problem, and have a significant impact on healthcare costs. the type of hip arthroplasty depends on the physiological age and patients level of activity and include unipolar or bipolar hemiarthroplasty (ha) and total hip arthroplasty (tha). numerous studies advocate early operative treatment to reduce morbidity and mortality. the purpose of this audit is to assess our patient cohort in terms of time to surgery and compare it with the literature. methods: a retrospective audit was done of all adult patients with femoral neck fractures treated with arthroplasty at a single academic hospital from january 2015 to december 2017. data captured was: demographics, time to admission and surgery, type arthroplasty and mortality.  ethics reference #: n18/03/029 results: a total of 338 patients (101 males and 237 females), with a mean age of 78 years (range 46–103) were included. average time from injury to admission was 10 days, with average time to surgery from admission being 155 hours. total hip replacement was used in 181 patients (53%), a cemented bipolar in 124 patients (37%) and 33 (10%) cemented thompsons. conclusions: the burden of femoral neck fractures is tremendous. “time to surgery” is one of the modifiable risk factors that can decrease the morbidity and mortality associated with this injury. we report on the surgical waiting time in our  cohort of patients, which is much longer compared with international data. paper 109 shoulder pain in elite cricketers : an underreported injury j gray, m dutton, n tam, s roche objectives: to determine the incidence and prevalence of shoulder injury in elite south african cricketers. design: prospective longitudinal cohort study methods: 105 elite south african cricket players were evaluated for previous shoulder injury and present shoulder function using the kerlanjobe othopaedic clinic shoulder and elbow score (kjoc score)  prior to the start of the season. non-contact dominant shoulder injuries were monitored throughout the season. results: during the 2016/2017 season, 18% (95% ci: 0.11 – 0.25) of cricketers sustained a non-contact dominant shoulder injury during the 2016/2017 season. injury risk was shown to double with a history of previous shoulder injury. those cricketers who had a history of previous shoulder injury demonstrated significantly lower pre-season kjoc scores (p = 0.001) indicating reduced shoulder function at the start of the season. eleven injuries occurred during matches, while seven occurred during cricket specific training.  the highest injury incidence occurred during five-day test matches for the national squad at a rate of 4.1 shoulder injuries per 1000 player hours. overall the national players were approximately 17 times more likely to develop a shoulder injury in the 2016/2017 season than the franchise squad players (annual incidence of 3.04 compared to 0.18). conclusion:  shoulder injury incidence in cricket is severely understated. a greater focus on preventative programmes to reduce injury are warranted. paper 110 how did the introduction of global fee for arthroplasty affect my practice? br gelbart, m street, p firer background: alternative reimbursement models (arm’s) is the buzzword in arthroplasty. this has manifested in the global fee arrangements proposed and implemented by a number of healthcare funders. we undertook a trial of a combined surgeon/ funder managed reimbursement model implemented in our knee arthroplasty practice. we chose to implement a plan whereby the variable fees would be the hospital fee and the surgeons fee and that these would be renegotiated at 6 month intervals. we hypothesized that our practice would become more cost efficient without a change in short term outcomes. methods: we retrospectively reviewed a sample of cases from before implementation of the global fee arrangement and compared that to the cases done post implementation of the global fee arrangement. we then subdivided the “post” cases into those cases who were included into the fee arrangement and those who were performed at the same time on a fee for service basis. we assessed duration of hospital stay, theatre time, theatre costs and readmission rates and short term post-operative complications. page 27sa orthop j 2019;18(1) results: this is a current ongoing study and we continue to collect results and currently our numbers are too small to draw conclusions. however, we do believe that due to the interest, controversy and pressure that this new model is placing on all stakeholders, that we should present our data at this meeting. conclusion: global fees and alternative reimbursement models are being implemented by funders. we feel that as the surgeons we should be critically analysing our data and discussing how we can ensure safety and sustainability of these models. paper 111 high incidence of lucent lines on postoperative radiographs of short femoral stems l mokete, jrt pietrzak, k sikhauli, d van der jagt background: short cementless femoral stems in hip replacement surgery are an attractive concept because of the potential for bone preservation. however, there is concern about the stability of the short prosthesis and implantation can be more technically challenging than in a standard length prosthesis. methods: we initiated a prospective randomized trial to study blood metal ion levels in total hip replacements with either a monolithic or a modular neck short femoral stem of the same design (smith and nephew smf and smf modular stems).  to the best of our knowledge these are the only femoral stems of the same design that were available in monolithic and modular neck forms. the stems were coupled to 36mm oxinium heads and all patients received a metal acetabular shell with a highly cross-linked polyethylene liner. the aim of the study was to determine the contribution of the neck modularity to blood metal ions. results: the trial was stopped prematurely after recruitment of 17 patients (8 modular, 9 monolithic, 11 females, average age 61 years, range 39-73) because of a high incidence of post-operative radiolucent lines around the femoral stems. the lucent lines were seen in both the monolithic and modular neck stems. they became evident at six months and continued to progress at two years followup. all but two patients (modular stems) had radiolucent lines on radiographs in more than one zone at two years follow-up. sepsis work-up was negative.  the primary diagnosis was osteoarthritis in 13 patients, osteonecrosis in two and neck of femur fracture in two patients. the patients remained active with ucla activity scores of six or higher at one and two year follow-up excepting one patient with a score of 5 who underwent revision surgery before the two years follow-up. average two years blood ion levels for the modular stem were 13.04nmol/l (chromium) and 35.14nmol/l (cobalt) and 5.58nmol/l (chromium) and 3.16nmol/l (cobalt) for the monolithic stem. conclusion: we report an unexpected high incidence of radiolucent lines in both the modular and monolithic smf short stems following total hip replacement. the modular stem has subsequently been recalled but we would urge caution in the use of the monolithic stem. paper 112 cadaver validation study of computer model for insertion site of latissimus dorsi tendon transfers s thompson, s roche, s sivarasu, d henderson background: latissimus dorsi (ld) tendon transfers have been shown to be an effective treatment for massive or irreparable tears posterior rotator cuff tears. this procedure can have unpredictable outcomes this may be due to different suggested insertion sites used for the ld tendon transfer. aims and objectives: the aim of this study is to use a cadaver study to validate a previously completed computer model simulating ld tendon transfer using different insertion points on the humerus. methods: 4 fresh frozen cadaver torsos (8 shoulders) were mounted into a specifically designed rig. the ld was transferred to 7 points of the humeral head. the strain generated by the humerus in rotation on the clamps was measured at 0° and 90° of forward flexion for each point. the results were analysed using a one-way anova with post hoc tukey test.  the cadaver and in-silico  results were compared by scaling the in-silico results to be overlayed on the cadaver results and then visually compared.  results: the maximum rotation load was generated at point 1. the second most optimal set of points for generating rotation were points 2,3, and 6. points 4 6 were not significantly different from one another, but were all significantly different from points 1 3 (p = 0.00) conclusions: the cadaver study confirmed the  in-silico  model that the lesser tuberosity is the optimal point for maximum rotation strength at 0° of flexion and no flexion strength. for maximum rotation strength and no flexion throughout the motion of flexion, the face of the greater tuberosity is the optimal point. for maximum rotation throughout the flexion moment and flexion strength at low angles, points 4 and 5 (the posterior edge of the greater tuberosity) is the optimal point. paper 113 early south african experience with robotic joint replacement surgery l mokete, jrt pietrzak, e hoosen, k sikhauli, d van der jagt background: the ultimate joint replacement would be one that consistently satisfies the expectations of the patient and outlasts the patient. modifications in prosthesis design, implant materials and implantation techniques have all contributed in helping us to page 28 sa orthop j 2019;18(1) get closer to the ideal joint replacement.  robotic assisted joint replacement surgery is the latest technology introduced to improve implantation of hip and knee prosthesis. we have had access to this technology since november 2016 and we report our early experience. methods: we retrospectively studied all patients who underwent total hip or uni-compartmental knee replacement surgery using the mako robotic assisted arm (stryker) and unicondylar knee replacement and total knee replacement using the navio robotic guided hand-held platform (smith and nephew).   the mako workflow requires a pre-operative ct scan and the navio uses image based real time hand held ct free technology. results: 15 total hip replacements and 13 unicondylar knee replacements were done using the mako robotic arm. four total knee replacements and four partial knee replacements were done using navio technology. the pathology in the hips replaced consisted of osteoarthritis in the main but also included protrusio and dysplasia. average surgical time for the mako hip replacements was 120 minutes (69 – 138mins). the average time for the mako unicondylar knee replacement was 124 mins (105-157mins). cup placement was within 2 degrees of planned orientation (inclination and version) and limb alignment was within 3 degrees of planned alignment in all cases. there were intra-operative registration error conflicts in two hip replacements. these were resolved with satisfactory completion of the cases. there were no adverse events. conclusion: both technologies were associated with a learning curve and increased operative time was the consequence. in addition, there was a price premium for using the technology. however, we achieved consistently accurate placement of implants. we found the mako technology especially useful in the planning and execution of complex hip replacements. paper 114 grip strength following total wrist arthrodesis a prospective study a alexander, o koch, tlb le roux background: to determine the change in grip strength and patient reported outcome measurements postoperatively, as compared to the same side preoperative values, in subjects undergoing total wrist arthrodesis. methods: this prospective study included patients with wrist arthritis(inflammatory arthritis excluded), aged from 19 to 86 with a minimum follow up of 1 year. grip strength was measured preoperatively and at least  1 year postoperatively using the jamar(patterson medical) dynamometer in the standardised method,  as part of  a set protocol. functional outcomes were assessed by the disabilities of arm, shoulder and hand(dash) scores, completed preoperatively and at 1 year postoperatively. the differences in measurements were assessed using a  paired samples ttest, as well as  the percentage changes between measurements. results:  20 patients were analysed, with 15 patients having surgery on  the right and 5 on the left, with a mean age of 48,05 (+-67). the mean percentage gain in postoperative grip strength was 111,3%(p<0,01; ci 95%) and 449,9%(p<0,035; ci 95%) on the right and left respectively. the mean improvement in dash score was 27,3(p<0,0000006; ci95%). further analysis revealed mean  postoperative grip strengths, to within 5% (+-87,2) and 19%(+-48,1) of age  related normative values, on the right and left respectively. the analysis of the nonoperative sides showed a mean grip strength increase of 24%(+-276). conclusion: the results of this study show that total wrist arthrodesis, when performed in subjects with wrist degeneration other than inflammatory arthritis, is associated with improvement in grip strength and patient reported outcome.  paper 116 combined use of acute and gradual correction with the external fixator in blount’s disease ks bila, ma morule, rg golele background: the treatment of blount’s disease could be challenging and diverse.   there are numerous surgical methods in the treatment of this condition. moreover, no one method could be perceived as superior to the other. the use of external fixator is becoming popular to address complex deformities. gradual correction has been used with good outcome. however, in severe deformities, this method could mean a prolonged period in a frame and incomplete correction due consolidation before full correction is achieved. acute correction only could predispose to compartment syndrome. the combination of the two methods mitigate complications associated with the use of each method alone. aims and objectives: to determine the effectiveness of the combined acute and gradual correction with the external fixator in blount’s disease in terms of correction, union and complications. methods:  a retrospective study was conducted where the records and x-rays of the patients treated using the combined acute and gradual correction were retrieved. from 2013 to 2017 a total of 17 patients were surgically treated for blount’s. eight patients met the criteria for they were treated using the combination of the acute and gradual correction methods (7 had bilateral blount’s, however one patient with bilateral disease, had one limb treated by the said combination). the degree of correction of varus was assessed on pre-operative and post-correction x-rays. internal rotation deformity correction and limb length inequality were assessed clinically. complications such as neurovascular compromise, minor and major pin tract infection and hardware complications were documented. the pre-operative planning, surgical technique and post-operative treatment protocol is reviewed. results: the varus ranged from 20 degrees to 45 degrees. the correction ranged from 5 degrees to -7 degrees. the internal rotation was corrected to between 5° to 10° of external rotation in all patients. the mean time in the frame was 90 days. one patient had residual varus of 8 degrees, three patients had peroneal palsy that recovered  fully,  and one patient needed an additional acute correction due to struts  loosening . one patient needed surgical debridement of the osteotomy site due to infection. conclusion: combined acute and gradual correction using the external fixator for severe blount’s  is effective and could shortened the treatment period. page 29sa orthop j 2019;18(1) paper 117 survivorship of patients who underwent forequarter amputation of the upper limb for tumour treatment ks bila, w steenkamp, ma morule, rg golele background: forequarter amputation is one of the surgical treatment of advanced cancer involving the proximal humerus.  the procedure leaves both surgical and emotional scars there are times where both the surgeon and the patient are left with no other option of treatment modality.   aims and objectives: to look at the survivorship and patient satisfaction following this treatment method. methods:   a retrospective study was conducted where the records  and x-rays of the patients treated  for proximal humerus malignancies  by way of forequarter amputation.  during the period 2015 to 2017 a total of three patients were treated for proximal humerus malignant tumours. the patients were assessed with respect to their quality of life post-surgical intervention. results: there were three female patients aged , 7, 11 and 27 years respectively who presented with stage iv malignancy. they were clinically assessed and investigated appropriately. the histological findings, : 2 were osteosarcoma  and one was a chondrosarcoma . those with osteosarcoma had lung metastasis at presentation.  the indication for surgery was for palliation  as the disease was advanced . they all underwent the procedure. the osteosarcoma patients were subjected to chemotherapy before and after surgery. the follow up period ranges from  8 to 32 months.  they are all still alive and reported better quality of life for the pain is well controlled. conclusion: this surgical modality could still be used in advanced malignant disease. paper 118 superior capsule ligament reconstruction: results at one year np bhagwan background: to assess the clinical and radiological results of the first 11 patients who underwent superior capsular  reconstruction using a porcine patch methods: 11 patients who were operated on for irreparable supraspinatus tears between 2015  and 2017 were followed for a minimum of 12 months using a variety of clinical scores and mri. results: all patients showed improvements in pain and range of motion. however, there was no significant gains in strength. mri detected presence of the graft at one year but no improvement in the acromio-humeral distance. no significant complications were noted. conclusion: superior capsule reconstruction provides another safe option for the treatment of irreparable supraspinatus tears. the indications remain to be defined. paper 120 medium term outcomes of two version of guided motion total knee replacement design n sikhauli, n sikhauli, l mokete, trj pietrzak , k nokweyi, r kgabo, dr van der jagt background: the journey total knee replacement was introduced as a new class of knee replacement prosthesis designed to simulate normal knee kinematic. in vivo studies demonstrated that the bicruciate substituting design did not have paradoxical anterior shift which was common with earlier designs of contemporary knee replacement. furthermore, there was enhanced posterior femoral rollback in keeping with normal knee kinematics. however, the journey knee replacement was subsequently recalled because adverse events, complication specific to this design included instability and iliotibial band friction syndrome. the design was modified with the introduction of journey ii knee replacement. we had the unique opportunity of implanting both the journey and journey ii in the context of controlled trial. material and methods: we studied the outcome of patient that were entered in to a controlled randomised trial single blinded to compare implant alignment with and without the use of computer assisted navigation system following total knee arthroplasty. the trial commenced february 2011 and ended august 2013. preoperative knee, functional and womac score were documented. standard post-operative knee follow-up was adhered to and postoperative knee scores were completed as a standard practice in our clinic. results: 140 eligible patients were enrolled to the trial, 67 journey and 77 journey ii 109 patients were traceable with 16 confirmed dead at a minimum of 5years’ follow-up, further 3 patients were excluded because they had moved cities and had only followed up once since operation. journey and journey ii pre-op knee score averaged 38 (9-63) and 39 (-10-66) respectively and their functional score mean 61 (-5 -85) and 63 (-10-95) respectively. at 6 years’ minimum follow-up journey and journey 2 knee score mean 88 (22-105) and 73 (24-99) respectively and their functional score mean 75 (5-103) and 67 (5-100) respectively. there was also a significant improvement in womac score.the complication ranged from dislocations, periprosthetic fracture, periprosthetic joint infection, medial collateral rupture, and extensor mechanism disruption. conclusion: there were slightly more revision cases in journey compared to journey ii especially dislocation at 16 month, but equitable non-implant specific complications. the knee functional score plateau at 12-18month post operation and there was no significance difference or both groups at average 6 years (64-86 month) follow-up. this would suggest that the journey knee cases that were not complicated by instability do as well as journey ii beyond 18 month and further. page 30 sa orthop j 2019;18(1) paper 121 distressingly low levels of vitamin d in arthroplasty patients could increase periprosthetic infections aa van zyl, d dippenaar, jf van der merwe background: vitamin d has gained increased attention in recent times not only in its role in bone health and calcium homeostasis but also for its role in immunomodulation. even in sunny south africa most people avoid the sun or use sunblock creams thus decreasing the skins ability to manufacture this essential vitamin. elderly patients, who are the group mostly seen for joint replacements, are more prone to having low vit d levels. decreased vit d has now been implicated as a contributory factor in the incidence of peri-prosthetic infections. all immune cells express vit d receptors, as well as showing 1a-hydroxylase activity and supports the differentiation of cd4 & t cells which could explain the decreased immune response and associated increased sepsis risk of patients with low levels of vit d. methods: since january 2017 march 2018 all patients, who were planned from lower limb joint replacements, were tested for vitamin d (25 dh cholecalciferol) as part of a general screening for fitness before operations. results: a total of 451 patients were screened, 166 had hip replacements, 253 had knee replacements. (32 patients were screened but did not have an operation for various reasons). of these patients 75 % had decreased vit d levels (<30ng/ml) with a range of 7 – 50ng/ml. 25,9% had vit d levels below 20ng/ml, 23,8% had vit d levels between 20 – 24,9 ng/ml, 25% had vit d levels between 25 – 29,9 ng/ml, 25% had vit d levels of 30 and above ng/ml. all patients with levels below 30ng/ml were treated with cholecalciferol 50,000 iu weekly for 8 weeks as well as b-cal-d (400 iu vit d3 and 500mg calcium carbonate) daily preoperatively and were encouraged to continue with b-cal-d dly for life. no patients developed infection in the time frame of this study. the cost of vit d lab test(ampath) = r190.30 and the cost of initial treatment = r 200.00, total costs = r390.30. of futher orthopaedic interest is that low vit d levels is implicated in osteoporosis, loss of muscle power, as well as effect on neuro inflammatory and neurodegenerative illnesses like multiple sclerosis, neuromyelitis and alzheimer disease, all of which have an increase of falls and hip fractures which could lead to joint replacements. prevention of surgical site infections when operation on these patients is of utmost importance. due to the common low levels of vit d seen in our patients we propose that all patients who are planned for joint replacements screened for vit d levels and should be treated prior to, as well as post-operatively with vit d supplements as a preventative measure for the prevention of peri-prosthetic infections. conclusion: we believe that this would be a cost-effective test considering the huge costs / morbidity if peri-prosthetic infection should occur. south african orthopaedic journal orthopaedic oncology and infections doi 10.17159/2309-8309/2021/v20n1a4 venter rg et al. sa orthop j 2021;20(1) citation: venter rg, tanwar ys, grey jp, ferreira n. the management of chronic osteomyelitis in adults: outcomes of an integrated approach. sa orthop j 2021;20(1):33-38. http://dx.doi.org/10.17159/23098309/2021/v20n1a4 editor: dr franz birkholtz, walk-a-mile centre for advanced orthopaedics, pretoria, south africa received: july 2020 accepted: september 2020 published: march 2021 copyright: © 2021 venter rg. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this manuscript. conflict of interest: all the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background this study presents the outcomes of the management of chronic osteomyelitis of the appendicular skeleton according to an integrated approach at a dedicated bone infection unit in south africa. methods a retrospective record review identified 80 patients who were treated between january 2016 and december 2018. results sixty patients (75%) presented with fracture-related infections, 17 patients (21%) developed chronic osteomyelitis following haematogenous spread and three (4%) from contiguous wounds. according to the cierny and mader classification, 21 patients presented with anatomical type i, 14 with type ii, 24 with type iii and 21 with type iv chronic osteomyelitis. positive microbial cultures were obtained in 63 (79%) cases. follow-up for the cohort ranged from 1 to 29 months, with a mean follow-up of 10.4 months. the overall complication rate for the cohort was 6% and included sterile drainage from the surgical site after management with bioactive glass (s53p4), refracture after hardware removal, and development of non-union. five patients experienced recurrence after the initial procedure to eradicate infection, resulting in an overall resolution rate of 94%. conclusion using single-stage surgeries and tailored dead space management strategies according to a comprehensive integrated approach developed in south africa, results comparable to international literature can be achieved. level of evidence: level 4 keywords: chronic osteomyelitis, dead space management, bioactive glass, lautenbach technique the management of chronic osteomyelitis in adults: outcomes of an integrated approach rudolph g venter , yashwant s tanwar , jan-petrus grey , nando ferreira* division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, tygerberg hospital, stellenbosch university, cape town, south africa *corresponding author: nferreira@sun.ac.za introduction chronic osteomyelitis is notoriously difficult to eradicate, and high failure rates have been reported in the literature.1,2 the fact that certain bacteria form biofilm with metabolically inactive colonies and can become dormant intracellularly in osteocytes, contributes to the difficulty in achieving cure in these cases.3-8 although no evidence-based treatment guidelines exist for the management of chronic osteomyelitis, the ideal treatment strategy can be outlined as: resection of all necrotic tissue, dead space management, followed by soft tissue and bony reconstruction as required.3,9-12 concurrent antibiotic therapy is initiated as an adjunct to surgical management.12 the most widely used classification system is that of cierny and mader, incorporating both the local extent of the disease, and the physiological status of the patient to guide management.3 however, a limiting factor is that host stratification is a subjective judgment made by the treating surgeon as to what the patient’s response to treatment will be.13 judicious resection of necrotic tissue increases the chance of resolution of infection, but depending the anatomical type of chronic osteomyelitis, this surgical approach can potentially result in large defects or dead space.3,10 several strategies have been employed to manage this dead space including gentamycin beads, physiciandirected custom cement spacers, irrigation systems, antibioticloaded calcium sulphate pellets and, more recently, bioactive glass and gentamycin-impregnated collagen sponges.12,14 there is no treatment regimen that suits all patients, but current literature supports single-stage treatment strategies that incorporate a form of active dead space management.15 these singlehttp://dx.doi.org/10.17159/2309-8309/2021/v20n1a4 http://dx.doi.org/10.17159/2309-8309/2021/v20n1a4 https://orcid.org/0000-0003-0022-6969 https://orcid.org/0000-0003-4606-7801 https://orcid.org/0000-0001-5073-0173 https://orcid.org/0000-0002-0567-3373 page 34 venter rg et al. sa orthop j 2021;20(1) stage strategies are driven in a large part by newer techniques of dead space management that do not require removal at a second sitting, such as polymethyl methacrylate (pmma) spacers and gentamycin-impregnated beads, and success rates are comparable to traditional two-stage approaches.16 empiric antibiotic regimens reported in the literature are varied, and the agents used should be tailored to local bacterial isolates and antibiogram patterns, and changed to pathogen-directed adjuvant therapy as soon as culture results are available.16 this study aims to present the outcome of management of chronic osteomyelitis of the appendicular skeleton according to an integrated approach at a dedicated bone infection unit. methods a retrospective review of patient records was performed for the period from january 2016 to december 2018. during this time, all patients presenting to our unit with chronic osteomyelitis of the appendicular skeleton underwent treatment according to an integrated approach, demonstrated in figure 1. this strategy represents our current standard of care for patients presenting with chronic osteomyelitis. exclusion criteria included patients younger than 12 years of age, infections of the spine and pelvis, and patients who did not attend at least one follow-up visit. ethical approval as well as hospital board approval was obtained prior to data collection. chronic osteomyelitis was defined as: infection involving bone, with a duration of at least ten days, where the causative organisms were thought to have persisted either intracellularly or in interactive biofilm-based colonies.17,18 pre-operative evaluation involved a thorough history, including main complaint, comorbid conditions, smoking, alcohol and substance abuse, previous surgical interventions and prior antibiotic therapy, as well as a comprehensive clinical examination. clinical examination included evaluation of the local soft tissue quality, vascularity and neurological status of the affected limb. neoadjuvant antibiotics ± intralesional debridement chronic suppressive antibiotic therapy (csat) ± intralesional debridement acute infection following osteosynthesis (optimal biomechanical environment) debridement dead space management soft tissue cover stabilisation adjuvant antibiotics skeletal reconstruction abscess/cellulitis yes (c-host) yes yes ex fix csat ± debridement consider amputation alternative palliative yesno no palliative curative no no (a/b host) risk factor modification potential to unite? ≥ 1 major risk factor ≥ 3 minor risk factors severe impairment + instability minimal impairment + stability + no identifiable nidus figure 1. treatment selection algorithm (reproduced, without any changes, under the terms of the creative commons attribution 4.0 international license from: marais l, ferreira n, aldous c, le roux t. the outcome of treatment of chronic osteomyelitis according to an integrated approach. strat traum limb recon. 2016;11:135-42. [http://creativecommons.org/licenses/by/4.0/]) table i: modified version of the original cierny and mader classification system that served to guide treatment strategy selection classification characteristic physiological type a host type b host type c host no risk factors fewer than three minor risk factors one major and/or three or more minor risk factors pathoanatomy i – medullary ii – cortical iii – combined (stable) iv – combined (unstable) no cortical sequestration direct contiguous involvement in cortex only both cortex and medullary regions involved as for iii plus unstable prior to debridement nidus sequestrum implant no identifiable nidus cortical sequestrum present biofilm-based infection in the presence of implant minimal necrosis osteomyelitis impairment minimal severe patient able to perform activities of daily living unable to perform activities of daily living (reproduced, without any changes, under the terms of the creative commons attribution 4.0 international license from: marais l, ferreira n, aldous c, le roux t. the outcome of treatment of chronic osteomyelitis according to an integrated approach. strat traum limb recon. 2016;11:135-42. [http://creativecommons.org/licenses/by/4.0/]) page 35venter rg et al. sa orthop j 2021;20(1) plain radiographs were used to identify any sequestra or cloaca and assess skeletal stability. computed tomography (ct) was predominantly used in type iii and type iv cases where skeletal stability was in doubt and more anatomical detail was required for surgical planning. anatomical classification of disease, according to the cierny and mader classification, was based on radiological findings. laboratory investigations assisted in stratifying the patient’s physiological status and comprised a full blood count, iron studies, renal and liver function tests and a nutritional profile. routine infection markers included leukocyte count (wcc), erythrocyte sedimentation rate (esr) and c-reactive protein (crp) levels. in cases of specific chronic illnesses, supplementary tests included cd4 count and viral load for hiv infection, and hba1c in cases of diabetes mellitus. host stratification into type a, b or c hosts was done according to the modification of the cierny and mader classification as proposed by marias et al. set out in table i.13 the major and minor risk factors are listed in table ii.13 definitive surgical management was preceded by host optimisation and governed by five general principles comprising: judicious debridement of necrotic tissue according to point-of-care testing, dead space management, adjuvant-directed antibiotic therapy, soft tissue coverage and bone reconstruction as required. pointof-care testing refers to the surgeon’s decision on bone viability considering the intra-operative assessment of bone colour, texture, timbre (sound) and capacity to bleed (paprika sign). the management of cierny and mader type i osteomyelitis included removal of the intramedullary nail, indirect unroofing with debridement via reaming of the medullary canal and dead space management using a modified lautenbach irrigation system.19 debridement consists of over-reaming of the canal, starting with reamer size equal to the diameter of the removed nail. the reamer sizes are then sequentially increased until bony debris is obtained, and no more biofilm is returned on reaming extractions. debridement of the interlocking screw holes with a high-speed burr is followed by irrigation of the canal with a pulse-lavage system. an improvised continuous irrigation system delivering 1 litre of isotonic saline containing 80 mg gentamycin at a rate of 125 ml per hour is used. irrigation was allowed to run freely until the effluent was clear. no routine cultures of the effluent were done. type ii and type iii osteomyelitis were managed by direct unroofing using a high-speed burr followed by dead space management and soft tissue reconstruction as required. dead space management consisted of soft tissue reconstruction with or without garacol® gentamycin-loaded fleece insertion (innocoll pharmaceuticals, ireland) in type ii osteomyelitis and bonalive® table ii: risk factors used to stratify the physiological status of the host major risk factors minor systemic risk factors minor local risk factors cd4 count <350 cells/min3 albumin <30 g/l hba1c ≥8% cellulitis or abscess formation malignancy at site of infection pathological fracture hiv infection anaemia smoking diabetes mellitus rheumatoid arthritis chronic lung disease chronic cardiac failure paraplegia/quadriplegia drug or substance abuse chronic corticosteroid use active tuberculosis ischaemic heart disease cerebrovascular disease compliance and motivation age >65 years poor soft tissue requiring flap chronic venous insufficiency peripheral vascular disease previous radiation therapy surgery will result in instability adjacent joint stiffness/arthritis heterotopic ossification failed reconstruction elsewhere foot involvement pelvic involvement adjacent joint involvement segmental resection ≥60 mm required to achieve cure (reproduced, without any changes, under the terms of the creative commons attribution 4.0 international license from: marais l, ferreira n, aldous c, le roux t. the outcome of treatment of chronic osteomyelitis according to an integrated approach. strat traum limb recon. 2016;11:135-42. [http://creativecommons.org/licenses/by/4.0/]) ho: haematogenous osteomyelitis fri: fracture-related infection : gunshot fractures (included in fri) humerus fri = 7, 8.2% femur fri = 15, 17.6% ho = 9, 10.6% metatarsal ho = 1, 1.2% calcaneus ho = 1, 1.2% tibia fri = 36, 42.3% ho = 7, 8.2% contiguous = 4, 4.7% radius fri = 2, 2.4% ho = 1, 1.2% ulna fri = 2, 2.4% total cases in cohort: 85, 100% figure 2. distribution of anatomical sites of osteomyelitis page 36 venter rg et al. sa orthop j 2021;20(1) bioactive glass (s53p4) (bonalive biomaterials ltd, turku, finland) in all type iii osteomyelitis cases.20 most patients with diffuse osteomyelitis and skeletal instability (type iv) were managed by segmental resection of the necrotic bone followed by insertion of a physician-directed custom antibioticloaded cement spacer for dead space management. palacos r+g cement (heraeus medical), containing 0.5 g of gentamycin per 40 g pack, was used to construct the cement spacers. once soft tissue reconstruction was achieved, bony reconstruction was considered. bone defects smaller than 20 mm were treated by circular external fixation gradual shortening while larger defects were reconstructed by bone transport through an induced membrane using fine wire circular external fixation.12 type c patients, irrespective of the anatomical grading, that had serious impairment of daily function, skeletal instability or active cellulitis were treated with an ‘alternative strategy’ including limited surgical interventions and chronic suppressive antibiotic therapy (csat). in cases where there was a reasonable chance of achieving union, limited debridement with external fixation was considered. in type c patients that had no realistic chance of union, that would have an un-reconstructable bone or soft tissue defect post-debridement or would be left with a non-functional limb, amputation was considered. results between january 2016 and december 2018, 88 patients were treated for chronic osteomyelitis of the appendicular skeleton. eight cases were excluded: one patient younger than 12 years of age, one pelvic infection, four patients who had simple soft tissue abscesses and two patients who were still waiting for definitive surgery. after exclusions, the final cohort consisted of 80 patients, comprising 59 men and 21 women with a mean age of 36.25 years (sd 13.39, range 12 to 67) (table iii). the involved anatomical sites are illustrated in figure 2. the follow-up for the cohort ranged from 1 to 29 months, with an average of 10.4 months. the case distribution according to the anatomical classification is shown in table iv. positive microbial cultures were obtained in 65 (77%) cases (table v). bacterial culture information and sensitivity profiles were used to guide table iii: general and clinical characteristics of all patients n=80 age (years) 36.25±13.39 (80) sex (% male) 74% (59) original pathology fracture-related infection 75% (60) haematogenous infection 21% (17) contiguous infection 4% (3) data is presented as mean±standard deviation for parametric data, median (interquartile range) for non-parametric data or frequencies, with the number of participants in parentheses. table iv: case distribution according to cierny and mader anatomical classification com anatomical type complications (n) recurrence (n) type 1 (n=21, 26%) 10% (2) 10% (2) type 2 (n=14, 18%) 0% (0) 7% (1) type 3 (n=24, 30%) 4% (1) 4% (1) type 4 (n=21, 26%) 10% (2) 5% (1) total (n=80, 100%) 6% (5) 6% (5) data is presented as frequencies with counts indicated in parentheses. table v: bacterial isolates stratified according to cierny and mader anatomical type culture information c&m i (n=21) c&m ii (n=14) c&m iii (n=24) c&m iv (n=21) total (n=80) organism cultured no growth 33% (7) 14% (2) 25% (6) 10% (2) 21% (17) single organism 29% (6) 71% (10) 67% (16) 57% (12) 55% (44) multiple organisms 38% (8) 14% (2) 8% (2) 33% (7) 24% (19) gram-positive bacteria methicillin-sensitive staphylococcus aureus 24% (5) 29% (4) 40% (8) 23% (6) 28% (23) methicillin-resistant staphylococcus aureus 10% (2) 14% (2) 25% (5) 12% (3) 15% (12) enterococci 14% (3) 7% (1) 5% (4) enterobacter cloacae 14% (2) 12% (3) 6% (5) streptococci 10% (2) 5% (1) 4% (1) 5% (4) bifidobacterium 5% (1) 1% (1) gram-negative bacteria proteus species 29% (6) 29% (4) 19% (5) 19% (15) pseudomonas aeruginosa 5% (1) 10% (2) 19% (5) 10% (8) acinetobacter baumanni 4% (1) 1% (1) providencia stuartii 4% (1) 1% (1) klebsiella pneumoniae 10% (2) 4% (1) 4% (3) escherichia coli 5% (1) 1% (1) morganella morganii 5% (1) 1% (1) serratia marcescens 7% (1) 1% (1) citrobacter freundii 5% (1) 1% (1) data is presented as frequencies with counts indicated in parentheses. page 37venter rg et al. sa orthop j 2021;20(1) antimicrobial therapy, but a full report on the antibiograms was beyond the scope of this article. the overall complication rate for the cohort was 6% and included sterile drainage from the surgical site after management with bioactive glass (s53p4), refracture after hardware removal, infection of a bone graft site and development of non-union. five patients experienced recurrence of infection after the initial procedure to eradicate infection, resulting in an overall resolution rate of 94%. type i twenty-one patients (26%) were treated for medullary osteomyelitis. all cases had prior insertion of an intramedullary nail. treatment included removal of the intramedullary nail, indirect unroofing with intramedullary reaming and dead space management using a continuous irrigation system. nine (43%) patients did not complete six months follow-up, but all nine had complete resolution of symptoms at the last visit. complications were observed in two cases (10%). one patient who initially received treatment for a septic cephalo-medullary femoral nail sustained a refracture four months after removal of the nail. the patient was deemed infection-free at the time of repeat nail insertion and no recurrence of infection was experienced 11 months after fracture fixation. a second patient who had a septic tibial nail removed was thought to have achieved union at the time of surgery, but at follow-up was found to have had a non-union. union was achieved after circular external fixator application and the patient was infection-free at last follow-up, one year after the initial surgery. two patients (10%) experienced recurrence of infection. the first defaulted antibiotic therapy during incarceration and was awaiting reoperation at the time of review. the second patient was a known smoker, who experienced recurrence of femoral osteomyelitis symptoms. he underwent a sequestrectomy five months later after which resolution of the symptoms was achieved. type ii fourteen patients (18%) were diagnosed with superficial osteomyelitis, including 11 (79%) fracture-related infections, one (7%) case of osteomyelitis of exposed bone following burn wounds, one case (7%) of penetrating injury without an underlying fracture, and one case (7%) of chronic osteomyelitis one year following haematogenous spread. all cases underwent singlestage debridement and soft tissue closure either by primary closure or flap. seven (50%) patients were lost to follow-up before six months. one patient (7%) had recurrence of infection. this case was a 26-year-old smoker and known substance abuser with osteomyelitis of the humerus after fracture fixation. he defaulted initial follow-up and returned four months later with an acute recurrence of infection. type iii twenty-four patients (30%) had localised osteomyelitis with a full thickness cortical sequestrum. twelve cases (50%) were due to fracture-related infections, 11 (46%) were secondary to haematogenous spread and one (4%) followed a severe burn that resulted in exposed bone. all were treated with judicious debridement and the use of bioactive glass (s53p4) as dead space management and either primary closure or flap. one patient (4%) did not complete six months follow-up but was asymptomatic at last review. one patient (4%) experienced a period of persistent wound drainage after dead space management with bioactive glass which later resolved spontaneously. the patient was asymptomatic at 24 months follow-up. one patient (4%) with osteomyelitis of the humerus after fracture fixation experienced recurrence of symptoms after the initial procedure. he is known to be a smoker and a poorly controlled type ii diabetic. this patient had eradication of infection following repeat debridement and dead space management with bioactive glass. type iv twenty-one patients (26%) were diagnosed with diffuse osteomyelitis and skeletal instability, of which 17 (81%) were secondary to fracture-related infections and four (19%) were secondary to haematogenous spread. seven (33%) patients were managed by segmental resection followed by insertion of a physician-directed custom gentamycinloaded cement spacer. bone defect reconstruction was accomplished by frame-assisted gradual shortening in four cases, of which one patient had proximal tibial lengthening after the initial shortening, and three instances of bone transport through an induced membrane with routine bone grafting at the docking site. one patient (5%) was treated with debridement and soft tissue closure while in all-wire frame fixation for an open tibia fracture, one (5%) was treated with debridement and frame-assisted ankle arthrodesis, and one patient (5%) was treated with a cement nail. eleven patients (52%) underwent limb ablation: four above-knee amputations, four below-knee amputations, one through-knee amputation, one above-elbow amputation and one ray amputation of the metatarsal. five of these patients (46%) were type c hosts that could not undergo extensive reconstruction. the rest were type a or b patients in which either an adjacent joint was also septic, the soft tissue defect was too extensive to reconstruct, or the patient requested ablation. two (10%) patients in this group did not complete six months follow-up, but both these patients had complete resolution of symptoms at the time of the last visit. two patients (10%) experienced complications. one, who had had a septic femoral nail removed in 18 years prior, subsequently defaulted csat and follow-up, and presented to our unit as a type c host with skeletal instability, acute cellulitis and systemic sepsis. the patient passed away after initial treatment with debridement and lautenbach irrigation followed by above-knee amputation. the second patient was a 52-year-old smoker who sustained an open tibia fracture with bone loss. he underwent bone transport through an induced membrane to reconstruct an 80 mm bone defect. docking site sepsis and an adjacent knee flexion contracture brought about the patient’s request for limb ablation. one patient (5%) experienced recurrence, a 12-year-old girl, who initially presented with acute staphylococcal septicaemia and osteomyelitis of the tibia. she underwent resections of necrotic bone and frame-assisted bone transport through an induced membrane. stability was achieved, but the infection recurred 11 months later. discussion the aim of this retrospective review was to evaluate the outcome of management of chronic osteomyelitis of the appendicular skeleton according to an integrated approach at a dedicated bone infection unit. a 2013 cochrane review of four randomised control trials reported a combined remission rate of 79% at 12 months.21 more recently, the management of osteomyelitis in dedicated multidisciplinary page 38 venter rg et al. sa orthop j 2021;20(1) bone infection units have been shown to produce better results illustrating the highly specialised nature of this work.22-24 similar results were seen in our series with successful eradication of infection in all cierny and mader anatomical types in 94% of cases using a single-stage approach and a tailored dead space management strategy. apart from obviating the need for second surgery, single-stage management of chronic osteomyelitis is also more cost-effective and has been shown to offer similar if not better clinical outcomes in resolution rates of infection.23,25 in a systematic review of single-stage management of osteomyelitis over a 20-year period, pincher et al. described non-recurrence rates of 79% to 100% when all ‘simple-debridement only’ approaches were excluded.16 the authors concluded that not one dead space management technique was superior but that debridement without dead space management should be avoided. more specifically, pincher et al. reported successful eradication of intramedullary infection in 83% of patients using the lautenbach irrigation system, while a success rate of 96% was observed with the use of bioactive glass as dead space management following debridement. our results support these findings, where success rates, for continuous irrigation and bioactive glass dead space management of 91% and 96%, respectively, were observed. factors potentially contributing to the increased success rates include judicious debridement protocols, the availability of biodegradable antibiotic delivery systems as dead space management agents, improved sampling techniques intra-operatively, well-directed antibiotic therapies and the advances in prosthetic limb designs paving the way for a lower threshold of amputation surgery. failure to isolate an infecting organism was seen in 17 of the 80 patients (21%) in our cohort. this is similar to the review by pincher et al. in which 19% of the patients never had positive cultures.16 this review is limited by its retrospective nature and the relatively short mean follow-up time (ten months), compared to international literature (41.9 months) as well as the high rate of patients defaulting follow-up (5%).16 in the south african setting poverty combined with large travel distances appears to affect general follow-up among research participants. up to 21% of patients never returned for any post-operative visits in an observational study conducted on trauma patients in the northern cape.26 similarly, a study conducted on patients receiving treatment for spinal tuberculosis, observed that 75% of patients were lost to follow-up within two years of diagnosis.27 it is, however, important to note that because of strict referral patterns within south africa, should any patient return with complications, they will be referred back to the original treating facility. conclusion the management of chronic osteomyelitis is complicated and resource-intensive. using single-stage surgeries and tailored dead space management strategies according to a comprehensive integrated approach developed in south africa, results comparable to international literature can be achieved. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethics approval was obtained from the stellenbosch university human research ethics committee n18/08/082 prior to commencement of data collection. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions rgv: data capture, data analysis, first draft preparation, manuscript preparation yst: data capture, manuscript revision jpg: data capture, manuscript revision nf: study conceptualisation, data capture, data analysis, manuscript revision references 1. hall bb, rosenblatt je, fitzgerald rh. anaerobic septic arthritis and osteomyelitis. orthop clin north am. 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deakin m, latham jm. chronic osteomyelitis. j bone joint surg br. 2001;83-b(april):403-407. 11. parsons b, strauss e. surgical management of chronic osteomyelitis. am j surg. 2004;188(1):57-66. 12. marais lc, ferreira n, aldous c, le roux tlb. the management of chronic osteomyelitis : part ii – principles of post-infective recontruction and antibiotic therapy. sa orthop j. 2014;13(3):32-39. 13. marais lc, ferreira n, aldous c, le roux tlb. the outcome of treatment of chronic osteomyelitis according to an integrated approach. strateg trauma limb reconstr. 2016;11(2):135-42. 14. marais lc, ferreira n, aldous c, le roux tlb. the management of chronic osteomyelitis : part i – diagnostic work-up and surgical principles. sa orthop j. 2014;13(2):42-48. 15. metsemakers w-j, fragomen at, moriarty tf, et al. evidence-based recommendations for local antimicrobial strategies and dead space management in fracture-related infection. j orthop trauma. 2020;34(1):18-29. 16. pincher b, fenton c, jeyapalan r, barlow g, sharma hk. a systematic review of the single-stage treatment of chronic osteomyelitis. j orthop surg res. 2019;14(1):393. 17. lew dp, waldvogel fa. osteomyelitis. lancet. 2004;364(9431):369-79. 18. mader jt, norden c, nelson jd, calandra gb. evaluation of new anti-infective drugs for the treatment of osteomyelitis in adults. infectious diseases society of america and the food and drug administration. clin infect dis. 1992;15(suppl 1):s155-61. 19. hashmi ma, norman p, saleh m. the management of chronic osteomyelitis using the lautenbach method. j bone joint surg br. 2004;86-b(2):269-75. 20. oosthuysen w, venter r, tanwar y, ferreira n. bioactive glass as dead space management following debridement of type 3 chronic osteomyelitis. int orthop. 2020;44(3):421-28. 21. conterno lo, da silva filho cr. antibiotics for treating chronic osteomyelitis in adults. cochrane database of systematic reviews. 2009;(3):cd004439. 22. arias ca, betancur mct, pinzon ma, et al. differences in the clinical outcome of osteomyelitis by treating specialty: orthopedics or infectology. plos one. 2015;10(12):1-14. 23. mcnally ma, ferguson jy, lau ack, et al. single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/ hydroxyapatite biocomposite: a prospective series of 100 cases. bone jt j. 2016;98-b(9):1289-96. 24. jiang n, zhao x, wang l, et al. single-stage debridement with implantation of antibiotic-loaded calcium sulphate in 34 cases of localized calcaneal osteomyelitis. acta orthop. 2020;3674:1-7. 25. geurts j, van vugt t, thijssen e, arts jj. cost-effectiveness study of one-stage treatment of chronic osteomyelitis with bioactive glass s53p4. materials (basel). 2019;12(19):3209. 26. badenhorst dhs, van der westhuizen ca, britz e, burger mc, ferreira n. lost to follow-up: challenges to conducting orthopaedic research in south africa. south african med j. 2018;108(11):917-21. 27. mann tn, davis jh, dyers r. loss to follow-up among patients diagnosed with spinal tuberculosis at a tertiary hospital in western cape province, south africa: a retrospective cohort study. south african med j. 2020;110(4):284-90. orthopaedics vol3 no4 sa orthopaedic journal summer 2014 | vol 13 • no 4 page 19 retrospective analysis of adverse reactions to metal-on-metal lumbar disc arthroplasties in 378 consecutive patients s berg md, phd stockholm spine center, löwenströmska hospital, stockholm, sweden n jansen m eng north-west university (potchefstroom campus), south africa correspondence: dr svante berg stockholm spine center löwenströmska hospital 19489 upplands väsby se-195 89 stockholm sweden email: svante.berg@spinecenter.se introduction neck or back pain associated with degenerative changes of the functional spinal unit is one of the leading causes of disability among adults. chronic low back pain (clbp) with a prevalence in excess of a one-year period is as high as 73%.1 disc degeneration is a frequent cause of clbp, and conservative treatment including physiotherapy and exercise is the first step in attempting to reduce pain and improve function. should conservative treatment fail, surgical intervention, which includes fusion or disc replacement procedure, is considered as a last resort.2 the gold standard in surgical treatment of clbp has been fusion. in the past decade, spinal disc arthroplasty and dynamic stabilisation devices have received growing acceptance as treatment for back and neck pain.3,4 finite element studies have confirmed that unnatural disc kinematics result in higher stress imparted to adjacent discs.5,6 unnatural kinematics may be caused by sclerotic, degenerated or fused intervertebral discs. experience and knowledge gained from treatment of other joints with arthroplasty have led to the development of artificial discs (disc prostheses). the rationale for selecting total disc replacement (tdr) over fusion is a desire to preserve motion between vertebral bodies that might reduce adjacent segment disease.6,7 abstract background: spinal disc arthroplasty implants are primarily manufactured from metal/polymer materials. biological reaction to wear debris ultimately requires clinical studies for assessment. research into biological reaction of metal-on-polyethylene and metal-on-metal wear debris of knee and hip arthroplasties is well progressed as opposed to similar research on spinal arthroplasties. materials and method: the swedish spine register provides a resource for the evaluation of adverse events and clinical outcome to lumbar metal-on-metal total disc replacements. the resource will be used for a retrospective analysis of the cases in this study. the material reviewed consists of a total of 378 swedish patients treated between october 2003 and may 2009 (181 male, 197 female); average age was 39.2 years. by means of a questionnaire, 94% of the patients were followed up after two years and 88% after five years. results: no reported cases were found of suspected or confirmed metal hypersensitivity or pseudotumors. this may be due to symptom-producing pseudotumors being extremely rare and the difficulty to form questions which would be able to indicate the presence of the adverse outcome. conclusion: based on the results from this study, it can be concluded that the results do not exclude the possibility that patients might have non-symptomatic pseudotumors, but being non-symptomatic, the authors doubt the importance and relevance of further investigating those isolated cases. key words: spinal arthroplasty, metal-on-metal, pseudotumors, hypersensitivity, metallosis, swespine saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 1� page 20 sa orthopaedic journal summer 2014 | vol 13 • no 4 in all joint replacement surgery there are four main questions to be answered: what is 1) the correct indication for the procedure, 2) the best surgical technique to be used, 3) the most favourable design of the implant and 4) the most appropriate materials to use? this study focuses on the fourth questions, namely, the specific material frequently used. hip and knee replacements have been performed since the 1970s, providing knowledge that particulate wear debris may be associated with post-operative complications such as peri-implant osteolysis or pseudotumors characterised as an enlargement of benign tissue.8 selection of the wear couple material is for the most part a compromise between the wear rate, robustness and toxicity. there seems to be no single hip bearing material combination which reduces all clinical complications.9 in most cases, hip bearing design includes metal-onpolymer (mop), metal-on-metal (mom), or ceramic-onceramic (coc) wear couples. soft bearing wear, such as polyethylene, in general is dominated by adhesive wear, while hard-on-hard bearings such as mom or coc are dominated by abrasive and surface fatigue wear.10 the use of mom as a hip bearing has become popular in the last years due to the possibility to reduce the risk of joint luxation by larger femoral heads, but also perceived advantages of being more robust than mop or coc, as well as having a lower volumetric wear than mop.11-13 osteolysis associated with mom bearing implants is seldom reported, and is considered as the prime motivation for a return to mom wear couples.14,15 recently a particular mom hip arthroplasty has been found to have poor short-term results. hexter et al. suggest that a substantial portion of the blood ion levels are as a result of corrosion at the taper interface between the hip stem and ball and not the intended wear couple.16 bernthal et al. suggest that the design flaw lies not with the specific implant but rather with the ultra large monobloc cobaltchromium-molybdenum (ccm) acetabular shells.17 over the medium to long term, the mechanical advantages of mom over mop are potentially offset by a higher frequency of foreign-body tissue reaction due to smaller particle size of wear debris, as well as bioactive cobalt and chrome ion release.15,18 the most common cause of total hip arthroplasty (tha) failure is loosening of the acetabular cup or femoral part due to osteolysis.19-22 case studies indicate that failure due to metallic debris infiltration have also been reported.23-25 it is reported that reaction to polyethylene particles is that a fibrotic granulation tissue typically develops.26 if the degree of metallosis (such as adjacent tissue staining in black or grey) is significant and probably a certain size of the particles is produced, a ‘foreign body reaction’ may take place because submicron and micron-sized wear particles are encapsulated by the host body.27 fibroblast and inflammatory cells within the tissue are activated, and as a result foreign body granulation tissue develops. the tissue tends to be fibrotic, but may undergo additional changes such as necrosis, and heterotopic ossification. local inflammation is mostly dependent on three factors; particle load, shape and chemical reactivity. in general, a higher inflammatory response will be produced with a higher concentration of debris per tissue volume (particle load), elongated fibres and more chemically reactive composition.20 particle load is a function of the accuracy of device placement, as misalignment may lead to fouling between components near articulation extremes. the fixed centre of rotation spinal disc replacements is likely to increase the volume of wear debris if not accurately placed.28 the effects of pseudotumors have been found to be locally destructive, requiring revision surgery in a high proportion of patients.29 the extent of the encapsulation may be significant enough to appear on computed tomography scans.27 potential risks associated with mom hip implants are a biological, foreign body reaction. engh et al. suggest that the process starts as an inflammatory response progressing to a necrotic tissue involving soft and/or hard tissue.30 the most appropriate blood fraction is controversial when studying effects of mom implants.29 the acceptable limit of blood cobalt levels is therefore yet to be established.31,32 the potential for the release of metal ions was examined in a subset of kineflex mom cervical disc subjects from a us ide clinical study, which included sample collection at all investigational sites participating in the study that were qualified and had the facilities to do the collection. these sites collected samples from 32 subjects for analysis. metal ion analysis was evaluated by a core laboratory (rush university). figure 1. serum metal ion levels (µg/l) for kineflex disc subjects over time osteolysis associated with mom bearing implants is seldom reported, and is considered as the prime motivation for a return to mom wear couples saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 20 sa orthopaedic journal summer 2014 | vol 13 • no 4 page 21 mean serum cobalt and chromium serum levels ranged from 0.37 to 1.24 µg/l and 0.27 to 1.11 µg/l, respectively, at follow-up times ranging from 6 weeks to 72 months after implantation. as shown in figure 1, data through extended follow-up with the metal ion cohort showed metal ion levels were stable or decreasing over time after 12 months post-operative through the 72-month visit. metal ion data through extended follow-up with the metal ion cohort showed metal ion levels levelling off and decreasing over time after approximately 12 months postsurgery. maximum serum metal ion levels associated with kineflex implants were substantially lower than those found with other metal-on-metal implants, and substantially lower than threshold values that have been proposed as indicative of metallosis in literature for orthopaedic implants. longterm follow-up data showed the metal ion levels associated with the kineflex disc to be approximately five to 26 times lower than the 7 µg/l threshold of concern set by the british mhra medical alert for mom hip replacements issued on 22 april 2010.33 further, mom hips and mom lumbar discs are substantially different in implant design, joint size and environment (synovial vs non-synovial), loads and range of motion, and in vitro and in vivo wear. hypersensitivity to metal ions may either occur within minutes (initiated by anti-body or formation of antibodyantigen complexes) or days (by a cell-mediated response).34,35 on the contrary, metallosis is a well-known phenomenon, being the infiltration of metal, predominantly oxidised, in the tissues in contact with the implant. the only known effect of metallosis is that the periprosthetic tissue is stained black, with microscopic necrosis.27 materials commonly used for the manufacture of total disc replacements spinal disc arthroplasty devices mostly feature mom and mop bearings in either fixed or mobile centre of rotation configurations. the most popular metal and polymer used by tdr device wear surfaces are cobalt-chromium-molybdenum (ccm), and ultra-high molecular weight polyethylene (uhmwpe). polyether ether ketone (peek) is a polymer which has a high degree of biocompatibility, and is under investigation as a mop wear couple.36 materials presently used for lumbar and cervical spinal disc replacement devices, which are us food and drug administration (fda) approved, are listed in tables i and ii respectively. although comprehensive laboratory tests as well as animal studies are performed prior to clinical trials, novel uses of biomaterials lead to difficulty in predicting in vivo performance.26,37 retrieval analyses of motion preserving spinal devices have to a large extent validated the high mechanical strength and low wear advantages of mom over mop. uhmwpe wear surfaces have displayed the potential to crack or plastically deform in both hip and spinal applications.26,27,46 ooij et al.2 report on high wear rates of the polyethylene component of the sb charité iii lumbar disc replacement, suggesting that the device would have a lifespan of less than 40 years.2 the nature of wear particles obtained by in vitro wear simulation tests of hip, knee, and spinal wear are of a similar morphology.20 over the short term, the increase of ion levels in blood after a single level mom lumbar disc replacement (maverick™) was found to be of the same order of magnitude as that of a well-functioning mom hip arthroplasty.47 subsequent to this publication it has been reported that a specific mom hip arthroplasty has been shown to exhibit much higher wear or metal ion release, but in this instance, it is believed to be related to the design of this specific implant.48 table i: list of presently fda-approved lumbar disc arthroplasties manufacturer device name pma filed fda approval wear couple reference depuy spine, inc. charite™ 2004.02.13 2004.10.26 ccm-polyethylene 38 s synthes spine, inc. prodisc®-l 2005.03.15 2006.08.14 ccm-polyethylene 39 table ii: list of presently fda-approved cervical disc arthroplasties manufacturer device name pma filed fda approval wear couple reference medtronic sofamor danek bryan® 2006.06.29 2009.05.12 ti-polyethylene 40 prestige® 2006.05.19 2007.07.16 stainless steel 316 41 s synthes spine, inc. prodisc™-c 2007.01.03 2007.12.17 ccm-polyethylene 42 globus medical, inc. secure®-c 2010.09.17 2012.09.28 ccm-polyethylene 43 nuvasive, inc. pcm® 2010.04.01 2012.10.26 ccm-polyethylene 44 ldr spine usa, inc. mobi-c® 2011.01.14 2013.08.07 ccm-polyethylene 45 hypersensitivity to metal ions may either occur within minutes or days saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 21 page 22 sa orthopaedic journal summer 2014 | vol 13 • no 4 hallab reviewed published data on concentrations of metal in body fluids, reporting that co ion levels in blood serum increased from < 0.2–0.6 to 1.9–4.8 parts per billion (ppb) for tdr and 0.6–7.9 ppb for mom total hip arthroplasties.20 cr-ion levels were found to be higher in tha than tdr, 9.1 and 2.4 ppb respectively. it is therefore noted that in lumbar tdr, co and cr ion levels are lower than after tha.20,47 complications such as peri-implant osteolysis and metal hypersensitivity are rare and make for a challenging diagnosis.30,49 biological reaction to wear debris depends on volume as well as morphology of wear debris generated.50 recently a few cases of suspected ‘pseudotumors’ after cervical or lumbar tdr were reported.51,52 the purposes of this study were to analyse in what patient material mom tdrs were used and to report on the clinical symptomatic incidence of pseudotumors or metal hypersensitivity brought on by mom wear couples in lumbar spinal disc arthroplasties. material and methods this is a retrospective study on consecutive patients who had received mom tdr between 8 october 2003 and 13 may 2009 due to chronic low back pain, where pain and dysfunction were not reduced after prolonged conservative treatment over at least one year. all surgeries were carried out at stockholm spine center in sweden; 88 per cent of the procedures were performed by one surgeon (sb). follow-up on patients was performed two and five years after surgery with the swedish spine register, but for this study, medical record data were also examined together with a follow-up visit with clinical examination when more than two years had passed since treatment. the swedish spine register (swespine) is a non-profit organisation owned and administered by the swedish society of spinal surgeons. swespine was founded in 1993, and is currently a national registry.53 one of the aims of the registry is to provide outcomebased feedback from patients after surgical intervention, and thereby provide continuous improvement of spinal treatments. adverse medical conditions are recorded within the register, which therefore serves as a rigorous report of patient feedback for the recorded period. the swespine database was used to select only lumbar arthroplasties featuring mom wear couples. the prostheses utilised were maverick™ (medtronic, memphis, te, usa), kineflex™ (southern medical, centurion, sa) and flexicore™ (stryker, kalamazoo, mi, usa) (figures 2–4). figure 2. maverick™54 figure 3. kineflex™55 figure 4. flexicore™54 all surgeries were carried out at stockholm spine center in sweden; 88 per cent by one surgeon saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 22 sa orthopaedic journal summer 2014 | vol 13 • no 4 page 23 to evaluate the outcome and quality of spinal treatment, patients answer questionnaires at one, two, five and ten year intervals after treatment. the questionnaires are sent to the patients with an attached pre-paid return envelope. all returned questionnaires are registered at one place by a single secretary. the questionnaires include present work status and medication, but also re-operations, euroqol (eq-5d), visual analogue scale (vas) for back and leg pain, sf-36, global assessment (ga) of back pain and the original oswestry disability index (odi). at time of surgery, the surgeon records diagnosis, type of surgery, treated segments, implants, dates of in-hospital stay and immediate complications. re-operations are recorded in the register, including patients treated with mom disc prostheses. since more than 95% of tdr surgery in sweden is performed in the clinic from which these results are obtained, a re-operation would most likely also be performed there. thirty-seven per cent of the patients in this study were examined by mri after more than two years had passed since surgery. the reason for the examination was most frequently because the patients were part of other studies, but in some cases they were performed due to recurrent or persistent lbp. these mri scans were investigated for the occurrence of pseudotumors. results the analysis of the treated patients showed that a total of 378 swedish patients (181 male, 197 female), with average age and weight of 39.2 years and 77.1 kg respectively were treated. a total of 111 patients had previous spinal operations; 297 were active in sports, 45 were smokers. all patients were treated with a total of 642 mom total lumbar disc replacements at one, two or three segments. followups were performed with 94 per cent of the patients after two years (356/378). in april 2013 317 of the patients had answered their five-year questionnaires (the 88% that had passed five years). the average time of follow-up was just over six years (4–10). tdrs were performed utilising maverick™ in 227 cases, kineflex™ in 140 cases and flexicore™ in 11 cases. no reported cases of pseudotumors were found in the material, neither presented with clinical symptoms in questionnaires or by words at clinical visit, nor identified on mri in the individual cases that had that examination late post-operatively. no case of suspected or verified metal hypersensitivity was found. three patients were re-operated due to misplaced disc prostheses, all within a week after index surgery. no metallosis or inflammation was observed at this early stage after initial surgical treatment. in one patient who underwent a late decompression and fusion at a segment that three years previously had been treated with a mom prosthesis, a slight metallosis was observed at one side posteriorly in the annulus fibrosus, but without any local reaction. discussion information from other joint replacements (tha and tdr) has been discouraging regarding the use of uhmwpe. this is due to the concern of high wear rates, early plastic deformation or component failure, and local reactions such as osteolysis that may be caused by wear-particles. when tdrimplants are compared with repeated movements under loaded conditions, the volumetric wear of mom is half of that of mop per million cycles.56 these factors have induced the development of tdr-implants that do not use uhmwpe. at this stage of disc development, other materials now used for bearing couples in lumbar tdr are ccm and peek. metallosis is the black or grey stain colouring of soft tissue that is often seen when implants are removed. this is seen even after fusion, when mobility-induced wear is not present or limited. when discussing adverse events resulting from the implantation of metal components into humans, confusion prevails. in the authors’ opinion this is because metallosis is not considered a complication, as it is not linked to any symptoms, but rather as a normal occurrence due to surface corrosion or deposition of wear debris. it is possible that there is an occurrence of true hypersensitivity to any of the metals in the implant. this is however almost unreported and it might occur whether or not the implant also consists of polyethylene. the frequency of hypersensitivity reactions is not well known.15 due to the rarity of metal hypersensitivity, as well as low accuracy of allergy tests, it is debatable whether screening should be performed prior to surgery.34 the formation of foreign body granulomas that can develop into pseudotumors can be considered as a physiological phenomenon. this is similar to what is observed if, for example, a needle tip is left in human tissue and there is no allergic reaction. in recent reports there is a high frequency of foreign body reactions leading to the formation of pseudotumors after mom total hip replacements. this is concerning as a large portion of tdrs performed today in sweden are mom. the proposed mechanism for the development of pseudotumors is that metal wear particles start a ‘foreign-body reaction’ in the host that encapsulates the wear particles. this encapsulation is what forms the pseudotumor. it is also reasonable to believe that the total size of the encapsulating tissue is dependent on the amount of wear particles. the total weight-strain on a hip prosthesis is assumed to be within the same range as that on a tdr implant. the loading pattern and total joint mobility is, however, far larger in a hip than in an artificial disc. the authors hypothesise that wear debris in a mom artificial joint is, besides design and placement differences, dependent on load and actual ‘travelled distance’ between joint surfaces per time unit. if this hypothesis is relevant, fewer wear particles would be expected in a tdr than in a tha and therefore there is a lower likelihood of adverse reactions on wear products emerging. saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 23 page 24 sa orthopaedic journal summer 2014 | vol 13 • no 4 in the case series of swedish patients, no reports were seen on ‘symptoms producing’ pseudotumors. this could be due to the difficulty of forming questions that are directed to finding patients who had developed pseudotumors. therefore the study has clear limitations. despite this, the result states that none of the patients had developed pseudotumors that caused neurological symptoms or local pain. the material is from scandinavia’s largest spine clinic, where until now more than 95% of lumbar tdrs in sweden were performed; therefore, these results can be considered to be valid. the swedish spine register (swespine) covers not only index surgery but also re-operations. furthermore, the patients treated at stockholm spine center are all referred from general practitioners or other orthopaedic clinics, where the receiving surgeons are expected to deal with any complications or need of re-operations that might occur. as a consequence of this study there has been a continuous and highly frequent use of mom prostheses after april 2009 at the clinic, still without any discovered cases of ‘pseudotumors’. conclusion based on the results from this study, it can be concluded that symptom-producing pseudotumors after tdr with mom implants are extremely rare. the results do not exclude the possibility that patients might have non-symptomatic pseudotumors, but being non-symptomatic, the authors doubt the importance and relevance of further investigating those isolated cases. references 1. rumboldt z. degenerative 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surgery. swedish society for spinal surgery. acta orthop 2001; 72: 99-106. 54. singh k, vaccaro ar, et al. assessing the potential impact of total disc arthroplasty on surgeon practice patterns in north america. spine j., 2004; 4: s195-s201. 55. hähnle ur, weinberg ir, et al. kineflex (centurion) lumbar disc prosthesis: insertion technique and 2-year clinical results in 100 patients. sas journal 2007; 1:28-35. 56. bushelow m, walker j, coppes j, et al. comparison of wear rates: metal/uhmwpe and metal-on-metal total disc arthroplasty. spine j. 2007; 7:97s. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 25 south african orthopaedic journal hand doi 10.17159/2309-8309/2021/v20n3a1 naude jj et al. sa orthop j 2021;20(3) citation: naude jj, koch o, schmidt lw, le roux tlb. positive patient experience of wide awake local anaesthesia no tourniquet (walant) hand surgery in the government setting: a prospective descriptive study. sa orthop j 2021;20(3):141-146. http://dx.doi.org/10.17159/23098309/2021/v20n3a1 editor: dr duncan mcguire, university of cape town, cape town, south africa received: june 2020 accepted: november 2020 published: august 2021 copyright: © 2021 naude jj. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background the purpose of this study was to establish a subjective patient experience with wide awake local anaesthesia no tourniquet (walant) procedures performed in the institution from may 2019 to march 2020. walant surgery was initiated to improve standard operating procedure and to decrease theatre burden. methods this prospective, descriptive study included 100 patients with a mean age of 59 years who required either a carpal tunnel or trigger finger release. the patients’ pain experience was documented on the visual analogue scale (vas) for the local anaesthetic injection and the surgical procedure. overall experience was assessed on the patient’s preference to have the procedure performed by the walant method or the conventional method. results one hundred patients were included, of which 67 had medical comorbidities. the mean vas score was 1.5 (sd±1.6) with pain on injection. the mean vas pain score during the surgical procedure was 0.2 (sd±0.7). one hundred per cent of patients (100/100) felt they would do the walant outpatient procedure again instead of admission to hospital and surgery in the theatre. two complications occurred related to wound care problems, and were successfully managed. none of the patients required reoperations for incomplete release of the carpal tunnel or trigger finger surgery. conclusion the results of this study suggest that minor hand surgery using the walant protocol can be performed effectively and with high patient satisfaction rates in the orthopaedic outpatient clinic, and is a useful tool in the skillset of a hand surgeon. level of evidence: level 4 keywords: walant, hand surgery, trigger finger, carpal tunnel release positive patient experience of wide awake local anaesthesia no tourniquet (walant) hand surgery in the government setting: a prospective descriptive study jaco j naude,¹* odette koch,² ludwig w schmidt,¹ theo lb le roux² ¹ steve biko academic hospital, department of orthopaedic surgery, university of pretoria, south africa ² 1 military hospital, department of orthopaedic surgery, university of pretoria, south africa; netcare pretoria east hospital *corresponding author: jacojnaude@yahoo.com introduction carpal tunnel surgery and trigger finger release are commonly performed procedures in hand surgery, with over 400 000 procedures per year in the united states.1 however, with increasing cost and the limited resources faced by many government institutions, some surgeons have looked at alternative, less expensive and more accessible venues to perform minor procedures.2 there has been an increased interest in and experience with performing surgical procedures on the hand and wrist utilising local anaesthesia in an unsedated patient. these surgical procedures can be safely performed on an outpatient basis using wide awake local anaesthetic no tourniquet (walant).3 this technique has been popularised and well described by plastic surgery.3 walant surgery makes it possible to do smaller cases of the hand in a more cost-effective manner in a clinic or outpatient setting, as shown in studies in america and canada.1,2 patient satisfaction is high with this technique because the pre-surgical survey is not needed, and post-anaesthetic recovery is rapid, due to a reduction in anaesthetic-related complications.2,4-8 even though the success of walant surgery is well recorded in developed world countries, limited data exists from south africa, and even more so in the government setting. the authors postulated that this method of surgery could solve problems currently existing in many state hospitals, including a large number of patients with limited theatre availability, multiple anaesthetic cancellations, long waiting lists and limited priority of cold/elective surgery. https://orcid.org/0000-0003-1448-4272 page 142 naude jj et al. sa orthop j 2021;20(3) the benefits of the walant approach include: • no sedation and no tourniquet increase patient comfort and convenience • simpler draping decreases surgical time; patients can have hand surgery in much the same way as a minor procedure at the dentist • eliminating the anaesthetic component decreases treatment time for minor procedures such as carpal tunnel releases, improving efficiency and workflow • during a surgical procedure, the patient can flex and extend fingers to show complete release, assisting in postoperative compliance • surgeons can discuss postoperative care and rehabilitation with the patient, improving patient compliance • immediate patient discharge postoperatively decreases the recovery process3,4 the current main theatre protocol at the institution includes admission at 7 o’clock the morning before surgery. preoperative workup for theatre for all patients above 40 years of age, regardless of the procedure, includes the following: chest x-ray, electrocardiogram (ecg), lung function tests and blood workup, which consists of a minimum of fbc and u&e. if indicated, extended biochemistry, including thyroid functions, calcium, magnesium and phosphate levels and liver function tests are conducted. an anaesthetic registrar or medical officer sees the patient the afternoon before surgery, and possibly asks for more tests, often including heart sonars and even angiograms. if further investigations are not completed before the planned procedure, the patient is cancelled and rescheduled after complete workup. once the required test results are available, the patient will be null per os from 10 o’clock the evening before surgery and be operated the following day, after which they will be discharged the same day postoperatively. hand surgeons and anaesthetists in government are currently reluctant to start using walant. in the protocol without walant, there is unnecessary preoperative workup for minor hand procedures, which waste valuable resources, workforce and money. incorporating the principle of ‘first do no harm’, the authors had to prove to the management of the hospital that the patients would not be caused damage and suffering as a result of walant. therefore, the objective of the current study was to establish a subjective patient experience with walant procedures performed at the institution from may 2019 to march 2020. the secondary objective was to assess if there were any differences in the level of pain during carpal tunnel and trigger finger release, or between males and females. patients and methods study design and research methodology this prospective, descriptive study was done over ten months, from may 2019 to march 2020, and included 100 patients with trigger fingers or carpal tunnel syndrome requiring surgical release. consecutive inclusion was applied as the sampling method. patient description and inclusion criteria patients were included in the study if they required surgery for carpal tunnel release or trigger finger release; were above the age of 18 years; with or without any associated medical comorbidities. patients were excluded from the study if they did not give consent; were anxious about the local procedure; were not suitable for walant surgery based on the surgeon’s discretion. patient demographics, including age, sex, diagnosis and walant procedure, were recorded. the research and ethics committee of the institution approved the study before study commencement. patients were enrolled voluntarily. all patients signed and dated the patient information leaflet and informed consent document on the day of the surgery. procedure description a room in the orthopaedic outpatient department was equipped for the surgical procedures (figure 1), with a specialised hand surgeon and two registrars performing all of the surgeries. cases were limited to eight per day as the hospital has a total of 12 handsets. the main theatre had access to the other four handsets. these cases were performed in the clinic between 8 and 12 o’clock in the morning. central sterile services department (cssd) supplied the sterile sets on the morning of the surgery. patients reported at the clinic at 8 o’clock on the morning of the procedure, and consent for the surgery was signed. the patients were infiltrated with local anaesthetics. the infiltrations were performed sequentially, infiltrating three cases from 8 o’clock, and thereafter infiltrating the next cases between surgeries as the list progressed. all injections were performed with the patients on a bed in the supine position as some patients may experience a vasovagal attack with lightheadedness from the infiltration. the volume of 20 ml (20 cc) infiltration fluid required for carpal tunnel release under walant surgery (figures 2 and 3) consists of:9 • lignocaine 1% (10 ml) • adrenalin 1:100 000 (2 ml) • bicarbonate 8.4%: 1 ml in each 10 ml infiltration to increase the ph from 4.7 to 7.4. this decreases the burning pain during infiltration (2 ml) • sterile water (6 ml) figure 1. image of walant theatre room in the orthopaedics outpatient department figure 2. carpal tunnel infiltration location9 (used with permission from lalonde and wong) page 143naude jj et al. sa orthop j 2021;20(3) a total of 4 ml of the same mixture of infiltration fluid was used for every trigger finger release (figure 4). a 27or 30-gauge needle was used to ensure minimal pain during insertion. the small gauge of the needle slowed the injection down, making it less painful. sensory noise was created by proximally pinching the injection site. the needle was inserted perpendicular to the skin, not injecting intradermally to minimise pain. the ‘blow before you go’ injection technique was followed. the solution was injected slowly before the needle progressed deeper into the tissue. using this technique, the nerve endings were blocked before the needle reached the deeper tissue. the following injections stayed within 10 mm of indurated areas to decrease pain. all injections were below the safe limit of 7 mg/kg for lignocaine injection. the patients were then given a resting period of 30 minutes to give the epinephrine and anaesthesia time to take effect. patients were operated in a sterile field, prepping the hand with chlorhexidine and alcohol. three towels or drapes were used per procedure (two to drape, and one rolled-up towel as positioner under the hand), as well as sterile gloves and masks. the surgeons were not gowned or capped. during the procedure, the surgeon communicated with the patient, relying on verbal feedback. no vital signs were monitored during the process. the resuscitation trolley was within reach and regularly checked. sterile dressings were placed, comprising gauze without the use of elastic bandages. no prophylactic antibiotics were given. in the case of trigger finger release, the patient was asked to flex and extend the finger to ensure complete release on the table. the occupational therapist gave the patient information regarding a home programme for hand therapy during the procedure. dressings were removed at home, and a follow-up consultation was scheduled two weeks following the procedure for all cases. outcome measures patients were asked to grade the pain on the vas (numerical and wong–baker pain score) in order to establish the patients’ subjective experience at completion of the surgery. two separate questions were used to grade the pain according to vas: 1. grade the pain of the injection during infiltration on a scale of 0–10. 2. grade the pain during the surgical procedure on a scale of 0–10. additionally, an open-ended question was asked to give context to the walant surgery experience. patients were asked if they had to have a similar procedure done in the future, if they would do it via the walant protocol again, or if they would rather do it via the main theatre protocol, with early admission, full workup and surgery under general anaesthesia. statistical analysis one hundred patients were included with trigger fingers and carpal tunnel syndromes that required surgical release from may 2019 to march 2020. means, standard deviations, medians and interquartile ranges were used to describe continuous variables. frequencies and proportions were used to describe categorical variables, including the percentage of patients who would have the procedure again. the mann–whitney non-parametric test was used to compare pain ratings between groups since the pain ratings were not normally distributed and unbalanced. statistical significance was taken at 5% (p=0.05). tests were conducted using stata 15. results one hundred patients underwent carpal tunnel and trigger finger release under walant at the institution from may 2019 until march 2020. all patients were followed up until wounds healed, complications resolved or the clinical condition improved, with most patients discharged from the clinic at two weeks. no patient was lost to follow-up as these patients can only be seen in the institution or at the institution’s sickbays due to the nature of the specific medical aid. no revision surgery to date was required for incomplete release of carpal tunnel syndrome or trigger finger. no patients were excluded from the study. the study included 57 females and 43 males, with a mean age of 59 years, ranging from 28 to 82 years (sd±12.8). sixty-seven patients had comorbidities, mostly consisting of hypertension, diabetes and hypercholesterolaemia (table i). the mean vas score with pain on injection was 1.5, ranging from 0 to 9 (sd±1.6). the mean vas pain score during the surgical procedure was 0.2, ranging from 0 to 5 (sd±0.7) (table ii). there were no significant differences in pain between the diagnosis of carpal tunnel syndrome and trigger finger release with pain on injection (p=0.45) or pain during the procedure (p=0.69). there was no significant difference between males and females with pain on injection (p=0.32) or pain during the procedure (p=0.74). asked if they would prefer to do the surgery again under walant or rather in theatre under general anaesthetics, 100% of patients reported that they would prefer to have it under walant. there were no cases of artery or nerve penetration, no terminal finger cyanosis or ischaemic skin changes. no local intraoperative figure 3. blanching after carpal tunnel infiltration figure 4. trigger finger infiltration location9 (used with permission from lalonde and wong) page 144 naude jj et al. sa orthop j 2021;20(3) complications occurred. there was one incident of a patient who had a vasovagal response after the infiltration, which resolved with standard treatment principles. no patients needed to be cancelled or changed to other anaesthetic methods due to failure of walant. one patient developed chronic regional pain syndrome (crps) of the hand after a carpal tunnel release for which they received occupational therapy. the symptoms of the cprs and the carpal tunnel resolved. two adverse events related to wound complications occurred that were not infiltration related. both of the cases required admission to hospital and secondary surgery. the first case was a 71-year-old male, who was on double platelet therapy (pradaxa and cardiodisprin), with two previous cardiac bypasses and a cardiac ejection fraction of 35%. he had a carpal tunnel and trigger finger release under walant. five days postop, the patient was admitted to the hospital for a haematoma in the forearm. the patient required secondary surgery to debride the forearm. the clinical symptoms of the presenting complaint and wound complication resolved. the second case was a 60-year-old female who attended the clinic two weeks after carpal tunnel release. the patient’s wound was assessed as clean, and sutures were removed in the procedure room by nursing staff. the nursing staff removed the most proximal mattress suture with difficulty. the patient was admitted three days later (17 days after the surgery) with a wound infection in the forearm. she required a secondary procedure for debridement of the infection in the forearm. she received intravenous antibiotics and was admitted for seven days. the wound infection resolved. discussion the current study confirmed that positive subjective patient experiences were universally reported when walant surgery was used for minor hand procedures. one hundred per cent of patients were prepared to undergo second surgeries using this method. acceptable vas pain scores were also noted. walant surgery is widely accepted for many wrist and hand surgeries.7,10-12 rhee et al.6 had 73% of patients estimate their pain scores as less painful than a dental procedure. they had a mean maximum vas pain score for carpal tunnel release of 5.0/10 (±3.1). this was also their first experience with walant surgery. the researchers postulate that the meticulous technique used during injection ensured low pain vas scores, with a mean of 1.5 during injection, as well as during surgery, with a mean of 0.2. other techniques to decrease pain on injection include warming the local anaesthetic, distracting the patient or the area of injection, stabilising the syringe, thus preventing the needle from wobbling, and pausing after 0.5 ml injection to let it take effect, then injecting an additional 2 ml before moving the needle. it is crucial to learn from each infiltration via patient feedback.5 the effectiveness of vasoconstriction of the adrenaline lasts four to five hours.4 older patients with extensive comorbidities and chronic illnesses may have physiological derangements and decompensation precipitated by anaesthesia. in this study, there were 67 patients with medical comorbidities, potentially complicating general anaesthesia. the current study included three patients who were not fit for general anaesthetics due to their medical comorbidities. by allowing patients to come to the outpatient department the morning of surgery, and be discharged immediately after surgery, the researchers have significantly decreased the length of stay compared to the standard protocol of staying over in hospital for one night.1-3,6,13 all of the above advantages assisted with patients’ satisfaction, ensuring that all of the patients opted to have the walant procedure again if need be. as demonstrated in the current study, and as advocated by the walant university, patients are part of the surgery.14 they are able to see that their finger has a full range of motion and no longer locks. this sense of inclusion on the part of the patient might add further to the positive patient experience. it was once widely believed that injected epinephrine frequently caused finger ischaemia and necrosis. this goes back to the table i: various patient comorbidities in the study population comorbidity total diabetes 14 hypertension 44 hypercholesterolaema 17 gout 3 asthma 1 copd/emphysema 3 gord 1 porphyria 1 psoriasis 1 tracheal stenosis 1 peripheral vascular disease 1 cardiac pathology (including mi, valve pathology, cardiac bypass, pacemakers) 7 previous scoline apnoea 1 multiple allergies 1 rheumatoid arthritis 3 table ii: results on vas pain scores comparing diagnosis and age diagnosis variable min max sd median p25 p75 iqr carpal tunnel syndrome (n=69) age (years) 28 82 13.9 58 48 69 21 injection vas 0 9 1.7 1 0 0 2 procedure vas 0 2 0.4 0 0 0 0 trigger finger & carpal tunnel syndrome (n=6) age (years) 46 77 11.6 70 61 76 15 injection vas 0 5 1.9 1.5 0 2 2 procedure vas 0 3 1.2 0 0 1 1 trigger finger (n=25) age (years) 44 78 9.4 59 51 65 14 injection vas 0 4 1.4 1 0 2 2 procedure vas 0 5 1.0 0 0 0 0 total (n=100) age (years) 28 82 12.8 59 49 69 20 injection vas 0 9 1.6 1 0 2 2 procedure vas 0 5 0.7 0 0 0 0 page 145naude jj et al. sa orthop j 2021;20(3) 1950s when procaine was used, which caused isolated cases of finger ischaemia and necrosis.15 procaine was replaced by lignocaine, which was introduced in 1948. procaine has a ph of 3.4 and can decrease to a ph of 1 if stored for long periods. this acidity can cause finger necrosis and is not associated with the use of epinephrine.16 large studies have confirmed that clinical epinephrine can be used without inducing infarction.1,15,17-21 this has also been shown with high-dose (1:1 000) epinephrine injections in the fingers.19 in walant procedures, 1:100 000 epinephrine is used. level 1 evidence has shown that phentolamine, an alphablocker, reliably reverses epinephrine vasoconstriction in the finger.22 however, its use is seldom required in clinical practice. in this study, no patient had signs of finger ischaemia, and no patient required phentolamine to reverse the vasoconstrictor effect. one of the questions around moving surgical procedures out of theatre is the incidence of infection and sterility fields. leblanc et al.23 looked at 1 504 consecutive patients treated with open carpal tunnel release in a sterile field, outside of the theatre setting. six superficial infections were reported; four of those six patients received oral antibiotics, and two were not severe enough to require antibiotics. not one deep postoperative wound infection was encountered, and no patient received or required an incision and drainage or intravenous antibiotics. their study, therefore, had a superficial infection rate of 0.4% and a deep infection rate of 0% following a minor surgical procedure outside of the theatre. rhee et al.6 had a superficial infection rate of 3%. in the current study, there were two patients (2%) who developed wound complications requiring readmission and follow-up surgery, one of which was a deep infection of the forearm. the similar infection rate to rhee’s study may indicate that there is a learning curve in performing successful walant surgery repeatedly. the implementation of a new technique requires a successful, reproducible system to allow procedures to run smoothly and to minimise complications. this also indicates the importance of monitoring oneself during the injection procedure to improve accuracy and decrease patient discomfort. infection risk remains minimal and comparable to the in-theatre setting.23 it has been shown that outpatient procedures like carpal tunnel releases have an improved efficiency compared to in-theatre procedures. up to 20 cases can be done in an outpatient setting in a ten-hour day, compared to only ten cases in a theatre setting, as shown in a study in the united states.1 in canada, a similar study has shown improved efficacy by doing nine cases of carpal tunnel release in an outpatient setting in a three-hour block, compared to four cases in theatre.2 both these studies have also shown outpatient surgery cost savings and efficiency improvement in their respective settings. the researchers managed to perform eight cases on a morning list in the outpatient clinic between 8 and 12 o’ clock. this is limited to eight to prevent system overload and because we only have eight handsets available from cssd. the researchers have noticed that this has caused the elective theatre waiting time to decrease. by removing the smaller procedures from the elective list, the average waiting time for elective surgery has been reduced from eight to 12 weeks, to on average four to six weeks. the walant procedures also decrease the burden on an already over-stressed healthcare system, not only with regard to costs but also personnel usage, as only one staff nurse is required for the list. leblanc also considered the possible environmental impact of using the main theatre sterility.14 although they have not studied it in detail, they estimated that the amount of garbage that is generated by the main operating theatre sterility is at least ten times that of minor procedure field sterility.14 the current study provided similar findings, as the total refuse after a morning list in the outpatient department has decreased to one bag. this decrease in refuse will have a positive impact on the environment in the long run. the limitations of the study were the relatively small number of patients compared to similar studies. the study is, however, sufficient to indicate the positive patient experience with walant surgery due to the definitive patient response. the sample population was selected from only one hospital. there may still be differences in the larger population and in other government hospitals, leading to some selection bias. this study only reports on the subjective experience of a small group of patients, and socioeconomic, educational and cultural factors were not considered. the higher rate of complications in this study can be explained by the learning curve of the walant protocol. it is evident that the current theatre protocol at the institution is excessive for minor procedures of the hand. there is room for improvement, specifically in the government setting. conclusion this study confirmed that the patients at the institution had a positive subjective experience when walant surgery was used for minor hand surgery. one hundred per cent of patients were prepared to undergo second surgeries using this method. acceptable vas pain scores were also noted. this study shows that there are significant benefits to walant surgery and that walant surgery is a useful tool in the skillset of a hand surgeon. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. all procedures performed in studies involving human participants were following the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. ethics approval was gained from the 1mhrec (1 military hospital research and ethics committee) 1mh/302/6/02.05.2019. informed consent was obtained from all individual participants included in the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions jjn: study conceptualisation and design, data collection, data analysis, manuscript preparation ok: study conceptualisation and design, data collection, data analysis, manuscript preparation lws: data collection and data analysis tlbr: study conceptualisation and design and liaising between the 1mhrec and the investigators orcid jj naude https://orcid.org/0000-0003-1448-4272 o koch https://orcid.org/0000-0003-1871-9569 lw schmidt https://orcid.org/0000-0002-1144-6433 tlb le roux https://orcid.org/0000-0003-1871-9569 references 1. chatterjee a, mccarthy je, montagne sa, et al. a cost, profit and efficiency analysis of performing carpal tunnel surgery in the operating room versus the clinic setting in the united states. ann plast surg. 2011;66(3):245-48. https:// doi.org/10.1097/sap.0b013e3181db7784. 2. leblanc mr, lalonde j, lalonde dh. a detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in canada. hand. 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hand surg am. 2017;42:e13947. https://doi.org/10.1016/j.jhsa.2016.11.019. 7. lalonde dh. ‘hole-in-one’ local anesthesia for wide-awake carpal tunnel surgery. plast reconstr surg. 2010;126:1642-44. https://doi.org/10.1097/ prs.0b013e3181f1c0ef. 8. steiner mm, calandruccio jh. use of wide-awake local anesthesia no tourniquet in hand and wrist surgery. orthop clin n a.m 2018;49:63-68. https:// doi.org/10.1016/j.ocl.2017.08.008. 9. lalonde dh, wong a. dosage of local anesthesia in wide awake hand surgery. j hand surg. 2013;38a:2025-28. https://doi.org/10.1016/j.jhsa.2013.07.017. 10. lalonde d, higgins a. wide awake flexor tendon repair in the finger. plast reconstr surg glob open. 2016;4(7):e797. https://doi.org/10.1097/ gox.0000000000000756. 11. lalonde dh. wide-awake extensor indicis proprius to extensor pollicis longus tendon transfer. j hand surg am. 2014;39:2297-99. https://doi.org/10.1016/j. jhsa.2014.08.024. 12. gregory s, lalonde dh, fung ll. minimally invasive finger fracture management: wide-awake closed reduction, k-wire fixation, and early protected movement. hand clin. 2014;30:7-15. https://doi.org/10.1016/j. hcl.2013.08.014. 13. flatt ae. tourniquet time in hand surgery. arch surg. 1972;104:190-92. https:// doi.org/10.1001/archsurg.1972.04180020070013. 14. walant university. walant surgery. [online] available from: https://walant. surgery/walant-university/. accessed 29 apr 2020. 15. lalonde d, martin a. epinephrine in local anesthesia in finger and hand surgery: the case for wide-awake anesthesia. j am acad orthop surg. 2013;21:443-47. https://doi.org/10.5435/jaaos-21-08-443. 16. pires neto pj, moreira la, las casas pp. is it safe to use local anesthesia with adrenaline in hand surgery? walant technique. rev bras orhop. 2017;52:383-89. https://doi.org/10.1016/j.rboe.2017.05.006. 17. lalonde dh, bell m, benoit p, et al. a multicentre prospective study of 3110 consecutive cases of elective epinephrine use in the fingers and hand: the dalhousie project clinical phase. j hand surg am. 2005;30(5):1061-37. https:// doi.org/10.1016/j.jhsa.2005.05.006. 18. chowdhry s, seidenstricker l, cooney dss, et al. do not use epinephrine in digital blocks: myth or truth? part ii. a retrospective review of 1111 cases. plast reconstr surg. 2010;126(6):2031-34. https://doi.org/10.1097/ prs.0b013e3181f44486. 19. fitzcharles-bowe c, denkler ka, lalonde dh. finger injection with high dose (1:1000) epinephrine: does it cause finger neurosis and should it be treated? hand.2007;2(1):5-11. https://doi.org/10.1007/s11552-006-9012-4. 20. muck ae, bebarta vs, borys dj, morgan dl. six years of epinephrine digital injections: absence of significant local or systemic effects. ann emerg med. 2010;56(3):270-74. https://doi.org/10.1016/j.annemergmed.2010.02.019. 21. tang jb, zhou x, pan zj, et al. strong digital flexor tendon repair, extension flexion test, and early active flexion: experience in 300 tendons. hand clin. 2017;33:455-63. https://doi.org/10.1016/j.hcl.2017.04.012. 22. nodwell t, lalonde dh. how long does it take phentolamine to reverse adrenaline induced vasoconstriction in the finger and hand: a prospective, randomised, blinded study: the dalhousie project experimental phase. can j plast surg. 2003;11(4):187-90. 23. leblanc mr, lalonde dh, thoma a et al. is main operating room sterility really necessary in carpal tunnel surgery: a multicentre prospective study of minor procedure room field sterility surgery. hand. 2011;6(1):60-63. https://doi. org/10.1007/s11552-010-9301-9. _hlk40114731 _hlk40114011 _hlk68842322 page 50 south african orthopaedic journal http://journal.saoa.org.za saoj south african orthopaedic journal cpd questionnaire. march 2020 vol 19 no 1 femoral lengthening in children (horn a, sipilä m) 1. in this study, the most common diagnosis resulting in leg length discrepancy was: a. post-infectious growth arrest a b. post-traumatic growth arrest b c. hemihypertrophy c d. congenital short femur d e. achondroplasia e 2. fifty per cent of patients in this study sustained a fracture either through or adjacent to the regenerate bone. which factor was not associated with an increased rate of fracture? a. healing index a b. underlying diagnosis of congenital short femur b c. level of the osteotomy c d. percentage length gained d e. absolute length gained e 3. regarding the mean healing index (hi) in this cohort of patients: a. the hi was comparable to other published series a b. there was a significant association between the hi and the amount of length obtained b c. an increased hi was associated with a higher rate of deep pinsite infection c d. the hi was increased in patients with congenital shortening of the femur d e. a decreased hi was not associated with an increase in fracture rate e an epidemiology of paediatric cervical spine injuries at the red cross war memorial children’s hospital over a ten-year period (noconjo l, horn a) 4. the following are the characteristics of paediatric cervical spine anatomy except: a. increased ligamentous laxity a b. wedge-shaped vertebral bodies b c. cervical lordosis c d. pseudo-subluxation d e. horizontal orientation of the facet joint e 5. in this study, the most common cause of injury was: a. physical abuse a b. motor vehicle accident (mva) b c. recreation and sports c d. drowning d e. gun shot e 6. children under 8 years of age sustained most cervical spine injuries at: a. c1–c4 a b. c1–c2 b c. c3–c4 c d. c2–c7 d e. c5–c7 e 18f-fdg pet/ct as a modality for the evaluation of persisting raised infective markers in patients with spinal tuberculosis (davis jh, burger mc, pienaar g, lamberts rp) 7. a positive gene xpert test on tissue from a site with increased activity on a 18f-fdg pet/ct scan could fit with: a. the presence of tuberculosis bacterial dna in a healed tb lesion a b. a myeloproliferative condition b c. an alternate type of granulomatous infection c d. a metastatic lesion d e. all of the above e 8. the only way to confirm the diagnosis of ongoing spinal tuberculosis infection after initial chemotherapy, is with: a. persistent raised esr>100 a b. a positive 18f-fdh pet/ct scan b c. a positive gene xpert test c d. histology showing a predominant leucocyte infiltrate d e. histology showing granulomatous inflammation e 9. the incidence of multi-drug resistant tb (mdr-tb) of the spine, as reported in this study and other supporting western cape-based studies, falls in the following range: a. 1–5% a b. 5–15% b c. 15–25% c d. 1–3% d e. 5–25% e the accuracy of pre-operative digital templating in total hip arthroplasty performed in a low-volume, resource-constrained orthopaedic unit (wiese kr, kock fw, blake ca, franken t, jordaan jd) 10. the goals of total hip arthroplasty include: a. restoration of normal hip biomechanics only a b. pain relief only b c. pain relief, total correction of leg length discrepancy and no improvement in function c d. pain relief, restoration of normal hip biomechanics and improvement in function d e. none of the above e page 52 south african orthopaedic journal http://journal.saoa.org.za subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm.co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online • once you have completed the answers, go back to the top of the page next to the registration option. there is another icon “find my cpd certificate”. (you will have to answer the two questions regarding your internship and last cpd audit once you have completed a questionnaire and want to retrieve your certificate). • if you click on that icon it will open your certificate which you can print or save on your system. • please call mpc helpdesk if you have any questions: 0861 111 335. 11. in the templating process, as described by bono, step 2 consists of: a. determining if a leg length discrepancy is present a b. determining the pelvis axis b c. determining the centre of rotation of the hip joint c d. determining the size of the femoral stem component d e. none of the above e 12. katz et al. define a high-volume arthroplasty unit as the following: a. more than 500 cases annually a b. more than 1 000 cases annually b c. more than 250 cases annually c d. more than 100 cases annually d e. none of the above e surgical anatomy of the sciatic nerve and its relationship to the piriformis muscle with a description of a rare variant (asmall t, gunston g, venter r, henry bm, keet k) 13. what is the nerve root origin of the sciatic nerve? a. l4, l5, s1, s2, s3 a b. l5, s1, s2, s3, s4 b c. s1, s2, s3, s4, s5 c d. l3, l4, l5, s1, s2 d e. l2, l3, l4, l5, s1 e 14. in which region of the lower limb does the sciatic nerve most commonly bifurcate into the common fibular and tibial nerves? a. gluteal a b. superior third of thigh b c. inferior third of thigh c d. popliteal d e. middle third of thigh e intramedullary nailing of tibial non-unions using the suprapatellar approach: a case series (botma n, graham s, held m, laubscher m) 15. the advantages of the suprapatellar nail above the infrapatellar nail include the following except: a. easier and improved tibial alignment a b. improved post-operative knee range of motion b c. a decrease in the incidence of post-operative sepsis c d. a decrease in the incidence of anterior knee pain d e. enabling a straight working channel for reamers in knee extension e 16. the surgical technique is this study included: a. reamed intramedullary nail using the suprapatellar approach a b. insertion of blocking (poller) screws if needed b c. fibula osteotomy if fibula united c d. fracture site compression (controlled compression) d e. all of the above e 17. what was the union rate in this study? a. 100% a b. 95% b c. 90% c d. 80% d e. 60% e bursal synovial chondromatosis overlying a solitary osteochondroma of the distal femur: a case report (tanwar y, potgieter m, oosthuizen m, schubert p, ferreira n) 18. which of the following might indicate malignant transformation of an osteochondroma? a. acute onset of pain following direct trauma to a pedunculated osteochondroma a b. increase in size during puberty b c. pain following physical exertion, like playing soccer c d. presentation with multiple osteochondromas d e. progressive enlargement after skeletal maturity e 19. osteochondromas represent true neoplastic lesions because: a. both sporadic and hereditary forms are encountered a b. they have potential for malignant transformation b c. they have the potential to grow during skeletal growth c d. they may be irritated by overlying structures d e. they show underlying genetic abnormalities e 20. osteochondromas have been shown to have underlying genetic abnormalities in which of the following genes? a. c-myc and c-fos a b. ewsr1 and fli1 b c. ext-1 and ext-2 c d. her2/neu and mdm2 d e. tp53 and rb1 e medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 south african orthopaedic journal orthopaedic oncology and infections doi 10.17159/2309-8309/2022/v21n2a5 mugla w et al. sa orthop j 2022;21(2) citation: mugla w, bauer hcf, vogel j, hosking kv, campbell n, hilton tl. modular prosthetic reconstruction for primary bone tumours of the distal tibia in ten patients. sa orthop j. 2022;21(2):95-99. http://dx.doi. org/10.17159/2309-8309/2022/v21n2a5 editor: prof. theo le roux, university of pretoria, pretoria, south africa received: may 2021 accepted: november 2021 published: may 2022 copyright: © 2022 mugla w. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: authors kvh and tlh are consultants for lrs. nc is the biomechanical engineer and managing director at lrs implants. nc provided information based solely on the manufacturing of the implant. the remaining authors declare that they have no conflicts of interest that are directly or indirectly related to this research. abstract background below-knee amputation (bka) is the safest treatment for benign aggressive and malignant bone tumours of the distal tibia, yielding good oncological and functional results. however, in selected patients where limb salvage is feasible and amputation unacceptable to the patient, limb salvage using a distal tibial replacement (dtr) can be considered. this study aims to present the oncological and functional results of the use of the latter treatment method in our unit. methods a retrospective folder review was performed for all ten patients who received a modular dtr between 1 january 2005 and 31 january 2019 for a primary bone tumour, either benign aggressive or malignant. six were female and the mean age was 31 (12–75) years. there were five patients with giant cell tumour of bone, four with osteosarcoma and one with a lowgrade chondrosarcoma. the patients with osteosarcoma had neoadjuvant chemotherapy before surgery. function was assessed by the musculoskeletal tumor society (msts) score. results two patients had local recurrence treated with a bka and one other patient died of metastases three years postoperatively. at a mean follow-up of three years, the remaining eight patients had a mean msts score of 83% (67–93%). there were no radiological signs of loosening, and no revision surgeries. conclusion endoprosthetic replacement of the distal tibia for primary bone tumours can be a safe treatment option in very selected cases. level of evidence: level 4 keywords: distal tibia, endoprosthetic replacement, osteosarcoma, giant cell tumour, limb salvage, amputation modular prosthetic reconstruction for primary bone tumours of the distal tibia in ten patients walid mugla,¹ henrik cf bauer,² jonathan vogel,³ keith v hosking,⁴ neil campbell,⁵ thomas l hilton⁶* 1 sarcoma unit, groote schuur hospital; faculty of medicine and health sciences, department of surgery, division of orthopaedics, university of cape town, cape town, south africa ² department of molecular medicine and surgery, karolinska institute, stockholm, sweden; visiting professor in the faculty of medicine and health sciences, department of surgery, division of orthopaedics, university of cape town, cape town, south africa ³ faculty of medicine and health sciences, department of surgery, division of orthopaedics, university of cape town, cape town, south africa ⁴ vincent pallotti life orthopaedic hospital, cape town; faculty of medicine and health sciences, department of surgery, division of orthopaedics, university of cape town, cape town, south africa ⁵ lrs implants, cape town, south africa ⁶ groote schuur hospital and life vincent pallotti orthopaedic hospital, cape town; faculty of medicine and health sciences, department of surgery, division of orthopaedics, university of cape town, cape town, south africa *corresponding author: thomas@drthilton.com introduction limb-sparing surgery for primary bone tumours of the distal tibia is fraught with difficulties due to the paucity of soft tissue coverage and difficulties in creating a durable fixation of the prosthetic components.1 wide surgical margins and acceptable function of the ankle joint can seldom be achieved.1,2 therefore, belowknee amputation (bka) is the surgical method of choice. while oncologically safe, it also provides excellent function with the everimproving external prosthetics.3 in selected cases where a wide surgical margin is possible and amputation unacceptable to the patient, limb salvage may be attempted.3 with the advent of additive manufacturing and improvements in polyethylene components and manufacturing, distal tibial replacement (dtr) design has provided solutions to previous problems and reduced implant cost by creating an ‘off-the-shelf’ prosthesis rather than an expensive and time-consuming custom prosthesis.3,4 the aims of this study https://orcid.org/0000-0002-2961-7296 https://orcid.org/0000-0002-6178-5062 page 96 mugla w et al. sa orthop j 2022;21(2) are to present the oncological and functional assessment of ten patients treated with resection of the distal tibia and reconstruction with a dtr. our objectives are to do this through a retrospective folder review of all patients treated in this manner in our unit. patients and methods a medical record and image review was performed of ten patients who underwent a dtr between 1 january 2005 and 31 january 2019 for enneking benign aggressive or malignant primary bone tumour.5 no patient was excluded due to missing data or lost to follow-up. data capture included patient demographics, procedural complications, revision procedures, local recurrence, tumour metastases and death. the histological diagnosis was established by core needle biopsy using a jamshiditm 12g needle.6 functional outcome was assessed using the musculoskeletal tumor society (msts) score. the msts scoring system is a specific scoring system to determine the physical and mental health of patients with extremity sarcoma. the system assigns numerical values (0–5) for six categories. a numerical score and per cent rating is calculated to allow for comparison of results.7 recommendations regarding amputation and limb salvage were made at multidisciplinary team conferences. there were six females and four males, with a mean age of 31 (12–75) years. five patients had a giant cell tumour (gct) of bone (figure 1), four an osteosarcoma, and one a low-grade chondrosarcoma. the four osteosarcoma patients had neoadjuvant chemotherapy, and none of the gct patients had preoperative demosumab. description of the prosthesis the distal tibia replacement used in this study is an lrs distal tibia replacement (www.lrs.com). it is a modular reconstruction system that allows for different resection lengths of the distal tibia in 10 mm increments. the implant is not side specific. the talar side of the prosthesis creates a metal (titanium ti6al4v) talar dome. it is made up of two parts: the talar base plate, and the talar dome. the base plate is 3d printed in titanium, incorporating a trabecular mesh structure for bone ingrowth. it is based on cementless fixation. there are three 8 mm pegs which are impacted into the talus. all surfaces in contact with the talus contain the trabecular mesh structure to encourage bone ingrowth. the talar dome is attached to the base plate by a morse taper. the dome is titanium with a titanium oxide ceramic surface. it has a ‘saddle’ shape similar to that of a native talus, to provide tibial tracking and a degree of varus–valgus support. the orientation of the dome can be adjusted prior to impaction onto the talar base plate. the talar dome articulates with an ultra-high molecular weight polyethylene (uhmwpe) bearing to replicate the natural range of motion of the ankle. the prosthesis is not constrained, except for the congruent ‘saddle’ fit of the talar dome and the polyethylene bearing surface. the bearing sizing is available in 3 mm increments to allow for balancing of the implant and soft tissues. the bearing is impacted onto a titanium mount which then attaches to diaphyseal extensions whose number and length are matched to fill the defect left by the resection. the implant is secured into the tibia by a cemented titanium intramedullary stem, with additional fixation provided by a trabecular 3d-printed extra-cortical fork to limit rotation of the implant in the bone and encourage bone ingrowth. surgical technique the patient is positioned supine, and an above-knee tourniquet is applied. an anteromedial approach is performed to access the distal tibia and ankle joint (figure 2). the biopsy site is included in the resected specimen. the tendons of tibialis anterior and extensor digitorum communis along with the neurovascular bundle are dissected away from the tumour, and the deltoid ligament, ankle syndesmotic ligament and capsule are cut. this allows for the distal tibia to be delivered from the leg. the remaining soft tissue figure 2. clinical picture showing endoprosthetic replacement through anteromedial approach figure 1. sagittal mri image of giant cell tumour of the distal tibia page 97mugla w et al. sa orthop j 2022;21(2) is dissected off the tibia. the tibial diaphysis may be transected proximally before the ankle ligaments are cut to allow for easier manipulation of the distal tibia. once the specimen is removed, it is placed nearby to assist with measurement of the length of prosthesis to be inserted. the talus is then cut transversely with an oscillating saw. a high-speed burr and a guide are used to create three peg holes which will accept the uncemented talar baseplate and titanium pegs (figure 3). the articulation of the prosthetic ankle joint consists of the titanium tibial dome and polyethylene bearing. the distal tibia body and appropriately sized extra-cortical fork and diaphyseal extensions are attached to an intramedullary stem which is then cemented into the proximal tibia after sequential reaming of the proximal tibia shaft and trialling for length. care must be taken during reduction not to fracture the fibula which is left intact and provides lateral support to the construct. the ankle is immobilised in a below-knee backslab for two weeks. the patient is then placed into a moon boot or below-knee plaster for a further four weeks (see figure 4 for postoperative x-ray). thereafter, the patient begins physiotherapy consisting of graduated weight bearing and active and passive ankle dorsiflexion and plantar flexion. results one patient died three years after treatment due to metastatic disease. two patients had local recurrence, one of whom also had a deep infection, and both were treated with a bka. after amputation, both patients remain disease free (table i). functional outcome and complications after a mean follow-up of 43 months (6–116), of the eight patients who did not undergo a bka, the mean msts score was 83% (70–93). two patients complained of mild ongoing pain around their lateral malleolus and had an antalgic gait on examination. there were no radiological signs of loosening, and no revision surgeries. they scored modestly in their msts assessment which has grades, none, modest and severe. the patients’ pain was controlled with oral analgesia only. figure 4. anteroposterior and mortise x-rays showing distal tibia dtr cemented intramedullary stem (ti6al4v) cortical support fork (ti6al4v) diaphyseal extension (ti6al4v) distal tibial bearing mount (ti6al4v) ultra-high molecular weight polyethylene bearing (uhmwpe) talar dome (ti6al4v) talar base plate (ti6al4v) figure 3. labelled assembly of the distal tibia construct page 98 mugla w et al. sa orthop j 2022;21(2) discussion this retrospective study of ten patients with primary bone tumours of the distal tibia shows that acceptable oncological and functional results can be achieved in the short to medium period of follow-up. nevertheless, bka will remain the treatment of choice, providing safe oncological margin and excellent function.3 in south africa, the management of primary bone tumours of the appendicular skeleton with limb ablation is often met with strong opposition due to cultural and traditional beliefs. these usually preclude amputation, often with increased morbidity and mortality of the patient.8 brown et al. described the challenges associated with cross-cultural communication in this regard, and highlighted the family-centred decision-making unit, which often refuses a limb ablation.8 in these circumstances, an alternative treatment, potentially with higher oncological risks, needs to be considered to prevent morbidity and possible mortality that may result from rejection of medical treatment. we, therefore, propose that in south africa, and many other countries across the african continent, an attempt at limb-sparing surgery and distal tibial replacement may be considered. in resource-limited countries like south africa, bka is often recommended as it is supposedly cheaper than megaprosthetic replacement, and also minimises complications and repeat surgery. however, in these countries adequate external prosthetics cannot be assured during the patient’s whole life span. grimer et al. have also showed that in the long run, limb-sparing surgery, in general, is cost effective when compared to amputations due to the accrued cost of repair and replacement of artificial limbs.9 furthermore, with modular systems of megaprosthetics, as reported here, unit costs should come down compared to custom-made implants. there are only a few reports of dtr in primary bone tumours. interestingly, none of the reports have more than six patients and all are at least ten years old.1,2,10,11 similar to our study, they report a good functional outcome, reasonable complication rates and prosthesis longevity (table ii). infection and recurrence were the most common causes of secondary amputation. mechanical failure was reported, whereas we did not have any cases of mechanical failure in our series. in our series of ten patients, two were amputated because of tumour recurrence and infection. for comparison, the final amputation rate after limb-sparing surgery for tumours of the proximal tibia is around 10%.12 in the proximal tibia, there are similar problems to the distal tibia of soft tissue coverage and restoring active joint function. the reason why amputation is seldom the procedure of choice for the proximal tibia is probably that a knee disarticulation or through-thigh amputation is considered more debilitating than a below-knee amputation. the most common mechanical complication of ankle joint replacement is aseptic loosening of the talar tray.11 we had no cases of mechanical loosening at final follow-up. abudu et al. and shekkeris et al. both described loosening of the tibial baseplate in one patient each, and lee et al. reported talar collapse in one.1,3,13 the uncemented, grown titanium design of the implant may prove to reduce the risk of talar prosthetic complications but the follow-up and number of patients is too small to be conclusive.10,11 future research is needed to determine how this procedure can be of benefit in those instances where patients refuse amputation at any cost for cultural reasons but will accept limb-sparing surgery. this is difficult due to the small number of patients that may have this procedure and a national and international sarcoma registry would assist in providing more data on the subject. engagement with cultural leaders would also help with earlier presentation of these patients to sarcoma centres and allow limb-sparing surgery. conclusion reconstruction of the distal tibia after resection for primary bone tumours with a distal tibial megaprosthesis yields good functional results with a high msts score and acceptable oncological outcomes with only a 20% local recurrence rate in the short to table i: details of results patient age sex diagnosis resection follow-up (months) msts (%) complications 1 43 m gct r0 29 local recurrence & infection – bka 2 25 m gct r0 116 27 (90%) 3 29 f gct r0 45 28 (93%) 4 20 f gct r0 39 21 (70%) constant ankle pain 5 59 m gct r0 35 26 (87%) intermittent ankle pain 6 15 m osteosarcoma r0 36 28 (93%) dod 7 14 f osteosarcoma r0 43 21 (70%) 8 14 f osteosarcoma r0 30 local recurrence – bka 9 12 f osteosarcoma r0 6 24 (80%) 10 75 f chondrosarcoma r0 54 28 (93%) mean 31 43 25 (83%) table ii: summary of current literature describing dtr study and year number of patients follow-up (years) local recurrence metastases infection amputation functional outcome shekkeris et al.3 2009 6 9.6 0 0 2 2 msts: 70% lee et al.13 1999 6 5.3 0 0 1 0 isols: 80% natarajan et al.2 2000 6 3.4 2 0 1 3 msts: 80% abudu et al.1 1999 4 4.6 1 1 1 0 msts: 64% current study 2021 10 3.6 2 1 1 2 msts: 83% page 99mugla w et al. sa orthop j 2022;21(2) medium term. therefore, this procedure can be considered as an alternative to limb ablation in selected cases. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethical approval number hrec 734/2019. for this retrospective study, formal consent was not required. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions wm: study conceptualisation, study design, data capture, state patients’ follow-up and scoring, first draft preparation, manuscript preparation hcfb: data analysis, manuscript preparation jv: data capture, first draft preparation kvh: private patients’ data capture and score nc: description of the prosthesis and pictures tlh: involved in all aspects of this article orcid mugla w https://orcid.org/0000-0002-2961-7296 bauer hcf https://orcid.org/0000-0002-3557-0252 vogel j https://orcid.org/0000-0003-1156-6168 hosking kv https://orcid.org/0000-0002-3557-0252 hilton tl https://orcid.org/0000-0002-6178-5062 references 1. abudu a, grimer rj, tillman rm, carter sr. endoprosthetic replacement of the distal tibia and ankle joint for aggressive bone tumours. int orthop. 1999;23(5):291-94. https://doi. org/10.1007/s002640050374. 2. natarajan mv, annamalai k, williams s, et al. limb salvage in distal tibial osteosarcoma using a custom mega prosthesis. int orthop. 2000;24(5):282-84. https://doi.org/10.1007/ s002640000172. 3. shekkeris as, hanna sa, sewell md, et al. endoprosthetic reconstruction of the distal tibia and ankle joint after resection of primary bone tumours. j bone joint surg br. 2009;91(10):1378-82. https://doi.org/10.1302/0301-620x.91b10.22643. 4. hilton t, campbell n, hosking k. additive manufacturing in orthopaedics: clinical implications. sa orthop j. 2017;16(2):63-67. 5. enneking wf, spanier ss, goodman ma. a system for the surgical staging of musculoskeletal sarcoma. clin orthop relat res. 2003;(415):4-18. https://doi. org/10.1097/01.blo.0000093891.12372.0f. 6. kundu zs. classification, imaging, biopsy and staging of osteosarcoma. indian j orthop. 2014;48(3):238-46. https://doi.org/10.4103/0019-5413.132491. 7. enneking wf, dunham w, gebhardt mc, et al. a system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. clin orthop relat res. 1993;(286):241-46. 8. brown o, goliath v, van rooyen r, et al. communicating about prognosis with regard to osteosarcoma in a south african cross-cultural clinical setting: strategies and challenges. sa orthop j. 2019;18(4):46-51. 9. grimer rj, carter sr, pynsent pb. the cost-effectiveness of limb salvage for bone tumours. j bone joint surg br. 1997;79(4):558-61. https://doi.org/10.1302/0301-620x.79b4.7687. 10. harris n. total ankle arthroplasty. pract proced elect orthop surg pelvis low extrem. 2013;6(8):269-72. 11. gross ce, palanca aa, deorio jk. design rationale for total ankle arthroplasty systems: an update. j am acad orthop surg. 2018;26(10):353-59. https://doi.org/10.5435/jaaos-d-1 6-00715. 12. summers sh, zachwieja ec, butler aj, et al. proximal tibial reconstruction after tumor resection: a systematic review of the literature. jbjs rev. 2019;7(7):e1. https://doi. org/10.2106/jbjs.rvw.18.00146. 13. lee sh, kim hs, park yb, et al. prosthetic reconstruction for tumours of the distal tibia and fibula. j bone joint surg br. 1999;81(5):803-807. https://doi.org/10.1302/03 01-620x.81b5.9588. https://orcid.org/0000-0002-2961-7296 https://orcid.org/0000-0002-3557-0252 https://orcid.org/0000-0003-1156-6168 https://orcid.org/0000-0002-3557-0252 https://orcid.org/0000-0002-6178-5062 _hlk76063671 south african orthopaedic journal knee doi 10.17159/2309-8309/2022/v21n4a3 nansook a et al. sa orthop j 2022;21(4) citation: nansook a, ryan p. a retrospective comparative study of complications after total knee replacement in rheumatoid arthritis and osteoarthritis patients. sa orthop j. 2022;21(4):207-211. http://dx.doi. org/10.17159/2309-8309/2022/ v21n4a3 editor: dr david north, paarl hospital, western cape, south africa received: february 2022 accepted: may 2022 published: november 2022 copyright: © 2022 nansook a. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background total knee arthroplasty (tka) rates have significantly increased over the past few decades; consequently, so too have the absolute number of complications. international literature expounds on complications in the rheumatoid arthritis (ra) and osteoarthritis (oa) subgroups from the developed context, but these findings cannot be generalised to the developing world, where access to medication, medical facilities and patient characteristics may differ. the purpose of this study was to determine the comparative rates and nature of complications that occur post total knee arthroplasty in ra and oa patients at a single south african quaternary hospital. methods this was a retrospective comparative study of complication rates in two groups following tka at inkosi albert luthuli central hospital (ialch) arthroplasty unit, between 1 january 2014 and 29 february 2020. the data was collected retrospectively, utilising the digitised patient management system at the hospital. data extraction included patient demographics, time to surgery, indication for surgery and early complication rates. descriptive analysis was performed to quantify complications, comparing the two groups. results the chart review yielded 332 cases, comprising 41 ra and 291 oa patients. the mean age of the combined participant group was 65 years (standard deviation [sd] 8). most cases were female (87%, 289 of 332), with males comprising 13% (43 of 332). concomitant human immunodeficiency virus (hiv) was present in 6% of patients (20 of 332), and 24% (80 of 332) had diabetes mellitus (dm). the absolute number of complications was greater in the oa group, where revision surgery was performed in 3% (8 of 291) of cases, infection occurred in 1% (3 of 291), mechanical complications in 3% (10 of 291), and deep vein thrombosis (dvt) in 1% (2 of 291) of cases. there was one complication, a dvt, in the ra group (2%, 1 of 41). conclusion in the current study, complications after tka occurred predominantly in the oa group, 8% (23 of 291) as compared to the ra group, 2% (1 of 41). complications included dvt, revision surgery, infection and mechanical complications. the study was underpowered to detect significant differences between the groups. further large-scale investigation will be required to determine if differences in complication rate are significant when low complication incidence is anticipated. level of evidence: level 4 keywords: arthroplasty, complications, osteoarthritis, rheumatoid, knee a retrospective comparative study of complications after total knee replacement in rheumatoid arthritis and osteoarthritis patients adisha nansook,* paul ryan school of clinical medicine, university of kwazulu-natal, durban, south africa *corresponding author: adisha08@gmail.com introduction the number of total knee arthroplasties (tkas) has increased significantly from 2003 to 2013, with studies in australia and the united states of america (us) estimating that by the year 2050, there will be a 276% increase in tkas being performed each year.1-3 the most common conditions contributing to this burden are primary osteoarthritis and inflammatory arthropathies, and much attention has been paid to comparing them. osteoarthritis (oa) and rheumatoid arthritis (ra) both require tka at the end stage of disease; however, patient factors including age, sex and comorbidities, in addition to the disease processes, vary.4 consequently, one would expect variability in outcomes between these groups. there has been an increase in the number of oa patients requiring tka (almost doubling over 14 years in one us study), compared to ra, which in the us has decreased from 21% in 1991, to as low as 2.4% in 2014.5-8 this could be accounted for by medical advances in understanding the disease process and improving pharmacological treatments available. however, research comparing complication rates has had conflicting findings, with some reports reflecting higher complication rates in ra, while others show no difference between the two.4-8 https://orcid.org/0000-0002-0365-6393 page 208 nansook a et al. sa orthop j 2022;21(4) although international studies have shown a decrease in ra patients requiring tka, these studies are generally based in developed countries.9 in finland for example, fewer ra patients required tka, suggesting aggressive medical therapy may alter the natural history of the disease progression to resemble oa.9 studies are lacking in lowand middle-income countries (lmics) with poorly controlled and late-presenting ra.10 a study based in africa and the middle east reported the incidence of ra was higher than figures quoted in studies internationally (0.06–3.4% as compared to 0.24%).10 this study concluded that lack of community education about the disease, and limited management options available, contribute to the late presentations with more advanced disease.10 the same concern was highlighted in a local study, which demonstrated that despite appropriate treatment, a large proportion of ra patients still develop significant functional impairment.11 no local studies have evaluated complications after tka comparing these two groups. the purpose of this retrospective study was to determine the comparative rates and nature of complications that occur post tka in rheumatoid and osteoarthritis patients at a single south african quaternary hospital. methods this study was a retrospective comparative study of complication rates in two groups of tka patients from inkosi albert luthuli central hospital (ialch) arthroplasty unit, between 1 january 2014 and 29 february 2020. the data was collected retrospectively, utilising the digitised patient management system at the hospital. the individual patient files were accessed to determine eligibility and for data extraction purposes. all patients with ra (identified based on seropositive markers or antibodies) or oa, receiving primary total knee replacement with a minimum two-year followup, were eligible for inclusion. patients presenting at the initial visit for a revision tka, post-traumatic oa, postinfective oa, or other indications for primary tka were excluded. those patients that had required joint-preserving procedures, such as high tibial osteotomies, prior to tka were also excluded. data extraction included patient demographics, comorbidities (human immunodeficiency virus [hiv] and diabetes mellitus [dm]), time to surgery (time from first visit to surgery), indication for tka, follow-up, and the documentation of early complications, defined herein as occurring within two years of tka. complications were subdivided into five categories. revision surgery included all noninfective causes for revision of components, such as malalignment due to subsidence of implants, aseptic loosening and periprosthetic fractures. the second category was infection: if revision was required for infection the case was counted as infection and not included in the revision surgery group, and infection was defined as early if it occurred within four weeks of surgery, or late, if it occurred after four weeks.12 mechanical complications included aseptic loosening awaiting revision or actively monitored cases, medial collateral ligament (mcl) insufficiency, stiffness post tka, and persistent knee pain. for the latter three examples, further surgery may have been performed but did not require component alteration. the final two categories were deep vein thrombosis (dvt), and death. no patients had more than one complication. jamovi (version1.6.23.0) was used for data analysis. categorical data were summarised using counts and percentages. numerical continuous variables were represented with means and standard deviations (sd) when normally distributed, or as medians with interquartile ranges (iqr) where non-parametric. associations between categorical variables were tested using chi-square with exact two-sided significance tests, or fisher’s exact test where counts were less than five in a sample. means were compared between two groups using t-tests. the non-parametric mann– whitney u test was used to compare time to surgery and follow-up between the two groups. table i: demographics of (n = 332) study participants, comparing osteoarthritis and rheumatoid arthritis groups combined oa ra count (%) count (%) count (%) p-value* sex 332 (100%) 291 (88%) 41 (12%) 1.00 female 289 (87%) 253 (87%) 36 (88%) male 43 (13%) 38 (13%) 5 (12%) mean (sd) mean (sd) mean (sd) p-value# age at time of operation (years) 65 (8) 66 (8) 59 (6) < 0.001 count (%) count (%) count (%) p-value* race 332 (100%) 291(88%) 41 (12%) 0.407 asian 96 (29%) 79 (27%) 17 (42%) black african 176 (53%) 157 (54%) 19 (46%) coloured 19 (6%) 18 (6%) 1 (2%) white 40 (12%) 36 (12%) 4 (10%) other 1 (0%) 1 (0%) 0 (0%) comorbidities count (%) count (%) count (%) p-value* hiv 20 (6%) 18 (6%) 2 (5%) 1.000 dm 80 (24%) 68 (23%) 12 (29%) 0.408 median (iqr) median (iqr) median (iqr) p-value** time to surgery (months) 21 (32) 19 (27) 33 (41) 0.003 follow-up (months) 32 (20) 31 (20) 34 (27) 0.533 ra: rheumatoid arthritis; oa: osteoarthritis; sd: standard deviation; hiv: human immunodeficiency virus; dm: diabetes mellitus; iqr: interquartile range * fisher’s exact test; # independent samples t-test; ** mann–whitney u test where significant differences occur between the groups, p-values are bolded. page 209nansook a et al. sa orthop j 2022;21(4) results demographics (table i) the database search yielded 530 patients who had undergone primary total knee replacement for oa or ra. no patients underwent simultaneous bilateral tka, and in patients who received a tka for both knees on separate occasions, each tka was considered a separate case. two hundred and twenty-nine patients were lost to follow-up at approximately six months. a further seven patients were erroneously coded as oa or ra but had post-traumatic osteoarthritis or postinfective osteoarthritis. combined, a total of 236 patients were excluded. a total of 332 patients were included in the study, comprising 41 ra and 291 oa patients. most cases were female (87%, 289 of 332), 13% were males (43 of 332), and this trend was reflected in both subgroups. the mean age of the combined groups was 65 years (sd 8). there was a significant age difference between the ra and oa groups (p < 0.001), with a mean age of 66 years (sd 8) in the oa group and 59 years (sd 6) in the ra group. the median time from initial visit to date of surgery was calculated for each group and was 33 months (iqr 27) for the ra group and 19 months (iqr 41) for the oa group, representing a statistically significant difference (p = 0.003). comorbidities the comorbid diagnoses of hiv and dm were captured to explore their potential confounding effect. six per cent of patients in this study (20 of 332) had concomitant hiv: 6% (18 of 291) in the oa group and 5% (2 of 41) of the ra group. twenty-four per cent of patients (80 of 332) had dm, 23% (68 of 291) and 29% (12 of 41) in the oa and ra groups respectively, but no statistical difference was found between the groups. no patients had both hiv and dm. complications one complication was found in the ra group (2%, 1 of 41): one patient developed a dvt which was treated successfully with oral anticoagulants. the remaining complications occurred in the oa group. revision surgery revision surgery was performed in 3% (8 of 291) of the oa cases. indications for revision were as follows: one patient was revised to a hinged implant due to a medial collateral ligament (mcl) rupture (discovered at the six-week postoperative visit, no documentation of mechanism); three patients were revised for aseptic loosening (the tibial tray only in two cases and in one case both tibial and femoral components); one patient sustained a periprosthetic tibial fracture with consequent tibial component loosening; one patient had postoperative coronal plane instability which was managed by replacing the polyethylene tibial insert component with a size bigger; and two patients with persistent anterior knee pain underwent patella resurfacing (not performed routinely with tka at our centre). infection infection occurred in 1% (3 of 291) of cases. all infections were defined as late infections and underwent surgical intervention. one patient developed infection more than two years post surgery, was treated with a poly exchange and had no recurrence. the remaining two patients required multiple surgeries, developed polymicrobial multidrug-resistant infection and each had a poor local soft tissue envelope. one patient required amputation and the other a knee fusion. mechanical mechanical complications occurred in 3% (10 of 291) of patients. aseptic loosening occurred in three patients: two are awaiting revision surgery and one is being actively monitored. four patients developed stiffness post tka and each required manipulation under anaesthesia (mua), two required arthroscopic release in addition to attain satisfactory range of motion (rom). the first patient had a rom of 0–110° prior to tka, developed stiffness 16 days after tka with a rom of 0–45°, and after mua a rom of 0–110° was restored. the second patient prior to tka had 0–80° rom, almost two years after tka had a rom of 0–45° which required mua and arthroscopic release to restore a 0–95° rom. the third patient initially had 10–90° rom, at 75 days post tka had a 5–30° rom, and following mua and arthroscopic release had a 0–90° rom. the fourth and final patient had a range of 0–90° prior to tka, 60 days post tka a rom of 10–45°, and after mua a rom of 0–110°. one patient was found to have an insufficient mcl post tka and underwent an augmentation with a tendo-achilles autograft. the final two patients reported persistent pain post tka; both patients had a biopsy and debridement performed, one patient had an anterior release performed at the same setting, and both patients had resolution of their symptoms. dvt dvt occurred in 1% of patients (2 of 291) in the oa group. both were successfully treated with oral anticoagulants. there was no statistical difference in the combined or individual complications between the ra and oa subgroups; however, the study was underpowered to detect significance (table ii). there were no reported mortalities in either of the groups. table ii: comparative table of complications between the osteoarthritis and rheumatoid arthritis groups combined (n = 332) oa (n = 291) ra (n = 41) count (%) count (%) count (%) p-value* combined complications 24 (7%) 23 (8%) 1 (2%) 0.335 complications requiring revision surgery 8 (2%) 8 (3%) 0 0.602 infection 3 (1%) 3 (1%) 0 1.000 mechanical complication 10 (3%) 10 (3%) 0 0.618 dvt 3 (1%) 2 (1%) 1 (2%) 0.327 death 0 0 0 ra: rheumatoid arthritis, oa: osteoarthritis *p-values representing results of fisher’s exact test no statistically significant differences were detected between the groups. post-hoc power analysis utilising overall complication rates between the two groups found a power of 17.9% for an alpha of 0.05. page 210 nansook a et al. sa orthop j 2022;21(4) discussion our study included 332 patients undergoing tka for either oa or ra: 89% were oa patients and the remaining 11% were ra. this was a much higher ra representation than a similar us populationbased study where ra represented only 3% of cases requiring tka.13 this could reflect the late-presenting and more advanced disease of rheumatoid patients requiring tka in south africa, as is the case in other lmics.10 it may also be as a result of the large number of patients lost to follow-up, potentially patients with oa. as in a us study, we also found that ra patients typically underwent tka earlier than oa patients (a difference in mean age of seven years in our study), and both studies found this difference to be statistically significant. this correlates with the natural history of ra as the pathological process within the knee generally progresses faster in ra than in primary oa.14 the age difference between the subgroups (59 years in ra vs 66 years in oa) could be a contributing factor to differing complication rates seen in this study; however, no significant difference in age was found for any of the complication groups. we explored dm and hiv as potentially contributory to our complication rate. the seroprevalence of hiv in patients undergoing tka was 6% (20 of 332) and dm was 24% (80 of 332). the hiv percentage was comparative to that of a local study by maharaj et al. who quoted a figure of 6% seroprevalence in their patient population of 1 007 who had undergone tka.15 of the 20 patients with hiv, only one complication occurred in a patient with oa who developed a dvt. this mirrors conclusions drawn in an article by boylan et al., who found that hiv did not increase their tka patients’ overall risk of complications.16 there is limited data on the concomitant diagnosis of dm and ra as factors potentially increasing tka complications rates; however, dm alone has been shown to increase the risk of complication post joint replacement.17 this study looked specifically at the complications following tka. we found an overall 7% (24 of 332) complication rate. in comparison to other studies, our overall complication rate was higher in some instances, likely due to comparative studies having greater patient volumes.18 in alternative studies our complication rates were lower; these studies, however, included complications that we did not investigate in our study, and other primary indications for surgery such as post-traumatic and postinfective oa, which could account for the difference.19 the demographics in these studies also differ, potentially contributing to a different complication profile. one such study showed a low overall complication rate compared to our study, a surprising finding as all patients in this study were over 80 years old. they reported higher mortality (asa > 2), congestive heart failure and chronic obstructive pulmonary disease.20 our overall complication rate was 7% (24 of 332). comparing the complications rates between oa and ra, 7% (23 of 332) of cases complicated and had oa, and 0.3% (1 of 332) complicated and had ra. for the overall complication rate and each of the five subcategories, there was no statistical difference between the groups; however, the study was underpowered to detect statistical significance in the findings. we found that revision surgery occurred exclusively in the oa group and comprised 33% of the overall complications (8 of 24). this finding is in contrast to several research papers that reported higher occurrence in ra subgroups, or no difference compared to oa.4,21 infection too was exclusive to the oa subgroup, accounting for 13% (3 of 24) of all complications in the study. all the infections reported were late infections (presenting after four weeks). we found no infections in the ra group, in contrast to the findings of goodman and hawker who explored the outcomes of total joint arthroplasty in ra patients. they found that tka in ra patients carries an overall risk for infection of 2%, a two-fold increased risk of infection as compared to their oa group.8 with respect to time from initial presentation to surgery, the oa group had a shorter time to surgery compared to the ra group, and this was found to be statistically significant (power of 79%, for an alpha of 0.05). the study was, however, underpowered to determine if this finding was contributory to the differing complication rates. the study had several limitations, most notably the small sample due to a large number of patients being lost to follow-up, with resultant exclusion. the small numbers limited calculation of significant differences between the ra and oa groups and the inability to determine the impact of many potential confounding variables. evaluation was also limited to the variables routinely captured within the digitised patient management system, which restricted comparison to existing studies that explored additional variables. to ascertain if there is a true difference in complication rate among these groups, a larger, prospective study would be required. there appears to be a deficit in research investigating ra patients that require arthroplasty in the south african literature. conclusion in the current study, the overall complication rate was noted to be 7% (24 of 332), predominantly affecting the oa group (7%, 23 of 332) as compared to the ra group (0.3%, 1 of 332). complications included infections, deep vein thrombosis, component revision surgery and mechanical complications. we were unable to detect statistically significant differences due to the small number of complications. further large-scale investigation will be required to determine if differences in complication rate are significant when low complication incidence is anticipated. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. the study complied with the south african department of health ethics guidelines (2015), and the university of kwazulu-natal policy on research ethics. prior to commencement of this research, the appropriate ethical approval was obtained from the biomedical research ethics committee of ukzn (brec/00000013/2019). declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions an: study conceptualisation, study design, data capture and analysis, first draft manuscript preparation and finalisation of edits to manuscript pr: study conceptualisation, supervising of manuscript preparation and revisions orcid nansook a https://orcid.org/0000-0002-0365-6393 ryan p https://orcid.org/0000-0002-0957-6482 references 1. ackerman in, bohensky ma, zomer e, et al. the projected burden of primary total knee and hip replacement for osteoarthritis in australia to the year 2030. bmc musculoskeletal disorders. 2019;20(1):90. 2. ruiz d, koenig l, dall t, gallo p. the direct and indirect costs to society of treatment for end stage knee osteoarthritis. j bone joint surg am. 2013;95(16):1473-80. 3. inacio mcs, paxton ew, graves se, et al. projected increase in total knee arthroplasty in the united states – an alternative projection model. osteoarthritis cartilage. 2017;25(11):1797-803. 4. ravi b, escott b, shah ps, jenkinson r, et al. a systematic review and meta-analysis comparing complications following total joint arthroplasty for rheumatoid versus for osteoarthritis. arthritis rheum. 2012;64(12):3839-49. 5. mertelsmann-voss cls, pan tj, goodman sm, et al. us trends in rates of arthroplasty for inflammatory arthritis including rheumatoid arthritis, juvenile idiopathic arthritis, and spondyloarthritis. arthritis rheumatol. 2014;66(6):1432-39. https://orcid.org/0000-0002-0365-6393 https://orcid.org/0000-0002-0957-6482 page 211nansook a et al. sa orthop j 2022;21(4) 6. quam jp, michet cj, wilson mg, et al. total knee arthroplasty: a population-based study. mayo clin proc. 1991;66(6):589-95. 7. jonsson h, olafsdottir s, sigurdardottir s, et al. incidence and prevalence of total joint replacements due to osteoarthritis in the elderly: risk factors and factors associated with late life prevalence in the agesreykjavik study. bmc musculoskelet disord. 2016;17(14):8. 8. goodman sm, ravi b, hawker g. outcomes in rheumatoid arthritis patients undergoing total joint arthroplasty. int j clin rheumatol. 2014;9(6):567-74. 9. skyttä et, honkanen pb, eskelinen a, et al. fewer and older patients with rheumatoid arthritis need total knee replacement. scand j rheumatol. 2012(41):345-49. 10. almoallim h, saleh ja, badsha h, et al. a review of the prevalence and unmet needs in the management of rheumatoid arthritis in africa and the middle east. rheumatol ther. 2021(8):1-16. 11. hodkinson b, musenge e, ally m, et al. functional disability and health-related quality of life in south africans with early rheumatoid arthritis. scand j rheumatol. 2012(41):366-74. 12. coughlan a, taylor f. classifications in brief: the mcpherson classification of periprosthetic infection. clin orthop rel res. 2020;478:903-908. 13. stundner o, 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2006;88(3):480-85. 19. claus a, asche g, brade j, et al. [risk profiling of postoperative complications in 17,644 total knee replacements]. der unfallchirurg. 2006;109(1):5-12. 20. yohe n, funk a, ciminero m, et al. complications and readmissions after total knee replacement in octogenarians and nonagenarians. geriatr orthop surg rehabil. 2018;9:2151459318804113. https://doi.org/10.1177/2151459318804113 21. ravi b, croxford r, hollands s, et al. increased risk of complications following total joint arthroplasty in patients with rheumatoid arthritis. arthritis rheumatol. 2014;66(2):254-63. https://doi.org/10.1002/art.38231 _hlk114557914 _hlk114558180 _hlk101179130 _hlk101179278 _hlk101179585 _hlk101180489 _hlk101595941 _hlk101595898 _hlk101180936 _hlk101595996 _hlk101596020 _hlk101181384 _hlk86399098 _enref_1 _enref_2 _enref_3 _enref_4 _enref_5 _enref_6 _enref_7 _enref_8 _enref_9 _enref_10 _enref_11 _enref_12 _enref_13 _enref_14 _enref_15 _enref_16 _enref_17 _enref_18 _enref_19 _enref_20 _hlk113966894 _enref_21 404 not found ferreira n et al. sa orthop j 2020;19(4) doi 10.17159/2309-8309/2020/v19n4a1 south african orthopaedic journal http://journal.saoa.org.za trauma and general orthopaedics citation: ferreira n, jordaan k, du preez g, burger m. fixation of femoral neck fractures in patients younger than 65 years: a retrospective descriptive study at a high-volume trauma centre. sa orthop j 2020;19(4):200-205. http://dx.doi.org/10.17159/2309-8309/2020/v19n4a1 editor: prof. sithombo maqungo, university of cape town, cape town, south africa received: april 2020 accepted: june 2020 published: november 2020 copyright: © 2020 ferreira n. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding has been received for this manuscript. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: the management of femoral neck fractures in the younger patient remains contentious, with high failure rates being reported in the literature. patient age usually plays a major role during decision-making with regard to head-sparing versus head-sacrificing surgical strategies. the aim of this study was to review the outcomes of fixation of femoral neck fractures in patients younger than 65 years in an attempt to identify factors that might predict fixation failure. methods: a retrospective study, evaluating the outcome of fixation of femoral neck fractures in patients younger than 65 years of age was conducted. factors affecting the outcome of treatment were explored in an attempt to identify variables that might predict fixation failure. results: the final cohort comprised 51 men (76%) and 16 women (24%) with a mean age of 43.9±12.2 years (95% ci 41.0–46.8; range 23–64) and a median follow-up of 8.7 months (iqr 6.2–17.4). thirteen patients (19%) presented with undisplaced (garden i and ii) fractures while 54 (81%) presented with displaced (garden iii and iv) fractures. twenty-four patients (36%) met the definition of failure. these included 15 cases (22%) of non-union, seven cases (10%) of femoral neck collapse and two cases (3%) of avascular necrosis. sixteen patients (24%) underwent conversion to total hip arthroplasty. all cases of failure occurred in patients who presented with garden iii and iv displaced fractures. factors associated with failure included the presence of fracture comminution (p<0.001) and the increased vertical orientation of the fracture line according to the pauwels classification (p<0.001). neither patient age (p=0.117), time from injury to surgery (p=0.204), mechanism of injury (p=0.136), smoking (p>0.999) nor alcohol abuse (p=0.528) was associated with failure. conclusion: the incidence of fixation failure following surgical management of femoral neck fractures in patients younger than 65 years of age remains high. while undisplaced fractures heal readily regardless of time from injury to surgery, mechanism of injury or fixation method, displaced fractures remain a difficult problem to solve. in our series, fixation failure was observed in one in three patients, while one in four required revision to total hip arthroplasty. level of evidence: level 4 keywords: femoral neck fracture, fixation, failure, non-union, avascular necrosis fixation of femoral neck fractures in patients younger than 65 years: a retrospective descriptive study at a high-volume trauma centre ferreira n,¹ jordaan k,² du preez g,³ burger m4 1 bsc, mbchb, fc orth(sa), mmed(orth), phd; associate professor, consultant orthopaedic surgeon and head of tumour, sepsis and reconstruction unit; department of surgical sciences, tygerberg hospital, stellenbosch university, cape town, south africa ² mbchb, hdip orth(sa), fc orth(sa); consultant orthopaedic surgeon and head of arthroplasty unit; department of surgical sciences, tygerberg hospital, stellenbosch university, cape town, south africa ³ mbchb, fc orth(sa); consultant orthopaedic surgeon and head of trauma; department of surgical sciences, tygerberg hospital, stellenbosch university, cape town, south africa 4 bsc, b(med)sc hons, m(med)sc, phd; researcher, division of orthopaedic surgery; department of surgical sciences, tygerberg hospital, stellenbosch university, cape town, south africa corresponding author: prof. nando ferreira, division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, tygerberg hospital, stellenbosch university, cape town, 7505, south africa; tel: +27 (21) 938 5456; email: nferreira@sun.ac.za https://orcid.org/0000-0002-0567-3373 https://orcid.org/0000-0002-6150-9463 https://orcid.org/0000-0003-2760-7307 https://orcid.org/0000-0003-2831-4960 page 201ferreira n et al. sa orthop j 2020;19(4) introduction femoral neck fractures are among the most frequently encountered injuries facing orthopaedic surgeons.1 the usual presentation is that of a fragility fracture in an elderly individual.2,3 whereas consensus has generally been reached on the management of femoral neck fractures in elderly patients, the same is not true for the management of these injuries in patients younger than 65 years.4-10 traditionally, the decision between head-sparing and headsacrificing procedures is based on the patient’s age, fracture displacement and time from injury, where the age of the patient generally carries the most weight during decision-making.11,12 despite the overall risk of failure being estimated at between 39% and 43%, the benefit of restoring the native hip joint has been thought to outweigh the risk of failure.13,14 the longevity of arthroplasty has been a further concern in the younger patient, adding to the call for head-sparing strategies in this population group. however, when this strategy fails, salvage arthroplasty surgery is technically more demanding and produces inferior results when compared with primary replacement.15-18 a 2018 study by bartels et al. examined data from the norwegian hip fracture register and reported that when compared to internal fixation, patients treated with arthroplasty had fewer operations, better patient satisfaction, less pain and better quality of life. the authors suggested lowering the age at which patients with displaced intra-capsular femoral neck fractures should be considered for arthroplasty.19 exactly how comorbid conditions like diabetes mellitus, hiv, osteoporosis, mechanism of injury and general life expectancy affect this management decision remains to be established. this study aims to present our experience of fixation of femoral neck fractures in patients younger than 65 years of age. factors affecting the outcome of treatment were explored in an attempt to identify variables that might predict fixation failure. methods a retrospective investigation of clinical records and serial radiographs of all skeletally mature patients who underwent fixation for a femoral neck fracture between january 2011 and december 2014 in a single, high-volume institution was performed. ethical approval as well as hospital board approval was obtained prior to data collection. patients younger than 65 years, presenting with orthopaedic trauma association (ota) type 31 b fractures who were treated by fracture fixation were included for review.20 pathological fractures and fractures treated by head-sacrificing procedures were excluded. admission records were assessed for mode of injury, associated injuries and comorbid conditions. imaging studies consisted of an antero-posterior radiograph of the pelvis as well as antero-posterior and lateral view radiographs of the affected hip. traction view radiographs were performed where excessive shortening was encountered, and computerised tomography (ct) scans were obtained when accurate fracture configuration could not be ascertained from plain radiographs. fracture line orientation was assessed using the annotative measurement tools of the phillips intellispace picture archiving and communication system (pacs). laboratory investigations comprised a full blood count, renal and liver function tests and a nutritional profile. surgical management consisted of either open or closed reduction followed by fixation with three cannulated screws in an inverted triangle configuration or a sliding hip screw with or without an anti-rotation cannulated screw. open reduction was performed where a leadbetter manoeuvre failed to produce an acceptable closed reduction and was performed through the smith-peterson approach.21,22 the use of a calcar plate to maintain position following open reduction was used at the discretion of the operating surgeon. the decision to use cannulated screws in an inverted triangle configuration, or in combination with a sliding hip screw, was made on the basis of bone quality; in cases with poor bone quality, a sliding hip screw in combination with an anti-rotation screw was preferred. standard post-operative antibiotic prophylaxis consisted of 24 hours of a first-generation cephalosporin. outpatient follow-up consisted of a two-week, six-week, threemonth, six-month and 12-month review. at the two-week clinic follow-up, sutures were removed, and the wound inspected. outpatient notes and follow-up radiographs were reviewed for complications experienced during healing. union was confirmed by a minimum score of 18 according to the radiographic union score for hip (rush).23 failure was defined as any revision surgery, including re-fixation or conversion to arthroplasty, femoral neck collapse of greater than 10 mm, any varus collapse, screw cut-out or joint penetration, as well as avascular necrosis of the femoral head. data was analysed using statistica version 12.0 (statsoft inc., tulsa, ok, usa). captured clinical and demographic data is presented as median and interquartile ranges (iqr) for nonparametric data, and means and standard deviation for parametric data. categorical data is presented as frequencies. independent t-tests or mann-whitney u tests were used to detect differences between groups for parametric and non-parametric data, respectively, while the pearson’s chi-squared or fisher’s exact test was used to detect differences between categorical variables. significance was accepted at the p<0.05 level. results a total of 108 patients underwent fixation for femoral neck fractures. twenty-five patients were older than 65 years and were subsequently excluded. sixteen patients (19%) were lost to follow-up prior to confirmation of union or failure. the final cohort comprised 51 men (76%) and 16 women (24%) with a mean age of 43.9±12.2 years (95% ci 41.0–46.8; range 23–64) (figure 1) (table i). the median follow-up was 8.7 months (iqr 6.2–17.4). figure 1. antero-posterior radiograph with comminuted fracture of the right femoral neck page 202 ferreira n et al. sa orthop j 2020;19(4) table i: general and clinical characteristics of patients   n=67 age (years) 43.9±12.2 (67) sex (% male) 76% (51) affected side (% right) 63% (42) polytrauma 16% (11) mechanism of injury low energy fall 43% (29) mva/pva 22% (15) fall from height 18% (12) gunshot 10% (7) assault 6% (4) displacement undisplaced (garden i & ii) 19% (13) displaced (garden iii & iv) 81% (54) follow-up time (months) 8.7 (6.2–17.4) (67) data is presented as mean±standard deviation for parametric data, median (interquartile range) for non-parametric data or frequencies, with the number of participants in parentheses. mva: motor vehicle accident; pva: pedestrian vehicle accident medical comorbidities were observed in 18 patients (27%). these included five hiv-positive patients, two diabetic patients, four patients with confirmed cardiovascular disease and five patients with known epilepsy. all hiv-positive patients were on highly active anti-retroviral (haart) treatment. the prevalence of these comorbidities was too low to measure association with fixation failure. twenty-nine patients (43%) were active smokers and 13 (19%) admitted to excessive alcohol intake. time delays between injury, admission and surgery are indicated in table ii. table ii: time delays between injury, admission and surgery delays hours (n=67) injury to admission (hours) 12 (4–26) admission to surgery (hours) 47 (27–96) injury to surgery (hours) 75 (46–123) data is presented as median (interquartile range) seventeen patients (25%) required an open reduction to achieve an anatomically acceptable position. in five patients (8%) open reduction was supplemented with a calcar plate (figure 2). fixation was achieved with a sliding hip screw combined with an anti-rotation cannulated screw in the majority of cases (n=31, 46%) followed by the use of cannulated screws in an inverted triangle configuration (n=19, 28%) and sliding hip screw alone (n=16, 24%). in one case, an undisplaced femoral neck fracture with an ipsilateral femoral shaft fracture was treated with a third-generation cephalo-medullary nail. twenty-four patients (36%) met the definition of failure. these included 15 cases (22%) of non-union, seven cases (10%) of femoral neck collapse and two cases (3%) of avascular necrosis. all cases of failure occurred in patients who presented with displaced fractures while no failures occurred after fixation of undisplaced fractures. fifty-four patients who sustained displaced fractures completed follow-up to union or failure (table iii). fixation failure occurred in 24 (44%) of these cases (figure 3). factors associated with failure included the presence of fracture comminution (p<0.001), the vertical orientation of the fracture line according to the pauwels figure 2. intra-operative image of reduced facture with three cannulated screws and calcar plate figure 3. anteroposterior radiograph of right hip showing non-union and fixation failure figure 4. antero-posterior radiograph showing conversion to right hip arthroplasty page 203ferreira n et al. sa orthop j 2020;19(4) classification (p<0.001), and the need for open reduction (p<0.001). neither patient age (p=0.117), time from injury to surgery (p=0.204), mechanism of injury (p=0.136), smoking (p>0.999) nor alcohol abuse (p=0.528) was associated with failure. sixteen patients (24%) underwent conversion to total hip arthroplasty (figure 4). mode of failure for patients requiring arthroplasty included 14 of the 15 cases of non-union and both patients who developed avascular necrosis. all seven cases where femoral neck collapse occurred united with resultant shortening of the femoral neck, with none of these patients requiring arthroplasty at latest follow-up. discussion a recent survey among orthopaedic surgeons reported a lack of consensus in the management of femoral neck fractures in young adults and called for definitive clinical trials to resolve this issue.8 the aim of the present study was to review the outcomes of fixation of femoral neck fractures in patients younger than 65 years in an attempt to identify factors that might predict fixation failure. it is concerning that, apart from fracture comminution and geometry, no other evaluated factors were shown to predict failure, including age, mechanism of injury, comorbidities or time from injury to fixation. these findings and similar results by other authors might demand a paradigm shift towards arthroplasty during the management of displaced femoral neck fractures in the younger patient. longevity of arthroplasty has remained a major concern regarding head-sacrificing strategies in the young femoral neck fracture patient, but as life expectancy varies significantly between geographic areas, the term ‘young’ patient should also be taken in the context of geographic location. the difference in life expectancy between hong kong (ranked 1) and the central african republic (ranked 191), for example, is almost 31 years (85.29 vs 54.36).24 despite norway being listed as having a life expectancy of almost 83 years (ranked 17th), bartels et al. still suggested that patients as young as 55 years would benefit from total joint arthroplasty for displaced femoral neck fractures.19,24 it stands to reason that patients in countries with significantly lower life expectancy might potentially benefit from this approach at an even younger age. table iii: details of displaced fracture cases   failure yes (n=24) failure no (n=30) p-value age (years) 45.9±13.0 (24) 40.7±10.8 (30) 0.117 delay: injury to surgery (hours) 83.5 (44.0–120.5) (24) 57.0 (42.0–100.0) (30) 0.204 mechanism of injury low energy fall 45 (10) 55 (12) 0.136 mva/pva 29 (4) 71 (10) fall from height 36 (4) 64 (7) gunshot 75 (3) 25 (1) assault 100 (3) 0.0 (0) fracture comminution yes 94 (16) 6 (1) <0.001 no 22 (8) 78 (29) pauwels classification type 1 0 (0) 100 (3) <0.001type 2 17 (2) 83 (10) type 3 56 (22) 44 (17) smoking smoker 46 (12) 54 (14) >0.999 non-smoker 43 (12) 57 (16) alcohol abuse yes 54 (7) 46 (6) 0.528 no 41 (17) 59 (24) reduction open 82 (14) 18 (3) <0.001 closed 27 (10) 73 (27) type of fixation dhs & anti-rotation screw 46 (13) 54 (15) 0.744 dhs 43 (6) 57 (8) cannulated screws 45 (5) 55 (6) cephalomedullary nail 0.0 (0) 100 (1) data is presented as mean±standard deviation, median (interquartile range) or frequencies, with the number of participants indicated in parentheses. mva: motor vehicle accident; pva: pedestrian vehicle accident; dhs: dynamic hip screw page 204 ferreira n et al. sa orthop j 2020;19(4) stockton et al. conducted a retrospective cohort study of 796 patients between the ages of 18 and 50 years who underwent internal fixation for femoral neck fractures and found that one in three patients required a re-operation and one in seven were converted to a total hip arthroplasty.25 we observed similar outcomes, where failure was observed in one in three patients, while one in four required revision to total hip arthroplasty. in addition to non-union, fracture collapse with resultant shortening of the femoral neck was also a prominent complication seen in our series. contradictory to zlowodzki et al. who reported a large proportion of patients treated with cannulated screws ended with shortening, all patients who collapsed in the current cohort were treated with a sliding hip screw, with or without an anti-rotation screw.26 despite the fact that all cases of collapse eventually united, a significant impact on physical activity can be anticipated as a result of this femoral neck shortening.26 recent advances in implant technology has produced devices like the targon® fn (bbraun, melsungen, germany) and conquest fn® (smith & nephew, memphis, tn, usa), specifically designed for fixation of femoral neck fractures.27 both these implants are an attempt to solve the issue of non-union and fracture collapse/ implant failure.28-32 as these devices would not foreseeably alter the incidence of avascular necrosis, especially following displaced fractures, this remains an unresolved issue. with fracture collapse and non-union being observed more frequently than avascular necrosis in the current series, this new family of devices might prove beneficial, but remains to be investigated thoroughly. various limitations prohibit the generalisability of these results, including the retrospective nature of the study design, the small sample size and the single centre cohort which might not be representative of other centres. the results might also be skewed by the fact that nearly 20% of patients were lost to follow-up prior to confirmation of union. conclusion undisplaced femoral neck fractures in patients younger than 65 years heal readily regardless of time from injury to surgery, mechanism of injury or fixation method. displaced fractures in the young patient remains a difficult problem to solve. in our series, fixation failure was observed in one in three patients, while one in four required revision to total hip arthroplasty. apart from fracture comminution and geometry, no other evaluated factors were shown to predict failure, including age, mechanism of injury or time from injury to fixation. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethical approval for this study was obtained from the stellenbosch university human research ethics committee (n18/03/029). all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions nf contributed towards study conceptualisation, acquisition, analysis and interpretation of data, first draft preparation, revision and submission of the final manuscript. kj contributed towards study conceptualisation, data acquisition, manuscript preparation and revision, and approval of the final manuscript. gdp contributed towards study conceptualisation, manuscript preparation and revision, and approval of the final manuscript. mb contributed towards analysis and interpretation of the data, manuscript preparation and revision, and approval of the final manuscript. orcid ferreira n https://orcid.org/0000-0002-0567-3373 jordaan k https://orcid.org/0000-0002-6150-9463 du preez g https://orcid.org/0000-0003-2760-7307 burger m https://orcid.org/0000-0003-2831-4960 references 1. somersalo a, paloneva j, kautiainen h, et al. incidence of fractures requiring inpatient care. acta orthop. 2014;85(5):525-30. 2. dhanwal dk, dennison em, harvey nc, cooper c. epidemiology of hip fracture: worldwide geographic variation. indian j orthop. 2011;45(1):15-22. 3. filipov o. epidemiology and social burden of the femoral neck fractures. j of imab. 2014;20(4):516-18. 4. roberts kc, brox wt, jevsevar ds, sevarino k. management of hip fractures in the elderly. j am acad orthop surg. 2015;23(2):131-37. 5. grace l, keller rb, littenberg b, wennberg je. outcomes after displacement fractures of the femoral neck. j bone joint surg am. 1994;76(1):15-25. 6. miyamoto rg, kaplan km, levine br, egol ka, zuckerman jd. surgical management of hip fractures: an evidence-based review of the literature. i: femoral neck fractures. j am acad orthop surg. 2008;16(10):596-607. 7. florschutz av, langford jr, haidukewych gj, koval kj. femoral neck fractures: current management. j orthop trauma. 2015;23(6):460-64. 8. slobogean gp, sprague sa, scott t, mckee m, bhandari m. management of young femoral neck fractures: is there a consensus? injury. 2015;46(3):435-40. 9. ly tv, swiontkowski mf. treatment of femoral neck fractures in young adults. instr course lect. 2009;58:69-81. 10. chan ds. femoral neck fractures in young patients: state of the art. j orthop trauma. 2019;33 suppl 1:s7-s11. 11. zielinski sm, meeuwis ma, heetveld mj, et al. dutch femoral neck fracture investigator group. adherence to a femoral neck fracture treatment guideline. int orthop. 2013;37(7):1327-34. 12. shah ak, eissler j, radomisli t. algorithms for the treatment of femoral neck fractures. clin orthop relat res. 2002;399:28-34. 13. lu-yao gl, keller rb, littenberg b, wennberg je. outcomes after displaced fractures of the femoral neck. a meta-analysis of one hundred and six published reports. j bone jt surg am. 1994;76(1):15-25. 14. pauyo t, drager j, albers a, harvey ej. management of femoral neck fractures in the young patient: a critical analysis review. world j orthop. 2014;5(3):204-17. 15. archibeck mj, carothers jt, tripuraneni kr, white re. total hip arthroplasty after failed internal fixation of proximal femoral fractures. j arthroplasty. 2013;28(1):168-71. 16. morice a, ducellier f, bizot p. total hip arthroplasty after failed fixation of a proximal femur fracture: analysis of 59 cases of intraand extra-capsular fractures. orthop traumatol surg res. 2018;104(5):681-86. 17. paley d, herzenberg je. principles of deformity correction. new york: springer-verlag; 2001. 18. srivastav s, mittal v, agarwal s. total hip arthroplasty following failed fixation of proximal hip fractures. indian j orthop. 2008;42(3):279-86. 19. bartels s, gjertsen je, frihagen f, rogmark c, utvåg se. high failure rate after internal fixation and beneficial outcome after arthroplasty in treatment of displaced femoral neck fractures in patients between 55 and 70 years: an observational study of 2,713 patients reported to the norwegian hip fracture register. acta orthop. 2018;89(1):53-58. 20. marsh jl, slongo tf, agel j, et al. fracture and dislocation classification compendium 2007. j orthop trauma. 2007;21(10 suppl):s1-133. 21. leadbetter gw. a treatment for fracture of the neck of the femur. clin orthop relat res. 2002;399:4-8. 22. smith-peterson m. a new supra-articular subperiosteal approach to the hip joint. j bone jt surg am. 1917;s2-15(8):592-95. https://orcid.org/0000-0002-0567-3373 https://orcid.org/0000-0002-6150-9463 https://orcid.org/0000-0003-2760-7307 https://orcid.org/0000-0003-2831-4960 page 205ferreira n et al. sa orthop j 2020;19(4) 23. bhandari m, chiavaras mm, parasu n, et al. radiographic union score for hip substantially improves agreement between surgeons and radiologists. bmc musculoskelet disord. 2013;14:70. 24. no life expectancy of the world population [internet]. available from: https://www.worldometers.info/demographics/ life-expectancy/. 25. stockton dj, o’hara lm, o’hara nn, et al. high rate of reoperation and conversion to total hip arthroplasty after internal fixation of young femoral neck fractures: a population-based study of 796 patients. acta orthop. 2019;90(1):21-25. 26. zlowodzki m, ayieni o, petrisor ba, bhandari m. femoral neck shortening after fracture fixation with multiple cancellous screws: incidence and effect on function. j trauma. 2008;64(1):163-69. 27. duffin m, pilson ht. technologies for young femoral neck fracture fixation. j orthop trauma. 2019;33 suppl 1:s20-s26. 28. xiao yp, shu dp, bei mj, et al. the clinical application of a novel method of internal fixation for femoral neck fractures-dynamic locking compression system. j orthop surg res. 2018;13(1):131. 29. griffin xl, parsons n, achten j, costa ml. the targon femoral neck hip screw versus cannulated screws for internal fixation of intracapsular fractures of the hip: a randomised controlled trial. bone joint j. 2014;96-b(5):652-57. 30. osarumwense d, tissingh e, wartenberg k, et al. the targon fn system for the management of intracapsular neck of femur fractures: minimum 2-year experience and outcome in an independent hospital. clin orthop surg. 2015;7(1):22-28. 31. eschler a, brandt s, gierer p, mittlmeier t, gradl g. angular stable multiple screw fixation (targon fn) versus standard shs for the fixation of femoral neck fractures. injury. 2014;45 suppl 1:s76-80. 32. biber r, brem m, bail hj. targon femoral neck for femoral-neck fracture fixation: lessons learnt from a series of one hundred and thirty-five consecutive cases. int orthop. 2014;38(3):595-99. _hlk49867777 404 not found du toit j et al. sa orthop j 2020;19(3) doi 10.17159/2309-8309/2020/v19n3a3 south african orthopaedic journal http://journal.saoa.org.za traumapaediatric orthopaedics citation: du toit j, salkinder r, burger mc, du preez g, lamberts rp. short-term outcomes of submuscular bridge plating of length-unstable paediatric femoral shaft fractures in children: insights from a south african tertiary hospital setting. sa orthop j 2020;19(3):145-149. http://dx.doi. org/10.17159/2309-8309/2020/v19n3a3 editor: prof. leonard c marais, university of kwazulu-natal, durban, south africa received: november 2019 accepted: february 2020 published: august 2020 copyright: © 2020 du toit j. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the study. abstract background: femoral diaphyseal fracture is a common paediatric orthopaedic injury; however, the management of these fractures remains controversial in children between the ages of 6 and 13 years. the preferred approach for children appears to be surgical, enabling early mobilisation. some studies have reported that submuscular bridge plating (sbp) might be a good alternative treatment method with favourable outcomes. the aim of this study was to determine whether sbp a) leads to union in length-unstable fractures with a low complication rate; b) leads to reasonable alignment and leg length equality; and c) has acceptable clinical outcomes in a south african tertiary hospital setting. methods: all patients with predominantly length-unstable femoral diaphyseal fractures who were treated between 1 january 2011 and 31 december 2012 were included in this study. patients were treated with sbp using standard of care techniques, and hardware removal was performed at approximately eight months post-operatively. the nine months post-operative assessment between the affected and unaffected leg was used to assess the effectiveness of the sbp intervention. results: a total of 29 patients (mean age 9±2 years) were included. the majority of the fractures (n=27, 93%) were length-unstable. two patients (7%) had transverse fractures with >2 cm overlap and/or weighing >45 kg. all fractures healed within expected time frames. no overall leg length discrepancy (p=0.94) or coronal mechanical axis deviation (p=0.51) was observed between the affected and unaffected lower limbs at nine months post-surgery. no differences between the operated and non-operated sides were observed for hip flexion (p=0.88), hip external rotation (p=0.36), hip internal rotation (p=0.12) or knee flexion (p=0.96). conclusion: sbp provides reliable outcomes in children with diaphyseal femoral fractures and is our preferred method of fixation for a) length-unstable fractures; b) fractures close to the metaphysis; and c) children weighing more than 45 kg. level of evidence: level 4 keywords: femoral fractures, paediatric, orthopaedic surgery, children short-term outcomes of submuscular bridge plating of length-unstable paediatric femoral shaft fractures in children insights from a south african tertiary hospital setting du toit j1 , salkinder r2, burger mc3 , du preez g4 , lamberts rp5 1 mbchb, fc orth(sa), msc, phd; professor and head of division, division of orthopaedic surgery, faculty of medicine and health sciences, stellenbosch university, tygerberg, south africa 2 mbchb, fc orth(sa), mmed; orthopaedic surgeon, cape town mediclinic, oranjezicht, cape town, south africa 3 phd; lecturer and scientific research coordinator, division of orthopaedic surgery, faculty of medicine and health sciences, stellenbosch university, tygerberg, south africa 4 mbchb, fc orth(sa); senior specialist, division of orthopaedic surgery, faculty of medicine and health sciences, stellenbosch university, tygerberg, south africa 5 msc, phd, fecss; professor and head of orthopaedic research, division of orthopaedic surgery, faculty of medicine and health sciences, stellenbosch university, tygerberg, south africa corresponding author: prof. robert p lamberts, division of orthopaedic surgery, department of surgical sciences, stellenbosch university, tygerberg campus, po box 19063, tygerberg, 7505, south africa; tel: +27 (0)21 938 9266; email: rplam@hotmail.com or roblam@sun.ac.za https://orcid.org/0000-0002-0958-5450 https://orcid.org/0000-0003-2831-4960 https://orcid.org/0000-0003-2760-7307 https://orcid.org/0000-0003-1112-2604 page 146 du toit j et al. sa orthop j 2020;19(3) introduction femoral shaft fractures are among the most common major paediatric orthopaedic injuries,1 accounting for between 1.4 and 1.7% of all fractures seen in the paediatric population.2 there remains much controversy surrounding the management of these fractures, most notably in the 6–13 years of age group, with researchers failing to reach consensus regarding the treatment strategy of choice. historically the majority of paediatric femoral shaft fractures have been managed conservatively,3 by means of balanced traction, splints/harnesses and/or hip spicas.3 although most paediatric femoral fractures unite, complications including delayed union, non-union, re-fracture, leg length discrepancies and/or angular deformities are reported.1 the preferred approach for children of school-going age (6–13 years) appears to be surgical, thus enabling early mobilisation and return to school. the most appropriate surgical options remain controversial.1 the flexible intramedullary nailing system is considered to be the most appropriate option for transverse or short oblique length stable fractures in children who weigh below 45 kg.4,5 this method is not suitable for metaphysealdiaphyseal junction or spiral/long oblique/comminuted fractures, or patients weighing in excess of 45 kg, given the decreased ability of flexible nails to maintain fracture length and rotational stability.6 in adult patients the locked intramedullary nail is the treatment of choice for femoral shaft fractures, but reports of avascular necrosis of the femoral head in children when using the piriformis entry point, make this technique a poor choice for use in paediatric populations.7 studies investigating the result of the lateral trochanteric entry nails for children older than 8 years of age are reporting promising results, with no reports of avascular necrosis or significant alteration in the neck shaft angle.3,6 however, lateral trochanteric entry rigid nails cannot address proximal and distal fracture extension and need larger medullary canals.8 similarly, external fixation is considered to be a safe and effective method of treatment,9,10 but reports of quadriceps contractures, re-fracturing, unsightly scars and associated pin-tract infections are significant drawbacks of this surgical approach.11,12 traditional compression plating provides excellent stability and maintains fracture length and alignment but complications include the risk of hardware failure, re-fracture at the plate-bone interface due to stress risers, possible severe femoral overgrowth secondary to periosteal stripping, as well as a non-union rate as high as 10%.13,14 additionally, the necessity for a large incision during surgery further limits the acceptance of this technique.14,15 another technique to be considered is submuscular bridge plating (sbp). this technique is considered minimally invasive thus causing minimal soft tissue disruption, acts as an internal splint and provides relative stability to the fractured diaphysis, and is reported to maintain length and angulation, thus allowing for maximal biological healing.8,16 in addition, use of this technique avoids the growth plates as well as possible injury of the blood supply to the femoral head. although it appears that sbp might avoid some of the complications and problems associated with other methodologies, reported outcomes of this treatment in children ages 6 to 13 years are limited. therefore, the aim of the study was to prospectively evaluate the outcome of sbp of predominantly length-unstable femoral shaft fractures in children between 6 and 13 years of age, who are treated in a south african tertiary hospital setting. length-unstable fractures are defined as those that have a comminuted or spiral fracture pattern and/or >2 cm of shortening. methods study design included in this study were 30 children between the ages of 6 and 13 years, admitted to the division of orthopaedic surgery at tygerberg hospital, western cape, south africa, with a lengthunstable femoral shaft fracture. two children who sustained transverse diaphyseal fractures with >2 cm of shortening and who weighed more than 45 kg were included in the cohort. surgical procedure patients awaiting surgery were stabilised and placed in balanced traction with a thomas splint as an interim immobilisation technique until the definitive surgical intervention. the patient was placed supine on a traction table and the fracture was provisionally reduced by in-line traction. moderate coronal and sagittal malalignment were accepted as this is corrected by the subsequent placement of the pre-contoured plate, but rotation and length were confirmed as corrected both clinically and with fluoroscopy. a synthes® 4.5 mm staggered low contact-dynamic compression (lc-dc) plate with locking options was used. the plate was overlaid over the injured thigh and the appropriate plate length was selected under fluoroscopic guidance. it was contoured using a bending press to the shape of the femur using the pre-operative radiographs as well as the intra-operative screening radiographs as templates. a 3–4 cm longitudinal lateral incision was placed proximally for more proximally situated fractures and distally for distal or midshaft fractures (figure 1). the plate was then advanced sub-muscularly along the femoral shaft (figure 2a), after which the figure 1. entry portal for the submuscular bridge plate: the patient was placed supine on a traction table and the fracture was provisionally reduced by in-line traction. a 3–4 cm longitudinal lateral incision was placed proximally for a more proximally situated fracture. page 147du toit j et al. sa orthop j 2020;19(3) plate was centred and screws were inserted through stab incisions placed over the desired holes, and the fracture was reduced to the plate (figures 2b–e). the first two screws were placed near the proximal and distal ends of the plate and thereafter two compression screws were placed proximal and distal to the fracture. if indicated, these compression screws aided in fracture reduction. the aim was to obtain fixation into six cortices on either side of the fracture. compression screws were used unless the fracture extended into the metaphysis or there were concerns with regard to stability. in these cases, locked screws were used on that side. wounds were closed in layers with subcutaneous absorbable sutures for the skin. a post-operative radiograph was taken prior to discharge to assess the initial fixation. patients were discharged once they were able to mobilise with partial weight bearing using either crutches or a walking frame. progressive weight bearing was allowed once fracture callus was seen on follow-up radiographs. radiographic measurements radiographs (antero-posterior and lateral) were taken on admission. the fractures were classified according to the anatomic and descriptive classification systems as previously described. patients returned to the hospital for follow-up assessments at two weeks, six weeks and three months, and radiographs were taken for assessment of fracture union, acceptable alignment and/or hardware complications. approximately eight months post-operatively, patients returned to the hospital for the removal of the plate during a second surgical intervention. a final follow-up assessment was performed at nine months post-surgery. in addition to the normal clinical assessment of range of motion and rotational profile, long leg standing antero-posterior and lateral radiographs were taken to assess the mechanical lateral distal femoral angle (mldfa). these were compared to the nonoperated side using the pacs radiological system. leg length differences between the operated and non-operated sides were also assessed with the use of these radiographs, and any woundrelated complications recorded. statistical analysis the data was analysed with statistica 11.0 (sta-soft inc, tulsa, ok, usa). distribution and homogeneity of the data was checked with a levene test. as data was normally distributed, data was expressed as mean±standard deviation. differences at nine months between the affected and unaffected leg were analysed with the t-test for independent samples. a significant difference was accepted at a p<0.05. results participant characteristics a total of 30 patients were included in this study with one patient failing to complete follow-up. general characteristics of the included patients are shown in table i. all patients presented with closed fractures barring one that sustained a gustilo-anderson grade 1 open femur fracture. surgical details the mean operating time was 66±15 minutes, with average total incision length of 10.4±2.7 cm (range 6–16). incision length was calculated as the sum of the initial proximal or distal incision (entry portal for the submuscular plate) as well as the three to five additional stab incisions for indirect screw placement. a13-hole plate was used most frequently for fixation. the mean radiation exposure amounted to 88±28 seconds (range 23–138) and the average blood loss during the procedure amounted to 121±83 ml (range 20–400). radiographic and clinical outcomes all 29 patients revisited the hospital for their twoand six-week follow-ups as well as the three-month follow-up assessment. figure 2. radiographs illustrating the fracture (a) advancing of the plate sub-muscularly along the femoral shaft; (b, c) fracture reduction to the plate using cortical screws through stab incisions (d); and a view of the overall bridge plating fixation (e) table i: descriptive characteristics statistics of the patients (n=29) variable age (years) 9±2 sex (m, f) 20 (69%), 9 (31%) fractured side (r, l) 17 (59%), 12 (41%) mechanism of injury low-energy fall 12 (41%) struck by an inanimate object 6 (21%) vehicle accidents 5 (17%) sports injury 4 (14%) altercation 2 (7%) fracture type spiral 15 (52%) oblique 6 (20%) long oblique 2 (7%) comminuted 4 (14%) transverse 2 (7%) data expressed as mean±standard deviation or n (percentage) m, male; f, female; r, right; l, left page 148 du toit j et al. sa orthop j 2020;19(3) radiographs showed that all fractures were fully united by three months post-surgery. plates were removed at an average of 8±3 months post-plating. mean surgical time was 32±9 minutes and blood loss 48±39 ml. screening time ranged from 0.01 to 60 seconds with the mean being 6±12 seconds. outcomes of the nine-month follow-up assessment which included leg length, coronal mechanical axis, as well as hip and knee flexibility are shown in table ii. due to severe bony overgrowth overlying the plate, with subsequent difficulty of plate removal, a prolonged screening time (60 seconds) was necessary in one case. one major complication of a femur being plated in 25 degrees of internal rotation occurred but did not cause any functional or cosmetic disturbance to the patient. the patient and his parents decided against further surgical correction. one final, minor complication of hypertrophic scars was observed, which was treated conservatively. discussion the treatment of paediatric femoral shaft fractures, particularly in the 6 to 13 year age group, has in recent times moved away from the traditionally conservative approach.17 several methods of fixation are available with the fracture pattern and specific patient and economic factors guiding the decision of which approach to use.17,18 although each surgical approach has its merit, each also comes with specific drawbacks, depending on the patient characteristics and fracture pattern. the flexible nail, for example, is appropriate for use in stable fractures in smaller patients, but use in complex, proximal or distal fractures or in heavier children is associated with higher complication rates.4,5,8,19 in turn, compression plating requires large incisions with the associated increased risk of infection and delayed healing.14,15 external fixation preserves blood supply and offers increased stability, but has a higher incidence of pin-tract infections and high refracture rates.20 the main finding of this study is that sbp is a viable and predictable method of fixation for length-unstable paediatric femoral shaft fractures. this technique was used in 30 patients with lengthunstable fractures, and fracture reduction was maintained with no significant leg length discrepancy or malalignment in the axial or coronal planes. reduction was maintained and all fractures were united within three months. we report one major complication of rotational malalignment, which was caused by a preventable technical error. in-theatre variables compare favourably with other methods of fixation: the mean operating time of 67±14 minutes for the index procedure in this study was less than that reported in two previous studies where submuscular plating was used, where the mean operating time was reported to be 89 minutes and 106 minutes, respectively.8,16 theatre time is an important factor to take into account, especially in high-volume settings. the time required in this study compares well to other methods of fixation, with a mean surgical time of 56 minutes for external fixation and 74 minutes for flexible intramedullary nail fixation for femoral shaft fractures being reported by bar-on et al. in 1999.21 screening time should ideally be kept as limited as possible. the current study’s mean exposure time of 88 seconds was slightly increased compared to the means of 56 and 84 seconds reported, respectively, for similar studies,8,16 but compares favourably against external fixation and the flexible nail which had reported screening times of 1.4 and 2.6 minutes, respectively.21 open reduction techniques such as compression plating allow for minimum screening exposure but this invasive technique is not generally recommended due to the large incision, loss of the fracture haematoma as well as the moderate blood loss associated with this technique. caird et al. reported an average blood loss of 200 ml (range 40–1 500) during a series of 60 compression plating procedures.14 similarly, in their bridge plating study of 69 femoral fractures, abdelgawad et al. reported blood loss to be 121 ml (range 20–500).8 all fractures that were included in the present study had united by three months post-surgery.22,23 no differences between leg length, hip and knee range of motion and alignment in the axial or coronal planes were observed at our final follow-up visit at nine months post-surgery. these results were not influenced by patient age, mechanism of injury or type of fracture. in their study which also utilised sbp, kanlic et al. reported leg length discrepancies of between 5 and 23 mm in 8% of their study population (n=4 of 51).16 the elastic nail, which is considered a treatment of choice for length-stable fractures, does not compare as favourably when used to treat length-unstable fractures, with a reported complication rate of 80% in a 2005 study using this technique.19 similarly, studies using external fixation for femoral shaft fractures in children report less than desirable outcomes including malrotation in 43% of patients10 and leg length discrepancies of up to 20 mm.9-11,21 we agree with previous authors who suggested that external fixation be reserved for polytrauma patients or those with high-grade open femur fractures.20,21 we report one patient where difficulty was encountered in removing hardware that had been in situ for ten months and we therefore recommend removal at six months post-surgery. we experienced no refractures, hardware failures or wound infections. we do, however, report on one major complication with a patient’s femur being plated in 25 degrees of internal rotation. in critical review of the case, it was determined that during placement of the patient on the traction table, the upper body and pelvis were inadvertently rotated externally in relation to the distal femur, while the knee was maintained with the patella facing anterior which caused the malrotation. reported complications in previous bridge plating studies ranged from none,22,24 two reports of hardware failure,8,16 one report of deep infection in a polytrauma patient8 and one refracture.16 conclusion the findings of the current study show that in a south african tertiary hospital setting, good results can be achieved when treating length-unstable paediatric femoral shaft fractures with sbp. these finding are in line with previous sbp studies which showed that this technique is a potential alternative to treatment of length-unstable femoral fractures, regardless of fracture type/location, mechanism of injury, patient age or patient weight. it is a minimally invasive table ii: overview of the assessment outcomes performed at nine months post-operatively variables affected side unaffected side p-value leg length (cm) 70.8±6.6 70.9±6.6 0.94 mechanical axis 87±3 87±2 0.51 hip flexion (degrees) 126±14 127±13 0.88 external rotation (degrees) 32±12 35±11 0.36 internal rotation (degrees) 50±10 46±9 0.12 knee flexion (degrees) 147±13 148±13 0.96 values are expressed as mean±standard deviations page 149du toit j et al. sa orthop j 2020;19(3) technique with resultant small, well-accepted scars which allows for early mobilisation and discharge. similar to other surgical options, the only major disadvantage is the requirement for a secondary surgical procedure for hardware removal. this study is, however, not without limitations which include the relatively small sample size and short follow-up study. although reporting these initial findings of this bridge plating, it is also important to conduct a long-term follow-up study focusing on the long-term effects of this treatment regimen in children who are being treated in a south african tertiary hospital setting. in conclusion, this study provides further evidence supporting the use of sbp in length-unstable femoral shaft fractures in children between the ages of 6 to 13 years who are being treated in a south african tertiary hospital setting. ethics statement prior to participation, the parents of all patients were informed about the procedures and gave written informed consent. this study was approved by the health research ethics committee of the faculty of medicine and health sciences within the university of stellenbosch (n10/11/350) and institutional permission was obtained, while the principles outlined in declaration of helsinki were followed.25 declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions jdt: conceptualisation, design, manuscript preparation, supervisor rs: manuscript preparation, design, data collection mb: manuscript preparation gdp: manuscript preparation rl: design, data analyses, manuscript preparation, supervisor orcid du toit j https://orcid.org/0000-0002-0958-5450 burger mc https://orcid.org/0000-0003-2831-4960 du preez g https://orcid.org/0000-0003-2760-7307 lamberts rp https://orcid.org/0000-0003-1112-2604 references 1. flynn jm, schwend rm. management of pediatric femoral shaft fractures. j am acad orthop surg. 2004;12(5):347-59. https://doi. org/10.5435/00124635-200409000-00009. 2. kocher ms, sink el, blasier rd, et al. treatment of pediatric diaphyseal femur fractures. j am acad orthop surg. 2009;17(11):718-25. https://doi.org/10.5435/00124635-2009110 00-00006. 3. chitgopkar sd. internal fixation of femoral shaft fractures in children by intramedullary kirschner wires (a prospective study): its significance for developing countries. bmc surg. 2005;5:6. https://doi.org/10.1186/1471-2482-5-6. 4. li y, stabile kj, shilt js. biomechanical analysis of titanium elastic nail fixation in a pediatric femur fracture model. j paediatr orthop. 2008;28(8):874-78. https://doi.org/10.1097/ bpo.0b013e31818f1136. 5. barry m, paterson jmh. flexible intramedullary nails for fractures in children. j bone joint surg br. 2004;86(7):947-53. https://doi. org/10.1302/0301-620x.86b7.15273. 6. flynn j, hresko t, reynolds r, et al. titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. j paediatr orthop. 2001;21(1):4-8. https://doi.org/10.1097/00004694-200101000-00003. 7. macneil j, francis a, el-hawary r. a systematic review of rigid, locked, intramedullary nail insertion sites and avascular necrosis of the femoral head in the skeletally immature. j pediatr orthop. 2011;31(4):2009-12. https://doi.org/10.1097/ bpo.0b013e3182172613. 8. abdelgawad a, sieg r, laughlin m, shunia j, kanlic e. submuscular bridge plating for complex pediatric femur fractures is reliable. clin orthop relat res. 2013;471(9):2797-807. https:// doi.org/10.1007/s11999-013-2931-9. 9. blasier rd, aronson j, tursky ea. external fixation of pediatric femur fractures. j paediatr orthop. 1997;17(3):342-46. 10. sola j, schoenecker pl, gordon je. external fixation of femoral shaft fractures in children : enhanced stability with the use of an auxiliary pin. j paediatr orthop. 1999;19(5):587-91. 11. miner t, carroll kl. outcomes of external fixation of pediatric femoral shaft fractures. j pediatr orthop. 2000;20(3):405-10. 12. keeler ka, dart b, luhmann sj, et al. antegrade intramedullary nailing of pediatric femoral fractures using an interlocking pediatric femoral nail and a lateral trochanteric entry point. j paediatr orthop. 2009;29(4):345-51. https://doi.org/10.1097/ bpo.0b013e3181a53b59. 13. fyodorov i, sturm pf, robertson wwj. compression-plate fixation of femoral shaft fractures in children aged 8 to 12 years. j paediatr orthop. 1999;19(5):578-81. 14. caird ms, mueller ka, puryear a, farley fa. compression plating of pediatric femoral shaft fractures. j paediatr orthop. 2003;23(4):448-52. 15. eren ot, kucukkaya m, kockesen c, kabukcuoglu y, kuzgun u. open reduction and plate fixation of femoral shaft fractures in children aged 4 to 10. j paediatr orthop. 2003;23(2):190-93. 16. kanlic em, anglen jo, smith dg, morgan sj, pesántez rf. advantages of submuscular bridge plating for complex pediatric femur fractures. clin orthop relat res. 2004:426:244-51. https:// doi.org/10.1097/01.blo.0000138961.34810.af. 17. gardner mj, lawrence bd, griffith mh. surgical treatment of pediatric femoral shaft fractures. curr opin pediatr. 2004;16(1):5157. https://doi.org/10.1097/00008480-200402000-00010. 18. beaty jh. operative treatment of femoral shaft fractures in children and adolescents. clin orthop relat res. 2005;434:11422. https://doi.org/10.1097/01.blo.0000163463.05141.1c. 19. sink el, gralla j, repine m. complications of pediatric femur fractures treated with titanium elastic nails: a comparison of fracture types. j paediatr orthop. 2005;25(5):577-80. https://doi. org/10.1097/01.bpo.0000164872.44195.4f. 20. kanlic e, cruz m. current concepts in pediatric femur fracture treatment. orthopedics. 2007;30(12):1015-19. https://doi. org/10.3928/01477447-20071201-03. 21. bar-on e, sagiv s, porat s. external fixation or flexible intramedullary nailing for femoral shaft fractures in children. a prospective randomized study. j bone joint surg br. 1997;79(6):974-78. https://doi.org/ 10.1302/0301-620x.79b6.7740. 22. sink e, hedequist d, morgan s, hresko t. results and technique of unstable pediatric femoral fractures treated with submuscular bridge plating. j paediatr orthop. 2006;26(2):177-81. https://doi. org/10.1097/01.bpo.0000218524.90620.34. 23. agus h, kalenderer o, eryanilmaz g, omeroglu h. biological internal fixation of comminuted femur shaft fractures by bridge plating in children. j pediatr orthop. 2013;23(2):184-89. 24. samora wp, guerriero m, willis l, klingele ke. submuscular bridge plating for length-unstable, pediatric femur fractures. j pediatr orthop. 2013;33(8):797-802. https://doi.org/10.1097/ bpo.0000000000000092. 25. sussman md. ethical standards in the treatment of human subjects involved in clinical research. j pediatr orthop. 1998;18(6):701-702. https://orcid.org/0000-0002-0958-5450 https://orcid.org/0000-0003-2831-4960 https://orcid.org/0000-0003-2760-7307 https://orcid.org/0000-0003-1112-2604 _hlk37169859 _hlk44330683 404 not found 404 not found 404 not found south african orthopaedic journal editorial doi 10.17159/2309-8309/2022/v21n1a0sa orthop j 2022;21(1) modern orthopaedics and the forgotten child anria horn* red cross war memorial children’s hospital and maitland cottage children’s orthopaedic hospital, university of cape town, cape town, south africa *corresponding author: anriahorn@gmail.com the french physician, nicholas andre, coined the term ‘orthopaedics’ in 1741, having derived it from the greek orthos meaning straight, and paedeia meaning the rearing of children. therefore, ‘orthopaedics’ can be loosely translated as the art of making children straight. much has changed in the subsequent 300 odd years, and the field of orthopaedic surgery has evolved and expanded beyond anything that andre and his peers could have foreseen, displacing the management of children’s deformities further and further into the background. there are many reasons for this diminishing prominence of paediatric orthopaedic surgery. certain common causes of deformity in children, such as rickets and polio, have become largely, if not completely, obsolete. bone and joint tuberculosis, historically a frequent cause of deformity in children and adults, seldom leads to long-term complications these days as it is diagnosed early and effective antitubercular treatment exists.1 at the same time, the ever-growing ageing population results in many more patients developing disabling degenerative disease requiring surgery. older people have higher functional demands and want to be pain-free and mobile. coupled with the success of arthroplasty and other reconstructive surgery, the proliferation of the device industry has meant more and more of these operations are sought after and performed. another important contributing factor to the decline of paediatric orthopaedics is the poor professional remuneration. the monetary units for common paediatric procedures are disproportionately low, to the point of being a disincentive to practising paediatric orthopaedics. for instance, using standard (albeit creative) coding bundles, a carpal tunnel release will earn you 417 units, whereas an open reduction for a congenital hip dislocation with application of a spica cast will earn you 458 units. in a recent meeting by members of the south african paediatric orthopaedic society (sapos) about this very issue, one member stated that closed reduction and k-wiring of a distal radius fracture is the most lucrative procedure they perform. imagine that. add to that the stress of operating on children and dealing with anxious parents, and it is no wonder that there are so few of us around. according to statssa, 28% of the south african population is younger than 15 years of age, and 34% is younger than 18. yet, of the 897 members of the saoa, only 41 are members of sapos, and of those 41, only 18 are in full-time paediatric practice. with the most recent estimate of our population being 59 million, this translates to a surgeon to patient ratio of approximately 1/500 000 for paediatric orthopaedics. furthermore, the few paediatric orthopaedic surgeons in south africa are based in and around the major centres, whereas there are none in mpumalanga, north west, limpopo or the northern cape. there is a great need for paediatric orthopaedic fellowships in south africa. without local fellowships, aspiring paediatric surgeons are obliged to do international fellowships, increasing the risk of their being recruited by overseas practices and never returning home. the main reason for the absence of paediatric fellowships is lack of funding. paediatric orthopaedic surgery is not implant intensive, resulting in less interest and buy-in from the implant industry, who sponsors most of the existing fellowship to a degree. i am currently in negotiations to obtain some funding for a fellowship at uct, but even if i succeed, it will not be enough to constitute a full salary. due to this general lack of interest and specialised training, the largest group of children with deformity remains poorly managed, neglected and misunderstood. i am, of course, referring to those children with cerebral palsy (cp). the incidence of cp in south africa is not exactly known, but the reported incidence ranges from 2/1 000 to as high as 10/1 000 live births.2 the vast majority of children with cp will develop musculoskeletal deformities, deformities that are amenable to surgical correction. that amounts to a huge burden of disease. as a dedicated cp surgeon, i have often heard the cynical joke: ‘what do you get if you operate on a cp? an operated cp.’ what a staggering misconception. the literature abounds with high level evidence to support orthopaedic surgery for patients with cp. once you have experienced the joy of a child who can walk for the first time because they had well-timed tendon surgery, or the teenage boy that can exchange his kaye-walker for a single crutch, or the mother who can carry her child on her back after an adductor release, you will not need much more convincing. i am fortunate to work in a well-organised cp clinic at red cross hospital, where there is a lot of cross-pollination due to the multidisciplinary nature of the clinic where therapists, paediatricians, orthotists and surgeons all contribute. after five years of combined clinics, the paediatricians have become adept at hip surveillance, and it is rare these days for a patient to be referred from within our system with an established hip dislocation. a triumph indeed. the next step will be a national hip surveillance programme, similar to what exists in many developed countries.3 to grow this field nationally, a paediatric fellowship in a highvolume practice is essential. this of course requires funding, a scare commodity at present. out-of-the-box thinking is required to grow this very worthwhile and fundamental area of our profession. references 1. vajapey s, horn a. tuberculosis of the extra-axial skeleton in paediatric patients. sa orthop j. 2021;20(1):21-26. https://doi.org/10.17159/2309-8309/2021/v20n1a2. 2. katangwe tj, van toorn r, solomons rs, et al. a south african cerebral palsy registry is needed. s afr med j. 2020;110(5):353-54. https://doi.org/10.7196/samj.2020.v110i5.14504. 3. shore b, spence d, graham h. the role for hip surveillance in children with cerebral palsy. curr rev musculoskelet med. 2012;5(2):126-34. https://doi.org/10.1007/s12178-012-9120-4. sa orthop j 2021;20(1) cpd questionnaire. march 2021 vol 20 no 1 prevalence of pathological neck of femur fractures in patients undergoing arthroplasty at a tertiary referral hospital (khan s, wadee n, burger m, ferreira n, jordaan k) 1. mortality rate after surgery for femoral neck fractures in the elderly population is approximately: a. 5% a b. 12% b c. 33% c d. 55% d e. 66% e 2. select the most correct statement: a. metastatic lesions are the most common cause of femoral neck fractures. a b. metastatic lesions are the least common cause of pathological femoral neck fractures. b c. primary bony lesions are the most common cause of pathological femoral neck fractures. c d. metastatic lesions and multiple myeloma are the least common causes of pathological fractures. d e. fragility fractures are the most common cause of femoral neck fractures. e 3. which of the following primary malignancies most commonly metastasise to bone? a. brain, oesophagus, stomach a b. breast, thyroid, kidney, lung and prostate b c. breast, thyroid, ovarian, lung and prostate c d. breast, thyroid, brain, lung and prostate d e. breast, thyroid, kidney, lung and prostate e tuberculosis of the extra-axial skeleton in paediatric patients (vajapey s, horn a) 4. which of the following haematological studies are usually normal in children presenting with musculoskeletal tuberculosis? a. haemoglobin a b. white cell count b c. platelet count c d. erythrocyte sedimentation rate (esr) d e. c-reactive protein (crp) e 5. in children who are eventually diagnosed with musculoskeletal tuberculosis, the most common presenting physical complaint is: a. fatigue a b. weight loss and loss of appetite b c. joint stiffness c d. pain or limping d e. deformity e 6. in this study, the diagnostic test with the highest sensitivity or number of positive results was: a. tissue culture and sensitivity a b. genexpert b c. histological examination c d. microscopy d e. mantoux skin test e short-term comparison of the use of static and expandable intramedullary rods in the lower limbs of children with osteogenesis imperfecta (de jager lj, maré ph, thompson dm, marais lc) 7. what was the most frequent complication in the rush rod group? a. infection a b. articular penetration b c. distal deformity c d. metalware failure d e. failure to expand e 8. what was the most frequent complication in the fassier-duval rod group? a. infection a b. articular penetration b c. distal deformity c d. metalware failure d e. failure to expand e 9. what was the expected time to re-operation in the rush rod group? a. 6 months a b. 1 year b c. 2 years c d. 3 years d e. 5 years e the management of chronic osteomyelitis in adults: outcomes of an integrated approach (venter rg, tanwar ys, grey jp, ferreira n) 10. choose the most correct statement. considering current literature regarding ‘single-stage management’ of chronic osteomyelitis: a. it is less cost effective than two-stage treatment methods but has similar success rates. a b. it is more cost effective than two-stage treatment methods but has higher complication rates. b c. it is more cost effective than two-stage treatment methods and has similar success rates. c d. it is less cost effective than two-stage treatment methods but obviates the need for adjuvant systemic antimicrobial therapy. d e. it is more cost effective than two-stage treatment and obviates the need for adjuvant systemic antimicrobial therapy. e 11. the following are all accepted dead space management strategies mentioned in current literature, except: a. gentamycin-loaded pmma beads a b. antibiotic-loaded calcium-sulphate pellets b c. bioactive glass c d. hydroxyapatite powder d e. antibiotic-impregnated collagen sponges e south african orthopaedic journal page 54 sa orthop j 2021;20(1) 12. choose the most correct statement regarding a modern definition of chronic osteomyelitis: a. infection involving bone, with a duration of at least one month, with signs of sequestrum on plain film x-ray or ct scan. a b. infection involving bone, with a duration of at least one month, where the causative organisms were thought to have persisted either intracellularly or in interactive biofilm-based colonies. b c. infection involving bone, with a duration of at least ten days, where the causative organisms were thought to have persisted either intracellularly or in interactive biofilm-based colonies. c d. infection involving bone, with a duration of at least ten days, with signs of sequestrum on plain film x-ray or ct scan. d e. infection involving bone, with a duration of at least one month, with signs of both local and systemic signs of sepsis. e radiation-induced pathological fractures of the proximal femur: a case series considering an endoprosthetic solution (vogel j, de villiers s, mugla w, mccaul j, hosking k, hilton t) 13. standard trauma fixation methods, such as locked cephalo-medullary nails, used to treat radiation-induced pathological fractures of the proximal femur have a failure rate of: a. 10–20% a b. 20–40% b c. 40–60% c d. 60–80% d e. 80–100% e 14. the mechanism of radiation-induced pathological fractures is: a. local sarcopaenia a b. tumour recurrence b c. osteonecrosis c d. post-radiation osteomyelitis d e. osteoporosis e intra-operative extracorporeal radiation therapy for skeletally immature patients with malignant bone tumours (shah mr, shah mm, agrawal ak, shah md, desai sm) 15. the advantage/s of extracorporeal radiation is/are: a. useful in skeletally immature patients a b. high dose of radiation given in one sitting kills tumour cells better b c. patient’s own bone can be used c d. avoids prolonged radiation therapy d e. all of the above e 16. the following are treatment options for malignant bone tumours in skeletally immature bones except: a. amputation a b. tumour excision and replacement with non-expandable megaprosthesis b c. tumour excision and replacement with expandable megaprosthesis c d. ecrt d e. none of the above e 17. ecrt can be a choice of treatment in the case of multiple metastases. a. strongly disagree a b. disagree b c. agree c d. strongly agree d e. not sure e intraprosthetic dislocation after a revision hip replacement: a case report (sekeitto ar, van der jagt k, sikhauli n, mokete l, van der jagt dr) 18. a 75-year-old male with comorbid neuromuscular disease underwent a total hip arthroplasty for severe osteoarthritis of his hip. the orthopaedic surgeon who performed the procedure opted to use a dual mobility cup. which of the following explains the rationale for this implant choice? a. increased offset a b. increased stability b c. increased range of motion c d. poor bone stock d e. the patient’s sex e 19. a 75-year-old male who had a total hip replacement with a dual mobility cup a few weeks prior falls in the bathroom. he is brought into the accident and emergency department and after imaging is confirmed to have dislocated his previously operated hip. which of the following is the appropriate management? a. open reduction a b. closed reduction under conscious sedation b c. closed reduction under general anaesthesia c d. closed reduction under general anaesthesia and full muscle relaxation d e. revision of the components e 20. a 75-year-old male who is post-reduction of a dislocated dual mobility cup has a formal x-ray performed in recovery. review of the x-ray by his orthopaedic surgeon shows an intraprosthetic dislocation. which of the following is the appropriate management? a. open reduction a b. closed reduction under conscious sedation b c. closed reduction under general anaesthesia c d. closed reduction under general anaesthesia and full muscle relaxation d e. revision of the components e subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm.co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online • once you have completed the answers, go back to the top of the page next to the registration option. there is another icon “find my cpd certificate”. (you will have to answer the two questions regarding your internship and last cpd audit once you have completed a questionnaire and want to retrieve your certificate). • if you click on that icon it will open your certificate which you can print or save on your system. • please call mpc helpdesk if you have any questions: 0861 111 335. medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 blake ca et al. sa orthop j 2020;19(2) doi 10.17159/2309-8309/2020/v19n2a8 south african orthopaedic journal http://journal.saoa.org.za traumacurrent concepts review citation: blake ca, van staden gf, van der merwe jf, matshidza s. management of femur neck fractures in young adults under the age of 60 years. sa orthop j 2020;19(2):103-108. http://dx.doi.org/10.17159/2309-8309/2020/v19n2a8 editor: prof. lc marais, university of kwazulu-natal, durban, south africa received: december 2019 accepted: april 2020 published: may 2020 copyright: © 2020 blake ca. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: there are no funding sources to declare. conflict of interest: all authors confirm they have no conflicts of interest to declare with regard to this article. abstract femur neck fractures in young adults account for 3–10% of all hip fractures, and management remains a challenge for the orthopaedic surgeon. reoperation rates remain high after fixation of these fractures due to avascular necrosis, non-union, implant failure and removal of hardware. complication rates are higher in displaced fractures, and patients who undergo revision to total hip arthroplasty (tha) have poorer outcomes compared with primary tha. injury factors, fracture pattern, physiological age, timing of surgery, the role of capsulotomy and implant choice all need to be carefully considered in managing these fractures. preserving the native hip joint is the standard of care in these patients but primary tha is becoming an attractive option due to the improvements in bearing surfaces and longevity of implants. there is no role for conservative management of fractures in this age group. absolute anatomic reduction and stable fixation remains the goal of hip-preserving surgery. open reduction is often necessary. various fixation options are available from the more commonly used cannulated screws and dynamic hip screw to the newer generation hybrid plates with telescoping screws. cannulated screws (cs) are adequate for stable fracture (garden 1 and 2) patterns, whereas the dynamic hip screw (dhs) is biomechanically superior for unstable fractures. neck shortening after using sliding screws is common but does not seem to influence clinical outcomes. cephalomedullary nails are an acceptable load-bearing alternative. proximal femur locking plates have high failure rates and should be avoided. new generation hybrid plates have shown promising results with fewer non-union rates than cs and dhs systems. primary tha can be considered in exceptional cases where there are significant comorbidities, poor bone stock or in a patient that will be unable to tolerate a second surgery if fixation fails. hemiarthroplasty should be avoided in this age group. the management of these fractures in south african government hospitals should be supervised by experienced surgeons whenever possible. level of evidence: level 5 keywords: femur neck fracture, total hip arthroplasty, management, young adult, open reduction and internal fixation management of femur neck fractures in young adults under the age of 60 years blake ca¹ , van staden gf², van der merwe jf³ , matshidza s4 1 bsc, mbchb, mmed(ortho); consultant and head of limb reconstruction and sport* ² mbchb, fc orth(sa); consultant hand surgery* 3 mbchb, mmed(ortho); consultant and head of arthroplasty* 4 mbchb, fc orth(sa), mmed(ortho); consultant and head of department* department of orthopaedic surgery, school of clinical medicine, faculty of health sciences, university of the free state, bloemfontein, south africa corresponding author: dr ca blake, po box 339, department of orthopaedic surgery, francois retief building, university of the free state, 9300; tel: 0824952763; email: drcraigblake@yahoo.com https://orcid.org/0000-0002-3592-4823 https://orcid.org/0000-0002-5554-4887 page 104 blake ca et al. sa orthop j 2020;19(2) introduction femoral neck fractures (ao/ota type 31b) in young adults are challenging injuries to manage with high complication rates and revision surgeries. these hip fractures are fortunately less common (3–10%)1,2 than in the elderly and are often associated with high-energy trauma.3 there is a male predominance in these types of high-energy fractures. total hip arthroplasty (tha) or hemiarthroplasty has become the standard of care for patients >65 years.4 preserving the native hip joint when possible is the goal of surgery in the younger patient.5 while there is a plethora of literature available, there is still no consensus about the definitive management of these fractures in patients under 60 years. common complications after hip-preserving surgery include non-union, avascular necrosis (avn) and implant failure. secondary surgery is often also necessary to remove implants.6 figures related to the incidence of avn (11.5–45%) and non-union (7.4–35%)2,7 after open reduction and internal fixation (orif) vary in the literature. all complication rates are higher in displaced fractures such as garden type 3, 4 and pauwels type 3 than in valgus impaction or undisplaced fractures (garden type 1, 2). pauwels type 3 fractures are the most vertical, with high shear loads and the highest rate of avn (11–86%) and non-union (16–56%).3 reoperation rates after internal fixation are as high as one in three6,8 and conversion to tha occurs in one in seven cases.6 it must also be noted that tha as a secondary procedure has higher complication rates.6,9 morbidity associated with multiple surgeries and the financial implication of lengthy and repeated absences from work need to be considered. patients should be adequately counselled about expectation and outcomes prior to surgical management. chronological age, physiological age, comorbidities, injury factors, fracture pattern, timing, economic factors and type of fixation or arthroplasty all need to be carefully considered during decision-making. injury factors and fracture patterns appropriate protocols must be followed when managing these fractures in the setting of high-energy trauma. following initial resuscitation, adequate imaging must be obtained, usually anteroposterior and lateral radiographs of the hip including the pelvis and femur. imaging of the contralateral side (if normal) is valuable for pre-operative planning. computer tomography (ct) is obtained as needed and can add information on fracture pattern for complex fractures. low-energy injuries can also cause femur neck fractures in this age group, often in the presence of metabolic or endocrine abnormalities. the ao, garden and pauwels fracture classification systems are most commonly used. displaced femur neck fractures (garden 3, 4) generally have worse outcomes after orif or closed reduction and internal fixation (crif) than undisplaced fractures.10 significant initial displacement, pauwels type 3 fractures and posterior neck comminution are associated with poor outcomes5 (figure 1). bone healing while a detailed discussion on the anatomy of the femoral head and its blood supply falls outside the scope of this review, it is important to discuss the healing process of these fractures. femur neck fractures are intrasynovial and thus unite by primary bone healing or contact healing11 with the absence of callous. strain must be less than 2% and the fracture gap minimal; cutting cones form at the bone ends and cross the fracture line, and these cavities are then filled with bone via osteoblasts. this requires anatomical reduction and compression with absolute stability constructs. small gaps may be tolerated and heal via gap healing11,12 but high strains across the fracture site are poorly tolerated. age physiological age is often more important than chronological age1 and, while the majority of patients under 60 years will be suitable candidates for orif, the select group of higher risk or physiologically older patients must be identified. the presence of medical comorbidities has a high predictive value for failure of internal fixation after displaced neck fracture in patients under 60 years.2 the younger group of patients have higher physiological reserves and good bone stock for internal fixation, and the goal is maintenance of the native joint as previously discussed.5 physiologically older patients with comorbidities or chronic disease often have poorer bone stock and fewer functional demands, and may be more suitable candidates for primary tha. this group of patients may also not tolerate a second surgery if internal fixation fails. technical and surgical factors quality of reduction is the most important technical factor associated with outcomes. regardless of implant, malreduction is consistently associated with non-union.5 non-union rates can be over 80% in these cases. residual varus, non-anatomic reduction with posterior comminution gives predictably poor outcomes.5 there should be a low threshold to perform open reduction. absolute anatomic reduction and stable fixation remains the goal of joint-preserving surgery in these fractures. haematoma decompression controversy exists over whether to perform an open capsulotomy to release intracapsular pressure (haematoma) and increase blood flow to the femoral head.1 there is no evidence that correlates capsulotomy with improved outcomes.1,5 in a study by upadhyay and another by gumustas et al., capsulotomy did not affect outcomes.10,13 pauyo et al., in their critical analysis, recommended against routine capsulotomy.1 a study by ly et al., however, recommended performing a capsulotomy until there is conclusive data to recommend against this practice.14 they propose it is low risk and easy to perform. type 1 up to 30° type 2 30–50° type 3 50° and more figure 1. pauwels classification page 105blake ca et al. sa orthop j 2020;19(2) timing of surgery previous advice to expedite fixation of these fractures to prevent avn and non-union is still controversial, and evidence for urgent fixation (<6 hours) is conflicting.7,15 generally, late surgery was associated with higher rates of revision surgeries and complications but a recent systematic review by papakostidis et al.16 showed no association between timing and incidence of avn, but that delays of more than 24 hours can increase risk of non-union. pauyo et al. recommended treating femur neck fractures on a urgent basis but acknowledged the existing controversial evidence.1 research from brazil17 found no influence between time to surgery and bone healing in patients <60 years. gumustas et al. found no evidence that early fixation decreases avn risk.10 upadhyay et al. found that managing fractures before or after 48 hours did not affect rates of union or avn.13 the current best evidence shows a lack of association between surgical timing and outcomes5 although fractures should be managed within a reasonable time to avoid other medical complications. the general recommendation is that these surgeries should be done on a day list with supervision available on a physiologically optimised patient. internal fixation and biomechanics the literature does not advocate the role of conservative treatment;5 only in non-ambulatory patients who are deemed unfit for anaesthesia may this be considered. young adults also commonly present with the more unstable vertical pauwels type 3 fractures which are challenging to manage.14 the stability of the fracture after reduction determines how much load the bone can share with the implant; for stable fractures the implant is load-sharing but for unstable fractures the implant needs to be load-bearing.18 fixation in varus or malreduction should be avoided. there is still no consensus as to which fixation modality is superior3,18 but analysis of the stability and personality of the fracture can guide decision-making. results of biomechanical testing of implants on cadaver bone and bone analogues must be carefully scrutinised as these do not necessarily represent real bone behaviour in vivo.18 reduction techniques closed reduction and internal fixation (crif) is often possible using gentle closed manoeuvres (leadbetter) in garden type 3 fractures; however, care must be taken as multiple attempts at closed reduction may lead to increased risk of avn.1 careful surgical setup and positioning of the image intensifier is needed to visualise the reduction of the neck. the surgical setup must be done so that an open reduction can be performed if needed. a femoral distractor may also be required using one pin in the pelvis and a second in the femur shaft to reduce and control position.15 fluoroscopy may be deceiving when assessing quality of reduction and direct visualisation of the reduction is the gold standard for anatomic reduction.15 if not reduceable by closed methods these fractures should all undergo open reduction, most commonly through a lateral (watsonjones) or anterior (smith-peterson or hueter) approach to ensure anatomic reduction despite the method of fixation used. the lateral incision allows hardware to be inserted via one incision while the anterior approach requires a second incision for instrumentation.15 provisional k-wires, schantz pin joysticks and collinear reduction clamp are valuable additional tools to assist with the reduction. internal fixation options cannulated screws cannulated screws (cs) are the most commonly performed type of fixation for these fractures7 (figure 2). they provide good torsional stability, are minimally invasive and preserve blood supply.15 cs are still recommended by the ao as an option for stable fracture configurations (ao/ota type 31b1.1–3 and 31b2.1). parallel partially threaded screws allow controlled axial compression and sliding. headless fully threaded cs have shown some biomechanical advantages18 but are more expensive. cs fixation is the procedure that can be performed in the shortest time and with the least blood loss.7 valgus impaction or undisplaced fractures can often be treated with percutaneous cs fixation in situ using the traditional inverted triangle configuration. cs show good outcomes in fixation of stable garden type 1 and 2 fractures;1,18 however, in unstable fractures an implant with more angular stability may be preferred such as the dynamic hip screw (dhs).1,7,19 the three-screw inverted triangle with partially threaded cannulated screws of diameter >6 mm is the most used configuration supported by biomechanical studies.18 washers may be used for increased compression or in osteoporotic bone;18 the biomechanical benefit of adding a fourth screw is unclear.5,18 fully threaded cs, combinations of fully and partially threaded screws and non-parallel screw placements are also used. it is important not to place screws below the level of the lesser trochanter as this may lead to a stress riser or iatrogenic subtrochanteric fracture.15 a literature review by rahman et al. found that cs have higher incidence of non-union, avn, implant failure and reoperation rates compared to dhs or targon femoral neck (tfn) plate, both of which will be discussed later.7 medial buttress plate augmentation with cs can also be used for vertically unstable (pauwels type 3) fractures3 (figure 3). good short-term outcomes (89% union rate in pauwels type 3 fractures) were described by ye et al.3 in 28 cases of young patients fixed with this method but longer follow-up is needed to assess the rate of avn. it is important to recognise the limitations of cs. in pauwels type 3, base cervical and comminuted fractures, a load-bearing figure 2. cannulated screws page 106 blake ca et al. sa orthop j 2020;19(2) implant must be used. these devices include the dhs preferably with derotation screw, cephalomedullary nail (cmn) or a hybrid implant.18 dynamic hip screw the dynamic hip screw (dhs) device with the appropriate tip apex distance (<25 mm) with at least two screws fixing the plate to the shaft is a very effective method of fixation.18 two screws are usually enough in good quality bone, and locking screws are often not necessary. longer plates with more screws may result in higher periprosthetic fracture risk in those patients converted to tha as the residual screw holes can lie adjacent to the tip of the femoral stem. dhs shows good results in all garden types especially displaced and unstable fractures. dhs with sliding screw or blade show better outcomes than cs for fixation of displaced fractures.19 the angle can be increased in pauwels type 3 fractures up to 150 degrees. adding a derotation screw prevents head rotation during insertion and provides additional mechanical support.18 helical blade systems, which use a rotating blade instead of the lag screw, have an advantage as they reduce the risk of rotational deformity associated the torque of traditional screw insertion.20 dynamic locking blade plate (dlbp) constructs show promising results21 but have no biomechanical advantage over the screw.18 more research is needed to compare clinical outcomes between conventional screw dhs and the dlbp. fibula strut grafts, allograft or autograft (biological dowel placed parallel to the lag screw), in combination with a dhs for unstable fractures has also been shown to be effective22 but is technically demanding and is associated with donor-site morbidity (autograft). neck shortening after cs or dhs can occur in up to 93% of cases.23 partially threaded parallel cs and the dhs allow controlled axial compression which can result in neck shortening. this can possibly be prevented by using fully threaded headless compression screws,24 a combination of partially and fully threaded screws25 or non-parallel screw fixation. galal et al.26 showed less neck shortening and good outcomes with non-parallel screw fixation than with conventional cs placement. however, in a study by chiang et al.,24 the use of fully threaded screws did not prevent neck shortening and was around eight times more expensive than regular cs. only limited data is available on the effects of neck shortening after fixation. a study by haider et al.23 found excellent functional outcomes after cs and dhs fixation in young patients despite shortening in 92.5 % of cases. more research is needed into these alternative cs configurations as well as the impact neck shortening has on functional outcomes. cephalomedullary nails cephalomedullary nails (cmn) are effective load-bearing devices for femur neck fractures; devices with two lag screws are preferred for additional rotational stability of the neck or additional cs can be added.18 cmn are as effective as dhs for pauwels type 3 and base of neck fractures, with both being superior to cs.18 cmn are stronger under axial load than cs and dhs systems.27 long nails are preferred in complex fractures or pathological bone. proximal femur locking plates contoured proximal femoral locking plates (pflp) show good early construct stiffness but are associated with high failure rates including screw breakage and loosening.18 pflps, despite being fixed angle devices, are not able to resist the shearing forces involved in the healing process in vertical femur neck fractures.28 berkes et al. describe catastrophic failures with the use of pflp systems and these should be avoided.27 hybrid plates new plate technology includes fixed angle plates with multiple telescoping screws which provide more rotational stability. examples include the targon femoral neck (tfn), conquest femoral neck (cfn), femoral neck system (fns) and hansson pinloc. some of these telescoping screws are spring loaded, the so called ‘pogo plate’. the ‘pogo plate’ such as the cfn has an internal spring-loaded mechanism to allow constant compression over the fracture site. figure 3. medial buttress plate figure 4. targon femoral neck page 107blake ca et al. sa orthop j 2020;19(2) the tfn plate (figure 4) shows higher loads to failure and better mechanical strength than cs and dhs.18 early clinical results using the tfn plate system are promising18 with fewer non-union and revision rates. tfn plates show lower post-operative complications in both undisplaced and displaced fractures in patients above 60 years;29 poorer results were described in patients below 60 years. parker et al.30 followed up 320 tfn cases and showed reduced complications but these included many older patients (mean 76 years). a systematic review by rahman et al.7 showed the tfn plate performed as well as the cs and dhs regarding avn and non-union rates but had fewer implant failures. the conquest system and fns need more published clinical trials to warrant further comment. arthroplasty hemiarthroplasty hemiathroplasty concerningly is still performed in many centres for femur neck fractures in this age group, up to 42.8% of 74 678 fractures below 65 years in a recent us publication.9 swart et al.4 concluded that hemiarthroplasty has worse outcomes at higher costs and is not recommended for patients <65 years. this surgical option remains a very poor choice for the young healthy patient. total hip arthroplasty primary total hip arthroplasty (tha) remains a management option and has superior outcomes over all types of fixation in patients older than 65 years.5 advances in bearing surfaces, increased longevity of implants and predictable results make primary tha an evermore attractive treatment option6 with a trend to increased usage in this age group.9 the ten-year survival rate for primary tha in the young population varies from 75–100%.4 as previously discussed, physiologically older patients with comorbidities or chronic disease often have poorer bone stock and fewer functional demands and may be more suitable candidates for primary tha. duckworth et al. concluded that primary tha should be considered in the presence of risk factors such as alcohol abuse and respiratory or renal diseases.2 swart et al. used chronological ages in an economic decision analysis4 and found that primary tha for femur neck fractures can be cost effective in patients between 45 and 65 years depending on comorbid diseases. johnson et al.9 found that there was increased use of primary tha for femur neck fractures in patients 45–64 years by 4.2-fold over the period 2002–2014 in the united states. they also noted that these patients had increased hospital costs, longer length of stay and more complications.9 tha may also be indicated where the fracture pattern or bone loss makes anatomic reduction and fixation impossible. it must be noted that tha should be the exception for management of femoral neck fractures under 60 years and only be performed after careful individualised risk analysis. south african challenges femur neck fractures in this younger age group are common in south africa as a result of both high-energy trauma and lowerenergy trauma in the ‘physiologically older’ group. alcoholism and chronic illnesses are also prevalent in these younger patients, so bone quality and healing potential needs to be carefully assessed during surgical decision-making. the main challenge faced in the government hospitals is timeous access to surgery due to our trauma burden, and it is only in exceptional cases that these fractures are operated within 24 hours. a brazilian study published in 2019, however, reviewed 81 patients with femur neck fractures under 60 years with a median waiting time of 17 days, which mimics the situation here in south africa. interestingly, they found that there was no difference between time to surgery and outcomes.17 upadhyay et al. from india in his study comparing open and closed reductions also mentions that all but three of the surgeries were delayed more than 12 hours and found equal effectiveness of internal fixation performed within one week.13 delayed surgery, as is the case in south africa, fortunately does not seem to result in poorer outcomes. our other challenge is that these surgeries are often carried out by junior medical officers and registrars without supervision. this frequently results in poor reductions being accepted as a junior surgeon may be more reluctant to open the hip joint. open reduction of a femur neck is a challenging procedure that should be performed or supervised by a senior surgeon preferably with arthroplasty experience. absolute anatomic reduction and stable fixation determine outcomes. experienced surgeons should thus be involved in the correct implant choice and insertion technique. conclusion all femur neck fractures in this age group need to be surgically addressed as accurate anatomic reduction (open or closed) with appropriate stable fixation is required for joint-sparing surgery. displaced fractures, pauwels type 3 and fractures with posterior comminution generally have poorer outcomes than undisplaced fractures. following joint-sparing surgery, revision rates to tha are concerningly high. capsulotomy is not associated with improved outcomes. there is a lack of association between surgical timing and outcomes. cs with standard configuration is recommended for stable fractures, but in unstable fractures a more angular stable load-bearing device is preferred such as a dhs. neck shortening after fixation with sliding screw devices does not seem to be clinically significant. pflp should be avoided. hybrid plates such as the tfn have shown promising results but more outcomesbased research is needed in this age group. hemiarthroplasty should not be performed in the physiologically young patient. tha can also be considered in patients who are physiologically older, have comorbidities2 or have fracture patterns in which accurate anatomic reduction and stable fixation is not possible. it is our opinion is that orif of femur neck fractures in patients under 60 years needs more supervision by senior surgeons in government hospitals in south africa. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethical approval for this study was not obtained – review article. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions cab contributed to the conception and design of the work, literature review, analysis, drafting of the work; and final approval of the version to be published. gfvs, jfvdm and sm all contributed to the conception and design of the work, revising it critically for important intellectual content; and final approval of the version to be published. page 108 blake ca et al. sa orthop j 2020;19(2) orcid blake ca https://orcid.org/0000-0002-3592-4823 van der merwe jf https://orcid.org/0000-0002-5554-4887 references 1. pauyo t, drager j, albers a, et al. management of femoral neck fractures in the young patient: a critical analysis review. world j orthop. 2014;5(3):204-17. 2. duckworth ad, bennet sj, aderinto j, keating jf. fixation of intracapsular fractures of the femoral neck in young patients: risk factors for failure. bone joint j. 2011;93(6):811-16. 3. ye y, chen k, tian k, et al. medial buttress plate augmentation of cannulated screw fixation in vertically unstable femoral neck fractures: surgical 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devices or pauwel screws? injury. 2016;47:1676-84. 20. duffin m, pilson ht. technologies for young femoral neck fracture fixation. j orthop trauma. 2019;33(1):20-26. 21. kalsbeek jh, van walsum adp, vroeman jpam, janzing hmj, winkelhorst jt, bretelink bp, et al. displaced femoral neck fractures in patients 60 years of age or younger: results of internal fixation with the dynamic locking blade plate. j bone jt surg. 2018;100(4):443-49. 22. lazaro le, birnbaum jf, farshad-amacker na, et al. endosteal biologic augmentation for surgical fixation of displaced femoral neck fractures. j orthop trauma. 2016;30(2):81-88. 23. haider t, schnabel j, hochpöchler j, wozasek ge. femoral shortening does not impair functional outcome after internal fixation of femoral neck fractures in non-geriatric patients. arch orthop trauma surg [internet]. 2018;138(11):1511-17. available from: http://dx.doi.org/10.1007/s00402-018-3011-0. 24. chiang m, wang c, fu s, hung c-c, yang r-s. does fully-threaded headless compression screw provide a lengthstable fixation in undisplaced femoral neck fractures? asian j surg [internet]. 2019;42(1):320-25. available from: https://doi. org/10.1016/j.asjsur.2018.05.009. 25. zhang b, liu j, zhu y, zhang w. a new configuration of cannulated screw fixation in the treatment of vertical femoral neck fractures. int orthop. 2018;42:1949-55. 26. galal s, nagy m. non-parallel screw fi xation for femoral neck fractures in young adults. j clin orthop trauma [internet]. 2017;8(3):220-24. available from: http://dx.doi.org/10.1016/j. jcot.2017.07.003. 27. berkes mb, little mtm, lazaro le, et al. catastrophic failure after open reduction internal fixation of femoral neck fractures with a novel locking plate implant. j orthop trauma. 2012;26(10):170-76. 28. samsami s, saberi s, bagheri n, rouhi g. interfragmentary motion assessment for three different fixation techniques of femoral neck fractures in young adults. biomed mater eng. 2016;27:389-404. 29. kilian m, csörgő p, šajter m, et al. locking plate fixation with multiple telescoping sliding screws for femoral neck fractures. ortop traumatol rehabiltacja. 2018;20(6):493-98. 30. parker m, cawley s, palial v. internal fixation of intracapsular fractures of the hip using a dynamic locking plate: two-year follow-up of 320 patients. bone joint j. 2013;95-b(10):1402-405. https://orcid.org/0000-0002-3592-4823 https://orcid.org/0000-0002-5554-4887 _hlk36637478 o’connor m et al. sa orthop j 2020;19(3) doi 10.17159/2309-8309/2020/v19n3a1 south african orthopaedic journal http://journal.saoa.org.za traumageneral orthopaedics citation: o’connor m, nieuwoudt l, marais lc. orthopaedics and covid-19: the surgery, the surgeon and the susceptible – a scoping review. sa orthop j 2020;19(3):129-137. http://dx.doi.org/10.17159/2309-8309/2020/ v19n3a1 editor: prof. nando ferreira, stellenbosch university, south africa received: july 2020 accepted: july 2020 published: august 2020 copyright: © 2020 o’connor m. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was required for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: the coronavirus disease of 2019 (covid-19) pandemic is taxing south africa’s already over-burdened healthcare system. orthopaedics is not exempt; patients present with covid-19 and musculoskeletal pathology and so surgeons should be familiar with the current evidence to best manage patients and themselves. the aims of this scoping review were firstly to inform peri-operative decision-making for covid-positive patients as well as the routine orthopaedic milieu during the pandemic; secondly to assess the outcomes of orthopaedic patients managed in endemic areas; and finally to determine the effect the pandemic has had on our orthopaedic peers. methods: a scoping review was conducted following the prisma-scr guidelines of 2018. the search terms ‘orthopaedics’ or ‘orthopedics’ and ‘covid-19’ or ‘coronavirus’ were used to perform the search on scopus, pubmed and cochrane databases. all peer-reviewed articles utilising evidence-based methodology and addressing one of the objectives were eligible. a thematic approach was used for qualitative data synthesis. results: seventeen articles were identified for inclusion. all articles represented level 4 and 5 evidence and comprised ten reviewtype articles, one consensus statement, two web-based surveys and four observational studies. most articles (n=11) addressed the objective of peri-operative considerations covering the stratification and testing of patients, theatre precautions and personal protective equipment (ppe). evidence suggests that patients should be stratified for surgery according to the urgency of their procedure, their risk of asymptomatic disease (related to the community prevalence of covid-19) and their comorbidities. the consensus is that all patients should be screened (asked a set of standardised questions with regard their symptoms and contacts). only symptomatic patients and those asymptomatic patients from high prevalence areas or those with high-risk contacts should be tested. healthcare workers (hcws) in theatre should maintain safety precautions considering every individual is a potential contact. in the operating room in addition to the standard orthopaedic surgery ppe, if a patient is covid positive, surgeons should don an n95 respirator. the three articles that addressed the effects on the orthopaedic surgeon showed a significant redeployment rate, effects on monetary renumeration of specialists and also effects on surgeons in training causing negative emotional ramifications. of the surgeons who have contracted the illness and have been investigated, all showed mild symptomatology and recovered fully. the final three articles concentrated on orthopaedic patient considerations; they all showed high mortality rates in the vulnerable patient populations investigated, but had significant limitations. conclusion: orthopaedics is significantly affected by the covid pandemic but there remains a dearth of high-quality evidence to guide the specialty. level of evidence: level 3 keywords: covid-19, sars-cov-2, coronavirus, orthopaedic, surgery orthopaedics and covid-19: the surgery, the surgeon and the susceptible – a scoping review o’connor m¹ , nieuwoudt l² , marais lc³ 1 mbbch, fc orth sa; consultant, department of orthopaedic surgery, university of kwazulu-natal; gjgm memorial hospital, kwadukuza, durban, south africa ² mbchb, fc orth sa; consultant, department of orthopaedic surgery, university of kwazulu-natal; grey’s hospital, pietermaritzburg, south africa ³ mbchb, fc orth sa, phd; head of department: orthopaedics, school of clinical medicine, university of kwazulu-natal, durban, south africa corresponding author: dr megan o’connor, department of orthopaedic surgery, gjgm memorial hospital, 23a king shaka street, kwadukuza, durban, 4450, south africa; tel: 082 441 0295; email: megsapod@gmail.com https://orcid.org/0000-0001-8864-4916 https://orcid.org/0000-0002-1309-2210 https://orcid.org/0000-0002-1120-8419 page 130 o’connor m et al. sa orthop j 2020;19(3) introduction the first case of covid-19 illness in south africa (sa), caused by the severe acute respiratory syndrome coronavirus-2 (sarscov-2), was diagnosed on 5 march 2020. this was several months after the index case in wuhan, people’s republic of china. south africa observed as the world health organization (who) declared the pandemic on 11 march and as it coursed the globe, declaring a national state of disaster and an eight-stage response to the pandemic on 24 march. in the initial stages, a national lockdown was instituted and a rigorous public screening and testing programme was established in an attempt to flatten the curve. south africa faces many of the healthcare challenges experienced globally, such as a shortage of test reagent and acquisition of personal protective equipment (ppe) to name a few. in addition, it is encumbered with the greatest human immunodeficiency virus (hiv) burden in the world, and the strain of 80% of the population reliant on the public service for care.1 currently, in the midst of the surge, each sector of the south african healthcare team has a duty to respond to the pandemic as it affects their field. we acknowledge that while orthopaedics is not on the frontline in medically managing the illness, we will encounter covid-19 patients during our scope of practice and be required to use resources responsibly, offering support to more burdened sectors. knowledge of infection control and prevention measures has been shown to have a protective effect on contraction of the covid-19 illness.2 therein the aim of the study, to keep orthopaedic surgeons informed. three objectives were identified to achieve this end: 1. to outline the peri-operative considerations highlighted in literature. 2. to assess the current evidence on orthopaedic patients and their outcomes. 3. to evaluate the effect the pandemic has had on our international orthopaedic counterparts. while there is a plethora of anecdotal evidence in the form of current status quo, there is a paucity of evidenced-based data, making presentation of the information suited to a scoping format. methods we conducted a scoping review following the prisma-scr guidelines of 2018.3 peer-reviewed articles pertaining to orthopaedic surgery and covid-19 were considered eligible for inclusion. requisite for inclusion was a focus on at least one of the three objectives. this included some peer-reviewed articles obtained online prior to print. editorials, letters to the editor, commentaries, articles pertaining to general surgery (not orthopaedic-specific) and situation reports were excluded. after completion of full text review, one additional article was identified from a reference. critical appraisal could not be performed in this analysis due to the heterogenous nature of the articles and broad thematic content. the search was performed on 23 may 2020 on the scopus, cochrane and pubmed databases. the search was performed with the terms ‘orthopaedics’ and ‘orthopedics’ applying the boolean operator ‘or’. similarly, ‘covid-19’ and ‘coronavirus’ were searched using ‘or’ and the operator ‘and’ was employed between the two groups. limitations applied included english language articles and those published from december 2019 (figure 1). search citations were exported to endnote (endnote x9.3.3, michael o. mccracken) and transferred to excel (microsoft excel for mac version 16.31, microsoft corporation) for data collation. for id e n ti fic a ti o n s c re e n in g e lig ib ili ty in c lu d e d scopus (n=173) pubmed (n=239) articles identified through database searching (n=498) records screened on title (n=390) articles excluded (n=277) records screened on abstract (n=113) full text articles assessed for eligibility (n=29) articles included in synthesis (n=17) articles excluded (n=84) articles excluded (n=1) situational report (n=9) theme not an objective (n=2) not pertaining to orthopaedic surgery additional articles identified through reference searching (n=1) records after duplicates removed (n=390) cochrane (n=86) figure 1. flow diagram depicting article selection for review3 page 131o’connor m et al. sa orthop j 2020;19(3) qualitative synthesis, columns were added to the spreadsheet to capture the article type, date of publication, country of origin, level of evidence, main theme or objective of the article as well as subthemes. a comments column was included for additional points of interest. two authors independently performed title, abstract and full text reviews in this format. in the event of disagreement, consensus was reached by discussion. results a total of 17 articles met the inclusion criteria. eight articles represented level 4 evidence and nine articles level 5 evidence. these articles comprised ten reviews (literature, rapid, narrative or scoping types), three of which followed systematic approach guidelines. there was one consensus statement that applied the delphi method, two web-based cross-sectional surveys and four observational cohort or case control studies. contributions were made from across the globe, with one international report, five from the united states, five from europe (namely spain, italy, belgium and scandinavia), three from india, and the remaining three came from china. interestingly, the majority (n=9) of the articles were published in may (actual print date and not the accessed date), reflecting a surge in publications immediately post-epidemiological peaks in europe and america respectively. some overlap was present regarding the main theme of each article; the majority of articles (n=11) addressed the first objective encompassing peri-operative considerations, three addressed the effects on the orthopaedic surgeon, and the remaining three concentrated on orthopaedic patient outcomes. an article overview is represented in table i. the main findings of each of the objectives are summarised hereafter. peri-operative decision-making patient operative urgency grading, testing and risk stratification there is agreement on grading the level of urgency of surgery for patients; however, a standard nomenclature has not emerged. table i: summarised details of reviewed articles primary author journal date published title origin article type level of evidence p e ri -o p e ra ti v e c o n si d e ra ti o n s viswanath journal of clinical orthopaedics and trauma 26 mar 20 working through the covid-19 outbreak: rapid review and recommendations for msk and allied heath personnel delhi rapid review 5 hirschman knee surgery, sports traumatology, arthroscopy 27 apr 20 covid-19 coronavirus: recommended personal protective equipment for the orthopaedic and trauma surgeon europe narrative review 4 awad the journal of the american academy of orthopaedic surgeons 10 apr 20 peri-operative considerations in urgent surgical care of suspected and confirmed covid-19 orthopedic patients: operating rooms protocols and recommendations in the current covid-19 pandemic usa literature review 5 fillingham journal of arthroplasty 20 apr 20 personal protective equipment: current best practices for orthopedic teams usa literature review 5 ding international orthopaedics 15 may 20 time-sensitive ambulatory orthopaedic soft-tissue surgery paradigms during the covid-19 pandemic belgium scoping review 4 basso acta orthopaedica 14 may 20 virus transmission during orthopedic surgery on patients with covid-19 – a brief narrative review scandinavia literature review 5 tang chinese medical journal 05 may 20 expert consensus on management principles of orthopedic emergency in the epidemic of coronavirus disease 2019 china consensus statement – delphi 5 service journal of bone and joint surgery america 13 may 20 medically necessary orthopaedic surgery during the covid-19 pandemic: safe surgical practices and a classification to guide treatment usa literature review 5 prada orthoevidence 01 jun 20 best practices for surgeons covid-19 evidencebased scoping review: a unifying report of global recommendations international scoping review 4 massey the journal of the american academy of orthopaedic surgeons 01 jun 20 orthopaedic surgical selection and inpatient paradigms during the coronavirus covid-19 pandemic usa literature review 5 kumar journal of clinical orthopaedics and trauma 12 may 20 perioperative covid-19 testing of orthopedic patients: current evidence india literature review 5 p a ti e n t c o n si d e ra ti o n s catellani journal of bone and joint surgery america 28 apr 20 treatment of proximal femoral fragility fractures in patients with covid-19 during the sars-cov-2 outbreak in northern italy italy cohort 4 mi journal of bone and joint surgery america 06 may 20 characteristics and early prognosis of covid-19 infection in fracture patients china cohort 4 muñoz vives journal of bone and joint surgery america 06 may 20 mortality rates of patients with proximal femoral fracture in a worldwide pandemic: preliminary results of the spanish hip-covid observational study spain case control 4 p e rt a in in g t o o rt h o p a e d ic su rg e o n s culp journal of arthroplasty 24 apr 20 covid-19 impact on young arthroplasty surgeons usa survey 4 sahu journal of clinical orthopaedics and trauma 12 may 20 impact of covid 19 lockdown on orthopaedic surgeons in india: a survey india survey 4 guo journal of bone and joint surgery america 20 may 20 survey of covid-19 disease among orthopaedic surgeons in wuhan, people’s republic of china china case control survey 4 page 132 o’connor m et al. sa orthop j 2020;19(3) table ii summarises the different terminologies utilised in the various texts and provides examples of cases ascribed to each grade. it is however not a fully comprehensive list, and several societies representing orthopaedic sub-disciplines have issued specific recommendations.4 the practical application of this is to guide patient selection based on the burden of covid-19 on resources at any point in time.5,6 in essence then, when the prevalence and resource demand is great, limit surgery only to emergency cases, but allow ongoing management of the routine burden when the covid load is low. singapore has adopted into policy dorscon levels which represents phasing of their response based on resource demands and disease prevalence.7 the specific resource limitation should also be considered. if for example it is a bed shortage, one can endeavour to address surgeries on an outpatient or day case basis, in this way affording more access to the ongoing need.6 ding et al. performed a review specifically on timing to surgery for traumatic soft tissue injuries in order to prevent negative outcomes.8 testing patients for sars-cov-2 is considered to be necessary for a myriad of reasons. first, there is a high proportion of asymptomatic patients shedding viral matter (estimates vary across a wide range, from 5 to 80%). secondly, the incubation period is on average 5–14 days and the virus has proven highly contagious with a reproduction number (r0) of 2.68, meaning that on average each covid-positive person will infect 2.7 people.5,9-11 thirdly, there is a growing body of evidence to suggest patients with covid-19 that undergo surgery have high morbidity and mortality rates.12-15 this should give us pause to earnestly evaluate the benefits of surgery in such patients who require lifeor limb-saving surgery and should prompt us to involve a multidisciplinary team early on.9 finally, it is self-evident that there will be far-reaching negative ramifications for any personnel involved in the intubation of a patient who is later found to be covid positive. in the ideal setting, each patient would be tested, but this is not feasible with a global reagent supply deficit. also, the real-time polymerase chain reaction (rt-pcr) test offered in sa has a false table ii: summary recommendations of operative urgency stratification5,7-8 terminology emergent or high acuity urgent urgent or medium acuity or semi-urgent or expedited short-term delayed elective or low acuity or non-urgent or long-term delayed definition requiring surgery within 24 hours to save life or limb requiring surgery within 48 hours needing surgery within 2 weeks or on the next semi-elective slate requiring surgery within 3 months when surgery can be delayed more than 3 months without harm to the patient tumours and sepsis necrotising fasciitis septic arthritis impending pathological fracture benign tumour procedures trauma foot and ankle compound fractures or impending compounds femur neck fractures in the young bleeding pelvic fractures vascular injury compartment syndrome external fixation for complex fractures femur neck and hip fractures intertrochanteric femur fractures talus neck fractures femur and tibia shaft fractures clavicle, scapula, humerus, radius, ulna, ankle, tibial plateau foot and pelvic and acetabulum fractures acromioclavicular dislocation delayed closure of wounds and flaps over compound fractures ankle arthroplasty or fusion spine closed reduction of cervical spine facet dislocation spinal cord injury epidural abscess or haematoma drainage spinal tumour with cord compression cauda equina decompression thoraco-lumbar fractures lumbar disc herniation with radiculopathy cervical radiculopathy cervical myelopathy spondylolisthesis spine deformity correction arthroplasty acute arthroplasty infection reduction of prosthetic joint dislocation periprosthetic fractures sub-acute arthroplasty infection hip and knee arthroplasty revision arthroplasty paediatrics supracondylar humerus fractures hip fracture dislocations slipped capital femoral epiphysis paediatric fractures hands and shoulder acute carpal tunnel syndrome pyogenic flexor tenosynovitis digit replantation reduction of joint dislocation hand fractures tendon and ligament injuries chronic carpal tunnel syndrome ulnar nerve compression rotator cuff repair in young patients recurrent shoulder dislocation for stabilisation shoulder and elbow arthroplasty trigger finger chronic rotator cuff repair superior labral repair tendinitis surgery knee and sport external fixation of knee dislocations repairable osteochondral fractures ligament avulsion repairs acute knee loose body removal locked knee from meniscal tear acl reconstruction multi-ligament knee reconstruction knee cartilage repair page 133o’connor m et al. sa orthop j 2020;19(3) negative rate that approaches 29% in one systematic review.16 furthermore, the test detects viral-rna genetic sequence which consequently does not inform us as to whether the virus is alive and infectious or not.11,16 computerised tomography (ct) scans and other blood diagnostics have been investigated to improve the sensitivity of testing but at this stage all prove to have a low specificity to diagnose covid illness.14 a blanket policy of treating all individuals as covid suspects is the logical progression of this argument, but again this would lead to rapid depletion of scarce ppe. on the matter of patient risk stratification in consideration for surgery, one also has to consider the scenario that despite being asymptomatic and pcr negative, that this result is falsely negative. the greater the prevalence rate, the more likely we are to encounter this scenario, hence the importance of establishing the local infection rate. two studies stratified community infection rates as a means to guide index of suspicion on patient positivity.5,13 they considered infection rates as low, medium or high, corresponding to infections of <50, 50–100 or >100 covid-19 cases per 100 000 inhabitants. for example then, if the prevalence is high, an institution should be more aggressive in testing asymptomatic patients and in adopting the practice of treating all individuals as suspects. if a patient should test positive and require surgery, one must also consider the physiological insult of the surgery to the body and the patient’s underlying comorbidities. these have the potential to affect the severity of covid illness. risk factors shown to predispose patients to more severe covid illness, and subsequent increased morbidity and mortality, include: age more than 60 years, smokers, body mass index (bmi) more than 30 kg/m2, hypertension, cardiovascular disease, diabetes, respiratory dysfunction, cancer, liver and renal dysfunction.17 for this purpose it is suggested that the least invasive form of surgery be performed, and other practical applications like the use of absorbable sutures and clear wound dressings be considered to minimise follow-ups.18 ultimately the orthopaedic surgeon will have to be flexible and considerate in their approach to the management of each patient. summary points: peri-operative decision-making • consider the community infection rate.5,13 • grade the urgency of the orthopaedic procedure.5,6,18 • consider if the procedure can be performed as an outpatient.6 • ideally screen all patients prior to surgery and if admitted, daily screening should be performed.5,18 • test all symptomatic patients. test asymptomatic patients with a high risk contact.9 maintain a high index of suspicion despite a negative result.11 consider testing asymptomatic patients in high prevalence areas.9 • if the patient tests positive, whenever possible, surgery should be delayed or non-operative management considered. the multidisciplinary team should be involved early if surgery is pursued.19 • in emergent cases where surgery must ensue, comorbidities and physiological stress of surgery should be considered in the risk– benefit equation.18 • the least invasive surgical option should be performed.19 • absorbable sutures and transparent wound dressings can help minimise follow-ups.18 personal protective equipment (ppe) sars-cov-2 is believed to be of zoonotic origin.11 viral transmission has been confirmed from direct contact but the predominant mode of transmission is respiratory droplets.11 airborne transmission can occur through the generation of aerosolised virus. aerosols have been shown to contain sars-cov-2 with the potential for transmission but this is yet to be confirmed. the mode of transmission is what determines which ppe to utilise.5,10,20-22 literature draws an important distinction between aerosols from cells of respiratory and intestinal origin as opposed to all other bodily fluids and tissue.21,22 the former have been shown to contain infectious virus where the latter have not. there is evidence in orthopaedic surgery, particularly when using a high-speed burr, power drills, oscillating saws, reamers, electrocautery and pulsed lavage, that blood and tissue aerosolised particles are found in an area up to 6×8 m around the operative field. essentially then transmission in this fashion is theoretically possible, but not proven.21 surgical masks by design are to protect the patient from infection derived from the surgeon. in addition they have been proven to adequately protect the surgeon from infectious disease during procedures when aerosols are not generated.22 the reverse is also true: patients wearing masks afford the healthcare worker (hcw) a certain amount of protection. this protective effect occurs assuming compliance with wearing masks and attention to safe doffing.2 respirators (such as n95 masks) are designed to protect the user and are 11.5–15.9 times more protective, with the emphasis on improved fit, seal and filtration ability.23 the european filtering face pieces (ffp) are graded 1 to 3 according to the filtration percentage of 300 nm particles. an ffp1 will filter 80%, ffp2 filters 94% and equates to the united states (us) centers for disease control and prevention (cdc) n95 mask. the number following the ‘n’ in the cdc grading corresponds to the percentage of 300 nm particles filtered. an n95 filters 95%, an n99 filters 99% and an n100 filters 99.97%. although the virus is on average 100 nm in diameter, it does not move linearly but rather it exhibits brownian motion and as such is trapped in a filter designed for larger particles.23 many of the recommendations support the use of powered air-purifying respirators, especially for longer duration use. these consist of a hood and have a motorised fan that directs air through a filter. they are not freely available in south africa.21 extended use refers to the continued use of the same respirator while treating different patients for a prolonged period of time. the current consensus on duration of use is 8–12 hours,10,20 provided that no soiling occurs.10 it is for this purpose that some recommendations include the addition of a surgical mask over the respirator when significant contamination is expected. reuse is defined as repeatedly donning and doffing the same ffp and does fall within the recommendations if strict donning and doffing technique is observed.10,18 donning and doffing technique is highlighted as it is poorly performed in general.10 a study from chicago showed incorrect doffing practice in 90% of hcws. a different study showed a 46% self-contamination rate at the wrist and neck during doffing.9,11 another recommendation to preserve ppe is to issue staff with five respirators. hcws should utilise the ffp as before, but after doffing should place the ffp in a paper bag. it should remain in the bag for a minimum of 72 hours, by which time the remaining viruses are not viable, and the respirator is again regarded as safe to use.18 counterintuitively, surgical hoods do not provide the protection of a respirator. they are designed to protect the wearer from particles in motion but not for particle filtration. so a surgical hood alone is not protective, but can be used in conjunction with a respirator provided it is adequately cleaned between cases.5,20 surgical gowns are rated by the association of advancement of medical instrumentation (aami) from 1 to 4 according to the protection they afford to the critical area, defined as the regions from cuff to elbow and chest to knees. class 4 offers the greatest protection.9,21 eye protection is commonplace in orthopaedic theatres but recommendations suggest that eye covering should page 134 o’connor m et al. sa orthop j 2020;19(3) extend to the areas above, below and to the sides of the eye to protect the vulnerable conjunctiva.21 goggles with side shielding afford this protection. double gloving is well established as the standard for orthopaedic surgery.21 summary points: personal protective equipment (figure 2) • a surgical mask, eye protection (goggles or shield), double gloving and aami grade 3 or 4 gowns are needed for orthopaedic surgery that entails production of aerosols.5,9,21 • additional requirements for a covid suspect, confirmed cases or high community prevalence rate, is the use of an n95 mask or equivalent (ffp2/3). a surgical mask can be worn over the respirator if contamination is anticipated.5,18,20,21 • if a surgical hood is utilised it needs to be in conjunction with a respirator.5,20,22 • extended use and re-use are recommended as preservation strategies for ppe ensuring correct donning and doffing technique and use not exceeding 12 hours.10,20 operating room considerations with the south african lockdown tapering and the alcohol ban lifted (at the time of writing), emergent and urgent trauma cases will increase with a concurrent rise in covid-19 infections.24 this will result in a greater likelihood of encountering covid-positive patients, both symptomatic and asymptomatic. the following summary points pertain to theatre complexes where at least one operating room (or) is dedicated to the management of covidpositive patients,18 mindful that each patient and hcw entering the complex is a potential covid suspect.9,20 general recommendations while in the theatre complex: • all hcws and patients are to practise hand hygiene and wear surgical masks.6,8,9,18,20 • all staff should practise social distancing.6,8 • regular decontamination of personal items such as stethoscopes and cellphones is to be done.9 • theatre should run with the minimum staff required.6,10,18 • a negative pressure or or an or where there is a minimum of between 5–20 air changes per hour should be used.9,18-20 if the theatre runs on a positive pressure system then a free-standing filter should be acquired.10 • minimise traffic through the theatre complex and each operating room.5,9,18 • all theatre surfaces should be disinfected between cases.18 recommendations for covid theatre: • a path from the ward to the or for covid-positive patients should be identified. this path should be separate from normal traffic and disinfected after each transport of a patient.10 • the or should have zones denoting potential risk. one recommendation refers to ‘hot’ and ‘cold’ zones where the highrisk area and or itself is ‘hot’. the ‘cold’ zone refers to the buffer continuous face mask use social distancing hand hygiene aami level 4 gown double glove surgical mask goggles and/or face shield aami level 3 or 4 gown respirator, n95 or ffp2/3 ensure eyes are protected from above, below and laterally figure 2. ppe recommendation infographic ppe recommendations upon entering the theatre complex ppe for: • covid-positive patients • covid suspects • agps when there is high local prevalence of covid ppe for orthopaedic aerosol generating procedures (agps) figure 2. ppe recommendation infographic page 135o’connor m et al. sa orthop j 2020;19(3) region between the normal areas and the hot zone.9,20 there should also be isolated areas for the purpose of donning and doffing.9,18 • only one access point should be allowed to the or while a procedure is taking place.10 • theatre should contain the minimum equipment required to proceed.18 • preference is shown for regional anaesthesia to prevent respiratory aerosol generation from intubation.5,10,18 • if intubation is required it is recommended that it be performed by the most senior anaesthetist present.10 only the two people involved with the intubation should be in the or during this time to decrease the number of staff exposed.18 alternatively the intubation can occur outside the or in a designated area like an icu.5,18 • post-operatively the patient should be recovered in the or. this will mitigate the risk of exposure to other patients in the general recovery room.10,18 • one should allow adequate time to elapse post-intubation before entering theatre and similarly, post-operatively a certain amount of time should elapse prior to re-entry to start decontamination. this timing is relative to the amount of air changes per hour of the filtration system, where each change removes 63% of the virus.25 most guidelines suggest that in 20 minutes the viral load is negligible; however, it is recommended to determine the individual specifications of each theatre complex.9,18 patient outcome studies while travel restrictions have decreased the high-energy motor vehicle accident (mva) rate, patients still require orthopaedic trauma care due to, for example, low-energy falls. these patients will now encounter a resource-depleted healthcare system adapted for covid-19. they will be susceptible to severe covid illness as they are usually elderly, frail, have multiple comorbidities and are slow to ambulate, predisposing them to the usual respiratory illness and covid illness.14 prior to the covid era, a mortality rate of 20–40% was reported for these patients, 7–8% of these occurring within the first 30 days. these vulnerable patients now risk contracting sarscov-2 in healthcare facilities where covid cases are centralised.5 thus far, three observational studies have been performed on patients with fractures and concomitant covid illness. the initial study originated from wuhan at the epicentre of the pandemic.14 a retrospective cohort of six confirmed covid-positive (pcr test of oropharyngeal swabs) and four highly suspicious patients (ct features suggestive of a viral pneumonia) who all had concomitant fractures, were included. a mortality rate of 40% was observed (four out of ten), four of the deaths were recorded in patients with comorbidities and the fourth had a concomitant brain injury. three out of ten patients had a community-acquired infection and the rest nosocomial. the most common symptoms were fever, cough and fatigue, each found in 70% of cases. ninety per cent of patients had abnormal d-dimer results. seven out of eight patients had raised procalcitonin, and all patients in whom c-reactive protein (crp) was tested had an elevated result. nine required supplemental oxygen and three non-invasive ventilation (ventilators were unavailable to these patients). all four patients died within two weeks of admission and three of those were not operated. the small sample size and lack of control group limit what can be concluded from this study. this study highlights: • the need for strict infection control measures to limit nosocomial transmission of the disease. • common symptoms of covid disease in fracture patients including fever, cough and fatigue. • multiple sensitive but non-specific laboratory findings. • the need for supplemental oxygen in most patients. • a mortality rate of 40% in covid-positive patients with concomitant fracture. the next study was conducted in italy using the strobe guidelines. it had a study population of 16 covid-positive patients (diagnosed with ct scan and oropharyngeal pcr) with a proximal femur fracture. three patients died pre-operatively and four died within seven days post-operatively; all deaths were attributed to respiratory failure. either a cephalomedullary nail or hemiarthroplasty was performed within three days of admission, and patients were mobilised the day after surgery. again, inferring conclusions from this study is difficult due to lack of a comparative sample. this study highlights: • a 44% early mortality rate in covid-positive patients with proximal femur fractures. • similar mortality rates, irrespective of receiving surgery or not. a spanish cohort study had the largest study population and aimed to assess the mortality rate of elderly patients with proximal femur fractures within a pandemic environment.13 a total of 136 patients were identified with a mean age of 85 years. of them, 23 were sars-cov-2 positive on oropharyngeal pcr swabs, 39 were negative and 74 were unknown. seventy patients came from high risk areas (>100 positive cases per 100 000) reflecting the high infection rate in spain during this time. within a mean of 2.4 days, 124 patients were operated. the remainder were not operated as they were deemed too unstable or had demised. a total of 13 patients died. seven of these were covid-positive cases, representing a 30.4% mortality rate in covid-positive patients and 10.3% for covid-negative patients. the study was designed to assess the mortality rate in the midst of a pandemic, so mention was made that the 14-day mortality rate of this cohort (9.6%) was higher than the 30-day mortality rate recorded in the spanish hip registry of patients with comparative age and american society of anesthesiologists (asa) classification. there are several limitations of this study. there were 74 covidunknown patients, which introduces a potential bias. potentially the more ill patients were selected for testing and would consequently have a higher mortality rate. secondly, the established high false negative rate of pcr testing was mitigated in the previous two studies with the use of ct scanning to aid in diagnosis. interestingly the study did not discuss that the mortality rate of covid-negative patients in this cohort was higher than that recorded in the spanish national registry for similar patients. this raises the concern that the pandemic is possibly resulting in an increased morbidity and mortality rate to the uninfected orthopaedic patient because of resource constraints or other limitations posed by the crisis. this study highlights: • 30.4% mortality rate in covid-positive patients with hip fractures. • 10.3% mortality in covid-negative patients. orthopaedic surgeons hcws are at an increased risk for contracting covid-19 disease as hospitals are high zones of transmission.19 there is an increased risk of developing more severe illness, shown to be the case with increased viral exposure.21 the crisis renders hcws emotionally and physically exhausted, and they are further stretched when colleagues fall ill, as provision of healthcare must be maintained with fewer team members. orthopaedic surgeons are providing page 136 o’connor m et al. sa orthop j 2020;19(3) less orthopaedic-related care and performing more duties outside their scope of practice. this was highlighted in an online survey completed by 136 european orthopaedic surgeons, concluding an overall reduction in orthopaedic activity of 73%. in the same survey 49% of respondents reported that either they themselves or a colleague had been shifted into the management of covid patients.26 finally, there is the prevailing concern of transmitting the virus to our families. three studies elaborated on the effects the pandemic has had on orthopaedic team members and the implications thereof. a cross-sectional study, by way of online survey, was distributed to sars-cov-2 infected orthopaedic surgeons in wuhan. the same survey was distributed to an age-matched uninfected group. the questionnaire engaged surgeons on their behaviours and practices during the preceding months.2 redeployed surgeons treating covid patients were excluded. twenty-four covidpositive surgeons with a mean age 36.1 years (range 25–48) were identified; only one reported comorbid diabetes. of them, 79% suspected they contracted the disease in a general ward. the most common symptoms were fever, cough and fatigue; 15 required hospitalisation, but all made a full recovery. in 25% of cases, transmission occurred to patients, colleagues, family and friends. a troubling finding was that 80% of these transmissions were to family members. regression analysis showed no demographic differences to the age-matched control group. not wearing an n95 respirator increased risk of contracting the virus (odds ratio of 5 and p=0.004). compliance with the correct technique of mask wear and a knowledge of infection control and prevention guidelines were found to be protective (odds ratio 0.15, p=0.004 and odds ratio 0.12, p=0.007 respectively). this study highlights: • most infections occurred in the general (non-covid) wards – deduced by the authors to be as a result of a false sense of security in wards not allocated for covid patients. • the symptomatology was mild with 100% recovery rate, albeit only one positive surgeon had a comorbidity. • compliant wearing of an n95 mask and a knowledge of infection control guidelines contribute to reducing the risk of contracting the virus. • there was a high number of virus transmissions to family members. a second web-based survey charted the qualitative impact of the pandemic on arthroplasty sub-specialty residents, fellows and junior consultants.27 this survey was distributed to arthroplasty surgeons in particular, so while it offers some insight, no deductions can be drawn for other orthopaedic sub-disciplines. this study highlights: • there was a 25% redeployment rate. • 56% of respondents reported a change to their monetary compensation. • with regard to trainees, 84% felt they had received adequate training to continue with exams, while 16% felt their exams may be delayed leading to a prolonged training time. a third survey aimed to assess orthopaedic surgeon stress levels in india during their national lockdown.28 responses were received from 611 surgeons, the majority of whom were between 30 and 40 years of age. most worked in the private sector only and performed no state work. twenty-three per cent reported being ‘definitely stressed out’ and 58% reported their work/life balance had been reversed. twenty-eight per cent of respondents were not stressed at all. interestingly 55% thought things would return to normal a couple weeks after the lockdown had ended in india. seventy per cent considered doing research during the lockdown. a younger age and an altered work/life balance were significantly associated with those feeling ‘definitely stressed out’. this study highlights: • the emotional toll the pandemic has on orthopaedic surgeons is evident. discussion this scoping review highlighted the need for further study with regard to covid-19 and orthopaedics. while there are numerous publications, most were institutional experiences or situational reports commenting on surgeons’ attempts to streamline their own practice during this time. there remains a paucity of scientific evidence-based research and several gaps have been identified. with regard to peri-operative considerations, patient stratification remains non-standardised and decisions to operate patients are largely at the discretion of the surgeon or institution. patient management would benefit from the development of a test for sars-cov-2 that is both rapid, sensitive and specific. in the or it is unknown whether aerosolised tissues containing virus other than respiratory and intestinal are able to cause disease, knowledge of which could better guide ppe use. the patient outcome studies at present are limited. case control studies are needed with matched comorbidities or regression analysis of comorbidities comparing covid and non-covid patients with fractures who demise. this would help determine if mortality and morbidity is in fact increased in covid-positive patients. the current studies focus on morbidity and mortality in a vulnerable population; it is possible that the pandemic may also be affecting healthy patients with emergent and urgent orthopaedic surgery requirements, for which there are no studies at present. orthopaedic surgeons have contracted the virus and fortunately recovered. however, they have experienced other negative consequences as a result of the pandemic. regarding the work environment, many have been redeployed, many are receiving reduced compensation and many trainees face doubtful futures. the reasons for distress arising out of the crisis have been identified and can serve to help us recognise and address them as the covid surge ensues. the main limitation of this study is that scant evidence-based methodological studies are available at present. the pandemic is evolving rapidly and so too is the research thereon. it is highly probable that more articles meeting the inclusion criteria will be available at time of publication of this study. at the time of the review, there were also no south african studies on orthopaedic patients with covid disease; these will be necessary in order to guide practice in our uniquely challenged health system. conclusion orthopaedics is significantly affected by the covid pandemic. orthopaedic surgeons, despite the emotional and physical toll on themselves, need to remain abreast of the strategies to safely continue surgery and maximise favourable patient outcomes. more scientific study is required to make informed decisions in this regard. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethical clearance was not required as no human participants were involved in the generation of this article. this article is a systematic literature review and therefore does not involve a study with human or animal participants performed by any of the authors. page 137o’connor m et al. sa orthop j 2020;19(3) declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions mo contributed to conceptualisation, design, literature review, study screening and selection, data analysis and manuscript preparation. ln contributed to design, literature review, study screening and selection, data analysis and manuscript review. lcm contributed to conceptualisation, design and manuscript review. orcid o’connor m https://orcid.org/0000-0001-8864-4916 nieuwoudt l https://orcid.org/0000-0002-1309-2210 marais lc https://orcid.org/0000-0002-1120-8419 references 1. abdool karim ss. the south african response to the pandemic. new england journal of medicine. 2020;382:e95. https://doi.org/ 10.1056/nejmc2014960. 2. guo x, wang j, hu d, et al. survey of covid-19 disease among orthopaedic surgeons in wuhan, people's republic of china. j bone joint surg am. 2020. https://doi.org/10.2106/jbjs.20.00417. 3. prisma extension for scoping reviews (prisma-scr): checklist and explanation. ann intern med. 2018;169:467-73. https://doi.org/ 10.7326/m18-0850%m30178033. 4. american college of surgeons. covid-19 guidelines for triage of orthopaedic patients. available from: https://www.facs.org/ covid-19/clinical-guidance/elective-case/orthopaedics (2020). 5. service bc, collins ap, crespo a, et al. medically necessary orthopaedic surgery during the covid-19 pandemic: safe surgical practices and a classification to guide treatment. j bone joint surg am. 2020. https://doi.org/10.2106/jbjs.20.00599. 6. massey pa, mcclary k, zhang as, et al. orthopaedic surgical selection and inpatient paradigms during the coronavirus (covid19) pandemic. j am acad orthop surg. 2020;28:436-50. https:// doi.org/10.5435/jaaos-d-20-00360. 7. tay k, kamarul t, lok w, et al. covid-19 in singapore and malaysia: rising to the challenges of orthopaedic practice in an evolving pandemic. malays orthop j. 2020;14(2). https://doi. org/10.5704/moj.2007.001. 8. ding btk, decruz j, kunnasegaran r. time-sensitive ambulatory or thopaedic soft-tissue surgery paradigms during the covid-19 pandemic. int orthop. 2020 https://doi.org/10.1007/ s00264-020-04606-w. 9. awad me, rumley jcl, vazquez ja, et al. peri-operative considerations in urgent surgical care of suspected and confirmed covid-19 orthopedic patients: operating rooms protocols and recommendations in the current covid-19 pandemic. j am acad orthop surg. 2020. https://doi.org/10.5435/jaaos-d-20-00227. 10. kumar a, kumar a, das s. perioperative covid-19 testing of orthopedic patients: current evidence. j clin orthop trauma. 2020. https://doi.org/10.1016/j.jcot.2020.04.031. 11. yung cs -y, fok kch, leung cn, et al. what every orthopaedic surgeon should know about covid-19: a review of the current literature. journal of orthopaedic surgery. 2020;28:2309499020923499. https://doi.org/10.1177/230949 9020923499. 12. lei s, jiang f, su w, et al. clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection. eclinicalmedicine. 2020;21:100331. https:// doi.org/10.1016/j.eclinm.2020.100331. 13. muñoz vives jm, jornet-gibert m, cámara-cabrera j, et al. mortality rates of patients with proximal femoral fracture in a worldwide pandemic: preliminary results of the spanish hip-covid observational study. j bone joint surg am. 2020. https://doi.org/10.2106/jbjs.20.00686. 14. mi b, chen l, xiong y, et al. characteristics and early prognosis of covid-19 infection in fracture patients. j bone joint surg am . 2020. https://doi.org/10.2106/jbjs.20.00390. 15. catellani f, coscione a, d'ambrosi r, et al. treatment of proximal femoral fragility fractures in patients with covid-19 during the sars-cov-2 outbreak in northern italy. j bone joint surg am. 2020. https://doi.org/10.2106/jbjs.20.00617. 16. woloshin s, patel n, kesselheim as. false negative tests for sars-cov-2 infection — challenges and implications. n engl j med. 2020. https://doi.org/10.1056/nejmp2015897. 17. vannabouathong c, devji t, ekhtiari s, et al. novel coronavirus covid-19: current evidence and evolving strategies. j bone joint surg am. 2020;102:734-44. https://doi.org/10.2106/jbjs.20.00396. 18. prada c, chang y, poolman r, et al. best practices for surgeons. covid-19 evidence-based scoping review. orthoevidence. 2020. https://doi.org/10.13140/rg.2.2.20752.76809/1. 19. tang pf, hou zy, wu xb, et al. expert consensus on management principles of orthopedic emergency in the epidemic of corona virus disease 2019. chin med j. 2020. https://doi.org/10.1097/ cm9.0000000000000810. 20. fillingham ya, grosso mj, yates aj, et al. personal protective equipment: current best practices for orthopedic teams. j arthroplasty. 2020. https://doi.org/10.1016/j.arth.2020.04.046. 21. hirschmann mt, hart a, henckel j, et al. covid-19 coronavirus: recommended personal protective equipment for the orthopaedic and trauma surgeon. knee surg sports traumatol arthrosc. 2020. https://doi.org/10.1007/s00167-020-06022-4. 22. basso t, dale h, langvatn h, et al. virus transmission during orthopedic surgery on patients with covid-19 – a brief narrative review. acta orthop. 2020:1-4. https://doi.org/10.1080/17453674. 2020.1764234. 23. viswanath a, monga p. working through the covid-19 outbreak: rapid review and recommendations for msk and allied heath personnel. j clin orthop trauma. 2020. https://doi.org/10.1016/j. jcot.2020.03.014. 24. the washington post. south africa’s alcohol ban during lockdown reveals its deadly drinking habits. available from: https://www. washingtonpost.com/world/africa/south-africa -coronavirus lockdown-alcohol-ban/2020/05/09/a2b964a2-8eef-11ea-9322a29e75effc93_story.html (2020). 25. cook tm. personal protective equipment during the coronavirus disease (covid) 2019 pandemic – a narrative review. anaesthesia 2020;75:920-27. https://doi.org/10.1111/anae.15071. 26. ranuccio f, tarducci l, familiari f, et al. disruptive effect of covid-19 on orthopaedic daily practice: a cross-sectional survey. j bone joint surg am. 2020 jul 15;102(14):e77. 27. culp bm, nb frisch. covid-19 impact on young arthroplasty surgeons. j arthroplasty 2020. https://doi.org/10.1016/j. arth.2020.04.058. 28. sahu d, agrawal t, rathod v, et al. impact of covid-19 lockdown on orthopaedic surgeons in india: a survey. j clin orthop trauma. 2020. https://doi.org/10.1016/j.jcot.2020.05.007. https://orcid.org/0000-0001-8864-4916 https://orcid.org/0000-0002-1309-2210 https://orcid.org/0000-0002-1120-8419 _enref_8 _enref_10 page 110 sa orthop j 2023;22(2) cpd questionnaire. may 2023 vol 22 no 2 complications of surgically managed pelvic and acetabular fractures (mbatha st, duma mtn, maqungo s, marais lc) 1. which of the following was not a risk factor for developing complications post pelvic and acetabular fracture fixation? a. sustaining a combined pelvic and acetabular fracture a b. a pelvic fracture with an associated sacral fracture b c. a partial articular acetabular fracture c d. kocher-langenbeck approach d e. intraoperative blood transfusion e 2. which injury was more commonly associated with a pelvic and/or acetabular fracture? a. traumatic brain injury a b. lung contusion b c. long bone fracture c d. aast grade 3 kidney injury d e. bladder contusion e 3. what was the most commonly encountered complication? a. early fracture-related infection a b. heterotopic ossification b c. avascular necrosis c d. increased need for postoperative blood transfusion d e. metalware failure e analysis of orthopaedic injuries in ct pan scans of polytrauma patients at a quaternary academic hospital (laney w, naicker d, milner b, omar s) 4. what was the most common mechanism of injury in this study? a. gunshot wounds a b. fall from height b c. stab wounds c d. road traffic accidents d e. assault e 5. what was the most common combination of injury found? a. rib fracture and traumatic brain injury a b. chest injury and pelvic/sacral fracture b c. tibia fracture and pelvic fracture c d. splenic rupture and femur fracture d e. traumatic brain injury and c-spine fracture e 6. road traffic accidents were significantly associated with which fractures? a. c-spine fractures a b. metacarpal fractures b c. tibial/fibular fractures c d. pelvic fractures d e. humerus fractures e the bridging infix: a modified, minimally invasive subcutaneous anterior pelvic fixation technique (strydom s, snyckers ch) 7. which of the following is not an indication for using the bridging infix? a. patients admitted to intensive care unit (icu) a b. obese patients b c. elderly patients with a pelvic fragility fracture c d. patients with purely ligamentous injuries resulting in pubic symphysis diastasis d e. to enhance anterior pelvic ring stability after adequate posterior fixation was done e 8. which of the following statements regarding the surgical approach for the bridging infix is true? a. a lateral window is made from the asis, extending 4 cm proximally along the crest a b. a middle window is made 2 cm inferior to the pubic symphysis b c. subcutaneous tunnels are made staying deep and parallel to the inguinal ligament c d. the subcutaneous tunnel should directly link the two lateral windows, remaining inferior to the umbilicus d e. dissection in the middle window should be through the rectus abdominis fascia to allow exposure of the pubic symphysis e 9. which statement regarding the bridging infix construct is false? a. two 4 mm plate-rods and a 6 mm straight rod is used a b. once the plate-rod has been fixed to the crest, absolutely no further bending of the construct is allowed b c. the tip of the rod is guided from the lateral to the middle window with a kocher forceps c d. one method to reduce the fracture is by using the distraction or compression instruments before securing the second rod-rod connector d e. posterior injuries must be reduced and stabilised before anterior fixation is done e 10. which statement is true? a. the wounds must be irrigated with povidone (iodine) solution prior to closure a b. all patients must remain non-weight-bearing for a period of six weeks b c. physiotherapy (in-bed mobilisation) can be started the same day as the surgery c d. a drain is routinely placed in the middle window d e. after fixation, patients must limit hip abduction for six weeks e orthopaedic surgical antibiotic prophylaxis administration compliance with prescribing guidelines in a private hospital in the north west province, south africa (jordaan m, du plessis j, rakumakoe d, mostert l) 11. surgical antibiotic prophylaxis (sap) redosing occurred in: a. all prolonged procedures a b. one of the three prolonged procedures b c. two of the seven prolonged procedures c d. none of the prolonged procedures d e. none of the above statements are correct e orthopaedic journal s o u t h a f r i c a n � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � contents � � � � � � � � � � t h e s o u t h a f r ic a n o r t h o pa e d ic a s s o c ia t io n e n ox a p a r i n s o d i u m vte, venous thromboembolism references: 1. sandoz sa (pty) ltd. noxfibra (solution for injection). professional information, v1.1 (20/01/2021), approved 25 february 2020. 2. south african health products regulatory authority. biosimilar medicines quality, non-clinical and clinical requirements. august 2014. 3. gonzález jm, monreal m, almagia ia, garín jl, et al. bioequivalence of a biosimilar enoxaparin sodium to clexane® after single 100 mg subcutaneous dose: results of a randomized, double-blind, crossover study in healthy volunteers. drug des devel ther. 2018;12:575-582. doi:10.2147/dddt.s162817. 4. sandoz sa (pty) ltd. data on file. pricing data. november 2022. 5. sandoz sa (pty) ltd. data on file. global noxfibra® syringe sales. november 2022. 6. sandoz sa (pty) ltd. data on file. south african noxfibra® syringe sales. november 2022. 7. sandoz sa (pty) ltd. data on file. updated psur reports. november 2022. 8. sanofi-aventis south africa (pty) ltd. clexane® (injection). professional information, approved 26 october 2012. 9. our history. sandoz. accessed november 8, 2022. https://www.sandoz.com/about-sandoz/our-history. noxfibra 20 (solution for injection). reg. no.: 52/8.2/0495. composition: noxfibra 20 pre-filled syringe contains enoxaparin sodium 20 mg/0,2 mℓ (equivalent to 2 000 iu anti factor xa). noxfibra 40 (solution for injection). reg. no.: 52/8.2/0496. composition: noxfibra 40 pre-filled syringe contains enoxaparin sodium 40 mg/0,4 mℓ (equivalent to 4 000 iu anti factor xa). noxfibra 60 (solution for injection). reg. no.: 52/8.2/0497. composition: noxfibra 60 pre-filled syringe contains enoxaparin sodium 60 mg/0,6 mℓ (equivalent to 6 000 iu anti factor xa). noxfibra 80 (solution for injection). reg. no.: 52/8.2/0498. noxfibra 80 pre-filled syringe contains enoxaparin sodium 80 mg/0,8 mℓ (equivalent to 8 000 iu anti factor xa). pharmacological classification: a8.2 anticoagulants. for full prescribing information refer to the sandoz professional information approved by the south african health products regulatory authority (sahpra). sandoz sa (pty) ltd, reg. no. 1990/001979/07, magwa crescent west, waterfall city, jukskei view, midrand, 2090. tel: +27 (11) 347 6600. sancal customer call centre: 0861 726 225. reporting of aes: https://www.report.novartis.com san.noxf.2022.11.95 visit your online sandoz portal: https://my-sandoz.com/za-en/en connecting. educating. enabling. script by name, expect the same1-3 bioequivalence, approved indications and dosing that match the reference medication1,3,5-8 brought to you by sandoz, a global leader in high-quality generics and biosimilars9 an affordable option with a proven real-world track record1,4-7 noxfibra®, the 1st enoxaparin sodium biosimilar to market, is indicated for the prevention and treatment of vte1,4 9713 sandoz noxfibra refresh kv.indd 19713 sandoz noxfibra refresh kv.indd 1 2022/12/12 10:192022/12/12 10:19 page 112 sa orthop j 2023;22(2) 12. the study identified orthopaedic sap practice burdens in the following areas: a. route of administration, choice of sap and incorrect dosing a b. sap overuse, prolonged duration of use and surgical site infections (ssis) b c. ssis, administration time and incorrect dosing c d. prolonged duration of use, overuse and incorrect dosing d e. overuse, unattended dose adjustments and route of administration e 13. orthopaedic sap choice was deemed correct if the following were prescribed: a. cefazolin, ceftriaxone or cefuroxime a b. vancomycin, clindamycin or teicoplanin b c. amoxicillin-clavulanic acid or moxifloxacin c d. options a and b d e. options b and c e 14. sap guidelines require the following replacement to be used in the presence of penicillin allergy: a. cefazolin a b. clindamycin b c. moxifloxacin c d. teicoplanin d e. none of the above e acute haematogenous osteomyelitis in the paediatric population: a current concepts review (thiart m, nansook a) 15. kingella kingae accounts for the majority of acute haematogenous osteomyelitis (ahom) cases in which age group? a. neonates a b. babies under 6 months b c. children between 6 months and 5 years c d. adolescents d e. children between 5 and 10 years of age e 16. negative cultures are seen in up to 50% of cases in ahom. what factors contribute to this? a. moderate bacterial load a b. a gram-negative organism b c. using blood culture bottles c d. older children d e. difficult surgical approach e 17. the most common clinical feature seen in children with ahom is? a. localised signs/symptoms a b. fever b c. decreased range of motion c d. pain d e. inability to bear weight e 18. the empiric antibiotic of choice in infants from birth to under 3 months with a community-acquired infection is: a. cloxacillin and first-generation cephalosporin a b. vancomycin and linezolid b c. linezolid and rifampicin c d. co-amoxiclav and rifampicin d e. cloxacillin and third-generation cephalosporin e cutaneous adenoid cystic carcinoma: clinical conundrum of a lower limb mass (philip s, kgagudi mp) 19. adenoid cystic carcinoma (acc) accounts for what percentage of all salivary gland tumours? a. 50% a b. 22% b c. 10% c d. 0.7% d e. 33% e 20. what is the suggested management of primary acc? a. intralesional curettage and cryoablation a b. chemotherapy b c. neoadjuvant therapy and excision c d. wide local excision and radiotherapy d e. immunotherapy e subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm. co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online. • complete the questionnaire and click on submit. • your points are automatically submitted to the relevant authority. • please call mpc helpdesk if you have any questions: 0861 111 335. medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 mdb015/069/01/2023 orthopaedics vol3 no4 page 40 sa orthopaedic journal autumn 2015 | vol 14 • no 1 pantoea agglomerans as a rare cause of cervical spondylodiscitis c de v marais* mbchb(stell), dip pec registrar s mears* mbchb(stell), fcs(sa)orth consultant si dix-peek** mbbch, fcs(sa)orth, mmed consultant k pillay*** mbchb, pcpath(sa), frcpath(uk), mmed ant path(uct) consultant rn dunn* mbchb, mmed(orth), fcs(sa)orth professor and head of department *groote schuur hospital and red cross war memorial children’s hospital in department of orthopaedic surgery, university of cape town, south africa **head of paediatric orthopaedics red cross war memorial children’s hospital, division orthopaedic surgery university of cape town ***histopathologist/senior lecturer national health laboratory service and university of cape town and red cross war memorial children’s hospital, south africa correspondence: dr c de v marais email: christoff_marais@yahoo.com case report a 10-year-old girl presented with a nine-month history of progressive neck pain and reduced cervical spine range of motion. no obvious precipitating events or trauma were reported. the child was in good general health. she did not have a tuberculosis contact or any constitutional symptoms of tuberculosis. abstract objective: to present a case report of a rare cause for cervical spondylodiscitis caused by pantoea agglomerans. case presentation and intervention: a 10-year-old girl presented with a destructive lesion of the c4 vertebral body with raised infective markers and a radiological picture suggestive of tuberculosis spondylodiscitis. further investigations revealed multiple sites of involvement. no evidence of tuberculosis was found. histology after biopsy showed focal granuloma formation in response to necrotic bone fragments and on tissue cultures in which pantoea bacteria was isolated. the patient was successfully treated with a six-week course of co-amoxiclav. on follow-up the cervical lesion as well as the other sites of involvement showed signs of resolution. conclusion: pantoea agglomerans is a rare pathogen in the aetiology of spondylodiscitis. the organism is usually associated with penetrating trauma by plant material or contaminated intravenous products. neither of these factors was present in this case. key words: pantoea agglomerans, cervical spondylodiscitis, paediatrics x-ray examinations identified collapse of the c4 vertebral body with preservation of adjacent discs and posterior elements saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 40 sa orthopaedic journal autumn 2015 | vol 14 • no 1 page 41 on examination, there was posterior midline tenderness over the c4 vertebra and reduced range of motion, especially rotation. the neurological examination was normal. x-ray examinations identified collapse of the c4 vertebral body with preservation of adjacent discs and posterior elements (figure 1). her chest x-ray was normal. laboratory investigations showed a raised crp of 16.6 mg/l and an esr of 47 mm/hour. her wcc was 9.95 × 109. a working diagnosis of atypical tuberculosis was made – atypical due to the single body involvement. the mantoux test was negative. the mri confirmed collapse of the c4 vertebra with anterior extrusion of the vertebral body content into the prevertebral space. there was a prevertebral collection extending from c1–c5 (figure 2). similar signal abnormalities were present in vertebral body of t3, t10 and l2 (figure 3). a technetium-99m bone scan demonstrated increased uptake in the c4, t3 and t12 vertebrae (figure 4), as well as increased uptake in the right elbow and the right sacroiliac joint (figure 5). x-rays of the elbow and sacroiliac joint revealed no abnormalities. an open biopsy of the c4 vertebral body was performed via the smith-robinson approach and multiple specimens were sent for laboratory evaluation. histology of the bony fragments confirmed granulation tissue with a mixed acute and chronic inflammatory infiltrate and a focal foreign body granulomatous reaction to necrotic bony fragments. there was no evidence of caseation (figure 6). figure 1. lateral c spine x-ray with destruction of c4 vertebral body figure 3. mri lateral spine with signal abnormality in t3, t10 and l2 figure 2. mri lateral cervical spine with collapse of c4 and prevertebral collection figure 4. bone scan revealing increased uptake at multiple sites figure 5. bone scan with increased uptake at right elbow and right sacroiliac joint saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 41 page 42 sa orthopaedic journal autumn 2015 | vol 14 • no 1 multiple ziehl-nielsen stains on the tissue samples were negative for acid-fast bacilli. polymerase chain reaction (pcr) and cultures for tuberculosis were also negative.1 aerobic cultures isolated a pantoea species. although this can be a contaminant, the biopsy was a sterile procedure and histology confirmed chronic, noncaseating inflammation. all the tb tests were negative and the diagnosis of pantoea multifocal osteomyelitis was made. the patient was managed with a six-week course of amoxicillin clavulanate 375 mg 8 hourly. at the six-week follow-up the patient was pain-free and x-rays confirmed healing of the c4 vertebra with some kyphosis (figure 7). a follow-up bone scan showed normal uptake at the previous abnormal sites of the elbow, sacroiliac joint, t3 and t12 vertebrae. increased uptake at level c3/c4 was reported as a result of healing rather than continuing infection. a follow-up mri confirmed that the prevertebral collection had resolved and no further changes were noted at levels t3, t10 and l2. the patient will be followed up until skeletal maturity due to the risk of progression of kyphosis. discussion pantoea agglomerans, previously known as enterobacter agglomerans, is a gram-negative bacterium from the enterobacteriaceae family. it is mainly a plant epiphyte commonly found on plant material and in soil, but it has been reported as an opportunistic pathogen in humans.2,3 destructive bone lesions after direct penetrating injuries have been described. it is an uncommon cause, with only 31 cases found in the literature (pantoea was however not isolated in all 31 cases).4,5 durr et al. published a case report of a destructive lesion in the first metatarsal bone. it was thought to be a tumour, but on biopsy a 2 cm thorn was found within the lesion. the cortex of the metatarsal was destroyed and replaced with granulation tissue. histology revealed chronic granulation and pantoea agglomerans was isolated in cultures.4 further reports of ten cases of osteomyelitis were found: one case after an open fracture, eight cases associated with penetrating injuries without fractures and one case after a closed fracture with overlying abrasions.3,6 a single case of discitis caused by pantoea has been reported. the case involved a 22-year-old farmer on long-term tetracycline therapy for acne. the author postulated that the patient’s normal flora may have been altered and was colonised by pantoea.7 figure 6a. foreign body granulomatous reaction to necrotic bony fragments figure 6b. haemorrhagic granulation tissue with a mixed neutrophilic and chronic inflammatory infiltrate figure 7. lateral cervical spine showing consolidation of c4 vertebra saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:57 pm page 42 sa orthopaedic journal autumn 2015 | vol 14 • no 1 page 43 this case report is unique as no direct inoculation occurred and haematogenous spread from an unnoticed skin penetration is the presumed cause. the child was not on long-term antibiotics or immunocompromised to predispose her to opportunistic infections. although pantoea agglomerans is a rare cause of infection of the spine, it may be worth including in a differential diagnosis. currently pantoea agglomerans strains are considered as promising biocontrol agents for a number of bacterial and fungal plant diseases by the agricultural industry. several strains of pantoea agglomerans are already registered and sold as commercial biocontrol agents in new zealand, the united states and canada.8 in future contact with and interaction between humans and pantoea agglomerans are bound to increase. this case highlights the need for biopsy and cultureguided antibiotic treatment rather than empiric antibiotic treatment. due to the favourable antibiotic resistance profile, the pantoea infection would have resolved with nearly any antibiotic regimen, including tuberculosis treatment. this would have exposed the patient to an unnecessary prolonged antibiotic course with multiple side effects.9,10 the content of this article is the sole work of the authors. no benefits in any form have been or are to be received from a commercial party related directly or indirectly to the subject of this article. ethics approval was obtained from the university of cape town ethics committee as well as informed consent from the parents of the patient. references 1. laubscher m, held m, zar hj, dunn r. genexpert polymerase chain reaction for spinal tuberculosis an accurate and rapid diagnostic test. valencia: s.n., 2014. imast meeting. 2. andrews jh, harris rf. the ecology and biogeography of microorganisms on plant surfaces. annual review phytopathology 2000; 38: 145 180. 3. cruz at, cazacu ac, allen ch. pantoea agglomerans, a plant pathogen causing human disease. journal of clinical microbiology 2007; june: 1989 1992. 4. durr hr, muller pe, refior hj. thorn-induced pseudotumor of the metatarsal. the journal of bone & joint surgery 2001; april: 580 585. 5. kratz a. pantoea agglomerans as a cause of septic arthritis after palm tree thorn in jury. arch dis child 2003; 88: 542544. 6. labianca l, montanaro a, turturbo f. osteomyelitis caused by pantoea agglomerans in a closed fracture in a child. orthopedics 2013; 36: 252 256. 7. porter p, wray c. enterobacter agglomerans spondylodiscitis. spine 2000; 25: 1287 1289. 8. rezzonico f, smits t, montesinos e, frey j, duffy b. genotypic comparison of pantoea agglomerans plant and clinical strains. bmc microbiology 2009; 9: 204. 9. yee d, valiquette c, pelletier m, parisien i, rocher i, menzies d. incidence of serious side effects from first line antituberculosis drugs among patients treated for active tuberculosis. american journal of respiratory and critical medicine 2003; 167: 1472 1477. 10. schaberg t, rebhan k, lode h. risk factors for sideeffects of isoniazid, rifampin and pyrazinamide in patients hospitalized for pulmonary tuberculosis. european respiratory journal 1996; 9: 2026 2030. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj this case report is unique as no direct inoculation occurred and haematogenous spread from an unnoticed skin penetration is the presumed cause saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:57 pm page 43 page 126 south african orthopaedic journal http://journal.saoa.org.za letter to the editor we are a practice consisting of two orthopaedic surgeons working in private practice in hilton where the first south african case of covid-19 was reported on 5 march 2020. isolation of patient zero at the designated government facility, grey’s hospital, was swift and aggressive. the patient’s general practitioner (gp), the pathologist who did the diagnostic nasal swab and other close contacts were all quarantined. public response varied from anxiety and fear to an indifferent ‘it’s just like normal flu’. new south african cases slowly started increasing and the national lockdown started on 26 march 2020. we expected a surge of cases as community spread became more prevalent but there were no new cases diagnosed at our institution’s covid-19 testing facility between 27 march and 25 april. monday 1 june saw our first patient that required admission. at the time of writing, on 15 july 2020, there are 42 cases admitted to the hospital with confirmed covid-19, all elective surgery cases have been curtailed, the surgical ward has been turned into a general covid-19 ward, and icu is at capacity utilising anaesthetic machines as extra ventilators. we are fortunate to have four intensivists and a large anaesthetic practice that manage three of the icus across hilton and pietermaritzburg. they anticipated the surge and proactively recruited help across the medical fraternity. during lockdown, the intensivists provided tutorials on basic icu management, all well attended by gps and specialists from all disciplines. they planned for a shift system that would include willing non-icu doctors. day shift spanned from 08h00 to 20h00, night shift from 18h00 to 09h00. 1 july saw a sudden increase of covid-19 admissions and the shift system was started on 6 july. icu ‘recruits’ generally help during the day shift as part of the icu team. the whole icu and high care (16 beds) are now utilised for covid-19 positive patients and theatre recovery has been repurposed as a covid-19 negative (green) icu and high care. as approximately 15 years have passed since our icu rotations during our orthopaedic training, it has been extremely daunting to be involved in the care of these critically ill patients. it is helpful to remember though that in icu every little bit counts, especially when why is there an orthopod in my icu? an orthopaedic perspective during the covid-19 pandemic mcallister j1, smit r2 1 bsc, mbchb, fc orth(sa); midlands orthopaedics, hilton life private hospital, hilton, kwazulu-natal, south africa; email: james@midorth.co.za 2 mbchb: da(sa), fc orth(sa); midlands orthopaedics, hilton life private hospital, hilton, kwazulu-natal, south africa; tel: 083 448 9121; email: rianwsmit@gmail.com covid-19 icu. different types of ppe: a full-face mask, a half-face mask with goggles and a soft n95 mask with a visor. the hard mask filters are n95 and n99/p3 and last up to 6 months. page 128 south african orthopaedic journal http://journal.saoa.org.za there are severe staff shortages among doctors and nurses alike. the shortages are due to staff being ill with covid-19 themselves, isolating due to first-degree exposure or understandably avoiding icu due to older age and other comorbidities. unfortunately, full icus, low patient survival rates and fear for your own safety is probably also resulting in low morale and increased absenteeism. the work includes helping with regular blood gases and rechecking and confirming infusions to placing new central lines and arterial lines and adjusting inotropes. you may even find yourself adjusting fio2 and more glorious work before long! the work experience is consistent with how our colleagues in the usa report their experiences.1 the most difficult part of the work is contacting family and discussing the poor prognosis with them. we try to phone each patient’s family at least once a day but you can’t leave icu or remove your mask repeatedly during the day. you end up speaking very loudly through a mask to family who is not allowed to visit their loved ones who have sometimes been in icu more than ten days and are quite likely not to survive. on the flip side, much has changed since we did icu. ultrasoundguided lines are so much easier than you would imagine and there are youtube and vumedi videos on everything from donning and doffing to ‘abg made easy’. we are in the thick of it now and it has been very rewarding to be involved, albeit in a small way, in the management of a pandemic that is affecting so many lives. the covid-19 pandemic has also had a massive impact on the lives of all orthopaedic surgeons.2,3 we are juggling our practice by taking turns to work in icu and covering our rooms and calls. as stated by dyer and lipa, ‘for surgeons, there is no bold answer to the virus’.4 sometimes one of us just goes in for a few hours and asks, ‘what can i do?’ and there is always something needing to be done. there are many advantages to getting involved, not least of which is the cohesion and camaraderie that results from being part of a multidisciplinary team – something that is often absent in private orthopaedic practice in south africa. we would strongly recommend that our orthopaedic colleagues get involved in fighting this pandemic in any way that they see fit. references 1. sarpong no, forrester la, levine wn. what’s important: redeployment of the orthopaedic surgeon during the covid-19 pandemic: perspectives from the trenches. j bone joint surg am. 2020;102(12):1019-21. https://doi.org/10.2106/jbjs.20.00574. 2. haleem a, javaid m, vaishya r, vaish a. effects of covid-19 pandemic in the field of orthopaedics. clin orthop trauma. 2020;11(3):489-89. https://doi.org/10.1016/j.jcot.2020.03.015. 3. culp bm, frisch nb. covid-19 impact on young arthroplasty surgeons. j arthroplasty. 2020;35(7 suppl):s42-s44. https://doi. org/10.1016/j.arth.2020.04.058. 4. dyer gsm, lipa sa. what’s important: covid-19 – helpers, not heroes. j bone joint surg am. 2020;102(12):1032-33. https://doi. org/10.2106/jbjs.20.00601. layout 1 south african orthopaedic journal mkize s and ferreira n. saoj 2017;16(3) http://journal.saoa.org.za doi 10.17159/2309-8309/2017/v16n3a7 trauma outcome of bilateral circular fixators in complex lower limb fractures s mkize,1 n ferreira2 1 mbchb, hdip orth (sa), fc orth (sa), department of orthopaedic surgery, grey’s hospital, nelson r mandela school of medicine, university of kwazulu-natal 2 bsc, mbchb, fc orth (sa), mmed (orth), phd, prof and head clinical unit: tumour, sepsis and reconstruction, division of orthopaedic surgery, department of surgical sciences, stellenbosch university, cape town corresponding author: dr sandile mkize, department of orthopaedic surgery, grey’s hospital, 3201, pietermaritzburg, email: khabzo99@icloud.com, tel: +27 33 897 3000 abstract circular external fixators are increasingly being used for complex lower limb trauma. when these injuries are sustained to both lower limbs, the ideal management is unclear. we present the results of 25 consecutive patients who were treated with bilateral circular external fixators for complex tibial trauma. the final cohort consisted of 23 men and two women with a mean age of 31.8 years (range 21–62 years) and a median follow-up was 16.4 months (range 6–37 months). bony union was achieved in 96% (48 out of 50) of the tibia fractures. the mean time to union was 26 weeks (range 13–71 weeks). serious complications included chronic osteomyelitis that developed in one patient following a high-grade open fracture and unilateral non-unions in two patients. bilateral circular external fixators are a viable treatment option for patients who sustain bilateral complex lower limb trauma. key words: bilateral circular fixators, complex tibia fractures, compound tibia fractures, soft tissue injury, pin site sepsis citation: mkize s, ferreira n. outcome of bilateral circular fixators in complex lower limb fractures. saoj 2017;16(3):51-54. doi 10.17159/2309-8309/2017/v16n3a7 editor: prof anton schepers, university of the witwatersrand received: september 2016 accepted: january 2017 published: august 2017 copyright: © mkize s, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for the writing of this article. conflict of interest: drs s mkize and n ferreira have no conflict of interest to declare. the content of the article is the original work of the authors. no benefits of any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. introduction complex tibial injuries are common and the ideal management is controversial. the tibia’s anatomical location and subcutaneous nature makes it vulnerable during high-energy trauma, and highgrade open fractures are often the result. non-union rates of up to 30% and infection rates of up to 40% have been reported following open fractures of the tibial diaphysis.1 apart from open fractures, peri-articular injuries to the tibia also pose significant treatment challenges to the orthopaedic surgeon tasked with their management. these injuries affect major weightbearing joints and are associated with significant morbidity.2,3 the thin soft tissue layer of the proximal and distal tibia is frequently severely injured and intolerant of extensive dissection.4 the use of circular external fixators for the management of these complex injuries has been evaluated and shown to be effective at decreasing the complications that are frequently encountered.5-7 these fixators are attractive for the management of complex injuries due to their minimal invasive application and inherent threedimensional stability that affords early functional rehabilitation.8-11 the modularity of circular fixators further allows for frame designs specific for each patient and fracture configuration as well as the ability to address post-traumatic bone loss and limb length discrepancies. previous literature has been able to show the benefit of treating complex tibial injuries in circular external fixation.5,6 when these injuries are bilateral, however, most surgeons would opt not to use bilateral circular external fixators because of the perceived morbidity and difficulty in mobilising with bilateral circular external fixators. we propose that bilateral circular external fixators would allow immediate weight bearing in patients with bilateral complex tibial fractures. the purpose of this study is to present our experience with the use of bilateral circular external fixators for bilateral complex tibia fractures. saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:01 pm page 51 page 52 mkize s and ferreira n. saoj 2017;16(3) method we retrospectively reviewed all patients with acute lower limb trauma who were treated with bilateral circular external fixators between january 2007 and december 2015. ethical approval was obtained from our institutional ethics committee before commencement of data collection. eligible patients were identified from a prospectively collected database. patients were excluded if they sustained major associated injuries such as spinal, pelvic and head injury. soft tissue injures were classified according to tscherne and oestern for closed injuries, and gustilo and anderson for open injuries.12,13 articular fractures that involved the tibial plateau were classified according to the schatzker classification while injuries to the tibial plafond were classified according to the ruedi and allgower classification.13,14 pin site infections were graded according to the checketts and otterburn classification.15 all patients were assessed and managed according to the advanced trauma life support (atls) principles on presentation. open fractures were managed according to a standardised treatment protocol that included emergency department antibiotic administration (first generation cephalosporin and gram-negative cover), wound irrigation and splinting. subsequent urgent surgical debridement and temporary mono-lateral external fixation stabilisation were performed. a 48-hour wound inspection and closure was performed by either delayed primary closure, soft tissue flap or split skin graft. all patients were offered voluntary counselling and testing for human immunodeficiency virus (hiv) during their hospital admission. circular external fixators were individually designed according to the fracture characteristics for each patient and applied under the supervision of a consultant with limb reconstruction experience. the surgical technique followed meticulous preoperative planning and the use of pre-constructed frames. a proximal reference wire, parallel to the knee joint, followed by frame application and distal reference wire parallel to the ankle joint was placed. this aligned the fracture in the coronal plane. sagittal plane alignment was achieved under fluoroscopy and all wires were tensioned to 130 nm. fixation was completed through the application of at least two tensioned wires per ring. unstable knee injuries and tibial plafond fractures were managed by extending the frames across the knee and ankle joints respectively. where frames were extended across joints, the extensions were removed after approximately three weeks. hexapod external fixators were used in cases where intentional fracture site deformity was used to facilitate soft tissue closure or where acute fracture reduction was unsuccessful. these fixators were applied using the ‘rings first’ method that entailed the independent, orthogonal application of the proximal and distal rings to their respective bone segments. the frame was completed by the addition of six oblique struts between the rings. post-operative radiographs were used for planning correction of any deformity, which was commenced once the soft tissues were deemed suitable. all patients were encouraged to mobilise full weight bearing as early as possible under the guidance of a physiotherapist. pin site care followed a strict protocol, which involved twice-daily cleaning with a chlorhexidine in alcohol solution.16 outpatient follow-up was scheduled at two-weekly intervals until a robust rehabilitation programme was established. thereafter, the interval between follow-up appointments was increased to four weeks. radiological union was assessed by evidence of bridging callus of at least three out of four cortices. at this point, a staged ‘trial of union’ protocol was initiated by dynamisation of the external fixator. the site of the uniting fracture was manually stressed and if this did not cause any pain or deformity the patient was allowed to bear weight. if the patient was able to walk without pain, they were allowed to return home with a fully dynamised frame and encouraged to mobilise full weight bearing for a period of two weeks. repeat radiographs were then compared with those before the trial of union; if no deformity had developed, union was deemed confirmed and the external fixator removed. results twenty-five patients met the inclusion criteria. no patients were excluded. the final cohort consisted of 23 men and two women with a mean age of 31.8 years (range 21–62 years). median follow-up was 16.4 months (range 6–37 months). there were 29 (58%) open tibia fractures (12 gustilo-anderson 3a and 17 gustilo-anderson 3b). twelve injuries (24%) were peri-articular and consisted of ten tibial plateau fractures and two pilon fractures. the plateau fractures consisted of seven schatzker vi, two schatzker iv and one schatzker ii injuries. both pilon fractures were classified as ruedi and allgower type 2 injuries. all closed periarticular fractures were associated with significant soft tissue injuries. table i illustrates the distribution of injuries. the mechanism of injury included motor vehicle accidents in 12 patients, nine pedestrian vehicle accidents, three assaults and one fall from height. medical comorbidities were identified in 12 patients (48%). ten patients (40%) were hiv-positive with clusters of differential (cd4) counts that ranged from 153 to 1 056 cells/mm3. eight hiv-infected patients were on highly active anti-retroviral treatment (haart). twelve (48%) patients were known smokers and one patient was diabetic and hypertensive on treatment. a single patient was a known mental health care user. the majority of injuries (41 out of 50) were stabilised with traditional ilizarov-type fine wire circular external fixators. these included 31 truelok fixators (orthofix, verona, italy) and ten ilizarov fixators (smith & nephew, memphis, tennessee). nine injuries were treated with hexapod circular external fixators and consisted of five taylor spatial frames (smith & nephew, memphis, tennessee) and four truelok-hex fixators (orthofix, verona, italy). four tibial plateau fractures had frames that were initially spanned across the knee and two tibial pilon fractures were initially spanned across the ankle. the average time in external fixator was 26 weeks (range 13–71 weeks). all patients attended regular follow-up and bony union was obtained in 48 out of 50 (96%) fractures. angular deformity was observed in two fractures post frame removal. these fractures developed less than 5 degrees valgus and varus angulation respectively and did not require further intervention. two fractures united with slight translation at the facture site without any cosmetic or functional consequences. two patients developed unilateral non-unions. both patients were active smokers. these patients required a secondary procedure to achieve bony union. the most serious complication was seen in one patient who developed chronic osteomyelitis following an open fracture. this patient was treated with chronic suppressive antibiotics and achieved union without additional surgical intervention. a single patient developed post-traumatic osteoarthritis of the knee. this patient had a complex tibial plateau (schatzker vi) fracture which required an across-knee extension of the circular fixator. knee stiffness post removal of the circular fixator was noted in three patients who had an initial across-knee extension of the circular fixator. all these patients required extensive physiotherapy to improve the knee range of motion. pin site infection developed in two of 50 (4%) cases. both these infections were mirror according to the checketts, otterburn and maceachern classification and responded to local pin site care and oral antibiotics.15 saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:01 pm page 52 mkize s and ferreira n. saoj 2017;16(3) page 53 discussion the aim of this study was to present our experience with the use of circular external fixation for bilateral complex tibia fractures. the use of circular external fixation for deformity correction, limb lengthening, non-union management, and complex trauma is increasing exponentially. these devices are able to maintain stability and allow early mobilisation and full weight bearing. this can be achieved with minimal iatrogenic bone and soft tissue damage, preserving the remaining biological potential of the limb while simultaneously providing the mechanical environment that supports bone healing.17 circular fixators further allow a shorter hospital stay due to earlier full weight bearing.18,19 in our case series all our patients mobilised full weight bearing with crutches immediately post-op. keeling et al. reviewed 67 high-energy tibial shaft fractures that were sustained secondary to war zone blast injuries. a total of 21 grade iiia and 13 grade iiib injuries were treated in circular fixators. all fractures healed with less than 5 degrees of coronal or sagittal malalignment at an average time of 220.8 days in external fixator.20 ozturkmen et al. reported their results of 24 segmental tibia fractures treated in traditional ilizarov-type circular fixators. seven of these injuries were closed while the remaining 17 were open fractures (nine grade iiia, five grade iiib, two grade ii and one grade i). the authors reported that 22 out of 24 patients achieved union with adequate alignment. two cases united in 15-degree and 10-degree procurvatum respectively. one patient required a secondary procedure for nonunion of the middle segment of the tibia and eventually united. the mean time for proximal fracture union was 36.4 weeks while the distal fracture healed at a mean of 39.8 weeks.17 sidharthan et al. treated 18 closed and 24 open tibia fractures (four grade i, three grade ii, eight grade iiia and nine grade iiib) in ilizarov-type circular external fixators. the authors reported 100% union with 92% of the cases healing with adequate alignment. all the fractures in this case series united at an average of 5.3 months (3.5 to 8.5 months). 21 our series showed bony union in 48 out of 50 fractures (96%) at a mean time of 26 weeks (range 13–71) after the initial treatment. two cases developed non-union that required a secondary procedure before uniting and two cases developed 5 degrees of varus and valgus post frame removal. pin site sepsis was noted in two cases and this settled down with oral antibiotics with neither patient requiring exchange of the offending wire. one case developed chronic osteomyelitis during treatment. this patient responded to chronic suppressive antibiotics without a secondary procedure to achieve bony union. our results are in keeping with a number of published studies that have shown that circular fixators can be used in the treatment of complex tibia fractures. one of the primary goals of the management of open tibia fractures is to prevent infection and the infection rate in our study was 6% (one chronic osteomyelitis and two pin site sepsis). the non-union rate in our series was 4%; both these fractures needed a secondary procedure to achieve union. there were two cases of malunion in our series: varus and valgus deformity of five degrees. this is lower than the reported malunion rate after the use of external fixators. these patients had no functional disability, and no secondary procedures were performed to correct the deformities. in our study, no patient required removal of the circular fixator prior to bony union. table i: distribution of injuries patient no. right lower limb left lower limb 1 proximal third tibia fracture proximal third compound tibia fracture (ga iii a) 2 midshaft compound tibia fracture (ga iii b) midshaft compound tibia fracture (ga iii b) 3 plateau fracture (schatzker ii) midshaft compound tibia fracture (ga iii a) 4 tibial plateau and distal femur fracture (schatzker iv) distal tibia and ankle fracture 5 midshaft compound tibia fracture (ga iii a) proximal tibia fracture with knee dislocation 6 midshaft compound tibia fracture (ga iii b) midshaft compound tibia fracture (ga iii b) 7 midshaft compound tibia fracture (ga iii b) midshaft compound tibia fracture (ga iii a) 8 midshaft compound tibia fracture (ga iii a) distal tibia fracture closed 9 midshaft compound tibia fracture (ga iii b) midshaft tibia fracture 10 midshaft compound tibia fracture (ga iii b) midshaft compound tibia fracture (ga iii b) 11 midshaft compound tibia fracture (ga iii b) midshaft compound tibia fracture (ga iii b) 12 midshaft compound tibia fracture (ga iii a) midshaft compound tibia fracture (ga iii a) 13 midshaft tibia fracture segmental tibia fracture 14 midshaft tibia fracture midshaft tibia fracture with knee dislocation 15 midshaft compound tibia fracture (ga iii b) tibial plateau compound (schatzker iv), ga iii a 16 tibial plateau (schatzker vi) and compound tibia (ga iii a) midshaft compound tibia fracture (ga iii b) 17 midshaft compound tibia fracture (ga iii b) midshaft compound tibia fracture (ga iii a) 18 tibial plateau (schatzker vi) tibial plateau (schatzker vi) 19 midshaft compound tibia fracture (ga iii a) midshaft compound tibia fracture (ga iii a) 20 segmental tibia fracture midshaft tibia fracture 21 tibial plafond fracture (ruedi-allgower ii) tibial plafond fracture (ruedi-allgower ii) 22 midshaft compound tibia fracture (ga iii b) midshaft compound tibia fracture (ga iii b) 23 tibial plateau (schatzker vi) tibial plateau (schatzker vi) 24 midshaft compound tibia fracture (ga iii b) midshaft compound tibia fracture (ga iii b) 25 tibial plateau (schatzker vi) tibial plateau (schatzker vi) saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:01 pm page 53 page 54 mkize s and ferreira n. saoj 2017;16(3) high-energy tibial plateau fractures are serious injuries that harbour significant morbidity and demand adequate treatment and optimal rehabilitation to achieve good results. there is no universally accepted treatment for these fractures. immediate internal fixation has some advantages although this treatment may be associated with complications such as soft tissue breakdown and chronic osteomyelitis.22 ilizarov fixation of high-energy bicondylar tibial plateau fracture (schatzker v and vi) allows early weight bearing without jeopardising fracture stability and healing. it also has the advantage, independently of fracture pattern, to operate on all patients without delay. in this way, the surgeon can avoid disturbing the healing process with other further interventions to the soft tissues, which may delay rehabilitation.23 numerous studies have reported good to excellent results with the use of circular fixators. kataria et al. reported their results of 38 patients who were treated with fine wire external fixators and showed no cases of non-union or septic arthritis.24 in a series by singh et al., 20 patients with tibial plateau fracture were treated with circular fixators. the authors reported excellent results in 12 patients (60%), good results in five patients (25%), fair in two patients (10%) and bad in one patient (5%). in their series, only one case (5%) developed non-union.25 in our study ten patients had tibial plateau fractures, three were compound fractures gastillo-anderson 3a and seven were closed fractures. the soft tissue injury was graded as tscherne 2 for two fractures and tscherne 3 for five fractures. bony union was noted in all the fractures at an average of 20.7 weeks (14–31 weeks). four patients had kneespanning external fixators and three patients developed knee stiffness, which responded well to extensive physiotherapy. only one patient from our series developed post-traumatic osteoarthritis of the knee. pilon fractures remain an unsolved problem with various methods and philosophies of treatment. due to the substantial risk of early soft tissue complications and risk of deep infection with open surgical repair of comminuted tibial pilon fractures, alternative methods of treatment have been investigated.26 the best results have been achieved with reconstruction of the articular surface of the tibia, stable fixation, and only a short period of joint immobilisation.27 vidyadhara et al. reported their results of 21 consecutive patients with complex tibial pilon fractures that were treated using percutaneous reduction and fixation with ilizarov circular external fixation. nine patients from this series had open fractures. all fractures united without the need for secondary bone grafting.28 leung et al. reviewed 31 distal tibial fractures, with 16 being classified as c type (ao) injuries, that were treated with a non-bridging circular external fixator. one fracture developed a non-union while another fracture was complicated by infection.29 in our case series we had two pilon fractures. soft tissue injury in these fractures was graded as tscherne 2 and both fractures were closed injuries. these injuries were treated with circular external fixator that crossed the ankle joint. bony union was achieved in both fractures at 12.5 weeks (12–13 weeks) and no complications were noted. this study has several limitations including a retrospective design, single-centre cohort and lack of a control group. although the outcome of 50 circular external fixators is reported, the patient cohort consisted of only 25 individuals, making strong recommendations difficult. conclusion the treatment of complex lower limb fracture requires a thorough knowledge of the available treatment options and their application. in rare occasions where patients sustain bilateral complex lower limb injuries, the use of bilateral circular external fixators is a viable option and can be considered without fear of negatively impacting mobilisation and rehabilitation. compliance with ethics guidelines ethical approval was obtained from our institutional ethics committee before commencement of data collection. references 1. webb lx, bosse mj, castillo rc, mackenzie ej. analysis of surgeon-controlled variables in the treatment of limb-threatening type-iii open tibial diaphyseal fractures. j bone joint surg[am]. 2007;89a:923-28. 2. papagelopoulos pj, partsinevelos aa, themistocleous gs, mavrogenis af, korres ds, soucacos pn. complications after tibial plateau fracture surgery. injury. 2006;37:475-84. 3. gaston p, will em, keating jf. recovery of knee function following fracture of the tibial plateau. j bone joint surg [br]. 2005;87-b:1233-36. 4. barei dp, nork se, mills wj, bradford henley m, benirschke sk. complications associated with internal fixation of high-energy bicondylar tibial plateau fractures utilizing a two-incision technique. j orthop trauma. 2004;18:649-57. 5. dickson dr, moulder e, hadland y, giannoudis pv, sharma hk. grade 3 open tibial shaft fractures treated with a circular frame, functional outcome and systematic review of literature. injury. 2015;46:751-58. 6. ferreira n, marais lc. bicondylar tibial plateau fractures treated with fine wire circular external fixation. strat traum limb recon. 2014;9:25-32. 7. ferreira n, marais lc, aldous c. management of tibial non-unions: prospective evaluation of a comprehensive treatment algorithm. sa orthop j. 2016;15(1):60-66. 8. podolsky a, chao ey. mechanical performance of ilizarov circular fixators in comparison with other external fixators. clin orthop relat res. 1993;293: 61-70. 9. cunningham jl. the biomechanics of fracture fixation. current orthopaedics. 2001;15:457-64. 10. caja vj, kim w, larsson s, chao eys. comparison of the mechanical performance of three type of external fixators: linear, circular and hybrid. clin biomech. 1995;10:401-406. 11. bronson dg, samchukov ml, birch jg, browne rh, ashman rb. stability of external circular fixation: a multi-variable biomechanical analysis. clin biomech. 1998;13:441-48. 12. bode g, strohm pc, sudkamp np, hammer to. tibial shaft fractures management and treatment options. a review of the current literature. acta chir orthop traumatol cech. 2012;79(6):499-505. 13. bonar sk, marsh jl. tibial plafond fractures: changing principles of treatment. j am acad orthop surg. 1994;2:297-305. 14. subramanyam nm, rao p, manoj-thomas a, mohanty k. the classification systems for tibial plateau fractures: how reliable are they? injury. 2008;39: 1216-21. 15. checketts rg, maceachern ag, otterburn m. pin track infection and the principles of pin site care. in: de bastiani a, graham apley a, goldberg a (eds) orthofix external fixation in trauma and orthopaedics. 2000. springer, berlin heidelberg new york, pp 97-103. 16. ferreira n, marais lc. pin tract sepsis: incidence with the use of circular fixators in a limb reconstruction unit. sa orthop j. 2012;11(1):10-18. 17. ozturkmen y, karamehmetoglu m, karadeniz h, azboy i, caniklioglu m. acute treatment of segmental tibial fractures with the ilizarov method. injury. 2009;40:321-26. 18. demiralp b, atesalp as, bozkurt m, bek d, tasatan e, ozturk c, basbozkurt m. spiral and oblique fractures of distal one-third of tibia-fibula: treatment results with circular external fixator. ann acad med singapore. 2007;36:267-71. 19. narayan b, marsh dr. the ilizarov method in the treatment of fresh fractures. curr orthop. 2003;17:447-57. 20. keeling jj, gwinn de, tintle sm, andersen rc, mcguigan fx. short-term outcomes of severe open wartime tibial fractures treated with ring external fixation. j bone joint surg am. 2008;90:2643-51. 21. sidharthan s, sujith a, rathod a, pathak r. management of high energy tibial fractures using the ilizarov apparatus. internet j orthop surg. 2004;2(2) 22. young mj, barrack rl. complications of internal fixation of tibial plateau fractures. orthop rev. 1994;23:149-54. 23. ramos t, ekholm c, eriksson bt, karlsson j, nistor l. the ilizarov external fixator a useful alternative for the treatment of proximal tibial fractures. a prospective observational study of 30 consecutive patients. bmc musculoskelet disord. 2013;14:11. 24. kataria h, sharma n, kanojia rk. small wire external fixation for high-energy tibial plateau fractures. j orthop surg. 2007;15(2):137-43. 25. singh h, misra rk, kaur m. management of proximal tibia fractures using wire based circular external fixator. j clin diagn res. 2015;9(9):rc01-rc04. 26. bozkurt m, ocguder da, ugurlu m, kalkan t. tibial pilon fracture repair using ilizarov external fixation, capsuloligamentotaxis, and early rehabilitation of the ankle. j foot ankle surg. 2008;47(4):302-306. 27. koulouvaris p, stafylas k, mitsionis g, vekris m, mavrodontidis a, xenakis t. long-term results of various therapy concepts in severe pilon fractures. arch orthop trauma surg. 2007;127:313-20. 28. vidyadhara s, rao sk. ilizarov treatment of complex tibial pilon fractures. int orthop. 2006;30:113-17. 29. leung f, kwok hy, pun ts, chow sp. limited open reduction and ilizarov external fixation in the treatment of distal tibial fractures. injury. 2004;35: 278-83. saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:01 pm page 54 orthopaedics vol3 no4 sa orthopaedic journal winter 2016 | vol 15 • no 2 page 49 do ponseti plasters delay gross motor milestones of south african children treated for idiopathic clubfeet? m street bsc, mbbch, fcs(orth)sa orthopaedic consultant y ramguthy mbbch, fcs(orth)sa orthopaedic consultant gb firth mbbch, fcs (orth) sa, mmed (orth) head: paediatric orthopaedics division of orthopaedic surgery, chris hani baragwanath hospital, university of the witwatersrand, johannesburg corresponding author: dr mr street dept of orthopaedics wits medical school tel: (011) 717-2538 fax: (011) 717-2551 email: mattstreet@vodamail.co.za introduction the ponseti method1-3 of treating idiopathic clubfoot is the gold standard and the method used in this study at a tertiary level hospital clubfoot clinic. treatment of children with clubfoot involves serial weekly casting (above knee) with sequential manipulation of the clubfoot to achieve reduction of the navicular on the talar head with abduction of the foot to 60°. a percutaneous achilles tenotomy is required in most cases to correct the remaining equinus deformity. foot abduction orthoses (fao) are worn full-time for three months and then at night and nap time up to the age of 4 years.1-3 on average 12 new cases of clubfoot per month are treated at our clinic. a number of parents expressed concern that the plasters and brace will hamper their child’s future walking capability. sala et al. from the new york ponseti clubfoot centre showed that children treated using the ponseti method showed pre-ambulatory gross motor milestone achievement delay of at most 1.5 months except for independent ambulation where a two-month delay was found.4 abstract introduction: the ponseti method for the treatment of idiopathic club foot is the gold standard of treatment in south africa. a study in new york reviewed attainment of eight gross motor milestones in these children and found that independent ambulation was delayed on average by 2 months compared to unaffected children. methods: a retrospective review of gross motor milestones was performed in patients treated at a south african clubfoot clinic. all patients were ambulating independently at review and ages at attainment of three motor milestones were recorded (sitting, crawling and walking independently). the world health organisation (who) published the normal range for achievement of these milestones in six regions across the world. we compared the results of our patients to the 50th percentile in that study. results: results show that patients in our study sat at a mean of 5.8 (standard deviation ± 1.3) months and crawled at a mean of 8.3 (sd ± 1.7) months, both equal to the who 50th centiles for unaffected children. independent walking, however, was achieved at a mean of 15.3 (sd ± 2.3) months which is statistically significantly different to the 50th centile for unaffected children in the who study (p<0.05). in our study, 86% of children achieved independent walking within 18 months. no statistical difference was found between unilateral and bilateral cases. conclusion: children treated for idiopathic clubfoot (unilateral or bilateral) can expect no delays in sitting or crawling. minimal delays in achieving independent walking of about three months can be expected with an 86% chance of walking within the accepted normal range for unaffected children. key words: ponseti plasters, idiopathic club foot, motor milestones, children http://dx.doi.org/10.17159/2309-8309/2016/v15n2a8 page 50 sa orthopaedic journal winter 2016 | vol 15 • no 2 the purpose of this study was to assess whether there is a delay in patients with idiopathic clubfoot, treated with the ponseti method in a south african setting, achieving three gross motor milestones as compared to the world health organisation (who) normal values as published in 2006. the 2006 growth reference study looked at the normal variation in ages of milestone achievement among healthy children.5 children from five different countries were studied, namely ghana, india, norway, oman and usa (figure 1).5 the advantage of using this reference data set was that it used five different countries, including two developing world countries, making it more reliable for our population. aim the primary aim of the study was to assess the achievement of three gross motor milestones: independent sitting, crawling and independent walking. the achievement of these milestones was compared with age of achievement to the 50th percentile in the who study. a subsidiary aim was to compare delay in gross motor milestones in bilateral vs unilateral cases. materials and methods this is a retrospective study of prospectively collected data from patients treated between 2008 and 2012 in a dedicated clubfoot clinic by the first author (ms). parents of children with clubfoot who had been treated by the ponseti protocol who were ambulating independently were interviewed to determine the age of gross milestone achievement of independent sitting, crawling and independent walking. the age and gender of the patient, bilaterality and the age at commencement of plasters was noted. weekly plasters were applied until abduction of about 60 degrees was attained. the majority of patients required a tendo-achilles tenotomy and placed into a cast for three weeks. foot abduction braces (steinbeek braces) were worn full-time for three months and then at night and nap time till 4 years of age. all children with idiopathic clubfoot deformities presenting for follow-up between 1 january 2013 and 31 may 2013 were included. exclusion criteria included teratological clubfeet (associated hip dysplasia, arthrogryposis, myelomeningocoele, etc.), any recurrence requiring recasting, and patients still in the casting phase, and patients in the first three months of full-time brace wear. the who growth reference study5 used six parameters to assess achievement of gross motor milestones in children from five different countries. the data from this reference base was used to compare three things in our study population, namely time at which independent sitting, crawling and independent walking were achieved. statistical analysis was done using statistica (2009), using the one-sample student t-test to compare the mean age of each milestone achievement and the who mean of unaffected children. a p-value <0.05 was considered statistically significant. the mean and range was calculated for the age at time of first cast application and number of casts used. results sixty-nine caregivers of children with idiopathic clubfoot deformities were interviewed. forty-one (59%) of the affected children were males and 28 were females (41%). forty-one (59%) of the cases were bilateral and 28 (41%) were unilateral. figure 1.5 who box and whisker plot indicating the normal windows of milestone achievement of six gross motor milestones. we used the milestones circles in red to compare to our patients. age in months 4 5 6 7 8 9 10 11 12 13 14 15 n um be r o f p at ie nt s 18 16 14 12 10 8 6 4 2 0 figure 2. graph showing the age at which the patients had completed full-time steinbeek brace wearing sa orthopaedic journal winter 2016 | vol 15 • no 2 page 51 the mean number of plasters applied to achieve correction per patient was 10 (range 2–20) with the mean age at first plaster application seven weeks (range 5 days–35 weeks). figure 2 shows the age at which the patients had completed their full-time fao (steinbeek brace) period of three months. only nine out of the 69 patients were still in the abduction brace full time at 12 months of age. children in this study achieved independent sitting at a mean age of 5.8 months (sd 1.3 months). the who mean for sitting is 5.9 months on the 50th percentile for unaffected children. this result is not statistically significant (p=0.42). the children in the current study achieved crawling at a mean age of 8.3 months (sd 1.7 months) which is the same as the 50th percentile in the who study; therefore, no statistical difference. seven of the 69 children did not crawl prior to walking. independent walking was achieved at a mean age of 15.3 months (sd 2.3 months) which is statistically significantly different compared to the who 50th percentile group which achieved independent walking at the age of 12 months (p<0.05) (figure 3). fifty per cent of children were independently walking by the age of 14 months. eighty-six per cent were walking by the age of 18 months, which is the upper limit of the normal achievement of independent walking. no statistically significant difference was found when comparing the children affected bilaterally to those affected unilaterally, with respect to independent sitting, crawling and independent walking. discussion the population of 69 children in our group reflects similar characteristics to populations treated with the ponseti method reported in the literature. in the current population 59% were male. there were slightly fewer males in this study group compared to the literature (range 60%–75% males) but bilateral cases (59%) were equal to that described in the literature.6-9 ten plasters were on average required to obtain correction. this compares favourably to studies where plasters were started after six weeks10,11 but is more than other studies where plasters were started within the first few weeks of life.12,13 sala et al. looked at achievement of gross motor milestones in 36 patients (53 feet). children in their study had their first cast applied at a mean age of 15 days with a mean number of five casts (range 4–7).4 the current study is the first of its kind in an african setting. it had almost double the number of patients studied in new york4 with 69 children who had their first cast applied over a month later compared with this study (on average at 7 weeks with a range from 5 days to 35 weeks). there are many reasons for the later commencement of treatment in our study population. one reason is due to the referral patterns in our hospital system and the population’s access to our facility. many patients are referred from a clinic to a secondary facility and then on to our facility, which takes time. other reasons include poor access to transport, poor education about the treatment modalities available for clubfeet and traditional beliefs. despite the later application of the plasters in our study population the results of milestone achievement were similar to this study from new york.4 this makes the current findings more significant in an african context as the plasters were applied closer to the achievement of the early motor milestones and yet did not delay them more than when applied before the achievement of independent sitting. the new york study looked at eight gross motor milestones and showed six of eight were delayed. fifty per cent of the children in their study were ambulating independently by 14 months and 90% were ambulating independently by 18 months.4 they concluded that, although statistically significant, children receiving ponseti plasters had minimal delays in achieving gross motor milestones with delays being at most two months. this, as in the current study, was not clinically significant.4 the current study has demonstrated similar results looking at three of these eight milestones. fifty per cent were walking by 14 months and 86% ambulating independently by 18 months. therefore 14% of the children fall outside the 99th percentile for independent walking as seen in the who study figures. independent walking was delayed by a mean of three months compared to the 50th percentile of the who study figures. although patients in this study received more plasters and were treated for longer, no additional delay of gross motor milestones were observed. as a result parents can be reassured that although delays in walking are seen in these children, they are minimal, and not clinically significant. children with clubfeet have an 86% chance of walking within what is considered a normal time frame (18 months).5 one can also inform them that sitting and crawling should not be affected. the attainment of three gross motor milestones (independent sitting, crawling and independent walking) was recorded in the current study retrospectively. 16 14 12 10 8 6 4 2 0 sitting crawling walking study group who 50% figure 3. graph comparing our study group with the who 50%. only independent walking (arrow) was found to be statistically different (p<0.05) to the who 50%. page 52 sa orthopaedic journal winter 2016 | vol 15 • no 2 we chose to record only the above three milestones to ensure that parents could remember them easily and thus improve the reliability of our results. the literature supports this in a study done in poland by mrożekbudzyn et al. where they found that parents were able to reliably recall the main gross motor milestones achieved when their children were 3 years of age. they supported the use of parent reporting of gross motor milestones retrospectively in children at low risk for developmental delays.14 this would be in keeping with our study population of children with idiopathic clubfeet. another study done in malawi used a developmental milestones checklist for parents of children aged 24 months or less. they found that the retrospective caregiver reports were both reliable and consistent on retesting, which supports the methodology of recalling milestones retrospectively by parents.15 donoghue et al. concluded that a clinical interview assessing a child’s milestones has limitations but its use is still justified. walking age was particularly well recalled by the patients they interviewed.16 another paper reinforcing that obtaining gross motor milestones retrospectively are reliable is abubaker et al. who found that caregiver reports for milestones were reliable in a rural african setting.17 a limitation of our study was that it was retrospective and all children included had already started walking. lastly we only interviewed the parents to record the milestones at one visit. conclusion children treated for idiopathic clubfoot can expect no delays in independent sitting or crawling when treated using the ponseti protocol. minimal delays in achieving independent walking (of about three months) can be expected but 86% of children will walk within the accepted normal range for unaffected children and this delay was not clinically significant. compliance with ethics guidelines this article has been submitted to an ethical committee for approval. the content of this article is the sole work of the authors. m street, y ramguthy and gb firth have received no benefits of any form derived from any commercial party related directly or indirectly to the subject of this article. references 1. ponseti iv. treatment of congenital club foot. j bone joint surg am. 1992;74:448-54. 2. ponseti iv. congenital clubfoot: fundamentals of treatment. 1st edition. oxford; new york: oxford university press; 1996. p 140. 3. ponseti iv. clubfoot management. j pediatr orthop. 2000;20:699-700. 4. sala da, chu a, lehman wb, and van bosse hjp. achievement of gross motor milestones in children with idiopathic clubfoot treated with the ponseti method. j pediatr orthop. 2013;33(1):55-58. 5. who multicentre growth reference study group. who motor development study: windows of achievement for six gross motor development milestones. acta paediatrica supplement. 2006;450:86-95. 6. changulani m, garg nk, rajagopal ts, et al. treatment of idiopathic club foot using the ponseti method: initial experience. j bone joint surg br. 2006;88:1385–87. 7. dobbs mb, rudzki jr, purcell db, et al. factors predictive of outcome after use of the ponseti method for the treatment of idiopathic clubfeet. j bone joint surg am. 2004;86:22–27. 8. chu a, labar as, sala da, et al. clubfoot classification: correlation with ponseti cast treatment. j pediatr orthop. 2010;30:695–99. 9. herzenberg je, radler c, bor n. ponseti versus traditional methods of casting for idiopathic clubfoot. j pediatr orthop. 2002;22:517–21. 10. cooke sj, balain b, kerin cc, kiely nt. clubfoot. current orthopaedics. 2008;22:139-49. 11. lourenço af, morcuende ja. correction of neglected idiopathic club foot by the ponseti method. j bone joint surg [br]. 2007;89:378-81. 12. bor n, coplan ja, herzenberg je. ponseti treatment for idiopathic clubfoot. minimum 5-year follow-up. clin orthop relat res. 2009;467:1263–70. 13. gupta a, singh s, patel p et al. evaluation of the utility of the ponseti method of correction of clubfoot deformity in a developing nation. international orthopaedics (sicot). 2008;32:75–79. 14. mrożek-budzyn d, kiełtyka ma, majewska r. validity and clinical utility of children development assessment using milestones reported by mothers. przegl epidemiol. 2014;68:71-75. 15. gladstone m, lancaster ga, umar e, nyirenda m, kayira e, van den broek nr, et al. the malawi developmental assessment tool (mdat): the creation, validation, and reliability of a tool to assess child development in rural african settings. plos medicine. 2010;7(5):e1000273. 16. donoghue ec, shakespeare ra. the reliability of paediatric case-history milestones development. med child neurol. 1967;9:64-69. 17. abubakar a, holding p, van de vijver f et al. developmental monitoring using caregiver reports in a resource-limited setting: the case of kilifi, kenya. acta pediatr. 2010;99(2):291-97. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj orthopaedics vol3 no4 page 48 sa orthopaedic journal autumn 2015 | vol 14 • no 1 synovial chondromatosis: a review of the literature and report of two cases st rangoako* mbchb ej raubenheimer** mchd, phd, dsc k mafeelane* mbchb, fcsa(orth) *department of orthopaedic surgery **metabolic bone disease laboratory faculty of health sciences, medunsa campus, university of limpopo correspondence: prof e j raubenheimer room fdn 110 medunsa campus university of limpopo 0204 south africa tel: +27 12 521 4838 email: erich.raubenheimer@ul.ac.za introduction and review of the literature synovial chondromatosis is a pathological condition in which mesenchymal cell rests in the synovial membrane form one or more cartilage nodules.1,2 although the pathogenesis remains speculative, various theories have been proposed. most authors favour the concept of the cartilage masses representing benign neoplastic growths. this is supported by their unrestricted growth potential and tendency to become large,3,4 undergo chondrosarcomatous change,5-8 and recur if incompletely excised.5,9,10 an infective cause for the stimulus to form cartilage in the synovial membrane is discounted by negative cultures obtained from synovial fluid samples.1 although a significant proportion of patients report trauma as a possible association, the majority give no history of injury of the affected joint.1 an appealing explanation for the presence of cartilaginous masses in the synovium relates to the acknowledged phagocytic capacity of the synovial membrane.10 fragments of cartilage (and bone) resulting from wearing down of articular surfaces in an osteoarthritic joint may be absorbed by the synovial lining and proliferate in the synovial membrane.1,11 in order for this theory to be plausible, the majority of cases should be reported in elderly patients, which is not the case. abstract synovial chondromatosis is a rare benign condition which develops in the synovial tissue of a joint, bursa or tenosynovial sheath. it is characterised by formation of cartilaginous nodules which may enlarge and grow into larger masses. although radiological imaging contributes to a differential diagnosis, a final diagnosis can only be established with histological examination. meticulous examination of the lesions is essential in ruling out sarcomatous change. we present a review of the literature and report two cases of synovial chondromatosis of the knee joints diagnosed over a ten-year period in the orthopaedic unit of a tertiary hospital serving mainly an urbanand peri-urban population sample. key words: synovium, chondromatosis, knee joint saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:57 pm page 48 sa orthopaedic journal autumn 2015 | vol 14 • no 1 page 49 synovial chondromatosis affects patients over a wide age range reportedly between 17 to 64 years with a peak during middle age,1,5 with degenerative joint disease only present in few.5 the condition is mono-articular and the most common joints involved are the knee followed by the hips.5,12 several case reports describe lesions involving the temporomandibular joint,2,13-15 joints of the hands,3,10,16 ankle, upper extremity,17,18 hip8 and vertebrae.19 synovial chondromatosis is more common in males.1,5 pain and limitation of movement are the most frequently reported presenting symptoms, usually of many years’ duration.1,2,7 large lesions result in pseudo-fusion of the involved joint.3 intra-articular loose bodies are more frequent in patients with small lesions and may cause locking of the joint. giant loose intra-articular bodies are rare.4 the typical early radiological appearance is stippled calcification in and around an affected joint. computed tomography (ct) is the technique of choice for defining the state of the bony surfaces of the articular joint but is inferior to magnetic resonance imaging (mri) for the identification of non-calcified intra-articular bodies15 and all other structural soft tissue changes.15 conventional radiographs frequently reveal the typical ‘ring-and-arc’ appearance following mineralisation of the chondroid mass.12 erosion of bony facets is frequently seen in synovial chondromatosis.12 chondrosarcomas develop in up to five per cent of patients with synovial chondromatosis.5,7,20 the histological features of a low grade chondrosarcomas are often ambiguous, and careful clinicopathological correlation is required.21 biopsy should be performed in cases where malignant transformation is suspected. microscopic examination should therefore always be supplemented by clinical features indicative of sarcomatous change, which include a clinical history of multiple recurrences,5 sudden enlargement of a lesion6 and radiological findings of endosteal scalloping7 and bone marrow infiltration.12 no mri features are reported which could be helpful in distinguishing cases with sarcomatous change from synovial chondromatosis alone.20 however mri is useful in differentiating chondrosarcoma and other bone tumours from synovial chondromatosis and should be viewed as the imaging tool of choice if there is doubt about the diagnosis. missing a primary malignant bone tumour and performing an intralesional resection leads to extensive tumour contamination with subsequent amputation and poor long-term prognosis. despite radical surgery, metastatic dissemination has been reported in 29% of cases of synovial chondromatosis with secondary sarcomatous change.8 other conditions which should be considered in the clinical differential diagnosis of synovial chondromatosis includes pigmented villonodular synovitis, synovial haemangioma, lipoma arborescens21 and all the causes for intra-articular loose bodies such as osteochondral fractures as well as chondrosarcoma and parosteal osteosarcoma.1 the principles of treatment of synovial chondromatosis include removal of the tumour(s) using arthrotomy with or without partial synovectomy for large lesions1-3 or arthroscopic removal for small to medium-sized bodies attached to the synovium.18,22 complete synovectomy is impractical in the knee joint and synovectomy of the hip joint requires dislocation. the latter is not justifiable due to the danger of avascular necrosis of the femoral head secondary to joint dislocation with subsequent fracture. cases with intra-articular disease have a higher tendency for recurrent growths.16 the purpose of this paper is to report two cases of synovial chondromatosis diagnosed in an orthopaedic unit in a tertiary hospital which serves mainly a rural and peri-urban patient sample of the northern regions of south africa. case 1 a 60-year-old male employed as a machine operator in a factory was referred to our hospital following a four-year history of severe pain in the left knee, swelling and difficulty in walking due to frequent locking of the joint. minimal relief was experienced after the use of nsaids and analgesics. he consulted traditional healers with no improvement in the condition. his family history was negative and he suffered no associated morbidities. clinically he presented with significant swelling of the knee and the loose bodies were not palpable. pre-operative radiographs showed three radiopaque bodies around the knee joint and a patellar osteophyte (figure 1a and b). arthroscopic surgery and partial synovectomy of the hypertrophied synovium was performed and two anterior parapatellar tendon portals were used for removal of the three loose bodies. figure 1a. case 1: anterior-posterior view of the knee joint. note the ring-and-arc radiological appearance (white arrows) and the mass in the joint space (black arrow). figure 1b. case 1: lateral view. note the three masses demonstrated in figure 1a. the arrow indicates a patellar osteophyte.the typical early radiological appearance is stippled calcification in and around an affected joint saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:57 pm page 49 page 50 sa orthopaedic journal autumn 2015 | vol 14 • no 1 the masses had a smooth surface and white appearance and measured between 2 and 3 cm in diameter. on the cut surface the circular band of mineralised tissue was clearly visible (figure 2). due to the presence of mineralised tissue in the specimen, it was demineralised for microscopic processing and sectioning. microscopically the specimen showed formation of hyaline cartilage in the centre covered by a layer of mineralised bone and fibrous tissue towards the outside. the features were compatible with those of synovial chondromatosis (figure 3). case 2 a 43-year-old unemployed male was referred from a district hospital following a two-year history of progressive pain of the left knee, intermittent swelling, restricted joint movement and frequent locking of the joint. his daily activities were affected due to severe pain and limitation of movement. he reported previous left knee injury during a football game when he was 17 years of age. his family history was negative for bone and joint diseases. physical examination revealed a mildly swollen tender knee with positive patellofemoral crepitus. he could fully extend his knee and flex it from 0–85 degrees. two firm masses were palpable on the anterolateral aspect of the knee. conventional radiographs showed multiple radiopaque loose bodies associated with the knee joint (figure 4). arthroscopy using two anterior parapatellar tendon portals was performed. ten white, oval, chondritic loose bodies, measuring between 1.9 × 1.4 cm and 1.1 × 1 cm in diameter were removed (figure 5). during the procedure a velvety red appearing and hypertrophied synovium was identified and a partial synovectomy was performed. microscopic examination showed features resembling those of the lesions in case 1 and confirmed the diagnosis of synovial chondromatosis. post-operative radiographs showed no residual bodies. although the patient experienced slight discomfort and mild swelling after prolonged activity, full function of the joint was restored. figure 2. case 1: cut surface of one of the tumours. note the circular appearance of the zone of mineralised tissue (circular line following the tips of the arrows) which corresponds with the ring-and-arc radiographic features depicted in figure 1. figure 4. case 2: note the ring-and-arc appearance of the cartilaginous tumours on the anterior-posterior and lateral radiograph of the knee. figure 3. case 1: microscopic appearance showing the band of mineralised bone (between the arrows) which corresponds with the ring-and-arc feature highlighted in figures 1 and 2. figure 5. the typical white, well-circumscribed and lobulated appearance of the tumours removed from case 2. saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:57 pm page 50 sa orthopaedic journal autumn 2015 | vol 14 • no 1 page 51 discussion over a period of ten years only two cases of synovial chondromatosis were recorded in our orthopaedic unit, which serves as a referral centre for patients from clinics in the northern and north-western sections of south africa. this infrequency underscores the rarity of the disease. in both patients the knee joints were affected, supporting the preference for the involvement of the large joints of the lower extremity. pain and reduced mobility due to locking of the joint were the main complaints of both our patients. case 2 gave a history of trauma to the joint 24 years before clinical manifestations. whether this bears any reference to the development of the lesion remains speculative. in the first case, no association with trauma to the knee joint could be recalled by the patient. the ages of both cases fall within the range reported for the disease and both patients are males, supporting the male predominance reported in the literature.1,5 the lesions removed from case 1 will fall in a category described as ‘very large’3 in the literature. the larger lesions tend to mineralise and this facilitates a radiological diagnosis on plain films. the typical ring-andarc radiological feature12 resulting from the zone of bone formation between the outer fibrous capsule and the core of hyaline cartilage was demonstrated histologically in both our cases, suspending the need for the employment of additional imaging techniques. the histological assessment of the lesions removed is important in ruling out a primary malignant bone tumour, which has disastrous consequences if missed. our study is the only one in the english literature which demonstrates the macroscopic and microscopic appearances of the ring-and-arc radiological feature resulting from the process of mineralised bone formation within the chondritic bodies in synovial chondromatosis. both our cases were treated with arthroscopic surgery and partial synovectomy as the technique offered the advantage of better visualisation, less peri-operative morbidity and the prevention of secondary joint changes such as arthrofibrosis which is more common in open joint surgery. the post-operative follow-up of our patients is short and we can subsequently not comment on the longterm success of the treatment employed. references 1. jeffreys te. synovial chondromatosis. j bone joint surg 1967;49b:530-34. 2. reed ls, foster md, hudson jw. synovial chondromatosis of the temporomandibular joint: a case report and literature review. cranio 2013;31:309-13. 3. maramatsu k, hashimoto t, tominaga y, taguchi t. large synovial osteochondromas arising from the interphalangeal joint of the thumb: a case report and review of the literature. anticancer res 2014;34:1057-62. 4. sourlas i, brilakis e, mavrogenis a, stravropoulos n, korres d. giant intra-articular osteochondromata of the knee. hippokratia 2013;17:281-83. 5. davis ri, hamilton a, biggart jd. primary synovial chondromatosis: a clinicopathologic review and assessment of malignant potential. hum pathol 1998;29:683-88. 6. hallam p, ashwood n, cobb j, fazal a, heatley w. malignant transformation of synovial chondromatosis of the knee? knee 2001;8:239-42. 7. yao ms, chang cm, chen cl, chan wp. synovial chondrosarcoma arising from synovial chondromatosis of the knee. jbr-btr 2012;95:360-62. 8. campanacci da, matera d, franchi a, capanna r. synovial chondrosarcoma of the hip: report of two cases and literature review. chir organi mov 2008;92:139-44. 9. church js, breidahl wh, janes gc. recurrent synovial chondromatosis of the knee after radical synovectomy and arthrodesis. j bone joint surg br 2006;88:673-75. 10. loonen mp, schuurman ah. recurrent synovial chondromatosis of the wrist: case report and literature review. acta orthop belg 2005;71:230-35. 11. murphy fp, dahlin dc, sullivan cr. articular synovial chondromatosis. j bone joint surg 1962;44-a:7. 12. murphey md, vidal ja, fanburg-smith jc, gajewski da. imaging of synovial chondromatosis with radiologic-pathologic correlation. radiographics 2007;27:1465-88. 13. peyrot h, motoriol pf, beziat jl, barthelemy i. synovial chondromatosis of the temporomandibular joint: ct and mri findings. diagn interv imaging 2014, feb 20: (e publication ahead of print). 14. shah sb, ramonojam s, gadre pk, gadre ks. synovial chondromatosis of the temporomandibular joint: journey through 25 decades and a case report. j oral maxillofac surg 2011;69:2795814. 15. testaverde l, perrone a, caporali l, ermini a, et al. ct and mr findings in synovial chondromatosis of the temporomandibular joint: our experience and review of the literature. eur j radiol 2011;78:414-18. 16. roulot e, le vliet d. primary synovial osteochondromatosis of the hand wrist. report of a series of 21 cases and literature review. rev rhun engl ed 1999;66:256-66. 17. santiago t, mariano c. primary synovial chondromatosis of the ankle joint presenting as a monoarthritis. bmj case rep 2013; dec 10: pii: bcr2013202186. 18. griesser mj, harris jd, likes rl, jones gl. synovial chondromatosis of the elbow causing mechanical block to a range of motion: a case report and review of the literature. am j orthop 2011;40:253-56. 19. gallia gl, weiss n, cambell jn, mccarthy ef, tufaro ap, gokaslan zl. vertebral synovial chondromatosis. report of two cases and review of the literature. j neurosurg spine 2004;1:21118. 20. wittkop b, davies am, mangham dc. primary synovial chondromatosis and synovial chondrosarcoma: a pictorial review. eur radiol 2002;12:2112-19. 21. adelani ma, wupperman rm, holt ge. benign synovial disorders. j am acad orthop surg 2008;16:268-75. 22. krebs ve. the role of hip arthroscopy in the treatment of synovial disorders and loose bodies. clin orthop relat res 2003;406:48-59. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:57 pm page 51 sa orthopaedic journal spring 2014 | vol 13 • no 3 page 21 the rise and fall of large bore metal-on-metal hip prostheses prof ian d learmonth mbchb, frcs, frcs(ed), fcs(sa)orth emeritus professor, university of bristol correspondence: prof ian learmonth 21 grove village 37 stuart road 7700 rondebosch cape town introduction metal-on-metal (mom) was the bearing of choice in the early 1960s, using a monobloc stem with a large head. these prostheses (mckee-farrar, huggler, müller etc.) were made of cobalt-chromium molybdenum alloy, and exhibited a very low wear, even up to 20 years after implantation.1 poor component design – low head neck offset, poor prosthetic fixation, etc. – often led to early failure. however brown et al.2 reported an 84% survivorship of the mckee-farrar (figure 1) at 20-year follow-up, while jacobsson et al.3 noted that the long-term results of the mckee-farrar were comparable to those of the charnley low friction arthroplasty. the high early incidence of loosening of these early large bore mom articulations was attributed to increased shear stresses at the fixation interface consequent upon the high friction at the bearing interface. this led to charnley introducing low friction hard-on-soft bearings – metal on ultrahigh molecular weight polyethylene. abstract metal-on-metal was the first articular couple to be successfully used in total hip replacement. large heads and high frictional torque resulted in a high incidence of implant loosening. this led charnley to introduce the low friction arthroplasty where the torque was reduced by using small heads and low friction hard-on-soft bearings. osteoarthritis is a disease of cartilage, and resurfacing arthroplasty is therefore intuitively the logical conservative surgical solution. the early resurfacing devices with metal-on-plastic bearings were associated with catastrophic wear of the plastic. in the 1990s resurfacing was revisited, and metal-on-metal was selected to resolve the challenge of the bearing surface. various factors were not initially recognised as being critical for the successful outcome of these implants. these include the importance of component orientation, the significance of an adequate ‘arc of cover’, the prevalence of edge loading, and the impact of microseparation. in addition the biological response – pseudotumour/alval etc. – was unpredicted and unexpected. femoral neck fractures in patients with a resurfacing arthroplasty were treated by revision to a stemmed implant with a large head. however this option was seen to have a wider application than resurfacing, was perceived as a ‘high performance bearing’ and addressed the problem of dislocation – one of the commonest causes of revision. these large bearings provided a dislocation ‘safety net’ to surgeons, many of whom consequently became less meticulous about component orientation. liberation of metallic debris by fretting and corrosion at the taper junction between the large head and the taper of the stem – totally unforeseen by the bioengineers – emerged as a real problem in these hips. this paper attempts to scientifically place some of these issues in perspective against the backdrop of hysteria created by legal colleagues and the media. key words: hip, large metal bearings, failure this paper attempts to scientifically place some issues in perspective against the backdrop of hysteria created by legal colleagues and the media. saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 2:46 pm page 21 page 22 sa orthopaedic journal spring 2014 | vol 13 • no 3 in 1995 harris noted that ‘the problem is osteolysis’.4 aseptic loosening was the commonest cause of failure of total hip replacement, and osteolysis was the commonest cause of aseptic loosening. by this time it was recognised that osteolysis was particle and particle access disease, and that micron and submicron particles of polyethylene were the main culprit. in a hard-on-soft bearing, wear is proportional to load and distance travelled. the larger the bearing, the greater the distance travelled. early attempts at resurfacing with a polyethylene cup and a metal head in the 1970s resulted in predictably high volumetric wear of the plastic, which was associated with osteolysis and catastrophic failure.5 the recognised limitations of high density polyethylene resulted in the development of alternative bearings – highly cross-linked polyethylene, metal-on-metal and ceramic-onmetal. mom bearings do not fracture, are selfhealing, generate very low volumetric wear, and can be used for large bore couples. mom therefore met the requirements for resurfacing, namely, the use of thin components to avoid undue resection of the femoral head and acetabulum, the use of large heads, and the use of materials with an established record in clinical practice. the ring prosthesis (figure 2), a monobloc large-bore mom hip, had a survivorship of 95% at 15–16 years.6 recognising the potential value of this technology, mcminn approached corin medical ltd (cirencester) whose engineers had experience of manufacturing the ring prosthesis. this collaboration produced a mom resurfacing device that was the forerunner of the birmingham hip resurfacing (bhr).7 resurfacing arthroplasty (ra) gained substantial traction at the turn of the century and increasing patient and surgeon demand dictated that virtually all orthopaedic companies included a resurfacing device in their portfolio. femoral neck fractures occur in up to 1.5% of ras, and are the commonest cause of early failure of these devices. in these circumstances it is only necessary to revise the femoral component. all companies therefore manufactured a range of modular large diameter metal heads that would articulate with the monolithic resurfacing cups and could be applied to stemmed femoral implants. crownshield⁸ noted that large heads were associated with a decreased risk of dislocation, both because of the increased range of movement to impingement, and because of the increased jump distance – represented by the radius of the femoral head. the reduced incidence of dislocation associated with larger heads was confirmed in clinical practice.9,10 hip registries identified dislocation as the commonest cause of early revision and the second commonest cause of revision. large bore mom bearings seemed like a panacea: a ‘high performance bearing’ with virtually no risk of dislocation, no risk of fracture and very low wear. so what went wrong? resurfacing arthroplasty arthritis of the hip primarily involves the articular surfaces and subchondral bone of the joint. intuitively therefore resurfacing of the joint is the logical conservative surgical option. it should be recognised at the outset that some resurfacing prostheses have performed remarkably well in selected patients. mcminn et al.11 reported a 99% and 98% survivorship of the bhr at 10 and 15 years respectively in male patients with osteoarthritis. coulter et al.12 reported a 97.5% survivorship of the bhr in males at a mean followup of 10.4 years. the survivorship in females was only 89.1%. figure 1. mckee-farrar prosthesis. note the monobloc stem and the unusual design of the cup. figure 2a and b. ring prosthesis. the fixation stem of the acetabulum dictates that the component is always inserted closed. factors contributing to the failure of ra devices include poor patient selection rheumatoid arthritis, osteoporosis, avascular necrosis, etc ba saoj spring 2014_orthopaedics vol3 no4 2014/07/31 11:48 am page 22 sa orthopaedic journal spring 2014 | vol 13 • no 3 page 23 the aggressive promotion of the early success of ra resulted in an increased demand for resurfacing around 2005–2007 (figure 3). however an unexpectedly high failure and revision rate (figure 4) resulted in a marked decrease in resurfacing activity over the past few years (figure 3). factors contributing to the failure of ra devices include poor patient selection – rheumatoid arthritis, osteoporosis, avascular necrosis, etc. – which was often associated with an increased incidence of femoral neck fracture. loosening of the acetabular component is one of the commonest causes of failure of large bore mom implants. one of the main contributory factors is the significant torque generated by the high frictional resistance encountered at the articular interface of these bearings in the absence of a favourable lubrication regimen13 – for example, when rising from a sitting position, edge loading, etc. it should be noted that edge loading will itself markedly increase torque on the cup. in addition acetabular implants with a low clearance and a thin shell – designed to limit bone resection – were susceptible to deformation and equatorial binding when inserted into hard sclerotic bone. this produced enormous shear forces at the fixation interface which often culminated in loosening of the cup. an increased generation of metallic debris is associated with an increased incidence of pathological biological responses, which often predicates the need for revision. factors contributing to an increased generation of metallic debris include: 1. any of the following factors that reduce the ‘arc of cover’ (figure 5) and increase the wear at the articular interface: • small acetabular components (more commonly used in females) • cups that are more vertically orientated • sub-hemispherical cups (as depicted in figure 5) • a trendelenburg gait, which is associated with a functional reduction in the ‘arc of cover’ • other design features of the cup – such as the locator groove for the cup insertion device of the asr • developmental dysplasia of the hip: the morphology of the acetabulum dictates that the cup is often inserted too ‘open’. 2. rim or edge loading can occur where the cup is malorientated – either too vertical or with excessive ante or retroversion. morlock et al.14 have shown that rim-loaded implants exhibited an average 21to 27fold higher wear rate than implants without rim loading. in addition, rim-loaded implants showed a steeper mean cup inclination than their non-rimloaded counterparts (59° vs 50°). it should be remembered that the articular relationship between the femoral head and the acetabular component is affected by the orientation of both components. the orientation of the femoral components is seldom considered in the literature – even though a markedly valgus or retroverted head will provoke edge loading. 3. microseparation is a potent cause of increased wear. leslie et al.15 noted that bearings tested with a cup inclination of 60° had nine-fold higher wear rates than bearings tested with a cup inclination of 45°. however, if the increased cup angle was combined with microseparation, wear rates increased by 17-fold compared to the standard. microseparation provokes edge loading and can occur following ra where poor bone quality or avascular bone dictates that more bone than usual is moved from the pole of the head. as resurfacing does not readily allow for the adjustment of length, microseparation may occur at the articular interface. collagen deficiency and joint laxity – as for example encountered with ehlers danlos syndrome – can also result in microseparation. microseparation can therefore be the cause of increased metal wear even where the implants appear radiologically perfectly orientated. figure 3. data from the 10th report (2013) of the uk and wales njr showing the increase rate of resurfacing from 2005–2007, but reducing to 1% by 2012 figure 4. data from the 8th report (2011) of the uk and wales njr showing the increased failure rate of resurfacing. this is surpassed by mom bearings (mostly 36 mm or larger) by year 6. an increased generation of metallic debris is associated with an increased incidence of pathological biological responses saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 2:46 pm page 23 page 24 sa orthopaedic journal spring 2014 | vol 13 • no 3 xl-thr the genesis of xl-thr has been described above. the concept of a high performance bearing with virtually no risk of dislocation proved very attractive to surgeons, and the use of xl-thr rapidly surpassed that of ra. however, unexpectedly the failure and revision rate of these implants exceeded those of ra.16 garbuz et al. reported that the blood metal ion levels were approximately ten-fold higher with the xl-thr than in a matched cohort of ra. long et al.17 reviewed 181 xl-thr at mean follow-up of 1–2 years, and noted that 15% had been revised while 14% had clinical and/or radiological signs of impending failure. xl-thr is susceptible to the same issues at the mom articular interface as ra. however, all total hip replacements with large mom bearings are also susceptible to fretting and corrosion at the head/taper junction. this is associated with the liberation of metallic debris and a significant incidence of adverse reaction to metallic debris (armd). there are many factors that would predispose to fretting or corrosion with failure at the taper junction. these include: 1. a contaminated taper (blood/fat etc.): it is essential with any modular head to meticulously clean and dry the taper before application of the head. 2. the head is not sufficiently firmly impacted to fully engage the taper. 3. the head is not applied axially in line with the taper. this can prevent full seating of the head, consequently provoking early micromotion with fretting and corrosion. 4. cone angles have been reduced and trunnions have been made shorter with resultant increased localised stresses. 5. most of these large ‘endoheads’ are applied onto a sleeve which is fitted to the taper. some of these sleeves are titanium, and the titanium/titanium junction in this setting is associated with significant fretting and corrosion. 6. larger heads are associated with an increased ‘arc of cover’ and reduced wear in ra. however, the larger the head in an xl-thr, the greater the head taper offset (figure 6).18 this results in increased torque and bending moments at the taper, with a consequent increased risk of fretting and associated corrosion. high body weights and activities are associated with higher loads, which could increase the risk of fretting-induced implant failure in the clinical setting. it was probably the unexpectedly high failure rate of these thrs with large bore mom bearings (>36 mm) which induced smith et al.19 to comment that ‘metal-on-metal stemmed implants give poor implant survival compared to other options and should not be implanted’. biological response to metal debris it should be recognised that metal ions are released from any metal implanted in the body. these can be widely distributed throughout the body even with a metal-onpolyethylene bearing.20 well-functioning metal-on-metal bearings have very low volumetric wear, but generate a very large number of tiny nanometre particles. mom bearings functioning in adverse conditions are associated with increased volumetric wear, and the generation of larger particles. the uptake of particles smaller than 150 nm is mediated by the cell membrane through endocytosis and pinocytosis.21 particles larger than 150 nm can stimulate phagocytosis by specialised cells such as macrophages.22 particle size will therefore influence the genesis of the biological response. co and cr ions may cause mutagenicity (dna damage, aneuploidy), allergy, type four t-cell mediated hypersensitivity (aseptic lymphocyte-dominated vasculitis-associated lesion or alval), toxicity (cell death) and a cyto-chemical response (chronic inflammatory/granulomatous). figure 5. the ‘arc of cover’ is represented by ‘a’ in the diagram. any factor that reduces the ‘arc of cover’ may contribute to increase wear. figure 6. with xl-thr the larger the head, the larger the lever arm generating torque and bending moment at the taper junction saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 2:47 pm page 24 sa orthopaedic journal spring 2014 | vol 13 • no 3 page 25 the biological response to metallic debris is influenced both by the volume of debris and the morphology of the particles. daley et al.23 showed that wear debris damaged chromosomes in a dose-dependent manner. however, after reviewing the evidence, the mhra (medicines and health regulatory agency – uk) concluded that there was no evidence that elevated levels of co and cr were associated with clinical effects. nevertheless, given the long-term latent period to the expression of small particle disease, learmonth and case24 have noted that ‘there is no room for complacency’. ‘pseudotumours’ in association with mom resurfacing were first reported by pandit et al. in 200825 in three different resurfacing devices. these lesions can be cystic or solid, and can be very large, invading the periprosthetic soft tissues (figures 7a and b). these patients typically present with pain and a local or regional swelling, but may also exhibit a neuropathy, instability, etc. pseudotumours’ are typically characterised histologically by extensive necrosis, although there may also be heavy infiltrates of lymphocytes. these lesions are usually dose-dependent, although they can occur in asymptomatic patients, and in patients with normal levels of metal ions. non-dose-dependent biological reactions to metallic debris include allergies and alval (aseptic lymphocyte-dominated vasculitis-associated lesion). allergies associated with metal implants are well documented in the literature, but are relatively rare. they may be elicited by nickel, cobalt and chromium –constituents of all ra and xl-thr bearings. these patients often present with widespread rashes on the trunk and limbs, which quickly resolve when the implants are exchanged for titanium alloy implants combined with a ceramic/ceramic or ceramic/polyethylene articulation. alval was reported by willert et al.26 in 2005 in a series of patients with 28 mm mom heads. the patients presented clinically with pain around the hip and signs of synovitis and an effusion. it is typically associated with low wear, and the diagnosis confirmed histologically with perivascular lymphocytic cuffs together with plasma cells and macrophages that contain metal particles. davies et al.27 reported similar findings and suggested that this was some form of immunological response that could represent a novel biological mechanism that could lead to early failure of mom devices. alval appears to be an idiosyncratic delayed t-cell type four hypersensitivity reaction, which seems to occur relatively rarely. discussion a metal-on-metal bearing produces very low wear, is ‘selfhealing’ and does not fracture. so what went wrong? randelli et al.28 have reported a 95% survivorship of 28 mm metasul mom bearings at 15-year follow-up. a huge number (>100 000) of these bearings have been inserted without reports of adverse reaction to metallic debris (armd) – except for the occasional case of alval. histological patterns similar to alval were noted in the periprosthetic tissue around a small number of mckeefarrar prostheses.29 these were probably the wellfunctioning bearings. conditions of high wear (edge loading etc.) were usually associated with high frictional torque, and the fixation of the mckee-farrar implants was not adequate to prevent early loosening and failure. the periprosthetic soft tissues were therefore seldom presented with a significant volume of debris consisting of larger particles of metal. figure 7 a and b. ‘pseudotumours’ are generally large and may be either cystic (a) or solid (b). the biological response to metallic debris is influenced both by the volume of debris and the morphology of the particles. ba saoj spring 2014_orthopaedics vol3 no4 2014/07/31 11:49 am page 25 page 26 sa orthopaedic journal spring 2014 | vol 13 • no 3 the design features of mom resurfacing components that contributed to an increased vulnerability to wear have been alluded to above. however it should be recognised that all large bore mom bearings are less forgiving of technical errors. in addition resurfacing arthroplasty is a technically challenging procedure. it is therefore of interest that the implant that was released with a ‘no train no use’ policy has the best results in the national registries! most resurfacing devices were extensively tested in simulators in the laboratory. however these regimens did not test true activity of daily living cycles, nor did they test performance under adverse conditions. this has been acknowledged by fisher et al.,30 and new testing protocols have been modified to address these issues. however, the orthopaedic community should by now have learnt of the danger of exporting concepts generated from simulators in the rarefied environment of the laboratory to the highly complex biological system that is the human body. it should be mandatory that there is a critical objective assessment of shortand mid-term clinical outcomes before any new implant is released to the wider patient community. hart et al.31 have noted that edge loading was the most important predictor of wear rate, but the majority of retrieved implants did not have excessive edge loading. microseparation can of course provoke edge loading in well-orientated implants. vossinakis et al.32 observed that the inclination of the sourcil was a good predictor as to whether a patient would develop supero-lateral arthritis or medial pole arthritis of the hip. this was a function of the joint kinematics and the resultant vectoral force. a more lateral vectoral force could provoke functional edge loading, and conversely a more vertically orientated cup could be protected from edge loading by a more medially orientated vector. the xl-thr was developed to address the problem of femoral neck fracture in ra. this allowed only the femoral component to be revised. the incidence of dislocation following conventional thr was reported as 2–3%, and dislocation was identified as the commonest cause of early revision. it appeared that the xl heads (>36 mm) addressed the problem of dislocation, and the technology was enthusiastically embraced by surgeons. the xl bearings were regarded as a ‘safety net’ against dislocation, and meticulous attention to component placement was neglected – and this with a device that was less forgiving of imperfect technique! charnley33 reported an incidence of dislocation of 0.4% using a 22.2 mm head, and felt that even this incidence could be reduced or eliminated by the use of a neck length jig. these outstanding results are attributable to a meticulous and reproducible technique. companies should not be designing implants to address the technical inadequacies of the surgeon – the focus should be on appropriate instrumentation, technique and training. no one anticipated the problem of micromotion and instability at the cone taper junction producing fretting and corrosion. retrospectively i believe it is fair to say that the implications of the reduction in taper size together with the increased torque and bending moments produced by large heads should at least have been considered by our engineering colleagues. the problem has dramatically declared itself clinically, and i fear the reactive research activity is now too little and too late. langton et al.34 introduced the term armd. it is nonspecific and encourages clinicians not to distinguish between the discrete aetiopathogenetic entities that constitute the biological reactions to metallic debris. the biological response to metallic debris is still poorly understood. the diagnostic entities of ‘pseudotumour’ and alval have not been clearly defined. confusion and inconsistencies exist between clinician, radiologist and histopathologist. in some cases there may well be an overlap of diagnostic features. some findings may be incidental and of no consequence. it has been suggested that armd lesions may occur in up to 50% of patients with large bore mom bearings. indeed an incidence of 28% at 5 years has been reported with the bhr,35 the best performing ra. many of these ‘lesions’ may prove to be normal incidental findings, and more severe lesions only occur in approximately 5% of cases. jacobs et al.36 has noted that the biological implications of elevated metal levels in the blood and urine remain the most significant concern about mom couples. however there is currently no established toxicity threshold for the degradation products of cobalt alloy implants. mom bearings have been successfully used in clinical practice. today the adverse biological reaction to metal debris, the media attention and associated ‘hysteria’ have resulted in their use being largely abandoned (figure 8). at present this is appropriate. however, we should recognise that it is not just the metal-on-metal bearing that is culpable: the manufacturing companies, our bioengineering colleagues and we, the orthopaedic community, are jointly and severally responsible. the author is a consultant for de puy, but no benefits of any form have been or will be received from a commercial party related directly or indirectly to the subject of the article. mom bearings have been successfully used in clinical practice, but today the adverse biological reaction to metal debris and the media attention and associated ‘hysteria’ have resulted in their use being largely abandoned figure 8. the uk and wales njr shows that the use of metal-onmetal bearings has fallen from a high of approximately 15 000 in 2008 to just a few hundred today. saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 2:47 pm page 26 sa orthopaedic journal spring 2014 | vol 13 • no 3 page 27 references 1. willert hg, buchhorn gh, gobel d, koster g, schnaffner s, schenk r, semlitsch m. wear behaviour and histopathology of classic metal-on-metal hip endoprostheses. clin ortop rel res 1996;329 suppl:s187-205. 2. brown sr, davies wa, deheer dh, swanson ab. long term survival of mckee farrar total hip prostheses. clin orthop rel res 2002 sept;402:157-63. 3. jacobsson sa, djerf k, wahistrom o. twenty year results of the mckee farrar versus the charnley prosthesis. clin orthop rel res 1996 aug;329(suppl):s60-80. 4. harris wh. the problem is osteolysis. clin orthop rel res 1995 feb;311:46-53. 5. howie dw, cambell d, mcgee m, cornish bl. wagner resurfacing hip arthroplasty. the results of one hundred consecutive arthroplasties after 8-10 years. j bone joint surg am 1990 jun;72(5):708-14. 6. ring pa. press-fit prosthesis: clinical experience. in: osteoarthritis and the young adult hip – options for surgical management. freeman mar, reynolds da (eds). churchilllivingstone 1989;220-23. 7. mcminn d, treacy r, lin kyaw, pynsent p. metal-on-metal surface replacement of the hip. experience of the mcminn prosthesis. clin orthop rel res 329s, august 1996;s89-98. 8. crowinshield rd, maloney wj, wentz dh, humphrey sm, blanchard cr. biomechanics of large femoral heads: what they do and don’t do. clin orthop rel res 2004 dec;429:102107. 9. stroh da, issa k, johnson aj, delanois re, mont ma. reduced dislocation rates and excellent functional outcomes with large diameter femoral heads. j arthroplasty 2013 sept;28(8):1415-20. 10. jacobs jj. large (36 or 40mm) femoral heads decreased the rate of dislocation after revision hip arthroplasty. j bone joint surg am 2012 nov 21;94(22):2095. 11. mcminn dj, daniel j, ziaee h, pradhan c. indications and results of hip resurfacing. int orthop 2011 feb;35(2):231-37. 12. coulter g, young da, dalziel re, shimmin aj. birmingham hip resurfacing at a mean of ten years: results from an independent centre. j bone joint surg br 2012 mar;94(3):315-21. 13. bishop ne, hothan a, morlock mm. high friction moments in large hard on hard hip replacement bearings in conditions of poor lubrication. j orthop res 2013 may;31(5):807-13. 14. morlock mm, bishop n, zustin j, hahn m, ruther w, amling m. modes of hip failure after hip resurfacing: morphological and wear analysis of 267 retrieval specimens. j bone joint surg am 2008 aug;90 suppl 13:89-95. 15. leslie ij, williams s, isaac g, ingham e, fisher j. high cup angle and microseparation increases the wear of hip surface replacements. clin orthop rel res 2009;467(9):2259-65. 16. garbuz ds, tanzer m, greidanus nv, masri ba, duncan cp. the john charnley award: metal-on-metal hip resurfacing versus large diameter head metal-on-metal total hip replacement: a randomized clinical trial. clin orthop rel res 2010 feb;468(2):318-2 17. long wt, dastane m, harris mj, wan z, dorr ld. failure of the durom metasul acetabular component. clin ortop rel res 2010 feb;468(2):400-405. 18. langton dj, sidaginamale r, lord jk, nargol avf, joyce jt. taper junction failure in large diameter metal-on-metal bearings. bone and joint research april 2012;1(4):56-63. 19. smith aj, dieppe p, vernon k, porter m, blom aw. failure rates of stemmed metal-on-metal replacements; analysis of data from the national joint registry of england and wales. lancet 2012 mar 31;379(9822):1199-204. 20. langkamer vj, case cp, heap p, taylor a, collins c, pearse m, solomon l. systemic distribution of wear debris after hip replacement. a cause for concern? j bone joint surg br 1992 nov;74(6):831-79. 21. shukla r, bansal v, chandhary m, basu a, bhonde rr, sastry m. biocompatibility of gold nanoparticles and their endocytic fate inside the cellular compartment: a microscopic overview. langmuir 2005 nov 8:21(23):10644-54. 22. trindade mc, lind m, sun d, schurman dj, goodman sb, smith rl. in vitro reaction to orthopaedic biomaterials by macrophages and lymphocytes isolated from patients undergoing revision surgery. biomaterials 2001 feb;22(3):253-59. 23. daley b, doherty at, fairman b, case cp. wear debris from hip or knee replacements causing chromosomal damage in human cells in tissue culture. j bone joint surg br 2004 may;86(4):598-606. 24. learmonth id, case cp. metallic debris from orthopaedic implants. lancet 2007 feb;369(9561):542-44. 25. pandit h, glyn-jones s, mclardy-smith p, gundle r, whitwell d, gibbons clm, ostlere s, thanasou n, gill hs, murray dw. pseudotumors associated with metal-on-metal hip resurfacing. j bone joint surg (br) 2008;90-b(7):847-45. 26. willert h-g, buchhorn gh, fayyazi a, flury r, windler m, koster g, lohman ch. metal-on-metal bearings and hypersensitivity in patients with artificial hip joints. a clinical and histomorphological study. j bone joint surg 2005;67-a(1):2836. 27. davies p, willert h-g, campbell pa, learmonth id. case pc. an unusual perivascular lymphocytic infiltration in tissues around contemporary metal-on-metal joint replacements. j bone joint surg 2005 jan;87(1):18-27. 28. randelli f, banci l, d’anna a, visentin o, randelli g. cementless metal-on-metal total hip arthroplasties at 13 years. j arthroplasty 2012 feb;27(2):186-92. 29. willert h-g, buchhorn g, fayyazi a, lohman c. histopathological changes around metal/metal joints indicate delayed type hypersensitivity. preliminary results in 14 cases. osteologie 2000;9:2-16. 30. leslie i, williams s, isaac g, hatto p, ingham e, fisher j. wear of surface engineered metal-on-metal bearings for hip prostheses under adverse conditions with the head loading on the rim of the cup. proc inst mech eng 2013 apr;2247(4):345-49. 31. hart aj, muirhead-allwood s, porter m, mathies a, maggiore p, underwood r, cann p, cobb j, skinner ja. which factors determine the wear rate of large-diameter metal-on-metal hip replacements? multivariate analysis of 276 components. j bone joint surg am 2013 apr 17;95(8):67885. 32. vossinakis lc, karnezis la, parry k, learmonth id. radiographic associations for ‘primary’ hip osteoarthrosis: a retrospective cohort study of 47 patients. acta orthop scand 2001 dec;72(6):600-608. 33. charnley j. in: low friction arthroplasty of the hip. springer verlag 1979 chapter 19 post-operative dislocation:314-19. 34. langton dj, jameson s, joyce t, hallab nj, natu s, nargol av. early failure of metal-on-metal bearings in hip resurfacing and large diameter total hip replacement: a consequence of excessive wear. j bone joint surg br 2010 jan;92(1):38-46. 35. bisschop r, boomsma mf, van raay jj, tiebosch at, maas m, gerritsma cl. high prevalence of pseudotumor in patients with a birmingham hip resurfacing prosthesis: a prospective cohort study of 129 patients. j bone joint surg am 2013 sep;95(17):1554-60. 36. jacobs jj, skipor ak, campbell pa, hallab nj, urban rm, amstutz hc. can metal levels be used to monitor metal-onmetal hip arthroplasties? j arthroplasty 2004 dec;19(8suppl):59-65. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 2:48 pm page 27 404 not found south african orthopaedic journal orthopaedic oncology and infections doi 10.17159/2309-8309/2021/v20n3a8 de stadler jl et al. sa orthop j 2021;20(3) citation: de stadler jl, kruger n, singh s, banderker e, dixpeek s, pillay k. malignant transformation in an 11-year-old child with multiple hereditary exostosis. sa orthop j 2021;20(3):183a-e. http://dx.doi. org/10.17159/2309-8309/2021/ v20n3a8 editor: prof. theo le roux, university of pretoria, pretoria, south africa received: august 2020 accepted: november 2020 published: august 2021 copyright: © 2021 de stadler jl. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background multiple hereditary exostosis (mhe) is a rare autosomal dominant disorder predisposing to the development of multiple osteochondromas. malignant transformation is an uncommon complication of osteochondromas and is especially rare in the paediatric population. making a diagnosis of malignant transformation is recognised as a challenge globally. methods we obtained informed consent and ethics approval prior to reviewing the hospital file, radiology and pathology of our index patient, as well as conducting a directed literature search. results an 11-year-old male with mhe presented with new onset pain in the right leg with an associated inability to weight bear. plain radiographs and magnetic resonance imaging (mri) showed features consistent with malignant transformation. the child underwent a malawer 1 resection of the proximal fibula with no complications. the pathology confirmed a grade 1 secondary peripheral chondrosarcoma (cs) arising in an osteochondroma. the rate of malignant transformation in mhe is as high as 36.3% in select specialist tertiary centres. ninety per cent of the resultant malignancies are chondrosarcomas. malignant transformation before the age of 20 years is exceptional. plain radiology is routinely used for monitoring of patients with mhe. other modalities exist to assess for cartilage cap thickness, a much-debated criterion of malignant change. pathology is essential for confirmation of malignant transformation as well as to exclude high grade lesions. treatment is wide local excision (wle) with limb-sparing surgery and long-term follow-up to detect for local recurrences. conclusion the malignant transformation of osteochondromas occurs more frequently in individuals with mhe and may even arise in the paediatric population. in the presence of suspicious clinical or radiological features, en-bloc surgical resection and histopathological correlation is mandatory to make the diagnosis. we encourage a multidisciplinary team approach with collaboration between the orthopaedic surgeon, radiologist and pathologist. level of evidence: level 5 keywords: multiple hereditary exostosis (mhe), chondrosarcoma, osteochondroma, malignant transformation malignant transformation in an 11-year-old child with multiple hereditary exostosis janet l de stadler,¹* neil kruger,² shivani singh,¹ ebrahim banderker,³ stewart dix-peek,⁴ komala pillay¹ ¹ division of anatomical pathology, groote schuur and red cross war memorial children’s hospital, national health laboratory services, university of cape town, cape town, south africa ² department of orthopaedics, groote schuur and red cross war memorial children’s hospital, life kingsbury hospital, university of cape town, cape town, south africa ³ department of diagnostic radiology, red cross war memorial children’s hospital, university of cape town, cape town, south africa ⁴ paediatric orthopaedic unit, red cross war memorial children’s and maitland cottage hospitals, university of cape town, cape town, south africa *corresponding author: rbljan001@myuct.ac.za https://orcid.org/0000-0001-6246-1716 de stadler jl et al. sa orthop j 2021;20(3)page 183b introduction multiple hereditary exostosis (mhe), also known as multiple osteochondromas (mo), is a rare autosomal dominant disorder with a prevalence of approximately 1 in 50 000 in the general population.1 the majority have germline mutations in either the ext1 or ext2 tumour suppressor genes, which encode proteins involved in chondrocyte proliferation and differentiation.2,3 osteochondromas are variably sized, benign cartilaginous neoplasms arising from the external, juxtaepiphyseal region of bones which have formed by endochondral ossification. they may be sessile or pedunculated and are composed of an external cartilage cap, underlying cortical bone, and an innermost medullary cavity which merges with that of the bone of origin.1,4 the most frequently affected sites include the distal femur, proximal tibia and humerus.1 mhe is more likely to affect males and is characterised by multiple osteochondromas, often accompanied by short stature with or without angular or limb length deformities. individuals with a family history and at least two juxtaepiphyseal long bone osteochondromas are diagnosed clinically. genetic testing is not required. these osteochondromas may present soon after birth and continue to grow throughout childhood until the growth plates close. the majority of affected individuals are diagnosed by the age of 12 years.1,2 osteochondromas are frequently painless and slow growing, mostly causing a cosmetic deformity.4 however, the direst complication is that of malignant transformation, invariably due to a secondary chondrosarcoma (cs).4 this transformation, as discussed later, is especially rare in children.2 case report an 11-year-old male, known to the orthopaedic department at red cross war memorial children’s hospital with mhe, presented with new onset right knee pain and an associated inability to fully weight bear for three days. there were no associated fevers or systemic upset. he was first diagnosed at the age of 4 years. by 10 years he had osteochondromas in both proximal humeri, both femurs (proximally and distally), both proximal tibias, the right distal tibia, the right mid-distal ulna and the right proximal fibula. clinically he had an antalgic gait and the pain was localised to the distal medial femoral condyle. there was no effusion. he achieved full extension, but flexion beyond 90° was resisted. concern regarding sarcomatous change was raised on plain radiographs of the knee. comparison with images two years prior yielded sinister interval morphological change and exuberant growth of a singular osteochondroma located at the medial metaphysis of the right proximal fibula (figures 1 and 2). preand post-contrast enhanced magnetic resonance imaging (mri) then demonstrated aggressive bone changes commensurate with malignant transformation (figures 3 and 4). most notable was the irregularity of the overlying cartilage cap and abrupt margination of an enhancing t2 hyperintense underlying intramedullary soft tissue mass. the child underwent a malawer 1 resection, an en bloc yet marginal resection of the proximal fibula and tumour, sparing the common peroneal nerve (cpn) and anterior tibial artery.5 the resected specimen was large (figure 5a), and the cpn had to be figure 1. lower limb frontal radiograph (9 years of age). multiple, bilateral, sessile osteochondromas (bony exostoses). note typical metaphyseal location with cortical and medullary continuity of the lesion and the underlying native bone. figure 2. frontal radiograph of the right lower limb (11 years of age). disproportionate expansile growth of the medial metaphyseal osteochondroma of the right proximal fibula (red arrow) when compared with the other bony exostoses (blue arrows). note increased bony sclerosis and indistinct superomedial cortex (yellow arrows). de stadler jl et al. sa orthop j 2021;20(3) page 183c mobilised near the full length of the incision to ensure complete excision. the bulbous growth of the tumour both into and below the proximal tibiofibular joint notched into the adjacent tibia and made deep dissection difficult. the proximal tibiofibular joint and a small segment of adjacent tibial metaphysis were excised. the lateral collateral ligament complex, having been initially detached from the proximal fibula, was whipstitched with a 3 ethibond and reattached to the proximal lateral tibia via transosseous drill holes and periosteal suturing. the tourniquet was released to ensure meticulous haemostasis. the wound was closed in layers and a pressure dressing applied. he was discharged home in an aboveknee backslab after an uneventful hospital stay. he attended outpatient physiotherapy and was reviewed at two, four, six and ten weeks post-surgery. wound healing was slow, with some sloughing and necrosis of the edges. by ten weeks, he was partially weight-bearing without assistance and had 10–120° range of movement at the knee. he was completely well at his five-month follow-up, and was asked to return in six months to continue annual surveillance. cut section of the specimen confirmed the irregularity of the overlying cartilage cap (figure 5b). microscopy confirmed a figure 3. coronal mri right lower limb: t2 fat suppressed (stir). homogeneously t2 hyperintense cartilage cap, measuring 13 mm maximally (double-headed blue arrow), overlies the serrated bony margin. the underlying heterogeneous medullary bone lesion is sharply marginated against the fat-suppressed normal fatty marrow. note linear as well as dot and arc low signal foci within the t2 hyperintense matrix of the medullary bone lesion. a b c post-gadolinium post-gadolinium figure 4. coronal mri right lower limb 4a. pre-contrast t1-weighted image without fat suppression (fs). note the t1 hypointense soft tissue underlying the intensely low signal cartilage cap (yellow star) sharply contrasted against the normal high signal marrow fat. 4b (without fs) and 4c (with fs) post-gadolinium t1-weighted images. note the avid enhancement of the soft tissue component of the heterogeneous medullary soft tissue. a b figure 5. right proximal fibula resection 5a. whole specimen. the specimen measured 90 mm × 65 mm × 55 mm. note the medial expansile osteochondroma (blue circle). 5b. cut section. note the irregular cartilage cap, measuring 18 mm maximally. the intramedullary soft tissue component identified radiologically is inconspicuous on gross dissection. de stadler jl et al. sa orthop j 2021;20(3)page 183d grade 1 secondary peripheral cs/atypical cartilaginous tumour (act) arising in an osteochondroma (figure 6). discussion the rate of malignant transformation in mhe is between 3% and 5%,4 although figures are as high as 36.3% in specialist tertiary centres which see a preselected high-risk population.6 the rate is higher for centrally located lesions, for example, in the pelvis, compared to peripherally located lesions, such as around the knee.7-9 this may be the result of early excision of peripheral lesions due to more frequent benign complications.9 the average time to malignant transformation is 9.8 years from initial diagnosis. ninety per cent of the resultant malignancies are cs.8 act is the preferred term for a grade 1 peripheral cs arising in the appendicular skeleton and, apart from their location, are identical to the axial counterpart grade 1 peripheral cs.1 making a diagnosis of a secondary cs is recognised as a challenge globally,6 and emphasis is placed on a multidisciplinary team approach with collaboration between the orthopaedic surgeon, radiologist and pathologist.7 clinical malignant transformation before the age of 20 years is exceptional4 and most data are from case reports or series.3,6,9 one may suspect malignant transformation in an adult presenting with an enlarging osteochondroma and/or pain,2,6 or due to changes noted at annual review.6 in contrast, growth and pain of a pre-existing lesion in the skeletally immature population are not as concerning.3 case reports, however, do describe mild pain, gait abnormalities, and a clinically enlarging lesion as features prompting investigation and eventual diagnosis of secondary cs in children.3 in this case, the non-localising pain was likely a red herring prompting imaging which then raised the suspicion for further investigation. this was three months ahead of his scheduled annual review. as the excised lesion was a grade 1 act, later detection at this date would have been unlikely to have affected the outcome. radiology plain radiology is routinely used for monitoring of patients with mhe for malignant change. features to note include irregularity of the surface, foci of radiolucency, heterogeneity, non-uniform calcification, erosion of the adjacent bone and an associated soft tissue mass.4,6 mri is necessary to determine the cartilage cap thickness in suspected cases. in addition, mri can more accurately delineate a soft tissue mass, and allow for surgical planning.6,8 ultrasound scanning may also be used to measure cartilage cap thickness.4 while a cartilage cap thickness of 2 cm or greater has been suggested to be 100% sensitive and 98% specific for secondary cs using mri,8 a thickness of 1.5 cm or greater is still considered sufficiently concerning.3,4 furthermore, several conflicting case reports of cs show measurements between 0.5 and 1.5 cm.6,7 some authors propose that the cartilage cap quality may be more important than the thickness,6 while others advocate that cartilage cap thickness should not be used as an indicator of malignant transformation in the paediatric population at all.4 in this case, placing too much reliance on a cartilage cap cut-off of 2 cm would have resulted in misdiagnosis and delayed treatment. pathology as in this case, up to 85% of secondary cs are grade 1 lesions.4,6,7,9 distinguishing a grade 1 peripheral cs/act from an osteochondroma on histology is subjective. features such as nodularity, binucleate chondrocytes, myxoid degeneration and irregular calcifications may frequently be present in both lesions.7 an infiltrative growth pattern6 and invasion of surrounding soft tissue and bone cortex, when present, may assist in the diagnosis.4 in our case, the clear transition from low to high cellularity within the thickened cartilage cap, as well as the infiltration of fatty marrow by myxomatous cartilage and irregular calcifications in the areas corresponding with the t2 hyperintensity on mri were compatible with transformation. microscopy is also essential to exclude a grade 2, 3 or dedifferentiated cs by observing the lack of mitotic activity, nuclear pleomorphism and a malignant spindle cell component.7 in addition, it is useful for subtyping, the majority of which are cs, not otherwise specified (nos). alternate subtypes may impact both treatment and prognosis.10 management and prognosis cs ideally require wide local excision (wle) with limb-sparing a c b figure 6. microscopy 6a. low power (4×). note the marked increase in cellularity from right to left within the cartilage cap. also note the replacement of fatty marrow (right) by disorganised growth plate, myxoid degeneration and irregular calcification (left), corresponding with the t2 hyperintense intramedullary mass. 6b. intermediate power (10×). note the increased cellularity in the areas of increased cartilage cap thickness overlying t2 hyperintense intramedullary mass. 6c. high power (20×). occasional chondrocyte binucleation (arrow) is present. note the lack of significant nuclear pleomorphism and mitotic activity. de stadler jl et al. sa orthop j 2021;20(3) page 183e surgery to prevent recurrence. care must be taken to excise the entire perichondrium and prevent myxomatous cartilage leak into the surgical bed to minimise the risk of recurrence.3,4,6,7 marginal excision may be considered in surgically challenging locations.6,7 both chemotherapy and radiotherapy are of little benefit as cs are mostly resistant.4,6,10 if there is uncertainty of malignant transformation, close follow-up with serial imaging and timely surgical treatment is appropriate.2,3,8 pre-excision biopsy is not advised, unless a high-grade malignancy is suspected.3 long-term follow-up is essential to detect local recurrences, which often occur in the first five years after surgery and occur slightly more often in individuals with mhe.6 recurrence rates in wles are low, between 0% and 15%, whereas rates in marginal or intralesional resections are much higher, between 57% and 78%.4 regardless, annual clinical review and radiological screening, ideally mri, is recommended for all individuals with mhe.1,2 the majority of deaths are due to complications of a local recurrence, highlighting the need for adequate surgical excision. importantly, repeated excisions for recurrent lesions can result in eventual progression to a higher-grade cs.6 the frequency of follow-up of cases with prior malignant transformation is not addressed by the literature reviewed. conclusion the malignant transformation of osteochondromas occurs more frequently in individuals with mhe and may even arise in the paediatric population. the diagnosis is especially challenging in this age group. in the presence of suspicious clinical or radiological features, en-bloc surgical resection and histopathological correlation is mandatory to make the diagnosis. long-term follow-up is essential to detect recurrences. we encourage a multidisciplinary team approach with collaboration between the orthopaedic surgeon, radiologist and pathologist. acknowledgement we thank jurgen geitner, senior technical officer at the university of cape town (uct) pathology learning centre, for providing the whole slide images for the micrographs. ethics statement prior to commencement of the study, ethical approval was obtained from the human research ethics committee, faculty of health sciences, university of cape town. hrec ref: 675/2020, and written informed consent was obtained from the legal guardian. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions de stadler jl: primary author, conceptualisation, design, data collection, analysis, and manuscript preparation, critical revision for important intellectual content and final approval of the version submitted to the journal kruger n: data collection, analysis, manuscript preparation, critical revision for important intellectual content and final approval of the version submitted to the journal singh s: data collection, critical revision for important intellectual content and final approval of the version submitted to the journal banderker e: manuscript preparation, critical revision for important intellectual content and final approval of the version submitted to the journal dix-peek s: critical revision for important intellectual content and final approval of the version submitted to the journal pillay k: critical revision for important intellectual content and final approval of the version submitted to the journal orcid de stadler jl https://orcid.org/0000-0001-6246-1716 kruger n https://orcid.org/0000-0002-0929-2092 dix-peek s https://orcid.org/0000-0002-3382-8790 pillay k https://orcid.org/0000-0003-1971-900x references 1. bovée jvmg, hogendoorn pcw, sangiorgi l. genetic tumour syndromes of 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patients. j orthop sci. 2007;12(5):415-23. available from: https://pubmed.ncbi.nlm.nih.gov/17909925/. 10. wu a-m, li g, zheng j-w, et al. chondrosarcoma in a paediatric population: a study of 247 cases. j child orthop [internet]. 2019 feb;13(1):89-99. available from: https://online.boneandjoint.org.uk/doi/10.1302/1863-2548.13.180109. https://orcid.org/0000-0001-6246-1716 https://orcid.org/0000-0002-0929-2092 https://orcid.org/0000-0002-3382-8790 https://orcid.org/0000-0003-1971-900x _hlk68842322 gericke e et al. sa orthop j 2020;19(2) doi 10.17159/2309-8309/2020/v19n2a3 south african orthopaedic journal http://journal.saoa.org.za arthroplasty citation: gericke e, de beer j, deacon m, marais lc. percutaneous intra-articular tranexamic acid following total knee arthroplasty without drainage to reduce blood loss. sa orthop j 2020;19(2):74-78. http://dx.doi.org/10.17159/2309-8309/2020/v19n2a3 editor: dr michael held, university of cape town, south africa received: june 2019 accepted: november 2019 published: may 2020 copyright: © 2020 gericke e. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for the purposes of performing this study. conflict of interest: all authors confirm they have no conflicts of interest to declare with regard to this article. abstract background: administration of tranexamic acid (txa) peri-operatively is a well-recognised strategy used by orthopaedic surgeons to reduce blood loss during total knee arthroplasty (tka). furthermore, not using a drain has been advocated to be a safe and effective way to further reduce blood loss. the main aim of this study is to assess the effect of a combination of these two strategies on total blood loss associated with tka. methods: this is a retrospective study conducted on a single surgeon’s data gathered over a two-year period. this study compares the blood loss in two groups of patients. the control group received no antifibrinolytic agents and a drain was inserted, while the study group received txa and the drain was omitted. results: a total of 109 patients were included in the analysis, with 86 patients in the study group and 23 patients in the control group. the two groups were compared in terms of pre-operative haemoglobin, american society of anesthesiologists (asa) score and body mass index (bmi). the mean age of the study group was lower than that of the control group (64±8 years vs 68±9 years; p=0.03). the mean total blood loss was lower in the study group compared to the control group (mean difference 171.8 ml; 95% ci 31.2–312.2; p=0.01). duration of hospital stay was also reduced in the study group (2.4 days vs 3.1 days; p=0.003). there was, however, no difference in the functional outcome according to the knee injury and osteoarthritis outcome score (koos). conclusion: these findings are in accordance with previous studies, indicating that intra-articular administration of txa and omission of negative pressure drainage may be associated with a reduction in blood loss following tka. larger, well-designed studies are required to determine the optimal txa administration strategy. level of evidence: level 4 keywords: total knee arthroplasty, tranexamic acid, intra-articular, blood loss percutaneous intra-articular tranexamic acid following total knee arthroplasty without drainage to reduce blood loss gericke e1 , de beer j2 , deacon m3 , marais lc4 1 mbchb; orthopaedic registrar, department of orthopaedic surgery, university of kwazulu-natal; king edward hospital, durban, south africa ² mbchb, hdip(ortho), fc ortho(sa); specialist orthopaedic surgeon, gateway private hospital and alberlito hospital, durban, south africa ³ mbchb, mmed(hdip(ortho), fc ortho(sa); specialist orthopaedic surgeon, gateway private hospital and alberlito hospital, durban, south africa 4 mbchb, fc orth sa, mmed(ortho), phd; head of department of orthopaedic surgery, university of kwazulu-natal, nelson r mandela school of clinical medicine, durban, south africa corresponding author: dr e gericke, po box 177, winklespruit, 4145; tel: 083 276 8703; email: bertusgericke@gmail.com https://orcid.org/0000-0002-7613-9266 https://orcid.org/0000-0002-2692-4717 https://orcid.org/0000-0002-1100-1370 https://orcid.org/0000-0002-1120-8419 page 75gericke e et al. sa orthop j 2020;19(2) introduction blood loss is a common and challenging complication in total knee arthroplasty (tka), which has been reported as ranging from 700 ml to 1 700 ml.1,2 substantial blood loss could lead to allogeneic blood transfusion, which in itself may be associated with complications and risks to the patient. disease transmission, immunological reaction and increased risk of peri-prosthetic joint infection are some of the unwanted consequences that have been described.3-5 blood loss could also lead to an increase in duration of hospital stay, delayed rehabilitation, an increase in morbidity and increased overall cost per patient.3 blood loss can be attributed to numerous intra-operative, but also post-operative factors. some of the intra-operative factors are the actual surgical intervention itself, the surgical technique and the specific haemostatic measures that were taken during surgery. postoperative blood loss mainly involves a disproportional fibrinolytic activity. the increase in fibrinolytic activity relates to tissue damage caused by surgery, but may also be associated with the use of a pneumatic tourniquet which causes release of tissue plasminogen activator from the vascular endothelium.5,6 furthermore, the use of a drain contributes to increased post-operative blood loss, and it is postulated that it could be due to the loss of tamponade effect.7 multiple strategies have been proposed to reduce blood loss following tka, which can be divided into pre-, intraand postoperative strategies.8 administration of tranexamic acid (txa) peri-operatively is one of the strategies used to reduce blood loss during tka. this approach has been researched extensively, and numerous studies on the topic have recently been published.4-6 furthermore, not using a drain has been advocated to be a safe and effective way to further reduce blood loss.1,9,10 the main aim of this study is to assess the effect of the combination of these two strategies, namely, injecting txa intra-articularly and omitting negative pressure draining post-operatively, on total blood loss associated with tka. patients and methods a retrospective cohort study was conducted on a single surgeon’s data gathered over a two-year period, from january 2016 to december 2017. all patients who had primary cemented unilateral tka (posterior-cruciate substituting) were included in the study. procedure-related exclusion criteria were: primary complex or revision tka, simultaneous bilateral tka, and tka combined with other surgical procedure in the same setting. patient-related exclusion criteria were: patients allergic to txa, inflammatory arthritis as the primary reason for tka, pre-operative anaemia that required pre-op transfusion, history of thromboembolic event, and inability to cease all anticoagulants with exception of low-dose aspirin before surgery. a total of 109 patients were included in the study after the exclusion criteria were met. the surgeon changed his blood loss management protocol within the month of may 2016 from not using antifibrinolytic agents and inserting a drain, to the use of intraarticular txa and omitting a drain. this study compares the two groups of patients. the study group contained 86 patients who received percutaneous intra-articular txa and no suction drain, and the control group included 23 patients who received no txa but had suction drains inserted. data was extracted from patient records. patients’ demographic profiles and general medical health data were collected, which included: age, sex, weight, height, body mass index (bmi), on which side the replacement was done, pre-operative haemoglobin (hb) levels and asa class (american society of anesthesiologists classification).11 furthermore, surgical time, duration of hospital stay and knee injury and osteoarthritis outcome score (koos)12 scores were collected. koos scores were calculated preoperatively and six weeks post-operatively. however, not all koos scores were complete in all patient records. only 65 out 86 patient records in the study group had pre-operative and post-operative koos scores, and 18 out of 23 patient records in the control group had pre-operative and post-operative koos scores. complications during the hospital stay, wound and soft tissue condition, and thromboembolism events were also monitored. patients were given either general anaesthesia with a femoral nerve block or a spinal according to anaesthetist recommendation or patient request. all patients received intravenous prophylactic antibiotics prior to surgery and two further doses post-operatively. a first-generation cephalosporin was used unless contraindicated. a standard midline skin incision with medial para-patellar approach was used with tourniquet inflation only prior to cementing. tourniquet inflation continued for the remaining duration of the surgery until a compressive dressing was applied. the patella was not resurfaced and only debrided from osteophytes if needed. axial alignment was achieved with an extramedullary guide for the tibia and an intramedullary rod guide for the femur. once bony cuts were made, standard soft tissue balancing was used to achieve sagittal and coronal balancing. the posterior cruciate ligament was resected in all patients and a posterior-cruciate substituting (ps) implant was used. all components were fixed with cement. in the study group 2 g (two ampules of 10 ml each, 1  000 mg/10 ml) txa was injected percutaneously and intra-articularly immediately after skin closure prior to tourniquet deflation. this was similar to the method used by wang et al.1 although a higher dose of txa was used in this study. in the control group, a 3 mm closed-circuit portable vacuum drain was inserted and no txa was given to the patient. the drain was removed the next day. the implants used were either the persona® (ps) or the vanguard® (ps) knee system, both from zimmer biomet (warsaw, indiana, usa). the only variation to implants used was one patient from the study group that received a unity kneetm (corin cirencetser, usa). forty-six patients received a persona® implant, 39 patients received the vanguard® implant and one patient received a unitytm implant in the study group. one patient received the persona® implant and 22 patients received the vanguard® implant in the control group. post-operatively all patients in the two study groups were given the same thrombo-prophylactic regimen. a low molecular weight heparin (lmwh) was given post-operatively and continued until discharge. thereafter the lmwh was discontinued and a low-dose aspirin (ecotrin® 81 mg; mercury pharma) was given for a month at home. the lmwh used was 40 mg enoxaparin sodium (clexane® injection; sanofi-aventis, south africa [pty] ltd) subcutaneously as a single dose in the morning. rehabilitation started on the first post-operative day and discharge criteria were: patient could mobilise independently to the bathroom and back, could climb stairs with assistance, could achieve knee flexion of at least 90 degrees, and pain was well controlled. once discharged, patients were followed up after two weeks to assess the wound and range of movement. further followup was at six weeks for assessment of mobility, range of movement and radiological evaluation. thereafter patients were assessed at 6to 12-month intervals, at the surgeon’s discretion. the measurements indicating degree of blood loss included: pre-operative hb levels, post-operative hb levels on day 1 postoperatively and total blood volume loss. the latter was calculated with the formula described by nader et al.13 and sehat et al.14 it is based on the hb decrease adjusted for the weight, height and sex of the patient. page 76 gericke e et al. sa orthop j 2020;19(2) formula: total blood loss (ml) = 100 × hbloss/hbi hbloss = bv × 10 × (hbi − hbe) bv (l) = estimated total body blood volume in litres = 0.3669 × h3 + 0.03219 × w + 0.6041 (men) = 0.3561 × h3 + 0.03308 × w + 0.1833 (women) where h is the patient’s height (m); w is the body mass (kg); hbi is haemoglobin concentration prior to surgery (g/dl), and hbe is haemoglobin concentration post-operatively (g/dl). statistical analyses were performed using stata statistics/data analysis software, version 15.0 (statacorp llc. 4905 lakeway drive, college station, texas, 77845, usa). continuous variables were reported as mean (±sd) or median (with interquartile range) and categorical variables as number and percentages, unless otherwise stated. the two-sided t-test with equal variances was used to analyse parametric data. the two-sample wilcox ranksum (mann-whitney) test was used for non-parametric data. the fisher’s exact or chi-squared test was used for categorical data comparisons. a difference of p≤0.05 was considered to be significant. results the baseline characteristics of the two groups are depicted in table i. the mean age of the study (txa) group was lower than that of the control group (64±8 years vs 68±9 years; 95% confidence interval [ci] 60.4–67.4 vs 66.7–70.7; p=0.03). the comparison between the outcome measures in the study group and the control group is summarised in table ii. the mean blood loss in the txa group was 776.8±308.9 ml. the mean total blood loss was lower in the study group in comparison to the control group (mean difference 171.8 ml; 95% ci 31.2–312.2; p=0.01). duration of hospital stay was also shorter in the study group compared to the control group (2.42 days vs 3.13 days, p<0.01). there was no significant difference in the pre-operative and post-operative (at six weeks post-operatively) koos scores of the study group and control group (24.8±2.2 vs 24.5±4.7). two patients in the study group had minor post-operative swelling of the knee which resolved uneventfully, two patients had minor oozing of the wound necessitating dressing change on postoperative day 1 and two patients had decreased range of movement, of which one had to receive manipulation under anaesthesia later. one patient from the control group had swelling of the knee. this patient’s swelling was more significant and doppler ultrasound was done to exclude thrombosis. discussion this study aimed to investigate the impact of the use of intraarticular txa injection without the use of negative drainage on peri-operative blood loss following uncomplicated unilateral knee replacement. our findings suggest that intra-articular txa may reduce total blood loss. txa is a synthetic antifibrinolytic, preventing the formation of plasmin by blocking the conversion of plasminogen to plasmin.15 at higher concentration, txa acts directly to inhibit plasminogen and binding of plasmin to fibrin.6 the end result is the inhibition of fibrin degradation and breakdown of clots. benoni et al. was first to describe the benefit of using txa in tka in 1995.16 numerous randomised controlled trials1,5,17,18 and meta-analyses19,20 have since been published; however, there is no consensus on the method of administration and dose required for optimal effect with the least number of possible side effects and complications. there are five methods of txa administration described in tka to reduce blood loss which can be used either individually or in combination, namely: oral,20,21 topical,18,22 intravenous,3,22 intra-capsular3 and intra-articular.1,22-24 earlier studies focused on intravenous injections, although there were some concerns about thromboembolic complications.23,25 it is also generally accepted that only a small percentage of txa reaches the target location.1,26 chen et al. compared intra-articular with intravenous administration of txa in tka and found no difference in blood loss.17 similar studies have been conducted comparing the other different methods of txa administration with similar results.3,22,23 the preferred method of txa administration remains controversial and has not yet been defined. however, topical intra-articular txa may have a theoretical advantage in that it is applied directly when and where it is needed to control bleeding.27 different methods of intra-articular administration of txa have also been described. some authors inject the txa once after table i: summary of patients’ profiles variable study group (n=86) control group (n=23) p-value age 64.0±8.2 68.7±9.3 0.0303 sex (male/female) 26/60 7/16 bmi 31.3±7.1 31.6±1.33 0.8334 pre-op hb (g/dl) 13.56±1.26 13.92±1.46 0.5113 asa score 2.14±0.61 2.22±0.95 0.6360 tka side (rt/lt) 13/10 46/40 table ii: summary of results variable study group (n=86) control group (n=23) p-value post-op hb (g/dl) 11.38±0.14 11.16±0.31 0.2376 bv loss ml 776.84±33.31 948.60±56.90 0.0170 days in hospital 2.42 3.13 0.0037 study group (n=65) control group (n=18) koos pre-op 35.27±1.51 31.94±14.23 0.3264 koos post-op 68.08±1.79 63.33±3.72 0.3264 diff in koos 24.80±2.20 24.56±4.72 0.9621 page 77gericke e et al. sa orthop j 2020;19(2) completion of fascial closure to prevent leakage.24 injecting the txa percutaneously immediately after the skin has been closed has also been described.1 other studies described injecting txa through the drain and clamping the drain for some period afterwards.4 in this study, txa was administered percutaneously following skin closure as per the surgeon’s discretion. the use of a drain in tka has also come into question in numerous studies;8,9,10 it is postulated that the tamponade effect is lost with a drain and this could lead to post-operative blood loss.7 wang et al. confirmed the efficacy of tka without using drainage in terms of blood loss.1 other studies also reported the safety of nondrainage in tka.9,10 the method we used was injecting the txa percutaneously immediately after the skin was closed and before deflation of the tourniquet. wang et al. published a double-blind, randomised, placebocontrolled trial; comparing 30 patients who had a 500 mg txa intraarticular injection immediately after skin closure without drainage, and 30 patients with saline intra-articular injections immediately after skin closure. findings showed a significant reduction of mean blood loss of 560.55 ml (999.22 ml vs 1 559.77 ml; p<0.01) between the groups at day 5 post-operatively.1 an earlier study by wong et al. (2010), which was one of the first publications to evaluate the benefit of topical txa administration without the use of a drain, also showed reduction of blood loss (1 208 ml txa 3 g vs 1 295 ml txa 1.5 g vs 1 610 ml placebo).18 craik et al. and yang et al. also used intra-articular txa without a surgical drain and they had similar results.24,28 the findings in our study were similar to previously mentioned studies.1,18,24,28 we noted a significant reduction in blood loss of 171.76 ml (776.8 ml vs 948.60 ml; p<0.01). the duration of hospital stay was also reduced (2.42 days vs 3.13 days; p=0.003). there was, however, no difference in the functional outcome according to the koos scores. there are several shortcomings to this study. it was a retrospective study and selection bias could not be excluded. the difference in age between the two groups is notable. the study did not identify which one of the two changes in treatment, namely administrating txa or omitting a drain, were responsible for the reduction of blood loss, nor did it identify the degree of independent contribution each one of the treatments made. the use of lmwh as thromboprophylaxis deserves mention as it may have contributed to an increased blood loss in both groups.29 the sample size was small, especially in the control group, and it was not sufficiently powered to assess thromboembolic events and wound complications. similarly, the low event rate prevents drawing any conclusions in terms of allogenic blood transfusion rates. furthermore, post-operative blood tests were done the next day and not at a fixed time interval, and no further blood test comparisons were conducted after that. follow-up of the patients was insufficient, as can be seen in the incomplete koos scores: only 65 out 86 in the study and 18 out of 23 control group were complete. despite the large number of publications on the topic of txa in arthroplasty, it appears that some controversy remains in terms of the optimal strategy. future research including randomised controlled studies and meta-analysis are needed to assess the most appropriate dose, route and most effective method for txa administration. conclusion these findings are in accordance with other studies, indicating that intra-articular administration of txa and omission of negative pressure drainage may be associated with a reduction in blood loss following tka. larger, well-designed studies are required to determine the optimal txa administration strategy. ethics statement this study received prior approval from a level 1 ethics committee (ref brec311/17). the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ge contributed to the conception and design of the work; the literature review; developed the study protocol and submitted the study for ethics approval; the acquisition, analysis and interpretation of the data for the work; drafting the work and submitting the final version to be published. dbj was the primary surgeon in all the cases, contributed in the gathering of patient data and revised the article critically for important intellectual content. dm contributed to the conception and design of the work, and the developing of the study protocol; and revised the article critically for important intellectual content. mlc revised the article critically for important intellectual content, compiling the statistics and final approval of the version to be submitted to the journal. orcid gericke e https://orcid.org/0000-0002-7613-9266 de beer j https://orcid.org/0000-0002-2692-4717 deacon m https://orcid.org/0000-0002-1100-1370 marais 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arthroplasty. j orthop surg res. 2012;7:32. 27. moskal jt, capps sg. intra-articular tranexamic acid in primary total knee arthroplasty: meta-analysis. j knee surg. 2018;31(1):56-67. 28. craik jd, ei shafie sa, kidd ag, twyman rs. can local administartion of tranexamic acid during total knee arthroplasty reduce blood loss and transfusion requirements in the absence of surgical drains? eur j orthop surg traumatol. 2014;24(3):379-84. 29. xia zn, zhou q, zhu w, weng xs. low molecular weight heparin for the preevntion of deep venous thrombosis after total knee arthroplasty: a systemic review and meta-analysis. int j surg. 2018;54:265-75. _goback page 192 south african orthopaedic journal http://journal.saoa.org.za acknowledgement of reviewers the south african orthopaedic journal is able to publish good quality, peer-reviewed articles thanks to the valuable input provided by its tireless and generous section editors (se) and peer reviewers. by applying their insights and knowledge gained in their areas of expertise, the reviewers ensure the scientific integrity and research quality of the articles. this they do without any reward, and we wish to thank them most sincerely for their contribution to the journal. trauma and general orthopaedics f birkholtz (se) n ferreira (se) s maqungo (se) b bernstein s bruwer mtn duma r du plessis g du preez c frey n gibson m laubscher lc marais s matshidza l nieuwoudt m o’connor s swanepoel arthroplasty m held (se) c snyckers (se) d north (se) j de vos pg erasmus p firer d frantzen b gelbart ie goga t hilton jd jordaan j mcallister m nortje u plenge c reid b riemer m roussot r smit s sombili d van der jagt j van der merwe a van huysteen a van zyl j walters spinal surgery j davis (se) rn dunn (se) e coetzee s eisenstein sa khan n kruger m lukhele s miseer m ngcelwane a puddu rl ramlakan ja shipley gj vlok hand surgery a ikram (se) d mcguire (se) m carides a rocher c serfontein m solomons research methodology and statistics m burger (se) paediatric orthopaedics j du toit (se) g firth (se) s dix-peek r goller eb hoffman a horn k koch p maré a naidoo ajf robertson pd rollinson jpj smit m thiart d thompson k troisi foot and ankle g mccollum (se) n saragas (se) p ferrao f louw c marais k mcintyre m mehtar c narramore i stead a strydom j van niekerk a van zyl shoulder and elbow s roche (se) c anley (se) a barrow c breckon jp du plessis l rajah b vrettos p webster orthopaedic oncology and infections t hilton (se) t le roux (se) pj ehlers k hosking o koch bgp lindeque pg mthethwa a olivier icm robertson ja shipley j viljoen erasmus lj et al. sa orthop j 2020;19(2) doi 10.17159/2309-8309/2020/v19n2a2 south african orthopaedic journal http://journal.saoa.org.za arthroplasty citation: erasmus lj, fourie ff, van der merwe jf. low dislocation rates achieved when using dual mobility cup hip implants for femur neck fractures. sa orthop j 2020;19(2):70-73. http://dx.doi.org/10.17159/2309-8309/2020/v19n2a2 editor: dr michael held, university of cape town, south africa received: june 2019 accepted: december 2019 published: may 2020 copyright: © 2020 erasmus lj. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: total hip replacements done for intracapsular neck of femur fractures (nof) have a dislocation rate of up to 14%. this is seven times higher than in total hip arthroplasty (tha) done for osteoarthritis. using a dual mobility cup (dmc) has been shown to be effective in addressing dislocation in elective tha. our hypothesis is that the use of dmc in nof will do the same. this study aims to determine the incidence proportion of dislocation of dmcs one year after surgery in patients who received tha for nof and to compare it to dislocation rates as documented in existing studies. methods: a retrospective study was done on 86 patients treated with dmc tha for an intracapsular nof fracture from 2012 until 2016. a minimum one-year follow-up period was required for inclusion into the study. the number of dislocations at one year after surgery was noted. results: forty-one patients with a mean age of 60.7 years were included (26 females and 15 males). all patients were operated via the posterior approach. none of the patients had dislocated after one year. conclusion: low dislocation rates can be achieved using dmc tha in the management of intracapsular nof fractures. our one-year dislocation rate of 0% compares favourably to conventional tha and is comparable to similar dmc studies done outside of south africa. level of evidence: level 4 keywords: dual mobility cup, neck of femur fracture, dislocation, total hip arthroplasty, intracapsular low dislocation rates achieved when using dual mobility cup hip implants for femur neck fractures erasmus lj1 , fourie ff2 , van der merwe jf3 1 mbchb; orthopaedic surgery registrar, university of the free state, universitas academic hospital, bloemfontein, south africa 2 mbchb, mmed(ortho), fc orth(sa); orthopaedic surgeon, life st dominic’s hospital, east london, south africa 3 mbchb, mmed(ortho), fc orth(sa); head of arthroplasty unit, university of the free state, universitas academic hospital, bloemfontein, south africa corresponding author: dr lourens j erasmus, universitas academic hospital, 1 logeman street, bloemfontein, free state, 9301; po box 37140, langenhovenpark, 9330; tel: +27 74 149 8383; email: cobuserasmus@gmail.com https://orcid.org/0000-0003-4522-2873 https://orcid.org/0000-0001-8961-4874 https://orcid.org/0000-0002-5554-4887 page 71erasmus lj et al. sa orthop j 2020;19(2) introduction the total hip replacement may have been rated as the best operation of the 20th century, but it is not without its complications.1 dislocation of the hip prosthesis post-operatively remains one of the most common complications encountered after total hip arthroplasty (tha). rates of 1.9% at one year and increasing up to 7% over 25 years have been reported in primary tha.2 postoperative dislocations are the indication for surgery in 22.5% of revision cases and, even after revision surgery, 30% of patients will have persistent instability of their hip.3,4 the dislocation rate of tha done for fractures is much higher still, and thus of even more concern than in primary tha. when using the posterior approach for tha done for femur neck fractures, enocsen found a dislocation rate of 12–14%.5 this is seven times higher than in primary hip arthroplasty. hummel reported a dislocation rate of 2–8% when using the anterolateral approach for similar indications.6 if done for a failed open reduction and internal fixation of a femur neck fracture, 22% of hips dislocated post-operatively.7 when the patient was also demented, dislocation rates shot up to 32%.7 as a local comparison, a study done at the university of cape town and published in 2018 found a 4.3% risk for early dislocation after total hip arthroplasty for neck of femur (nof) fractures.8 there are several patient risk factors that increase the risk for dislocation after tha. these include dementia, psychiatric disorders, alcohol abuse, age higher than 80 years old, neuromuscular disorders and non-compliance with post-operative movement and rehabilitation instructions.9,10 besides patient risk factors, there are also surgical risk factors that contribute to dislocation. some of these are the surgical approach used, the positioning of the acetabular and femoral components, soft-tissue tension and the surgeon’s experience.9 great emphasis was previously placed on putting the implant in the so-called ‘safe zone’ with the acetabular cup at 40°±10° inclination and 15°±10° anteversion.11 this has recently been found not to be as much of a protective factor as previously thought, with 58% of all hip prosthesis dislocations being in the safe zone. abdel, who headed the study, concluded that hip dislocations post tha are multifactorial in cause, and a holistic approach needs to be taken to minimise the risk of dislocation.12 a modern solution to the problem of dislocation after tha has been suggested, namely the dual mobility cup (dmc). designed by prof. gilles bousquet and andré rambert in france in 1974, it features two articulations: the acetabular cup with the polyethylene insert and the polyethylene insert with the head of the femoral component.13-15 it is available in both cemented and uncemented options. this implant has been suggested as an option to reduce dislocation rates in very high-risk patients. dmcs theoretically decrease dislocation risk for the same reasons a large effective femoral head does. it increases the head-to-neck ratio, allowing for a greater range of motion before impingement starts taking place.16,17 it also increases jump distance, allowing for a greater amount of lateral head movement before dislocation takes place.17 some authors recommend caution when using it for standard primary tha and in young patients as there is some concern about increased wear rates and aseptic loosening. this concern is mainly because of the lack of long-term follow-up data and not because high rates of wear or aseptic loosening have actually been found.13 there may in fact be decreased wear with dmcs as there are two articulating interfaces and thus less friction and sliding at each.18,19 regarding real-world outcomes measured thus far, medium-term follow-up of these prostheses has been done by philippot, who found a very favourable 15-year socket survival rate of 96.3% (±3.7%).20 several companies currently offer dmc options for tha. some examples are shown in table i. this study aims to determine whether dmcs used in nof fractures are a possible solution to the high dislocation rates mentioned above. it intends to do so by retrospectively determining the cumulative incidence of dislocation in our study group at one year post-surgery and then comparing the numbers found to existing studies of dislocations in conventional total hip replacements as well as dmc studies done in other countries. methods we did a retrospective cohort study at a single tertiary level hospital in bloemfontein (universitas academic hospital). we identified all the patients who had received dmc hip arthroplasty for intracapsular nof fractures from july 2012 until december 2016. a total of 86 patients were identified. electronic records (meditech) and admission data, clinic files, radiological records and telephonic follow-up were then used to determine whether these patients had dislocated their hips post-operatively. surgeon experience and the method of implant fixation were also documented. a minimum follow-up time of one year (at our clinic or telephonic) was required to be included in the study. patients who did not complete a full year of follow-up at our clinic were phoned to find out whether they had dislocated or not. patients with incomplete records were excluded from the study. those who had less than one year of follow-up time and were untraceable telephonically or otherwise were excluded. the department of home affairs assisted in identifying patients who passed away within the first year of surgery. these patients were also excluded. those who had arthroplasty done for failed open reduction and internal fixation of intracapsular nof fractures were also excluded. age was not an exclusion criterion. some younger patients received dmc hip arthroplasty because of a high risk for dislocation. this decision was at the discretion of the attending consultant. after determining the cumulative incidence of dislocations in our study group, we planned to compare our numbers to those of existing studies on hip dislocation in standard and dmc hip arthroplasty done for intracapsular nof fractures. all patients had a primary hip arthroplasty with a polarcup® prosthesis. this product is manufactured by smith & nephew table i: dual mobility cups available company trade name hxpe* cemented head sizes (mm) smith & nephew polarcup yes yes 22, 28 tornier dual mobility cup yes yes 22, 28 stryker mobile hip system yes yes 22, 28 zimmer-biomet avantage active articulation yes yes yes no 22, 28 28 depuy gyros yes no 22.5, 28 *hxpe: highly cross-linked polyethylene page 72 erasmus lj et al. sa orthop j 2020;19(2) orthopaedics ag of rotkreuz, switzerland. several other companies also manufacture similar prostheses and the choice of this specific implant was based on departmental protocol. both cemented and uncemented techniques were used for acetabular cups and femoral components, depending on patient indications. all the patients were operated via the posterior approach (kocherlangenbeck approach). this is departmental protocol and makes comparison with other dmc studies much easier and more accurate, as the vast majority (>95%) of similar studies done previously also utilised the posterior approach. results forty-one of the 86 patients identified were included in the study. a total of 45 patients were excluded. eight had incomplete files, four passed away during the first year after surgery and the rest did not complete a full year of follow-up and could not be contacted telephonically. thirty-four of these patients followed up at our clinic for one year or more. seven patients did not complete a full year of follow-up at the clinic but were reached telephonically more than one year after surgery was performed and were confirmed not to have dislocated. the mean age of the patients included was 60.7 years (sd 8.6). twenty-six (63.4%) of the patients were females, with the youngest being 42 years, the oldest 81 years and with a mean age of 62 years (sd 9.5). there were 15 (36.6%) males among the patients included, with the youngest being 49, the oldest 67 and with a mean age of 58.4 years (sd 6.3). patient demographics are shown in table ii. the risk factors for dislocation common to all the patients in the cohort were that they received tha for a nof fracture via the posterior approach. surgeon experience could not be controlled for and prostheses fixation was variable (according to patient indications). regarding the experience of the surgeon, 24 cases (58.5%) were performed by a registrar, 12 cases (29.3%) by a registrar with consultant supervision and five (12.2%) by a consultant. both cemented and uncemented prostheses were used in different combinations depending on specific patient indications. a cemented cup and stem was used in 29 of the cases (70.7%). an uncemented cup and cemented stem (hybrid implant) was used in six patients (14.6%). a cemented cup and uncemented stem (reverse hybrid implant) was used in four of the cases (9.8%) and an uncemented cup and stem was used in two patients (4.9%). details of the surgeries performed are summarised in table iii. some complications other than dislocation were encountered. two of the patients developed deep wound infections. one of these patients ended up having a girdlestone excisional arthroplasty and the other had to undergo two-stage revision surgery. the main aim of this study was to determine the cumulative incidence of dislocation of dmc hip prostheses used for intracapsular nof fractures one year after surgery was performed. we found that none (n=0) of the patients included in our study had dislocated one year after surgery. discussion by using dmc tha in the management of intracapsular nof fractures we achieved a 0% dislocation rate at one-year followup. this is significantly better than the rates reported with conventional tha for this indication.5,7,8 (this is compared to total hip replacements for nof fractures in general, and not for specific prostheses like big femoral head components that might compare more favourably with dmc implants.)21 the dislocation rates for dmcs found in this study are similar to the results found by other authors in recent years. table iv shows a comparison of the results of similar studies done. all the studies shown in table iv used the posterior approach, except for the study done by adam et al. in which 20% of cases were performed via the anterolateral approach.22 a limiting factor to this study is the large number of patients lost to follow-up. universitas academic hospital has a catchment area that includes the free state, northern cape, lesotho and parts of the eastern cape. many of these areas are very remote and table ii: patient demographics characteristics (n=41) age in years (mean; sd) 60.7; 8.6 females 62; 9.5 males 58.4; 6.3 sex (n; %) females 26; 63.4% males 15; 36.6% table iii: details of surgeries performed surgeries performed (n=41) prosthesis n (%) smith & nephew polarcup 41 (100%) approach posterior (kocher-langenbeck) 41 (100%) surgeon experience registrar 27 (58.5%) registrar with consultant supervision 12 (29.3%) consultant 5 (12.2%) fixation method cemented cup and stem 29 (70.7%) uncemented cup and cemented stem 6 (14.6%) cemented cup and uncemented stem 4 (9.8%) uncemented cup and stem 2 (4.9%) table iv: dislocation rates of dual mobility cups used for neck of femur fractures authors year country follow-up number of patients (n) dislocations (n) dislocation rate (%) current study 2019 south africa 12 months 41 0 0% tarasevicius et al.23 2010 lithuania 12 months 42 0 0% adam et al.22 2012 france 9 months 214 3 1.4% bensen et al.24 2014 denmark 21 months 175 8 4.6% nich et al.25 2016 france 36 months 45 3 6.7% boukebous et al.26 2018 france 24 months 98 3 3.1% zagorov et al.27 2018 bulgaria 29 months 49 0 0% rashed et al.28 2018 egypt 12 months 31 0 0% page 73erasmus lj et al. sa orthop j 2020;19(2) rural which makes it difficult for patients to follow up in the long term. this is coupled with inadequate record-keeping, with many patients being admitted to hospital without having their telephone numbers or identity numbers captured. despite excluding these patients from the study, we believe it is unlikely that many, or even any, of them dislocated. the structure of the health system in the free state is such that patients who dislocated would have to be referred to universitas academic hospital for reduction and would likely have been picked up in this manner. future researchers may consider doing a prospective study in which they can better control data capture and possibly attain a higher level of long-term follow-up. a prospective study could also look at whether patients have other risk factors for dislocation besides the ones that the patients in our cohort shared, namely tha done via the posterior approach for nof fractures. conclusion the results obtained in this study were comparable to similar studies done abroad and show promise for the use of dmcs to achieve low dislocation rates in this high-risk group of patients. ethics statement the author/s declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethical clearance for the study was received from the university of the free state ethics committee (hsrec 165/2016). permission to use medical records was obtained from the free state department of health. formal consent was not required for this study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions lje collected and analysed the data, and wrote and edited the manuscript. ff contributed to the protocol and management of patients. fjvdm proposed the study concept, supervised the study and managed patients. acknowledgements we thank mr fc van rooyen of the department of biostatistics of the university of the free state for his help in analysing the data used in this study. orcid erasmus lj https://orcid.org/0000-0003-4522-2873 fourie ff https://orcid.org/0000-0001-8961-4874 van der merwe jf https://orcid.org/0000-0002-5554-4887 references 1. learmonth id, young c, rorabeck c. the operation of the century: total hip replacement. lancet. 2007;370(9597):1508-19. 2. berry dj, von knoch m, schleck cd, harmsen ws. effect of femoral head diameter and operative approach on risk of dislocation after primary total hip arthroplasty. j bone joint surg am. 2005;87(11):2456. 3. bozic kj, kurtz sm, lau e, et al. the epidemiology of revision total hip arthroplasty in the united states. j bone joint surg am. 2009;91(1):128-33. 4. woo ry, morrey bf. dislocations after total hip arthroplasty. j bone joint surg am. 1982;64(9):1295-306. 5. enocson a, hedbeck c, tidermark j, et al. dislocation of total hip replacement in patients with fractures of the femoral neck. acta orthop. 2009;80(2):184-89. 6. hummel mt, malkani al, yakkanti mr, baker dl. decreased dislocation after revision total hip arthroplasty using larger femoral head size and posterior capsular repair. j arthroplasty. 2009;24(6 suppl):73-76. 7. johansson t, jacobsson sa, ivarsson i, knutsson a, wahlström o. internal fixation versus total hip arthroplasty in the treatment of displaced femoral neck fractures: a prospective randomized study of 100 hips. acta orthop. 2000;71(6):597-602. 8. shituleni s, maqungo s. displaced intracapsular neck of femur fractures: dislocation rate after total hip arthroplasty. sa orthop j. 2018;17(1). 9. dargel j, oppermann j, brüggemann gp, eysel p. dislocation following total hip replacement. dtsch arztebl int 2014;111:884-90. 10. woolson s, rahimtoola z. risk factors for dislocation during the first 3 months after primary total hip replacement. j arthroplasty. 1999;14(6):662-68. 11. lewinnek g, lewis j, tarr r, compere c, zimmerman j. dislocations after total hip-replacement arthroplasties. j bone joint surg am. 1978;60(2):217-20. 12. abdel m, von roth p, jennings m, hanssen a, pagnano m. what safe zone? the vast majority of dislocated thas are within the lewinnek safe zone for acetabular component position. clin orthop relat res. 2015;474(2):386-91. 13. grazioli a, ek e, rüdiger h. biomechanical concept and clinical outcome of dual mobility cups. int orthop. 2012;36(12):2411-18. 14. ko l, hozack w. the dual mobility cup. bone joint j. 2016;98-b (1 suppl a):60-63. 15. de martino i, triantafyllopoulos gk, sculco pk, sculco tp. dual mobility cups in total hip arthroplasty. world j orthop. 2014;5(3):180-87. 16. malik a, maheshwari a, dorr l. impingement with total hip replacement. j bone joint surg am. 2007;89(8):1832-42. 17. banerjee s, pivec r, issa k, et al. large-diameter femoral heads in total hip arthroplasty: an evidence-based review. am j orthop. 2014;43(10):506-12. 18. stulberg s. dual poly liner mobility optimizes wear and stability in tha: affirms. orthopedics. 2011;34(9):e445-e448. 19. netter j, hermida j, chen p, nevelos j, d'lima d. effect of microseparation and third-body particles on dual-mobility crosslinked hip liner wear. j arthroplasty. 2014;29(9):1849-53. 20. philippot r, farizon f, camilleri j, et al. survival of cementless dual mobility socket with a mean 17 years follow-up. chir orthop reparatrice appar mot. 2008;94(8):e23-e27. 21. pituckanota k, arirachakaran a, tuchinda h, et al. risk of revision and dislocation in single, dual mobility and large femoral head total hip arthroplasty: systematic review and network meta-analysis. eur j orthop surg traumatol. 2018:28(3):445-55. 22. adam p, philippe r, ehlinger m, et al. dual mobility cups hip arthroplasty as a treatment for displaced fracture of the femoral neck in the elderly. a prospective, systematic, multicenter study with specific focus on postoperative dislocation. orthop traumatol surg res. 2012;98(3):296-300. 23. tarasevicius s, busevicius m, robertsson o, wingstrand h. dual mobility cup reduces dislocation rate after arthroplasty for femoral neck fracture. bmc musculoskelet disord. 2010;11(1). 24. bensen a, jakobsen t, krarup n. dual mobility cup reduces dislocation and re-operation when used to treat displaced femoral neck fractures. int orthop. 2014;38(6):1241-45. 25. nich c, vandenbussche e, augereau b, sadaka j. do dual-mobility cups reduce the risk of dislocation in total hip arthroplasty for fractured neck of femur in patients aged older than 75 years? j arthroplasty. 2016;31(6):1256-60. 26. boukebous b, boutroux p, zahi r, azmy c, guillon p. comparison of dual mobility total hip arthroplasty and bipolar arthroplasty for femoral neck fractures: a retrospective case-control study of 199 hips. orthop traumatol surg res. 2018;104(3):369-75. 27. zagorov m, mihov k, dobrilov s, et al. dual mobility cups reduce dislocation rate in total hip arthroplasty for displaced femoral neck fractures. j of imab. 2018;24(2):2077-2081. 28. rashed r, sevenoaks h, shabaan a, et al. functional outcome and health related quality of life after dual mobility cup total hip replacement for displaced femoral neck fractures in middle aged egyptian patients. injury. 2018;49(3):667-72. https://orcid.org/0000-0003-4522-2873 https://orcid.org/0000-0001-8961-4874 https://orcid.org/0000-0002-5554-4887 _goback _goback _goback orthopaedics vol3 no4 page 26 sa orthopaedic journal winter 2017 | vol 16 • no 2 assessment of emotional distress and parenting stress among parents of children with clubfoot in south-western nigeria o esan mbchb, fwacs, fmcs(ortho) senior lecturer, department of orthopaedic surgery and traumatology, obafemi awolowo university, ile-ife, nigeria a akinsulore mbchb, mph, fwacp, fmcpsych senior lecturer, department of mental health, obafemi awolowo university, ile-ife, nigeria mb yusuf mbchb, fwacs consultant orthopaedic surgeon, department of surgery, ekiti state university teaching hospital, ado-ekiti, nigeria oo adegbehingbe mbchb, fmcs(ortho) associate professor, department of orthopaedic surgery and traumatology, obafemi awolowo university, ile-ife, nigeria corresponding author: dr adesanmi akinsulore department of mental health obafemi awolowo university ile-ife, osun state, nigeria phone: +2348033968554 email: sanmilore@gmail.com introduction clubfoot or congenital talipes equinovarus (ctev) is the most common orthopaedic congenital deformity of the lower limb seen in the tropics.1,2 the diagnosis of clubfoot is usually made at birth but it can be detected in the third trimester of pregnancy using ultrasound. clubfoot affects one or both feet, and males are more affected than females.3 the incidence of clubfoot in studies from the developed countries ranges from 1.1 to 2.57 per 1 000 births.4 in the eastern part of africa, the incidence was estimated to be up to 2 per 1 000 births5 while among black south africans, it was reported to be 3.5 per 1 000 births.6 in nigeria, the incidence was estimated to be 3.4 per 1 000 births.7 the birth of a baby is a major life event for parents, and in the south-western part of nigeria it is a celebrated event. after first observing the baby’s deformed limb, parents are initially shocked and then tend to experience emotional distress characterised by mood disturbances such as anxiety, abstract background: clubfoot, the commonest orthopaedic congenital deformity in the tropics, is usually recognised from birth and affects one or both feet. the discovery of the child’s deformity may diminish the joy of childbirth with attendant emotional reactions. hence, this study assessed the levels of emotional distress and parenting stress among parents of children with clubfoot in nigeria. methodology: this was a cross-sectional study conducted among 58 parents of children with clubfoot attending the clubfoot clinic of a tertiary health institution in nigeria. they completed a socio-demographic questionnaire, the hospital anxiety and depression scale (hads) and parenting stress index short form. results: the prevalence of emotional distress and parenting stress were 15.5% and 12.0% respectively. the mean score of parenting stress and its subscales were 67.44 (sd=18.07); parental distress 26.71 (sd=8.82); parents–child dysfunctional interaction 19.13 (sd=5.91) and difficult child 21.60 (sd=7.19). the patient age group was significantly associated with emotional distress level (χ2=13.566, p=0.004). pearson’s correlation showed significant positive correlation between parental stress and the patient’s age (r=0.277, p<0.05) and hads depression score (r= 0.290, p<0.05). conclusion: this study has provided relevant information on the experiences of nigerian parents caring for children with clubfoot. health care professionals involved with the care of children with clubfoot should also pay attention to the emotional wellbeing of the parents. key words: clubfoot, emotional distress, parenting stress, nigeria http://dx.doi.org/10.17159/2309-8309/2017/v16n2a2 sa orthopaedic journal winter 2017 | vol 16 • no 2 page 27 depression, anger and fearfulness.8,9 the obvious deformity of clubfoot makes the child’s foot a source of worry for most parents. before commencement of treatment, parents tend to worry about the diagnosis, the long-term functioning of the child, treatment availability, selection of the treatment and competing sources of information. the process of managing a child with clubfoot involves diagnosis, treatment and follow-up. this process is obviously emotionally charged, resulting in high levels of stress for parents.10 furthermore, caring for a child with clubfoot is also very stressful for many parents as a result of increased demands for their time and energy as well as worries about the functional future of the child.11 thus, parents have to cope with the emotional aspect of the child’s treatment. mothers, given their traditional family roles, usually take up more of the emotional and practical responsibility of caring for the child.12 to achieve a good treatment outcome in a patient with clubfoot, it is imperative that parents are active members of the managing team. however, a very important barrier or factor to becoming an active member of the managing team is the parent’s emotional state. an earlier study conducted among mothers of children with clubfoot reported a negative impact of the diagnosis of clubfoot on their psychological well-being.13 to this end, we set out to determine the levels of emotional distress and parenting stress among parents of nigerian children with clubfoot and identify associated risk factors. furthermore, in nigeria there is a dearth of research undertaken to assess the experiences of parents of children with clubfoot. therefore, this study examines the experiences of parents caring for a child with clubfoot with the intention of utilising the findings to develop a better and more effective service for these families. methodology setting and sample the cross-sectional study was conducted over a period of two years (july 2013–june 2015) in obafemi awolowo university teaching hospitals complex (oauthc), ile-ife, a tertiary hospital in south-western nigeria. study participants were parents of children with clubfoot attending the clubfoot clinic of the hospital and were undergoing the ponseti method of clubfoot treatment. this centre has personnel that have undergone training in the ponseti method of clubfoot treatment. inclusion criteria were: being a parent of a child with clubfoot receiving treatment for the clubfoot. parents with a history of mental illness and with a child with other additional congenital abnormalities were excluded from the study. procedure and assessment the study protocol was approved by the ethics and research committee of the institution. written informed consent was taken from all the parents after the objectives of the study had been explained to them. the respondents were assessed using the following questionnaires: • socio-demographic characteristics: this questionnaire was designed specifically for this study and elicited information such as age, gender, relationship to child and other related data. • hospital anxiety and depression scale (hads): this was developed to assess anxiety and depressive symptoms among non-psychiatric patients in the hospital.14 the instrument consisted of seven questions each for both anxiety and depression. the scales are rated on a four-point scale ranging from 0–3. a cut-off point of 8 and above in either the anxiety or depressive subscale indicates depression or anxiety. we categorised the respondents in this study into two groups based on their scores in the hads. respondents with a score of 8 and above in either or both of the hads subscales were considered to have emotional distress. those with scores of less than 8 in both subscales were considered to be normal. • parenting stress index short form (psi-sf): parenting stress was assessed using the psi-sf15 which is a selfreported questionnaire with 36 questions rated on a five-point likert scale ranging from 1–5. it has three subscales: parental distress (pd), which measures impaired sense of competence in the parenting role; parents–child dysfunctional interaction (pcdi), which assesses the failure of the child to meet their parents’ expectation; and difficult child (dc), which examines the characteristics of the child that makes them easy or difficult to manage. each of the three subscales consists of 12 items with scores ranging from 12–60. the total stress score is the sum of the three subscales which can range from 36–180. a total parenting stress score between 36 and 55 is said to be a low level of stress; between 56 and 85 is normal stress; between 86 and 90 is a high level of stress; and above 90 is said to be a clinically significant stress level. statistical analysis of data was done using the spss version 20 software for windows. descriptive statistics were calculated as frequencies, percentages and means. the chi-square test and independent t-test was used to test for associations. correlations between parents’ and patients’ age, depression, anxiety and parenting stress were studied using pearson’s product moment correlation coefficient. the level of significance was considered to be a p-value less than 0.05. results a total of 58 parents were recruited into the study. table i shows the socio-demographic variables of parents of patients with clubfoot. the mean age of the parents was 31.10 years (sd=6.22) with the majority between 26 and 35 years (62.1%). mothers constituted 82.8% with a male to female ratio of 1:5. most of the respondents (86.3%) had at least secondary education. among the patients with clubfoot, most of them were males (70.7%) with a male to female ratio of 2.4:1. page 28 sa orthopaedic journal winter 2017 | vol 16 • no 2 the mean age of patients was 18.43 months (sd=22.26) with most of them presenting in the first 12 months of life (55.2%). half (50%) had bilateral clubfoot, and the majority of patients (70.7%) had siblings. in table ii, emotional distress based on the hads scores was found among nine (15.5%) parents. this consisted of anxiety (n=6; 10.4%), depression (n=6; 10.4%) and co-morbid anxietydepression (n=3; 5.2%) among the parents. parenting stress based on psi-sf scores was found among seven (12.0%) parents with one (1.7%) having high stress and six (10.3%) clinically significant stress. the mean score of parenting stress was 67.44 (sd=18.07) while the score for the subscales were: parental distress 26.71 (sd=8.82); parents–child dysfunctional interaction 19.13 (sd=5.91); difficult child 21.60 (sd=7.19). the association between emotional distress, parenting stress and sociodemographic variables of the parents is shown in tables iii and iv. a test of association between level of emotional distress among parents and their socio-demographic variables showed that only the patients’ age group (χ2=13.566, p=0.004) was significantly associated with emotional distress levels. pearson’s correlation between parents’ and patients’ age, hads score and parenting stress and its subscales showed significant positive correlation between parental stress and the patients’ age (r=0.277, p<0.05) and hads depression score (r= 0.290, p<0.05). there was also significant positive correlation between parenting stress score and hads depression scores of parents (r=0.285, p<0.05) (table v). discussion the study of emotional distress and parenting stress associated with caring for children with clubfoot in a tertiary hospital is a pioneering effort in nigeria. there are few studies in the literature on the experiences of parents of children with clubfoot.8,13 however, research focusing on the experiences of parents/caregivers of patients with chronic diseases in the clinical setting is increasing.16-19 this study assessed emotional distress and parenting stress associated with caring for children with clubfoot using hads and psi-sf in which nine (15.5%) parents reported emotional distress and seven (12.0%) had parenting stress. the majority of parents in this study were mothers and this is understandable as it is a common tradition that women are saddled with the duties of care for their children in the family. since most of the patients were infants, they were dependent on their mothers for feeding and other care. the mean age of the caregivers was 31.10 years (sd=6.22) with the majority between 26 and 35 years of age (62.1%). most of the parents in this study were in their most productive age range. this implies that the caregiving role of parents, especially mothers, may interfere with their effectiveness at work, leading to reduced or loss of productivity with significant economic impact on the family. table i: socio-demographic variables of the respondents variable frequency percentages (%) age group 18–25 years 12 20.7 26–35 years 36 62.1 36–45 years 10 17.2 relationship father 10 17.2 mother 48 82.8 educational level illiterate 2 3.4 primary 6 10.3 secondary 28 48.4 tertiary 22 37.9 patient’s sex male 41 70.7 female 17 29.3 patient age group 1–12 months 32 55.2 13–36 months 20 34.5 37–60 months 2 3.4 >60 months 4 6.9 patient deformity unilateral 29 50.0 bilateral 29 50.0 other siblings no 17 29.3 yes 41 70.7 table ii: prevalence of emotional distress and levels of parenting stress among respondents variable frequency percentages (%) mean (sd) anxiety none 52 89.6 mild 3 5.2 moderate 3 5.2 depression none 52 89.6 mild 5 8.7 moderate 1 1.7 emotional distress none 49 84.5 present 9 15.5 parenting stress low stress 19 32.8 normal stress 32 55.2 high stress 1 1.7 clinically sign. stress 6 10.3 parenting stress subscales parental distress 26.71 (8.82) parents–child dysfunctional interaction 19.13 (5.91) difficult child 21.60 (7.19) parenting stress 67.44 (18.07) sa orthopaedic journal winter 2017 | vol 16 • no 2 page 29 most of the patients were male children and this finding is similar to previous studies that reported male preponderance in clubfooted babies.3,7 this study also reported that 50% of children with clubfoot had it bilaterally, which is in contrast with findings of a study conducted in southeast nigeria that reported that 60% of clubfoot cases are bilateral.7 the prevalence of emotional distress in this study was 15.5% which is relatively low when compared with the prevalence of 65.7% reported among caregivers of patients with epilepsy in the northern part of nigeria using a similar questionnaire.16 the prevalence of high/clinically significant parenting stress was 12.0%, and the level of parenting stress was highest for parental distress and lowest for parent–child dysfunctional interaction. since clubfoot is a non-life threatening birth defect without any associated pain in the child’s limb, some parents may not really worry. in addition, some of the patients and caregivers started assessing care during the period of data collection which might explain the low level of emotional distress and parenting stress observed in this study. another possible explanation is that some parents have access to the internet where they were able to obtain information about the management of clubfoot. in this study, emotional distress was significantly associated with a patient’s age in the range of 3–5 years. a possible explanation for this observation is that this is the period when the child is expected to leave the home (such as when commencing schooling) and mix with other children outside the home. however, the obvious deformity of clubfoot makes it embarrassing and emotionally distressing to the parents. this study has shown that parents of patients with clubfoot experience emotional distress as well as parenting stress as a result of caring for their children. the attendant discomfort of having a child with obvious deformity could be responsible for the association between emotional distress and parenting stress. in this study, increasing age of patients was related to greater severity of parental distress experienced by parents of children with clubfoot. this implies that older parents were more vulnerable to parenting stress than younger ones. similarly, increased severity of depression symptoms as measured by hads was related to increased severity of parental distress as well as increased severity of parenting stress. the findings of this study should be interpreted in the context of some limitations. this study assessed the crosssectional association between child characteristics, parenting stress and emotional distress; thus causality cannot be table iii: association between emotional distress and socio-demographic variables of the respondents variable no emotional distress (%) emotional distress (%) statistics df χ2 p-value age group 18–25 years 9 (75.0) 3 (25.0) 2 1.128 0.56926–35 years 31 (86.1) 5 (13.9) 36–45 years 9 (90.0) 1 (10.0) sex male 9 (90.0) 1 (10.0) 1 0.281 0.596 female 40 (83.3) 8 (16.7) educational level illiterate 2 (100.0) 0 (0.0) 3 4.083 0.253 primary 6 (100.0) 0 (0.0) secondary 21 (75.0) 7 (25.0) tertiary 20 (90.9) 2 (9.1) patients’ sex male 33 (80.5) 8 (19.5) 1 1.703 0.192 female 16 (94.1) 1 (5.9) patient’s age group 1–12 months 26 (81.2) 6 (18.8) 3 13.566 0.004 13–36 months 19 (95.0) 1 (5.0) 37–60 months 0 (0.0) 2 (100.0) >60 months 4 (100.0) 0 (0.0) patient’s deformity unilateral 25 (86.2) 4 (13.8) 1 0.132 0.717 bilateral 24 (82.8) 5 (17.2) other siblings no 14 (82.4) 3 (17.6) 1 0.083 0.773 yes 35 (85.4) 6 (14.6) page 30 sa orthopaedic journal winter 2017 | vol 16 • no 2 implied. therefore, research with a longitudinal approach is required to clarify if parenting stress and emotional distress are actually caused by the child’s problem. moreover, a selfreported questionnaire was used which was based on parents’ subjective assessment of their condition. despite these limitations, the strength of the study lies in the use of a standardised instrument to measure parenting stress and emotional distress. in conclusion, this study has provided relevant information on the experiences of nigerian parents caring for children with clubfoot. the results of this study highlight that parents of children with clubfoot experience low levels of emotional distress and parenting stress. however, there is need for psychological support for parents of children with clubfoot. it is important that the health professionals involved with the care of children with clubfoot pay attention to the emotional needs of the parents so as to reduce associated emotional distress and parenting stress. compliance with ethical guidelines i, a akinsulore, hereby declare that this article is the origianl work of the co-authors and myself. this article has never been published and is submitted exclusively to the south african orthopaedic journal for publication. table iv: association between parenting stress, socio-demographic variables and level of emotional distress of the respondents variable low/normal parenting stress high/clin. sign. parenting stress statistics df χ2 p-value sociodemographic variables age group 18–25 years 10 (83.3) 2 (16.7) 2 1.724 0.42226–35 years 31 (86.1) 5 (13.9) 36–45 years 10 (100.0) 0 (0.0) sex male 10 (100.0) 0 (0.0) 1 1.658 0.148 female 41 (85.4) 7 (14.6) educational level illiterate 2 (100.0) 0 (0.0) 3 2.166 0.539 primary 6 (100.0) 0 (0.0) secondary 23 (82.1) 5 (17.9) tertiary 20 (90.9) 2 (9.1) patients’ sex male 34 (82.9) 7 (17.1) 1 3.301 0.069 female 17 (100.0) 0 (0.0) patient’s age group 1–12 months 27 (84.4) 5 (15.6) 3 4.584 0.205 13–36 months 19 (95.0) 1 (5.0) 37–60 months 1 (50.0) 1 (50.0) >60 months 4 (100.0) 0 (0.0) patient’s deformity unilateral 26 (89.7) 3 (10.3) 1 0.162 0.687 bilateral 25 (86.2) 4 (13.8) other siblings no 14 (82.4) 3 (17.6) 1 0.705 0.401 yes 37 (90.2) 4 (9.8) emotional distress none 46 (93.9) 3 (6.9) 1 10.52 0.001 emotionally distressed 5 (55.6) 4 (44.4) table v: pearson’s correlation between parents’ and patients’ age, depression, anxiety and parenting stress age patient’s age anxiety depression parental distress −0.81 0.277* 0.190 0.290* parents–child dysfunctional interaction −0.99 −0.150 −0.171 0.182 difficult child −0.188 −0.157 −0.017 0.214 parenting stress −0.146 0.023 0.030 0.285* * p <0.05 sa orthopaedic journal winter 2017 | vol 16 • no 2 page 31 all the authors have no conflict of interest and have received no commercial benefits of any kind for the writing of this article. the study protocol was approved by the ethics and research committee of our institution. written informed consent was taken from all the parents after the objectives of the study had been explained to them. references 1. omololu b, ogunlade so, alonge to. pattern of congenital musculoskeletal malformations in an african teaching hospital. west african journal of medicine 2005;24(2):92-95. 2. orimolade ea, adepiti ae, ikuomola aa, ige oo. congenital anomalies in a state specialist hospital: a secondary level of healthcare. east and central africa journal of surgery 2014;19(2):44-48. 3. chesney d, barker s, macnicol mf, porter rw, maffulli n. management of congenital talipes equinovarus in scotland: a nationwide audit. journal of the royal colleges of surgeons of edinburgh and ireland 2004;2:47–51. 4. barker s, chesney d, miedzybrodzka z, maffulli n. genetics and epidemiology of idiopathic congenital talipes equinovarus. journal of paediatric orthopaedics 2003;23:265-72. 5. mkandawire n, kaunda e. incidence and patterns of congential talipes equinovarus (clubfoot) deformity at queen elizabeth central hospital. east and central african journal of surgery 2004;2:2-31. 6. ballantyne j a, macnicol, m f. congenital talipes equinovarus (clubfoot): an overview of the aetiology and treatment. mini-symposium: the paediatric foot. current orthopaedics 2002;16:85-95. 7. ukoha u , egwu oa , okafor ij , ogugua pc , udemezue oo , olisah r , anyabolu ae incidence of congenital talipes equinovarus among children in southeast nigeria. international journal of biological and medical research 2011;2(3):712-15. 8. pietrucin-materek m, van teijlingen er, barker s, keenan kf, miedzybrodzka z. parenting a child with clubfoot: a qualitative study. international journal of orthopaedic and trauma nursing 2011;15:176-84. 9. goldbeck l. the impact of newly diagnosed chronic paediatric conditions on parental quality of life. quality of life research 2006;15:1121-31. 10. skari h, malt uf, bjornland k, egeland t, haugen g, skreden m, et al. prenatal diagnosis of congenital malformations and parental psychological distressa prospective longitudinal cohort study. prenatal diagnosis 2006;26:1001-1009. 11. wallander jl, venters tl. perceived role restriction and adjustment of mothers of children with chronic physical disability. journal of paediatric psychology 1995;20:619-32. 12. quittner al, espelage dl. opipari lc, carter b, eid n, eigen h. role strain in couples with and without a child with a chronic illness: associations with marital satisfaction, intimacy, and daily mood. health psychology 1998;17:112-24. 13. coppola g , costantini a, tedone r, pasquale s, elia l, barbaro mf, d’addetta i. the impact of the baby’s congenital malformation on the mother’s psychological well-being: an empirical contribution on the clubfoot. journal of paediatric orthopaedics 2012;32(5):521-26. 14. zigmond as, snaith rp. the hospital anxiety and depression scale. acta psychiatrica scandinavica 1983;67:361-70. 15. abidin rr. parenting stress index, psychology press, odessa 1995. 16. yusuf aj, nuhu ft, olisah vo. emotional distress among caregivers of patients with epilepsy in katsina state, northern nigeria. african journal of psychiatry 2013;16:4144. 17. feizi a, najmi b, salesi a, chorami m, hoveidafar r. parenting stress among mothers of children with different physical, mental, and psychological problems. journal of research in medical sciences 2014;19(2):145-52. 18. larson nc. parenting stress among adolescents mothers in the transition to adulthood. child and adolescent social work journal 2004;21(5):457-75. 19. leung c, leung s, chan r, tso t, ip f. child behaviour and parenting stress in hong kong families. hong kong medical journal 2005;11:373-80. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj south african orthopaedic journal orthopaedic oncology and infections doi 10.17159/2309-8309/2021/v20n1a5 vogel j et al. sa orthop j 2021;20(1) citation: vogel j, de villiers s, mugla w, mccaul j, hosking k, hilton t. radiation-induced pathological fractures of the proximal femur: a case series considering an endoprosthetic solution. sa orthop j 2021;20(1):39-42. http://dx.doi. org/10.17159/2309-8309/2021/ v20n1a5 editor: prof. theo le roux, university of pretoria, pretoria, south africa received: june 2020 accepted: october 2020 published: march 2021 copyright: © 2021 vogel j. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: authors kh and th are consultants for lrs. the remaining authors declare that they have no conflicts of interest that are directly or indirectly related to this research. abstract background radiation-induced pathological fractures of the proximal femur are difficult to treat due to frequent non-union and hardware failure using standard fracture fixation techniques. this case series investigates endoprosthetic replacement as a treatment option. methods a retrospective folder review from a private hospital in cape town, of patients who had sustained a radiation-induced pathological fracture, was reviewed using descriptive statistics. results six patients met the inclusion criteria. one patient was excluded as the minimum follow-up time of six months was not met. of the five patients that were analysed, all five sustained transverse, subtrochanteric femur fractures. prior to definitive treatment with a proximal femoral replacement, three patients were treated with standard trauma instrumentation prior to referral to the unit, and one patient was treated with a vascularised fibular graft as their initial treatment while at the unit. one patient was treated with an endoprosthetic replacement as their first procedure at the unit. among the three patients treated with standard trauma fixation and the one patient treated with a vascularised fibular graft, there was a 100% failure rate. one standard trauma instrumentation patient had an ablation due to free musculocutaneous flap failure and periprosthetic infection after endoprosthetic replacement. this was the only complication of endoprosthetic replacement. at a median follow-up of 15 months (min 7, max 55) the median musculoskeletal tumour society score was 74% (min 63%, max 93%). conclusion this case series seeks to highlight the high failure rates seen when treating this condition with standard trauma instrumentation or biological methods. further research is needed, but endoprosthetic replacement may be a viable alternative solution. level of evidence: level 4 keywords: radiation-induced fracture, pathological fracture, endoprosthetic replacement radiation-induced pathological fractures of the proximal femur: a case series considering an endoprosthetic solution jonathan vogel1* , shaun de villiers2 , walid mugla3 , jeannie mccaul4 , keith hosking5 , thomas hilton6 ¹ faculty of medicine and health sciences, university of cape town, cape town, south africa ² faculty of medicine and health sciences, university of cape town, cape town, and frere hospital, east london, and faculty of medicine and health sciences, walter sisulu university, mthatha, south africa ³ cape sarcoma unit, groote schuur hospital, faculty of medicine and health sciences, university of cape town, cape town, south africa ⁴ groote schuur hospital and victoria hospital, cape town; faculty of medicine and health sciences, university of cape town, cape town, south africa ⁵ vincent pallotti life orthopaedic hospital, cape town; faculty of medicine and health sciences, university of cape town, cape town, south africa ⁶ groote schuur hospital and vincent pallotti life orthopaedic hospital, cape town; faculty of medicine and health sciences, university of cape town, cape town, south africa *corresponding author: jonnovogel@gmail.com http://dx.doi.org/10.17159/2309-8309/2021/v20n1a5 http://dx.doi.org/10.17159/2309-8309/2021/v20n1a5 http://dx.doi.org/10.17159/2309-8309/2021/v20n1a5 https://orcid.org/0000-0003-1156-6168 https://orcid.org/0000-0003-0023-5152 https://orcid.org/0000-0002-2961-7296 https://orcid.org/0000-0003-1011-5912 https://orcid.org/0000-0002-3557-0252 https://orcid.org/0000-0002-6178-5062 page 40 vogel j et al. sa orthop j 2021;20(1) introduction external beam radiation therapy (ebrt) is frequently used to treat soft tissue sarcomas. it may cause significant side effects to the adjacent skeleton including osteomyelitis, growth plate arrest and osteonecrosis.1-4 the proximal femur is vulnerable to these complications during ebrt for tumours of the thigh and pelvis. osteonecrosis after ebrt may result in a pathological fracture of the proximal femur, which has a reduced ability to heal and remodel due to the high stressors during weight bearing and poor blood supply in this area. in our experience, a transverse pathological fracture typically occurs at the subtrochanteric region. figure 1 demonstrates the macroand microscopic differences between fat necrosis in marrow caused by ebrt and normal marrow. the healing potential of these fractures is markedly impaired.5 multiple studies have shown that treating these fractures with standard trauma fixation methods results in failure rates as high as 63% to 82%.4-6 these non-unions are so refractory to treatment that in a study by sternheim et al., 46% of patients required more than one revision procedure.5 because of the poor outcomes associated with standard methods of fixation, multiple authors have opted for more aggressive surgical management of these fractures. these include combined vascularised fibula autograft and plating,7 vascularised periosteal free-flap graft8 and prophylactic intramedullary nailing of patients at high risk of fracture (table i).9-11 kim et al. demonstrated a low complication rate with the use of primary prosthetic joint replacement. they showed a statistically significant improvement in time to mobilisation, and a decrease in the incidence of complications and re-operations when compared to standard fixation methods.4 mavrogenis et al. confirmed this with his own study using primary prosthetic joints to treat these fractures.12 both authors suggested further investigation of primary joint replacement as a treatment option for radiotherapyinduced pathological fractures of the femur. due to the absence of level 1 and 2 studies, soares et al. could not determine the most effective and safest method of treatment in their recent systematic review. they highlighted the importance of understanding that these fractures have poor longterm outcomes when treated with standard methods of internal fixation.1 we describe a case series of patients who were referred to our unit after failing treatment for their radiation-induced pathological fracture using standard fracture fixation and/or biological reconstructive techniques. our aim is to highlight this diagnosis and the difficulty in its management using standard fracture fixation principles. materials and methods this study was conducted after institutional review board and ethical approval. a retrospective folder review was conducted between 1 january 2012 and 31 january 2016. the criterion used to select patients for inclusion in the folder review was a diagnosis of a radiation-induced pathological fracture of their proximal femur. this diagnosis was made in patients with a history of ebrt to the pelvis or proximal thigh, and imaging consistent with a pathological fracture. the criteria for excluding patients were: missing data, less than six months of follow-up and whether the fracture was secondary to metastases or trauma. we recorded the following: patient age, tumour type, radiotherapy dose, time from diagnosis to fracture, time from fracture to endoprosthetic replacement (epr), number of surgeries, followup time, complications requiring surgery and musculoskeletal tumour society (msts) score. descriptive statistics were used to present the results. results six patients met the inclusion criteria and one was excluded as the minimum follow-up time was not met. the results are shown in table ii. three of the patients (patients a, b and c) had ebrt as adjuvant treatment after resection of a soft tissue sarcoma from the proximal thigh, while two patients (patients d and e) had ebrt for proximal femoral breast metastases prior to any surgical intervention. these metastases did not cause a pathological fracture themselves but rather the radiotherapy used to treat the lesions caused a radiation-induced fracture. all five patients sustained a transverse subtrochanteric proximal femur fracture (figure 2). three of the five patients (patients c, d and e) were referred to us after multiple failed trauma fixation attempts using standard instrumentation (figure 3 and 4). this failed in all three patients due to continued non-union of the fracture. patient c haemorrhagic marrow a b fat necrosis in the marrow fat necrosis in the marrow both reactive and degenerative bony spicules normal marrow figure 1a and b. demonstrating ebrt-induced fat necrosis macroscopically and microscopically, respectively table i: risk factors for radiation-associated fracture1,9-11 risk factor 1 larger tumour size 2 advanced age 3 female sex 4 tumour located in anterior compartment of thigh 5 periosteal stripping at time of tumour resection 6 high dose radiotherapy (controversial)1 page 41vogel j et al. sa orthop j 2021;20(1) failed two intramedullary (im) nails, patient d failed an im nail followed by a sliding hip screw and patient e failed an im nail. after referral to our unit, all three patients (patients c, d and e) were then converted to an endoprosthetic replacement (epr) (figure 5). two patients were referred to us prior to any fixation attempts (patients a and b). patient a underwent a vascularised fibular graft and plating, which failed to incorporate. this was then converted to an epr. patient b had an epr performed as the primary surgery. at final follow-up the median msts score was 74% (min 63%, max 93%). the patient who had an epr as their initial treatment had an msts score of 93%. one of the patients (patient c) who failed standard fixation techniques required a free musculocutaneous flap to cover the epr due to poor soft tissue after ebrt and repeated surgeries. the flap failed and dehisced resulting in a peri-prosthetic joint infection (pji). the patient chose amputation as their treatment option. there were no other complications noted after epr in the other four patients. discussion the incidence of radiation-induced pathological fractures is unknown but thought to be rare.4 however, elliot et al. showed that pelvic irradiation increases the incidence of proximal femur fractures by up to 76%.2 therefore, it is important to be alert to the possibility of this diagnosis in patients at high risk (table i) who present with a fracture. although we cannot quantify this statistically due to the rarity of this condition, it is our experience that pain is the main symptom that precedes or identifies an impending radiationinduced pathological fracture and can be useful in its diagnosis and treatment. our results are in keeping with the current literature which holds that standard fracture fixation methods and biological reconstruction techniques have an unacceptably high failure rate. all four patients who were not treated primarily with an epr had failures of instrumentation, multiple revision surgeries and required an epr as their definitive treatment. the decision to perform an epr first has been suggested to deliver a more predictable outcome and reduce the need for repeat surgeries.4 this is consistent with our series, as the only patient to have an epr as their initial fracture treatment only required one surgical procedure and had the highest msts score of 93%. having an epr first may prevent ongoing morbidity and cost to the patient, and maximise their quality of life and function. the median time of 41 months from fracture to final surgery and total number of surgeries, median 3, in our series highlights the impact this may have on the patient. epr however, is not without its own set of significant complications, one of which is infection. in our series, we had one case of deep infection. the patient had received significant radiotherapy of 66 gy to the proximal thigh and had two previous surgeries using standard trauma instrumentation which failed to induce union of their fracture. as a result, the soft tissues were severely compromised and required a free musculocutaneous flap to cover the definitive proximal femoral replacement. the flap, however, failed, which led to a pji, and an ablation of the limb was performed. the patient chose this treatment option over a staged revision of his epr. we table ii: patient results patient age (years) sex interval from diagnosis to fracture (months) interval from fracture to epr (months) radiation dose (gy) number of surgeries follow-up (months) msts score (%) a 46 f 180 69 66 3 30 63 b 63 f 40 1 66 1 55 93 c 66 m 111 43 66 3 12 n/a (ablation) d 65 f 208 41 20 3 7 80 e 45 f 27 5 20 3 15 67 median 63 111 41 66 3 15 73.5 figure 2. antero-posterior (ap) pelvis x-ray demonstrating a radiationinduced pathological fracture of the proximal femur. note the transverse nature of the fracture, adjacent sclerosis and its subtrochanteric location. figure 3. ap and lateral x-rays showing failure of dynamic hip screw of the same patient (patient d) figure 4. ap and lateral x-rays of fractured intramedullary nail inserted into the patient (patient d) page 42 vogel j et al. sa orthop j 2021;20(1) regard this as due to failure of soft tissue cover rather than the use of an epr. biological methods of treatment of radiation-induced pathological fractures have been described in the literature. one such method includes using a vascularised fibula autograft to reconstruct the femoral defect after excision of the pathological fracture.7 this was attempted in one of our patients but it failed to incorporate, possibly due to the underassessment of the extent of devascularised bone. this under-resection occurred despite 7 cm of femur, including the fracture site, being resected to healthy bleeding bone. this patient had required radiation to a large area of the proximal thigh, which resulted in extensive avascular necrosis (avn) of the femur. it is our view that the degree of avn in this scenario is difficult to assess using advanced imaging such as mri (figure 6) or by intraoperative observations. many cases of radiotherapy-induced pathological fracture are mislabelled as pathological fractures due to metastases.3 this is because differentiating between the two types of fracture on modern imaging can be difficult, but it is important to do so as the treatments are different for both and unnecessary investigations and treatments must be avoided. it has also been our observation that radiation-induced avn may show cortical scalloping and intracortical collections that may be misdiagnosed as chronic osteitis on mri scans by reporting radiologists. this may mislead the treating surgeon and result in the incorrect management of the patient. we acknowledge several limitations of our study. these include the small number of patients which makes statistical analysis difficult. our follow-up period is also short to medium term and therefore there may be late complications of epr that are not included in this series, such as aseptic loosening. longer followup is needed. we have presented our case series, not to make definitive conclusions, but to highlight the difficulties surgeons face when treating patients with this problem. our results match those reported in the current literature and suggest that more aggressive treatment of these fractures with epr may provide a more predictable outcome for the patient. conclusion radiation-induced pathological fractures are notoriously difficult to treat and can lead to multiple surgeries, severe morbidity and prolonged hospitalisation. in patients with a history of ebrt to the pelvis or proximal thigh, medical practitioners need to be highly alert to this condition. our case series, as well as the literature reviewed, suggest that a more aggressive treatment with primary epr may provide a more predictable outcome for the patient. ethics statement for this retrospective study formal consent was not required. ethical approval number hrec 889/2019. the author/s declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions jv: study design, data collection, data analysis, manuscript preparation sd: study design, data analysis, manuscript preparation wm: data analysis, data collection, manuscript preparation jm: data analysis, manuscript preparation th: study conceptualisation and design, data collection and analysis, manuscript preparation kh: study conceptualisation and design as well as data collection and analysis references 1. soares bcg, de araujo id, pádua bj, et al. pathological fracture after radiotherapy: systematic review of literature. rev assoc med bras. 2019;65(6):902-908. https://doi.org/10.1590/1806-9282.65.6.902. 2. elliott sp, jarosek sl, alanee sr, et al. 3-dimensional external beam radiotherapy for prostate cancer increases the risk of hip fracture. cancer. 2011;117(19):612-26. https://doi.org/10.1002/cncr.25994.3. 3. iğdem s, alço g, ercan t, et al. insufficiency fractures after pelvic radiotherapy in patients with prostate cancer. int j radiat oncol biol phys. 2010 jul 1;77(3):818-23. https://doi.org/10.1016/j.ijrobp.2009.05.059. 4. kim hj, healey jh, morris cd, boland pj. site-dependent replacement or internal fixation for postradiation femur fractures after soft tissue sarcoma resection. clin orthop relat res. 2010;468:3035-40. https://doi.org/10.1007/ s11999-010-1405-6. 5. sternheim a, saidi k, lochab j, et al. internal fixation of radiation-induced pathological fractures of the femur has a high rate of failure. bone joint j. 2013;95(8):1144-48. https://doi.org/10.1302/0301-620x.95b8.31832. 6. helmstedter cs, goebel m, zlotecki r, scarborough mt. pathologic fractures after surgery and radiation for soft tissue tumors. clin orthop relat res. 2001;(389):165-72. 7. duffy g, wood m, rock m, sim f. vascularized free fibular transfer combined with autografting for the management of fracture nonunions associated with radiation therapy. j bone jt surg. 2000;82(4):544-54. https://doi. org/10.2106/00004623-200004000-00009. 8. fuchs b, steinmann sp, bishop at. free vascularized corticoperiosteal bone graft for the treatment of persistent nonunion of the clavicle. j shoulder elb surg. 2005;14(3):264-68. https://doi.org/10.1016/j.jse.2004.06.007. 9. gortzak y, lockwood ga, mahendra a, wang y. prediction of pathologic fracture risk of the femur after combined modality treatment of soft tissue sarcoma of the thigh. cancer. 2010;116(6):1553-59. https://doi.org/10.1002/ cncr.24949. 10. cannon c, lin p, lewis vo, yasko aw. management of radiation-associated fractures. am acad orthop surg. 2008;16(9):541-49. 11. lin pp, schupak kd, boland pj, brennan mf, healey jh. pathologic femoral fracture after periosteal excision and radiation for the treatment of soft tissue sarcoma. cancer. 1998;(82):2356-65. 12. mavrogenis a, pala e, romantini m, guerra g, et al. side effects of radiation in musculoskeletal oncology: clinical evaulation of radiationinduced fractures. int j immunopathol pharmacol. 2011;24:29-37. https://doi. org/10.1177/03946320110241s207. figure 6. mri t1 trim cor showing a segment of medullary hyperintensity in the proximal femur. report noted sharply defined proximal and distal margins with no cortical expansion or disruption. figure 5. ap x-ray after endoprosthetic replacement of the proximal femur _hlk36216070 _hlk57729893 404 not found 404 not found south african orthopaedic journal trauma and general orthopaedics doi 10.17159/2309-8309/2021/v20n4a6abramson m et al. sa orthop j 2021;20(4) citation: abramson m, maqungo s, dey r, laubscher m. incidence of radius shortening following intramedullary nail fixation for gunshot fractures: a retrospective radiological audit. sa ortho j 2021;20(4):226-230. http://dx.doi.org/10.17159/23098309/2021/v20n4a6 editor: prof. nando ferreira, stellenbosch university, cape town, south africa received: september 2020 accepted: december 2021 published: november 2021 copyright: © 2021 abramson m. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background intramedullary nail fixation is an option to manage highly comminuted fractures of the radius shaft resulting from gunshot wounds. however, complications including nail migration and malunion are well documented. we have noticed some patients presenting to our clinic with radiological shortening following nail fixation. this may result in chronic pain, reduced pronation and supination, poor grip strength and early onset arthrosis. this study aimed to quantify the incidence of radiological shortening following fixation of isolated gunshot wound (gsw) fractures of the radius with an intramedullary nail. our secondary objectives were to identify if length of the zone of comminution and anatomical location of the fractures were risk factors for shortening, and to assess whether shortening was a result of surgical error, or whether shortening occurred over time. methods we performed a retrospective review of all (n = 40) isolated radius nails performed between january 2012 and january 2019. two doctors assessed the latest anterior-posterior forearm x-ray of every patient, using the rule of perpendiculars to calculate ulnar variance (uv). shortening was defined as a uv > 5.0 mm. if the radius was deemed shortened by consensus, then the immediate postoperative x-ray was also assessed to gauge when shortening occurred. anatomical location in thirds and length of comminution (mm) were also assessed. results forty patients with a mean age of 32 years (range 15–59) were included. twelve patients’ radiuses were assessed as radiologically short. all 12 were deemed to have been fixed short. one case shortened further over time. we found the incidence of shortening being dependent on the fracture location (p = 0.03), with the fractures occurring in the middle third of the arm shortening more. the measured zone of comminution between the shortened and non-shortened groups was not found to be statistically significant (p = 0.55). conclusion the radius nail remains useful to manage comminuted radius shaft fractures following gsw. meticulous technique is needed to avoid radiological shortening, seen in 30% of our series. this can lead to chronic pain, reduced grip strength and early onset arthrosis. we found no evidence that shortening develops over time. we found that the incidence of shortening is dependent on fracture position but did not find any causative relationship between length of the zone of fracture comminution and shortening. level of evidence: level 4 keywords: radial nail, shortening, gunshot incidence of radius shortening following intramedullary nail fixation for gunshot fractures: a retrospective radiological audit michael abramson,¹,²* sithombo maqungo,¹,² roopam dey,¹,² maritz laubscher¹,² ¹ department of orthopaedic surgery, groote schuur hospital, university of cape town, cape town, south africa ² orthopaedic research unit (oru), division of orthopaedic surgery, university of cape town, cape town, south africa *corresponding author: michaeljames1984@gmail.com introduction fractures of the forearm resulting from gunshot wounds (gsw) are often highly comminuted, involving a sizable bone segment, and can be very challenging to treat.1 the new generation locking intramedullary (im) nail is an option to manage these highly comminuted fractures.2,3 minimal disruption to the soft tissue envelope together with its stress-shielding biomechanical properties makes the im nail an attractive alternative to conventional bridge plate techniques.4,5 the im nail is not without its problems, and issues such as nail migration and malunion have been highlighted in the literature.6,7 at our institution we have been using interlocking im nails for isolated gunshot fractures of the radius since 2012. at follow-up we have noted some patients presenting with radius shortening following nail fixation to treat gsw fractures. radius shortening is associated with clinical sequelae such as chronic pain, reduced https://orcid.org/0000-0001-6677-3506 page 227abramson m et al. sa orthop j 2021;20(4) proand supination, poor grip strength and early onset arthrosis of the distal radioulnar and radiocarpaljoints.8-11 our study aimed to quantify the incidence of radiological radius shortening following radius nails for gsw fractures at our institution. our secondary objectives were to identify whether the radius was fixated in a shortened position or whether it shortened over time. we also tried to identify any risk factors for radius shortening, specifically looking at whether length of the zone of comminution or anatomical location of the fractures contribute to its incidence. patients and methods we performed a retrospective review of all (n = 40) isolated radius nails for gsw fractures performed at our institution between january 2012 and january 2019. we used the database from the nail provider (afmed pty ltd) to confirm all cases were included in the study. any radius nail with an ipsilateral fracture of the ulna that required fixation was excluded. the latest ap forearm x-ray of each patient was assessed by two surgeons experienced in orthopaedic trauma. the rule of perpendiculars was used to calculate ulnar variance (uv)12 (figure 1). all x-rays were assessed on our philips intellispace digital pacs (philips, netherlands). shortening was defined in this study as a positive uv greater than 5.0 mm. if the radius was deemed to be short by consensus using this criterion, then the immediate postoperative x-ray was also assessed to gauge if the fracture was fixed short or if shortening developed over time. this x-ray was taken within 48 hours of surgery. all the cases where index x-rays were deemed not to be shortened were followed up radiologically to confirm that they remained outside the criteria for shortening stipulated in the study. no patients were found to cross over from the normal into the shortened category over the study period. anatomical location (dividing radius shaft into thirds) and length of the zone of comminution in millimetres were assessed by two independent assessors (and a third in cases of disagreement). the measurements were segregated into short and not-short groups. the distribution of the data was checked using the shapirowilk test. normally distributed data were compared using student’s t-test, and non-normally distributed data were compared using mann-whitney u test. pearson chi-squared test and fisher’s exact test were appropriately used to find the dependence of shortening with the degree of fracture comminution and fracture location. the condition for statistical significance was set at p < 0.05. all the statistical analyses were performed using ibm spss v.26 (ibm corp, armonk, ny, usa). surgical technique the procedure is performed with the patient supine on a radiolucent arm table, with the aid of a tourniquet. prior to commencing the operation, the contralateral forearm is screened to pre-select the appropriate length and diameter of the nail, as well as to assess the patient’s baseline uv in order to try replicate a similar uv on the affected side. there are three different length nails available (acumed, usa), ranging from 190 to 230 mm. when deciding between two different lengths, we used the shorter of the two to avoid the possibility of a proud nail distally. the entry point, just ulnar to listers tubercle and 5 mm proximal to the articular surface, is found with the aid of fluoroscopy. a 1 cm dorsally based longitudinal incision is then made, and blunt dissection performed down to the bone, taking care to avoid injury to the extensor pollicus longus tendon or a small branch of the radial sensory nerve that may cross the surgical field. the near cortex is breached with the entry awl, paying careful attention to the ap and lateral direction of the awl. inaccuracy of these initial steps, particularly in the ap plane, can result in a malreduction of the radius bow. directing the awl in a slight radial direction can aid in avoiding figure 1. an example of how to measure ulnar variance: draw a line tangential to the articular surface of the ulnar. draw a second line tangential to lunate fossa of radius and perpendicular to shaft. measure the distance between these two lines. in this example, the uv is measured at 10.7 mm, and would be considered shortened in this study (normal: uv −4.1 to +2.3). table i: the distribution of fracture occurrences and the incidences of shortening across the proximal, middle and distal region of the radius bone region fracture (%) shortening (%) proximal 48 17 middle 40 58 distal 13 25 figure 2. an ap x-ray of a patient, taken three months post surgery. note the significant ulnar plus (measured at 11.7 mm). she presented with functional loss of supination, requiring revision surgery. page 228 abramson m et al. sa orthop j 2021;20(4) this error. the 3.1 mm reamer is then inserted into the medullary canal, the fracture reduced, and the reamer passed across the fracture, stopping at level of the biceps tuberosity. depending on the ease of the pass, and the preoperative radiological assessment of the bone’s canal diameter, the surgeon may choose to pass the 3.7 mm reamer to enlarge the medullary cavity to aid in the insertion of a larger calibre nail. the appropriately selected nail is then passed, making sure the fluted nail tip is seated firmly in the subchondral bone proximally to improve purchase. tapping of the nail using a mallet is often needed to ensure adequate seating of the nail. restoration of radius length is then achieved radiologically, and rotation confirmed using evans rule, which states that the biceps tuberosity and radial styloid should be visualised 180° to one another in a normally rotated radius.13 the nail is then locked with the forearm in supination, using a single dorsal 3.5 mm locking screw. blunt dissection down to the bone is needed to avoid injury to important structures including the extensor tendons or a branch of the superficial radial sensory nerve. careful intraoperative screening is needed post insertion to ensure the screw is not proud, as this may lead to extensor and flexor tendon irritation. an examination under fluoroscopy is performed to confirm whether the fixation is rotationally stable. if not, an above-elbow slab is used to limit proand supination, for a minimum of four weeks, or until soft callus is seen on x-ray. results forty patients met the criteria for inclusion in the study. no cases were excluded from analysis. thirty-seven (93%) were male, with a mean age of 32.6 years (range 15–59). twelve cases (30%) were assessed as radiologically short by both assessors. the mean shortening of the affected group was 7.4 mm (range 5.1–13.0). all 12 were deemed to have been fixed in a shortened position. one case was assessed to further shorten over time by approximately 2 mm. figure 3. same patient as in figure 2, demonstrating her maximum active supination of the affected side figure 4. same patient as in figure 2, demonstrating her maximum active supination of the normal side figure 5. an ap x-ray of the same patient (figure 2), following an ulnar shortening osteotomy and plating aimed at restoring her native distal radial ulnar joint relationship figure 6. photo demonstrating patient’s (figure 2) improved supination range of motion, six weeks post ulnar shortening procedure figure 7. ap x-ray of a case where a k-wire was used to maintain the length of the distal radioulnar joint page 229abramson m et al. sa orthop j 2021;20(4) most fractures affected the proximal and middle third of the radius. the anatomical distribution of all the fractures was five (13%) distal, 16 (40%) middle and 19 (48%) proximal. the majority (58%) of all shortened fractures were found in the middle third of the radius. postoperative shortening had a statistically significant (p = 0.03) dependency on the position of fracture. refer to table i for a summary of results. we found no statistically significant (p = 0.55) difference between the average length of the zone of comminution (41.6 ± 25.9 mm in the shortened group and 35.6 ± 18.9 mm in the not-shortened group) and the incidence of shortening between the two groups. discussion the surgical goals of any forearm shaft fracture fixation are the restoration of axial and rotational alignment, maintaining stability of the proximal and distal radioulnar joints and early range of motion.1,3 for most forearm fractures, compression plating remains the gold standard, as anatomical reduction and primary bone healing are considered fundamental in achieving the best functional outcome.3 complications associated with plate fixation include a 0.8–2.3% risk of infection,14 attributed to the extensive soft tissue dissection required, and up to 30% refracture rate when the plate is removed.15 fracture comminution however, a constant feature following gsw,1 poses unique treatment challenges and precludes primary bone healing strategies in favour of secondary bone healing. secondary bone healing can be achieved either by nonoperative means with the use of a plaster cast, or surgically, utilising either bridge plating techniques or im nailing. nonoperative management of adult diaphyseal radius fractures is associated with high complication rates, most notably failure to maintain reduction, radius shortening and stiffness.5 the benefits of an intramedullary device over bridge plating include a smaller incision, improved cosmesis and less soft tissue dissection, while also maintaining a more optimal environment for healing due to minimal disruption to the fracture haematoma.6,7 its stress-sharing biomechanics also promote a predictably stronger fracture callus compared to bridge plating.6 the early radial nails were criticised for their potential to result in iatrogenic injury to the posterior interosseus nerve during proximal locking.6 this led to the development of the currently available radial nail, which has a flanged proximal end, eliminating the need for proximal locking while still providing rotational control through a press-fit mechanism into the unreamed subchondral bone. this requires attention to detail in the reaming step of the surgery (see surgical technique) as reaming beyond the bicipital tuberosity can potentially reduce the proximal purchase into the subchondral bone and therefore reduce the rotational control the nail provides. the modern nail is not without problems either, with nail migration and malunion (failure to restore radial bow) have been highlighted.14 many authors have investigated the clinical and biomechanical consequences of radius shortening. crisco et al. reported that radius shortening changes the axis of rotation of the forearm, resulting in reduced joint congruency, reduction in rotation and changes in stress across the triangular fibrocartilage complex (tfcc).16 adams concluded that the greatest change in kinematics at the distal radius ulnar joint is due to radius shortening, which results in increased strain in the articular disc, and volar and dorsal radioulnar ligaments of the tfcc, leading to reduced grip strength.17 they also reported that radius shortening results in changes in radiocarpal and radioulnar joints and that radius shortening has the most direct correlation with increased symptoms, including an increased risk of arthrosis. lidstrom concluded their work by claiming that restoring radius length is the most important factor associated with a good clinical outcome.18 fernandez showed that radius shortening can result in reduced proand supination.19 one of the patients in our series presented for her follow-up with significantly reduced supination, affecting her activities of daily living. her postoperative x-rays show a positive ulnar variance of 11.7 mm (figure 2). comparative pictures shown in figures 3 and 4 demonstrate her limitation in supination compared to the unaffected side. she underwent an ulnar shortening osteotomy (figure 5) to alleviate some of her symptoms. figure 6 shows her improved clinical picture, six weeks post revision surgery. distal radioulnar joint pain, ulnar impaction syndrome, tfcc tears and early onset osteoarthritis are the other commonly associated conditions attributed to radius shortening.8,9,16 ulnar variance (uv) is a commonly used radiological method to assess for radius shortening. plain radiographs are proven to be acceptably accurate to measure uv.10,12 being a dynamic measurement, it is influenced by several factors including rotation, grip and beam direction,20 and therefore, normal reference ranges differ. while international consensus on uv ranges is lacking, most quoted studies of uv in a neutral, relaxed position is 0.9 mm (range −4.1 mm to +2.3 mm).10 to accommodate for magnification error, potential positional variability when taking the x-ray, and to allow for the potential of a patient having a pre-existing ulnar plus of up to 2.5 mm, we defined radiological shortening as more than or equal to 5 mm positive uv. we used the rule of perpendiculars to measure uv, having been shown to have the best interobserver reliability of the three commonly practiced methods of assessing.10,12,21 there is ample published literature on the clinical impact of a positive uv. most of the literature suggests that 2.5 mm is the amount of radius shortening beyond which clinical symptoms develop.8-10,22,23 early onset osteoarthritis due to increase in the mechanical load though the ulnar,20 ulnar impaction syndrome, distal radius ulnar joint (druj) pain/degeneration, reduced grip strength and carpal instability are also reported in the literature.8,9,17,22 we could only find two articles that specifically looked at im nails in the setting of gsw. in the first, the author makes mention of a case where druj shortening occurs over the course of the healing process but does not elaborate further on its clinical significance.7 the second paper is an outcome-based study and does not specifically look at radius shortening.1 while formulating this study, we hypothesised that highly comminuted radius shaft fractures would shorten over time. we felt the mechanical properties of the im nail may not be adequate to maintain length for sufficient time to allow union, as biomechanical studies have proven them inferior to plates.5 the results of our study, however, seem to suggest that, should meticulous care be taken intraoperatively to restore the correct radius length before locking the nail, that shortening does not occur over time. we therefore advocate the following steps to ensure shortening is avoided. first, take measurements of the contralateral radius for length and diameter in order to plan which available nail will give you the optimal proximal subchondral purchase, without leaving it proud distally. if only a single distal locking screw is available, inadequate purchase of the fluted blade tip into unreamed bone may render the nail length unstable. pay careful attention to the relationship of the distal radius and ulnar of the unaffected side in order to reproduce it on the operated side. intraoperatively, the authors feel that tapping in of the nail to get adequate subchondral purchase may inadvertently result in shortening. to mitigate this potential problem, one of our surgeons held the reduced druj out to length before inserting the nail using a k-wire prior to the insertion of the nail (figure 7). the wire was left in-situ for three weeks, and the patient healed in an acceptable position. given what we now know about the nail’s seemingly consistent ability to hold fractures out to length if acceptably reduced, we feel that removing the wire at the conclusion of the surgery, thus limiting page 230 abramson m et al. sa orthop j 2021;20(4) the potential side effects of an in-situ wire, is appropriate. lastly, we wish to stress the importance of screening for stability at the conclusion of the surgery, and if there is any doubt, liberal use of an above-elbow back slab for four weeks, or until soft callus seen on x-ray, is advocated. the secondary outcome measures of the study aimed to determine if length of comminution or anatomical location of the fracture had any direct correlation with an increased incidence of shortening. while shortening was found to be dependent on the fracture position, with a predilection for the middle third of the radius, the length of the zone of fracture comminution was found to not be a significant contributing factor. the study is enhanced by its relatively large sample size, given the sparsity of this surgery, but it is limited by its retrospective design. being a retrospective review, we could not ensure all the x-rays were standardised, thus potentially affecting the dynamic nature of uv. as detailed in the discussion section, we attempted to overcome this by setting a relatively high positive uv as our cut-off to define shortening. finally, we are aware of the limitations in our detection methods for identifying and defining radius shortening, due mainly to a lack of formal contralateral control x-rays showing the patients’ baseline uv. obtaining intraoperative radiographs upon completion of the surgeries would have removed the remote possibility that the fracture was fixed correctly and shortened in the immediate postoperative period. while screening the contralateral side is an important intraoperative step, its accuracy in uv measurements for the purposes of this study is insufficient. conclusion the radius nail remains a useful tool to manage comminuted radius shaft fractures following gsw, yet careful attention to detail is needed intraoperatively to avoid radiological shortening, as seen in 30% of our case series. we found no evidence of subsequent shortening if the radius length is corrected before the nail is locked. we also did not find any causative relationship between length of the zone of fracture comminution and subsequent shortening but found a dependent relationship between fracture location and incidence of shortening. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. full ethics approval from the university of cape research committee (hrec 580/2019) was obtained for this study. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ma: study conceptualisation, study design, data capture, data analysis, first draft preparation, manuscript revision, manuscript preparation sm: first draft preparation, manuscript revision rd: data capturing, statistical analysis ml: manuscript revision, study design, study conceptualisation, manuscript preparation orcid abramson m https://orcid.org/0000-0001-6677-3506 maqungo s https://orcid.org/0000-0002-8735-8341 dey r https://orcid.org/0000-0002-3616-1995 laubscher m https://orcid.org/0000-0002-5989-8383 references 1. maqungo s, kauta n, mccollum g, roche s. clinical outcome of isolated low velocity gunshot radius fractures treated with closed reduction and locked intramedullary nailing. bone jt surg orthop proc. 2018;96-b(suppl 19). 2. weckbach a, blattert tr, weißer c. interlocking nailing of forearm fractures. arch orthop trauma surg. 2006;126(5):309-15. 3. saka g, saglam n, kurtulmuş t, et al. new interlocking intramedullary radius and ulna nails for treating forearm diaphyseal fractures in adults: a retrospective study. injury. 2014;45(suppl 1):s16-s23. 4. hong g, cong-feng l, chang-qing z, et al. internal fixation of diaphyseal fractures of the forearm by interlocking intramedullary nail: short-term results in eighteen patients. j orthop trauma. 2005;19(6):384-91. 5. rehman s, sokunbi g. intramedullary fixation of forearm fractures. hand clin. 2010;26(3):391-401. 6. ozkaya u, kilic a, ozdogan u, et al. comparison between locked intramedullary nailing and plate osteosynthesis in the management of adult forearm fractures. acta orthop traumatol turc. 2009;43(1):14-20. 7. gelbart b, aden a. evaluation of intramedullary nailing in low-velocity gunshot wounds of the radius and ulna. sa orthop j. 2013;12(3):35-41. 8. pogue dj, viegas sf, patterson rm, et al. effects of distal radius fracture malunion on wrist joint mechanics. j hand surg am. 1990;15(5):721-27. 9. bu j, patterson rm, morris r, et al. the effect of radial shortening on wrist joint mechanics in cadaver specimens with inherent differences in ulnar variance. j hand surg am. 2006;31(10):1594-600. 10. laino dk, petchprapa cn, lee sk. ulnar variance: correlation of plain radiographs, computed tomography, and magnetic resonance imaging with anatomic dissection. j hand surg am. 2012;37(1):90-97. 11. miyake j, murase t, yamanaka y, et al. three-dimensional deformity analysis of malunited distal radius fractures and their influence on wrist and forearm motion. j hand surg eur vol. 2012;37(6):506-12. 12. steyers cm, blair wf. measuring ulnar variance: a comparison of techniques. j hand surg am. 1989;14(4):607-12. 13. evans em. rotational deformity in the treatment of fractures of both bones of the forearm. j bone jt surg. 1945;27(3):373-79. 14. lee yh, lee sk, chung ms, et al. interlocking contoured intramedullary nail fixation for selected diaphyseal fractures of the forearm in adults. j bone jt surg. 2008;90(9):1891-98. 15. nagy l, jankauskas l, dumont ce. correction of forearm malunion guided by the preoperative complaint. clin orthop relat res. 2008;466(6):1419-28. 16. crisco jj, moore dc, marai ge, et al. effects of distal radius malunion on distal radioulnar joint mechanics an in vivo study. j orthop res. 2007;25(4):547-55. 17. adams bd. effects of radial deformity on distal radioulnar joint mechanics. j hand surg am. 1993;18(3):492-98. 18. lidström a. fractures of the distal end of the radius: a clinical and statistical study of end results. acta orthop scand. 1959;30(suppl 41):1-118. 19. fernandez dl. should anatomic reduction be pursued in distal radial fractures? j hand surg br. 2000;25(6):523-27. 20. tomaino mm. the importance of the pronated grip x-ray view in evaluating ulnar variance. j hand surg am. 2000;25(2):352-57. 21. thuysbaert g, ringburg a, petronilia s, et al. measurement of ulnar variance and radial inclination on x-rays of healed distal radius fractures. with the axis of the distal radius or ulna? acta orthop belg. 2015;81(2):308-14. 22. palmer a, werner f. biomechanics of the distal radioulnar joint. clin orthop relat res. 1984;187:26-35. 23. dumont ce, pfirrmann cwa, ziegler d, nagy l. assessment of radial and ulnar torsion profiles with cross-sectional magnetic resonance imaging: a study of volunteers. j bone jt surg am. 2006;88(7):1582-88. https://orcid.org/0000-0001-6677-3506 https://orcid.org./0000-0002-8735-8341 https://orcid.org/0000-0002-3616-1995 https://orcid.org./0000-0002-5989-8383 404 not found south african orthopaedic journal editorial doi 10.17159/2309-8309/2022/v21n2a0marais lc sa orthop j 2022;21(2) data and decision making – from odd to artificial leonard c marais* department of orthopaedics, school of clinical medicine, university of kwazulu-natal, durban, south africa *corresponding author: lcmarais@saoj.co.za with my term as editor-in-chief of the saoj coming to an end soon, i cannot help but reflect on some of my past experiences in this role. perhaps the most challenging (and satisfying) was the need to get to grips with some of the more intricate aspects of research methodology and statistics. at first glance, these concepts seem fairly straightforward, but almost ubiquitously become exceedingly complex the harder you look. the odds ratio (or) is an excellent case in point. there are a number of ways in which the measure of association between an exposure and an outcome can be expressed. ors are probably the most commonly used. the current emphasis on reporting 95% confidence intervals (ci), rather than only p-values, has resulted in us seeing and doing a lot more logistic regression. along with the 95% ci, the statistical program also provides the or, which is then reported in our results. now, ors are tricky things. to justify this statement, i am going to have to go way back to the start, where all good research should start, with the definitions. a ratio is simply a number obtained by dividing one number by another number, and there is not necessarily a relationship between the numerator and denominator. a proportion is a ratio that relates a part to a whole, thus there is a relationship between the numerator and denominator. rate is a proportion where the denominator also takes into account another dimension, typically time. defining probability (p) is a minefield, but for our purposes, we will limit it to the measure of the likelihood that an event will occur. with the basics out of the way, let us delve a little deeper. relative risk (rr), also known as the risk ratio, is a descriptive statistic commonly used in analytical studies. risk can be defined as the probability of the outcome of interest occurring. rr is therefore essentially a ratio of proportions. in statistical terms, rr is equal to the event rate in the exposed group divided by the event rate in the non-exposed (control) group (figure 1). for example, imagine we are performing a study comparing the risk of developing infection following grade iii open fractures when antibiotics are given within an hour of the injury (treatment group) or not (control group). if 5 out of 100 patients in the treatment group and 20 out of 100 patients in the control group get an infection, we have a relative risk of 0.25. rr = 0.25 means exposed patients (i.e., in the treatment group) are 0.25 times as likely to develop the outcome of interest. we could also state that patients receiving antibiotics within an hour were 75% (0.75 = 1 − 0.25) less likely to develop infection. as clinicians we generally prefer to think in terms of probabilities and relative risk. the other commonly used descriptive statistic to report measure of association is the odds ratio (or). odds can be defined as the relative probability of the outcome of interest occurring. so, what is this probability relative to? – the probability of outcome not occurring. in other words, odds represent the ratio of the probability of the event occurring over the probability of the event not occurring. odds can mathematically be defined as equal to (p/1−p). the or then is a ratio of ratios and equal to odds of outcome in the exposed group divided by odds of outcome in the non-exposed control group. an or < 1 means a reduced odds of the outcome of interest occurring while an or > 1 implies increased odds. thus, in our open fracture example study, the or would be 0.21. this would mean that the odds (not risk) of infection is 79% lower in the group that received antibiotics. if an or is 3.8, that would mean that odds of the outcome of interest occurring was increased by 3.8 times. for the sake of completeness, i will also mention number needed to treat (nnt), which is essentially the number of patients that need to receive the exposure to prevent one unwanted outcome. it is defined as the inverse of the absolute risk reduction (arr). arr is equal to event rate in the control group (cer) minus the event rate in the exposed group (eer). at this point, it might be useful to reflect on the origin of ors. the first rationale has to do with study design. in cross-sectional studies, the rr can be calculated from the prevalence. in cohort studies rr can be calculated from the incidence. if the incidence or prevalence is not available in case-control studies, then or may be the only option to provide an indication of the measure of association.1 it is important to remember that case-control studies are typically used to study rare diseases or events. why this is relevant, will hopefully make more sense shortly. the second reason for ors’ existence is statistical in nature and somewhat more complex. basically, logistic regression provides an or rather than rr, even in a cohort study, because of the frequency of convergence problems during the mathematical modelling.2 what is a convergence problem? the explanation is beyond the scope of this piece, and my understanding. it has something to do with the fact that regression aims to maximise the likelihood (by finding + outcome – outcome + exposure a b – exposure c d odds ratio or = (a/b)/(c/d) log odds ln(odds) absolute risk treatment group (event rate in exposure group) art = a (a+b) absolute risk control group (event rate in control group) art = c (c+d) relative risk rr = art/arc relative risk reduction rrr = arc – art = 1 – rr arc absolute risk reduction arr = arc – art number needed to treat nnt = 1 arr figure 1. commonly used terms in the reporting of risk page 66 marais lc sa orthop j 2022;21(2) the maximum log likelihood) through iteration and the problem occurs when the process cannot converge on a best-fit model. but i digress … now before we examine ors any further, we need to have a look at how ors are computed by our statistical software. please bear with me as things are about to get messy. in our open fracture example above, the baseline odds for infection was 0.25; thus 20 infections/80 no infections. now imagine we increase our sample size by 1 000 and we have improved our treatment to the extent that we still only have 20 infections. this will equate to an odds of 0.02 for infection. but if we turn it around and ask what are the odds of not getting an infection, it will be 54 (1080/20). it’s a problem of scale; 0.02 looks much closer to 1 than 54. while representing exactly the same event, the odds of infection not occurring appear to be a lot bigger than infection occurring. how did statisticians solve the problem? by using the logarithm (log) function. (note: in logistic regression, log means the natural log [loge or ln]). log odds is the log of the odds, i.e., loge(odds). why use log odds? basically, to create a fair comparison scale. log odds for infection occurring = loge(20/1080) = −3.99. log odds for infection not occurring = loge(1080/20) = 3.99. using log odds creates symmetry in the scale by creating outputs that are normally distributed around zero.3 when logistic regression is performed by a statistical program it uses the logit function, where logit (p) = ln p . 1-p the regression coefficient (b) reported in the output table is the amount of change expected in the log odds when there is a one unit change in the exposure variable with all of the other variables in the model being held constant. the or is then computed as the exponential function of the regression coefficient associated with a one-unit increase in the exposure. in mathematical terms or = eb1 (where e= 2.718). so what, i hear you ask. well, there are a number of implications. first, it’s important to recognise that ors should not be interpreted as an equivalent to rr. it is incorrect to say that with an or of 4 there is a ‘four-fold increase in the risk’. or always overestimates the rr and represents a poor approximation of relative risk when the baseline risk (in the control group) for the outcome of interest is high (roughly more than 5–10%).4 as with all statistical tests, certain assumptions are made and this one is called the ‘rare disease assumption’. in rare diseases, the odds are close to the risk as the number of non-events is close to the total number of subjects.5 thus, with a baseline risk of around 5%, an or of 4 would equate to a relative risk of roughly 3.5. with a baseline risk of 25%, an or of 4 would equate to the relative risk of about 2.5, and at 50%, an or of 4 a relative risk of only about 1.5. you will notice the exponential nature of the relationship. methods have been described by which the or estimated by logistic regression can be converted to a ‘corrected’ risk ratio which is closer to the ‘true’ risk ratio.6 this may be necessary in cohort studies where the event rate is more than 10% and the or more than 2.5 or less than 0.5. secondly, when the or is calculated by performing logistic regression, the sample size is important. logistic regression calculates the or from the regression coefficient where or = eb. to determine the coefficient, it uses a maximum likelihood estimation (mle). mle is a method of estimating the value of the parameters of a model from observed data in a way that these values will maximise the probability that the process described by the model produces the actually observed data. you might be wondering, as i did, how the regression coefficient is calculated. you will have to trust me when i say: let’s not go there. what is important though is to recognise that the behaviour of maximum likelihood estimation is unpredictable when dealing with small sample sizes. some say that 100 should be the minimum sample size.7 thirdly, we have the problem of ‘non-collapsibility’. since most of the predictors we use in a multivariate model are correlated to some degree, it is common for regression coefficients to change from one model to the next. in fact, as you include more variables in a model that are predictive of an outcome, the magnitude of the coefficient of a variable unrelated to others will keep increasing.8 ultimately this also creates problems for us in meta-analysis. the ors used in meta-analysis will come from different studies using different models with varying degrees of omitted variables and may not be directly comparable. i will admit that i may have embellished here somewhat and it is difficult to say exactly how large the effect size of the mentioned problems are in the studies we typically read. furthermore, i am not trying to imply it is wrong to report ors, it should just be interpreted correctly. and it remains vital that we do not only report relative measures of association (like ors and rrs), but ensure that we also clearly communicate absolute measures, like event rates in the respective groups. others have recommended that we should try and report at least one other measure of effect size alongside the or.8 the result is that we clinicians may have to familiarise ourselves with a host of new statistical methods and concepts like poisson regression and negative binominal regression.9 but will these more complex statistical methods improve our decision making? one can foresee us working in this, let us call it, ‘analytical’ way for some time and therefore an understanding of these concepts remains valuable. however, the issues with ors also highlight the fragility of our analytical approach, which may have more profound implications. as clinicians, we aim to base our treatment on the highest levels of evidence, mainly meta-analysis. thus, we will, for example, decide to, or not to, internally fixate a patient’s fractured clavicle based on this evidence. yet we are often left with the nagging feeling that the analytics we are using and the inferences we have drawn may have not accounted for all the complexity involved in the decision-making process. do the observations from a population as a whole provide meaningful evidence for decision making at a patient level?10 we recognise the shortcoming of the or measure itself, and know there are others. there is power, reliability, validity, fragility, heterogeneity and a host of other confounders that could have crept in at the individual study level or during the synthesis. then there is the fact that we are using the output of our analytical approach as a constant function, i.e., whatever the input into the equation, the output remains constant. if we choose operative management of clavicle fractures based on the or for non-union, for example, the 16-year-old motocross enthusiast will get treated with internal fixation, as will the 36-year-old accountant who occasionally cycles. an oversimplification, i agree, but there may be some truth to the argument. the impact of a host of input variables may remain unaccounted for when the decision is based on a few outcome variables from the study sample as a whole only. there may well be circumstances where a certain combination of input variables like patient factors, fracture pattern and displacement, etc., might result in an or that would favour nonoperative management. will adding more inferential statistics to our results or computing them in much more elaborate ways really improve our ability to choose the correct treatment for the patient sitting in front of us? or will a larger sample size or the ‘big data’ approach solve our problem? it may well help, but there may be alternative ways in which data can be used to provide us with an output that assists us with choosing the optimal management strategy at individual patient level. ironically, the answer again lies in the form of logistic regression and the logit function. this mathematical function has found major application in artificial intelligence (ai), and machine learning in particular. machine learning involves the building of a model by looking at data and identifying patterns, and then using those insights to better complete its assigned task. any task that page 68 marais lc sa orthop j 2022;21(2) requires a set of data inputs or rules can be automated using machine learning, even the more complex tasks. and the machine learns from new data, continuously refining the model. the decision to fixate or not fixate a clavicle might therefore become ‘ai-based’. while it would still be founded on the available data, i.e., evidence-based, the algorithms and models will be so complex it would likely be beyond our comprehension. and we are not talking about the distant future here. if you look at any edition of a prominent orthopaedic journal these days, you are bound to find at least one machine-learning article. currently these models are mostly focused on detection of pathology (pattern recognition) or the prediction of an outcome, prognosis or complications. a systematic review published in 2021 identified 34 papers that evaluated machine learning as a patient–provider decision-making tool.10 the majority of these studies focused on risk prediction and patient stratification, which can then be used to inform decision making. for example, the international spine study group worked on a model to predict major complications after spinal deformity correction surgery.11 some took it a step further, venturing into the field of making the actual decision. azimi et al., for example, use an artificial neural network to select surgery for patients with lumbar spinal stenosis.12 i agree, that hits close to home. while it is not inconceivable that these novel decision-making tools may become part of our practice in the future, some things won’t change. we will still want, and need, to have an understanding of how it works and how to use it correctly. the rabbit hole will most likely just get a bit deeper. references 1. sacket dl, deeks jf, altman dg. down with odds ratios! evidence-based med. 1996;1(6):164-66. 2. williamson t, eliasziw m, hick gh. log-binomial models: exploring failed convergence. emerg them epidem. 2013:10(1):14. https://doi.org/10.1186/1742-7622-10-14. 3. agarwal p. what and why of log odds. towards data science. 9 july 2019. available from: https://towardsdatascience.com/https-towardsdatascience-com-what-and-why-of-log-odds64ba988bf704. accessed 14 february 2022. 4. schmidt co, kohlmann t. when to use the odds ratio or the relative risk? int j public health. 2008;53(3):165-67. https://doi.org/10.1007/s00038-008-7068-3. 5. schulz kf, grimes da. an overview of clinical research: the lay of the land. lancet. 2002;359(9300):57-61. https://doi.org/10.1016/s0140-6736(02)07283-5. 6. zhang j, yu kf. what is relative risk? a method of correcting the odds ratio in cohort studies of common outcomes. jama. 1998;280(19):1690-91. https://doi.org/10.1001/ jama.280.19.1690. 7. ucla advanced research computing. logistic regression with stata chapter 1: introduction to logistic regression with stata. available from: https://stats.oarc.ucla.edu/stata/webbooks/ logistic/chapter1/logistic-regression-with-statachapter-1-introduction-to-logistic-regressionwith-stata/. accessed 14 february 2022. 8. uanhoro jo, wang y, o’connel aa. problems with using odds ratios as effect sizes in binary logistic regression and alternative approaches. j exp educ. 2021;89(4):670-89. 9. schober p, vetter tr. count data in medical research: poisson regression and negative binomial regression. anesth analg. 2021;132(5):1378-79. https://doi.org/10.1213/ane.00 00000000005398. 10. brnabic a, hess lm. systematic literature review of machine learning methods used in the analysis of real-world data for patient-provider decision making. bmc med inform decis mak. 2021;21(1):54. https://doi.org/10.1186/s12911-021-01403-2. 11. scheer jk, smith js, schwab f, et al. development of a preoperative predictive model for major complications following adult spinal deformity surgery. j neurosurg spine. 2017;26(6):736-43. https://doi.org/10.3171/2016.10.spine16197. 12. azimi p, mohammadi hr, benzel ec, et al. use of artificial neural networks to decision making in patients with lumbar spinal canal stenosis. j neurosurg sci. 2017;61(6):603-601. https://doi.org/10.23736/s0390-5616.16.03078-2. hirschmann a et al. sa orthop j 2020;19(3) doi 10.17159/2309-8309/2020/v19n3a2 south african orthopaedic journal http://journal.saoa.org.za general orthopaedics citation: hirschmann a, pillay t, fang kw, ramokgopa mt, frey c. defcon 5: the chris hani baragwanath academic hospital orthopaedic department’s covid-19 proactive action plan. sa orthop j 2020;19(3):138-144. http://dx.doi.org/10.17159/2309-8309/2020/v19n3a2 editor: prof nando ferreira, stellenbosch university, south africa received: may 2020 accepted: july 2020 published: august 2020 copyright: © 2020 hirschmann a. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for the purposes of performing this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: on 11 march 2020 the world health organization (who) declared covid-19 a worldwide pandemic and a threat to global public health. in this paper we aim to describe the measures implemented to combat the covid-19 pandemic in the department of orthopaedic surgery at chris hani baragwanath academic hospital (chbah), soweto, johannesburg, the largest hospital in africa with approximately 3 200 beds and about 6 760 staff members. at the time of writing this report, we have transitioned from level 5 to level 3 lockdown. methods: we performed a literature review and drew on the experiences of previous pandemic response plans worldwide. a working group comprising all relevant disciplines was created to develop standard operating procedures in line with governmental policy. results: we found that by developing a multi-phase plan, we were able to maintain service delivery to all emergent patients while protecting medical staff and patients alike. this plan also allowed coordination with other disciplines and made provision for staff from within the department of orthopaedic surgery to be made available to work within other departments as and when required. the implementation of this plan had to evolve constantly, adjusting to the changes in the national lockdown level and the demands of the developing situation. conclusion: we hope that by sharing our plan with our colleagues domestically and abroad, we can promote discussion and improve our ability to better prepare and deal with this unprecedented healthcare scenario. in order for us to win as individuals, we must fight as a team. level of evidence: level 5 keywords: covid-19, orthopaedics, plan, response, baragwanath defcon 5: the chris hani baragwanath academic hospital orthopaedic department’s covid-19 proactive action plan hirschmann a1 , pillay t2 , fang kw3 , ramokgopa mt4 , frey c5 1 fc ortho(sa), bada(hons)(wits); registrar, department of orthopaedic surgery, university of the witwatersrand, johannesburg, south africa; chbah ² fc ortho(sa); registrar, department of orthopaedic surgery, university of the witwatersrand, johannesburg, south africa; chbah 3 fc ortho(sa); registrar, department of orthopaedic surgery, university of the witwatersrand, johannesburg, south africa; chbah 4 fcs(sa)orth; head of department, department of orthopaedic surgery, university of the witwatersrand, johannesburg, south africa; chbah 5 fcs(sa)orth; head of arthroplasty unit, department of orthopaedic surgery, university of the witwatersrand, johannesburg, south africa; chbah *chbah: chris hani baragwanath academic hospital corresponding author: dr adam hirschmann, university of the witwatersrand, 7 york road, parktown, johannesburg, 2193; po box 92089, norwood, johannesburg, 2117, south africa; tel: +27 (82) 567 8407; email: adamhmann@gmail.com https://orcid.org/0000-0003-1776-9214 https://orcid.org/0000-0001-9202-9449 https://orcid.org/0000-0002-9020-1556 https://orcid.org/0000-0002-8430-986x https://orcid.org/0000-0003-1692-9749 page 139hirschmann a et al. sa orthop j 2020;19(3) introduction in this paper we aim to describe the measures implemented to combat the covid-19 pandemic in the department of orthopaedic surgery at chris hani baragwanath academic hospital (chbah), soweto, johannesburg. with the growing threat of this global pandemic, the authors would like to provide a transparent action plan that can be discussed, criticised, partially/wholly implemented and, most importantly, promote safety among all parties while allowing optimal service delivery to our patient population. we used the term defcon which is the defense readiness condition – a state of alertness used by the united states armed forces. there are five levels. level 5 is lowest state of readiness and implies that there may be necessary preparations for war.1 it is essential that, despite this growing invisible threat, patient care is not compromised, including those patients who may not be covid-19 afflicted. this principle was a driving force for the development of a comprehensive standard operating procedure (sop) that would allow for the emergent treatment of both covid-19 positive and covid-19 negative orthopaedic patients (figure 1). the sop is structured such that we would be able to provide staff members to assist in other departments that may be overrun with medical patients and require additional human resources in response to the expected overwhelming patient influx2 while still preserving staff to provide optimal patient care for those patients requiring orthopaedic management. during these exceptional times, it is imperative to consider the possibility that surgical facilities become hampered by staff sickness, reduced supply of surgical materials, and the use of operating rooms (ors), facilities, and even anaesthesiologists for improvised intensive care unit (icu) ‘pods’ for patients with covid-19.3,4 background covid-19 (corona virus disease 2019) is the disease caused by the sars-cov-2 virus, which belongs to the coronaviradae family.5 on 11 march 2020 the world health organization (who) declared covid-19 a worldwide pandemic and a threat to global public health.6 the chris hani baragwanath academic hospital (chbah) is the largest hospital in africa (and third largest hospital in the world), occupying around 173 acres (0.70 km2), with approximately 3 200 beds and about 6 760 staff members.7 the department of orthopaedic surgery at chbah sees an average of 246.8 patients per day (five days a week) in the outpatient department (opd), admitting 5.6 patients per day (table i). the 2019 orthopaedic opd monthly average was 1 353 patients consulted. there is an additional daily average of 45 emergent patient consultations (table ii) in orthopaedic intake (opit) via the accident and emergency (a&e) unit with 15 average admissions daily (seven days per week). figure 1. timeline of relevant events in the development and implementation of chbah department of orthopaedic surgery covid-19 response standard operating procedure (sop) march 2020 12 march hod and senior staff raise concerns about growing pandemic in south africa 01 13 march suggested action plan proposed and immediate policies implemented 02 april 2020 09 10 1 june south africa moves to level 3 11 may 2020 june 2020 16 march chbah covid19 working group established 03 15 march a state of national disaster declared 04 23 march presidential address announcing national lockdown 05 25 march proposed orthopaedic departmental protocol presented to department 06 27 march national lockdown in effect at 00h01 07 08 30 march chbah covid-19 sop distributed among departments 1 april chbah department of orthopaedic surgery publishes its own sop 2 may south africa moves to level 4 figure 1. timeline of relevant events in the development and implementation of chbah department of orthopaedic surgery covid-19 response standard operating procedure (sop) 70 000 60 000 50 000 40 000 30 000 20 000 10 000 0 45 656 55 015 58 658 60 271 66 265 63 903 2014 2015 2016 2017 2018 2019 orthopaedic opd daily consultations table i: column chart comparing the 2014–2019 orthopaedic opd total patient volume 16 416 15 841 16 396 16 778 16 236 5 125 5 689 5 119 4 955 5 504 daily consultations daily admissions 18 000 16 000 14 000 12 000 10 000 8 000 6 000 4 000 2 000 0 2015 2016 2017 2018 2019 table ii: column chart comparing the 2015–2019 orthopaedic opit total patient volume page 140 hirschmann a et al. sa orthop j 2020;19(3) the 2019 monthly orthopaedic opd and opit average was 5 325 and 1 353 patients, respectively. given that public gatherings and close-quarter contact increases the spread of the sars-cov-2 virus,8 it was imperative for us to implement an urgent strategy to reduce these numbers, thereby protecting our patient population and staff contingent. the department of orthopaedic surgery at chbah has 225 beds (96–112% average daily occupancy with patients also allocated to outlying wards) available among seven dedicated orthopaedic wards (table iii). at the time of this action plan, there were 68 members of the doctor staff, of which 53 are considered permanent staff (table iv). measures staffing considerations we developed an unvalidated scoring system (table v) that allowed us to categorise staff into low, increased, moderate and high risk (table iv) based on articles by yang et al.9 and guan et al.,10 the chbah sop and the centers for disease control and prevention (cdc) published guidelines.11 all increased and moderate risk personnel would be classified as low risk in the initial phases of the department sop. once the admitted population of covid-19 positive patients is >10% and >20%, the increased and moderate risk personnel, respectively, would fall under the high-risk category. table iii: description, bed allocation and ward number of orthopaedic surgery beds at chbah ward patient category total no. of beds 9 male septic 40 11 male trauma/hands 43 12 female trauma/hands female septic 38 47 elective cases (male) 24 48 elective cases (female) 24 49 paediatric trauma/hands paediatric septic 28 50 paediatric elective cases (including spine) 28 total 225 table iv: chbah department of orthopaedic surgery staff contingent and risk stratification   total high risk low risk consultants 23 9 14 registrars 22 1 22 medical officers 7 0 7 interns 16 1 15 total 68 11 58 table v: scoring system for human resource risk stratification in the department of orthopaedic surgery at chbah chbah orthopaedic staff covid-19 risk stratification score risk factor score age >50 years 1 living in a nursing home or long-term care facility 1 chronic lung disease 1 moderate to severe asthma 1 immune-compromised state: chemotherapy, smoker, bone-marrow/organ transplant recipient, immune deficiencies, poorly controlled hiv, aids, prolonged use of corticosteroids or other immune-weakening medications 1 severe obesity: bmi=40 or higher 1 people with type 1 or 2 diabetes 1 people with chronic kidney disease 1 people with liver disease 1 scoring: 0: low risk; 1: increased risk; 2: moderate risk; 3 or greater: high risk table vi: table showing the comparison of daily consultations/admissions between orthopaedic opd and opit from the 2019 average and the current national lockdown average   2019 average 2020 level 5 lockdown daily average (27/03/2020 to 01/05/2020) 2020 level 4 lockdown daily average (02/05/2020 to 30/05/2020) 2020 level 3 lockdown daily average (01/06/2020 to 10/06/2020) daily orthopaedic opd consultations 246.8 112.7 135.4 124.6 daily orthopaedic opd admissions 5.6 0.3 0.65 2.1 daily orthopaedic opit consultations 45 19.7 24.6 35.9 daily orthopaedic opit admissions 15 6.8 9.9 13 page 141hirschmann a et al. sa orthop j 2020;19(3) internationally, orthopaedic surgeons have already been infected by covid-19 in the workplace.12 the goal of this risk stratification system was to protect staff members considered to be at higher risk of severe disease while maintaining staff numbers for as long as possible. workstreams workstreams were broadly divided into ‘non-covid-19’ and ‘covid-19’ (figure 2). the concept of splitting the workstreams was to both protect the high-risk staffing contingent from exposure to covid-19 positive patients as well as to maintain service delivery to all orthopaedic emergency patients. this system of workstream allocation would also provide a team to care for covid-19 positive orthopaedic emergency cases as the number of infected patients grows domestically. • workstreams are divided into covid-19 and non-covid-19: ▫ covid-19 workstreams were further divided into: a. covid-19 auxiliary medical support for non-orthopaedic covid-19 patients admitted under internal medicine (to bolster the work force and provide operational support to the potentially hardest hit departments) b. covid-19 suspected/confirmed patients requiring orthopaedic care ▫ non-covid-19 workstreams (routine orthopaedic patients) the allocation of staff to the auxiliary medical support workstream as well as the separation of non-covid-19 and covid-19 orthopaedic workstreams was set to occur in an incremental fashion according to a phased response depending on the need. the secondary objective was to also try allocating expertise accordingly to optimise care provided in the relevant group. this dynamic construct was assessed on a daily basis by the chbah covid-19 working group and the phases published in the chbah sop. the interns rotating though orthopaedic surgery at the time were allocated to non-covid-19 workstreams based on their temporary presence within in the department and subsequent rotation to other healthcare facilities. we felt it would not be wise to expose them thereby not only risking their well-being but also possibly increasing risk of transmission to the subsequent healthcare institutions. the preservation of a designated covid-19 orthopaedic workstream was based on contingency measures in the event we experience civil unrest during this period which would allow us to effectively deploy staff to address the potential influx of orthopaedic trauma. a decision was taken to maintain consultant orthopaedic surgeons within the department at all times. this was to ensure maximum service delivery and maintain leadership within the respective units as the situation unfolds and the health system becomes more constrained. medical officers and junior registrars (who had volunteered) were initially identified as better candidates for the auxiliary medical services workstream given the more recent rotation through intensive care units (icu) and current ventilation practices thereby also preserving the low-risk groups of surgically proficient registrars and consultants for management of the covid-19 afflicted orthopaedic patients. theatre all non-urgent elective cases were postponed in keeping with the published national directive on 22 march 2020. from this date onwards, elective lists would be populated with semi-urgent elective cases involving trauma/sepsis/malignancy or patients booked on the emergency clean or septic lists respectively. all surgeons were advised to be hypervigilant at all times in theatre, especially with regard to using appropriate ppe13 when indicated and to be aware of airway-related risks regarding intubation/extubation and the potential of aerosolisation of the virus.14 as per the chbah sop, two theatres were identified as covid-19 specific theatres to be used for both elective and emergent surgeries across all disciplines in the event of a highly suspicious or confirmed covid-19 positive patient. these theatres would either be cleaned with a medical fogging machine or a lightstrike™ germ-zapping™ robot between cases, and preventive measures were implemented as per the chbah sop. the use of additional theatres would be available once the numbers necessitate the change. training by the infection prevention and control (ipc) unit, infectious diseases (id) unit as well as the department of anaesthesia in donning and doffing procedures and safe intubation technique (for absolute emergencies and where the dedicated covid-19 airway team was not available) was available to all department of orthopaedic surgery personnel on a daily basis. initially, our sop stated that once a member of the orthopaedic department operates on a known covid-19 positive patient, they would become part of the covid-19 orthopaedic workstream. they would then remain on the workstream for the remainder of the covid-19 protocol, or if they complete a two-week period where they have no contact with any covid-19 patients and need to be orthopaedic services auxiliary medical services non-covid-19 orthopaedic cases high-risk group 9 consultants 1 registrar covid-19 cases covid-19 orthopaedic cases low-risk group low-risk group 14 consultants 20 registrars 5 medical officers 2 registrars 2 medical officers non-covid-19 cases figure 2. organogram of staff allocation to the covid-19 auxiliary medical services, covid-19 orthopaedic services and the non-covid-19 workstreams page 142 hirschmann a et al. sa orthop j 2020;19(3) moved onto the non-covid-19 workstream. staff members from the two workstreams would not be permitted to work together or in the same environment at the same time. this was unfortunately limited by the lack of availability of tests for all patients requiring surgery resulting in a number of low-risk ‘unknown’ exposures to asymptomatic covid-19 positive patients. the doctors exposed to these patients would then continue to work in their workstream because at the time of writing this, our covid-19 positive orthopaedic patient population is still relatively low and a dedicated covid-19 workstream has not been implemented. outpatient department the average number of patients seen at the orthopaedic opd at chbah in 2019 was 246.8 patients per day across all units with an average of 5.6 admissions from opd daily. given the estimate of a similar volume of patients daily as per the trend in table i since 2014, the department needed to aggressively implement a system to debulk the opd. during level 5 lockdown, the daily orthopaedic opd average dropped to 112.7 patients per day (with 0.3 admissions per day) with a steady increase in both patients seen and admitted as the lockdown level changed to level 4 and 3 respectively (table vi). the higher number of patients in lockdown level 4 may be attributable to the backlog during level 5 lockdown and the associated difficulties in terms of public and private transport. on arrival at the hospital, all opd patients across all disciplines should be directed to be screened for covid-19 (by means of a questionnaire and basic vitals if indicated) at any one of the three large screening marquees being managed by the department of medicine and the department of emergency medicine. only low-risk patients would be allowed to proceed to the orthopaedic opd, while moderateor high-risk patients would undergo further screening and/or testing under the chbah sop. the triage nursing staff in opd then complete another covid-19 screening questionnaire to ensure patients are redirected appropriately as mentioned above, or if covid-19 is not suspected, patients would be advised by clinic staff and signage to drop off their opd cards/ files at the opd for internal orthopaedic screening. while cards/files are screened, patients are advised to wait in the corridor outside the opd or in the erected marquee for the orthopaedic opd in which all chairs are at least one metre apart and many signs regarding social distancing are posted in multiple languages. cards/files are triaged into patients who could be provided with a follow-up date without having to be seen (elective patients arriving for admission, patients arriving for cold case follow-up or patients seeking prescription renewal for chronic medications) and patients who need to be seen (blood/tissue results, wound reviews, control x-rays and physical examination reviews). in the event that patients need to be reviewed in the opd, only ten patients are allowed into the opd at a given time, only one patient is allowed in a consultation room with one doctor at a time, all patients are asked to sit at least one metre apart and strict hand sanitisation is required before entering and exiting the opd. with the increasing numbers seen during level 3 lockdown, a decision to adapt the sop was taken and all the staff of a specific unit whose clinic was running on the given day were asked to attend the clinic. orthopaedic intake (opit) via the accident and emergency department (a&e) the average number of patients seen at orthopaedic opit at chbah in 2019 was 45 patients per day with an average of 15 admissions from opit daily. during level 5 lockdown, the daily orthopaedic opit average dropped to 19.7 patients per day (with 6.8 admissions per day) with a steady increase in both patients seen and admitted as the lockdown level changed to levels 4 and 3 respectively (table vi). the physical location of where our staff members would review patients was moved to allow for the development of a suspected covid-19 positive holding area in the medical acute care unit (macu). the new area is within the trauma emergency unit (teu) allowing close proximity to the most common referral source. any patient, including polytrauma patients who were not screened would be suspected as covid-19 positive until proven otherwise. any confirmed or suspected covid-19 positive patient would be initially treated with isolation procedures and adequate ppe worn in the teu resuscitation area or the macu if they were stable enough from an orthopaedic/trauma perspective. all suspected cases would be tested and if found to be positive, admitted to a covid-19 dedicated ward where ongoing orthopaedic and medical care would be administered (please see organogram in figure 3). in-patient management all personnel are to implement social distancing, improved hand sanitisation and vigilance in terms of appropriate ppe use as and when required. clerking of patients is to be done with a one-metre distance for history-taking. where possible, a single physical examination is undertaken to reduce patient–doctor contact. all pens, surfaces such as desks/tables are to be regularly cleaned with appropriate cleaning products to reduce fomite contact. any resuscitation of a patient with respiratory symptoms, pyrexia or any covid-19 suspicious symptomology necessitates contacting the anaesthetic covid-19 airway response team and alerting the infectious diseases team on call as per the chbah sop. in the initial phases, all orthopaedic covid-19 positive patients would be admitted to one of the covid-19 designated medical wards. as the number of covid-19 positive patients increased, the plan to differentiate medical and surgical designated wards would be implemented. unstable/polytrauma: assumed covid-19 admission to covid-19 ward admission to covid-19 ward trauma resuscitation area medical acute care unit (covid-19) orthopaedic consulting area in teu covid-19 suspected orthopaedic consult covid-19 not suspected stable: screening at main triage marquee on helipad figure 3. patient assessment and admission organogram page 143hirschmann a et al. sa orthop j 2020;19(3) to date, with the increasing number of covid-19 positive patients, the initial number of dedicated covid-19 wards have been inundated. this has resulted in one of the orthopaedic department wards being taken over by internal medicine as more wards are required to manage covid-19 admissions. this has placed strain on the ability to create in-patient social distancing (by having one to two metres between patients’ beds) despite the department’s best efforts. departmental restructuring we developed a phased system to restructure the department of orthopaedic surgery in response to the demands and challenges of this unprecedented dynamic situation. the goals of this system are to protect healthcare workers and mitigate the risk of transmission as far as possible (table vii). discussion as the number of cases continues to rise rapidly across the world, there is growing concern that healthcare systems will quickly become saturated and unable to adequately respond to the outbreak.15 while our fellow south africans are mostly being instructed to stay home, we as medical practitioners have a professional and moral duty as essential services workers to do the opposite. when this sop was drawn up, we were in the most stringest form of lockdown (level 5). this allowed us time to develop an sop based largely on international experiences and data. the sop remained unchanged until the last week of level 4 lockdown where we made a decision that we would have to make changes in anticipation of the level 3 lockdown (figure 1). we identified the trend of increasing emergency admissions and established that the on-call team would have to revert to phase 1 implementation (two registrars and two interns on site for 24 hours at a time) in order to provide adequate service delivery to the increasing number of patients. from 1 june 2020, phase 1 was implemented for opit management (table vii). presently, the infection rate continues to climb with new national record highs being reported almost daily. despite being in the midst of battle, we hope to be able to adapt our sop to the evolving challenges we face on a daily basis. the goal of sharing this sop is to allow it to be evaluated, criticised, developed and hopefully improved with the sole objective of protecting service delivery to our patients and saving more lives. the effects on orthopaedic surgery departments are predominantly indirect, with widespread cessation of all non-essential orthopaedic care. while this is vital to system-sustaining measures of isolation and resource re-allocation, there is profound detriment to orthopaedic training programmes and a risk to maintaining service delivery.16 we promote online learning platforms and other means to provide ongoing academic programmes during this unprecedented situation. we advocate that every hospital should create a contingency plan and develop sops suited to their requirements and conditions.17 orthopaedic surgeons are at risk and have to become increasingly vigilant and take more precautions to avoid infection with the sars-cov-2 virus.12 we took advantage of the level 5 nationwide lockdown as an opportunity to devise and implement a battle plan to face this invisible enemy. we have had to make changes to the implementation of our sop based on the increasing patient volumes in both the orthopaedic opd and opit. challenges along the way have included the shortage of covid-19 tests, ppe shortages, delays or decreased access to theatre/wards due to decontamination procedures following confirmed exposure to a covid-19 patient, indirect staff shortages (increased absenteeism in other departments that directly affect orthopaedic surgery) and direct staff shortages (increased absenteeism within the orthopaedic department). conclusion we hope that by sharing our plan with our colleagues domestically and abroad, we can promote discussion and improve our ability to better prepare and deal with this unprecedented healthcare scenario. victory loves preparation. in order for us to win as individuals, we must fight as a team. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. prior to commencement of the study ethical approval was obtained from the following ethical review board: wits hrec (medical) clearance m170415. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. table vii: departmental restructuring in a phased response system phase criteria implication phase 1 declaration of national disaster • all morning handover meetings, academic and group meetings suspended • all non-urgent elective cases cancelled • opds triaged and numbers limited • wards filled to half capacity phase 2 admission of confirmed case to chbah • limited on-site staff complement per unit (one registrar and one consultant on site per unit) • afterhours shift system (12-hour shifts vs the previous 24-hour call system) • one auxiliary member deployed to covid-19 workstream phase 3 suspected orthopaedic covid-19 case chbah covid-19 case prevalence >25% • unit re-organisation into damage-control firms • internal workstreams allocated to firms • covid-19 orthopaedic workstream activated • afterhours shift system (8-hour shifts) phase 4 confirmed covid-19 orthopaedic staff chbah covid-19 case prevalence >75% • staff and firm treatment and quarantine according to nicd hcw guidelines • limited orthopaedic theatre – emergent cases only • opd shutdown nicd: national institute for communicable diseases; hcw: healthcare worker page 144 hirschmann a et al. sa orthop j 2020;19(3) author contributions ah contributed to the conceptualisation, methodology, original manuscript preparation and revision of the study. tp contributed to the conceptualisation and original manuscript of the study. kf contributed to the conceptualisation and original manuscript of the study. mr contributed to the conceptualisation and supervised the study. cf contributed to the conceptualisation, manuscript revision and supervised the study. orcid hirschmann a https://orcid.org/0000-0003-1776-9214 pillay t https://orcid.org/0000-0001-9202-9449 fang kw https://orcid.org/0000-0002-9020-1556 ramokgopa mt https://orcid.org/0000-0002-8430-986x frey c https://orcid.org/0000-0003-1692-9749 references 1. defcon 2020. available from: https://en.wikipedia.org/wiki/ defcon (14/04/2020). 2. murray cj. forecasting covid-19 impact on hospital bed-days, icu-days, ventilator-days and deaths by us state in the next 4 months. medrxiv [pre-print].   https://doi.org/10.1101/2020.03.27.2 0043752. 3. wong j, goh qy, tan z, et al. preparing for a covid-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in singapore. can j anaesth. 2020 jun;67(6):73245. https://doi.org/10.1007/s12630-020-01620-9. 4. rodrigues-pinto r, oliveira a, sousa r. preparing to perform trauma and orthopaedic surgery on patients with covid-19. j bone joint surg am. 2020;102(11):946-50. https://doi. org/10.2106/jbjs.20.00454. 5. gorbalenya ae, baker sc, baric rs, et al. for the coronaviridae study group of the international committee on taxonomy of viruses. the species severe acute respiratory syndrome-related coronavirus: classifying 2019-ncov and naming it sars-cov-2. nature microbiology. 2020;5(4):536-44. 6. world health organization [internet]. covid-19 fact sheet. c2020 [covid-19 updated fact sheet]. available from: https://www.who. int/emergencies/diseases/novel-coronavirus-2019. 7. chrishanibaragwanathhospital.co.za. [internet]. chris hani baragwanath hospital. the world's 3rd biggest hospital, in south africa. c2020. available from: https://www.chrishani baragwanathhospital.co.za. [accessed 11 march 2020]. 8. centers for disease contral and prevention [internet]. interim guidance for coronavirus disease 2019 (covid-19). c2020 available from: https://www.cdc.gov/coronavirus/2019-ncov/ community/large-events/mass-gatherings-ready-for-covid-19.html. [accessed 29 march 2020]. 9. yang j, zheng y, gou x, et al. prevalence of comorbidities and its effects in coronavirus disease 2019 patients: a systematic review and meta-analysis. int j infect dis.  2020;94:91-95. https://doi. org/10.1016/j.ijid.2020.03.017. 10. guan w-j, liang w-h, zhao y, et al. comorbidity and its impact on 1590 patients with covid-19 in china: a nationwide analysis. eur respir j. 2020;55(5):2000547. https://doi. org/10.1183/13993003.00547-2020 11. centers for disease contral and prevention [internet]. people who are at higher risk for severe illness. c2020. available from: https:// www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/ people-at-higher-risk.html. [accessed 11 april 2020]. 12. guo x, wang j, hu d, wu l. the orthopaedic forum: survey of covid-19 disease among orthopaedic surgeons in wuhan, people’s republic of china. j bone joint surg. 2020;102(10):84754. https://doi.org/10.2106/jbjs.20.00417. 13. alhazzani w, møller mh, arabi, et al. surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (covid-19). intensive care med. 2020 may;46(5):854-87. https://doi.org/10.1007/s00134-020-06022-5. 14. d'silva df, mcculloch tj, lim js, et al. extubation of patients with covid-19. br j anaesth. 2020;125(1)e192–e195.  https://doi. org/10.1016/j.bja.2020.03.016. 15. vannabouathong c, devji t, ekhtiari s, et al. the orthopaedic forum: novel coronavirus covid-19 current evidence and evolving strategies. j bone joint surg am. 2020;00:e1(1-11). https://doi.org/10.2106/jbjs.20.00396. 16. schwartz am, wilson j. managing resident workforce and education during the covid-19 pandemic evolving strategies and lessons learned. jbjs open access. 2020;5(2):e0045. https://doi. org/10.2106/jbjs.oa.20.00045. 17. cao y, li q, chen j, et al. hospital emergency management plan during the covid-19 epidemic. acad emerg med. 2020 apr;27(4):309-11. https://doi.org/10.1111/acem.13951. https://orcid.org/0000-0003-1776-9214 https://orcid.org/0000-0001-9202-9449 https://orcid.org/0000-0002-9020-1556 https://orcid.org/0000-0002-8430-986x https://orcid.org/0000-0003-1692-9749 south african orthopaedic journal arthroplasty doi 10.17159/2309-8309/2021/v20n4a2maharaj z et al. sa orthop j 2021;20(4) citation: maharaj z, pillay t, mokete l, pietrzak jrt. preoperative asymptomatic bacteriuria in patients undergoing total joint arthroplasty in south africa. sa orthop j 2021;20(4):202-206. http://dx.doi. org/10.17159/2309-8309/2021/ v20n4a2 editor: prof. michael held, university of cape town, cape town, south africa received: october 2020 accepted: april 2021 published: november 2021 copyright: © 2021 maharaj z. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background periprosthetic joint infections (pjis) are a leading cause of revision for total hip arthroplasty (tha) and total knee arthroplasty (tka), worldwide. asymptomatic bacteriuria (asb) is an independent risk factor for pjis; however, a paucity of data relevant to developing countries exists. the aim of this study was to describe the prevalence of preoperative asb and the subsequent incidence of pjis in patients undergoing total joint arthroplasty (tja) in south africa. methods we retrospectively reviewed primary tha and tka patients. all patients were screened for asb preoperatively. patients with positive urinalysis for asb were identified and treated prior to surgery (treated-asb). the primary outcome was asb prevalence and the incidence of pjis and other perioperative complications. secondary outcomes included risk factors for asb and subsequent pjis in treated-asb patients, respectively, compared to those with no evidence of asb (non-asb). lastly, we aimed to compare the infective microorganisms cultured from preoperative urinalysis and perioperative sampling of pjis. results we included 179 patients (67 tha; 80% female) with mean follow-up of 2.45 years. asb prevalence was 22% (n = 39). patients older than 70 years were 3.5 times more likely to have asb compared to younger patients (p = 0.005). the prevalence of asb was 22% (n = 10) for human immunodeficiency virus (hiv) positive and 22% (n = 29) for hiv-negative patients (p = 0.084). pji incidence was 8% (n = 3) in the treated-asb and 1% (n = 1) in non-asb. treated-asb patients had an 11.6-fold increased likelihood of pjis than non-asb patients (p = 0.046). pji microorganisms cultured did not correlate to isolates from urine cultures. conclusion the prevalence of asb in a tja population in south africa is 22% which is higher than reported findings worldwide. although the value of preoperative antibiotic therapy for asb remains controversial, there is a role for routine urinalysis preoperatively to identify patients predisposed to pji. this is of specific significance in the management of hiv-positive patients and in developing countries to guide healthcare providers in resource-constrained environments. level of evidence: level 2 keywords: total hip arthroplasty, total knee arthroplasty, asymptomatic bacteriuria, periprosthetic joint infection, developing country preoperative asymptomatic bacteriuria in patients undergoing total joint arthroplasty in south africa zia maharaj,* tristan pillay, lipalo mokete, jurek rt pietrzak arthroplasty unit, division of orthopaedic surgery, charlotte maxeke johannesburg academic hospital, university of the witwatersrand, johannesburg, south africa *corresponding author: maharajzia@gmail.com introduction a significant demand for total joint arthroplasty (tja) exists, with over 1 million procedures performed in the united states of america (usa) annually alone.1 the average rate of total hip arthroplasty (tha) has increased by approximately 30%, while the performance of total knee arthroplasty (tka) procedures doubled globally between 2000 and 2015.2 demand for tja continues to rise and is projected to continue increasing through 2030.3 the increasing demand for tja translates into a massive economic burden for global healthcare systems further compounded by postoperative readmissions for complications such as periprosthetic joint infections (pjis).4 pjis are infective postoperative complications ranging from surgical site infections (ssis) to deep intra-articular infections. pjis are the third most common cause of tha revisions and the most common cause of tka revisions, globally.5 the annual cost for revisions due to pji is expected to increase to us$1.62 billion by 2020 and has a five-year mortality rate of 21.12% after primary tja.5 the serious implications of pji have led to increased efforts to limit infections by the strict adherence to antibiotic prophylaxis, laminar airflow systems in operating theatres, extensive patient perioperative clinical optimisation and stringent sterilisation protocols.6 the incidence of pji after primary tja, however, remains at 1.4% rates despite the implementation of preventative measures.7 https://orcid.org/0000-0001-9172-911x page 203maharaj z et al. sa orthop j 2021;20(4) asymptomatic bacteriuria (asb) from the genitourinary tract may be a source of infection for pji through haematogenous seeding.8,9 a multicentre study including institutions from the united kingdom (uk), portugal and spain identified asb as an independent risk factor for pji (p = 0.001), especially those due to gram-negative microorganisms.8 similarly, a systematic review and meta-analysis of ten tja studies showed an increased risk for pji with asb (odds ratio [or]:3.64; 95% confidence interval (ci) 1.40–9.42).9 however, sousa et al. (2019) reported that the pji microorganisms were unrelated to those in the urine of the patients with asb.9 furthermore, there is evidence demonstrating an association between postoperative urinary tract infections (uti) and pji.10-12 identifying underlying characteristics, especially modifiable risk factors which predispose tja patients to infection, is essential to mitigate the risk of adverse outcomes. there is no international consensus guideline for the screening and management of asb in patients for tja. the british orthopaedic association recommends routine urinalysis for all tja patients preoperatively; however, they are not specific on management of positive results.13 the spanish society of infectious diseases and clinical microbiology recommends treating asb while the antibiotic therapeutic guidelines for australia do not support treatment of asb preoperatively.14,15 a meta-analysis by sousa et al. (2019) concluded that preoperative antibiotic treatment for asb does not influence pji risk and should not be implemented routinely.9 however, no studies have been reported for an african population, particularly concerning demographic risk factors such as human immunodeficiency virus (hiv) and body mass index (bmi). furthermore, there is a paucity of data relating to the association between asb and ssi. there are also economic implications of increased costs for routine screening in less-developed countries that must be considered. the aim of this study was to assess the prevalence of asb in patients for primary tja in south africa. secondarily, we sought to determine the incidence of pjis in tja patients with no preoperative asb (non-asb) compared to those who received tja after the treatment of asb (treated-asb). lastly, we evaluated risk factors for both asb and subsequent pjis in this tja population. we hypothesise that the high prevalence rates of hiv in south africa would predispose this sample population to high rates of asb and subsequent infective complications. materials and methods we conducted a retrospective review of prospectively collected data for patients undergoing primary tja at an academic referral institution in johannesburg, south africa. the study was conducted between january 2015 and december 2016. patients included in the study were adults aged 18 years or older, undergoing primary, elective tha or tka and who provided consent for voluntary participation in the study. exclusion criteria included revision tha, revision tka and patients for primary tja who did not provide consent. all patients eligible for study inclusion were screened for evidence of symptomatic uti. symptoms of uti that were assessed included a history of urinary frequency or urgency, foul-smelling urine, abnormal colour of urine, dysuria or burning on micturition and a sensation of incomplete bladder emptying.16 patients with symptoms of uti were excluded from the sample population and received appropriate treatment prior to their elective operations. demographic data was recorded for all study participants, including age, sex, bmi and tobacco use. medical comorbidities documented included diabetes mellitus, hypertension and hiv status, and the american society of anesthesiologists classification (asa class) was noted. all patients provided a mid-stream urine sample that was sent for microscopy, culture and sensitivity (mc&s) by the national health laboratory services (nhls) of south africa three days prior to surgery. the urinary specimen was considered positive for bacterial isolation if > 100 000 colony-forming units/ml and antibiotic sensitivity was identified. patients with evidence of asb on urinalysis had their operation postponed and were treated for five days with an oral antibiotic according to microorganism sensitivity. urine mc&s was subsequently performed, and patients received tja only once their urine sample was sterile. all patients underwent tja by the same three fellowshiptrained arthroplasty surgeons in a laminar-flow surgical theatre. both tha and tka procedures were performed under general anaesthesia (ga). all patients received both tranexamic acid (txa) and a weight-adjusted prophylactic dose of first-generation cephalosporin intravenously at least 30 minutes before the first surgical incision. clindamycin was given preferentially in penicillinallergic patients. prophylactic antibiotics were continued for 24 hours postoperatively. all tha procedures were performed using a modified anterolateral surgical approach, and an uncemented pinnacle acetabular shell and uncemented corail femoral stem (depuy synthes, midrand, south africa) in all cases. all tka were performed by a medial parapatellar surgical approach after a midline skin incision. a cruciate-sacrificing fixed-bearing cemented tka, using genesis ii (smith and nephew, durban, south africa) tka implants was used in all cases. all components inserted in all tka cases were cemented using palacos® r + g antibiotic-loaded cement (hereaus group, hanau, germany). a drain was used and was table i: demographic data for total joint arthroplasty sample population (n = 179) characteristic sample tja, n (%) tha tka 67 (37) 31 (17) age (years), mean (range) 61.5 (33–83) sex, n (%) female male 144 (80) 35 (20) bmi (kg/m2), n (%) ≤ 30 31–39 ≥ 40 77 (43) 73 (41) 29 (16) aetiology, n (%) primary oa inflammatory oa avn post-traumatic oa other 107 (60) 40 (22) 23 (13) 5 (3) 4 (2) asa class, n (%) 1 2 3 48 (27) 103 (58) 28 (16) comorbidities, n (%) diabetes hypertension hiv 30 (17) 74 (41) 45 (25) tobacco use, n (%) smoker non-smoker 45 (25) 134 (75) surgical time (minutes), mean ± sd tha tka 94 ± 18 108 ± 23 tja: total joint arthroplasty; tha: total hip arthroplasty; tka: total knee arthroplasty; bmi: body mass index; oa: osteoarthritis; avn: avascular necrosis; asa class: american society of anesthesiologists classification; hiv: human immunodeficiency virus; sd: standard deviation page 204 maharaj z et al. sa orthop j 2021;20(4) removed within 48 hours of surgery. physiotherapy was initiated the day after surgery and patients were discharged once they were able to mobilise independently and negotiate steps with two crutches. postoperatively all patients were routinely followed up 14 days after surgery for wound assessment. subsequent follow-up assessments were at three months, six months and one year after tja and annually thereafter. all patients’ records were assessed for readmission rates and implant failures. retrospective review of preoperative and intraoperative patient data was conducted, and all postoperative complications were noted. all infective complications across the spectrum, from wound dehiscence and ssi to deep intra-articular pji, were investigated to confirm the diagnosis of pji definitively. the diagnosis of pji was determined according to the modified criteria proposed by the musculoskeletal infection society (msis) in 2014.17 subsequent advances in the field of pji diagnosis led to the development of new evidence-based criteria that has demonstrated a higher sensitivity of 97.7% compared to the older msis definition (79.3%).17 the retrospective design of our study allowed for the diagnosis of pji to be confirmed on both the traditional msis criteria and the current evidence-based criteria defined by parvizi et al. (2018).17 all cases suspected of infective complications, including prolonged wound drainage (> 72 hours), deep pji and infected wound dehiscence, were treated surgically in the same laminarflow theatre as per treating unit protocol by the surgeon who had performed index primary tja. at least five tissue samples were taken surgically from separate sites. specimens were handdelivered immediately postoperatively to the same laboratory for extended mc&s and fungal culture. for statistical analysis, the patients were divided into two groups: patients who received treatment preoperatively for asb (treatedasb) and those without asb (non-asb). bootstrapped statistics with 1 000 samples was performed. two-sided tests were conducted for sex, age, bmi and comorbidities using chi-squared testing with continuity correction. odds proportions were used to calculate risk ratio (rr) for an outcome of interest, and all pairwise comparisons were calculated using the bonferroni correction. two-sided statistical significance was p ≤ 0.05 and confidence interval of 95% (95% ci) with respective standard error (se) was determined. all statistical analyses were performed using stata (version 14) statistical package. results there were 179 patients, including 67 that underwent tha and 112 tka respectively. all patients (100%) were evaluated at a mean follow-up of 2.45 years. demographic details of the sample population are shown in table i. the prevalence of asb for our tja sample was 22% (se 3.1; 95% ci 15.7–27.9). prevalence of asb according to demographics and comorbidities is depicted in table ii. females were 3.6 times more likely to have asb than males (p = 0.060). the prevalence of asb according to age was 42% (n = 15) for patients 70 years or older, 18% (n = 20) for those 51–69 years of age and 13% (n = 4) for those 50 years or younger, respectively (p = 0.005). patients 70 years or older are 3.5 times more likely to have asb compared to patients younger than 70 (odds asb positive: ≥ 70 years = 0.71; < 70 years = 0.2). patients with an asa class of 3 were 4.6 times more likely to have asb compared to patients with asa class 1 (odds asb positive: asa 1 = 0.12; asa 3 = 0.54; p = 0.026). there were seven patients (16%) who used tobacco and 32 patients (24%) who did not use tobacco that presented with asb, respectively (p = 0.046). the prevalence of asb was 22% (n = 10) for hiv-positive patients and 22% (n = 29) for hiv-negative patients (p = 0.084). table ii: asymptomatic bacteriuria prevalence by demographic and comorbid factors characteristic asb positive (n) asb prevalence (%) ± se (95% ci) p-value sex male female 3 36 8.6 ± 4.7 (0–20) 25 ± 3.6 (18.8–32.6) 0.060 age (years) ≤ 50 51–69 ≥ 70 4 20 15 13.3 ± 6.2 (3.3–26.7) 17.7 ± 3.7 (11.6–25) 41.7 ± 8.0 (25–58.3) 0.005 bmi (kg/m2) ≤ 30 31–39 ≥ 40 18 12 9 23.4 ± 4.9 (14.5–34.2) 16.4 ± 4.2 (7.1–24.3) 31 ± 9.9 (13.6–50) 0.688 asa class 1 2 3 4 27 8 8.3 ± 5.0 (2.6–21.2) 26.2 ± 3.9 (14.7–31) 28.6 ± 10.4 (15–55) 0.026 diabetes yes no 3 36 10 ± 5.7 (0–21.7) 24.2 ± 10.1 (0–42.9) 0.666 hypertension yes no 9 30 12.2 ± 4.4 (5.6–21.1) 28.6 ± 28.1 (20–37.1) 0.828 hiv positive negative 10 29 22.2 ± 5.5 (14–30) 21.6 ± 4.3 (10.2–30.5) 0.084 tobacco use smoker non-smoker 7 32 15.6 ± 7.1 (9.7–38.7) 23.9 ± 3.3 (15.9–29) 0.041 asb: asymptomatic bacteriuria; bmi: body mass index; asa class: american society of anesthesiologists classification; hiv: human immunodeficiency virus table iii: postoperative complications, readmissions and reoperations for total sample (n = 179), asb-positive group (n = 39) and asbnegative group (n = 140) complication total, n (%) asb-positive, n (%) asb-negative, n (%) total 13 (7) 5 (13) 8 (6) medical pe dvt pneumonia 4 (23) 1 (1) 2 (1) 1 (1) 1 (3) 0 (0) 1 (3) 0 (0) 3 (2) 1 (1) 1 (1) 1 (1) surgical nerve palsies pji ssi deep pji 9 (53) 2 (1) 4 (2) 3 (2) 1 (1) 4 (10) 0 (0) 3 (8) 2 (5) 1 (3) 5 (4) 2 (1) 1 (1) 1 (1) 0 (0) periprosthetic fractures* intraoperative postprosthetic 3 (2) 2 (1) 1 (1) 1 (3) 1 (3) 0 (0) 2 (1) 1 (1) 1 (1) readmission rate < 30 days 60 days 90 days 8 (5) 5 (3) 3 (2) 0 (0) 4 (10) 3 (8) 1 (3) 0 (0) 4 (3) 2 (1) 2 (1) 0 (0) revision tja pji periprosthetic fracture 2 (1) 1 (1) 1 (1) 1 (3) 1 (3) 0 (0) 1 (1) 0 (0) 1 (1) pji: periprosthetic joint infection; ssi: surgical site infection; tha: total hip arthroplasty *mean follow-up 2.45 years page 205maharaj z et al. sa orthop j 2021;20(4) there were 13 (7%) perioperative complications, eight (5%) readmissions and two (1%) revisions at a follow-up of 2.45 years, respectively (table iii). there were two (5%) non-infective complications in the treated-asb group (95% ci 0–12.8) and seven (5%) in the non-asb group (95% ci 2.1–9.3), respectively. there were four (2%) infective complications including three (2%) ssis and one (1%) deep pji. the microorganisms cultured from urinalysis in patients with asb (figure 1) were different from the microorganisms cultured from postoperative infections in treatedasb patients (table iv). there were three (8%) pjis in the treatedasb group (95% ci 0–17.9) and one (1%) in the non-asb group (95% ci 0–2.1), respectively. patients with asb were 11.6 times more likely to have wound complications than non-asb patients (p = 0.046). discussion the prevalence of preoperative asb in patients undergoing tja in a single referral institution in south africa was 22% (n = 39). this is higher than reports for similar populations in other countries. studies indicate that the prevalence of asb for tja patients in spain varies between 5.1 and 18.2%.9,18,19 similarly the asb prevalence rates for the uk range from 3.2% to 12.1%,6,8 while finland and portugal have reported asb prevalence of 6.8% and 11.2% respectively for tja patients.8,20 patients with preoperative asb have been reported to be at increased risk for pji.6,8,9 in our study we found an overall incidence of 2% (n = 4) for postoperative infections, i.e., ssi and pji after a mean follow-up of 2.45 years. despite being treated preoperatively, patients with asb were 11.6 times more likely to have wound complications than non-asb patients. a similar study of 4 368 patients reported a preoperative asb prevalence of 3.2%, and all patients received appropriate antibiotic treatment prior to tja.6 weale et al. found a significantly higher rate of pji in the asb group (4.3%) compared to the non-asb group (1.4%), respectively (p = 0.001).6 furthermore, patients with asb who were not treated preoperatively have been associated with a greater risk of pji than patients who received antibiotic treatment. in a study of 20 226 tja patients, honkanen et al. reported a pji incidence of 0.3% in patients treated for asb compared to 0.6% for a control group who were not given treatment.20 in a multicentre study, sousa et al. reported the respective incidence of pji as 3.9% and 4.7% for asb patients who received treatment and did not receive treatment preoperatively.8 no international consensus exists to determine whether asb should be treated preoperatively despite the association with infective complications. although patients for tja with asb have an established increased risk for pji, the causative microorganisms are interestingly not consistently associated.6,8,9 the microorganisms cultured in the urine of asb patients were all different from the pji cultures in our study. while some studies report similar isolates between the asb and pji microorganisms, a systematic review and meta-analysis including 28 588 tja patients reported that there was no causal association between microorganisms (or: 0.98; 95% ci 0.39– 2.44).6,8,9 therefore, the value of preoperative testing for asb may be controversial, especially in resource-constrained developing countries. however, an additional consideration in our demographic is that the prevalence of asb was higher for hivpositive patients than hiv-negative patients (p = 0.084). although this was not statistically significant, this finding must be highlighted as south africa accounts for the most people living with hiv and the highest seroprevalence, worldwide.21 there were 7.7 million people living with hiv in 2020 and 240 000 new adult infections each year. there is an established association between hiv, highly active anti-retroviral treatment (haart) and osteodegenerative pathology, which predisposes patients to tja.22 in a study of 1 007 tja patients in south africa, the seroprevalence of hiv in patients for tha was higher than the general population.21 furthermore, the 2018 international consensus on orthopaedic infections determined that hiv is an independent risk for pji.23 this emphasises the importance of asb in hiv-positive patients that may determine a further predisposing risk factor for pji. screening for asb may allow healthcare providers to identify patients at increased risk for pjis to guide management of evolving perioperative complications. it may be used as a surrogate marker to identify those individuals likely to have infective complications. furthermore, the strong correlation with wound complications may provide motivation for more elaborate wound care postoperatively – this, however, needs to be validated in further studies. there were several significant findings according to demographic characteristics such as sex, age, asa class and tobacco use in our study population. there is an associated increased prevalence of asb associated with increasing age and female sex in the general population.24 in our tja population, females were 3.6 times more likely to have asb than males (p = 0.060). sousa et al. similarly reported an increased asb prevalence for females (16.3%) compared to males (5%) (p < 0.001).8 our study also found that patients 70 years or older had the highest prevalence (18%) and were 3.5 times more likely to have asb compared to patients younger than 70 (p = 0.005). additionally, patients with an asa class of 3 were 4.6 times more likely to have asb compared to patients with asa class 1 (p = 0.026). however, patients with a table iv: summary of cultured microorganisms patient asymptomatic bacteriuria periprosthetic joint infection 1 escherichia coli mssa 2 escherichia coli mssa 3 streptococcus agalactiae mrsa 4 n/a mssa n/a: not applicable; mssa: methicillin-sensitive staphylococcus aureus; mrsa: methicillin-resistant staphylococcus aureus 25 4 3 2 1 1 1 1 1 escherichia coli proteus mirabilis klebsiella pneumoniae enterococcus faecalis morganella morganii streptococcus agalactiae citrobacter freundii escherichia fergusonii unknown figure 1. urinalysis results page 206 maharaj z et al. sa orthop j 2021;20(4) higher asa class were also older in age, which might account for the higher asb prevalence noted in this group. to the authors’ knowledge, this is the first study to investigate the prevalence of asb in a tja population in sub-saharan africa. there were several limitations identified in the study. first, the population size was small and there was no stratified sampling to identify significant risk factor associations, and type 2 error should be considered. the asb prevalence description for a south african population may be incorporated into future systematic reviews and meta-analyses. the study may guide future research for management recommendations in immunocompromised individuals such as a randomised control trial with treated asbpositive patients to evaluate any perceived benefit. despite these weaknesses, there were relevant statistically and clinically significant findings to guide further research and add to current knowledge. the results for microorganism cultures may guide future aetiological studies to better ascertain the pathophysiology of pjis. conclusion the prevalence of asb in a tja population in south africa is 22% and higher than reported findings worldwide. there is an established association between preoperative asb and increased risk of infective complications, which was reflected in our study. although the value of antibiotic therapy for asb remains controversial, there is a role for routine urinalysis preoperatively to identify patients predisposed to infective complications that may warrant more elaborate investigation to identify modifiable risk factors not yet known. the high prevalence of hiv represents a large immunecompromised population in south africa. furthermore, these findings may guide improved management of patients in other resource-constrained environments such as better wound care in these individuals at risk – a randomised control trial with treated asb positive patients would need to be done to evaluate any perceived benefit. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. medical clearance was obtained from the university of the witwatersrand human research ethics committee (medical) registered with the national health research ethics council (nhrec) of the national department of health (m160716). informed consent was obtained from all patients prior to being included in the study. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions zm: first draft preparation, manuscript revision tp: data capture, first draft preparation lm: study conceptualisation, manuscript revision jrtp: study conceptualisation, study design, manuscript revision orcid maharaj z https://orcid.org/0000-0001-9172-911x pillay t https://orcid.org/0000-0001-9202-9449 mokete l https://orcid.org/0000-0001-9227-0515 pietrzak jrt https://orcid.org/0000-0001-5694-0016 references 1. american academy of orthopaedic surgeons, american joint replacement registry (ajrr). fifth ajrr annual report on hip and knee arthroplasty data (2018). downloaded from: http://connect.ajrr.net/2019-ajrr-annual-report. accessed 7 jan 2020. 2. organisation for economic co-operation and development (oecd) (2017), health at a glance 2017: oecd indicators, oecd publishing, paris. https://doi.org/10.1787/ health_glance-2017-en. 3. sloan m, premkumar a, sheth np. projected volume of primary total joint arthroplasty in the u.s., 2014 to 2030. j bone joint surg am. 2018;100:1455-60. https://doi.org/10.2106/ jbjs.17.01617. 4. kurtz sm, lau ec, ong kl, et al. which clinical and patient factors influence the national economic burden of hospital readmissions after total joint arthroplasty? clin orthop relat res. 2017;475:2926-37. https://doi.org/10.1007/s11999-017-5244-6. 5. beam e, osmon d. prosthetic joint infection update. infect dis clin n am. 2018;32(4):84359. https://doi.org/10.1016/j.idc.2018.06.005. 6. weale r, el-bakri f, saeed k. pre-operative asymptomatic bacteriuria: a risk factor for prosthetic joint infection? j hosp infect. 2019;101:210-13. 7. natshara km, shelton tj, meehan jp, lum zc. mortality during total hip periprosthetic joint infection. j arthroplasty. 2019;34(7 suppl):s337-42. https://doi.org/10.1016/j. arth.2018.12.024. 8. sousa r, munoz-mahamud e, quayle j, et al. is asymptomatic bacteriuria a risk factor for prosthetic joint infection? clin infect dis. 2014;59:41-47. 9. sousa rjg, md, abreu ma, wouthuyzen-bakker m, soriano av. is routine urinary screening indicated prior to elective total joint arthroplasty? a systematic review and meta-analysis. j arthroplasty. 2019;34:1523-30. https://doi.org/10.1016/j.arth.2019.03.034. 10. cordero-ampuero j, de dios m. what are the risk factors for infection in hemiarthroplasties and total hip arthroplasties? clin orthop relat res. 2010;468(12):3268-77. 11. david ts, vrahas ms. perioperative lower urinary tract infections and deep sepsis in patients undergoing total joint arthroplasty. j am acad orthop surg. 2000;8:66-74. 12. pulido l, ghanem e, joshi a, et al. periprosthetic joint infection: the incidence, timing, and predisposing factors. clin orthop relat res. 2008;466:1710-15. 13. british orthopaedic association. primary total hip replacement: a guide to good practice. london: boa; 2012. available from: https://www.britishhipsociety.com/uploaded/blue%20 book%202012%20fsh%20nov%202012.pdf. accessed jan 2020. 14. ariza j, gomis m, barberan j, et al. protocolos clinicos seimc: infecciones osetoarticularles y de partes blandas [seimc clinical protocols: osteoarticular and soft tissue infections]. madrid: sociedad espanola de enfermedades infecciosas y microbiologia clinica; 2000. available from: https://www.seimc.org/contenidos/documentoscientificos/ procedimientosclinicos/seimcprocedimientoclinicovi.pdf. accessed jan 2020. 15. antibiotic expert groups. surgical prophylaxis; therapeutic guidelines: antibiotic. version 15. melbourne: therapeutic guidelines limited; 2016. available from: https://tgldcdp.tg.org.au/ index. accessed jan 2020. 16. ipe ds, sundac l, benjamin wh jr, et al. asymptomatic bacteriuria: prevalence rates of causal microorganisms, etiology of infection in different patient populations, and recent advances in molecular detection. fems microbiology letters. 2013 sep;346(1):1-10. https:// doi.org/10.1111/1574-6968.12204. 17. parvizi j, tan tl, goswami k, et al. the 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. j arthroplasty. 2018;33:1309-14. https:// doi.org/10.1016/j.arth.2018.02.078. 18. martinez-velez d, gonzalez-fernandez e, esteban j, cordero-ampuero j. prevalence of asymptomatic bacteriuria in knee arthroplasty patients and subsequent risk of prosthesis infection. eur j orthop surg traumatol. 2016;26:209-14. 19. garcia-nuno l, villamil c, gonzalez-cuevas a, et al. usefulness of urinoculture to patients with dementia and femoral neck fracture at admission to hospital: preliminary results. geriatr orthop surg rehabil. 2017;8:10-13. 20. honkanen m, jamsen e, karppelin m, et al. the impact of preoperative bacteriuria on the risk of periprosthetic joint infection after primary knee or hip replacement: a retrospective study with a 1-year follow up. clin microbiol infect. 2017;24:376-80. 21. maharaj z, pietrzak j, sikhauli n, et al. the seroprevalence of hiv in patients undergoing lower limb total joint arthroplasty in south africa. sicot j. 2020:6(3). published online 2020 sep 19. https://doi.org/10.1051/sicotj/2019042. 22. pietrzak j, maharaj z, mokete l, et al. human immunodeficiency virus in total hip arthroplasty: no more (immuno-)compromise. efort open rev. 2020;5(3):164-71. https:// doi.org/10.1302/2058-5241.5.190030. 23. zainul-abidin s, amanatullah df, anderson mb, et al. general assembly, prevention, host related general: proceedings of international consensus on orthopedic infections. j arthroplasty. 2019;34(2):s13-35. 24. nicolle le, bradley s, colgan r, et al. infectious diseases society of america guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. clin infect dis. 2005;40:643-54. https://orcid.org/0000-0001-9172-911x https://orcid.org/0000-0001-9202-9449 https://orcid.org/0000-0001-9227-0515 https://orcid.org/0000-0001-5694-0016 http://connect.ajrr.net/2019-ajrr-annual-report https://doi.org/10.1787/health_glance-2017-en https://doi.org/10.1787/health_glance-2017-en https://doi.org/10.2106/jbjs.17.01617 https://doi.org/10.2106/jbjs.17.01617 https://doi.org/10.1007/s11999-017-5244-6. https://doi.org/10.1016/j.idc.2018.06.005 https://doi.org/10.1016/j.arth.2018.12.024 https://doi.org/10.1016/j.arth.2018.12.024 https://doi.org/10.1016/j.arth.2019.03.034 https://www.britishhipsociety.com/uploaded/blue%20book%202012%20fsh%20nov%202012.pdf https://www.britishhipsociety.com/uploaded/blue%20book%202012%20fsh%20nov%202012.pdf https://www.seimc.org/contenidos/documentoscientificos/procedimientosclinicos/seimcprocedimientoclinicovi.pd https://www.seimc.org/contenidos/documentoscientificos/procedimientosclinicos/seimcprocedimientoclinicovi.pd https://tgldcdp.tg.org.au/index https://tgldcdp.tg.org.au/index https://doi.org/10.1111/1574-6968.12204 https://doi.org/10.1111/1574-6968.12204 https://doi.org/10.1016/j.arth.2018.02.078 https://doi.org/10.1016/j.arth.2018.02.078 https://doi.org/10.1051/sicotj/2019042 https://doi.org/10.1302/2058-5241.5.190030 https://doi.org/10.1302/2058-5241.5.190030 _hlk82003977 _hlk43977449 _hlk43977826 _hlk43977918 _hlk43978008 _hlk43979543 _hlk43979957 _hlk43979989 _hlk43980015 _hlk43980170 _hlk82377700 _hlk43980393 404 not found rankin m et al. sa orthop j 2019;18(3) doi 10.17159/2309-8309/2019/v18n3a6 south african orthopaedic journal http://journal.saoa.org.za traumaknee citation: rankin m, mohideen maf. anthropometric differences in the tibial tuberosity to trochlear groove measurement in an african population. sa orthop j 2019;18(3):53-57. http://dx.doi.org/10.17159/2309-8309/2019/v18n3a6 editor: dr c snyckers, university of pretoria, pretoria, south africa received: january 2019 accepted: may 2019 published: august 2019 copyright: © 2019 rankin m, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: the tibial tuberosity to trochlear groove (tttg) is a well-described radiographic measurement around the knee, which is of clinical significance in the assessment of patients with patellar instability. the tttg is clinically relevant when considering the type of surgical procedures that may be required. the purpose of this retrospective observational study was to measure the tttg measurement in the black african population and to compare it to the quoted norms in the literature. methods: a random sample was obtained of 100 consecutive ct scans of lower limbs for vascular pathologies from black african patients. the tttg was measured by a single observer on the siemens® syngo.plaza software. results: ct scans of 162 knees from 88 patients met the inclusion criteria. the median age was 34 years (range 19–85 years; interquartile range [iqr] 24–50). the majority of cases were male (75%; n=121). the mean tttg was 20.3 mm (standard deviation [sd] 16.1; range 1–29.2 mm). the mean tttg in males was 20.7 mm (95% confidence interval [ci] 19.9–21.5 mm) and 19.1 mm (95% ci 17.6–20.5 mm) in females (p=0.06). there was no correlation found between age and tttg (p=0.12). conclusion: according to our study, barring some limitations, it appears that there may be a noteworthy difference in the tttg measurement in the black african population. larger comparative studies would be required to confirm these findings and to determine the clinical relevance. level of evidence: level 4 key words: tibial tuberosity trochlear groove distance, measurement, anatomical variation, ethnic differences anthropometric differences in the tibial tuberosity to trochlear groove measurement in an african population rankin m¹ , mohideen maf² 1 mbchb(ukzn), fc orth (sa); registrar, department of orthopaedics, school of clinical medicine, university of kwazulu-natal ² bsc(ukzn), mbchb(medunsa), fc orth(sa); orthopaedic consultant, westville life hospital corresponding author: dr mario rankin, nelson r mandela school of medicine ukzn, department of orthopaedics, 719 umbilo road, durban, 4001; email: mario.rankin@gmail.com; cell: +27731421476 https://orcid.org/0000-0001-5247-4062 https://orcid.org/0000-0003-1205-0702 page 54 rankin m et al. sa orthop j 2019;18(3) introduction the tibial tuberosity to trochlear groove (tttg) measurement was first described by goutallier and bernageau in 1978 as a radiographic measurement on x-rays. the measurement was described on the ap x-ray with the knee in 30° flexion and neutral rotation, measuring the horizontal distance between two vertical parallel lines passing through the summit of the tibial tuberosity and the bottom of the trochlear groove.1 this measurement is of clinical significance in the assessment of patella instability.2 it plays a pivotal role when deciding on the need for surgery.2 the tttg has been widely researched in the western world using various modalities of imaging such as x-rays, computerised tomography (ct) scans and magnetic resonance imaging (mri).3-5 in most studies, the normal tttg measurement is less than 15 mm.6-10 the literature also suggests that in cases with a tttg above 20 mm, a bony surgical procedure (e.g. medialising osteotomy of tibial tuberosity) should be considered in addition to the soft tissue realignment or stabilising procedures.6,11,12 the original studies on the tttg were, however, performed among the french population. there is no published data on the tttg distance in the african population. this is relevant because several studies have been done in recent years that have shown how the human skeleton and orthopaedic measurements may vary across different ethnic groups. koerner et al. found differences in the femoral version of the african american population.13 igbigbi et al. did a study on the tibio-femoral angle of the malawian population and the results showed ethnic differences from caucasian values.14 hence this may have importance with regard to the threshold for choice of surgical intervention and could possibly make way for improved protocols encompassing ethnic differences. the purpose of this retrospective observational study was to measure the tttg measurement in the black african population and compare it to the quoted norms in the literature. methods this was a retrospective observational study by means of a chart review. a random sample of 100 consecutive cases were identified from a database figure 1. ct scan slices illustrating a sample measurement in a case with a normal tttg measurement. (a) the axial slice of the initial reference line perpendicular to the posterior condylar line and through the deepest part of the trochlear groove is illustrated; (b) the line parallel to the reference line through the summit of the tibial tuberosity is shown; the tttg measurement line (red dotted line measurement 1.50 cm) perpendicular to both yellow dotted lines is also shown; (c) the navigated sagittal slice confirming the summit of the tibial tuberosity (a) (c) (b) figure 1. ct scan slices illustrating a sample measurement in a case with a normal tttg measurement. (a) the axial slice of the initial reference line perpendicular to the posterior condylar line and through the deepest part of the trochlear groove is illustrated; (b) the line parallel to the reference line through the summit of the tibial tuberosity is shown; the tttg measurement line (red dotted line measurement 1.50 cm) perpendicular to both yellow dotted lines is also shown; (c) the navigated sagittal slice confirming the summit of the tibial tuberosity (a) (c) (b) figure 1. ct scan slices illustrating a sample measurement in a case with a normal tttg measurement. (a) the axial slice of the initial reference line perpendicular to the posterior condylar line and through the deepest part of the trochlear groove is illustrated; (b) the line parallel to the reference line through the summit of the tibial tuberosity is shown; the tttg measurement line (red dotted line measurement 1.50 cm) perpendicular to both yellow dotted lines is also shown; (c) the navigated sagittal slice confirming the summit of the tibial tuberosity figure 2. ct scan slices illustrating a sample measurement in a case with an abnormal tttg measurement. (a) shows the axial slice of the initial reference line perpendicular to the posterior condylar line and through the deepest part of the trochlear groove; (b) shows the line parallel to the reference line through the summit of the tibial tuberosity, as well as the tttg measurement line (red dotted line measurement 2.65 cm) perpendicular to both yellow dotted lines; (c) the navigated sagittal slice confirming the summit of the tibial tuberosity (a) (b) (c) figure 2. ct scan slices illustrating a sample measurement in a case with an abnormal tttg measurement. (a) shows the axial slice of the initial reference line perpendicular to the posterior condylar line and through the deepest part of the trochlear groove; (b) shows the line parallel to the reference line through the summit of the tibial tuberosity, as well as the tttg measurement line (red dotted line measurement 2.65 cm) perpendicular to both yellow dotted lines; (c) the navigated sagittal slice confirming the summit of the tibial tuberosity (a) (b) (c) figure 2. ct scan slices illustrating a sample measurement in a case with an abnormal tttg measurement. (a) the axial slice of the initial reference line perpendicular to the posterior condylar line and through the deepest part of the trochlear groove; (b) the line parallel to the reference line through the summit of the tibial tuberosity, as well as the tttg measurement line (red dotted line measurement 2.65 cm) perpendicular to both yellow dotted lines; (c) the navigated sagittal slice confirming the summit of the tibial tuberosity page 55rankin m et al. sa orthop j 2019;18(3) at a tertiary level hospital as patients referred from the vascular surgery department to radiology for ct angiograms between years 2013 and 2018. these were patients admitted to the vascular department predominantly for elective atraumatic vascular pathologies (e.g. peripheral vascular disease, vascular stab injuries, etc.), and hence were considered asymptomatic from an orthopaedic perspective. the ethnic classification of patients as black africans was self-reported by patients and recorded during administrative registration of the patient on the hospital information system. exclusion criteria included: knee dislocations, periarticular fractures, gross arthritic changes of the knee and previous bony knee surgery. the tttg was measured using the syngo.plaza software (siemens®, munich, germany). the actual tttg measurement was performed as described by dejour et al.,8 using the axial cuts of the ct scan of the knee joints, with the navigation tool of the sagittal cuts used to improve landmark accuracy (figure 1). patients were positioned supine with the knees in extension. a tangential line was drawn along the posterior femoral condyles on the axial cuts. a perpendicular line was then drawn in the ap plane on the axial cut at the centre and the most anterior point of the tibial tuberosity. a parallel line was drawn through the deepest point of the trochlear groove. these points were confirmed by utilising the sagittal cuts in the navigation window to improve accuracy of identifying the anatomical landmark. a measurement was then obtained by measuring the distance between the two parallel lines in the ap plane. this was done in the left and the right knees of all cases that met the patient selection criteria. statistical analysis was performed using stata 15.0 (statacorp. college station, texas). continuous variables were reported as mean (± sd) or median (with interquartile range) and categorical variables as number and percentages, unless otherwise stated. differences in tttg by sex were compared using the unpaired t-test. spearman correlation was used to correlate tttg by age. all tests were two-sided and the level of significance was set at p<0.05. results ct scans of 100 patients were viewed. a total of 88 patients met the inclusion criteria. thirty-eight knees were excluded from the analysis: 12 had severe oa, 11 had significant trauma, 12 scans were not peripheral enough to measure appropriately, two knees were in excessive flexion, and one patient had an above-knee amputation of one leg. this left 162 knees on which measurement and analysis was performed (figure 2). the median age was 34 years (range 19–85 years; interquartile range [iqr] 24–50). the majority of cases were male (75%; n=121). the mean tttg was 20.3 mm (standard deviation [sd] 16.1; range 1–29.2 mm) (figure 3). while the tttg was slightly larger in males than females, the difference was not significant in this cohort. the mean tttg in males was 20.7 mm (95% confidence interval [ci] 19.9–21.5 mm) and 19.1 mm (95% ci 17.6–20.5 mm) in females (p=0.06). there was no correlation found between age and tttg (p=0.12). discussion the aim of this study was to measure the tttg measurement in the black african population and compare it to the quoted norms in the literature. we found that the mean tttg was 20.3 mm. the difference between sexes was not significant in this cohort. there was also no correlation found between age and tttg. in most studies the normal tttg measurement is less than 15 mm.6-10 these original studies were performed by dejour et al. among the french population.8 there is no published data on the tttg distance in the african population. researchers from china, korea and india have also undertaken studies to compare the differences in their respective populations with regard to tttg measurements. they all found differences in the average tttg distance among their populations when compared to the western quoted norm measurements. the study performed in korea yielded a mean tttg measurement of 10.24 mm.15 in this study they also measured the tttg on ct scans of 100 patients (50 of each sex); however, only 85 of them were asymptomatic patients meeting the inclusion criteria. the mean age in this study was 55 years (range 25–82 years). another strong point about this study was that measurements were done in a blinded manner by three separate observers, on two occasions. kulkarni et al. concluded that the tttg distance in the indian population, using mri as the measurement modality, is significantly different when compared to the published western data.16 a mean of 13.5 mm, with a range of 7.3–19.8 mm, was reported in a sample size of 100 knees. the mean age in this sample was 37 years (range 20–61 years). in the chinese population, a smaller average measurement was found in asymptomatic individuals used as a control group, with mean of 10.1 mm in a sample size of 73 control knees.17 the mean age in this cohort was 27 years (range 16–38 years). this age group is more appropriate for the concerned pathology which is usually present in adolescents and young adults.18,19 one of the possible reasons for varying measurement results between studies may potentially be explained by the ethnic differences. in a systematic review, kim et al., also highlighted morphological differences that exist in certain anatomical features and measurements around the knee.20 koerner et al. have also questioned the definition of ‘normal’ femoral versions among sexes and ethnicities.13 our data brings about the discussion of possible ethnic differences when it comes to the tttg measurement. furthermore, the clinical implication of such a finding remains unclear. tse et al., for example, suggested that the threshold for tibial tuberosity transfer should be lower in chinese patients due to these differences.17 some points for discussion may be raised regarding limitations to this study. although the sample size for this study was relatively small (n=162 knees), it did exceed the required sample size of 68, with a chosen confidence level (cl) constant at 95%, an acceptable margin of error (moe) of 10% and an sd of 0.5. previous international studies of this nature utilised comparable sample sizes of between 73 and 100.10,15-17 the consideration of inter-observer reliability with regard to performing the actual measurement should be taken into figure 3. the mean tibial tuberosity to trochlear groove (tttg) measurement was found to be 20.3 mm (n=162) page 56 rankin m et al. sa orthop j 2019;18(3) account when evaluating the strength of this study.21-23 in this study only a single individual (a senior orthopaedic registrar) performed the measurements for data collection. to improve the accuracy of average measurements, as with any study of this nature, it would be beneficial to have more than one person performing measurements. the exact degree of knee flexion was not measured in this study. to our knowledge, at the time of this study, only six publications were noted to have assessed the tttg through different ranges of knee flexion.24-29 dietrich et al. reported that the tttg increases significantly at the end stage of extension of the knee due to a biomechanical action known as the ‘screw-home mechanism’.25 carlson et al. also showed that a static tttg measurement cannot accurately predict dynamic lateral displacement of the patella.26 in our study, the ct scans were performed with the patients lying supine with knees in extension. current literature mentions that the routine ct scan should be taken with the knee in full extension.8,30 it does not, however, specify the range of knee flexion at which the ct scan can be deemed acceptable for tttg measurement. we do know, however, that most patella instability occurs from 0° to 30° of knee flexion.29 ct slice thickness of 3 mm was used in the majority of cases. this in itself can play a role in determining the landmarks for measurement.22 accuracy may be improved with a smaller slice thickness. although all of the patients in this study were self-reported as black african by race, the results may not necessarily be generalisable. a much larger sample from different regions throughout africa will be required for this purpose. some might argue that the assumption that given that these patients were chosen from the vascular surgery department does not mean that they are completely asymptomatic for patella–femoral instability. this is a valid point because no patients were screened for signs and symptoms of patella instability prior to ct scanning. future research on this topic will help verify this data. ideally a larger comparative series involving symptomatic and asymptomatic individuals of various ethnicities is required to determine clinically relevant reference values. accuracy of data can be improved by involving multiple blinded experienced observers with low thickness ct slices and consistent knee flexion angles. conclusion according to our study, barring some limitations, it appears that there may be a difference in the tttg measurement in the asymptomatic black african population when comparing it to data published elsewhere. this may be of significance with regard to the threshold for choice of surgical intervention. larger comparative studies would be required to confirm these findings and to determine the clinical relevance. ethics statement all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (reference number be631/16) and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. for this study formal consent was not required. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions mr contributed to the original study concept, proposal write-up, data collection and analysis, and final article write-up. mahm contributed to the study design, layout and final article concepts. orcid rankin m http://orcid.org/0000-0001-5247-4062 mohideen mah http://orcid.org/0000-0003-1205-0702 references 1. goutallier d, bernageau j, lecudonnec b. [the measurement of the tibial tuberosity. patella groove distanced technique and results (author’s transl)]. revue de chirurgie orthopedique et reparatrice de l’appareil moteur 1978;64(5):423-28. 2. liu jn, steinhaus me, kalbian il, et al. patellar instability management: a survey of the international patellofemoral study group. am j sports med 2017:363546517732045. doi: 10.1177/0363546517732045 3. schoettle pb, zanetti m, seifert b, et al. the tibial tuberositytrochlear groove distance; a comparative study between ct and mri scanning. the knee 2006;13(1):26-31. doi: 10.1016/j. knee.2005.06.003 4. thakkar rs, del grande f, wadhwa v, et al. patellar instability: ct and mri measurements and their correlation with internal derangement findings. knee surgery, sports traumatology, arthroscopy: official journal of the esska 2015 doi: 10.1007/ s00167-015-3614-8 5. ho cp, james ew, surowiec rk, et al. systematic techniquedependent differences in ct versus mri measurement of the tibial tubercle-trochlear groove distance. am j sports med 2015;43(3):675-82. doi: 10.1177/0363546514563690 6. grawe b, stein be. tibial tubercle osteotomy: indication and techniques. j knee surg 2015;28(4):279-84. doi: 10.1055/s-0035-1544973 7. alemparte j, ekdahl m, burnier l, et al. patellofemoral evaluation with radiographs and computed tomography scans in 60 knees of asymptomatic subjects. arthroscopy : the journal of arthroscopic & related surgery: official publication of the arthroscopy association of north america and the international arthroscopy association 2007;23(2):170-77. doi: 10.1016/j.arthro.2006.08.022 8. dejour h, walch g, nove-josserand l, et al. factors of patellar instability: an anatomic radiographic study. knee surgery, sports traumatology, arthroscopy : official journal of the esska 1994;2(1):19-26. 9. ding dy, kanevsky r, strauss ej, et al. anteromedialisation tibial tubercle osteotomy for recurrent patellar instability in young active patients: a retrospective case series. injury 2016;47(3):737-41. doi: 10.1016/j.injury.2015.10.005 10. pandit s, frampton c, stoddart j, et al. magnetic resonance imaging assessment of tibial tuberosity-trochlear groove distance: normal values for males and females. international orthopaedics 2011;35(12):1799-803. doi: 10.1007/s00264-011-1240-8 11. frosch s, balcarek p, walde ta, et al. [the treatment of patellar dislocation: a systematic review]. zeitschrift fur orthopadie und unfallchirurgie 2011;149(6):630-45. doi: 10.1055/s-0030-1250691 12. mulford js, wakeley cj, eldridge jd. assessment and management of chronic patellofemoral instability. j bone joint surg br 2007;89(6):709-16. doi: 10.1302/0301-620x.89b6.19064 13. koerner jd, patel nm, yoon rs, et al. femoral version of the general population: does ‘normal’ vary by gender or ethnicity? journal of orthopaedic trauma 2013;27(6):308-11. doi: 10.1097/ bot.0b013e3182693fdd 14. igbigbi ps, msamati bc. tibiofemoral angle in malawians. clinical anatomy 2002;15(4):293-6. doi: 10.1002/ca.10024 15. song ek, seon jk, kim mc, et al. radiologic measurement of tibial tuberosity-trochlear groove (tt-tg) distance by lower extremity rotational profile computed tomography in koreans. clinics in orthopedic surgery 2016;8(1):45-8. doi: 10.4055/cios.2016.8.1.45 16. kulkarni s, shetty ap, alva kk, et al. patellar instability in the indian population: relevance of tibial tuberosity and trochlear groove distance. sicot-j 2016;2:14. doi: 10.1051/sicotj/2016008 17. tse ms, lie cw, pan ny, et al. tibial tuberosity-trochlear groove distance in chinese patients with or without recurrent patellar dislocation. journal of orthopaedic surgery 2015;23(2):180-81. 18. atkin dm, fithian dc, marangi ks, et al. characteristics of patients with primary acute lateral patellar dislocation and their recovery within the first 6 months of injury. am j sports med 2000;28(4):472-79. doi: 10.1177/03635465000280040601 19. fithian dc, paxton ew, stone ml, et al. epidemiology and natural history of acute patellar dislocation. am j sports med 2004;32(5):1114-21. doi: 10.1177/0363546503260788 20. kim tk, phillips m, bhandari m, et al. what differences in morphologic features of the knee exist among patients of http://orcid.org/0000-0002-3689-0346 http://orcid.org/0000-0001-5247-4062 http://orcid.org/0000-0002-3689-0346 http://orcid.org/0000-0003-1205-0702 page 57rankin m et al. sa orthop j 2019;18(3) various races? a systematic review. clin orthop relat res 2017;475(1):170-82. doi: 10.1007/s11999-016-5097-4 21. dornacher d, reichel h, lippacher s. measurement of tibial tuberosity-trochlear groove distance: evaluation of interand intraobserver correlation dependent on the severity of trochlear dysplasia. knee surgery, sports traumatology, arthroscopy: official journal of the esska 2014;22(10):2382-87. doi: 10.1007/ s00167-014-3083-5 22. koeter s, horstmann wg, wagenaar fc, et al. a new ct scan method for measuring the tibial tubercle trochlear groove distance in patellar instability. the knee 2007;14(2):128-32. doi: 10.1016/j. knee.2006.11.003 23. miles je, jensen br, kirpensteijn j, et al. measurement repeatability of tibial tuberosity-trochlear groove offset distance in red fox (vulpes vulpes) cadavers. american journal of veterinary research 2013;74(6):888-94. doi: 10.2460/ajvr.74.6.888 24. izadpanah k, weitzel e, vicari m, et al. influence of knee flexion angle and weight bearing on the tibial tuberosity-trochlear groove (tttg) distance for evaluation of patellofemoral alignment. knee surgery, sports traumatology, arthroscopy: official journal of the esska 2014;22(11):2655-61. doi: 10.1007/s00167-013-2537-5 25. dietrich tj, betz m, pfirrmann cw, et al. end-stage extension of the knee and its influence on tibial tuberosity-trochlear groove distance (tttg) in asymptomatic volunteers. knee surgery, sports traumatology, arthroscopy: official journal of the esska 2014;22(1):214-18. doi: 10.1007/s00167-012-2357-z 26. carlson vr, sheehan ft, shen a, et al. the relationship of static tibial tubercle-trochlear groove measurement and dynamic patellar tracking. am j sports med 2017;45(8):1856-63. doi: 10.1177/0363546517700119 27. marquez-lara a, andersen j, lenchik l, et al. variability in patellofemoral alignment measurements on mri: influence of knee position. ajr am j roentgenol 2017;208(5):1097-102. doi: 10.2214/ajr.16.17007 28. tanaka mj, elias jj, williams aa, et al. correlation between changes in tibial tuberosity-trochlear groove distance and patellar position during active knee extension on dynamic kinematic computed tomographic imaging. arthroscopy : the journal of arthroscopic & related surgery: official publication of the arthroscopy association of north america and the international arthroscopy association 2015;31(9):1748-55. doi: 10.1016/j. arthro.2015.03.015 29. seitlinger g, scheurecker g, hogler r, et al. the position of the tibia tubercle in 0 degrees to 90 degrees flexion: comparing patients with patella dislocation to healthy volunteers. knee surgery, sports traumatology, arthroscopy: official journal of the esska 2014;22(10):2396-400. doi: 10.1007/s00167-014-3173-4 30. servien e, verdonk pc, neyret p. tibial tuberosity transfer for episodic patellar dislocation. sports med arthrosc rev 2007;15(2):61-67. doi: 10.1097/jsa.0b013e3180479464 _goback _hlk8818214 south african orthopaedic journal message from the president sa orthop j 2022;21(1) orthopaedic surgical career path – where’s the plan? robert n dunn* president: south african orthopaedic association *corresponding author: robert.dunn@uct.ac.za as i pen this piece, we are ramping up into the 4th wave of covid with the additional stressor of the unknown impact of the omicron variant. much of the disruption is due not to the virus itself but to our chosen responses of lockdowns, curfews and repetitive testing. i have personally undergone eight (negative) pcr tests in november alone to allow travel, run a marathon and undergo a minor surgical procedure. a quick r8 400 wasted at r850 a local test, reaching 100 us dollars in malawi and 88 euros in spain! then while lecturing in spain, the world went crazy isolating south africa after one of our virologists tweeted about the newest spike protein variant – without having any idea of its significance. we get so caught up in these in-your-face ‘crises’ with continual re-organisation and adaptation of our professional and personal worlds that it becomes difficult to think ahead. and a big think ahead is required. i wrote an editorial in the saoj some years ago in 2015 asking whether we were oversupplying the orthopaedic surgical market.1 i expressed my thoughts based on my perception of the situation at the time and concluded that this issue needed investigation and action. sadly, to my knowledge, nothing has happened in this area. recent events have reminded me of this issue. we simply take for granted that after years of orthopaedic training, at great cost to the individual and taxpayer, career opportunities will present themselves. we expect recently qualified surgeons to stay in sa and contribute to the health of our citizens, with at most a quick sojourn overseas for a fellowship. in cape town alone i am aware of two surgeons struggling to find a base to practise from. this has led to friction between them and resident surgeons at the private hospitals they have approached. we are constantly told that sa has too few doctors, and even fewer specialists. dell et al. in 2018 reported an average of 1.63 orthopaedic surgeons per 100 000 population compared to 4 in australia and canada, 7.5 in usa and uk and almost 20 in scandinavia.2 further analysis confirmed the private sector orthopaedic surgeon/population ratio to approximate the usa/ uk, with the public sector starved of surgeons. to my mind, these comparisons are not like-for-like as in sa the trainees carry a massive service load as opposed to the rest of the developed world. at groote schuur hospital, registrars performed 75% of the 3 147 orthopaedic surgical cases logged in 2018, and 90% of the trauma cases.3 this confirms that the registrar body is a significant contributor to service. this would add around 200 surgeons to the pool in sa. the actual number of active qualified specialists is difficult to ascertain. dell calculated 897. the south african orthopaedic association (saoa) currently has 476 full members and calculates this represents 88% of the total surgeons in the country. this implies 540 surgeons of working age. the hpcsa iregister offers 1 100 odd orthopaedic surgeons but running through the list, many are ‘terminated’, ‘erased’ or ‘suspended’. on personally reviewing the 144 listed under cape town, eight were ‘terminated’, and 12 marked as ‘active’ were in fact known to me as deceased, retired or emigrated. so, we don’t even have this basic data to work with. if we take a round number of 600 orthopaedic surgeons and assume (because that’s all we can do) that there is an even age distribution between 35 and 65 years, then it is about 20 per year of age, which implies 20 will retire a year. of course, there is illness and early death to consider, but judging by the saoa statistics this seems seldom before 65. so, in a static market, we need 20 replacements a year. from the cmsa fcs final pass rates, we are producing around double that per year (figure 1). there has been a gradual annual increase to around 40 a year in recent times. there was only one exam in the 2020 period due to covid, and 2021 still awaits the second semester exam. we are producing twice as many surgeons as compared to those leaving practice. admittedly, some of these exam candidates are supernumeraries from other countries who are meant to return home. this may contribute 10–15%, but there is still an oversupply if there is no growth in market opportunities. this is not the whole story as many surgeons continue to practise longer due to financial challenges. there is also a continued migration to the bigger cities due to local government challenges in some areas which are threatening the desired lifestyle. so where are the opportunities? although there are only 0.39 orthopaedic surgeons per 100 000 population in the public sector, posts remain static in many areas. in well-functioning facilities there is little turnover. there was massive emigration and movement into private in the 1990s and early 2000s resulting in relatively young surgeons being employed in the state rather than a generational 60 50 40 30 20 10 0 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 20 20 20 21 figure 1. fcs orth successful final candidates per year page 10 sa orthop j 2022;21(1) spread. our uct unit has not had a consultant resignation in 10 years, and the senior staff are still 7–10 years off retirement. on enquiring, the hods report there are few available funded consultant posts. ukzn is an exception with 23 vacant funded posts available, four being head of clinical units. many are regional. it is unclear why this is the case and may be due to the local restrictive rwop policy. subspeciality posts are generally more attractive than general trauma work which is available in private at far better reimbursement levels. despite the dearth of specialists in the eastern cape for example, and vacant posts, i find that our trainees give up waiting for the prolonged local hr processes and end up taking up other options out of desperation. private used to be an easy entry, but this seems to currently be less so, with reduced elective work resulting in more practitioners competing for the trauma calls. the private groups do not advertise opportunities and it requires the individual to approach the hospitals. the local physicians advisory boards (pabs) can be somewhat hostile with the trauma rosters sewn up limiting early earning potential of new entrants. on contacting the groups, life confirmed only four positions available nationally. two were in mpumalanga and umtata, with the other two requesting restricted practice of upper limb and sepsis management. so where to from here? we need to decide how many specialists are required. some parties would like more as this may result in downward price pressure due to competition for the work and dsp contracts. i however doubt this, as specialists have a lifestyle expectation and will strive to earn to support it with volume. this leads to the socalled supply-induced demand. this will increase the total health spend, especially when you consider the costs around surgery where the surgical fee is seldom more than 10% of the total cost. this requires a realistic expectation of what the system can afford, both in public and private models. with the current economic milieu and government’s focus on primary healthcare, i do not foresee great increases in elective surgical spend. based on this, the number of orthopaedic surgeons required can be calculated, both nationally and regionally, accepting the realities of geographic concentrations. it is all very well to expect a surgeon to work in a remote area, but often they are limited by their partner’s occupation and children’s schooling requirements. these are the realities that need to influence the model. from this the number of trainees required can be deduced along with the subspeciality needs. i suspect that this will be less than the current number of around 180–200 registrar posts, and these will need to be reduced. the real-time public service operational requirements cannot dictate the number of trainees; rather, the priority is adequate and appropriate training. the service shortfall will need to be managed differently. this is complex but not insurmountable. longer-term medical officers is the obvious solution, but not only those that want to proceed to specialist status. clinics can be supported with staff that only consult and do not operate. this model worked well in the uk when i was a fellow. non-mbchb staff such as physiotherapists can also participate in the clinics, assessing and triaging the patients. not every operation requires an mbchb-qualified assistant. i recall dinner with a world-renowned irish knee surgeon, david beverland, saying registrars just slowed him down and he preferred the use of a technician and mechanical leg support! the public system would be far more efficient with consultants performing the bulk of the surgery. thus, excess training posts can be converted to consultant posts. this will demand other system changes though. as registrars are passing through, keen to operate and learn, young and energetic, they can operate through the night, with the view that it’s transient and leading to the pot of gold. but this won’t fly for consultants over a 20–25 year period. the reliance on late night emergency lists will need to change, with improved access to theatre lists during the day to create sustainable working careers. we have been able to move heaven and earth to accommodate the covid service in the public hospitals, rearranging wards and icus, repurposing staff and getting the job done. there is no reason why we can’t reimagine a better orthopaedic service and reconstruct it to provide all of us with an acceptable and certain career path. the saoa is probably the common ground between the role players and needs to initiate this process. references 1. dunn rn. are we oversupplying the orthopaedic surgical market? sa orthop j. 2015;14(1):16-17. 2. dell aj, gray s, fraser r, held m, dunn r. orthopaedic surgeon density in south africa. world j surg. 2018;42(12):3849-55. https://doi.org/10.1007/s00268-018-4709-4. 3. dunn c, held m, laubscher m, et al. orthopaedic surgical training exposure at a south african academic hospital – is the experience diverse and in depth? accepted for publication sa ortho j. 2022;21(1):22-28. https://doi.org/10.17159/2309-8309/2022/v21n1a3. orthopaedics vol3 no4 sa orthopaedic journal autumn 2015 | vol 14 • no 1 page 25 reverse total shoulder arthroplasty for complex proximal humeral fractures in the elderly: how to improve outcomes and avoid complications p ryan mbchb(uct), fc(orth)(sa), mmed(orth)ukzn rp dachs mbchb(uct), fcs(sa)ortho, mmed(orth)uct jp du plessis mbchb(uct), fcs(sa)ortho, mmed(orth)uct b vrettos mbchb(zim), frcs(eng), fcs(sa)orth, mmed(orth)uct s roche mbchb(uct), lmmc, fcs(sa)ortho department of orthopaedic surgery, university of cape town correspondence: dr p ryan email: paullisa.ryan@gmail.com introduction proximal humeral fractures account for around 5% of humeral fractures. they are the third most common non-vertebral fragility fracture after the hip and distal radius.1 the incidence in females over the age of 50 is estimated overall at around 2.2 per 1 000 per year, and there is an exponential increase between the ages of 65 and 80 years.2 females are affected twice as frequently as males, and the severity of fracture is noted to increase with advancing age.3 as with other fragility fractures, there is an association with increased mortality rate in the postfracture period, which remains elevated for up to a decade; however, this is most likely a consequence of underlying medical co-morbidities.4 while most simple, minimally or non-displaced fractures can be managed successfully with non-operative means, the more complex threeand four-part displaced fractures remain difficult to treat and have worse outcomes. patient factors including advancing age, increased number and severity of co-morbidities, pre-existing rotator cuff abnormalities, osteoporosis, and ability to engage in post-operative rehabilitation all influence the management decision and the ability to regain functional independency. the complexity of these injuries is a function of fracture severity (and the associated risk of avascular necrosis), and the difficulty in attaining union of the greater and lesser tuberosities in anatomical position. avascular necrosis (avn) complicates between 21 and 75% of threeand fourpart fractures, and is related to the initial injury, the fracture pattern, the integrity and size of the medial cortical hinge, and surgical dissection. there is debate and conflicting literature regarding the optimal management of this difficult group, whether it be non-operative or surgical, and if surgical, which surgery. in order to evaluate the benefits and risks of the various surgical techniques, it is important first to understand the natural history of non-operatively managed fractures, and to know the outcomes of the different surgical options. abstract the use of reverse total shoulder arthroplasty for the management of complex proximal humerus fractures has gained popularity in the last five to ten years. we present a concise review of conservative and surgical treatment of proximal humerus fractures and a more detailed review of published series of reverse shoulder arthroplasty for fracture treatment. we discuss ways of optimising results and avoiding complications. key words: reverse shoulder, shoulder replacement, proximal humerus fracture saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 25 page 26 sa orthopaedic journal autumn 2015 | vol 14 • no 1 conservative management edelson et al. performed a prospective observational study of 76 patients with complex proximal humerus fractures managed non-operatively. they concluded that although the range of motion was limited, pain was minimal, and that the majority of patients had an acceptable functional status. patients were grouped according to a 3d classification of fracture pattern. the average forward flexion for the various groups ranged from 106 to 123°, external rotation 34 to 43°, and internal rotation from l3 to t9. pain at rest and with activity averaged 0.4 and 2.8 respectively on a 1–10 analogue pain scale.5 these results should be borne in mind when evaluating functional outcome and pain after surgical interventions. locked plate fixation locked plate technology for fixation of fractures associated with poor bone quality has expanded in recent years. however, there is conflicting evidence regarding the outcomes when used for proximal humerus fractures. in a recent prospective randomised control trial (prct) of 50 patients comparing non-operative management and locked-plate fixation for complex displaced fractures, it was reported that at 12 months the functional scores (american shoulder and elbow score ases, and constant score cs) were similar, and that the only significant difference was better radiographs in the operated group.6 complications of plate fixation, the most frequent relating to screw cut-out, are common. spross et al. reported on their results at one year in a group of 293 patients managed with locked plates. they had a 28.2% incidence of complications, the majority of which required re-operation. screw cut-out was seen in 11.2% and was related to secondary fracture displacement and avn. of note however, they report a median constant-murley score of 89/100 in patients who did not suffer a complication.7 in a systematic review (including 514 patients in 12 studies) of the use of locked plates for proximal humerus fractures, sproul et al. reported an overall complication rate of 33% (excluding varus malunion as a complication), which included 10% avn, 8% screw perforation, 6% subacromial impingement, and 4% infection.8 hemiarthroplasty in the early 1950s, neer introduced hemiarthroplasty for the treatment of proximal humerus fractures at high risk of avn. although he and others have published good results with this, it is understood that elderly patients have worse outcomes with hemiarthroplasty than their younger counterparts. clinical outcome is reliant upon the prosthesis height and version, and tuberosity position and union; however, in some studies up to 50% tuberosity malpositioning is seen, which can result in superior migration, stiffness, weakness, pain and lower functional scores (figure 1).9,10 factors associated with final tuberosity malposition are: prosthesis malposition, female sex, and age over 75 years. boons et al. in a recent prct comparing non-operative management with hemiarthroplasty in patients older than 65 years reported similar functional (cs, simple shoulder test) and pain scores at 12 months, and that the nonoperated group had better abduction strength at 3 and 12 months.11 olerud et al.12 in a prct of 55 patients evaluated at two years reported a statistically significant improvement in quality of life score (eq-5d) for hemiarthroplasty over non-operative treatment, but no significant differences regarding the cs or range of motion. although there was a trend towards improved dash and pain scores in the hemi group, this was not statistically significant. the eq-5d score includes patient responses regarding feelings of anxiety/depression, ambulatory ability, etc., and may have less significance than subjective patient scores which are specific to the anatomic region affected, such as the oxford shoulder score (oss). despite the above, there is general consensus that while hemiarthroplasty may be variable with regard to functional outcome, there is consistently good pain relief, with around 80% of patients experiencing no or minimal pain.13,14 figure 1. hemiarthroplasty with greater tuberosity non-union and superior migration in some studies up to 50% tuberosity malpositioning is seen, which can result in superior migration, stiffness, weakness, pain and lower functional scores saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 26 sa orthopaedic journal autumn 2015 | vol 14 • no 1 page 27 reverse total shoulder arthroplasty the reverse total shoulder arthroplasty (rtsa) was introduced for the treatment of glenohumeral arthritis with an incompetent/irreparable rotator cuff. initial designs met with unacceptably high complication and revision rates, and were abandoned by some. in the mid-1980s grammont’s work and design15 of a more medialised and lowered centre of rotation led to promising results when utilised for cuff deficient arthritic shoulders. since then, the indications for use of this design have expanded to include fracture sequelae, acute fractures, revision and tumour surgery. with better understanding and improvements in component design and biomechanics, as well as understanding of scapular morphology, some of the inherent problems with reverse shoulder arthroplasty are being addressed. indications currently the indication for rtsa in the trauma setting are: displaced complex fractures or fracture-dislocations in elderly patients (figure 2), who have pre-existing cuff pathology, or those in whom anatomic tuberosity healing is unlikely to occur.16 a strong smoking history may be considered as a relative indication due to its negative effect on tissue (and tuberosity) healing.17 outcomes results of rtsa used for fractures table i summarises some of the recent papers on the use of rtsa for acute fractures.18-22 results of rtsa vs hemiarthroplasty, and/or orif for fractures sirveaux et al.,23 in a prospective multicentric study, report improved anterior active elevation with rtsa compared to hemiarthroplasty (mean of 113° vs 88°). gallinet et al.24 retrospectively reviewed their proximal humeral fractures managed with arthroplasty. in the initial study period they performed hemiarthroplasty, and in the latter rtsa. age at time of surgery was similar for both groups (74 years). they report significantly better forward elevation in the rtsa group, but better internal and external rotation in the hemiarthroplasty patients. the rtsa patients had statistically significantly better constant scores. pain, mobility and activity favoured rtsa, while only strength was better in hemiarthroplasty. within the rtsa group, 27 underwent tuberosity repair versus 14 without. the cs for those with tuberosity repair was statistically significantly greater for those with tuberosity repair (60.1 vs 51.7). they highlight the speed at which the rtsa group regained functional autonomy. complication rates were similar between groups. contradicting this, young et al.,25 in their review of ten rtsas and eight hemiarthroplasties used for fractures in patients with mean ages of 77 and 75 years respectively, could not demonstrate any improvement in outcome scores (ases, oss) or range of motion for rtsa, suggesting its use in fracture management is still unclear, while also alluding to cost implications of rtsa, and the ability to revise hemiarthroplasty should the need arise. this is however a very small series. garrigues et al.26 retrospectively reviewed their hemiarthroplasty and rtsa results for acute fractures in an elderly population group. despite the hemiarthroplasty group being younger (mean 69 years vs 80 years), they demonstrated statistically significant improvement in forward elevation (121° vs 91°) and functional shoulder scores (ases 81 vs 47) in the rtsa group. the mean rotation was similar, which they attribute to tuberosity fixation undertaken in all cases of rtsa. four of their 12 hemiarthroplasties suffered complications (resulting in revision to rtsa in three cases), while only one of the rtsa was reported as having a complication (sirveaux grade 1 notching). in a review of the new zealand joint registry, boyle et al.27 showed improved patient reported outcomes at five-year follow-up (oss 41.5 vs 32.3) in patients who had rtsa compared to hemiarthroplasty for acute fractures. this is despite the rtsa group being significantly older (mean age 79.6 vs 71.9 years). in their study, there was no significant difference in revision rate or one-year mortality. it is noted, however that the proportion of surgeries performed by ‘high volume’ shoulder surgeons was far greater in the rtsa than the hemiarthroplasty group (72.7 vs 31%). more recently, chalmers et al.28 performed a retrospective cohort study in which they prospectively evaluated nine patients over the age of 65 years who underwent rtsa for acute fractures, and then retrospectively compared them to ageand gender-matched control groups who had undergone either open reduction internal fixation (orif) or hemiarthroplasty. at a minimum of one-year follow-up, there was no significant difference in their shoulder (sst and ases) and short-form 12-item scores. figure 2. 3d ct scan of 5-month-old fracture dislocation with tuberosity malunion saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 27 page 28 sa orthopaedic journal autumn 2015 | vol 14 • no 1 st ud y st ud y de si gn n um be r of pa tie nt s m ea n pa tie nt a ge (y ea rs ) fo llo w -u p (m on th s) m ea n fo rw ar d fle xi on m ea n ab du ct io n m ea n ex te rn al ro ta tio n m ea n pa in sc or e co m pl ic at io n ra te co m pl ic at io ns o ut co m es v a le n ti et al. 1 6 r c s 2 7 7 8 ( a ll > 6 6 ) 2 2 .5 (1 2 – 3 9 ) 1 1 2 ( 8 5 – 1 5 0 ) 9 7 (8 0 – 1 6 0 ) 1 2 .7 ( 0 – 4 0 ) 5 5 ( in a b d ) 1 3 .5 o n c s 7 % -7 4 % 1 t ra n si e n t d e lt o id p a ra ly si s, 1 p ro g re ss iv e g le n o id lu ce n cy , (1 4 g t r e so rb ti o n s, 1 4 e ct o p ic b o n e f o rm a ti o n ) c s 5 4 .9 r e it m a n et al. 1 8 r c s 1 3 7 0 ( 5 8 – 9 0 ) 2 9 ( 8 – 4 6 ) 1 2 5 ( 8 5 – 1 7 0 ) 1 1 4 – 1 1 o n c s 2 3 % 2 a x il la ry n e rv e p a ls ie s 1 r a d n e rv e 1 r e -o p e ra ti o n f o r h a e m a to m a c s 6 7 l e v y et al. 1 9 r c s 7 8 6 ( 7 8 – 9 1 ) 1 4 ( 1 2 – 2 3 ) 1 1 7 ( 9 5 – 1 5 0 ) 8 0 ( 6 5 – 9 0 ) 1 9 ( 0 – 3 0 ) 0 .6 ( v a s ) 4 3 % 1 p a ti e n t w it h a cr o m ia l fr a ct u re a n d g t n o n -u n io n , 1 h e te ro to p o ss if ic a ti o n a s e s f u n ct io n 3 9 .2 k le in et al. 2 0 p c s 2 0 7 5 ( 6 7 – 8 5 ) 3 3 ( 2 4 – 5 2 ) 1 2 2 ( 6 0 – 1 7 5 ) 1 1 2 (6 0 – 1 8 0 ) 2 5 ( 1 0 – 3 5 ) – 1 5 % 1 d is lo ca ti o n , 2 d e e p i n fe ct io n s d a s h 4 6 a s e s 6 8 c s 4 4 ( 6 6 % ) b u fq u in et al. 2 1 p c s 4 3 7 8 ( 6 5 – 9 7 ) 2 2 ( 6 – 5 8 ) 9 7 ( 3 5 – 1 6 0 ) 8 6 8 3 0 ( in a b d ) 1 2 .5 o n c s 2 8 % 3 r s d , 5 n e u ro lo g ic a l, 1 d is lo ca ti o n , 1 a cr o m ia l fr a ct u re , 1 d e lt o id d e h is ce n ce c s 4 4 ( 6 7 % ) c a z e n e u e v , c ri st o fa ri 2 2 p c s 3 6 7 5 ( 5 8 – 9 2 ) 6 .6 y e a rs (1 – 1 6 ) 7 .5 o n c s 6 .5 o n c s 1 o n c s 1 2 o n c s 1 9 % 4 d is lo ca ti o n s, 2 r s d , 1 d e e p i n fe ct io n c s 5 3 ( 6 7 % ) l e n a rz et al. 1 7 r c s 3 0 7 7 ( 6 5 – 9 4 ) 2 3 ( 1 2 – 3 6 ) 1 3 9 ( 9 0 – 1 8 0 ) – 2 7 ( 0 – 4 5 ) 1 ( v a s ) 1 0 % 1 p a ti e n t w it h c r p s , d v t , a n d g t r e so rp ti o n , 1 p a ti e n t w it h g t m a lu n io n , 1 p a ti e n t w it h g ra d e 1 n o tc h in g a s e s 7 8 ta bl e i : r es ul ts o f r ts a fo r f ra ct ur es saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 28 sa orthopaedic journal autumn 2015 | vol 14 • no 1 page 29 the rtsa group however achieved significantly better movement. all nine patients attained forward elevation greater than 90°, and significantly more reached external rotation of 30°. in their costs analysis (including prosthesis and physical therapy) they report similar expenditure for orif and rtsa, and greater cost for hemiarthroplasty. this they attribute to the rtsa group for the most part not needing a structured supervised physical therapy programme. although there are advantages to rtsa, including improvement in the range of motion, which may result in better shoulder scores, one should remain cognisant of the expense involved, and the increased complication rate inherent to rtsa. avoiding complications/optimising results the overall complication rate and long-term survival in rtsa is inferior to anatomic tsa with an intact rotator cuff. infection the rate of infection with rtsa approximates that of total shoulder arthroplasty and is reported at between 0 and 3%.29 the rate seen in primary surgery is equivalent for various indications such as fractures, fracture sequelae and cuff tear arthropathy; however, the rate of infection is increased up to 8% when a reverse prosthesis is used for revision surgery.30 the most common infecting organisms post total shoulder arthroplasty are gram-positive staphylococcus aureus, staphylococcus epidermidis and proprionibacterium acnes (p acnes).31 although initially considered a non-pathogenic bacterium and a contaminant of microbiological specimens, there is a growing body of evidence supporting the significance of p acnes post rotator cuff, instability and arthroplasty surgery of the shoulder.32-36 p acnes is a gram-positive anaerobic bacillus which is found to colonise areas with abundant sebum-rich hair follicles. in a study comparing colonisation of various sites, patel et al.37 reported a greater prevalence around the shoulder compared to other sites such as the hip and knee. in this study, they demonstrate a similar prevalence of colonisation in the shoulder as s aureus. men have a greater burden of colonisation than women due to increased hair and perspiration in the area, and are more frequently affected by infection due to p acnes.33,37 simple measures such as sealing off of the axilla with a sterile occlusive drape prior to skin incision, as well as the use of a suitable prophylactic antibiotic such as clindamycin 600–900 mg is advocated to reduce the risk of p acnes infection. if the humeral component is cemented, appropriate antibiotic-loaded cement should be used. in a retrospective review of over 500 rtsas, nowinski et al. demonstrated a 3% infection rate in the group who had no antibiotics in the cement, and no infections in the group who had either tobramycin, or vancomycin, or a combination of both added to the cement.29 there are also concerns regarding potential periprosthetic ‘dead space’ post rtsa, due to the morphology of the implanted components, and to the surgical procedure, which entails excision of part of the rotator cuff. although there is no compelling evidence to support the use of post-operative low pressure closed drainage systems post shoulder arthroplasty, they are commonly used for short post-operative periods as post-operative haematoma formation may be complicated by positive cultures, and re-operation for haematoma is associated with poor clinical results.36 boileau et al.38 reported on frequent subacromial haematoma formation, and on one case in which the haematoma by means of a ‘piston mechanism’ became interposed between the components, and resulted in prosthetic instability. they recommend drain insertion as well as abduction bracing for three weeks to prevent this complication. whether a drain is utilised or not, meticulous haemostasis is imperative. notching notching (figure 3) refers to the loss of bone from the inferior pole of the scapular neck. the cause is a mechanical impingement of the medial aspect of the humeral component on this area when the arm is adducted.39 the mechanical impingement may cause polyethelene wear leading to focal osteolysis and notch progression.40 figure 3. inferior glenoid notching the rate of infection is increased up to 8% when a reverse prosthesis is used for revision surgery saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 29 page 30 sa orthopaedic journal autumn 2015 | vol 14 • no 1 the incidence and severity of notching is seen to increase with advancing follow-up,39 and may progress to the extent that it causes glenoid component loosening and instability. the anatomy of the scapula with relation to glenoid component positioning and the resultant scapular notching has been studied. in a computer-generated biomechanical model, de wilde et al. evaluated the maximal adduction or notch angle (humeral component in conflict with the inferior scapular neck) for the following circumstances: a change in the humeral neck shaft inclination, change in the polyethylene cup depth, lateralisation of the centre of rotation, inferior glenoid inclination, increase in glenosphere radius, and increased inferior prosthetic overhang. of these six scenarios, increasing the inferior overhang resulted in the most significant gain of notch angle.41 this is borne out in clinical studies where positioning of a glenoid component in the inferior aspect of the native glenoid, and increasing the inferior glenosphere overhang, reduces the incidence of notching.30 other authors have investigated the effect of lateralisation of the centre of rotation on glenoid notching. boileau et al.42 utilised a composite bone graft and component, while valenti et al.43 investigated a modified glenoid component that lateralised the centre of rotation without the need for bone grafting. while the latter showed neither notching nor glenoid loosening in 76 shoulders at a minimum of twoyears’ follow-up, there remain concerns regarding the resultant increase in torque and shear forces associated with lateralisation that may increase the rate of glenoid component loosening. instability the incidence of component dislocation (figure 4) post rtsa ranges from 0.01% to 28% for the various indications for surgery.43,44 dislocation has been related to inadequate deltoid tensioning, tuberosity malunion (with resultant impingement) as well as tuberosity excision and inability to repair the tuberosities. it is more frequently seen in revision surgery. in a shortto mid-term analysis of their cases, wellman et al. showed a four-fold increase in the dislocation rate for revision surgery compared to primary rtsa for cuff tear arthropathy.30 in a recent study on instability and infection rates, trappey et al. report an instability rate of 12% in the patients with an irreparable subscapularis tendon, and a <1% instability when the subscapularis was repairable. their highest rate of instability was seen in the fracture sequelae group with 28% instability. they attribute this to the difficulty in managing the subscapularis musculotendinous unit as the lesser tuberosity is often malunited, non-united or resorbed. the second most affected group in their series was those with a massive cuff tear with involvement of the subscapularis tendon.44 this association of subscapularis insufficiency and instability post rtsa has been confirmed by other authors.45 acromial fractures acromial fractures (figure 5) complicate between 1 and 7% of rtsa. they have been classified by crosby and hamilton46 into three groups depending on the anatomic location. types 1 and 2 are lateral to the acromioclavicular joint, and type 3 is medial. the type 3 fractures commonly involve the spine of the scapula and are related to screw position. figure 4. instability post rtsa figure 5. axillary view of acromial fracture post rtsa saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 30 st ud y st ud y de si gn n um be r of pa tie nt s m ea n pa tie nt a ge (y ea rs ) fo llo w -u p (m on th s) m ea n fo rw ar d fle xi on m ea n ab du ct io n m ea n ex te rn al ro ta tio n m ea n pa in sc or e co m pl ic at io n ra te co m pl ic at io ns o ut co m es s ir v e a u x et al. 2 3 p c c s h e m i 8 8 r t s a 1 5 1 1 3 g a rr ig u e s et al. 2 6 r c c s h e m i 1 1 6 9 ( 5 7 – 8 7 ) 3 .6 y rs (1 .3 – 8 y rs ) 9 0 ( 3 0 – 1 4 0 ) – 3 1 ( 5 – 6 0 ) – 4 / 1 1 1 g t m a lu n io n , 1 r e so rb ti o n ; 2 b ra ch ia l p le x o p a th ie s. (3 r e v is io n s to r t s a ) a s e s 4 7 r t s a 1 4 8 1 ( 6 7 – 9 1 ) 1 2 2 ( 9 0 – 1 4 5 ) – 3 4 ( 1 0 – 4 5 ) – 1 / 1 4 1 g ra d e 1 n o tc h in g a s e s 8 1 g a ll in e t et al. 2 4 r c c s h e m i 1 7 7 4 ( 4 9 – 9 5 ) 1 6 .5 ( 6 – 5 5 ) 5 3 .5 6 0 ( 3 0 – 9 0 ) 1 3 .5 ( 0 – 3 0 ) 9 .2 / 1 5 o n c s 4 / 1 7 1 t e m p o ra ry n e rv e p a ls y , 2 r s d , 1 s u p e rf ic ia l in fe ct io n c s 3 9 r s t a 1 6 7 4 ( 5 8 – 8 4 ) 1 2 .4 ( 4 – 1 8 ) 9 7 .5 9 1 ( 1 0 – 1 5 0 ) 9 ( 0 – 8 0 ) 1 3 .1 / 1 5 o n c s 3 / 1 6 1 s u p e rf ic ia l in fe ct io n , 1 d e e p i n fe ct io n , 1 r s d c s 5 3 y o u n g et al. 2 5 r c c s h e m i 1 0 7 5 .5 4 4 1 0 8 ( 5 0 – 1 8 0 ) 4 8 ( 1 0 – 9 0 ) 2 / 1 0 1 i n fe ct io n a s e s 6 7 ( 2 6 – 1 0 0 ) o s s 2 2 .4 ( 1 2 – 3 4 ) r t s a 1 0 7 7 .2 2 2 1 1 5 ( 4 5 – 1 4 0 ) 4 9 ( 5 – 1 0 5 ) 0 / 1 0 1 s e v e re p a in – r e v is e d a s e s 6 5 ( 4 0 – 8 8 ) o s s 2 8 .7 ( 1 5 – 5 6 ) b o y le et al. 2 7 r e g is tr y re v ie w h e m i 3 1 3 7 1 .9 ( 2 7 – 9 6 ) 6 0 o s s 3 2 .3 r t s a 5 5 7 9 .6 ( 5 7 – 9 0 ) 6 0 o s s 4 1 .5 c h a lm e rs et al. 2 8 r c c s h e m i 9 m a tc h e d a g e a n d g e n d e r. a ll > 6 5 y rs 1 0 6 ( ± 2 9 ) 2 8 ( ± 1 9 ) 3 ( ± 3 ) 1 / 9 a rt h ro fi b ro si s a s e s 6 6 ( ± 3 1 ) o r if 9 1 0 8 ( ± 4 0 ) 4 6 ( ± 2 1 ) 1 ( ± 1 ) 1 / 9 a rt h ro fi b ro si s, a v n a s e s 7 5 ( ± 1 5 ) r t s a 9 1 3 3 (± 2 0 ) 4 1 ( ± 1 9 ) 1 ( ± 1 ) 1 / 9 c r p s ( re co v e re d ) a s e s 8 0 ( ± 1 1 ) ta bl e i i: re su lts fo r s tu di es co m pa rin g he m ia rt hr op la st y, a nd /o r o ri f an d rt sa fo r a cu te fr ac tu re s sa orthopaedic journal autumn 2015 | vol 14 • no 1 page 31 in a review of 52 acromial fractures post rtsa, otto et al.47 identify osteoporosis as a significant risk factor for acromial fracture. while 14 of their 16 spine fractures (type 3 fractures) occurred from a screw tip, there was no difference in screw orientation and length between this and the other groups. they were unable to show a causal relationship between screw placement and scapular spine fractures. their study highlights the usefulness of the radiographic features of a decreasing acromiohumeral distance, and increasing lateral acromial tilt on consecutive radiographs for the diagnosis of acromial fractures. as proximal humeral fractures are fragility fractures, it is incumbent upon the treating physician that these patients be investigated for osteoporosis, and managed accordingly. this should not only reduce their risk of acromial fracture, but also that of other fragility fractures, with their associated morbidity and mortality. range of movement inherent in gramont’s rtsa design is infero-medialisation of the centre of rotation of the new shoulder. this has the advantage of recruitment of a larger (more medial) proportion of the deltoid muscle, as well as placing the deltoid under sufficient tension to enable optimal abduction and forward elevation. however, this has secondary effects on the anterior and posterior cuff musculature as the humerus is also medialised,38 effectively reducing the medio-lateral spinatii excursion and altering the force vectors of the muscles. although abduction and flexion are reasonably reproducible with rtsa, as seen in tables i and ii, the results for rotation are less consistent. this is due in part to the evolving surgical technique, and differing management of the greater and lesser tuberosities. saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 31 page 32 sa orthopaedic journal autumn 2015 | vol 14 • no 1 gallinet et al. highlight the importance of anatomic tuberosity restoration in order to maximise rotation in rtsa when used for acute fractures.48 comparing a group of patients whose tuberosities united in anatomic position with a group without repair or who had malor non-union of the tuberosities, they showed improved external rotation (49° vs 10°) as well as improved outcomes (cs 56 vs 50 and dash 30 vs 40). of significance, they allude to the fact that tuberosity malor non-union is not as detrimental in rtsa as it is in hemiarthroplasty. this improvement in rotation was confirmed by valenti et al. who showed a difference of 8.6° vs 16.7° with greater tuberosity reinsertion. interestingly, in their study, patients who did not have lesser tuberosity re-insertion also had statistically better external rotation (17.9° vs 9.1°) compared to those that did. although they give no explanation for this, it is possibly due to the loss of the restriction of the subscapularis musculotendinous unit.16 obtaining union of the greater and lesser tuberosities in optimal position may be challenging in the setting of high grade comminuted fractures. in a small series of seven patients, levy et al.19 describe a novel technique in which they fashion a horseshoe-shaped graft from the discarded humeral head. this is then placed around the humeral prosthesis, and the tuberosities fastened around this. they obtained tuberosity union in six of the seven cases. at a minimum of 12 months follow-up, the external rotation averaged 19° (0–30°) and manual muscle strength testing revealed 5/5 power for both internal and external rotation. the significance of the remaining posterior cuff and specifically the teres minor in facilitating external rotation in rtsa for cuff-deficient shoulders has been emphasised in a number of publications. in order to attain optimal results, one should pay special attention to: 1. ensuring proper patient selection and indication for use of rtsa 2. minimising the infection risk: use appropriate prophylactic antibiotics and antibiotic-loaded cement; maintain an aseptic operating field (with occlusion of the axilla) 3. minimising the notching risk: ensure ideal placement of the glenoid base-plate (figure 6), and thus inferior glenosphere overhang 4. enhancing stability: use the correct humeral insert for the tension of the deltoid; avoid bony impingement; repair tuberosities 5. optimising range of motion: anatomic repair of the greater and lesser tuberosities 6. minimising the risk of acromial fractures: appropriate investigation and management of osteoporosis. summary complex proximal humeral fractures in elderly patients remain challenging to manage. pre-fracture shoulder function is never entirely regained, no matter what treatment modality is utilised. one should consider rtsa for complex proximal humeral fractures/fracture-dislocations in patients over the age of 70 years with pre-existing rotator cuff abnormalities, extensive osteoporosis, high likelihood of final tuberosity displacement, and the inability to participate in an extended rehabilitation programme. the content of the article is the sole work of the authors. no benefits of any form have been or are to be received from a commercial party related directly or indirectly to the subject of the article. references 1. hirzinger c, tauber m, resch h. [proximal humerus fracture: new aspects in epidemiology, fracture morphology, and diagnostics]. unfallchirurg, 2011;114(12): 1051-58. 2. pages-castella a, et al. burden of osteoporotic fractures in primary health care in catalonia (spain): a population-based study. bmc musculoskelet disord, 2012;13:79. 3. roux a, et al. epidemiology of proximal humerus fractures managed in a trauma center. orthop traumatol surg res, 2012;98(6):715-19. 4. melton lj, 3rd, et al. long-term mortality following fractures at different skeletal sites: a population-based cohort study. osteoporos int, 2013;24(5):1689-96. 5. edelson g, et al. natural history of complex fractures of the proximal humerus using a three-dimensional classification system. j shoulder elbow surg, 2008;17(3):399-409. 6. fjalestad t, et al. surgical treatment with an angular stable plate for complex displaced proximal humeral fractures in elderly patients: a randomized controlled trial. j orthop trauma, 2012;26(2):98-106. 7. spross c, et 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acute proximal humerus fracture, the multicentric study. in reverse shoulder arthroplasty. clinical results, complications, revision, ed. f. sirveaux. 2006, montpellier: sauramps medical. 24. gallinet d, et al. three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: a comparative study of 40 cases. orthop traumatol surg res, 2009;95(1):4855. 25. young sw, et al. comparison of functional outcomes of reverse shoulder arthroplasty versus hemiarthroplasty in the primary treatment of acute proximal humerus fracture. anz j surg, 2010;80(11):789-93. 26. garrigues ge, et al. hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients. orthopedics, 2012;35(5):e703-8. 27. boyle mj, et al. functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures. j shoulder elbow surg, 2013;22(1):32-37. 28. chalmers pn, et al. reverse total shoulder arthroplasty for acute proximal humeral fracture: comparison to open reductioninternal fixation and hemiarthroplasty. j shoulder elbow surg, 2014;23(2):197-204. 29. nowinski rj, et al. antibiotic-loaded bone cement reduces deep infection rates for primary reverse total shoulder arthroplasty: a retrospective, cohort study of 501 shoulders. j shoulder elbow surg, 2012;21(3):324-28. 30. wellmann m, et al. short and midterm results of reverse shoulder arthroplasty according to the preoperative etiology. arch orthop trauma surg, 2013;133(4):463-71. 31. sperling jw, et al. infection after shoulder arthroplasty. clin orthop relat res, 2001;382:206-16. 32. millett pj, et al. propionibacterium acnes infection as an occult cause of postoperative shoulder pain: a case series. clin orthop relat res, 2011;469(10):2824-30. 33. levy py, et al. propionibacterium acnes postoperative shoulder arthritis: an emerging clinical entity. clin infect dis, 2008;46(12):1884-86. 34. athwal gs, et al. deep infection after rotator cuff repair. j shoulder elbow surg, 2007;16(3):306-11. 35. sperling jw, et al. infection after shoulder instability surgery. clin orthop relat res, 2003;414):61-64. 36. cheung ev, sperling jw, cofield rh. infection associated with hematoma formation after shoulder arthroplasty. clin orthop relat res, 2008;466(6):1363-67. 37. patel a, et al. propionibacterium acnes colonization of the human shoulder. j shoulder elbow surg, 2009;18(6):897-902. 38. boileau p, et al. grammont reverse prosthesis: design, rationale, and biomechanics. j shoulder elbow surg, 2005;14(1 suppl s):147s-161s. 39. valenti p. delta 3 reversed prosthesis for arthritis with massive rotator cuff tear: long term results (> 5 years). 2001, saurups medical montpellier: 2000 shoulder prosthesis... two to ten year follow-up (eds g walch , p boileau , mole d). p. 253-59. 40. vanhove b, beugnies a. grammont’s reverse shoulder prosthesis for rotator cuff arthropathy. a retrospective study of 32 cases. acta orthop belg, 2004;70(3):219-25. 41. de wilde lf, et al. prosthetic overhang is the most effective way to prevent scapular conflict in a reverse total shoulder prosthesis. acta orthop, 2010;81(6):719-26. 42. boileau p, et al. bony increased-offset reversed shoulder arthroplasty: minimizing scapular impingement while maximizing glenoid fixation. clin orthop relat res, 2011;469(9):2558-67. 43. valenti p, et al. do less medialized reverse shoulder prostheses increase motion and reduce notching? clin orthop relat res, 2011;469(9):2550-57. 44. trappey gjt, o’connor dp, edwards tb. what are the instability and infection rates after reverse shoulder arthroplasty? clin orthop relat res, 2011;469(9):2505-11. 45. edwards tb, et al. subscapularis insufficiency and the risk of shoulder dislocation after reverse shoulder arthroplasty. j shoulder elbow surg, 2009;18(6):892-96. 46. crosby la, hamilton a, twiss t. scapula fractures after reverse total shoulder arthroplasty: classification and treatment. clin orthop relat res, 2011;469(9):2544-49. 47. otto rj, et al. scapular fractures after reverse shoulder arthroplasty: evaluation of risk factors and the reliability of a proposed classification. j shoulder elbow surg, 2013. 48. gallinet d, et al. improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty. j shoulder elbow surg, 2013;22(1):38-44. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 33 page 10 south african orthopaedic journal http://journal.saoa.org.za editorial as the saying goes, ‘the best things in life are free’ but this is hardly true for orthopaedic surgery. theatre nursing scrub staff shortages have led to prolonged turn-around times and resistance to starting cases after 15h00 in our state hospitals. this has negatively impacted productivity with surgical volume reduced by at least 25% on our elective lists this year. with the overwhelming demand due to failing services in some provinces and poor socioeconomic factors forcing more patients from private to state care, our elective waiting lists continue to grow.1 this is exacerbated by the massive burden of trauma and infection competing for theatre time.2,3 although this needs investment in resources to increase state capacity in the long term, shortto medium-term alternative solutions need to be explored. with universal health care (uhc) access and national health insurance (nhi) funding models being hot topics,4,5 collaboration with the private sector is a nobrainer. and so, besides a short-term bbeee compliance, private groups are looking to participate as a survival strategy and align themselves for possible future scenarios. there are many offers but is this the free lunch? the following editorial is written from a perspective of orthopaedic surgeons which might influence perceptions regarding other stakeholders such as patients, hospital management or auxiliary staff. our experience of these state–private collaborative initiatives is that of opportunity but also pitfalls (figure 1). they need to be carefully planned and executed as we describe below. ‘we just do the surgery in a different hospital, otherwise everything is the same,’ is what we told the first patient on our ‘project list’. in reality, complex administrative processes needed to be overcome. who takes responsibility? who transports patients? who provides post-operative pain medication? a formal administrative process is mandatory. it is often not very convenient. available private lists are usually friday afternoons or even weekends leading to additional weekend ward rounds – with no interns and registrars for sick certificates and discharge administration. increased surgical throughput requires increased outpatient clinic capacity with approximately six additional slots needed per case. this needs persuasive discussions with already frustrated clerks, nurses and physiotherapists to accommodate the increased patient load. some offers of private surgeons performing the surgery have been made but patient care continuity is a challenge. state surgeons don’t want to be reduced to supportive responsibilities without the fun, never mind being left with the complications. access to clinical notes and imaging across sites, consent and post-operative management communication are problematic and need a clearly established process to ensure safety. despite all these challenges, the benefits are massive for the patients and the state health care system. our year-long waiting list for soft tissue knee procedures quickly shrank to a point where we had to scramble for cases. patient feedback was positive and for many it was a very comfortable first private hospital experience. by processing straightforward cases of healthier patients on a project list, our state hospital lists were available for more complex surgery of state patients in private hospitals – a free lunch? held m¹, workman mi², le roux j³, nortje m4, dunn r5 ¹ md, phd, mmed orth, fcorthsa ² fcorthsa, mmed(orth)(uct), mbbch(wits), bsc(physio) ³ orth; mmed; da(sa); mbchb 4 mbchb, dippec, fcorthsa, mmed(orth)(uct) 5 mbchb(uct), mmed, fcs(sa)orth department of orthopaedic surgery, groote schuur hospital & red cross war memorial children’s hospital, orthopaedic research unit, university of cape town, south africa corresponding author: dr m held, orthopaedic research unit, division of orthopaedic surgery, groote schuur hospital, h49, old main building, 7925 cape town, south africa; tel: 021 404 5108; email: michael.held@uct.ac.za dr michael held • complex processes need to be established, initially often by clinicians • time-consuming preparation of lists for clinicians and administrators • more surgery results in higher volume for overburdened state health care staff • risk for breakdown in continuity of patient care between different systems • costs of theatre, consumables and staff for private hospital • additional patient travel time and costs to get to private hospital • backup for surgical complications might be compromised • private slots are often only available during downtime • interaction between state and private hospitals builds working relationships and insight • opportunity to increase social capital and transformation for private hospital • decrease of time to surgery for patients and overall volume of state-based surgical waiting lists • increasing spectrum and surgical volume for surgeons • exposure to elective surgery is protected • available state lists can be used for more complex cases • decreased costs of theatre, consumables and staff by state hospital • exposure of trainees to private hospitals and systems – + figure 1. summary of some advantages (+) and disadvantages (–) for the hospitals, clinicians and patients with surgery performed on state patients in private hospitals page 11south african orthopaedic journal http://journal.saoa.org.za cases requiring multidisciplinary peri-operative care and longer post-operative recovery time. furthermore, the interaction and cross-pollination of state and private health care workers was an incredible experience for both, always amicable and collegial. they felt part of a bigger solution and we enjoyed the golden handrails, automated coffee machines, sparkling clean theatre boots and quick turnaround times. it was a great experience for our trainees and fellows as well, most of whom will work in a private hospital in the future, and (for most) it is worth the extra admin. admittedly, one of the greatest personal benefits was that we could increase our exposure to a higher volume and spectrum of cases. a monthly full-day list increased our cases by around 50%. cases were processed more acutely, allowing different treatment approaches and options which directly translated into more surgery and variety in procedures. in our funding framework, the private hospital covers the theatre time and nursing staff, consumables, possible bed nights and anaesthetic locums. crutches, braces and implants are provided by the state facility, alongside already employed surgeons. only day surgery of healthy patients is done. the pre-operative assessment and follow-up are performed at the state facility and patients arrived at the private hospital on the day of surgery. a simplified checklist (table i) is important to explore when considering such a collaboration. regarding equity, there is still a long way to go in the attempt to reduce the great divide between the two sectors. unfortunately, there is no such thing as a free lunch. all involved require a clear understanding of the costs and benefits to ensure sustainability without the risk of compromise in patient care or overloading individuals involved. we have found it worthwhile – growing a successful relationship between private and public partners with true social value to our patients. patient outcomes, financial and administrative factors will however dictate viability and longevity. references 1. kavalier t, nortje m, dunn r. hip and knee arthroplasty waiting list – how accurate and fair? samj. 2017;107(4):323-26. 2. beveridge m, howard a. the burden of orthopaedic disease in developing countries. jbjs. 2004;86(8):1819-22. 3. dunn r. musculoskeletal burden of disease: do we have any idea? sa orthop j. 2012;11(2):20-22. 4. hofman kj, mcgee s, chalkidou k, tantivess s, culyer aj. national health insurance in south africa: relevance of a national priority-setting agency. samj. 2015;105(9):739-40. 5. mofolo n, heunis c, kigozi gn. towards national health insurance: alignment of strategic human resources in south africa. afr j prim health care fam med. 2019;11(1):7. table i: simplified collaboration checklist management establish an interhospital agreement ensure medicolegal risk is clear for all parties set up a non-clinical task team (at least one per partner) for administrative processes register state doctors and patients on private hospital system surgeons consent – done at hospital sick note for post-operative period tto medication for post-op period physiotherapy referral gp/day hospital letter appropriate investigations pre-operatively backup plan for surgical complications – transfer back to state high care/icu arrange pharmacy for medication arrange physiotherapy for braces ecg/bloods/imaging as required administrators copy of patient’s identity document hospital admission form copy of notes/hospital folder cd/portable device with imaging erratum the article, ‘antifragile orthopaedic surgeons: a reflection on the training experience’ by dr rg venter, published in the south african orthopaedic journal november 2019 vol 18 no 4 pp 12–13, had an error on the second page. the sentence starting ‘the implication here is that 10 cm of stretching will generate much more strain’ should read: ‘the implication here is that 10 cm of stretching will generate a lot less strain’. this has been rectified in the online version of the article. south african orthopaedic journal spinal surgery doi 10.17159/2309-8309/2021/v20n2a3 ayik gdd et al. sa orthop j 2021;20(2) citation: ayik gdd, mukabeta tdm, nyandoro g, osborne c, kruger na. adherence to a standard operating procedure for patients with acute cervical spine dislocations: review of a tertiary, referral, academic hospital in south africa. sa orthop j 2021;20(2):81-87. http://dx.doi. org/10.17159/2309-8309/2021/ v20n2a3 editor: dr johan davis, stellenbosch university, cape town, south africa received: february 2019 accepted: june 2020 published: may 2021 copyright: © 2021 ayik gdd. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background to analyse the impact that the adoption of our institutional standard operating procedure (sop) for cervical spine dislocations had on the timing of closed reduction at our hospital. methods the study was a retrospective review of patients who presented to our institution with cervical dislocation injuries and who were managed with closed reduction. the patient records of acute cervical spine dislocations from 2015 to 2018, data from the acute spinal cord injury database along with patient’s demographic information were gathered and compared. participants within the study time frame were diagnosed with a cervical facet dislocation based on clinical examination findings and radiological confirmation. patients who had reduction performed at other referring hospitals were excluded from the study. results the practice within all tertiary hospitals in the western cape is to perform closed reduction of cervical fracture dislocations as soon as possible after injury. in this study the time between injury and closed reduction before introducing the sop was 13 h 13 min and after introducing the sop, the time increased to an average of 14 h 28 min. the main cause of delay was the transfer time from the site of injury to the emergency ward. other reasons for the delay include missed diagnosis, orthopaedic registrar unavailability and incomplete reduction bed. conclusion this study found that the time taken for orthopaedic management of cervical dislocations increased by an hour after introduction of the sop. additionally, the overall time to reduction also increased. this was due to delays in transfer to the emergency ward and referral to orthopaedics. we recommend that, in our setting, reduction could be initiated within an hour of patient arrival, if emergency ward doctors rapidly identified the problem and commenced cervical traction when the orthopaedic team was not immediately available. our impression was that there was poor adherence to the new sop guidelines on time management by the trauma team, and possibly transport delays prior to hospital admission. a further study to investigate the bottlenecks of the referral system is advisable. level of evidence: level 4 keywords: acute outcomes, cervical spine, dislocation injuries adherence to a standard operating procedure for patients with acute cervical spine dislocations: review of a tertiary, referral, academic hospital in south africa goud dd ayik,¹* takura dm mukabeta,¹ george nyandoro,² charles osborne,³ nicholas a kruger¹ ¹ division of orthopaedic surgery, university of cape town, cape town, south africa ² department of community medicine, college of health sciences, university of zimbabwe, zimbabwe ³ nhs lothian edinburgh royal infirmary, university of aberdeen, edinburgh, scotland *corresponding author: gooddeng_75@yahoo.com https://orcid.org/0000-0002-4205-8820 page 82 ayik gdd et al. sa orthop j 2021;20(2) introduction cervical dislocations are acute, high-risk injuries associated with a range of potentially catastrophic long-term disabilities. regional hospital data has shown that up to 60% of spinal trauma, which accounts for 3–6% of all trauma admissions, involve injury to the cervical region.1 the most common mechanism of injury results from motor vehicle accidents (mvas), violent assault or falls, with the typical patient being a male under the age of 30 years.2,3 these injuries have the potential to cause a profound change in lifestyle, with the resulting neurological deficit affecting the motor, sensory and autonomic nervous system.4 patients require lifelong supportive care, impacting patients’ quality of life, independence and psychological wellbeing.5,6 additionally, given the aetiology of the injury, a large proportion of those affected are earning an income with dependants reliant on them. as such, cervical spine injuries tend to have a profound effect on not only the individual patient but also on their direct family members and society. unless there are any contraindications, the best management for patients with cervical dislocations is early reduction, with skeletal traction to realign the vertebrae.7 the objective of early reduction is to align the vertebral column and alleviate external pressure on the spinal cord. successful early reduction may potentially reduce subsequent neurological deficits.7 a key variable in this treatment method was found to be the time between the offending injury and the intervention being performed.8 a retrospective review of rugby players with cervical dislocations found a 63% difference in reported neurological improvement if closed reduction was performed within four hours of the injury – a larger quantified effect on patient recovery than surgical intervention.9 all western cape hospitals strive to perform closed reduction of cervical dislocations within four hours of the injury,10 partly to comply with a 2015 constitutional court ruling but also to adhere to best medical practice.11 this is, however, particularly challenging as the mean transport time between sustaining a spinal injury and receiving medical care was previously found to be three hours, which leaves little room to comply with the four-hour ruling.10 therefore, a new management protocol was introduced in june 2016 – the ‘early reduction protocol’ – requiring all closed reductions to be performed within one hour of admission. this study aims to assess adherence and the effect of the ‘early reduction sop or protocol’ on the timing of the reduction of cervical dislocations and its influence on the neurological outcomes of patients managed at our institution during the time period of the study. materials and methods this was a retrospective analysis of records for patients managed at our institution from 2015 to 2018. the study compared the management of patients with low and high velocity injuries treated before the introduction of the early reduction standard operating procedure (sop) in june 2016 against those treated after. low velocity injuries were classified as injuries sustained during sport activities or falls from a low height where the patients sustain purely ligamentous dislocation. high velocity injuries were classified as mva and violent assaults where the patients sustain fracture dislocations. from the acute spinal cord injury database, records and notes of patients who presented to our institution from 2015 to 2018 with acute cervical dislocation and received subsequent closed reduction management were reviewed by the principal author (the researcher). the sop requirement for cervical reduction was set to be within one hour after patients arriving at the primary emergency ward (er). variables such as the american spinal injury association (asia) score, time to reduction, duration of hospital stay, along with patient mortality and morbidity, were retrieved. data collected included age, sex, date, mechanism of injury, neurological examination findings and radiological diagnoses. a qualitative interview was conducted with the emergency room personnel at groote schuur hospital (gsh) to complement our quantitative analysis findings. patients who presented to our institution in a conscious state with cervical injuries within the given time frame of the study and were diagnosed with a cervical facet dislocation based on clinical examination findings with radiological confirmation (x-rays or ct scan) were included in the study. all patients who were managed outside our institution with closed reduction were excluded from the study as were patients with other injuries such as open head injuries, an obtunded state or decreased level of consciousness. qualitative assessment the qualitative assessment was conducted by the principal author between august and september 2018 on emergency personnel (er nurses, er doctors and orthopaedic registrars) at gsh. the participants were individually interviewed in person and asked to complete the ‘yes/no’ answers in table i based on their area of speciality. statistical analysis data was summarised using descriptive statistics. continuous variables were summarised using means and standard deviations, whereas categorical or nominal variables were summarised using percentages. matched t-tests were used to test for significance between continuous variables, while chi-squared tests were used for categorical or nominal variables. graphical analysis was used to display the distribution of variable(s) and to illustrate findings visually. results the study comprised 19 participants, of whom 79% were male and 21% female. the median (iqr) age of participants was 48 years (26.0–55.0); range from 20 to 80 years (figure 1). there was a pre-hospital delay between injury and arrival at the primary emergency ward (er) of seven hours. the mean time between injury and closed reduction before introducing the new sop was 13 h 13 min (table ii). after introducing the new sop, the time to 6 5 4 3 2 1 0 20–29 30–39 40–49 age fr eq ue nc y 50–59 60–69 70+ figure 1. distribution of patients’ age (in years) in the study page 83ayik gdd et al. sa orthop j 2021;20(2) closed reduction increased significantly (p<0.0001) to a mean of 14 h 28 min (table ii). other associated injuries were cervical fractures (63.1%) and pelvic fractures in 26%. furthermore, most common cervical fractures were bilateral lamina fractures in 21% and vertebral body fractures in 11% (figures 2a and 2b). the main time delays (figure 3) were between injury and arrival at the er (7 h 43 min after the new sop). there was minimal change between preand post-introduction of the new sop, with only a 6% decrease in time taken between injury and arrival at the er. a matched t-test was used to compare preand post-mean changes on the asia scale, pre-reduction and post-reduction (table iii), and no significant changes were found (preversus post p=0.331). similarly, there were no significant changes between admission versus discharge for: asia motor score, p=0.078; asia light touch, p=0.454; asia pinprick, p=0.662. table iv presents the time delays in the referral system at gsh. the median time delay from injury to the er was increased by 55% (07 h 13 min), whereas the median time from the er to the orthopaedic registrar on call was increased by 12% (01 h 36 min). times from start to completion of reduction by the orthopaedic registrar were increased by a median of 8% (01 h 00 min) and 6% (00 h 45 min), respectively. in this study, there were equal rates of reduction success before the new sop and after the new sop (p=50%) (figure 4). table i: the qualitative assessment questionnaire tailored to area of specialty questions er nurses er doctors orthopaedic registrars 1. are you aware of the sop for rapid reduction? yes/no yes/no yes/no 2. what is the four-hour rule under the constitutional court? yes/no yes/no yes/no 3. do you know where the reduction bed and equipment are kept? yes/no yes/no yes/no 4. what patients require urgent neck x-rays? yes/no yes/no n/a 5. which doctors can apply cervical traction in an emergency? yes/no yes/no n/a 6. do you know who to refer to for neck dislocations? n/a yes/no n/a 7. with a cervical dislocation, do you request an mri scan? n/a yes/no n/a 8. is there always available radiography for rapid reductions? n/a n/a yes/no 9. list causes that delay initiating reductions. n/a n/a yes/no 10. if you are scrubbed in theatre and are referred a cervical dislocation, what action do you take? n/a n/a yes/no table ii: time delays summary period (time in hours:minutes) injury to er er to ortho referral ortho referral to assessment ortho time to start reduction ortho time to complete reduction injury to reduction total time p-value before new sop mean (n=8) 7:45±8:33 1:56±1:14 1:08±0:41 1:21±0:44 1:01±0:17 13:13±9:07 <0.0001 median (n=8) 03:17 01:40 00:57 01:07 00:54 09:19 minimum 01:14 00:34 00:05 00:25 00:45 04:00 maximum 24:00 04:00 02:00 02:44 01:30 05:30 percentiles 25 01:30 00:51 00:40 01:00 00:46 06:50 75 15:13 02:57 01:55 01:57 01:15 21:56 after new sop mean (n=11) 07:43±04:39 02:50±03:24 01:14±01:10 01:51±02:48 00:47±00:34 14:28±08:53 median (n=11) 08:30 01:36 01:00 00:30 00:36 13:15 minimum 02:00 00:19 00:15 00:15 00:19 03:30 maximum 13:56 10:15 04:19 09:00 02:20 07:15 percentiles 25 02:19 00:20 00:30 00:15 00:30 04:35 75 12:06 04:25 01:04 03:05 00:45 22:25 table iii: comparison of admission versus discharge for post-reduction clinical measurements paired t-test (two-tailed) mean n std deviation std error mean p-value pair 1 pre-reduction asia scale 2.1 19 1.6 0.4 0.331 post-reduction asia scale 2.2 19 1.6 0.4 pair 2 admission asia motor score 25.1 19 32.5 7.5 0.078 discharge asia motor score 29.7 19 36.9 8.5 pair 3 admission asia light touch 39.5 19 40.6 9.3 0.454 discharge asia light touch 42.0 19 44.2 10.2 pair 4 admission asia pinprick 40.5 19 40.2 9.2 0.662 discharge asia pinprick 41.8 19 44.3 10.2 page 84 ayik gdd et al. sa orthop j 2021;20(2) the common injuries were sustained from mvas (37%) and falling (37%). the most common pattern of injury was c5/c6 bifacet dislocation (32%). common neurological deficits were c4 motor complete sensory complete (mcsc) (26%) and c5 mcsc (21%). most patients had a pre-reduction asia-a, 63% and the most common post-reduction score was asia a, 63% (table v). qualitative findings additional in-depth qualitative interviews were used to complement evidence gathered quantitatively. table vi summarises themes that emerged from in-depth interviews with five er nurses, five er doctors and five orthopaedic registrars. the red colour coding highlights answers indicating poor understanding of the management of cervical dislocations while answers in green demonstrate a better knowledge of cervical dislocation management. there was no awareness of the sop for rapid reduction among er nurses 0% (n=5) and er doctors 0% (n=5); the exception was the orthopaedic registrars who had 100% (n=5) level of awareness. in addition, orthopaedic registrars had 100% (n=5) level of awareness on the ‘four-hour ruling under the constitutional court’, while er nurses had 0% (n=5) and er doctors had 20% (n=1). only two out five (40%) er nurses knew ‘where the reduction bed and equipment were kept’; this shows a knowledge gap since er nurses attend most cases during admissions. surprisingly, only one out of five (20%) orthopaedic registrars ‘knew where the reduction bed and equipment are kept’. figure 2a. injuries and medical conditions sustained by patients in the study cervical injuries (63%) pelvic fracture (26%) aki/htn (5%) nil (5%) bilateral c4 lamina fracture (21%) c6 body fracture (11%) c6 spinous process fracture (5%) c5 transverse process fracture (5%) c7 superior facet fracture (5%) c5 body burst fracture spinal stenosis (5%) right facet fracture, c6 compression fracture (5%) chip fracture left interior facet (5%) figure 2b. cervical injuries sustained by patients in the study % c on tr ib ut io n delay points in ju ry to e r ti m e e r to o rth o re fe rr al ti m e a rr iv al ti m e to o rth o o rth o tim e to co m m en ce re du ct io n o rth o tim e to co m pl et e re du ct io n before after 70% 60% 50% 40% 30% 20% 10% 0% figure 3. change in time delays in the emergency referral system, before and after new sops was reduction successful? answer: yes prior to sop following sop 50% 50% figure 4: percentage of successful reduction preand post-introduction of the sop page 85ayik gdd et al. sa orthop j 2021;20(2) discussion cervical dislocations are serious injuries associated with a range of potentially catastrophic long-term disabilities. previous regional hospital data has shown that up to 60% of spinal trauma, which accounts for 3–6% of all trauma admissions, is caused by injury to the cervical region.1 the most common mechanism of injury is the result of an mva, violent assault or fall – with the typical patient being a male under the age of 30 years.2,3 in this study mva and falls were the most common causes of injury: mva 37% and falls 37%. previously, it had been recommended that the time between injury and closed reduction should be within four hours in order to have favourable neurological outcomes.9,12 in this study, the mean time between injury and closed reduction before introducing the new sop was 13 h 13 min, with median time of 9 h 19 min. after introducing the new sop, the mean time significantly increased to 14 h 28 min and median time of 13 h 15 min. based on the study findings, the intended potential benefits of the sop were not achieved. there was no significant improvement in reduction times from initial injury. the main delay was from injury to arrival at the er. in-depth study reflected the challenges of low awareness of the sop for rapid reduction; lack of knowledge of where the reduction bed and equipment are kept; and inconsistency on preparations before surgery. reduction beds and equipment might not be maintained and not always prepared, all of which point to low availability of adequate resources. these gaps explain why there was no significant improvement on several continuous outcomes and increased time delays along the referral chain before actual reduction. it took 1 h 21 min to 1 h 51 min from assessment to initiating reduction, with a variety of factors causing delays including doctors needing to look for equipment. the sop failed to improve on this time to initiate reduction. although recent table iv: time delays in the referral system post-sop injury to er er to ortho referral ortho referral to assessment ortho time to start reduction ortho time to complete reduction injury to reduction total time mean (hours:minutes) 07:44 (56%) 02:27 (18%) 01:11 (8%) 01:39 (12%) 00:53 (6%) 13:56 (100%) median (hours:minutes) 07:13 (55%) 01:36 (12%) 01:00 (8%) 01:00 (8%) 00:45 (6%) 13:05 (100%) std deviation 06:21 02:41 00:58 02:09 00:28 08:45 minimum 01:14 00:19 00:05 00:15 00:19 03:30 maximum 00:00 10:15 04:19 09:00 02:20 07:15 percentiles 25 02:00 00:34 00:40 00:25 00:34 06:45 75 12:06 03:00 01:43 02:10 01:15 22:25 table v: common description of patient notes variable categories frequencies (%) cause of injury assault 1 5 diving accident 1 5 falling 7 37 mva 7 37 pva 1 5 surfing accident 1 5 train accident 1 5 cervical level c4/5bfd 1 5 c4/5ufd 1 5 c4/c5bfd 3 16 c4/c5ufd 1 5 c5/c6bfd 6 32 c5/c6ufd 2 11 c6/7ufd 1 5 c6/c7bfd 2 11 c6/c7ufd 2 11 neurological deficit c3–4misi 1 5 c3–5mcsc 1 5 c4–c5mcsc 2 11 c4mcsc 5 26 c4misi 1 5 c5mcsc 4 21 c5mcsi 1 5 c5misi 2 11 nil 2 11 other injury or medical conditions aki, hypertension 1 5 bilateral c4 lamina fracture 4 21 c5 body burst fracture spinal stenosis 1 5 c5 transverse process fracture 1 5 c6 body fracture 2 11 c6 spinous process fracture 1 5 nil 1 5 rt facet fracture,c6 compare fracture 1 5 scapula and pelvic fracture c7 superior facet fracture c7 transverse process 1 5 chip fracture left inferior facet 1 5 pelvic fracture 5 26 table v: continued variable categories frequencies (%) pre-reduction asia scale a 12 63 b 1 5 c 1 5 d 2 11 e 3 16 post-reduction asia scale a 12 63 c 2 11 d 2 11 e 3 16 aki: acute kidney injury; asia scale: american spinal injury association scale; bfd: bifacet dislocation; mcsc: motor complete sensory complete; misi: motor incomplete sensory incomplete; mva: motor vehicle accident; pva: pedestrian vehicle accident; ufd: unifacet dislocation page 86 ayik gdd et al. sa orthop j 2021;20(2) table vi: in-depth interviews with er nurses, er doctors and orthopaedic registrars er nurses 1. are you aware of the sop for rapid reduction? 2. what is the four-hour rule under the constitutional court? 3. do you know where the reduction bed and equipment are kept? 4. what patients require urgent neck x-rays? 5. which doctors can apply cervical traction in an emergency? 1 no, i’m not aware observation of a patient yes patient with long bone fracture, poly trauma patient neurosurgeon 2 no, i’m not aware i don’t know no spine injury, mva, neck pain, fall from height i don’t know 3 no, i’m not aware i don’t know yes neck pain, fall from height, mva orthopaedic doctor 4 no, i’m not aware i don’t know no mva, fall from height, gunshot, knife stab orthopaedic doctor, neurosurgeon 5 no, i’m not aware i don’t know yes neck pain orthopaedic doctor, asci er doctors 1. are you aware of the sop for rapid reduction? 2. what is the four-hour rule under the constitutional court? 3. do you know where the reduction bed and equipment are kept? 4. what patients require urgent neck x-rays? 5. which doctors can apply cervical traction in an emergency? 6. do you know who to refer to for neck dislocations? 1 no not sure yes mva, fall from height, neck pain orthopaedic, neurosurgeon, asci orthopaedic, asci 2 no not sure yes fall from height, mva, gunshot, knife stab orthopaedic orthopaedic, neurosurgeon, asci 3 no not sure yes fall from height, mva, gunshot, knife stab orthopaedic, asci, neurosurgeon orthopaedic, neurosurgeon 4 no not sure yes neck pain, significant tenderness, neurological fallout orthopaedic orthopaedic on call 5 no neck dislocation should be reduced within four hours yes low gcs, suspected c-spine injury, focal neurological deficit in polytrauma orthopaedic orthopaedic on call orthopaedic registrars 1. are you aware of the sop for rapid reduction? 2. what is the four-hour rule under the constitutional court? 3. are the reduction bed and equipment maintained and always prepared? 4. is there always available radiographer for rapid reduction? 5.list causes that delay initiating reduction? 6. if you are scrubbed in theatre and are referred a cervical reduction, what do you do? 1 yes c-spine dislocation must be reduced in four hours not always yes late referral, late presentation will ask someone on call to do it 2 yes c-spine dislocation must be reduced in four hours not always yes late referral, late presentation will ask the senior trauma doctor to do it 3 yes c-spine dislocation must be reduced in four hours yes yes late referral, late presentation will ask someone on call 4 yes c-spine dislocation must be reduced in four hours not always yes late referral, late presentation will ask to call consultant 5 yes c-spine dislocation must be reduced in four hours not always yes late referral, late presentation ask someone in trauma to reduce it gcs: glasgow coma scale page 87ayik gdd et al. sa orthop j 2021;20(2) data showed that the average transport time between sustaining a spinal injury and receiving medical care was three hours, in this study the average time was 13 h 56 min after a new management protocol was introduced as of june 2016 whereby all closed reductions should be performed within one hour of admission. this indicates a discrepancy in terms of policy availability and/or sop adherence and implementation of guidelines regarding this issue. the sop was an effort to improve reduction times; however, our review found that the overall time from injury to reduction had not appreciably improved. furthermore, the time taken for er doctors to assess the patient and refer to orthopaedics had increased from 1 h 56 min to 2 h 56 min. the possible reasons for this were difficulties in locating required equipment, lack of equipment, policy unavailability and very low sop adherence. we recommend that, in our setting, reduction could be done within an hour of patient arrival if other er doctors activate the early reduction protocol, even in the absence of an orthopaedic registrar. furthermore, we recommend pre-hospital diagnosis by paramedics be done at the scene of the accident and in-hospital activation of the sop by the er staff which would then result in time-saving. in the qualitative assessment of staff, results showed only orthopaedic doctors were aware of the new sop for cervical dislocation injuries and had knowledge of the four-hour constitutional rule for performing early reduction of cervical dislocation injuries. based on these findings, we recommend that all er staff must be educated and made aware of the sop and the four-hour rule. the sop should be available on large posters in the er. limitations of the study are that the new sop did not include the transport time (it addresses the time from arrival in the er to reduction). secondly, most of the study patients had high energy mechanisms of injury thus other associated injuries resulted in their exclusion from having acute reduction performed. thirdly, due to the retrospective aspect of the study, selection bias and misclassification or information bias might have been introduced. conclusion in this study, motor vehicle accidents and falls were the most common causes of injury. the time taken from the site of injury to an assessment and complete reduction was significantly increased after introduction of the new sop. there were no significant changes in asia scales post-introduction of the new sop. the main message is that there is very poor adherence to the new sop guidelines on time management along the emergency health referral system by healthcare workers (nurses and general doctors). future study is needed to examine the role of patient assessment at a primary care level prior to transfer to a tertiary hospital for patients with suspected spinal injury. ethics statement this study was approved by the university of cape town human ethics committee (2018/137). verbal consent was obtained from doctors and nurses that participated in the study. there was no direct involvement of patients, thus no need for verbal or oral consent. the study comprised patient notes and records, with each patient identified by their hospital number only. all study data storage was password protected. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ayik gdd: primary author; study design, data collection, data analysis mukabeta tdm: data collection and analysis nyandoro g: information technology and data analysis osborne c: data collection and analysis kruger na: conceptualisation, study design, manuscript revision and supervision orcid ayik gdd https://orcid.org/0000-0002-4205-8820 mukabeta tdm https://orcid.org/0000-0002-6581-5660 nyandoro g https://orcid.org/0000-0001-8991-0948 osborne c https://orcid.org/0000-0003-1334-8156 kruger na https://orcid.org/0000-0002-8543-5745 references 1. ghafoor a, martin t, gopalakrishnan s, viswamitra s. caring for the patients with cervical spine injuries: what have we learned? j clin anesth. 2005;17:640-49. 2. joseph c, delcarme a, vlok i, et al. incidence and aetiology of traumatic spinal cord injury in cape town, south africa: a prospective, population-based study. spinal cord. 2015;53:692-96. 3. sothmann j, stander j, kruger n, dunn r. epidemiology of acute spinal cord injuries in the groote schuur hospital acute spinal cord injury (gsh asci) unit, cape town, south africa, over the past 11 years. s afr med j. 2015;105:835. 4. savic g, devivo m, frankel h, et al. long-term survival after traumatic spinal cord injury: a 70-year british study. spinal cord. 2017;55:651-58. 5. malhotra m, bhatoe b, sudambrekar s. spinal cord injuries. med j armed forces india. 2010;66:325-28. 6. oderud t. surviving spinal cord injury in low-income countries. afr j disabil. 2014;3:1-9. 7. gelb d, hadley m, aarabi b, et al. initial closed reduction of cervical spinal fracture-dislocation injuries. j neurosurg. 2013;72:73-83. 8. storey r, singhal r, inglis t, et al. urgent closed reduction of the dislocated cervical spine in new zealand. anz j surg. 2017;88:56-61. 9. newton d, england m, doll h, gardner b. the case for early treatment of dislocations of the cervical spine with cord involvement sustained playing rugby. bone joint j. 2011;93-b:1646-52. 10. potgieter m, badenhorst dh, mohideen m, et al. closed traction reduction of cervical spine facet dislocations: compelled by law. s afr med j. 2019;109:854-58. 11. oppelt v head: health, department of health provincial administration: western cape (cct185/14) [2015] zacc 33; 2016 (1) sa 325 (cc); 2015 (12) bclr 1471 (cc) (14 october 2015). 12. storey rn, singhal r, ingli t. urgent closed reduction of the dislocated cervical spine in new zealand. anz j surg. 2018;88:56-61. https://orcid.org/0000-0002-4205-8820 https://orcid.org/0000-0002-6581-5660 https://orcid.org/0000-0001-8991-0948 https://orcid.org/0000-0003-1334-8156 https://orcid.org/0000-0002-8543-5745 _hlk52448249 _hlk42424488 _hlk42504664 _hlk42508246 _hlk40018346 _hlk40018407 _hlk53245290 _hlk53407752 _hlk53406382 _hlk40092414 _hlk39927059 _hlk53411366 404 not found orthopaedics vol3 no4 page 58 sa orthopaedic journal winter 2017 | vol 16 • no 2 rapid mobilisation following total hip and knee arthroplasty b riemer mbchb(uct), fc orth(sa), frcs tr&orth(eng) arthroplasty fellow k macintyre mbchb(us), fc orth(sa) arthroplasty fellow m nortje mbchb(uct), fc orth(sa), mmed(uct) consultant surgeon b dower mbchb(uct), fcs orth(sa) consultant surgeon g grobler mbchb(uct), frcs(edin), fcs orth(sa), mmed(uct) consultant surgeon m springfield bsc(physio)wits, mbchb(wits), fca(sa), msc(health informatics)ucl consultant anaesthetist division of orthopaedic surgery, groote schuur hospital, cape town corresponding author: dr b dower tel: 021 506 5610/50 fax: 021 506 5619 email: brendan@capehipandknee.co.za 3rd floor life orthopaedic hospital vincent pallotti hospital alexandra road 7405 pinelands introduction total joint arthroplasty has become established as a very successful method of treating end-stage arthritis of the hip and knee with excellent long-term outcomes.1,2 with an ageing population, there is an increased demand for services relating to joint arthroplasty. individual patient’s demands and expectations are also increasing, with patients desiring a quicker return to normal functioning with minimal discomfort after their joint replacement surgery. in today’s climate of limited resources and global financial strain we need to investigate ways of containing cost while enabling and maintaining safe effective treatment with optimised results. any alteration to the surgical management of hip and knee arthroplasty should never compromise patient safety and outcomes. abstract introduction: a rapid recovery protocol for hip and knee replacement surgery is a multidisciplinary, standardised pathway to meet the increasing demands for surgery and enhancement of recovery. this is the idea behind the recent global push by funders for cost effective, elective primary hip and knee arthroplasty. we report on a pilot study to assess the implementation and feasibility of a standardised care pathway in a south african private hospital setting. materials and methods: eligible patients presenting for primary hip or knee arthroplasty were enrolled in a rapid recovery programme. the protocol that was implemented was based on current literature and international best practices. it involved members of a multidisciplinary team and the standardisation of the treatment of patients undergoing elective hip and knee arthroplasty. results: forty-six patients were enrolled in the pilot study and 43 patients were successfully discharged by the third post-operative day. there were no major complications and high patient satisfaction was recorded. conclusion: this pilot study successfully implemented a multidisciplinary and standardised treatment protocol for hip and knee arthroplasty in a south african setting. the rapid recovery protocol proved to be safe and effective for the management of hip and knee replacements. key words: rapid recovery arthroplasty, short stay protocol, enhanced recovery after surgery (eras) http://dx.doi.org/10.17159/2309-8309/2017/v16n2a8 sa orthopaedic journal winter 2017 | vol 16 • no 2 page 59 within the analysis of the joint replacement care pathway, there are aspects of the pathway that can be optimised and standardised to reduce cost. the cost of the prosthesis and that of the surgical and anaesthetic clinical services are relatively fixed; however, effective ways to reduce the cost of the joint replacement surgery may be: • patient pre-operative education to set expectations regarding length of hospital stay and early mobilisation • pre-operative anaesthetic assessment to identify and mitigate potential risk that may lead to adverse patient outcomes • pre-operative optimisation of the patient’s medical conditions and comorbidities. • standardisation of implant selection to ensure volumebased discounts • standardisation of the care pathway to ensure optimal use of theatre time and drug administration • limitation of high care admission where unnecessary • early mobilisation to reduce overall duration of hospital stay and post-operative complications. this is the essence of the rapid recovery protocol. the first description of a standardised care pathway was used in colorectal surgery and has successfully been applied to other areas of general surgery.3 specifically, the protocol has found a niche in elective orthopaedic surgery. orthopaedic-specific standardised pathways were first developed and rolled out in high-volume specialised orthopaedic centres in the united kingdom and have subsequently been utilised in smaller units. the use of orthopaedic-specific rapid recovery protocols has resulted in improved patient satisfaction and reduced morbidity and cost.4 our aim was to assess the feasibility of the implementation and utilisation of an orthopaedic-specific standardised care pathway in a south african private hospital setting. we conducted a pilot study to assess the safety and efficacy of using the pathway in our practice. materials and methods a pilot study was conducted at a dedicated private orthopaedic hospital and a senior author performed all the surgeries. informed consent to participate in the pilot study was obtained from all patients. we report an audit of our series of patients. exclusion criteria were: 1. american society of anesthesiology (asa) score of greater than 3, or poorly controlled medical conditions 2. patients with morbid obesity with a body mass index (bmi) greater than 40 3. any patients identified to require intensive or high care admission post-surgery 4. patients with cognitive impairment 5. patients with poor home circumstances or support the standardised care pathway described was developed by the senior authors and is based on experience, current literature and international best practices. it was developed for the south african context in consultation with a multidisciplinary team that included anaesthetic, physiotherapy and nursing staff. this multidisciplinary approach is centred on patient education, and in developing a positive perception that the post-operative processes will run smoothly and result in an early discharge from hospital.5 the protocol involves specific standardised interventions for each patient from the enrolment date to discharge and the final independent telephonic consultation rating the patient experience. these interventions started with various appointments in the pre-operative phase. the surgeon, anaesthetist, practice nurse and physiotherapist assessed the patients prior to surgery. the principal goal was preoperative patient optimisation to ensure early mobilisation post-procedure with early discharge. the surgical episode was standardised as far as possible in terms of prosthesis company choice, intra-operative care, and post-operative regimens. all patients returned to a standard orthopaedic ward. patients were operated on in groups and grouped together in 2and 4-bed wards with a senior nursing sister assigned to the ward to provide postoperative care. the key to the process was constant reinforcement of the standardised care pathway. rapid recovery protocol pre-operative phase the process begins at the first consultation when the decision has been made for joint replacement surgery and extends beyond hospital discharge. the surgeon introduces the concept of rapid recovery pre-operatively while the anaesthetist and physiotherapist continue to affirm the concept. the anaesthetist assesses the patient’s medical fitness for the procedure two to four weeks pre-operatively to: 1. ensure that medical conditions and comorbidities are optimised for the surgery; 2. identify and mitigate anaesthetic and medical risk; and 3. obtain full informed consent for the anaesthetic. the physiotherapy team assesses the patient, and weekly sessions of pre-habilitation over a four-week period is undertaken. these visits educate and reinforce the concepts of rapid mobilisation and enhanced post-operative recovery. the patients are fitted with crutches, given exercises and taught stretching techniques pre-operatively. written educational material is provided to the patients regarding the procedure and the recovery process.6 where possible the physiotherapy sessions are conducted in page 60 sa orthopaedic journal winter 2017 | vol 16 • no 2 small groups with patients who will have their surgery scheduled on the same day. this allows for a shared patient experience and camaraderie. importantly, the patient’s home and support circumstances are assessed to ensure early and safe discharge post-surgery. the practice nurse makes contact with the patient and will become the patient’s main contact point for any support that the patient may need post-operatively. peri-operative care all patients are admitted on the morning of surgery. they are encouraged to maintain oral hydration up to 2 hours pre-operatively. all receive a premedication of 1 g paracetamol, 10–20 mg temazepam and 300 mg gabapentin.7-11 ideally a regional spinal anaesthetic with sedation is administered. a prophylactic dose of antibiotics is administered within 30 minutes of skin incision and an antiemetic is administered to decrease postoperative nausea.12 meticulous cautery of any bleeding points and intravenous tranexamic acid is used to decrease blood loss.13-15 surgical drains and the use of urinary catheters are avoided. limited intravenous fluids are given intra-operatively, sufficient only to replace blood and fluid losses. meticulous haemostasis is maintained throughout surgery so as to limit blood loss. a large volume of local anaesthetic, bupivacaine 0.125% with adrenalin, is administered into the joint by the surgeon. this is to decrease blood loss and to reduce post-operative pain.16 three volumes of 50 ml are used during the surgery. the first volume is used just after the skin incision and is injected subcutaneously. the second volume is used at the time of prosthesis implantation; in total hip replacements this is injected into the capsule and surrounding structures and in total knee replacements this is injected through the posterior capsule either side of the neurovascular bundle. the final volume is used immediately prior to deep layer closure and is injected into the soft tissues specifically targeting the incised muscle surfaces. before leaving theatre, all patients who are able to receive a non-steroidal anti-inflammatory agent, receive a suppository to aid post-operative pain control. once back in the ward intravenous fluids are stopped; patients are encouraged to start oral hydration. as soon as normal muscle tone has returned, the patient is seen by physiotherapy and mobilised.17 this usually is possible six hours after the spinal anaesthetic was performed. dvt prophylaxis is provided; clexane 40 mg subcut daily from day 1 and then discharged on xarelto 10 mg daily for three weeks. nursing staff are actively involved in the postoperative care with routine observations and hydration as well as the regular administration of oral non-opiate analgesia. patients are routinely given 300 mg gabapentin twice daily (two days), 1 g paracetamol four times a day, 400 mg ibuprofen three times a day. in addition, 10 mg of oxycodone 12 hourly (three doses) is available to patients identified in the pre-operative period to have high analgesic requirements. rescue analgesia in opiate form is prescribed but rarely required. once mobilised, patients are encouraged to dress in comfortable clothing and to self-care as much as possible. patients are mobilised as often as possible, ideally at least two to three times a day with the physiotherapist until discharge. the decision as to the timing of discharge is dependent on the multi-disciplinary team being satisfied with all aspects of the patient’s recovery, but is planned for the third post-operative day. the primary outcome measured in the pilot was length of hospital stay. secondary outcomes evaluated included the need for readmission; the use of inpatient opiate analgesia for breakthrough pain; wound or dressing complications requiring intervention after discharge; and the need for postoperative urinary catheterisation. lastly, all patients were contacted telephonically at three months following surgery by an independent investigator. patient satisfaction and willingness to undergo the same standardised care pathway again were assessed. western ontario and mcmaster universities osteoarthritis index (womac18) scores were also measured at 3 months postoperatively by a physiotherapist and were compared to scores obtained during the pre-operative physiotherapy assessment. results forty-six patients undergoing hip and knee joint replacement surgery were enrolled. twelve males and 33 females were included. the mean age was 60.4 years (range 25–89). thirty-two underwent total hip replacements and 14 had total knee replacements. forty-three of 46 (93%) patients were discharged by the third post-operative day. the average length of hospital stay was 2.8 days with a range of 2 to 4 days. this is well below the national joint registry of england and wales average of 6.3 days.2 factors preventing discharge within 3 days (target) were post-operative pain and orthostatic hypotension. three elderly female patients required catheterisation for urinary incontinence on the first night following surgery. eight patients required additional imi opiate analgesia during their inpatient stay. seven patients required an additional change of dressing at home within sa orthopaedic journal winter 2017 | vol 16 • no 2 page 61 the first post-surgical week. one total knee replacement required a manipulation at six weeks for poor range of motion. no major complications, including dvt or pe were recorded within 90 days of surgery. there were no other readmissions or re-operations. all patients reported that they were extremely satisfied with the surgical result at three months; however, one patient said that they would prefer not to undergo a ‘rapid recovery process’ again, as they felt hurried and stressed by the early discharge. the mean pre-operative womac score was 35, compared to a mean score of 85 at three months post-procedure. discussion our experience suggests that a rapid recovery protocol with an enhanced discharge pathway is safe, feasible and acceptable in a south african private hospital setting. this protocol requires multidisciplinary team contributions and active involvement by the patients. the findings demonstrate that one can reduce the length of hospital stay and that high care admissions are not routinely required post joint replacement surgery. previously our average length of stay was 5.5 days with one day in high care. this has resulted in an immediate cost saving of r10 000. we have subsequently implemented aspects of this protocol for suitable total arthroplasty patients and are hoping to extend this practice to a parallel service in a state hospital. patient pre-operative assessments, optimisation and education, in conjunction with protocol-driven perioperative care and safe early mobilisation has resulted in decreased length of hospital stay and no post-operative high care. this has financial ramifications for both public and private institutions as well as health care funders and government. there are also other potential health benefits that have not been explored in detail in this pilot study. the risk of deep vein thrombosis could be reduced as a result of the rapid mobilisation process. shorter hospital stays may also result in fewer hospital-acquired infections. the usage of tranexamic acid with meticulous cautery, and minimising the usage of site drains and urine catheterisation, reduces the risk of potential prosthesis-related infection and catheter-related urinary tract infections. the womac score improvements seen in our study population are comparable to those in the published literature.19 an additional benefit has been the improved inter-disciplinary communications as a result of our close working together in the care of our patients. we have noticed improved staff morale when dealing with the rapid recovery patients as all team members feel they have an important role to play in the recovery of these patients. the primary aim of assessing the implementation, feasibility and acceptability of a standardised enhanced discharge pathway in the specific setting of the south african private sector has been achieved by this pilot study. considerable additional information regarding length of hospital stay, level of care and analgesia required has been gathered. this study is an internal pilot study and it may form part of a larger study assessing the outcomes of implementing a standardised pathway in the wider south africa context. it is purely descriptive and the weakness of this study is the lack of comparative controls. a longer-term prospective randomised trial comparing a rapid recovery group with a traditional care cohort would be an ideal study design; we hope to publish a larger series in future. in conclusion, a standardised enhanced discharge pathway with a rapid mobilisation protocol in a south african private hospital setting is a safe and effective way of managing total joint arthroplasty patients without compromising surgical care or rehabilitation. compliance with ethics guidelines this article is the sole work of the authors and no financial benefit has been or will be received, related to this work. informed consent to participate in the pilot study was obtained from all patients; institutional ethics approval was not obtained. dr dower and dr springfield are directors of icps. references 1. learmonth id, young c, rorabeck c. the operation of the century: total hip replacement. lancet 2007 oct 27;370(9597):1508-19. 2. no authors listed. national joint registry for england and wales 10th annual report, 2013. www.njrcentre.org.uk 3. kehlet h. multimodal approach to control postoperative pathophysiology and rehabilitation. br j anaesth. 1997 may;78(5):606-17. 4. larsen k, hansen tb, thomsen pb, christiansen t, soballe k. cost-effectiveness of accelerated perioperative care and rehabilitation after total hip and knee arthroplasty. j bone joint surg am. 2009 apr;91(4):761-72. 5. wainwright t, middleton r. an orthopaedic enhanced recovery pathway, current anaesthesia & critical care (2010), doi10.1016/j.cacc.2010.01.003 6. yoon rs, nellans kw, geller ja, kim ad, jacobs mr, macaulay w. patient education before hip or knee arthroplasty lowers length of stay. j arthroplasty 2010 jun;25(4):547-51. 7. mallory th, lombardi av, fada ra, dodds kl, adams jb. pain management for joint arthroplasty: preemptive analgesia. j arthroplasty 2002 jun 17;4 (suppl 1):129-33. 8. bromley l. pre-emptive analgesia and protective medication. what is the difference? biomed pharmacotherapy. 2006 aug;60(7):336-40. 9. buvanendran a, kroin js, della valle cj, kari m, moric m, tuman kj. perioperative oral pregabalin reduces chronic pain after total knee arthroplasty: a prospective, randomized, controlled trial. anaesth&analg 2010 jan 1;110(1):199-207. page 62 sa orthopaedic journal winter 2017 | vol 16 • no 2 10. carmichael nm, katz j, clarke h, kennedy d, kreder hj, gollish j, mcartney cj. an intensive perioperative regimen of pregabalin and celecoxib reduces pain and improves physical function scores six weeks after total hip arthroplasty: a prospective randomized controlled trial. pain res manag. 2013 may-jun;18(3):127-32. 11. white pf, kehlet h, neal jm, schricker t, carr db, carli f. the role of the anesthesiologist in fast-track surgery: from multimodal analgesia to perioperative medical care. anesthanalg 2007 jun;104(6):1380-96. 12. backes jr, bentley jc, politi jr, chambers bt. dexamethasone reduces length of hospitalization and improves postoperative pain and nausea after total joint arthroplasty: a prospective, randomized controlled trial. j arthroplasty 2013 sep;28(8 suppl):11-17. 13. sukeik m, alshryda s, haddad fs, mason jm. systemic review and meta-analysis of the use of tranexamic acid in total hip replacement. j bone joint surg br. 2011 jan;93(1):39-46. 14. alshryda p, sarda p, sukeik m, nargol a, blenkinsopp j, mason jm. tranexamic acid in total knee replacement: a systematic review and meta-analysis. j bone joint surg br. 2011 dec;93(12):1577-85. 15. irisson e, hemon y, pauly v, parratte s, argenson jn, kerbaul f. tranexamic acid reduces blood loss and financial cost in primary total hip and knee replacement surgery. orthop and traumatol surg res 2012 sep;98(5):477-83. 16. busch ca, whitehouse mr, shore bj et al. the efficacy of periarticular multimodal drug infiltration in total hip arthroplasty. clinorthoprelat res 2010 aug;468(8):215259. 17. juliano k, edwards d, spinello d, capizzano y, epelman e, kalowitz j, lempel a, ghomrawi h. initiating physical therapy on the day of surgery decreases length of stay without compromising functional outcomes following total hip arthroplasty. hss j 2011 feb;7(1):1620. 18. bellamy n, buchanan ww, goldsmith ch, campbell j, stitt lw. validation study of womac: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. j rheumatology 1988 dec;15(12):1833-40. 19. amlie e, havelin li, furnes o, baste v, nordsletten l, hovik o, dimmen s. worse patient-reported outcome after lateral approach than after anterior and posterolateral approach in primary hip arthroplasty. actaorthop 2014 jun23;1-7. (epup ahead of print) this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj page 8 south african orthopaedic journal http://journal.saoa.org.za conferences, courses & symposia local combined 65th south african orthopaedic congress 2019 – ‘unity in diversity’ 02 september – 06 september 2019 icc durban includes the following sub-specialty groups: 1. sa arthroplasty society (saas) 2. sa knee society (saks) 3. sa shoulder and elbow surgeons (sases) 4. sa foot surgeons’ association (safsa) 5. sa orthopaedic trauma society (saots) 6. sa paediatric orthopaedic society (sapos) 7. sa society for hip arthroscopy (sasha) 8. launch and inaugural meeting of the sa orthopaedic oncology and limb preservation society (sols) contact: chairman of the saoa congress committee: dr ian stead, email: iwstead@gmail.com invited speakers australia prof peter choong – melbourne, australia – saas & sols dr david martin – adelaide, australia – saks & sapos mr marinis pirpiris – melbourne, australia – saots belgium prof peter verdonk – antwerp, belgium – saks brazil prof kodi kojima – sao paulo, brazil – saots canada dr mark glazebrook – halifax, canada – safsa france dr mathieu thaunat – lyon, france – saks scotland prof colin howie – edinburgh, scotland – saas singapore dr christopher pearce – jurong east, singapore – safsa switzerland prof andreas imhoff – basel, switzerland – sases & saks dr mario morgenstern – basel, switzerland infection – saots uk mr phil chapman-sheath – southampton, uk – saas mr andrew porteous – bristol, uk – saas mr nick nicolaou – sheffield, uk – sapos prof lee jeys – birmingham, uk – sols prof phil turner – manchester, uk – saas mr andy williams – london, uk – saks mr anthony perera – cardiff, uk – safsa mr tony andrade – reading, uk – sasha usa prof christopher harner – pittsburgh, usa – saks dr christopher digiovanni – boston, usa – safsa prof marc safran stanford – usa – sasha germany dr ludwig seebauer – munich, germany – sases italy dr alberto constantini – rome, italy – sasha netherlands dr jaap willems – amsterdam, netherlands – sases new zealand mr rod maxwell – christchurch, new zealand – saas & safsa international november 2019 12th international conference on orthopedics, osteoporosis & trauma 13 november 2019 – 14 november 2019 london, united kingdom amstel elbow course 21 november 2019 – 22 november 2019 amsterdam, netherlands esska advanced knee arthroscopy course – all about posteromedial & posterolateral laxities 2019 21 november 2019 – 22 november 2019 cologne, germany sports medicine international congress moscow 2019 21 november 2019 – 22 november 2019 moscow, russia xiv spat congress 28 november 2019 – 29 november 2019 braga, portugal epos bat advanced course: pediatric hand and upper extremity surgery 29 november 2019 – 30 november 2019 vienna, austria december 2019 ao foundation davos courses 2019 01 december 2019 – 11 december 2019 davos, switzerland 40th sicot orthopaedic world congress muscat 2019 05 december 2019 – 07 december 2019 muscat, oman efas advanced symposium helsinki 2019 06 december 2019 – 07 december 2019 helsinki, finland 13th international conference on arthritis and rheumatology 09 december 2019 – 10 december 2019 barcelona, spain sfa rennes 2019 11 december 2019 – 14 december 2019 rennes, france 404 not found 404 not found sa orthopaedic journal spring 2016 | vol 15 • no 3 page 33 amputation rate following tibia fractures with associated popliteal artery injuries dr ma roussot1 mbchb, mphil(sports and exercise medicine) dr m held1 mbchb, mmed, fc orth (sa) dr m laubscher1 mbchb, mmed, fc orth (sa) prof aj nicol2 mbchb, phd, fcs (sa) prof ph navsaria2 mbchb, mmed, fcs (sa) a/prof sjl roche1 mbchb, fc orth (sa) dr s maqungo1 mbchb, mmed, fc orth (sa) 1 division of orthopaedic surgery, groote schuur hospital 2 trauma centre, groote schuur hospital presented in part at the south african orthopaedic association congress in sun city, south africa, september 2013; and selected for representation at the ‘best of the saoa congress’, cape town, south africa october 2013 correspondence: dr mark roussot division of orthopaedic surgery h49 old main building groote schuur hospital south africa cell: 082 499 2744 fax: 021 447 2709 email: markroussot@gmail.com introduction vascular injury following extremity trauma is uncommon with a reported incidence of less than 1%;1-5 however, patients with fractures and dislocations about the knee represent a subgroup of individuals that are at increased risk.1,6 popliteal vascular trauma carries the highest risk of limb loss of any peripheral vascular injury7-9 with amputation rates reported between 11% and 28% for penetrating and blunt trauma respectively.6 although a variety of scoring systems have been developed and evaluated to assist in the decision of limb salvage versus amputation for major extremity trauma, shortcomings with respect to sensitivity, specificity, subjectivity and failure to predict functional outcome have repeatedly been demonstrated.10-13 delay to revascularisation, however, has frequently been associated with poor outcome.4,14-16 abstract background: patients with fractures or dislocation about the knee are at increased risk of vascular injury and subsequent limb loss. our objectives were to: a) determine the amputation rate; and b) identify risk factors in patients with proximal tibial and diaphyseal fractures and associated popliteal artery injuries. methods: we conducted a retrospective case-control study of 30 patients with popliteal artery injuries with ipsilateral tibia fractures at a level 1 trauma centre. primary and delayed amputation rates were determined. risk factors tested for significance (fischer’s exact) included: mechanism of injury, limb viability, compartment syndrome, fracture pattern, surgical sequence, and time delay from injury or presentation to revascularisation. results: primary amputation was performed in seven and delayed in ten patients (overall rate 57%). the ‘miserable triad’ of a proximal tibia fracture (ota 41) with signs of threatened viability, and delay to revascularisation ≥6 hours from injury or ≥2 hours from presentation was predictive of amputation (p = 0.036 and p = 0.018 respectively), and almost quadrupled the amputation rate. conclusions: we should aim to intervene within 6 hours following injury or 2 hours following presentation to reduce the risk of amputation. this provides a target for trauma teams even with uncertain time of injury. key words: vascular injury, tibia fracture, amputation http://dx.doi.org/10.17159/2309-8309/2016/v15n3a4 saoj spring 2016_bu.qxp_orthopaedics vol3 no4 2016/08/02 14:05 page 33 page 34 sa orthopaedic journal spring 2016 | vol 15 • no 3 our primary objective was to determine the amputation rate in patients with proximal tibial and diaphyseal fractures and associated popliteal artery injuries presenting to a level 1 trauma unit draining a large geographical region. our secondary objective was to evaluate risk factors for amputation. we hypothesised that a delay to the operating room of 6 hours or more from the time of injury places these patients at increased risk of limb loss. patients and methods a retrospective analysis was performed on 31 consecutive patients with tibia fractures and confirmed popliteal artery injuries admitted through a level 1 trauma unit from 1 january 1999 to 31 december 2010. popliteal vascular injury was confirmed by angiography or intra-operatively. the medical records and radiological investigations were analysed in terms of: • patient demographics (age, gender) • date and time of injury, presentation to the trauma unit and surgical intervention • injury data – mechanism of injury, classification of skeletal and vascular injury • surgical sequence of revascularisation and external fixation • limb viability on presentation • associated injuries • amputation or limb salvage as the final outcome. tibia fractures were described in accordance with the orthopaedic trauma association (ota) classification (table i).17 limb viability was graded in accordance with the rutherford classification (table ii).18 primary amputation was defined as ablation of the limb at the time of the first operative procedure without an attempt at limb salvage. delayed amputation was defined as ablation of the limb following an initial attempt at limb salvage. risk factors analysed and tested for significance with the fischer’s exact test were mechanism of injury, clinical signs of threatened viability (rutherford grading), compartment syndrome, fracture pattern, surgical sequence (external fixation prior to revascularisation or vice versa), delay from injury to operating room (or) of ≥6 hours, and delay from admission to or of ≥2 hours. exclusion criteria: • traumatic amputation • knee dislocations and fracture-dislocations • vascular injury proximal to adductor hiatus or distal to the trifurcation of the popliteal artery. results thirty-one patients with tibia fractures and popliteal artery injuries were seen at our trauma unit from 1 january 1999 to 31 december 2010. one patient was excluded because of missing medical records, leaving 30 patients for analysis: 22 males with a median age of 29 years (range 15–63 years), and eight females with a median age of 28 years (range 17–48 years). the average length of stay in hospital for the study group was 23 days (5–65 days) and the mean duration of follow-up after discharge from hospital was 8.8 months (1–36.5 months). three patients were transferred to peripheral hospitals, one patient died in the intensive care unit with multi-organ failure and three patients were lost to follow-up resulting in a follow-up rate of 89% (23 patients, n = 26). table ii: rutherford classification of limb viability18 grade description i viable iia marginally threatened or salvageable if promptly treated iib immediately threatened or salvageable with immediate revascularisation iii unsalvageable table i: orthopaedic trauma association classification of tibial fractures17 anatomical region group fracture pattern 41 (proximal) a extra-articular b partial articular c complete articular 42 (diaphyseal) a simple b wedge c complex 43 (distal) a extra-articular b partial articular c complete articular figure 1. mechanism of injury and type of arterial injury saoj spring 2016_bu.qxp_orthopaedics vol3 no4 2016/08/02 14:05 page 34 sa orthopaedic journal spring 2016 | vol 15 • no 3 page 35 the mechanisms of injury (figure 1) included 17 motor vehicle accidents (mvas), 11 gunshot wounds (gsws), a train accident, and a fall from a height. associated injuries occurred in 21 patients, and included pelvic fractures in five patients, other long bone fractures in five patients, blunt chest trauma in four patients, head injury in four patients, and blunt abdominal trauma in three patients. the initial assessment in casualty revealed non-viability (rutherford iii) of the limb in three patients, immediately threatened (rutherford iib) in 16 patients, and marginally threatened (rutherford iia) in six patients. compartment syndrome was diagnosed clinically in ten patients. an angiogram was performed on 26 patients, ten in the emergency room, ten in the radiology suite, and six were performed on the operating table. the four patients in whom angiography was not performed underwent immediate surgical exploration upon which the clinical diagnosis was confirmed. nineteen patients presented with ota type 41 fractures (41a = 8, 41b = 2, 41c = 9) and seven patients presented with ota type 42 fractures (42b = 3, 42c = 4). images were missing for four patients. popliteal artery transection was found in 16 patients, intimal tears in five patients, thrombosis in four patients, partial laceration in one patient, and in four patients findings were not recorded (figure 1). no significant difference was found in terms of the type of arterial injury (i.e. transection, thrombosis, intimal tear or laceration) relative to the mechanism of injury. the arterial injury was repaired with reverse saphenous vein graft in 17 patients, primary repair in four patients, and polytetrafluoroethylene (ptfe) in two patients. fasciotomy was performed in 26 patients, ten therapeutically and 16 prophylactically. five patients underwent primary amputation immediately after fasciotomy as the limb was deemed to be unsalvageable. primary amputation was performed in seven patients, three of whom presented with non-viable limbs and four of whom were assessed to have a non-viable limb in the operating room after attempted fasciotomy (table iii). delayed amputation was performed in ten patients after a mean of eight days, resulting in a total amputation rate of 57% (17 patients, n = 30). reported reasons for delayed amputation included graft failure in four patients, the development of compartment syndrome in two patients for whom prophylactic fasciotomy was not performed, and massive soft tissue injury in two patients. the surgical sequence was recorded in 23 patients who underwent limb salvage. thirteen patients were explored prior to external fixation (seven went on to amputation) and ten patients underwent external fixation prior to exploration (six went on to amputation). this had no significant impact on the amputation rate. the median delay from injury to presentation (table iv) was 5 hours (range 1–144 hours, n = 27); median delay from presentation to or was 4 hours (range 1–47 hours, n = 30); and median delay from injury to or was 10 hours (range 4–150 hours, n = 27). analysis of the risk factors (namely mechanism of injury, initial assessment of viability, presence of compartment syndrome, fracture pattern, and delay to intervention) revealed that each variable was associated with higher amputation rates, but none was individually predictive of amputation with statistical significance (table v). however, patients with a proximal tibia fracture (ota 41), clinical signs of threatened viability, and a delay from injury to the or of ≥6 hours showed a significantly higher amputation rate of 67% versus 18% (p = 0.036). similarly patients with a proximal tibia fracture (ota 41), clinical signs of threatened viability and a delay from presentation to the or of ≥2 hours showed a significantly higher amputation rate of 69% versus 18% (p = 0.018). discussion more than half of the patients presenting with proximal tibia fractures with associated popliteal artery injuries underwent amputation despite attempts at limb salvage. notably, the ‘miserable triad’ of a proximal tibia fracture with clinical signs of threatened viability and a delay to or of ≥6 hours from injury or ≥2 hours from presentation resulted in a statistically significant increased risk of limb loss, suggesting that every attempt should be made to intervene with this subgroup of patients within 6 hours of injury or 2 hours of presentation to hospital in order to improve outcome. this finding provides trauma teams with a target even if the exact time of injury is uncertain. the reported amputation rate in patients with popliteal artery injuries varies greatly among authors, averaging 28% for blunt and 11% for penetrating trauma, but has been reported as high as 71%.6,19 the amputation rate in the present study was 57%, which included seven primary and ten delayed amputations. this is greater than that reported in a series of 136 popliteal artery injuries conducted at the same institution, which demonstrated an overall amputation rate of 37.5%.14 table iv: delay to revascularisation time from injury to presentation (hours) time from presentation to or (hours) time from injury to or (hours) mean 10.4 8.7 19.3 median 5.0 4.0 10.0 range 1–144 1–47 4–150 n 27 30 27 table iii: amputation rate number of patients % of study group (n = 30) primary amputation 7 23% delayed amputation 10 33% total amputation 17 57% saoj spring 2016_bu.qxp_orthopaedics vol3 no4 2016/08/02 14:05 page 35 page 36 sa orthopaedic journal spring 2016 | vol 15 • no 3 the higher risk of amputation in patients with complex extremity trauma involving popliteal vascular injury combined with skeletal trauma, in comparison to either injury in isolation, is well documented;6,7,8,15,20,21 however, the reasons for this are not clear. delay in recognition due to the presence of multiple injuries, inadequate soft tissue coverage, and the high incidence of compartment syndrome are factors that may contribute to higher amputation rates in this setting.6-8 the rarity of major vascular injuries in orthopaedic trauma and subsequent lack of experience in managing them has also been postulated to impact on outcome.3 in this study only 31 patients with tibial fractures and popliteal artery injuries were seen at our level 1 trauma unit over an 11-year period. the temporal relationship between ischaemic time and amputation rate is supported by clinical and experimental studies6,22,23 and generally accepted as one of the most important factors in determining the ultimate fate of a limb with vascular injury;4,6,8,15 hence, early intervention is associated with improved prognosis.3,8,15 however, the definition of ‘early’ differs among authors, some of whom have challenged the traditionally recommended goal of injury to or time of less than 6 hours and have even demonstrated the benefit of vascular reconstruction in patients with a delay of more than 12 hours.3 in the present study the majority of patients reached or 6 hours or more following injury. this may be explained in part by delays to presentation at the trauma unit, but are also due to delays to the or once in the trauma unit. the reasons for delay need to be evaluated in this setting and cannot be entirely attributed to the inclusion of rural drainage areas alone. the initial clinical assessment of threatened viability was associated with increased risk of limb loss in this study group, although not with statistical significance. this association has been highlighted as an independent predictor of outcome in previous studies.6,8 the finding that the majority of patients in this study group (70%) were polytrauma victims emphasises the need for a multidisciplinary team approach, prioritising diagnostic and therapeutic procedures. identifying vascular injury in this context requires extra clinical vigilance, a high index of suspicion, liberal use of doppler ultrasound and appropriate use of angiography.6 on-table angiography has been shown to prevent delays associated with formal angiography,3,9 which should be reserved for patients with reasonable distal perfusion in whom the diagnosis of arterial injury is in doubt.24 the sequence of revascularisation and external fixation in this study group appeared to have no association with limb loss. while the timing of stabilisation of fractures in the context of vascular injury is contentious,1,2,6 a meta-analysis has demonstrated no difference in the amputation rates in patients undergoing vascular repair prior to stabilisation versus those undergoing stabilisation prior to vascular repair.2 at our institution the fracture is stabilised with external fixation prior to vascular repair unless the surgical team assesses that the limb is in need of immediate revascularisation. in this case, a shunt may be introduced, and then manipulation and external fixation performed, followed by definitive vascular repair. this approach is regarded as safe and is common practice.6,8,9,23 we further recommend that the surgical team prioritises revascularisation prior to external fixation if external fixation is likely to proceed beyond the target of 6 hours post injury or 2 hours post presentation to the trauma unit. owing to the difficulty in accurate post-operative clinical assessment of compartment pressures and the high incidence of compartment syndrome following revascularisation, we strongly recommend that prophylactic fasciotomy is performed following revascularisation in all of these patients, which is supported by previous studies.3,6,14,22,25 table v: analysis of risk factors amputation n n p-value mechanism of injury 0.264 mva 17 11 gsw 11 6 other 2 initial assessment of limb viability 0.179 viable 6 2 threatened 21 12 non-viable 3 3 compartment syndrome 0.705present 10 6 absent 20 11 fracture pattern (ao) 0.190 41 19 12 a 8 5 b 2 0 c 9 7 42 7 2 a 0 0 b 3 1 c 4 1 timing of stabilisation 1.000exploration first 13 7 exploration after exfix 10 6 delay from injury to or 0.294≥6 hours 23 14 <6 hours 4 1 delay from admission to or 0.360≥2 hours 24 15 <2 hours 6 2 ao 41 + threatened + delay from injury to or ≥6 hours 0.036yes 12 8 no 11 2 ao 41 + threatened + delay from admission to or ≥2 hours 0.018yes 13 9 no 11 2 saoj spring 2016_bu.qxp_orthopaedics vol3 no4 2016/08/02 14:05 page 36 sa orthopaedic journal spring 2016 | vol 15 • no 3 page 37 seven patients had tibial diaphyseal fractures and popliteal artery injuries. one was related to a gunshot wound with the bullet tract involving the vessel. the remaining six were polytrauma victims related to motor vehicle accidents and the fractures were all located in the proximal diaphysis. while it would seem intuitive that diaphyseal fractures are more likely to cause vascular injury distal to the trifurcation, it is recognised that this does not preclude more proximal vascular injuries.6 the movement of the popliteal vessels is restricted inferiorly by the fibrous soleus arch, placing the artery at risk in the context of high energy trauma that results in soft tissue tension or disruption at or below this level.6 despite advances in trauma care the outcome of lower limb trauma in the presence of popliteal arterial injury still tends to be poor.3,6,7,9 resource utilisation is high owing to prolonged hospital stays and numerous visits to the or,12,13 and the choice between primary amputation and limb salvage remains challenging. this should provide the impetus to intervene timeously. to our knowledge, this is the largest series of proximal tibia fractures with associated popliteal artery injuries in a resource-limited level 1 trauma centre. follow-up was performed to obtain enough information for the primary outcome (amputation or limb salvage); however, the assessment of functional outcome and patient satisfaction through long-term follow-up was not conducted. conclusions tibia fractures with associated popliteal artery injuries have an amputation rate of 57%. the subset of patients with the ‘miserable triad’ of a proximal tibia fracture, clinical signs of threatened viability and a delay to or of ≥6 hours from injury or ≥2 hours from admission have a significantly increased risk of amputation (nearly four-fold). the authors recommend that trauma teams aim to intervene in these patients within 6 hours of injury or 2 hours of presentation. compliance with ethics guidelines conflicts of interest and source of funding: none ethics approval was obtained through the university of cape town human research ethics committee (hrec ref: 413/2013) no benefits of any form have been received from a commercial party related directly or indirectly to the subject of this article. references 1. halvorson jj, anz a, langfitt m, et al. vascular injury associated with extremity trauma: initial diagnosis and management. j am acad orthop surg 2011 aug;19(8):495-504. 2. fowler j, macintyre n, rehman s, et al. the importance of surgical sequence in the treatment of lower extremity injuries with concomitant vascular injury: a meta-analysis. injury. 2009 jan;40(1):72-76. 3. allen mj, nash jr, ioannidies tt, bell prf. major vascular injuries associated with orthopaedic injuries to the lower limb. ann r coll surg eng 1984;66:101-104. 4. howard pw, makin gs. lower limb fractures with associated vascular injury. j bone joint surg br. 1990 jan;72(1):116-20. 5. porter mf. arterial injuries in an accident unit. br j surg. 1967 feb;54(2):100-105. 6. frykberg er. popliteal vascular injuries. surg clin north am 2002;82:67-89. 7. mullenix ps, steele sr, andersen ca, starnes bw, salim a, martin mj. limb salvage and outcomes among patients with traumatic popliteal vascular injury: an analysis of the national trauma data bank. j vasc surg 2006 jul;44(1):94-100. 8. pourzand a, fakhri ba, azhough r, hassanzadeh ma, hashemzadeh s, bayat am. management of high-risk popliteal vascular blunt trauma: clinical experience with 62 cases. vasc health risk manag 2010 aug 9;6:613-18. 9. subasi m, cakir o, kesemenli c, arslan h, necmioglu s, eren n. popliteal artery injuries associated with fractures and dislocations about the knee. acta orthop belg 2001 jun;67(3):259-66. 10. dirshl dr, dahners le. the mangled extremity: when should it be amputated? j am acad orthop surg 1996;4:182-190. 11. ly tv, travison tg, castillo rc, bosse mj, mackenzie ej, leap study group. ability of lower-extremity injury severity scores to predict functional outcome after limb salvage. j bone joint surg am 2008;90:1738-43. 12. simmons jd, gunter jw 3rd, schmieg re jr, manley jd, rushton fw jr, porter jm, mitchell me. popliteal artery injuries in an urban trauma center with a rural catchment area: do delays in definitive treatment affect amputation? am surg 2011 nov;77(11):1521-25. 13. bosse mj, mackenzie ej, kellam jf, burgess ar, webb lx, swiontkowski mf, sanders rw, jones al, mcandrew mp, patterson bm, mccarthy ml, cyril jk. a prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. j bone joint surg am. 2001 jan;83-a(1):3-14. 14. banderker ma, navsaria ph, edu s, bekker w, nicol aj, naidoo n. civilian popliteal artery injuries. s afr j surg. 2012 nov 12;50(4):11923. 15. mccabe cj, ferguson cm, ottinger lw. improved limb salvage in popliteal artery injuries. j trauma. 1983 nov;23(11):982-85. 16. pretre r, bruschweiler i, rossier j, et al. lower limb trauma with injury to the popliteal vessels. j trauma 1996;40:595-601. 17. marsh jl, slongo tf, agel j, et al. fracture and dislocation classification compendium – 2007: orthopaedic trauma association classification, database and outcomes committee. j orthop trauma. 2007;21 supplement 10 pp: s1-s163. 18. rutherford rb, baker jd, ernst c, et al. recommended standards for reports dealing with lower extremity ischemia: revised version. j vasc surg. 1997 sep;26(3):517-38. 19. conkle dm, richie re, sawyers jl, et al. surgical treatment of popliteal artery injuries. arch surg 1975;110:1351-54. 20. applebaum r, yellin ae, weaver fa, et al. role of routine arteriography in blunt lower extremity trauma. am j surg 1990;160:221-25. 21. downs ar, macdonald p. popliteal artery injuries: civilian experience with sixty-three patients during a twenty-four year period (1960 through 1984). j vasc surg. 1986 jul;4(1):55-62. 22. debakey me, simeone fa. battle injuries of the arteries in world war ii; an analysis of 2,471 cases. ann surg. 1946 apr;123:534-79. 23. miller hh, welch cs. quantitative studies on the time factor in arterial injuries. ann surg. 1949 sep;130(3):428-38. 24. yahya mm, mwipatayi bp, abbas m, rao s. popliteal artery injury: royal perth experience and literature review. anz j surg 2005;75:882-86. 25. hafez hm, woolgar j, robbs jv. lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss. j vasc surg. 2001 jun;33(6):1212-19. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj spring 2016_bu.qxp_orthopaedics vol3 no4 2016/08/02 14:05 page 37 phillias sc et al. sa orthop j 2020;19(4) doi 10.17159/2309-8309/2020/v19n4a5 south african orthopaedic journal http://journal.saoa.org.za traumaorthopaedic oncology and infections citation: phillias sc, ngcelwane mv, marais lc. tumour volume as a predictor of metastases in patients presenting with high-grade conventional osteosarcoma of the extremities. sa orthop j 2020;19(4):223-228. http://dx.doi.org/10.17159/2309-8309/2020/v19n4a5 editor: prof. theo le roux, university of pretoria, pretoria, south africa received: april 2020 accepted: august 2020 published: november 2020 copyright: © 2020 phillias sc. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare that they have no known competing financial interests or personal relationships that could have influenced the work reported in this paper. abstract background: the aim of this study was to compare the initial tumour volume in patients with and without pulmonary and/or skeletal metastases at time of presentation. the secondary aim was to compare the value of tumour volume in the prediction of metastases at time of presentation with known predictive factors, namely serum alkaline phosphatase (alp) and lactate dehydrogenase (ldh). materials and methods: a retrospective cross-sectional analysis was performed comparing the primary tumour volume in patients with and without metastases. all patients with histologically confirmed high-grade conventional osteosarcoma over a five-year period were included. results: the study comprised 61 patients. the mean age was 21 years (sd: 11.9, range 5–56) with an equal distribution of males and females (51% vs 49%). there was no correlation between tumour volume and age at presentation (p=0.31). there was no evidence of metastases in only 20% (n=12) of patients. skeletal metastases were present in 28% (n=16) of the patients and pulmonary metastases were present in 44 cases (72%). there was no significant difference in the tumour volume at presentation between patients with and without pulmonary metastases (p=0.11). however, tumour volume did appear to predict the presence of skeletal metastases (p=0.02). a tumour volume of 1 383 cm³ had a negative predictive value (npv) of 92% and positive predictive value (ppv) of 55% for the presence of skeletal metastases (area under curve [auc]=0.76; sensitivity 66%; specificity 87%). a tumour volume of 480 cm³ had a 100% npv for the presence of skeletal metastases (auc=0.74). a tumour volume ≥1 380 cm³ had an odds ratio (or) of 13.6 (p<0.01; 95% ci 2.6–72.5) as an independent variable in relation to skeletal metastases. multivariate analysis (with alp and ldh) of tumour volume ≥1 380 cm³ yielded an or of 8.6 (p=0.04; 95% ci 1.1–67) for presence of skeletal metastases. conclusion: in this series of conventional high-grade osteosarcoma of the extremities, we found a very high rate of metastases at time of diagnosis. while there was no association with pulmonary metastases, increased tumour volume was associated with an increased risk for the presence of skeletal metastases. more studies in the developing world clinical setting are required to investigate this further; the high rate of metastases seen at time of diagnosis also requires further investigation. level of evidence: level 4 keywords: osteosarcoma, metastases, tumour volume, prognosis, staging tumour volume as a predictor of metastases in patients presenting with high-grade conventional osteosarcoma of the extremities phillias sc¹ , ngcelwane mv² , marais lc3 1 mbchb(medunsa); registrar, department of orthopaedic surgery, steve biko academic hospital, university of pretoria, pretoria, south africa ² mbchb(ukzn), msc(orth)london, fcs(sa)(orth); head of department of orthopaedic surgery, steve biko academic hospital, university of pretoria, pretoria, south africa ³ mbchb, fc orth(sa), mmed(ortho), phd; head of department of orthopaedic surgery, school of clinical medicine, university of kwazulu-natal, durban, south africa corresponding author: dr sc phillias, po box 191, siyathuthuka, 1102, south africa; tel: 079 256 1701; email: scphillias@outlook.com https://orcid.org/0000-0001-7452-5721 https://orcid.org/0000-0001-7564-3308 https://orcid.org/0000-0002-1120-8419 page 224 phillias sc et al. sa orthop j 2020;19(4) introduction osteosarcoma is the most common primary malignancy involving bone, excluding myeloma. nonetheless, it is rare disease, representing less than 1% of all cancers diagnosed annually in the united states of america and as a result has been classified as rare disease by the world health organization.  conventional osteosarcoma is largely a disease of the young, with a second peak of incidence in the elderly.1 surveillance, epidemiology and end results (seer) program data indicated an annual incidence for patients younger than 25 years and older than 60 of 4.4 and 4.2 per million population, respectively.2 osteosarcoma is the fifth most common cancer in adolescents, amounting to more than 10% of all solid cancers in this age group.3 conventional osteosarcoma, representing approximately 80–90% of all osteosarcomas, is a high-grade malignancy with a high rate of reported lung metastases, and has a tendency to recur if not completely excised.3,4 in developed countries, less than 25% of patients are diagnosed with metastatic disease at presentation.3 in south africa, patients unfortunately present much later, with previous studies finding metastatic disease in 46–66% of patients at presentation.5,6 skeletal metastases at the time of diagnosis (socalled synchronous bone metastases) are rare in osteosarcoma and are associated with a poor prognosis.7 furthermore, bones are the first site of subsequent (metachronous) metastases in less than 10% of cases.8 prior to the advent of chemotherapy, the survival rate, with surgery alone, was extremely poor, with a five-year survival rate of only 10%.9 with current multimodality treatment protocols, which include chemotherapy, survival rates have been found to be in the region of 60–70% in localised and 20–40% in metastatic disease.3 several factors have been identified with significant prognostic implications in osteosarcoma including increasing age, the size and site of the primary tumour, serum alkaline phosphatase (alp) and lactate dehydrogenase (ldh) levels, as well as a poor histological response to neo-adjuvant chemotherapy. metastatic disease is, however, the single most important predictor of a poor outcome.10 risk factor stratification and the detection of metastases are not only important for accurate prognostic purposes, but also allow early identification of high-risk patients who may require a more aggressive treatment strategy. early detection of metastases is important as all metastases need to be surgically resected to improve survival, and alternative agents or second-line chemotherapy need to be considered. therefore, this study sets out to investigate tumour size as a predictor of the presence of metastases at time of presentation in patients with conventional osteosarcoma of an extremity. materials and methods a retrospective cross-sectional analytical study was performed with data collected at the time of first presentation. following approval of the study by the relevant ethics boards, records of all patients with osteosarcoma referred to a tertiary level orthopaedic oncology unit in kwazulu-natal, south africa, over five years from 2010 to 2014 were obtained. inclusion criteria included diagnosis of osteosarcoma confirmed on biopsy after formal open incisional biopsy, high-grade conventional osteosarcoma histology and osteosarcoma of the extremities. patients excluded were those with osteosarcoma of the pelvis and axial skeleton, soft tissue osteosarcoma, osteosarcoma variants and surface lesions, where tumour volume or staging data were not available. diagnosis of osteosarcoma was confirmed after formal open incisional biopsy was done and subsequently confirmed at a combined radiology–histology meeting. as part of the initial patient workup at presentation, the tumour size was measured on magnetic resonance imaging (mri), pulmonary metastases on computerised tomography (ct), and skeletal metastases (skip lesions in same bone and distant bone) on technetium bone scan. due to the retrospective nature of the study, information regarding body weight and height was unavailable, therefore tumour volume was measured using a previously defined formula for an ellipsoidal mass (width × height × diameter × 0.52).11 the demographic characteristics (age and sex of patients, and anatomic location of primary tumour) in patients with and without metastases were recorded. the initial tumour volume on mri in patients with metastases (skeletal and/or pulmonary) was compared to patients without metastases at time of presentation, i.e. prior to any treatment. the strength of association between tumour volume and the presence of metastases at presentation was then evaluated. we also compared the value of tumour volume in the prediction of metastases at time of presentation with other known predictive factors (serum alp and ldh). statistical analysis data was processed and analysed using stata 13.0 se (statacorp, 2013. stata statistical software: release 13. college station, tx: statacorp lp) and r statistical package 3.0.3 (r core team, 2015. r: a language and environment for statistical computing. r foundation for statistical computing, vienna, austria). spearman’s correlation test was used to assess the association between patient age and tumour volume. differences in tumour volume by metastases were assessed using the standard two-sample t-test. receiver operating characteristic (roc) curves was used to determine the optimal breakpoint for the classification of metastatic cancer based on tumour volume. the discriminatory power was evaluated by the area under the roc curve (area under curve or auc). an auc value of 0.5 indicates no discriminative ability while an auc exceeding 0.8 suggests good to excellent predictive capability. sensitivity and specificity based on the optimal identified cut-points were calculated, along with 95% confidence intervals (ci). logistic regression analysis was employed to estimate the strength of association between tumour volume and metastases. a p-value of <0.05 was considered statistically significant for all tests. results sixty-seven patients were identified with histologically confirmed osteosarcoma involving an extremity. six patients were excluded from the study. one patient demised prior to completion of systemic staging investigations, and five patients were diagnosed with osteosarcoma variants. sixty-one patients met the inclusion criteria and their clinical characteristics are provided in table i. bone scan was not performed in four patients due to their poor general medical condition which did not allow transfer to the facility where the scan was performed. ten patients had no tumour volume data available, and were therefore excluded from the tumour-volume analysis. the mean patient age was 21 years (standard deviation [sd] 11.9 years; range 5–56) and there was an equal distribution between male and female patients (51% vs 49%). there was no correlation between tumour volume and age at presentation (p=0.31). the femur (57%) and tibia (31%) were the most commonly involved sites. there was no evidence of metastases in only 20% (n=12) of the patients. skeletal metastases were present in 28% (n=16) of the patients and pulmonary metastases were present in 44 page 225phillias sc et al. sa orthop j 2020;19(4) cases (72%). of those with skeletal metastases on presentation, 69% (n=11) had concomitant pulmonary metastases. five patients with skeletal metastases had more than one bony metastasis, four had single metastases and the number of bony metastases was unknown in seven cases. with respect to pulmonary lesions, 33 patients had multiple lesions, two single metastases, and the number of lesions was unknown in nine cases. the median time to presentation was four months (interquartile range [iqr] 2.5–7, range 1–36 months, n=44). the overall mean tumour volume at presentation was 1 114 cm3 (sd 1 285 cm3, range 164–6 821 cm3). for patients without any metastases, the mean tumour volume at presentation was 422 cm3 (range 164–1 678 cm3). the mean tumour volume in patients who presented without pulmonary metastases was 1 169 cm3 (95% ci 115–2 224 cm3) compared to 1 093 cm3 (95% ci 745–1 441 cm3) in patients with pulmonary metastases. the mean tumour volume in patients who presented without skeletal metastases was 829 cm3 (95% ci 523–1 136 cm3) compared to 2 016 cm3 (95% ci 487–3 545 cm3) in patients with skeletal metastases. analysis of the association between tumour volume and metastases showed that there was no significant difference in the tumour volume at presentation between patients with and without pulmonary metastases (p=0.851). however, tumour volume did appear to predict the presence of skeletal metastases (p=0.010). table i: clinical characteristics of cohort characteristic n (%) mean range sd tumour volume (cm3) 51 1 114 164–6 821 1 286 age (years) 61 (100%) 21.3 5–56 11.9 sex male 31 (51%) female 30 (49%) site femur 35 (57%) tibia 19 (31%) fibula 3 (5%) humerus 3 (5%) ulna 1 (2%) pulmonary metastases yes 44 (72%) no 17 (28%) skeletal metastases yes 16 (26%) no 41 (67%) unknown 4 (7%) figure 1(a). receiver operating characteristic (roc) curve optimal cutpoint analysis of tumour volume for prediction of skeletal metastases figure 1(b). optimal cut-point roc analysis, optimised for 100% sensitivity of tumour volume as predictor of skeletal metastases figure 2. optimal cut-point roc analysis optimised for 100% sensitivity of tumour volume as predictor of skeletal metastases page 226 phillias sc et al. sa orthop j 2020;19(4) roc analysis (figure 1) was then used to identify the optimal cut-off volumes to predict the presence of metastases. a tumour volume of 1 383 cm3 had a negative predictive value (npv) of 92% and positive predictive value (ppv) of 55% for the presence of skeletal metastases (auc=0.76; sensitivity 66%; specificity 87%). when optimising to achieve a 100% sensitivity (figure 2), a tumour volume of 480 cm3 had a 100% npv for the presence of skeletal metastases (auc=0.74). using univariate logistic regression to assess the strength of association of the tumour volume ≥1 380 cm3 as an independent variable in relation to skeletal metastases, an odds ratio (or) of 13.6 (p<0.01; 95% ci 2.6–72.5) was identified. multivariate analysis (with alp and ldh) of tumour volume ≥1 380 cm3 yielded an or of 8.6 (p=0.04; 95% ci 1.1–67) for presence of skeletal metastases, (table ii). discussion osteosarcoma is the most frequent malignant bone tumour in paediatric patients.12 several prognostic factors have been proposed including detectable metastases, advanced age, non-extremity locations, large tumour volume, elevated ldh or alp, and poor histological response to chemotherapy. of these, metastatic disease, large tumour sizes and poor response to neoadjuvant chemotherapy have consistently been associated with a poor outcome.13 tumour size may reflect the tumour burden and/or the extent of disease. a large primary tumour is more likely to be associated with distant metastases.14 furthermore, tumour size has been associated with an increase in risk of mortality. patients with tumours of diameter of >15 cm have a three-fold higher risk of death, whereas with tumour diameters of <15 cm survival is better.15 there is a paucity of literature relating to tumour volume as a prognostic indicator from lowto middle-income countries. in addition, few studies have previously studied the relationship between tumour volume and the presence of lung and skeletal metastases, independently. furthermore, there is a lack of data relating to the cut-off values, in terms of tumour volume, for presence of metastases. a previous study, for example, only looked at cut-off values for tumour volume in predicting lung metastases and excluded skeletal metastases.14 with this study we aimed to assess the association of tumour volume with pulmonary and skeletal metastases in a developing world setting. in our study, the majority of patients presented with relatively large tumours, with a mean tumour volume of 1 114 cm3. tumour size >10 cm in length has previously been shown as an adverse prognostic factor for overall survival.16 another multivariate model incorporating factors predicting treatment failure also found patients with large tumour size (>12 cm in length) to have a statistically significant worse prognosis for survival.12 in south africa, patients often present with advanced disease, with previous studies reporting metastatic disease in 46% to 66% of patients at time of diagnosis.5,6 a previous study from south africa also found advanced stage of disease at presentation, with 48% of cases having detectable metastases at time of presentation.6 in their series, only 28% of tumours were <10 cm in length. the authors concluded that the presence of metastases at diagnosis and size >10 cm in length were associated with a poor prognosis. our study found a considerably higher incidence of clinically detectable metastatic disease at initial presentation when compared to expected rates in developed countries (10–20%).17 in particular, the high rate (28%) of skeletal metastases at time of presentation is noteworthy. it remains unclear if the high rate of metastases seen in our series is related to a delay in diagnosis or if it might be related to a more aggressive phenotype of osteosarcoma. a pooled analysis by marko et al. found the highest prevalence of metastases at diagnosis of osteosarcoma in countries with a medium or low human development index (hdi).17 the prevalence of metastatic osteosarcoma at diagnosis in very high hdi, high hdi, and medium or low hdi groups was found to be 15%, 20% and 31%, respectively. they suggested that socioeconomic status, educational levels, as well as healthcare system and resource constraints in countries with medium/low hdi may result in a treatment delay with resulting increase in the rate of metastases at diagnosis.17 irrespective of the cause, these findings are particularly relevant in the south african clinical setting and again highlight the need for early referral of cases to specialised orthopaedic oncology units. it has been noted that patients who present with metastases have a shorter interval between onset of symptoms and diagnosis.18 this finding is somewhat counter-intuitive and suggests that aggressive biologic behaviour may be more important in the pathogenesis of metastases than delay in diagnosis. tumour volume at time of presentation may also be similarly difficult to interpret and patients with smaller tumours do not necessarily have a lower rate of metastases. initial tumour volume has, however, been shown to be of high prognostic value, and 150 cm3 tumour volume has been proposed as the cut-off point in predicting relapse and the development of metastases.19 kaste et al. found a median tumour volume of 717 cm3 in patients with lung nodules at diagnosis.20 due to the wide range of values (63–3 520 cm3) in the 28 patients with metastases at diagnosis, the authors were, however, unable to correlate the primary tumour volume with the presence of metastases or overall survival. bacci et al. found the incidence of metastases to be 20% and 12% in patients with tumour volumes >150 ml and <150 ml, respectively. tumour volume >150 ml, however, remained a significant predictor of the presence of metastases following multivariate logistic regression analysis.18 in our series, tumour volume was not a significant predictor for the presence of pulmonary metastases at diagnosis. munajat et al. previously looked at the association between tumour volume and lung metastases; 47% of their patients had evidence of lung metastases at presentation.14 they found a significant difference in primary tumour volumes in patients with and without metastases. their cut-off value of tumour volume was at 371 cm3. munajat et al. did not report on skeletal metastases.14 while we found no association with pulmonary metastases, we found that tumour volume was associated with the presence of skeletal metastases in our series. the lung remains the most common site for metastases in osteosarcoma, with only about 10% of cases reported to develop skeletal metastases.21 skeletal metastases have also been associated with a particularly poor survival.22 the 2014 european society of musculoskeletal oncology (esmo) guidelines recommend that all patients undergo a technetium bone scan during staging to search for the presence of skeletal metastases.23 in general, the aim is to conclude all staging investigations as soon as possible so as to not delay the treatment of the malignancy. in resource-poor developing countries like south africa, however, it might be difficult to obtain nuclear imaging studies, or in some cases, waiting times may be exceedingly long. thus, it may be useful to identify other markers table ii: multivariate analysis of risk factors for the presence of skeletal metastasis at time of diagnosis odds ratio 95% ci p-value ldh≥850 iu/l 2.7 0.36–20.04 0.330 alp≥280 iu/l 9.8 1.35–70.87 0.024 tumour volume ≥1 380 cm3 8.7 1.11–67.18 0.039 page 227phillias sc et al. sa orthop j 2020;19(4) that can be used to confirm or exclude the presence of skeletal metastases in patients with osteosarcoma. in this cohort, univariate analysis showed that patients with a tumour volume ≥1 380 cm3 had a 13 times higher risk of having skeletal metastases at the time of diagnosis. in a multivariate model with alp and ldh, the or decreased to 8.6 but the association remained significant. roc analysis revealed that a tumour volume cut-off value of 1 383 cm3 yielded a 92% npv for skeletal metastases. the absence of skeletal metastases could be predicted with a sensitivity of 100% by reducing this value to 480 cm3. our findings suggest that, in this series, patients with a tumour volume below 480 cm3 were highly unlikely to have clinically detectable skeletal metastases at time of diagnosis. furthermore, patients with a tumour volume higher than 1 380 cm3 at time of presentation have an increased risk of skeletal metastases. consideration could be given to the use of more sensitive screening investigations in patients with such large tumours, for example. the sensitivity and specificity of bone scintigraphy for detection of bone metastases is 78% and 48%, respectively.24 recently, 18f-fluorodeoxy-d-glucose positron emission tomography (18f-fdg pet) and positron emission tomography with computed tomography (pet ct) has emerged as a useful investigation to identify skeletal lesions.24 a meta-analysis by liu et al. demonstrated a sensitivity of 93% and specificity of 97% for 18f-fdg pet and pet ct.25 while these findings are interesting, there are numerous shortcomings to this study which need to be considered. first, the small sample size makes any definitive recommendation in this regard impossible. this is evident when looking at the wide 95% ci in our multivariate regression analysis. secondly, it would have been ideal to correlate tumour volume not only with presence of metastases but also overall survival. a large number of patients were, however, lost to follow-up, which precluded longitudinal prognostication. the major confounding factor is that there are numerous factors that have an influence on the prognosis of osteosarcoma and our multivariate model may not have been sufficiently robust to exclude the association of other factors with the presence of skeletal metastases at time of diagnosis. due to the retrospective nature of the study, data on the time to presentation and the specific histological subtype were not uniformly available. these measurements should be included in future studies as they have important bearing on the rate of metastases and overall patient survival. larger, well-designed studies with long-term follow-up are thus needed to determine the association of tumour volume with the risk of pulmonary and skeletal metastases in the developing world setting. further research is also needed to investigate the high incidence of metastases, and skeletal metastases in particular, at time of presentation. conclusion in this series of conventional high-grade osteosarcoma of the extremities, we found a very high rate of metastases at time of diagnosis. while there was no association with pulmonary metastases, increased tumour volume was associated with an increased risk for the presence of skeletal metastases. more studies in the developing world clinical setting are required to investigate this further; the high rate of metastases seen at time of diagnosis also requires further investigation. acknowledgements we would like to thank ms tshifhiwa nkwenika from the south african medical research council, biostatistics research unit in pretoria, and prof. benn sartorius for their input on the statistical aspects of the study. ethics statement all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. for this study formal consent was not required. the database from which eligible patients were identified received ethical approval from the uherb ethics review board (ref no. 02-012013). further ethical approval for the study was obtained from the university of pretoria ethics board (ref no. 585/2018). declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions scp: primary author, responsible for data collection and interpretation, manuscript preparation and revision. mvn: study supervisor, responsible for manuscript preparation and revision. lcm: study supervisor, responsible for conceptualisation and study design, data collection; assisted with statistical analysis and interpretation, manuscript preparation and revision. orcid phillias sc https://orcid.org/0000-0001-7452-5721 ngcelwane mv https://orcid.org/0000-0001-7564-3308 marais lc https://orcid.org/0000-0002-1120-8419 references 1. dean bjf, whitwell d. (i) epidemiology of bone and soft-tissue sarcomas. orthopaedics and trauma. 2009;23(4):223-30. https:// doi.org/10.1016/j.mporth.2009.05.006. 2. mirabello l, troisi rj, savage sa. osteosarcoma incidence and survival rates from 1973 to 2004: data from the surveillance, epidemiology and end results program. int j cancer. 2009;115(7):1531-43. https://doi.org/10.1002/cncr.24121. 3. hogendoorn pcw, athanasou n, bielack s, et al. bone sarcomas: esmo clinical practice guidelines for diagnosis, treatment, and follow-up. ann oncol. 2010;21(supplement 5):v204-v213. https:// doi.org/10.1093/annonc/mdq223. 4. kim hj, chalmers pn, morris cd. pediatric osteogenic sarcoma. curr opin pediatr. 2010;22:61-66. https://doi.org/10.1097/ mop.0b013e328334581f. 5. ferriera n, marais lc. osteosarcoma presentation stages to a tumour unit in south africa. s afr med j. 2012;102(8):673-76. https://doi.org/10.7196/samj.5835. 6. shipley ja, beukes ca. outcomes of osteosarcoma in a tertiary hospital. s afr orthop j. 2012;11(1):18-22. 7. kager l, zuobek a, kastner u, et al. skip metastases in osteosarcoma: experience of the cooperative osteosarcoma study group. j clin oncol. 2006;24:1535-41. 8. bacci g, ferrari s, longhi a, et al. pattern of relapse in patients with osteosarcoma of the extremities treated with neoadjuvant chemotherapy. eur j cancer. 2001;37:32-38. 9. campanacci m, bacci g, bertoni f, et al. the treatment of osteosarcoma of the extremities: twenty years’ experience at the istituto ortopedico rizzoli. cancer. 1981;48:1569-81. https://doi.org/10.1002/1097-0142(19811001)48:7<1569::aid cncr2820480717>3.0.co;2-x. 10. stokkel mpm, linthorst mfg, borm jjj, taminiau ah, pauwels ekj. a reassessment of bone scintigraphy and commonly tested pretreatment biochemical parameters in newly diagnosed osteosarcoma. j cancer res clin oncol. 2002;128:393-99. https:// doi.org/10.1007/s00432-002-0350-5. 11. shin kh, moon sh, suh js, yang wi. tumor volume change as a predictor of chemotherapeutic response in osteosarcoma. clin or thop relat res. 2000;376:200-208. https://doi. org/10.1097/00003086-200007000-00027. 12. vasquez l, tarrillo f, oscanoa m, et al. analysis of prognostic factors in high-grade osteosarcoma of the extremities in children: a 15-year single-institution experience. front oncol. 2016;6:22. https://doi.org/10.3389/fonc.2016.00022. 13. ahmad o, soodeh a, ali m. osteosarcoma: current concepts, challenges, and future directions. curr or thop pract. https://orcid.org/0000-0001-7452-5721 https://orcid.org/0000-0001-7564-3308 https://orcid.org/0000-0002-1120-8419 page 228 phillias sc et al. sa orthop j 2020;19(4) 2015;26(2):181-98. https://doi.org/10.1097/bco.00000000000 00199. 14. munajat wz, norazman mz, wan faisham wi. tumour volume and lung metastasis in patients with osteosarcoma. j orthop surg. 2008;16(2):182-85. https://doi.org/10.1177/230949900801600211. 15. petrilli as, de camargo b, filho vo, et al. results of the brazilian osteosarcoma treatment group studies iii and iv: prognostic factors and impact on survival. j clin oncol. 2006;24:1161-68. https://doi.org/10.1200/jco.2005.03.5352. 16. berner k, hall ks, monge or, et al. prognostic factors and treatment results of high-grade osteosarcoma in norway: a scope beyond the ‘classical’ patient. sarcoma. 2015;3:1-14. https://doi. org/10.1155/2015/516843. 17. marko a, diessner bj, spector lg. prevalence of metastasis at diagnosis of osteosarcoma: an international comparison. pediatr blood cancer. 2016;63:1006-11. https://doi.org/10.1002/ pbc.25963. 18. bacci g, ferrari s, longhi a, et al. high-grade osteosarcoma of the extremity: differences between localized and metastatic tumors at presentation. j pediatr hematol oncol. 2002;24:27-30. https://doi. org/10.1097/00043426-200201000-00008. 19. bieling p, rehan n, winkler p, et al. tumor size and prognosis in aggressively treated osteosarcoma. j clin oncol. 1996;14(3):84858. https://doi.org/10.1200/jco.1996.14.3.848 . 20. kaste sc, pratt cb, cain am, jones-wallace dj, rao bn. metastases detected at the time of diagnosis of primary pediatric extremity osteosarcoma at diagnosis. cancer. 1999; 86(8):1602-08. ht tps://doi.org/10.1002/ (sici)1097-0142(19991015)86:8<1602::aid-cncr31>3.0.co;2-r. 21. bacci g, longhi a, bertoni f, et al. bone metastases in osteosarcoma patients treated with neoadjuvant or adjuvant chemotherapy: the rizzoli experience in 52 patients. acta orthop. 2006;77(6):938-43. https://doi.org/10.1080/17453670610013268. 22. ferrari s, briccoli a, mercuri m, et al. postrelapse survival in osteosarcoma of the extremities: prognostic factors for long-term survival. j clin oncol. 2003;21:710-15. https://doi.org/10.1200/ jco.2003.03.141. 23. esmo/european sarcoma networking group. bone sarcomas: esmo clinical practice guidelines for diagnosis, treatment and follow-up. ann oncol. 2014;25(s3):iii113-iii123. https://doi. org/10.1093/annonc/mdu256. 24. o’sullivan gj, carty fl, cronin cg. imaging of bone metastasis: an update. world j radiol. 2015;7(8):202-11.  https://doi. org/10.4329/wjr.v7.i8.202. 25. liu f, zhang q, zhiu d, dong j. effectiveness of  18f-fdg pet/ct in the diagnosis and staging of osteosarcoma: a meta-analysis of 26 studies. bmc cancer. 2019:323. https://doi.org/10.1186/ s12885-019-5488-5. _hlk19586894 _hlk19586565 _hlk19304258 _hlk50035814 _hlk20357884 idx5 idx6 idx8 _hlk20358818 idx12 lor idx18 idx15 _hlk20358937 _hlk19593118 _hlk19593168 _hlk20359476 _hlk19593251 _hlk20359055 _hlk19593300 _hlk19593330 _hlk19582417 _hlk20354436 _hlk46230229 _hlk19835865 _hlk20361545 _hlk50729692 _hlk51337629 _hlk50037371 _hlk50037647 _hlk50037707 south african orthopaedic journal paediatric orthopaedics doi 10.17159/2309-8309/2022/v21n1a5mwelase sm et al. sa orthop j 2022;21(1) citation: mwelase sm, maré ph, thompson dm, marais lc. the fassier technique for correction of proximal femoral deformity in children with osteogenesis imperfecta. sa orthop j 2022;21(1):34-38. http://dx.doi. org/10.17159/2309-8309/2022/ v21n1a5 editor: dr greg firth, university of the witwatersrand, johannesburg, south africa received: january 2021 accepted: february 2021 published: march 2022 copyright: © 2022 mwelase sm. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was secured for this research. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background children with osteogenesis imperfecta frequently present with coxa vara. skeletal fragility, severe deformity and limited fixation options make this a challenging condition to correct surgically. our study aimed to determine the efficacy of the fassier technique to correct coxa vara and determine the complication rate. methods we retrospectively reviewed the records of a cohort of eight children (four females, 12 hips) with osteogenesis imperfecta (6/8 sillence type iii, 2/8 type iv) who had surgical treatment with the fassier technique for proximal femoral deformity between 2014 and 2020. results the mean age at operation was 5.8 years (range 2–10). the mean neck-shaft angle (nsa) was corrected from 96.8° preoperatively to 137º postoperatively. at a mean follow-up of 38.6 months, the mean nsa was maintained at 133°, and 83% (10/12) of hips had an nsa that remained greater than 120°. there was a 42% (5/12) complication rate: three fassier–duval rods failed to expand after distal epiphyseal fixation was lost during growth; one rush rod migrated through the lateral proximal femur cortex with recurrent coxa vara; and one rush rod migrated proximally and required rod revision. conclusion the fassier technique effectively corrected coxa vara in children with moderate and progressively deforming osteogenesis imperfecta. the deformity correction was maintained in the short term. the complication rate was high, but mainly related to the failed expansion of the fassier–duval rods. further studies are required to determine the long-term outcome of this technique. level of evidence: level 4 keywords: osteogenesis imperfecta, coxa vara, fassier–duval, neck-shaft angle, deformity the fassier technique for correction of proximal femoral deformity in children with osteogenesis imperfecta sandile m mwelase,¹* pieter h maré,² david m thompson,¹ leonard c marais³ 1 department of orthopaedic surgery, grey’s hospital, school of clinical medicine, university of kwazulu-natal, south africa ² clinical unit paediatric orthopaedics, department of orthopaedic surgery, grey’s hospital, school of clinical medicine, university of kwazulu-natal, south africa ³ department of orthopaedic surgery, school of clinical medicine, university of kwazulu-natal, south africa *corresponding author: sandilemwelase@gmail.com introduction osteogenesis imperfecta (oi) is a rare genetic disorder characterised by abnormal type 1 collagen production. the condition manifests as varying degrees of skeletal fragility and deformities of the axial and appendicular skeleton. coxa vara (cv) is a deformity of the proximal femur defined as an abnormally decreased femur neck-shaft angle (nsa). there is a relatively high prevalence of cv in children with severe oi.1 the proximal femoral deformity in oi is thought to be due to the soft-tissue tension during growth and recurrent insufficiency fractures.2 the proximal femoral deformity results in abnormal stresses on the femur, leading to progressive deformity and an increased risk of fracture. the deformed proximal femur also causes a limp and leg length discrepancy if it is asymmetrical, leading to functional impairment. the surgical treatment of cv aims to improve these functional deficits and to prevent progressive deformity and fracture. standard plate and screw constructs used to stabilise the osteotomies to correct cv from other causes are not advised in oi due to the resultant stress risers and the likelihood of peri-implant fractures.3 several authors have described, adapted and combined surgical techniques to achieve deformity correction, improve fixation of the proximal segment and allow intramedullary fixation in cv due to oi.2,4-6 these studies are all limited by small numbers without confirmation of external validity. the proximal femoral deformity in oi is also complex. severe procurvatum may result in an apparently decreased nsa, so-called ‘false coxa vara’.2 proximal control and fixation are also essential during deformity correction of these cases. the fassier technique provides increased proximal control during deformity correction, and improved fixation, compared to an intramedullary rod alone.2 https://orcid.org/0000-0001-9952-0986 page 35mwelase sm et al. sa orthop j 2022;21(1) our study aimed to evaluate the fassier technique of correction of the proximal femoral deformity in oi. our primary objectives were to determine the magnitude of correction as measured by the nsa, and to determine whether this correction was maintained at the latest follow-up. the secondary objective was to determine the short-term complication rate of this technique. patients and methods following ethical approval from our institution’s research ethics committee, we used non-probability purposive sampling to identify all patients treated with the fassier technique at our tertiary paediatric orthopaedic unit between 2014 and 2020. all oi patients younger than 18 years who were treated for proximal femoral deformity with or without visible stress fractures with expandable fassier–duval rods or rush rods and k-wire fixation utilising the fassier technique as the primary procedure were included. the study cohort included eight children (four females, 12 hips) with a proximal femoral deformity corrected with the fassier technique after one hip was excluded from analysis as surgery was done to revise a failed valgus osteotomy and plating of the right hip. the plating resulted in severe translation and distortion of the proximal femur anatomy, and we were unable to adequately correct this deformity or achieve stable fixation with the fassier technique. bilateral deformity correction (staged in three children) was required in four children. eight hips were diagnosed as cv with an nsa of less than 110° (figure 1).1,2 two hips had a decreased nsa (113° and 114°, respectively) that did not meet the diagnostic criteria of cv. the remaining two hips were diagnosed as ‘false coxa vara’ with an nsa measured as 124° and 130°, respectively.2 false cv was diagnosed when a severe procurvatum deformity was apparent on the lateral femur x-ray that resulted in the appearance of cv on the ap x-ray (figure 2). fassier et al. previously described the surgical technique.2 our indication for the procedure was any child with oi and proximal femoral deformity that required correction through a subtrochanteric osteotomy. the lateral approach was used to expose the proximal femur. two k-wires were inserted along the femoral neck axis from the posterolateral proximal femur to anteromedial in the femoral head, and from the anterolateral proximal femur to posteromedial in the femoral head. we used these wires to control the proximal fragment after a transverse proximal femoral osteotomy was performed just below the level of the lesser trochanter. in severe true cv (figure 1), the proximal entry was established in a retrograde direction from the lateral cortex. in false cv, the retrograde entry was made from within the intramedullary canal (figure 2). the proximal tip of the male component of the fassier– duval (fd) rod was passed in a retrograde direction through the proximal fragment exiting at the piriformis fossa and through a separate more proximal skin incision. the male component was then advanced, and the threaded distal end seated into the distal femur epiphysis. the female component of the fd rod was then inserted antegrade over the male component and the proximal threaded portion secured in the proximal femur. the k-wires were then cut and bent and secured to the proximal femoral shaft with two cerclage wires. all the children with oi received the intravenous bisphosphonate zoledronic acid (0.05 mg/kg zoledronic acid in 50 ml normal saline over 30 minutes) at six-monthly intervals for metabolic control of the disorder.7 clinical data was extracted from our paediatric orthopaedic database and combined with the radiological data stored in our picture archiving and communication system (pacs). data points included age at surgery, sex, body mass index percentile for age and sex (bmi percentile), mobility status, preoperative neck-shaft angle (nsa), immediate postoperative nsa, nsa at latest followup, delta nsa (the change between the immediate postoperative nsa measurement and the nsa measured at latest follow-up), and complications. figure 1. a) ap pelvis radiograph a 5-year-old boy with healed proximal femur stress fractures and coxa vara with the neck-shaft angle (x) indicated on the right hip. b) postoperative ap radiograph after bilateral fassier technique deformity correction. c) standing ap pelvis and femurs radiograph one year postoperatively with maintenance of deformity correction and expansion of the fassier–duval rods visible. b c a page 36 mwelase sm et al. sa orthop j 2022;21(1) the magnitude of nsa correction and the extent to which this correction was maintained during follow-up were the primary outcome variables. the incidence of complications was the secondary outcome variable. possible complications were recurrent deformity, loss of epiphyseal fixation with failed rod expansion (fd rods), transcortical rod migration, periprosthetic fracture, rod breakage, infection, growth arrest and hip avascular necrosis. statistical analysis statistical analysis was performed using jamovi version 1.2.18.0 open-source software.8 continuous variables were reported as mean (standard deviation [sd], range) or median (interquartile range [iqr], range), and categorical variables as number and percentages. the shapiro–wilk test was used to analyse the distribution of data. normally distributed data were compared using the unpaired student’s t-test, whereas the mann–whitney test was used for non-parametric data. categorical data were analysed using the chi-squared test unless the expected value in any cell was below 5 when fisher’s exact test was used. correlation between normally distributed continuous variables was tested with pearson’s correlation coefficient. all tests were two-sided, and the level of significance was set at p < 0.05. binomial logistic regression was used to determine the odds ratio (ors) and 95% confidence interval (95% ci) of the primary outcome measure. figure 2. a) ap radiograph of the right femur of a 4-year-old boy with false coxa vara. b) a lateral x-ray shows the procurvatum deformity which results in the appearance of coxa vara. c) postoperative radiograph demonstrates the multilevel osteotomies and fassier technique of fixation. the proximal entry is retrograde but intramedullary because there is no true coxa vara. d) standing ap radiograph three years postoperatively showing maintenance of deformity correction and expansion of the fassier–duval rod. a b c d table i: descriptive data of children with osteogenesis imperfecta treated with the fassier technique for proximal femoral deformity no oi typea ageb sex side nsac preop nsac postop nsac latest delta nsad f/ue w/cf bmig complications rodh 1 iii 8 m r 84 130 132 −2 1 0 no – rr 2 iii 5 f r 97 138 137 1 45 0 yes – fd f l 114 142 140 2 45 0 yes – fd 3 iv 3 m r 130 137 128 9 72 0 yes loss of distal epiphyseal fixation fd 4 iii 10 f r 113 152 153 −1 61 1 no – fd 1 f l 102 137 118 19 63 1 no loss of distal epiphyseal fixation fd 5 iii 5 f r 94 139 127 12 22 0 no loss of distal epiphyseal fixation fd f l 124 142 133 9 22 0 no – fd 6 iii 6 m r 56 144 142 2 12 0 no – fd m l 78 140 142 −2 12 0 no – fd 7 iii 5 f l 73 128 107 21 49 1 no proximal lateral transcortical migration rr 8 iv 2 m l n/a 137 140 −3 59 0 no proximal rod migration rr a) sillence type of osteogenesis imperfecta; b) age in years; c) neck-shaft angle in degrees; d) the difference in nsa between the postoperative and latest measurement; e) follow-up duration in months; f) wheelchair use for all mobility preand postoperatively; g) bmi > 95th percentile; h) rr: rush rod, fd: fassier–duval rod page 37mwelase sm et al. sa orthop j 2022;21(1) results the descriptive data are summarised in table i. the mean age of the patients at operation was 5.8 years (sd 2.4 years, range 2–10). of the eight children, two had sillence type iv oi, and six had type iii oi. obesity (bmi > 95th percentile for sex and age) was present in two children (three hips). intramedullary fixation was achieved with rush rods (rr) in three, and fd expandable rods in nine hips. the mean nsa preoperatively was 97° (sd 23°, range 56–130) and mean nsa postoperatively was 137° (sd 5°, range 128–148). the mean follow-up was 39 months (sd 24 months, range 1–72). at the latest follow-up, the mean nsa was 133º (sd 12.4, range 107–153). the mean delta nsa was −6° (sd 8°, range +3 to −21). the nsa remained corrected to > 120° in 83% (10/12) of hips at latest follow-up. there was no correlation between delta nsa and age at surgery (p = 0.791), bmi percentile (p = 0.722), sillence type oi (p = 0.653) or ambulatory status (p = 0.193). there was also no correlation between a lower preoperative nsa or longer length of follow-up (p = 0.174) and a higher delta tfa at latest follow-up (p = 0.567). there was a 42% (5/12) complication rate in our series. there was a 30% (3/9) incidence of loss of distal epiphyseal fixation of the male fd rod with failed rod expansion during growth. in case number 7, lateral transcortical migration of the proximal rr occurred with recurrent cv. the nsa measured 107° at latest follow-up. this child was wheelchair-bound before and after surgery due to severe recurrent kyphoscoliosis and opposite lower limb deformity, and surgical revision was not advised. the final complication occurred when the rr in case number 8 migrated proximally into the gluteal region, causing pain and hip abduction limitation. the rr was exchanged to an fd rod that was inserted percutaneously. this was the only case that underwent revision surgery. comparative analysis of data showed that age at surgery (p = 0.342), preoperative nsa (p = 0.765), oi type (p = 0.067), type of rod used (fd vs rr) (p = 0.310) and bmi percentile (p = 0.735) were not associated with a higher complication rate. discussion the role of orthopaedic surgery in oi is primarily to prevent and manage fractures or deformities. long bone deformity correction and intramedullary stabilisation improve function and decrease the incidence of fractures.9 our study aimed to evaluate the use of the fassier technique for the correction of proximal femur deformities in oi.2 the technique resulted in a correction of the nsa to within the normal range in all cases, and this correction was maintained in 83% of cases at a mean three-year follow-up. complications related to the rods used occurred in five cases, with one patient that required reoperation. the incidence of cv in oi was reported as 10% by aarabi et al. with an average nsa of 99 degrees.1 ambulatory children with cv will limp due to the shortened lever arm of the femoral neck with resultant abductor weakness muscles and a trendelenburg gait. finidori described a technique to correct cv using telescopic rods inserted retrograde on the lateral cortex of proximal femur and exiting at the piriformis fossa.10 wagner described using multiple k-wires to achieve and maintain the deformity correction of cv in young children.11 the specific surgical technique to correct cv in oi that we used combined the techniques of finidori and wagner and was first described by fassier in 2003.4 fassier et al. published their experience with this technique in 18 hips of children with oi in 2008.2 in south africa, robertson and george described a similar surgical technique for cv in oi type iii, using k-wires and a williams rod in five hips.5 the advantages of this technique are that the k-wires allow for proximal control during deformity correction, the k-wire cerclage combination provides fixation of the proximal fragment, and intramedullary fixation of the femur is still achieved with the intramedullary rod. we achieved correction of the nsa from 96.8° preoperatively to 137° postoperatively in 13 hips. this result compares favourably with those of fassier et al. (18 hips, nsa 84.6° to 119.5°) and robertson and george (five hips, nsa 60° to 130°), who both used a similar technique.2,5 compared to these two studies, our cohort had a less severe deformity, but a higher postoperative nsa. we demonstrated maintenance of this correction with a mean nsa of 133° at 39 months (3.25 years) follow-up. in the short term, this compares well with the results reported by fassier et al. (nsa of 114.4 at 4.3 years). all patients in this study received intravenous bisphosphonate treatment. while el-sobky et al., in a comparative study, concluded that surgery plus bisphosphonate treatment improves the ambulatory status of patients with oi, we were not able to confirm an improvement in ambulatory status as we only had data related to wheelchair use.12 preoperatively, two of the eight patients were wheelchair-bound, and they remained so postoperatively. none of the patients had intraoperative complications. implantrelated complications were observed in 41% (5/12) of hips. while the complication rate is relatively high, the most common complication is a 30% (3/9) incidence of distal loss of epiphyseal fixation of the male component of the fd rod and subsequent failure of rod expansion. this rate compares favourably to the 45% failure of rod expansion reported by landrum et al.13 in a recent paper, holmes et al. found that eccentric epiphysial placement may predispose the rod to fail to expand, and we now pay particular attention to achieving this outcome.14 one rr that migrated proximally required revision, and this was revised to an fd rod. the last complication was a recurrent deformity due to lateral transcortical migration of the proximal rr and loss of fixation in a child with severe oi type iii. all patients achieved radiological union, and there were no cases of postoperative infection or avascular necrosis of the hip. we could not demonstrate an association between the loss of correction of the nsa and age at surgery, bmi, sillence type oi, ambulatory status, or length of follow-up. due to our small sample size and relatively short follow-up, our results were prone to a type 2 error. further studies with larger numbers and longer follow-up are required to determine whether the deformity correction will be lasting, and which factors are associated with loss of correction. despite the small sample size, there are very few studies that report on the results of treatment of the proximal femoral deformity in oi, and its findings are therefore important. a further limitation of this study is that we were unable to measure the hilgenreiner’s epiphyseal angle (hea) accurately due to pelvic distortion and variable positioning of the lower limbs during ap pelvis x-rays during follow-up. despite this shortcoming, we were able to measure the nsa reliably. this was a single-centre study, and external validity needs to be confirmed with further studies. we included cases of ‘false cv’ and cases with a decreased nsa that was not lower than 110°. we included these because the proximal deformity in oi is varied and often multiplanar, and the advantages of the fassier technique make it applicable in all these situations. despite these shortcomings, we were able to report effective and safe deformity correction with the fassier technique in this series of children with cv secondary to oi in the short term. conclusion the fassier technique effectively corrected cv in children with moderate and progressively deforming oi. the deformity correction was maintained in the short term. the complication rate page 38 mwelase sm et al. sa orthop j 2022;21(1) was high, but mainly related to the failed expansion of the fd rods. further studies are required to determine the long-term outcome of this technique. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, ethics approval was obtained from the university of kwazulu-natal biomedical research ethics committee brec/00001850/2020. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions smm: data capture, data analysis, first draft preparation, manuscript preparation phm: study conceptualisation, study design, data capture, data analysis, manuscript revision dmt: study conceptualisation, data capture, manuscript revision lcm: study design, manuscript revision orcid mwelase sm https://orcid.org/0000-0001-9952-0986 maré ph https://orcid.org/0000-0003-1599-7651 thompson dm https://orcid.org/0000-0003-2607-3999 marais lc https://orcid.org/0000-0002-1120-8419 references 1. aarabi m, rauch f, hamdy r, fassier f. high prevalence of coxa vara in patients with severe osteogenesis imperfecta. j pediatr orthop. 2006;26(1):24-28. https://doi. org/10.1097/01.bpo.0000189007.55174.7c. 2. fassier f, sardar z, aarabi m, et al. results and complications of a surgical technique for correction of coxa vara in children with osteopenic bones. j pediatr orthop. 2008;28(8):799805. https://doi.org/10.1097/bpo.0b013e31818e19b7. 3. noonan k, enright w. bone plating in patients with type iii osteogenesis imperfecta: results and complications. iowa orthop j. 2006;26:37-40. 4. fassier f, glorieux fh. osteogenesis imperfecta. in: surgical techniques in orthopaedics and traumatology. paris: elsevier sas; 55-050-d-30,2003, 8. 5. robertson a, george ja. a surgical technique for coxa vara in osteogenesis imperfecta. sa orthop j. 2005;4(1):16-19. 6. georgescu i, gavriliu s, nepaliuc i, et al. burnei’s technique of femoral neck variation and valgisation by using the intramedullary rod in osteogenesis imperfecta. j med life. 2014;7(4):493-98. 7. palomo t, fassier f, ouellet j, et al. intravenous bisphosphonate therapy of young children with osteogenesis imperfecta: skeletal findings during follow up throughout the growing years. j bone miner res. 2015;30(12):2150-57. https://doi.org/10.1002/jbmr.2567. 8. the jamovi project (2020). jamovi (version 1.2)[computer software]. downloaded from: https://www.jamovi.org on 30 august 2020. 9. esposito p, plotkin h. surgical treatment of osteogenesis imperfecta: current concepts. curr opin pediatr. 2008;20(1):52-57. https://doi.org/10.1097/mop.0b013e3282f35f03. 10. finidori, g. treatment of osteogenesis imperfecta in children. ann n y acad sci. 1988;543:167-69. https://doi.org/10.1111/j.1749-6632.1988.tb55329.x. 11. widmann rf, hresko mt, kasser jr, millis mb. wagner multiple k-wire osteosynthesis to correct coxa vara in the young child: experience with a versatile ‘tailor-made’ high angle blade plate equivalent. j pediatr orthop b. 2001;10(1):43-50. 12. el-sobky ma, zaky hanna aa, basha ne, et al. surgery versus surgery plus pamidronate in the management of osteogenesis imperfecta patients: a comparative study. j pediatr orthop b. 2006;15(3):222-28. https://doi.org/10.1097/01.bpb.0000192058.98484.5b. 13. landrum m, birch c, richards bs. challenges encountered using fassier-duval rods in osteogenesis imperfecta. curr orthop pract. 2019;30(4):318-22. 14. holmes k, gralla j, brazell c, et al. fassier-duval rod failure: is it related to positioning in the distal epiphysis? j pediatr orthop. 2020;40(8):448-52. https://doi.org/10.1097/ bpo.0000000000001513. https://orcid.org/0000-0001-9952-0986 https://orcid.org/0000-0003-1599-7651 https://orcid.org/0000-0003-2607-3999 https://orcid.org/0000-0002-1120-8419 https://doi.org/10.1097/01.bpo.0000189007.55174.7c https://doi.org/10.1097/01.bpo.0000189007.55174.7c https://doi.org/10.1097/bpo.0b013e31818e19b7 https://doi.org/10.1002/jbmr.2567 https://www.jamovi.org https://doi.org/10.1097/mop.0b013e3282f35f03 https://doi.org/10.1111/j.1749-6632.1988.tb55329.x https://doi.org/10.1097/01.bpb.0000192058.98484.5b https://doi.org/10.1097/bpo.0000000000001513 https://doi.org/10.1097/bpo.0000000000001513 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 53 early complications of human bites to the hand in hiv-positive patients dr mtn duma mbchb senior registrar (pre-finals), department of orthopaedic surgery dr lc marais mbchb, fcs(ortho), mmed(ortho), cime, phd hod, tumour sepsis and reconstruction unit, department of orthopaedic surgery grey’s hospital, nelson r mandela school of medicine, university of kwazulu-natal, south africa corresponding author: dr mtn duma grey’s hospital town bush road pietermaritzburg 3201 email: mlekelelid@icloud.com cell: 0768195659 introduction human-inflicted bite wounds to the hand are serious injuries that may carry grave consequences. this has been evident in medical literature since the nineteenth century. in 1870 a man’s teeth marks were matched to his dead mistress and in 1894 a dentist died following a bite from a patient.1,2 in 1910 a case of a gangrenous paronychia was reported in a seven-year-old girl who had been a habitual nail-biter, and the first case of a clenched fist injury was reported in 1911.3 surgical debridement has always formed an essential part of management, even during the earlier days where ‘electrocautery and irrigation with fuming nitric acid’ was a recognised method of treatment.3 abstract background: human-inflicted bite wounds to the hand are serious injuries that may result in significant morbidity and permanent impairment. irrespective of the mechanism, they are associated with a high complication rate and this has been attributed to the unique anatomy of the hand and the pathogens involved in human bites. hiv (human immunodeficiency virus) infection is known to compromise the immune system through immune exhaustion and senescence. this potentially increases the risk of complications following human bites to the hand in hiv-positive patients. the aim of this study was to determine if hiv infection is associated with an increased risk for the development of early complications following human bites to the hand. patients and methods: we retrospectively reviewed the records of a cohort of consecutive patients treated between june 2013 and october 2014. patient charts were reviewed and information extracted with regard to demographics, the location and mechanism of the bite, occurrence of complications, hiv status and cd4 counts, as well as whether they were taking arv (antiretroviral) medication at the time. the time from injury to presentation was recorded, as well as the time from injury to surgical intervention. results: thirty-nine patients were included in the study and there were no exclusions. the mean age of patients was 31.5 years (range 14–60 years), with an approximately equal distribution between males and females. sixteen patients (41%) in our study cohort were found to be hiv-positive, 15 patients were hiv-negative (38%), and in eight cases (21%) the hiv status was unknown. of the hiv-positive patients, 44% had cd4 counts below 350 cells/mm3 but only four (25%) were on art (anti-retroviral therapy) at the time of injury. complications occurred in 88% (14/16) of the hiv-positive patients compared to 80% (12/15) in the hiv-negative group (risk ratio [rr] = 1.09; 95% confidence interval [ci] = 0.8–1.5; p=0.65) conclusions: hiv infection was not associated with an increased risk of developing complications following human bites to the hand in this series. an increase in the time from injury to presentation was however associated with an increased risk of amputation. key words: human bite, hand, hiv, complications, sepsis, infection http://dx.doi.org/10.17159/2309-8309/2016/v15n4a8 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 53 page 54 sa orthopaedic journal summer 2016 | vol 15 • no 4 human bite injuries of the hand may be classified as either occlusive or clenched fist (fight bite). irrespective of the mechanism, they are associated with a high complication rate and this has been attributed to the unique anatomy of the hand and the pathogens involved in human bites.3,4 in addition, wounds are generally small in size resulting in a casual approach to their management. about a third of patients who present with a human bite injury to the hand may present a different cause of their injury rather than a human bite and thus it is important to have a high index of suspicion when viewing injuries over the dorsal area of the metacarpals.3-5 complications of a human bite include cellulitis, septic arthritis, tenosynovitis, hand stiffness, lymphangitis and osteomyelitis.4,6,7 certain developing regions have been experiencing a growing level of social and interpersonal violence.8 as a result, human bites to the hand have also been encountered more frequently. the increasing prevalence of this injury complex exposed the paucity of literature on the topic of human bites to the hand in hiv-positive patients. in the region where this study was performed an estimated 21.5% of adults between the ages of 15 and 50 years are living with hiv.9-11 hiv infection is known to compromise the immune system, through immune exhaustion and senescence. this potentially increases the risk of complications following human bites to the hand in hiv-positive patients. the aim of this study was to determine if hiv infection is associated with an increased risk for the development of early complications following human bites to the hand. patients and methods we retrospectively reviewed the records of a cohort of consecutive patients who were referred to our regional level orthopaedic unit with human bites of the hand between june 2013 and october 2014. ethical approval was obtained from our institution’s ethics review board prior to commencement of the research (brec ref: be 020/15). approval was also received from the provincial department of health and the hospital where the research was performed (ref: hrkm 70/15). all patients over the age of 13 years with human bite injuries to the hand were included. cases where the human bite injury did not involve the hand or where the bite was not caused by a human were excluded. patients with hand infection prior to suffering a human bite were also excluded. patient charts were reviewed and information extracted with regard to demographics, the location of the bite, occurrence of complications, microscopy and culture results, antibiotic sensitivity profiles, hiv status of patients and their cd4 counts, as well as whether patients were on anti-retroviral medication at the time of presentation. the time from injury to presentation was recorded, as well as the time from injury to surgical intervention. complications were defined as cellulitis, septic arthritis, tenosynovitis, osteomyelitis and surgical amputation. statistical analysis was performed using stata 13.0 (statacorp. college station, texas). continuous variables were reported as mean (± sd) or median (with interquartile range) and categorical variables as numbers and percentages, unless otherwise stated. differences in continuous variables were compared with the use of the unpaired t-test or the mann-whitney test (depending on the distribution of the data). categorical data was compared using the fisher’s exact test (if any cell count was below 5) or the chi-squared test (if no cell count below 5). all tests were two-sided and the level of significance was set at p ≤ 0.05. results a total of 39 patients were included in the study and there were no exclusions. the mean age of patients was 31.5 years (range 14–60 years; standard deviation [sd] = 11.4 years), with an approximately equal distribution between males (n=20) and females (n=19). there was no significant difference in the age of patients by gender (p=0.48). the type of injuries were occlusional bites (64%), fight bites (15%), traumatic amputation (18%) and one self-inflicted occlusion bite (3%). the most commonly injured digit(s) were the thumb and ring finger (26% each), followed by the middle finger (18%), with the remaining digits affected equally. forty-three per cent of middle finger injuries were the result of a fight bite. in 8% of cases the anatomical location of the bite injury was not specified in the records. a total of 16 patients (41%) in our study cohort were found to be hivpositive, 15 patients were hiv-negative (38%), and in eight cases (21%) the hiv status was unknown. of the hiv-positive patients, 44% had a cd4 counts below 350 cells/mm3 but only four (25%) were on art (antiretroviral therapy) at the time of injury. the mean time to presentation, time from injury to initial debridement and duration of hospital stay is given in table i. the duration of hospital stay was found to be independent of the time to presentation (p < 0.01) (figure 1). the duration of hospital stay was significantly longer in the hiv-positive group (9.9 vs 4.7 days; p < 0.01). none of the patients in our study group required admission to a critical care unit. complications occurred in 77% (30/39) of cases and the development of a complication was associated with an increased duration of hospital stay (p=0.05) these included cellulitis (n=17), soft tissue loss requiring split skin graft (n=2), septic arthritis (n=6), osteomyelitis (n=3), tenosynovitis (n=1) and surgical amputation (n=5). there was no significant difference in the time to presentation (median = 3 days, interquartile range [iqr] = 6) of the group of patients who did develop complications in comparison to the group without complications (median = 1 day, iqr = 2) (p=0.07). we did, however, observe an increased time to presentation (median = 7 days, iqr = 27) in the subset of patients who required amputation (p=0.05). saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 54 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 55 page 56 sa orthopaedic journal summer 2016 | vol 15 • no 4 hiv-positive and -negative patients (p=0.65). hiv-positive status was however associated with an increased duration of hospital stay (p=0.05). the cases in our cohort were somewhat older (mean 31.5 years) than those in previous studies and we found an equal distribution of males and females, in comparison to other studies where mostly males were affected with an average age of 24 years.3,7,8 the most common type of human bite injury to the hand has previously been reported to be fight bites.3-5 this was not our experience as 67% of cases involved the occlusive type of bite injuries. delay in presentation has been documented extensively in the literature as the single most important determinant of morbidity following human bites to the hand.3,6,7,12,15,16 in our series, the association between time to presentation and the development of complications did not reach statistical significance (p=0.07). there was however an increased risk of surgical amputation in cases with a delay in presentation (p=0.05). there have been several recent clinical studies in orthopaedics that have shown that the hiv-positive population is not at an increased risk of infection or fracture non-union when compared to the hiv-negative population. ferreira and marais investigated the rate and severity of pin track sepsis in hiv-positive and hiv-negative patients treated with circular external fixators. in their retrospective analysis of 229 patients they found no statistically significant difference in the incidence of pin track sepsis (p=0.94) and no statistically significant difference in the severity of pin track sepsis (p=0.9) between the two groups. they also found that the cd4 count had no influence on either the incidence (p=0.57) or the severity (p= 0.21) of pin track sepsis.10 graham et al., in their prospective single blinded controlled study, presented 91 hiv-positive patients who underwent 103 procedures which involved the insertion of 111 implants. they followed up this group for a mean of 27 months, and found no association between the hiv status and developing late implant sepsis following internal fixation in acute trauma. they also found that if the hiv-positive patient develops early (< 6 weeks) infection and they receive appropriate management it is unlikely that they will develop late implant sepsis.17 gardner et al. looked at fracture union following internal fixation in the hiv-positive population, in the largest study to date investigating fracture union in the hiv-positive population. of 506 consecutive patients they had 96 hiv-positive patients with 107 factures that required internal fixation, with an average age of 37.8 years. they observed a non-union rate of 7.7% in femur fractures (the most frequent injury in their study) which was comparable to that found in series involving seronegative patients, whose non-union rate ranged from 0–10% in the femur.18 immune compromise has been mentioned as a risk factor for the development of infection following human bites to the hand.7,12-15,19 our data suggests that an hiv-positive patient is not necessarily at increased risk for the development of early complications, irrespective of anti-retroviral therapy or the patient’s cd4 count. hiv-positive status was however associated with an increased duration of hospital stay (p < 0.01). our data on the microbiology of infections was insufficient to draw any definitive conclusions in this regard. previous studies identified streptococcus spp and staphylococcus spp, followed by eikenella corrodens and anaerobes, as the most common organisms involved in human bites of the hand.5,7,20 we observed a similar trend, except we did not identify eikenella corrodens in any of our specimens. screening for exposure to hepatitis b virus was not performed in any of our patients. this is of concern as hepatitis b virus is 20–100 times more likely to be transmitted from a human bite than hiv.7,14 we recognise the fact that this study has various limitations. the retrospective nature creates a problem in terms of the completeness of the data. this was illustrated by the fact that microscopy and culture results were only recorded in a small number of cases. a longer follow-up is required in order to assess the impact of hiv infection on a wider range of complications and permanent impairment. in addition the small difference in the frequency of complications in hiv-positive and -negative patients necessitates a much larger sample size. we propose that a larger prospective study is undertaken in order to determine the association of hiv infection and infectious complications as a result of human bites to the hand. conclusion patients with human bite injuries to the hand are at a high risk of developing complications. as such, they require urgent surgical debridement and administration of broad spectrum empiric antibiotic therapy that should be tailored to the suspected organism and adjusted according to the culture results and clinical response. in this series, hiv infection was not associated with an increased risk of developing complications following human bites to the hand. an increase in the time from injury to presentation was however associated with an increased risk of amputation. compliance with ethics guidelines • conflict of interest drs duma and marais have no financial or personal relationships with any individual and/or organisation that has or could have influenced their work. this article is the sole work of the authors and no benefits have been received from a commercial entity related directly or indirectly to the subject of this article. • ethics statement this article was not submitted to an ethical committee for approval. ethical approval was obtained from our institution’s ethics review board prior to commencement of the research (brec ref: be 020/15). approval was also received from the provincial department of health and the hospital where the research was performed (ref: hrkm 70/15). saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 56 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 57 references 1. pierce l, strickland d. the case of ohio vs robinson. an 1870 bite mark case. am j forensic med pathol 1990;11(2):171-77. 2. hyson jm jr. patient bites dentist: an 1894 case report. j hist dent 1998;46(2):76. 3. tonta k, kimble fw. human bites of the hand: the tasmanian experience. anz j surg 2001;71(8):467-71. 4. kennedy s, stoll el, lauder as. human and other mammalian bite injuries of the hand: evaluation and management. j am acad orthop surg 2015;23(1):47-57. 5. green dp, wolfe sw, hotchkiss rn, pederson wc, kozin sh. green’s operative hand surgery. edn 6, vol. 1, elsevier churchill livingstone, usa, 2011, 73-74. 6. dreyfuss uy, singer m. human bites of the hand: a study of one hundred six patients. j hand surg 1985;11:884-89. 7. kelly ip. management of human bite injuries of the hand. injury 1996;27:481-84. 8. website. [www.crimestatssa.com/precinct.php]. visited on 08 august 2015. 9. marais lc, ferreira n. osteosarcoma in adult patients living with hiv/aids. isrn onco. 2013 mar 14; 2013: 219369. doi:10.1155/2013/219369. 10. ferreira n, marais lc. the effect of hiv infection on the incidence and severity of circular external fixator pin track sepsis: a retrospective comparative study of 229 patients. strat traum limb recon 2014;9:111-15. 11. website. [http://www.health-e.org.za/wp-content/ uploads/2014/05/ashivherp_report2014_22may2014. pdf]. visited 03 july 2015. the 2012 national antenatal sentinel hiv & herpes simplex type-2 prevalence survey in south africa. 12. harrison m. a 4-year review of human bite injuries presenting to emergency medicine and proposed evidence-based guidelines. injury 2009;40:826-30. 13. broder j, jerrard d. low risk of infection in selected human bites treated without antibiotics. am j emerg med. 2004 jan;22(1):10-13. 14. morgan m. hospital management of animal and human bites. j hosp infect 2005; 61:1-10. 15. raval p, khan w, haddad b, anant narayan mahapatra. bite injuries to the hand review of the literature. open orthop j 2014;8:204-208. 16. mennen u, howells cj. human fight-bite injuries of the hand. a study of 100 cases within 18 months. j hand surg br 1991;16(4):431-35. 17. graham sm, bates j, mkandawire n, harrison wj. late implant sepsis after surgery in hiv positive patients. injury 2015;46(4):580-84. 18. gardner ro, bates j, ng’oma e, harrison. fracture union following internal fixation in the hiv population. injury 2013;44(6):830-33. 19. griego rd, rosen t, orengo if, wolf je. dog, cat, and human bites: a review. j am acad dermatol 1995;33(6):1019-29. 20. talan da, abrahamian fm, moran gj, et al. clinical presentation and bacteriologic analysis of infected human bites in patients presenting to emergency departments. clin infect dis 2003;37(11):1481-89. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 57 page 194 south african orthopaedic journal http://journal.saoa.org.za doi 10.17159/2309-8309/2020/v19n4a0 editorial as i write this, we are coming to a plateau phase in the covid-19 pandemic and things seem to be slowly returning to some form of normality. we hope that fears of a second peak will not be realised and that our country will indeed proceed to a semblance of its prior self. despite the last chills in the air, spring is also setting in and there are blossoms on the trees and birds singing in the garden. in the veld it is time for the baby animals, and new life abounds. at this time of renewal after the long and hard winter, it is useful to reflect on lessons learnt during this pandemic. in the words paraphrased from and attributed to winston churchill: ‘it would be a shame to let a good crisis go to waste.’ in this spirit, allow me to share some observations and lessons learnt during these interesting times. the three important lessons i have taken to heart are resilience, gratitude and simplicity. we will focus on resilience in different spheres of life and how that can position us to withstand life’s storms. resilience in this sense is not about resisting change, but about being able to withstand a changing and challenging environment and how to thrive despite the turbulence around us. this unprecedented worldwide situation has decimated economies, destroyed livelihoods and taken lives. in south africa we have been hard hit against a backdrop of an already struggling economy. it is clear that the ability to weather different aspects of this storm has been essential in surviving through these tough times. it will also be a key aspect in being able to negotiate a future which seems uncertain in most places in the world. this resilience is needed on a personal, family, community and business level to survive and eventually thrive. on a personal level it has been exceptionally important to remain strong and fulfil our leadership roles in different spheres of life. it has been important to withstand the storm and to remain mentally calm and strong – despite the lack of an alcoholic beverage or two! i have found that regular exercise prior to the pandemic has created a mental toughness which has been very useful in withstanding the psychological stresses of the pandemic and lockdown. during the lockdown phase, exercise continued to create resilience by providing a much-needed daily routine as well as a sense of purpose in a world that seemed to have gone crazy. at family level i have been incredibly impressed with children transitioning into online schooling with reasonable ease despite the challenges of not having sports or social events. of course, this came at a price – an astronomical bill for internet services and data! it is important to build resilience into children and to empower them to be strong yet adaptable. for younger kids, a routine is critically important and, coupled with age-appropriate information, it turns a seemingly hopeless situation into something that they feel they have some control over. older children respond well to chores, responsibilities and boundaries, all of which serve to create tenacity. again, the power of exercise cannot be overstated. burning all the extra nervous energy is extremely useful, but so is the mental tenacity needed to push through pain and fatigue boundaries. being increasingly self-sufficient in terms of water, electricity and food is a growing worldwide trend and can improve a family’s resilience greatly. a good starting point is to grow a vegetable and herb garden, keep a few chickens and to collect rainwater. installing a solar panel electrical system or generator can be extremely useful, especially against the backdrop of loadshedding starting up again. all of these strategies will serve to improve resilience of the family unit. at community level it has been inspiring to see communities banding together to help themselves, but also others. community resilience can be improved through initiatives like neighbourhood security groups, bartering and exchange of goods and services and by buying products or services from local providers. setting up a community-based directory to list all available service providers and their contact details within a community is a useful way to facilitate this. as a doctor and orthopaedic surgeon, it has always been my belief that the sacrifices made as a student and registrar early on in life would be offset by job security later on in our careers. it has become clear that job security for specialists in private practice is a somewhat fuzzy concept. within a very short space of time, our ability to work and earn a living was severely impacted due to no fault on our part. elective surgery effectively ground to a halt and hospitals became no-go zones for patients. many a colleague wondered whether it would be beneficial to start doing trauma calls again. it is clear that our practices are not immune to crises and that we should build resilience here too. group practices have the benefit of having multiple partners with slightly different skill sets. this allows practices to function in different teams during the pandemic, effectively protecting the continuity of the business should any one team member get infected. having different skill sets or interests allows the practice to continue functioning and surviving even when one type of procedure is limited or impossible. a good example during the pandemic was that trauma orthopaedics could continue somewhat despite the fact that arthroplasty ground to a halt in most practices. lessons learnt from a pandemic: how to create resilience birkholtz f mbchb, mmed(orth), fcorth(sa) orthopaedic surgeon at walk-a-mile centre and extraordinary lecturer at the department of orthopaedics, university of pretoria, south africa corresponding author: dr franz birkholtz, email: fbirkholtz@gmail.com dr franz birkholtz page 196 being up to date with tax payments and also assistants’ and serviceprovider payments prior to a crisis allows a practice to postpone or stagger some of these payments in the event of a crisis, optimising cash flow. remember that buying the latest car or hunting rifle does not constitute a crisis! having a healthy overdraft facility as well as a sizeable nest egg in the bank account is essential in weathering cashflow storms in the practice. advice from business coaches and business analysts is to have approximately three months’ worth of operating expenses in the bank in case a crisis hits and earning potential is limited. having staff that are motivated, loyal and multi-skilled means that in times of crisis a practice can cope with less staff if need be in order to limit the effects of a high wage bill during a crisis. working in different facilities and also having day clinic lists improves resilience greatly and allows a practice to continue working even if one facility is compromised. creating different revenue streams has been shown to be not only useful, but in a certain sense essential in having a resilient practice. orthopaedic surgeons generate income most effectively when operating. it is, however, useful to add additional revenue generators like medico-legal reporting, educational consulting and product development work to the practice. outside of the practice it can be beneficial to develop an investment portfolio to render a passive income revenue stream. property is a useful asset in this regard, provided that it is not overleveraged. at the end of the day life will present us with challenges which are mostly outside of our control. it is up to us to position ourselves to be able to respond to these with purpose and resilience and to thrive despite them. south african orthopaedic journal http://journal.saoa.org.za south african orthopaedic journal shoulder and elbow doi 10.17159/2309-8309/2022/v21n1a8meier w et al. sa orthop j 2022;21(1) citation: meier w, tsama m, aden aa. a rare occurrence of ganglion cysts on the posterolateral aspect of the elbow without neurological manifestations: a case series and review of the literature. sa orthop j 2022;21(1):52-56. http://dx.doi. org/10.17159/2309-8309/2022/ v21n1a8 editor: prof. theo le roux, university of pretoria, pretoria, south africa received: march 2021 accepted: may 2021 published: march 2022 copyright: © 2022 meier w. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to this study. abstract background the occurrence of ganglion cysts around the elbow is rare, and the occurrence of these lesions without any symptoms of compression to the nearby structures is even rarer. most published cases of elbow ganglions have reported patients with symptoms relating to compression of the radial nerve, or branches thereof secondary to anteriorly located cysts. we present two cases of ganglions occurring on the posterolateral aspect of the elbow with no pressure symptoms to the radial nerve. case series the first case is a 33-year-old male, with a seven-month history of a spontaneous, slow-growing mass on the posterolateral aspect of his left elbow. the second case is a 38-year-old female, with a 12-month history of a spontaneous mass on the posterolateral aspect of her left elbow. in both cases, the reason for presentation was the unsightly elbow with an enlarging mass. the lesions were painless and both patients were neurologically intact with no restriction on range of motion of the joint. both patients underwent excision of the mass for aesthetic reasons. discussion patients with elbow ganglions usually have cysts located anterior to the radiocapitellar joint and almost invariably present with an associated motor, or less commonly, a sensory deficit of the radial nerve. various treatment modalities have been reported; however, the vast majority undergo open surgical excision due to their association with progressive neurological symptoms. this usually leads to resolution of symptoms, and recurrence is rare. conclusion the clinical presentation of the two patients reported in this case series seems to be far less frequent than patients presenting with a neuropathy of the radial nerve due to an anteriorly located elbow ganglion. it cannot, however, be excluded that there is an underreporting of asymptomatic elbow ganglions. according to our review of the english literature, this is only the third report of an asymptomatic elbow ganglion in the lateral compartment of the elbow. level of evidence: level 5 keywords: elbow, ganglion, cyst a rare occurrence of ganglion cysts on the posterolateral aspect of the elbow without neurological manifestations: a case series and review of the literature warren meier,* mluleki tsama, abdirashid a aden department of orthopaedic surgery, university of the witwatersrand, helen joseph hospital, johannesburg, south africa *corresponding author: meier@vodamail.co.za introduction ganglion cysts are benign lesions commonly found around the wrist and hand, with the dorsum of the wrist being the commonest location.1,2 the occurrence of these cystic lesions around the elbow is rare, and when they do occur, they often present with symptoms related to the pressure they exact on the nearby structures.2 in most published cases of elbow ganglions, the cyst is located anterior to the radiocapitellar joint and patients usually present with motor and/or sensory fallout in the distribution of the radial nerve and its branches, depending on the level of compression.2,3 these cystic lesions may also present with pain and restriction of joint movement.2 the occurrence of ganglion cysts around the elbow with no pressure symptoms to the nearby structures is a rarity. herein, we present two cases of such cystic lesions occurring spontaneously on the posterolateral aspect of the elbow with no pressure symptoms to the radial nerve. in both cases, the reason for presentation was the unsightly elbow with an enlarging mass. case 1 a 33-year-old male, unemployed, right hand dominant, presented to our unit with a seven-month history of an asymptomatic, slowgrowing mass on the posterolateral aspect of his left elbow. he reported no specific antecedent traumatic event and the reason for his presentation was the cosmetically unappealing mass. he had no pain and there was no associated weakness or numbness in the limb. the patient had no medical comorbidities and requested removal of the mass for aesthetic reasons. https://orcid.org/0000-0002-1958-147x page 53meier w et al. sa orthop j 2022;21(1) on clinical examination, he had a bi-lobed mass on the posterolateral aspect of his left elbow, with each lobe measuring 1.5 cm × 1.5 cm (figure 1). the mass was non-tender and firm to palpation with limited mobility and non-adherent to the overlying skin. the mass transilluminated on application of a light source. the elbow range of motion was unaffected compared to the contralateral side. the pulses distally were normal, as was the neurological examination. x-rays showed a soft tissue swelling in the area of the mass over the radiocapitellar joint, with a normal osseous anatomy (figure 2). the patient was taken to theatre for an excisional biopsy under general anaesthesia. the limb was elevated and a tourniquet applied for a clear field of dissection. a kocher approach was utilised to expose the mass. a septated cystic mass measuring 1.0 cm × 2.0 cm was found protruding through the common extensor–supinator muscle fascia. the stalk of the lesion was followed down to its origin on the lateral aspect of the radiocapitellar joint. when the mass was ruptured, it contained the typical clear, thick gelatinous fluid of a ganglion cyst (figure 3). the mass was carefully separated from the surrounding soft tissue and removed from the base of its stalk in its entirety. at the six-week follow-up, the patient had full elbow range of movement and was neurologically intact with no recurrence of the lesion. case 2 a 38-year-old housewife, right hand dominant, presented to us with a 12-month history of a spontaneous mass on the posterolateral aspect of her left elbow. there was no history of trauma or any exacerbating factors. the patient complained of minimal discomfort and requested excision of the mass for cosmetic reasons. there was no associated weakness or numbness in the limb. the discomfort was localised and did not radiate down the arm. the patient was otherwise healthy with no medical comorbidities. clinical examination revealed a small mass on the posterolateral aspect of the left elbow (figure 4). the mass was firm and nontender to palpation. it felt fixed to the underlying structures but not to the overlying skin. on application of a light source, the mass transilluminated. the range of motion of the elbow was unaffected compared to the contralateral side. her neurological examination was normal, as were the distal pulses. the x-rays of the affected elbow were normal. the patient was taken to theatre for an excisional biopsy. under general anaesthesia, the limb was elevated and a tourniquet applied for a clear field of dissection. a kocher approach was used, and revealed a cystic mass measuring 1.2 cm × 2.5 cm. the mass had a stalk originating from the radiocapitellar joint. it was carefully separated from the surrounding soft tissue and removed from the base of its stalk. when the mass was ruptured post removal, it contained the typical clear, thick gelatinous fluid of a ganglion cyst. at the six-week follow-up the patient had full elbow range of movement and was neurologically intact with no recurrence of the lesion. discussion the clinical diagnosis of a soft tissue swelling around the elbow joint can at times be challenging. common pathologies include bursitis, gouty tophi, rheumatoid nodules and lipomas. because the diagnosis of an elbow ganglion is rare, the majority of cases reported in the literature are confirmed preoperatively figure 1. preoperative clinical pictures demonstrating the bi-lobed mass on the posterolateral aspect of the left elbow figure 2. preoperative ap and lateral x-rays of the left elbow showing a soft tissue shadow over the area of the mass with normal osseous anatomy page 54 meier w et al. sa orthop j 2022;21(1) by ct, mri and/or ultrasonography.2-14 the vast majority of these cases reported on, unlike our two cases, were of patients presenting with anteriorly located ganglions and symptomatic compression of various regions of the radial nerve. ganglions around the wrist occur commonly, and have characteristic features on physical examination. wrist ganglions are frequently diagnosed clinically and excised without additional imaging. few cases of elbow ganglions being excised without requiring additional further imaging aside from x-rays have been reported.6,15-17 the clinical presentation and examination findings of patients with elbow ganglions varies among the cases reported. the majority of these cases present with weakness or numbness in the distribution of the radial nerve or posterior interosseous nerve.3-6,8-11,13-18 many cases present with an indiscrete elbow swelling with or without pain or neurology.4,5,8-10 some cases present only with neurological symptoms and no identifiable swelling or mass and are subsequently found to be ganglions on advanced imaging studies or on surgical exploration.5,6,10,11,14-16 only ogino et al. in 1991 reported on a case series in which two of six patients had clinical examination findings clearly suggesting a ganglion.5 both our cases had clinical features typical of any ganglion. there have been very few cases that have been reported in patients with a confirmed ganglion arising from the elbow joint without any neurological fallout. in 2000, feldman reported a 47-year-old female who had a nine-month history of a painless anterior elbow mass. diagnosis of a ganglion was made on mri and the patient opted for conservative management but returned two and a half years later for arthroscopic excision. at no point did she experience any neurological fallout.7 in 2014, erol et al. presented a case of a 62-year-old female who presented with pain in her elbow that radiated down the dorsoradial aspect of her forearm. although this suggests compression of the superficial radial nerve, the authors reported no motor fallout and no altered sensation in the distribution of the superficial radial nerve. initially diagnosed as radial tunnel syndrome, the patient was treated conservatively but after four weeks with no resolution, returned and was diagnosed with a ganglion anterior to the radiocapitellar joint on mri. the cyst was decompressed by ultrasound-guided aspiration and her symptoms resolved.12 in 2014 vaishya et al. reported on a 45-year-old female who presented with a tender mass on the anterolateral aspect of her elbow but with no evidence of a compressive neuropathy. mri revealed a ganglion anterior to and communicating with the radiocapitellar joint, and this was confirmed after open excision of the mass which was sent for histological examination.2 in 2019, gnany et al. presented a 60-year-old male patient with a painful mass on the anteromedial aspect of his left elbow and arm. mri revealed a multi-lobed mass which was in close proximity to the ulnar nerve; however, the patient had no features of a compressive neuropathy. the mass was excised, and histopathological examination confirmed the diagnosis of a ganglion cyst.19 in this case, the ganglion originated from the medial compartment of the elbow, unlike our two cases and the rest of the cases referenced in this article which originated from the lateral compartment. both of our cases had no pain, no motor fallout and normal sensation, with no pain radiating in the distribution of the superficial radial nerve. in contrast to the above cases, both of our cases had cysts on the posterolateral aspect of the elbow. the vast majority of elbow ganglions reported in the literature have been associated with a neuropathy of the radial nerve and have been found anterior or anterolateral to the radiocapitellar joint in the region of the radial tunnel. depending on the location of the ganglion and what part of the radial nerve the ganglion compresses, patients have presented with three different clinical scenarios.5,13 some have had mixed motor and sensory symptoms figure 3. clinical pictures of the mass intraoperatively: the left picture shows the typical thick gelatinous fluid of a ganglion cyst originating from the mass; the right picture shows the mass post excision figure 4. preoperative clinical pictures demonstrating a mass on the posterolateral aspect of the left elbow page 55meier w et al. sa orthop j 2022;21(1) when the ganglion compressed the common radial nerve or both the posterior interosseous nerve and the superficial sensory branch.3,5,18 some have had purely motor symptoms if the ganglion compressed only the posterior interosseous nerve, while others have had purely sensory symptoms when the ganglion only compressed the superficial sensory branch of the nerve.3,5,13 the most common clinical entity of the three is patients who present with isolated motor fallout due to compression of the posterior interosseous nerve from an anteriorly located elbow ganglion (table i). in 2007, yamazaki et al. described two types of ganglions of the elbow according to their anatomic location in relation to the arcade of frohse. type a elbow ganglions are located proximal to the arcade of frohse, while type b elbow ganglions are located distal to it. the authors described that type a ganglions displace the posterior interosseous nerve, the superficial sensory branch and the motor branch to the extensor carpi radials longus muscle anteriorly. because only the posterior interosseous nerve travels under the arcade, unlike the other two divisions, patients with type a elbow ganglions are more likely to present with purely motor symptoms.3 in contrast to this, miralles et al. in 2016 described a case series of eight elbow ganglions in seven patients who presented with type a elbow ganglions who had purely sensory changes in the distribution of the superficial radial nerve, with no motor fallout.13 both our cases display ganglions that originated posterolateral to the radiocapitellar joint. they did not protrude anteriorly toward the supinator where the radial tunnel is located. they therefore could not be classified according to the system proposed by yamazaki et al. we therefore propose a new classification system for elbow ganglions (table ii) modified from the original classification system by yamazaki et al. various treatment modalities have been reported for elbow ganglions. the majority of cases reported, unlike our two cases, were symptomatic. as a result, the vast majority of cases are treated by decompression or excision of the cyst. lee et al. in 2013 reported a 65-year-old female with an ultrasoundand mriconfirmed ganglion of the elbow and associated weakness of finger extension who deferred aspiration. the patient followed up three months later and had slight improvement of symptoms. this is the only report of a conservatively treated elbow ganglion that could be found in the literature.11 two cases of elbow ganglions treated with ultrasound-guided aspiration have been reported. erol et al.’s case reported in 2014 with ultrasound-guided aspiration of an elbow ganglion remained symptom free at nine-month follow-up.12 in 2017, seki reported a case of a 77-year-old male with an ultrasound-confirmed elbow ganglion and a posterior interosseous nerve palsy, who was treated with ultrasound-guided aspiration. the patient’s symptoms table i: summary of the cases reviewed with demographic data, clinical presentation and mode of treatment used author year sex age (years) location of mass on elbow type of nerve palsy treatment bowen and stone15 1966 m 57 anterior pin open excision mass, et al.16 1982 f 41 anterior pin open excision hermansdorfer, et al.17 1986 f 30 anterolateral srn open excision mccollam, et al.4 1988 2f 1m 16–52 2 anterior, 1 posterolateral 2 pin 1 pin + srn open excision ogino, et al.5 1991 5f 1m 27–56 anterior 3 pin + srn 2 pin 1 srn open excision steiger and vögelin6 1998 1f 1m 1? 31–64 anterior and anterolateral pin open excision feldman7 2000 f 47 anterior none arthroscopic excision matsubara, et al.18 2006 4m 3f 31–66 anterior 6 pin 1 pin + srn open excision yamazaki, et al.3 2007 8m 6f 40–65 anterior and anterolateral pin 12 open excision 1 aspiration 1 conservative lifchez, et al.8 2008 2m 56 + 73 anterior 1 srn 1 pin + srn 1 open excision 1 patient died before open excision mcfarlane, et al.9 2008 f 45 anterior srn open excision jou, et al.10 2009 2f 31 + 36 anterior and anterolateral 1 pin 1 srn open excision lee, et al.11 2013 f 65 anterior pin + srn conservative (aspiration declined by patient) erol, et al.12 2014 f 62 anterior ? pain in srn distribution but no altered sensation aspiration (ultrasound-guided) miralles, et al.13 2016 7f 1m 33–52 anterior srn open excision vaishya, et al.2 2016 f 45 anterior none open excision seki14 2017 m 77 anterior pin aspiration (ultrasound-guided) gnany, et al.19 2019 m 60 medial none open excision meier, et al. 2021 1m 1f 33 + 38 posterolateral none open excision m: male; f: female; pin: posterior interosseous nerve palsy; srn: superficial branch of the radial nerve palsy page 56 meier w et al. sa orthop j 2022;21(1) resolved and he remained symptom-free at the 17-month followup.14 data is lacking with regard to long-term follow-up of patients with elbow ganglions treated with aspiration, but recurrence rates of ganglions treated elsewhere in the body have been shown to be over 50% when treated with aspiration.20 feldman’s report of an arthroscopically excised elbow ganglion in 2000 is the only case that has been reported with this modality of treatment. the patient developed a transient neuropraxia of the superficial sensory branch of the radial nerve postoperatively, which resolved within one week and there was no evidence of recurrence at the 18-month followup.7 the vast majority of cases reported have been treated with open surgical excision of the cyst, with symptom resolution and no recurrence.2-4,6,8-10,13,15-18 conclusion ganglions that occur around the elbow are infrequently encountered. most cases reported on in the literature consist of case reports and small case series. they appear to occur more commonly in females and usually present between the third and sixth decades of life. the most common clinical scenario reported in the literature occurs secondary to an anterior elbow ganglion in the region of the radial tunnel. these patients usually present with lateral-sided elbow pain, commonly initially misdiagnosed as lateral epicondylitis, with or without associated neurological symptoms of the radial nerve. most patients have motor weakness due to compression of the posterior interosseous nerve; less frequently, patients have sensory disturbances in the distribution of the superficial sensory branch of the radial nerve. unlike our two patients, most cases are not easily diagnosed clinically and require further advanced imaging. this case series presents two patients with asymptomatic posterolateral elbow ganglions who requested removal for aesthetic reasons. this clinical presentation seems to be far less frequent than patients presenting with a neuropathy of the radial nerve; however, it cannot be excluded that there is an underreporting of asymptomatic elbow ganglions in the literature. according to our review of the english literature this is only the third report of an asymptomatic elbow ganglion in the lateral compartment of the elbow. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, ethical approval was obtained from the following ethical review board: university of the witwatersrand human research ethics committee (medical), reference number: m210285. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was obtained from all patients for being included in the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions wm: study conceptualisation, data capture, first draft preparation, manuscript preparation, manuscript revision mt: study conceptualisation, manuscript revision aaa: study conceptualisation, data capture, manuscript revision orcid meier w https://orcid.org/0000-0002-1958-147x tsama m https://orcid.org/0000-0001-6681-0848 aden aa https://orcid.org/0000-0001-5589-2972 references 1. plate a, lee s, steiner g, posner m. tumorlike lesions and benign tumors of the hand and wrist. j am acad orthop surg. 2003;11(2):129-41. https://doi.org/10.54 35/00124635-200303000-00007. 2. vaishya r, kapoor c, agarwal a, vijay v. a rare presentation of ganglion cyst of the elbow. cureus. 2016;8(7):e665. https://doi.org/10.7759/cureus.665. 3. yamazaki h, kato h, hata y, murakami n, saitoh s. the two locations of ganglions causing radial nerve palsy. j hand surg eur vol. 2007;32(3):341-45. https://doi.org/10.1016/j. jhsb.2006.09.014. 4. mccollam s, corley f, green d. posterior interosseous nerve palsy caused by ganglions of the proximal radioulnar joint. j hand surg am. 1988;13 a(5):725-28. https://doi.org/10.1016/ s0363-5023(88)80134-5. 5. ogino t, minami a, kato h. diagnosis of radial nerve palsy caused by ganglion with use of different imaging techniques. j hand surg am. 1991;16(2):230-5. https://doi.org/10.1016/ s0363-5023(10)80102-9. 6. steiger r, vögelin e. compression of the radial nerve caused by an occult ganglion. j hand surg eur vol. 1998;23 b(3):420-21. https://doi.org/10.1016/s0266-7681(98)80073-9. 7. feldman m. arthroscopic excision of a ganglion cyst from the elbow. arthroscopy. 2000;16(6):661-64. https://doi.org/10.1053/jars.2000.4628. 8. lifchez s, dzwierzynski w, sanger j. compression neuropathy of the radial nerve due to ganglion cysts. hand (n y). 2008;3(2):152-54. https://doi.org/10.1007/s11552-007-9083-x. 9. mcfarlane j, trehan r, olivera m, et al. a ganglion cyst at the elbow causing superficial radial nerve compression: a case report. j med case rep. 2008;2:122. https://doi. org/10.1186/1752-1947-2-122. 10. jou i, wang h, wang p, yong i, su w. compression of the radial nerve at the elbow by a ganglion: two case reports. j med case rep. 2009;3:7258. https://doi.org/10.40 76/1752-1947-3-7258. 11. lee s, kim s, oh-park m. ganglion cyst of radiocapitellar joint mimicking lateral epicondylitis: role of ultrasonography. am j phys med rehabil. 2013;92(5):459-60. https:// doi.org/10.1097/phm.0b013e31824ad635. 12. erol b, cakir t, kose o, ozyurek s. radial nerve entrapment caused by a ganglion cyst at the elbow: treatment with ultrasound-guided aspiration. am j phys med rehabil. 2014;93(11):e6-7. https://doi.org/10.1097/phm.0000000000000153. 13. miralles rj, cisneros nl, escolà a, et al. type a ganglion cysts of the radiocapitellar joint may involve compression of the superficial radial nerve. orthop traumatol surg res. 2016;102(6):791-94. https://doi.org/10.1016/j.otsr.2016.05.014. 14. seki y. posterior interosseous nerve palsy caused by a ganglion: conservative treatment with ultrasound-guided needle aspiration. j ultrason. 2017;17(68):73-35. https://doi. org/10.15557/jou.2017.0010. 15. bowen t, stone k. posterior interosseous nerve paralysis caused by a ganglion at the elbow. j bone joint surg br. 1966;48 b(4):774-76. 16. mass d, tortosa r, newmeyer w, kilgore e. compression of posterior interosseous nerve by a ganglion – case report. j hand surg am. 1982;7(1):92-94. https://doi.org/10.1016/ s0363-5023(82)80022-1. 17. hermansdorfer j, greider j, dell p. a case report of a compressive neuropathy of the radial sensory nerve caused by a ganglion cyst at the elbow. orthopedics. 1986;9(7):1005-1006. https://doi.org/10.3928/0147-7447-19860701-14. 18. matsubara y, miyasaka y, nobuta s, hasegawa k. radial nerve palsy at the elbow. ups j med sci. 2006;111(3):315-20. https://doi.org/10.3109/2000-1967-057. 19. gnany j, gupta k, kadwad a, joshi m. a rare presentation of ganglion cyst of the elbow. int j orthop sci. 2019;5(4):1036-39. 20. suen m, fung b, lung cp. treatment of ganglion cysts. isrn orthop. 2013;2013:940615. https://doi.org/10.1155/2013/940615. table ii: proposed new classification system for elbow ganglions, modified from the original system proposed by yamizaki, et al.3 type site occurrence clinical presentation type 1 subtypes a and b anterior/anterolateral • type 1a = proximal to arcade of frohse • type 1b = distal to arcade of frohse most common may present with features of a radial nerve neuropathy (posterior interosseous nerve and/or superficial radial nerve) type 2 posterolateral rare unlikely to present with any neurological manifestations type 3 medial rare may present with a neuropathy of the ulnar nerve if large enough https://orcid.org/0000-0002-1958-147x https://orcid.org/0000-0001-6681-0848 https://orcid.org/0000-0001-5589-2972 https://doi.org/10.5435/00124635-200303000-00007 https://doi.org/10.5435/00124635-200303000-00007 https://doi.org/10.7759/cureus.665 https://doi.org/10.1016/j.jhsb.2006.09.014 https://doi.org/10.1016/j.jhsb.2006.09.014 https://doi.org/10.1016/s0363-5023(88)80134-5 https://doi.org/10.1016/s0363-5023(88)80134-5 https://doi.org/10.1016/s0363-5023(10)80102-9 https://doi.org/10.1016/s0363-5023(10)80102-9 https://doi.org/10.1016/s0266-7681(98)80073-9 https://doi.org/10.1053/jars.2000.4628 https://doi.org/10.1007/s11552-007-9083-x https://doi.org/10.1186/1752-1947-2-122 https://doi.org/10.1186/1752-1947-2-122 https://doi.org/10.4076/1752-1947-3-7258 https://doi.org/10.4076/1752-1947-3-7258 https://doi.org/10.1097/phm.0b013e31824ad635 https://doi.org/10.1097/phm.0b013e31824ad635 https://doi.org/10.1097/phm.0000000000000153 https://doi.org/10.1016/j.otsr.2016.05.014 https://doi.org/10.15557/jou.2017.0010 https://doi.org/10.15557/jou.2017.0010 https://doi.org/10.1016/s0363-5023(82)80022-1 https://doi.org/10.1016/s0363-5023(82)80022-1 https://doi.org/10.3928/0147-7447-19860701-14 https://doi.org/10.3109/2000-1967-057 https://doi.org/10.1155/2013/940615 page 16 sa orthopaedic journal autumn 2014 | vol 13 • no 1 ‘money makes the world go round’ message from the president in economic terms, austerity describes policies used by government to reduce budget deficits during adverse economic conditions. britain’s david cameron popularised the phrase ‘the age of austerity’ during a speech in april 2009, in which he committed to end years of excessive government spending. in south africa we live in the shadows of projects like nkandla and sanral’s e-toll. i leave it to you to decide if austerity is a principle embraced by our government of the day. what is indisputable, however, is that the current healthcare system is unsustainable. south africa spends 8.9% of its gdp (gross domestic product) on healthcare, which compares with that of the uk. (in the usa this figure is 18%). but 60% of our healthcare budget is spent on about 8.7 million private insured lives, constituting 20% of the population, and only 40% of the budget is spent on 80% of the population, those not privately insured (about 43 million). you can certainly argue that the 40% expenditure in the public sector is not used wisely and that only 10% of the population contributes to personal income tax, but i challenge you with the thought that healthcare wastage is prevalent and enormous in both the public and private sectors. waste can be defined as expenditure on healthcare that can be eliminated without reducing the quality of care. some areas of concern are: fraud, unnecessary services, inefficient care, administrative costs and inflated prices. according to a mckinsey global institute report,1 the us spends about $650 billion more on healthcare than other developed countries even when adjusting for the relative wealth of the us economy. in south africa we spend 3% more than the world health organisation’s recommendation for a developing economy. south africa’s ‘financial cake’ is limited in size. the healthcare budget is but one slice of the metaphorical cake, and orthopaedic surgery a small portion of it. an amount of r24 billion was paid to medical specialists in 2012.2 of that, r5.1 billion was paid to pathologists and r4.27 billion to radiologists,3 totalling r9.37 billion for the two groups. this is more than double the total of all the other specialities together (r4.63 billion). my concern is that r13.1 billion was paid for non-healthcare costs.2 managed care has failed dismally in the usa in controlling the healthcare expenditure.4 i think managed care has added to the spiralling healthcare cost rather than controlling it. there is an onslaught on the financial position of the individual surgeon because we are soft targets. if we, as south african orthopaedic surgeons, don’t protect our portion of the metaphorical cake, nobody will. the private hospital groups (r37.9 billion paid out by the medical funders to them in 2012) are strong, and the pathologists (r5.1 billion), radiologists (r4.27 billion) and anaesthesiologists (r2.06 billion) have secured their ‘portions’. we, as surgeons complain about those groups, but they have stood together, united in their approach of securing their ‘slices’. my plea is that we stand together; we can be strong in association. this is the slogan i have chosen for my presidential term because i strongly believe in it. another firm belief of mine is that we should take charge and prove to the funders that we are concerned about healthcare expenditure. prove to them that we are concerned about the wastage that occurs regularly in the care of our patients. allow me to note a few examples. • how long does it take to transfer a patient from a hospital to a step-down facility? is it in the interest of the individual hospital to expedite the transfer? it is definitely not, unless it is a per diem case. is it in the interest of the attending physician (if applicable)? definitely not, he/she is paid per hospital visit. is it in the funders or your interest to transfer the patient as soon as possible? of course! we should take control and drive this. austerity’ is a word that has become part of the current global lingua franca. ‘financial austerity’ is a term thatis used with more frequency in the healthcare environment than ever before. but what does it mean and should we be concerned about it in south africa? my plea is that we stand together; we can be strong in association ‘ saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 16 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 17 • you are consulting and the patient tells you that he has left his x-rays at home, which happens to be 160 km away. what do you do? do you request new x-rays? is that not wastage? the same applies for blood tests. • what is your view about the ‘early discharge protocol’? although i know it might be financially beneficial, i have rejected it. yes, i have rejected it for the wrong reasons. i have rejected it because we as orthopaedic surgeons are not in control! it is a project being forced on us, driven by an external force in conjunction with medical funders. we are not in control! can we gain control? i believe we can if we change our attitude. what is happening globally? joshua jacobs, president of the american academy of orthopaedic surgeons (aaos), has released the following statement: ‘identifying tests, procedures or treatments that show little to no value not only helps our patients by preventing unnecessary care, but will end up saving health care dollars.’ the aaos provided the following five recommendations for the ‘choose wisely’ campaign: 1. avoid performing routine post-operative deep venous thrombosis ultrasonography screening in patients who undergo elective hip or knee arthroplasty. 2. do not use needle lavage to treat patients with symptomatic  osteoarthritis of the knee for long-term relief. 3. do not use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee. 4. do not use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee. 5. do not use post-operative splinting of the wrist after carpal tunnel release for long-term relief. not all the us orthopaedic surgeons agree with him, but the contrary should be proven with appropriate evidence. by 2015 the nhs in the united kingdom needs to reduce their annual spending by ₤20 billion. how do they envisage doing it? tim briggs, president of the british orthopaedic association, has compiled a comprehensive report called: ‘get it right first time’ (girft). the crux of this report is that you should get the right patient to the right surgeon at the right time for the right and final procedure. new zealand has opted for so-called ‘prioritisation’. this is the same as rationing of services. the doctors have to devise protocols. the outcome of procedures will be looked at in terms of cost efficiency. different patients’ circumstances will be compared in creating a patient-andprocedure priority list. the common denominator in all of the above is to use evidence in decision-making. what are we doing in south africa? i think it is high time that we start picking winner tests and procedures. in this sense i have chosen ‘beneficence through evidence’ as the theme for our annual scientific meeting at our 60th saoa congress, to be held in september 2014 in cape town. we should base our decisions on evidence. we should work collectively, in association, instead of individually. if we use evidence to prove our point and we do it in association, we will be strong and we will be in control. references 1. farrell, jensen et al. accounting for the cost of us health care: a new look at why americans spend more. mckinsey global institute. december 2008. 2. press release 16 of 2013. regulator of medical schemes launches annual report. 3. beeld. 11/09/2013. 4. blumenthal et al. health care spending – a giant slain or sleeping? n engl j med 2013;369:2551-57. jan de vos president: south african orthopaedic association we should take charge and prove to the funders that we are concerned about healthcare expenditure saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 17 orthopaedics vol3 no4 sa orthopaedic journal winter 2016 | vol 15 • no 2 page 57 traumatic simultaneous bilateral femoral neck fracture in a child: a case report patrick wendpouiré hamed dakouré, md fwcs associate professor in orthopaedics and trauma at the university hospital of bobo-dioulasso (burkina faso) malick diallo, md lecturer in orthopaedics and trauma surgery at the university hospital of bobo-dioulasso (burkina faso) antonio martinez puente, md orthopaedic surgeon souleymane ouédraogo, md junior resident massadiami soulama, md orthopaedic surgeon correspondence: dr malick diallo malikijallo@yahoo.com malick-diallo@univ-bobo.bf phone: (+226) 65193236 study performed at trauma & orthopedics department, chu sourô sanou de bobo dioulasso, avenue du gouverneur william ponty, 01 bp 676 bobo-dioulasso, burkina faso (west africa) phone: (+226) 20970044 or 20970045 or 20970047. introduction a traumatic fracture of the femoral neck in children is a rare occurrence, comprising less than 1% of all paediatric fractures.1 bilateral fractures are even rarer, with only ten cases reported in the literature.2-10 usually, a high energy trauma is involved, such as a fall from a height and motor vehicle accident.1,4,6,8,11 we report the case of a 9-year-old schoolgirl who presented with traumatic bilateral fractures of the femoral neck after a fall from a height. primary skin traction and secondary closed reduction with percutaneous cannulated screws fixation (pcsf) was performed. the girl recovered completely in seven months. anatomical characteristics, mechanism of injury and late surgical management are discussed. case presentation a 9-year-old schoolgirl with no history of hip disease presented to our emergency unit with closed trauma of both her hips. when playing with schoolmates, she slipped and fell off a 17 foot-high bridge. first, her right limb struck an edge of the bridge and then she fell down on her left hip. abstract background: traumatic bilateral fracture of femoral necks in healthy children is a rare occurrence. a delay in surgery can impair anatomic closed reduction of a femoral neck fracture. case presentation: the authors report a rare case of a traumatic bilateral fracture of the femoral neck in a 9-yearold schoolgirl. this case was an unusual association of a transcervical fracture and an intertrochanteric fracture. this is the first known case of these two fracture types described in the same patient. primary skin traction and a late closed surgical management gave a good result, although if possible early surgery is advised. conclusion: the main mechanism of injury in this case is a two-step trauma. in this case, a delay to surgery by closed reduction and internal fixation by percutaneous screw fixation led to an acceptable outcome. key words: traumatic, child, femoral neck fracture, bilateral bone screws http://dx.doi.org/10.17159/2309-8309/2016/v15n2a10 page 58 sa orthopaedic journal winter 2016 | vol 15 • no 2 on admission, the patient laid in supination with the two lower limbs externally rotated. she complained of severe pain in the groin area and could not move her hips. distally, the neurovascular status was normal. the ap pelvic radiograph showed a displaced transcervical fracture of the right femoral neck and an intertrochanteric fracture of the left femoral neck, classified as delbet type iii and iv respectively (figure 1). skin traction was first applied. on the seventeenth day, under general anaesthesia, closed reduction was performed by traction and internal rotation. fluoroscopicguided percutaneous partially threaded cannulated screws with washers were used as internal fixation. a double plaster spica was applied immediately after surgery. the reduction was perfect on the left side with a measured cervicodiaphyseal angle (cda) of 130 degrees. on the right side, the reduction was acceptable with a cda of 128 degrees (figure 2). the delay was due to our hospital’s lack of materials, and the screws were the best we had available at the time of surgery. the post-operative period was uneventful. no post-operative rehabilitation was performed. the surgical wounds were healed in ten days, the spica was removed after a month and partial weight-bearing with crutches was allowed after seven weeks. ten weeks after surgery, the hips were pain-free and she was able to walk without crutches. follow-up pelvic radiographs showed signs of union at seven weeks, consolidation at seven months and signs of bone remodelling at 14 months. screws were removed at seven months. there was no radiographic sign of femoral head necrosis or osteoarthritis but a shortened femoral neck and overgrowth of the greater trochanter was present on the left side (figure 3). at 28 months, there was no lower limb shortening and the range of motion of both hip joints was: 120° for flexion, 15° for extension, 60° for abduction, 45° for adduction, 45° for external rotation and 30° for internal rotation (figure 4). finally the patient returned in school. figure 1. initial ap view of the pelvis showing displaced transcervical fracture of the right femoral neck and intertrochanteric fracture of the left femoral neck figure 2. post-operative ap view of the pelvis demonstrating fracture reductions with cannulated screws figure 3. ap view of the pelvis at seven months figure 4. photographs demonstrating range of mobility 28 months after surgery t a b le i : l it er a tu re r ev ie w o f p a ed ia tr ic c a se s o f b il a te ra l fr a ct u re o f fe m o ra l n ec k 2 -7 ,9 -1 1 u p a d h y a y 6 g il b a n e t a l. 7 t o g ru l et a l. 8 k u m a r9 s a ie d & j a li li 2 m a z u re k e t a l. 1 0 g o p in a th a n 5 d h a r3 s a n e e t a l. 4 c u rr e n t ca se c a se 1 c a se 2 a g e 11 8 5, 5 6 8 4 5 10 9 9 9 s ex m f f m f m m m f f f d ia g n o si s d el ay 10 w . 4d . . . . . . . . t ra u m a a et io lo g y f f h ( ro o f) f f h m v a f f h f f h ( tr ee ) c em en t b lo ck m v a f f h m v a f f h ( tr ee ) f f h ( b ri d g e) m ec h an is m o f in ju ry in d ir ec t (2 i n ju ri es ) in d ir ec t (2 i n ju ri es ) ? ? in d ir ec t (2 i n ju ri es ) d ir ec t (1 i n ju ry ) in d ir ec t (a xi al l o ad ) ? ? in d ir ec t (2 i n ju ri es ) in d ir ec t (2 i n ju ri es ) f ra ct u re s (d el b et t y p e) r ig h t h ip ? ii ii i ii i ii i ii ii i ii i ii ii i ii i l ef t h ip ? ii ii i ii i ii i i ii i ii ii i ii iv a ss o ci at ed l es io n s h y p ov ol ae m ic s h oc k n o y es n o n o n o n o n o n n n o n o n o b ra in c on cu ss io n y es n o n o n o n o n o n o n o n o n o n o in tr ac er eb ra l h ae m or rh ag e n o n o n o n o n o n o n o n o y es n o n o f ra ct u re s n o p el v ic t ib ia . n o p el v ic d is ta l ra d iu s n o t ib ia , p el v ic n o n o t ra ct io n 1w n o n o . 10 d n o . . . 2d 17 d p er io d o f su rg er y 11 w 1d 4d . 10 d 12 h 3d 2d h o u rs 2d 17 d t re at m en t c r if sc re w s sc re w s sc re w s + p la te s d h s n o p in s n o sc re w s sc re w s sc re w s sc re w s o r if n o n o n o n o sc re w s n o b la te p la te s n o n o n o n o s u p p le m en ta ry i m m o b il is at io n n o y es y es . . . . . . . . . s p ic a . . 16 w . . 8w 8w 6w 9w 6w 4w t ra ct io n . . . . 3w . . . . . . t im e o f w ei g h tb ea ri n g 12 w 16 w . . . . 12 w ( r s id e) 12 w 10 w c o n so li d at io n 18 w 12 w 14 w 52 w 20 w 28 w f o ll o w -u p t im e 20 m 30 m 16 m 9m 30 m 24 m 17 y 18 m 24 m 5m 28 m c om p li ca ti on s n o n o a v n , v ar u s (l ) n o n o n o v al g u s (r < l ), h y p er tr o p h ic g t ( r ) n o n o n o a v n o u tc o m e g oo d y es y es n o y es y es y es . y es y es y es y es s h or te n ed l ow er l im b . . . . . . y es . . n o n o p oo r n o n o y es n o n o n o n o n o n o n o n o m : m al e, f : f em al e, h : h o u rs , d : d ay s, w : w ee k s, m : m o n th s, y : y ea rs , r : r ig h t l : l ef t f f h : f al l fr o m h ei g h t, m v a : m o to r v eh ic le a cc id en t c r if : c lo se d r ed u ct io n a n d i n te rn al f ix at io n , o r if : o p en r ed u ct io n a n d i n te rn al f ix at io n , d h s : d y n am ic h ip s cr ew g t : g re at er t ro ch an te r sa orthopaedic journal winter 2016 | vol 15 • no 2 page 59 page 60 sa orthopaedic journal winter 2016 | vol 15 • no 2 discussion a traumatic bilateral fracture of the femoral neck in children is an unusual injury. all previous cases described in the literature were due to high energy trauma as a result of a motor vehicle accident or fall from a height (table i).2-10 in polytrauma cases, it is important to check the hips to avoid a delayed diagnosis.6 the average age at time of trauma was seven years (range 4–11) and the male to female ratio was 1:1.2. anatomical characteristics cervicotrochanteric and transcervical fractures are more frequently reported in the cases published in the literature2-7,9-11 (table i). saied et al.2 reported one case of associated transepiphyseal fracture (delbet type i). no such case of associated intertrochanteric fracture was previously reported with another contralateral proximal femur fracture. mechanism of injury a traumatic fracture occurs as a result of a particular position of the limb, and a precise point of impact to produce the injury. in reported cases of traumatic bilateral fracture of femoral neck, three main kinds of mechanisms were hypothesised: a direct ‘one-injury fracture’,2 an indirect ‘two-injury fracture’,4,6,9 and an indirect axial load fracture:10 • in the one-injury fractures, the mechanism is a lateral compression (lc) on a fixed pelvis. this mechanism seems similar to the lc type of the young-burgess system classification.12 • in the two-injury fractures or ‘abduction-adduction fractures’, the first indirect impact occurs on the medial side of the thigh with the leg forced in abduction and external rotation, and the second direct impact occurs on the hip lateral side with the leg in adduction and internal rotation. • in the axial load fractures, the force is transmitted from feet to flexed hips, through extended knees. we are of the opinion that the mechanism in our case was that of a two-injury fracture type. injury management the management of displaced femoral neck fractures is surgical by reduction and internal fixation.1,7 the closed reduction with pcsf followed by a spica plaster for seven weeks (4–16) gave best results in bilateral femoral neck fractures.3,4,6,7 according to dhār,3 early surgery was necessary for a good outcome. good results, however, were also observed with delayed surgery from two to 77 days with or without skin traction mainly by open reduction5,6,9,10 (table i). our 17-day delay explains the non-anatomic reduction at the right hip. we think that primary skin traction is important for pain management. many authors used a hip spica cast as complementary immobilisation.2-5,7,10 it secures the internal fixation for eight weeks on average (range 4–16) without any secondary hip stiffness. the weight bearing time is linked to radiographic signs of bone union. full weight bearing is allowed at around 12 weeks.4-6 the mean time of bone consolidation was 24 weeks in the literature described (range 12–52) (table i). reported complications of surgical management are avascular necrosis of the femoral head, osteoarthritis, premature closure of the proximal femoral epiphysis, varus or valgus deformity,7,10 shortening of the femoral neck and overgrowth of the greater trochanter.10 a non-perfect reduction of a transcervical fracture (delbet type iii) may lead to shortening of the femoral neck and overgrowth of the greater trochanter. the current case shows avn and coxa vara on the right side with no complications on the left side. according to togrul et al.,8 avn is more frequent in bilateral hip fractures. the literature review found only one other case of avn and varus deformity on a delbet type iii fracture7 (table i). we think that a longer follow-up time and the use of mri would be useful to evaluate the true rate of avn. a non-perfect anatomic reduction of a delbet type iii fracture led to an earlier physeal closure with overgrowth of the greater trochanter and varus/valgus deformity.7,10 conclusion the authors reported a first case of bilateral hip fracture in a child with a delbet iii and a delbet type iv fracture. the mechanism of injury of the current case confirms the twoinjury theory. a significant delay to surgery did not result in an adverse clinical result. however, a better outcome is observed with an earlier and perfectly closed reduction and a pcsf. acknowledgements the authors thank dr hervé ouattara for his help in the preparation of this paper. compliance with ethics guidelines informed consent: the patient and her parents were informed that data concerning the case would be submitted for publication. they agreed to this. they granted permission to use photographs. patient confidentiality will be protected according to the us health insurance portability and accountability act (hipaa). competing interests: pwh dakouré, m diallo, am puente, s ouédraogo and m soulama declare that they have no competing interests. references 1. ratliff ahc. fractures of the neck of the femur in children. j bone joint surg br. 1962;44-b(3):528-42. 2. saied a and jalili a. bilateral simultaneous femoral neck fractures in a child. eur j orthop surg traumatol. 2009;19(5):349-51. sa orthopaedic journal winter 2016 | vol 15 • no 2 page 61 3. dhār d. bilateral traumatic fracture of neck of femur in a child: a case report. malays orthop j. 2013;7(3):34-36. 4. sané jc, kassé an, kéita k, diallo mb, diallo m, camara ehs, thiam b, bousso a and sy mh. bilateral femoral neck fractures of the chilhood, diagnostic & management of a case. orthop emmerg afr. 2013;2(4):34-35. 5. gopinathan nr, chouhan d, akkina n and behera p. case report: bilateral femoral neck fractures in a child and a rare complication of slipped capital epiphysis after internal fixation. clin orthop relat res. 2012;470(10):2941-45. 6. upadhyay a, maini l, batra s, mishra p and jain p. simultaneous bilateral fractures of femoral neck in children—mechanism of injury. injury. 2004;35(10):1073-75. 7. gilban hm, mirdad tm and jenyo m. simultaneous post traumatic bilateral cervico-trochanteric femoral neck fractures in a child: a case report. west afr j med. 2005;24(4):348-49. 8. togrul e, bayram h, gulsen m, kalacı a and özbarlas s. fractures of the femoral neck in children: long-term followup in 62 hip fractures. injury. 2005;36(1):123-30. 9. kumar p, singh gk and singh mp. traumatic simultaneous bilateral fractures of femoral neck in children—mechanism of injury. j orthop. 2006;3(3). 10. mazurek t, lorczyński a and ceynowa m. bilateral femoral neck fracture in a child: a 17-year follow-up. j pediatr orthop b. 2011;20(5):295-98. 11. mirdad t. fractures of the neck of femur in children: an experience at the aseer central hospital, abha, saudi arabia. injury. 2002;33(9):823-27. 12. young jw, burgess ar, brumback rj and poka a. pelvic fractures: value of plain radiography in early assessment and management. radiology. 1986;160(2):445-51. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj 404 not found page 9south african orthopaedic journal http://journal.saoa.org.za editorial towards the end of last year, a prominent uk newspaper carried a leading article ‘revealed: faulty medical implants harm patients around the world’.1 this was followed shortly after by a bbc news article on the same subject.2 the implant files project, an international group coordinated by the international consortium of investigative journalists, published some impressive statistics about implant problems. the main targets were meshes for pelvic floor and hernia reconstruction, breast implants, cardiac pacemakers and a contraceptive, but orthopaedics did not escape unscathed. problems with total hip, knee and intervertebral disc replacements also featured prominently. even allowing for journalistic dramatisation and over-simplification, the figures quoted are worrying. between 2015 and 2018, 62 000 adverse events with implants were reported in the uk alone, a third of them causing serious complications, including 1 004 deaths. in the usa the fda recorded 5.4 million events over the past decade, with 500 000 implants requiring removal, and 83 000 deaths. prof derek alderson, the president of the royal college of surgeons, was quoted as saying there had been enough incidents involving flawed devices to ‘underline the need for drastic regulatory changes’, including the introduction of mandatory national registries for all implantable devices. ‘in contrast to drugs, many surgical innovations are introduced without clinical trial data or centrally held evidence,’ he said. ‘this is a risk to patient safety and public confidence.’ three years ago, i wrote in an editorial for this journal, ‘new techniques need to be validated independently before, not after, they are released on the market. and as commercially naïve, enthusiastic and adventurous surgeons we must learn not to confuse novelty with progress’. i still feel the same, and think we need improved enforcement of the present imperfect regulation of implants. the criticisms of the present system can be reduced to the following: • absence of independent clinical trials of implants in humans (as opposed to pigs!) before their release on the market • failure of manufacturers to respond constructively to complaints about their products • failure of manufacturers to reveal previous rejections by regulatory bodies when making application to a new body • considerations of commercial confidentiality obstructing enquiries • acceptance by a regulatory body of an implant on the grounds of approval by another regulator, or similarity to another implant, without performing an independent evaluation medical implants in the usa are licensed by a single body, the reputable fda, although the process is slow. but in the eu there is no overall regulator; and a ‘ce mark’ of approval can be issued by any one of 58 ‘notified bodies’. these are non-governmental companies, and if one declines approval of a product, application may be made at another one with no need to disclose the rejection elsewhere. regulation in the eu is due to be upgraded in 2020, but apparently there is doubt as to how effective this will be. the medicines control council of south africa is the official regulator in this country but it is dysfunctional. so should we simply rely on european or usa licencing for protection even though their processes are open to criticism? i think this would be a mistake for two main reasons and believe that that we need to evaluate any implant under south african conditions, while remaining alert for problems encountered in other countries. my first reason is that different countries have different profiles of patients and implant use, and different surgical traditions or preferences, often regional. this may skew results in different locations, such as our country, and local registers are needed to identify poor performers. there is a second important aspect. implant problems can be divided into design errors, which would apply to every implant used, and manufacturing problems where a certain batch of implants may be flawed for some reason. design errors in devices from reputable manufacturers will become obvious in time, especially in countries where large numbers of the implant are used and registers are kept. this would allow recognition of a problem implant irrespective of where it is used. manufacturing problems and implants from little known manufacturers may be different, however. in a small market like south africa, it would be quite possible for an occasional sub-standard batch of implants from a recognised company to form a substantial proportion of an importer’s order. this would cause a localised problem with an implant that is not noticeable against the background of its success elsewhere, and would only be picked up by a register in the area where they are concentrated. another problem is the use of cheap implants from unknown sources often in the far east. they usually have no history of performance and are imported by opportunistic entrepreneurs, often to supply a provincial tender. again, any low-cost devices that are below standard would only be recognised if their use is recorded and tracked. so south african implant registers may be very important for the identification of such problem batches or imports, and the patients who are at risk following their use. i agree with prof alderson that mandatory registers for all implants have become necessary. south african implant registers imperfect regulation of implants prof ja shipley mmed orth ufs, fc orth sa, emeritus professor of orthopaedics, university of the free state, bloemfontein, south africa; shipleyja@gmail.com page 10 south african orthopaedic journal http://journal.saoa.org.za would certainly make a contribution to the global experience, but they are probably more valuable for their ability to recognise inappropriate implant use and manufacturing defects in this region. the government cannot be expected to organise this without our help, and it would be ridiculous to expect the fiercely competitive orthopaedic industry to police itself. i believe the onus is on each surgeon to record his implant use in a register owned and administered by the respective professional body – in our case the saoa and its sub-groups. we are all aware of past problems in south africa with arthroplasty registers, and this would probably need some form of legislation to motivate our less compliant colleagues. as a back-up, the hospital groups should also be made responsible for recording implant use, including details of the patient and surgeon. costs could be recovered from a small levy added to the price of each implant. the medical aids could be expected to support such registers as they would benefit financially from identifying and eliminating substandard hardware and their attendant complications. medical aid and hospital administration systems could certainly be programmed to record and forward data to central registers at minimal cost and inconvenience to all concerned. i have written this editorial as one with no experience of implant registers or the practical problems around them. i realise this is a controversial subject but i hope that a dispassionate, objective examination of the matter will result in increased understanding and support for the saoa and the leaders in our speciality in their efforts to achieve this ideal. i believe we have a professional obligation to do so. references 1. the guardian. 5 november 2018 2. bbc health news 25 november 2018 404 not found sa orthopaedic journal winter 2014 | vol 13 • no 2 page 17 the differential diagnosis of neurogenic and referred leg pain ja louw mbchb(pret), mmed(orth), phd, md full-time private practice, pretoria, south africa correspondence: dr ja louw po box 24 moreleta plaza 0167 introduction leg pain is a common presenting symptom of lumbar disc herniation due to neurological compression. if conservative management fails, a large number of these patients might undergo lumbar spine surgery. magnetic resonance imaging (mri) is considered to be the cornerstone special investigation to confirm the diagnosis of a lumbar disc herniation. however, between 38% and 52% of asymptomatic individuals demonstrated significant lumbar disc bulging on mri.1,2 given the high prevalence of these findings and of back pain, the discovery by mri of disc bulges may frequently be coincidental and the leg pain caused by an unrelated condition. it is therefore essential to consider all possible aetiological factors when evaluating leg pain. literature reviews combined with the author’s personal experience in the examination of more than 15 000 patients with back pain were used to propose an aetiological classification of conditions to consider when evaluating leg pain. conditions to consider when evaluating leg pain 1. systemic conditions metabolic neuropathy diabetes mellitus is the most common metabolic neuropathy. its most common presentation is the distal symmetrical polyneuropathy with bilateral symmetrical pain in the lower extremities starting distally and moving proximally.3,4 other subtypes include proximal diabetes, truncal, cranial, median and ulnar neuropathies. diabetic autonomic neuropathy affects each tissue, organ and system in the whole body and is strongly involved in the development of foot ulceration.5 a less common diabetes presentation is diabetic amyotrophy6 which has most probably a vasculitis aetiology with ischaemia followed by axonal degeneration and demyelination. the main features are unilateral weakness, wasting and pain most commonly in the quadriceps. it spreads later to the contralateral side in an asymmetrical manner. abstract background: neurogenic and referred leg pain are some of the most challenging clinical problems in spinal surgery due to the diversity of conditions that can act as aetiological factors. methods: the literature was reviewed and combined with case studies to demonstrate different aetiological factors. results: at least 300 conditions were identified that might cause neurogenic and referred leg pain. an aetiological classification of neurogenic and referred leg pain is presented. the classification includes systemic conditions, conditions from the brain, spinal cord, cervical and thoracic spinal canal, lumbar spinal canal, lumbar nerve root canal, lumbar extraforaminal area, the pelvis and the lower extremity. each one of these conditions can mimic a lumbar disc herniation accurately. conclusion: the aetiological classification can be used as a checklist when evaluating neurogenic and referred leg pain. each condition deserves careful consideration and when overlooked might result in a missed diagnosis. key words: neurogenic, leg pain, nerve root saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 17 page 18 sa orthopaedic journal winter 2014 | vol 13 • no 2 other metabolic neuropathies to consider are alcoholic and uraemic neuropathies.7,8 vasculitic neuropathy the primary pathology of vasculitic neuropathies is a vasculitis of the small and medium-sized vessels in the peripheral nervous system9 with an area of infarction in the nerve.10,11 the presenting symptoms are severe pain localised to the region of the infarction, motor deficit, numbness and paraesthesias. vasculitic neuropathies are classified into primary and secondary vasculitides.10 primary vasculitic neuropathy includes churg-strauss syndrome, microscopic polyangiitis, classic polyarteritis nodosa and wegener granulomatosis. secondary vasculitis occurs as a complication of connective tissue disease (systemic lupus erythematosus, rheumatoid arthritis and sjögren syndrome), infection (hepatitis b and c, human immunodeficiency virus, lyme disease, cytomegalovirus, herpes zoster virus and various bacterial infections), medication (sulphonamides, other antibiotics and anti-viral agents) and malignancies representing a paraneoplastic vasculitis.11-15 paraneoplastic peripheral neuropathy in addition to the paraneoplastic vasculitis and the local effect of the tumour, malignancies can also cause a paraneoplastic sensorimotor neuropathy which might even be more debilitating than the cancer itself.16 the detection of anti-neuronal antibodies and emg changes help to identify the neuropathy as paraneoplastic. a paraneoplastic myopathy might also develop which can cause leg pain.16,17 case 1 this 53-year-old female patient presented with severe acute onset unilateral pain in the l5 nerve root distribution. the mri of the lumbar spine failed to demonstrate any neurological compression. the coronal images of the mri thoracic spine demonstrated a lesion in the lung which was biopsied and turned out to be a bronchus carcinoma (figure 1). the antineuronal antibodies and emg confirmed a paraneoplastic neuropathy. case 2 this 64-year-old male patient presented with severe unilateral pain in the l5 and s1 nerve root distribution 25 months after an uncomplicated l4 to s1 decompression and fusion procedure. the plain radiographs demonstrated an uncomplicated fusion and the mri a wide decompression without neurological compression. the anti-neuronal antibodies demonstrated a positive anti-pnma(ma/ta) which is associated with small cell bronchus carcinoma. this prompted a chest ct scan which demonstrated a small lesion in the apex of the right lung. a lung biopsy demonstrated a bronchus carcinoma. vascular occlusion vascular occlusion can mimic neurogenic claudication. the peripheral pulses should therefore be palpated in every back pain examination. 2. brain brain-related causes of leg pain include multiple sclerosis,18,19 parkinson’s disease,20 motor neurone disease,21 post-stroke pain in lenticulo-capsular haemorrhages22 and space-occupying lesions. case 3 this 57-year-old male patient presented with spontaneous onset pain in the right lower extremity 12 years after an l4 to s1 fusion, neurological decompression and instrumentation. the plain radiographs failed to demonstrate any complications and no neurological compression could be demonstrated on the mri lumbar spine. the history of the systemic diseases revealed resection of a melanoma behind the right scapula three years before. a ct scan of the brain demonstrated multiple melanoma metastases (figure 2). 3. spinal cord spinal cord conditions which should be excluded in the evaluation of leg pain are multiple sclerosis,18,19 motor neurone disease,21 transverse myelitis,22,23 syringomyelia,24,25 and any posterior (compression of substantia gelatinosa at the tip of the posterior column) or anterolateral (compression of lateral spino-thalamic tract)26 situated space-occupying lesion, for example intervertebral disc herniation,27,28 tumour, haematoma or abscess. an atypical brown-sequard lesion can also be produced, with loss of pain and thermal sensation on the contralateral side and leg pain on the ipsilateral side.27,29 figure 1. the coronal mri demonstrated a lesion in the lung apex (bronchus carcinoma) saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 18 sa orthopaedic journal winter 2014 | vol 13 • no 2 page 19 case 4 this 73-year-old female patient presented with excruciating pain in the l5 distribution of the right lower extremity and was booked for an emergency laminectomy. when the patient presented for a second opinion, the mri of the lumbar spine demonstrated a small disc bulging on the asymptomatic side. an mri thoracic spine was requested which demonstrated a posterior situated meningioma at t7 (figure 3) which was removed and the l5 nerve root symptoms resolved completely. 4. cervical and thoracic spinal canal any posterior or anterolateral situated space-occupying lesion in the cervical and thoracic spinal canal may cause compression on the lateral spino-thalamic tract and substantia gelatinosa at the tip of the posterior column of the spinal cord with resulting leg pain, for example haematoma, abscess, soft tissue or bone tumours, etc.26-29 5. conus medullaris at the conus medullaris the nerve roots are positioned lateral to the spinal cord (figure 4). a parasagittal disc herniation or any other space-occupying lesion (for example intradural or extradural tumours, haematoma, abscess, primary bone tumours, metastases, etc.) can therefore cause compression of the nerve roots with leg pain without much compression on the spinal cord. an mri thoracic spine demonstrated a posterior situated meningioma at t7 figure 2. brain ct scan with multiple melanoma metastases in a patient who presented with leg pain only figure 4. the conus medullaris. the nerve roots (between the arrows) are positioned lateral to the spinal cord. figure 3 (a) figure 3 (b) figure 3. a patient with leg pain only. figure 3 (a) demonstrates a small disc bulging on the asymptomatic side on the lumbar spine mri. figure 3 (b) demonstrates a t7 meningioma responsible for the leg pain. saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 19 page 20 sa orthopaedic journal winter 2014 | vol 13 • no 2 case 5 this 58-year-old male patient presented with severe pain in the right lower extremity in the l4 nerve distribution seven years after a t12 to s1 fusion and pedicle instrumentation. the ct myelogram demonstrated intervertebral disc and gas sequestration in the right parasagittal position with severe compression on the nerve roots but only slight displacement of the conus medullaris (figure 5). removal of the gas and disc sequestration alleviated the l4 symptoms completely. 6. lumbar spinal canal as far back as 1933, baastrup30 reported on the interspinous bursa (kissing spines, baastrup’s disease) as a cause of leg pain31,32 (figure 6). the bursa can communicate with an epidural cyst with severe neurological compression.33 in facet joint syndrome, osteoarthrosis of the facet joint with a normal spinal canal and nerve root canal can give buttock and leg pain34,35 (figure 7). hypertrophy of the facet joints gives spinal stenosis and leg pain (figure 8). a facet joint cyst can compress the nerve root with leg pain. with both superior or inferior rotational instability, the facet joints may rotate into the spinal canal with neurological compression and leg pain (figure 9). in degenerative spondylolisthesis, the vertebral body and inferior facet joints displace anteriorly. the inferior facet joints move forwards and compress the dural sac and nerve roots against the posterior aspect of the cranial vertebral body. if the flexion radiographs demonstrate superimposed instability with further anterior translation of the inferior facet joints in the flexed position, the compression on the dural sac is aggravated significantly. this dynamic compression on the dural sac is not demonstrated on the mri and can only be appreciated on the stress radiographs (figures 10 and 11). any space-occupying lesion in the lumbar spinal canal can give leg pain, for example intervertebral disc herniation or sequestration, soft tissue or bone tumours, haematoma, etc. 7. lumbar nerve root canal inside the nerve root canal the facet joint might give leg pain with a combination of loss of disc height and posterior subluxation when the superior articular process moves upwards and forwards and might impinge the nerve root against the pedicle or the posterior aspect of the vertebral body, especially the inferior endplate (figure 12). in spondylosis osteophytes from the superior facet joint or posterior inferior vertebral endplate (figure 13) may compress the nerve root. anterior subluxation of the vertebra in degenerative spondylolisthesis might be associated with hypertrophy of the superior facet joint with extension of the superior facet joint into the nerve root canal with compression of the nerve root and resulting leg pain. any nerve root lesion, for example a nerve root cyst or nerve root tumour, should be considered. the most common benign nerve root tumours are the schwannomas, neurofibromas36 and less common haemangioblastomas37,38 and non-hodgkin lymphomas.39 nerve sheath tumours can originate from the intradural or extradural position.40 figure 6. the interspinous bursas are demonstrated between the red arrows. figure 5 (a) figure 5 (b) figure 5. a patient with l4 leg pain. in figure 5 (a) gas (blue arrows) and disc (red arrows) sequestrations are demonstrated. in figure 5 (b) the gas sequestration (blue arrow) is positioned over the nerve roots lateral to the spinal cord with only slight displacement of the spinal cord. figure 7 figure 8 facet joint disease. facet joint osteoarthrosis in figure 7 and facet joint hypertrophy with spinal stenosis in figure 8. saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 20 sa orthopaedic journal winter 2014 | vol 13 • no 2 page 21 malignant peripheral nerve sheath tumours (mpnsts) are grouped together by the world health organisation as mpnst and include previous terminology such as malignant neurilemmomas, neurogenic sarcoma and neurofibrosarcoma.41 in isthmic spondylolisthesis the nerve root canal is narrowed by the combination of disc bulging and pars interarticularis hypertrophy. the pedicle moves down and might compress the nerve root in complete loss of disc height in combination with spondylolisthesis (figure 14) and degenerative scoliosis. intervertebral disc herniation into the nerve root canal is the most common cause of nerve root canal narrowing and neurological compression. a nerve root anomaly might easily be mistaken for a disc fragment with grave consequences. the most common anomaly is the conjoint nerve root with two nerve roots derived from a common dural sheath followed by two nerve roots in one foramina.42-44 8. lumbar extraforaminal area a far lateral disc herniation may compress the nerve root after it has left the nerve root canal (figure 15). the corporotransverse ligament extends from the vertebral body to the transverse process of the same vertebra.45 it may entrap the nerve root in rotatory subluxation in combination with complete disc space narrowing. psoas pathology, for example abscess, haematoma, tumour or any other space-occupying lesion, may compress the nerve root in its course through the psoas.46 in spondylolisthesis with severe disc space narrowing, the l5 nerve root may be impinged between the l5 transverse process and the ala of the sacrum (figure 14). this may also occur in degenerative scoliosis with tilting of l5 and depression of the concave l5 transverse process (figure 16). figure 9 (a) figure 9 (b) figure 9 (c) figure 9. rotational instability. both the superior in figure 9 (b) and inferior facet joint in figure 9 (c) can rotate into the spinal canal with neurological compression. figure 10 (a) figure 10 (b) figure 10. degenerative spondylolisthesis. the space available for the dural sac between the posterior aspect of the vertebral body and the anterior aspect of the inferior facet joints (between the red arrows) measured 15 mm with the back in extension with 4 mm anterior displacement [figure 10 (a)] and decreases to only 4 mm in flexion when the anterior displacement increases to 16 mm with severe dural sac compression [figure10 (b)]. figure 11 (a) figure 11 (b) figure 11. the mri was done with 4 mm anterior displacement of l4 on l5 in figure 11 (a) and (b). at 16 mm anterior displacement, as demonstrated on the stress radiographs in figure 10, the inferior facet joints and lamina at the position of the white arrows in figure 11 (b) will move forwards to the position of the red arrows with severe aggravation of the existing compression. the mri fails to demonstrate the effect of this additional dynamic compression of instability which is well demonstrated on plain stress radiographs (figure 10). a facet joint cyst can compress the nerve root with leg pain saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 21 page 22 sa orthopaedic journal winter 2014 | vol 13 • no 2 9. pelvis at the entrance to the pelvis, a large osteophyte from the l5 transitional vertebra pseudoarthrosis might compress the l5 nerve root (figure 17). the lumbosacral ligament47 extends from the l5 vertebra to the ala of the sacrum and forms the roof of the lumbosacral tunnel through which the l5 nerve root passes. ossification of the lumbosacral ligament in combination with osteophytes from the inferior l5 vertebral body endplate may impinge the l5 nerve root.47 a stress fracture of the sacrum can give back, buttock, groin and thigh pain.48 it may also give direct compression or a neuropathy of the nerve root.49 the most common associated stress fracture is that of the ipsilateral, contralateral or both pubic rami.50 it may remain undetected on plain radiographs for months but readily demonstrated on the stir and t2 weighted mri images (figure 18).51 mri alone identifies 99, 2% of stress fractures compared to 69% with the ct scan alone.51 the mri remains the investigation of choice in these cases. figure 15. the position of a far lateral disc herniation is demonstrated on the cadaver dissection (black arrow) on the left side and the mri (red arrow) on the right. figure 12. the superior facet joint moves upwards and forwards (red arrow) in loss of disc height with possible nerve root compression. figure 13. an osteophyte from the inferior vertebral endplate extends into the nerve root canal with nerve root compression. figure 14. the pedicle moves down with nerve root compression. figure 16. tilting of l5 with dipping down of the left l5 transverse process (red arrows) and l5 nerve root compression figure 17. an osteophyte from the l5 transitional vertebra pseudoarthrosis extends medially with l5 nerve root compression. saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 22 sa orthopaedic journal winter 2014 | vol 13 • no 2 page 23 degenerative sacroiliitis can give buttock, groin and thigh pain.52 an osteophyte from the sacroiliac joint extending anteriorly can compress a nerve root. any type of infectious sacroiliitis (tuberculosis, brucellosis and piogenic)53 and tumours of bone and the soft tissue in and around the sacroiliac joint can give pain in a similar distribution.54 the sero-negative spondyloarthropathies (ankylosing spondylitis, psoriatic arthritis, reactive arthritis and behcet’s disease) should also be considered.55 a lumbosacral radiculoplexus neuropathy presents with asymmetrical lower limb pain, weakness, atrophy and paraesthesia.56 it can be caused by diabetic lumbosacral radiculoplexus neuropathy, non-diabetic lumbosacral radiculoplexus neuropathy, chronic inflammatory demyelinating polyneuropathy, connective tissue disease, lyme disease, sarcoidosis, hiv and cytomegalovirusrelated polyradiculopathy.56,57 the typical mri neurography findings (figure 19) are increased signal intensity and enlargement of the nerve and blurring of the perifascicular fat on the t2 weighted neurography sequences58,59 (long echo times, radiofrequency saturation pulses to suppress signals from adjacent vessels and frequencyselective fat suppression).60,61 emg, fasting blood glucose levels, sedimentation rate, rheumatoid factor, antinuclear antibodies, antineutrophil cytoplasmic antibodies, extractable nuclear antigen, hiv,56 serum antibodies associated with neurological disorders (antineuronal, antiganglioside and anti-astrocyte antibodies)62 and csf evaluation are some of the special investigations of diagnostic value. in the piriformis muscle syndrome hypertrophy, spasm, contracture or inflammation of the piriformis muscle may compress the ischiadic nerve with pain in any part of the ischiadic nerve distribution (figure 20). the diagnostic accuracy of a wide variety of clinical tests (tenderness on deep palpation over the piriformis,63 pace’s sign,64 freiberg’s sign,65 fair test [flexionadductioninternal rotation],66 persistent piriformis position in external rotation) remain controversial.67 the imaging diagnosis with an mri of the pelvis is based on enlargement of the piriformis and mri neurography.59 enlargement of the piriformis alone has a specificity of 66% and a sensitivity of 64%. if in addition the mri neurography demonstrates an increased signal intensity and enlargement of the ischiadic nerve (figure 21), the specificity increases to 93% and the sensitivity to 64%.68 figure 18 (a) figure 18 (b) figure 18. the stress fracture of the sacrum is not visible on the plain radiographs in figure 18 (a) but well demonstrated (red arrow) on the stir sequences of the mri in figure 18 (b). figure 21 (a) figure 21 (b) figure 21. the piriformis syndrome. figure 21 (a) demonstrates enlargement of the right piriformis muscle (between red arrows) and the normal size on the left side (yellow arrows). figure 21 (b) demonstrates a neuropathy of the underlying ischiadic nerve with enlargement and increased signal intensity (between red arrows). figure 19. the mri neurography demonstrates a neuropathy of the left ischiadic nerve (between black arrows) with enlargement, increased signal intensity, blurring of the perifascicular fat and loss of the normal fascicular appearance. a normal nerve is demonstrated between the red arrows. figure 20. posterior view of the right gluteal area. the ischiadic nerve emerges from underneath the piriformis and courses over the obturator internus. (ipf: infrapiriformis foramina; ssl: sacrospinalis ligament; sg: superior gemellis muscle; ig: inferior gemellis muscle; qf: quadratus femoris muscle; pfcn: posterior femoral cutaneous nerve) saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 23 page 24 sa orthopaedic journal winter 2014 | vol 13 • no 2 the ischiadic nerve passes underneath the piriformis and then over the obturator internus (figure 20). swelling and inflammation of the obturator internus might displace and irritate the ischiadic nerve with resultant leg pain (figure 22).69 superior gluteal nerve entrapment syndrome is caused by any condition which narrows the suprapiriformis foramen (figure 20), for example enlargement or spasm of the piriformis muscle,70 superior gluteal nerve perforating the piriformis,71 aneurysm or pseudoaneurysm of the superior gluteal artery,72 direct injury to the superior gluteal nerve during hip surgery,73 percutaneous placement of iliosacral screws,74 abscess and pelvic fracture. the clinical diagnosis is based on the triad of buttock pain, weakness of hip abduction and marked tenderness on deep palpation in the region just lateral to the greater schiadic notch.75 case 6 this 55-year-old male patient presented with the clinical triad of superior gluteal nerve entrapment. the mri pelvis demonstrated sacroiliitis on the right side with an effusion and a neuropathy of the superior gluteal nerve with enlargement and an increased signal intensity (figure 23). the inferior gluteal nerve entrapment syndrome is caused by any condition which narrows the infrapiriformis foramen, for example an aneurysm of the inferior gluteal artery,63 pelvis fracture and abscess.76 in the pudendal nerve entrapment syndrome the pudendal nerve is compressed in the pudendal or alcock’s canal between the sacrospinous and sacrotuberous ligaments. the nerve might become ensheathed by ligamentous expansions that form a perineural compartment, by the falciform process of the sacrotuberous ligament or by duplication of the obturator fascia.77-79 it causes chronic perineal pain typically presenting as pain in the penis, scrotum, labia, perineum, anorectal area and medial proximal thighs.77 there are special considerations in female patients regarding leg pain which deserve mentioning. sciatica in pregnancy can be caused by direct compression of the gravid uterus on the lumbosacral plexus and blood vessels.80,81 incorrectly positioned leg stirrups on the obstetrical table can cause common peroneal nerve pain and weakness.80,82 obstetric neuropathy of the sciatic nerve during vaginal labour can be caused by continuous pressure of the foetus on the lumbosacral plexus as it crosses the pelvic brim during prolonged labour.83 piriformis syndrome can be caused during labour following a piriformis haematoma after prolonged labour, and a piriformis abscess after epidural anaesthesia and forceps delivery.84 sciatica secondary to pathological conditions80 include leiomyomas with lumbosacral plexus compression,85 endometriosis with infiltration or compression of the sciatic nerve86 and a large retroverted uterus with compression on the lumbosacral plexus.80 sciatica secondary to iatrogenic trauma includes vaginal procedures which might be complicated by ischiadic neuropathy,87 superior gluteal artery aneurysm with superior gluteal nerve compression and the superior gluteal nerve neuropathy due to stretching of the superior gluteal nerve. case 7 this 29-year-old female patient presented after two years of diligent conservative treatment for a small l5/s1 disc bulging with progressive deterioration of buttock and leg pain. the mri pelvis demonstrated a large ovarian cyst which displaced a large uterus lateral and posterior with an underlying large piriformis muscle, and an increased signal intensity and enlargement of the ischiadic nerve (figure 24). figure 22. the ischiadic nerve (black arrows) is displaced posteriorly by the obturator internus muscle (between red arrows) with an area of increased signal intensity in the muscle. figure 23. the mri pelvis demonstrates a sacroiliitis on the right side (black arrow) with an effusion and area of high signal intensity around the joint. a neuropathy of the right superior gluteal nerve is demonstrated (red arrow) with enlargement and an increased signal intensity. piriformis syndrome can be caused during prolonged labour, and a piriformis abscess after epidural anaesthesia and forceps delivery saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 24 sa orthopaedic journal winter 2014 | vol 13 • no 2 page 25 10. lower extremity greater trochanter bursitis and gluteus medius tendinitis remain some of the most common causes of leg pain in patients above 60 years of age. a stress fracture of the femur neck, intertrochanteric area and the proximal femur presents with pain in the groin and anterior aspect of the proximal thigh. plain radiographs may remain normal for a considerable time. an mri and bone scan are useful in the early stages to confirm the diagnosis. iliopsoas88 and iliopectineal89 bursitis and synovitis present with pain in the groin and anterior aspect of the proximal thigh. they might also give femoral nerve palsy and pain. non-traumatic focal mononeuropathies may present with symptoms indistinguishable from a lumbar disc herniation and include the following conditions: 1. compression neuropathies: acute, chronic and hereditary.90 2. infectious neuropathies: herpes zoster, lyme disease, acquired immunodeficiency syndrome (aids), leprosy mononeuropathy, hepatitis b and c, cytomegalovirus, epstein-barr virus, various bacterial infections.11-15 3. inflammatory/vasculitic neuropathies: churg-strauss syndrome, microscopic polyangiitis, classic polyarteritis nodosa, wegener granulomatosis, systemic lupus erythematosus, rheumatoid arthritis, sjögren syndrome.11-15 4. drug-related neuropathies: sulphonamides, other antibiotics, anti-viral agents.11-15 5. metabolic neuropathies: diabetic amyotrophy, alcoholic and uraemic.6-8 6. paraneoplastic neuropathies: paraneoplastic vasculitis, paraneoplastic sensorimotor neuropathy.16,17 7. radiation neuropathy.90 8. nerve and nerve sheath tumours.90 9. hereditary: familial amyloid polyneuropathy,91 hereditary compression neuropathy.90 the nerve entrapment syndromes of the lower extremity include the following conditions: the iliohypogastric (t12, l1), ilioinguinal (t12, l1) and genitofemoral (l1, 2) entrapment syndromes usually occur after lower abdominal surgery.92 entrapment of the lateral femoral cutaneous nerve (l2-4) is also known as meralgia paraesthetica. symptoms include anterior and lateral thigh burning, tingling and numbness.92 the femoral nerve (l2-4) is usually entrapped below the inguinal ligament where it lies in close proximity to the femoral head, the tendon insertion of the vastus intermedius, the psoas tendon, and the hip joint and hip joint capsule, all of which can cause entrapment.92 other causes of entrapment include methylmethacrylate heat during total hip arthroplasty, pelvic procedures requiring acutely flexed, abducted and externally rotated positioning, compression by a foetus in difficult childbirth, pelvic fractures and radiation.92 the saphenous nerve (l3,4) is the terminal and longest branch of the femoral nerve. it can become entrapped as it pierces the roof of the adductor canal, by femoral vessels, pes anserine bursitis, varicose vein operations and medial knee surgery.92,93 common peroneal neuropathy is the most common mononeuropathy of the lower extremity. it is most commonly entrapped as it courses along the lateral aspect of the fibula neck through a fibro-osseous tunnel by tight plaster casts, knee surgery, osteophytes, synovial cysts or ganglions and sitting in a prolonged crossed leg position.93-96 repetitive exercises involving inversion and pronation (for example runners and cyclists) stretch the common peroneal nerve against the fibula neck and fibrous arch of the peroneal tunnel.93 many cases are idiopathic in origin.97 the deep peroneal nerve travels in the anterior compartment of the leg between the extensor digitorum longus and the extensor hallucis longus tendon until it reaches the ankle where it courses under the extensor retinaculum to enter the anterior tarsal tunnel where most of the entrapment occurs, referred to as the anterior tarsal tunnel syndrome with symptoms referring to the dorsum of the foot.98,99 the entrapment is usually sport related.93 the superficial peroneal nerve courses through the anterolateral compartment of the leg until it pierces the deep fascia of the lateral compartment approximately 10 to 15 cm above the ankle where it may become entrapped. this is commonly seen in dancers in whom the nerve may become stretched during inversion or plantar flexion injuries.99,100 proximal tibial entrapment neuropathy is uncommon, owing to the deep location of the nerve and abundant surrounding muscle tissue. entrapment is usually related to space-occupying lesions in the popliteal fossa such as tumours, popliteal cyst, popliteal artery aneurysm and ganglia.99 figure 24 (a) figure 24 (b) figure 24 (c) figure 24. the mri pelvis demonstrates a large ovarian cyst, displacing a large uterus (a) against a large piriformis (b) with an underlying large ischiadic nerve with an increased signal intensity on mri neurography (c). saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 25 page 26 sa orthopaedic journal winter 2014 | vol 13 • no 2 distal tibial entrapment usually occurs in the tarsal tunnel causing tarsal tunnel syndrome. entrapment follows trauma (fracture, surgery and scarring), space-occupying lesion (tumour, ganglia, varicosities and an anomalous muscle) and foot deformities.99,101 the sural nerve runs distally between the two heads of the gastrocnemius beneath the crural fascia until it pierces the fascia between the middle and distal thirds of the calf. compression of the nerve by mass lesion, scar tissue, ganglion, surgical trauma and thrombophlebitis has been reported. extrinsic compression can occur from tight ski boots or casts. the crural fascia may act as a compression or fixation point in athletes with stretching of the nerve.92,102-104 at the distal branches of the tibial nerve, medial plantar nerve neuropathy (jogger’s foot) can develop owing to repetitive trauma to the nerve while running with increased heel valgus and foot pronation.99,105 entrapment of the inferior calcaneal nerve, the first branch of the lateral plantar nerve, often manifests as heel pain (baxter neuropathy).99 interdigital neuropathy (morton neuroma) is caused by a fibrotic nodule of the interdigital nerve most commonly at the second and third intermetatarsal spaces. the patients present with web space pain, tingling, numbness and paraesthesias.99,106 medial plantar proper digital neuropathy (joplin’s neuroma) is an entrapment neuropathy of the plantar proper digital nerve which is particularly susceptible to repetitive trauma.99,107,108 the diagnosis of an entrapment neuropathy is based on a good clinical examination, typical emg findings, mri of the nerves and muscle, and blood investigations as mentioned under lumbosacral radiculoplexus neuropathy. the mri includes signs of nerve entrapment, increased signal intensity, enlargement of the nerve, loss of the normal fascicular appearance or blurring of perifascicular fat.57 the indirect signs of nerve injury are seen in the muscles supplied by the nerve with an increased signal intensity followed by atrophy and fat placement of the muscle.59,99 leg pain may also be caused by myositis or myopathy. palpation of the muscle may reveal local tenderness which is more pronounced than what would be expected of neurological compression, swelling and oedema, atrophy or hypertrophy and overlying skin changes. one of four basic patterns of abnormality may be present on the mri, namely muscle oedema with an increased signal intensity, muscle atrophy with an increased fat content, mass within a muscle or an accessory muscle.109 the aetiology of muscle oedema is inflammatory myopathy (dermatomyositis, polymyositis and inclusion body myositis), polymyositis, myositis in collagen vascular disease (rheumatoid arthritis, systemic lupus erythematosus, mixed connective tissue disease and sjögren syndrome), radiation myositis, graves’ disease, drug-induced myositis (lipid-lowering statins, antiretroviral medication), hiv myositis, myositis due to infection (high risk patients include diabetes, immuno-compromised patients, penetrating wounds), polymyositis, necrotising fasciitis and sarcoidosis. the denervation phases include a normal mri in the acute phase, mixed oedema and paradoxical hypertrophy in the early subacute phase, mixed oedema and atrophy in the late subacute phase and atrophy in the chronic phase.109 sport-related leg pain110 includes tibial and fibular stress fractures,111 medial tibial stress syndrome,112 chronic exertional compartment syndrome,113 tendinopathies,114,115 nerve entrapment syndromes,116 vascular syndromes117,118 and myopathies.119 finally, leg pain may be associated with three poorly understood neurological conditions, namely complex regional pain syndrome,120,121 restless leg syndrome122 and painful legs and moving toes syndrome.123 discussion at least 300 conditions were identified that might cause neurogenic and referred leg pain. table i is presented as an aetiological classification for neurogenic and referred leg pain and can serve as a checklist to ascertain that all appropriate conditions are evaluated. each one of these conditions deserves careful consideration and if overlooked might result in a missed diagnosis or even the disaster of the creation of yet another failed back. our treatment can only be as good as our diagnosis. if the diagnosis is missed, the treatment will obviously fail. each one of these conditions deserves careful consideration and if overlooked might result in a missed diagnosis continued on next page 1. systemic diseases table i: aetiological classification of neurogenic and referred leg pain saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 26 sa orthopaedic journal winter 2014 | vol 13 • no 2 page 27 2. brain 8. lumbar extraforaminal area 9. pelvis 3. spinal cord 4. cervical and thoracic spinal canal 5. conus medullaris 6. lumbar spinal canal 7. lumbar nerve root canal 10. lower extremity saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 27 page 28 sa orthopaedic journal winter 2014 | vol 13 • no 2 the content of this article is the sole work of the authors, and no benefit of any form has been received or will be received from any commercial party. references 1. quiros-moreno r, lezama-suárez g, gómes-jimenez c. disc alterarions of the lumbar spine on magnetic resonance images in asymptomatic workers. rev med inst mex sequro 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2004;110:495-98. 121. wasner g, schattschneider j, binder a, et al. complex regional pain syndromediagnostic, mechanisms, cns involvement and therapy. spinal cord. 2003;41:61-75. 122. bogan rk, cheray ja. restless legs syndrome: a review of diagnosis and management in primary care. postgrad med. 2003;125: 99-111. 123. reich sg. painfull legs and moving toes. handb clin neurol. 2011;100:375-83. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 30 404 not found page 4 south african orthopaedic journal http://journal.saoa.org.za page 4 south african orthopaedic journal http://journal.saoa.org.za conferences, courses & symposia sassh (sa society for surgery of the hand) refresher course 23-25 february 2018 pretoria 18th congress sa spine society 24-26 may 2018 elangeni hotel, durban 64th congress of the south african orthopaedic association 3-6 september 2018 csir, pretoria january 2018 2nd international consensus meeting on orthopaedic infections 25 january 2018 26 january 2018 philadelphia, united states focus on arthroplasty symposium: unicondylar knee replacement 26 january 2018 27 january 2018 frankfurt am main, germany 19th annual aaos/aana/aossm sports medicine course 31 january 2018 04 february 2018 park city, united states february 2018 bernese hip symposium 2018 01 february 2018 03 february 2018 bern, switzerland paris shoulder symposium 2018 01 february 2018 03 february 2018 paris, france scandinavian hand surgical dissection course 05 february 2018 06 february 2018 copenhagen, denmark endoprosthetics congress berlin 2018 22 february 2018 24 february 2018 berlin, germany march 2018 aaos 2018 annual meeting 06 march 2018 10 march 2018 new orleans, united states kiel arthroscopy course 2018 09 march 2018 10 march 2018 kiel, germany utrecht spine course: complex paediatric spine 09 march 2018 10 march 2018 utrecht, netherlands annual meeting of the orthopaedic research society – ors 2018 10 march 2018 13 march 2018 new orleans, united states 12th international congress of sports medicine society of greece / 12th hellenic-cypriot conference 16 march 2018 18 march 2018 thessaloniki, greece 12th international meeting of the austrian foot society 22 march 2018 24 march 2018 going am wilden kaiser, austria european pelvic course 2018 22 march 2018 24 march 2018 hamburg, germany local international conferences, courses & symposia local 19th congress of the south african spine society 30 may 2019 – 01 june 2019 csir international convention centre, pretoria congress organiser: hendrika van der merwe, tel: +27 (0)21 981 3081; website: congress@saspine.org combined 65th south african orthopaedic congress 2019 – ‘unity in diversity’ 02 september – 06 september 2019 icc durban includes the following sub-specialty groups: 1. sa arthroplasty society (saas) 2. sa knee society (saks) 3. sa shoulder and elbow surgeons (sases) 4. sa foot surgeons’ association (safsa) 5. sa orthopaedic trauma society (saots) 6. sa paediatric orthopaedic society (sapos) 7. sa society for hip arthroscopy (sasha) 8. launch and inaugural meeting of the sa orthopaedic oncology and limb preservation society (sols) contact: chairman of the saoa congress committee: dr ian stead, email: iwstead@gmail.com international july 2019 12th oswestry shoulder & elbow course 03 july 2019 – 04 july 2019 oswestry, united kingdom american orthopaedics society for sports medicine – aossm boston 2019 annual meeting 11 july 2019 – 14 july 2019 boston, united states september 2019 the 38th annual meeting of the european bone and joint infection society 12 september 2019 – 14 september 2019 antwerp, belgium intercontinental 3d surgery course 2019 18 september 2019 – 21 september 2019 munich, germany october 2019 ista 2019 toronto – international society for technology in arthroplasty 32nd annual congress 02 october 2019 – 05 october 2019 toronto, canada 15th icrs world congress vancouver 2019 05 october 2019 – 08 october 2019 vancouver, canada the foot and ankle show 2019 11 october 2019 – 12 october 2019 liverpool, united kingdom 5th world congress on spine and spinal disorders 16 october 2019 – 17 october 2019 rome, italy annual meeting of the american shoulder and elbow surgeons ases 2019 16 october 2019 – 19 october 2019 new york, united states eurospine 2019 16 october 2019 – 18 october 2019 helsinki, finland esska advanced knee arthroscopy course: all about meniscus 2019 17 october 2019 – 18 october 2019 watford, united kingdom university of leiden musculoskeletal oncology course 31 october 2019 – 02 november 2019 leiden, netherlands 404 not found south african orthopaedic journal arthroplasty doi 10.17159/2309-8309/2021/v20n2a2ngwazi m et al. sa orthop j 2021;20(2) citation: ngwazi m, ryan p, goga i, marais lc. the association between hiv infection and periprosthetic joint infection following total hip replacement in young adults. sa orthop j 2021;20(2):76-80. http://dx.doi. org/10.17159/2309-8309/2021/ v20n2a2 editor: dr michael held, university of cape town, south africa received: july 2020 accepted: november 2020 published: may 2021 copyright: © 2021 ngwazi m. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background the hiv burden in south africa is high. hiv-positive patients are at risk of developing avascular necrosis of the femoral head, necessitating total hip arthroplasty (tha) at a relatively young age. the primary aim of this study was to investigate the relationship between hiv infection and the risk of periprosthetic joint infection (pji) in young adults following total hip replacement. secondly, we aimed to evaluate the association of hiv infection with venous thromboembolic events, reoperation and revision surgery. methods we undertook a retrospective cohort study involving patients under the age of 55 years who underwent tha between 2009 and 2016 at a tertiary level arthroplasty unit. in total, 290 cases in 213 patients were analysed, with 77 patients requiring bilateral tha. the median age of patients was 43 years (interquartile range [iqr] 39–48, range 26–54 years). sixty-two per cent of patients were hiv positive (n=180) with a median cd4 count of 520 cells/mm³ (iqr 423–659, range 238–1308 cells/mm³). seventy-eight per cent (n=141) of the hiv-positive patients were on antiretroviral medication before surgery. almost all cases performed in the hiv-positive group were for avascular necrosis (n=178, 99%). results at a median follow-up of four years (range 2–10) there were no revisions in either group. the incidence of pji was 1.1% in the hiv-positive group vs 0.9% in the hiv-negative group. the odds ratio for the development of pji in hiv-positive patients was 1.22 (95% ci 0.11 to 13.67, p=0.869). there was no association between the cd4 count of hiv-positive patients and the development of pji (p=0.171). there was no difference in the rate of venous thromboembolic events between the hiv-positive and hiv-negative groups (4% vs 6%, p=0.340). conclusion we report on a cohort of young adult patients who underwent tha. patients living with hiv infection were not found to be at increased risk for pji following tha, when compared to hivnegative patients. the premise that hiv infection increases the risk for pji following tha remains to be substantiated. this study was underpowered in terms of the primary outcome measure and larger studies are required to verify these findings. level of evidence: level 4 keywords: total hip arthroplasty, hiv, aids, avascular necrosis, hip, periprosthetic joint infection the association between hiv infection and periprosthetic joint infection following total hip replacement in young adults muzi ngwazi,¹* paul ryan,¹ ismael goga,² leonard c marais³ ¹ inkosi albert luthuli hospital, school of clinical medicine, division of medicine, department of orthopaedic surgery, university of kwazulu-natal, durban, south africa ² inkosi albert luthuli hospital, durban, south africa ³ school of clinical medicine, division of medicine, department of orthopaedic surgery, university of kwazulu-natal, durban, south africa *corresponding author: ngmuzi@gmail.com and muzingw@ialch.co.za https://orcid.org/0003-3831-3830 page 77ngwazi m et al. sa orthop j 2021;20(2) introduction the burden of hiv infection in south africa in general, and in kwazulu-natal in particular, is high. hip disease (avascular necrosis) associated with hiv infection is common, and patients present at a relatively young age requiring total hip arthroplasty (tha). although tha is a well-established surgical procedure with excellent outcomes reported in the treatment of advanced hip disease, there is scant information on the outcomes in hivpositive patients, and controversy remains regarding the risks of complications, specifically periprosthetic joint infection (pji).1 current literature is contradictory, and studies lack long-term follow-up. most reports emanate from high-income countries, and these results may not necessarily be applicable to a developing world setting.2,3 many of the previous studies on the topic focused on haemophilic patients and intravenous drug abusers with hiv co-infection, the results of which may not be applicable to other hiv-positive patients.4-8 in our unit, we encounter a large number of relatively young patients with hiv requiring total hip replacement. the subset of younger patients requiring tha present their own challenges as they have increased activity levels, physical demands, and need longevity of their implanted components. the primary aim of this study was to compare the risk of pji in hiv-positive and hiv-negative young adult patients, following total hip replacement surgery. secondly, we aimed to evaluate the association of hiv infection with venous thromboembolic events (vte), reoperation and revision surgery. methods we performed a retrospective cohort study. subjects were identified from a prospectively maintained electronic database. all patients below the age of 55 years who received tha at our institution between 2009 and 2016 were deemed eligible for inclusion. patients with less than a two-year follow-up, incomplete data or an unknown hiv status were excluded. patient notes were canvassed for demographics, diagnosis, risk factors, hiv status, antiretroviral (arv) treatment and cd4 count, and extracted. in terms of outcome, we recorded mortality, the development of pji, deep venous thrombosis or pulmonary embolism, the need for reoperation or revision and the merle d’aubigné hip score as recorded at six months postoperatively.9 we also evaluated radiographs for evidence of radiographic incorporation, as well as complications such as subsidence or loosening. pji was defined according to the criteria provided by the international consensus group.10 superficial infection was defined as a superficial incisional surgical site infection (ssi), as defined by the us centers for disease control and prevention (cdc) that did not meet the diagnostic criteria for periprosthetic infection.11 deep venous thrombosis and pulmonary embolism were diagnosed on the basis of clinical findings along with confirmatory laboratory and radiological findings. reoperation was defined as any surgical procedure necessitated by the index tha or any subsequent reoperations, while revision implies a reoperation involving removal and reimplantation of the acetabular cup and/or femoral stem (i.e., isolated acetabular liner exchange was not counted as a revision procedure). from the review period a total of 316 records were identified and screened. twenty-six patients were excluded on the basis that their hiv status was not known, leaving 290 cases in 213 patients included for analysis. each tha procedure was treated as a unique case, with 77 patients requiring bilateral tha. the median age of patients was 43 years (interquartile range [iqr] 39–48, range 26–54 years). forty-six per cent (n=132) of cases were male, the right side was operated in 165 cases (57%) and staged bilateral hip replacement was required in 36 patients (14%). avascular necrosis (avn) was the indication for surgery in 78% (225/290) of cases (figure 1) and osteoarthritis was the indication for surgery in the remainder. in terms of additional risk factors, 21% of cases were current cigarette smokers, 22% current alcohol users and 23% had a history of previous corticosteroid use. sixty-two per cent of patients were hiv positive (180/290) with a median cd4 count of 520 cells/mm3 (iqr 423–659, range 238–1 308 cells/mm3). the majority of these patients 78% (n=141) were on arv medication prior to the tha. almost all cases performed in the hiv-positive group were for avn (n=178, 99%). operative procedure a standard preoperative assessment protocol was used for all patients admitted for joint replacement, irrespective of hiv status. this included a clinical examination, standard ap and lateral x-rays, baseline blood parameters and urine for microscopy, culture and sensitivity. all patients who were planned for joint arthroplasty were encouraged to undergo voluntary counselling and testing (vct) for hiv, but this was not deemed as mandatory. in hiv-positive patients, a cd4 blood count was obtained. unit protocol is to table i: comparison of demographic and clinical characteristics of the hiv-positive and hiv-negative groups characteristic hiv-positive n (%) hiv-negative n (%) p-valuei cases 180 (62%) 110 (38%) age (median years [iqr]) 42 (38–48) 43 (40–48) 0.115ii male sex 49 (27%) 83 (75%) <0.001 left side operated 72 (40%) 53 (48%) 0.172 bilateral tha required 54 (30%) 23 (16%) 0.009 indication for surgery avascular necrosis 178 (99%) 56 (43%) <0.001 comorbidities smoking 43 (24%) 18 (16%) 0.127 chronic alcohol use 38 (21%) 24 (22%) 0.887 corticosteroid use 37 (21%) 28 (25%) 0.332 i: pearson’s chi-squared test, unless stated otherwise; ii: mann–whitney test figure 1. case example illustrating typical findings in a patient with bilateral avn page 78 ngwazi m et al. sa orthop j 2021;20(2) proceed to joint replacement only if the cd4 count is more than 350 cells/mm3; however, there were six patients in which the cd4 count was less than 350 cells/mm3 (but more than 200 cells/mm3). due to the severity of symptoms and the resultant incapacity, it was decided to proceed with surgery in these few patients. three of these patients required bilateral tha and the lower cd4 count was recorded at the time of the second procedure. there were no cases performed on patients with bmi>40 kg/m2, as this is also a unit protocol exclusion. patients requiring bilateral tha were staged at separate sittings. the prosthesis used was an uncemented corail®/pinnacle system (de puy, warsaw) in all patients. the use of drains was at the discretion of the operating surgeon. three doses of prophylactic intravenous antibiotics were administered in all cases postoperatively. thromboprophylactic therapy was initiated 12 hours post-surgery in the form of low molecular weight heparin (40 mg enoxaparin daily) which then converted to oral rivaroxaban 10 mg daily within two days and was continued for a total of 14 days post-surgery. tranexamic acid was not used in this cohort of cases. patients were discharged on crutches once mobilised and were allowed to weight-bear as tolerated. the patients were followed up clinically and radiologically at six weeks, six months, and annually thereafter. statistical methods statistical analysis was performed using stata 15.0 (statacorp. college station, texas). continuous variables were reported as mean (± standard deviation [sd]) if normally distributed or median (with iqr) if skewed and categorical variables as number and percentages, unless otherwise stated. apart from the merle d’aubigné hip score, all continuous variables were non-normally distributed. differences in continuous variables were compared with the use of the student’s t-test or mann–whitney test, as appropriate. categorical data were compared using the fisher’s exact test or the chi-squared test. the association between pji and hiv status was tested using binominal logistic regression analysis. all tests were two-sided, and the level of significance was set at p<0.05. results the median follow-up was four years (iqr 2–5, range 2–10 years). the follow-up was marginally longer in the hiv-positive group (p=0.021). comparative characteristics of the hiv-positive and hiv-negative groups is provided in table i. the hiv-positive group also contained fewer male patients (27% vs 75%, p<0.001), more cases with avn (99% vs 43%, p<0.001) and more cases requiring staged bilateral tha (30% vs 16%, p=0.009). with regard to postoperative complications, there were six cases of superficial wound infection (one hiv-positive patient and five hiv-negative patients) which settled with dressings and short courses of antibiotics. there were three cases of periprosthetic joint infection, two of which occurred in hiv-positive patients (1.1% in hiv-positive group vs 0.9% in hiv-negative group, table ii). the odds ratio for the development of pji in hiv-positive patients was 1.22 (95% ci 0.11 to 13.67, p=0.869) (table iii). there was no association between the cd4 count of hiv-positive patients and the development of pji (p=0.171). in addition, patients who were not on arv medication were not more prone to pji. all cases of pji were successfully treated by reoperation in the way of debridement, irrigation, polyethylene exchange and implant retention. one hiv-positive patient demised seven days post-surgery due to a pulmonary embolism, which was confirmed at post-mortem. notably, there was no difference in the rate of vte between the hiv-positive and hiv-negative groups (4% vs 6%, p=0.340). radiological review confirmed stem integration on all x-rays at last follow-up with no signs of loosening or subsidence. there were no dislocations during the follow-up period. the patient-reported outcome, as represented by the merle d’aubigné hip score at six months postoperatively, was similar among hiv-positive and hivnegative patients (p=0.154). discussion south africa has a high burden of hiv disease. prevalence of up to 46% in patients between the ages of 25 and 40 years has been reported.12 antiretroviral therapy (art) has made a drastic impact on adult life expectancy, with a reported increase of 17 years from 2001 to 2014.13 however, while there have been significant improvements in survival, there remains a considerable burden of morbidity in patients living with hiv, including osteoarticular manifestations. avn of the hip is up to 40 times more likely to develop in hivinfected individuals compared to the general population.14 the disease may progress faster and have more intense symptoms in people living with hiv. it was previously thought that art might be associated with this increased risk; however, recent studies have called this long-held belief into question.15 a meta-analysis performed in 2014 reported a two-fold increase in the odds of avn in patients exposed to protease inhibitors.16 conversely, a large international cohort study found that no arvs were associated with osteonecrosis and that the increased risk may be related to hiv infection itself.17 the current literature on the outcomes and complications fol lowing tha in patients with hiv infection is conflicting. a nationwide survey from the usa involving 9 275 patients with hiv who table ii: comparison of outcome measures and follow-up in the two groups characteristic hiv-positive n (%) hiv-negative n (%) p-valuei cases 180 (62%) 110 (38%) complications periprosthetic joint infection 2 (1%) 1 (1%) 0.869iii aseptic loosening 0 (0%) 0 (0%) venous thromboembolism 7 (4%) 7 (6%) 0.345 reoperation 2 (1%) 1 (1%) 1.000 mortality 1 (1%) 0 (0%) 1.000 follow-up duration (median years [iqr]) 4 (3–6) 4 (2–5) 0.021 promiv (median [iqr]) 14 (13–15) 14 (13–15) 0.154ii i: pearson’s chi-squared test, unless stated otherwise; ii: mann–whitney test; iii: binominal logistic regression; iv: merle d’aubigné hip score table iii: odds ratios for the development of complications in hiv-positive patients compared with hiv-negative patients complication odds ratio 95% confidence interval p-value periprosthetic joint infection 1.22 0.11–13.67 0.869 venous thromboembolism 0.59 0.20–1.7 0.345 reoperation 1.22 0.11–13.67 0.869 aseptic loosening 1 mortality 1 page 79ngwazi m et al. sa orthop j 2021;20(2) underwent tha before 2010 showed an increased risk of both major and minor complication in hiv patients.18 early reports on arthroplasty in hiv-positive patients also raised concerns about the possible increased risk of complications, early failure and periprosthetic infection.19,20 the combination of these factors, namely the high prevalence of hiv infection, an increased need for tha and the concerns about an increased risk of pji, along with the dearth of data from the developing world makes this study particularly relevant in the south african clinical setting. we found no difference in the rate of pji, vte, aseptic loosening, patient-reported outcome at six months, reoperation, revision or mortality between the two groups at a median four-year follow-up. notably, 78% of hiv-positive patients were on arv medication at the time of surgery and only patients with an absolute cd4 count above 200 cells/mm3 were considered eligible for surgery. in addition, we found no association between hiv-positive patients’ cd4 count or arv status and the development of infection. the existing data on the infection risk in hiv-positive patients undergoing arthroplasty is conflicting. a recent meta-analysis on the outcome of knee and hip arthroplasty in hiv patients found an elevated risk of complications in hiv-positive patients (relative risk = 2.28; 95% ci 2.14–2.43).21 however, the authors were not able to analyse the infection risk separately due to heterogenous reporting of data on the topic. some of the early studies on arthroplasty in hiv patients did have a control group.2,19 others included patients with additional risk factors for infection like haemophilia or intravenous drug abuse (ivda).4-8 naziri and colleagues interrogated a large us database and found an increased risk of ‘wound infection’ (0.7% vs 0.2%; or 2.38; 95% ci 1.32–4.30).18 while the authors defined ‘implant infection’ as a minor complication, these were not reported in the results of the study. the authors also recognised that the limitations of their study included the fact that infections could not adequately be assessed using the inpatient data alone and that the data was restricted to the diagnosis recorded during the hospital stay without providing further data relating to the long-term outcomes. while this study, therefore, provides compelling evidence of an increased risk of complications in hiv-infected patients, it is difficult to draw conclusions on the association with infection specifically. in 2013 capogna et al. suggested that the rate of early joint infection might be lower than previously suggested.22 our finding that hiv infection may not necessarily be associated with an increased risk for infection is certainly not a novel one. graham et al. reported the outcome of 43 thas in hiv patients without haemophilia or ivda and found no early or late infections at a mean 3.5-year follow-up.3 they also had no revision cases and no signs of aseptic loosening. while a study by brijlall also showed good outcomes, patients were given antibiotics for an extended period.2 similarly, graham et al. also routinely prescribed long-term antibiotic cover in the form of co-cotrimoxazole.3 we used prophylactic antibiotics for a maximum of 24 hours only. this appears not to have been associated with an increased infection rate, but further studies would be required to confirm this. there are numerous other studies that have also failed to show an increased risk of infection. tornero et al. found no significant difference in terms of either outcome or complications when comparing 18 cases of tha in hiv-positive patients with those of 27 hiv-negative cases.23 snir et al. reported one deep infection out of 41 non-haemophilic hiv-positive cases. their study unfortunately did not have a control group.24 powell and colleagues analysed their results over a 27-year period in haemophiliacs with hiv and noted three infections per 205 joint-years in the hiv-positive group with no increased risk for pji.5 falakassa et al. reported that, at a mean follow-up of 14 months, they encountered no pjis in 31 total hip arthroplasties in non-haemophiliac patients who were all on highly active anti-retroviral therapy (haart).25 wang and coworkers also reported in no infection in ten hip, knee and shoulder arthroplasties at an average follow-up of 38 months.26 similarly, lubega and colleagues from malawi reported no deep sepsis among 14 hiv patients who underwent arthroplasty surgery.27 perhaps most striking is the systematic review by enayatollahi and colleagues which concluded that patients on haart and optimised comorbidities appear to have a lower rate of pji.28 these results are not dissimilar from the findings of our study. in other orthopaedic sub-disciplines, the assumption that hiv infection increases the risk of infection has also been questioned. a recent meta-analysis looking at the risk of infection following fracture surgery noted that in the era of antiretroviral therapy, hiv-infected patients did not appear to have an elevated risk of fracture-related infection in open or closed fractures.29 aside from the risk of infection, there are concerns about several other complications related to arthroplasty in hiv-positive patients. there is data suggesting a greater tendency to thromboembolic phenomena in hiv-positive patients (twoto ten-fold increased risk), with patients younger than 50 years appearing to be particularly succeptible.30 however there are few reports from the developing world regarding this. in our study period, one patient demised seven days postoperatively. she had a history of treated pulmonary tuberculosis for more than ten years previously. the preoperative cd4 count was 944 cells/mm3 and bmi was 26. she was started on thromboprophylaxis and mobilised as per protocol from day 1. post-mortem results confirmed a pulmonary embolism. the current study did not show any increased incidence in vte using a standardised prevention strategy. concerns have also been raised regarding the possibility of stem subsidence or periprosthetic fractures related to the decreased bone quality associated with hiv infection.15,31,32 while some authors have opted for cemented prostheses using antibioticimpregnated bone cement, we opted for uncemented prostheses in all cases.3 a review of the postoperative x-rays of the hip and pelvis in these patients showed excellent osteointegration (figure 2), with no signs of loosening or stem subsidence. radiological assessment showed no differences between hiv and non-hiv patients. the details of these radiological features have been published previously.33 we believe that both uncemented and cemented stems can be used with good outcomes, although the limitation of our relatively short follow-up needs to be kept in mind. the choice of implants should follow the standard selection criteria based mainly on the quality of bone of that patient. figure 2. case example illustrating bilateral total hip arthroplasties with no signs of loosening at four-year review page 80 ngwazi m et al. sa orthop j 2021;20(2) there were several limitations to this study, primarily due to its retrospective nature. the preoperative hip functional outcomes scores were not available in some of the patients and we could only report consistently on the six months postoperative measure. therefore, we are not able to make any conclusions in terms of the functional outcome in hiv-positive versus hiv-negative patients. furthermore, there were insufficient data relating to risk factors such as obesity, diabetes mellitus and nutritional status to allow sub-group analysis. while this may be the largest cohort study of its nature, it remains underpowered for the primary outcome measure. with a low event rate a much larger sample size will be needed to provide high level evidence. the relatively short median followup of four years needs to be taken into account when considering aseptic loosening and the risk of periprosthetic fractures. conclusion we report on a cohort of young adult patients who underwent tha. patients living with hiv infection were not found to be at increased risk for pji following tha, when compared to hiv-negative patients. the premise that hiv infection increases the risk for pji following tha remains to be substantiated. this study was underpowered in terms of the primary outcome measure and larger studies are required to verify these findings. ethics statement the author/s declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study ethical approval was obtained from the following ethical review board: ukzn brec, reference number be079/16. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions mn: study conceptualisation, data capture, data analysis, first draft preparation, manuscript revision pr: first draft preparation, language and grammar correction, data analysis ig: first draft preparation, language and grammar correction, data analysis lcm: data analysis and final draft preparation orcid ngwazi m https://orcid.org/0000-0003-3831-3830 ryan p https://orcid.org/0000-0002-0957-6482 marais lc https://orcid.org/0000-0002-1120-8419 references 1. pietrzak jrt, maharaj z, mokete l, sikhauli n. human immunodeficiency virus in total hip arthroplasty. efort open rev. 2020;5:161-71. 2. brijlall s. hip arthroplasty in hiv-infected patients. sa orthop j. 2008;7(1):10-16. 3. graham sm, lubega n, mkandawire n, harrison wj. total hip replacement in hiv positive patients. j bone joint surg (br). 2014;96-b(4):462-66. 4. hicks jl, ribbans wj, buzzard b, et al. infected joint replacements in hiv positive patients with haemophilia. j bone joint surg (br) 2001;83-b(7):1050-54. 5. powell dl, whitener cj, dye ce, et al. knee and hip arthroplasty infection rates in persons with haemophilia: a 27-year single-centre experience during the hiv epidemic. haemophilia. 2005;11(3):233-39. 6. goddard nj, mann ha, lee ca. total knee replacement in patients with end-stage haemophilic arthropathy: 25-year results. j bone joint surg (br). 2010;92-b(8):1085-89. 7. habermann b, eberhardt c, kurth aa. total joint replacement in hiv positive patients. j infection. 2008;57(1):41-46. 8. ragni mv, crossett ls, herndon jh. post-operative infection following orthopaedic surgery in human immunodeficiency virus-infected haemophiliacs with cd4 counts < or = 200/mm3. j arthroplasty. 1995;10(6):716-21. 9. ugino f, carolina r, alves d. evaluation of the reliability of the modified merle d’aubigne and pastel method. acta ortop bras. 2012:20(4):213-17. 10. parvizi j, gehrke t. definition of periprosthetic joint infection. j arthroplasty. 2014;29:1331. 11. dindo d, demartines n, clavien pa. classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. ann surg. 2004;240:205-13. 12. de oliveira t, kharsany abm, gräf t, et al. transmission networks and risk of hiv infection in kwazulu-natal, south africa: a community-wide phylogenetic study. lancet hiv. 2017;4:e41-50. 13. zaidi j, grapsa e, tanser f, newell ml, barnighausen t. dramatic increase in hiv prevalence after scale-up of antiretroviral treatment. aids. 2013;27:2301-305. 14. mazzotta e, agostinone a, rosso r, et al. osteonecrosis in human immunodeficiency virus (hiv)-infected patients: a multicentric case-control study. j bone miner metab. 2011;29(3):383-88. 15. mary-krause m, billaud e, poizot-martin i, et al. risk factors for osteonecrosis in hiv-infected patients: impact of treatment with combination antiretroviral therapy. aids. 2006;20(12):1627-35. 16. permpalung n, ungprasert p, summachiwakij s, leeaphorn n, knight el. protease inhibitors and avascular necrosis: a systematic review and meta-analysis. int j antimicr agents. 2014;44:93-95. 17. borges ah, hoy j, florence e, et al. anti-retrovirals, fractures, and osteonecrosis in a large international hiv cohort. clin inf dis. 2017;64(10):1413-21. 18. naziri q, boylan mr, issa km, et al. does hiv infection increase the risk of perioperative complications after tha? a nationwide database study. clin orthop rel res. 2015;473(2):581-86. 19. parvizi j, sullivan ta, pagnano mw, trousdale rt, bolander me. total joint arthroplasty in human immunodeficiency virus-positive patients: an alarming rate of early failure. j arthroplasty. 2003;18(3):259-64. 20. lehman cr, ries md, paiement gd, davidson ab. infection after total joint arthroplasty in patient with human immunodeficiency virus or intravenous drug use. j arthroplasty. 2001;16(3):330-35. 21. dimitriou d, ramokgopa m, pietrzak jrt, van der jagt d, mokete p. human immunodefiniency virus infection and hip and knee arthroplasty. jbjs reviews. 2017;5(9):e8. 22. capogna bm, lovy a, blum y, et al. infection rate following total joint arthroplasty in hiv population. j arthroplasty. 2013;25(8):1254-58. 23. tornero e, garcía s, larouse m, et al. total hip arthroplasty in hiv-infected patients: a retrospective, controlled study. hiv med. 2012;13(10):623-29. 24. snir n, wolfson ts, schwarzkopf r, et al. outcomes of total hip arthroplasty in human immunodeficiency virus-positive patients. j arthroplasty. 2014;29:157-61. 25. falakassa j, diaz a, schneiderbauer m. outcomes of total joint arthroplasty in hiv patients. iowa orthop j. 2014;34:102-106. 26. wang ti, chen cf, chen wm, et al. joint replacement in human immunodeficiency virus-infected patients. j chin med assoc 2012;75(11):595-99. 27. lubega n, mkandawire nc, sibande gc, norrish ar, harrison wj. joint replacement in malawi. j bone joint surg br. 2009;91:341-43. 28. enayatollahi m, murphy d, maltenfort m, parvizi j. human immunodeficiency virus and total joint arthroplasty: the risk for infection is reduced. j arthroplasty. 2016:31(10):2146-51. 29. nieuwoudt l, rodseth rn, marais lc. fracture-related infections in hiv infected patients: a systematic review and meta-analysis. j orthop. 2020;18:248-54. 30. kiser kl, badowski me. risk factors for venous thrombosis in patients with human immunodeficiency virus infection. pharmacotherapy. 2010;30(12):1292-302. 31. martin a, moore c, mallon pw, et al. bone mineral density in hiv participants randomised to raltegravir and lopinavir/ritonavir compared with standard second-line therapy. aids. 2013;27(15):2403-11. 32. sharma a, tian f, yin mt, et al. association of regional body composition with bone mineral density in hiv-infected and hiv-uninfected women: women’s interagency hiv study. j acquir immune defic syndr. 2012;61(4):469-76. 33. bakkai a, ryan p, goga i, et al. tapered uncemented ha-coated femoral stems: a radiological study. s afr orthop j. 2017;16(3)27-30. https://orcid.org/0000-0002-1120-8419 _hlk67590521 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 23 orthopaedic research activity in south africa measured by publication rates in the 15 highest impact journals related to population size and gross domestic product prof e hohmann mbbs, frcs, frcs (tr&orth), md, phd medical school, university of queensland, australia dr v glatt phd institute of health and biomedical innovation, queensland university of technology, brisbane, queensland, australia prof k tetsworth md, fracs department of orthopaedic surgery, royal brisbane hospital, herston, queensland, australia department of surgery, school of medicine, university of queensland, australia queensland university of technology orthopaedic research centre of australia corresponding author: prof erik hohmann musculoskeletal research unit po box 4045 rockhampton, qld 4700, australia email: ehohmann@hotmail.com introduction research is a major component of innovation and can contribute to health improvements through a knowledge-toaction-process.1 in general, the total number of publications by a country is one of the indicators of research output and productivity and is an important aspect of clinical excellence.2-4 while the developing world contains more than 75% of the world’s population and has the largest burden of musculoskeletal disease, less than 10% of publications originate from these countries.1 aluede et al. investigated the representation of developing countries in four high impact orthopaedic journals over a three-year period, and determined that less than 0.4% of all articles (n=15) were published by authors from sub-saharan africa, with only six publications originating from south africa.5 abstract background: the purpose of this study was to investigate the number of publications and impact of south african surgeons in the 15 highest impact orthopaedic journals over a five-year period methods: the abstracts between january 2010 and december 2014 were screened and the total number of publications and impact points were collated. normalisation to population size, gdp and per capita gdp was performed. results: of the 23 021 orthopaedic articles from 66 countries, south africa published 19 articles and ranked 41st overall for the number of publications and 40th for impact. when compared to the other african countries it ranked 2nd. the following ranks were calculated for adjusting population (51st overall, 2nd in africa), gdp (51st overall, 3rd in africa), gdp per capita (31st overall, 3rd in africa). conclusion: this study demonstrated that south africa ranked in the lower third of all countries that published in the top 15 highest impact orthopaedic journals. in africa, egypt was the leading country for total publications and impact factor maintaining the first rank even when adjusted for population size, gdp, gdp per capita and research funding in percentage of gdp. key words: bibliometrics, orthopaedic surgery, impact factor, publication productivity http://dx.doi.org/10.17159/2309-8309/2016/v15n4a3 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 23 page 24 sa orthopaedic journal summer 2016 | vol 15 • no 4 yamey interviewed academic leaders from low and middle income countries about potential obstructions for health interventions and reported that limited human resources, lack of leadership, financial constraints and lack of political will are some of the perceived barriers.6 similarly, bouchard et al. demonstrated that poor leadership, high cost, poor healthcare structure, inadequate human resources and especially corruption are barriers to orthopaedic care and research.7 shipley suggested that the lack of resources in public hospitals, administrative support, funding and motivation in south africa are possible barriers despite an abundance of subjects addressing local and continental topics.8 bibliometric analysis is commonly used as a proxy for research output and several authors have previously performed bibliometric analysis of orthopaedic publications.9-11 only ireland and turkey have specifically investigated their country’s individual contribution to orthopaedic literature with a focus on the institution, individual authors and distribution of publications among journals.12,13 however, the total number of publications may not account for economic discrepancies and population size.11 in addition, the availability of funding would certainly result in higher publication output by countries with a larger population size and more powerful economies in particular when considering the economic realities of low income and developing countries.11,14 to adjust for these inconsistencies the use of gross domestic product (gdp) and gross domestic product per capita may result in more meaningful results and allow for comparisons between countries.15 the purpose of this study was threefold: 1) to investigate the number of publications and impact of south african surgeons in the 15 highest impact orthopaedic journals over a five-year period and relate these variables to population size, gdp and gdp per capita; 2) to establish the number of publications required for south africa to be equal with the country having the overall highest research output, to establish the number of publications required for south africa to be comparable to the average; 3) and to compare south africa’s research output to other african countries. methods the 2015 journal citation report was accessed on the web of science (thomson reuters, new york, usa).16 the 15 highest ranked journals based on the 2015 impact factor were selected from the category ‘orthopedics’. journals that were not directly related to the field of orthopaedic surgery or their main purpose was to provide narrative review articles were excluded from this list (table i). only research articles (level 1–4), systematic reviews, metaanalysis, non-solicited review articles and case reports were included. letters to the editor, editorials, editorial comments, historical articles, errata, proceeding papers, meeting abstracts and notes were excluded. the abstracts of these articles published between january 2010 and december 2014 were screened via the journals’ websites. the level of evidence was recorded for each published article. if the journal did not assign the level of evidence, the ‘levels of evidence’ chart published by the journal of bone and joint surgery was used.17 discrepancies were solved by agreement between the two senior authors. the country of origin was defined as the country of origin of the corresponding author if the manuscript did not provide details about study location. gdp and gdp per capita were sourced from the world bank website18 and population size was extracted from the cia world factbook.19 for the african countries that had published articles in the top 15 journals, more demographic information was collected: gdp composition as a percentage of gdp, health and education expenditure in percentage gdp, literacy rate, physicians and hospital beds per 1 000 population, the country’s position rank on the corruption index and corruption perception index. these variables were used for qualitative analysis of research output on the african continent. the total number of publications and the total number of impact points were collated. to adjust the number of publications for population size, the population size was divided by the total number of publications. table i: impact factors (2015 journal citation reports – thomson reuters) and total number of included publications from 2010–2014 journal impact points publications 2010–2014 1 journal of bone and joint – american volume 5.280 1 833 2 american journal of sports medicine 4.362 1 561 3 the bone and joint journal 3.309 1 379 4 arthroscopy – the journal of arthroscopic and related surgery 3.206 1 072 5 knee surgery sports traumatology arthroscopy 3.053 1 747 6 journal of orthopaedic research 2.986 1 301 7 acta orthopaedica 2.771 565 8 clinical orthopaedics and related research 2.765 2 027 9 journal of arthroplasty 2.666 1 873 10 spine journal 2.426 1 029 11 spine 2.297 2 848 12 journal of shoulder and elbow surgery 2.289 1 324 13 injury – international journal of the care of the injured 2.137 1 133 14 international orthopaedics 2.110 1 477 15 european spine journal 2.066 1 852 total number of publications 23 021 excluded journals: osteoarthritis cartilage (no. 3 if: 4.165); journal of physiotherapy (no.4 – if: 3.708); journal of orthopaedic sports physiotherapy (no. 8 – if: 3.011); gait posture (no. 12 – if: 2.752); journal of the american academy of orthopaedic surgeons (no. 14 – if: 2.527); physical therapy (no 15 – if: 2.526); clinical journal sports medicine (no 19 – if: 2.268) saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 24 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 25 the resulting value reflected the population size per publication (pspp); in other words, the calculated value described the population size per published article, which allowed for better comparison of research output between countries. similarly, population size was divided by the total impact points (psip). for further analysis, the gdp was divided by the total number of publications and impact points. the established values provided an overview of the gross cost of producing a manuscript (gdpp), respectively one impact point (gdpi) for each country. to adjust for population size and economic strength, the gdp per capita was divided by the total number of publications and impact points. the established values provided a more detailed overview of the gross cost per capita producing a manuscript (gdppc), respectively one impact point (gdpic) for each country. the country list for gdppc was then ranked and the number of publications of the country ranked median was used to calculate the number of publications each country should achieve to be equivalent with the median. the following formula was used: 1. per capita gdp (in usd)/number of publications = benchmark factor (of ‘median’ country) 2. per capita gdp of each country/benchmark factor = required publications to be equal with median there is no published evidence for this approach, yet the ‘papers’ to be published provide an excellent overview of the relative output and research strength between countries corrected for economic power (gdp/capita) and population size. finally, the gdppc was used to calculated the numbers of publications needed to become equal with the perceived current global leader in orthopaedic research, namely the united states. results a total of 23 021 orthopaedic articles were published within the study period between january 2010 and december 2014 (table i). table ii demonstrates the number of south africa’s publications within these journals. a total of 19 publications were recorded (table iii). nine publications were published from cape town; eight of these were university-based and one was from a private practice. four publications were from johannesburg, two from durban and stellenbosch, and the remaining two from east london and pietermaritzburg; all of these papers were university-based. of the 19 publications, three studies were published by physiotherapists and engineers having no input from orthopaedic surgeons. a total of 66 countries have published at least one article. the country ranked as ‘medium’ (poland) published 61 articles. table iv shows the top 15 countries with the united states being the leading country with a total of 8 149 publications and a total of 24 744 impact points. south africa ranked 41st overall for the number of publications and 40th for impact. when compared to the other african countries it ranked 2nd, both for the number of publications and impact. when adjusting for population size, switzerland was the leading country with one publication per 15.300 and one impact point for 5.400 (table v). south africa ranked 51st for the number of publications and 48th for impact. when compared to the other african countries it ranked 3rd for the number of publications and 2nd for impact. the number of publications and impact points related to gdp were highest for croatia with one publication per 772.000 usd and producing one impact point per 359.000 usd (table vi). south africa ranked 50st for both the number of publications impact. when compared to the other african countries it ranked 4th for the number of publications and 5th for impact. when adjusting for gdp per capita, china produced one publication per 6.200 usd and for impact the usa produced one impact point per 2.200 usd (table vii). south africa ranked 31st for both the number of publications and for impact. when compared to the other african countries it ranked 3rd for the number of publications and for impact. when using the median number (n=61) of publications per gdp/capita (gdppc) calculated for all 66 countries which contributed with at least one publication in these top 15 journals over the study period, and calculating the ‘required’ number of publications to be equivalent with the median, 28 countries reached this benchmark figure (table viii). interestingly, egypt and malawi published more papers than required and were the only african countries to meet the benchmark. south africa ranked 31st. to meet the required benchmark, the number of publications was calculated to be n=28 but only 19 articles (68%) were published. using the gdppc to calculate the required number of publications to be equivalent with the global research leader (usa), south africa would have been required to publish 968 articles (table ix). table ii: number of south african publications between 2010 and 2014 journal 2010 2011 2012 2013 2014 total jbjs-am 0 0 0 0 0 0 am j sports med 0 1 0 0 0 1 bjj 1 1 0 0 1 3 arthroscopy 0 0 0 0 0 0 kssta 1 0 0 0 0 1 j orthopaedic research 0 0 1 2 0 3 acta orthopaedica 0 0 0 0 0 0 corr 1 0 0 0 0 1 j arthroplasty 0 0 2 0 0 2 spine journal 0 0 1 0 1 2 spine 0 1 0 0 1 2 j shoulder elbow surg 0 0 0 0 1 1 injury 0 0 1 1 0 2 international orthopaedics 0 0 0 0 0 0 european spine journal 0 0 0 1 0 1 total 3 3 5 4 4 19 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 25 page 26 sa orthopaedic journal summer 2016 | vol 15 • no 4 on the african continent, south africa was among the countries with the highest health and education expenditure, the largest number of hospital beds, highest literacy rate and the lowest corruption ranking and corruption perception indices on the continent (table x). however, it ranked only 3rd for physicians per 1 000 population (0.78) with both egypt (2.83) and tunisia (1.12) having higher number of physicians. when comparing south africa to the uk, it is noteworthy that health expenditure and education expenditure in percentage gdp, hospital beds per 1 000 population and literacy rate were very similar. discussion the results of this study demonstrated that south africa is consistently ranked in the lower third of the 66 countries that published in the top 15 ranked orthopaedic journals. on the african continent, egypt was the leading country for total publications and impact, maintaining the first rank even when adjusted for population size. gdp and gdp per capita are indicators of economic strength representing the value of all goods and services produced over a specific time period.12 the lower the cost of producing a research paper per capita/gdp should be a direct indicator of a country’s research productivity. when adjusting for gdp and gdp per capita, south africa ranked in the lowest quarter. comparing south africa’s performance to the other african countries, malawi, egypt and tunisia were better performers. this is somewhat surprising as the economic realities and figures in these countries are similar and one would expect a linear relationship between economic data and research productivity. research output of the african countries is obviously not directly related to the highest per capita gdp; if it were, then south africa would be the leader followed by nigeria and egypt. a similar observation was made in the developed world, where none of the five leading countries had the highest per capita gdp. the us is ranked 8th, germany 15th, the uk 17th, japan 23rd and korea 27th. earlier research by meo et al.14 and halpenny et al.15 could not demonstrate a correlation between per capita gdp, total number of publications, or h-index in various science and social science journals, but did show a strong and positive correlation between the number of publications and the percentage of gpd spent on research. the available data from the world bank from 2012 shows that egypt (0.68%), south africa (0.73%), ethiopia (0.61%) and tunisia (0.68) spend very similar percentages of their gdp on research funding.16 based on these figures these countries should produce a very similar research output. table iii: detailed list of publications between 2010 and 2014 no authors location institution journal and year level of evidence impact points 1 hemmerich, van der merwe, batterham, vaughan cape town university of cape town ajsm 2011 laboratory 4.362 2 lewis, gibson durban university of kwa zulu bjj 2010 v 3.309 3 garrett, hoffman, carrara cape town university of cape town bjj 2011 iv 3.309 4 held, laubscher, zar, dunn cape town university of cape town bjj 2014 iv 3.309 5 de beer, bhatia, van rooyen, du toit cape town private practice kssta 2010 iv 3.053 6 nell, van der merwe, cook, handley, collins, september cape town university of cape town j orth res 2012 iii 2.986 7 saunders, van der merwe, posthumus, cook, handley, collins, september cape town university of cape town j orth res 2013 iii 2.986 8 rahim, gibbon cape town university of cape town j orth res 2013 iii 2.986 9 firth, robertson, schepers, fatti johannesburg wits university corr 2010 iv 2.765 10 schepers, cullingworth, van der jagd johannesburg wits university j arthroplasty 2012 i 2.666 11 peters, greeff, goldstein, frey johannesburg wits university j arthroplasty 2012 iv 2.666 12 *de beer, scheffer stellenbosch stellenbosch university spine j 2012 laboratory 2.426 13 **olivier, stewart, mckinon johannesburg wits university spine j 2014 iv 2.426 14 dunn, zondagh, candy cape town university of cape town spine 2011 iv 2.296 15 **louw, diener, landers, puentedura stellenbosch stellenbosch university spine 2014 ii 2.296 16 dachs, ryan, vrettos, roche cape town university of cape town j shoulder elbow 2014 v 2.289 17 grey, rodseth, muckart durban university of kwa zulu injury 2013 iv 2.137 18 grey, rodseth, muckart pietermaritzburg university of kwa zulu injury 2013 iv 2.137 19 daniel, dunn east london walter sisulu university european spine j 2013 iv 2.137 *engineering, **physiotherapists saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 26 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 27 table iv: highest number of publications and impact points for the top 15 countries and african countries rank country publications rank country impact points 1 usa 8 149 1 usa 24 744 2 united kingdom 1 644 2 united kingdom 4 776 3 japan 1 467 3 japan 4 053 4 korea 1 354 4 korea 3 765 5 germany 1 272 5 germany 3 491 6 china 1 222 6 china 3 034 7 canada 930 7 canada 2 774 8 italy 737 8 holland 2 155 9 holland 663 9 italy 1 982 10 france 548 10 switzerland 1 507 11 switzerland 527 11 australia 1 412 12 australia 485 12 france 1 382 13 sweden 403 13 sweden 1 187 14 spain 311 14 spain 833 15 austria 295 15 austria 801 31 egypt 68 31 egypt 168 41 south africa 19 40 south africa 52 48 nigeria 7 49 nigeria 15 50 tunisia 5 52 tunisia 11 52 malawi 2 56 malawi 5 52 morocco 2 56 uganda 5 53 ethiopia 1 57 morocco 4 53 sudan 1 58 ethiopia 3 53 uganda 1 59 sudan 3 table v: number of publications (pspp) and impact (psip) normalised for population size rank country psip rank country psip 1 switzerland 15.3 1 switzerland 5.4 2 norway 21.1 2 norway 6.7 3 denmark 22.3 3 holland 7.8 4 sweden 24.1 4 denmark 7.9 5 holland 25.4 5 sweden 8.2 6 austria 28.7 6 austria 10.6 7 finland 32.3 7 canada 12.1 8 canada 35.9 8 luxemburg 12.6 9 luxemburg 38.9 9 usa 12.9 10 korea 38.9 10 united kingdom 13.4 11 united kingdom 38.9 11 finland 13.4 12 usa 39.3 12 korea 13.6 13 australia 44.3 13 australia 15.2 14 belgium 51.1 14 belgium 18.2 15 hong kong 55.3 15 singapore 18.3 42 egypt 1176.5 44 egypt 476.2 48 tunisia 2178 48 south africa 915.2 51 south africa 2571.4 49 tunisia 990 54 malawi 8180 54 malawi 32720 55 ethiopia 9410 60 uganda 75160 61 morocco 16505 62 morocco 82525 63 nigeria 24800 63 nigeria 115733.3 65 uganda 37580 64 sudan 126533.3 66 sudan 37976 66 ethiopia 313666.7 table vi: number of publications (gdpp) and impact (gdpic) normalised for gdp per capita rank country gdpp rank country gdpi 1 croatia 772 1 croatia 359 2 korea 1 042 2 korea 375 3 greece 1 294 3 holland 408 4 holland 1 326 4 greece 464 5 switzerland 1 330 5 switzerland 465 6 denmark 1 348 6 sweden 481 7 sweden 1 417 7 denmark 482 8 slovenia 1 417 8 slovenia 576 9 austria 1 547 9 austria 579 10 finland 1 630 10 united kingdom 626 11 united kingdom 1 818 11 canada 644 12 taiwan 1 852 12 norway 662 13 canada 1 920 13 taiwan 671 14 norway 2 083 14 finland 677 15 malawi 2 129 15 usa 704 30 egypt 4 213 18 malawi 852 45 tunisia 9 722 32 egypt 1 706 50 south africa 16 671 46 tunisia 4 419 53 uganda 26 998 48 uganda 5 400 57 morocco 55 004 50 south africa 5 934 58 ethiopia 55 621 55 ethiopia 18 540 61 sudan 74 202 58 sudan 24 734 64 nigeria 81 215 60 morocco 27 502 63 nigeria 37 901 table vii: number of publications (gdppc) and impact (gdpic) normalised for gdp per capita rank country gdpp rank country gdpi 1 china 6.2 1 usa 2.2 2 india 6.4 2 india 2.4 3 usa 6.7 3 china 2.5 4 korea 20.7 4 korea 7.4 5 japan 24.7 5 japan 8.9 6 united kingdom 28.2 6 united kingdom 9.7 7 germany 37.6 7 germany 13.7 8 turkey 44.7 8 turkey 16.7 9 egypt 47 9 italy 17.6 10 italy 47.4 10 canada 18.1 11 canada 54 11 egypt 19 12 brazil 77.4 12 holland 24.2 13 france 78 13 brazil 27.9 14 holland 78.7 14 france 30.9 15 iran 83.7 15 iran 31.3 20 malawi 127.5 22 malawi 51 31 south africa 308.7 31 south africa 109.9 37 nigeria 457.6 36 uganda 143 43 ethiopia 574 41 ethiopia 191.3 48 uganda 715 44 nigeria 213.5 50 tunisia 884.2 51 sudan 371.7 53 sudan 1115 53 tunisia 401.9 57 morocco 1595 59 morocco 797.5 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 27 page 28 sa orthopaedic journal summer 2016 | vol 15 • no 4 table viii: number of publications to be published to achieve the median numbers per head gdp rank country published publications 2010-2014 papers to be published percentage of published papers 1 china 1 222 32 3 783 2 india 246 7 3 656 3 usa 8 149 235 3 505 4 korea 1 354 119 1 137 5 japan 1 467 235 952 6 united kingdom 1 644 197 833 7 germany 1 272 203 625 8 turkey 235 45 525 9 egypt 68 14 499 10 italy 737 148 496 11 canada 930 214 435 12 brazil 147 48 303 13 france 548 182 301 14 holland 663 222 298 15 iran 65 23 280 20 malawi 2 1 200 31 south africa 19 28 68 37 nigeria 7 14 50 43 ethiopia 1 2 50 48 uganda 1 3 33 50 tunisia 5 19 26 53 sudan 1 5 20 57 morocco 2 14 15 table ix: number of publications to be published to be equivalent with the leader (usa) rank country published publications 2010-2014 papers to be published percentage of published papers 1 china 1 222 1 132 108 2 india 246 236 104 3 usa 8 149 8 149 100 4 korea 1 354 4 174 32 5 japan 1 467 5 402 27 6 united kingdom 1 644 6 915 24 7 germany 1 272 7 138 18 8 turkey 235 1 569 15 9 egypt 68 477 14 10 italy 737 5 210 14 11 canada 930 7 498 12 12 brazil 147 1 699 8.6 13 france 548 6 378 8.6 14 holland 663 7 787 8.5 15 iran 65 812 8 20 malawi 2 38 5.2 31 south africa 19 968 2 34 nigeria 7 487 1.5 36 ethiopia 1 86 1.2 39 uganda 1 107 0.94 41 tunisia 5 660 0.76 44 sudan 1 166 0.6 47 morocco 2 476 0.42 t a b le x : o v er v ie w o f a fr ic a ’s e co n o m ic f ig u re s c o u n tr y g d p g d p p e r ca p it a h e a lt h e x p . in % g d p p h y si ci a n s p e r 1 0 0 0 p o p h o sp it a l b e d s p e r 1 0 0 0 p o p e d u ca ti o n in % g d p l it e ra cy ra te i n % *c o rr u p ti o n ra n k in g 2 0 1 5 ** c o rr u p ti o n p e rc e p ti o n i n d e x e g y p t 2 8 6 .5 4 3 1 9 9 5 .1 2 .8 3 0 .5 3 .8 7 4 7 7 3 6 s o u th a fr ic a 3 5 0 6 4 8 3 8 .9 0 .7 8 2 .8 6 .2 9 4 5 2 4 4 n ig er ia 5 6 8 .5 3 2 0 3 3 .9 0 .4 1 0 .5 3 n / a 6 0 1 2 0 2 6 t u n is ia 4 8 .6 4 4 2 1 7 .1 1 .1 2 2 .1 6 .2 8 2 6 5 3 8 m a la w i 4 .2 6 2 5 5 8 .3 0 .0 2 1 .3 5 .4 6 6 9 8 3 1 m o ro cc o 11 0 3 1 9 0 6 0 .6 2 0 .9 6 .6 6 8 7 7 3 6 e th io p ia 5 5 .6 5 7 4 5 .1 0 .0 3 6 .6 4 .7 4 9 1 3 7 3 3 s u d a n 7 4 .2 1 1 1 5 6 .5 0 .2 8 0 .8 2 .2 2 3 1 4 7 1 2 u g a n d a 2 7 7 1 5 9 .8 0 .1 2 0 .5 3 .3 7 8 1 2 2 2 5 u s a 1 7 4 1 9 5 4 6 2 9 1 7 .1 2 .4 5 2 .9 5 .2 8 6 1 4 7 6 u n it ed k in g d o m 2 9 8 9 4 6 3 3 2 9 .1 2 .8 1 2 .9 6 9 9 1 0 8 1 *w o rl d a u d it .o rg : b a se d o n d a ta o f 1 5 0 c o u n tr ie s ** tr a n sp a re n cy .o rg : ra te s h o w c o rr u p t a c o u n tr y ’s p u b li c se ct o r is p er ce iv ed t o b e; r a n g e fr o m 0 ( h ig h ly c o rr u p t) t o 1 0 0 ( v er y c le a n ) saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 28 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 29 however, egypt consistently publishes more articles than south africa. the reason for this is not clear but may be related to the fact the egypt has a higher rate of physicians per population. we have developed a benchmark measure based on the median publications by dividing the per capita gdp with the median. in our opinion this benchmark allows for a more direct comparison between countries of research output related to per capita gdp. the result of this equation provided a clear value on how many publications were needed to achieve the median number of publications based on the individual country’s per head gdp. as expected the usa was the overwhelming leader. for the african countries, south africa ranked 31st overall and fell short by nine articles of reaching the benchmark. again, egypt was the african leader with a total of 68 publications requiring only 14 to reach the benchmark. given that the economic indicators are comparable, the differences in physician density may again be the only explanation for the differences between the two countries. research output is an important determinant of economic growth and an increase in service delivery, education and innovation is often an indicator of a society’s shift from a producing to a knowledge-based economy.20 in fact, publications of scientific literature can indicate the progress of science and technology.10 the number of publications in south africa in the top 15 journals between 2010 and 2014 has been steady; in contrast, egypt showed a 20% increase in publications between 2010 and 2014 despite volatile political circumstances. obviously the below average publication record of south africa cannot be explained by economic figures alone. shipley suggested that staff shortages and chaotic record systems hinder prospective and retrospective studies especially where long-term follow-up is required.8 however, these problems can be overcome by modern technology, personal engagement and involvement in the public sector, especially in the private sector of metropolitan areas. shipley concedes that the underlying problem is possibly a lack of research ethos in the south african medical schools, lack of motivation of the individual and lack of recognition.8 one potential solution to increase the number of research publications certainly lies within the medical schools. many orthopaedic registrars enrol in a master’s of medicine (mmed) programme and research is a compulsory part of completion of the degree. these studies are possibly often not published and one could argue that in order to complete specialty training, a peer-reviewed publication should be compulsory. this is a common practice in other countries. a potential barrier to this approach is a lack of successful, motivated and well-trained academic teachers to provide individual guidance. there are many other barriers in africa that most likely affect the low research output on the continent. elliot et al. have identified 19 barriers by conducting semi-structured interviews.21 these barriers range from resource constraints (funding, lack of protected research time, access to literature) to research processes (lack of training, record keeping, mentoring) to institutional barriers (culture, trauma burden, lack of collaboration). simba et al. highlighted that despite the existence of adequate numbers of highly skilled researchers in africa, the number of publications per faculty is low.22 this was attributed to the security of public employment, difficulties attracting research grants and outside work engagement with consultancies that assure additional income. corruption is another major impediment to access healthcare in low-income countries and has an effect on research.23 bouchard et al. demonstrated that one of the largest barriers to access orthopaedic and trauma care is corruption.7 the ranking of the included african countries on the 2015 corruption ranking index and corruption perception index, clearly demonstrates a high level of corruption in all countries. this is even more significant as the who has identified that the development of healthcare infrastructure is partly dependent on locally produced research, demonstrating the complex relationship between healthcare delivery, infrastructure and research. interestingly, south africa has very similar health and education expenditure in per cent/gdp and based on these facts could theoretically have a comparable and efficient health system to the united kingdom. however, the uk ranks 10th on the 2015 corruption ranking and 81 on the corruption perception index, whereas south africa ranks 52nd respectively and has a perceived corruption index of 44, indicating a medium level of corruption. corruption may certainly be one factor explaining the differences between the two countries. the question must be asked how the south african healthcare system would perform if it had similar corruption indices. what are the potential solutions? they are clearly related to building local capacity. shipley suggested multi-centre studies, university-funded posts to promote research, cooperation with private surgeons and remunerated work outside the public service.8 aluede et al. believes that multinational and cross-institutional collaborations and the initiation of educational programmes will generate more studies.5 the most important step might be the implementation of a mentoring programme. however, the lack of willingness of senior scientists and surgeons, and the lack of protected time are major limitations that must be addressed for this to be successful.5,21,22 bennett et al. have suggested that mentoring could also be achieved by training mentors in the developed world.24 finally the sa orthopaedic journal should be encouraged to apply to be indexed on medline for worldwide dissemination of african-based research. this study has limitations. the research was limited to the 15 highest impact orthopaedic journals. the inclusion of more journals may have resulted in a different outcome. the individual quality of each article was not assessed, making it possible that there was a significant discrepancy of the manuscript quality between countries, potentially introducing a selection bias. the selection of impact factor as an outcome measure for publication quality has been criticised saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 29 page 30 sa orthopaedic journal summer 2016 | vol 15 • no 4 as it is determined by technicalities not related to the scientific quality.25,26 citation analysis was not performed and it is acknowledged that the number of citations are a proxy measure of influence reflecting the recognition and quality of the published research by its peers.27 over-citation, biased citing, audience size, biased data and ignorance of the literature are common criticisms.28 nevertheless, using impact reflects citation counts as article citation rates determine the journal’s impact factor.25 this study developed a new approach to bibliometric analysis by using the median of all publications and relating it to the gdp per capita. this technique has not been validated and may lack the robustness of citation and content analysis. however, similar to classic bibliometrics, the calculated variable seems to allow for better comparisons between countries by establishing the number of publications required for a particular country to be equivalent with the average research output for a defined period of time taking the economic power per capita into consideration. conclusions the results of this study demonstrated that south africa ranked in the in the lower third of all 66 countries that published in the top 15 ranked orthopaedic journals. on the african continent, egypt was the leading country for total publications and impact and maintained the first rank even when adjusted for population size, gdp, gdp per capita and research funding by the percentage of gdp. finally south africa missed the benchmark and published only 68% of the publications required to be equivalent. compliance with ethics guidelines prof hohmann, dr glatt and prof tetsworth declare that the content of this article is their original work. no benefits of any form have been received from a commercial party related directly or indirectly to the subject of this article. references 1. coloma j, harris e. from construction workers to architects: developing scientific research capacity in lower income countries. plos biology 2009;7(7):e1000156. 2. carey rm, wheby ms, reynolds re. evaluating faculty clinical excellence in the academic health sciences center. academic medicine 1993;68(11):813-17. 3. christmas c, kravet sj, durso sc, wright sm. clinical excellence in academia: perspectives from masterful academic clinicians. mayo clinic proceedings 2008;83(9):989-94. 4. luo x, liang z, gong f, bao h, huang l, jia z. worldwide productivity in the field of foot and ankle research from 2009–2013: a bibliometric analysis of highly cited journals. j foot ankle res 2015;8:12. 5. aluede ee, phillips j, bleyer j, jergesen he, coughlin r. representation of developing countries in orthopaedic journals. clin orth relat res 2012;470:2313-18. 6. yamey g. what are the barriers to scaling up health interventions in low and middle income countries? a qualitative study of academic leaders in implementation science. globalization health 2012;8:11. 7. bouchard m, kohler jc, orbinski j, howard a. corruption in the health care sector: a barrier to access of orthopaedic care and medical devices in uganda. bmc int health human rights 2012;12:5. 8. shipley j. orthopaedic research in south africa – the unstable pot. sa orthopaedic journal 2010;4:4. 9. bosker bh, verheyen ccpm. the international rank order of publications in major clinical orthopaedic journals from 2000 to 2004. j bone joint surg br 2006;88-b(2):156-58. 10. hui z, yi z, peng j. bibliometric analysis of the orthopaedic literature. orthopedics 2013;36(10):e1225-e1232. 11. lee km, ryu ms, chung cy, choi ih, kwon dg, kim tw, sung kh, seo sg, park ms. characteristics and trends of orthopedic publications between 2000 and 2009. clinics orthop surg 2011;3:22529. 12. gurbuz y, sugun ts, ozaksar k. a bibliometric analysis of orthopedic publications originating from turkey. acta orthop traumatol turc 2015;49(1):57-66. 13. kennedy c, o’sullivan po, bilal m, walsh a. ireland’s contribution to orthopaedic literature: a bibliometric analysis. the surgeon 2013;11:267-71. 14. meo sa, al masri aa, usmani am, memom an. impact of gdp, spending on r&d, number of universities and scientific journals on research publications among asian countries. plos one 2013;8(6):e66449. 15. halpenny d, burke j, mcneill g, snow a, torreggiani wc. geographic origin of publications in radiological journals as a function of gdp and percentage of gdp spent on research. academic radiology 2010;17(6):768-71. 16. journal citation reports for scientific information, 2015. www.webofknowledge.com 17. marx r, wilson sm, swiontowski mf. updating the assignment of levels of evidence. j bone joint surg am 2015;97:1-2. 18. world bank list of economies. world bank data development group. available at http://data.worldbank.org. accessed january 20, 2016. 19. the world factbook. central intelligence agency. available at https://www.cia.gov/library/publications/resources/the-worldfactbook. accessed january 20, 2016. 20. wong cy, goh kl. the pathway of development: science and technology of nies and selected asian emerging economies. scientometrics 2012;92:523-48. 21. elliott is, sonshine db, akhavan s, shantz as, caldwell a, shantz js, gosselin ra, coughlin r. what factors influence the production of orthopaedic research in east africa? a qualitative analysis of interviews. clin orthop relat res 2015;473:2120-30. 22. simba d, mukose a, bazeyo w. institutional capacity for health systems research in east and cnetral african schools of public health: strengthening human and financial resources. health res policy systems 2014;12:23. 23. kohler j. fighting corruption in the health sector. methods. united nations development programmes: tools and good practices 2011. 24. bennett s, paina l, ssengooba f, waswa d, m’imunya jm. mentorship in african health research training prgrams: an explanatory study of fogarty international programs in kenya and uganda. education health 2013;26(3):183-87. 25. seglen po. why the impact factor of journals should not be used for evaluating research. bmj 1997;314:498-502. 26. whitehouse gh. impact factors: facts and myths. eur radiol 2002; 12:715–717. 27. lefaivre ka, shadgan b, o’brien pj. 100 most cited articles in orthopaedic surgery. clin orth relat res 2011; 469:1487-97. 28. mac roberts mh, mac roberts br. problems of citation analysis. scientometric 1996; 36(3):435-444. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 30 sa orthopaedic journal winter 2014 | vol 13 • no 2 page 35 metatarsophalangeal joint instability of the lesser toes: review and surgical technique james r. jastifer, md michael j. coughlin, md st alphonsus coughlin foot and ankle clinic, boise, idaho, usa correspondence: james r. jastifer md saint alphonsus coughlin foot & ankle clinic 1075 north curtis road suite 300 boise, id 83706 tel: (616)-481-8151 email: jastifermd@gmail.com introduction metatarsalgia is a commonly encountered problem in clinical practice and can have a number of causes (table i).1-3 first described by coughlin in 1987,4 the term ‘second crossover toe’ was introduced to characterise the clinical deformity. the pathology of the crossover toe, however, does not always include crossing over the hallux. in the early stages of disease it may manifest as a subtle deviation of the toe. although the second toe was first described and is most commonly involved, deformity in the other lesser toes is also common.1,5-9 nonetheless, the eponym second crossover toe has been widely accepted and repeatedly used when referring to this pathologic entity. the cause of mtp joint instability is multifactorial, and may have an acute or insidious onset. newly developed clinical staging and surgical grading systems help to define the magnitude and pattern of plantar plate tears, and assist the clinician in the treatment of mtp joint instability.9-12 importance of the plantar plate the plantar plate is a stout structure that originates on the metatarsal head just proximal to the metatarsal articular surface and inserts onto the plantar base of the proximal phalanx.2,13,14 its function is to primarily resist tensile loads in the sagittal plane as well as to provide cushioning to the mtp joint during weight bearing.3,7 careful dissection of the second mtp joint has shown that the plantar plate is the major stabilising structure of the lesser toe due to its central location and multiple attachments.3,15,16 instability of the mtp joint, on the other hand, has been linked to the integrity of the plantar plate.1,10,17-20 it has been thought that attenuation and tearing of the plantar plate and collateral ligaments may eventually lead to sagittal and transverse plane instability of the mtp joint.21,22 pathology in the plantar plate observed in cases of second mtp joint instability has been noted near its insertion at the base of the proximal phalanx.2,10,13,15,17,18,23,24 abstract metatarsalgia of the lesser toes is commonly caused by metatarsophalangeal (mtp) joint instability. the clinical presentation varies but often includes pain on the plantar aspect of the forefoot that often progresses to the development of coronal and transverse plane malalignment. in some cases, frank mtp joint dislocation can develop. operative treatment has historically included indirect surgical realignment utilising soft tissue release, soft tissue reefing, tendon transfer, and periarticular osteotomies. an improved understanding of plantar plate tears has recently led to the development of a clinical staging and anatomic grading system that helps guide treatment. a dorsal surgical approach, with the exposure augmented utilising a weil osteotomy, allows the surgeon to directly access and repair the plantar plate. early clinical results suggest that direct plantar plate repair may be a significant advancement in the reconstruction and realignment of lesser mtp joint instability. key words: lesser toe instability, crossover toe, plantar plate, mtp instability, forefoot saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 35 page 36 sa orthopaedic journal winter 2014 | vol 13 • no 2 during normal gait, the mtp joint hyperextends during the terminal stance phase of gait. the plantar plate provides passive resistance, along with the intrinsic musculature (lumbricals and interossei) which provide active resistance, to this dorsiflexion force which propels the body forward. with plantar plate deterioration, the proximal phalanx subluxes dorsally. additionally, the interossei are displaced dorsal to the axis of rotation of the mtp joint and thus lose their capacity to plantarflex the mtp joint. the lumbrical, located medially, is tethered by the deep metatarsal ligament and becomes a medial deforming force which adds an adduction force vector to the toe causing medial deviation.10,11,14,25 the collateral ligaments are likely to contribute to both transverse and sagittal plane malalignment of the digit.10,26 based on cadaveric and surgical findings, as well as the reports of other authors,9-11,18,26,27 we believe that plantar plate insufficiency is the primary pathologic finding that leads to this mtp joint instability. demographics mtp joint instability has been associated with a long second metatarsal, acute trauma, chronic inflammation, hallux valgus, hallux varus, pes planus, hallux rigidus, interdigital neuromas, and hammertoe deformities, but the cause may also be insidious and idiopathic.5-7,16,18,19,22,28 these pathologic processes likely alter the loading characteristics of the lesser toes and therefore contribute to instability patterns. while mtp joint instability is frequently seen in older sedentary women, it has been reported in younger male athletes as well.1,16 while an acute disruption of the plantar plate can lead to instability of the lesser mtp joint,19,29,30 more often an insidious and idiopathic onset of symptoms is seen likely resulting from attritional changes which lead to an eventual plantar plate tear.9 a high incidence of lesser mtp joint instability in older females has led some to suggest that the long-term use of high-fashion footwear may lead to chronic hyperextension forces of the mtp joint and eventual plantar plate insufficiency.5,7,9 although originally described as a deformity of the second mtp joint,4 nery et al.9 observed in a large series of 55 plantar plate tears (28 patients) that twothirds of patients had second toe involvement, while a third of patients had third or fourth toe involvement. history and physical exam determining the primary cause of metatarsalgia can be difficult.31 the most common physical examination finding in patients presenting with plantar plate tears is focal tenderness on the plantar aspect of the forefoot at the base of the second toe. this tenderness may be isolated to the plantar base of the proximal phalanx, where transverse plantar plate tears typically occur. initially, the swelling associated with the tears may be seen without associated deformity. with time, sagittal and coronal plane deviation develops with continued attenuation of the plantar plate and collateral ligaments. the development of a gap between adjacent toes or medial deviation of a toe is a frequent finding.1,5,10,21 a hyperextension deformity is seen in later stages, and as the deformity progresses the pathologic toe may cross over or under the adjacent digits.16 chronic pain and malalignment often lead to the development of an associated hammertoe deformity at the proximal interphalangeal joint.3,5 other clinical findings that may be associated with mtp joint instability include digital swelling, swelling on the plantar aspect of the mtp joint, neuritic symptoms, and mtp joint malalignment.7,9-11,23 the most specific finding is a positive drawer test (80.6% sensitivity, 99.8% specific ).32 klein et al.32 studied the pre-operative clinical findings and compared them to intra-operative findings. several key findings were highly sensitive for detecting plantar plate tears including gradual onset of pain (93%), previous first ray surgery (100%, despite an incidence of 18%), pain at the second metatarsal head (98% sensitive), and oedema at the second metatarsal head (95.8% sensitive). acute onset of pain and toe deformity was rare but telling (7% incidence, 100% specificity). some patients may describe radiating pain or numbness into the toes, and this should raise the awareness of a possible adjacent neuroma.33 coughlin et al.,8 reported the concomitant presence of an interdigital neuroma in patients with lesser mtp joint instability in nearly 20% of the cases. compression of the transverse metatarsal arch in the presence of joint instability typically does not illicit a ‘mulder click’ or numbness and pain radiating into the toes, which can be typical in the presence of an interdigital neuroma.16,33,34 even so, differentiating a symptomatic interdigital neuroma from an unstable lesser mtp joint can be difficult, especially in the early stages. the use of sequential injections in adjacent mtp joints and intermetatarsal spaces may help lead to an accurate diagnosis.5,16,35 the drawer test is a pathognomonic finding associated with mtp joint instability.9,16,32,36 this test is performed by grasping the proximal phalanx of the involved digit and applying a vertical stress in a dorsal direction. this manoeuvre may reproduce the patient’s pain and often the examiner will feel the mtp joint sublux or dislocate (figure 1). the plantar flexion strength of the digit may be decreased, and this can be quantified by using the ‘paper pull-out test’.18 a strip of paper (1 cm × 6 cm) is placed under the affected toe tip. while the patient plantar flexes the affected digit and grasps the paper, the examiner pulls the paper strip out from beneath the toe (figures 2a and b). a positive test is seen when there is no digital purchase present, and the paper strip is pulled out intact without tearing. these clinical exam findings can be correlated to provide a reliable means for diagnosing plantar plate tears. • instability of the lesser mtp joints • freiberg’s infraction • degenerative arthritis of lesser mtp joints • systemic arthritis with involvement of lesser mtp joints • mtp joint synovitis • metatarsal stress fracture • interdigital neuroma • synovial cyst formation table i: differential diagnoses of forefoot pa we believe that plantar plate insufficiency is the primary pathologic finding that leads to this mtp joint instability saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 36 sa orthopaedic journal winter 2014 | vol 13 • no 2 page 37 sung et al.37 found a high degree of clinical accuracy in the pre-operative physical exam when later compared to the findings of both advanced imaging and surgery. evaluation of the magnitude of deformity, and the associated instability on drawer testing allows the clinician to pre-operatively stage the condition on a 0–3 scale (table ii). staging is a useful tool in predicting the degree of surgical correction necessary at the time of operative intervention. imaging studies standard anteroposterior and lateral weightbearing radiographs should be used to assess joint congruity, angular deformity, and intra-articular arthritic changes of the foot.16 common findings include a disruption in the metatarsal parabola of the symptomatic foot, increase in the 1–2 intermetatarsal angle, medial deviation of the second toe and splaying of the digits.38 additional imaging modalities should also be considered in evaluating mtp joint pathology. arthrography of the mtp joints has been used to determine the presence of plantar plate tears, but this is limited in defining the size or pattern of the tear.14,27,39 yao et al.40 first described the utility of mri for evaluating a plantar plate tear. nery et al.9 and sung et al.37 reported mri to be specific and reliable in determining the presence and extent of plantar plate pathology. ultrasound should be considered but may be limited by the experience of the technologist. while ultrasound and mri are both appropriate imaging modalities for plantar plate tears, ultrasound is more sensitive than mri (91.5% versus 73.9%) while mri is more specific (100% versus 25%).37,41,42 an experienced musculoskeletal radiologist is helpful in assessing the presence and magnitude of tears on mri. we have found that a 3 tesla mri can provide excellent visualisation, and we no longer use arthrography to assist in making a diagnosis (figure 3). classification several grading schemes for describing second mtp joint instability have been described,14,25,27,43 but only recently has the plantar plate involvement in lesser mtp joint instability been thoroughly evaluated and classified.9-12,20,23,27,44,45 we use two staging systems to guide the treatment of plantar plate dysfunction. first, we use a comprehensive clinical staging system based on physical exam findings which incorporates many of the principles of previous rating systems (table ii).7,9,14,25,27,43 second, an anatomic grading system been developed based on dissection of cadaveric specimens with plantar plate tears (table iii). these systems address plantar plate dysfunction and are helpful in quantifying the magnitude of the deformity and the pre-operative planning for surgical repair of the specific type of tear. nery et al.9 reported on a series of 55 plantar plates evaluated arthroscopically prior to open repair, and found that a grade 3 tear was most common and accounted for almost half of all tears. they used the same grading system described in this article to evaluate these patients (figures 4a–d). conservative treatment early detection of plantar plate tears is difficult. because of the insidious onset of the pain and deformity, delay in the evaluation and treatment is quite common. frequently, patients become concerned only after progression of the deformity and the presence of a fixed hammertoe.5 the initiation of conservative measures may reduce painful metatarsalgia, but rarely will this alter the progression of symptoms or malalignment.31 there are several conservative treatment options (figures 5a–d). an alteration in footwear with a reduced heel height and roomy toe box may reduce pressure on the symptomatic digit. a graphite footplate may help diminish stress on the mtp joint in the terminal stance phase of gait.10,35 the footplate can be accompanied by a soft insole with a metatarsal pad placed proximal to the symptomatic metatarsal head to reduce plantar discomfort by redistributing pressure.6,10 a symptomatic hammertoe deformity may be padded with a silicon toe sleeve to reduce pain. taping the affected toe in the early stages may increase sagittal plane stability, with the goal of position control of the toe while scarring or healing of the tissue occurs. taping is unsuccessful in cases of complete capsular disruption when the toe is moderately subluxed or dislocated.5 figure 1. drawer test figure 2. photos of a) before and b) after ‘paper pull out test’ early detection of plantar plate tears is difficult frequently, patients become concerned only after progression of the deformity and the presence of a fixed hammertoe b a saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 37 page 38 sa orthopaedic journal winter 2014 | vol 13 • no 2 coughlin reported on a small series of patients with crossover deformity and found that taping of the digit slowed progression of the deformity but the patients continued to experience joint pain.1,4 due to the composition of the plantar plate, which is largely type 1 collagen, it is reasonable to expect that a complete tear is unlikely to heal spontaneously with time.20,24,27 long-term taping can occasionally cause ulceration of the toe or chronic oedema.6 while conservative measures may temporarily relieve the pain of an unstable lesser mtp joint, they will not permanently correct the deformity.4–6 some clinicians use nonsteroidal anti-inflammatory drugs (nsaids) to manage discomfort but these should be used with caution, especially in older patient populations. selective corticosteroid injections may be diagnostic and therapeutic, as described above, but must be used with caution.10,35 injections can potentially mask symptoms, allowing further capsular and plantar plate degeneration with subsequent joint subluxation or dislocation.6,10 thus, with increasing pain and deformity associated with capsular instability and plantar plate tears, surgical intervention should be considered. surgical technique the thought process for treating plantar plate tears has progressed through several iterations. until recently, surgical treatment of lesser toe mtp instability was done indirectly. some of the treatments included simple synovectomy, soft tissue capsular or tendon release, tendon transfers, and bony decompression.7,14,16,22,43,45,46 direct plantar plate repair has been reported through a plantar approach;18,27 however, we directly repair the plantar plate through a dorsal approach (figures 6a and b).2,9,44 table ii: clinical staging of exam for second mtp joint instability grade alignment physical examination 0 no mtp joint malalignment; prodromal phasewith pain but no deformity mtp joint pain, thickening or swelling of the mtp joint, diminished toe purchase, negative drawer 1 mild malalignment of mtp joint; widening of theweb space, medial deviation mtp joint pain, swelling of mtp joint, reduced toe purchase, mildly positive drawer ( < 50% subluxable) 2 moderate malalignment; medial, lateral, dorsal, or dorsomedial deformity, hyperextension of the mtp joint mtp joint pain, reduced swelling, no toe purchase, moderately positive drawer ( > 50% subluxable) 3 severe malalignment; dorsal or dorsomedial deformity; the second toe can overlap the hallux; may have fexible hammertoe joint and toe pain, little swelling, no toe purchase (dislocatable mtp joint), flexible hammertoe abbreviation : mtp, metatarsophalangeal table iii: surgical grading of plantar plate tears grade patterns of tears 0 plantar plate or capsular attenuation, and/ordiscolouration 1 transverse distal tear (adjacent to insertion into proximal phalanx (< 50%); edial/lateral/central area) and/or midsubstance tear (< 50%) 2 transverse distal tear (> 50%); medial/lateral/central area and/or midsubstance tear (< 50%) 3 transverse and/or longitudinal extensive tear (may involve collateral ligaments). frequently a distal transverse tear present also. 4 extensive tear with button hole (dislocation); a combination of transverse and longitudinal tears, with an extensive tear, little plantar plate to repair. figure 3. a) mtp plantar plate anatomy; b) mri of plantar plate tear; c) mri 12 months post successful repair. note the artefact from weil osteotomy screw fixation while conservative measures may temporarily relieve the pain of an unstable lesser mtp joint, they will not permanently correct the deformity a b c saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 38 sa orthopaedic journal winter 2014 | vol 13 • no 2 page 39 an approximately 3 cm long dorsal longitudinal incision is made in the adjacent web space of the affected toe. the incision is deepened in the interval between the extensor tendons. the dorsal mtp joint capsule is incised and the medial and lateral collateral ligaments are released at their insertion onto the proximal phalanx. the metatarsal capsular attachments with the associated medial and lateral vascular supply to the metatarsal head are preserved. a weil metatarsal osteotomy is performed parallel to the plantar aspect of the foot, and the metatarsal head is translated proximally 8 to 10 mm. it is fixed temporarily in a proximal position with a vertical kirschner wire. the remaining 2–3 mm of the dorsal metaphyseal flare is removed to improve visualisation of the plantar plate. a second vertical kirschner wire is placed centrally in the proximal phalanx metaphysis. a joint distractor is positioned over the two kirschner wires and used to open the joint and directly inspect the plantar plate for pathology. the tear type guides the suturing technique. a distal transverse tear, grade 1 or 2, is repaired with a mechanical suture passer (‘mini-scorpion’ © arthrex, inc. naples, fl) by placing one or two horizontal mattress sutures. a longitudinal grade 3 tear is often repaired using a hand-held manual suture passer (suture lasso © arthrex, inc. naples, fl). following suture placement in the plantar plate, two vertical holes are drilled in the base of the proximal phalanx. the sutures are then passed through the phalangeal drill holes, the weil osteotomy is fixed into final position, and the sutures are tied over a dorsal bone bridge. if a transverse plane deformity remains, a capsular reefing suture is placed on the convex side of the deformity to achieve further realignment. the drawer test is routinely negative following surgical repair. after a standard closure, a gauze and tape compression dressing is applied. strengthening, stretching, and range of motion exercises are commenced at 10–14 days post-operatively, and protected weight bearing in a postoperative shoe is continued for 6 weeks after surgery. for those returning to athletic activity, the patients are allowed to commence exercising with full forefoot weight bearing at the sixth post-operative week. a graphite insole with a soft prefab orthotic covering this stiff insole is placed in the athletic shoe to prevent excessive dorsiflexion. this is used for an additional 12 weeks, and is continued in athletes participating in contact sports. taping of the involved digit is frequently advocated to protect the toe from further injury. surgical outcomes a literature review on the operative treatment of lesser toe mtp joint instability demonstrates that historically an indirect repair of the mtp joint has been performed. this is largely due to the fact that the pathology of plantar plate tear was not well defined, the surgical exposure was difficult, and few surgical instruments were available to achieve repair in such a confined space. the most frequently reported surgical techniques included mtp joint synovectomy,21 capsular soft tissue release with reefing,1,4,6,16,29,43,46 extensor and flexor tendon transfers,1,4,8,14,16,18,25,43,46 phalangeal and metatarsal osteotomies,7,14,25 and even digit amputation.47 distal metatarsal osteotomies to decompress and realign the involved joint showed unimpressive results.6,7,14,25 none of these surgical techniques addresses the principle cause of mtp joint instability, the plantar plate. the plantar plate, in conjunction with the medial and lateral collateral ligaments, is the key stabilising structure of the mtp joint.4,7,9-11,26,48 ê ê ê figure 4. a) grade 1; b) grade 2; c) grade 3; and d) grade 4 plantar plate tears a b c d figure 5. a–d) methods of conservative treatment a b c d saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 39 page 40 sa orthopaedic journal winter 2014 | vol 13 • no 2 operative techniques have evolved to achieve direct repair of plantar plate tears.9,10,18,24,27,44 in a cadaveric study, ford et al.45 compared different surgical procedures including primary plantar plate repair, a flexor tendon transfer (ftt), and a combined tendon transfer and plantar plate repair, and concluded that a primary plantar plate repair was a viable alternative to fft in stabilising the lesser mtp joint. it is intuitive to repair a plantar plate tear through a plantar incision, which has been reported to achieve satisfactory results.18,27 with the plantar approach however, it is difficult to expose adjacent joints and it may also put the patient at risk for a painful plantar scar. cooper and coughlin,2 in a cadaveric study, showed that adequate exposure of a lesser mtp joint could be achieved utilising a dorsal approach and a weil osteotomy. others9,12,44 have reported satisfactory pain relief and good results of plantar plate repairs done through a dorsal approach using a weil osteotomy. in a prospective study of a direct plantar plate repair using a dorsal approach, coughlin et al. and nery5,9 reported on 22 patients (40 mtp joints) and noted excellent pain relief with improved digital strength and realignment at an average follow-up of 1.5 years. since the original description of crossover second toe deformity in 1987,4 there has been an evolution in the evaluation and treatment of lesser toe mtp joint instability. staging of the deformity based on the clinical examination, and grading of the tear based on surgical findings, helps define the magnitude of the deformity and the severity of the plantar plate tear. after exhausting nonoperative treatment, we now treat plantar plate tears with direct surgical repair and advancement with the technique described above. this involves visualisation of the plantar plate through a dorsal approach and primary repair of the tear with non-absorbable suture. we advise any surgeon considering the adoption of this new technique to gain experience in the laboratory setting as it can be technically difficult. excellent early results have been reported with this surgical technique. no benefits were received for the publication of this manuscript. this paper is our original unpublished work and it has not been submitted to any other journal for reviews. (all figures and tables reproduced with permission from michael j. coughlin md) references 1. coughlin mj. second metatarsophalangeal joint instability in the athlete. foot ankle, 1993;14(6):309-19. 2. cooper mt, coughlin mj. sequential dissection for exposure of the second metatarsophalangeal joint. foot ankle int, 2011;32(3):294-99. 3. duvries hl. dislocation of the toe. jama, 1956;160:728. 4. coughlin mj. crossover second toe deformity. foot ankle, 1987;8(1):29-39. 5. coughlin mj. when to suspect crossover second toe deformity. j musculoskeletal medicine, 1987: p. 39-48. 6. coughlin mj. subluxation and dislocation of the second metatarsophalangeal joint. orthop clin north am, 1989;20(4):53551. 7. coughlin mj. lesser toe deformities, in surgery of the foot and ankle, mj coughlin, cl mann, cl saltzman, editors. 2007, mosby elsevier inc.: philadelphia, pa. p. 363-464. 8. coughlin mj, et al. concurrent interdigital neuroma and mtp joint instability: long-term results of treatment. foot ankle int, 2002;23(11):1018-25. 9. nery c, et al. lesser metatarsophalangeal joint instability: prospective evaluation and repair of plantar plate and capsular insufficiency. foot ankle int, 2012;33(4):301-11. 10. coughlin mj, baumfeld ds, nery c. second mtp joint instability: grading of the deformity and description of surgical repair of capsular insufficiency. phys sportsmed, 2011;39(3):13241. 11. coughlin mj, et al. metatarsophalangeal joint pathology in crossover second toe deformity: a cadaveric study. foot ankle int, 2012;33(2):133-40. 12. weil l, jr, et al. anatomic plantar plate repair using the weil metatarsal osteotomy approach. foot ankle spec, 2011;4(3):14550. 13. gregg j, et al. histologic anatomy of the lesser metatarsophalangeal joint plantar plate. surg radiol anat, 2007;29(2):141-47. 14. mendicino rw, et al. predislocation syndrome: a review and retrospective analysis of eight patients. j foot ankle surg, 2001;40(4):214-24. figure 6. a) diagram of dorsal approach for plantar plate tear; b) typical exposure and use of suture passer a b saoj winter 2014_orthopaedics vol3 no4 2014/05/05 10:49 pm page 40 sa orthopaedic journal winter 2014 | vol 13 • no 2 page 41 15. bhatia d, et al. anatomical restraints to dislocation of the second metatarsophalangeal joint and assessment of a repair technique. j bone joint surg am, 1994;76(9):1371-75. 16. kaz aj, coughlin mj. crossover second toe: demographics, etiology, and radiographic assessment. foot ankle int, 2007;28(12):1223-37. 17. borne j, et al. [plantar plate and second ray syndrome: normal and pathological us imaging features and proposed us classification]. j radiol, 2010;91(5 pt 1):543-48. 18. bouche rt, heit ej. combined plantar plate and hammertoe repair with flexor digitorum longus tendon transfer for chronic, severe sagittal plane instability of the lesser metatarsophalangeal joints: preliminary observations. j foot ankle surg, 2008;47(2):125-37. 19. brunet ja, tubin s. traumatic dislocations of the lesser toes. foot ankle int, 1997;18(7):406-11. 20. deland jt, et al. anatomy of the plantar plate and its attachments in the lesser metatarsal phalangeal joint. foot ankle int, 1995;16(8):480-86. 21. mann ra, mizel ms. monarticular nontraumatic synovitis of the metatarsophalangeal joint: a new diagnosis? foot & ankle, 1985;6(1):18-21. 22. mann ra, coughlin mj. the rheumatoid foot: review of literature and method of treatment. orthop rev, 1979;8:105-112. 23. deland jt, sung ih. the medial crosssover toe: a cadaveric dissection. foot ankle int, 2000;21(5):375-78. 24. johnston rb, 3rd, smith j, daniels t. the plantar plate of the lesser toes: an anatomical study in human cadavers. foot ankle int, 1994;15(5):276-82. 25. yu gv, et al. predislocation syndrome. progressive subluxation/dislocation of the lesser metatarsophalangeal joint. j am podiatr med assoc, 2002;92(4):182-99. 26. barg a, et al. role of collateral ligaments in metatarsophalangeal stability: a cadaver study. foot ankle int, 2012;33(10):877-82. 27. powless sh, elze me. metatarsophalangeal joint capsule tears: an analysis by arthrography, a new classification system and surgical management. j foot ankle surg, 2001;40(6):374-89. 28. morton dj. metatarsus atavicus:the identification of a distinctive type of foot disorder. journal bone joint surgery, 1927;9:531-44. 29. murphy jl. isolated dorsal dislocation of the second metatarsophalangeal joint. foot ankle, 1980;1(1):30-32. 30. rao jp, banzon mt. irreducible dislocation of the metatarsophalangeal joints of the foot. clin orthop relat res, 1979;145:224-26. 31. coughlin mj. common causes of pain in the forefoot in adults. j bone joint surg br, 2000;82(6):781-90. 32. klein ee, et al. clinical examination of plantar plate abnormality: a diagnostic perspective. foot ankle int, 2013;34(6):800804. 33. coughlin mj, pinsonneault t. operative treatment of interdigital neuroma. a long-term follow-up study. the journal of bone and joint surgery (am), 2001;83-a(9):1321-28. 34. mulder jd. the causative mechanism in morton’s metatarsalgia. the journal of bone and joint surgery (br), 1951;33-b(1):94-95. 35. trepman e, yeo sj. nonoperative treatment of metatarsophalangeal joint synovitis. foot ankle int, 1995;16(12):771-77. 36. thompson fm, hamilton wg. problems of the second metatarsophalangeal joint. orthopedics, 1987;10(1):83-89. 37. sung w, et al. diagnosis of plantar plate injury by magnetic resonance imaging with reference to intraoperative findings. j foot ankle surg, 2012;51(5):570-74. 38. klein ee, et al. the underlying osseous deformity in plantar plate tears: a radiographic analysis. foot ankle spec, 2013;6(2):108-18. 39. blitz nm, ford la, christensen jc. second metatarsophalangeal joint arthrography: a cadaveric correlation study. j foot ankle surg, 2004;43(4):231-40. 40. yao l, et al. magnetic resonance imaging of plantar plate rupture. foot ankle int, 1996;17(1):33-36. 41. klein ee, et al. musculoskeletal ultrasound for preoperative imaging of the plantar plate: a prospective analysis. foot ankle spec, 2013;6(3):196-200. 42. klein ee, et al. magnetic resonance imaging versus musculoskeletal ultrasound for identification and localization of plantar plate tears. foot ankle spec, 2012;5(6):359-65. 43. haddad sl, et al. results of flexor-to-extensor and extensor brevis tendon transfer for correction of the crossover second toe deformity. foot ankle int, 1999;20(12):781-88. 44. gregg j, et al. plantar plate repair and weil osteotomy for metatarsophalangeal joint instability. foot ankle surg, 2007;13(3):116-21. 45. ford la, collins kb, christensen jc. stabilization of the subluxed second metatarsophalangeal joint: flexor tendon transfer versus primary repair of the plantar plate. j foot ankle surg, 1998;37(3):217-22. 46. myerson ms, jung hg. the role of toe flexor-to-extensor transfer in correcting metatarsophalangeal joint instability of the second toe. foot ankle int, 2005;26(9):675-79. 47. gallentine jw, deorio jk. removal of the second toe for severe hammertoe deformity in elderly patients. foot ankle int, 2005;26(5):353-58. 48. sarrafian sk, topouzian lk. anatomy and physiology of the extensor apparatus of the toes. j bone joint surg am, 1969;51(4):669-79. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 41 south african orthopaedic journal foot and ankle doi 10.17159/2309-8309/2021/v20n4a3alexander an et al. sa orthop j 2021;20(4) citation: alexander an, saragas np, ferrao pnf. patient-reported outcomes following plantar incisions in foot surgery. sa orthop j 2021;20(4):208-212. http://dx.doi.org/10.17159/23098309/2021/v20n4a3 editor: dr graham mccollum, university of cape town, cape town, south africa received: october 2020 accepted: january 2020 published: november 2021 copyright: © 2021 alexander an. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background plantar incisions may be used in a variety of surgical procedures. despite numerous studies reporting on procedures which use plantar incisions and thus inadvertently demonstrating good results with plantar incisions, most surgeons still avoid this approach due to the fear of developing a painful plantar scar. there is a shortage of studies demonstrating a clear correlation between plantar scar formation and poor patient-reported outcomes. the aim of this study is to assess the clinical outcome of plantar incisions in various procedures. methods in this retrospective study we identified all patients who underwent surgery using a plantar incision between january 2000 and december 2019. a total of 23 patients were available for assessment. three common procedures were identified: lesser metatarsal head resection, plantar fibromatosis excision and lateral sesamoidectomy. demographic data was collected, and clinical outcome was assessed using the self-reported foot and ankle score (sefas) questionnaire. twenty-one female (22 feet) and two male patients (two feet) were included. the mean follow-up was 124 (range 8–231) months in the plantar fibromatosis group, 111.5 (range 28–177) months in the lateral sesamoidectomy group and 106.3 (range 42–157) months in the lesser metatarsal head excision group. the study included 12 patients in the sesamoidectomy, nine patients in the plantar fibromatosis and two patients in the lesser metatarsal head excision groups. the mean age of the study population was 45 (range 20–71) years. results the mean postoperative sefas score in our series was 44 (range 22–48). nineteen (82%) patients scored as excellent, two (10%) patients as good, one (4%) patient as fair and one (4%) as poor. all wounds healed well with no symptomatic callosities on clinical examination requiring revision. conclusion this study demonstrates that plantar incisions, irrespective of indication and orientation (21 longitudinal and three transverse), heal well and with good patient-reported outcomes. we believe that it would be erroneous to ‘avoid plantar incisions at all costs’ and that plantar incisions must be considered if deemed technically superior and with less risk than a dorsal approach. level of evidence: level 4 keywords: plantar incisions, patient-reported outcome patient-reported outcomes following plantar incisions in foot surgery alwich n alexander,¹* nikiforos p saragas,² paulo nf ferrao² ¹ linksfield foot and ankle fellowship programme; department of orthopaedics, university of pretoria, steve biko academic hospital, pretoria, south africa ² linksfield foot and ankle fellowship programme; department of orthopaedics, university of the witwatersrand, johannesburg, south africa *corresponding author: alwich23@gmail.com introduction the plantar skin is unique in that it is considerably thicker than the rest of the foot.1 it is more keratinised, hairless, and filled with an abundance of sweat glands.1 fibrous septae originate from the plantar fascia and attach to the plantar skin to provide increased mechanical support in resisting shear forces during the gait cycle.2 the superficial fascia has abundant fibrous-fatty tissue that assists in impact absorption.2 courtiss et al. demonstrated that dermal collagen is orientated perpendicular to the axis of muscle and that the collagen in a scar is parallel to the direction of the scar.3 hypertrophic scars can be caused by distraction or tension across an incision area. since skin tension is greatest in the direction of the relaxed skin tension lines (rstls), an incision made parallel to the rstls would lessen the chance of painful hypertrophic scar formation.3,4 also, the incision is then parallel to collagen bundles and perpendicular to muscle contraction, which results in finer and stronger scar lines.3,4 unfortunately, most pathologies require a longitudinal incision which is perpendicular to the transversely oriented rstls (figure 1). plantar incisions can be utilised in several pathologies, with the excision of morton’s neuromas being the most common indication. plantar fibromatosis (ledderhose disease) is a relatively rare pathology of the plantar aponeurosis characterised by disordered https://orcid.org/0000-0002-4023-7550 page 209alexander an et al. sa orthop j 2021;20(4) fibrous tissue proliferation and the subsequent formation of nodules.5 surgical management has generally been reserved for pain relief, as this condition is of a benign nature. however, more recently, indications for surgery include both pain refractory to conservative treatment as well as local aggressiveness of the lesion.6 three main techniques have been employed in the surgical management of plantar fibromatosis: local excision, wide excision and complete fasciectomy. apart from recurrence, other reported complications that adversely affect patient outcomes include impaired wound healing, painful scarring, nerve entrapment and loss of arch height.6 lateral (fibular) sesamoidectomy can be performed via a dorsal or plantar approach. the dorsal approach has been the preferred approach as it avoids the possibility of causing wound problems or the formation of irritating scars secondary to the plantar approach.7,8 however, excision of the lateral sesamoid via a dorsal approach can be difficult with suboptimal exposure and the risk of damage to the adductor mechanism and interdigital nerve. metatarsal head resection arthroplasty, as described by hoffman, is a surgical technique in which a transverse plantar approach is utilised to excise the metatarsal heads.9 this procedure is described for complex forefoot deformities usually associated with irreducible dislocation of the metatarsophalangeal joints of the lesser toes. the technique has been modified by various surgeons with good outcomes. however, numerous complications, such as painful callosities associated with these procedures, have been reported. the extent to which these complications affect patient satisfaction, however, remains unclear. historically, the use of plantar surgical incisions by orthopaedic and foot surgeons alike have been avoided due to fears of complications, particularly scar formation in those patients for whom postoperative non-weight-bearing wound protection would be difficult. the use of this surgical approach was first published in 1940, with betts et al. reporting its use for the resection of morton’s neuroma, yielding no complications.10 despite numerous studies advocating plantar incisions for certain pathological entities, many surgeons still advise avoiding this approach if possible. we believe that plantar incisions heal well with little risk of a long-term symptomatic hypertrophic scar and do not necessarily correlate with poor subjective outcomes. the aim of this study was to evaluate patient-reported outcomes following plantar incisions and assess clinically for the development of hypertrophic and/or painful scar formation. materials and methods following ethical approval, we retrospectively reviewed the records of all patients who underwent foot surgery using a plantar incision between january 2000 and december 2019. inclusion criteria included patients older than 18 years, and a minimum of six-months follow-up. patients were excluded if their records were incomplete, or they were not available for follow-up. all surgeries were performed at a single centre by two foot-and-ankle surgeons. subjective outcome was assessed using the validated self-reported foot and ankle score (sefas) questionnaire.11 the sefas score ranges from 0 to 48, with 0 representing the most severe disability and 48 as normal function. the grading is assessed as excellent when scoring > 41; good 34–41; fair 27–33; and poor < 27. for statistical analyses, simple descriptive statistical tools were used. all numerical values are presented as a mean with a range. basic demographic data were also recorded. twenty-three patients (24 feet) met the inclusion criteria and were available for clinical evaluation and to complete the questionnaire. the study population included 21 females and two males with a mean age of 45 (range 20–71) years and a mean follow-up of 116 figure 1. rstl and surgical approaches table i: indications for lateral sesamoidectomy diagnosis number of patients sesamoiditis 8 fracture 2 avascular necrosis 1 rheumatoid arthritis 1 table ii: plantar fibroma size patient p1 p2 p3 p4 p5 p6 p7 p8 p9 size in mm 25×15×10 30×20×8 54×13×5 38×18×10 40×20×4 20×10×5 46×10×3 17×13 30×18×5 page 210 alexander an et al. sa orthop j 2021;20(4) (range 8–231) months. three common procedures were identified: lateral sesamoidectomy, excision of plantar fibromatosis and metatarsal head resection. the cohorts included 12 patients with lateral sesamoidectomy, nine patients with plantar fibromatosis excision and two patients with metatarsal head resections. the indications for lateral sesamoidectomy are outlined in table i. the indications in the plantar fibromatosis group included eight solitary lesions and one patient with multifocal disease. all plantar fibromatosis patients presented with pain refractory to conservative management with no history of previous local steroid injections. all metatarsal head resections were performed as part of rheumatoid forefoot reconstruction. the mean follow-up was 111 (range 28– 177) months in the lateral sesamoidectomy group, 124 (range 8–231) months in the plantar fibromatosis group, and 106 (range 42–157) months in the metatarsal head excision group. operative technique in all conditions, surgery was performed with a thigh tourniquet under a bloodless field. sesamoidectomy: the lateral sesamoid was approached through a plantar curvilinear incision in the first web plantar crease. soft tissue dissection was meticulous, taking care to preserve the plantar nerve and protect the flexor hallucis longus tendon and adductor mechanism. following excision, the flexor hallucis brevis (fhb) was repaired. the wound was closed in layers and the skin closed with 4-0 nylon interrupted sutures. the postoperative protocol entailed two weeks of strict elevation with weight bearing as tolerated in a forefoot offloading shoe. the hallux and second toe were taped together for a total of eight weeks to protect the repaired fhb. physiotherapy was commenced at six weeks with transition to normal shoes. excision of plantar fibromatosis: a lazy-s or medially based plantar longitudinal incision was utilised for exposure of the plantar aponeurosis. excision of the nodules with a 1 cm border of normal tissue was performed. wounds were closed in a routine manner with 4-0 nylon interrupted sutures for the skin. the postoperative protocol entailed two weeks of back slab immobilisation and strict non-weight-bearing. sutures were removed at three weeks. once the wound had healed fully, the patient was advised to massage the wound with an oil rich in vitamin e, and weight bearing was allowed as tolerated in supportive shoes. metatarsal head resections: as part of the rheumatoid forefoot reconstruction, a plantar-based transverse incision, based over the lesser metatarsal heads, excising an elliptical piece of the overlying skin and superficial subcutaneous tissue was performed. following careful soft-tissue dissection and protection of important structures, excision of the lesser metatarsal heads was carried out with an oscillating saw while maintaining the normal cascade of the lesser metatarsals. k-wires were then used to align the proximal phalanges to the metatarsals. the plantar incision was closed in a routine manner using 4-0 interrupted nylon sutures while performing a dermodesis. the postoperative protocol entailed two weeks of strict elevation with weight bearing as tolerated in a forefoot offloading postoperative wedge shoe. sutures were removed at three weeks and k-wires at six weeks post surgery. results five patients underwent surgical excision of plantar fibromatosis nodules through a lazy-s incision and four patients through a longitudinal plantar medial approach. no patient received radiotherapy postoperatively. all specimens were confirmed histologically, and no patient developed recurrence of nodules during follow-up. the nodular sizes are reported in table ii. in the metatarsal head resection group, both patients were being treated with methotrexate and the patient with bilateral disease used additional disease-modifying antirheumatic drugs (dmards) and steroids. a biologics-free window was strictly adhered to in this patient prior to having surgery. none of the patients in the cohorts had delayed wound healing or wound infection necessitating additional surgical intervention. on clinical examination at final follow-up, all plantar incisions had healed well with no painful callosities or hypersensitivity requiring scar revision (figures 2 and 3). the mean postoperative sefas score in our series was 44 (range 22–48). nineteen (82%) patients scored as excellent, two (10%) patients as good, one (4%) patient as fair and one (4%) as poor. the sefas score according to procedure is reported in table iii. the one patient who scored poorly had bilateral rheumatoid forefoot reconstruction, and complained of persistent swelling of the foot and the permanent need for orthotics due to recurrence of the lesser toe deformities. this patient had no complaints related to the plantar scars. discussion there is a paucity in the literature addressing the subjective outcomes of plantar incisions. most reports on the outcome of plantar incisions are indirectly addressed in studies evaluating figure 2. healed scar following lateral sesamoidectomy figure 3. healed scars following bilateral forefoot reconstruction through plantar elliptical incision table iii: sefas grading g ra d in g n u m b e r o f p a ti e n ts l a te ra l se sa m o id e c to m y p la n ta r fi b ro m a to si s m e ta ta rs a l h e a d re se c ti o n excellent (> 41) 19 (82%) 12 7 good (34–41) 2 (10%) 1 1 fair (27–33) 1 (4%) 1 poor (< 27) 1 (4%) 1 page 211alexander an et al. sa orthop j 2021;20(4) outcomes of various pathologies.7,9,10,12,13 there is still a reluctance to utilise this approach due to the fear of complications, particularly a painful scar. to the best of our knowledge, richardson et al. conducted the only study in modern literature, reviewing specifically the outcome of plantar incisions for a heterogenous group of conditions.14 they included 89 patients who underwent plantar incisions for conditions such as adductor release, morton’s neuroma excision and resection of metatarsal heads. ninety-six per cent of these patients were satisfied with the outcome. the average follow-up in their study was 25 months, which is considerably less than the current study. in a prospective study assessing the outcome of longitudinal plantar incisions for excision of morton’s neuroma, akermark et al. demonstrated that 90% and 98% of their study population reported none to slight scar tenderness and restriction of daily activity respectively.15 ishie et al., amin et al. and hamalainen and raunio all reported satisfactory results utilising a plantar approach for forefoot reconstruction in rheumatoid patients.16-18 however, none of these studies included a clear description regarding the effect of plantar scar formation on patient satisfaction. matsumoto et al., and hulse and thomas demonstrated that painful callosity formation of the plantar scar is associated with recurrence of the deformity and is responsible for unsatisfactory outcomes in 40–58% of rheumatoid forefoot reconstruction cases.19,20 in comparison, canedo et al. demonstrated a 100% patient satisfaction rate despite one patient developing a plantar callosity.21 it is important to be cognisant of the fact that rheumatoid arthritis is a chronic inflammatory disease which may lead to further foot involvement following forefoot reconstruction. this may lead to great variability in patient satisfaction as demonstrated by the above-mentioned results. in keeping with the literature, in our study both rheumatoid patients (one bilateral) reported well-healed scars with no hypersensitivity or pain, despite one patient scoring as poor (bilateral). this patient had recurrence of deformities requiring shoe modifications and orthotics, which was the reason for her dissatisfaction. plantar fibromatosis is a benign but locally aggressive fibrous tissue tumour.22 in a recent systematic review, the recurrence rate was reported to be 74.3% in primary cases; hence, most of the literature pertaining to this condition focuses on this complication.23 sammarco and mangone formulated a preand intraoperative tumour-staging system based on the nodularity, the presence of skin adherence, involvement of the plantar fascia and tumour extension to the overlying flexor tendon sheath (table iv).24 this tumour staging showed good correlation with postoperative wound complications and recurrence. isolated and solitary nodules can be excised using a transverse approach not crossing the rstls. in this study, the majority of patients had extensive lesions (large or multinodular) which required a longitudinal incision crossing the rstls, in order to gain adequate exposure. eight of the nine patients scored good to excellent on the sefas score with no wound complications or painful scar formation. only one patient scored as fair and upon reviewing the patient’s surgical records, it was noted that this patient had multifocal disease with tumour adherence to overlying skin (stage iii). lateral sesamoidectomy can be performed through either a dorsal or plantar approach. the dorsal is the favoured approach as it avoids the risk of plantar wound complications but is technically more difficult unless there is a relatively large web space due to metatarsus primus varus.7,8 richardson et al. included 105 longitudinal plantar incisions for various conditions and although sesamoid conditions were not included, the plantar incisions used were not dissimilar to the plantar incision we used for lateral sesamoidectomy.14 they found six patients with punctate keratosis which was asymptomatic in two of the patients. the remaining four patients complained of a tender scar, necessitating altering their shoe wear in three of the four patients. only two of these patients ultimately required excision of the keratosis and went on to heal without any sequelae. other complications in this group included four patients with mild, intermittent tenderness as well as four wounds that dehisced. all these patients required no further interventions. all the 12 lateral sesamoidectomy patients in our study healed without complications. saxena and krisdakumtorn evaluated return to sport following fibular sesamoidectomy and reported that the three patients who underwent plantar incisions returned to impact activity two weeks earlier than the group in which a dorsal approach was used.25 the sefas is a validated patient-reported outcome measure (prom), specifically for forefoot and ankle/hindfoot conditions.11 in the only other study utilising a scoring system to assess the surgical outcomes of plantar fibromatosis, sammarco and mangone reported an average postoperative aofas score of 77 and maryland foot score of 86.24 these are functional scoring systems and do not account for the patient’s satisfaction. this is the first study to report on outcomes using a validated patient-reported outcome score. the mean overall sefas score in our study was 44, with 92% of patients scoring their outcomes as excellent or good. the only poor outcome was in the rheumatoid patient who had bilateral surgery as discussed above. we found no difference in the sefas scoring according to surgery-specific cohorts. the limitations of this study include the small number of patients, limited procedures and retrospective design. in the literature, the most common indication for plantar incisions is excision of interdigital neuromas but in our unit, we routinely use dorsal incisions for both primary and revision cases. conclusion our findings show that plantar incisions heal well with a high patient satisfaction. we believe that good clinical outcome is directly related to sound surgical technique and meticulous soft tissue handling. plantar incisions must be considered if they are deemed technically superior and with less risk of collateral damage as compared to using a dorsal approach, without the unfounded fear of developing a ‘painful scar’. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. table iv: plantar fibromatosis tumour-staging system tumour grade description i focal disease isolated to a small area on the medial and/or central aspect of the fascia no adherence to skin no deep extension to the flexor sheath ii multifocal disease, with or without proximal or distal extension no adherence to the skin no deep extension to the flexor sheath iii multifocal disease, with or without proximal or distal extension either adherence to the skin or deep extension to the flexor sheath iv multifocal disease, with or without proximal or distal extension adherence to the skin and deep extension to the flexor sheath page 212 alexander an et al. sa orthop j 2021;20(4) prior to the commencement of this study, ethical approval was obtained from the following ethical review board: human research ethics committee, hrec ref: m191168. informed consent was obtained from all patients prior to being included in the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ana: study conceptualisation, data collection, data analysis, manuscript preparation, manuscript revision nps: study conceptualisation, manuscript revision pnff: study conceptualisation, manuscript revision orcid alexander an https://orcid.org/0000-0002-4023-7550 saragas np https://orcid.org/0000-0002-5566-7588 ferrao pnf https://orcid.org/0000-0003-4639-0326 references 1. thoolen m, ryan tj, bristow i. a study of the skin of the sole of the foot using high frequency ultrasonography and histology. foot. 2000;10:14-17. 2. crowe cs, cho dy, kneib cj, et al. strategies for reconstruction of the plantar surface of the foot: a systematic review of the literature. plast reconstr surg. 2019;143(4):1223-44. 3. courtiss eh, longacre jj, destefano ga, et al. the placement of elective skin incisions. plast reconstr surg. 1963;31(1):31-44. 4. borges af, alexander je. relaxed skin tension lines, z-plasties on scars, and fusiform excision of lesions. br j plast surg. 1962;15:242-54. 5. young jr, sternbach s, willinger m, et al. the etiology, evaluation, and management of plantar fibromatosis. orthop res rev. 2019;11:1. 6. carroll p, henshaw rm, garwood c, et al. plantar fibromatosis: pathophysiology, surgical and non-surgical therapies: an evidence-based review. foot ankle spec. 2018;11(2):168-76. 7. milia mj, cohen be, anderson rb. plantar approach for isolated fibular hallux sesamoidectomy. tech foot ankle surg. 2003;2:268-71. 8. taylor cf, butler m, parsons sw. problems associated with the excision of the hallux sesamoids. foot ankle clin. 2014;19:425-36. 9. hoffman p. an operation for severe grades of contracted or clawed toes. am j orthop. 1911;9:441. 10. betts lo. morton’s metatarsalgia: neuritis of the fourth digital nerve. med j aust. 1940;1:514-15. 11. coster mc, rosengren be, bremander a, et al. comparison of the self-reported foot and ankle score (sefas) and the american orthopedic foot and ankle society score (aofas). foot ankle int. 2014;35(10):1031-36. 12. kates a, kessel l, kay a. arthroplasty of the forefoot. j bone joint surg. 1967;49b:552-57. 13. fowler aw. a method of forefoot reconstruction. j bone joint surg br. 1959;41:507-13. 14. richardson eg, brotzman sb, graves sc. the plantar incision for procedures involving the forefoot. jbjs. 1193;75(5):726-31. 15. akermark c, saartok t, zuber z. a prospective 2-year follow-up study of plantar incisions in the treatment of primary intermetatarsal neuromas (morton’s neuroma). j foot ankle surg. 2008;14(2):67-73 16. ishie s, ito h, azukizawa m, et al. delayed wound healing after forefoot surgery in patients with rheumatoid arthritis. mod rheumatol. 2015;25(3):367-72. 17. amin a, cullen n, singh d. rheumatoid forefoot reconstruction. acta orthop belg. 2010;76(3):289-97. 18. hamalainen m, raunio p. long term followup of rheumatoid forefoot surgery. clin orthop relat res. 1997;340:34-8. 19. matsumoto t, kadono y, nishino j, et al. midterm results of resection arthroplasty for forefoot deformities in patients with rheumatoid arthritis and the risk factors associated with patient dissatisfaction. j foot ankle surg. 2014;53(1):41-6. 20. hulse n, thomas am. metatarsal head resection in the rheumatoid foot: 5-year follow-up with and without resection of the first metatarsal head. j foot ankle surg. 2006;45(2):107-12. 21. do couto canedo l, pereira filho mv, et al. effect of plantar incision for metatarsal head resection arthroplasty of the small toes. scientific journal of the foot & ankle. 2018;12(2):117-22. 22. kadir hka, chandrasekar cr. partial fasciectomy is a useful treatment option for symptomatic plantar fibromatosis. foot. 2017;31:31-34. 23. fuiano m, mosca m, caravelli s, et al. current concepts about treatment options of plantar fibromatosis: a systematic review of the literature. j foot ankle surg. 2019;25:559-64. 24. sammarco gj, mangone pg. classification and treatment of plantar fibromatosis. foot ankle int. 2000;21:563-9. 25. saxena a, krisdakumtorn t. return to activity after sesamoidectomy in athletically active individuals. foot ankle int. 2003;24:415-9. https://orcid.org/0000-0002-4023-7550 https://orcid.org/0000-0002-5566-7588 https://orcid.org/0000-0003-4639-0326 page 57sa orthop j 2022;21(1) cpd questionnaire. march 2022 vol 21 no 1 evaluating the design modifications of an intramedullary forearm nail system: a cadaver study (pretorius hs, burger mc, ferreira n) 1. maintaining length in a comminuted forearm fracture with an intramedullary nail is problematic with conventional nails because: a. the nails are not of a sufficient diameter a b. the nails do not have non-driving end locking b c. the nails have poor modulus of elasticity c d. the nail’s entry reamer is too large d e. the nail’s radius of curvature is not equal to the native forearm e 2. iatrogenic radial nerve injuries are common with proximal radius locking and have been reported in up to 11% of cases. the reason for this is: a. the proximity of the nerve to the radial neck in the pronator muscle a b. the reports are only for sensory branches of the nerve b c. the proximity of the nerve to the radial neck in the brachialis muscle c d. the proximity of the nerve to the radial neck in the supinator muscle d e. the proximity of the nerve to the radial neck anteriorly e 3. radiation exposure for intramedullary locking is always a concern for surgeons. the radiation exposure in the study is lower than other reported studies and attributed to: a. poor reporting by other authors a b. surgeon experience only b c. design modifications only c d. surgeon experience and locking hole design d e. poor radiographer measurements in studies e a retrospective file audit of preoperative anaemia in patients referred to an anaesthesiology clinic before elective orthopaedic surgery (van marle a, acho p-m, chepape co, mahlaba rm, dlamini p, magugu s, mahlohla kk, teis n, kachelhoffer am, joubert g, coetzee mj) 4. preoperative anaemia has been associated with: a. increased risk of postoperative mortality a b. prolonged hospital stay b c. admission to critical care units c d. increased rate of blood transfusions d e. all of the above e 5. the recommended cut-off value for preoperative anaemia: a. depends on the patient’s age and underlying comorbidities a b. is 12 g/dl for women and 13 g/dl for men b c. should be adjusted according to the height above sea-level c d. is 13 g/dl in both sexes d e. is 12 g/dl in both sexes e orthopaedic surgical training exposure at a south african academic hospital – is the experience diverse and in depth? (dunn c, held m, laubscher m, nortje m, roche s, dunn r) 6. with the overwhelming trauma load in south africa, the orthopaedic registrars’ exposure to elective and trauma cases was: a. very low a b. low b c. similar c d. more d e. much more e 7. at our training hospital, the number of orthopaedic cases performed after hours was around: a. 10% a b. 20% b c. 30% c d. 40% d e. 50% e 8. which sub-discipline contributed the most elective cases? a. upper limb a b. lower limb b c. hands c d. paediatrics d e. spine e not strong enough? movements generated during clinical examination of sagittal and rotational laxity in a cadaver knee (le roux ja, bezuidenhout cw, klopper j, hobbs h, von bormann r, held m) 9. the anterolateral structures of the knee were originally described by: a. freddie fu a b. paul segond b c. david dejour c d. robert laprade d e. mininder kocher e 10. the most reliable test to clinically assess for an anterolateral ligament (all) injury is: a. anterior drawer test a b. posterior drawer test b c. pivot-shift manoeuvre c d. internal rotation of tibia in relation to the femur d e. no clinical test has been validated to reliably test for an all injury e orthopaedic journal s o u t h a f r i c a n � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � contents � � � � � � � � � � t h e s o u t h a f r ic a n o r t h o pa e d ic a s s o c ia t io n page 58 sa orthop j 2022;21(1) 11. clinical factors to consider when deciding to reconstruct the all ligament are: a. age a b. high grade meniscal tear b c. hypermobility c d. poor patient compliance d e. all of the above e the fassier technique for correction of proximal femoral deformity in children with osteogenesis imperfecta (mwelase sm, maré ph, thompson dm, marais lc) 12. osteogenesis imperfecta is characterised by abnormal: a. type 2 collagen a b. type 1 collagen b c. cftr protein c d. type 4 collagen d e. elastin e 13. finidori described a technique to correct coxa vara using: a. intramedullary k-wires a b. plates b c. cast c d. telescopic rods d e. external fixator e patient satisfaction following wide awake local anaesthetic no tourniquet hand surgery (de buys bm, tsama m, aden aa) 14. walant hand surgery as described by lalonde involved the following: a. patient is sedated, tourniquet used for haemostasis and local anaesthetic given for postoperative pain a b. selective nerve block given depending on area of surgical field b c. radial, ulnar and median nerve block at level of mid-forearm c d. lignocaine/adrenaline mixture injected in a tumescent fashion at surgical site d e. lignocaine/adrenaline mixture injected directly into radial and ulnar digital nerves of finger to be operated on e 15. lalonde recommends the following drug to be available to reverse adrenaline-induced vasoconstriction: a. phenylephrine a b. phentolamine b c. nitroglycerine c d. propofol d e. magnesium sulphate e transarticular gunshot injuries: a systematic review of 150 years of management (ferreira n, anley c, joubert e) 16. what is the antibiotic of choice for transarticular gunshot injuries according to the included literature? a. penicillin a b. gentamycin b c. first-generation cephalosporin c d. second-generation cephalosporin d e. third-generation cephalosporin e 17. what is the most common long-term complication following retained intra-articular bullets and bullet fragments? a. avascular necrosis a b. post-traumatic osteoarthritis b c. chronic osteomyelitis c d. lead arthropathy d e. systemic lead toxicity (plumbism) e 18. the highest infective complications were seen following transarticular gunshot injuries to which joint? a. elbow a b. hip b c. knee c d. shoulder d e. wrist e a rare occurrence of ganglion cysts on the posterolateral aspect of the elbow without neurological manifestations: a case series and review of the literature (meier w, tsama m, aden aa) 19. all of the following conditions can present with pain on the lateral aspect of the elbow with an associated paraesthesia except: a. c6-7 cervical radiculopathy a b. shingles b c. tennis elbow c d. anterolateral elbow ganglion d e. lateral antebrachial cutaneous neuropathy e 20. ganglion cysts occur commonly around the wrist and hand. they are rare around the elbow, but when they do occur, the most frequent presentation is: a. asymptomatic, slowly growing mass on the lateral aspect of the elbow a b. vague anterolateral elbow pain with numbness/ paraesthesia on the dorso-radial aspect of the hand b c. vague anterolateral elbow pain with numbness/ paraesthesia on the dorso-radial aspect of the hand and difficulty extending the fingers and thumb, and weak radial deviation when asked to extend the wrist c d. vague anterolateral elbow pain with difficulty extending the fingers and thumb, and weak radial deviation when asked to extend the wrist d e. mass on the medial aspect of the elbow with clawing of the little and ring fingers and numbness of the ulnar one and a half fingers e subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm. co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online. • once you have completed the answers, go back to the top of the page next to the registration option. there is another icon “find my cpd certificate”. (you will have to answer the two questions regarding your internship and last cpd audit once you have completed a questionnaire and want to retrieve your certificate). • if you click on that icon it will open your certificate which you can print or save on your system. • please call mpc helpdesk if you have any questions: 0861 111 335. medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 mdb015/137/01/2022 joubert ja. sa orthop j 2020;19(2) doi 10.17159/2309-8309/2020/v19n2a4 south african orthopaedic journal http://journal.saoa.org.za traumatrauma citation: joubert ja. the use of three-dimensional models to improve the reliability of tibial plateau fracture classification and their influence on surgical management. sa orthop j 2020;19(2):79-83. http://dx.doi.org/10.17159/2309-8309/2020/v19n2a4 editor: prof. nando ferreira, stellenbosch university, south africa received: july 2019 accepted: november 2019 published: may 2020 copyright: © 2020 joubert ja. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for the purposes of performing this research. conflict of interest: the author has no conflicting interests with respect to this article. abstract background: to compare three-dimensional (3d) printed models with 3d computed tomography (ct) images in terms of the reliability of the classification of tibial plateau fractures using the hohl and moore and the schatzker classification systems, and whether there was any influence on surgical management. method: the sample comprised the 20 ct scans of patients with tibial plateau fractures available in the radiology archive of dr george mukhari academic hospital (ga-rankuwa). standardised illustrated guides to the schatzker and the hohl and moore classification systems were used by six observers of varying orthopaedic experience. they completed questionnaires individually in three different sessions. in session one the observers had access to the 3d ct images only. on average two to five days later, in session two the observers assessed only the 3d models. in the third session, another two-to-five days later, the observers assessed the 3d ct images while handling and inspecting the corresponding 3d model. results: the inter-observer reliability of the schatzker system (moderate reliability) was superior to the hohl and moore system (fair reliability) when comparing the assessment using the images and models separately. when all observations were combined, there was no difference between the systems. for the six possible surgical management options given to the observers, there was an overall difference in agreement based on assessing only the ct images compared with assessing only the models, of 19% (23 of the possible 120 procedures). of these 23 differing procedures, 15 were more invasive. the 3d models were considered superior to 3d ct imaging in terms of spatial awareness and the observers’ ability to assess intra-articular fracture patterns. the models were assessed as being superior to the imaging when considering the ability to estimate the quantity of bone graft required. conclusion: although the inter-rater reliability of classification was not significantly improved, there were several advantages to using the 3d-printed models both separately from the ct images and together with the images. the effect of 3d models on patient outcome remains untested. the clinical impact of the use of 3d models (including cost, manufacturing time and radiation exposure) should be weighed against the potential benefits. level of evidence: level 4 keywords: tibial plateau fracture classification, 3d ct images, 3d-printed models the use of three-dimensional models in tibial plateau fractures joubert ja mbchb, fc orth(sa), mmed(orth); orthopaedic surgeon, department of orthopaedics, sefako makgatho health sciences university, ga-rankuwa, south africa corresponding author: dr ja joubert, life mercantile hospital, room 306, korsten, port elizabeth, 8020; tel: 0871511811; email: drjajoubert@gmail.com https://orcid.org/0000-0001-6502-9806 page 80 joubert ja. sa orthop j 2020;19(2) introduction one of the objectives of orthopaedic surgery is to assess and classify fractures as a standardised methodical approach, specific to each fracture site, that directs patient treatment and warns against certain complications. computed tomography (ct) and subsequent three-dimensional (3d) rendering has improved the surgeon’s ability to visualise and classify intra-articular fractures, thereby influencing the decision to operate. three-dimensional printing is a rapidly expanding technology and if applied as an adjuvant to ct, could add a tangible element to fracture assessment and classification. the reliability of current classification systems of tibial plateau fractures has been assessed in a variety of publications. taşkesen et al.1 assessed the intraand inter-observer reliability of the arbeitsgemeinschaft für osteosynthesefragen-orthopaedic trauma association (ao-ota), schatzker, hohl and moore, luo and revised duparc systems using plain (2d) radiography as well as ct. the inter-observer reliability of the schatzker system was substantial when ct was used and moderate for plain radiographs. the ao-ota classification, the hohl and moore, and the luo classifications were all moderate for both ct and standard radiographs. the duparc classification system was the least reliable. mellema et al.2 compared the inter-observer reliability of the schatzker system with the luo classification system using either 2d ct images or 2d as well as 3d ct images. both systems showed only fair reliability, with the schatzker classification being significantly better. however, the added use of 3d ct did not improve the reliability. maripuri et al.3 compared the interobserver reliability of the ao-ota, schatzker, and hohl and moore systems. although the schatzker system was better, none was ideal as the reliability ranged from poor to moderate. millar et al.4 carried out a systematic review of tibial plateau fracture classification systems. they identified 38 systems, of which five were sub-classifications of existing systems, and only 11 systems associated fracture classification with clinical outcome. the review concluded that 2d and 3d ct improved interobserver reliability estimates, but that more detailed assessment was required to help predict outcomes and to guide clinical decisions. a medline search using the pubmed search engine using the search terms ‘three dimensional/3d printing assisted tibial plateau fracture’ revealed five studies, one of which was in chinese, and none of which assessed the inter-observer reliability of tibial plateau fracture classification. huang et al.5 showed that a 3d-printed template improved the accuracy of plating and screwing for complicated tibial plateau fractures. yang et al.6 assessed 3d model use in seven lateral tibial plateau malunions and concluded improved outcome. lou et al.7 compared conventional tibial plateau surgery with surgery assisted by 3d-printing technology in 72 patients. the authors reported a decrease in intra-operative blood loss, operative time and fluoroscopy use in the 3d printing-assisted group. a systematic review8 of 3d printing in tibial plateau fracture management found shorter operative time, less intra-operative blood loss and faster union times when 3d model-assisted open reduction internal fixation (orif) was used compared with conventional orif. however, there was no significant difference in follow-up outcomes or complications. in light of the fact that it is accepted that 3d ct is known to assist in surgical preparation and planning, it is not known whether these technologies can assist in reliably classifying tibial plateau fractures. the aim of this retrospective study was therefore to compare 3d models with 3d ct in terms of the reliability of classification of tibial plateau fractures using the hohl and moore and the schatzker classification systems, and to establish whether 3d model use might influence surgical management in the future. materials and method the sample comprised the 20 ct scans of patients with tibial plateau fractures available in the radiology archive of dr george mukhari academic hospital, ga-rankuwa. of the 27 knee ct scans available on the patient archive system, only 20 scans identified tibial plateau fractures. thus, all the available data was used. this study did not involve patient contact and did not consider the injuries commonly associated with tibial plateau fractures (fracture dislocation, meniscal and multi-ligamentous injuries). no assumptions were made regarding patient demographics, mechanism of injury, or open or closed injuries. for the purpose of the study, soft tissue injuries were not considered, and all patients were presented as adults (fit for surgical management). the ct data was processed digitally (phillips intellispace portal system, phillips, netherlands) to produce 3d images to be assessed on a computer screen (figure 1) and which could be rotated in all planes at the observer’s discretion. patient identifiers were replaced with research numbers. the volumetric data from the ct scans was converted to standard tessellation language files used to print corresponding 3d models at a 1:1 scale by additive printing (ultimaker ii 3d printer, ultimaker bv, netherlands). the models used (both 3d ct and 3d-printed models) consisted of a distal femur and proximal tibia. the patella was removed as it has no bearing on classification. polylactic acid was used as the medium because it is a rigid, bio-friendly plastic and is manufactured in a matt white colour resembling cortical bone (figure 2). all models were printed using a 20 µm definition setting in the same printer using the same batch of material. the cost of 3d model figure 1. a screenshot of a digital 3d ct scan used page 81joubert ja. sa orthop j 2020;19(2) manufacturing at the time of publication was estimated at r1 500 per model. manufacturing time was estimated at roughly 24 hours, depending on the model size and complexity. standardised descriptive illustrated classification guides were used by all observers: these were of the schatzker system types i–vi as described by zeltser and leopold1 and the hohl and moore classification system types i–v.3 six observers practising in the field of orthopaedic surgery volunteered to complete a series of questionnaires. the observers comprised two senior surgeons with more than ten years of experience (as a registered orthopaedic surgeon), two junior surgeons with less than ten years of experience (as a registered orthopaedic surgeon), and two registrars. all the observers were employed as full-time staff in an orthopaedic department. they completed the questionnaires individually in three different sessions. the 3d images were viewed on a computer screen and the 3d models were assessed by means of tactile examination and direct inspection. in session one the observers had access to the 3d ct images only. in session two, several days later, depending on availability (estimated at a two-to-five day delay), the observers assessed only the 3d models. in the third session (estimated two-to-five day delay from session 2), the observers assessed the 3d ct images while handling and inspecting the corresponding 3d model, in order to assess aspects that would more directly influence treatment and management. as the aim of the study was to compare 3d models to 3d ct, the observers did not have access to plain radiographs nor to 2d ct data. the first and second session questionnaires required the observers to: • classify the specific tibial plateau fracture using the two classification systems if applicable according to the observer • choose between surgical and conservative management for each case, assuming the patient was healthy and fit for surgery • if the management was to be surgical, specify the approach: ▫ non-operative management ▫ percutaneous screw fixation ▫ circular external fixation ▫ intramedullary nail ▫ single plate and screw construct ▫ multiple plate and screw constructs • assess whether it was possible to estimate how much bone graft would be required, as ‘yes/no/maybe/not applicable’ for the third questionnaire the observers were asked their opinion on whether the 3d model was inferior, equal or superior to the 3d ct image with regard to the following characteristics: fracture description; fracture classification; decision-making; spatial awareness; and assessment of the intra-articular fracture pattern. in addition, they were asked if they would consider printing a 3d model for future intra-articular fracture classification/decision making, on a scale of yes/no/maybe. the kappa coefficient system was used to evaluate interand intra-observer reliability. cohen’s kappa was used for two raters and the fleiss kappa (an adaptation of cohen’s kappa) for three or more raters. all statistical procedures were performed on ibm spss statistics 22 running on microsoft windows. the kappa interpretation is given in table i. results the inter-observer reliability kappa values for classifying the fractures are shown in table ii. there was fair agreement in the hohl and moore classifications and moderate agreement in the schatzker classification system. when assessing the classification systems by comparing the 3d ct image with the 3d model for each observer, an average value for all comparisons for all observers was obtained for each of the classification systems, and this revealed a moderate agreement and no difference between the classification systems (table iii). when the observers assessed cases in terms of surgical vs conservative treatment using only the 3d ct images, only three out of 120 responses (six observers × 20 cases) precluded conservative treatment, with all other responses being surgical. when assessing cases using the 3d models only, only one response precluded conservative management. for the six possible surgical management options given to the observers, there was an overall difference in agreement between the decisions based on assessing only the 3d ct images compared with assessing only the 3d models, of 19% (23 of the possible figure 2. a picture of a 3d printed model used table i: kappa scale interpretation kappa value interpretation <0 poor agreement 0.01–0.20 slight agreement 0.21–0.40 fair agreement 0.41–0.60 moderate agreement 0.61–0.80 substantial agreement 0.81–1.00 almost perfect agreement table ii: kappa inter-observer values for all six observers system 3d ct image reliability kappa value 3d-printed model reliability kappa value kappa interpretation hohl and moore 0.319 0.318 fair agreement schatzker 0.57 0.48 moderate agreement page 82 joubert ja. sa orthop j 2020;19(2) 120 procedures). in order to investigate whether the assessment of the models would result in a less, equal, or more invasive procedure, the procedures were scored on a scale of 1 to 6, representing the six options given, with 1 being least, and 6 the most invasive procedure. of the 23 differing procedures, 15 were more invasive (65% of differing proposed procedure cases or 12.5% of the total), and eight were less invasive (35% of differing proposes procedure cases or 6.7% of the total) (figure 3). the ability to assess the quantity of bone graft required was assessed on a yes/no/maybe/not applicable scale. the ‘yes’ category was scored more frequently when assessing the 3d models (75% vs 64%) (table iv). the observers’ opinions on whether the 3d model was of inferior, equal or superior value in assessing the various characteristics are shown in table v. finally, the observers were asked if they would consider printing a 3d model in the future and their responses were positive, based on case-specific needs. those mentioned were comminuted intraarticular fractures; severely displaced fractures; bony defects; and schatzker types iv–vi. discussion three-dimensional models have been described as useful in preoperative planning9 and the effect of model use on patient outcome has been investigated;7 however, no publications were found on the influence of 3d models on patient management or on the interobserver reliability in tibial plateau fracture classification regardless of the classification system used. of the 38 classification systems used to classify tibial plateau fractures, none appears to be ideal.3 for example the schatzker classification system was found to be more reliable when 3d ct was used to assess tibial plateau fractures compared with plain radiography in one study1 but not in another.2 in this study, the schatzker system (moderate reliability) was superior to the hohl and moore system (fair reliability) which was in agreement with taşkesen et al.1 when used for acetabular fracture classification, the use of 3d models has been reported to have improved inter-observer reliability compared with 3d ct.10 in this study, however, comparison of these 3d tools (ct and models) showed no statistically significant benefit in inter-observer reliability with 3d model use irrespective of the classification system used. this should imply that a more reliable approach to tibial plateau fracture classification remains elusive and the addition of 3d models did not replicate the success reported in acetabular fractures.10 the application of 3d models in the medical field has expanded dramatically in the last five years. the benefit of their use in orthopaedic pre-operative planning is frequently reported but poorly defined.9 the influence of 3d models on decision-making remains broadly untested in terms of surgical or conservative management. in this study, the observer responses indicated that 1% more cases would have received surgical management when the assessment was based on the 3d model. in addition, the theoretical proposed procedure based on 3d model assessment differed from the proposed procedure based on 3d ct assessment in 19% of cases, implying that the use of 3d models should be seen as an adjunct to planning and should not be used alone. this could alter management in nearly one out of every five tibial plateau patients managed surgically. the use of 3d models alone would have resulted in a theoretically more invasive procedure in 12.5% of patients and a theoretically less invasive procedure in 6.5% of patients. although 3d models changed the specific proposed procedure in 19% of cases, the change was in a relatively neutral direction, meaning (based on a scoring system) it was neither more nor less invasive. a recent literature review11 on the use of 3d models in the medical field reported several advantages but no definitive conclusions on the influence on surgical outcomes. it did, though, point out the need for a formal cost-effectiveness analysis. various publications7,8,12 have reported decreased intra-operative blood loss and shorter operative time associated with 3d model use, but lack explanations as to the root of the benefit and there is no evidence to support improvements in outcome. this study found 3d models to be superior to 3d ct imaging in terms of spatial awareness and specifically the observer’s ability to assess intraarticular fracture patterns. although these are promising features, the effect on patient outcomes needs more study. it should also table iii: average kappa values across all six observers when comparing each observer’s scores for ct image classification compared with their score for ct model classification system kappa value kappa interpretation hohl and moore 0.56 moderate agreement schatzker 0.52 moderate agreement 8 15 97 more invasive procedure same procedure proposed less invasive procedure 23 differing proposed procedures figure 3. effect on surgical management due to 3d model table iv: observers’ opinions on whether it was possible to assess the quantity of bone graft required opinion 3d ct image 3d model no. % no. % yes 64 53 75 63 no 32 27 23 19 maybe 17 14 19 16 not applicable 7 6 3 3 table v: observers’ opinions on whether the 3d model was of inferior, equal or superior value feature inferior equal superior no. % no. % no. % fracture description 19 16 61 51 40 33 fracture classification 8 7 90 75 22 18 decision-making 9 18 65 54 46 38 spatial awareness 9 8 20 17 91 76 intra-articular fracture pattern assessment 7 6 33 28 80 67 page 83joubert ja. sa orthop j 2020;19(2) be noted that publications7 reporting on decreased operative time using 3d models also reported increased time spent on preoperative planning. although the observers in this study assessed 3d models as being superior to 3d ct when considering the ability to estimate the quantity of bone graft required, this could not be confirmed intra-operatively. if the use of 3d models is considered a valuable adjunct to treatment, the cost must also be considered. cost assessment should include the ct scan, model manufacturing consumables, printing time, as well as time spent on pre-operative surgical simulation. a broader consideration of the true cost of 3d models may have a negative impact on their use. the limitations of this study include a fairly small population group. as the patient archive system was manually stored off site only a limited number of ct scans were available. the use of a basic fundamental imaging modality (radiographs) was excluded in order to compare novel strategies. the observers did not have access to 2d ct images. due to the various observers’ obligations to patient care, the timing of questionnaire sessions was not strictly standardised. the study considers only tibial plateau fractures and does not consider associated soft tissue injuries. the study involves retrospective analysis of patient data and therefore no conclusion can be drawn relating to patient outcome. conclusions inter-observer reliability was not significantly different when assessing the schatzker or hohl and moore classification systems using either the 3d models or the 3d ct images. the assessment of the 3d models did not favour surgical or conservative treatment significantly but did alter the observers’ proposed surgical procedures in 19% of cases observers reported 3d models equal to 3d ct imaging in terms of fracture description, fracture classification and decision-making. model use was superior to 3d ct in terms of spatial awareness and intra-articular fracture description. the use of 3d models in tibial plateau fracture pre-operative planning needs further study. the clinical impact of 3d model use (including cost, manufacturing time and radiation exposure) should be weighed against the potential benefits. acknowledgements the author would like to thank dr s matshidza and dr e d’alton for their support and guidance in carrying out this research, which was carried out in partial fulfilment for the degree mmed. supervisor: dr steven matshidza, consultant and head of clinical department, orthopaedics ufs/ universitas hospital, bloemfontein co-supervisor: dr eduard johan d’alton, dr george muhkari hospital, sefako makgatho health sciences university, ga-rankuwa, pretoria ethics statement the author declares that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, ethical approval was obtained from the university’s research ethics committee (approval number smurec/m/258/2015: pg). declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions jaj contributed to the conception and design of the work; the acquisition, analysis and interpretation of the data for the work; drafting the work, and submitting the final version to be published. orcid joubert ja https://orcid.org/0000-0001-6502-9806 references 1. taşkesen a, demirkale i̇, okkaoğlu mc, et al. intra-observer and inter-observer reliability assessment of tibial plateau fracture classification systems. eklem hastalik cerrahisi.  2017;28:177-81. doi: 10.5606/ehc.2017.56816. 2. mellema jj, doornberg jn, molenaars rj, et al. inter-observer reliability of the schatzker and luo classification systems for tibial plateau fractures. injury. 2016;47:944-49. doi: 10.1016/j. injury.2015.12.022. 3. maripuri sn, rao p, manoj-thomas a, mohanty k. the classification systems for tibial plateau fractures: how reliable are they? injury. 2008;39:1216-21. doi: 10.1016/j.injury.2008.01.023. 4. millar sc, arnold jb, thewlis d, fraysse f, solomon lb. a systematic literature review of tibial plateau fractures: what classifications are used and how reliable and useful are they? injury. 2018;49:473-90. doi: 10.1016/j.injury.2018.01.025 5. huang h, hsieh mf, zhang g et al. improved accuracy of 3d-printed navigational template during complicated tibial plateau fracture surgery. australas phys eng sci med. 2015;38:109-17. doi: 10.1007/s13246-015-0330-0. 6. yang p, du d, zhou z, et al. 3d printing-assisted osteotomy treatment for the malunion of lateral tibial plateau fracture. injury. 2016;47:2816-21. doi: 10.1016/j.injury.2016.09.025 7. lou y, cai l, wang c, et al. comparison of traditional surgery and surgery assisted by three  dimensional printing technology in the treatment of tibial plateau fractures. int orthop.  2017;41:1875-80. doi: 10.1007/s00264-017-3445-y. 8. xie l, chen c, zhang y, et al. three-dimensional printing assisted orif versus conventional orif for tibial plateau fractures: a systematic review and meta-analysis. int j surg.  2018;57:35-44. doi: 10.1016/j.ijsu.2018.07.012. 9. bizzotto n, sandri a, regis d, et al. three-dimensional printing of bone fractures: a new tangible realistic way for preoperative planning and education. surg innov. 2015;22:548-51. doi: 10.1177/1553350614547773. 10. hurson c, tansey a, o'donnchadha b, et al. rapid prototyping in the assessment, classification and preoperative planning of acetabular fractures. injury. 2007;38:1158-62. epub 2007 sep 19. 11. tack p, victor j, gemmel p, annemans l. 3d-printing techniques in a medical setting: a systematic literature review. biomed eng online. 2016;15:115-36. doi: 10.1186/s12938-016-0236-4. 12. giannetti s, bizzotto n, stancati a, santucci a. minimally invasive fixation in tibial plateau fractures using an pre-operative and intra-operative real size 3d printing. injury.  2017;48:784-88. doi: 10.1016/j.injury.2016.11.015. https://orcid.org/0000-0001-6502-9806 https://www.ncbi.nlm.nih.gov/pubmed/29125816 https://www.ncbi.nlm.nih.gov/pubmed/?term=a+systematic+literature+review+of+tibial+plateau+fractures%3a+what+classifications+are+used+and+how+reliable+and+useful+are+they%3f https://www.ncbi.nlm.nih.gov/pubmed/?term=lou%20y%5bauthor%5d&cauthor=true&cauthor_uid=28396929 https://www.ncbi.nlm.nih.gov/pubmed/?term=cai%20l%5bauthor%5d&cauthor=true&cauthor_uid=28396929 https://www.ncbi.nlm.nih.gov/pubmed/?term=wang%20c%5bauthor%5d&cauthor=true&cauthor_uid=28396929 https://www.ncbi.nlm.nih.gov/pubmed/?term=comparison+of+traditional+surgery+and+surgery+assisted+by+three+dimensional+printing+technology+in+the+treatment+of+tibial+plateau+fractures. https://www.ncbi.nlm.nih.gov/pubmed/?term=giannetti%20s%5bauthor%5d&cauthor=true&cauthor_uid=27889111 https://www.ncbi.nlm.nih.gov/pubmed/?term=bizzotto%20n%5bauthor%5d&cauthor=true&cauthor_uid=27889111 https://www.ncbi.nlm.nih.gov/pubmed/?term=stancati%20a%5bauthor%5d&cauthor=true&cauthor_uid=27889111 _goback _goback _goback _goback _goback _goback south african orthopaedic journal current concepts review doi 10.17159/2309-8309/2022/v21n1a7ferreira n et al. sa orthop j 2022;21(1) citation: ferreira n, anley c, joubert e. transarticular gunshot injuries: a systematic review of 150 years of management. sa orthop j 2022;21(1):44-51. http://dx.doi.org/10.17159/23098309/2022/v21n1a7 editor: prof. sithombo maqungo, university of cape town, cape town, south africa received: june 2021 accepted: september 2021 published: march 2022 copyright: © 2022 ferreira n. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background this review aims to collate all published work on the management of transarticular gunshot injuries to better inform decision-making when managing these injuries. methods a systematic review using the preferred reporting items for systematic reviews and metaanalysis (prisma) was undertaken. a literature search of major electronic databases was conducted to identify journal articles relating to the management of transarticular gunshot injuries published from database inception until 31 january 2021. results sixty-eight publications reporting on the management of 544 patients were included. injuries to the lower limbs were reported in 438 cases (81%), while injuries to the upper limb accounted for 106 cases (19%). a total of 145 patients (27%) developed a deep infection. following the routine use of antibiotics, 6% of patients (14/251) developed an infection. a significantly higher hip joint infection rate was seen in patients who sustained associated hollow viscus injury (11/30, 37%). conclusion the management of transarticular gunshot injuries is currently based on limited high-quality evidence. modern antibiotic and surgical management practices have resulted in low overall septic complications; however, different joints have different injury and complication profiles. future research should be aimed at identifying joint-specific evidence-based care pathways. level of evidence: level 4 keywords: gunshot, ballistic, joint, transarticular, intra-articular transarticular gunshot injuries: a systematic review of 150 years of management nando ferreira,* cameron anley, etienne joubert division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa *corresponding author: nferreira@sun.ac.za introduction the global surge in civilian gun-related violence has focused a need for evidence-based management protocols.1-3 at present, the management of transarticular gunshot injuries remains controversial, with limited high-quality research to guide evidencebased management. controversies regarding the need for surgical debridement, the long-term local and systemic effects of retained bullets or bullet fragments, the choice and duration of antibiotic therapy, and the management of intra-articular fractures remain.4-9 this systematic review explores the literature reporting on the treatment of transarticular gunshot injuries and aims to interpret the data to provide physicians with evidence to guide the management of these cases. methods a systematic review using the preferred reporting items for systematic reviews and meta-analysis (prisma) was undertaken. the review was prospectively registered on the prospero database (crd42021233384). search strategy for the identification of relevant studies a literature search of databases was conducted and included medline, sciencedirect, articlefirst, sa epublications journal collection and web of science. the search terms included ‘gunshot’, ‘ballistic’, ‘bullet’, ‘joint’, ‘intra-articular’ and ‘transarticular’ with the boolean terms ‘and’ and ‘or’. searches were conducted from database inception to 31 january 2021 and were limited to human participants and publications in english. a manual search of the reference list of included studies was also undertaken to identify other studies meeting the inclusion criteria. inclusion and exclusion criteria the picott framework was used to develop the inclusion and exclusion criteria (table i). https://orcid.org/0000-0002-0567-3373 page 45ferreira n et al. sa orthop j 2022;21(1) study selection identified records were downloaded into mendeley desktop (version 1.19.4) and deduplicated. titles were screened by a single reviewer (nf). abstracts and then full texts were independently screened by two researchers (nf, ca) against the eligibility criteria, and any discrepancies were resolved through discussion. quality assessment included articles were assigned a level of evidence according to sackett’s rules of evidence that rank studies according to the probability of bias.10 data extraction and synthesis data extracted from the included studies were captured in microsoft excel for mac (version 16.45). information relating to the joint involved, injury characteristics, treatment instituted, and complications/outcomes were collected. additionally, the following information was listed for all articles: research theme, year of publication and geographic origin. a qualitative synthesis of studies with sufficient homogeneity was performed, while a narrative descriptive synthesis was used for the remaining data. results the search strategies identified 1 587 references after deduplication. full-text review of 97 studies resulted in 68 publications being retained for final review (figure 1). study characteristics the included studies spanned 153 years and were published between 1867 and 2020, with a marked increase in publications over the last two decades (figure 2).11-79 ten studies were published before 1944 (pre-antibiotic era), with the remaining 58 being published in the antibiotic era. the united states of america (n = 29) and the united kingdom (n = 11) contributed the bulk of the publications (n = 40, 60%) (figure 3).11-23,26,28-30,33,34,36,3840,44,46,48,49,52,64,65,66 the majority of publications consisted of case table i: eligibility criteria developed according to the picott framework inclusion exclusion population • all patients treated for transarticular gunshot injuries. included joints: shoulder, elbow, radiocarpal, hip, knee, and ankle • all bony and soft tissue injuries • patients presenting at any time point after injury • gunshot injuries to the small joints of the hand and foot, sacroiliac joints and spine • gunshot injuries not traversing a large joint • joint-penetrating injuries other than from gunshots intervention • gunshot injuries that traversed any of the following joints: shoulder, elbow, radiocarpal, hip, knee, ankle • any medical treatment would be included, including operative and nonoperative treatment control different management strategies identified in the review would serve as controls outcome studies reporting on outcomes in terms of infection, fracture union, arthropathy and systemic complications type of question therapeutic and prognostic type of study (design) all observational and interventional study designs were considered for inclusion • technical articles • review articles • non-peer-reviewed • opinion pieces records identified through database searching (n = 1 577) records after duplicates removed (n = 1 587) in cl ud ed el ig ib ili ty sc re en in g id en tif ic at io n records screened (n = 1 587) full-text articles assessed for eligibility (n = 97) studies included in qualitative synthesis (n = 68) records excluded (n = 1 490) full-text articles excluded (n = 29) • technical article (3) • review article (3) • non-peer-reviewed (2) • insufficient data (8) • other injuries (9) • instructional article (2) • radiographic study (2) additional records identified through other sources (n = 10) figure 1. flow diagram showing the identification and selection of studies page 46 ferreira n et al. sa orthop j 2022;21(1) studies (n = 45, 66%), while 22 (32%) were retrospective case series.11-60,62-79 only one randomised control trial was included.61 according to sackett’s rules of evidence, the included studies consisted of one level 2, 22 level 3 and 45 level 4 studies.10 the research themes for the included articles broadly fell into three categories: 1. the management and outcome of acute injuries (n = 22) 2. the presentation and management of late complications (n = 23) 3. bullet extraction techniques (n = 23) cumulative results of included cases sample sizes of the included papers ranged from 1 to 86 cases and included 544 transarticular gunshot injuries. injuries to the lower limbs were reported in 438 cases (81%), while injuries to the upper limb accounted for 106 cases (19%) (figure 4). two hundred and seventy-nine patients (51%) sustained an intra-articular fracture, and 490 patients (90%) underwent surgical debridement as part of their management. a total of 145 patients (27%) developed a deep infection because of their injury. the mean follow-up for the entire cohort was four months, ranging from 0 to 142 months. retained intra-articular bullets or bullet fragments were reported in 198 patients (36%). lead arthropathy due to retained bullet fragments was diagnosed in 24 patients (12%) and was seen after gunshots to 16 hips, three knees, two ankles, two wrists and one shoulder.21,22,28,30,50,54,58-60,63,65,69,71,73,76,77,79 these patients presented at a median of 42 months (range 3–624) following the injury. all patients underwent surgical joint exploration and bullet removal, including total joint arthroplasty in 15 patients (14 total hip arthroplasty, one total shoulder arthroplasty) and joint arthrodesis for two patients (one radiocarpal joint and one ankle). all papers reported good functional outcomes following arthroplasty for lead arthropathy. eleven patients (6%) presented with systemic lead toxicity at a median of 82 months (range 8–624) following the initial injury.21,54,58,60,65,69,71,73,77 all patients who developed systemic lead toxicity were also diagnosed with lead arthropathy due to retained intra-articular bullets or bullet fragments. involved joints included seven hips, two ankles, one knee and one wrist. seven patients were commenced on chelation therapy at presentation and, following bullet removal, the systemic complications resolved in all cases. the intra-articular bullet was not removed in one patient, and this patient returned two years later with repeat acute systemic lead toxicity.69 reviewing the management outcomes of acute presenting cases, a clear difference in septic complications is seen between the preantibiotic and antibiotic eras. before the routine use of antibiotics, 52% of patients (39/75) developed an infection compared to 6% (14/251) following the widespread use of antibiotics. however, many of the initial papers reported on patients already infected at the time of presentation. all reported sepsis-related deaths (n = 9) and amputations (n = 25) also occurred before the routine use of antibiotics (table ii). during this period, management generally consisted of repeat open debridements, joint excision or amputation and daily antiseptic solution irrigation. 45 40 35 30 25 20 15 10 5 0 18 60 –1 88 0 18 81 –1 99 0 19 01 –1 92 0 19 21 –1 94 0 19 41 –1 96 0 19 61 –1 98 0 19 81 –2 00 0 20 01 –2 02 0 2 3 4 0 1 4 12 42 figure 2. the number of publications per vicennial interval figure 3. geographic distribution of country of origin of publications figure 4. anatomical site distribution of included cases page 47ferreira n et al. sa orthop j 2022;21(1) table ii: complications following transarticular gunshot injuries cases (n) retained bullet (n, %) plumbism (n, %) lead arthropathy (n, %) sepsis (n, %) amputation (n, %) death (n, %) hip 157 82, 52% 7, 4% 16, 10% 17, 11% 0, 0% 0, 0% pre-antibiotic era 0 0, 0% 0, 0% 0, 0% 0, 0% 0, 0% 0, 0% antibiotic era 157 82, 52% 7, 4% 16, 10% 17, 11% 0, 0% 0, 0% knee 274 91, 33% 1, 0.4% 3, 1% 45, 16% 23, 4% 7, 3% pre-antibiotic era 156 47, 30% 0, 0% 0, 0% 43, 28% 23, 15% 7, 4% antibiotic era 118 44, 37% 1, 1% 3, 3% 2, 2% 0, 0% 0, 0% ankle 7 2, 29% 2, 29% 2, 29% 0, 0% 0, 0% 0, 0% pre-antibiotic era 0 0, 0% 0, 0% 0, 0% 0, 0% 0, 0% 0, 0% antibiotic era 7 2, 29% 2, 29% 2, 29% 0, 0% 0, 0% 0, 0% shoulder 29 13, 45% 0, 0% 1, 3% 4, 14% 0, 0% 1, 3% pre-antibiotic era 7 7, 100% 0, 0% 0, 0% 1, 14% 0, 0% 1, 14% antibiotic era 22 6, 27% 0, 0% 1, 5% 3, 14% 0, 0% 0, 0% elbow 71 8, 11% 0, 0% 0, 0% 34, 48% 2, 0.4% 1, 1% pre-antibiotic era 59 8, 14% 0, 0% 0, 0% 32, 54% 2, 3% 1, 2% antibiotic era 12 0, 0% 0, 0% 0, 0% 2, 17% 0, 0% 0, 0% wrist 6 2, 33% 1, 17% 2, 33% 0, 0% 0, 0% 0, 0% pre-antibiotic era 1 0, 0% 0, 0% 0, 0% 0, 0% 0, 0% 0, 0% antibiotic era 5 2, 40% 1, 20% 2, 40% 0, 0% 0, 0% 0, 0% total 544 198, 36% 11, 2% 24, 4% 100, 18% 25, 5% 9, 2% pre-antibiotic era 223 62, 28% 0, 0% 0, 0% 76, 34% 25, 11% 9, 4% antibiotic era 321 136, 42% 11, 3% 24, 7% 24, 7% 0, 0% 0, 0% table iii: management of acute presenting cases during the antibiotic era cases (n) management outcome antibiotics given (n, %) open arthrotomy (n, %) surgical dislocation (n, %) arthroscopy (n, %) fracture fixation (n, %) joint arthrodesis (n, %) arthroplasty (n, %) sepsis (n, %) non-union/ malunion/ avn (n, %) hip 108 64, 59% 50, 46% 17, 16% 16, 15% 33, 31% 0, 0% 2, 2% 9, 8% 17, 16% no fracture 22 10, 45%* 4, 18% 10, 45% 8, 36% 0, 0% 0, 0% 3, 14% fracture 81 54, 67%* 46, 57% 7, 8% 3, 4% 33, 41% 0, 0% 1, 1% 6, 7% 17, 21% acetabulum 52 46, 88%* 25, 48% 4, 8% 2, 4% 14, 27% 0, 0% 0, 0% 6, 12% 10, 19% femoral head 9 3, 33%* 4, 44% 2, 18% 1, 9% 3, 33% 0, 0% 0, 0% 0, 0% 0, 0% neck of femur 20 5, 25%* 17, 65% 1, 5% 0, 0% 16, 80% 0, 0% 1, 5% 0, 0% 7, 35% not reported 5 * 0, 0% 5, 100% 0, 0% knee 115 106, 92% 35, 30% 59, 51% 3, 3% 0, 0% 0, 0% 2, 2% 0, 0% no fracture 54 52, 96%* 16, 30% 17, 31% 2, 4% fracture 54 54, 100% 18, 33% 36, 67% 3, 6% 0, 0% 0, 0% 0, 0% 0, 0% not reported 7 * 1, 14% 6, 86% 0, 0% shoulder 20 20, 100% 12, 60% 4, 20% 0, 0% 3, 15% 4, 20% 3, 15% no fracture 7 7, 100% 1, 14% 2, 29% 0, 0% fracture 12 12, 100% 11, 92% 1, 8% 0, 0% 3, 25% 4, 30% 3, 25% not reported 1 1, 100% 0, 0% 1, 100% 0, 0% elbow 5 5, 100% 5, 100% 0, 0% 0, 0% 0, 0% 0, 0% 0, 0% no fracture 1 1, 100% 1, 100% 0, 0% 0, 0% fracture 4 4, 100% 4, 100% 0, 0% 0, 0% 0, 0% 0, 0% 0, 0% wrist 3 3, 100% 2, 67% 0, 0% 0, 0% 0, 0% 0, 0% 0, 0% fracture 3 3, 100% 2, 67% 0, 0% 0, 0% 0, 0% 0, 0% 0, 0% total 251 198, 79%* 104, 41% 17, 7% 79, 31% 36, 14% 3, 1% 5, 2% 14, 6% 17, 7% no fracture 84 70, 84%* 22, 26% 10, 12% 27, 32% 5, 6% 0, 0% fracture 154 127, 82%* 81, 53% 7, 5% 40, 26% 36, 23% 3, 2% 5, 3% 9, 6% 17, 11% not reported 13 1, 8%* 1, 8% 0, 0% 12, 92% 0, 0% 0, 0% * not reported in all publications page 48 ferreira n et al. sa orthop j 2022;21(1) management of acute injuries during the antibiotic era following the dawn of the antibiotic era, virtually every patient reported in the literature (99%, 198/199) who presented with an acute transarticular gunshot injury received systemic antibiotics as part of their management; the only patient who did not receive antibiotics left the hospital against medical advice before receiving medication (table iii).32 first-generation cephalosporins were the antibiotic of choice in most publications (84%, 166/198). one paper combined gentamycin with a first-generation cephalosporin for seven patients who sustained gunshot injuries to the shoulder.29 one report used a third-generation cephalosporin following gunshot injuries to the hip.26 although the authors did not expand on the motivation for using a third-generation rather than a first-generation cephalosporin, it is worthy to note that most of the patients in this report also sustained associated hollow viscus injuries.26 most cases (80%, 202/251) underwent surgical arthrotomy, debridement and joint lavage. an open debridement was performed in 123 patients (61%). in 19 cases of gunshot injuries to the hip, a surgical hip dislocation was performed to facilitate bullet removal. an arthroscopic debridement was performed in 79 patients (39%). two papers investigated the need for operative intervention of transarticular gunshot injuries. a 2018 study by maqungo et al. and a 2019 study by shultz et al. compared antibiotics alone versus antibiotics in addition to operative treatment of transarticular gunshot injuries.32,61 both studies showed no difference in infective complications, but when considering a baseline infection rate of 6% for acute presenting patients, these studies were possibly underpowered, and additional research is needed before the widespread adoption of this management strategy. intra-articular fractures were reported in 154 patients (65%). these injuries were treated nonoperatively in 110 cases, by fracture fixation in 36 cases, arthroplasty in five cases (four shoulders, one hip)27,29 and shoulder arthrodesis in three patients.29 poor outcomes requiring implant removal were experienced in all four shoulder arthroplasty cases (three periprosthetic joint infections and one painful implant loosening).29 thirty-three papers reported 157 transarticular gunshot wounds to the hip, including 30 patients who sustained transabdominal or transpelvic bullet trajectory with associated hollow viscus injury.24,26,48,49,62,74 bowel injury treatment consisted of primary repair in 20 cases and bowel diversion in ten patients. a significantly higher hip joint infection rate was seen in patients who sustained hollow viscus injury (11/30, 37%) than those who did not (6/127, 5%). the included papers did not provide enough information to discern any difference in infective complications following small bowel or large bowel injuries. late complications during the antibiotic era seventy patients presented with late complications (table iv) following transarticular gunshot injuries at a median of 15.7 months after the injury (range 3–624); 26 patients had retained intra-articular bullets, 24 of whom developed lead arthropathy, of which 11 had signs of systemic lead toxicity. all (n = 70, 100%) were managed surgically. fifty-five patients underwent arthroplasty for complications following transarticular gunshot injuries. these patients presented at a median of 15.7 months (range 3–624) following the initial injury. total joint arthroplasty of the hip was the most common procedure (n = 46). eight cases (17%) were complicated by periprosthetic joint infection, including both patients who sustained associated hollow viscus injuries; five patients underwent revision arthroplasty, while table iv: management of late complications during the antibiotic era cases (n) presentation management and outcome median time since injury in month (range) retained bullet (n, %) lead arthropathy (n, %) plumbism (n, %) surgery (n, %) sepsis (n, %) good outcome (n, %) hip 49 15.7 (3–624) 17, 35% 16, 33% 7, 14% 49, 100% 8, 16% 32, 65% open debridement 2 154 (8–300) 2, 100% 2, 100% 2, 100% 2, 100% 0, 0% 0, 100% arthroscopic debridement 1 4 1, 100% 0, 0% 0, 0% 1, 100% 0, 0% 1, 100% arthroplasty 46 15.7 (3–624) 14, 30% 14, 30% 5, 11% 46, 100% 8, 17% 31, 67% knee 3 22 (14–396) 3, 100% 3, 100% 1, 33% 3, 100% 0, 0% 3, 100% open debridement 1 396 1, 100% 1, 100% 0, 0% 1, 100% 0, 0% 1, 100% arthroscopic debridement 2 (14–22) 2, 100% 2, 100% 1, 50% 2, 100% 0, 0% 2, 100% ankle 7 27 (27–588) 2, 29% 2, 29% 2, 29% 7, 100% 0, 0% 7, 100% open debridement 1 480 1, 100% 1, 100% 1, 100% 1, 100% 0, 0% 1, 100% arthrodesis 6 27 (27–588) 1, 17% 1, 17% 1, 17% 6, 100% 0, 0% 6, 100% shoulder 2 35.5 (11–60) 2, 100% 1, 50% 0, 0% 2, 100% 0, 0% 2, 100% arthroplasty 2 35.5 (11–60) 2, 100% 1, 50% 0, 0% 2, 100% 0, 0% 2, 100% elbow 7 24 (17–39) 0, 0% 0, 0% 0, 0% 7, 100% 2, 29% 2, 29% arthroplasty 7 24 (17–39) 0, 0% 0, 0% 0, 0% 7, 100% 2, 29% 2, 29% wrist 2 152 (16–288) 2, 100% 2, 100% 1, 50% 2, 100% 0, 0% 2, 100% open debridement 1 16 1, 100% 1, 100% 0, 0% 1, 100% 0, 0% 1, 100% arthrodesis 1 288 1, 100% 1, 100% 1, 100% 1, 100% 0, 0% 1, 100% total 70 15.7 (3–624) 26, 37% 24, 34% 11, 28% 70, 100% 10, 14% 48, 69% open debridement 5 300 (8–480) 5, 100% 5, 100% 3, 60% 5, 100% 0, 0% 3, 60% arthroscopic debridement 3 14 (4–22) 3, 100% 2, 67% 1, 33% 3, 100% 0, 0% 3, 100% arthrodesis 7 27 (16–588) 2, 29% 2, 29% 2, 29% 7, 100% 0, 0% 7, 100% arthroplasty 55 15.7 (3–624) 16, 29% 15, 27% 5, 9% 55, 100% 10, 18% 35, 64% page 49ferreira n et al. sa orthop j 2022;21(1) one patient was treated by resection arthroplasty.30,50,54,63,65,67,71,77,79 seven total elbow replacements were performed of which five patients (71%) required implant removal for either septic (n = 4) or aseptic loosening (n = 1).41 good outcomes were reported in both patients who underwent shoulder arthroplasty.31,59 bek et al. reported a 100% fusion rate following ilizarov circular external fixation ankle arthrodesis in five patients who presented at a median of 27 months following gunshot injuries to the ankle joint.53 bullet extraction techniques twenty-three publications reporting on the management of 44 patients focused on extraction techniques for retrieving retained bullets from 27 hips, 13 knees and four shoulder joints. most publications (n = 20, 33 patients) described arthroscopic bullet removal, including 15 hips, 13 knees and four shoulder joints; one failed arthroscopic removal from a knee converted to an open arthrotomy.52 two publications (11 patients) reported a 100% success rate, without complications, with the use of surgical hip dislocation for removal of bullets lodged in the femoral head and acetabulum.23,57 krishnan et al. described a posterior approach and extracapsular cortical window to remove a bullet lodged in the posterior wall of the acetabulum.48 most authors reported the successful use of a pituitary rongeur to grasp loose bullets within the joint cavity during arthroscopic removal.24,34,35,38,39,42,47 budeyri and cankus resorted to using an arthroscopic shaver with high-pressure suction to ‘grasp’ the bullet and rongeur claw after the rongeur claw broke off in the joint.66 several authors noted instances of iatrogenic cartilage damage when embedded bullets were levered from their bony recesses. to circumvent this, singleton et al. and lee et al. described using a 3.2 mm threaded guide pin inserted into the bullet under power to capture the embedded bullet and extract it from the bone (figure 5).49,52 discussion the management of transarticular gunshot injuries is currently based on limited high-quality evidence. this systematic review aimed to explore the literature reporting on treating these injuries to interpret the data and provide physicians with evidence to guide their management. together with a surge in global civilian gun-related violence, a drive for evidence-based medical care has stimulated a reciprocal increase in gunshot injury research over the last 20 years. a recent bibliometric analysis and the current review have confirmed that most publications on orthopaedic ballistic injuries originated from developed countries, including the united states of america and the united kingdom, despite most gun-related violence reported in developing countries.80 el salvador, jamaica, eswatini, honduras and venezuela, for example, have the highest firearm-related homicide rates.81 yet, no publications on gunshot-related injuries have originated from any of these five countries. researchers and non-governmental organisations in countries that see high numbers of firearm-related trauma should be encouraged to report their experience of managing these injuries to assist the development of global gun violence care pathways. it is interesting to note that complication profiles were not consistent across different joints. the most prominent example was septic complications following transarticular gunshot injuries to the hip with associated hollow viscus injury, which was significantly higher than for any other joint (11/30, 37%). different infection rates were also observed for the other joints: 15% for shoulder, 8% for hip, 2% for knee and 0% for wrist and elbow injuries. from arthroplasty and arthroscopy research, it is evident that different joints experience different infective complications, which might also be true for transarticular gunshot injuries.82-87 it might therefore be plausible to develop individualised care pathways for gunshot injuries based on each joint and associated injuries. this will, however, require more extensive cohort studies focusing on specific joint injuries. the quality of the included publications limits recommendations that could be extracted from this review, most reports being either retrospective case series or case reports. no publications reported patient-reported outcomes following the management of gunshotrelated transarticular injuries. the heterogeneity and quality of the included studies precluded performing a meta-analysis. conclusion the contemporary management of transarticular gunshot injuries is based on limited high-quality evidence predominantly from developed countries. modern antibiotic and surgical management practices have resulted in low overall septic complications; however, different joints have different injury and complication profiles. future research should be aimed at identifying jointspecific evidence-based care pathways. key points 1. all intra-articular bullets or bullet fragments should be removed to mitigate long-term complications. 2. gunshot injuries to the hip joint with associated hollow viscus injury have a high infection incidence and should be treated aggressively. 3. although systemic lead toxicity is a severe complication, lead arthropathy is more common following retained intra-articular bullets and bullet fragments. 4. at present, there is insufficient evidence to propose nonoperative treatment of acute presenting transarticular gunshot injuries. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions nf: assembled the team of reviewers, coordinated the review process, conducted the primary review and compiled the manuscript ca: screened eligible manuscripts, assisted with data extraction, reviewed, and approved the final submission ej: assisted with data extraction, reviewed and approved the final submission figure 5. intra-articular bullet extracted 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low velocity transarticular gunshot injuries: a pilot study. sa orthop j. 2018;17(3):25-27. https://doi. org/10.17159/2309-8309/2018/v17n2a4. 62. ferro fp, bessa fs, ejnisman l, et al. arthroscopic bullet removal from the hip joint and concurrent treatment of associated full-thickness chondral defects: a case report. sage open med case reports. 2019;7:2050313x1982967. https://doi. org/10.1177/2050313x19829670. 63. pazarci o, kilinc s, camurcu y, bulut o. total hip arthroplasty after hip joint gunshot injury. j orthop surg. 2019;27(3):1-6. https://doi.org/10.1177/2309499019873113. 64. fournier mn, rider cm, olinger cr, et al. arthroscopic treatment of a low-velocity gunshot injury to a primary total hip arthroplasty. jbjs case connect. 2019;9(1):e18. https://doi. org/10.2106/jbjs.cc.18.00204. 65. rohlfing g, refaat m, kollmorgen r. pseudotumor caused by a retained intra-articular bullet: a case report. jbjs case connect. 2020;10(1):e0209. https://doi.org/10.2106/jbjs. cc.19.00209. 66. budeyri a, cankus mc. shaver suction technique for troubleshooting in arthroscopic double foreign body removal from the hip joint. cureus. 2020;12(10):e10911. https://doi. org/10.7759/cureus.10911. 67. özden r, davut s, doğramacı y, et al. treatment of secondary hip arthritis from shell fragment and gunshot injury in the syrian civil war. j orthop surg res. 2020;15(1):464. https://doi.org/10.1186/s13018-020-01993-z. 68. maqungo s, fegredo d, brkljac m, laubscher m. gunshot wounds to the hip. j orthop. 2020;22(august):530-34. https://doi.org/10.1016/j.jor.2020.09.018. 69. dillman ro, crumb ck, lidsky mj. lead poisoning from a gunshot wound. report of a case and review of the literature. am j med. 1979;66(3):509-14. https://doi. org/10.1016/0002-9343(79)91083-0. 70. parisien js, esformes i. the role of arthroscopy in the management of low-velocity gunshot wounds of the knee joint. clin orthop relat res. 1984;(185):207-13. 71. beazley wc, rosenthal re. lead intoxication 18 months after a gunshot wound. clin orthop relat res. 1984;(190):199-203. http://www.ncbi.nlm.nih.gov/pubmed/6488632. 72. sclafani sj, vuletin jc, twersky j. lead arthropathy: arthritis caused by retained intra-articular bullets. radiology. 1985;156(2):299-302. https://doi.org/10.1148/radio logy.156.2.4011890. 73. slavin re, swedo j, cartwright jj, et al. lead arthritis and lead poisoning following bullet wounds: a clinicopathologic, ultrastructural, and microanalytic study of two cases. hum pathol. 1988;19(2):223-35. https://doi.org/10.1016/s0046-8177(88)80353-8. 74. becker vv, brien ww, patzakis m, wilkins j. gunshot injuries to the hip and abdomen: the association of joint and intra-abdominal visceral injuries. j trauma. 1990;30(11):1324-29. https://doi.org/10.1097/00005373-199011000-00003. 75. berg ee, ciullo jv. arthroscopic debridement after intraarticular low-velocity gunshot wounds. arthroscopy. 1993;9(5):576-79. https://doi.org/10.1016/s0749-8063(05)80408-6. 76. janzen dl, tirman pf, rabassa ae, kumar s. lead ‘bursogram’ and focal synovitis secondary to a retained intraarticular bullet fragment. skeletal radiol. 1995;24(2):142-44. https://doi.org/10.1007/bf00198079. 77. peh wc, reinus wr. lead arthropathy: a cause of delayed onset lead poisoning. skeletal radiol. 1995;24(5):357-60. https://doi.org/10.1007/bf00197067. 78. latosiewicz r, murawski j, skowroński j. bilateral knee gunshot wounds successfully treated with arthroscopic bullet retrieval: a case report. arthroscopy. 1995;11(1):104-105. https://doi.org/10.1016/0749-8063(95)90096-9. 79. madureira pr de, de capitani em, vieira rj, et al. lead poisoning after gunshot wound. sao paulo med j. 2000;118(3):78-80. https://doi.org/10.1590/s1516-31802000000300006. 80. held m, engelmann e, dunn r, et al. gunshot induced injuries in orthopaedic trauma research. a bibliometric analysis of the most influential literature. orthop traumatol surg res. 2017;103(5):801-807. https://doi.org/10.1016/j.otsr.2017.05.002. 81. homicide 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https://doi.org/10.1302/2046-3758.812.bjr-2019-0340 https://doi.org/10.1007/s00167-021-06525-8 https://doi.org/10.26355/eurrev_201904_17502 ole_link1 ole_link2 sa orthopaedic journal autumn 2017 | vol 16 • no 1 page 49 early onset scoliosis: the use of growth rods rd govender mbbch(wits), fc orth(sa) aospine fellow at the spine surgery unit, groote schuur hospital rn dunn mbchb(uct), mmed(uct)orth, fcs(sa)orth pieter moll and nuffield chair of orthopaedic surgery and hod university of cape town corresponding author: prof rn dunn department of orthopaedic surgery h49 omb groote schuur hospital 7925 observatory cape town tel: 021 404 5387 fax: 021 447 2709 email: info@spinesurgery.co.za introduction the management of scoliosis in the growing child presents a unique challenge to the treating surgeon due to the patient’s small size, frequently associated comorbidities and pulmonary consequences with early fusion. early onset scoliosis (eos) is defined as scoliosis occurring before the age of 5 years. it affects not only the growing spine but also has a direct influence on the cardiopulmonary development and function of the child. cardiopulmonary function is compromised as a result of the decreased size of the thoracic cavity, which has a negative effect on lung alveolar development. the goal in the management of eos is to control the deformity and allow continued growth of the spine and thoracic cavity. non-fusion instrumentation facilitates this and allows ongoing respiratory development. abstract background: early onset scoliosis (eos) is defined as scoliosis occurring before the age of 5 years. the management presents a unique challenge where both natural history and fusion lead to impaired cardiopulmonary function of the child. aim: to assess the outcome of the use of non-fusion instrumentation and repetitive elongation (‘growth rods’) in eos. methods: a retrospective review of 14 consecutive patients who underwent growth rod implantation and lengthening procedure for eos was performed. growth rod constructs were constructed predominately from modular commercially available sets using laminar hooks, pedicle screws and connection blocks, with single or double rod constructs. vertical expanding prosthetic titanium ribs (veptr) were used in two patients. patients returned to theatre at six-monthly intervals for a lengthening procedure. patients were assessed with regard to type of scoliosis, age at surgery, number of lengthenings done, progression of cobb angle, amount of construct lengthening, amount of spine growth achieved and complications. results: the most common type of scoliosis seen was idiopathic (five), followed by neuromuscular (four), conjoined twins (two), syndromic (two), and congenital (one). five patients were followed until final fusion, one procedure was stopped due to wound complications and one patient was lost to follow-up. the 14 patients had a median of seven lengthenings each. the median pre-operative cobb angle was 56º (iqr 46.5º–59.5º) and median last followup cobb angle of 32.5º (iqr 27.0º–44.5º). the median spine growth achieved was 97 mm (iqr 69–122 mm). eight of the 14 patients (57%) experienced 14 complications during their lengthening procedures. conclusions: the growth rod instrumentation provides spinal deformity correction and control, while allowing ongoing growth of the spine. it is a labour-intensive process with significant incidence of complications. there is however very little other choice in these patients due to concerns of early fusion restricting pulmonary development. key words: spine, growth rods, scoliosis http://dx.doi.org/10.17159/2309-8309/2017/v16n1a7 saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/02/27 7:42 pm page 49 saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/02/27 7:42 pm page 50 saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/02/27 7:42 pm page 51 saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/02/27 7:42 pm page 52 sa orthopaedic journal autumn 2017 | vol 16 • no 1 page 53 vertical expandable prosthetic titanium rib (veptr): this technique was developed to treat thoracic insufficiency syndrome. the device is connected to the ribs to primarily expand the constricted thorax and secondarily allow spine growth and indirectly correct the scoliosis.7,14 the goal is to restore the growing thorax to maximise development of the lungs; thus it should be the treatment option when addressing a thoracic deformity.2 lengthening of the prosthesis is required every six months. complications are similar to growing rods, namely wound problems, rib fractures and creeping fusion.1 compression-based implants this technique uses the heuter volkman principle of compression forces inhibiting growth.9 vertebral staples are placed spanning the intervertebral disc spaces resulting in asymmetrical loading of the vertebral growth plates on the side that had the staple placement. limited correction is possible with stapling. the literature on stapling is limited and the clinical indications for stapling are not universally accepted.11 guided-growth implants: the luque trolley technique in which rods are attached to the spine using sublaminar wiring is largely of historical interest. due to the extensive subperiosteal dissection most patients had a spontaneous fusion of the instrumented region. the shilla technique allows spine growth to occur with screws that slide along the rods that are inserted proximally and distally.1 the management of early onset scoliosis is a prolonged and labour-intensive process. complications are frequent and should be expected. they are related to the number of surgical procedures performed and the length of treatment.15 wound breakdown, delayed healing and sepsis are frequent. due to the non-fusion technique, screw/hook dislodgement, rod or screw breakage are seen. junctional kyphosis and curve progression may also occur.13 these complications are the price to be paid for the non-fusion technique which allows ongoing thoracic growth and potential pulmonary development. this technique allows for early correction and control of the deformity which makes the definitive surgery at a later stage, less complex. conclusion early onset scoliosis remains a challenging condition to treat. the growth rod instrumentation provides an option to correct and control the spinal deformity, while gaining growth in torsal height. this allows thoracic wall growth and potentially allows for continued lung development. it is a labour-intensive process with significant incidence of complications. there is, however, very little other choice in these patients due to concerns of early fusion restricting pulmonary development and eventual function. acknowledgement dr peter hardcastle contributed to the initial data collection while a registrar in the department. compliance with ethics guidelines prof dunn and dr govender declare that this article is their original work. they have no conflict of interest and have received no commercial benefits of any kind for the writing of this article. ethics clearance was obtained for the use of the patient information. references 1. gomez ja, lee jk, kim pd, roye dp, vitale mg. ‘growth friendly’ spine surgery: management options for the young child with scoliosis. j am acad orthop surg 2011;19:722-27. 2. thompson gh, lenke lg, akbarnia ba, et al. early onset scoliosis: future directions. j bone joint surg am 2007;89-a:163-66. 3. karol l, johston c, mladenov k et al. pulmonary function following early thoracic fusion in non-neuromuscular scoliosis. j bone joint surg am 2008;90:1272-81. 4. goldberg cj, gillic i, connaughton o, et al. respiratory function and cosmesis at maturity in infantile-onset scoliosis. spine 2003;28:23972406. 5. dimeglio a, canavese f. the growing spine: how spinal deformities influence normal spine and thoracic cage growth. eur spine j 2012;21:64-70. 6. de groodt eg, van pelt w, borsboom gi. growth of the lung and thorax dimensions during the pubertal growth spurt. eur respir j 1988;1:102-108. 7. campbell rm, smith md, mayes tc et al. the characteristics of thoracic insufficiency associated with fused ribs and congenital scoliosis. j bone joint surg am 2003;85:399-408. 8. rowe de, bernstein sm, riddick mf, et al. a meta analysis of the efficacy of non-operative treatments for idiopathic scoliosis. j bone joint surg am 1997;79:664-74. 9. akbarnia ba, campbell rm, dimeglio a, et al. fusionless procedures for the management of early-onset spine deformities in 2011: what do we know? j child orthop 2011;5:159-72. 10. skaggs dl, akbarnia ba, flynn jm et al. a classification of growthfriendly spine implants. j pediatr orthop 2014;34(3):260-74. 11. cunningham me, frelinghuysen phb, roh js, et al. fusionless scoliosis surgery. curr opin pediatr 2005;17:48-53. 12. yazici m, emans j. fusionless instrumentation systems for congenital scoliosis. spine 2009;17:1800-1807. 13. akbarnia b, marks d. dual growing rod technique for the treatment of progressive early-onset scoliosis. spine 2005;30(17s), s46–s57. 14. campbell rm jr, hell-vocke ak. growth of the thoracic spine in congenital scoliosis after expansion thoracoplasty. j bone joint surg am 2003; 85:409-420. 15. bess s, akbarnia b. complications of growing-rod treatment for early-onset scoliosis. j bone joint surg am. 2010; 92:2533-43. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/03/03 9:57 am page 53 south african orthopaedic journal trauma and general orthopaedics doi 10.17159/2309-8309/2021/v20n2a1 gerafa m et al. sa orthop j 2021;20(2) citation: gerafa m, jakoet s, van heukelum m, le roux n, van der merwe s, makhubalo o, du preez g, burger m, ferreira n. treatment outcomes of civilian gunshot tibia fractures at a major trauma centre. sa orthop j 2021;20(2):71-75. http://dx.doi. org/10.17159/2309-8309/2021/ v20n2a1 editor: prof. leonard c marais, university of kwazulu-natal, durban, south africa received: july 2020 accepted: november 2020 published: may 2021 copyright: © 2021 gerafa m. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to this research. abstract background the aim of this retrospective longitudinal study was to describe the overall burden and outcomes of surgically managed gunshot tibia fractures at a major trauma centre. secondary objectives were to identify possible risk factors for complications including non-union and infection and to highlight any differences in outcomes between treatment modalities. methods all consecutive patients who sustained gunshot injuries to the tibia between january 2014 and december 2017 including children and multiple gunshots injuries were considered for inclusion. information related to patient demographics, injury characteristics, treatment information and treatment outcomes with respect to rate of fracture union and occurrence of infection were obtained from patient records. all patients with insufficient medical records were excluded. results the records of 197 patients who sustained gunshot tibia fractures were reviewed. the mean follow-up was 4.1 months (interquartile range [iqr] 2.5–6.8). the majority of cases were young males (89%) with a mean age of 29.2±10.2 years. extra-articular diaphyseal fractures were observed in the majority of cases (91%). definitive treatment included formal debridement in theatre and plaster cast immobilisation (44%), intramedullary nail fixation (27%), circular external fixation (22%) and plate fixation (7%). the study revealed an overall fracture-related infection (fri) rate of 11% and bone union rate of 91%. circular external fixation showed the lowest fracture union rate (86%) and highest fri rate (21%) of the modalities included in this study. no associations between independent risk factors and presence of complications were identified. conclusion the study reports encouraging outcomes for tibia fractures caused by civilian gunshot injuries. various definitive surgical stabilisation techniques showed high proportions of union and low burden of fri. level of evidence: level 4 keywords: tibia, gunshot, fracture, outcome treatment outcomes of civilian gunshot tibia fractures at a major trauma centre muaad gerafa, shafique jakoet, marcus van heukelum, nicholas le roux, simone van der merwe, obakeng makhubalo, gian du preez, marilize burger, nando ferreira* division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa *corresponding author: drferreiran@gmail.com introduction trauma accounted for 8.5% of global deaths as indicated in the 2015 global burden of disease study.1 trauma, specifically, can be classified into intentional injuries that occurred due to interpersonal or collective violence and self-inflicted injury, as well as unintentional injuries including motor vehicle collisions, falls and burns. the united nations office on drugs and crime (unodc) has ranked south africa (sa) 11th in terms of violence, with a homicide rate of 31.1 per 100 000 people.2 a 2019 study by zaidi et al. highlighted the high monthly load of trauma at a district hospital in the western cape province of south africa in which 44.4% of trauma cases were attributed to interpersonal violence, where 7.2% of these were firearm-related.3 insight into the south african burden of gunshot-related injuries on orthopaedic services was reported by engelmann et al. who reviewed 294 extremity gunshot injuries seen at a tertiary trauma centre in cape town over an 11-month period between june 2015 and april 2016, and reported that tibia fractures accounted for the majority (42.2%) of lower extremity injuries.4 a retrospective study by martin et al. reviewed 111 patients at a tertiary level hospital who had sustained 147 gunshot-induced fractures over a 12-month period. the authors reported that the majority of these injuries involved the lower extremity, and 95% of these patients inflicted with lower extremity gunshot-induced fractures required orthopaedic procedures at an average cost exceeding 13 times the annual average per patient afforded by the south african public health sector.5 in agreement with this, a recent study from a tertiary https://orcid.org/0000-0002-6028-0759 https://orcid.org/0000-0002-0567-3373 page 72 gerafa m et al. sa orthop j 2021;20(2) hospital in south africa reported a total of 1 449 gunshot-related orthopaedic fractures over a four-year period, resulting in a total cost of more than zar 50 million to the healthcare system.6 gunshot-induced tibia fractures are often associated with a myriad of complications presenting greater challenges to clinicians. gunshots involve the transfer of blast energy to the bone and soft tissue resulting in cavitary tissue damage and a large zone of injury.8 further, the risk of infection, compartment syndrome, nerve palsies, delayed union or non-union are increased due to the subcutaneous location of the tibia. moreover, poor correlation between external wound size and degree of underlying tissue damage may lead to an underestimation of the injury severity.8 several controversies regarding the management of gunshotinduced tibia fractures persist as a result of the heterogeneity of these injuries. management of these injuries can range from conservative management to formal debridement and skeletal stabilisation either in a single setting, or as a staged approach.9 advantages of temporary monolateral external fixation include bone stabilisation, and easy access for wound care.10 conversely, problems associated with monolateral external fixation include pin-site infection and loss of stability during long-term use.10 in comparison, studies have reported the efficacy of formal debridement and internal fixation in the same sitting, demonstrating the advantages such as access to soft tissue and low risk of deep infection.11 these reports add to the controversy regarding the management of gunshot-induced fractures and highlight the lack of evidence-based treatment guidelines. the present study aims to describe the treatment outcomes of civilian gunshot tibia fractures at a major trauma centre.12 secondary objectives were to identify possible risk factors for complications, including non-union and fracture-related infection (fri). methods a retrospective review of clinical records and serial radiographs of all patients who sustained gunshot tibia fractures between january 2014 and december 2017 was conducted. institutional ethics committee approval and hospital board approval was obtained prior to commencement of data collection. medical records of all adult and paediatric patients presenting with tibia fractures as a result of gunshot injuries in the study period were reviewed by the authors. demographic information of all included patients was recorded, and patient records were assessed to identify the extent of soft tissue injury and presence of associated injuries. patients that did not require surgical intervention, as well as all patients with incomplete medical records, were excluded. tibia fractures were classified according to the muller ao classification13 as intra-articular (ao 41b-c and 43b-c), metaphyseal (ao 41a and 43a) and diaphyseal (ao 42a-c) for analysis purposes. as per international protocol, intravenous antibiotics (cephazolin) were administered on presentation14 and the treatment modality used, as well as the timing thereof, was recorded. temporary external fixation was used for damage control and patients with vascular injuries. for definitive management, interlocked intramedullary nailing (imn) was used for diaphyseal tibia fractures where the soft tissue envelope was amenable to primary closure, while intra-articular and metaphyseal fractures were most often managed with plate fixation. fine wire circular external fixation was used for metaphyseal and intra-articular fractures with extensive soft tissue damage or where delays to surgery were encountered, due to the trauma burden at our institution. radiographs were reviewed to determine time to radiological union based on the radiographic union score for tibia fractures (rust score).15 the presence of an fri was deemed ‘suggestive’ or ‘confirmed’ using the guidelines outlined in the consensus document of metsemakers et al.16 minor complications, such as the presence of cast-associated pressure sores or pin-site infections, were not recorded. data was analysed using statistica version 13.5 (statsoft inc., tulsa, ok, usa) and data is presented as means ± standard deviations or median (interquartile range [iqr]), depending on the distribution, while categorical data is presented as frequencies and counts. associations between risk factors, including age, sex, hiv status, injury location and delay to surgical management, and known outcomes, specifically presence of i) non-union or ii) infection, were investigated using an independent t-test or mann–whitney u test for continuous data, while a pearson’s chisquare test or a fisher’s exact test was used for categorical data. table i: demographic information of included patients   n=197 age (years) (28.8±10.4) (197) sex male 89% (175) female 11% (22) hiv status positive 34% (67) negative 28% (56) unknown 38% (74) data is expressed as means ± standard deviations or as frequencies, with counts indicated in parentheses. table ii: injury characteristics of included patients   n=197 affected side left 50% (99) right 50% (98) anatomical site tibia 96% (189) tibia and fibula 4% (7) tibia and patella 0.5% (1) intra-articular no 95% (187) yes 5% (10) ao classification (tibia fracture) diaphysis 91% (179) 42b3 71% (140) 42a3 15% (30) 42b2 5% (9) proximal metaphysis 8% (16) 41c2 4% (8) 41a3 4% (8) distal metaphysis 1% (2) 43c2 0.5% (1) 43c3 0.5% (1) data is expressed as frequencies with counts in parentheses. page 73gerafa m et al. sa orthop j 2021;20(2) results a total of 213 patients who sustained gunshot tibia injuries were reviewed. sixteen patients who did not require surgery or had incomplete medical records were excluded. the final cohort therefore included 175 male patients (89%) and 22 female patients (11%) with a mean age of 28.8±10.4 years (table i). isolated tibial injures represented 96% of cases (n=189). the majority of injuries (91%, n=179) were diaphyseal fractures while 9% (n=18) were peri-articular injuries (table ii). patients underwent surgery at a median of 2.0 (iqr 2.0–5.0) days following admission. the majority of fractures were managed by fixation including imn fixation (27%, n=53), circulator external fixation (22%, n=44), and plate fixation (7%, n=14) while remaining fractures were managed through formal debridement and plaster cast immobilisation (44%, n=86). definitive soft tissue and fracture management was performed during a single theatre visit in all patients. median length of stay in hospital was 6.0 (iqr 4.0–9.0) days. patients were followed up for a median of 4.1 (iqr 2.5– 6.8) months. five (3%) patients were lost to follow-up prior to confirmation of union (table iii). bony union was achieved in 179 patients (91%) after the initial fixation. a total of 21 patients (11%) in the entire cohort developed fris (table iv). no associations between demographic or treatment-related risk factors and treatment outcomes were observed (table v). all definitive fixation procedures showed high proportions of union, with circular external fixators having the lowest union rate (86%). similarly, the presence of fri was highest in the circular fixation group (21%) (table vi). discussion the first finding of this study was the demographic sample and the predominant involvement of young males (89% male with a mean age of 29.2±10.2 years), which is similar to previous published reports on orthopaedic injuries following civilian gunshots.3,6,8 a recent study conducted in south africa reported a higher rate of intentional and gang-related violence together with the use of alcohol and illegal drugs among young, gunshot-injured males.5 while we did not test patients for alcohol or illegal drugs in the present study, our finding, together with the previous reports, again highlights this group of individuals to be a potential target for intervention in the future. the second important finding relates to our individualised approach to fracture management that produced an overall union table iii: treatment information of included patients n=197 time delay (admission to surgery) (days) 2 (2–5) (186) admitted to hospital 100% (197) admitted to icu 3% (6) temporary external fixator 8% (15) definitive procedure debridement and plaster cast 44% (86) intramedullary nail 27% (53) circular external fixator 22% (44) plate fixation 7% (14) hospital stay (days) 6 (4–9) (186) follow-up (months) 4.1 (2.5–6.8) (166) lost to follow-up before confirming union 3% (5) non-missing data is reported as medians (interquartile ranges) or as frequencies, with counts indicated in parentheses. icu: intensive care unit table iv: treatment outcomes of included patients   n=197 fracture healing union 91% (179) non-union 7% (13) unknown 3% (5) fracture-related infection no 87% (172) yes 11% (21) unknown 2% (4) non-missing data is reported as medians (interquartile ranges) or frequencies, with counts indicated in parentheses. outcomes of patients that were lost to follow-up are reported as ‘unknown’. table v: demographic-, clinicaland treatment-specific risk factors for non-union and infection risk factor union* (n=179) non-union* (n=13) p-value no infection** (n=172) infection** (n=21) p-value patient demographics age (years) 28.4±10.4 (179) 32.7±10.1 (13) 0.153 28.5±10.1 (172) 32.3±10.0 (21) 0.113 sex (% male) 88.3 (158) 100.0 (13) 0.367 87.2 (150) 100.0 (21) 0.139 hiv status % pos % neg % unknown 32.4 (58) 29.6 (53) 38.0 (68) 53.9 (7) 15.4 (2) 30.8 (4) 0.263 31.4 (54) 30.8 (53) 37.8 (65) 476 (10) 14.3 (3) 38.1 (8) 0.197 injury characteristics injury location % proximal % midshaft % distal 7.8 (14) 91.6 (164) 0.56 (1) 0.0 (0) 92.3 (12) 7.7 (1) >0.999# 7.6 (13) 91.9 (158) 0.6 (1) 9.5 (2) 85.7 (18) 4.8 (1) 0.406# intra-articular (% yes) 5.0 (9) 7.7 (1) 0.513 5.2 (9) 4.8 (1) >0.999 treatment characteristics time delay (days) 2.0 (2.0–5.0) (174) 3.0 (2.0–5.0) (13) 0.361 2.0 (2.0–4.0) (166) 3.0 (2.0–5.0) (21) 0. 457 non-missing data is reported as mean ± standard deviations, medians (interquartile ranges) or frequencies with counts in parentheses. *five patients had an unknown union outcome; **four patients had an unknown infection outcome – patients with unknown outcomes were excluded from the analysis. #fisher’s exact test for proximal and distal vs midshaft fractures page 74 gerafa m et al. sa orthop j 2021;20(2) rate of 91% and an fri rate of 11%. a recent retrospective study by metcalf et al. investigated the surgical outcome of tibia fractures managed with intramedullary nail fixation and observed a 30% nonunion rate and 9% infection rate for civilian gunshot tibia fractures which was comparable to our findings.17 in terms of length of stay, the current study results (median of 6.0 days) were slightly less than that reported by abghari et al. who investigated the outcome of civilian gunshot injuries and reported a median length of stay of 7.1 days for patients who sustained lower extremity fractures.18 there were no associations noted between the demographic or treatment-specific risk factors and the clinical outcomes. no associations between clinical outcome and hiv status were observed. very few studies have investigated the association between hiv and bone healing and this relationship remains poorly understood and unclear. an ongoing study investigating the association between union and hiv infection is nearing completion, and should provide important information on the effect of hiv on bone healing.19 patients in the present study waited a median of two days for surgery (iqr 2–5 days). this delay is attributed to the high burden of trauma cases at south african hospitals which hampers the ability of providing immediate surgery on admission.3 interestingly, the delay to surgery was not associated with an increased complication rate. kale et al. had previously reported an infection rate of 11.4% for patients with open fractures, most commonly arising from motor vehicle accidents, that received wound closure within a week of admission, compared to 77.8% for patients suffering infection when they had wound closure after two weeks, suggesting an association between delay in surgery and rate of infection.20 the lack of an association in the present study could potentially be as a result of the different injury mechanism, faster median time to surgery, or the fact that all surgeries were performed in a single setting, rather than in a staged process. ultimately, it is important to keep in mind that risk of infection is influenced by multiple factors. various definitive skeletal stabilisation procedures were included in this study. formal debridement followed by cast immobilisation, as well as plate fixation, showed the optimal union and lowest infection rates in the present study. there was no association of fri and union rates with length of stay. minor complications, such as the presence of pressure sores, were not recorded as part of this investigation. obvious selection bias for cast immobilisation of stable fracture patterns, isolated fractures, low energy transfer injuries and lower grade wounds should, however, be borne in mind when interpreting these results. for this reason, no statistical analysis was performed to investigate associations between treatment modality and outcome, because this relationship would be confounded by the differences in injury characteristics which guides clinical decision-making with regard to treatment modalities. imn fixation showed outcomes comparable to a previous publication by hilton et al. who reported a 76.9% initial union rate following intermedullary nailing for gunshot tibial shaft fractures, with three patients developing osteomyelitis.8 the union rate observed in the present study for imn was 91%. circular external fixation was generally reserved for patients who had complex fractures, significant soft tissue damage and delays to surgery, and showed lowest union rate when compared to other definitive fixation methods. a study conducted by van der walt and ferreira however reported higher union rates of 100% using circular external fixators in their gunshot-induced tibia fracture sample.21 the lower union rate with the use of circular external fixation observed in the present study may be attributed to the injury characteristics and delay in treatment for patients who were managed with this fixation modality. furthermore, circular external fixation showed the highest fri rates when compared to other definitive fixation methods, keeping in mind that circular fixation was reserved for patients with significant soft tissue injury or delay to surgery. fri rates were higher in the imn group (13%) compared to plate fixation (7%), but it is important to keep in mind that nail fixation was generally reserved for diaphyseal fractures compared to plate fixation, which was typically employed for metaphyseal injuries. unfortunately, there is very limited clinical data specifically investigating tibial plate fixation following lowenergy gunshot injuries. sitnik and beletsky reported an 8.75% infection rate in plate fixation in an investigation of 80 patients. this series, however, only included a single gunshot wound case and is therefore not directly comparable to the result of the present study, where a 7% infection rate was observed.22 it is again important to emphasise that risk of infection is influenced by multiple factors and as such, future experimental studies, where bias is largely removed, should investigate this finding further. the major study limitations include the retrospective design and single centre cohort which resulted in, albeit a large cohort compared to previous reports, too small a sample to detect large differences between sub-groups. the short follow-up period reported in this investigation is another limitation: we report a median follow-up time of 4.1 months, while these injuries should ideally be seen over a longer follow-up period. lost to follow-up is however a notorious problem in our setting that has previously been described by badenhorst et al.,23 and we believe that the results of the study are still meaningful, regardless of this limitation. finally, the observational nature of the study includes an inherent selection bias in the outcomes observed for the different treatment modalities used where some modalities were more likely to be used in more complex fractures than others. subsequently, we could not comment on the risk of specific outcomes following treatment with specific devices. conclusion tibial fractures caused by civilian gunshots remain challenging injuries to manage. this study found that an individualised approach to the treatment of these fractures can produce a satisfactory union rate with minimal complications if managed during a single stage by intramedullary nails, plate fixation or cast immobilisation. while the complications were higher in patients managed with circular table vi: outcomes related to union and infection of all patients per type of definitive treatment definitive procedure union % (n) infection % (n) debridement and pop (n=86) yes 93% (80) 5% (4) no 4% (3) 92% (79) unknown 4% (3) 4% (3) intramedullary nail (n=53) yes 91% (48) 13% (7) no 6% (3) 85% (45) unknown 4% (2) 2% (1) circular fixator (n=44) yes 86% (38) 21% (9) no 14% (6) 80% (35) plate fixation (n=14) yes 93% (13) 7% (1) no 7% (1) 93% (13) data is presented as frequencies with counts indicated in parentheses. pop: plaster of paris page 75gerafa m et al. sa orthop j 2021;20(2) external fixation, these devices were generally reserved for more severe injuries. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethical approval for this study was obtained from the stellenbosch university ethics committee, s18/07/139. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions mg: study conceptualisation, data capture, data analysis, first draft preparation, manuscript revision and approval of final manuscript sj: data capture and approval of final manuscript mvh: data capture and approval of final manuscript nlr: data capture and approval of final manuscript svdm: data capture and approval of final manuscript om: data capture and approval of final manuscript gdp: data capture and approval of final manuscript mb: data analysis, manuscript revision and approval of final manuscript nf: study conceptualisation, data analysis, first draft preparation, manuscript revision and approval of final manuscript orcid gerafa m https://orcid.org/0000-0002-6028-0759 jakoet s https://orcid.org/0000-0002-0009-2203 van heukelum m https://orcid.org/0000-0001-9160-7796 le roux n https://orcid.org/0000-0001-9115-7254 van der merwe s https://orcid.org/0000-0001-6892-4582 makhubalo o https://orcid.org/0000-0003-0085-0876 burger m https://orcid.org/0000-0003-2831-4960 ferreira n https://orcid.org/0000-0002-0567-3373 references 1. nunes ed. united nations office on drugs and crime (unodc). global study on homicide: trends, context, data. vienna: unodc; 2011. ciência & saúde coletiva. 2012;17:3447-9. 2. haagsma ja, graetz n, bolliger i, et al. the global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the global burden of disease study 2013. inj prev. 2016;122:3-18. https://doi.org/10.1136/ injuryprev-2015-041616. 3. zaidi aa, dixon j, lupez k, et al. the burden of trauma at a district hospital in the western cape province of south africa: prospective observational study. afr j emerg med. 2019:191:4-20. https://doi.org/10.1016/j.afjem.2019.01.007. 4. engelmann ew, maqungo s, laubscher μ, et al. epidemiology and injury severity of 294 extremity gunshot wounds in ten months: a report from the cape town trauma registry. sa orthop j. 2019;182:31-6. https://doi. org/10.17159/2309-8309/2019/v18n2a3. 5. martin c, thiart g, mccollum g, roche s, maqungo s. the burden of gunshot injuries on orthopaedic healthcare resources in south africa: retrospective review. s afr med j. 2017;107:626-30. https://doi.org/10.7196/samj.2017. v107i7.12257. 6. jakoet ms, burger m, van heukelum m, et al. the epidemiology and orthopaedic burden of civilian gunshot injuries over a four-year period at a level one trauma unit in cape town, south africa: a retrospective review. int orthop. 2020;121:8. https://doi.org/10.1007/s00264-020-04723-6. 7. sathiyakumar v, thakore rv, stinner dj, et al. gunshot-induced fractures of the extremities: a review of antibiotic and debridement practices. curr rev musculoskelet med. 2015;182:76-89. https://doi.org/10.1007/ s12178-015-9284-9. 8. hilton tl, kruger n, wiese kr, martin cw, maqungo s. gunshot tibia fractures treated with intramedullary nailing: a single centre retrospective review. sa orthop j. 2017;163:2-8. https://doi.org/10.17159/2309-8309/2017/v16n1a4. 9. cross iii ww, swiontkowski mf. treatment principles in the management of open fractures. indian j orthop. 2008;37-7. https://doi. org/10.4103/0019-5413.43373. 10. fang x, jiang l, wang y, zhao l. treatment of gustilo grade iii tibial fractures with unreamed intramedullary nailing versus external fixator: a meta-analysis. med sci monit. 2012;18(4):49-56. https://doi.org/10.12659/msm.882610. 11. su ca, nguyen mp, o’donnell ja, vallier ha. outcomes of tibia shaft fractures caused by low energy gunshot wounds. injury. 2018;49(7):1348-52. https://doi. org/10.1016/j.injury.2018.05.006. 12. hardcastle t. the 11 p’s of an afrocentric trauma system for south africa: time for action. s afr med j. 2011;101(3):160-2. https://doi.org/10.7196/samj.4578. 13. müller me, nazarian s, koch p. the comprehensive classification of fractures of long bones. springer-verlag: berlin; 1990. 14. papasoulis e, patzakis mj, zalavras cg. antibiotics in the treatment of low-velocity gunshot-induced fractures: a systematic literature review. clin orthop relat res. 2013;471-12:3937-44. https://doi.org/10.1007/ s11999-013-2884-z. 15. whelan db, bhandari m, stephen d, et al. development of the radiographic union score for tibial fractures for the assessment of tibial fracture healing after intramedullary fixation: retrospective review. j trauma acute care surg. 2010;168:629-32. https://doi.org/10.1097/ta.0b013e3181a7c16d. 16. metsemakers wj, morgenstern m, mcnally ma, et al. fracture related infection: a consensus on definition from an international expert group. injury. 2018;149:505-10. https://doi.org/10.1016/j.injury.2017.08.040. 17. metcalf kb, smith ej, wetzel rj, sontich jk, ochenjele g. comparison of clinical outcomes after intramedullary fixation of tibia fractures caused by blunt trauma and civilian gunshot wounds: a retrospective review. j orthop trauma. 2020;134:208-13. https://doi.org/10.1097/bot.000000000000170. 18. abghari m, monroy a, schubl s, davidovitch r, egol k. outcomes following low-energy civilian gunshot wound trauma to the lower extremities: results of a standard protocol at an urban trauma center. iowa orthop j. 2015;35:65-9. 19. graham sm, harrison wj, lalloo dg, et al. host study—hiv in orthopaedic skeletal trauma study: protocol for a multicentre case-cohort study. sa orthop j. 2018;17:53-8. https://doi.org/10.17159/2309-8309/2018/v17n3a7. 20. kale ar, sonawane cs, waghmare vu, kalambe h. open fractures and incidence of infection in tertiary care government hospital. int j sci stud. 2017;5(5):24-8. https://doi.org/10.17354/ijss/2017/386. 21. van der walt n, ferreira n. an audit of circular external fixation usage in a tertiary hospital in south africa: retrospective review. sa orthop j. 2018;17:1421. https://doi.org/10.17159/2309-8309/2018/v17n4a1. 22. sitnik aa, beletsky av. minimally invasive percutaneous plate fixation of tibia fractures results in 80 patients: retrospective review. clin orthop relat res. 2013;1471:2783-9. https://doi.org/10.1007/s11999-013-2841. 23. badenhorst dh, van der westhuizen ca, britz e, burger mc, ferreira n. lost to follow-up. challenges to conducting orthopaedic research in south africa: retrospective review. s afr med j. 2018;108:917-21 https://doi.org/10.7196/ samj.2018.v108i11.13252. https://orcid.org/0000-0002-6028-0759 https://orcid.org/0000-0002-0009-2203 https://orcid.org/0000-0001-9160-7796 https://orcid.org/000-0001-9115-7254 https://orcid.org/0000-0001-6892-4582 https://orcid.org/0000-0003-0085-0876 https://orcid.org/0000-0003-2831-4960 https://orcid.org/0000-0002-0567-3373 _hlk45350350 _hlk45315686 _hlk66964622 _hlk52099179 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 29 chronic kidney disease and the skeleton: pathogenesis, complications and principles of management b thibedi* bcur, mbchb ej raubenheimer** mchd, phd, dsc cee noffke** msc * nephrology unit, department of internal medicine, faculty of health sciences, medunsa campus, university of limpopo ** metabolic bone disease laboratory, faculty of health sciences, medunsa campus, university of limpopo correspondence: prof ej raubenheimer room fnd 110 medunsa campus university of limpopo 0204 south africa tel: +27 12 5214839 email: erich.raubenheimer@ul.ac.za introduction chronic kidney disease (ckd) has become a major health problem with about one in ten adults affected worldwide.1 as the kidney functions in ckd deteriorate, a progressive disruption of mineral homeostasis leads to skeletal and extraskeletal complications which impact on the quality of life and survival of patients. the skeletal changes, collectively referred to as renal osteodystrophy, received the focus of attention in the past. with the increased life expectancy resulting from improved management strategies, long-term extra-skeletal complications have become important prognostic determinants in the ckd patient. the designation ‘ckd-mineral bone disorder’ (ckd-mbd) has been introduced to encompass the skeletal and extra-skeletal morbidities in ckd patients.2 the aim of this manuscript is to present orthopaedic surgeons with an overview of ckdmbd with particular reference to skeletal involvement in the ckd patient. mineral homeostasis and bone maintenance of serum calcium and phosphate concentrations is dependent on the interaction between vitamin d, fibroblast growth factor 23 (fgf23) and parathyroid hormone (pth). activation of vitamin d is a multi-step process beginning with uv irradiation of the skin followed by hydroxylation in the liver, yielding 25-hydroxyvitamin d (25ohd), which is the main form in which vitamin d is stored.3 25ohd is further hydroxylated by the enzyme 1-α-hydroxylase in the kidney as well as in other tissue sites to produce 1,25 dihydroxyvitamin d (1,25(oh)2d), which represents the active metabolite.4 1,25(oh)2d, among its multiple effects on other metabolic activities, facilitates calcium, phosphorous and magnesium uptake in the gastrointestinal tract and retention of calcium in the kidneys.3 through its involvement in calcium homeostasis, 1,25(oh)2d has a regulatory influence on parathyroid gland function and the release of pth. if serum calcium concentrations fall, secondary hyperparathyroidism results in the release of pth which up-regulates osteoclastic activity, thereby elaborating calcium from the skeleton. fgf23 is a bone-derived hormone that influences phosphate concentrations by inhibiting its reabsorption in the proximal tubules of the kidney through a mechanism independent of pth. in addition, fgf23 has a negative influence on 1,25(oh)2d concentrations by facilitating its catabolism and suppressing the activity of 1-α-hydroxylase.4,5 abstract skeletal and extra-skeletal changes in chronic kidney disease are the result of deteriorating mineral homeostasis with disruption of the concentrations of phosphorous, calcium and circulating hormones. with the improved survival brought about by modern management strategies, early recognition of the prognostic determinants is of paramount importance in improving the morbidity and quality of life of renal patients. the aim of this review is to provide a skeletal perspective on the pathogenesis, radiological appearances, complications and principles of management of patients with chronic kidney disease. key words: uraemic osteodystrophy, osteitis fibrosa, hyperparathyroidism, renal failure, osteomalacia saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 29 page 30 sa orthopaedic journal autumn 2014 | vol 13 • no 1 pathogenesis of ckd-mbd a progressive retention of fgf23 in ckd, resulting from a drop in the glomerular filtration rate, has been reported to counteract hyperphosphataemia. the increase in the concentration of fgf23 also contributes to a reduction of the concentration of 1,25(oh)2d, with hypocalcaemia and induction of secondary hyperparathyroidism.5 pth induces increased bone remodelling which further stimulates the elaboration of fgf23 by bone cells. in the more advanced stages of ckd hydroxylation of 25ohd is progressively impaired due to the loss of functioning renal tissue. the lack of 1,25(oh)2d results in decreased absorption of calcium in the gastrointestinal tract and reduced retention of calcium by the diseased kidneys. the consequence is a further decrease in the serum calcium concentration. hyperphosphataemia stimulates pth secretion and elaboration of fgf23.5 the latter initially inhibits pth secretion but this inhibitory effect is lost with the development of parathyroid hyperplasia in advancing ckd. the impact on bone is defective mineralisation of osteoid (due to low serum calcium concentrations), up-regulation of bone metabolism with activation of osteoclasts (due to pth overproduction) resulting in loss of mineralised bone and enhanced release of fgf23. in uraemia the parathyroid glands becomes relatively resistant as evidenced by the high pth concentrations despite high fgf23 concentrations. although this mechanism serves as a feasible explanation for depletion of mineralised bone in patients with ckd, care should be taken not to oversimplify the disease process. the metabolic effects of ckd on the skeleton are compounded by several factors. in patients with prolonged secondary hyperparathyroidism, the parathyroid glands may fail to respond to serum calcium concentrations, and an irreversible phase of pth overproduction, designated as tertiary hyperparathyroidism, could develop.6 the mechanism involved in the transformation of parathyroid function towards autonomous pth release is unclear. with tertiary hyperparathyroidism the parathyroid response to conventional management becomes ineffective and may require parathyroidectomy to correct. if the release of calcium through bone catabolism results in prolonged hypercalcaemia, progressive soft tissue calcification, also referred to as ‘metastatic calcification’ occurs (figure 1). there is a significant correlation between hypercalcaemia and the higher risk of vascular and valvular calcifications in patients on long-term haemodialysis.7 more than half the deaths of patients with end-stage ckd are due to cardiovascular complications and the annual cardiovascular mortality rate is more than ten times that of age-matched non-renal disease patients.8 calciphylaxis, a rare and lifethreatening condition where progressive cutaneous necrosis secondary to cutaneous blood vessel calcification occur, may complicate ckd.9 long-term administration of corticosteroids, as part of the management regimen of certain chronic kidney diseases as well as in recipients of transplanted kidneys, contributes not only to a reduction of the activities of all cells involved in bone metabolism, but also suppresses intestinal calcium uptake.10 recent advances in the management of ckd impact positively on the survival of patients. for this reason other chronic complications like β2 microglobulin amyloidosis11 are becoming more pertinent in the literature. the latter results from a reduction of β2 microglobulin excretion, and although modern dialysis modalities allow improved removal of β2 microglobulin, long-term dialysis may contribute to deposits in joints, bone and the surrounding soft tissues12 (figure 2). the destructive arthropathy and development of subchondral radiolucencies due to the β2 microglobulin amyloid deposits are difficult to distinguish radiologically from brown tumours and it is not surprising that the presence of these deposits has been associated with an increased femoral fracture risk.13,14 β2 microglobulin has recently been reported to stimulate osteoclastogenesis,15 supporting its direct role in bone catabolism in patients with ckd. figure 2. β2 microglobulin amyloid deposits (arrows) in periarticular muscle of a patient with advanced ckd (h&e stain ×100) figure 1. metastatic calcifications in the soft tissue over the femoral neck (arrow) in a patient with tertiary hyperparathyroidism and hypercalcaemia. note the severe osteopaenia. there is a significant correlation between hypercalcaemia and the higher risk of vascular and valvular calcifications in patients on long-term haemodialysis saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 30 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 31 changes in the composition of tissue fluid, resulting from the accumulation of the catabolytes of metabolism due to the reduced glomerular filtration rate of advanced ckd, has a negative impact on metabolic activities of most cells, including those involved in bone metabolism. this together with the changes in volume distribution makes the interpretation of some of the biochemical parameters used to monitor bone metabolism in patients with advanced ckd debatable. for these reasons bone biopsy submitted to a laboratory acquainted with histomorphometric techniques provides superior information on the volumes of mineralised bone, osteoid and bone cell activities in the advanced stages of ckd.16 microscopic and radiological appearances of renal osteodystrophy the initial microscopic features of renal osteodystrophy are wide osteoid seams due to a reduced mineralisation rate and increased osteoclastic bone resorption due to elevated pth. these features are the hallmarks of osteomalacia (or rickets in the growing skeleton).14 with the aid of static and dynamic histomorphometry, which requires tetracycline labelling and special fixation techniques, these changes can be measured and compared to age-matched norms,14-17 providing valuable information on the stage of skeletal catabolism as well the monitoring of the efficiency of a management strategy employed. the earliest radiological signs of skeletal involvement are reported to be resorption of the phalanges (figure 3a and 3b) which starts as sub-periosteal resorption of the radial aspects of the middle phalanges of the hands and sub-endosteal and intra-cortical resorption of long bones. in a more advanced stage, a reduction of the cortical width of long bones and bowing or even fracture of weight-bearing bones occur, and a generalised lack of mineralised bone, with radiological features similar to osteoporosis may develop.16 vertebral fractures may change the shape of the thoracic cage and sacro-iliac deformities may impair the ability to walk. foci showing fulminant bone resorption with fibrous replacement (figure 4), referred to as osteitis fibrosa, is the result of surplus pth due to over-active parathyroid glands. this metabolic state is designated as ‘high turnover osteodystrophy’4 and manifests radiologically as well-defined areas of radiolucency often erroneously described as ‘osteitis fibrosa cystica’ or ‘brown tumours of hyperparathyroidism’18 (figure 5). ‘osteitis fibrosa cystica’, a term created by von recklinghausen in the nineteenth century19 is neither an ‘osteitis’ nor ‘cystic’, but merely the end stage manifestation of pth-induced fulminant bone resorption. the ‘brown tumour of hyperparathyroidism’ first described in 195320 is not a ‘tumour’ in a pathological sense but rather a reparative process. other sites in the skeleton may show a more diffuse granular appearance also described as a ‘salt and pepper’ appearance due to trabecular coarsening.18 bone replacement by fibrous tissue is particularly incapacitating in the growing skeleton. the radiological differential diagnosis of high turnover osteodystrophy in children includes fibrous dysplasia. the former is characterised by its poor corticomedullary definition, a feature not found in fibrous dysplasia.21 the term ‘uraemic leontiasis ossea’ was applied in the past to rare cases in which enlargement of the facial bones, due to the high turnover osteodystrophy, was a prominent clinical feature. in practice the distinction between the different skeletal changes may be difficult as osteomalacia, osteoporosis and high turnover osteodystrophy may occur together in the same patient. radiological demonstration of pseudofractures (or looser’s zones) affecting the scapula, pubic rami and proximal femurs may aid in diagnosing osteomalacia. in a significant number of patients a clear distinction between the skeletal changes is not possible and the term ‘mixed bone disease’ is used to describe this hybrid manifestation of renal osteodystrophy.6 adynamic bone disease is a variety of renal osteodystrophy characterised by a complete absence of metabolic activity on bone surfaces, no accumulation of osteoid and low-to-normal serum pth concentrations.6 figure 3a. radiograph of the right hand showing resorption of the terminal phalanges in a patient with ckd and hyperparathyroidism figure 3b. clubbing of the fingers of the patient depicted in figure 3a figure 4. multiple welldefined radiolucent lesions (‘osteitis fibrosa cystica’) in the diaphysis of the tibia of the left leg. the arrows indicate vascular calcifications. saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 31 page 32 sa orthopaedic journal autumn 2014 | vol 13 • no 1 this pattern is best diagnosed with a bone biopsy. it is found in a high percentage of patients on dialysis but also in ckd patients treated rigorously with calcium or vitamin d derivatives, diabetics or those who received unnecessary parathyroid surgery. although the pathogenesis is not clear and many factors may be implicated, it appears as if uraemia contributes to the down-regulation of pth receptors on bone cells.22 management of renal osteodystrophy addressing the bone changes associated with ckd is complex and it is not within the scope of this paper to provide a detailed account thereof. more information can be obtained from a recently published, evidence-based systematic review published under the auspices of kidney disease international global outcomes (kdigo).2 in summary the primary approach in the management should be focused on the restoration of renal function through dialysis or renal transplantation thereby preventing the adverse cardiovascular and skeletal complications of ckdmbd. from a skeletal perspective, the mainstay of the management includes normalisation of serum calcium, serum phosphate and pth concentrations. the use of calcimimetic drugs in end-stage renal disease have been shown to reduce the levels of pth, calcium and phosphate as they mimic the action of calcium.23,24 the manipulation of serum calcium can be supplemented by controlling dietary calcium intake and/or diasylate calcium content. a reduction of dietary phosphate intake contributes towards achieving phosphate homeostasis.6 administration of vitamin d metabolites (or calcitriol, a 1,25(oh)2d analogue25) corrects the deficiency of 1,25(oh)2d and suppresses secondary hyperparathyroidism, thereby addressing the skeletal morbidity of high turnover osteodystrophy. novel vitamin d analogues have been developed which may in future have advantages in preventing vascular calcifications resulting from the manipulation of the calcium–phosphate product in the extracellular fluid.26,27 a bone biopsy may provide decisive information as vitamin d metabolites do not improve adynamic renal osteodystrophy.28 indications for a parathyroidectomy are persistent and non-responsive hypercalcaemia due to tertiary hyperparathyroidism, progressive soft tissue calcification and persistent high turnover osteodystrophy after all strategies of reducing serum calcium concentrations have been exploited.26 conclusion an understanding of the pathogenesis of ckd-mbd is essential for preventing the slumbering skeletal and extraskeletal complications in the renal patient. restoration of serum calcium, phosphate and pth concentrations not only addresses the catabolism of bone but also plays an important role in improving the mortality rate and quality of life of patients suffering from renal disease. references 1. schiepatti a, remuzzi g. chronic renal disease as a health problem: epidemiology, social and economic implications. kidney int suppl 2005;68:7–10. 2. willis k, cheung m, slifer s. kdigo 2012 clinical practice guidelines for the evaluation and management of chronic kidney disease. kidney internat suppl 2013;1:1–150. 3. raubenheimer ej, noffke cee. vitamin d and health – a historical overview. s a orthopaedic j 2011;10(2):39-43. 4. al-badr w, martin kj. vitamin d and kidney disease. clin j am soc nephrol 2008;3:1555–60. 5. quarles ld. the role of fgf23 in vitamin d and phosphate metabolism: implications in chronic kidney disease. exp cell res 2012;318:1040–48. 6. smith r, wordsworth p, editors. clinical and biochemical disorders of the skeleton. oxford: university press. 2008;191–94. 7. raggi p, boulay a, chasen-taber s, et al. cardiac calcification in adult hemodialysis patients. a link between end-stage renal disease and cardiovascular disease. j am coll cardiol 2002;39(4):695–701. 8. foley rn, parfrey ps, samak mj. clinical epidemiology of cardiovascular disease. am j kidney dis 1998;32(suppl):s112–s119. 9. ivker ra, woosley j, briggaman ra. calciphylaxis in three patients with end-stage renal disease. arch dermatol 1995;131(1):63–68. 10. dovio a, perazzolo l, osella g, ventura m, termine a, milano e, bertolotto a. immediate fall of bone formation and transient increase of bone resorption in the course of highdose, short term glucocorticoid therapy in young patients with multiple sclerosis. j clin endocrinol metab 2004;89:4923–28. 11. mount sl, eliabbakh gh, hardin nj, et al. β-2 microglobulin amyloidosis presenting as bilateral ovarian masses. a case report and review of the literature. am j surg pathol 2002;26:130–33. 12. kay j, bardin t. osteoarticular disorders of renal origin; disease related and iatrogenic. baillis clin rheumatol 2001;14:285–305. 13. onishi s, andress dl, malone na, et al. beta-2 microglobulin deposition in bone in chronic renal failure. kidney int 1991;39:99–105. 14. fok wmm, leung hb. unresolved lytic lesions following parathyroidectomy in patients with chronic renal failure. j bone joint surg br 2008;90(4) 506–509. figure 5. the arrows indicate osteoclasts involved in active bone resorption in a biopsy of a patient with hyperparathyroidism. fibrous replacement is present in the area cleared of bone (indicated by the star) (h&e stain, magnification ×200). the primary approach in the management of renal osteodystrophy should be focused on the restoration of renal function through dialysis or renal transplantation saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 32 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 33 15. menaa c, esser e, sprague sm. β-2 microglobulin stimulates osteoclast formation. internat soc nephrol 2008; http://www. kidney-international.org 16. raubenheimer ej. part i: metabolic bone disease: histomorphometry as a diagnostic tool. s a orthopaedic j 2008;spring:19–23. 17. vigorita vj. the tissue pathological features of metabolic bone disease. orthop clin north am 1984;15:613–19. 18. wagener gww, sander m, hough fs. advanced osteitis fibrosa cystica in the absence of phalangeal sub periosteal resorption. a case report and review of the literature. samj 1985;67:31–32. 19. buchanan ww, kraag gr, palmer dg, cockshott wp. the first recorded case of osteitis fibrosa cystica. can med assoc j 1981;124:812–15. 20. campuzano-zuluaga g, velasco-perez w, martin-zuluaga ji. a 60-year old man with chronic renal failure and a costal mass: a case report and preview of the literature. j med case reports 2009;3:7258. 21. chang ji, som pm, lawson w. unique imageing findings in the facial bones of renal osteodystrophy. am j neuroradiol 2007;28:608–609. 22. coen g. adynamic bone disease: an update and an overview. j nephrol 2005;18:117-22. 23. zhang q, li m, you l, li h, ni l, gu y, hao c, chen j. effects and safety of calcimimetics in end stage renal disease patients with secondary hyperparathyroidism: a meta-analysis. plos one 2012;7:e48070. 24. elder g. use of calcimimetic drugs. www.medscape.com/ viewarticle/542490. 25. zhou h, xu c. comparison of intermittent intravenous and oral calcitrol in the treatment of secondary hyperparathyroidism in chronic hemodialysis patients: a meta-analysis of randomized control trials. clin nephrol 2009;71:276–85. 26. cozzolino m, galassi a, gallieni m, et al. pathogeneisis and treatment of secondary hyperparathyroidism in dialysis patients: the role of paricalcitrol. curr vasc pharmacol 2008;6(2):148–53. 27. teng m, wolf m, lowrie f, et al. survival of patients undergoing hemodialysis with paricalcitrol or calcitriol therapy. new engl j med 2003;349:446–56. 28. brandi l, dougaard h, nielsen pk, et al. long term effects of intravenous 1α(oh)d3 combined with caco3 and low calcium dialysis on secondary hyperparathyroidism and biochemical bane markers in patients on chronic hemodialysis. nephron 1996;74:89–103. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 33 south african orthopaedic journal editorial doi 10.17159/2309-8309/2023/v22n1a0bosch h sa orthop j 2023;22(1) is the same calendar day hip arthroplasty for everyone or a select few? hennie bosch* orthopaedic hip and knee surgeon, durbanville mediclinic, south africa *corresponding author: hb@hipdoc.co.za same-day hip surgery needs to be clearly defined and clarified. there are two different segments defined as same-day surgery. the one is the same calendar day or 6 to 8 hours post-surgery discharge to home, and the second segment is where people leave the hospital within 24 hours post-surgery. the introduction of global arthroplasty fees in july 2018 to the south african market has caused a decrease in the average length of hospital stay because of pressure on the surgeon to perform according to a tier grading. there is a worldwide trend to push for same-day surgery, and this is the same in south africa. during the 2022 arthroplasty meeting, surge (orthopaedic group) presented the results of the first same-calendar-day discharge arthroplasty cases. it caused a stir among fellow arthroplasty colleagues. the question: should you do it, or is it too risky? i have been an early adopter of new techniques and innovations since i returned from an arthroplasty fellowship in wales, uk. in 2006, i started with hip arthroscopy, which was very controversial at that stage, and anterior hip arthroplasty in 2010 and fully incorporated it into my practice in 2013. in 2018, i started investigating same-day hip surgery. during the covid-19 pandemic, i noticed the opportunity to implement elements of this in my practice. during a visit to an orthopaedic meeting in new york, it was evident that same-day surgery is implemented differently under the same name. for instance, you can operate on the patient in the day hospital, then discharge them to a subacute clinic or retreat, with the surgeon having financial connections to both. these pre-arranged agreements with a funder result in the surgeon and funder benefitting financially. same-day surgery, in this case, is a marketing tool with no clear differentiation between the same calendar day (6–8 hour hospital stay) or 24-hour hospital stay and discharge to a home or retreat. the problem with this model was that it is and is not same-day surgery. same-calendarday hip arthroplasty (6–8 hours) and discharge to the patient’s home is difficult to implement and needs a different care model to ensure that it is also beneficial to the patient, not only the surgeon and funder. the selection criteria and risk stratification tools that consider physical and social factors and clinical comorbidities are available. advances like minimally invasive surgical techniques, antifibrinolytic agents (tranexamic acid) to control blood loss, and multimodal anaesthesia made same-day hip and knee arthroplasty possible. adopting same-day hip arthroplasty (23 hours) into practice is feasible with more efficient standard care. surgeons who plan to adopt the same calendar day (6–8 hours) must realise that this model will need extra care and significant changes in their care model to do this safely. looking through the lenses of capability, comfort and calm for the surgeon and patient is of extreme importance for the success of this model. as surgeons, our primary responsibility lies with the patient, and any major complication could have a detrimental effect on the patient, the surgeon and the hospital, as well as medicolegal implications. pushing the barrier can thus be counterproductive. adopting a care team is pivotal in successfully introducing such a programme. a nurse navigator, social worker and anaesthetic team involved perioperatively and post-discharge is needed. where most papers quote failure of same-day surgery as readmission within 30 days and major and minor complications, this is seen from the surgeon and hospital’s viewpoint and not value-based patient-centred care. before discharge, patients should be capable of mobilising well, climbing stairs, and independently doing personal care. patients should be pain-free without any nausea and experience calm that they have access to the team during the first night post-surgery. outcomes that matter to our patients must be the aim. in south africa, hospital beds are scarce in private and public hospitals. same-day calendar day arthroplasty frees up more capacity and makes hip arthroplasty more economically viable for the wider population. creating a team who can provide same-day discharge hip arthroplasty will take a lot of planning and effort. the care model is then scalable to all arthroplasty patients and improves the outcomes accordingly. i want to motivate all hip arthroplasty surgeons who plan or aspire to do same-day discharge arthroplasty to introduce such a care team. it can lead to value-based patient care for all, not just same-day discharge patients. value-based care should be our primary aim as surgeons. 404 not found 404 not found south african orthopaedic journal orthopaedic oncology and infections doi 10.17159/2309-8309/2021/v20n1a6 shah mr et al. sa orthop j 2021;20(1) citation: shah mr, shah mm, agrawal ak, shah md, desai sm. intra-operative extracorporeal radiation therapy for skeletally immature patients with malignant bone tumours. sa orthop j 2021;20(1):43-48. http://dx.doi. org/10.17159/2309-8309/2021/ v20n1a6 editor: prof. theo le roux, university of pretoria, pretoria, south africa received: june 2020 accepted: october 2020 published: march 2021 copyright: © 2021 shah mr. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background management of malignant bone tumours has changed dramatically in recent years. neoadjuvant chemotherapy, irradiation and conservative surgery have improved local control as well as functional outcome. depending on the histology of the lesion, other modalities like chemotherapeutic agents or radiation can be selected in place of surgical intervention. operative intervention is the main modality with wide marginal excision and fixation of bone graft from different sources or mega prosthesis to maintain congruity of the bone anatomy. reconstruction, optimum fit and stability at the affected site are the major areas of concern with this modality. radiation given outside the body to kill the tumour cells in the bone is called extracorporeal radiotherapy (ecrt). after resection of the bone, it is cleaned of all the surrounding soft tissue and marrow contents and placed in a container. it is then subjected to 50 gy of radiation which kills all the tumour cells. methods the study was conducted from june 2014 to may 2020, and included 15 patients (out of 18) diagnosed with either ewing’s sarcoma or osteosarcoma. they were followed up for an average of 4.44 years, up to may 2020. all 15 cases were analysed for bony union at the osteotomy sites. cases reported with poorly differentiated sarcomas (total three) were subjected to immunohistochemistry and managed with other modalities of treatment. results the average time for union of irradiated bone was 8.1 months (range 5–10; the metaphyseal end united faster than the diaphyseal end). at the final follow-up, the functional status was determined using the musculoskeletal tumour society (msts) scoring system. ninety-three per cent of patients had involvement of the lower limb (14 out of 15). all patients (except one who developed recurrence) did not have symptoms of the disease and no one had died at last follow-up. conclusion biological limb salvage procedures are considered a successful treatment and a welcome alternative for patients who either cannot afford or be treated with an endoprosthesis. early diagnosis and referral to specialised unit is of vital importance. this procedure can be used for selected patients with malignant bone tumours. cost factors, and social and cultural considerations also play a role. level of evidence: level 4 keywords: ecrt, extracorporeal radiation therapy, malignant bone tumours, bone sarcoma, osteosarcoma, ewing’s sarcoma intra-operative extracorporeal radiation therapy for skeletally immature patients with malignant bone tumours manish r shah1* , manisha m shah2 , aditya k agrawal1 , malkesh d shah1 , sarvang m desai1 ¹ department of orthopaedics, dhiraj hospital, smt bk shah medical institute and research centre, sumandeep vidyapeeth deemed to be university, waghodia, vadodara, gujarat, india ² department of pathology, medical college and ssg hospital, vadodara, gujarat, india *corresponding author: manishshah2001in@yahoo.co.in http://dx.doi.org/10.17159/2309-8309/2021/v20n1a6 http://dx.doi.org/10.17159/2309-8309/2021/v20n1a6 http://dx.doi.org/10.17159/2309-8309/2021/v20n1a6 https://orcid.org/0000-0002-9381-9095 https://orcid.org/0000-0002-2252-9752 https://orcid.org/0000-0002-5143-1922 https://orcid.org/0000-0003-0512-6465 https://orcid.org/0000-0001-5147-1695 page 44 shah mr et al. sa orthop j 2021;20(1) introduction management of malignant bone tumours has changed dramatically in recent years. neoadjuvant chemotherapy, irradiation and conservative surgery have improved local control as well as functional outcome. depending on the histology of the lesion, other modalities like chemotherapeutic agents or radiation can be selected instead of surgical intervention. operative intervention is the main modality, with wide marginal excision and fixation of bone graft from different sources or metallic modular implant for maintaining congruity of the bone anatomy. reconstruction, optimum fit and stability at the affected site are the major areas of concern with this modality. this procedure is for a selected few cases done in a specialty unit after multidisciplinary discussion. some units have found it necessary to augment this segment with a vascularised fibular graft as an inlay technique. irrespective of method, fixation must be very stable. in 1968, spira and lubin used extracorporeal irradiation therapy (ecrt) of the resected bone intra-operatively for the first time in treating malignant bone tumours.1 irradiation provides the same individual’s strut graft for fixation in the intercalary gap and reconstruction with correct dimensions. such grafts are used in some cases of malignant bone tumours having less destructive (lytic) and more sclerotic changes.2 as per the literature, people have studied the use of the patient’s own bone after sterilisation by different methods. various processes of sterilisation include use of liquid nitrogen, microwave, autoclave, alcohol inactivation or ecrt. prosthesis reconstruction and composite arthroplasty have the most favourable results, such as better function and fewer adverse effects.3 however, the metallic modular implant has drawbacks in terms of durability, financial issues and being restricted in use to patients who have achieved skeletal maturity (or we need to consider expandable prostheses with high cost).4 in the paediatric age group, the issue of small canal diameter is another disadvantage. in developing countries, due to the financial burden, primary bone tumour patients have another option, namely excision of part of the limb proximal to the lesion (amputation). however, this is not acceptable to patient or family when other options are available. surgeries which preserve the patient’s own bone are therefore an attractive option. young growing children present extra challenges due to the fact that they have open physes and still need to grow substantially, making their reconstruction even more challenging. the option for reconstruction is custom endoprosthesis (growing implants for children) but it is very expensive in the developing world setting. allograft, autograft (vascularised and non-vascularised), extracorporeal radiated bone, distraction osteogenesis, a combination of the above, and rotationplasty (some centres still offer this procedure) are other options. radiation given outside the body to make the bone free of tumour is called extracorporeal radiotherapy (ecrt). after resection of the bone, it is cleaned of all the surrounding soft tissue and intramedullary contents and placed in a container. it is then subjected to 50 gy of radiation which kills all the tumour cells. the free radicals released during the radiation not only kill the tumour cells within the bone but also in the surrounding soft tissue. this renders the bone specimen tumour free; it is then brought back to the operating theatre and re-implanted by stabilising it with appropriate fixation devices. ideally radiation therapy in tumours requires 2 gy radiation (in vivo) per sitting, either daily or on alternate days for a minimum of 25 sittings. therefore, intra-operative ecrt provides, in one sitting, the equivalent of over a month of radiation therapy of 50–60 gy of radiation. this reduces the economic and financial burden on the patient. it also reduces the exposure to radiation in multiple sittings; the physical endurance in such treatment is thereby reduced and it becomes more acceptable to the patient. the advantages of re-fixation with the same bone is that you get an exact match to the resected bone which is tumour-free. postoperatively the joint is mobilised early, and weight bearing can be started according to the union of re-implanted bone. post-operative radiotherapy is avoided. the end facing towards diaphysis takes more time to unite than the metaphyseal end. there is comparatively less chance of recurrence and fewer chances of any limb length discrepancy (in comparison to limb salvage surgeries by non-expandable prostheses). if the tumour has caused extensive destruction of bone, pathological fracture or it is a metastatic tumour, it is not sound to reimplant it after ecrt; therefore, this method cannot be advised for such patients. irradiation given outside the body is a safe and physically stable construct procedure in reconstructing bony defects after tumour resection in skeletally immature patients. the aim of our study is to know functional results, survival rate and union status after the procedure. materials and methods the study was conducted between june 2014 and may 2020, and included 15 patients (out of 18) diagnosed with either ewing’s sarcoma or osteosarcoma (non-metastatic stage t1n0m0). cases reported with poorly differentiated sarcomas (total ) were subjected to immunohistochemistry (ihc) and managed with other modalities of treatment. institutional review board approval was obtained. all patients were informed about the procedure and informed consent was taken for each case. follow-up was done up to may 2020 and those who were on regular follow-up were included in the study. patients with open physis and non-metastatic tumour were included in the study; patients diagnosed with chondrosarcoma (uncommon in young age, and not radiation-sensitive, with radiation reserved for non-operable cases) and older than 18 years were excluded from the study. all patients were given neoadjuvant chemotherapy (nact) as per the advice of the oncologist. all investigations such as blood reports, x-rays, mri and positron emission tomography (pet) ct scan were done as per standard protocol. the patients eligible for the study underwent wide marginal excision followed by reimplantation of the same part after it had been given radiation outside the body (table i). we did not use vascularised or nonvascularised fibula graft in any of the cases as the dimensions of the irradiated bone were perfectly matched host bone and the whole construct was stable after fixation. on follow-up, for an average of 4.44 years up to may 2020, the complete medical records, radiological imaging, and status of the patient at the last follow-up including functions were recorded. fourteen males and one female with age ranging from 7.5 years to 16 years with average of 9.6 years were studied. proximal tibia was the commonest (11 of 15). distal femur (three of 15) and humerus (one out of 15) were also involved. mean complaints duration (time from initiation of pain or swelling to first reporting at the hospital) was 20 weeks (18 to 52 weeks). a pre-operative mri and histological diagnosis (by tru-cut bone biopsy needle) were obtained from all the patients in the study. patients in whom diagnosis was made elsewhere were included in the study (n=3). in the remaining patients (n=12), core needle biopsy was performed to confirm the diagnosis. a multispecialty approach (tumour board) was used, including a radiologist, pathologist and an oncologist to assess the patients and determine the treatment protocol based on the extent of the disease. a thorough examination of the patient was mandated to rule out metastasis at the time of presentation by primary screening of the chest (multidetector computed tomography), abdomen ultrasound and pet ct scan. page 45shah mr et al. sa orthop j 2021;20(1) none of the patients included in the study had any metastases on first consultation. as per the oncologist’s decision, preand postoperative chemotherapeutic agents were given. the extent of the lesion and neurovascular involvement were studied by ct angiography and mri. wide margin resection was performed with a 2.5–3 cm free margin as per the pre-operative plan based on the mri (figure 1). intra-operative frozen section was done from the proximal and distal canals to check for malignant cells. the resected bone specimen was cleared off the surrounding soft tissue and periosteum. it was then subjected to ecrt intra-operatively maintaining aseptic precautions. for irradiation, the resected bone was placed in a mop soaked with saline, povidone–iodine and vancomycin, and wrapped with sterile plastic drape in two layers. it was put in a surgical drum after being wrapped in two surgical towels and was then sent to the radiation unit (figure 2). the specimen was subjected to a tumoricidal dose of 50 gy, creating a dead autologous bone graft (figures 3a and b). time taken to transfer the bone out of theatre followed by the ecrt process, and receiving the graft ranged from 40 to 60 minutes (average 45 minutes). the irradiated bone was then prepared for re-implantation by reaming the marrow of its contents and subjecting it to a thorough lavage to remove any residual marrow tissue. the resected tissue was then placed back after ecrt at the operative site (figure 4), and fixation was done with anatomical plates (figure 5). in the younger age group, fixation was done with one locking compression plate and one k-wire. in older children two plates were used. in lower limb involvement, the patient was advised to immobilise with a long knee brace for four weeks postoperatively followed by gradual mobilisation of knee, and nonweight bearing walking after three months. for upper limb cases, a pouch arm sling was given for immobilisation. patients were followed up regularly every month. apart from local examination for recurrence, x-rays (ap and lateral views) were taken during follow-ups. the osteotomy site was examined for union in ap and lateral views by assessing two cortices in each view. a total of three out of four cortices in continuity are required to confirm union at the osteotomy site. patients are advised against weight bearing walking until osteotomy union has been established. a mean follow-up of 4.44 years (ranging from 1.8 to 5.6 years) for all patients was recorded. during their final visit, the status was decided by the musculoskeletal tumor society scoring method (msts score).5 there was no limb length discrepancy on follow-up in any of the patients. post-operative chemotherapy (adjuvant chemotherapy) was given as per the oncologist’s decision. table i: clinical details of patients s no. age (years) sex bone type fixation osteotomy union (months) complications f/u (years) msts score at last follow-up status 1 16 m pt os double plating 9 deep infection 5.5 19 patient walking fwb alive 2 9 m pt es single plating & k-wire 6 nil 4.5 29 patient walking fwb alive 3 15 m ph os locking compression plating 5 nil 4.2 30 patient walking fwb alive 4 8 m df os single plating & k-wire 10 superficial infection 4.3 22 patient walking fwb alive 5 12 m pt es single lateral plating 8 nil 1.8 24 patient walking fwb alive 6 8.5 m pt os single plate 9.3 nil 4.5 20 patient walking fwb alive 7 9.3 m pt os single plate 8 nil 5.6 18 patient walking fwb alive 8 8.2 f df es single plate & k-wire 8 superficial infection 4.8 22 patient walking fwb alive 9 11 m pt os single plate & k-wire 9 nil 4.2 24 patient walking fwb alive 10 9.5 m pt os single plate 8.5 nil 4 26 patient walking fwb alive 11 12 m pt os double plate 9.6 nil 4.8 22 patient walking fwb alive 12 10.2 m df os single plate 8.7 nil 5.3 20 patient walking fwb alive 13 7.5 m pt es single plate & k-wire 7.9 nil 4.8 22 patient walking fwb alive 14 8.9 m pt os single plate 8 nil 3.8 24 patient walking fwb alive 15 9.2 m pt es single plate & k-wire 7 recurrence 4.5 20 above-knee amputation alive pt: proximal tibia; ph: proximal humerus; df: distal femur; os: osteosarcoma; es: ewing’s sarcoma; f/u: follow-up; fwb: full weight bearing proximal tibial surface physis periosteal reaction proximal margin of tumour tumour distal margin of tumour periosteal reaction 25 mm 40 mm 90 mm 110 mm a b figure 1a. pre-operative mri of the tibia diagnosed with osteosarcoma involving the diaphyseal region of the proximal tibia figure 1b. pre-operative templating to decide level of resection page 46 shah mr et al. sa orthop j 2021;20(1) results the frozen sections taken intra-operatively provided the basis for a tumour-free margin and definitive histopathological diagnosis. one patient (case 1) had post-operative deep infection at the operative site with exposed bone and implant. two patients (13%) developed superficial infection (cases 4 and 8). the major concern against ecrt autograft is ruling out malignancy by microscopic examination and to re-confirm the resected specimen. examination of the gross specimen is not possible. on the patient’s follow-up (case 1) in the fifth month, there was evidence of dehiscence over the proximal suture line with an exposed implant (figure 6). in the patient with deep infection, the complication resulted in an advantage. the exposed lateral plate was removed as the osteotomy site union had already occurred. biopsy was taken from the previous tumour site, which revealed no evidence of tumour with marrow tissue necrosis and fibrohyalinisation. the patient did not have any other complications in the subsequent followups. the patient was followed up after three months and advised to fully weight bear as the x-rays suggested complete union (figure 7). the patients with superficial infection (cases 4 and 8) were treated with debridement and primary closure. one patient (case 15) developed recurrence at the local site without any metastasis (confirmed by pet scan) on follow-up at 2.5 years. he was advised to have an above-knee amputation. all 15 cases were analysed for bony union (assessed by union in three out of four cortices in ap and lateral views) of the graft. mean time ranged from five to ten months with a mean of figure 2. packing for ecrt with two mops soaked in saline mixed with vancomycin ba figure 3a. resected sample prior to ecrt with the resected surrounding soft tissue figure 3b. resected sample after ecrt figure 4. wide resected operative site figure 5. fixation of irradiated bone with medial and lateral anatomical plates page 47shah mr et al. sa orthop j 2021;20(1) 8.1 months. the metaphyseal end united faster (7.3 months) than the diaphyseal end (8.9 months). at the last visit, functions were determined using the msts score. scoring was done considering pain, activities of daily living and psychological acceptance apart from specific factors per limb. for the upper limb, position of hand, manual skill and lifting ability were tested; for the lower limb, need of support for mobilisation, ability to walk, and gait pattern were examined. scores of 0 to 5 were given for each factor (a total of seven) as per criteria; the score was therefore given out of a maximum of 35. the time for the last follow-up varied from 1.8 to 5.6 years with a mean of 4.44 years. we found an average msts score of 19 to 26 (mean 22.8). fourteen of the 15 patients had lower limb involvement, while one patient had upper limb involvement. at the time of the final followup, all except one were disease-free with no mortality recorded. one patient was treated with above-knee amputation due to recurrence diagnosed at 2.5 years of follow-up. all survived for more than four years from the index surgery. discussion zhang et al. studied early and late complications in reimplanted involved bone of limb malignancies post-ecrt and en bloc resection. in the retrospective study, fracture, infection, non-union and graft resorption were found in 11 patients out of 39. functions and longevity rates were better in spite of high re-surgery (39.1%) and complications (47.8%).6 other studies have also shown treatment by ecrt.7 ewing’s sarcoma (33%) and osteosarcoma (67%) were commonly found in our study, consistent with known numbers found in other studies.8 here we have studied the treatment protocol followed for osteosarcoma and ewing’s sarcoma. before surgery each patient was fully investigated, and biopsy and staging were done. surgery was planned after consultation with other relevant disciplines and tumour board members. all patients with ewing’s sarcoma and osteosarcoma were subjected to pre-operative (neoadjuvant) chemotherapeutic agents. postoperative (adjuvant) chemotherapy decisions were taken as per the oncologist’s opinion. advantages of this method are that the resected tumour undergoes ecrt (in vitro) immediately and the tissue is placed at the operative site thereafter. the autogenous tissue is placed back without subjecting the whole body to radiation and hence the amount of radiation the tumour tissue is exposed to is much higher, keeping in mind that there are no adverse effects to any normal tissue. there is no use of cement or graft to maintain the congruity of the bone. this is advantageous to the patient as there is no need for bone grafting with its associated complications. figure 6. case 1 presented with dehiscence over the proximal suture line with an exposed implant figure 7. radiographs of case 1 figure 7a. immediate post-operative radiograph in antero-posterior and lateral view figure 7b. radiograph in antero-posterior and lateral view after removal of lateral anatomical plate figure 7c. radiograph taken on follow-up showing bony union at all four cortices in antero-posterior and lateral view page 48 shah mr et al. sa orthop j 2021;20(1) it is relatively economical and compliance with treatment is also better. this limb-salvaging procedure also prevented the need for prosthesis in a 16-year-old child. advantages of this method include less or no risk of disease transmission or immunological reaction, availability of bone, no question of preservation of bone and biological reconstruction. poffyn et al. showed that patients with osteosarcoma and ewing’s sarcoma resection showed excellent response to en bloc resection with ecrt of the resected tumour.7 the study was conducted retrospectively from 1978 to 2009, and studied 107 patients with locally aggressive malignant bone tumours. in their study after resection and ecrt, orthotopic autografts were reimplanted. normal fracture healing times in irradiated grafts do not show accurate results. follow-up at two years showed healing in 62% (31 out of 50) and 64% at five years (27 out of 42). non-union was found in the remaining 15 of the orthotopic grafts.8 a similar study was done by puri et al. on non-metastatic diaphyseal sarcomas which were treated by wide marginal excision followed by ecrt (50 gy) and reconstruction of the same irradiated sterilised bone tumour.9 they studied a total of 32 patients (16 osteosarcoma plus 16 ewing’s sarcoma). thirtyone patients were followed up for between 12 and 74 months, and showed a mean union time of 7.3 months (3 to 28). at the final follow-up no disease was found in 19; 11 patients demised due to disease; and one patient had disease. puri et al.’s evaluation by mean functional msts score was found to be 87%. by comparison, our study found it to be 65%. puri et al. found it to be higher when compared with other methods using irradiated graft.9 nakamura et al. reported a study of six patients with ewing’s sarcoma of the mid-shaft femur treated by limb-sparing resection and reconstruction with cement augmentation with good results.10 we do not have such experience and did not feel the need to use cement in any of our cases. the limitations of our study include its small sample size. followups ranged from 1.8 to 5.6 years with an average of 4.44 years, which can be considered reasonable. the only disadvantage which can be mentioned is the non-availability of full specimens for deciding tumour necrosis by chemotherapy by this modality of treatment. as this procedure is relatively uncommon, suitable for a particular group of patients and being a pilot study, it is a useful guide. conclusion ecrt is a technique that is one of the treatment options of bone tumours in skeletally immature patients. ecrt is a relatively less expensive, versatile option for saving the limb in bone malignancies provided good bone stock is available. however, early diagnosis and referral to a specialised unit is of vital importance. this procedure can be used for selected patients with malignant bone tumours. cost factors, and social and cultural considerations also play a role. even if it results in longer surgical time, it is economical and lowers the financial burden compared to other treatment modalities. it is relatively safe, provides good functional results with preservation of the nearby joint. suitable implant and irradiated orthotopic host bone for internal fixation helps in achieving desired outcomes in patients with non-metastatic local bone tumours. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. institutional review board (irb) ethical approval was obtained: approval no. 3/2014/ sh. prior to commencement of the study ethical approval was obtained from the following ethical review board: sh (hrrp)-3/2014. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was obtained from all patients for being included in the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions mrs: study conceptualisation, data capture, data analysis, first draft preparation, manuscript revision mms: study design, design of testing set-up, manuscript preparation aka: data analysis, first draft preparation mds: data capture smd: design of testing set-up references 1. spira e, lubin e. extracorporeal irradiation of bone tumors. a preliminary report. isr j med sci. 1968 sep-oct;4(5):1015-19. pmid: 5251288. 2. böhm p, fritz j, thiede s, budach w. reimplantation of extracorporeal irradiated bone segments in musculoskeletal tumor surgery: clinical experience in eight patients and review of the literature. langenbecks arch surg. 2003 jan;387(9-10):355-65. 3. gilbert nf, yasko aw, oates sd, et al. allograft-prosthetic composite reconstruction of the proximal part of the tibia. an analysis of the early results. j bone joint surg am. 2009 july;91(7):1646-56. 4. hardes j, henrichs mp, gosheger g, et al. endoprosthetic replacement after extra-articular resection of bone and soft-tissue tumours around the knee. bone joint j. 2013;95b:1425-31. 5. enneking wf, dunham w, gebhardt mc, malawar m, pritchard dj. a system for the functional evaluation of reconstructive procedures after surgical treatment of tumors of the musculoskeletal system. clin orthop relat res. 1993:241-46. 6. zhang s, wang x-q, wang j-j, xu m-t. en bloc resection, intraoperative extracorporeal irradiation and re-implantation of involved bone for the treatment of limb malignancies. mol clin oncol. 2017 dec;7(6):1045-52. 7. poffyn b, sys g, mulliez a, et al. extracorporeally irradiated autografts for the treatment of bone tumours: tips and tricks. international orthopaedics (sicot) 2011;35:889-95. 8. unni kk. dahlin’s bone tumors: general aspects and data on 11,087 cases. 5th ed. philadelphia: lippincott-raven; 1996. p. 143-83. 9. puri a, gulia a, jambhekar n, laskar s. the outcome of the treatment of diaphyseal primary bone sarcoma by resection, irradiation and reimplantation of the host bone. j bone joint surg br. 2012;94-b:982-88. 10. nakamura t, abudu a, grimer rj, et al. the clinical outcomes of extracorporeal irradiated and re-implanted cemented autologous bone graft of femoral diaphysis after tumour resection. international orthopaedics, 2012 dec;37(4):647-51. sa orthopaedic journal autumn 2017 | vol 16 • no 1 page 39 sarcomas other than kaposi’s sarcoma in hiv s mohammedali mbchb, mmed(surg), hdiporth sa department of orthopaedics, university of kwazulu-natal, pietermaritzburg, south africa lc marais mbchb fc(orth)sa, mmed(ortho), cime, phd tumour sepsis and reconstruction unit, department of orthopaedics, school of clinical medicine, university of kwazulu-natal, south africa corresponding author: dr mohammedali shamshudin department of surgery the aga khan university hospital nairobi, kenya po box 030270-00100, nairobi, kenya tel: +254711092115 fax: +254203743935 email: shamshuza@yahoo.com introduction hiv/aids is an immune-compromising disease that may be accompanied by the development of opportunistic infections and malignancies. there is a high prevalence of hiv infection in south africa with an estimated 6.8 million cases in 2014.1 in the province of kwazulu-natal, where this research was performed, an estimated 21.5% of adults are living with hiv.2 significant strides have been made in terms of the management of hiv, and near-normal life expectancy can be expected if anti-retroviral therapy is timeously instituted.3 cancers can be categorised by their associations with hiv/aids as being aids-defining cancers (adcs) such as kaposi’s sarcoma, non-hodgkin’s lymphoma and cervical cancer, which are all virus-related, and non-aids-defining cancers (nadcs) (figures 1 and 2).4 the overall prevalence of cancers in hiv has declined following the introduction of anti-retroviral therapy but recent literature suggests that there may still be an increase in non-virus-related nadcs.5 abstract introduction: kaposi’s sarcoma and lymphoma are some of the malignancies known to be associated with hiv infection and afflict many people living with hiv/aids, as published widely in previous literature. in contrast, scarce information is available with regard to the occurrence of other primary musculoskeletal malignancies and whether there may be a causal relation between the occurrence of these malignancies and hiv. the aim of this study is to describe which sarcomas (other than kaposi’s) occur in patients living with hiv. methods: a retrospective chart review was performed of consecutive adult individuals who presented to our tumour unit with musculoskeletal sarcomas other than kaposi’s sarcoma. the histological diagnosis of tumours in hiv-positive patients were then compared to that of an age-matched cohort of hiv-negative patients. results: a total of 59 patients were included in the study. thirty patients were positive and 29 patients negative. we recorded a wider variety of sarcomas in hiv-positive individuals than previously reported. there was a tendency towards an increased number of cases of rhabdomyosarcoma in the hiv-positive group and chondrosarcoma in the hiv-negative group although this did not reach statistical significance, p=0.05 and 0.08 respectively. there was no difference in the prevalence of metastasis at the time of presentation with 16 cases having metastases in the hiv-positive group (53.3%) and 14 cases (48.2%) in the hiv-negative group, p=0.69. conclusion: the prevalence of musculoskeletal sarcomas other than kaposi’s sarcoma in hiv-positive patients and a tendency towards an increased prevalence of rhabdomyosarcoma requires further investigation. long-term studies to assess the influence of antiretroviral therapy on the prevalence and prognosis of these sarcomas are required. key words: hiv, non-kaposi’s sarcoma, musculoskeletal, non-aids defining cancers (nadcs) http://dx.doi.org/10.17159/2309-8309/2017/v16n1a5 saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/02/27 7:42 pm page 39 saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/02/27 7:42 pm page 40 sa orthopaedic journal autumn 2017 | vol 16 • no 1 page 41 methods study design we retrospectively reviewed the charts of all adult patients who were treated for sarcoma at our tumour unit from january 2011 to december 2015. eligible patients were identified from a prospectively gathered database. patients were included in the study if they were 18 years or older and there was a histologically confirmed diagnosis of sarcoma involving soft tissue and/or bone. the exclusion criteria were: patients whose clinical record was incomplete or in whom the histologic diagnosis was inconclusive for sarcoma; and patients with the diagnosis of lymphoma, myeloma or metastatic bone disease. the subjects’ charts were reviewed and data extracted in order to describe the patient demographics, location of the tumour, histological diagnosis, hiv status and the presence of metastases. all patients underwent local and systemic staging. local staging consisted of radiographs and a magnetic resonance imaging (mri) scan of the affected limb segment. systemic staging included workup for medical co-morbidities, laboratory investigations and computerised tomography (ct) scan of the chest and abdomen. informed consent for hiv testing was requested from all patients. histology was obtained by formal incisional biopsy, according to standard biopsy principles, in all cases. diagnosis was subsequently confirmed by combined radiological and histological evaluation. statistical methods data were analysed using stata 13.0 (statacorp lp 2013. college station, texas). continuous variables were summarised using mean and standard deviation values. categorical variables were summarised using frequency tables. an unpaired t-test was used to assess the age of patients in relation to hiv status. the association between hiv status and the presence of metastases was tested using the chi-square test. fisher ’s exact test (twotailed) was used to test the independence of tumour site and histology on hiv status. a p-value of <0.05 was considered statistically significant for all tests. ethical considerations all research was conducted according to the ethical principles for medical research on human subjects as defined by the world medical association declaration of helsinki (amended at the wma general assembly, seoul, october 2008). ethical approval for conducting this research was obtained from brec (biomedical ethics review board) prior to starting data collection. all research participants’ information was held strictly confidential. results sixty-one files were screened of which two were excluded due to missing hiv data. therefore, 59 patients met the eligibility criteria. the hiv-positive group consisted of 30 patients and hiv-negative group of 29 patients. patient demographics are provided in table i. as an age-matched cohort, there was no difference in the age range and mean age between hiv-positive (mean: 37.5 years; range: 21–64; sd [standard deviation] = 11.58) and hiv-negative group (mean: 43.4 years; range: 21–76, sd: 16.75) (p=0.11). there was an equal distribution of males and females. the distribution of tumours according to site is provided in table i. there was no significant difference in the rate of metastases at time of presentation, with 53.3% of patients in the hiv-positive group presenting with metastases compared to 48.2% in the hiv-negative group (p= 0.69). table i: patient demographics and distribution of bone and soft tissue sarcomas in hiv-positive and -negative patient groups characteristic hiv-positive n (%) hiv-negative n (%) p-value age mean (sd) 37.5 (11.58) 43.4 (16.75) 0.11* gender male 14 16 metastases present 16 14 0.69** bone tumours 20 20 0.85** femur 9 8 tibia 6 6 fibula 0 1 pelvis 1 2 humerus 4 1 ulna 0 1 radius 0 1 soft tissue tumours 10 9 0.85** thigh 6 2 pelvis 3 0 leg 0 2 foot 1 1 knee 0 2 arm 0 2 *t-test, **chi-square test saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/02/27 7:42 pm page 41 page 42 sa orthopaedic journal autumn 2017 | vol 16 • no 1 with regard to the type of sarcomas, the majority of patients in both groups were diagnosed with bone sarcomas, 20 (66.7%) hiv-positive and 23 (79.3%) hivnegative. osteogenic sarcoma was the most common bone sarcoma, 13 (43.3%) positive and 11 (37.9%) negative. of these, conventional (osteoblastic) osteosarcoma numbered the highest, six (20%) in the positive and seven (24.1%) in the negative group. there was a tendency towards chondrosarcoma being more common in the hiv-negative group, seven (24.1%) as compared to one (3.3%) in the hiv-positive group, but this difference did not reach statistical significance (p=0.08). of the soft tissue sarcoma type, the overall numbers were similar, with ten (33.3%) cases in the hiv-positive group vs six (20.6%) in the hiv-negative group. however, it was observed that there were more cases of rhabdomyosarcoma in the hiv-positive group, five (16.6%) hiv-positive vs zero (0%) hiv-negative, p=0.05). discussion the aim of this study was to describe the histological types of sarcomas that can occur in patients living with hiv and to compare it to an age-matched hiv-negative cohort over the same period. at our institution, we had noted a wider variety of tumours that had not previously been published, and therefore instituted this study to document the various sarcomas that can occur in hiv. in our cohort of patients older than 18 years, osteosarcoma was the most common diagnosis, with no significant difference between hiv-positive and -negative patients (p=0.35). while chondrosarcoma was more common in hiv-negative patients, the difference was insignificant (p=0.08). rhabdomyosarcoma was more common in hivpositive patients (p=0.05). the immunological basis of the development of malignancies in hiv-infected individuals is not yet completely understood. one direct mechanism whereby retroviruses can cause cancer is through oncogene transduction. this mechanism has, however, only been seen in simple retroviruses and not with complex retroviruses like hiv. many retroviruses do not possess viral oncogenes, but initiate tumour formation through the integration of proviral dna near normal cellular proto-oncogenes, thereby activating their expression, by a mechanism termed ‘proviral insertional mutagenesis’. expression of c-myc proto-oncogene has been shown to be induced during hiv infection.10 activation of c-myc oncogene has also been described in aids-associated lymphoma.11 furthermore the importance of the c-myc oncogene has been firmly established in the pathogenesis of certain sarcomas.12 these factors suggest that hiv infection may be related to the development of sarcomas. the reported occurrence of sarcomas in the nadcs group is rare. moreover, musculoskeletal sarcomas are rarely mentioned separately in nadc reports.13 newnham et al. reported five soft tissue sarcomas and one bone sarcoma with the sir (standardised incidence ratio) for soft tissue tumours being 3.6 and for skeletal malignancies 1.5. the specific histology of these sarcomas and their site was unfortunately not described, and it remains unclear if these included any of the sarcomas that we reported in our study.13 a study by bhatia et al. identified a total of 176 non-kaposi’s sarcomas in immune compromised patients in the seer database, 75 in people with hiv/aids and 101 in transplant recipients. leiomyosarcomas (n = 101) were the most frequently reported sarcomas, followed by angiosarcomas (n = 23) and fibrohistiocytic tumours (n = 17).14 leiomyosarcomas, angiosarcomas, osteosarcoma and fibrohistiocytic tumours are the only musculoskeletal malignancies previously associated with hiv.14-17 in our study, we noted a wider variety of cancers than any other prior study (table ii). there was a tendency to an increased number of cases of rhabdomyosarcoma in the hiv-positive group and chondrosarcoma in the hivnegative group but this was not statistically significant. individuals with sarcoma who have concomitant hiv infection tend to fare worse than hiv-negative individuals both in terms of poor response to chemotherapy and death due to distant spread rather than hiv related.15 in our study, we noted that the presence of metastasis at presentation was equal among hiv-positive and negative groups. this was in contrast to the american hiv/aids cancer match study (hacm). hacm data reported that 32.3 % of people living with hiv with cancer present with distant disease versus 17.7 % in the general population, p<0.01.18 the small number of cases in both groups is a shortcoming. the exclusion of adolescent patients (in whom osteosarcoma is most prevalent) further decreased the sample size which was too small, for example, to determine if there was an increased risk of metastases in any of the osteosarcoma subtypes. the retrospective nature of this study is a further limitation. we would have liked to follow these patients up prospectively to assess if they truly remained hiv-negative after recruitment into the study, and whether hiv influences the long-term outcome with concurrent sarcoma. we also did not assess for the usage of hiv treatment and its influence on outcomes. this study was also subject to referral bias as the database from which the information was retrieved comes from a single referral institution. the findings in this study may not be fully generalisable but our referral base and patient profile fit the majority in sub-saharan africa. our study reports a higher number and a wider variety of musculoskeletal sarcomas, other than kaposi’s, in hiv-positive patients compared to previous literature. large prospective multicentre trials are required in our environment to assess this trend, their response to chemotherapy, surgery and long-term survival of this particular group of patients. saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/02/27 7:42 pm page 42 sa orthopaedic journal autumn 2017 | vol 16 • no 1 page 43 compliance with ethics guidelines ethical considerations all research was conducted according to the ethical principles for medical research on human subjects as defined by the world medical association declaration of helsinki (amended at the wma general assembly, seoul, october 2008). ethical approval for conducting this research was obtained from brec (biomedical ethics review board) prior to starting data collection. all research participants’ information was held strictly confidential. table ii: histological diagnosis according to hiv status of the patient histology hiv-positive n (%) hiv-negative n (%) p-value bone osteosarcoma 0.35* conventional osteosarcoma osteoblastic 8 (27%) 7 (24.1%) chondroblastic 0 (0%) 2 (6.9%) fibroblastic 2 (6.6%) 0 (0%) osteosarcoma variants 0.42** telangiectatic osteosarcoma 1 (3.3%) 0 (0%) periosteal osteosarcoma 0 (0%) 1 (3.4%) parosteal osteosarcoma 2 (6.6%) 0 (0%) high-grade surface osteoarcoma 2 (6.6%) 1 (3.4%) ewing’s sarcoma 0 (0%) 0 (0%) 1.0 chondrosarcoma 1 (3.3%) 7 (24.1%) 0.08** fibrosarcoma 1 (3.3%) 1 (3.4%) 1.0 undifferentiated high-grade pleomorphic sarcoma 2 (6.6%) 2 (6.9%) 1.0 malignant giant cell tumour 0 (0%) 1 (3.4%) 0.49 admantinoma 1 (3.3%) 0 (0%) 1.0 soft tissue rhabdomyosarcoma 5 (16.6%) 0 (0%) 0.05** leiomyosarcoma 1 (3.3%) 0 (0%) 1.0 alveolar soft part sarcoma 0 (0%) 1 (3.4%) 0.49 synovial sarcoma 1 (3.3%) 2 (6.9%) 0.61 liposarcoma 0 (0%) 2 (6.9%) 0.24 malignant peripheral nerve sheath tumour 1 (3.3%) 1 (3.4%) 1.0 extra skeletal myxoid chondrosarcoma 1 (3.3%) 0 (0%) 0.49 fibromyxoid sarcoma 1 (3.3%) 1 (3.4%) 1.0 30 (100%) 29 (100%) *chi-square test, **fisher’s exact test conclusion patients living with hiv can develop a variety of musculoskeletal sarcomas other than ks. with universal access to antiretroviral therapy being legislated by many governments, these patients will live longer. therefore, programmes for increased awareness among the medical and orthopaedic community and early referral to an appropriate centre will set the ground for future studies and eventually improved outcomes. saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/02/27 7:42 pm page 43 page 44 sa orthopaedic journal autumn 2017 | vol 16 • no 1 references 1. unaids. http://www.unaids.org/en/regionscountries/ countries/southafrica/ accessed 13 january 2016. 2. welz t, hosegood v, jaffar s, batzing-feigenbaum j, herbst k, newell m. continued very high prevalence of hiv infection in rural kwazulu-natal, south africa: a population-based longitudinal study. aids 2007;21:1467-72. 3. johnson lf, mossong j, dorrington re, schomaker m, hoffmann cj, et al. life expectancies of south african adults starting antiretroviral treatment: collaborative analysis of cohort studies. plos med 2013;10(4):e1001418. doi:10.1371/journal.pmed.1001418 4. yanik el, napravnik s, cole sr, achenbach cj, gopal s, olshan a, dittmer dp, kitahata mm, mugavero mj, saag m, moore rd, mayer k, mathews wc, hunt pw, rodriguez b, eron jj. incidence and timing of cancer in hiv-infected individuals following initiation of combination antiretroviral therapy. clin infect dis 2013 sep;57(5):756-64. 5. albini l, calabresi a, gotti d, ferraresi a, festa a, donato f, magoni m, castelli f, quiros-roldan e. burden of non-aids-defining and non-virus-related cancers among hiv-infected patients in the combined antiretroviral therapy era. aids research and human retroviruses. jul 2013;29(8):1097-104. 6. j.u.n.p.o.h.a., global report: unaids report on the global aids epidemic 2013. geneva, switzerland. 7. robbins ha, et al. excess cancers among hiv-infected people in the united states. j natl cancer inst. 2015;107(4):1-8. 8. robbins ha, et al. epidemiologic contributions to recent cancer trends among hiv-infected people in the united states. aids. 2014;28(6):881-90. 9. bebawy ss, netto js, mcgowan cc, veloso vg, engels ea, sterling tr, grinsztejn b. hiv and cancer: a comparative retrospective study of brazilian and us clinical cohorts. *infect agent cancer. 2015 feb 2;10:4. doi: 10.1186/1750-9378-10-4. ecollection 2015. 10. sun y, clark ea. expression of the c-myc proto-oncogene is essential for hiv-1 infection in activated t cells. journal of experimental medicine. 1999;189(9):1391-97. 11. subar m, neri a, inghirami g, knowles dm, dalla-favera r. frequent c-myc oncogene activation and infrequent presence of epstein-barr virus genome in aids-associated lymphoma. blood. 1988;72(2):667-71. 12. broadhead ml, clark jcm, myers de, et al. the molecular pathogenesis of osteosarcoma: a review. sarcoma. 2011(1):1-12, article id 959248 13. newnham a, harris j, evans hs, evans bg, moller h. the risk of cancer in hiv-infected people in southeast england: a cohort study. br j cancer 2005;92:194-200. 14. bhatia k, shiels ms, berg a, engels ea. sarcomas other than kaposi’s sarcoma occurring in immunodeficiency: interpretations from a systematic literature review. curr opin oncol. 2012 september;24(5):537-46. 15. fizazi k, et al. soft tissue sarcomas in hiv-infected adult patients. eur j cancer. 1996;32a(10):1812-14. 16. chadwick eg, et al. tumors of smooth-muscle origin in hiv-infected children. jama. 1990;263(23):3182-84. 17. marais lc, ferreira n. osteosarcoma in adult patients living with hiv/aids. isrn oncology. volume 2013, article id 219369, 6 pages. available from http://dx.doi.org/10.1155/2013/219369 18. coghill ae, et al. elevated cancer-specific mortality among hiv-infected patients in the united states. j clin oncol. 2015;33(21):2376-83. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/02/27 7:42 pm page 44 south african orthopaedic journal hand surgery doi 10.17159/2309-8309/2022/v21n1a6 de buys m et al. sa orthop j 2022;21(1) citation: de buys m, tsama m, aden aa. patient satisfaction following wide awake local anaesthetic no tourniquet hand surgery at helen joseph hospital. sa orthop j 2022;21(1):39-43. http://dx.doi.org/10.17159/23098309/2022/v21n1a6 editor: dr duncan mcguire, university of cape town, cape town, south africa received: may 2020 accepted: april 2021 published: march 2022 copyright: © 2022 de buys m. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background wide awake local anaesthetic no tourniquet (walant) hand surgery is a rapidly growing technique for hand surgery whereby a lignocaine/adrenaline/bicarbonate mixture is injected into the hand or fingers where the procedure is to be carried out. methods this was a retrospective study with prospective recall analysing satisfaction of patients who underwent walant hand surgery at our academic hospital in the first year of its inception. data collection included a questionnaire to analyse demographics, comparison to dental procedures, subjective and objective experience of the procedure, overall experience, expectations, pain and surgical outcome. results we included 80 procedures in 67 patients; 87% would prefer walant in the future, and 87% would recommend walant to friends or family. for 79% of patients (who had dental procedures before), the pain was less or the same as a dental procedure, and 70% of patients said the experience was better than expected. average pain scores were 3.89/10 during local anaesthetic injection, 1.25/10 during the procedure and 5.20/10 postoperatively; with postoperative pain starting at an average of nine hours. eighty-five per cent of conditions were cured at follow-up and no cases of digital ischaemia or infection were noted. conclusion our study suggests walant hand surgery is a safe, effective and satisfactory method of performing hand surgery in the south african context. level of evidence: level 4 keywords: walant, hand surgery, local anaesthetic, carpal tunnel, de quervain’s, ganglion, patient satisfaction patient satisfaction following wide awake local anaesthetic no tourniquet hand surgery michael de buys,* mluleki tsama, abdirashid a aden department of orthopaedic surgery, helen joseph hospital, university of the witwatersrand, johannesburg, south africa *corresponding author: debuysm@gmail.com introduction wide awake local anaesthetic no tourniquet (walant) hand surgery, a concept developed in 2007 by dr lalonde, is gaining popularity worldwide.1,2 it involves surgery being carried out on a non-sedated patient without the need for a tourniquet with simply a local injection.3,4 a cocktail of 1% lignocaine/adrenaline 1:100 000 and 8.4% sodium bicarbonate in a 10:1 ratio is injected into the area of surgery in a tumescent-type manner. the lignocaine provides anaesthesia and adrenaline causes vasoconstriction and therefore a bloodless field.2,4,5 the sodium bicarbonate buffers the acidic nature of the lignocaine and in doing so optimises the speed of onset.2 traditionally, anaesthesia for hand surgery would either be general anaesthesia or some form of regional anaesthesia.6 the term ‘local anaesthetic’ previously implied local anaesthetic given together with some form of sedation, largely to overcome the discomfort of the applied tourniquet.1 the use of the tourniquet traditionally was vital to provide a bloodless field; however, the pain is severe if not combined with general or regional anaesthesia.7 in addition to discomfort, the tourniquet can cause nerve damage with subsequent neurological deficits, muscular damage and is time-limited to a maximum of two hours.7,8 a comparison between walant surgery and a local anaesthesia with tourniquet technique showed a difference in comfort, with walant being better tolerated.7 medical school teaches the mantra that local anaesthetic cannot be injected into extremities including fingers, toes, nose and the penis due to a fear of digital ischaemia.5 the idea is based around the belief that these are end artery type systems and the vasospasm from adrenaline is therefore likely to be catastrophic.9 numerous literature reviews have been conducted looking at this concept and have concluded that there has not been a single literature report of digital ischaemia where adrenaline and lignocaine have been used.9 the benefits of walant hand surgery are numerous and include benefits for the patient, the doctor and the hospital.4 walant hand https://orcid.org/0000-0002-8780-433x page 40 de buys m et al. sa orthop j 2022;21(1) surgery requires no general anaesthesia, sedatives or opiates, which ameliorates the possibility of deleterious side effects of these medications and provides a generally safer procedure.4 davison et al. showed that only 3% of patients undergoing walant hand surgery required preoperative blood tests, electrocardiogram and/or chest radiograph versus 48% of patients who were sedated.10 patients with medical comorbidities are typically not excluded from the procedure and chronic medication, including anticoagulants, does not need to be stopped.11 the procedure does not require intravenous (iv) lines, or intraoperative or postoperative monitoring, and the patient does not need hospitalisation.4,12 the patient can be educated on postoperative management protocols and likely expectations during the procedure.4 intraoperative visualisation by the patient of the surgical site allows the patient to visualise the repair, which aids understanding of the function allowed during rehabilitation.4 real-time and dynamic testing of the repair can be done by the surgeon prior to the skin being sutured and is exceptionally helpful for assessing tendon repair tension, glide of tendons in the sheath as well as the rotational component following metacarpal and phalanx fracture repair.1,4 numerous studies have been done demonstrating the cost– benefit of walant hand surgery. a study in canada and similarly in the united states of america (usa) showed that carpal tunnel release performed in a hospital was four times more expensive than carpal tunnel release done in a clinic.1 in the united kingdom (uk), a study comparing the cost of adopting walant versus normal anaesthetic showed a saving of $3.2 million in 1 000 patients.1 bismil et al. showed a cost reduction of 50–75% when adopting the walant technique for amenable hand surgery cases.13 rhee et al. demonstrated an 80% and 75% cost saving for carpal tunnel and a1 pulley release when done in their clinic via walant versus in their main theatres under general anaesthesia, respectively.12 teo et al. conducted a study looking at patient satisfaction in the first 100 consecutive patients who underwent walant hand surgery at their institution and concluded that 86% of patients would prefer to be awake again and 90% would recommend it to a friend.2 van demark et al. looked at patient satisfaction in walant hand surgery done in an office procedure room, with results showing 99% of patients would do walant in the office again and 99% would recommend it to a friend.1,14 davison et al. showed that 93% of patients undergoing carpal tunnel release by the walant technique would choose it again.10 rhee et al. conducted a study of 100 patients undergoing a cohort of procedures under walant and showed 94% of their followed-up patients would choose walant again. postoperative pain felt following walant hand surgery has been shown to be less than that of a dental procedure in 71% of patients.1,12 the south african population can be viewed as being significantly different from those studied in developed european countries, the usa and canada; this includes cultural and historical factors, values and belief systems. furthermore, there is significant diversity in the population of patients seen in a south african hospital when looking at parameters including level of highest education, prior contact with the medical sector (surgically or medically) and expectations when seeking medical assistance. this study was undertaken to assess the satisfaction of patients who underwent walant hand surgery at helen joseph hospital, a state hospital, to assess the eligibility of this method in the south african sector. methods we performed a retrospective cross-sectional study with prospective recall of patients who underwent walant hand surgery from 1 april 2017 to 31 march 2018, after obtaining hospital permission and ethics clearance. a questionnaire adapted from the work of teo et al. was created (with permission) assessing patient demographics, medical history, experience of the surgery and outcome.2 pain at each part of the procedure was assessed using the wong-baker faces chart (with permission, ©1983 wong-baker faces foundation). the wong-baker faces chart was selected as the assessment method for pain in an attempt to ensure pain could be evaluated by each patient irrespective of any cultural, language or educational differences. we included all adult patients (18 years and older) who had walant hand surgery performed during the specified time frame, were contactable by their phone number recorded in hospital records and who gave consent to being included in the study. descriptive analysis was done looking at patients’ demographics and medical history. the future anaesthetic choice of patients (walant versus general anaesthesia), comparison of experience versus expectation, likelihood to recommend walant to friends/ family and comparison to previous dental procedure(s) were analysed using descriptive parameters. level of pain felt was assessed at each part of the walant procedure (local anaesthetic injection/surgery/postoperatively). patients were questioned as to how much pain they would tolerate to have their condition cured and this was defined as ‘acceptable level of pain’. at follow-up, patients were assessed for evidence of sepsis or ischaemia, and an examination was performed to elucidate whether the condition for which surgery was done had been cured. 0 5 10 15 20 25 30 35 mua and k-wires hardware removal sepsis foreign body removal zancolli lasoo procedure tendon repair combination trigger finger release de quervain’s release ganglion carpal tunnel pr oc ed ur e number of procedures figure 1. distribution of surgical procedures performed. ‘combination’ procedures included carpal tunnel and de quervain’s release, and carpal tunnel release and ganglion removal (n = 80). 1 1 1 1 1 1 2 9 12 20 31 page 41de buys m et al. sa orthop j 2022;21(1) results during the defined study period, 134 procedures were performed in the theatre allocated for walant surgery. six procedures were excluded as they were operations of the foot and one excluded as the patient was less than 18 years of age, leaving 127 procedures eligible for the study. seventeen patients had two procedures done, leaving 110 different patients eligible to be included in the study. the final number of participants in the study was 67/110 (61%) with a total of 80/127 (63%) different procedures, with figure 1 showing the procedures included. the patients not included were not contactable via the contact details in hospital records. of the 67 patients, 51 patients were female and 16 were male. patient ages ranged from 18 to 90 years with a mean age of 44 years. the distribution of race, age and levels of education are shown in figure 2. the percentage of patients whose condition was cured when analysing the four most common procedures is given in table i. in this study, 60% of the procedures were done on the patient’s right hand and 40% on the left side. in addition, 57% of the procedures were done on the patient’s dominant hand. overall, 58 (87%) patients would choose walant and nine (13%) would prefer to be asleep if they were to have another operation of the hand in the future. furthermore, 47 (70%) patients said it was better than expected, 18 (27%) said it was the same as they expected and two (3%) said it was worse than expected. in addition, 70% of patients would definitely recommend walant to a friend/family, whereas 16% would probably recommend it, 5% would definitely not recommend it, 8% would probably not recommend it and 2% were unsure if they would (figure 3). in total, 58 (88%) patients had had a previous dental procedure, while nine (13%) patients had not. of the patients who had, 34 (59%) said the walant procedure was less painful, 12 (21%) said it was the same and 12 (21%) said it was more painful than the dental procedure. the average pain measured using the visual analogue scale (vas) during local anaesthetic (la) injection was 3.89, during the procedure 1.25, and following the procedure it was 5.20. the average time to maximal amount of pain postoperatively was approximately nine hours. sixty-five per cent of the patients’ procedures had a pain score of 0/10 during the surgery, with 93% of the procedures having a pain score less than or equal to 5/10 during the procedure. patients were questioned as to what the maximal amount of pain would be to have their condition cured. this was termed ‘acceptable level’ of pain and on average was 5.60/10. none of the cases required conversion to regional or general anaesthesia, there was no case of sepsis on follow-up, and not a single case of digital ischaemia was noted. discussion to date, there is no published data looking at the satisfaction, effectiveness and safety of walant hand surgery in the south african context. black african coloured indian white 11 a. b. c. 27 27 2 n um be r o f p at ie nt s n um be r o f p at ie nt s age categories level of education adolescent < high school young adult < matric middle-aged adult matric/ equivalent young-old adult after school studies old adult 35 30 25 20 15 10 5 0 35 30 25 20 15 10 5 0 2 3 17 29 32 16 15 19 1 figure 2. demographics of patients included in the study. a: race distribution, b: age distribution (categories as per haibach-beach et al.*),15 c: level of education (n = 670). *haibach-beach et al. age categories: adolescent (onset of puberty to 20 years); young adult (21–40); middle-aged adult (41–60); young-old adult (61–74); old adult (75–99); centenarian (100+)15 table i: percentage of patients whose condition was cured when analysing the four most common procedures procedure percentage cured (%) de quervain’s release 100 trigger finger release 89 carpal tunnel 80 ganglion 76 n um be r o f p at ie nt s likelihood to recommend definitely not probably not not sure probably definitely 50 40 30 20 10 0 3 5 1 11 47 figure 3. likelihood of recommending walant to friends or family (n = 67) page 42 de buys m et al. sa orthop j 2022;21(1) this study showed that 87% of the patients interviewed would prefer walant if they were to have another hand operation in the future. this is similar to the result of 86% seen by teo et al. and suggests a subjectively high level of satisfaction with the walant hand surgery technique.2 patients were asked the likelihood of their recommending walant as the anaesthetic method for hand surgery to their friends or family. this was to analyse the objective assessment of the walant hand surgery procedure by the patient and their understanding of it in terms of safety, efficacy, convenience and overall experience. this is in addition to the subjective view noted when asking what anaesthesia the patient would prefer for themselves in the future. we noted that 87% of participants suggested they were likely to recommend walant to their family and friends, very close to that of 90% published by teo et al.2 the preoperative surgical expectations of patients may be governed by multiple factors. these potentially include the preoperative counselling of the patient by the surgical team as well as other patient-specific factors including past surgical experiences, personality traits and understanding of the intricacies of the proposed procedure. this study comprised a heterogenous group of patients as illustrated by the diversity of patients’ age, race, sex, level of education and prior medical contact in this study. furthermore, with the large patient load compared to the number of doctors in the south african setting, insufficient explaining and counselling of patients about procedures may occur, which could potentially negatively affect the patient experience. with these concepts in mind, 70% of patients indicated their experience was better than expected, which is higher than the result seen by teo et al. (59%).2 only 3% of patients said it was worse than what they were expecting which is less than half the 7.7% noted by teo et al.2 this result suggests a positive response to the walant hand surgery technique and is a critical statistic that can be included in preoperative counselling sessions with patients as well as for discussions with practitioners reluctant to start implementing the walant technique. the literature states that walant hand surgery can be likened to a dental procedure, and this can be used as a method to inform patients on what to expect. in our heterogenous study population, 88% of patients did have a previous dental procedure to which they could relate. of these patients, 79% said the procedure was the same or less painful than their previous dental procedure, suggesting that this is a reliable predictor of what the patient can expect and an effective statistic to use when counselling the patient. in keeping with the literature, there was not a single incidence of digital ischaemia noted in the study and none of the cases required phentolamine rescue. this is a critical finding suggesting that walant is a safe method of anaesthesia for hand surgery and further adds to the literature base stating such.4,7-9 further, despite no prophylactic antibiotics being administered and minor field sterility used in this study, there were no instances of infection noted postoperatively, also in keeping with published literature.1 when analysing the amount of pain experienced by the patients in this study, we demonstrated on average the highest pain scores occurred postoperatively (average score 5.20). this is in keeping with rawal et al. who showed that 37% of hand patients suffered from moderate to severe pain following their procedure.16 this finding that the postoperative pain is more than the local anaesthetic injection contradicts the statement made by lee and is an important finding.6 the postoperative pain, however, cannot be entirely attributed to the walant technique but rather it is related to the surgery itself. this pain was on average maximal at approximately nine hours following the procedure. a further investigation is required to determine the most effective management protocol for postoperative surgical pain. patient education to begin regular analgesia immediately following the procedure prior to the block wearing off would potentially assist in managing pain. other mechanical methods, including splints (short term), may be useful adjuncts immediately following surgery and should be kept in mind. the average pain noted during local anaesthetic injection in this study of 3.89/10 is slightly lower than the value described by mohd rashid et al. of 4.66/10.17 when assessing the intraoperative levels of pain, 66% of patients felt no pain during the procedure, which is similar to that of 68% by teo et al.2 patients were asked to identify the maximal amount of pain they would say is acceptable for the procedure to have their condition cured; this was noted on average to be 5.60/10. in this study population, 93% felt pain less than or equal to 5/10, compared to 88% by teo et al., which is less than the average acceptable level of pain. in this study, walant hand surgery showed a high rate of cure (85%) of the condition for which surgical treatment was sought by the patient. we had a diverse group of procedures done but analysing the four most common procedures in our study suggests the cure rates are in keeping with published values. carpal tunnel release is stated to have a success rate of 75–90%, with our study demonstrating an 80% cure rate.18 literature suggests a success rate following de quervain’s tenosynovitis release and trigger finger release of 91–100% and 90–100%, respectively; this study population demonstrated success in 100% of the de quervain’s tenosynovitis and 89% of the trigger finger releases, respectively.19,20 ganglions have been described as having variable recurrence rates with values stated between 1% and 49%.21 in our study a recurrence rate of 24% was observed, which falls within those margins. no cost analysis was done due to the complexity of such multifactorial calculations; however, a large cost saving can be inferred based on the data presented. fifty-nine per cent of our patients had known comorbidities and required no work-up whatsoever prior to surgery, and none of the patients required admission preor postoperatively, thus further reducing hospital expenses. the number of staff members in theatre was reduced to a surgeon and a scrub nurse compared to the usual complement noted during a general anaesthesia case. in addition, minor field sterility was used, limiting the amount of waste and dirty linen created. despite being an innovative and informative study, several limitations exist and need to be addressed. this study relied on a retrospective recall of patients which may affect the results noted depending on the duration of time between surgery and the questionnaire. however, this concept was studied by teo et al. and the authors found no statistical difference in the results between patients who were classified into the early group (questionnaire completed 3–12 months postoperatively) and the late group (questionnaire completed 13–22 months postoperatively).2 all our patients had the questionnaire completed before the 22 months postoperative time period. this study noted a skewed enrolment of patients who underwent elective surgery versus those who underwent surgery for emergency injuries. an explanation for this observation is that elective surgery patients had reliable contact details which were used to contact them for their procedure and therefore had a higher likelihood of successful contact when the study was being conducted. patients who presented following an emergency admission were often noted not to have included a contact number in their file or the contact number was incorrect or suspected to have changed. to be enrolled in this study, patients had to have reliable contact details as they needed to visit the hospital to provide consent and page 43de buys m et al. sa orthop j 2022;21(1) complete the questionnaire, and the combination of these two factors potentially limited the number of enrolled patients. further studies looking at the possibility of using walant hand surgery in rural areas of the country may prevent the referral of patients to higher level of care facilities. in addition, looking at performing walant hand surgery in an adapted out-patient department and potentially operating on the index presentation of the patient would provide critical data and potentially improve the efficiency of the service provided significantly. finally, patient satisfaction in traumatic/bony procedures needs to be assessed and results compared to soft tissue only procedures to ensure our patients are reliably pleased with our method of anaesthesia; our study strongly favoured soft tissue procedures. conclusion based on the results obtained from this study, walant appears to be a safe, effective and well-tolerated anaesthetic method for hand surgery in the south african context with a high level of patient satisfaction. it has the potential to greatly improve all facets of hand surgery for the patient, the surgeon and the hospital. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, hospital permission obtained from the ceo of helen joseph hospital and ethics clearance from the university of the witwatersrand’s human research ethics committee (medical), ethics clearance certificate number m180450. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was obtained from all patients for being included in the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions mdb: study conceptualisation, study design, data capture, data analysis, first draft and subsequent draft preparation, manuscript preparation mt: study design, manuscript revision aaa: study conceptualisation, study design, data analysis, draft and manuscript revision orcid de buys m https://orcid.org/0000-0002-8780-433x tsama m https://orcid.org/0000-0001-6681-0848 aden aa https://orcid.org/0000-0001-5589-2972 references 1. van demark re, becker ha, anderson mc, smith vjs. wide-awake anesthesia in the in-office procedure room: lessons learned. hand. 2018;13(4):481-85. https://doi. org/10.1177/1558944717715120. 2. teo i, lam w, muthayya 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https://doi.org/10.1111/j.1399-6576.1997.tb04829.x https://doi.org/10.1177/2309499019833002 https://doi.org/10.1007/s11552-012-9429-x https://doi.org/10.1007/s00264-008-0667-z https://doi.org/10.1007/s00264-008-0667-z https://doi.org/10.1053/jhsu.1999.1071 https://doi.org/10.1053/jhsu.1999.1071 https://doi.org/10.4081/or.2009.e5 https://doi.org/10.4081/or.2009.e5 south african orthopaedic journal message from the past president sa orthop j 2021;20(1) 2020, a year of challenges and achievements on our path together into the future phillip webster* past president (2020): south african orthopaedic association *corresponding author: pwebster@global.co.za every year, the saoa is presented with hurdles to overcome, and 2020 certainly lived up to this. we have all been significantly affected by the covid-19 pandemic, but we have survived the onslaught and we live to fight another day. i commend all of you who were directly involved in treating patients during this period for the manner in which you buckled down to often menial tasks and working outside of your comfort zone. i congratulate all academic departments and the college of orthopaedic surgeons for your ability to adapt to the new virtual environment and continue with teaching our students and registrars. it was a remarkable achievement to have been able to host a virtual exit exam. no other english-speaking association was able to achieve this. the covid-19 pandemic has hit us hard, but as a nation, we appear to have come through the first surge without exceeding capacities, and the very low death rate as well as protection of valued healthcare practitioners has been a great success. during this time, the saoa has worked hard behind the scenes together with business for sa (b4sa), the south african medical association (sama), the south african private practitioners forum (sappf), hospital groups and the department of health (doh) to try to smooth the path through the pandemic as much as possible. we have managed to get indemnity for work outside scope of practice with insurers, and through the doh contract, we negotiated relief of premiums with malpractice and have played a role in securing ppe through a weekly meeting with b4sa. in a meeting held with dr nokutho bhengu, an independent economist, and subsequently the minister of health, honourable dr zweli mkhize, the following key points were stressed for all medical disciplines: 1. we must implement alternate reimbursement models (arms) for the future. 2. outcomes reporting is essential for any future negotiation with the government. a. practitioners must own the data. b. it will be impossible to negotiate tariffs without outcomes. c. independent outcomes are necessary to defend against claims of negligence, particularly in public practice. d. capture of clinical data, particularly patient-reported outcome measures (proms) must be done. 3. government has identified a problem with provider networks with regard to price in that there is no reference to quality of treatment provided. the saoa is way ahead of any other society in terms of meeting these goals because we have already set up a pathway for arms through the saoa event-based contract (ebc) and are producing valid independent outcomes from the south african orthopaedic registry (saor). many projects have been implemented through the year and i thank all the members of the exco who have worked tirelessly under difficult circumstances to achieve our goals of making the saoa more relevant and of greater benefit to you, our members. it is our aim to provide you with more and more benefits over the next few years and would value your feedback as to what you feel could benefit you the most. we are proud to report that our finances are sound, membership is finally up to date, the registry has absorbed all historical data from the south african national joint registry (sanjr) and the business core is up and running. the clinical practice committee has worked hard to negotiate better fees, and the path to alternate reimbursement models is well under way. the south african orthopaedic journal gets better and better and is, in my view, a world-class journal. south african orthopaedic registry (saor) the saoa has worked hard to introduce the saor and, although there are some teething problems, the implementation has gone well. all data from the sanjr has been cross-walked and surgeons who were inputting their results to the sanjr can continue on the saor. the registry is not limited to arthroplasty and there are currently 29 pathways spread throughout all fields of orthopaedic surgery. the registry belongs to us and therefore the outcomes generated are completely independent of any other parties. this is of key importance in the future in that it provides us with great leverage in negotiation with other parties, but will also provide an alternate income stream in the future. we acknowledge that the initial input of data is tedious, but the system is intelligent and with time the data input will be much easier. we all need to persevere and generate our own outcomes in the future; if we don’t do this, then funders will use their own data, often inaccurate, and use this to control us. participation in the saor is not a choice, it is essential for our future clinical autonomy and financial security. peer mentoring one of the key issues that the saoa has dealt with over the last few years has been registrar support and this accounts for the bulk of our net expenditure annually. we host the registrar congress, page 14 sa orthop j 2021;20(1) sponsor many registrars in full to attend the annual congress and arrange fellowships. in keeping with our support of members in fulltime public service, we offer significant discounts on subscriptions, congress attendance and levies for these members. we have realised that there is a need for support of junior surgeons, both in public and private practice, and the peer mentoring programme, which will be introduced in 2021, will address these issues. with the development of super-specialisation and separate meetings of specialty groups, we have abandoned support of general orthopaedic surgery. the combined congress addresses this problem by providing access to specialist education in one venue. i understand that it is ‘nicer’ for specialty groups to meet in smaller groups, but the reality is that it makes it impossible for registrars to attend all of these meetings and, given recent events, is unaffordable for our sponsors. the peer mentoring programme will be rolled out in 2021. it will require input by all parties involved in the provision of orthopaedic surgery, the saoa, funders, hospital groups and our trade partners. the aim of the programme is to bridge the gap between registrar and private practice and will involve fellowships, visitation, clinical teaching via cadaver courses and personal mentorship. the programme is not limited to junior surgeons and will be available to all members of the saoa. coding and fees another key issue that needs urgent attention is that of billing of fees. in recent times, this has escalated and there is an increasing prevalence of auditing by funders, sometimes clawing back three years. we have drawn your attention to double billing of fractures, and it is imperative that all codes billed for are reflected in your clinical notes. we have obtained legal advice as to the requirement of funders to notify surgeons of outlying codes and have had success in reducing the obligation of the quantum of claw-back demanded. it is very important to consult us before signing any obligation of debt or repayment agreements. the only way to resolve this impasse is to shift from fee-for-service to alternate reimbursement models of payment. we have been in negotiation with funders and hospital groups to provide a model that is fair, ethically compliant and supports experience and efficiency. these models are available for nearly all procedures and require only adherence to saoa clinical guidelines and compliance with the saor. the saoa will negotiate the quantum of the global fee on your behalf. the arm initiative is well under way and roll out will start from now. the model involves a global fee for the surgeon, anaesthetist, physiotherapist and hospital/prosthesis. the saoa will negotiate a global fee per procedure in conjunction with specialty groups with funders and hospital groups using the ae-ebc contract (administrative entity event-based contract). the surgeon joins the programme by signing the saoa event-based contract or ebc, which will be amalgamated with most existing contracts. there are two reimbursement options. the first is a fixed-fee model and the second a sliding scale model in which each surgeon negotiates a fee with their hospital manager based on experience and efficiency. the anaesthetist and physiotherapist portions remain fixed. the ebc requires that we practise according to saoa clinical guidelines (provided by specialty groups) and enter results in the saor. financial position despite the severe financial crisis caused by the extended lockdown and curtailment of surgery, i am pleased that the saoa remains financially sound and in a good position for the future. decreased revenue has been offset against a smaller congress and significant decrease in presidential travel. our profession is facing huge challenges in the near future. we have to contend with the financial devastation of the covid-19 pandemic and the requirement for reconstructive procedures as a result of delayed surgery, implant companies in dire straits and the real threat of implants not being available, vexatious and spurious litigation, and the threat of nhi. all of these factors will result in a higher demand for treatment at a lower cost and introduction of value-based care for our patients. in the past we have been fragmented by hospital groups and funders to their advantage, but we, as surgeons, are the gatekeepers of our profession and we have the ability to take care of our own destiny. we have been at these crossroads many times in the past and each time we have allowed third parties to dominate our clinical autonomy and reimbursement. i say enough! we are once again facing a precipice in our long-term financial sustainability and again we have the ability to control our destiny. you may well ask, what is different now? the answer to this is the sa orthopaedic registry. the leverage provided by robust outcomes is immense and with these, and alternate reimbursement models, it will be possible to once again take control of our profession. it is vital that we overcome the inconvenience of input of data to protect our future. please support the registry, it belongs to you. the second way to ensure financial sustainability is through group practices. these allow for sharing of costs, purchasing parity and transfer of knowledge to junior colleagues. the mayo clinic started as a small group practice. an efficient group practice will allow you to free up 30% of your time for billable procedures in addition to reducing the cost of maintaining your practice. in summary, through the extraordinary effort of my predecessors and a shared strategy over the last five years, together with the support of orthopaedic surgeons in south africa, the 2020 presidential line and executive committee have tried to introduce many programmes to support you through troubled times and we promise to continue to roll out more benefits in 2021. i believe that the saoa has become a representative and relevant body for all orthopaedic surgeons in public and private practice, and with your involvement will continue to add support to you in the practice of orthopaedic surgery. 404 not found page 13south african orthopaedic journal http://journal.saoa.org.za message from the president ‘we are on the verge of a digital revolution across every aspect of this sector, from the lab bench to the patient’s bed side’.1,2 it is predicted that three emerging technologies will drive the next wave of medical innovation: 1. internet of things: for example, wearable devices can track measures such as walking speed, balance and movement. such real-time data provides a better understanding of disease progression and impact of treatment. 2. artificial intelligence (ai) and machine learning: these technologies will revolutionise the way we interrogate data. 3. emerging data platforms: these will allow unprecedented computing power and advances in data management systems for analysis and insight generation referred to as big data. big data refers to the analysis of massive amounts of data points to gain novel insight; and its key characteristics may be understood by considering data, method and purpose.3 data big data is a massive shift in the ability to collect and analyse data quickly and cheaply. in the future we will routinely collect and analyse massive data sets from a larger number of individuals relevant to a phenomenon; and when possible, analyse all data collected, rather than just data samples. with big data, volume may be traded off against quality. the ‘unreasonable effectiveness of data’ maintains that heterogeneous sources for data of limited quality may be better if one generates a huge amount of it, compared to only a small amount of data at high quality.3 using comprehensive data leads us to ask a further question: when do we stop collecting data and what do we do with ‘new’ data? big data suggests tentativeness; learning is a summary of what is known of a dynamic phenomenon and necessitates reevaluation at regular intervals. method a big data approach requires the use of ai and its application to machine learning.4-6 ai refers to the ability of a machine to perform cognitive functions usually associated with the human mind (perception, reasoning, learning and problem solving). machine learning is the application of ai to massive data sets using complex self-learning algorithms to detect patterns, make predictions and generate hypotheses. the potential of ai is enormous: in 2017, google’s alpha zero program self-learning ai chess programme taught itself chess with no human instruction, and after only 8 hours beat the then reigning 2016 world computer chess champion stockfish 8. purpose there are two distinctive features of big data analysis. the first is the inductive nature of big data systems – analysis of a massive number of data points to identify patterns that prompt hypothesis generation; this in contrast to the conventional research method of using data to validate a human hypothesis. the second is that big data approaches are correlational. big data does not demonstrate causality, is agnostic to cause and has been criticised for lacking causal explanatory value. this is not a new argument: in 1847 the hygienist semmelweist identified that hand washing with chlorine in maternity wards dramatically decreased mortality rates.3 most of his colleagues rejected the findings (he inferred an incorrect underlying cause) and resisted hand washing with chlorine, causing the unnecessary deaths of tens of thousands. big data insights are going to raise similar issues in the future: what is sufficient evidence to act? how high is the burden of proof? the approaches need not be exclusionary. in a recent study of alzheimer’s disease, millions of variables were measured following dna and rna sequencing in different brain regions. conclusions were reached by allowing the data to speak to a likely driver of disease. the data analysis identified the immune system and microglial cells as a key driver of disease (as opposed to traditional concepts relating to tangles or plaques).7 this raised possible novel therapies, which may be evaluated using hypothesis-testing in prospective randomised controlled trials. big data may herald a change to a more staged discovery process – with correlational results and ensuing causal inquest. the usefulness of the big data approach in health care remains disputed, however – does it provide a future with novel insights or does it create more noise that drowns out true signals? jacofsky refers to these as: a lack of data set reliability and clarity; a preponderance of unstructured data; ineffective and inaccurate measures transposed to manage the behaviour of providers and income from payer claims or coders; a lack of intersystem reliability and inconsistent value of output from a system (analogous to a calculator providing a different answer to the same calculation).8 big data can impose the same challenges as small data; and adding more data without physicians to control and standardise definitions will most often not solve but merely magnify the problem. conclusion big data enthusiasts propose that medicine has changed to an information science.9 popular literature declares the physical big data and medicine leon rajah fcs(sa)orth president: sa orthopaedic association page 14 south african orthopaedic journal http://journal.saoa.org.za examination of a patient redundant.10 in our prime directive – ‘the only interest to be served is the interest of the patient’ – is embedded that human spirit to defend the integrity of clinical practice, thought and innovation; and posit clinical medicine as integral to a defence against a future dominated by digital dictatorship, financial oligarchy and human redundancy.11,12 references 1 3 things that will change medicine in 2018. vasant narasimhan, ceo, global head, drug development; novartis ag; world economic forum annual meeting on future of health and healthcare; 24 jan 2018. 2 the economist editorial: a revolution in health care is coming welcome to doctor you; 1st february 2018. 3 mayer-schonberger & ingelsson. big data and medicine: a big deal? journal of internal medicine, 2018;283:418-29. 4 hawking s. brief answers to the big questions. john murray publishers, great britain, 2018. 5 an executive’s guide to ai. mckinsey analytics, mckinsey & company, 2018. 6 domingos p. our digital double: ai will serve our species, not control it. scientific america special issue: the science of being human; september 2018. 7 the role of big data in medicine: interview with dr eric schadt of the icahn institute for genomics and multiscale biology at new york’s mount sinai health system by sastry chilukuri for mckinsey and company; november 2018. 8 jacofsky dj. instructional review: the myths of ‘big data’ in health care. bone joint j 2017;99-b:1571-76. 9 krumholz hm. big data and new knowledge in medicine: the thinking, training, and tools needed for a learning health system. health aff (millwood). 2014 july;33(7):1163-70. doi:10.1377/ hlthaff.2014.0053 10 kraft d. ‘connected’ and high-tech: your medical future. national geographic special issue: the future of medicine; january 2019. 11 varoufakis y. talking to my daughter about the economy a brief history of capitalism. penguin random house publishers; united kingdom 2017. 12 harari yn. 21 lessons for the 21st century. penguin random house publishers, united kingdom 2018. https://www.weforum.org/agenda/authors/vasant-narasimhan page 4 south african orthopaedic journal http://journal.saoa.org.za acknowledgement of reviewers the south african orthopaedic journal is able to publish good quality, peer-reviewed articles thanks to the valuable input provided by its tireless and generous reviewers. by applying their insights and knowledge gained in their areas of expertise, the reviewers ensure the scientific integrity and research quality of the articles. this they do without any reward, and we wish to thank them most sincerely for their contribution to the journal. trauma and general orthopaedics lc marais n ferreira s maqungo b bernstein f birkholtz c frey m laubscher s bruwer n gibson l nieuwoudt g du preez s matshidza r du plessis arthroplasty, knees and hips m held c snyckers a van zyl d van der jagt ie goga j de vos j walters p firer b gelbart m nortje t hilton r smit s sombili j mcalister j van der merwe pg erasmus m roussot spinal surgery rn dunn j davis ja shipley gj vlok m ngcelwane m lukhele s eisenstein e coetzee r ramlakan a puddu n kruger hand surgery a ikram d mcguire m solomons m carides c serfontein research methodology and statistics m burger paediatric orthopaedics j du toit g firth s dix-peek ajf robertson eb hoffman p mare d thompson m thiart a horn k troisi k koch foot and ankle n saragas g mccollum p ferrao j van niekerk c narramore f louw a strydom shoulder and elbow s roche p webster b vrettos a barrow c anley orthopaedic oncology and infections t hilton t le roux k hosking icm robertson ja shipley bgp lindeque j viljoen a olivier page 18 sa orthopaedic journal autumn 2014 | vol 13 • no 1 e d i t o r i a l academic standards in 2008, the academic standards committee of the south african orthopaedic association1 wrote that ‘… trauma patients are increasingly displacing elective cases from routine theatre lists. reduced elective surgery seriously threatens the ability of specialists to train registrars adequately’. indeed, a patient requiring an elective total joint replacement will find it difficult to compete for the same list with a patient with a fracture neck of femur. we have not improved much since 2008. if we do things the same way this situation is unlikely to change. as teachers we need to look at ways of making sure we produce specialists of the same standard we are known for. two health systems south africa has two health systems: the public sector and the private sector. they function parallel to each other. the public sector provides training for all doctors, including orthopaedic surgeons and other specialists. it has a large patient base that allows trainees to have ample clinical material to train on. all the orthopaedic surgeons in the country are trained through this system, including those in the private sector. the public health system has produced excellent doctors over the years, some pioneers in their fields. the first heart transplant in the whole world came from the public sector. the public sector continues to treat the bulk of orthopaedic trauma in the country, but this is now at the expense of non-trauma, elective orthopaedics. the private sector is much smaller, more refined, and treats selected patients from a much smaller patient base. over the years it has grown tremendously, doing most of the super-specialised elective orthopaedic surgery. indeed some of the surgeons in the private sector are world experts in their fields. as mentioned, the two systems work parallel to each other. if we want to improve our training we need to expose our registrars to both systems. more importantly, we need to expand the teaching platform to include other forms of training as well. there are two ways we can expand the teaching platform: 1) the private sector must be involved in the training of orthopaedic surgeons. 2) use must be made of simulators for the training orthopaedic surgeons. the private sector we need to get the private sector involved in the training of orthopaedic surgeons. each training institution needs to identify areas where their training programme is deficient or where it might be augmented. the registrar would then attend that practice and observe the procedures that his training programme is deficient in. admittedly this attachment involves only assisting, but repetitive assisting helps one understand the procedure and the trainee would be able to move to the next stage of training, namely operating under supervision. some training programmes are already making use of this method of expanding the teaching platform. it is however being done haphazardly, and perhaps illegally. increasing the number of doctors is a priority in our country, hence the cuban training programme and theincreased intake of medical students in our universities. equally important are adequately skilled orthopaedic surgeons and other specialists. our graduates are accepted all over the world because of their clinical skills. although we still produce, and will continue producing, well-skilled orthopaedic surgeons, our ability to continue to do so is being threatened. expanding the teaching platform we need to expose our registrars to both systems saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 18 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 19 registrars are employed by the provincial government, and have strict employment contracts. the hospital administrators want all their employees (including registrars) to be at their allocated posts of service delivery all the time. we need to engage our hospital administrators on this issue. they need to realise that if we are to improve service delivery, we need to improve training as well. we will have to prove to the provincial governments that we can do this in a regulated manner, and much better than we have been able to manage rwops (remunerative work outside the public service). we also have to show that there is benefit as far as training is concerned, that will in turn improve service delivery. the practice that has been identified for training may need to be accredited by the registering authority, the health professions’ council of south africa, as a training centre, just as the public hospitals have to be accredited as such in order for them to train doctors. research is becoming an important part of our training. data collection continues to be a major problem in our public hospitals because of irretrievable records. the private sector is much stronger than the public sector in this regard. expanding the teaching platform to include the private sector will improve the research output of the department concerned. simulators the second method of expanding the teaching platform would be to use simulators2 to improve the practical skills for both the procedures we do in the private sector and for the procedures we do not get good exposure to in the public sector. orthopaedic surgical procedures have become more hi-tech over the years. with the increase in medical litigation, it is important that by the time the surgeon has to do an operation in theatre, he/she is adequately trained. the concept of ‘see one, do one, teach one’ is no longer acceptable, and it is pivotal that the surgeon has adequate technical exposure to surgical procedures during his/her training. the figure attached to adequate exposure in a technical skill is still elusive, but what we do know is that repetitive behaviour improves technical skills. simulators provide us with the ability to perform these skills repeatedly. simulators are widely used in education in general. they range in fidelity or realism from hi-tech virtual cockpit flight simulators used to train airline pilots, to the inert sand bags used to train professional boxers. in simple terms a simulator is a person, device or set of conditions, which attempts to present problems authentically; the fidelity (or exactness of duplication) of the simulation is never completely isomorphic with the real thing. the limiting factors are costs, limits of engineering technology, academic design, ethics and time constraints.2 challenges in service delivery issues have been triggering the shift of medical education methods to simulators. the main trigger for the shift to simulation training in our country is the constantly decreasing exposure of our registrars to elective surgical procedures, because of the increased trauma burden. the second reason is the new techniques in orthopaedics. techniques such as arthroscopy, joint replacement and pedicle screw placement are best learnt in a simulation environment, before they can be practised in the operating theatre. the third reason is avoidance of medical errors and patient safety. the ao basic course for fracture fixation is the best simulator example that we have in our training programmes. there is no doubt that, after doing the course, registrars have a much better understanding of the concepts involved in the ao school, for instance compression of fractures, lagging of screws and tapping of screw holes. there is no doubt that these skills are best learnt on a simulator, so that by the time registrars have to do the operation in theatre, they only have to contend with issues of access to the bone, rather than the technical aspects of the plating procedure. not only should the academic departments send their registrars to such a course, they must also have skills laboratories in the departments for the registrars to perform these skills repeatedly. arthroscopy is a skill with a steep learning curve. triangulation and 3-d perception are skills the registrar needs to learn. the old method of learning these skills from the consultant in the theatre is not the best way. there are now very well manufactured plastic simulators where one can practise these skills, again best done in a department’s skills laboratory. the use of simulators as an educational tool has been evaluated in orthopaedics. tonetti3 evaluated a simulator for percutaneous iliac screw insertion and found it to be a valuable tool in training orthopaedic surgeons. joseph et al4 described the value of using models to teach registrars the complex movements and functions of the subtalar joint. the main trigger for the shift to simulation training in our country is the constantly decreasing exposure of our registrars to elective surgical procedures, because of the increased trauma burden saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 19 page 20 sa orthopaedic journal autumn 2014 | vol 13 • no 1 cadavers training using cadaver simulation is perhaps the closest to the real operation. it is what we should all be aiming for to train our registrars. cadaver training is already being used in some centres in our country, and the trend should spread to those centres are not yet using it. it should be extension of the teaching that the orthopaedic departments provide. the anatomy departments have to come closer to the clinical departments for us to be able to provide this type of training to our trainees. cadaver training has been evaluated by various authors. kuhls et al5 reported on cadaver training for trauma surgical registrars. they concluded that cadaver training improved the registrar’s time in exposing vital structures in acute abdominal surgery. in clinical rheumatology,6 a study was done where rheumatology registrars were taught arthrocentesis of various joints using cadavers, anatomical models and picture charts. although all these teaching interventions were helpful, the study concluded that cadaver training was the best method of teaching the registrars arthrocentesis. there is no doubt that in orthopaedics, cadaver simulation is a very good teaching method. we have seen it in our unit, rather anecdotally, in those registrars who have been fortunate enough to attend a cadaver training course in arthroscopy and in spine surgery offered by other institutions. it is a learning platform that we should increasingly use in our country. superficially there is no shortage of cadavers in our country, but of course there are factors that make them not universally available, notably the ethics of using human tissue for teaching, and cost. with the constraints we have in accessing cadavers, it is encouraging to note that, at least in the skill of arthroscopy, synthetic joint models perform just as well as cadavers in teaching registrars.7 conclusion in the wake of the challenges we have in our health system, we need to expand the teaching platform in order to maintain the standard of the orthopaedic surgeons we train. we can do this by involving the private sector in the training of orthopaedic surgeons, and by using simulators in all our training programmes for selected skills. references 1. van der jagt d, golele r, govender s, lukhele m, shipley ja, vlok gj, walters j. orthopaedic injuries in state hospitals compromised. samj 2008;98(8):601. 2. issenberg bs, mcgaghie wc, petrusa er, gordon dl, scalese rj. features and uses of high-fidelity medical simulations that lead to effective learning: a beme systematic review. medical teacher 2005;27(1):10-28. 3. tonetti j, et al. assessment of percutaneous iliac screw insertion simulation. orthop traumatol surg res 2009;95(7):471-77. 4. joseph b, rebello g, mayya s. the use of a working model for teaching functional and surgical anatomy of the subtalar joint. foot ankle int 2006;27(4):286-92. 5. kuhls da, risucci da, bowyer mw, luchette fa. advanced surgical skills for exposure in trauma: a new surgical skills cadaver course for surgery residents and fellows. j trauma acute care surgery 2013;74(2):664-70. 6. berman jr, ben-artzi a, fisher mc, bass ar, pillinger mh. a comparison of arthrocentesis teaching tools: cadaver, synthetic joint models, and the relative utility of different educational modalities in improving trainees’ comfort with procedures. j clinical rheumatology 2012;18(4):175-79. 7. martin kd, belmont pj, schoenfeld aj, todd m, cameron kl, owens bd. arthroscopic basic task performance in shoulder simulator model correlates with similar task performance in cadavers. jbjs am 2011;93(21):e1271-75. prof mthunzi ngcelwane head of orthopaedics, university of pretoria and steve biko academic hospital, pretoria, south africa saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 20 south african orthopaedic journal arthroplasty doi 10.17159/2309-8309/2021/v20n4a1oosthuizen cr et al. sa orthop j 2021;20(4) citation: oosthuizen cr, maposa i, magobotha s, pandit h. impact of correctable mediolateral tibiofemoral subluxation on unicompartmental knee arthroplasty implant survival in patients with anteromedial osteoarthritis. sa orthop j 2021;20(4):196-201. http://dx.doi. org/10.17159/2309-8309/2021/ v20n4a1 editor: dr david north, paarl hospital, western cape, south africa received: october 2020 accepted: november 2020 published: november 2021 copyright: © 2021 oosthuizen cr. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no benefits in any form have been received from a commercial party related directly or indirectly to the subject of this article. conflict of interest: the authors declare they have no conflicts of interest. abstract background medial unicompartmental knee arthroplasty (uka) is advocated for treating symptomatic anteromedial osteoarthritis (amoa). correctable mediolateral tibiofemoral (tf) subluxation can be safely ignored according to the uka enthusiasts. however, no clinical studies compare the results in amoa patients with and without subluxation. this study reports the early prospective clinical outcomes of medial uka in amoa, with and without correctable mediolateral tf subluxation and the comparison to the retrospective larger patient cohort. methods the results of an initial retrospective study (r) consisting of 436 consecutive uka cases (patients treated from may 2012 to october 2017) were compared to a prospective study (p) consisting of 272 consecutive uka cases in 248 patients with amoa (evaluated from november 2017 to may 2020). all patients in both cohorts underwent cementless oxford uka and were classified into two groups: group 1 (amoa without mediolateral subluxation) and group 2 (amoa with mediolateral subluxation) on anteroposterior (ap) radiological knee stress views. survival analysis methods (kaplan–meier and logrank test) were utilised to compare implant survival between the two groups (1 and 2) and the cohorts (r and p). the multivariable cox proportional hazards model was used to determine risk factors for time to revision. results the two cohorts, r and p, had patient groups (group 1 vs group 2) matched for age, sex, wear pattern, preoperative oxford knee score and follow-up period. the overall implant survival for the p cohort that had at least 20 months of follow-up was 98%. the overall implant survival for group 1 (99%) was significantly better compared to group 2 (93%). these results are amplified in the r cohort with an average follow-up of 54 months, and with the group 1 survival at 97% and group 2 at 86%. subsequent months of follow-up show more failures in group 2 compared to group 1. patient-reported outcome measures (proms) and range of movement were similar for both groups. conclusion patients with amoa and correctable mediolateral tf subluxation have a significantly higher risk of implant failure compared to those without subluxation. this study establishes this association, which has an important implication on patient selection, but does not confirm causality. level of evidence: level 4 keywords: unicompartmental knee arthroplasty, partial, osteoarthritis, x-ray, implant impact of correctable mediolateral tibiofemoral subluxation on unicompartmental knee arthroplasty implant survival in patients with anteromedial osteoarthritis christiaan r oosthuizen,¹* innocent maposa,² sebastian magobotha,³ hemant pandit⁴ ¹ private orthopaedic practice, johannesburg, south africa; and division of orthopaedic surgery, university of the witwatersrand, johannesburg, south africa ² faculty of health sciences, health sciences research office, university of the witwatersrand, johannesburg, south africa ³ division of orthopaedic surgery, university of the witwatersrand, johannesburg, south africa ⁴ leeds institute of rheumatic and musculoskeletal medicine (lirmm), chapel allerton hospital and university of leeds, united kingdom *corresponding author: c-c@mweb.co.za https://orcid.org/0000-0001-9973-5290 page 197oosthuizen cr et al. sa orthop j 2021;20(4) introduction medial unicompartmental knee arthroplasty (uka) is advocated for treating symptomatic anteromedial osteoarthritis (amoa). by definition, amoa has bone-on-bone medial compartment osteoarthritis (oa) in the presence of intact ligaments and a functionally intact lateral tibiofemoral (tf) compartment.1 to confirm the diagnosis of amoa, use of varus and valgus stress radiographs in addition to weight-bearing anteroposterior (ap) and lateral radiographs is recommended.2 these radiographs are performed with the patient lying supine and the knee under study flexed at 20°, with either manual or aided stress applied to the knee. the technique is well described elsewhere.2 a varus stress radiograph is the most reliable radiographic method to demonstrate full thickness loss of articular cartilage (bone-on-bone contact) between the medial femoral and tibial condyles.2,3 a valgus stress radiograph helps confirm normal thickness of articular cartilage in the lateral tf compartment and demonstrates that the intraarticular varus deformity is correctable (i.e., the medial collateral ligament is not shortened). in patients with amoa, the wear pattern on the medial tibial plateau does not extend to the posterior margin of the tibia, and in all the cases there is intact articular cartilage on the posterior margin of the medial tibial plateau.1,2 in a proportion of patients with amoa, a preoperative ap radiograph demonstrates the presence of mediolateral subluxation of the femur on the tibia. it is typically seen when there is significant loss of bone from the medial compartment (varus > 10°) and this subluxation persists with a varus stress view. the oxford group suggests that in such cases, if the valgus and varus stress views show complete reduction of the mediolateral subluxation, the presence of preoperative subluxation can be safely ignored.4 if the subluxation persists, it is indicative of anterior cruciate ligament (acl) deficiency and is therefore a contraindication for oxford uka (ouka).2 although this has been advocated, no studies exist comparing the long-term results of ouka in patients with correctable subluxation with those without any subluxation. does the subluxation on weight-bearing knee x-rays affect the results and outcome of uka? this single centre, single surgeon cohort study of consecutive cases has two aims: first, to present early prospective (p) results of ouka in patients with amoa between patients with correctable preoperative mediolateral tf subluxation and those without, from an independent centre; and second, to similarly compare the outcomes of a larger medium-term retrospective (r) amoa cohort followed up by the same surgeon until 2020. methods the prospective cohort (p) study comprised 272 consecutive amoa knees (248 patients) treated with medial ouka (zimmer biomet, warsaw, usa) over a 31-month period from november 2017 to may 2020. the larger retrospective cohort (r), comprising 436 cases from may 2012 to october 2017, was then similarly evaluated according to the selection criteria for ouka as per the published recommendations.2-4 all patients underwent a standardised preoperative work-up including detailed clinical assessments and a series of radiographs as described previously.5 preoperative oxford knee score (oks)6 and range of movement (rom) was recorded. the acl status and integrity of the lateral tf compartment were confirmed intraoperatively. if acl was found to be friable and fragmented or absent, the patient underwent a total knee arthroplasty (tka). in addition, the tibial wear pattern was carefully recorded using a method described by white et al.1 the wear pattern was labelled as either anterior, or central or posterior according to the location of the deepest area of wear in relation to the ap tibial plateau dimension. all plain radiographs were assessed by an independent assessor for the presence or absence of mediolateral tf subluxation and patients were grouped accordingly into group 1 (patients with amoa without any evidence of mediolateral subluxation on preoperative weight-bearing ap radiographs, figures 1 a–c) and group 2 (patients with amoa with presence of mediolateral subluxation on preoperative weightbearing ap radiographs, figures 2 a–c). in all cases in group 2, the mediolateral subluxation completely corrected on valgus stress view with parallel reduction of the lateral joint space thereby confirming the suitability for ouka. to simplify the assessment of subluxation on the ap views, it was defined as any overhang of the femoral condyle (excluding osteophytes) over the medial border of the tibia. figure 1. group 1 preoperative radiographs. a) 15° ap; b) varus stress view; c) valgus stress view a b c page 198 oosthuizen cr et al. sa orthop j 2021;20(4) all patients underwent a cementless medial ouka using the recommended surgical technique with microplasty® instrumentation with standardised postoperative management.7 patients were followed up at predetermined regular intervals (three months and then annually after surgery) with clinical and radiological assessment. clinical assessment included oks, a validated and widely used patient-reported outcome measure (prom) and active rom. all complications and/or further interventions on the index knee were recorded on an anonymised secure database. any surgical intervention needed for removal or exchange of an existing implant or addition of another implant was labelled as revision. statistical analysis description of categorical variables was reported as a number and percentage. associations between categorical variables were evaluated using chi-square (χ2) or fisher’s exact tests as appropriate. continuous variables were summarised and presented as mean and range, or as median and interquartile range (iqr). a student’s t-test for normally distributed data or mann-whitney u test for non-normally distributed data was used to compare group differences in continuous variables. survival analysis methods such as the kaplan–meier survival curves and logrank test were utilised to assess the patterns of implant survival between patients’ characteristics. the multivariable cox proportional hazards model was used to fit the predictive model for time to revision. a two-sided 5% significance level was used in all the statistical tests. results the prospective (p) cohort of 272 knees (248 patients) included 162 (60%) men and 110 (40%) women with an average age of 64 (40–92; sd = 10) years at time of operation. the mean follow-up was 20 months (range 4–34; sd = 10). the mean postoperative oks in the non-revised knees (at the time of last follow-up) was 43 (range 14–48; sd = 6.3), while for the revised knees it was 44 (range 26–48; sd = 5.6). the mean rom was 0.3° (range 0–3; sd = 0.86) to 140° (range 120–150; sd = 6.2). the retrospective (r) cohort of 436 knees (388 patients; 175 [40%] females and 261 [60%] males) had an average age of 64 years (range 42–87, sd = 8.7) at operation. the mean postoperative follow-up was 54 months. the mean postoperative oks in the nonrevised knees (at the time of last follow-up) was 44 (range 12–48, sd = 5.7), while for the revised knee it was 42 (range 22–48, sd = 8.0). the mean rom for this cohort was 0.68° (range 0–5, sd = 1.3) to 138° (range 110–150, sd = 8.2). the patient demographics (table i), implant survival rates (table ii), and clinical outcomes and complications (table iii) for group 1 and group 2 in the respective cohorts p and r are summarised accordingly. the two groups were well matched for all relevant patient demographics as well as preoperative scores, rom, followup period and tibial wear patterns. the complications were not associated with a specific wear pattern. reasons for revision in total, six knees underwent revision at a mean of 25 months (sd = 10.9; range: 8.1–33.2 months) post base year of follow-up in the p cohort. these included two for tibial subsidence, two for bearing dislocation and two for progression of arthritis in the lateral compartment. the r cohort had 23 knees that underwent revision, and these had a slightly longer duration before revisions. the detail of the complications and procedures performed are detailed in table iii. the life table analysis for patients who had surgery between 2012 and 2017 (r cohort) is presented in table ii with the a b c figure 2. group 2 preoperative radiographs. a) 15° ap; b) varus stress view; c) valgus stress view page 199oosthuizen cr et al. sa orthop j 2021;20(4) respective implant survival for group 1 and group 2. the first three years’ implant survival for patients in both group 1 and 2 was 100%. the implant survival in the subsequent two years was 99% (95% confidence interval [ci]: 96.9–99.6) among those who were diagnosed without mediolateral subluxation (group 1) and 96% (95% ci: 89.2–98.8) among those with mediolateral subluxation (group 2) respectively. the difference between the two groups was statistically significant overall (p = 0.0097) over the followup period. the p cohort had only three years of follow-up and in that period, survival for group 1 was 99% (95% ci: 96–99.6) while group 2 was 93% (95% ci: 80.3–97.8). figure 3 shows the failure patterns in the two groups for both cohorts. multivariate cox regression analysis showed that presence or absence of mediolateral subluxation was a significant independent table ii: life table analysis with 95% ci for implant revision for any cause in the 2012–2017 (r) cohort follow-up (years) group 1 group 2 no. at start survival (95% ci) no. at start survival (95% ci) 0–3 (base) 352 100% 84 100% 4–5 339 99% (96.9–99.6%) 83 96% (89.2–98.8%) 6–8 132 93% (88.3–96.5%) 52 80% (66.7–88.1%) ci: confidence interval table iii: clinical outcomes and complications for the two groups in cohort category prospective (p) cohort retrospective (r) cohort group 1 (n = 228) group 2 (n = 44) group 1 (n = 352) group 2 (n = 84) follow-up period in months; mean (sd) 21 (8.8) 18 (8.4) 57 (15.9) 66 (16.0) postoperative rom; mean (from–to) 0.3–140° 0–138° 1–138° 0–138° most recent postoperative oks; mean (sd) 43 (6.3) 44 (5.6) 44 (5.7) 43 (8.0) complications needing revision surgery 3 (1%) 3 (7%) 11 (3%) 12 (14%) average period to implant failure in months; mean (sd) 24 (13.5) 27 (10.3) 63 (17.1) 65 (16.6) bearing dislocation – with revision of medial uka (polyethylene replaced) 0 1 1 2 bearing dislocation – with revision of medial uka (implant replaced) 0 1 0 0 lateral compartment oa – with revision to lateral uka 2 0 3 3 tibial subsidence – with revision of medial uka (implant replaced) 1 1 1 0 tibial subsidence – with revision of medial uka (polyethylene replaced) 0 0 2 0 avascular necrosis in the lateral compartment – with revision to lateral uka 0 0 1 0 tibia fracture – with revision to tka 0 0 0 2 impingement – with revision of medial uka (implant replaced) 0 0 0 1 acl trauma and polyethylene dislocation – with revision of medial uka (polyethylene replaced) and acl reconstruction 0 0 0 1 loose prosthesis – with revision to tka 0 0 0 1 no bone growth to attach prosthesis – with revision to tka 0 0 1 0 complication unknown – patients underwent revision surgery to tka from other surgeons 0 0 2 2 sd: standard deviation; rom: range of movement; oks: oxford knee score; uka: unicompartmental knee arthroplasty; oa: osteoarthritis; tka: total knee arthroplasty; acl: anterior cruciate ligament table i: patient demographics and relevant preoperative data category prospective (p) cohort retrospective (r) cohort group 1 group 2 group 1 group 2 cases 228 44 352 84 age in years at operation; mean (sd) 64 (9.5) 66 (11.2) 65 (8.8) 64 (8.5) males 64 (9.5) 64 (9.9) 65 (8.4) 63 (8.6) females 64 (9.6) 70 (13.0) 64 (9.3) 64 (8.4) tibial wear pattern: anterior 51 (22%) 5 (11%) 87 (25%) 10 (12%) central 161 (71%) 35 (80%) 247 (70%) 67 (80%) posterior 16 (7%) 4 (9%) 18 (5%) 7 (8%) preoperative rom; mean (from–to) 3–128° 4–129° 2–131° 3–126° preoperative oks; mean (sd) 21 (8.1) 21 (10.1) 22 (8.0) 23 (8.6) sd: standard deviation; rom: range of movement; oks: oxford knee score page 200 oosthuizen cr et al. sa orthop j 2021;20(4) predictor of implant failure (table iv). a patient with preoperative mediolateral subluxation had, on average, a three times higher risk of surgical failure (adjusted hazard ratio [ahr] = 3.3; 95% ci: 1.4–8.7; p = 0.0170) compared to a patient without mediolateral subluxation. age, sex and wear pattern were not significantly associated with the risk of implant failure in this cohort (table iv). discussion this is the first prospective study to assess the impact of preoperative correctable mediolateral subluxation on the outcomes of uka in patients with amoa. although this is a short prospective study, it confirms the higher failure rate, contrary to the previous recommendations in the literature, when compared to those with amoa without preoperative mediolateral subluxation.4 amoa knee is an ideal indication for uka. various studies have demonstrated the clinical effectiveness and cost-savings of uka over tka in such patients.8-12 in a significant proportion of patients, preoperative ap radiographs reveal the presence of mediolateral subluxation. although the exact aetiology for such subluxation is unknown, it is believed to be associated with significant wear and/or bone loss and potentially acl deficiency – the latter being a contraindication for mobile-bearing uka.4 to ascertain the suitability of such patients for uka, it is recommended that patients should be assessed using stress views – particularly the valgus stress – and intraoperative assessment of the lateral compartment as well as acl integrity.5 if valgus stress and intraoperative inspection confirms suitability for uka, patients could be safely offered a uka. in this series, we prospectively collected data on all the patients undergoing uka. this included careful recording of preoperative patient demographics including radiological stress views, intraoperative assessment for suitability for uka, tibial wear patterns and regular clinical follow-up at predetermined intervals. in our cohort we noted correctable mediolateral subluxation in 27% of cases. the implant survival was significantly inferior in patients with correctable mediolateral subluxation compared to those without subluxation. there were no significant differences in demographics between the two patient groups. although the reasons for implant failure were similar in the two patient cohorts, the frequency of bearing dislocation was significantly higher in patients with mediolateral subluxation. the assessment of wear patterns was compared to the area of wear (table v), and no association of complications with a specific wear pattern could be found. if we assess the risk of implant revision based on the pattern of tibial wear, it is interesting to note that the risk increases when the wear pattern changes from anterior to central or posterior. the central/posterior area of wear may contribute to pseudolaxity and higher incidence of bearing dislocation. although the centre of the deepest portion of the wear pattern was posterior to midline in none of the cases, the wear extended to the posterior margin of the medial tibial plateau. in all cases, the acl was functionally intact a) retrospectively b) prospectively . 2 5 . 4 5 . 6 5 . 8 5 1 . 0 5 0 20 40 60 80 100 95% ci 95% ci group 1 group 2 s u r v i v a l p r o b a b i l i t y time to failure in months 0 . 2 5 . 5 . 7 5 0 5 10 15 20 25 30 35 95% ci 95% ci group 1 group 2 s u r v i v a l p r o b a b i l i t y time to failure in months a) retrospectively b) prospectively . 2 5 . 4 5 . 6 5 . 8 5 1 . 0 5 0 20 40 60 80 100 95% ci 95% ci group 1 group 2 s u r v i v a l p r o b a b i l i t y time to failure in months 0 . 2 5 . 5 . 7 5 0 5 10 15 20 25 30 35 95% ci 95% ci group 1 group 2 s u r v i v a l p r o b a b i l i t y time to failure in months a) retrospectively b) prospectively . 2 5 . 4 5 . 6 5 . 8 5 1 . 0 5 0 20 40 60 80 100 95% ci 95% ci group 1 group 2 s u r v i v a l p r o b a b i l i t y time to failure in months 0 . 2 5 . 5 . 7 5 0 5 10 15 20 25 30 35 95% ci 95% ci group 1 group 2 s u r v i v a l p r o b a b i l i t y time to failure in months a) retrospectively b) prospectively . 2 5 . 4 5 . 6 5 . 8 5 1 . 0 5 0 20 40 60 80 100 95% ci 95% ci group 1 group 2 s u r v i v a l p r o b a b i l i t y time to failure in months 0 . 2 5 . 5 . 7 5 0 5 10 15 20 25 30 35 95% ci 95% ci group 1 group 2 s u r v i v a l p r o b a b i l i t y time to failure in months time to failure in monthstime to failure in months s ur vi va l p ro ba bi lit y s ur vi va l p ro ba bi lit y 0 5 10 15 20 25 30 350 20 40 60 80 100 .2 5 . 45 .6 5 . 85 1. 05 0 .2 5 .5 .7 5 a) retrospectively b) prospectively figure 3. surgical failure in group 1 and group 2 by the presence or absence of mediolateral subluxation on preoperative radiographs in patients followed up a) retrospectively and b) prospectively table iv: factors affecting time to failure in cohort: multivariable cox regression model factor prospective (p) cohort retrospective (r) cohort ahr (95% ci) p-value ahr (95% ci) p-value mediolateral subluxation group 1 (subluxation absent) 1 1 group 2 (subluxation present) 11 (1.67–66.1) 0.012 2.9 (1.25–6.86) 0.013 sex female 1 1 male 0.41 (0.06–2.92) 0.372 0.67 (0.29–1.54) 0.349 wear pattern anterior 1 1 central/posterior 0.82 (0.08–8.58) 0.869 1.12 (0.37–3.37) 0.841 age at surgery 1.0 (0.91–1.1) 0.959 1.0 (0.56–1.05) 0.926 ahr: adjusted hazard ratio; ci: confidence interval page 201oosthuizen cr et al. sa orthop j 2021;20(4) (on intraoperative assessment), thereby confirming the patient’s suitability for uka as per established criteria. this study has certain limitations. it is a single surgeon, single centre study with a short prospective element conforming to the trend seen in the larger retrospective cohort which cannot yet be generalised. the prospective cohort also had very few failures (only six) for both groups, which could increase uncertainty in the risk estimate due to limited power. however, analysis of the prospective (p) cohort is still under continuous evaluation, and will be submitted when the five-year mean has been achieved. the study confirms association (and not causality) between higher implant failures and patients with pre-existing correctable mediolateral subluxation in patients with amoa. the indications for surgery, surgical technique and postoperative regimen were standardised. all patients were followed up with detailed records of their clinical outcomes and complications. the follow-up is adequate and overall implant survival is similar to other reported series with the use of cementless ouka. further work is needed to establish if similar findings are observed by other researchers, and attempts should be made to understand the association between smoking status, tibial wear patterns, coronal subluxation and implant failure. conclusion the amoa with anterior wear and without mediolateral subluxation is the most suitable knee for uka. in patients with correctable preoperative mediolateral subluxation, caution must be exercised when offering a cementless uka. acknowledgements the authors would like to thank margaret houman (research manager) and andricha viljoen (researcher) for their contributions. ethics statement all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. all procedures were in accordance with the ethical approval obtained from the human research ethics committee at the university of the witwatersrand (wits) with clearance certificate numbers m1704111 and m1704112. all patients provided informed consent for inclusion in the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. professor pandit is a national institute for health research (nihr) senior investigator. the views expressed in this article are those of the author(s) and not necessarily those of the nihr, or the department of health and social care. table v: patient characteristics for failed vs not failed implants variable prospective (p) cohort retrospective (r) cohort surgery failed, n (%) surgery not failed, n (%) p-value surgery failed, n (%) surgery not failed, n (%) p-value sex female 2 (2) 108 (98) 0.535* 11 (6) 164 (94) 0.440* male 4 (3) 158 (97) 12 (5) 249 (95) age in years (range) 64 (57–72) 64 (40–92) 0.865++ 64 (48–76) 65 (42–87) 0.907++ mediolateral subluxation group 1 3 (1.3) 225 (98.7) 0.056* 11 (3) 341 (97) <0.001* group 2 3 (6.8) 41 (93.2) 12 (14) 72 (86) tibial wear pattern anterior 1 (2) 55 (98) 0.739* 4 (4) 93 (96) 0.925* central 5 (3) 191 (97) 18 (6) 296 (94) posterior 0 (0) 20 (100) 1 (4) 24 (96) *chi-squared test ++ independent-samples student’s t-test author contributions cro: primary author, study conceptualisation, design, data collection and contribution, first draft preparation, manuscript preparation and revision, submission of final manuscript im: design, data analysis, manuscript preparation and revision sm: design, manuscript preparation and revision, supervisor, final approval of manuscript version submitted to the journal hp: design, manuscript preparation and revision, critical revision for important intellectual content orcid oosthuizen cr https://orcid.org/0000-0001-9973-5290 maposa i https://orcid.org/0000-0002-3448-4096 magobotha s https://orcid.org/0000-0003-4774-0420 pandit h https://orcid.org/0000-0001-7392-8561 references 1. white sh, ludkowski pf, goodfellow jw. anteromedial osteoarthritis of the knee. j bone joint surg br. 1991;73(4):582-86. https://doi.org/10.1302/0301-620x.73b4.2071640. 2. goodfellow j, o’connor j, pandit h, et al. unicompartmental arthroplasty with the oxford knee. 2nd ed. goodfellow publishers limited; 2015. 3. hamilton tw, pandit hg, lombardi av, et al. radiological decision aid to determine suitability for medial unicompartmental knee arthroplasty: development and preliminary validation. bone joint j. 2016;98-b(10 suppl b):3-10. https://doi.org/10.1302/0301620x.98b10.bjj-2016-0432.r1. 4. kendrick bj, rout r, bottomley nj, et al. the implications of damage to the lateral femoral condyle on medial unicompartmental knee replacement. j bone surg br. 2010;92(3):374-79. https://doi.org/10.1302/0301-620x.92b3.23561. 5. oosthuizen cr, takahashi t, rogan m, et al. the knee osteoarthritis grading system for arthroplasty. j arthroplasty. 2019;34:450-55. https://doi.org/10.1016/j.arth.2018.11.011. 6. murray dw, fitzpatrick r, rogers k, et al. the use of the oxford hip and knee scores. j bone joint surg br. 2007;89(8):1010-14. https://doi.org/10.1302/0301-620x.89b8.19424. 7. bell sw, stoddard j, bennett c, london nj. accuracy and early outcomes in medial unicompartmental knee arthroplasty performed using patient specific instrumentation. knee 2014;21(suppl 1):s33-6. https://doi.org/10.1016/s0968-0160(14)50007-5. 8. kazarian gs, lonner jh, maltenfort mg, et al. cost-effectiveness of surgical and nonsurgical treatments for unicompartmental knee arthritis: a markov model. j bone joint surg am. 2018;100(19):1653-60. https://doi.org/10.2106/jbjs.17.00837. 9. campi s, pandit h, hooper g, et al. ten-year survival and seven-year functional results of cementless oxford unicompartmental knee replacement: a prospective consecutive series of our first 1000 cases. knee. 2018;25(6):1231-37. https://doi.org/10.1016/j.knee.2018.07.012. 10. burn e, liddle ad, hamilton tw, et al. cost-effectiveness of unicompartmental compared to total knee replacement: a population-based study using data from the national joint registry for england and wales. bmj open. 2018;8(4):e020977. https://doi.org/10.1136/ bmjopen-2017-020977. 11. hamilton tw, pandit hg, jenkins c, et al. evidence-based indications for mobile-bearing unicompartmental knee arthroplasty in a consecutive cohort of thousand knees. j arthroplasty. 2017;32(6):1779-85. https://doi.org/10.1016/j.arth.2016.12.036. 12. beard dj, davies lj, cook ja, et al. topkat study group. the clinical and cost-effectiveness of total versus partial knee replacement in patients with medial compartment osteoarthritis (topkat): 5-year outcomes of a randomised controlled trial. lancet. 2019;394(10200):746-56. https://doi.org/10.1016/s0140-6736(19)31281-4. https://orcid.org/0000-0001-9973-5290 https://orcid.org/0000-0002-3448-4096 https://orcid.org/0000-0003-4774-0420 https://orcid.org/0000-0001-7392-8561 https://doi.org/10.1302/0301-620x.73b4.2071640 https://doi.org/10.1302/0301-620x.98b10.bjj-2016-0432.r1 https://doi.org/10.1302/0301-620x.98b10.bjj-2016-0432.r1 https://doi.org/10.1302/0301-620x.92b3.23561 https://doi.org/10.1016/j.arth.2018.11.011 https://doi.org/10.1302/0301-620x.89b8.19424 https://doi.org/10.1016/s0968-0160(14)50007-5 https://doi.org/10.2106/jbjs.17.00837 https://doi.org/10.1016/j.knee.2018.07.012 https://doi.org/10.1136/bmjopen-2017-020977 https://doi.org/10.1136/bmjopen-2017-020977 https://doi.org/10.1016/j.arth.2016.12.036 https://doi.org/10.1016/s0140-6736(19)31281-4 _hlk80978892 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 43 vitamin d status in patients undergoing arthroplasty dr rf snyders mbchb(stell) orthopaedic registrar, university of kwazulu-natal dr jd jordaan mbchb(stell), h dip orth, fc ortho(sa) consultant, orthopaedic surgeon dr mn rasool mbchb(ukzn), fcs orth(sa), phd(ukzn) consultant, paediatric orthopaedics, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa prof ie goga frcs(edin), fcs orth(sa) head of department: orthopaedic surgery, inkosi albert luthuli central hospital, durban, kwazulu-natal, south africa corresponding author: dr rf snyders department of orthopaedic surgery university of kwazulu-natal nelson r mandela school of medicine private bag 7 congella, durban, 4001 email: snyders.rob@gmail.com introduction lack of vitamin d has become a cause for concern in patients undergoing arthroplasty. undiagnosed vitamin d deficiency has in recent years become very topical in the literature. multiple studies have demonstrated inadequate vitamin d levels in populations who are otherwise healthy.1-3 recent literature has shown an association with inferior post-operative outcomes following arthroplasty.3,4 adverse outcomes are not just confined to arthroplasty, as shown in recent systematic review of prospective and retrospective studies.5 although the association with adverse outcomes has been identified, the direct causative effect of low vitamin d status is poorly understood and requires further investigation.5 in current literature there is no existing data on vitamin d deficiency from south africa in the population presenting for arthroplasty. the purpose of this retrospective chart review was to determine the prevalence of vitamin d deficiency in the population presenting to inkosi albert luthuli central hospital for arthroplasty surgical procedures from august 2012 to august 2013. materials and methods following ethical approval, we retrospectively reviewed the charts of all patients presenting for surgery at the arthroplasty unit for the period august 2012 to august 2013. the data was compiled using theatre registers and ward admissions. vitamin d levels are routinely done for patients presenting for elective arthroplasty. abstract vitamin d deficiency has, in recent literature, been associated with poorer outcomes following arthroplasty. this is a retrospective chart review of 209 patients presenting to a local arthroplasty unit in one year. the aim was to identify the prevalence of undiagnosed vitamin d deficiency in this group of patients. the results showed a 10% prevalence. in this study, indian and coloured female patients were most at risk (15–16% prevalence) and black patients had the lowest prevalence (6.9%). in conclusion, the population presenting for arthroplasty at this unit is at risk of vitamin d deficiency, and we advocate vitamin d levels to be part of a standard metabolic workup in our environment. key words: vitamin d deficiency, arthroplasty, poor outcomes http://dx.doi.org/10.17159/2309-8309/2016/v15n4a6 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 43 page 44 sa orthopaedic journal summer 2016 | vol 15 • no 4 all the patients with recorded vitamin d 25(oh)d3 levels were included in this study. all patients undergoing elective hip and knee replacement surgery were selected. patients previously diagnosed with, or on treatment, for vitamin d deficiency were excluded. the total admissions for surgical procedures for the time period numbered 345. of the total number of admissions, 136 patients were excluded due to incomplete results or files, inconclusive results, or chronically receiving treatment for vitamin d deficiency. the remaining 209 were selected to be included in the study. the data captured included gender, age, race, vitamin d level, and whether the patient underwent a total hip or knee replacement. insufficient and deficient levels were grouped together (group a) and compared to the sufficient group (group b). deficient was classified as <20 ng/ml, insufficient as <30 ng/ml, and sufficient as >30 ng/ml, as described by the endocrine society in their clinical practice guidelines.6-8 with regard to statistical analysis, the data was entered in microsoft excel and subsequently analysed in spss version 21. categorical variables were described using frequencies and percentages in tables and bar charts. continuous variables were summarised using mean, standard deviation and range. where the distribution was asymmetrical, median and interquartile range was used. a p-value of <0.05 was used to indicate statistical significance in the comparison of those with deficiencies or insufficient levels compared to those with sufficient levels. independent samples’ t-tests were used to compare ages between the two groups, and pearson’s chi-square test was used to compare the categorical variables between the two groups. results the results showed that 10% (n=21) of the study population presented with undiagnosed vitamin d deficiency and insufficiency (table i). of the 209 patients, 73.2% (n=153) were female and 26.8% (n=56) male. according to the race distribution, black patients were in the majority at 48.3% (n=101), indian people comprised 28.2% (n=59), white 20.6% (n=43) and coloured 2.9% (n=6). total hip replacements constituted the majority of surgical procedures at 59.3% (n=124) compared with total knee replacements at 40.7% (n=85) (table ii). the mean age for the insufficient group was 62.43 years and 61.43 years for the sufficient group. there was no statistical difference between group a and b (table iii). the total number of patients in the insufficient group was 21. seventeen (81%) were female and four (19%) male. when grouped according to race, there were nine (42.9%) indian, seven (33.3%) black, four (19%) white and one (4.8%) coloured patient. fifteen presented for total hip replacements and six for total knee replacements. we used pearson’s chi-squared test to compare categorical variables between the insufficiency and sufficient groups (table iv). there were no significant statistical differences found regarding gender, age, race or joint involvement comparing group a to group b. discussion vitamin d deficiency is a common problem in patients presenting for hip and knee arthroplasty. nawabi et al. showed a prevalence of 24% in their study of 62 patients presenting for hip arthroplasty.4 jansen et al. similarly measured vitamin d levels in 139 elderly patients presenting for knee arthroplasty and also found a 24% prevalence.3 both these studies dealt with mainly caucasian populations. although they were not specifically described for arthroplasty patients, an even higher prevalence has been found in other studies.2 data from the united states (us) national health and nutrition survey (nhanes) have found a prevalence nearing 30%.2 it is important to note that there is variation when it comes to the interpretation of vitamin d status. there is currently no consensus on the definition of vitamin d deficiency or which total serum levels are considered optimal.9 table i: total number of patients in this study group vit d levels number percentage group a deficient (<20 ng/ml) 6 2.9% insufficient (21–29 ng/ml) 15 7.2% group b sufficient (>30 ng/ml) 188 90% total 209 100% table ii: distribution of joint involvement joint group a group b total chi-squared p-value number % number % number % hip 15 71.4 109 58 124 59.3 0.349 knee 6 28.6 79 42 85 40.7 table iii: comparison of mean age study vit d levels number mean age t-test p-value this study group a 21 62.43 0.701 group b 188 61.43 nawabi, et al.4 71 jansen & haddad3 71.4 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 44 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 45 we considered the patient population presenting to this unit to be at risk for undiagnosed vitamin d deficiency. most of these patients present with more than a single risk factor. documented risk factors include darker skin, increasing age, obesity, and decreased sunlight exposure.10 the nhanes in the us found females and races of darker pigment (african americans and hispanics) to have lower vitamin d levels.2 a large percentage of the patients also present in advanced stages of their hip and knee pathology. socio-economic conditions are poor and therefore nutritional factors may also play a role. due to the burden of the lower limb pathology, they are constrained with regard to mobility, often presenting as home ambulators, and often have limited exposure to sunshine. this study population consisted of 81% darker pigmented patients, and 73.2% were female. this study showed only a 10% prevalence, which was lower than expected. males had a prevalence of 7.1%, and females 11.1%. therefore, despite multiple risk factors, our overall prevalence is lower than similar previous studies. further detailed analysis is required to identify why the prevalence in our study is not similar to comparable ones. these results may suggest that the local population’s cutaneous and dietary intake of vitamin d is sufficient. currently, there is no existing comparative data on vitamin d deficiency from south africa in the arthroplasty population. recent literature in vitamin d levels in arthroplasty patients has stimulated interest in this study. of particular concern is the association with adverse outcomes. the adverse outcomes are not confined to arthroplasty alone, as shown in a recent systematic review of prospective and retrospective studies.5 iglar and hogan identified diverse adverse outcomes associated with low pre-operative vitamin d status.5 these adverse outcomes related to orthopaedic procedures include decreased ambulation distance after surgery, increased pain scores, and decreased post-operative knee strength.3,5,11-13 nawabi confirmed that patients with vitamin d deficiency had lower pre-operative harris hip scores. post-operatively, this group was less likely to attain excellent harris hip scores.4 jansen and haddad found similar results in total knee arthroplasty with significantly lower knee society scores preand post-operatively in vitamin d deficient patients.3 further negative effects of vitamin d deficiency include poor bone mineralisation and detrimental effects on fracture healing.7 maier et al. have shown a statistically significant association with low vitamin d status and periprosthetic joint infection in hip, knee and shoulder arthroplasty.14 it must be highlighted that in this study there was no data collected to determine whether deleterious outcomes were associated with the 10% found to have deficient vitamin d status. specific race analysis showed indian and coloured race groups to have the highest prevalence. indian study subjects had a 15% prevalence and coloured 16% compared to white 9% and black only 6.9%. based on these findings the black population presenting for arthroplasty has the lowest prevalence. it also indicates that indian and coloured female patients are most at risk for presenting with vitamin d deficiency in our environment. although the mean age in both groups were similar, it was lower compared to similar studies. this may be due to the lower life expectancy of people in kwazulu-natal (kzn).15 according to a report published by statistics south africa in july 2014 the average life expectancy from birth for males in kzn is only 54.4 years, and 59.4 years for females.15 another contributing factor may be the increase of younger (<55 years) patients presenting with avascular necrosis (avn) of the hip. this unit identified avn to represent 67% of the aetiology of patients under the age of 55 years undergoing total hip replacement surgery.16 emphasis has mostly been placed on the association of low vitamin d status and adverse outcomes, but there is no current evidence that supplementation is of any benefit.17 it would be logical to use supplementation as treatment to optimise pre-operative vitamin d status. replacement therapy has shown improvements in intensive care mortality and optimal status is clearly beneficial, but more studies are required to define whether supplementation is beneficial in the peri-operative setting of deficiency relating to arthroplasty.18,19 table iv: study population characteristics characteristics group a group b total chi-squared p-valuenumber % number % number % gender female 17 81 136 72.3 153 73.2 0.603 male 4 19 52 27.7 56 26.8 race indian 9 42.9 50 26.6 59 28.2 0.366 black 7 33.3 94 50 101 48.3 coloured 1 4.8 5 2.7 6 2.9 white 4 19 39 20.7 43 20.6 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 45 page 46 sa orthopaedic journal summer 2016 | vol 15 • no 4 the strength of this study was the number of patients in the study population as well as the multiracial distribution. limitations in this study would include the disproportionate ratio of the various race groups, and the lack of consensus regarding definitions, which impair comparison to similar studies. since no functional assessment data was captured, we are also unable to comment about adverse outcomes, and whether, if any, association exists with low vitamin d status in our study population. more studies are required to accurately define the role vitamin d deficiency plays in the population of patients presenting for arthroplasty. further evidence is required regarding adverse outcomes following arthroplasty in patients with vitamin d deficiency, and whether they correlate with existing literature. this information may be valuable to prevent adverse outcomes in our patients. conclusion we conclude that the patient population presenting for arthroplasty at our unit is at risk of undiagnosed vitamin d insufficiency, although it is less than in similar study groups. more research is required regarding the association vitamin d deficiency has with adverse outcomes, especially in understanding whether there is a direct link or a mere association. compliance with ethics guidelines the content of this article is the original work of the authors. drs snyders, jordaan and rasool and prof goga have no conflicting interests, and received no benefits for writing this article. ethical approval was obtained. references 1. mithal a, wahl da, bonjour jp, et al. global vitamin d status and determinants of hypovitaminosis d. osteoporos int 2009;20:1807-20. 2. yetley ea. assessing the vitamin d status of the us population. am j clin nutr 2008;88:558-64. 3. jansen ja, haddad fs. high prevalence of vitamin d deficiency in elderly patients with advanced osteoarthritis scheduled for total knee replacement associated with poorer preoperative functional state. ann r coll surg engl 2013;95:569-72. 4. nawabi dh, chin kf, keen rw, haddad fs. vitamin d deficiency in patients with osteoarthritis undergoing total hip replacement: a cause for concern? j bone joint surg br 2010; 92:496-99. 5. iglar pj, hogan kj. vitamin d status and surgical outcomes: a systematic review. patient safety in surgery 2015;9:15. 6. binkley n, krueger d, cowgill cs, et al. assay variation confounds the diagnosis of hypovitaminosis d: a call for standardization. j clin endocrinol metab 2004;89:3152-57. 7. holick mf, binkley nc, bischoff-ferrari ha, gordon cm, hanley da, heaney rp, murad mh, weaver cm. endocrine society. evaluation, treatment, and prevention of vitamin d deficiency: an endocrine society clinical practice guideline. j clin endocrinol metab. 2011 jul;96(7):1911-30. 8. patton cm, powell ap, patel aa. vitamin d in orthopaedics. j am acad orthop surg 2012;20:123-29. 9. lefevre ml. screening for vitamin d deficiency in adults: us preventive services task force recommendation statement. ann intern med. 2014;162:133-40. 10. holick mf. vitamin d deficiency. n engl j med 2007;357:266-81. 11. unnanuntana a, rebolledo bj, gladnick bp, nguyen jt, et al. does vitamin d status affect the attainment of inhospital functional milestones after total hip arthroplasty? j arthroplasty. 2012;27:482-89. 12. mak jc, klein la, finnegan t, mason rs, et al. an initial loading-dose vitamin d versus placebo after hip fracture surgery: baseline characteristics of a randomized controlled trial (revitahip). bmc geriatr. 2014;14:101109. 13. barker t, martins tb, hill hr, kjeldsberg, et al. low vitamin d impairs strength recovery after anterior cruciate ligament surgery. j evid-based complement altern med. 2011;16:201-209. 14. maier gs, horas k, seeger jb, roth ke, et al. is there an association between periprosthetic joint infection and low vitamin d levels? int orthop. 2014;38:1499-1504. 15. statistics-sa. mid-year population estimates 2014 – report p0302/ statistics south africa. pretoria, 2014. 16. ryan p, goga ie. uncemented primary total hip arthroplasty in patients aged 55 years or younger: results at a minimum of 5 years in a consecutive series. sa ortho j. 2014 mar;13: 54-60. 17. straube s, derry s, straube c, et al. vitamin d for the treatment of chronic painful conditions in adults. cochrane database syst rev. 2015;5:cd007771. 18. zajic p, amrein k. vitamin d deficiency in the icu: a systematic review. minerva endocrinol. 2014;39:275-87. 19. amrein k, schnedl c, holl a, riedl r, et al. effect of highdose vitamin d3 on hospital length of stay in critically ill patients with vitamin d deficiency: the vitdal-icu randomized clinical trial. jama. 2014;312:1520-30. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 46 404 not found 404 not found page 183south african orthopaedic journal http://journal.saoa.org.za saoj south african orthopaedic journal cpd questionnaire. august 2020 vol 19 no 3 orthopaedics and covid-19: the surgery, the surgeon and the susceptible – a scoping review (o’connor m, nieuwoudt l, marais lc) 1. of patients who require emergent surgery in the covid environment, it is suggested that: a. all patients should be tested prior to surgery a b. only patients undergoing elective procedures should be tested b c. symptomatic patients and patients from high prevalence areas and high risk contacts should be tested c d. patients should be tested if they are symptomatic d e. all patients from high prevalence areas and with high risk contacts should be tested e 2. which group of personal protective equipment listed below reflects best the requirements for an orthopaedic procedure on a covid-positive patient? a. double glove, surgical hood, shoe covers, aami 3 gown a b. double glove, n95 respirator, visor, aami 2 gown b c. double glove, surgical mask, visor, aami 4 gown c d. double glove, n95 respirator, visor, aami 4 gown d e. double glove, surgical mask, glasses, aami 2 gown e 3. which of the following correctly describes a recommendation to conserve respirators? a. extended use of the mask describes continuous wear while attending to different patients for 8–12 hours a b. extended use of the mask describes repeatedly donning and doffing the mask between patients for 8–12 hours b c. extended use of the mask describes continuous wear while attending to different patients for 4–6 hours c d. re-use refers to continuous use of the mask while attending to different patients for 8–12 hours d e. re-use refers to continuous use of the mask while attending to different patients for 4–6 hours e defcon 5: the chbah orthopaedic department’s covid-19 proactive action plan (hirschmann a, pillay t, fang kw, ramokgopa mt, frey c) 4. chris hani baragwanath academic hospital is: a. the smallest hospital in the world a b. the largest hospital in the world b c. the largest hospital in the eastern cape c d. the largest hospital in africa d e. the third-largest hospital in south africa e 5. in terms of the chbah orthopaedic staff covid-19 risk stratification score: a. an age of >65 years is a criterion for 1 point a b. a score of 3 or more was considered as high risk b c. lung disease is not a recognised risk factor c d. only type 2 diabetes mellitus is considered as a risk factor d e. a score of 4 or more was considered as high risk e short-term outcomes of submuscular bridge plating of lengthunstable paediatric femoral shaft fractures in children: insights from a south african tertiary hospital setting (du toit j, salkinder r, burger mc, du preez g, lamberts rp) 6. paediatric femoral diaphyseal fractures can be treated by multiple modalities, but the age group that seems to create the most controversy is: a. 1–3 years a b. 3–6 years b c. 6–13 years c d. 13–16 years d e. 16 years and older e 7. the lateral entry nail is an excellent treatment option for children with femur fractures. what would be a correct absolute or relative contraindication for lateral entry nails for the treatment of femoral fractures in this population group? a. 8–16 years of age a b. diaphyseal femoral fractures b c. length-unstable fractures of the diaphysis c d. metaphyseal junction fractures with intra-articular or transphyseal extension d e. transverse diaphyseal fractures in a child older than 8 years e 8. which of the following short-term outcomes of the treatment of paediatric length-unstable diaphyseal femur fractures with sub-muscular bridge plating is incorrect? a. acceptable union rate a b. comparable blood loss when compared to the other operative treatment modalities b c. early mobilisation due to stable fixation c d. rotation abnormalities are not a problem due to the surgical technique d e. acceptable mechanical axis alignment on the frontal plane e outcomes of primary fusion in high-energy lisfranc injuries at a tertiary state hospital (panchoo p, wiegerinck ji, boskovic v, laubscher m, maqungo s, mccollum g, dey r) 9. choose the correct statement. the lisfranc ligament: a. runs on the dorsal aspect of the foot from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal a b. runs on the plantar aspect of the foot from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal b c. runs on the plantar aspect of the foot from the medial aspect of the middle cuneiform to the lateral aspect of the base of the first metatarsal c d. runs on the dorsal aspect of the foot from the medial aspect of the middle cuneiform to the lateral aspect of the base of the first metatarsal d e. runs on the plantar aspect of the foot from the base of the first metatarsal to the base of the second metatarsal e page 184 south african orthopaedic journal http://journal.saoa.org.za subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm.co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online • once you have completed the answers, go back to the top of the page next to the registration option. there is another icon “find my cpd certificate”. (you will have to answer the two questions regarding your internship and last cpd audit once you have completed a questionnaire and want to retrieve your certificate). • if you click on that icon it will open your certificate which you can print or save on your system. • please call mpc helpdesk if you have any questions: 0861 111 335. 10. what is the current accepted range of lateral meary’s angle? a. -4 to 4 degrees a b. 2 to 10 degrees b c. 16 to 20 degrees c d. 4 to 8 degrees d e. none of the above e peri-articular infiltration in the resource-restrained environment – still a worthwhile adjunct to multimodal analgesia post total knee replacement (van heukelum m, blake ca, franken t, burger mc, ferreira n, gobetz g) 11. peri-articular infiltration as part of a pre-emptive multimodal analgesic protocol has proven to provide: (choose the most correct answer) a. a complex analgesic modality requiring specific skills and equipment a b. analgesia associated with a complex side-effect profile b c. no improvement in post-operative analgesia c d. major heterogeneity surrounding infiltration techniques d e. good analgesia, is cost effective, has minimal side effects, is easy to perform e 12. considering post-operative analgesia following total knee replacement in a resource-poor environment: a. the efficacy of peri-articular infiltration is dependent on infiltrates including liposomal bupivacaine, ropivacaine and ketorolac a b. peri-articular infiltration using a widely available, inexpensive infiltration mix, calculated on a volume per kilogram basis remains a valuable addition to the multimodal analgesia pathway b c. peri-articular infiltration techniques are not possible as they require specialised skills and equipment c d. should be limited to opioid-based analgesic regimens d e. total knee replacement should not be performed in resourcepoor environments e the short-term outcome of hip revision arthroplasty with trabecular metal™ components and augments (noconjo l, nortje mb) 13. indications for hip revision include all of the following except: a. aseptic loosening a b. liner wear b c. infection c d. loose abductor muscle tension d e. peri-prosthetic fracture e 14. the main type of wear in hip arthroplasty is: a. adhesive a b. fatigue b c. abrasive c d. third body d e. linear e 15. type 3 acetabular defect is mostly associated with use of: a. morcellised femoral head allograft a b. morcellised femoral head autograft b c. porous hemispheric acetabular cup c d. cup cage d e. acetabular augment e freedman-bernstein musculoskeletal competence testing of south african intern doctors: is there a difference between health science faculties? (coetzee kp, gibson nw) 16. what is the validated pass mark for the freedman–bernstein musculoskeletal competency test? a. 20% a b. 50% b c. 90% c d. 70% d e. 30% e 17. what statistical test was used to compare mean values between multiple groups in our study? a. paired t-test a b. pearson correlation b c. anova c d. fisher’s test d e. multiple linear regression e 18. what percentage of south african intern doctors demonstrated basic musculoskeletal competence? a. 6% a b. 20% b c. 12% c d. 50% d e. 70% e infantile blount’s disease (maré ph, thompson dm) 19. a 3-year-old child is brought to you with the complaint of bilateral bow-leg deformity since birth and frequent falling. which of the following would make the diagnosis of blount’s disease most likely? a. mda ≥9° a b. bmi >95th percentile for age b c. mda ≥10°, ema >20° c d. the appearance of normal valgus alignment of the proximal tibia when performing the ‘cover-up’ test d e. the triangular appearance of the distal femoral and proximal tibial epiphyseal ossification centres e 20. an 8-year-old child is brought to you with the history of unilateral bow-leg deformity since birth. she has a thrust during the stance phase of gait on her affected leg, and her knee is unstable in full extension. x-ray shows langenskiöld stage 5 changes. which of the following would constitute the best treatment strategy? a. proximal tibial metaphyseal osteotomy (combined with fibula osteotomy) and realignment to physiological valgus a b. guided growth with a lateral proximal tibial tension-band plate b c. medial elevation osteotomy combined with proximal tibial realignment and lateral proximal tibia and fibula epiphysiodesis c d. hexapod assisted gradual correction of the proximal tibial metaphyseal deformity to re-orientate the plateau without elevation d e. medial epiphysiolysis, proximal tibial realignment osteotomy and lateral proximal tibial and fibula epiphysiodesis e medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 coetzee kp et al. sa orthop j 2020;19(3) doi 10.17159/2309-8309/2020/v19n3a7 south african orthopaedic journal http://journal.saoa.org.za traumateaching and training citation: coetzee kp, gibson nw. freedman–bernstein musculoskeletal competence testing of south african intern doctors: is there a difference between health science faculties? sa orthop j 2020;19(3):167-172. http://dx.doi.org/10.17159/2309-8309/2020/v19n3a7 editor: prof. leonard c marais, university of kwazulu-natal, durban, south africa received: january 2020 accepted: march 2020 published: august 2020 copyright: © 2020 coetzee kp. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: the study was funded by a discovery research grant. conflict of interest: both authors declare no conflicts of interest with regard to this study. abstract background: basic competency in musculoskeletal medicine is necessary for all graduating doctors due to the growing burden of disease. globally and nationally research has shown deficiencies in musculoskeletal knowledge according to the freedman–bernstein test. in south africa, different health science faculties show different approaches to training; this article considers if any of these demonstrate adequate training and whether significant differences exist between the faculties’ results. the aim of the study is to determine whether there are significant differences between musculoskeletal learning outcomes between graduates from different health science faculties. methods: a multi-centre, cross-sectional study was performed in which medical interns completed the freedman–bernstein test after graduation and prior to commencing their formal two-month block in orthopaedics. data was then analysed to determine whether significant differences existed between the test scores of the eight health science faculties’ graduates. results: a total of 259 completed tests were analysed. the mean score was 46% (range 4-88%, 95% ci 44-48%), and 244 of the 259 interns failed the test (94% failure rate). the lowest and highest mean scores, by health science faculty, was 34% (95% ci 28-40%) and 60% (95% ci 55-64%) respectively. an anova test indicated statistically significant differences between test scores of the different health science faculties (p<0.001). conclusion: we have demonstrated competency scores consistent with previous literature from south africa and shown that there are statistically significant differences between the health science faculties based on freedman–bernstein test scores. this evidence suggests differing levels of musculoskeletal knowledge attained at health science faculties in south africa, and no improvement in undergraduate education in the last decade. level of evidence: level 4 keywords: musculoskeletal, competence, freedman–bernstein, undergraduate training freedman–bernstein musculoskeletal competence testing of south african intern doctors: is there a difference between health science faculties? coetzee kp1 , gibson nw2 1 mbchb(uct); registrar, orthopaedic surgery, frere hospital, east london; walter sisulu university, mthatha, south africa 2 mbbch(wits), fcorth(sa); associate professor and head of department, orthopaedic surgery, frere hospital, east london; walter sisulu university, mthatha, south africa corresponding author: dr kaylem paul coetzee, department of orthopaedic surgery, frere hospital, amalinda main rd, amalinda, east london, 5247; tel: (043) 709 2000; email: coetzee.kaylem6@gmail.com https://orcid.org/0000-0003-0261-4447 https://orcid.org/0000-0003-1546-8485 page 168 coetzee kp et al. sa orthop j 2020;19(3) introduction the prevalence and cost of treating musculoskeletal disease have increased dramatically over the last several decades.1,2 musculoskeletal pathology also accounts for a substantial proportion of the global burden of disease.3 patients attending primary healthcare facilities in cape town showed a 36% prevalence of musculoskeletal conditions.4 with this increasing burden of disease, basic competence in the management of musculoskeletal conditions should be considered an essential prerequisite for graduating south african medical students. deficiencies have been highlighted in the ability of junior doctors to manage this musculoskeletal burden. naidoo showed the poor quality of orthopaedic referrals to a tertiary hospital in kwazulu-natal. basic principles of acute orthopaedic intervention were shown to be lacking, including splinting, analgesia and the handling of compound fractures.5 a study of community service doctors in rural kwazulu-natal showed skills and knowledge in orthopaedics to be inadequate, and management of major joint dislocations to be poor.6 undergraduate orthopaedic training was also shown to be deficient in south africa when a study showed junior doctors requested further basic orthopaedic training to fill the voids in their skill set. half of the topics chosen by south african doctors were orthopaedic essential practical skills such as wrist and ankle fracture reduction techniques, and management of open fractures.3 globally, deficiencies in musculoskeletal training and knowledge have also been highlighted. in 1998 freedman and bernstein designed and validated a musculoskeletal competency test.7 this 25 mark short-answer question paper was developed in the united states of america to test how well medical school graduates understood basic musculoskeletal problems and has a pass mark of 73% or 70%, validated by the chairs of both orthopaedic and internal medicine residency programmes respectively.7 multiple global studies have subsequently shown failure rates of 74–94% with this test.8-11 dachs et al. showed that deficiencies in undergraduate musculoskeletal training were evident when 72 of the 79 interns (91%) from south african health science faculties failed the freedman–bernstein test.12 this deficiency was perceived to be due to insufficient training time allocation at undergraduate level, with dachs et al. showing only 2% of training time (four to six weeks) dedicated to musculoskeletal medicine in south african health science faculties,13 a sentiment shared globally in multiple studies.7,14,15 south african universities differ with regard to curricular approach (systems approach/problem-based learning/mixed), programme length, entrance criteria, resources, setting (rural/urban) and teaching methods.16-18 the common goal is to create competent doctors to serve our population. the aim of this study was to determine whether the different faculties’ training programmes resulted in different levels of musculoskeletal knowledge. methods a multi-centre cross-sectional study was performed by administering the freedman–bernstein musculoskeletal competence test to qualified south african intern doctors prior to starting their formal orthopaedic rotation, with the aim of testing knowledge acquired as an undergraduate. interns were enrolled at frere hospital over a three-year period from january 2017 to january 2020 by the author and co-author after their orthopaedic block orientation session. similarly, interns were also enrolled in january 2020 from other training hospitals in gauteng, kwazulu-natal and the eastern cape. this was done to increase sample size and overcome selection bias. intern doctors are allocated to hospitals by the national intern allocation process and we obtained representation from all health science faculties at each site. invigilators were recruited from other centres by approaching the intern curator and orthopaedic head of department and arranging with a consultant or registrar to act as an invigilator. after a verbal informed consent, all tests were administered under invigilated examination conditions with no time limit. the tests were anonymous and voluntary, asking only for health science faculty name and year of qualification. only graduates from south africa’s eight health science faculties were enrolled. the population consisted of firstand second-year interns. once the tests were completed, and invigilators had couriered their tests to east london, they were marked by the author with the validated scoring system and answer key published in freedman and bernstein’s original article (table i), and results were recorded on excel data sheet tables. the pass mark of 70% was chosen as suggested by the chairs of internal medicine for our study.7 statistical analysis was done using ibm spss statistics version 25 to estimate means and their binomial exact 95% confidence intervals. a one-way analysis of variance (anova) was then performed to determine whether statistically significant differences existed between the health science faculty groups’ mean scores. once significance was confirmed then multiple comparisons between each faculty and the rest were done, with use of post hoc tests and the bonferroni adjustment, to check for significance of differences between specific faculties (p<0.05). results combined test analysis a total of 262 intern doctors completed tests; three of the doctors had graduated from international medical schools and were excluded. of the 259 included tests, 203 were from frere hospital and 56 were from the other centres. the mean score for the 259 interns was 46% (95% ci 44-48%). only 15 out of 259 interns (6%) achieved a score of 70% or more and therefore showed basic competence in the test, thus demonstrating a 94% failure rate. comparison between health science faculties the health science faculties were anonymised by numbering them 1 to 8 in order of ascending sample sizes. sample sizes ranged from 12 interns to 67 interns. the mean percentage of each health science faculty’s graduate group was then calculated (table ii, figure 1). the lowest performing health science faculty group mean was 34% (95% ci 28-40%) and the highest 60% (95% ci 55 -64%). in terms of failure rates, half of the health science faculties recorded 100% failure rates. of the health science faculties that recorded passing scores by graduates, the pass rate ranged from 2% to 22% (figure 2). the anova revealed a statistically significant difference between health science graduate groups (p<0.001). the post hoc tests and bonferroni correction do an additional 28 comparisons of the health science faculties against one another to check for significance. university 4 had a mean score significantly higher than each of the other seven faculties and health science faculty 3 had a significantly lower mean than each of the top three performing faculties (figure 3). discussion the results of our study show that there has not been a demonstrable improvement in musculoskeletal competence among graduates from our health science faculties from previous literature. our mean score of 46% (95% ci 44-48%) and failure rate of 94% are consistent with the work of dachs et al., ten years ago, of 45% page 169coetzee kp et al. sa orthop j 2020;19(3) table i: freedman and bernstein test with model answer key question answer 1. what common problem must all new-borns be examined for? congenital dislocation of the hip (cdh, dislocation, subluxation also accepted): 1 point 2. what is a compartment syndrome? increased pressure in a closed fascial space: 1 point 3. acute septic arthritis of the knee may be differentiated from inflammatory arthritis by which laboratory test? any analysis of fluid from aspiration (cell count, gram stain, culture): 1 point 4. a patient dislocates his knee in a car accident. what structure(s) is/are at risk for injury and therefore must be evaluated? must mention popliteal artery: 1 point 5. a patient punches his companion in the face and sustains a fracture of the 5th metacarpal and a 3 mm break in the skin over the fracture. what is the correct treatment, and why? irrigation and debridement; risk of infection: 1/2 point each 6. a patient comes to the office complaining of low back pain that wakes him up from sleep. what two diagnoses are you concerned about? tumour and infection: 1/2 point each 7. how is compartment syndrome treated? fasciotomy (surgery also accepted): 1 point 8. a patient lands on his hand and is tender to palpation in the ‘snuff box’ (the space between the thumb extensor and abductor tendons). initial radiographs do not show a fracture. what diagnosis must be considered? scaphoid fracture (carpal bone fracture also accepted): 1 point 9. a 25-year-old man is involved in a motor vehicle accident. his left limb is in a position of flexion at the knee and the hip, with internal rotation and adduction of the hip. what is the most likely diagnosis? hip dislocation: 1 point 10. what nerve is compressed in carpal tunnel syndrome? median nerve: 1 point 11. a patient had a disc herniation pressing on the 5th lumbar nerve root. how is motor function of the 5th lumbar nerve root tested? dorsiflexion of the great toe (toe extensors also accepted): 1 point 12. how is motor function of the median nerve tested in the hand? any median function (metacarpophalangeal finger flexion; thumb opposition, flexion, or abduction): 1 point 13. a 12-year-old boy severely twists his ankle. radiographs show only soft-tissue swelling. he is tender at the distal aspect of the fibula. what are two possible diagnoses? ligament sprain and salter-harris i fracture (sprain, fracture also accepted): 1/2 point each 14. a patient presents with new-onset low back pain. under what conditions are plain radiographs indicated? please name five (example: history of trauma). age >50 years; neurological deficit; bowel or bladder changes; history of cancer, pregnancy, drug use, or steroid use; systemic symptoms (night pain, fever); paediatric population: 1/4 point each 15. a patient has a displaced fracture near the fibular neck. what structure is at risk for injury? common peroneal nerve (peroneal nerve also accepted): 1 point 16. a 20-year-old injured his knee while playing football. you see him on the same day, and he has a knee effusion. an aspiration shows frank blood. what are the three most common diagnoses? ligament tear, fracture, peripheral meniscal tear (capsular tear, patellar dislocation also accepted): 1/2 point each, full credit for two correct responses 17. what are the five most common sources of cancer metastases to bone? breast, prostate, lung, kidney, thyroid: 1/4 point each, full credit for four correct responses 18. name two differences between rheumatoid arthritis and osteoarthritis. any two correct statements (i.e. inflammatory vs degenerative, proximal interphalangeal joint vs distal interphalangeal joint, etc): 1/2 point each 19. which malignancy may be present in bone yet typically is not detected with a bone scan? myeloma (full credit for haematological malignancies – leukaemia, lymphoma): 1 point 20. what is the function of the normal anterior cruciate ligament at the knee? to prevent anterior displacement of the tibia on the femur: 1 point 21. what is the difference between osteoporosis and osteomalacia? osteoporosis: decreased bone density; osteomalacia: decreased bone mineralisation (any true statement about epidemiology, pathophysiology, e.g. oestrogen vs vitamin d, also accepted): 1 point 22. in elderly patients, displaced fractures of the femoral neck are typically treated with joint replacement, whereas fractures near the trochanter are treated with plates and screws. why? blood supply to femoral head (avascular necrosis, non-union also accepted): 1 point 23. what muscle(s) is/are involved in lateral epicondylitis (tennis elbow)? wrist extensors (full credit for any wrist extensor – extensor carpi radialis brevis, extensor carpi radialis longus, extensor digitorum communis): 1 point 24. rupture of the biceps at the elbow results in weakness of both elbow flexion and _____? supination: 1 point 25. what muscle(s) control(s) external rotation of the humerus with the arm at the side? infraspinatus or teres minor accepted (full credit for rotator cuff): 1 point page 170 coetzee kp et al. sa orthop j 2020;19(3) (95% ci 42–48%) and 91% respectively.12 this shows a concerning trend that, in the face of a rising musculoskeletal burden of disease, our junior doctors’ competency scores have not increased and the recommended curricular reform and attention to musculoskeletal training has not been implemented. the 94% failure rate in our study is relatively high when compared to freedman and bernstein’s original rate of 82% and to global studies on graduates in nepal and the united kingdom, where failure rates of 94% and 79% respectively were demonstrated.7,8,10 furthermore, only half of our health science faculties managed to produce graduates who could pass the freedman–bernstein test. the primary aim of our study was to determine whether significant differences existed between the musculoskeletal knowledge of health science faculty graduates. we have shown that statistically significant differences exist, with a difference between highest and lowest averages reaching 25%. of the interns who passed the test, 13 out of 15 (87%) came from the top two health science faculties in our study. the recently published academy of science of south africa (assaf) report suggests that core competencies need to be developed by regulatory bodies, and that competency-based education should be subscribed to by health science faculties.19 botha, in her dissertation on curricular mapping of undergraduate medical programmes, showed that inter-institution differences were recognised and there is a need for collaboration and transparency between health science faculties to improve the curriculum.17 marais and dunn also noted that with the concurrent service demands and training time constraints, we need to review the way we educate to compensate for the expanding field of orthopaedics.20 we have found in the literature that there is a drive to align, standardise and improve undergraduate training programmes. we therefore performed a comparison of the training programmes with the highest and lowest mean scores to investigate possible reasons for these significant differences. we conducted telephonic interviews with the two lowest scoring health science faculties (mean scores 34% and 37%) and the two highest scoring faculties (60% and 49%) to obtain details on their undergraduate orthopaedic training programmes and look for similarities and differences which 100 90 80 70 60 50 40 30 20 10 0 a ve ra g e t e st s c o re ( % ) south african health science faculties 3 1 2 7 6 5 8 4 34.1 37.3 41.7 70% pass mark 42.0 48.5 49.4 59.9 figure 1. mean score of each health science faculty’s graduates in ascending order 43.6 100 90 80 70 60 50 40 30 20 10 0 te st s c o re ( % ) south african health science faculties a the mean score of the university differs significantly from the mean score of university 4 (highest score) b the mean score of the university differs significantly from the mean score of university 3 (lowest score) 3 1 2 7 6 5 8 4 a a a 70% pass mark a a b a b b figure 3. graph showing ascending order of mean scores and significance of difference from the highest and lowest scoring health science faculties a south african health science faculties 1 2 5 6 7 3 8 4 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% p e rc e n ta g e pass fail 77.8% 22.2% 95.5% 4.5% 89.5% 10.5% 97.7% 2.3% 100%100% 100%100% figure 2. pass/fail percentages of each health science faculty’s graduates page 171coetzee kp et al. sa orthop j 2020;19(3) could possibly account for differences in their test scores. all four of these faculties generally followed a similar structure of exposing students to theoretical training in the preclinical years, followed by clinical rotations in orthopaedics at training hospitals. the faculty with the highest mean value and pass rate was interestingly a five-year programme. there were small differences in total musculoskeletal training time in the clinical years between the four faculties, all consisting of between four to six weeks, either running concurrently or divided up between the last three years of study. the preclinical musculoskeletal exposure time differed between faculties. the top two performing faculties, which both had traditional teaching models, had longer formal preclinical rotations; one consisted of a six-week consecutive block, the other a full year of regular dissection-based anatomy training and didactic lectures, more in keeping with the recommendations of woolf et al.21 when looking at how the clinical teaching programme was structured, all four programmes generally followed a similar framework and timetable of teaching. all four programmes consisted of varying amounts of exposure to the essential elements of orthopaedic departments such as morning meetings, clinics, theatre, ward rounds, patient examination, after-hours duty, and all had small group tutorials scheduled. with similar teaching structures, one must consider that other factors may account for test score differences, such as perhaps enforcement of the programme or the quality of teaching received, as suggested in the discussion of weiss et al.’s article.22 an interesting distinguishing feature of the top performing faculty was the frequency with which they assessed their students, which was significantly more than any other faculty. their students complete orthopaedic blocks in each of their final three years (two weeks each) and need to pass examinations in the form of objective structured clinical examinations (osces), multiple-choice questions (mcqs) and clinical exams, occurring at the end of each block and again at the end of the year. they are therefore examined eight times on musculoskeletal course work before graduation. this requires revision of course material multiple times and may account for their higher test scores. with examinations occurring frequently and at different stages in their training, students who are struggling can be easily identified. these students are then either approached by faculty members or they can identify themselves as needing more help. those students are then given additional individual tutorials to assist them with their learning, a method which has proven to increase musculoskeletal competence in the literature.3,23 the assaf report supports this method by emphasising the need for adequate assessment tools to be incorporated into the syllabus that will guide the development of core competencies and are essential to enable best training practices to be developed.19 with regard to time dedicated to musculoskeletal training, the literature shows that increasing training time does not always result in improved competency scores.22 woolf et al. suggested that the ideal musculoskeletal training programme should consist of 12 weeks of clinical time and sufficient non-clinical background given before that.21 with all departments jostling for time in resourceconstrained undergraduate programmes, it may not be possible to extend clinical training to beyond six weeks. our health science faculties’ results are poor and major reform is needed. based on analysis of the top performing faculties in our study, we feel their teaching strategies may improve competence levels and help standardise results if adopted by other institutions, and should be the focus of further study. south africa’s universities differ with regard to setting, resources, demographics, training time, entrance criteria for students and curricular approach.16-18 some subscribe to a problem-based learning approach, others a more traditional systems approach or a hybrid version of the two.18 these differences are what make each faculty unique, and they have their advantages and disadvantages. these inherent differences may, however, result in differences in the mean test score of the faculties. botha highlighted these considerable differences between faculties and indicated the need for collaboration between health science faculties in order to formulate a plan to standardise the outcome of training, the common goal being to produce competent doctors with core competencies who can best serve their community.17 we feel the significant differences in the outcome of musculoskeletal training shown in our study should prompt efforts to collectively improve training regardless of these inter-institutional differences. there are limitations to our study. even though we tried to get a true representation of south african health science faculty graduates by our multi-centred approach and large sample size, there exists the possibility that our sample is not a true representation of the graduate population of the faculty. bias may have been introduced by the fact that interns select their hospitals of choice and therefore the sample is not truly random. we recruited interns over three years and the possibility exists that changes to the curriculum may have occurred during this time, which could affect our results. nearly half of our intern sample was obtained from new interns in january 2020; we did not feel a sub-group analysis was necessary to show similarity between these groups. our tests were administered under invigilated conditions to eliminate cheating, but the result obtained could be biased by interns having been previously exposed to the test questions. our sample was a mixture of first and second year interns which may have caused bias by the fact that first years were more recently trained and second years may have gained knowledge in other blocks; however, we do not table ii: table showing the mean scores of each health science faculty and corresponding 95% confidence interval and minimum/maximum values health science faculty number of interns tested mean test score standard deviation 95% confidence interval for mean minimum score maximum score lower bound upper bound 1 12 37.3 15.5 27.5 47.2 17 61 2 22 41.7 14.8 35.2 48.3 18 68 3 22 34.1 13.2 28.2 39.9 8 70 4 27 60.0 11.3 55.4 64.4 30 77 5 29 48.5 13.9 43.1 53.8 20 68 6 37 43.6 13.4 39.2 48.1 4 67 7 43 42.0 16.1 37.0 47.0 11 81 8 67 49.4 15.1 45.7 53.1 4 88 total 259 45.8 15.7 43.9 47.7 4 88 page 172 coetzee kp et al. sa orthop j 2020;19(3) think this would have altered our result. the freedman–bernstein test, although validated to test basic musculoskeletal competence, does not assess clinical skills and confidence, which are other aspects of competence that also need due consideration, perhaps in further studies. conclusion our study has confirmed that undergraduate training in south africa continues to produce graduates without the necessary basic musculoskeletal knowledge to deal with the rising burden of disease. we have furthermore provided evidence that statistically significant differences exist between the undergraduate training programmes. we feel this evidence strengthens the argument for inter-institutional collaboration to reform and standardise musculoskeletal curricula. acknowledgements we would like to thank dr pieter maré, dr jason du plessis, dr jason van heerden and dr jaco viljoen who enthusiastically identified interns at their institutions and helped in printing, obtaining consent, administering the tests and then couriering the test papers to us. statistical analysis by mrs marike cockeran, msc statistics, north-west university, potchefstroom, south africa. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. study approval was obtained from the walter sisulu university faculty of health sciences postgraduate education, training, research and ethics unit: protocol number 072/2019. informed consent was obtained from all individual participants included in the study. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions kpc contributed to the conceptualisation, design, data collection, data analysis and manuscript preparation. nwg contributed to conceptualisation, design, data collection, manuscript preparation and supervised the study. orcid coetzee kp https://orcid.org/0000-0003-0261-4447 gibson nw https://orcid.org/0000-0003-1546-8485 references 1. global alliance for musculoskeletal health [interntet]. available from: http://bjdonline.org/ [accessed 21 january 2020). 2. day cs, ho p. progress of medical school musculoskeletal education in the 21st century. j am acad orthop surg. 2016;24:762-68. https://doi.org/10.5435/jaaos-d-15-00577. 3. kalraiya a, buddhdev p. the trojan project: creating a customized international orthopedic training program for junior doctors. orthop rev (pavia). 2015;7:6-9. https://doi.org/10.4081/ or.2015.5750. 4. parker r, jelsma j. the prevalence and functional impact of musculoskeletal conditions amongst clients of a primary health care facility in an under-resourced area of cape town. bmc musculoskelet disord. 2010;11:2. 5. naidoo nd. an evaluation of the quality of orthopaedic trauma referrals to a regional hospital. sa orthop j. 2009;8(1):66-69. 6. nkabinde tc, ross a, reid s, nkwanyana nm. internship training adequately prepares south african medical graduates for community service – with exceptions. samj. 2013;103:930-34. https://doi.org/10.7196/samj.6702. 7. freedman kb, bernstein j. the adequacy of medical school education in musculoskeletal medicine. j bone jt surg. 1998;80:1421-27. https://doi.org/10.2106/00004623 199810000-00003. 8. al-nammari ss, pengas i, asopa v, jawad a, rafferty m, ramachandran m. the inadequacy of musculoskeletal knowledge in graduating medical students in the united kingdom. j bone jt surg. 2013;107:1-10. https://doi.org/10.2106/jbjs.f.01083. 9. al-nammari ss, james bk, ramachandran m. the inadequacy of musculoskeletal knowledge after foundation training in the united kingdom. j bone joint surg br. 2009;91-b:1413-18. https://doi. org/10.1302/0301-620x.91b11.22445. 10. tamrakar r, basnyat s, gyawali b, et al. adequacy of undergraduate orthopedic training at a nepalese medical academy. med j shree birendra hosp. 2017;15:13-18. https://doi. org/10.3126/mjsbh.v15i2.16112. 11. day cs, yeh ac, franko o, ramirez m, krupat e. musculoskeletal medicine: an assessment of the attitudes and knowledge of medical students at harvard medical school. acad med. 2007;82:452-57. https://doi.org/10.1097/acm.0b013e31803ea860. 12. dachs r, roche s, vrettos b, macintyre k, walters j. assessment of undergraduate orthopaedic training at medical schools in south africa. sa orthop j. 2010;9(4):33-37. 13. dachs r, roche s, vrettos b, et al. assessing musculoskeletal training in south africa. sa orthop j. 2014;13(3):57-63. 14. bhatnagar a, vadhel m, sethuraman v. inadequacy of musculoskeletal knowledge among undergraduate medical students. j orthop trauma rehabil. 2015;19:34-38. https://doi. org/10.1016/j.jotr.2014.03.003. 15. williams jr. the teaching of trauma and orthopaedic surgery to the undergraduate in the united kingdom. j bone joint surg br. 2000;82:627-28. 16. burch vc, sikakana c, gunston gd, whittle sr, murdoch-eaton d. pre-university education curriculum reform and the generic learning skills of medical school entrants: lessons learned from south africa. educ heal. 2018;29:1-8. https://doi.org/10.4103/efh. efh. 17. botha gc. the status of curriculum mapping of undergraduate medical programmes in south africa [dissertation] stellenbosch university; 2016. 18. seggie jl. mbchb curriculum modernisation in south africa – growing doctors for africa. african j heal prof educ. 2010;2:8-14. 19. academy of science of south africa. consensus study report: reconceptualising health professions education in south africa. 2018. 20. marais l, dunn r. teaching and training in orthopaedics. sa orthop j. 2017;16(4):15-19. https://doi.org/10.17159/2309 8309/2017/v16n4a1. 21. woolf ad, walsh ne, åkesson k. global core recommendations for a musculoskeletal undergraduate curriculum. ann rheum dis. 2004;63:517-24. https://doi.org/10.1136/ard.2003.016071. 22. weiss k, curry e, matzkin e. assessment of medical school musculoskeletal education. am j orthop. 2015;44:e64-67. 23. vermaak d, potgieter j. the evaluation of a new general trauma course with an orthopaedic focus. sa orthop j. 2012;11(2):68-71. https://orcid.org/0000-0003-0261-4447 https://orcid.org/0000-0003-1546-8485 _hlk43808432 _hlk37169859 meijer jg et al. sa orthop j 2020;19(4) doi 10.17159/2309-8309/2020/v19n4a4 south african orthopaedic journal http://journal.saoa.org.za foot and ankle citation: meijer jg, gräbe jc, greyling p. the outcome of first metatarsophalangeal joint arthrodesis using a locking compression plate. sa orthop j 2020;19(4):218-222. http://dx.doi.org/10.17159/2309-8309/2020/v19n4a4 editor: prof. n saragas, university of the witwatersrand, johannesburg, south africa received: march 2020 accepted: april 2020 published: november 2020 copyright: © 2020 meijer jg. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding has been received for this manuscript. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: arthrodesis of the first metatarsophalangeal joint (mtpj) is a common and frequently performed procedure in the practice of orthopaedic foot and ankle surgery. fusion techniques and preferred surgical implants have significantly evolved during recent years. it is however still under debate which surgical device provides the best outcome. one of the modern techniques described includes the use of a dorsal anatomical locking plate. these plates are usually used in combination with an additional compression cross screw across the arthrodesis site. the aim of this study was to assess the outcome of arthrodesis of the first mtpj using a dorsal locking plate without making use of additional compression cross screw fixation. methods: we retrospectively assessed data at an orthopaedic practice specialising in foot and ankle surgery. all patients who had a first mtpj arthrodesis with an anatomical locking plate system between 2010 and 2016 were identified. no additional compression cross screw fixation was done in any of these cases. standard standing dorsoplantar and lateral x-rays of the foot were taken six weeks after surgery. as a primary objective, these radiographs were assessed to determine the rate of radiological union. as a secondary objective, any other complications that occurred in the post-operative period were recorded. results: we included 115 patients in the study. fifteen of these patients underwent bilateral first mtpj arthrodesis surgery, making the total number of feet included in the study 130. of these, 86% (n=99) were female and 14% (n=16) were male. the mean age at the time of surgery was 54.7 years (range 37–74). an observed radiological union rate of 97% at three months after surgery was recorded. a total of four cases (3%) presented with symptomatic non-union. two of these were successfully revised and progressed to union before the nine-month follow-up. one patient had bilateral surgery for severe rheumatoid arthritis with poor bone quality. no union was achieved even after a revision procedure with bone grafting. a keller-type resection arthroplasty was eventually performed in this patient. another secondary complication that was recorded is an overall infection rate of 2%. conclusion: the results of this retrospective study suggest that high union rates and a low incidence of complications can be expected when fusing the first mtpj with the use of a locking plate system without the need for an additional compression cross screw. level of evidence: level 4 keywords: first metatarsophalangeal joint, fusion, arthrodesis, locking plate, union the outcome of first metatarsophalangeal joint arthrodesis using a locking compression plate meijer jg1 , gräbe jc2 , greyling p3 1 mbchb(pret); orthopaedic registrar, department of orthopaedics, kalafong hospital, university of pretoria, pretoria, south africa ² mbchb(pret), fcs orth(sa), mmed orth(pret); orthopaedic surgeon, department of orthopaedics, steve biko academic hospital, university of pretoria, pretoria, south africa ³ mbchb(pret), fcs orth(sa), mmed orth(pret); orthopaedic surgeon, department of orthopaedics, steve biko academic hospital, university of pretoria, pretoria, south africa corresponding author: dr jg meijer, 165c lys street, rietondale, 0084; tel: +27 (12) 318 6400; email: jansiemeijer@gmail.com https://orcid.org/0000-0001-7773-6081 http://orcid.org/0000-0003-1054-0505 https://orcid.org/0000-0002-2535-4812 page 219meijer jg et al. sa orthop j 2020;19(4) introduction arthrodesis of the first metatarsophalangeal joint (mtpj) is a relatively common and frequently performed surgical procedure in the practice of orthopaedic foot and ankle surgery. it was first described by clutton in 1894 for the treatment of severe hallux valgus.1,2 a wide variety of conditions may affect the first ray of the foot, ultimately leading to significant pain and deformity of the first mtpj. in these conditions fusion of the joint has proven to be a successful procedure. common indications include hallux valgus, hallux rigidus, inflammatory arthropathy, salvage procedures after failed previous surgery and neuromuscular conditions.2-6 as noted in the literature, successful first mtpj arthrodesis has been attained with the use of a wide variety of implants ranging from crossed kirschner wires, cerclage wiring, sutures, staples, axially or obliquely placed compression screws, intramedullary steinman pins, external compression clamps, and dorsal plate and screw constructs. most of these methods have demonstrated successful union rates ranging from 70% to 100%.3,4,6,7 a review of the available biomechanical studies in the literature shows that fixation using a lag screw and a dorsal plate construct has the best overall mechanical stability.8,9 small fragment compression plates were frequently used in the past, but because of their size and prominence often caused local irritation and pressure symptoms. because of this complication, a high rate of hardware removal was seen.10,11 this has led to an evolution of the dorsal plate. more recently, anatomically contoured plates with locking and nonlocking screw options became available. these locking plates have a low profile and are pre-contoured to match the anatomy of the patient better, therefore aiming to negate the pressure symptoms as previously experienced with more bulky constructs. with the advances of these anatomical locking plates it is expected that outcomes with regard to union rate and patient satisfaction should also improve. currently these plate-and-screw constructs are mostly being used in conjunction with a compression cross screw across the arthrodesis site.3-5,11 as these constructs are biomechanically more rigid than previously used implants, the question arises whether an additional compression cross screw is still necessary in order to achieve an adequate union rate when fusing the first mtpj. the purpose of this study was to assess the outcome of arthrodesis of the first mtpj using a dorsal locking plate without making use of additional compression cross screw fixation. materials and methods this study was conducted at an orthopaedic practice specialising in foot and ankle surgery. ethical approval was obtained from the research ethics committee of the university of pretoria prior to the commencement of data collection. the data of all patients who underwent first mtpj arthrodesis with a dorsal anatomical locking plate between january 2010 and december 2016 were retrospectively reviewed. patients were included if they were above 18 years and underwent first mtpj arthrodesis with a dorsal locking plate without additional compression cross screw fixation. patients were excluded in the case of revision arthrodesis surgery and if any device other than a dorsal locking plate in isolation was used. surgical procedure all patients were operated by the same surgeon (senior author, jcg). the same surgical technique was consistently used in all cases. an above-ankle tourniquet was applied and inflated to 250 mmhg. the first mtpj was accessed through a standard dorsal approach. joint surface preparation was done with spherical mtpj reamers. all cartilage was removed in order to achieve congruent cancellous surfaces in a concave–convex configuration. multiple small holes were drilled into both surfaces with a 1.9 mm drill bit until adequate bleeding was observed. to determine the correct fusion position, we simulated weightbearing by applying a flat surface to the sole of the foot. we used either the flat bottom area of a large kidney dish or the cover of the plate set. we aimed at a position of slight valgus and slight dorsiflexion of the big toe. there had to be a space of approximately 8–10 mm between the flat surface and the plantar skin of the proximal phalanx. the mtpj was then temporarily stabilised with one kirschner wire, and a titanium dorsal locking plate (acumed®, oregon, usa) was applied. the same plate was used in all cases and had the following specifications: 10° of lateral angulation (hallux valgus angle) and a 4° dorsiflexion angle. for some of the cases, the plate had to be manually bent to either increase or decrease the dorsiflexion angle. this adjustment depended on the alignment of the foot, where slightly more dorsiflexion was required for a cavus foot and a lower dorsiflexion angle was preferred for a flat foot. first, the two distal screws were inserted into the proximal phalanx. manual compression was applied and a compression screw was then inserted into the metatarsal shaft. post-operatively all patients were placed in a protective shoe for six weeks. heel weight-bearing was allowed as tolerated. wounds were inspected and sutures were removed two weeks after surgery. standard standing dorsoplantar and lateral foot radiographs were reviewed to assess the rate of radiological union. x-rays were routinely taken six weeks after surgery. in most patients there were already signs of union at six weeks. if union was not evident at six weeks, we repeated x-rays at three months and again at six months if there was still any doubt. a cut-off of six months was used to allow for timely intervention in cases of symptomatic non-union. union was defined as the presence of osseous trabeculation across the joint interface involving at least three of the four bridging cortices f a ile d p re vi o u s su rg e ry ( 1 3 % ) h a llu x ri g id u s (3 2 % ) h a llu x va lg u s (2 7 % ) h a llu x va ru s (4 % ) n e u ro m u sc u la r in st a b ili ty ( 6 % ) o th e r* (2 % ) 45 40 35 30 25 20 15 10 5 0 figure 1. number of cases performed per surgical indication *hallux flexus, osteochondral lesions and post-traumatic arthritis page 220 meijer jg et al. sa orthop j 2020;19(4) (medial and lateral cortices on the dorsoplantar view and superior and inferior cortices on the lateral view).12 radiological analysis was done by two experienced orthopaedic foot and ankle surgeons (senior authors jcg and pg). general complications other than non-union were also recorded. these mainly included the prevalence of post-operative wound problems and infection. the different indications for arthrodesis were documented as shown in figure 1. statistical analysis continuous variables were described using mean with a range. categorical variables were described using frequency and proportions. the rate of complications was expressed as a proportion of all cases with a 95% confidence interval. all analyses were conducted in excel 2013. results a total of 115 patients were included in the study. fifteen of these patients had bilateral first mtpj arthrodesis surgery, making the total number of feet included in the study 130. the study population consisted of 99 females (86%) and 16 males (14%). fourteen of the 15 patients who underwent bilateral first mtpj arthrodesis were female. these cases were predominantly performed for severe hallux valgus in patients with rheumatoid arthritis or neuromuscular conditions. the mean age at the time of surgery was 54.7 years (range 37–74). the majority of cases were performed for hallux rigidus (n=42; 32%). a total of 35 surgeries (27%) were done for hallux valgus and 17 (13%) for failed previous surgery of the hallux. of the 20 surgeries performed for inflammatory arthropathy, rheumatoid arthritis was the most common indication (n=17). other indications in this group were systemic lupus erythematosus, gout and psoriasis. eight cases were done for neuromuscular conditions (6%) and five cases for hallux varus (4%). the remaining cases were performed for hallux flexus, post-traumatic deformity with secondary joint degeneration and osteochondral lesions (figure 1). a total of seven complications in six patients were recorded, making the overall complication rate 5% (95% ci = 2–9%). each complication in relation to the initial indication for first mtpj arthrodesis is outlined in table i. an overall union rate of 97% was recorded. a total of 126 out of the 130 cases progressed to radiological union by the threemonth follow-up visit. four cases in three patients had evidence of radiological non-union, making the overall non-union rate 3% (95% ci 0.1–6.0%). of these patients, one was operated for hallux rigidus and another for neuromuscular deformity. the third patient developed non-union in both feet following bilateral first mtpj arthrodesis for rheumatoid arthritis. all three patients presented with a symptomatic non-union. two of these cases (hallux rigidus and neuromuscular deformity) were revised with the additional use of bone graft and progressed to radiological union within nine months of the index surgery.  a cross screw was not used in the revision surgeries. the bone quality of the patient with rheumatoid arthritis was too soft and we thought that an additional screw would not have given any more stability. a different plate was used due to the bone destruction of her proximal phalanges. the revision surgery of this rheumatoid patient also failed, and she was eventually revised to a keller-type procedure in both feet. the rate of infection in our study was 2% (95% ci 0.3–4.9%). three patients presented with infection in the post-operative period. arthrodesis in these cases was performed for two patients who had previously failed surgery and for one diabetic patient with severe hallux valgus and charcot arthropathy. the diabetic patient presented with infection nine weeks after surgery and the other two patients at 10 and 14 weeks. the stability of the fusions was evaluated clinically and radiologically, and all three cases were found to be solidly united. successful surgical debridement, hardware removal and antibiotic cover was done in each case, resulting in complete resolution of infection at the six-month followup. no secondary surgeries were required after debridement and hardware removal in all three patients. discussion arthrodesis is defined as the surgical fusion of a diseased joint for the purposes of obtaining pain relief and stability.13 the aim of first mtpj arthrodesis is to achieve an immobile, pain-free joint that contributes to forefoot stability, improved gait and, ultimately, an improvement in quality of daily living.6,14 this procedure is frequently performed in the practice of orthopaedic foot and ankle surgery and has a multitude of indications. common indications include hallux valgus, hallux rigidus, inflammatory arthropathy, salvage procedures after failed previous surgery and neuromuscular conditions.2-6 similar indications for first mtpj arthrodesis were found in our cohort. in the present study we assessed the outcome of first mtpj arthrodesis with the use of a dorsal locking plate system without the use of additional compression cross screw fixation. we had a low overall complication rate of 5%, consisting only of cases that included non-union and infection. this rate is in keeping with reported overall complication rates in the literature ranging between 2.6% and 13.3%.4,5,15 the recorded radiological union rate in this study was 97% (126 of 130). this is consistent with various previous studies that have also demonstrated the reliability of arthrodesis when managing a variety of conditions affecting the first mtpj.5,6,11,14,15 an example of a case where successful union was achieved following arthrodesis for severe hallux rigidus is shown in figures 2 and 3. we recorded a low infection rate of 2%. this is in keeping with infection rates published in the literature. a recent study by fazal et al. showed a 3% infection rate following first mtpj arthrodesis in their cohort of 26 patients.16 two of the infection cases in our study table i: surgical indications in relation to specific complications indication for surgery non-union infection hallux rigidus 1 0 rheumatoid arthritis 2 0 neuromuscular conditions 1 0 failed previous surgery 0 2 hallux valgus & charcot arthropathy 0 1 total 4 3 figure 2. pre-operative dorsoplantar and lateral x-rays showing a case of severe hallux rigidus page 221meijer jg et al. sa orthop j 2020;19(4) had previous failed surgery to the hallux and one had diabetes with charcot arthropathy. these indications for arthrodesis are known to have a higher post-operative infection risk.17 a multitude of different fixation techniques have been described for arthrodesis of the first mtpj.3-6,11,14 these range from crossed kirschner wires, cerclage wiring, sutures, staples, axially or obliquely placed compression screws, and dorsal plate and screw constructs with or without additional lag screw fixation. the most commonly used methods have demonstrated successful union rates ranging from 70% to 100% with an average of 90%.5,11 the ideal fixation device should be mechanically strong, biocompatible, bone-conserving, and should be inserted with a reproducible surgical technique. it should also not require routine removal.11 in a study by denning and van erve it was noted that currently the most used methods of fixation are either dorsal plates or crossed screw constructs.18 claassen et al. compared the outcomes of fixation using either crossed screws or dorsal plates and a cross screw and found a significantly higher non-union rate in the crossed screws group.5 biomechanical studies also indicate that a dorsal plate-and-screw construct provides greater mechanical stability and rigidity.8,9 in a study by politi et al. it was determined that the dorsal plate and lag screw offers the biomechanically strongest fixation method for first mtpj arthrodesis.9 there has been considerable advancement in the design of dorsal plates, with modern constructs having a lower profile and an anatomical contour that is more specific to the first mtpj. recent literature showed that successful union and high patient satisfaction can be expected when fusing the first mtpj with these dorsal anatomical locking plates.3,4,11,12 this construct also allows for earlier weight-bearing and improved rehabilitation in the post-operative period.4 younger and more active patients have also shown to benefit from this form of arthrodesis and can generally expect satisfactory results allowing them to return to a wide variety of sports and activities post-operatively.19 flavin and stephens reported that the combination of a low-profile contoured titanium plate with an additional cross screw and a ball-and-socket bone-end preparation had both operative and biomechanical advantages over other fixation techniques. their patients had significant improvements in outcomes scores, union rates and other radiological parameters.20 due to a concern that these plates may not achieve adequate compression over the fusion site, they are often used in combination with a compression cross screw. the results of the present study, however, show that a very high union rate can still be expected without the addition of a compression cross screw. this rate is comparable or even superior to the fusion rates found in studies assessing the outcomes following arthrodesis with a compression cross screw and dorsal plate.3,4,11 in a more recent retrospective study by cone and his colleagues, it was determined if the addition of a lag screw to a dorsal locking plate would influence union rate and final alignment after fusion.6 they noted that post-operative dorsiflexion angles were better maintained in cases where additional lag screw fixation was used, but found no statistically significant difference in the union rate when comparing fixation with a lag screw and dorsal plate to fixation with a dorsal plate in isolation. their overall union rate, regardless of the fusion method, was 86%. this is significantly lower than the 97% noted in our study. the principle limitation of this study is its retrospective nature. it therefore depended on accurate and reliable data collection. the primary author (jgm) meticulously reviewed all data collected to address this issue. another limitation is the fact that a control group where compression cross screws were used in conjunction with a locking plate could not be added to the study. the rate of radiological union was the main objective in this study. other outcome measures like patient satisfaction, gait analysis and improvement of radiological parameters like dorsiflexion and hallux valgus angles were not assessed. we also did not collect and analyse outcome scores. the use of outcome scores and radiological parameters other than union rate could provide a more encompassing assessment of outcome. the large sample size is considered a strength of this study. conclusion the results of this retrospective study suggest that an overall low complication rate specifically with regard to non-union and infection can be expected when fusing the first mtpj with a dorsal locking plate system. high union rates can be expected without the need for additional compression cross screw fixation. ethics statement approval from the faculty of health science’s ethics committee (university of pretoria) was obtained prior to commencement of the study (protocol number: 504/2017). ethical principles were adhered to, as outlined by the world medical association declaration of helsinki. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions jgm was responsible for data capture, data analysis, first draft preparation, manuscript preparation and manuscript revision. jcg and pg were study supervisors and responsible for study conceptualisation, manuscript preparation and manuscript revision. orcid meijer jg https://orcid.org/0000-0001-7773-6081 gräbe jc http://orcid.org/0000-0003-1054-0505 greyling p https://orcid.org/0000-0002-2535-4812 references 1. clutton hh. treatment of hallux valgus. st thomas hosp rep. 1894;22:1-12. 2. mahadevan d, korim mt, ghosh a, et al. first metatarsophalangeal joint arthrodesis: do joint configuration and preparation technique matter? foot ankle surg. 2015;21(2):103-107. 3. marudanayagam a, appan sv. first metatarsophalangeal joint fusion using a fyxis plate. j orthop surg. 2014;22(1):35-38. 4. mann jj, moon jl, brosky ta. low-profile titanium plate construct for early weightbearing with first metatarsophalangeal joint arthrodesis. j foot ankle surg. 2013;52(4):460-64. 5. claassen l, plaass c, pastor m, et al. first metatarsophalangeal joint arthrodesis: a retrospective comparison of crossed-screws, locking and non-locking plate fixation with lag screw. arch bone jt surg. 2017;5(4):221-25. figure 3. post-operative x-rays showing successful radiological union https://orcid.org/0000-0001-7773-6081 http://orcid.org/0000-0003-1054-0505 https://orcid.org/0000-0002-2535-4812 page 222 meijer jg et al. sa orthop j 2020;19(4) 6. cone b, staggers jr, naranje s, et al. first metatarsophalangeal joint arthrodesis: does the addition of a lag screw to a dorsal locking plate influence union rate and/or final alignment after fusion. j foot ankle surg. 2018;57(2):259-63. 7. fadel g, rowley d, abboud r. hallux metatarsophalangeal joint arthrodesis: various techniques. the foot. 2002;12:88-96. 8. neufeld sk, parks bg, naseef gs, melamed ea, schon lc. arthrodesis of the first metatarsophalangeal joint: a biomechanical study comparing memory compression staples, cannulated screws, and a dorsal plate. foot ankle int. 2002;23(2):97-101. 9. politi j, hayes j, njus g, bennett gl, kay db. first metatarsalphalangeal joint arthrodesis: a biomechanical assessment of stability. foot ankle int. 2003;24(4):332-37. 10. coughlin mj. arthrodesis of the first metatarsophalangeal joint with minifragment plate fixation. orthopedics. 1990;13:1037-44. 11. latif a, dhinsa bs, lau b, abbasian a. first metatarsophalangeal fusion using joint specific dorsal plate with interfragmentary screw augmentation: clinical and radiological outcomes. foot ankle surg. 2017;25(2):132-36. 12. sung w, kluesner aj, irrgang j, burns p, wukich dk. radiographic outcomes following primary arthrodesis of the first metatarsophalangeal joint in hallux abductovalgus deformity. j foot ankle surg. 2010;49(5):446-51. 13. parker l, singh d. the principles of foot and ankle arthrodesis. j orthop trauma. 2009;23(6):385-94. 14. hamilton ga, ford la, patel s. first metatarsophalangeal joint arthrodesis and revision arthrodesis. clin podiatr med surg. 2009;26(3):459-73. 15. roukis ts. nonunion after arthrodesis of the first metatarsalphalangeal joint: a systematic review. j foot ankle surg. 2011;50(6):710-13. 16. fazal ma, wong jh, rahman l. first metatarsophalangeal joint arthrodesis with two orthogonal two-hole plates. acta orthop traumatol turc. 2018;52(5):363-66. 17. boyd j, chmielewski r. prevention of infection in foot and ankle surgery. clin podiatr med surg. 2019;36(1):37-58. 18. dening j, van er ve rh. ar throdesis of the first metatarsophalangeal joint: a retrospective analysis of plate versus screw fixation. j foot ankle surg. 2012;51(2):172-75. 19. da cunha rj, macmahon a, jones mt, et al. return to sports and physical activities after first metatarsophalangeal joint arthrodesis in young patients. foot ankle int. 2019;40(7):745-52. 20. flavin r, stephens mm. ar throdesis of the first metatarsophalangeal joint using a dorsal titanium contoured plate. foot ankle int. 2004;25(11):783-87. _hlk31606137 _hlk31598127 _hlk30859234 404 not found sa orthopaedic journal winter 2014 | vol 13 • no 2 page 49 telangiectatic osteosarcoma of the radius: a missed diagnosis case report dr t msithini mbchb registrar, division of orthopaedics, university of witwatersrand prof m lukhele mbchb, mmed(orth), fcs(orth) clinical head of orthopaedics: charlotte maxeke johannesburg academic hospital, university of witwatersrand dr z linda mbchb, fcs(orth) head of tumour and sepsis unit, charlotte maxeke academic hospital, university of witwatersrand correspondence: prof m lukhele division of orthopaedics charlotte maxeke johannesburg academic hospital university of witwatersrand email: mkhululi.lukhele@wits.ac.za tel: +27117172038 introduction we present a case of an adolescent female with telangiectatic osteosarcoma (tos) of the radius and review the clinical, radiological and pathological features. on reviewing the literature no similar case involving the radius was found. case history a 15-year-old schoolgirl presented to a local hospital with a fracture of the left forearm after a trivial fall. the medical staff made a diagnosis of midshaft radius fracture and the pathological nature of the fracture was overlooked (figures 1 and 2). they went ahead and performed open reduction and internal fixation (figure 3). there were no notes on the intra-operative findings on the nature of surrounding soft tissue and quality of bone. three months later, she presented with swelling and pain of the left forearm. radiographic examination revealed an extensive lytic destructive lesion of radius. it was at that stage that the patient was referred to our centre. abstract telangiectatic osteosarcoma is a rare variant of osteosarcoma accounting for 3%–11% of all primary osteosarcomas.1 it has well described distinctive radio-pathological features. radiographically, these tumours appear as purely lytic destructive lesions located in the metaphyses of long bones. on gross clinical examination, it presents as a soft and cystic mass. histologically findings are that of aneurysmally dilated spaces lined by osteoidproducing atypical stromal cells. this is a report on a patient with an atypical telangiectatic osteosarcoma which was missed by the primary treating medical team. key words: pathologic fracture, telangiectatic osteosarcoma, awareness figures 1 and 2. pathological fracture of the radius (note permeative lytic diaphyseal lesion of the radius with no periosteal reaction and endosteal scalloping.) saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 49 page 50 sa orthopaedic journal winter 2014 | vol 13 • no 2 physical examination revealed a massively distended forearm with associated epitrochlear and axillary adenopathy (figure 4). there was no neurovascular deficit or elbow/wrist involvement clinically. the rest of the physical assessment was unremarkable. plain radiographs confirmed an extensively destructive lesion of the radius, with massive soft tissue swelling, soft tissue spicules and failure of fixation (figure 5). laboratory investigations were unremarkable with a slightly raised erythrocyte sedimentation rate (esr) 15 mm/hr. the haemoglobin level was 12 and liver function test were normal with alkaline phosphatase 101. computerised tomography scan (volumetric ct) of the chest, showed evidence of metastasis to the lungs (figure 6). scintigraphy (technetium 99m diphosphate scan) revealed an increase uptake in all three phases on left forearm and ribs (figure 7). magnetic resonance imaging had severe artefact as a result of the plate and screws but confirmed the extensive soft tissue involvement. at this stage it was clear that we were dealing with a malignant tumour with metastasis. she was taken to theatre for an open biopsy of the lesion. intra-operatively, the tumour was found to be pale yellow in colour and highly vascularised with areas of necrosis. the histopathology was reported by the pathologist to show blood-filled pseudo-cystic spaces surrounded by tumour cells with osteoid deposition and formation of cartilage by malignant cells. the pathologist made a diagnosis of telangiectatic osteosarcoma with foci of chondroblastic cells. the patient was referred to the paediatric oncology department for neoadjuvant chemotherapy with the plan of performing an amputation. unfortunately she demised during the chemotherapy courses. figure 3. post-operative radiographs figure 5. extensive lytic destructive lesion of the diaphysis of radius with cortical destruction and infiltration of surrounding soft tissue. there is associated soft tissue swelling and implant loosening. figure 4. mass on the left forearm, striations and healed surgical scar figure 6. arrow shows metastases on the right lower lobe saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 50 sa orthopaedic journal winter 2014 | vol 13 • no 2 page 51 discussion telangiectatic osteosarcoma (tos) was first described by paget (1854). gaylord considered these tumours to be malignant aneurysms of bone (1903). ewing was the first to consider and describe tos as a variant of osteogenic osteosarcoma.2 tos is primarily a tumour of long tubular bones with the metaphysis as a site of origin. the incidence varies in different studies from 3%–10%.1 there is male predominance with a ratio of 2:1 (males:females) and median age of 17.5 years (15–20 years). clinical presentation resembles conventional osteosarcoma, presenting with local pain, soft tissue mass or both. pathological fractures are an occasional presentation, but have been reported in study as 29% at initial diagnosis or during the course of the disease, compared to 12% for conventional osteosarcoma.3 the risk factors for pathological fractures include large dimensions, diaphyseal location, and progressive loss of bony matrix, osteolytic radiographic pattern, telangiectatic type and prior biopsy. the metaphyseal region of long bones is the most common location at presentation with the following distribution pattern: distal femur (41.6%), proximal tibia (16.9%), proximal humerus (9.2%), proximal femur (7.7%), mid femur (6.2%), mid humerus (4.6%), mid tibia (3.1%) pelvis (3.1%), fibula (1.5%), skull (1.5%) and ribs(1.5%).4 extra-osseous tos has been described in soft tissues. the aggressive, expansile and osteolytic nature of this tumour is the radiographic hallmark. the dilemma associated with radiological diagnosis of tos is due to the fact that it is almost indistinguishable from an aneurysmal bone tumour. a combined modality approach with use of strict pathological and radiological criteria is crucial.4 there is a high rate of pathological fracture in patients with tos.5 our patient is atypical as our literature search revealed no similar case of tos being described as occurring in the diaphysis of the radius. the permeative lytic lesions seen in the first x-rays are also atypical unless the tos was in its early stages. the histological pattern is also atypical in the sense that cartilage formation has not been described in tos. an argument can be made that the cartilage and osteoid formation is a result of the open reduction and internal fixation of the fracture of the radius. the aggressive nature of the progression of the lesion and its vascularity does simulate tos. the lesson to be learned from the initial assessment by the primary doctors is that pathological fractures should always be kept high on the list of possibilities. for a young patient to sustain a fracture of the radius significant force is required. it is therefore important to always take a history of the mechanism of injury. if the force involved turns out to be minor, further history on pre-fracture symptoms must be solicited. in this particular patient a fracture of the radius without an associated fracture of the ulna or disruption of the distal radio-ulna joint should have raised an alarm. this case emphasises the need for continuous professional education on musculoskeletal pathology for primary care providers including community medical officers given that not enough time is allocated to orthopaedics during undergraduate training. at the same time it supports encouraging medical officers at district and provincial hospitals to register and take the higher diploma in orthopaedics already provided by the colleges of medicine of south africa. conclusion it very important to identify pathological fractures at the outset, and then to investigate and manage them appropriately. clinicians should have a high index of suspicion in atypical mechanisms of injury and relook at the fracture pattern to exclude a pathological fracture. the content of this article is the sole work of the authors. the primary author has received a research grant from the south african orthopaedic association for research relating to chronic osteomyelitis. references 1. sangle a, layfield j. telangiectatic osteosarcoma. arch pathol lab med. 2012;136:572-76. 2. yeon-lim suh, je g. telangiectatic osteosarcoma. journal of korean medical science 1989;4(2):97-101. 3. mutsuno t, unni kk, mcleod ra, dahlin dc. telangiectatic osteogenic sarcoma. cancer 1976;38(6):2538-47. 4. huvos ag, rosen g, bretsky ss, butler a. telangiectatic osteogenic sarcoma a clinicopathologic study of 124 patients. cancer 1982;49(8):1679-89. 5. weiss a, khoury j, hoffer f, wu j, heck r, quintana j, poe d, rao b, daw n. telangiectatic osteosarcoma: the st. jude children’s research hospital’s experience. cancer 2007;109:1627-37. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. figure 7. scintigraphy results • saoj plain radiographs confirmed an extensively destructive lesion of the radius saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/06 12:15 pm page 51 404 not found south african orthopaedic journal current concepts review doi 10.17159/2309-8309/2023/v22n1a6 sukati fm et al. sa orthop j 2023;22(1) citation: sukati fm, viljoen j, alexander a. intertrochanteric femur fractures: a current concepts review. sa orthop j. 2023;22(1):41-47. http:// dx.doi.org/10.17159/2309-8309/2023/ v22n1a6 editor: prof. nando ferreira, stellenbosch university, cape town, south africa received: march 2022 accepted: june 2022 published: march 2023 copyright: © 2023 sukati fm. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract intertrochanteric fractures are common injuries around the hip, especially among the elderly. with the rising incidence of these injuries, they are expected to double by 2050. incidence rates are higher in females than males and in white patients than black african patients. osteoporosis weakens the local trochanteric anatomic support leading to an increased susceptibility to fractures. disruption of the posteromedial calcar region results in fracture instability. optimal lag screw position and fracture reduction are significant determinants for postoperative outcomes. the tip apex distance and reduction criteria determine lag screw cut-out risk and fracture reduction quality, respectively. a calcar-referenced tip apex distance is comparable if not better than the tip apex distance in predicting cut-out risk. optimal reduction is in slight valgus, a positive medial cortex apposition and smooth anterior cortex apposition. high mortality rates are observed with non-surgical treatment. surgical management is therefore the gold standard for intertrochanteric fractures. treatment options are categorised into extramedullary fixation, intramedullary fixation and proximal femur replacement. they include the dynamic hip screw (dhs), cephalomedullary nails (cmn) and arthroplasty. although still in use, the proximal femur locking plate is falling out of favour due to high complication rates. fracture stability and pattern influence the treatment choice. there is, however, a growing use of cmns which has been attributed to surgical training background. modification of older cmn designs has improved treatment outcomes. systematic meta-analyses of randomised controlled trials (rcts) do not show superiority of one treatment option over another; therefore, there is no consensus on the best treatment choice. the proximal femur nail antirotation (pfna) has better outcomes compared to other fixation options with respect to intraoperative blood loss and harris hip scores. as a group, cmns have a better 120-day postoperative quality of life compared to the dhs. no significant difference in complications has been found between treatment options. in light of the anticipated increased incidence of intertrochanteric fracture, more work is needed in planning national resource allocation, devising preventative methods and improving clinical interventions in south africa. level of evidence: level 5 keywords: intertrochanteric femur fracture, dynamic hip screw, cephalomedullary nail, arthroplasty intertrochanteric femur fractures: a current concepts review falethu m sukati,¹* jaco viljoen,² alwich alexander³ ¹ trauma and spine units, department of orthopaedics, steve biko academic hospital, university of pretoria, pretoria, south africa ² trauma and tumour limb reconstruction and sepsis units, department of orthopaedics, steve biko academic hospital, university of pretoria, pretoria, south africa ³ trauma and foot units, department of orthopaedics, steve biko academic hospital, university of pretoria, pretoria, south africa *corresponding author: falethu.sukati@up.ac.za introduction the intertrochanteric region is defined as the extracapsular portion of the proximal femur between the intertrochanteric line and a horizontal line at the lower end of the lesser trochanter.1 the fractures occur due to high or low energy trauma, the latter being common in patients with osteoporotic bone. with the use of computed tomography (ct) scans, understanding of intertrochanteric fracture patterns and management thereof has improved. in this paper we review the current knowledge on this injury, its management options and outcomes, and relate these to the south african context. epidemiology intertrochanteric femur fractures have a bimodal distribution, occurring as high energy injuries in young adults and more commonly as low energy, osteoporotic fractures in elderly patients.2,3 dela et al. recently reported a hip fracture incidence rate of 68.6 per 100 000 for the total south african population, with 87.5 and 46.2 per 100 000 for females and males, respectively.4 this represents a significant increase from the incidence rate of 5.6 per 100 000 reported by solomon in 1968.5 based on sex and ethnicity, the incidence rate for females was 175.9, 43.6, 73.2 and 147.7 in the white, black african, coloured and indian groups, respectively. for males the incidence rate was 76.5, 31.1, 39.7 and 69.2 in the white, black african, coloured and indian groups, respectively. of note is the average age at fracture in that study was lower than in developed countries.4 anatomical considerations the intertrochanteric region is a well-vascularised region connecting the femoral neck with the diaphysis, and to fully understand the fixation of fractures in the intertrochanteric region, one needs to be cognisant of the alignment of the femoral neck to the shaft. in the coronal plane, the neck shaft angle of a normal adult ranges from 120° to 135°. in the transverse plane, alignment of the femoral neck to shaft is 10° to 15° of anteversion relative to the femoral condyles. the intertrochanteric region is highly dependent on the https://orcid.org/0000-0002-1235-3597 page 42 sukati fm et al. sa orthop j 2023;22(1) structural integrity of a cancellous bony arcade, stretching from the femoral head to the lesser trochanter where the solid nature of this area transitions to the tubular femoral canal.6 the vertical column originates in the lower medial femoral neck and ascends vertically into the femoral head and conveys compression forces.7 the horizontal column originates at a bony buttress in the inner anterior upper femoral shaft from which it extends horizontally towards the anterior aspect of the femoral head, conveying tension force.7 the calcar and beams of bone trabeculae (compression, tension, oblique/secondary compression) form a loading system–truss system.8 the calcar is a vertical plate composed of multiple layers of compact bone, typically no thicker than 1 mm, which is situated deep to the lesser trochanter but posterior to the neutral axis of the femoral neck.9 it contributes to the strength of the femoral neck and can bear compressive load, redistributing the load from the femoral head to the proximal femur shaft. during single limb stance, the proximal femur simultaneously bears bending and torsional moment and the femur grows to adapt to these mechanical requirements.9 the posteromedial lesser trochanter calcar fragment frequently extends to the posterior cortex.7,8 disruption of the calcar results in decreased efficiency in transforming bending and torque moments, affecting the stress pattern in the proximal femur and thus rendering fractures that involve this portion of the proximal femur unstable.9,10 technical and surgical factors reduction baumgaertner and colleagues proposed what is currently the most widely used criteria for assessing the risk for failure of fixation.11 more recently chang et al. proposed criteria for assessing the quality of fracture reduction between the head-neck fragment and femur shaft. the point-based system categorises a reduction as good, acceptable or poor.12 a good intertrochanteric reduction has a normal or slight valgus alignment and positive medial apposition on the anteroposterior (ap) x-ray view. on a lateral view, there is central axial alignment with smooth anterior cortex contact. medial displacement > 4 mm of any fragment on ap and angulation > 20° on lateral view are not acceptable. the maximum cortical thickness is 4 mm, therefore a reduction with < 4 mm translation ensures cortical contact. a reduction is considered acceptable when it meets either the alignment or displacement criteria. a poor reduction does not meet any of the criteria.12 poor reduction quality and loss of medial wall support are independent factors for implant failure.13 application of a circumferential cerclage cable after intramedullary fixation of reverse oblique intertrochanteric fractures reduces the risk of implant failure.14,15 the quantity and range of the posteromedial fragment significantly correlates with postoperative telescoping and varus collapse of the femoral head and neck component.2 anteromedial cortical support reduction for unstable intertrochanteric fractures introduced by chang and colleagues in 2015 is an extension of the nonanatomic positive cortex buttress concept by gotfried et al.12,16 this reduction aims at using the medial wall of the femur shaft fragment as a functional buttress for the medial cortex of the neck fragment. it enables a controlled fracture impaction leading to axial and torsional stability. the reduction is termed positive, neutral or negative depending on the anteromedial cortical alignment on ap and lateral views. if the head-neck fragment is medial on ap or anterior on lateral view to the shaft fragment, it is deemed positive reduction (figure 1). a negative reduction arises when the head-neck xap xcalap ba caltadap = [xcalap x (d true / dap) ] caltad = caltadap + tadlat tad = [xap x (d true / dap)] + [xlat x (d true / dap)] figure 1. radiograph showing the calcar-referenced tip apex distance on ap and a reduction with positive medial cortex support (pmcs); b) tip apex distance on ap caltadap = [xcalap × (d true / dap)] caltad = caltadap + tadlat page 43sukati fm et al. sa orthop j 2023;22(1) fragment is lateral on ap or posterior on lateral view in relation to the shaft fragment. the ideal reduction is positive on both ap and lateral views. chang’s group further combined their concept with that of baumgaetner’s group to develop a postoperative stability scoring system.17 tad and cal-tad optimal position of the lag screw has been defined by various methods, one of which is the tip-apex distance (tad) introduced by baumgaetner and colleagues in 1995.11 other methods used to assess the position of the cephalic fixation are the cleveland zone system, parker’s ratio index and calcar-referenced tip-apex distance (caltad). the cleveland zone system and parker’s ratio index effectively illustrate the location of the cephalic fixation in relation to the rest of the head by assigning it to a zone or calculating a ratio. the tad measures the depth of the cephalic fixation. by referencing the tad to the calcar, the caltad combines illustration of the cephalic fixation location with measurement of its depth.18 the first component of the caltad is measured in the anteroposterior radiograph using a line drawn adjacent to the femoral calcar and parallel to the neck axis. the second component is measured on the lateral view and is similar to that of the tad as shown in figure 1.19 the risk of cut-out is influenced by the quality of intraoperative reduction, positioning of the screw in the femoral head and the type of fracture. in biaxial cepalomedullary nail fixation, the calcarreferenced tad is a better predictor for cut-out than the tad.20 regarding caltad, although there was a tendency for more failure with caltad > 25 mm (p = 0.06) and even with caltad > 20 mm (p = 0.07), this difference did not reach statistical significance (p = 0.05). in light of the finding by lopes-coutinho et al., the femur head size is an important factor.21 in the biomechanical study by kane et al., no significant difference was found in screw placement between the centrecentre and low-centre positions. however, it must be noted that the study was powered to detect a 20% difference in the magnitude of loading cycles or fracture translation between treatment groups. even though the results did not show statistical significance, the low-centre position consistently had better results. based on kinematic evaluation, the authors then inferred that the low-centre position may provide a more stable fixation than the centre-centre position.22 lopes-coutinho et al. did not explore the influence of implant choice, which may have influenced their findings.21 as the nail is driven deeper in the shaft to achieve a low-centre position for the cephalic screw, there is a risk of lateralising the proximal end of the nail. this can lower the integrity of the lateral wall and precipitate varus collapse. the same proximal valgus angulation of the nail can also result in vulgarisation of the neck-shaft angle in patients with stronger bone, thus conferring an advantage. by combining the illustration of cephalic fixation location with depth measurement, the caltad becomes a better predictor of implant failure as shown by yang et al.18 in this study on intertrochanteric fractures in geriatric patients fixed with cephalomedullary nails, they found no significant difference between the failure and nonfailure groups for the cleveland zone system, and parker’s ratio index in the univariate and multivariate analysis. for the tad, significant differences were found in univariate analysis but not multivariate analysis. the caltad showed significant differences in both univariate and multivariate analysis. furthermore, it showed an almost perfect interclass correlation coefficient. they therefore concluded that among the tools for measuring cephalic fixation position, the caltad is the only significant predictor for implant failure in geriatric intertrochanteric fractures with cephalomedullary nail (cmn) fixation.18 these findings are similar to those of kashinga et al., whose study was not limited to geriatric patients.23 the tad is still considered a reliable predictor for screw cut-out. a lower value of 20 mm may be even better than the original value of 25 mm. the caltad is equally reliable if not better than the tad. management options dynamic hip screw the dynamic hip screw (dhs), also known as a sliding hip screw (shs), has historically been considered the mainstay for fixing intertrochanteric fractures but some now consider cephalomedullary devices (cmds) to be the gold standard.24 fracture fixation with the dhs is recommended by the nice guidelines for ao 31a1 and a2 fractures and aaos for unstable intertrochanteric fractures.25,26 both recommendations are not evidence-based as most metaanalyses have not shown superiority between the dhs and the intramedullary nail (imn).27-31 a key factor for using the dhs is lateral wall integrity described as wall greater than 20.5 mm. absence of an intact lateral wall renders intertrochanteric fractures unstable for management with a dhs. a dhs, through its angular construct, maintains the neck shaft angle while the lag screw slide creates a compression force at the fracture site. flattened sides of the lag screw limit rotational forces (figure 2). an intact lateral wall acts as a buttress, limiting further lateral displacement. addition of an antirotation screw reduces lag screw migration and cut-out.32 advantages of the dhs are cost effectiveness, fracture stability, an option to add a trochanteric stabilisation plate, and early mobilisation of patients. disadvantages are its limited use to stable fractures and more prominent hardware that may need removal later. proximal femur locking plate the proximal femur locking plate (pflp) is another extramedullary device for intertrochanteric fracture fixation (figure 3). it is a fixedangle, static construct and the plate offers lateral wall buttress. a precontoured design enables anatomical reduction and fixation against the plate, and the convergent proximal locking screws enhance fixation stability (figure 4).33 advantages versus the dhs in unstable fractures are that it can address complications like shortening, medialisation of the distal fragment, implant figure 2. dynamic hip screw page 44 sukati fm et al. sa orthop j 2023;22(1) cut-out, lateralisation of proximal fragment and varus collapse. adductor muscle pull tends to medially displace the distal fragment in unstable intertrochanteric fractures and a pflp resists this deforming force. the locking mechanism in a pflp creates a non-collapsing implant which overcomes the forces that otherwise develop at the screw-plate junction in a dhs with coaxial collapse of the proximal fragment. bone preservation is an important factor for fracture union, and the pflp is superior to the dhs in this respect owing to the smaller screw size.34 compared to cmns the pflp is better at keeping free bone fragments in the greater trochanter together. in such patterns the lateral trochanteric wall usually shatters, and cleavage occurs in the coronal plane. furthermore, insertion of an imn may worsen the instability through additional lateral wall damage.35 indications for the pflp are limited, e.g. unstable intertrochanteric (it) fractures in patients with a narrow femoral canal. some surgeons use it for patients with reverse oblique fractures and those exiting at the greater trochanter thereby compromising nail entry. poorly defined indications and application beyond the limits contribute to high failure rates. application of the pflp may be justified for its superior abilities to restore and maintain anatomy. this especially holds true for a younger subgroup of patients. however, if anatomical reduction is not achieved and patient compliance is low, the use of a pflp should be carefully weighed against other implants especially in unstable intertrochanteric or subtrochanteric fractures.33 moreover the recent paper by parker et al. concluded that unstable intertrochanteric fractures should not be treated with fixed/static plates. pflp are therefore not the first choice in unstable intertrochanteric fractures.31,36 cephalomedullary nails the cephalomedullary nail (cmn) was introduced in the 1980s and its use over the years has increased. this increasing use of the cmn is higher among younger surgeons and is influenced by training, setting and postgraduate experience. however, it is not supported by literature as there is no superiority demonstrated between the cmn and dhs.27-31 cmns resist the deforming forces in intertrochanteric fractures which otherwise lead to medialisation and varus collapse of the proximal fragment. the medullary placement of a cmn creates a buttress which resists medialisation, and the fixed angle construct helps in preservation of the neck-shaft angle. this is more important in unstable intertrochanteric fractures. in the treatment of unstable fractures, patients fixed with cmn are more likely to maintain reduction, avoid limb length discrepancy and fully weight bear earlier. the advantage of a cmn over dhs in improved mobility was demonstrated by hardy as limited to the first three postoperative months in stable fractures and persisting to the twelfth month in unstable fractures.37 in studies that showed no superiority of cmn over dhs, the findings have been attributable by some authors to a failure to distinguish between stable and unstable fractures, differences in the general health of patients and variations in postoperative rehabilitation protocols.38 however, more recent cochrane reviews have also found no superiority of cmn over fixed angle extramedullary devices like the dhs.39,40 mismatch of radii of curvature between femur and nail is a known problem, with long femur nails commonly resulting in complications such as anterior cortical abutment, encroachment, erosion and penetration.41 consideration of the anatomical variations led to the development of short nails and further modifications thereof.42 modifications to the short nail have reduced the complication rate. zhang et al. modified the short nail in three key areas. they changed the proximal diameter to 16.5 mm, introduced an anterior curve below the 4° valgus angle and fluted the distal 30 mm of the nail.43,44 numerous studies have shown the superiority of short versus long nails with regard to reoperation rate, radiation exposure, estimated blood loss and operative time.43-45 with this background, there are still some scenarios where long nails are recommended. these include fractures with primary lateral wall rupture (ao 31 a3, with subtrochanteric extension (ao 31 a2.3), with wider proximal medullary canal, large coronal fractures of the lateral wall and revision for a short nail.17 essentially the preference for long nails is in unstable fracture patterns where reduction is unlikely to be maintained with short nails. some recent studies have shown that short nails can be comparable with long nails in treating unstable fractures. in a biomechanical study blum et al. found no significant difference in figure 3. proximal femur locking plate side view figure 4. proximal femur locking plate top view page 45sukati fm et al. sa orthop j 2023;22(1) axial load to failure values between long and short imn fixation in unstable intertrochanteric fracture patterns. fractures fixed with short nails showed greater torsional stiffness than with long nails. they hypothesised that this was due to the shorter working length in short nails.45 similarly hulet et al. showed that there was no difference in overall complications between short and long cmn treatment for unstable intertrochanteric fractures.46 once a decision is made to use a cmd, current evidence favours a short nail but surgeons should consider the factors listed above to judge if the reduction is likely to be lost. most of the studies comparing locked versus unlocked nails or static versus dynamic locking are based on short cmns, the mean age of the study populations being over 70 years. in the biomechanical study by lacroix, the addition of a distal screw led to a 35.7% decrease of the mean failure to load in torsion.47 the authors postulated that the drill holes acted as stress risers. in stable fractures a distal screw has no effect on the load distribution as shown by the lack of pattern in proximal femur strain pattern.48 this is due to the axial load being transferred from the trochanteric region to the femur cortex. a few recently published meta-analyses have shown superior results in stable fractures for the unlocked nail with significant differences in operation time, fluoroscopy exposure time, blood loss and total incision length.49-51 there are differences in the complication profile between locked and unlocked nails. distal locking is associated with iatrogenic fractures, thigh pain, vascular injury, delayed union and non-union. the most frequent among these is thigh pain.52 lil et al. found distal locking in long nails to be associated with a gradual decrease in neck-shaft angle which led to varus collapse and construct failure in 21.4% of patients.53 the authors described how distal locking blocks migration of the nail, ultimately leading to a windshield effect of the cephalic screw and cut-out. significantly lower rates of thigh pain and other complications have been demonstrated with unlocked nails.51,54 peri-implant fractures and anterior cortical impingement occur but are not unique to unlocked nails. skála-rosenbaum et al. found a higher peri-implant fracture rate in unlocked nails compared to dynamically locked nails for ao 31-a1 and a2 fractures. the authors described two types of fracture patterns, both of which can be attributed to surgical planning and/or technique errors.55 techniques for eliminating these complications have been described. it is important to check for rotational instability. after placing the cephalic screw in rotationally stable fractures, the femur moves as one unit.51 rotationally unstable fractures do better with distal locking.50 stable trochanteric fractures can be adequately treated with distally unlocked nails.49-51,56-58 another decision to be made when using a cmn is whether to use a monoor biaxial lag screw device. screw cut-out and migration of the proximal fragment are known complications for cmns. the development of biaxial screws was aimed at improving these outcomes. common devices available in the market are the intertan for biaxial screws and the gamma3 nail for monoaxial screws. the intertan shows less screw cut-out and migration compared to the gamma3 nail or pfna. a meta-anaylsis by nherera et al. found the intertan had fewer complications, fewer revisions and fewer patients complaining of pain compared to the pfna.59 however the meta-analysis by ma et al. found the two to be comparable when assessing blood loss, revision rate, fluoroscopy time, union and length of hospital stay. although they found lower cut-out and femur fracture rates with the intertan, these did not translate to statistically significant lower revision rates.60 current evidence therefore indicates that biaxial cmn has lower cut-out rates compared to monoaxial cmn but is equally comparable on other factors. comparison between a lag screw and helical blade shows no difference in cut-out rate.61 arthroplasty surgical stabilisation that quickly restores pre-injury mobilisation and avoids complications offers the ideal outcome in intertrochanteric fractures. at times internal fixation does not meet these goals. high failure rates due to fracture instability and osteoporosis with internal fixation have led others to consider arthroplasty as a treatment option. numerous authors have shown that hemiarthroplasty (ha) and total hip arthroplasty (tha) are viable treatment options for unstable intertrochanteric fractures.62-64 however, meta-analysis of several randomised controlled studies have not demonstrated superiority of arthroplasty over internal fixation.65-67 the metaanalysis by kumar et al. concluded that internal fixation with a proximal femur nail was superior to ha for management of ao/ota a2 and a3 intertrochanteric femur fractures in the elderly.68 interest in arthroplasty for intertrochanteric fractures has been low in the past partly due to low non-union and avascular necrosis rates after internal fixation. currently there is an increasing interest. patients who sustain intertrochanteric fractures with pre-existing significant hip osteoarthritis, rheumatoid arthritis or proximal femur and periacetabular pathological fractures may be better managed with arthroplasty.69 with recent meta-analysis studies favouring internal fixation with a proximal femur nail over arthroplasty for unstable intertrochanteric fractures, the latter should be used with caution in carefully selected patients.65-68 furthermore, resource constraints must be considered in those countries where they are a significant factor. outcomes zha et al. proposed three requirements for an ideal internal fixation for intertrochanteric fracture: 1) femoral neck screw with at least three-dimensional structures of the fixed system; 2) minimal angle between the femoral neck screw axis and the femoral shaft and thus maximum alignment between the angle of normal hip joint weight-bearing line and the femoral graft axis (normally 25°); and 3) ability of the implant to prevent the rotation of the femoral head. unfortunately, none of the currently used devices can fully meet these three criteria.70 consequently implant-related complications arise. cui et al. reported a pooled estimate of the one-year mortality rate at 17.47% after femoral intertrochanteric fracture and 9.83% after femoral neck fracture.71 these are still better than the mortality rate of 34.6% in conservatively treated intertrochanteric fractures.72 in the largest network meta-analysis to date, the pfna was the most preferable surgical method with less blood loss and higher harris hip score. this study included 36 rtcs and compared eight intramedullary and extramedullary internal fixation methods. the pfna and gamma nail had lower operative times than the dhs. no significant differences were found with respect to complications.73 marks et al. found the 120-days postoperative quality of life significantly favoured the cmn over the shs (dhs).74 although arthroplasty has not proven to be superior to internal fixation, it still offers some benefits such as early postoperative weight bearing, a shorter hospital stay, and lower implant-related complications and reoperation rate.65,66 internal fixation has shorter operative times and lower blood loss. data on harris hip scores and one-year mortality rate favour internal fixation in some studies and show no difference in others. south african context in 2021, the elderly (60+ years) were estimated to be at 5.51 million, 9.15% of the south african population. this is an increase from 4.89 million (8.5%) in 2018, in keeping with the improving page 46 sukati fm et al. sa orthop j 2023;22(1) life expectancy. the eastern cape has the highest proportion of elderly patients in south africa (11.5%) and gauteng has the second lowest at 8.5%.75 by 2050, it is predicted that the elderly will constitute 24.3% of the south african population, more than double the current numbers.76 high levels of income inequality in south africa place more than half the population below the poverty line. among this population there is a high level of communicable diseases (e.g. hiv/aids), protein calorie malnutrition and suboptimal daily calcium intake. these lead to low bone mineral density (bmd). on the other end of the economic spectrum, high alcohol use and smoking are significant contributors to a low bmd.4,77 all these factors will lead to a rise in fragility hip fractures. a two-tiered healthcare system, higher urban distribution of orthopaedic surgeons, higher rural distribution of elderly patients and the absence of an event-based funding model in the public sector make delivery of optimal care for intertrochanteric fractures to the most affected patients difficult at a national level. clinicians can still improve care at a more local level by developing units that are geared to handle these patients, e.g. an ortho-geriatrics unit as shown by li et al.78 furthermore costs can be reduced by as much as 18% without reduction of quality measures through the use of an algorithm for intertrochanteric fracture treatment.78 more work still needs to be done to understand local fracture patterns. conclusion operative management of intertrochanteric fractures is essential for optimal outcomes. stable fractures can be managed by either a dhs or cmn, depending on surgical expertise and resources. there is currently no evidence favouring one option over the other. the pflp should be avoided in these injuries. unstable intertrochanteric fractures require a good understanding of the fracture pattern and careful implant selection for good outcomes. available meta-analyses of randomised controlled trials (rcts) have not shown superiority between the dhs and cmn or cmn and arthroplasty. cmns have better outcomes compared to the dhs and arthroplasty with respect to operative time and blood loss. similar outcomes have been shown for cmns on harris hip scores compared to the dhs and to a certain extent in arthroplasty. the lack of superiority for arthroplasty over cmns and a more recent rct showing superiority of the proximal femur nail over hemiarthroplasty further limit the use of arthroplasty as a surgical option for unstable intertrochanteric fractures. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions fms: literature review, epidemiology, technical and surgical factors, dynamic hip screw, cephalomedullary nails, outcomes, south african context, first draft preparation, manuscript preparation jv: introduction, arthroplasty aa: anatomical considerations, proximal femur locking plate orcid sukati fm https://orcid.org/0000-0002-1235-3597 viljoen j https://orcid.org/0000-0002-8775-6913 alexander a https://orcid.org/0000-0002-4023-7550 references 1. parker mj. trochanteric hip fractures. in: tornetta p iii, editor. rockwood and green’s fractures in adults. 9th ed. philadelphia: wolters kluwer; 2020. p. 2285-317. 2. ren h, ao r, wu l, et al. effect of lesser trochanter posteromedial wall defect on the stability of femoral intertrochanteric fracture using 3d simulation. j orthop surg res. 2020 jul 3;15(1):242. https://doi.org/10.1186/s13018-020-01763-x 3. tsabasvi m, davey s, temu r. hip fracture pattern at a major tanzanian referral hospital: focus 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[chinese] 44. chang sm, hu sj, ma z, et al. femoral intertrochanteric nail (fitn): a new short version design with an anterior curvature and a geometric match study using post-operative radiographs. injury. 2018 feb;49(2):328-33. 45. blum le, yee ma, mauffrey c, et al. comparison of reamed long and short intramedullary nail constructs in unstable intertrochanteric femur fractures: a biomechanical study. ota int. 2020 may 5;3(2):e075. 46. hulet da, whale cs, beebe mj, et al. short versus long cephalomedullary nails for fixation of stable versus unstable intertrochanteric femur fractures at a level 1 trauma center. orthopedics. 2019 mar 1;42(2):e202-e209. 47. lacroix h, arwert h, snijders cj, fontijne wp. prevention of fracture at the distal locking site of the gamma nail. a biomechanical study. j bone joint surg br. 1995 mar;77(2):274-76. 48. rosenblum sf, zuckerman jd, kummer fj, tam bs. a biomechanical evaluation of the gamma nail. j bone joint surg br. 1992 may;74(3):352-57. 49. yan ws, cao wl, sun m, et al. distal locked or unlocked nailing for stable intertrochanteric fractures? a meta-analysis. anz j surg. 2020 jan;90(1-2):27-33. 50. buruian a, silva gomes f, roseiro t, et al. distal interlocking for short trochanteric nails: static, dynamic or no locking? review of the literature and decision algorithm. efort open rev. 2020 aug 1;5(7):421-29. 51. chouhan d, meena s, kamboj k, et al. distal locked versus unlocked intramedullary nailing in intertrochanteric fracture: a systematic review and meta-analysis of randomized and non-randomized trials. bull emerg trauma. 2020 apr;8(2):56-61. 52. rosen m, kasik c, swords m. management of lateral thigh pain following cephalomedullary nail: a technical note. spartan med res j. 2020 jun 8;5(1):12931. 53. lil na, makwana vr, patel td, patel ar. comparative study of intertrochanteric fracture fixation using proximal femoral nail with and without distal interlocking screws. world j orthop. 2022 mar 18;13(3):267-77. 54. hardy dc, drossos k. slotted intramedullary hip screw nails reduce proximal mechanical unloading. clin orthop relat res. 2003 jan;(406):176-84. 55. skála-rosenbaum j, džupa v, bartoška r, et al. distal locking in short hip nails: cause or prevention of peri-implant fractures? injury. 2016 apr;47(4):887-92. 56. ciaffa v, vicenti g, mori c, et al. is distal locking with short intramedullary nails necessary in stable pertrochanteric fractures? a prospective, multicentre, randomised study. injury. 2016 oct;47 suppl 4:s98-s106. 57. ciaffa v, vicenti g, mori cm, et al. unlocked versus dynamic and static distal locked femoral nails in stable and unstable intertrochanteric fractures. a prospective study. injury. 2018 nov;49 suppl 3:s19-s25. 58. lanzetti rm, caraffa a, lupariello d, et al. comparison between locked and unlocked intramedullary nails in intertrochanteric fractures. eur j orthop surg traumatol. 2018 may;28(4):649-58. 59. nherera l, trueman p, horner a, et al. comparison of a twin interlocking derotation and compression screw cephalomedullary nail (intertan) with a single screw derotation cephalomedullary nail (proximal femoral nail antirotation): a systematic review and meta-analysis for intertrochanteric fractures. j orthop surg res. 2018 mar 2;13(1):46. 60. ma jx, kuang mj, fan zr, et al. comparison of clinical outcomes with intertan vs gamma nail or pfna in the treatment of intertrochanteric fractures: a meta-analysis. sci rep. 2017 nov 21;7(1):15962. 61. ng m, shah ns, golub i, et al. no difference between lag screw and helical blade for cephalomedullary nail cut-out a systematic review and meta-analysis. eur j orthop surg traumatol. 2021 oct 19. 62. fan l, dang x, wang k. comparison between bipolar hemiarthroplasty and total hip arthroplasty for unstable intertrochanteric fractures in elderly osteoporotic patients. plos one. 2012;7(6):e39531. 63. haentjens p, casteleyn pp, de boeck h, et al. treatment of unstable intertrochanteric and subtrochanteric fractures in elderly patients. primary bipolar arthroplasty compared with internal fixation. j bone joint surg am. 1989 sep;71(8):1214-25. 64. chan kc, gill gs. cemented hemiarthroplasties for elderly patients with intertrochanteric fractures. clin orthop relat res. 2000 feb;(371):206-15. 65. nie b, wu d, yang z, liu q. comparison of intramedullary fixation and arthroplasty for the treatment of intertrochanteric hip fractures in the elderly: a meta-analysis. medicine (baltimore). 2017 jul;96(27):e7446. 66. ju jb, zhang px, jiang bg. hip replacement as alternative to intramedullary nail in elderly patients with unstable intertrochanteric fracture: a systematic review and meta-analysis. orthop surg. 2019 oct;11(5):745-54. 67. chen wh, guo wx, gao sh, et al. arthroplasty vs proximal femoral nails for unstable intertrochanteric femoral fractures in elderly patients: a systematic review and meta-analysis. world j clin cases. 2021 nov 16;9(32):9878-88. 68. kumar p, rajnish rk, sharma s, dhillon ms. proximal femoral nailing is superior to hemiarthroplasty in ao/ota a2 and a3 intertrochanteric femur fractures in the elderly: a systematic literature review and meta-analysis. int orthop. 2020 apr;44(4):623-33. 69. waddell jp, morton j, schemitsch eh. the role of total hip replacement in intertrochanteric fractures of the femur. clin orthop relat res. 2004 dec;(429):49-53. 70. zha gc, chen zl, qi xb, sun jy. treatment of pertrochanteric fractures with a proximal femur locking compression plate. injury. 2011 nov;42(11):1294-99. 71. cui z, feng h, meng x, et al. age-specific 1-year mortality rates after hip fracture based on the populations in mainland china between the years 2000 and 2018: a systematic analysis. arch osteoporos. 2019 may 25;14(1):55. 72. guo y, yang hp, dou qj, et al. efficacy of femoral nail anti-rotation of helical blade in unstable intertrochanteric fracture. eur rev med pharmacol sci. 2017 jul;21(3 suppl):6-11. 73. cheng yx, sheng x. optimal surgical methods to treat intertrochanteric fracture: a bayesian network meta-analysis based on 36 randomized controlled trials. j orthop surg res. 2020 sep 10;15(1):402. 74. marks l, pass b, knobe m, et al. quality of life, walking ability and change of living situation after trochanteric femur fracture in geriatric patients–comparison between sliding hip screw and cephalomedullary nails from the registry for geriatric trauma. injury. 2021 jul;52(7):1793-800. 75. mid-year population estimates. pretoria: statistics south africa (stats sa); 2021. available from: http://www.statssa.gov.za/publications/p0302/p03022021.pdf. accessed 14 mar 2022. 76. fuleihan g. the middle east and africa audit (2011) international osteoporosis foundation. available from: https://www.aub.edu.lb/fm/cmop/downloads/me_audit-e.pdf. accessed 14 mar 2022. 77. van tonder e, gardner l, cressey s, et al. adult malnutrition: prevalence and use of nutrition-related quality indicators in south african public-sector hospitals. south afr j clin nutr. 2019;32(1):1-7. 78. li xp, zhang p, zhu sw, et al. all-cause mortality risk in aged femoral intertrochanteric fracture patients. j orthop surg res. 2021 dec 20;16(1):727. http://www.statssa.gov.za/publications/p0302/p03022021.pdf https://www.aub.edu.lb/fm/cmop/downloads/me_audit-e.pdf sa orthopaedic journal summer 2016 | vol 15 • no 4 page 37 comparative study of children with calciopaenic and phosphopaenic rickets seen at chris hani baragwanath hospital dr f agaba mbbch, fcpaed(sa), mmed department of paediatrics, charlotte maxeke academic hospital and faculty of health sciences, university of the witwatersrand, johannesburg, south africa dr jm pettifor mbbch, fcpaed(sa), phd(med) department of paediatrics and mrc/wits developmental pathways for health research unit, chris hani baragwanath academic hospital and faculty of health sciences, university of the witwatersrand, johannesburg, south africa dr k thandrayen mbbch, fcpaed(sa), mmed, phd, certificate in endocrinology and metabolism (paeds) department of paediatrics, chris hani baragwanath academic hospital and faculty of health sciences, university of the witwatersrand, johannesburg, south africa corresponding author: dr k thandrayan po box 832 2061 bassonia cell: +27837792574 tel: +27119331530 (office) fax: 0865534540 email: kebashni.thandrayen@wits.ac.za this research was conducted in partial fulfilment of the requirements for the degree of masters of medicine in the branch of paediatrics to the faculty of health sciences, university of the witwatersrand, johannesburg, 2015. abstract introduction: the majority of causes of rickets can be divided into two large pathogenic groups, namely calciopaenic and phosphopaenic. few studies have compared the clinical and biochemical presentations of the two forms of rickets. the aim of this study was to compare the demographic, clinical and biochemical presentations and response to therapy of children with calciopaenic and phosphopaenic rickets. methodology: the study is a retrospective chart review of children diagnosed with rickets at chris hani baragwanath academic hospital (chbah) in johannesburg, south africa, between 2006 and 2012. the radiological response to therapy was evaluated using the thacher scoring system to assess the severity of rickets. results: the study comprises 112 patients from 2 months to 18 years of age diagnosed with rickets (53% with calciopaenic rickets and 47% with phosphopaenic rickets). the calciopaenic group was younger than the phosphopaenic group (20 [7–26] vs 36 [24–51] months; p<0.001), but the phosphopaenic group was more severely stunted than the calciopaenic group at presentation (haz scores −3.3 [−4.5 to −2.1] vs −2 [−3.4 to 0.7]; p<0.001). following treatment, 75% of patients in the calciopaenic group had biomarkers that had normalised completely within a median of 13 (9–18) weeks while only 10% in the phosphopaenic group had normalised within a median of 17 (17–50) weeks. radiological healing in response to treatment was better in the calciopaenic group compared to the phosphopaenic group (67.5% vs 18%; p-value <0.01). conclusion: calciopaenic rickets (mainly vitamin d deficiency) presented at a younger age and response to therapy was better compared to phosphopaenic rickets (mainly x-linked hypophosphataemic rickets). this study highlights the significant differences between calciopaenic and phosphopaenic rickets, which may be helpful to attending orthopaedic surgeons and paediatricians in differentiating between these two groups of rickets and in the management thereof. summary of abstract: this study highlights the differences between calciopaenic and phosphopaenic rickets, which may be of assistance to attending orthopaedic surgeons and paediatricians in the management of rickets. the study shows that in children with calciopaenic rickets, the majority are vitamin d deficient, and present at a younger age with craniotabes and less severe lower limb deformities compared to children with phosphopaenic rickets who mainly have x-linked hypophosphataemic rickets and are severely short in stature and have genu valgum deformities. the medical management of the two types of rickets differs and response to medical therapy is better in the calciopaenic compared to the phosphopaenic group. key words: rickets, calciopaenic, phosphopaenic, thacher score, johannesburg, x-linked hypophosphataemic rickets, vitamin d deficiency http://dx.doi.org/10.17159/2309-8309/2016/v15n4a5 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 37 page 38 sa orthopaedic journal summer 2016 | vol 15 • no 4 introduction with the discovery of the role of vitamin d in the pathogenesis of rickets nearly a century ago, the various causes were divided into those responsive to and those resistant to vitamin d therapy.1 as the pathogenesis of various types of rickets became more apparent, the underlying mechanisms were classified into those associated primarily with disturbances in calcium (calciopaenic rickets) and those related to perturbed phosphate homeostasis (phosphopaenic rickets).2 table i lists the different causes of these two forms of rickets.2,3 table ii: biochemical differences between calciopaenic and phosphopaenic rickets biochemistry calciopaenic rickets phosphopaenic rickets serum calcium (2.15–2.75 mmol/l) ↓ or n n serum inorganic phosphate (1.30–2.6mmol/l)* ↓ or n ↓↓ serum 25(oh)d (>30 nmol/l) ↓ (vitamin d deficiency only) n serum alkaline phosphatase (100–350 iu/l)* ↑↑ ↑ serum parathyroid hormone (1.1–6.9 pmol/l) ↑↑ n or slightly ↑ normal values shown within brackets; *age-dependent table i: the causes of calciopaenic and phosphopaenic rickets calciopaenic causes phosphopaenic causes a. abnormalities in vitamin d metabolism • nutritional rickets • dietary deficiency of vitamin d • inadequate exposure to sunlight • impaired absorption of vitamin d • steatorrhea, e.g. coeliac disease • biliary obstruction, e.g. biliary atresia • impaired hydroxylation of vitamin d to 25-hydroxyvitamin d • liver immaturity • prematurity • increased metabolism of vitamin d • anticonvulsant drugs, e.g. phenobarbitone • decreased renal synthesis of 1,25-dihydroxy-vitamin d • renal failure • vitamin d-dependency rickets (type i) • end-organ resistance to 1,25-dihydroxy-vitamin d • vitamin d-dependency rickets (type ii) b. dietary deficiency of calcium • diets deficient in dairy products • decreased intake of phosphate • prematurity • decreased intestinal absorption of phosphate • ingestion of large amounts of aluminium hydroxide • increased renal losses of phosphate • hypophosphataemic vitamin dresistant rickets: x-linked or sporadic • fanconi syndrome • mesenchymal tumours the biochemical findings differ between the two groups of rickets while the skeletal changes are clinically similar3,4 although there are some differences in clinical presentation. management of rickets depends on the underlying cause. previous studies suggest that calciopaenic rickets presents earlier than phosphopaenic rickets.5,6 the severe calciopaenic form of rickets usually presents with delayed motor milestones, severe bone pain and deformities, and hypotonia,7 while the common form of phosphopaenic rickets presents with short stature and leg deformities. table ii shows the important differences in the biochemical findings between calciopaenic and phosphopaenic rickets.1,3,4,8 the commonest cause of calciopaenic rickets is vitamin d deficiency which is easily corrected by oral administration of vitamin d.3 x-linked hypophosphataemic rickets is the most common form of phosphopaenic rickets and is currently treated with calcitriol and phosphate supplements.9,10 in south africa, there are little published data on the prevalence and presentation of the different types of rickets in children. the clinical, biochemical and radiological differences between calciopaenic and phosphopaenic rickets may not be easily recognised by the attending health care workers in primary and secondary health care facilities. this study aims to describe the demographic, clinical, biochemical and radiological findings together with the management of these children presenting with calciopaenic and phosphopaenic rickets to the metabolic bone disease clinic in johannesburg. methodology the study was a retrospective, descriptive study of all the rachitic patients (a total of 112 patients from 1 month to 18 years of age) referred to the clinic. no patients were excluded from the study. the records of patients who were reviewed were seen at the paediatric metabolic bone disease clinic at chris hani baragwanath academic hospital (chbah), the major referral hospital for the communities of soweto, johannesburg and surrounding areas from january 2006 until december 2012. the classification of calciopaenic and phosphopaenic rickets was based on the final diagnosis of the attending clinicians. the final diagnosis was based on the biochemical changes on presentation and on the response of the rickets to the prescribed therapy as these two types of rickets are treated differently. the diagnosis of rickets was confirmed on radiographs of the wrists or knees. saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 38 information on the demographic, clinical, radiological and biochemical findings were collected. radiological findings were evaluated by fa and thereafter checked by kt using the thacher scoring system for severity of rickets.11 data was analysed using statistica statistical software version 10.0 (stat soft, usa). continuous variables were described using medians and interquartile ranges (iqr) because they were not normally distributed. categorical variables were described using percentages. comparisons between patients with calciopaenic and phosphopaenic rickets were done using chi-squared or fisher’s exact statistical methods for categorical data and mann-whitney u test for continuous variables. a p-value of <0.05 was considered to be statistically significant. height for age z score (haz) and weight for age z score (waz) were calculated using the who anthroplus software (http://www.who.int/growthref/tools/en). the study was approved by the human research ethics committee (hrec) of the university of the witwatersrand (approval number m130225). permission from the chief executive officer at chbah was obtained to conduct the study. results demographic data this study comprised 112 patients aged between 2 months and 18 years diagnosed with rickets. fifty-nine patients were classified as having calciopaenic rickets (52.7%) and 53 with phosphopaenic rickets (47.3%). there was a greater number of males compared to females in the calciopaenic group (38 [64%] vs 21 [36%]; p<0.01) and a greater number of females compared to males in the phosphopaenic group (35 [66%] vs 18 [34%]; p<0.01). in both the calciopaenic and phosphopaenic groups, the majority of children were black african (51 [87%] and 45 [84%] respectively) with the remaining 13% and 16% comprising indian/pakistani, white or mixed ancestry ethnic groups. in both groups, more than 80% of children were from gauteng and the rest from other provinces within south africa. in both the groups, more than two-thirds of the patients were referred from peripheral hospitals or a paediatrician, followed by orthopaedic surgeons, clinics and general practitioners. in the calciopaenic group, two (3%) patients had a family history of rickets (one patient had an elder sibling with vitamin d deficiency and the other patient had an uncle who had had a possible diagnosis of rickets but had not been treated). in the phosphopaenic group, 22 (42%) had a family history of rickets. age and anthropometric measurements at presentation and referral the ages at initial referral and at the most recent follow-up visit together with the anthropometric measurements at the initial referral of the patients are shown in table iii. the calciopaenic group presented at a younger age compared to the phosphopaenic group (20 [7–26] vs 36 [24–51] months; p<0.001), but the phosphopaenic group were more stunted (haz scores −3.3 [−4.5 to −2.1] vs −2 [−3.4 to 0.7] respectively; p<0.001). pathogenesis of rickets in the calciopaenic and phosphopaenic groups in the calciopaenic group, the majority of patients (54/59) presented with vitamin d deficiency rickets; two presented with probably dietary calcium deficiency rickets; two patients were diagnosed as having vitamin d dependency rickets (vddr) type i (one of whom was confirmed on genetic testing); and one child had renal osteodystrophy. sa orthopaedic journal summer 2016 | vol 15 • no 4 page 39 table iii: chronological ages and anthropometric measurements in the calciopaenic and phosphopaenic groups chronological ages and anthropometric measurements all patients (n=112) median (iq range) calciopaenic rickets (n=59) median (iq range) phosphopaenic rickets (n=53) median (iq range) p-value* age at diagnosis or at initial presentation (months) 24 (16–41) 20 (7–26) 36 (24-51) <0.001 age at first consultation at metabolic bone disease clinic (months) 26 (17.5–48) 20 (7–26) 41 (25–71) <0.001 age at most recent follow-up (months) 42 (24–93) 27 (15–36) 89 (50–132) <0.001 weight (kg) 10.3 (7.5–11.3) 9.2 (6.5–11.2) 12 (9.4–16) <0.001 waz score −1.6 (−2.9 to -0.4) −1.2 (−3 to -0.01) −1.9 (−2.7 to −1.3) 0.05 height (cm) 80 (71–88.4) 76 (64–83) 85 (77–96) <0.001 haz score −2.9 (−3.9 to −1.4) −2 (−3.4 to −0.7) −3.3 (−4.5 to −2.1) <0.001 head circumference (cm) 48 (45.5–50) 46.7 (43–48.5) 50 (48–51) <0.001 *mann-whitney u test saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 39 in the phosphopaenic group, 33/53 patients (62%) presented with a clinical diagnosis of x-linked hypophosphataemic rickets. the remaining 20 patients (38%) in the phosphopaenic group presented with rickets secondary to other renal tubulopathies (proximal rta 9 [17%], distal rta 4 [8%]) and sporadic hypophosphataemic rickets (7 [13%]). clinical characteristic features of rickets the most common clinical presenting features in both groups were widened wrists, rachitic rosary and frontal bossing in more than 80% of patients. there was a greater number of patients in the phosphopaenic group presenting with genu valgum of the lower limbs compared to those patients with calciopaenic rickets (64% vs 32%; p<0.01). craniotabes and a lack of lower limb deformities were the two clinical features more prevalent in the calciopaenic group compared to the phosphopaenic group (27% vs 11%; p<0.05 and 27% vs 4%; p<0.01 respectively). results of biomarkers on presentation and on follow-up or discharge table iv shows the baseline biochemical variables on referral and on one-year follow-up or at discharge (after therapy) of the calciopaenic and phosphopaenic groups of patients. total serum calcium levels were significantly lower in the calciopaenic group (2.1 [2–2.3] mmol/l) compared to the phosphopaenic group (2.3 [2.1–2.4] mmol/l). in the calciopaenic group, 41% (24/58) had hypocalcaemia, while in the phosphopaenic group, 27% (14/52) were hypocalcaemic. the calciopaenic group also had significantly higher serum parathyroid hormone (pth) and alkaline phosphatase (alp) levels. the median phosphate level was lower in the phosphopaenic group than the calciopaenic group (p<0.001). in the phosphopaenic group, 96% (50/52) were phosphopaenic compared to the 60% (34/57) in the calciopaenic group. the ionised calcium and 25-hydroxyvitamin d (25(oh)d) levels were not significantly different, but the number of patients with measurements was small in both groups. at one-year follow-up or on discharge after therapy, total serum calcium levels in both groups were within the normal reference range but serum inorganic phosphate levels remained low in the phosphopaenic group (p<0.001). after treatment, data were available on 96 children, 35/47 (75%) in the calciopaenic group had biochemical markers of rickets that had normalised completely within a median of 13 (9–18) weeks while only 5/49 (10%) in the phosphopaenic group had within a median of 17 (17–50) weeks (75% vs 10%; p value <0.001). page 40 sa orthopaedic journal summer 2016 | vol 15 • no 4 table iv: baseline measurements of biomarkers on referral and on one-year follow-up or at discharge (after therapy) in patients with calciopaenic and phosphopaenic rickets all groups calciopaenic rickets phosphopaenic rickets biomarkers on referral n median (iq range) n median (iq range) n median (iq range) p-value* calcium (ionised) (mmol/l) 27 1.3 (1.2–1.3) 11 1.2 (0.9–1.3) 16 1.3 (1.2–1.3) 0.05 total serum calcium (mmol/l) 110 2.2 (2.1–2.3) 58 2.1 (2.0–2.3) 52 2.3 (2.1–2.4) <0.01 phosphate (mmol/l) 109 0.9 (0.8–1.3) 57 1.1 (0.9–1.6) 52 0.8 (0.7–0.9) < 0.001 serum alkaline phosphatase (iu/l) 105 711 (469–1053) 55 864 (493–1484) 50 577 (464–893) 0.03 serum parathyroid hormone (pmol/l) 96 12 (5.7–26.1) 49 21 (12–36) 47 7.4 (4.6–16.1) < 0.001 serum 25(oh)d (nmol/l) 42 58.2 (32.4–84.6) 24 53 (32–82) 18 69 (34–85) 0.3 biomarkers at 1-year follow-up or discharge n median (iq range) n median (iq range) n median (iq range) p-value* calcium (ionised) (mmol/l) 5 1.3 (1.2–1.3) 3 1.3 (1.2–1.3) 2 1.3 (2.2–2.4) 0.4 total serum calcium (mmol/l) 93 2.3 (2.2–2.4) 46 2.3 (2.2–2.4) 47 2.3 (2.2–2.3) 0.2 phosphate (mmol/l) 94 1.3 (0.8–1.7) 46 1.7 (1.4–1.8) 48 0.87 (0.76–1.2) < 0.001 serum alkaline phosphatase (iu/l) 94 452 (315–681) 47 379 (272–543) 47 600 (375–781) < 0.001 serum parathyroid hormone (pmol/l) 82 5.1 (3.4–9.6) 39 4.7 (3–8.6) 43 5.5 (3.7–12.3) 0.5 thacher score n median (iq range) n median (iq range) n median (iq range) p-value* initial thacher score 94 9 (6–10) 47 9 (4–10) 47 10 (6–10) 0.1 thacher score at 1-year follow-up or on discharge 78 2 (0–7) 40 0 (0–2) 38 6 (1.5–8) < 0.001 *mann-whitney u test used saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 40 the grading of radiological findings of rickets using the thacher scoring system the thacher scoring system was utilised to assess the severity of the radiological features of rickets at the wrist and/or knee on initial presentation and at one-year follow-up or on discharge (table iv). the initial median thacher score for all patients was 9 (iqr 6–10). there was no difference in the thacher score at presentation between the phosphopaenic and calciopaenic groups of patients (median 10 [iqr 6–10] vs 9 [iqr 4–10]; p = 0.12). at oneyear follow-up or on discharge, the thacher score had fallen but remained high in the phosphopaenic group while in the calciopaenic group it had returned to nearly normal (<1.5) (median 6 [iqr 1.5–8] and 0 [iqr 0–2] respectively; p<0.001). in the calciopaenic group of patients, 27 (67.5%) patients had resolution of the radiological features (thacher score ≤1.5) at the time of discharge. not all children had a radiographic assessment on discharge, especially if they had improved clinically and biochemically. some were also discharged before complete healing because the clinical and biochemical response had been good. at follow-up in the phosphopaenic group, seven (18%) had resolution of radiological features of rickets while 31 (82%) did not show complete resolution of radiological features. thus, radiological healing in response to treatment was better in the calciopaenic group compared to the phosphopaenic group (67.5% vs 18%; p-value <0.001). treatment of the rickets of the 112 patients, 41 (37%) had been started on treatment prior to their referral to our clinic as shown in figure 1. twenty-five of the 41 patients referred on treatment had calciopaenic rickets and the remaining 16 had phosphopaenic rickets. of the 16 patients with phosphopaenic rickets, 50% (8) were being treated as calciopaenic rickets on vitamin d at the time of referral. discussion although the current literature on rickets does highlight the salient features and management of the various forms of rickets, this study provides an overview of the differences between calciopaenic and phosphopaenic rickets so that these patients can be more easily recognised early in the disease process and thereafter treated or referred to a tertiary centre for further management if warranted. this retrospective study compares an almost equal number of calciopaenic and phosphopaenic patients (52.7% vs 47.3%) presenting to the paediatric metabolic bone disease clinic at chbah between 2006 and 2012. the majority of patients were referred by paediatricians (36.6%), peripheral hospitals (33%) and by the orthopaedic surgeons within the hospital’s major referral area. the preponderance of female patients in the hypophosphataemic group (66% female) is in keeping with the majority of patients in that group being diagnosed with x-linked hypophosphataemic rickets, 42% of whom had a family history. these findings are similar to studies from the republic of korea and north india,5,12 which found a greater number of female patients (82% and 70.5% respectively) than male patients with hypophosphataemic rickets. in these studies, a positive family history was noted in 29% and 35.3% respectively. in the calciopaenic group of rickets, the most common cause of rickets was vitamin d deficiency. in the phosphopaenic group, 75% of patients presented with suspected x-linked hypophosphataemia (xlh) and sporadic hypophosphataemic rickets while the remaining 25% presented with phosphopaenic rickets secondary to an underlying renal tubular dysfunction. unlike an indian study, in which two-thirds of patients with refractory rickets were found to have renal tubular acidosis (rta), the majority being distal rta,13 in the present study only a quarter had rta. the younger age of the calciopaenic patients (20 months compared to 36 months in the phosphopaenic group) reflects the characteristically earlier age of presentation of vitamin d deficiency rickets. as was noted in mumbai (western india), children with vitamin d deficiency rickets or renal tubular acidosis more frequently presented in the first 2 years of life while those with x-linked hypophosphataemic rickets after 2 years of age,13 findings similar to the patterns described in this study. the phosphopaenic group of children were also more stunted than the calciopaenic group at the time of referral (haz score −3.3 vs −2; p<0.001), reflecting the more chronic nature of x-linked hypophosphataemic rickets (xlh) compared to vitamin d deficiency rickets. sa orthopaedic journal summer 2016 | vol 15 • no 4 page 41 figure 1. flow diagram demonstrates treatment at the time of referral of children with suspected rickets to the paediatric metabolic bone disease clinic 22 final diagnosis: calciopaenic 8 final diagnosis: phosphopaenic 8 final diagnosis: phosphopaenic 3 final diagnosis: calciopaenic 30 on vitamin d 8 on combination therapy lenolax, one alpha, mist kcl infants and scholls solution 3 on one alpha or titralac 41 treatment started prior to referral 71 not on treatment prior to referral n=112 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 41 page 42 sa orthopaedic journal summer 2016 | vol 15 • no 4 • saoj the most common clinical presenting features in both calciopaenic and phosphopaenic groups of rickets were widened wrists, rachitic rosary and frontal bossing (>80% of patients), which is similar to that reported by soliman et al.14 who studied infants and young children with vitamin d deficiency rickets. another study on nutritional rickets in kenya also reported on the most common clinical findings being swelling of the wrists (89%), frontal bossing (67%) and rachitic rosary of the chest (54%).15 thacher et al. screened nigerian children with rickets and found that there were five clinical features of rickets that independently predicted active rickets of which wrist and costochondral enlargement had the highest positive predictive values for active rickets which supports the clinical findings of this study.16 surprisingly in this study, 25(oh)d levels were found to be in the normal range (>50 nmol/l) in the majority of children with both types of rickets. the most likely explanation for these apparently inappropriate levels of 25(oh)d in the calciopaenic group is because over one-third of patients were on vitamin d treatment on referral. furthermore, only 24 of 59 patients with calciopaenic rickets had their vitamin d status assessed. using the thacher scoring system, the radiological severity of rickets at presentation was similar in the two groups, but at the time of discharge or at 12 months, radiological healing was less evident in the phosphopaenic group than the calciopaenic group (18% vs 67.5%; p-value <0.001). these findings suggest that the majority of patients with phosphopaenic rickets do not heal completely with therapy. this finding highlights the chronic nature of the underlying causes of phosphopaenic rickets and helps differentiate the two types of rickets. the retrospective nature of this study has limitations, as not all relevant data could be traced. furthermore, not all clinical findings may have been reported or looked for at the time of initial assessment, thus influencing the prevalence of clinical findings. finally, 18 (16%) patients at initial consultation did not have x-rays and 34 (30%) patients did not have x-rays after one year of follow-up, thus possibly influencing the interpretation of the radiographic findings. conclusion in conclusion, this study highlights the differences between calciopaenic and phosphopaenic rickets, which may be of assistance to the attending orthopaedic surgeons and paediatricians in the management of rickets. the study shows that in children with calciopaenic rickets, the majority are vitamin d deficient, and present at a younger age with craniotabes and less severe lower limb deformities compared to children with phosphopaenic rickets who mainly have x-linked hypophosphataemic rickets and are severely short in stature and have genu valgum deformities. the medical management of the two types of rickets differs and response to medical therapy is better in the calciopaenic compared to the phosphopaenic group. compliance with ethics guidelines drs f agaba, jm pettifor and k thandrayen have no conflicts of interest to declare. this study was self-funded and thus there is no need for disclosure of funding by the authors. the study was approved by the human research ethics committee (hrec) of the university of the witwatersrand (approval number m130225). permission from the chief executive officer at chbah was obtained to conduct the study. references 1. pettifor jm. nutritional rickets: deficiency of vitamin d, calcium, or both? am j clin nutr. 2004;80(6 suppl):1725s-9s. 2. pettifor jm. nutritional rickets in developing countries. forum nutr. 2003;56:176-78. 3. pettifor jm, thandrayen k. rickets and metabolic bone disorders. in: green rj, editor. coovadia’s paediatrics and child health. 7th ed. south africa: oxford university press southern africa limited; 2014:224-41. 4. jagtap vs, sarathi v, lila ar, bandgar t, menon p, shah ns. hypophosphatemic rickets. indian j endocrinol metab. 2012;16(2):177-82. 5. bhadada sk, bhansali a, upreti v, dutta p, santosh r, das s, et al. hypophosphataemic rickets/osteomalacia: a descriptive analysis. indian j med res. 2010;131:399-404. 6. tezer h, siklar z, dallar y, dogankoc s. early and severe presentation of vitamin d deficiency and nutritional rickets among hospitalized infants and the effective factors. turk j pediatr. 2009;51(2):110-15. 7. naude ce, carey pd, laubscher r, fein g, senekal m. vitamin d and calcium status in south african adolescents with alcohol use disorders. nutrients. 2012;4(8):1076-94. 8. pettifor jm. calcium and vitamin d metabolism in children in developing countries. ann nutr metab. 2014;64 suppl 2:15-22. 9. holm ia, econs mj, carpenter to. familial hypophosphatemia and related disorders. in: glorieux fh, pettifor jm, juppner h, editors. pediatric bone: biology and diseases. london: elsevier; 2012:699-726. 10. linglart a, biosse-duplan m, briot k, chaussain c, esterle l, guillaume-czitrom s, et al. therapeutic management of hypophosphatemic rickets from infancy to adulthood. endocr connect. 2014;3(1):r13-30. 11. thacher td, fischer pr, pettifor jm, lawson jo, manaster bj, reading jc. radiographic scoring method for the assessment of the severity of nutritional rickets. j trop pediatr. 2000;46(3):132-39. 12. cho hy, lee bh, kang jh, ha is, cheong hi, choi y. a clinical and molecular genetic study of hypophosphatemic rickets in children. pediatr res. 2005;58(2):329-33. 13. joshi rr, patil s, rao s. clinical and etiological profile of refractory rickets from western india. indian j pediatr. 2013;80(7):565-69. 14. soliman a, de sanctis v, adel a, el awwa a, bedair s. clinical, biochemical and radiological manifestations of severe vitamin d deficiency in adolescents versus children: response to therapy. georgian med news. 2012(210):58-64. 15. edwards jk, thiongo a, van den bergh r, kizito w, kosgei rj, sobry a, et al. preventable but neglected: rickets in an informal settlement, nairobi, kenya. public health action. 2014;4(2):122-27. 16. thacher td, fischer pr, pettifor jm. the usefulness of clinical features to identify active rickets. ann trop paediatr. 2002;22(3):229-37. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 42 404 not found south african orthopaedic journal current concepts review paediatric orthopaedics doi 10.17159/2309-8309/2023/v22n2a5thiart m et al. sa orthop j 2023;22(2) citation: thiart m, nansook a. acute haematogenous osteomyelitis in the paediatric population: a current concepts review. sa orthop j. 2023;22(2):92-104. http://dx.doi. org/10.17159/2309-8309/2023/ v22n2a5 editor: prof. nando ferreira, stellenbosch university, cape town, south africa received: february 2023 accepted: march 2023 published: may 2023 copyright: © 2023 thiart m. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract acute haematogenous osteomyelitis (ahom) is a bacterial infection localised in bone that usually occurs after an episode of bacteraemia. this infection is commonly encountered by doctors in lowand middle-income countries (lmics) and, if not recognised early and managed appropriately, can harbour significant early and late complications, including death. this narrative review aims to summarise the current management of ahom, highlight the controversies and report on new advances in diagnosis and treatment. ahom is typically a monomicrobial disease. staphylococcus aureus remains the most common pathogen globally, accounting for 70–90% of all cases. diagnostic work-up includes complete blood cell count, serum c-reactive protein, erythrocyte sedimentation rate, imaging and blood culture. management of ahom includes empiric intravenous (iv) antibiotics based on the most likely causative agents; source control entailing surgery to drain any abscesses and obtain specimens for microscopy, culture and sensitivity (mcs), as well as debridement of any necrotic bone; and subsequent targeted antibiotic therapy effective against the identified pathogen with the narrowest spectrum. treatment response is monitored with repeat crp every 48–72 hours. the decision to switch from iv to oral antibiotics is made if there is clinical improvement and the crp is < 20 mg/l. the total duration of antibiotics is six weeks. treatment of paediatric ahom is multidisciplinary and includes orthopaedic surgeons, paediatricians, infectious diseases specialists, physiotherapists, dieticians, nurses and social workers. ahom can cause devastating destruction of the bone due to tissue necrosis, leading to late sequelae. these complications are more common in children in lmics. level of evidence: level 5 keywords: acute haematogenous osteomyelitis, paediatric acute haematogenous osteomyelitis in the paediatric population: a current concepts review marí thiart,* adisha nansook division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa *corresponding author: marithiart@sun.ac.za introduction acute haematogenous osteomyelitis (ahom) is a bacterial infection localised in bone that usually occurs after an episode of bacteraemia.1 acute haematogenous osteomyelitis is commonly encountered by doctors in lowand middle-income countries (lmics) and, if not recognised early and managed appropriately, can harbour significant early and late complications, including death. premature growth arrest, limb deformity and leg length discrepancy lead to severe disability, especially in this young population.2-6 predictors of poor outcome include concomitant septic arthritis, as damage to the joints in these young patients leads to severe degenerative arthritis.4,6-9 although perhaps not very high, a mortality rate of 1.06% is significant, especially for a treatable condition.10 this narrative review aims to summarise the current management of ahom, highlight the controversies and report on new advances in diagnosis and treatment. pubmed, cochrane and google scholar search engines were searched for articles published since 2018 with the keywords ‘acute haematogenous osteomyelitis’ and ‘paediatric’. the titles were then screened for relevance. those included were then read for content. the bibliographies of included articles were also screened for relevant articles. if novel ideas were quoted, the original articles were sought and cited. epidemiology the annual incidence of ahom in high-income countries is reported as 8 per 100 000, while the incidence in lmics is as high as 43 to 200 per 100 000.11-13 munshi et al. speculated that this increased prevalence is due to the warmer tropical climate, low socioeconomic status, use of traditional medicine and predisposing genetic factors.14 seasonal variations have been observed, with a peak in late summer and autumn.15 lindsay et al. reported that most children were admitted in summer and found a correlation between the severity of illness and the average temperature during the summer season and a correlation with the average humidity change during the winter months.15 http://dx.doi.org/10.17159/2309-8309/2023/v22n2a5 http://dx.doi.org/10.17159/2309-8309/2023/v22n2a5 http://dx.doi.org/10.17159/2309-8309/2023/v22n2a5 https://orcid.org/0000-0001-9942-8012 page 93thiart m et al. sa orthop j 2023;22(2) children under the age of 5 years are generally affected and present three to four days after the onset of symptoms.2-4,7,12,16-18 some studies have reported a higher median age of presentation of between 6.7 and 11.1 years.5,8,14,19-37 males appear to be between 1.2 and 3.6 times more affected than females. the femur (23–29%), tibia (19–26%) and humerus (5–13%) are most commonly affected, but 10–25% can involve the short or non-tubular bones, and 5% are polyostotic.2-4,7,11,16,18,38-41 preceding trauma is reported in 30–60% of cases.4,12,15 concomitant septic arthritis is present in 30% of cases, but this could be as high as 75% in cases involving neonates.2,7 most infections occur in healthy children with no predisposing conditions.7,18,38,42 some specific associations have been described, including sickle cell disease and salmonella infections, upper respiratory tract infections and kingella kingae (k. kingae) infections,42-44 and trauma or varicella blisters and group a streptococcus infections.4,7,11,16,18,42,44 methicillin-resistant staphylococcus aureus (mrsa) has an increased incidence in children with prolonged prior hospital stays, such as neonates, and in regions like the usa, where the incidence of mrsa is between 30% and 40%.2 bacteriology despite a low positive yield (10–50%), a blood culture should be performed before starting empiric antibiotics.2-4,7,12,19,39-42,45,46 when blood cultures are taken before the administration of systemic antibiotics, the positive yield improves from 69–95%.45,47 if the blood culture is positive, it should be repeated every 48 hours until negative.4,16 ahom is typically a monomicrobial disease48 (table i). staphylococcus aureus (s. aureus) remains the most common pathogen globally, accounting for 70–90% of all cases.1-4,7,12,17-19,29,31,40-42,44,45,48-65 other causative organisms include streptococcus spp (s. pyogenes and s. pneumoniae being the most common),16,18,48 s. agalactiae in infants under three months,7,18 k. kingae,11,12,19,40,43,45,48,66,67 haemophilus influenzae, anaerobes, gram-negative bacilli including enterobacter spp and neisseria gonorrhoeae, and candida species.2-4,7,12,17,19,29,31,42,45,48-64,68 staphylococcus aureus the prevalence of s. aureus infection can be ascribed to 25–30% of the global population and 50–70% of healthcare workers are colonised with the bacteria.48 multiple factors contribute to s. aureus’ virulence, including cytolytic toxins, immune-evasion factors, superantigens, antioxidant systems and adhesions.43,48 adhesion to host tissues is a critical first step in the pathogenesis of ahom.43,48 s. aureus releases toxins and degradative exoenzymes that incapacitate the immune cells and expresses surface-bound and secreted immune-evasion factors.48 s. aureus protein a (spa) promotes immune evasion by binding fc regions of antibodies, interfering with complement activation and serving as a b-cell superantigen.48 spa also binds to the osteoblasts via tumour necrosis factor receptor-1 (tnfr-1), leading to apoptosis.4,43,48 the secretion of proinflammatory cytokines leads to bone resorption via osteoclast activation.43,48 these factors could provide potential targets for immunotherapeutic agents and vaccines.36 panton-valentine leukocidin (pvl) is a necrotising toxin seen in methicillin-sensitive s. aureus (mssa) and methicillinresistant s. aureus (mrsa) bacteria, and is seen with increasing frequency.7,11,17,40,69,70 this toxin targets white blood cells causing destruction and tissue necrosis.7,18,70 pvl-producing s. aureus strains are particularly virulent in the paediatric population, causing profound inflammatory responses and severe complications.4,41,68,69,71-74 it results in more extensive disease and septic shock, leading to extended hospital stays, prolonged antibiotic requirements and more surgical interventions.1,2,12,52-55,57,60,74-78 the incidence of pvl-positive s. aureus in europe is 18%, while limited data is available in lmics.7 mrsa infections are associated with higher c-reactive protein (crp), erythrocyte sedimentation rate (esr) and white cell count (wcc) levels.7,18,19 mrsa also present clinically with high fever, tachycardia and a painful limp.2 mrsa infection often has an increased severity of local infection (abscess formation, myositis, pyomyositis, interosseous involvement and septic arthritis).8 kingella kingae gram-negative bacteria account for between 60% and 82% of cases in children under the age of 4 years.60,71 k. kingae is a fastidious gram-negative coccobacillus, extremely difficult to culture, even when inoculating infected bone fluid into blood culture bottles.65 olijve et al. reported the increased incidence of k. kingae in young children coincides with the eruption of deciduous teeth.44 k. kingae infection presents indolently with low fever, moderately elevated inflammatory markers and is most frequently seen in children between 6 months and 5 years.2,3,7,16,18,42,44,45,48,65,67,68,79,80 thakolkaran and shetty reported that less than 15% of children with k. kingae infection had fever on admission, and 39% had normal crp levels.2 k. kingae represents 15–31% of all cases of ahom.65 the epiphyses and apophyses, normally spared by other organisms, are frequently involved in k. kingae infections.18,65 because of the indolent nature, k. kingae infections can often evolve into subacute osteomyelitis, forming a lucent lesion within the bone (brodie’s abscess).65 haemophilus influenzae h. influenzae accounts for 10–15% of ahom cases in unvaccinated children under three months in low-income countries.2 this bacteria typically leads to pneumonia and meningitis in infancy.27 the south african vaccination schedule includes the vaccine against h. influenzae type b and is given at six weeks, ten weeks, 14 weeks and 18 months.81 streptococcus pneumoniae infections caused by h. influenzae and s. pneumoniae are more common in children under 5 years of age.27 unvaccinated children who develop s. pneumoniae ahom have a higher risk of developing severe disease with resultant bacteraemia, meningitis, pneumonia table i: bacteriology according to patient age4,9,45 neonate (birth to < 1 year) young child (1–4 years) older child (5–12 years) adolescent (13–18 years) group b streptococcus staphylococcus aureus staphylococcus aureus staphylococcus aureus staphylococcus aureus kingella kingae streptococcus pyogenes neisseria gonorrhoeae coagulase-negative staphylococcus streptococcus pyogenes pseudomonas (puncture wounds) mycobacterium tuberculosis other streptococci salmonella (sickle cell disease) enteric gram-negative organisms page 94 thiart m et al. sa orthop j 2023;22(2) and bone and joint infections.2 it is also worth noting that not all s. pneumoniae sub-types are covered by vaccination, and s. pneumoniae ahom can still be seen in vaccinated children.27 the south african vaccination schedule includes the pneumococcal conjugated vaccine (pcv1) given at six weeks, 14 weeks and nine months. streptococcus pyogenes while the incidence of s. pneumoniae has declined due to vaccination, s. pyogenes is still a bacteria implicated in ahom.45 salmonella giaccai and idriss reported that salmonella (typhi and paratyphoid b) caused ahom in 0.2–0.85% of all cases.82 the incidence increases to between 1.5% and 12% in children with sickle cell disease.83 it is interesting to note that a prior review article by burnett et al. in 1998 indicated a higher ratio (1.4:1) of salmonella ahom compared to s. aureus in patients with sickle cell disease.84 this ratio was even lower than a report from 1981, which reported that 50 out of 68 positive cultures yielded salmonella.85 this seems to indicate a decreasing incidence of salmonella infection over time. multifocal osteomyelitis is common, but the disease is mild with minimal bone destruction.82 some authors have speculated that children with sickle cell disease suffer small gastrointestinal tract infarctions, leading to a salmonella bacteraemia.86 the increased incidence of bone infarction, combined with the sluggish microcirculation, causes the salmonella bacteraemia to localise to the metaphysis of bone and present like the typical ahom.86 however, salmonella osteomyelitis has been reported as typically affecting the diaphysis of long bones, particularly the femur and humerus, as well as the vertebrae.82,83 negative cultures negative cultures are seen in 33–55% of cases.3,16,48,60,66 this could be due to a low bacteria load, a fastidious organism or an inaccurate microbiology sampling modality preceding antibiotic therapy.48,65,87 searns et al. reported that culture-negative infections have a distinct clinical phenotype: they are younger, less febrile and less likely to have an abscess, and postulated that a smaller volume of blood collected, decreased inoculum, and a more difficult surgical approach may all contribute to negative cultures.87 nucleic acid amplification methods (real-time polymerase chain reaction [pcr]) have improved the detection of bacteria not cultured by routine methods.7,42,88 this becomes important in cases of prior antibiotic use and pathogens notoriously difficult to culture such as k. kingae.3,4,42,45 supplemental techniques to improve culture yield include inoculation of blood or chocolate agar plates intraoperatively.3,12,16 when available, culture-negative specimens can be sent for further molecular testing to better identify the underlying causative agent and guide antibiotic therapy.3,4,87 o’rouke et al. reported that real-time pcr testing (testing for s. aureus, group a streptococcus, s. pneumoniae and k. kingae) could play a role in culture-negative cases as a second-line investigation,80 and this was confirmed by a few authors.2,7,38,44,66,67,79 16s rrna pcr utilisation showed no additional yield when compared to target real-time pcr and should be reserved for cases where the culture and targeted pcr remained negative.80,87 diagnosis early diagnosis is the key to successful management and the prevention of long-term sequelae.7,37,40 a high suspicion index is required to diagnose ahom, especially in neonates.7,12,16,48 the differential diagnosis list is given in table ii. the diagnosis of ahom can be made using symptoms (present for 14 days or less) together with at least one of the following four criteria:7,16,19,20,89 • positive culture or gram stain of bone • positive blood culture • abnormal imaging • an abnormal clinical examination45,49-54,75 waldvogel added an additional criterion: surgical findings of an intraosseus pus collection.38,90,91 table ii: differential diagnosis of ahom39 infections myositis pyomyositis congenital syphilis acute appendicitis inflammatory conditions transient synovitis discitis rheumatic fever polymyositis juvenile idiopathic arthritis chronic recurrent multifocal osteomyelitis post-infective arthralgias coagulation disorders deep vein thrombosis tumours benign malignant bone pain leukaemia vitamin a deficiency undisplaced fractures sickle cell anaemia bone infarction avascular necrosis figure 1. clinical picture depicting a 3-year-old boy with a swollen left thigh for three days. this patient had a distal femur ahom. page 95thiart m et al. sa orthop j 2023;22(2) the presentation can vary from a well-localised infection to multifocal infection and septic shock.39 for toddlers, pain can be expressed as failure to bear weight or pseudoparalysis, as seen in neonates.9,39,41 a 2012 systematic review reported the most common clinical features to be: pain (81%), localised signs/ symptoms (70%), fever (62%), decreased range of motion (50%) and inability to bear weight (49%)2,11 (figure 1). a limp or refusal to walk, along with back pain and fever, may be associated with vertebral osteomyelitis.2,4,39 children with pelvic or sacroiliac infections can present nonspecific abdominal, back or flank pain.4,16 morgan and yates in 1966 reported pelvic osteomyelitis presented with four clinical syndromes: hip joint; abdominal; buttock and sciatic syndrome.92 the hip joint syndrome presents with clinical features like those of a hip septic arthritis.92 the abdominal syndrome features are similar to acute appendicitis with iliac fossa pain.92 buttock syndrome presents with pain radiating down the thigh to the knee; this differs from sciatic syndrome which presents with pain along the distribution of the sciatic nerve and represents sacroiliac joint arthritis secondary to iliac ahom.92 lack of coordinated care may result in missed or delayed diagnosis, and current level iii evidence suggests a multidisciplinary team to streamline the diagnostic work-up, improve efficiency and increase the rate of positive cultures.88 special investigations diagnostic work-up includes complete blood cell count, serum c-reactive protein (crp), erythrocyte sedimentation rate (esr), radiographs and blood culture.3,4,7,12,16,48,80,88 the blood culture should be drawn on admission, even if the child is apyrexial, and repeated during a temperature spike.7 it is recommended that 2–4 ml blood be drawn in a child weighing 1–2 kg, 6 ml in a 2–12 kg child, 10–20 ml in a 13–40 kg child and 40 ml in a child weighing > 40 kg.16 because the crp level rises within six hours, has a half-life of 19 hours, and normalises by 7–10 days, it is used to monitor the response to treatment.2-4,11,12,42,48,92 crp is elevated in 81–98% of patients and up to 100% by day 3 of the disease.4 the 2021 pediatric infectious diseases society and the infectious diseases society of america guidelines recommend performing a serum crp on the initial evaluation because of its sensitivity.19,39 although raised inflammatory markers are not specific to ahom, a normal crp and esr are rarely seen in these patients.48 van der merwe et al. found that the crp on presentation was the most reliable predictor of culture yield, duration of hospital stay and the number of debridements needed.33 esr is elevated in 91–95% of children but peaks in three to five days and normalises by three weeks.2–4,7 it has a lower specificity for ahom.4 white blood cell count (wbc) is a poor indicator of disease and is only elevated in 35% of patients; it also correlates poorly with response to treatment.4,7,11 the use of serum procalcitonin (pct) is not advocated as it has a sensitivity of 85% and specificity of 87% and thus does not outperform crp.4,39 imaging radiographs of the affected limb should be requested to exclude other diagnoses such as fractures and malignancy.2-4,11,12,39,41,46,48 x-rays are often normal in early ahom as it takes up to two weeks for radiographic changes to appear, because lytic changes in bone require 50% of the bone mineral density to be depleted before becoming evident on x-rays.3,7,16,37,42,48,94 ultrasound is a cheap, readily available and non-ionising investigation.20 ultrasound can guide diagnostic or therapeutic aspiration of fluid collections, but the sensitivity and specificity are low.4,7,12,16 ultrasound is used to screen for possible deep vein thrombosis (dvt).3 the advantage of ultrasound is that it is non-invasive and does not require sedation but it is operator dependent.3 the ultrasound criteria needed to diagnose ahom include any one of the following:20 • deep soft tissue fluid collection around the bone • periosteal thickening or elevation with a thin layer of subperiosteal fluid collection • increased vascularity within or around the periosteum on doppler sonography mri is particularly useful in detecting pelvic osteomyelitis and discitis.7 mri can document bone oedema within 24–48 hours from the onset of infection and is considered the gold standard for imaging of ahom.4,7,18,37,39,42,48,56,68,93,95,96 mri sensitivity is 80–100%, and the specificity is 50–100% compared to x-rays or bone scintigraphy.2,7,12,19,38,40,46,94 the mri criteria to diagnose ahom includes:20,41,96 • alteration of normal signal intensity (low signal on t1-weighted images and high signal of stir or t2-weighted images). on fat-suppressed gadolinium-enhanced t1-weighted images, it is seen as increased enhancement relative to the adjacent marrow • subperiosteal collection the mri scan details bone and soft tissue involvement and helps with surgical planning.2-4,39,42 (figure 2). gadolinium may enhance figure 2. a) coronal view of the right femur of a pd (proton density) fat-suppressed mri sequence depicting an intraosseous abscess as well as soft tissue pus collection; b) mri stir axial cut of the same patient showing the intraosseous pus collection and soft tissue pus collection. the images are slightly unclear due to the child moving during the mri scan. a b page 96 thiart m et al. sa orthop j 2023;22(2) clinical efficacy by detecting intramedullary or muscular abscesses and necrosis.4,7,16,95 diffusion-weighted imaging (dwi) relates to the composition of tissue and fluid, for example, high cellularity and the viscosity of pus.95,96 habre et al. reported that dwi can be used to detect ahom (restricted diffusion in soft tissue or bone) and could potentially negate the use of contrast.95 however, one does need an experienced radiologist.95,96 contrast-enhanced sequences should be used for young children under 3 years of age, where proximal femoral head involvement is suspected, as the non-contrasted images are less sensitive due to the proximity of the epiphysis.95,96 repeat mri does not have a role in routine surveillance but could be useful if the current treatment fails.4 end-of-therapy imaging (mri or x-rays) is only recommended if the physis was involved.39 mri does not come without limitations – scan times can potentially be long, and the child needs anaesthesia or deep sedation to prevent movement.2,4,7,16,42 a diagnostic mri can be successful in non-sedated infants younger than six months when swaddled and asleep.96 the cost of mri can be justified because its use leads to fewer surgeries and days spent in hospital.22 where mri is not possible, contrasted computed tomography (ct) to detect abscess formation, bone scan or scintigraphy and ultrasound have been used.42,48 ct involves high-dose radiation with decreased sensitivity for marrow and soft tissue pathology but is excellent at defining bony pathology.2-4,20 technetium radionuclide scan can be used to identify multifocal osseous involvement.7,16,42 it has high sensitivity but less specificity and can give false positive results in infancy and with virulent bacteria like mrsa.4,7,11,12,42 triphasic technetium scanning includes a flow phase (2–5 seconds after injection), a blood pool phase (5–10 minutes after injection) and a delayed phase (2–4 hours after injection).7 ahom leads to focal absorption in the third phase, and the brighter the signal, the more osteoblastic activity.7 this modality is a functional scan and cannot give information on whether pus collections are present.4,7 technetium radionuclide scan involves a significant amount of radiation exposure (200–750 chest x-rays) but could still be faster and more accessible than mri in some centres.42 management the management for ahom includes:3,43,48,68 • empiric iv (intravenous) antibiotics based on the most likely causative agents3,42 • source control: surgery to drain any abscesses and obtain specimens for microscopy, culture and sensitivity (mcs), as well as debride any necrotic bone3,12,29,39,41,42,48,68 • targeted antibiotic therapy that is effective against the identified pathogen with the narrowest spectrum, lowest adverse effect profile and the fewest side effects39,45,48 • monitoring response with repeat crp every 48–72 hours10,16,39,45 • iv antibiotics until clinical improvement and crp is < 20 mg/l, followed by oral antibiotics for a total period of six weeks in children who are systemically well, systemic antibiotics should be delayed until after culture samples are taken.46 in children who appear severely ill, starting empiric antibiotics is recommended as the yield of positive cultures obtained within 24–48 hours of suspected ahom subperiosteal/extraosseous abscess iv empiric antibiotics until pathogen identified on blood culture repeat crp every 48 hours culture-guided iv antibiotics crp < 20 mg/l and clinical improvement change to oral antibiotics for six weeks take to theatre* incisions dependent on collections** irrigation drill metaphysis specimen collection – mcs + histology blood culture, crp, wcc, esr exclude dvt – duplex doppler whole body stir mri keep npo systemically ill/ positive blood culture/ multifocal bone involvement chest x-ray refer to infectious diseases cardiac echo to exclude vegetations no no no yes yes yes figure 3. proposed management algorithm for ahom in south africa * all patients to be started on iv empiric antibiotics until positive blood/tissue culture ** avoid anteromedial incisions on the tibia; take note of skin bridges between tibia, knee and femur incisions page 97thiart m et al. sa orthop j 2023;22(2) initiation of antibiotics is equivalent to those obtained before the administration of antibiotics.39,46 van der merwe et al. reported that, in matched groups, antibiotic administration before surgery did not decrease surgical culture yield.33 some children with ahom can be severely ill with septicaemia.5 septicaemia could lead to acute multiorgan failure, including septic pulmonary emboli and dvt.60,72 the early course of infection may be complicated by persistent bacteraemia, prolonged fever, sepsis, thrombophlebitis, longer hospital stays and prolonged course of parenteral antibiotics.5,12 the prolonged bacteraemia may reflect inadequate source control, the establishment of endovascular foci (endocarditis and septic venous thromboembolism) or metastatic infection.97 gouveia et al. reported a 30% association with concomitant pyomyositis and a 68% association with septic arthritis.98 manz et al. reported that the incidence of concomitant ahom and septic arthritis was higher than initially thought in children older than 6 years.37 the incidence of concomitant ahom and septic arthritis has been reported as 46% below 2 years of age; 28% in 2 to 5 year olds, and for 6 years and older, 40%.26,37,38 yi et al. reported that children with concomitant infections have a higher intensive care unit (icu) admission frequency and significantly longer hospitalisation.59 concomitant infection also produced higher inflammatory markers.59 primary treatment failure can occur, and if so, the adequacy of the antibiotic treatment should be assessed and the need for surgical intervention evaluated.39 the rate of complications has been reported at 6–9%, and patient nonadherence to treatment accounted for 43% of treatment failures.59 amaro et al. showed a link between the peak level and duration of crp elevation and the risk of thrombotic complications in children with musculoskeletal infections.99 the theory is that the prolonged acute phase response due to the infection predisposes to thromboembolism.99 at the peak crp of 180 mg/l, the predicted probability of venous thromboembolism was 4.9%, while the risk increased to 50.9% at a peak crp of 420 mg/l.99 the risk of dvt and pulmonary embolism increases from 0.4–6%3,12 to as high as 40% in children older than 8 years old with mrsa infection and a crp > 60 mg/l.4,7,100 some studies suggest that each child with mrsa infection should be screened for a dvt.42,54,71,74,76,77 those at particular risk are infections of the femur and tibia.74 hester et al. aimed to improve the care of their patients by implementing four quality improvement interventions: 1) infectious disease education, 2) centralisation of admission, 3) communication between orthopaedics and radiology, and 4) application of a management algorithm.101 they aimed to decrease peripherally inserted central catheter (picc) use by 50%, reduce the number of sedation episodes, and reduce empirical vancomycin by 50%.101 the use of picc lines decreased, but this was already noticed before the improvement intervention was implemented. sedation episodes decreased as the use of picc lines decreased. empiric use of vancomycin did not decrease.101 treatment of ahom is multidisciplinary and includes orthopaedic surgeons, paediatricians, infectious diseases specialists, physiotherapists, dieticians, nurses and social workers.2,48,71 figure 3 depicts a proposed treatment algorithm for the south african system. copley and colleagues established guidelines in the context of a multidisciplinary team.48,102 this included daily ward rounds by orthopaedic surgeons, paediatricians, infectious disease specialists, nurses and social workers.48,102 the key to successful treatment included a dedicated mri slot for children with suspected ahom, with an immediate transition to the operating room if necessary.3,48,102 a multidisciplinary approach with interdisciplinary mri protocols has been shown to decrease time to mri and surgery and thus decrease days in hospital; mri has great utility as an initial screening test.3 quick et al. reported that involving the paediatric orthopaedic services immediately upon admission improved communication and created a timely diagnosis and treatment plan.88 the prearranged early morning mri slot and reserved operating room facilitates the surgeon’s availability to perform the relevant surgery following a positive mri.88 griswold et al. reported on this protocol: the mri is scheduled for 7 am the morning after the admission. the consultant orthopaedic surgeon and radiologist review the mri in real-time.22 a scout view was done to scan for any unexpected foci; t1 with or without contrast, t2 fat-suppressed and stir images in all planes were done.22,96 an operating room was kept on hold, and the patient was transported to the operating room for surgery without being awakened.22 the authors studied the patients treated before and after the implementation of the mri protocol and found that preoperative mri significantly reduced the number of surgeries and unplanned returns to the operating room.22 the duration of hospital stay was reduced, and this was clinically significant.22 this protocol led to a reduction of after-hours mri scans and after-hour surgical debridements being done.22 in 1997, roine et al. reported on the early detection of sequelae.24 they used a clinical scoring system tabulated in table iii and the patient’s crp level. the crp cut-off limits were as follows: day one 190 mg/l, day two 202 mg/l, day three 178 mg/l, day five 86 mg/l. their research reported that a clinical score of ≥ 1, plus a crp exceeding the cut-off on the taken day, was statistically significant in predicting sequelae.24 copley et al. subsequently created a scoring system to assess the severity of ahom.25,48 this scoring system used clinical and laboratory findings (table iv).25 severity was the sum of the parameters, with mild being (0–3), moderate (4–7), and severe (8–10).3,25 copley et al. reported that their clinical experience suggested that the clinical and laboratory response of the child during the first four to five days of treatment served to determine the severity score.3,25 disseminated disease included children with meningitis, septic shock, toxic shock, multifocal infection, endocarditis, dvt, septic pulmonary emboli, empyema or pneumonia (figure 4).3,9,25,40,59 it is not clear but assumed that a patient would only need one of these associated symptoms to deem it a disseminated disease. mignemi et al. also reported a classification system.25,103 in their study, disseminated infection was defined as ahom with subperiosteal abscess extension, while local infection was defined as isolated ahom with no subperiosteal pus formation.103 these patients with disseminated infection were more likely to have longer hospital stays as well as icu admissions, more surgeries performed, more positive blood cultures, longer duration of antibiotics, more pyrexial days and more imaging studies.103 inflammatory markers were also higher in disseminated infections.103 no extrapolation was given regarding predictive factors which could be useful on admission to determine prognosis. sanchez et al. reported that children with severe severity scores had concomitant endocarditis, thrombophlebitis and septic pulmonary emboli.97 children with severe illness underwent more surgical debridement and cultured mrsa as the primary pathogen more frequently.10,97 table iii: roine et al.’s clinical scoring system24 element points axillary temperature > 37.4 °c for > 7 days 1 marked local swelling or warmth for > 10 days 1 marked local pain or limited motility for > 10 days 1 additional surgical drainage after the initial one 1 more than one focus of osteomyelitis or septic shock 1 page 98 thiart m et al. sa orthop j 2023;22(2) empiric antibiotics empiric antibiotic therapy is determined by the geographic resistance patterns, age of the child and laboratory results, and targets the most likely causative agent.1,2,4,7,39,44,48,57,60,76,77,104 antibiotic bioavailability and bone penetration should also be considered.7 a summarised version of the empiric antibiotics per age group is reported in table v. first-generation cephalosporins and anti-staphylococcal penicillins such as cloxacillin or clindamycin form the mainstay of antibiotic treatment with additional gram-negative cover (third-generation cephalosporin) for neonates and young children.2,4,9,17,18,45,54,56,57,60,68,72,77,105 in europe, empiric guidelines include clindamycin plus a first-generation cephalosporin.4,42,48 cefuroxime 150 mg/kg/day ivi q8h can be used empirically if you suspect h. influenzae in unvaccinated children under 4 years of age.16 first-generation cephalosporins provide dual cover against k. kingae and s. aureus. it is important to note that the antistaphylococcal penicillins, clindamycin and glycopeptides are ineffective against k. kingae.18,42,68 in cases of mssa pvl-positive infections, first-generation cephalosporins plus clindamycin is suitable.2,18,42 in vitro evidence has shown that clindamycin, linezolid and rifampicin inhibit the production of pvl, and thus, adding these antibiotics will inhibit toxin production.7,42,56,70 if the mrsa prevalence is > 10%, the infectious disease society of america has recommended the empirical antibiotic choice be vancomycin or clindamycin.2,4,7,12,18,48,53,68,72,74,76,77,93,100 clindamycin has excellent bone penetration and is safe, inexpensive and effective against mssa and mrsa.2,18,68,100 other alternatives for mrsa include daptomycin and linezolid in patients who do not respond to vancomycin.2,18,68,93,100,106 linezolid has excellent bone penetration.18 table iv: the severity score developed by copley et al.25 crp initial respiratory rate febrile days on antibiotics < 100 = 0 ≥ 125% of midrange norm = 1 < 2 = 0 100–150 = 1 < 125% = 0 ≥ 2 = 1 > 150 = 2 crp 48 hours respiratory rate mid-range icu admission < 50 = 0 infant (birth–1 year) 45 no = 0 50–100 = 1 toddler (1–3 years) 32 yes = 1 > 100 = 2 preschool (3–6 years) 28 crp 96 hours school-age (6–12 years) 24 disseminated disease < 50 = 0 adolescent (12–18 years) 14 no = 0 50–100 = 1 yes = 1 > 100 = 2 figure 4. chest x-ray of a 15-year-old boy with staphylococcal septicaemia. he presented with a four-day history of depressed level of consciousness, fever, multiple swollen joints and tachypnoea. table v: empiric antibiotics according to the child’s age39,42 age birth to 3 months 3 months to 4 years older child (5–18 years) organisms s. aureus, gram-negative bacilli and group b streptococcus s. aureus, group a streptococcus, s. pneumoniae, if h. influenzae not suspected s. aureus iv empiric antibiotics cloxacillin plus third-generation cephalosporin first-generation cephalosporin first-generation cephalosporin or cloxacillin if suspect meningitis third-generation cephalosporin and cloxacillin if suspect h. influenzae give third-generation cephalosporin or co-amoxiclav if toxic shock add clindamycin if hospital-associated, consider mrsa and cover for hospitalassociated gram-negatives vancomycin or linezolid ± gram-negative cover based on hospital profile page 99thiart m et al. sa orthop j 2023;22(2) in some european studies, amoxicillin-clavulanate is widely used in low mrsa prevalent areas.68 serrano et al. reported using amoxicillin-clavulanic acid in more than 60% of their cases as empirical oral therapy.17 the epidemiology and pathogen distribution in serrano et al.’s study was similar to other literature.17 other options include nafcillin or oxacillin in conjunction with vancomycin for severely ill children with mssa, although they are not typically used in south africa due to lack of availability.74 vancomycin-resistant s. aureus (vrsa) infections are emerging.41 if a vrsa strain is suspected, a paediatric infectious disease specialist should be consulted.41 in cases of a negative culture, the antibiotic recommendation is a first-generation cephalosporin in mrsa-low regions and clindamycin with or without first-generation cephalosporin in high mrsa regions.2,4,40,42 the dosages of the empiric antibiotics as well as the susceptible organisms are tabulated in table vi. these dosages have been advised using the european literature and verified using the south african medical formulary.68,107,108 biopsy and source control nonoperative management with only antibiotics can cure early ahom in up to 90% of cases.2,4,11,12,35,40,42,68 there is insufficient literature on indications and techniques for the surgical management of ahom, and consensus regarding the need for surgery is lacking.3,4,21,42,98 bacterial biofilm, abscess formation and bone necrosis impact antibiotic delivery.48 these factors highlight the importance of surgery to decompress the abscess, decrease disease burden by debriding any necrotic tissue and obtain tissue cultures.21,48,89 clinical response to antibiotic therapy, the presence of an abscess, persistent fever or elevated crp and mrsa or pvlpositive bacterial infections should be considered when deciding on surgical management.2-4,16,21,41,42,48 woods et al. recommended surgical debridement in patients with sepsis or rapidly progressive infection and stable patients with large abscesses (greater than 2 cm).11,39,46 independent predictors of surgical intervention in upasani et al.’s study were multifocal infection, ambulatory status, elevated crp on admission and elevated platelet count on admission.21 upasani reported that there is marked variability in the surgical management of these patients in centres in the usa, and the overall surgical rate was 62%.21 the decisions were based primarily on institutional practice or dogma. secondarily, the clinical presentation did affect the surgery rate in centres that did not frequently use surgical management to treat ahom.21 there was more consensus if patients had multifocal disease, and even in institutions where surgery was not the norm, these patients were taken to theatre for debridement.21 once ahom is diagnosed, a biopsy is needed to obtain a culture to guide antibiotic therapy.7,21,42,46,48 this can be done through a percutaneous biopsy or open debridement.48 deep cultures are not influenced by preceding antibiotics if taken within 72 hours of initiating antibiotic therapy.4,41,45 interventional radiology-guided table vi: empiric antibiotics with the dosages for ahom and susceptible organisms68,106,107 antibiotics dosage spectrum cloxacillin 25–50 mg/kg/dose (max 2 g/dose) 4–6 hourly to a max 8–12 g/day mssa cns penetration cefazolin (first-gen cephalosporin) 100–150 mg/kg/day into three to four divided doses to max 12 g/day renal adjustment is needed if gfr < 50 mssa, group a streptococcus, s. pneumoniae, k. kingae, community-acquired gram-negative organisms co-amoxiclav (dosing is based on the amoxicillin component and the formulations’ amoxicillin: clavulanic acid ratio) 50–100 mg/kg/day daily of amoxicillin component divided 8 hourly max 1 000 mg of amoxicillin per dose max 800 mg of clavulanic acid per dose renal adjustments if gfr < 30 ml/min mssa, group a streptococcus, s. pneumoniae, h. influenzae, community-acquired gram-negative organisms clindamycin (caution: significant drug-to-drug interactions exist) 15–25 mg/kg 8 hourly to max 1.8 g/day mssa, group a streptococcus, s. pneumoniae reduces toxin production in staphylococcus and streptococcus ceftriaxone (third-gen cephalosporin) 50–100 mg/kg daily* to max 2 g/day avoid in neonates (give cefotaxime) *if suspect concomitant meningitis, 50 mg/kg 12 hourly to max 2 g 12 hourly mssa, group a streptococcus, s. pneumoniae, k. kingae, h. influenzae, community-acquired gram-negative organisms cns penetration cefotaxime (third-gen cephalosporin) age < 7 days 50–100 mg/kg/dose 12 hourly > 7 days to 3 weeks 50–100 mg/kg/dose 8 hourly > 1 month 50 mg/kg/dose 6 hourly max 3 g/dose renal adjustment is needed if gfr < 50 ml/min mssa, group a streptococcus, s. pneumoniae, k. kingae, h. influenzae, community-acquired gram-negative organisms cns penetration vancomycin loading dose recommended – 25 mg/kg then 15–20 mg/kg/dose 8 hourly to achieve auc24 of 400 µg × hr/l* (based on mic = 1 mg/l) *this is a concentration equation: 400 µg multiplied by hour per litre renal adjustment is needed if gfr < 50 ml/min monitoring of levels is needed mrsa linezolid <12 years 10 mg/kg 8 hourly >12 years 10 mg/kg 12 hourly max dose 600 mg/dose mrsa page 100 thiart m et al. sa orthop j 2023;22(2) cultures avoid surgical morbidity and could potentially be used to obtain deep cultures in mild disease.40 direct microbiological samples from bone or the abscess collection have improved yield (64–87%) compared to blood culture yield and are higher if obtained through an open procedure versus a percutaneous biopsy.4,7,45 all bone, tissue and fluid samples should be placed in sterile containers.16 the use of pus swabs is discouraged due to low yield.16 any fluid should be placed in blood culture bottles.16 some samples should be stored for further molecular testing if no bacteria are cultured.16 the reported rates of surgical management vary widely from 8–80%, primarily due to inconsistencies with the description of the procedure.4,38 the fundamental principle is source control.4 a corticotomy can be performed for intraosseous collections, and drains are routinely placed. bone drilling is required in patients with subperiosteal or intramedullary abscesses.41 placing plastic tubing into a drill hole and irrigating the medullary canal has been described89 (figure 5). montgomery et al. reported that when not drilling the cortex and irrigating the medulla, patients were six times more likely to need a re-debridement and recommended drilling the cortical bone (even if subperiosteal abscess is present) one to three times and flushing the canal.109 of those who undergo a surgical debridement, 15–33% need a repeat debridement.4 infections with mrsa increase the risk for multiple procedures.4,10 indicators of a secondary procedure include persistent pain, clinical deterioration and increasing inflammatory markers, as well as the presence of mrsa.10 localised delivery of antibiotics could be advantageous – it leads to a higher drug concentration at the infected site while limiting systemic toxicity.89 routine surgical-site antimicrobial agents remain controversial, with little evidence recommending their use.39 wang et al. reported on antibiotic-loaded calcium sulphate beads versus conventional surgery (removal of pus, the entire length of the canal debrided to remove the infected debris and endosteal bone) used in the treatment of ahom.89 the calcium sulphate beads were impregnated with vancomycin in combination with a negative-pressure dressing.89 vancomycin beads were placed in the medulla at the initial surgery and changed with each surgery.89 the authors found that the vancomycin group needed fewer surgeries, but the complication rates were the same.89 the vancomycin group had a quicker clinical response with a drop in crp level seen (4.8 ± 2.5 days versus 13 ± 9.6 days).89 targeted antibiotic therapy cephalosporins and anti-staphylococcal penicillins are bacteriostatic and bactericidal depending on the serum concentration, and continuous iv infusions can increase the serum concentration to make the antibiotic bactericidal.45 high-dose cefazolin (100–150 mg/kg/day divided q8h) is well tolerated and has a clinical cure rate above 95% for susceptible bacteria.16,45 cefazolin is preferred over nafcillin or oxacillin due to their adverse side effects.45 s. pyogenes has been exquisitely susceptible to ampicillin and amoxicillin.45 ampicillin-sulbactam and amoxicillin-clavulanic acid should be reserved for situations where narrow-spectrum, firstline drugs cannot be administered.45,68 serrano et al. reported few cases of recurrence and sequelae (0.9%) when using amoxicillinclavulanic acid.17 amoxicillin-clavulanic acid can be used in young children because of its q8h schedule, palatability and seemingly good efficacy in areas with a low prevalence of mrsa.17,105 intravenous clindamycin should be considered in patients who do not have ongoing bacteraemia and in hospitals with low clindamycin resistance. however, this is controversial as some clinicians have good outcomes with clindamycin, even in the presence of bacteraemia.42,48,93 rifampicin is bactericidal and may prevent s. aureus resistance to other antibiotics, such as fluoroquinolones.45 another benefit is the synergism in bacteraemia and its ability to penetrate biofilms, but there is no substantial evidence that this is the case in vitro.18,45 however, the low rate of adverse effects makes this an attractive adjuvant.45,105 it is important to note that rifampicin should never be used as monotherapy.45,105 the rifampicin dose is 10 mg/kg q12h, and the duration should be based on clinical judgement.45 it has excellent oral bioavailability and is also available in an intravenous preparation.18,68 salmonella infection, common in sickle cell anaemia, should be treated with a third-generation cephalosporin or a fluoroquinolone.2,7,18 adverse reactions to vancomycin include ototoxicity and nephrotoxicity, so hearing and renal function should be monitored during its use.29,100 as the half-life of vancomycin may be prolonged, it is important to monitor the trough concentration.2,18,29 fosfomycin is a bactericidal antibiotic against gram-positive and gram-negative pathogens.110 it is effective in acidic and low-oxygen environments, like in an abscess.110 tsegka et al. investigated the efficacy of fosfomycin against ahom.110 fosfomycin was successful in 82.2% of patients; it has low toxicity and high bone and abscess penetration, making it a drug to consider.110 future therapies include dalbavancin, an intravenous concentration-dependent bactericidal drug with a prolonged halflife (202 hours) and thus could potentially be given once daily.100 the duration of antibiotics should be a minimum of four to six weeks, but there is no consensus on duration.2,3,11,16,18,37,45,48,89 oral therapy should be continued for three to four weeks.94 shorter durations are recommended in an uncomplicated course where pvl-positive pathogens are not suspected.39,45,94 some authors have reported that children with negative cultures or k. kingae had a lower mean treatment duration.44,65 some groups report that neonates should receive four weeks of intravenous antibiotics.18 the european guidelines are shorter, with the total therapy (iv and oral combined) being three to four weeks for ahom; these children must have crp levels under 100 mg/l on admission.4,42,64 longer therapy (up to six weeks) should be given in children with crp levels above 100 mg/l; resistant or unusual pathogens; children under the age of three months; slow or poor figure 5. intraoperative photo of the feeding tube irrigating the medullary canal proximally, and pus being expressed distally through distal drill holes. this illustrates the extent of pantibial osteitis and the importance of drilling the cortex and irrigating the medulla. drill holes are present with a feeding tube placed intramedullary and irrigated. note the periosteal stripping. feeding tube placed in a drill hole irrigating the tibia pus escaping through the distal drill holes ivory tibia with marked periosteal stripping page 101thiart m et al. sa orthop j 2023;22(2) response to treatment; any complications; pelvic or spinal ahom; septicaemic children or immunocompromised children.4,37,42,64 the decision between oral therapy once ready for discharge versus outpatient parenteral antibiotic therapy (opat) via a picc line sways towards a switch to oral therapy.39,45,88,111 this avoids high costs and harm to the patient.3,39,45,88,111 however, opat is preferred over a prolonged inpatient hospital stay if oral therapy is not feasible.39 prolonged intravenous antibiotics are associated with risks, including catheter-associated complications such as thrombophlebitis.2,4,16,18,45 oral therapy is contraindicated in cases of poor medication compliance or follow-up, malabsorption or a slow resolution of infection.16 the timing of the switch to oral therapy is still debated.7,18,38,68 some authors recommend at least five to seven days of intravenous treatment.18 an early oral switch has been used if the child shows clinical improvement.4,41,42,97 improvements may include:2,4,5,7,12,16,40,42,68,89,105 • apyrexial for 24–48 hours • decreased local inflammation and pain • halving of crp from the maximum value • no systemic symptoms (endocarditis, pneumonia or dvt) • pathogen not salmonella, mrsa or pvl-positive • negative blood cultures after previously being positive • mild and moderate illness severity scores39,97 faust et al. considered an oral switch safe if the crp value is under 20 mg/l or at least two-thirds of its maximum peak.7,112 flucloxacillin is a narrow spectrum, semisynthetic penicillin and can be prescribed for sensitive s. aureus but bear in mind the poor taste of the oral suspension.7,11,16,111 flucloxacillin has bactericidal properties but little evidence that, in vitro, there is good bone penetration.111 preiss et al. conducted a narrative review on oral flucloxacillin to treat ahom.111 the experience of most publications reports good outcomes with oral flucloxacillin, despite the poor bone penetration.111 adverse effects include hypersensitivity, gastrointestinal symptoms, nephrotoxicity and myelotoxicity.111 drug–drug interactions have been reported with paracetamol and rarely with warfarin and rifampicin.111 most clinicians recommend 100 mg/kg/day.16 cephalexin is an oral first-generation cephalosporin and has demonstrated positive outcomes in 82–100% of patients.45 the dosage should be 100–150 mg/kg/day q6h to improve the minimum inhibitory concentration (mic).45 the half-life is short (one hour); thus, the six-hour dosing is better than eight hours.16 for mrsa, oral therapy with clindamycin, trimethoprimsulfamethoxazole or linezolid can be considered with careful monitoring.16,68,100 bradley et al. reported on the efficacy of daptomycin.34 when compared to vancomycin, daptomycin performed as well as vancomycin regarding successful treatment and was better tolerated.34,100 daptomycin and linezolid should be considered second-line drugs.100 outcomes the incidence of complications after ahom is unclear – highincome countries report the incidence to be 27%113 but it has been reported as high as 48% in south african literature.114 risk factors for a more prolonged hospital course and long-term complications include high-virulence organisms (such as mrsa), contiguous septic arthritis, positive cultures, younger children, location of the disease and delay in care and source control.4,6,10,11,41,89,94,113-115 osteonecrosis or chondrolysis, seen in 8% of cases, is correlated with the initial illness severity and leads to premature arthritis.4,6 to protect the hip from dislocation, abduction skin traction can be applied when proximal femur ahom and hip septic arthritis is diagnosed.118 the common complications are tabulated in table vii. ahom can cause devastating destruction of the bone due to tissue necrosis, leading to late sequelae like chronic osteomyelitis (1.7%)3 and pathological fractures5,23,31,36 (figure 6). complications such as these are more common in children in lmics.50,54,55 belthur et al. described the incidence of pathological fracture as 4.6–5%; however, popsecu et al. reported an incidence of almost 10%.31,119,120 in addition, on admission, large subperiosteal abscesses extending into the muscle were more likely to fracture within 72 days of presentation.3,4,7,71,74 the limb segment should be protected in the first six weeks to prevent a pathological fracture.42 calvo et al. reported that children with contiguous infections also had the highest incidence of surgery (46%), complications (18%) and sequelae (10%).56 table vii: common complications of ahom pathological fractures avascular necrosis contractures leading to pain chronic osteomyelitis chondrolysis leading to arthritis physeal growth arrest table viii: the aand c-scores5 the a-score bone abscess 2 fever > 48 hours 2 suppurative arthritis 3 disseminated disease 4 delayed source control (three days in hospital) 4 maximum score 15 the c-score crp ≥ 100 mg/l 2–4 days after starting antibiotics 1 disseminated disease 1 bone debridement 2 maximum score 4 figure 6. lateral and ap x-ray of a 5-year-old boy with a femur pathological fracture six weeks post admission for ahom. note the involvement of the left proximal tibia as well. page 102 thiart m et al. sa orthop j 2023;22(2) other complications include avascular necrosis, angular deformities and limb-length discrepancy due to physeal growth arrest or overgrowth.1,5,6,12,49,50,53,54,57,60,72,76,115,121 these children can also develop joint contractures, chronic pain and gait disturbances.9,42,76 sequelae at one-year follow-up are higher in infants under 3 months.9 predictors of poor outcome in neonates include hip and shoulder involvement, concomitant septic arthritis with ahom, bacteraemia and s. aureus infection (especially with mrsa).7-9 the recurrence rate has been reported as between 3% and 6.8%.3,23,88 mcneil et al. reported that infection with agr iii (accessory gene regulator iii) s. aureus organism, fever more than four days after admission and delayed source control were associated with significant increase in orthopaedic complications.31,41 the fracture risk increased significantly with more than three debridements.31 alhinai et al. developed an a-score and c-score to predict acute and chronic complications (table viii).5 the negative predictive value of the a-score ≤ 4 was ≥ 91%, and the c-score ≤ 3 was ≥ 95%.5 vij et al. found similar results in their study and concluded that the a-score should be used in combination with clinical judgement to determine optimal timing for early care decisions like an oral antibiotic switch.30 the c-score can be used to consider specific decisions regarding the development of chronic osteomyelitis and the need for prolonged (> 12 weeks) antibiotics, as well as to rule out pathological fractures and avascular necrosis.30 rehabilitation is an integral part of management, with prompt mobilisation crucial to prevent contractures.42 prolonged orthopaedic follow-up for up to 12 months is recommended in those with infections around the physis and any patient who underwent surgical debridement and even longer if the pelvis, spine or hip were involved.4,39,42 hunter and baker reported on the quality of life of children treated for ahom.23 the most common complaints were pain, stiffness (mostly related to sport) and anxiety.23 there are no validated assessment tools to assess the quality of life after ahom.23 the recommendation is for a disease-specific assessment tool to analyse the longer-term outcomes.23 conclusions a multidisciplinary approach to managing acute haematogenous osteomyelitis should be the standard of care. proactive mri protocols may improve patient care and should be implemented in centres where mri is available. local antibiogram profiles should govern empiric antibiotics, and clindamycin should be considered for its anti-toxin properties in systemically ill children. if an abscess is present, surgical management to decompress the pus and obtain a biopsy is needed. the bone should be drilled even if there is subperiosteal pus. a total of six weeks of antibiotics is key in complicated cases of ahom. more research from lmics should be published to guide local treatment algorithms. a proposed management algorithm is proposed for the south african system (figure 3). acknowledgements the authors would like to thank prof. helena rabie from the department of paediatrics and child health, dr pieter nel from the department of medical microbiology and dr veshni pillay-fuentes lorente from the department of clinical pharmacology, faculty of health sciences, stellenbosch university, for their contributions regarding the empiric antibiotic choices, dosages and spectrum. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethics approval was not obtained (review article). declaration the authors declare authorship of this article and that they have followed sound scientific 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antimicrobial stewardship [internet]. sanford guide antimicrobial stewardship. available from: https://marketing-staging.sanfordguide.com/. accessed 28 feb 2023. 109. montgomery co, porter a, sachleben b, et al. treatment of subperiosteal abscesses in children: is drainage of the intramedullary canal required? j pediatr orthop b. 2017 nov;26(6):497-500. 110. tsegka kg, voulgaris gl, kyriakidou m, et al. intravenous fosfomycin for the treatment of patients with bone and joint infections: a review. expert rev anti infect ther. 2022;20(1):33-43. 111. preiss h, kriechling p, montrasio g, et al. oral flucloxacillin for treating osteomyelitis: a narrative review of clinical practice. jbji. 2020;5(1):16-24. 112. faust sn, clark j, pallett a, clarke nmp. managing bone and joint infection in children. arch dis child. 2012 jun;97(6):545-53. 113. johnston jj, murray-krezan c, dehority w. suppurative complications of acute hematogenous osteomyelitis in children. j pediatr orthop b. 2017 nov;26(6):491-96. 114. horn a, wever s, hoffman eb. complications following acute severe haematogenous osteomyelitis of the long bones in children. sa orthop j. 2019;18(3):23-29. 115. manz n, krieg ah, buettcher m, et al. long-term outcomes of acute osteoarticular infections in children. front pediatr. 2020 nov 25;8:587740. 116. nunn t, rollinson p. haematogenous pyogenic bone and joint sepsis reducing avoidable morbidity. s afr med j. 2007;97(6):456-60. 117. wang e, zhao q, zhang l, et al. the split-heel technique in the management of chronic calcaneal osteomyelitis in children. j pediatr orthop b. 2009;18(1):23-27. 118. prince s, tulasi r. case report on pediatric septic arthritis of the hip. ejifcc. 2020 sep 29;31(3):248-53. 119. belthur mv, birchansky sb, verdugo aa, et al. pathologic fractures in children with acute staphylococcus aureus osteomyelitis. j bone jt surg am. 2012;94(1):34-42. 120. popescu b, tevanov i, carp m, ulici a. acute hematogenous osteomyelitis in pediatric patients: epidemiology and risk factors of a poor outcome. j int med res. 2020;48(4):300060520910889. available from: https://pubmed.ncbi.nlm.nih.gov/32249643/ 121. laurent e, petit l, maakaroun-vermesse z, et al. national epidemiological study reveals longer paediatric bone and joint infection stays for infants and in general hospitals. acta paediatr int j paediatr. 2018;107(7):1270-75. _hlk129604089 404 not found page 52 sa orthop j 2023;22(1) cpd questionnaire. march 2023 vol 22 no 1 low dislocation rate one year after total hip arthroplasty at a tertiary hospital in south africa (fourie pj, erasmus rd, botha t, jacobs hw) 1. most dislocations after total hip arthroplasty (tha) occur: a. intraoperatively a b. while the surgical wound is still healing b c. during the first year c d. after five years d e. after ten years e 2. the most common complication after tha surgery is: a. periprosthetic fracture a b. infection b c. dislocation c d. aseptic loosening d e. metallosis and immune responses e 3. the following factor potentially decreases the risk for posttha dislocation: a. increasing cup anteversion above 30° a b. increasing cup abduction above 60° b c. using a femur head size ≥ 32 mm c d. alternating surgical approaches to remain rehearsed in all of them d e. using single mobility implants e functional outcome of free fibula grafting in benign non-reconstructable bone tumours involving the hand (shah mr, shah mm, shah im) 4. what are the advantages of use of the free fibula graft in treatment of benign non-reconstructable bone tumours involving the hand? a. provides strut support a b. relatively easy to procure b c. medullary canal helps in fixation c d. shape matches with small hand bones d e. all of the above e 5. criteria for non-reconstructable hand tumours in the article means? a. non-contained lesions a b. lytic expansile lesions with more than 70% bone destruction b c. pathological fractures c d. conventional bone grafting is not possible d e. all of the above e 6. at final biopsy, tumours in the study were histopathologically of the following varieties except? a. aneurysmal bone cyst a b. enchondroma b c. benign histiocytic lesion c d. chondrosarcoma d e. giant cell tumour e a survey on the educational value of an mhealth referral app for orthopaedics in south africa (kauta nj, owolabi eo, salence b, swanepoel s, roche s, chu km) 7. one of the key messages from the results of this study is: a. more than 60% of users felt that orthopaedic referral group (org) was a good platform to keep up to date with current principles of fracture management and for on-the-job continuous medical education a b. while the platform helps expedite the management of trauma cases in community health centres (chcs), thanks to the advice from the specialist team, there is no educational value to it b c. the platform is not a sustainable mhealth strategy for telementoring due to a large volume of cases being discussed from different chcs c d. fifty per cent of users felt overburdened with the frequency of clinical queries and responses posted on org d e. most users were dissatisfied with org because of massive delays in getting responses from the specialist team e 8. org users were able to improve their conservative management skills for the following injuries: a. femur fracture, tibia fracture, hip dislocation a b. ankle fractures, distal radius fractures, shoulder dislocations b c. ankle fractures, tibia fractures, clavicle fractures c d. shoulder dislocation, clavicle fractures, distal radius fractures d e. hip dislocation, shoulder dislocation, knee dislocation e 9. when contemplating sharing patients’ information for clinical discussion with peers or mentors on social platforms, which one of the following ethical statements is correct? a. patient consent is not needed if the information shared informs the patient management plan a b. patient consent should be obtained before information is shared b c. the provider has the right to share any patient information c d. patient consent is not needed if an encrypted platform is used d e. patient consent is not needed if the information shared is deidentified e enhancing healthcare services in an orthopaedic department utilising a system dynamics and participatory action research perspective to optimise patient flow (ansermeah mmf, proches cg, snyders r) 10. in the participatory action research process, which of the following is correct: a. the primary researcher is not considered to be an active agent of transformation a b. the researcher is relegated to being a mere passive observer b c. this methodological process involves cyclical processes of reflection, action and observation c d. the researcher is not considered to be part of the affected community d e. participants who are directly affected by the challenges being studied are excluded e orthopaedic journal s o u t h a f r i c a n � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � contents � � � � � � � � � � t h e s o u t h a f r ic a n o r t h o pa e d ic a s s o c ia t io n page 54 sa orthop j 2023;22(1) 11. answer true or false: ‘systems-as-cause’ thinking promotes the idea that we have to play an active role in taking responsibility for our own actions instead of seeking to allocate blame to other sources. a. true a b. false b factors associated with dissemination and complications of acute bone and joint infections in children (mdingi vs, maré ph, marais lc) 12. what was the overall rate of chronic osteomyelitis in the study? a. 11% a b. 31% b c. 45% c d. 20% d e. 5% e 13. which of the following statements is true? a. sixty-five per cent of the children included were female a b. the median time between onset of symptoms and presentation at our institution was two days b c. locally advanced disease was defined as adjacent acute haematogenous osteomyelitis and septic arthritis c d. the median age at presentation at our institution was 4 years d e. four patients met the pediatric sepsis consensus conference (pscc) criteria for septic shock e 14. what was the culture-negative rate in our study? a. 30% a b. 4% b c. 50% c d. 15% d e. 25% e intertrochanteric femur fractures: a current concepts review (sukati fm, viljoen j, alexander a) 15. when assessing the reduction quality for intertrochanteric femur fractures, which of the following is the best reduction? a. central axial alignment and a native neck shaft angle a b. central axial alignment with smooth anterior cortex contact b c. a neutral medial cortical apposition and a native neck shaft angle c d. slight valgus neck shaft angle and positive medial cortical apposition d e. slight anterior neck on lateral view and a neutral medial cortical apposition e 16. which of the following is not true with regard to the bony arcade in the intertrochanteric region? a. the vertical column originates in the lower lateral femoral neck a b. the vertical column conveys compression forces b c. the horizontal column originates in the femoral shaft c d. the horizontal column conveys tension forces d e. the calcar is situated posterior to the neutral axis of the femoral neck e 17. cephalomedullary nails (cmns) are commonly used to fix intertrochanteric fractures. which of the following statements is true when comparing cmn treatment options? a. fractures fixed with long nails show greater torsional stiffness than with short nails a b. distal locked short cmns have a higher mean failure to load in torsion than unlocked short cmns b c. thigh pain is less common in patients with distally locked than unlocked cmns c d. biaxial cmn has lower cut-out rates compared to monoaxial cmn d e. patients treated with cmn have better mobility at four months than those treated with dynamic hip screw (dhs) e 18. arthroplasty has some benefits over internal fixation, except: a. early postoperative weight bearing a b. shorter hospital stay b c. lower implant-related complications c d. lower re-operation rate d e. lower blood loss e a subungual glomus tumour of the finger with five reappearances: a rare case report (nkosi cs, sefeane ti) 19. which of the following does not fit into the classic triad of glomus tumour symptoms? a. paroxysmal pain a b. cold intolerance b c. exquisite tenderness to touch c d. infection d e. all of the above e 20. a 65-year-old female presents with 6 months of worsening pain in her middle finger. she had previous surgical excisions with positive histology results for glomus tumours from the same finger. what is the most likely diagnosis? a. infection a b. recurrent glomus tumour b c. fracture c d. malinger d e. osteoarthritis e subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm. co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online. • complete the questionnaire and click on submit. • your points are automatically submitted to the relevant authority. • please call mpc helpdesk if you have any questions: 0861 111 335. medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 mdb015/069/01/2023 south african orthopaedic journal paediatric orthopaedics doi 10.17159/2309-8309/2021/v20n4a5 mniki ta et al. sa orthop j 2021;20(4) citation: mniki ta, maré ph, marais lc, thompson dm. the short-term outcomes of hip arthrodesis in children and adolescents with end-stage hip disease. sa orthop j 2021;20(4):219-225. http://dx.doi. org/10.17159/2309-8309/2021/ v20n4a5 editor: dr greg firth, university of the witwatersrand, johannesburg, south africa received: september 2020 accepted: january 2021 published: november 2021 copyright: © 2021 mniki ta. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to this work. abstract background the management of end-stage hip disease in children and adolescents is a challenging clinical problem. while total hip replacement (thr) offers the benefit of improved mobility, this is offset by the risk of multiple revisions. hip arthrodesis remains a salvage option to relieve pain and restore function at the cost of hip movement. this study aimed to determine the shortto medium-term outcome of hip arthrodesis in paediatric and adolescent patients in a developing world setting. methods all children and adolescents under the age of 18 years who underwent hip arthrodesis between 2010 and 2014 were included in the study. measurements included diagnosis, preoperative deformity, fusion position, fusion rate and functional outcomes. our surgery involved transarticular compression screw fixation and subtrochanteric osteotomy. postoperative skeletal traction maintained optimal limb position for two weeks, after which spica cast immobilisation was used. results nineteen patients (11 female) had hip fusions at a mean age of 12 years (range 5–18). the mean follow-up period was 5 years (range 1–8). most cases were due to end-stage tb arthritis (12/19; 63%). other causes were septic arthritis (3/19; 16%); neglected slipped capital femoral epiphysis (1/19; 5%); post-traumatic avascular necrosis (1/19; 5%); and idiopathic chondrolysis (2/19; 11%). primary fusion was achieved in 68% (13/19) of cases. six patients developed complications. complications included adduction drift (3/19), failed fusion (3/19), screw malpositioning (1/19) and screw breakage (1/19). eight reoperations were required in six patients. in two of these patients, one additional surgery had to be performed to achieve fusion or correct limb position. the mean fusion position was 31° (range 20 to 50) flexion, 2° (range 10 to −10) abduction, and 1° (range 10 to −10) external rotation. mean leg length discrepancy was 1.8 cm (range 0 to 4.5) of shortening. all except one patient reported relief of hip pain and satisfaction with the procedure. conclusion while hip arthrodesis is a technically challenging procedure, high fusion rates and reliable pain relief may be expected in these patients. however, complications should be anticipated, and reoperation may be required to achieve fusion and an optimal limb position. level of evidence: level 4 keywords: end-stage hip arthritis, tb hip, hip arthrodesis, hip fusion, subtrochanteric osteotomy the short-term outcomes of hip arthrodesis in children and adolescents with end-stage hip disease thato a mniki,¹* pieter h maré,² leonard c marais,³ david m thompson¹ ¹ department of orthopaedic surgery, grey’s hospital, school of clinical medicine, university of kwazulu-natal, south africa ² clinical unit paediatric orthopaedics, department of orthopaedic surgery, grey’s hospital, school of clinical medicine, university of kwazulu-natal, south africa ³ department of orthopaedic surgery, school of clinical medicine, university of kwazulu-natal, south africa *corresponding author: t.mniki@yahoo.com introduction management of paediatric and adolescent patients with end-stage hip arthritis remains challenging, and the trends in management have changed over time.1,2 when hip preservation is not possible, the treatment options are either total hip replacement (thr) or hip arthrodesis. there is limited evidence to support the choice of one procedure over the other.3 hip arthrodesis is indicated as a salvage procedure for end-stage hip disease.4-7 the goals of hip arthrodesis are a pain-free, stable hip joint that will improve function.1 the procedures’ success was first reported in 1894. since then, a variety of fusion techniques and modifications have been published, resulting in improved union rates with a decrease in complications.8 total joint replacement in younger patients has been gaining popularity due to the advantage of retained hip mobility and potential for improved functional outcomes. however, the risk of multiple revisions due to the demand placed on the prosthesis is of significant concern.2,9-13 furthermore, appropriate patient selection for thr is crucial. septic arthritis is a frequent cause of end-stage hip disease in children and adolescents. prosthetic joint infection due to reactivation of infection is an additional risk in these patients, making hip arthrodesis an attractive alternative.14,15 https://orcid.org/0000-0003-1410-4508 page 220 mniki ta et al. sa orthop j 2021;20(4) hip arthrodesis has performed relatively well in the pre-arthroplasty era, demonstrating good to excellent long-term functional outcomes.16-20 more recently, similar results have been reported.21,22 the occurrence of adjacent joint degenerative disease is a wellknown long-term complication of hip arthrodesis. up to 21% of patients require fusion takedown and conversion to thr.18-19,23-27 in the developing world, young patients often present late with advanced disease, severe pain and functional impairment. furthermore, the prevalence of infective causes like tuberculosis (tb) or septic arthritis is high. in these cases, an abductor-sparing hip arthrodesis may be a good option to relieve pain and improve function. there is limited data on the outcome of hip arthrodesis in children and adolescents, particularly from the southern african region. our study aims to determine the shortto medium-term outcome of hip arthrodesis in paediatric and adolescent patients in a developing world clinical setting. our objectives were to determine the cause of end-stage hip disease, to measure the fusion position, to document the complication rate and report the subjective functional outcome in a cohort of children who underwent hip arthrodesis. materials and methods we completed a single-centre retrospective descriptive study of all children and adolescents, under the age of 18 years, who had a hip arthrodesis at our tertiary paediatric orthopaedic unit between 2010 and 2014. all patients 18 years and younger who underwent hip arthrodesis for end-stage hip disease and had follow-up for at least one year were included for analysis. all patients who had a hip arthrodesis after the age of 18 years and patients with active infection of the hip were excluded. patient selection patients were considered eligible for arthrodesis following failure of non-operative management for unilateral end-stage hip arthritis. failed non-operative treatment was defined as inability to achieve or maintain functional position of the hip or inability to control pain sufficiently to allow functional activities of daily living. prior to the procedure, active infection was excluded through clinical examination, as well as imaging and laboratory investigations. surgical technique an anterior approach (extended smith-peterson) was used to access the hip joint. this was followed by an anterior hip dislocation and acetabular exposure. mechanical reamers designed for hip resurfacing were used to remove the remaining articular surface of the acetabulum and femoral head. once bleeding cancellous bone surfaces were obtained, appropriately sized transarticular cannulated compression screws were inserted under fluoroscopic control in the position of maximal bone contact. a combination of autogenic and allogenic bone graft was used in certain cases with insufficient femoral bone stock. an additional subtrochanteric osteotomy was performed without supplemental fixation. the subtrochanteric osteotomy achieved two goals: first, the strain of the lower limb on the fusion site was removed. secondly, because optimal bone contact was prioritised at the fusion site, the limb could be placed in the ideal functional position through the osteotomy site (15–40° flexion, 0–10° abduction and 0–10° external rotation).1,6-7,24,28 during the immediate postoperative period, patients were placed in skeletal traction for a period of two weeks. this facilitated soft tissue healing and wound review, while maintaining the optimal alignment, and allowed for some initial soft callus formation. subsequently a hip spica was applied under general anaesthesia and fluoroscopic table i: patient demographics patient sex (female/ male) hip affected (right/ left) age at fusion (years) diagnosis presentation preoperative traction use 1 f r 14 chronic scfei progressive painful stiff hip no 2 m r 14 idiopathic chondrolysis progressive hip pain no 3 f l 10 sahii acute pain, non-ambulatory yes 4 f r 10 idiopathic chondrolysis progressive pain limp no 5 m l 16 tb hipiii progressive pain limp yes 6 f l 14 tb hip progressive painful stiff hip no 7 f l 18 tb hip progressive painful limp no 8 f r 11 tb hip progressive pain, limp, sinus yes 9 m l 8 sah acute pain, non-ambulatory yes 10 f l 5 tb hip progressive hip pain yes 11 f l 12 tb hip progressive pain stiff – jog movement no 12 m r 6 tb hip progressive painful limp yes 13 m r 14 tb hip progressive pain, limp ankylosis no 14 f l 9 tb hip progressive pain, non-ambulatory yes 15 m r 18 tb hip hip pain, non-ambulatory yes 16 f l 14 avn post-traumatic progressive hip pain no 17 f r 12 tb hip progressive hip pain no 18 m l 14 tb hip progressive hip pain yes 19 m r 15 sah progressive hip pain no i) slipped capital femoral capital epiphysis, ii) septic arthritis, iii) tuberculosis page 221mniki ta et al. sa orthop j 2021;20(4) guidance to maintain the desired limb position for a further eight to ten weeks. patients were allowed to mobilise partial weightbearing with crutches, as pain allowed. a standardised follow-up schedule was maintained involving clinical and radiological review at two weeks, six weeks and three months, three months, six months and yearly, thereafter. the spica was removed at ten to 12 weeks postoperatively and union of the subtrochanteric osteotomy was confirmed clinically and radiologically. data collection demographic and clinical data were collected and analysed. data points included age, sex, initial diagnosis, side affected, preoperative position of the hip (degree of flexion, abduction, rotation) and leg length discrepancy. the leg length and alignment were assessed in the supine position with the pelvis squared. the amount of hip adduction/abduction can be measured as compared to the non-arthrodesed hip. with addition of the thomas test, the amount of flexion was obtained. the true leg length discrepancy was measured while placing the limbs in identical positions. outcome measurements included complications, reoperation, fusion rate, final fusion position and patient satisfaction. all secondary procedures were analysed to determine their indications and subsequent outcome. clinical fusion was defined as no pain or movement at the hip on clinical examination. radiological fusion was categorised as either definite fusion (trabecular lines crossing fusion site and clinically fused), probable fusion (no trabecular lines crossing, but no lucency around the screws and no change in position on serial x-rays and clinically fused) or failed fusion (lucent zone across fusion site, with lucency around screws and change in position on serial x-rays; along with movement or pain at the hip on ambulation or examination). the final functional outcome was conducted in person or by telephonic interview. the components assessed included pain of the fused hip, ipsilateral knee joint, contralateral hip and the lumbar spine. limitations in sitting and walking were also recorded including the use of assistive devices. an excellent functional outcome was defined as no associated pain and limitations in the activities of daily living (sitting and walking). a good functional outcome was defined as adjacent joint pain with some limitation in activities of daily living. poor functional outcome was defined as pain of the fused hip with or without adjacent joint pain that was associated with functional limitation (e.g. use of assistive device or inability to sit for a prolonged period). statistical analysis was performed using jamovi version 1.2.18.0 open-source software.29 continuous variables were reported as means with ranges, and categorical variables as number and percentages. differences in continuous variables were compared with the use of the unpaired t-test or the mann-whitney u test (depending on the distribution of the data). categorical data was compared using the fisher’s exact test (if any expected cell count was below 5) or the chi-squared test (if no cell count below 5). all tests were twosided and the level of significance was set at p < 0.05. binomial logistic regression analysis was used to determine odds ratios (ors) and 95% confidence intervals (95% ci). results nineteen patients (11 females) were included in the study from a total of table ii: outcome measures variable immediate postoperative final follow-up hip positioni flexion (degrees) 43 (30 to 50) 31 (20 to 50) abduction (degrees) 8 (15 to −10) 2 (10 to −10) external rotation (degrees) 3 (10 to −10) 1 (10 to −10) leg lengthsi shortening (cm) 1.6 (1 to 2.5) 1.8 (0 to 4.5) unionii definite union – 13 (68%) probable inion – 3 (16%) non-union – 3 (16%) i) mean (range), ii) n (%) figure 1. ap radiograph of the pelvis of a 15-year-old girl presenting with a ‘mortar and pestle’ type tuberculosis of the right hip. features of secondary degenerative joint changes are evident (decreased joint space and osteophyte formation superolaterally, with subchondral sclerosis of the acetabulum and femoral head, and joint irregularity). figure 2. preoperative clinical picture of a 14-year-old boy demonstrating a) fixed flexion deformity; and b) adduction contracture of the left hip a b page 222 mniki ta et al. sa orthop j 2021;20(4) 22 patients who underwent hip arthrodesis (table i). two patients were lost to follow-up within the first year following surgery and subsequently excluded. one patient with active bacterial septic arthritis was also excluded. the mean age at surgery was 12 years (range 5–18). the causes of end-stage hip disease were tb of the hip in 63% (12/19) (figure 1); septic arthritis in 16% (3/19); 11% (2/19) due to idiopathic chondrolysis; and the remaining two cases were due to post-traumatic avascular necrosis (5%) and complicated slipped capital femoral epiphysis (5%), respectively. progressive, chronic and debilitating hip pain was the presenting complaint in 84% (16/19) of patients. this pain was associated with variable degrees of hip stiffness and deformity. with regard to the mean fixed flexion deformity, the data available in 16 patients was 44° (range 20–70). for the mean adduction contracture, the data available in 13 patients was 16° (range 5–30) (figure 2). for the true leg length discrepancy, the data available in six patients was a mean of 3 cm (range 2–5). preoperative skeletal traction was used in 47% (9/19) in an effort to improve limb position. transarticular fixation comprised two half-threaded compression screws in 18 cases (figure 3). a single screw was used in the remaining case. the intended limb position was maintained in a hip spica until clinical and radiological healing of the osteotomy site was evident at 10–12 weeks postoperatively. the mean limb positions obtained immediately out of hip spica were: 43.3° flexion, 8.3° abduction, 2.5° external rotation with an apparent lld of 1.6 cm (table ii). the mean follow-up time was five years (range 1–8). definite fusion was obtained in 68% (13/19) of patients (figure 4), probable fusion in 16% (3/19) and the remaining 16% (3/19) developed a failed fusion after the initial fusion procedure (figure 5). the complication rate was 32% (6/19). the complications (table iii) included flexion and adduction drift (3/19), failed fusion (3/19), screw malpositioning (1/19) and screw breakage (1/19). there were no non-unions of the subtrochanteric femoral osteotomies. eight reoperations were required in six patients. in two of these patients, one additional surgery had to be performed in each patient to achieve fusion or correct limb position. reoperations included valgus and extension osteotomies (3/8) for flexion and adduction drift; debridement and autologous bone grafting (3/8) for failed fusion; screw reposition (1/8) for screw malposition; and lastly revision surgery with plate osteosynthesis (1/8) for failed fusion with screw breakage. subgroup analysis revealed that the quality of fusion was associated with the need for reoperation (p = 0.003). five out of six patients that developed complications and subsequently underwent reoperation were either classified as probable fusion (2/5) or as a failed fusion (3/5). at final follow-up, hip fusion was achieved in all patients (19/19). the mean hip position at last follow-up was 31° flexion (range 20–50), 2° abduction (range 10° abduction to 10° adduction) and 1° external rotation (range 10° internal rotation to 10° external rotation. the mean apparent lld was 1.8 cm (range 0–4.5) (table ii). figure 3. perioperative images a) demonstrating patient positioning and skin marking for the planned incisions – the extended smith-petersen approach to the hip and straight lateral incision for the subtrochanteric osteotomy; b) the superficial dissection of the extended smith-petersen approach, with care to be taken in identifying and protecting the lateral femoral cutaneous (lfc) nerve; c) intraoperative ap fluoroscopic image confirming the appropriate screw length and placement, transarticular compression and subsequent subtrochanteric osteotomy; d) postoperative transtibial skeletal traction to allow initial soft tissue healing and to position limb in an optimal alignment a b c d table iii: summary of patients with complications patient sex age (years) aetiology complication intervention time to reoperation (months) 1 female 14 scfe adduction deformity valgus derotation osteotomy 45 2 female 10 sa hip failed fusion revision surgery, bone graft and refixation 10 3 male 8 sa hip failed fusion with screw breakage revision surgery, bone graft and refixation 24 4 female 5 tb hip screw malposition screw revision 5 adduction deformity valgus derotation osteotomy 29 5 male 6 tb hip failed fusion revision surgery, bone graft and screw refixation 2 failed fusion with screw breakage revision surgery and refixation with dynamic hip screw 51 6 female 9 tb hip adduction deformity valgus derotation osteotomy 29 scfe: slipped capital femoral capital epiphysis; sa: septic arthritis; tb: tuberculosis page 223mniki ta et al. sa orthop j 2021;20(4) all but one patient was free of hip pain at final follow-up. this patient experienced pain of the fused hip with long distance walking and when sitting for more than an hour. the same patient also reported ipsilateral knee and lumbar pain. a contributing factor to the symptoms may have been the leg length discrepancy of 3 cm. the clinical outcomes were reported to be excellent in 16 patients and good in three patients. in the three patients with good results, the average apparent leg length discrepancy was 3.5 cm (range 3–4). this was managed with a shoe raise. no lengthening procedures or epiphysiodesis were performed. we found increased odds for complications (odds ratio [or] 1.5, 95% ci 1.1 to 2.3, p = 0.028) and the need for reoperation (or 2.07, 95% ci 1.1 to 3.9, p = 0.022) in patients of younger age. we were unable to demonstrate an association between the cause of end-stage hip disease and the development of complications (p = 0.322) or the need for reoperation (p = 0.240). discussion the management of children and adolescents with end-stage hip disease remains a major challenge for orthopaedic surgeons. there is limited data available regarding the outcomes of hip arthrodesis in the developing world where patients often present late with more advanced disease and where infectious causes are common.4,7,30 our study aimed to determine the shortto mediumterm outcome of hip arthrodesis in children and adolescents in a developing world clinical setting. hip arthrodesis remains a treatment option in children and adolescents presenting with unilateral end-stage hip disease with contraindications for joint preservation and replacement surgery.1,4-7,22 post-infective and post-traumatic hip arthrosis have been identified as the leading indications for hip arthrodesis. postinfective causes account for up to 75%, and trauma for up to 47% of cases.18,22-23,30 in keeping with these findings, 79% of our cases were the result of previous tb or septic arthritis. two cases were due to idiopathic chondrolysis, and the remaining two cases were due to avascular necrosis following a neck of femur fracture, and chondrolysis following a slipped capital femoral epiphysis. the indications for hip arthrodesis are debilitating hip pain and deformity due to end-stage hip disease when conservative management fails. the goal of hip arthrodesis is to obtain a painfree hip in a functional position.1,6-7,31-33 in our series, 16 of the patients presented with debilitating pain that was associated with hip deformity (fixed flexion deformity, adduction contracture and leg length discrepancy). the ideal functional fusion position is still an area of debate with conflicting recommendations.1,4-8 the current recommended position of the limb is 15–40° of flexion, 0–10° of abduction or adduction, and 0–10° external rotation.1 in our series, the final fusion position achieved was in keeping with these recommendations, with 31° flexion, 2° abduction and 1° of external rotation. iobst and stanitski showed a greater degree of hip flexion (average 30°) was important in achieving a rhythmic gait and to facilitate sitting.5 on the other hand, karol et al. noted a better gait pattern with a lesser degree of flexion of between 20° and 25°.26 benaroch et al. demonstrated that slight abduction was necessary to compensate for the progressive adduction drift.24 however, duncan et al. showed that any amount of abduction was associated with later knee varus deformity and instability and recommended neutral abduction-adduction.34 there appears to be consensus that internal rotation should be avoided to prevent interference with the opposite limb during walking.1 the mean leg length discrepancy in our patient group was 1.8 cm. symptomatic leg length discrepancy above 2 cm was treated with a shoe raise. leg length discrepancy above 4 cm may require a staged femoral lengthening but was not required in any of our cases.1 multiple surgical techniques are described in the literature.1,4-8,27,32-38 the options include internal fixation with transarticular screws (e.g., cannulated compressing screws or dynamic hip screw system) or extra-articular fixation (e.g., cobra plate, low-contact dynamic compression plate). in the transarticular technique with compression screw, the use of a supplementation external fixation (e.g., ao modular ex-fix) is also described.28 cobra plates were designed to address high rates of pseudarthrosis seen with transarticular techniques by providing a rigid internal fixation. these plates, however, damage the abductor mechanism, making later conversion to a thr challenging.37,38 the use of external fixators is frequently complicated by pin-track infections and knee stiffness.28,36 the procedure we preferred for hip arthrodesis has the following potential advantages: transarticular compression, sparing of the abductor muscles, and preservation of both bone stock and the vascular supply of femoral neck and head. the disadvantages include the prolonged hospital stay and cumbersome spica cast immobilisation. the potential benefits and drawbacks of performing a subtrochanteric osteotomy also need to be considered. subtrochanteric osteotomy potentially increases the chances of union of the arthrodesis by decreasing the length of the lever arm and the resulting strain at the fusion site. furthermore, as the hip is positioned in the optimal position to achieve union, figure 5. postoperative ap radiographs a) demonstrating probable fusion, evident with a clear lucent zone at the fusion site; however, no lucency around the screws and clinically pain-free; and b) failed fusion, evident with fusion site lucency, screw halos and pain with weight bearing ba figure 4. postoperative ap radiographs a) of the left hip of a 14-year-old girl and b) of the right hip of a 14-year-old boy demonstrating definite fusion. the trabecular crossing sign is evident with no lucency around the screws. ba page 224 mniki ta et al. sa orthop j 2021;20(4) the alignment of the limb can be adjusted at the subtrochanteric osteotomy site. however, thr following a previous proximal femoral osteotomy can be technically challenging with increased complication and revision rates compared to a primary total hip arthroplasty.39,40 while we achieved fusion in all cases, reoperations were required in 32% (6/19). we found that a younger age at surgery was associated with increased odds of reoperation (or 2.07, 95% ci 1.1–3.9, p = 0.022). reoperations were required to either obtain fusion, or to maintain a functional position due to adduction and flexion drift. fusion quality was also associated with reoperation (p = 0.003). all three failed fusions required reoperation to relieve pain and improve poor hip position. two out of three patients that were categorised as ‘probable fusion’ also required reoperation, both due to adduction drift which was likely the result of incomplete fusion. brien et al., in their study of 16 patients fused with an anterior compression plate, demonstrated a 31% reoperation rate for fusion.33 however, wagner and wagner had a reoperation rate for fusion of 8% with the use of the cobra plate.37 in a series involving 17 patients fused with cobra plates, mahran and omar also demonstrated a high fusion rate with a 6% reoperation rate.22 hoekman et al. augmented the transarticular compression with an anterior plate and showed a 94% fusion rate.21 while there are no comparative studies to show the superiority of one surgical technique over the other, the use of an anteriorly placed plate to supplement transarticular fixation may improve fusion rates.1,21 good to excellent short-term subjective functional outcome was achieved in 95% of our patients, with one patient reporting symptoms of adjacent joint pain. this is comparable to other studies on the functional outcome after hip arthrodesis. schafroth et al. evaluated the long-term outcome of 30 patients that underwent hip arthrodesis and showed that when the optimal limb alignment is achieved, complaints relating to the adjacent joints is minimal and acceptable quality of life is attainable.27 hoekman et al. has demonstrated a high satisfaction rate in his 35-patient cohort and reported a good to a very good quality of life.21 after skeletal maturity, the management of end-stage hip disease is controversial, with some authors advocating for thr over hip fusion.3 thr has clear short-term advantages but uncertain longterm outcomes. takenaga et al., in a ten-year follow-up study looking at patients 50 years and younger, reported a 15% revision rate.11 furthermore it has been shown that further revisions can be expected in this group of patients (up to 30%) with shorter implant survival times.10 hip arthrodesis therefore remains a viable option in this high-demand patient group due to the concerns of implant loosening and the risk of multiple revisions.1,6 while hip arthrodesis restores function and relieves pain in end-stage hip disease, it is frequently complicated by adjacent joint degeneration in the long term.27 later conversion of the fused hip to total hip arthroplasty may be considered to halt these processes and increase function, with improved quality of life.41 however, complications are relatively common in comparison to primary tha, occurring in up to 13% of cases, and the ten-year survival rate of the procedure varies from 74–96%.42 there are several limitations to this study. as the study was retrospective, not all the preoperative measurements were documented in the medical records. the data regarding the disease course and the time from initial diagnosis to arthrodesis was also not available. despite this limitation, these patients all met the indication for hip arthrodesis: a painful hip in a poor position, with end-stage hip disease that has failed non-operative management. the study was also subject to attrition bias with two patients being lost to follow-up. the small sample size is due to the relative rarity of end-stage hip disease in children and adolescents. we found no obvious explanation for the finding that there is an association between younger age and increased complications and need for reoperation. this may also, possibly, be a function of the small sample size. despite the small sample size, the study was sufficiently powered to detect an association between age and the odds of reoperation (post hoc power analysis = 98% power). this is a short-term outcome study on a young group of patients that underwent hip arthrodesis. long-term complications include flexion and adduction drift and degenerative disease of other joints (ipsilateral knee, opposite hip and lumbar spine). long-term follow-up is required to accurately determine the outcome of hip fusion in our patient cohort. as this is a single-centre study, further research is required to confirm external validity. further study is also required to determine the association between underlying cause of hip disease and outcome, as well as the optimal surgical fusion technique. conclusion hip arthrodesis can provide reliable pain relief in selected children and adolescents with end-stage hip disease. the procedure is technically challenging with a significant complication and reoperation rate. younger age may be associated with an increased risk of reoperation. ethics statement institutional review board ethical approval was obtained from the university of kwazulu-natal biomedical research ethics committee via an expedited application referenced: be602/18 prior to commencement of the study. the author/s declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. the study was conducted with compliance to the south african national research ethics guidelines (2015). all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was not obtained for the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions tam: data capture, manuscript preparation, manuscript revision phm: manuscript review and revision lcm: manuscript review and revision dmt: study design, data capture, manuscript review orcid mniki ta https://orcid.org/0000-0003-1410-4508 maré ph https://orcid.org/0000-0003-1599-7651 marais lc https://orcid.org/0000-0002-1120-8419 thompson dm https://orcid.org/0000-0003-2607-3999 references 1. bittersohl b, zaps d, bomar jd, hosalkar hs. hip arthrodesis in the pediatric population: where do we stand? orthop review. 2011;3(2):e13. 2. swarup i, lee y, chiu y, et al. implant survival and patient-reported outcomes after total hip arthroplasty in young patients. j arthrop. 2018;33:2893-8. 3. kelman mg, studdert dm, callaghan jj, et al. the choice between total hip arthroplasty and arthrodesis in adolescent patients: a survey of orthopedic surgeons. j arthroplasty. 2016;31:70-75. 4. clohisy jc, beaulé pe, o’malley a, et al. hip disease in the young adult: current concepts of aetiology and surgical treatment. j bone joint surg am. 2008;90(10):2267-81. 5. iobst ca, stanitski cl. hip arthrodesis: revisited. j pediatr orthop. 2001;21:130-4. 6. stover md, beaule pe, matta jm, et al. hip arthrodesis: procedure for the new millennium? clin orthop relat res. 2004;418:126-33. 7. beaulé pe, matta jm, mast jw. hip arthrodesis: current indications and techniques. j am acad orthop surg. 2002;10:249-58. https://orcid.org/0000-0003-1410-4508 https://orcid.org/0000-0003-1599-7651 https://orcid.org/0000-0002-1120-8419 https://orcid.org/0000-0003-2607-3999 page 225mniki ta et al. sa orthop j 2021;20(4) 8. dabov g. hip arthrodesis. in: azar fm, canale st, beaty jh, editors. campbell’s operative orthopaedics.13th ed. elsevier; 2016, p. 337-44. 9. tsukanaka m, halvorsen v, nordsletten l, et al. implant survival and radiographic outcome of total hip replacement in patients less than 20 years old. acta orthop. 2016;87(5):479-84. 10. lee pth, lakstein dl, lozano b, et al. midto long-term results of revision total hip arthroplasty in patients aged 50 years or younger. bone joint j. 2014;94-b:1047-51. 11. takenaga rk, callaghan jj, bedard na, et al. cementless total hip arthroplasty in patients fifty years of age or younger: a minimum ten-year follow-up. j bone joint surg am. 2012;94:2153-59. 12. clohisy jc, oryhon jm, seyler tm, et al. function and fixation of total hip arthroplasty in patients 25 years of age or younger. clin orthop relat res. 2010;468:3207-13. 13. toschia me, klassen ra, bianco aj. total hip arthroplasty with cement in patients less than twenty years old. long-term results. j bone joint surg. 1996;78(7):995-1003. 14. cherney dl, amstutz hc. total hip replacement in the previously septic hip. j bone j surg. 1983;65(9):1256-65. 15. balderston ra, hiler wd, iannotti jp, et al. treatment of the septic hip with total hip arthroplasty. clin orthop relat res. 1987 aug;(221):231-7. 16. fulkerson jp. arthrodesis for disabling hip pain in children and adolescents. clin orthop relat res. 1977 oct;(128):296-302. 17. lipscomb pr, mccaslin fe jr. arthrodesis of the hip: review of 371 cases. j bone joint surg am. 1961;43:923-50. 18. sponseller pd, mcbeath aa, perpich m. hip arthrodesis in young patients. a long-term follow-up study. j bone joint surg am. 1984;66:853-59. 19. callaghan jj, brand ra, pedersen dr. hip arthrodesis: a long-term follow-up. j bone joint surg am. 1985;97:1328-35. 20. mowery ca, houkom ja, roach jw, et al. a simple method of hip arthrodesis. j pediatr orthop. 1986;6:7-10. 21. hoekman p, idé g, kassoumou as, et al. hip arthrodesis with the anterolateral plate: an innovating technique for an orphaned procedure. plos one. 2014;9(1):e85868. 22. mahran m, omar uf. hip arthrodesis for arthritic hip in children and young adults. al-azhar assiut med j. 2015;13(4):38-42. 23. vicente jr, ulhoa ca, leonhardt af, et al. hip arthrodesis: minimum 20-year follow-up retrospective study. act orthop bras. 2011;19(5):286-88. 24. benaroch te, richards bs, haideri n, et al. intermediate follow-up of a simple method of hip arthrodesis in adolescent patients. j pediatr orthop. 1996;16:30-36. 25. roberts cs, fetto jf. functional outcomes of the hip fusion in the young patient: follow-up study of 10 patients. j arthrop. 1990;5:89-96. 26. karol la, halliday se, gourineni p. gait and function after intra-articular arthrodesis of the hip in adolescents. j bone joint surg am. 2000;82:561-69. 27. schafroth mu, blokzijl rj, haverkamp d, et al. the long-term fate of the hip arthrodesis: does it remain a valid procedure for the selected cases in the 21st century? int orthop. 2010;34(6):805-10. 28. tavares jo, frankovitch kf. hip arthrodesis using the ao modular external fixator. j pediatr orthop. 1998;18:651-56. 29. the jamovi project (2020). jamovi (version 1.2) [computer software]. retrieved from: https:// jamovi.org. 30. banskota ak, shrestha sp, banskota b, et al. hip arthrodesis in children: a review of 28 patients. indian j orthop. 2009;43(4):383-88. 31. saha d, gard s, fatone s, et al. the effect of trunk-flexed posture on balance and metabolic energy expenditure during standing. spine. 2007;32(15):1605-11. 32. matta jm, siebenrock ka, gautier e, et al. hip fusion through an anterior approach with the use of a ventral plate. clin orthop. 1997;337:129-78. 33. brien ww, golz rj, kuschner sh, et al. hip joint arthrodesis utilizing anterior compression plate fixation. j arthrop. 1994;9(2):171-76. 34. duncan cp, spangehl m, beauchamp c, et al. hip arthrodesis: an important option for advanced disease in the young adult. can j surg. 1995;38:s39-45. 35. scher dm, jeong gk, grant ad, et al. hip arthrodesis in adolescents using external fixation. j pediatr orthop. 2001;21(2):194-97. 36. endo n, takahashi he, toyama h, et al. arthrodesis of the hip joint using an external fixator. j orthop sci. 1999;4:343-46. 37. wagner m, wagner h. hip arthrodesis using the cobra plate. indications, technique, outcome. der orthopäde. 1996;25(2):129-39. 38. klemme wr, preston j, skinner r. results of hip arthrodesis in adolescents by using the cobra-head plate for internal fixation. j pediatr orthop. 1998;18(5):648-50. 39. shinar a, harris w. cemented total hip arthroplasty following previous femoral osteotomy. j arthop. 1998;13(3):243-53. 40. boos n, krushell r, ganz r, et al. total hip arthroplasty after femoral osteotomy. j bone joint surg br. 1997;79(2):247-53. 41. juaregui jj, kim jk, shield wp, et al. hip fusion takedown to a total hip arthroplasty – is it worth it? a systematic review. int orthop. 2017;41:1535-42. 42. flecher x, ollivier m, maman p, et al. long-term results of custom cementless-stem total hip arthroplasty performed in hip fusion. int orthop. 2018;42:1259-64. south african orthopaedic journal paediatric orthopaedics doi 10.17159/2309-8309/2021/v20n2a5 ben salem ka et al. sa orthop j 2021;20(2) citation: ben salem ka, maré ph, goodier m, marais lc, thompson dm. polio-like deformity: a diagnostic dilemma. sa orthop j 2021;20(2):93-97. http://dx.doi.org/10.17159/23098309/2021/v20n2a5 editor: prof. jacques du toit, stellenbosch university, south africa received: july 2020 accepted: october 2020 published: may 2021 copyright:© 2021 ben salem ka. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was secured for this research. conflict of interest: the authors have no conflict of interest to declare. abstract background significant advances have been made in the global effort to eradicate polio. vaccine-associated poliovirus, or other enteroviruses, may still affect the anterior horn cell and cause acute flaccid paralysis. following the acute disease, residual paralysis results in lower motor neuron weakness, altered growth and deformity. our study aims to describe the clinical manifestations of a group of children that mimic that of classic paralytic poliomyelitis. methods we identified six children from our paediatric orthopaedic database that presented with polio-like deformities. their clinical and imaging records were reviewed and described, together with the clinical manifestations of paralytic poliomyelitis. results limb hypoplasia, pathological gait patterns and foot deformities were consistent features. the median leg length discrepancy was 2.5 cm (range 2–4 cm). the gait patterns observed included a trendelenburg gait in 33% (n=2), a short limb gait in 50% (n=3), and one case with a combination of trendelenburg, short limb and steppage gait. tensor fascia lata contracture was present in 50% (n=3) of our patients. foot deformities ranged from calcaneo-cavo-valgus to equino-cavo-varus deformities. conclusion despite significant advances made in the global fight to eradicate polio, we still see children with clinical manifestations reminiscent of the disease. orthopaedic surgeons should remain familiar with the assessment and diagnosis of the sequelae of paralytic poliomyelitis. level of evidence: level 5 keywords: poliomyelitis, vaccine-associated paralytic poliomyelitis, polio-like deformity, acute flaccid paralysis polio-like deformity: a diagnostic dilemma khaled a ben salem,¹ pieter h maré,¹* matthew goodier,² leonard c marais,³ david m thompson¹ ¹ department of orthopaedic surgery, grey’s hospital, school of clinical medicine, university of kwazulu-natal, south africa ² department of radiology, grey’s hospital, school of clinical medicine, university of kwazulu-natal, south africa ³ department of orthopaedic surgery, school of clinical medicine, university of kwazulu-natal, south africa *corresponding author: phmare@gmail.com introduction the last case of wild-strain poliomyelitis in south africa was reported in 1989.1 despite this, we still see patients with clinical deformities resulting from paralysis reminiscent of that caused by the poliovirus (so-called polio-like deformity). most orthopaedic surgeons familiar with the assessment and management of polio are nearing the end of their careers.2 current orthopaedic reference textbooks have removed sections on polio. as availability bias may limit our ability to consider and diagnose uncommon conditions, it is essential that orthopaedic surgeons remain familiar with the clinical manifestations of paralytic polio.3 the most common viral motor neuronopathy in children presenting as acute flaccid paralysis (afp) results from enterovirus infections. these viruses include coxsackievirus, enterovirus 68 and 71, echovirus and polio.4 previously the focus was mainly on poliovirus. significant strides have been made in the fight to eradicate polio globally. however, this goal has not been achieved yet and polio may still be imported from endemic areas. south africa lost its ‘polio-free’ status in 2017 due to insufficiencies in its vaccination programme and surveillance systems.5 this was reinstated by the who’s african regional certification committee (arcc) in september 2019. limitations in surveillance may result in some cases of afp being missed. vaccine-associated paralytic polio (vapp) and circulating vaccine-derived poliovirus (cvdpv) remain a risk with the use of the oral attenuated polio vaccine (opv). there has recently been a resurgence of interest in virus strains other than polio that have caused outbreaks of a febrile paralytic illness initially described as ‘polio-like illness’.6 this syndrome was eventually named acute flaccid myelitis (afm) to differentiate it from disease caused by the poliovirus. residual lower motor neurological deficit was noted in 84% of cases at median nine-month follow-up.6 while several causes of polio-like paralysis remain, the entity itself and its clinical characteristics in particular, remains poorly characterised. we could find no previous reports on the orthopaedic manifestations of paralytic enterovirus infection. this study aims to describe a cohort of patients presenting with polio-like deformities. https://orcid.org/0000-0003-2778-3140 https://orcid.org/0000-0003-1599-7651 page 94 ben salem ka et al. sa orthop j 2021;20(2) methods we retrospectively reviewed data from cases who presented to our tertiary level paediatric orthopaedic unit over the seven years from january 2011 to december 2018. the unit serves a population of approximately 4.3 million people, of which 1.6 million are children between the ages of 0 and 14 years.7 following ethical approval, cases were identified from our paediatric orthopaedic database. all patients, below the age of 18 years, presenting with polio-like deformity were included. ‘poliolike deformity’ was defined as the combination of asymmetric lower motor neuron (lmn) paralysis, deformity and altered growth consistent with that seen with poliomyelitis. spine mri investigation was routinely performed to identify features suggestive of previous neuroinvasive viral infection. patients with deformity and neurological deficit due to other causes were excluded. the differential diagnosis for this presentation includes other causes of lower motor neuropathy, such as hereditary motor sensory neuropathies, congenital spinal abnormalities (spinal dysraphism), previous traumatic or toxic neuritis as well as neuroinvasive viral infection. the records were reviewed for vaccination history, any previous significant febrile illness (with or without signs of meningism) and history of afp. clinical records were reviewed for the pertinent findings during neurological evaluation, as well as documentation of joint contractures, deformities and leg-length discrepancy (lld). x-ray and mri records were reviewed from our institution’s pacs and included in our analysis. motor function was assessed by testing and grading power according to the medical research council (mrc) grading.8 decreased or absent tone and reflexes were findings consistent with an lmn lesion. the indication for mri was any child who presented with unexplained lmn weakness and deformity or altered growth in keeping with the typical findings of poliomyelitis. all mri scans were performed using a 1.5 tesla phillips intera mri machine. standard spine sequences included stir, t2 and t1 sagittal acquisitions and t2 and t1 axial acquisitions. intravenous gadolinium was not routinely used. five of the mri scans were evaluated by a specialist radiologist with seven years’ experience and a postgraduate diploma in neuroradiology. axial images were evaluated for the presence of ventral nerve root atrophy which was considered to be present if the ventral (motor) nerve roots of the cauda equina were markedly smaller in calibre than the dorsal (sensory) roots at the same level. one of the scans (patient 4) did not have mri images available for review, and the mri report from the patient records was used. results we identified six patients that met the clinical criteria for polio-like deformity. mri findings consistent with previous neuroinvasive viral infection were present in 67% (n=4). their mean age was 8 years (range of 2–14). their presenting complaints and clinical findings are summarised in table i. all patients had some degree of limb hypoplasia with lld of median 2.5 cm (range 2–4). limp was another consistent feature with 33% (n=2) presenting with trendelenburg gait, a short limb gait was present in 50% (n=3), and one child presented with a combination of trendelenburg, short limb and steppage gait. tensor fascia lata (tfl) contracture is a classic feature of polio and was present in 50% (n=3) of our patients. foot deformities were present in all cases. these ranged from mere hypoplasia to calcaneo-cavo-valgus (figures 1 and 2) at one end, and equinocavo-varus deformity at the other end of the spectrum. vapp was confirmed in one patient who presented to the paediatric service with afp after opv administration during infancy. she presented at our orthopaedic unit at the age of 8 years with an lmn paresis affecting the left lower limb and classic deformities of polio in the hip, knee and foot and ankle (figure 3). no clear history of afp could be elicited in any of the other cases. two of the mri scans were normal. three of the patients had a clear subjective reduction in the calibre of the ventral nerve roots of the cauda equina (figure 4). in one patient, this finding was present bilaterally, and in two patients, this finding was unilateral. one patient had long segment signal abnormality involving the entire spinal cord. discussion polio is caused by three related enteroviruses (types 1, 2 and 3). fewer than 1% of polio infections in children result in afp.9 a recovery phase follows afp during which the muscle recovers rapidly in the first six months and slower over the subsequent table i: summary of clinical findings patient age (years) sex presenting complaint gait hip knee foot and ankle lld 1 4 m hypoplastic left lower limb short limb gait calcaneo-cavo-valgus deformity (figures 1 and 2) 2 cm 2 10 f limp and hypoplastic left lower limb trendelenburg gait left hip dislocation (figure 6) equino-cavo-varus deformity 3 cm 3 2 m limp and foot deformity trendelenburg gait itb contracture (figure 5) hypoplastic left foot (figure 7) 2 cm 4 8 f lower limb paralysis and deformity (figure 3) history of afp post opv at age 1 year paralytic gait (combined) itb contracture hip flexion power 3/5 quadriceps power 3/5 tibialis anterior paralysis 0/5 equino-cavo-varus deformity 4 cm 5 14 f hypoplastic left lower limb short limb gait itb contracture normal, thigh muscles wasting equinus deformity 4 cm 6 7 f right lower limb weakness and shortening short limb gait hip flexion power 4/5 hypoplastic thigh musculature fixed forefoot adduction 2 cm page 95ben salem ka et al. sa orthop j 2021;20(2) months until up to two years. no recovery occurs after this in the residual paralysis phase. residual paralysis following enterovirus infection may be mild. asymmetric weakness and incomplete recovery of paralysis result in muscle imbalance. in the growing child, active muscles shorten, and paralysed muscles overlengthen. over time this results in altered bone growth and joint contractures. a greater disparity in strength will result in earlier deformity. a mild discrepancy, however, over a long period, will also result in deformity, altered growth and joint development. these deformities often manifest years after the initial paralysis and are recognised as the typical manifestations of paralytic polio.10 our study describes a cohort of patients with the typical clinical features of paralytic polio. the typical joint contractures and deformities seen in polio occur during growth as a result of the muscle imbalance in the residual paralysis phase after neuroinvasive viral infection. a shortened limb is due to interference with growth.11 the pattern of paralysis is classically asymmetric. all our patients had asymmetric growth disturbance and presented with varying degrees of limb hypoplasia and shortening. sharrard published detailed and extensive analyses of the pattern of cell destruction in the spinal cord, as well as muscle recovery in poliomyelitis.12,13 muscles most frequently completely paralysed have their anterior horn cells located in a narrow zone in the spinal cord (e.g. tibialis anterior).14 muscles that have their anterior horn cells in a wider region may still be frequently affected (e.g. the quadriceps femoris), but will seldom be completely paralysed.10 this pattern was seen in the child with confirmed vapp who had complete paralysis of tibialis anterior, (0/5 power) but paresis of the quadriceps (3/5 power). sensory loss is infrequent. subsequent motor dysfunction and deformity will depend on the pattern of paralysis.15 a trendelenburg gait is a common feature due to abductor paralysis. gluteus maximus paralysis may result in an extensor lurch during the stance phase of gait. three children in our series figure 1. clinical images in the frontal and sagittal plane demonstrating calcaneo-cavo-valgus foot deformity figure 2. lateral x-ray demonstrating calcaneo-cavus deformity with calcaneal pitch measured at 49° figure 3. ap pelvis x-ray showing left hip dislocation with acetabular dysplasia and hypoplastic proximal femur figure 4. t2-weighted axial mri image showing atrophy of the ventral nerve roots most marked on the left (white arrow) compared to the right (white arrowhead) and left dorsal nerve roots (white open arrow) figure 5. clinical picture of a positive ober’s test in patient 3; this test confirms tensor fascia lata (tfl) and ilio-tibial band (itb) contracture page 96 ben salem ka et al. sa orthop j 2021;20(2) had a trendelenburg gait due to abductor weakness. we did not see any children with gluteus maximus paralysis. hip contractures are typically into an abducted, externally rotated and flexed position.2 abduction contracture is in part the result of tfl contracture. ober’s test identifies tfl contracture (figure 5). less frequently, hip instability and dislocation may occur due to paralysed gluteal muscles and strong hip adductors and flexors. this is associated with coxa valga, persistent anteversion and acetabular dysplasia.10 itb contracture was found in three children in our series. one child presented with a paralytic dislocation (figure 6). quadriceps weakness makes a ‘hand on thigh’ gait necessary to lock the knee during stance.2 genu recurvatum deformity may develop if a child bears weight on a flail limb by locking the leg into hyperextension during every stance phase.10 fixed flexion deformity of the knee occurs more frequently due to quadriceps weakness and strong knee flexors.10 contracture is often severe. tfl contracture also results in external tibial torsion. quadriceps weakness was found in one child, while in two children thigh hypoplasia was present without weakness. none of the children in our series had knee flexion or recurvatum deformities. tibialis anterior is one of the most frequently completely paralysed muscles.10 this results in a foot drop and fixed equinus deformity. depending on the pattern of paralysis, a range of deformities may occur. these include equinus, calcaneus, hindfoot varus or valgus, pes cavus or pes planus, or any combination of these.2 foot deformities were present in all children in our series. these ranged from calcaneo-cavo-valgus deformity in one child (figures 1 and 2) to equino-cavo-varus deformities in two children. one child each had forefoot adduction, pure equinus and hypoplasia (figure 7). mri findings consistent with previous poliomyelitis were present in 69% (n=4). this is consistent with a report by teoh et al., which found 75% (n=3) abnormal spine mris in cases of afp due to neuroinvasive viral infection.16 only one of our cases had a clear history of afp. this was confirmed as vapp. it is possible that the other cases may have been the result of undiagnosed enterovirus infection, causing lower motor neuronopathy. once the child presents with the late sequelae of paralytic enterovirus infection, no serological test or imaging investigation can confirm the diagnosis definitively. spine mri investigation may strengthen the clinical suspicion. during the acute phase of the disease, mri features could include diffuse signal abnormality in the cord (as was present in patient 4). in the chronic phase the only changes may be that of ventral root atrophy (these features were observed in patients 1–3). significant progress has been made since 1988 by the global polio eradication initiative (gepi) and the world health organization. since 2000, 13 million cases of polio have been prevented by the oral polio vaccine (opv), and the disease has been reduced by more than 99%.17 only wild poliovirus (wpv) type 1 remains endemic in pakistan and afghanistan. the last case of wpv type 2 was recorded in 1999, and wpv type 3 in 2012.18 south africa has a well-established vaccination programme which has been massively successful in eradicating wild polio infection. in rare instances the attenuated sabin poliovirus administered as the opv may undergo genetic drift during replication, developing neurovirulent properties. this may cause afp identical to that caused by wpv. the rate has been reported between 3.8 and 4.7 cases per million live births.19 these viruses may be transmitted as circulating vaccine-derived poliovirus (cvdpv). the small risk of vapp and cvdpv is offset by the immense public health benefit of opv. ironically, the management of a cvdpv outbreak is ensuring efficient vaccination in the area to stop the spread of the mutated neurovirulent viral strain. while there are advantages to opv, it is being phased out as wild polio is eradicated to prevent the occurrence of vapp and cvdpv. this started in april 2016 as a global coordinated effort to change from trivalent opv (containing types 1, 2 and 3) to bivalent opv (type 1 and 3).17 several limitations of our study warrant consideration. due to the rarity of the syndrome we were able to identify only a small number of cases. we were unable to confirm a history of afp in all but one child. this may be explained by a situation where the meningitic nature of a febrile illness was not appreciated. a mild neurological deficit, especially in young children, can easily be missed. as the subsequent clinical course is that of progressive figure 6. clinical picture in the frontal plane demonstrating hypoplasia of the left lower limb, genu valgus and equinovarus foot deformity, all classic features of polio figure 7. clinical picture showing hypoplasia of the left foot in patient 3 page 97ben salem ka et al. sa orthop j 2021;20(2) recovery, healthcare opinion may not have been sought. this is supported by the 2016 report that south african national afp surveillance was below the heightened who target for 2015/16 of 4/100 000 with several districts reporting 0 or 1/100 000 cases.18 electrophysiological testing would have been useful but was not available for paediatric patients at our hospital during the study period. despite these shortcomings, the classic clinical findings of paralytic polio, supported by mri findings in most cases, prompted us to compile this report. we could not find any previous published reports of this clinical entity. clinicians should remain familiar with sequelae of paralytic polio because, to quote the philosopher george santayana, ‘those who cannot remember the past are condemned to repeat it’.20 conclusion while major strides have been made towards worldwide polio eradication, non-polio enteroviruses, vapp and cvdpv may still cause a polio-like deformity. afp surveillance should be strengthened to ensure all cases are identified early and deformities prevented or treated early. if the child presents years later, thorough clinical evaluation should exclude other causes of lower motor neuronopathy. typical features include asymmetric limb hypoplasia combined with lmn weakness and tfl contracture. mri may be useful to identify features of previous neuroinvasive viral infection. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. ethical approval was granted by the university of kwazulu-natal biomedical research ethics committee (be380/18). declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions kabs: data capture, first draft preparation, manuscript revision phm: manuscript revision and review mg: manuscript preparation and review lcm: manuscript revision and review dmt: study design, data capture, manuscript review orcid ben salem ka https://orcid.org/0000-0003-2778-3140 maré ph https://orcid.org/0000-0003-1599-7651 goodier m https://orcid.org/0000-0002-6091-1768 marais lc https://orcid.org/0000-0002-1120-8419 thompson dm https://orcid.org/0000-0003-2607-3999 references 1. khuzwayo ls, kuonza lr, ngcobo nj. evaluating the acute flaccid paralysis surveillance system in south africa, 2005–2009: an analysis of secondary data. pan afr med j. 2013;14:86. 2. joseph b, watts h. polio revisited: reviving knowledge and skills to meet the challenge of resurgence. j child orthop. 2015;9:325-38. 3. morgenstern j. cognitive errors in medicine: the common errors. first10em blog, september 15, 2015. available at: https://first10em/cognitive-errors/. 4. teoh h, carey k, sampaio h, et al. inherited paediatric motor neuron disorders: beyond spinal muscular atrophy. neural plast. 2017:6509493. https://doi.org/10.1155/2017/6509493. 5. no authors listed. south africa certified polio-free. https://www.nicd.ac.za/ south-africa-certified-polio-free/. [accessed 19 june 2020]. 6. messacar k, schreiner tl, van haren k, et al. acute flaccid myelitis: a clinical review of us cases 2012–2015. ann neurol. 2016;80(3):326-338. https://doi. org/10.1002/ana.24730. 7. no authors listed. 2018 kwazulu-natal citizen satisfaction survey: analytical report. http://www.statssa.gov.za/publications/report-03-00-07/report-03-00072018.pdf. [accessed 19 june 2020]. 8. medical research council. aids to the investigation of the peripheral nervous system. memorandum no. 45. london, her majesty’s stationery office; 1976. 9. centers for disease control and prevention. chapter 18: poliomyelitis. in: hamborsky j, kroger a, wolfe s, editors. epidemiology and prevention of vaccine-preventable diseases. 13th ed. washington d.c. public health foundation; 2015. 10. sharrard wjw. affectations of the lower motor neurone. in: sharrard wjw. paediatric orthopaedics and fractures. 2nd edition. blackwell scientific publications; 1979. p. 889-942. 11. faraj aa. poliomyelitis: orthopaedic management. curr orthop. 2006;20:41-46. 12. sharrard wjw. correlation between changes in the spinal cord and muscle paralysis in poliomyelitis – a preliminary report. proc r soc med. 1953;46(5):346-49. 13. sharrard wjw. muscle recovery in poliomyelitis. j bone joint surg (br). 1955;37-b:63-79. 14. sharrard wjw. the distribution of the permanent paralysis in the lower limb in poliomyelitis. j bone joint surg (br). 1955;37-b:540-58. 15. sharrard wjw. paralytic deformity in the lower limb. j bone joint surg (br). 1967;49-b:731-47. 16. teoh h, mohammad ss, britton pn, et al. clinical characteristics and functional motor outcomes of enterovirus 71 neurological disease in children. jama neurol. 2016;73(3):300-307. 17. world health organization. poliomyelitis. https://www.who.int/news-room/q-adetail/poliomyelitis. [accessed 19 june 2020]. 18. howard w, moonsamy s, manamela j, et al. acute flaccid paralysis surveillance for polio, south africa and other african countries. nicd communicable diseases surveillance bulletin. 2017;15(1):3-8. 19. platt lr, estivariz cf, sutter rw. vaccine-associated paralytic poliomyelitis: a review of the epidemiology and estimation of the global burden. j infect dis. 2014;210(s1):s380-389. 20. santayana g. reason in common sense. 1905. p. 284. https://orcid.org/0000-0003-2778-3140 https://orcid.org/0000-0003-1599-7651 https://orcid.org/0000-0002-6091-1768 https://orcid.org/0000-0002-1120-8419 https://orcid.org/0000-0003-2607-3999 panchoo p et al. sa orthop j 2020;19(3) doi 10.17159/2309-8309/2020/v19n3a4 south african orthopaedic journal http://journal.saoa.org.za foot and ankle citation: panchoo p, wiegerinck ji, boskovic v, laubscher m, maqungo s, mccollum g, dey r. outcomes of primary fusion in high-energy lisfranc injuries at a tertiary state hospital. sa orthop j 2020;19(3):150-155. http://dx.doi.org/10.17159/2309-8309/2020/v19n3a4 editor: prof. np saragas, university of the witwatersrand, johannesburg, south africa received: october 2019 accepted: march 2020 published: august 2020 copyright: © 2020 panchoo p. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no external funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: high-energy lisfranc injuries are relatively uncommon but can lead to severe disability and morbidity. primary fusion is a treatment option that can improve outcomes and reduce the reoperation rate. the aim of this study was to evaluate our series of primary fusions for high-energy lisfranc injuries, looking specifically at type of fusion, time to union, non-union rates, reoperation rates and quality of reduction. methods: patients who underwent surgery for lisfranc injuries were identified from the redcap surgical database and then retrieved from records. only cases of primary fusion in adults were included. we excluded low-energy sprains and athletic injuries, ipsilateral lower limb injuries and cases where reduction and fixation were done. radiographs were analysed from the isite enterprise pacs system (philips®). results: between 2013 and 2018, 12 cases of high-energy lisfranc injuries were identified where primary fusion was done. seven patients (58%) underwent fusion of the first, second and third tarsometatarsal (tmt) joints. the first and second tmt joints were fused in only one case (8%), and the second and third tmt joints were fused in four cases (33%). only one patient (8%) had removal of implants. compression plating was the technique of choice used for fusion. there was 100% union rate and average time to union was 84 days. acceptable reduction was observed in nine cases (75%). three cases (25%) of malreduction were found, among which one patient had pre-existing hallux valgus. conclusion: the majority of patients who underwent primary fusion of at least one tmt joint had good radiological outcome. further studies with better clinical follow-up are needed. level of evidence: level 4 keywords: lisfranc, tarsometatarsal, outcome, fusion outcomes of primary fusion in high-energy lisfranc injuries at a tertiary state hospital panchoo p1 , wiegerinck ji2, boskovic v3 , laubscher m4 , maqungo s5 , mccollum g6 , dey r7 1 mbchb; orthopaedic registrar, department of orthopaedics surgery, groote schuur hospital, university of cape town, south africa ² md, phd; consultant, department of orthopaedics, joint research, olvg hospital amsterdam, the netherlands 3 mbchb; orthopaedic registrar, department of orthopaedics, groote schuur hospital, university of cape town, south africa 4 mbchb(ufs), dip pec, fc orth(sa), mmed(orth)(uct); consultant, department of orthopaedics, groote schuur hospital, university of cape town, south africa 5 mbchb(natal), fc orth(sa), mmed(orth)(uct); consultant, department of orthopaedics, groote schuur hospital, university of cape town, south africa 6 mbchb, mmed(uct), fc orth(sa); consultant, department of orthopaedics, groote schuur hospital, university of cape town, south africa 7 phd; post-doctoral fellow, faculty of health sciences, university of cape town, south africa; groote schuur hospital, university of cape town, south africa corresponding author: dr p panchoo, department of orthopaedics, old main building, groote schuur hospital, anzio road, observatory, cape town, 7925, south africa; tel: +27 (82) 815 0238; email: praveshpanchoo@gmail.com https://orcid.org/0000-0003-1688-9214 https://orcid.org/0000-0001-9275-2151 https://orcid.org./0000-0002-5989-8383 https://orcid.org./0000-0002-8735-8341 https://orcid.org./0000-0002-1982-4654 https://orcid.org/0000-0002-3616-1995 page 151panchoo p et al. sa orthop j 2020;19(3) introduction lisfranc fracture dislocations also known as tarsometatarsal (tmt) fracture dislocation, consist of injuries to the bases of the five metatarsals, their articulations with the four distal tarsal bones, and disruption of the lisfranc ligamentous complex.1-4 the main stabilising ligament of the midfoot (the lisfranc ligament) runs on the plantar aspect of the foot from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal.1,3 it functions to stabilise the tmt articulation of the foot. injury to the ligament and the tmt complex can lead to chronic pain, midfoot arthritis, decreased function, and loss of quality of life.1,5-7 these injuries include any combination of bony and ligament disruption to this complex, hence classifying the pattern of injury can be difficult. computer tomography (ct) scans are therefore invaluable and virtually mandatory for all lisfranc injuries. this is a relatively uncommon injury with an incidence of approximately 0.2% of all fractures.1,6,8 often lisfranc injuries are missed in a polytraumatised patient, or in low-energy athletic injuries leading to poor functional outcomes. historically they have been associated with high-energy mechanisms such as motor vehicle accidents, falls or crush injuries.4,6,8 the treatment of these high-energy injuries has evolved over time with authors now agreeing that an anatomic reduction through open surgery is of critical importance.1-8 recently, more research on lisfranc injuries has focused on relatively low-energy mechanisms and lisfranc injuries in athletes.7 anatomic reduction and rigid stabilisation are known to be the standard of care.1-8 both open reduction and internal fixation (orif) and primary fusion have been evaluated as treatment options. with orif there is a high reoperation rate to remove the internal fixation or to perform a fusion of the midfoot due to ongoing midfoot arthritis.1-6 this has led some authors to believe that a primary fusion should be performed in the first setting. in a systematic review in 2012, sheibani-rad et al.9 concluded that both methods were acceptable, but no consensus was reached as to which is superior. the aim of this study is to evaluate our series of primary fusions for high-energy lisfranc injuries, looking specifically at time to union, non-union rates, reoperation rates and quality of reduction. methods after local institution review board approval, patients who underwent primary fusion for lisfranc injuries at groote schuur hospital (gsh) between january 2013 and december 2018 were identified. post-operative radiographs at six weeks, three months and six months were reviewed by two independent reviewers, jiw and pp, assessing quality of reduction, union rate and removal of implants. all radiographs were taken weight bearing and according to international standards. jiw is an orthopaedic surgeon from the netherlands with two years of consultant experience. pp is a thirdyear orthopaedic registrar at gsh. all measurements were further verified by the supervisor gm who is head of the foot and ankle department. figure 1. (a) first intermetatarsal angle (ima) and medial cuneiform–first metatarsal angle; (b) coronal shift; (c) lateral meary’s angle; and (d) sagittal shift page 152 panchoo p et al. sa orthop j 2020;19(3) cases of high-energy lisfranc injuries were retrieved from the orthopaedic surgery database redcap®, and corresponding radiographs were analysed from our local picture archiving and communication system, isite intellispace® software. injuries were classified using the myerson classification of lisfranc injuries.10 union was assessed by the formation of crosstrabeculation and the absence of fracture line on two views. quality of reduction was assessed by measuring the following parameters11,12 on ap view: first intermetatarsal angle (ima), medial cuneiform–first metatarsal angle, coronal shift. on lateral view: talus–first metatarsal angle (lateral meary’s angle), sagittal shift (figure 1). any value outside of the normal range11,12 (table i) was qualified as a malreduction/malunion. cases of implant removal and reoperation were obtained from patients’ files. surgical technique a ct scan was performed prior to surgery in all patients to assess fracture displacement and intra-articular comminution. the surgical technique used is a dorsal two-incision approach to gain access to the medial and middle columns. the medial column incision is placed dorsally over the first tmt joint just medial to the extensor hallucis longus tendon. the lateral incision is centred between the second and third metatarsal to gain access to the second and third tmt joints and maintain an adequate soft tissue bridge. a third incision between the fourth and fifth metatarsal is used in case open reduction of the fourth and fifth tmt is needed. a single incision over the first tmt joint or between the second and third tmt joints is used in cases where the first and second, or second and third, tmt joints are fused. our method of primary fusion was careful preparation of the joint by debriding the cartilage layer, reduction of the fracture dislocation, bone grafting of the defect with autograft taken from ipsilateral calcaneus followed by dorsal compression plating. the number of tmt joints fused depended on its involvement in the fracture pattern and its congruency. the first, second and third tmt joints were considered for fusion in the case of intra-articular comminution and joint incongruency. fourth and fifth tmt joints were never considered for fusion; no cases of intra-articular fractures involving these joints were identified. subluxation of the fourth and fifth tmt joints were addressed with temporary kirschner wires removed at six weeks. all surgeries were performed by the foot-and-ankle consultant as primary surgeon. patients were immobilised in a below-knee circular cast for six weeks and kept non-weight bearing for at least 12 weeks until radiological evidence of union. results between 2013 and 2018, 17 cases of lisfranc injuries were identified. twelve of them underwent primary fusion and five cases were excluded (in one case the file could not be retrieved, two were cases of closed reduction and percutaneous screw fixation, and two underwent open reduction and internal fixation). the study group comprised ten male and two female patients (figure 2a), with a mean age of 38.9 years (range 18–60) (figure 2b). all patients were involved in high-energy injury mechanisms, the commonest being table i: definition and normal range of measured parameters anteroposterior (ap) and lateral weight-bearing radiographs definition11,12 normal range11,12 first intermetatarsal angle (ap view) angle formed by the line drawn bisecting the first metatarsal and bisecting the second metatarsal 6–10° medial cuneiform–first metatarsal angle (ap view) angle formed by the bisection of the medial cuneiform and the anatomic axis of the first metatarsal 16–20° lateral meary’s angle (lateral view) angle formed by the bisection of the talar neck and the anatomic axis of the first metatarsal 2–10° sagittal shift (lateral view) superior translation of second metatarsal with respect to the anterior cortex of the middle cuneiform <2 mm coronal shift (ap view) lateral translation of the second metatarsal with respect to the medial cortex of the middle cuneiform <2 mm male female a 18-30 31-40 41-50 51-60 7 6 5 4 3 2 1 0 b figure 2. (a) sex demographics of the patient group used for this study; (b) distribution of patients in various age groups 17% 83% n u m b e rs age groups (years) page 153panchoo p et al. sa orthop j 2020;19(3) fall from height, followed by pedestrian vehicle accident (figure 3). most of our cases were myerson10 type a lateral, representing 66%. the remaining were one case each of type a medial, b1, b2 and c2 respectively. seven patients (58%) underwent fusion of the first, second and third tmt joints; the first and second tmt joints were fused in only one case (8%) and the second and third tmt joints fused in four cases (33%). acceptable reduction was observed in nine cases (75%); three cases (25%) of malreduction were noted, among which one patient had pre-existing hallux valgus which can give false negative values in measuring the ima. our measured reduction parameters for all the patients is shown in table ii. average reduction parameters in the well-reduced group were as follows (table iii): ima of 8.05°, medial cuneiform–first metatarsal angle of 16.9°, lateral meary’s angle 5.9°, coronal shift 0.7 mm. only one patient had a sagittal shift of 1.6 mm; the remaining radiographs had no sagittal shift. average time to union in our series was 84 days, and no case of non-union was identified (100% union rate). we also compared the number of tmt joints fused to the quality of reduction (table iv). we found better results in cases where either the first, second and third metatarsals (86%) or second and third metatarsals were fused (75%). there was one case of fusion of only first and second metatarsals which was malreduced. one patient (8%) had removal of implants for prominent hardware. discussion the most common complication following orif is post-traumatic osteoarthritis (ptoa) with rates estimated between 20% and 50%.13 teng et al.14 performed gait analysis on patients following orif and demonstrated, despite restoration of normal anatomy and gait mechanics, patients still had poor american orthopedic foot and ankle score (aofas) midfoot scores. in the setting of ptoa and continued pain, secondary arthrodesis was used as a salvage procedure. in a prospective randomised study, ly and coetzee15 compared orif versus primary fusion in primarily ligamentous lisfranc injuries. seventy-five per cent of patients who underwent orif had some loss of correction and degenerative joint changes at the final follow-up visit at a mean of 42.5 months post-operatively. they concluded that primary fusion provides fall from height pedestrian vehicle accident motor vehicle accident assault figure 3. mechanism of injury table ii: measurements for all patients (the well-reduced cases are highlighted in blue and the malreduced cases in yellow)  patient no. ima (degrees) medial cuneiform–first metatarsal angle (degrees) meary’s angle (degrees) sagittal shift (mm) coronal shift (mm) 1 5.7 16.5 5.6 0 0 2 6.2 16.1 6.9 0 0 3 9.3 17.4 5.5 0 1.2 4 8.5 16.1 8.2 0 0.8 5 8.9 16.2 8.6 1.6 1.4 6 6.9 17.6 8.6 0 0 7 9.4 19.8 4.3 0 1.5 8 9.8 16.2 2.1 0 0 9 7.8 16.5 3.8 0 1.5 10 20.9 26.9 5.8 0 1.5 11 12.4 30.2 7.5 1.0 1.2 12 13.5 23.0 13.6 4.2 0 table iii: average reduction parameters normal range10,11 average measured value first intermetatarsal angle 6–10° 8.1° medial cuneiform– first metatarsal angle 16–20° 16.9° lateral meary’s angle 2–10° 6.0° sagittal shift <2 mm only one case of 1.6 mm shift coronal shift <2 mm 0.7 table iv: effect of the number of bones fused on the quality of reduction fused bones number of cases improper reduction proper reduction first, second and third tmt 7 1 (14%) 6 (86%) first and second tmt 1 1 (100%) 0 second and third tmt 4 1 (25%) 3 (75%) 8% 42% 33% 17% page 154 panchoo p et al. sa orthop j 2020;19(3) better shortand medium-term outcomes than orif for primarily ligamentous injuries. sheibani-rad et al.9 performed a qualitative, systematic review comparing primary fusion and orif and found six reports with a combined total of 193 patients. the one-year follow-up aofas score for the orif group was 72.5 versus 88.0 for the primary fusion group. they concluded that both procedures yield satisfactory results, but primary fusion might have a slight advantage in clinical outcomes.9,16 in most of these studies, the complexity and energy of the injury has not been stated. lowenergy athletic injuries have been grouped with high-energy injuries, which we believe have a different prognosis if a primary fusion is not performed. our study did not compare outcome of orif versus primary fusion, but we analysed the results of patients who had primary fusion in high-energy lisfranc fractures. as described in the literature, our series of patients showed good results in terms of reduction (75%) and reasonable time to union (84 days). twentyfive per cent of malreduction was observed but this figure did not necessarily correlate with a poor clinical result. despite much effort to trace the patients, only two responded and came for follow-up. we calculated the aofas scores for these two patients and both scored 90/100. the remaining patients were untraceable. only one case of implant removal (8%) was identified due to symptomatic hardware. the latter correlated with the low revision or repeat surgery described in literature. better quality of reduction was observed with fusion of the first, second and third tmt and second and third tmt joints (86% and 75% respectively). the first tmt joint frequently involves primarily ligamentous injury with minimal fractures of the first metatarsal base and medial cuneiform. fusion of the first tmt joint stabilises the medial column and acts as a buttress to further stabilise adjacent fracture-dislocation injuries.16 a reason for the 25% malreduction rate can be attributed to significant comminution, bone loss and gross instability. there may have been some cases where the medial column was unstable but not included in the fusion leading to worsening of the reduction parameters mentioned. figure 4 illustrates a case of high-energy lisfranc injury operated at gsh with fusion of the first, second and third tmt joints appropriately reduced. in conclusion, our data suggests that primary fusion may be a viable option in these high-energy lisfranc injuries with good radiological outcome, 100% union and low reoperation rate. the malreduction rate may be improved by including the medial column in the fusion construct. our study was limited by a small population size and the lack of clinical parameters to compare with the radiological results. however, this is a short-term study and the long-term consequences of arthrodesis in young, athletic patients remain unknown. long-term, prospective studies of highenergy injuries with adequate clinical follow-up would be beneficial to establish and evaluate indications for primary fusion in this population. ethics statement this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, ethical approval was obtained from the following ethical review board: human research ethics committee, hrec ref: 446/2019. this article does not contain any studies with human participants or animals performed by any of the authors. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions pp: study conceptualisation, manuscript preparation, data capturing, data analysis, manuscript revision jiw: data capture, manuscript revision vb: study conceptualisation, manuscript revision ml: data capture, manuscript preparation sm: data capture, manuscript revision gm: study conceptualisation, data capture, manuscript revision rd: data analysis, manuscript revisions orcid panchoo p https://orcid.org/0000-0003-1688-9214 boskovic v https://orcid.org/0000-0001-9275-2151 pre-operative six months post-operative figure 4. preand post-reduction radiographic evidence of a well-reduced lisfranc injury https://orcid.org/0000-0003-1688-9214 https://orcid.org/0000-0001-9275-2151 page 155panchoo p et al. sa orthop j 2020;19(3) laubscher m https://orcid.org./0000-0002-5989-8383 maqungo s https://orcid.org./0000-0002-8735-8341 mccollum g https://orcid.org./0000-0002-1982-4654 dey r https://orcid.org/0000-0002-3616-1995 references 1. kirzner n, zotov p, goldbloom d, curry h, bedi h. dorsal bridge plating or transarticular screws for lisfranc fracture dislocations a retrospective study comparing functional and radiological outcomes. bone joint j. 2018;100-b:468-74. https://doi. org/10.1302/0301-620x.100b4.bjj-2017-0899.r2. 2. ponkilainen vt, laine hj, mäenpää hm, mattila vm, haapasalo hh. incidence and characteristics of midfoot injuries. foot & ankle international. 2019;40(1):105-12. https://doi. org/10.1177/1071100718799741. 3. knijnenberg lm, dingemans sa, terra mp, et al. radiographic anatomy of the pediatric lisfranc joint. j pediatr orthop. 2018;38(10):510-13. https://doi.org/10.1097/bpo.000000000000 0864. 4. cochran g, renninger c, tompane t, bellamy j, kuhn k. primary arthrodesis versus open reduction and internal fixation for low-energy lisfranc injuries in a young athletic population. foot & ankle international. 2017;38(9):957-63. https://doi. org/10.1177/1071100717711483. 5. diacon al, kimmel la, hau rc, gabbe bj, edwards er. outcomes of midfoot and hindfoot fractures in multitrauma patients. injury. 2019;50(2):558-63. https://doi.org/10.1016/j. injury.2018.11.021. 6. pigott mt,  shah r,  chan j,  et al. initial displacement does not affect loss of reduction after  lisfranc  fracture  dislocations. foot & ankle specialist. 2019;12(6):535-39. https://doi. org/10.1177/1938640018823067. 7. hong cc, pearce cj, ballal ms, calder jd. management of sports injuries of the foot and ankle. bone joint j. 2016;98-b(10):1299311. https://doi.org/10.1302/0301-620x.98b10.37896. 8. hawkinson mp, tennent dj, belisle j, osborn p. outcomes of lisfranc injuries in an active duty military population. foot & ankle international. 2017;38(10):1115-119. https://doi.org/10.1177/ 1071100717719532. 9. sheibani-rad s, coetzee jc, giveans mr, digiovanni c. ar throdesis versus orif for lisfranc fractures. orthopedics. 2012;35(6):868-73. https://doi.org/10.3928/014 77447-20120525-26. 10. stavlas p, roberts cs, xypnitos fn, giannoudis pv. the role of reduction and internal fixation of lisfranc fracture-dislocations: a systematic review of the literature. int orthop. 2010;34(8):1083-91. https://doi.org/10.1007/s00264-010-1101-x. 11. hatch dj, smith a, fowler t. radiographic relevance of the distal medial cuneiform angle in hallux valgus assessment. j foot ankle surg. 2015;55(1):85-89. https://doi.org/10.1053/j.jfas.2015.06.026. 12. gibboney md, laporta ga, dreyer ma. interobserver analysis of standard foot and ankle radiographic angles. j foot ankle surg. 2019;58(6):1085-90. https://doi.org/10.1053/j.jfas.2018.12.037. 13. schepers t, oprel pp, van lieshout em. influence of approach and implant on reduction accuracy and stability in lisfranc fracture-dislocation at the tarsometatarsal joint. foot & ankle int. 2013;34(5):705-10. https://doi.org/10.1177/1071100712468581. 14. teng al, pinzur ms, lomasney l, mahoney l, havey r. functional outcome following anatomic restoration of tarsal-metatarsal fracture dislocation. foot & ankle int. 2002;23(10):922-26. https:// doi.org/10.1177/107110070202301006. 15. ly tv, coetzee jc. treatment of primary ligamentous lisfranc joint injuries: primary arthrodesis compared with open reduction internal fixation. j bone joint surg am. 2006;88(3):514-20. https:// doi.org/10.2106/jbjs.e.00228. 16. boffeli tj, collier rc, schnell kr. combined medial column arthrodesis with open reduction internal fixation of central column for treatment of lisfranc fracture-dislocation: a review of consecutive cases. j foot ankle surg. 2018;57(6):1059-66. https:// doi.org/10.1053/j.jfas.2018.03.026. https://orcid.org./0000-0002-5989-8383 https://orcid.org./0000-0002-8735-8341 https://orcid.org./0000-0002-1982-4654 https://orcid.org/0000-0002-3616-1995 https://www.ncbi.nlm.nih.gov/pubmed/?term=pigott%20mt%5bauthor%5d&cauthor=true&cauthor_uid=30666884 https://www.ncbi.nlm.nih.gov/pubmed/?term=shah%20r%5bauthor%5d&cauthor=true&cauthor_uid=30666884 https://www.ncbi.nlm.nih.gov/pubmed/?term=chan%20j%5bauthor%5d&cauthor=true&cauthor_uid=30666884 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2989076/ https://www.ncbi.nlm.nih.gov/pubmed/26359620 https://www.ncbi.nlm.nih.gov/pubmed/26359620 https://www.ncbi.nlm.nih.gov/pubmed/26359620 https://doi.org/10.1177/107110070202301006 https://doi.org/10.2106/jbjs.e.00228 https://doi.org/10.1053/j.jfas.2018.03.026 _hlk7310316 _hlk44403116 horn a et al. sa orthop j 2020;19(1) doi 10.17159/2309-8309/2020/v19n1a1 south african orthopaedic journal http://journal.saoa.org.za paediatric orthopaedics citation: horn a, sipilä m. femoral lengthening in children. sa orthop j 2020;19(1):12-17. http://dx.doi.org/10.17159/2309-8309/2020/v19n1a1 editor: prof. j du toit, stellenbosch university, south africa received: may 2019 accepted: september 2019 published: march 2020 copyright: © 2020 horn a. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: both authors have no conflicts of interest to declare. abstract background: we evaluated the outcomes following femoral lengthening by distraction osteogenesis in children. additionally, we determined the incidence and nature of complications, the management thereof and factors associated with the development of complications. method: a retrospective review was performed of all patients who underwent femoral lengthening as an isolated procedure at our institution. data regarding presenting details and clinical course were collected and x-rays analysed. the healing index (hi) and the percentage lengthened were calculated. complications were defined as deep sepsis, joint contracture, fracture and neurological injury. results: fifteen patients underwent 16 femoral lengthenings from 2008–2018. nine patients had congenital short femur or proximal focal femoral deficiency, three patients had sequelae of meningococcaemia and four had various other pathologies. the median age at time of surgery was 9 years (6–13). median follow-up was 1.6 years (0.5–6.6). the median hi was 32 days/cm (20–60). leg lengths were equalised to ≤2.5 cm in 11 patients; length achieved was as planned in all but three patients. eight patients sustained fractures on average six days (2–57) after frame removal, five through the regenerate. four required surgery. thirteen patients developed joint contractures of which six required additional procedures to address this. two deep infections required surgery. two patients developed neurological symptoms of which one recovered fully. higher percentage length gained (>20%) was associated with increased fracture and joint contracture rate. diaphyseal osteotomy, as opposed to metaphyseal, was associated with increased risk of fracture (71% vs 25%). a diagnosis of congenital short femur was associated with increased fracture rate. spanning the knee did not prevent joint stiffness in 4/5 patients but did prevent subluxation. conclusion: femoral lengthening using external fixation can be successful in achieving leg length equality, but complications are common and often require additional surgery. limiting lengthening to less than 20% of the original bone length and performing the osteotomy through the metaphysis decreases the risk of fracture and joint contracture. level of evidence: level 4 keywords: femoral lengthening, distraction osteogenesis, leg length discrepancy, congenital short femur femoral lengthening in children horn a¹ , sipilä m² 1 mbchb(up), mmed ortho(uct)(hons), fc orth(sa); consultant orthopaedic surgeon, red cross war memorial children’s hospital, cape town; department of orthopaedic surgery, university of cape town, south africa ² mbchb; registrar, department of surgery, kymenlaakson keskussairaala hospital, helsinki, finland corresponding author: dr anria horn, department of orthopaedic surgery, room h49, old main building, groote schuur hospital, observatory, cape town, 7701; tel: +27 21 404 5108; email: anria.horn@uct.ac.za https://orcid.org/0000-0002-4159-6520 https://orcid.org/0000-0002-3751-7666 page 13horn a et al. sa orthop j 2020;19(1) introduction leg length discrepancy (lld) may arise secondary to a variety of conditions including congenital deficiencies, overgrowth syndromes and post-traumatic or post-infectious sequelae. lld can result in gait inefficiency and back pain. osteoarthritis of the hips and spine in adulthood have been associated with lld.1 less than 2 cm lld is normally compensated for, or a shoe raise may be used if symptomatic. up to 5 cm lld can be treated with epiphysiodesis of the longer leg. an lld of more than 5 cm is best treated with limb lengthening with or without contralateral epiphysiodesis.2 this is achieved by performing distraction osteogenesis or callotasis, as described by ilizarov3 and debastiani.4 there are three commonly used devices for performing femoral lengthening: a circular fixator, a monolateral rail or an intramedullary device.1,5 circular fixators provide more stability than monolateral rails. they also provide the option of deformity correction but are generally poorly tolerated. monolateral rails are better tolerated, but more commonly lead to regenerate deformation.1 intramedullary devices have been proven to be effective and very well tolerated, but excessive cost limits its use in developing countries. complications using external devices are universal. nearly all patients get pin-site infection, and many develop fractures, either through the regenerate or through the pin sites. neurological complications and joint contractures are frequently encountered but are also seen with the use of intramedullary devices.3,5-7 spanning the knee has been suggested to prevent stiffness and subluxation of the knee joint.7 the purpose of this study is to evaluate the outcomes and complications following femoral lengthening at the maitland cottage children’s orthopaedic hospital in cape town, south africa, between 2008 and 2018. we also wish to identify any modifiable factors, if present, that predisposes to the development of complications. patients and methods we performed a retrospective review of all patients that underwent femoral lengthening as a primary procedure from 2008–2018 at our institution. patients were excluded if the femoral lengthening formed part of a pelvic support osteotomy. medical records were analysed and data collected with regard to presenting pathology, procedures performed, clinical course, complications and outcome. radiographs were frequently taken throughout the course of treatment. leg length views were taken prior to surgery to measure the lld. radiographs of the affected femur were taken immediately post-op to ensure completeness of the osteotomy and correct pin placement. during the distraction period, radiographs were repeated on a two-weekly basis, and once lengthening was complete, four-weekly until adequate consolidation was evident. regenerate was deemed adequately consolidated once three out of four cortices measured at least 2 mm on radiographs and the lengthening device was subsequently removed (figure 1). for each patient the ratio between the amount of length obtained and the total length of the bone, measured from the tip of the greater trochanter to the intercondylar notch, was calculated and expressed as a percentage. the healing index (hi) was calculated by determining the amount of time spent in the external device for the amount lengthened using the units days/cm.4 we documented whether the osteotomy was performed in the proximal or distal metaphyseal area, or in the diaphysis. x-rays taken just prior to removal of the lengthening device were analysed to determine the amount of lengthening achieved and the presence or absence of three out of four cortices on the ap and lateral projections. for our series, complications were defined as pin-site infections requiring surgical revision, adjacent joint stiffness or subluxation, neurological injury and fracture. fractures were classified using the system suggested by simpson et al.8 (table i). lengthening protocol all except one patient had lengthening performed using a monolateral rail (orthofix, verona, italy). in the remaining patient a taylor spatial frame (tsf, smith & nephew, memphis, tennessee) was used. (this method was tried once but abandoned due to patient discomfort and complications.) fixating pins and wires were placed in the standard fashion and the osteotomy was performed as described by debastiani.4 antiseptic dressings were applied to the pin sites until healing was evident. following surgery, a latency period of 5–7 days was observed prior to initiation of lengthening. lengthening was performed at a rate of 1 mm a day, 0.25 mm six hourly. lengthening was slowed down, and on occasion reversed, if joint stiffness or subluxation became evident. lengthening was terminated once the desired length was achieved or once joint stiffness, subluxation or neurological symptoms precluded any further lengthening. all patients remained in hospital during the period of lengthening, and the majority of patients remained until consolidation and removal of the lengthening device. during the a b figure 1a and b. ap and lateral projections of the right femur following lengthening and adequate consolidation showing three out of four cortices measuring >2 mm in thickness table i: simpson classification of fractures following distraction osteogenesis8 fracture type description type i regenerate fracture type ia acute collapse type ib gradual collapse type ii fracture at junction of regenerate and normal bone type iii fracture through pin fixation site type iv fracture at peripheral site page 14 horn a et al. sa orthop j 2020;19(1) hospitalisation period, patients received daily physiotherapy with progressive weight bearing and joint mobilisation. for the purpose of this study, complications were defined as deep infection requiring surgical revision, joint stiffness or subluxation requiring intervention, neurological injury and fracture. patient outcome was evaluated retrospectively on the grounds of clinical notes and radiographs. factors considered were equalisation of leg lengths, presence of residual deformity and joint mobility. due to the relatively small number of patients, no formal statistical analysis was performed. descriptive statistics will be presented. results following exclusions, we identified 15 patients that underwent 16 femoral lengthenings for various aetiologies. the presenting details, as well as the details of surgery and healing are summarised in table ii. the median age at surgery was 9 years (6–13 years). median follow-up was 1.6 years following femoral lengthening (0.5–6.6 years) the most common cause for femoral shortening was congenital short femur followed by the sequelae of meningococcal septicaemia. an orthofix limb reconstruction system (lrs) was used in all patients except patient 5 in whom a tsf was used. the knee was spanned in six patients and the hip in one. mean length obtained was 54 mm (range 35–80). the mean percentage lengthened was 20% (range 8–32%). the mean hi was 32 days/cm (range 20–60). lengthening was abandoned prior to the desired length being obtained in four patients due to knee stiffness or knee/hip subluxation. complications encountered and outcome following femoral lengthening is summarised in table iii. leg length equality was achieved in five patients. six patients had residual discrepancies at latest follow-up of ≤2.5 cm which was managed with an orthosis and well tolerated (figure 2). in four patients, a significant lld remains. one patient is still awaiting tibial lengthening (pt 10), two patients have residual discrepancies of 5 cm and 12 cm respectively (pts 14 and 7) but are functioning well and do not desire any further surgery. patient 5 has ongoing neurological pain and lld as well as contracture of the knee and ankle. amputation was offered but the family refused any further surgery. our patients developed many complications. nine patients (50%) sustained fractures of which seven were through the regenerate (figure 3). fracture occurred on average six days (range 2–57) following removal of the distracting device. four patients required additional procedures to manage the fracture. thirteen patients developed joint contractures and six required additional procedures including one quadricepsplasty, one distal femoral extension osteotomy and one guided growth procedure for a fixed flexion deformity of the knee. table ii: demographic and surgical details patient sex age (years) side diagnosis osteotomy site adjacent joint spanned original length (mm) length obtained (mm) percentage lengthened (%) time spent in frame (days) healing index (days/cm) 1 male 8 left meningococcal septicaemia distal no 275 50 18 120 24 2 female 13 left hemiplegic cerebral palsy, previous varus osteotomy distal no 390 32.5 8 196 60 3 female 13 right congenital short femur midshaft knee 280 55 20 163 30 4 male 6 right femoral malunion distal no 412 49 12 119 24 5 male 8 right congenital short femur fibular hemimelia distal knee 250 43 17 230 53 6 male 8 left congenital short femur midshaft no 245 60 24 118 20 7 male 8 13* right proximal focal femoral deficiency distal midshaft knee knee 177 288 35 80 20 29 118 224 33 28 8 male 9 left tom smith’s arthritis midshaft hip 320 85 27 230 27 9 female 11 left congenital short femur fibular hemimelia midshaft knee 310 65 21 174 27 10 male 9 right congenital short femur midshaft no 280 50 18 181 36 11 female 10 left meningococcal septicaemia distal no 320 35 11 134 38 12 male 13 left post-traumatic distal femoral physeal bar midshaft knee 250 80 32 184 23 13 female 11 right congenital short femur distal no 285 57 20 159 28 14 female 6 left congenital short femur midshaft no 208 50 24 153 31 15 male 12 right meningococcal septicaemia midshaft no 334 45 13 100 22 *patient 7 had two episodes of lengthening, five years apart page 15horn a et al. sa orthop j 2020;19(1) eight of our patients developed superficial pin-site infections requiring oral antibiotics and pin-site care only. two patients developed deep infections requiring surgery. two patients developed neurological symptoms, of which one recovered fully. there was no difference in age between patients who sustained fractures (11.4 years) and those who did not (11.3 years). the diagnosis of congenital short femur was associated with an increased rate of fracture following lengthening. five out of seven patients with this diagnosis sustained a fracture. patient 15 lost all the length gained due to the regenerate fracture; the other fractures did not result in any significant loss of length. the development of a fracture was associated with a higher average percentage lengthened (21.4% vs 16.9%). the incidence of fracture in patients who had ≥20% lengthened was 62.5% compared to 37.5% in those with <20% lengthened. regenerate fractures occurred in six out of seven patients in whom the osteotomy was performed in the mid-diaphysis. there was no clear association between the hi and the development of fractures. the median hi was 30 days/cm (20–38) and 28 days/cm (22–60) for those that sustained fractures and those that did not, respectively. nearly all patients developed loss of range of motion in either the knee or the hip. there was no association between the percentage length gained and the need for secondary procedure for joint stiffness. spanning of the knee did not prevent joint stiffness but did prevent joint subluxation. only one patient, patient 7, developed a knee subluxation during his second lengthening. the fixator was subsequently extended to cross the knee joint. the same patient, and one other (patient 13) developed hip subluxation. patient 7 underwent a shelf acetabuloplasty to address the subluxation; patient 13 still had a subluxed hip at last follow-up but refused further surgery. there were no cases of premature consolidation. delayed consolidation was not documented but no patients underwent bone graft or cyst aspiration during the consolidation phase. discussion there are many conditions that can result in an lld requiring limb lengthening. the majority of cases in our study were congenital shortening, with the rest consisting of post-traumatic, postinfectious and neurological causes. a similar spectrum of disease is described in other published series.5,9 the hi for our patients was on average 30 days/cm. this is quite low when compared to the literature. launay et al.,5 and aston et al.10 reported hi in their series of 45.1 days/cm and 39.97 days/cm respectively. it is likely that our high fracture rate may be ascribed table iii: complications, subsequent surgeries and outcome patient complications subsequent surgeries outcome 1 knee flexion deformity distal femoral extension osteotomy residual 2 cm lld 2 knee extension contracture mua knee quadricepsplasty residual 2 cm lld 3 regenerate fracture simpson ib none asymptomatic residual deformity at site of fracture; 2 cm lld 4 fracture simpson iii orif leg lengths equalised 5 deep infection sciatic nerve neuropraxia knee ffd revision of half-pin mua knee ongoing neurological pain and knee ffd 6 regenerate fracture simpson ib none leg lengths equalised 7 (1st lengthening) fracture simpson iii none residual lld 20 cm 7 (2nd lengthening) peroneal nerve palsy knee subluxation hip subluxation implant fracture revision of distractors mua knee spanning of knee for subluxation adductor release shelf acetabuloplasty 12 cm lld, stiff knee mobile and pain-free 8 regenerate fracture simpson ia orif washout for sepsis ×2 removal of plate leg lengths equalised sepsis resolved 9 regenerate fracture simpson ia none desired length achieved awaiting tibial lengthening 10 regenerate fracture simpson ia orif femur leg lengths equalised 11 knee stiffness regenerate fracture simpson ib mua knee corrective osteotomy desired length achieved 12 deep infection washout 2.5 cm lld satisfied 13 knee ffd hip subluxation anterior distal femur stapling 2.5 cm lld hip subluxed 14 regenerate fracture simpson ib periprosthetic fracture spica external fixation for fracture removal of external fixator residual distal femoral deformity and 5 cm lld 15 knee stiffness none leg lengths equalised lld: leg length discrepancy; mua: manipulation under anaesthesia; orif: open reduction and internal fixation; ffd: fixed flexion deformity page 16 horn a et al. sa orthop j 2020;19(1) to premature removal of the fixator device, although there was no difference in the hi between those that fractured and those that did not. fracture following removal of the lengthening device was the most common complication in our series (8/16 segments). fracture rates described in the literature vary from 9.3% to 56%.8,10 in our series we found an association between the percentage of bone lengthened and the incidence of fractures, with an increased rate of fracture in those lengthened more than 20%. aston et al. found an increased rate of delayed consolidation in patients lengthened more than 6 cm and an increased rate of fracture in those lengthened more than 20%.10 launay et al. reports a more conservative upper limit for percentage lengthened of 15%.5 simpson et al., in a large series of 157 adults and adolescents, demonstrated no association between the length of the regenerate and fracture rate.8 we had an increased rate of fracture in patients with congenital deficiencies (five out of seven limbs lengthened). patients with congenital shortening are known to develop poor regenerate and to be more prone to fractures through the regenerate, with rates of up to 56% reported.5,10 efforts have been made to reduce the rate of fracture by lengthening over an intramedullary nail. a significant decrease in fracture rate is reported with this modification, as well as reduced time before removal of the fixator.10,11 superficial pin-site infection developed in 50% of our patients and is regarded as a problem, not a complication.12 all superficial infections responded well to oral antibiotics and pin-site care. deep pin-site infection requiring surgical revision occurred in two patients (13%). these rates are comparable to the published literature.9,10 we had no pin breakages but one fracture of the distracting device requiring revision. seven patients developed joint stiffness or subluxation requiring a surgical intervention, often in the form of a manipulation under anaesthesia. we found no association between the amount lengthened or the underlying diagnosis and the incidence of stiffness/subluxation. higher rates of stiffness and subluxation have been reported in patients with congenital deficiencies, possibly due to inherent instability of the knee.9,10 two of our patients developed sciatic and peroneal nerve injury, of which one resolved. the patient in whom the neurological injury did not resolve underwent simultaneous femoral and tibial lengthening. aston et al. reports a 10% rate of neurological injury, all of which resolved spontaneously and were more common in ipsilateral tibial and femoral lengthening.10 despite the high rate of complications, we had satisfactory outcomes in 80% of our patients in whom leg lengths were equalised (five patients) or insignificant discrepancy remained (six patients), and joint mobility was restored to a functional range. the use of intramedullary lengthening nails, particularly the new generation magnetic lengthening nails, has offered a less invasive and more acceptable option for lengthening in the absence of significant deformity. these devices reduce the rate of devicerelated complications such as pin-site sepsis, muscle tethering and scarring, but do not reduce the rate of complications inherent to the distraction procedure such as premature or delayed consolidation, neurological injury and joint stiffness or subluxation.13 the use of these devices is mostly limited by their excessive cost, and limb lengthening using an external fixator remains the gold standard, especially in small paediatric bones and in the presence of significant deformity. limitations of this case series include that it is retrospective and therefore lengthening protocols were not standardised. no formal outcome classification was used, and we relied on case notes and radiographs to determine the outcome. a small number of patients were included, making relevant statistical analysis impossible. our patients suffered from various conditions and our numbers were too small to elucidate any specific role that aetiology may play. a b figure 3a and 3b. ap and lateral x-rays of the right femur of a 10-year-old male (patient 8) with lld secondary to tom smith’s arthritis. following removal of the lengthening device, he sustained a regenerate fracture (simpson ib). the fracture was internally fixed with a plate and screws. unfortunately, he subsequently developed implant infection requiring serial washouts with retention of the implant. once the fracture had healed, the plate was removed. he remains infection free at one-year follow-up. a b figure 2a. pre-operative leg length views of a 9-year-old boy (patient 10) with congenital short femur on the right and a 6 cm lld figure 2b. final leg length view following lengthening of 5 cm. there is an insignificant residual discrepancy of 1 cm. the patient sustained a regenerate fracture following removal of the frame, and plate osteosynthesis was performed. page 17horn a et al. sa orthop j 2020;19(1) conclusion we present a small series of patients undergoing femoral lengthening for the treatment of lld due to a variety of aetiologies. our complication rate, though high, is comparable to the existing literature and our outcomes satisfactory in 80% of patients. more complications are encountered when distracting more than 20% of the initial length of the bone and when performing osteotomies in the mid-diaphysis. it is advisable to span the adjacent joint if a long lengthening is planned. fracture rate may be reduced by lengthening over an intramedullary nail. patients should be adequately counselled regarding the expected complications and the management thereof. ethics statement prior to commencement of this study, ethical approval was obtained from the university of cape town human research ethics committee. ref 260/2018 dr anria horn 15/05/2019. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ah and ms both contributed to data capturing and compiling of the final submission. orcid horn a http://orcid.org/0000-0002-4159-6520 sipilä m http://orcid.org/0000-0002-3751-7666 references 1. halanski ma, noonan kj. limb length discrepancy. in: weinstein sl, flynn jm (eds). lovell and winter’s paediatric orthopaedics. 7th ed. philidelphia: lippincott williams & wilkins; 2011:1341. 2. dahl mt, gulli b, berg t. complications of limb lengthening. a learning curve. clin orthop relat res. 1994;301:10-18. 3. ilizarov ga. the tension-stress effect on the genesis and growth of tissues. part i. the influence of stability of fixation and soft-tissue preservation. clinic orthop relat res. 1989;238:249-81. 4. debastiani g, aldegheri r, renzi-brivio l, trivella g. limb lengthening by callus distraction (callotasis). j pediatr orthop. 1987;7(2):129-34. 5. launay f, younsi r, pithioux m, chabrand p, bollini g, jouve j-l. fracture following lower limb lengthening in children: a series of 58 patients. orthop traumatol surg res. 2013;99(1):72-79. 6. dammerer d, kirschbichler k, donnan l, kaufmann g, krismer m, biedermann r. clinical value of the taylor spatial frame: a comparison with the ilizarov and orthofix fixators. j child orthop. 2011;5(5):343-49. 7. prince de, herzenberg je, standard sc, paley d. lengthening with external fixation is effective in congenital femoral deficiency. clinic ortho relat res. 2015;473(10):3261-71. 8. simpson a, kenwright j. fracture after distraction osteogenesis. j bone joint surg br. 2000;82(5):659-65. 9. eralp l, koacoglu m, bilen fe, balci hi, toker b, ahmad k. a review of problems, obstacles and sequelae encountered during femoral lengthening: uniplanar versus circular external fixator. acta orthop belg. 2010;76(5):628. 10. aston w, calder p, baker d, hartley j, hill r. lengthening of the congenital short femur using the ilizarov technique: a singlesurgeon series. j bone joint surg br. 2009;91(7):962-67. 11. popkov d, popkov a, haumont t, journeau p, lascombes p. flexible intramedullary nail use in limb lengthening. j pediatr orthop. 2010;30(8):910-18. 12. paley d. problems, obstacles, and complications of limb lengthening by the ilizarov technique. clin orthop relat res. 1990;250:81-104. 13. paley d. precice intramedullary limb lengthening system. expert rev med devices. 2015;12(3):231-49. http://orcid.org/0000-0002-4159-6520 http://orcid.org/0000-0002-3751-7666 _goback _goback page 111sa orthop j 2022;21(2) cpd questionnaire. may 2022 vol 21 no 2 the impact of the covid-19 lockdown restrictions on orthopaedic trauma admissions in a central academic hospital in johannesburg (foster m, du plessis j, jansen van vuuren m, jingo m, pietrzak jrt) 1. where was this retrospective review conducted? a. durban a b. cape town b c. pretoria c d. johannesburg d e. stellenbosch e 2. what was the decrease in trauma admissions between 2019 and 2020? a. 55% a b. 10% b c. 25% c d. 68% d e. 5% e 3. what percentage of covid-19 tests were positive in patients once mandatory testing began? a. 30% a b. 10% b c. 2% c d. 22% d e. 45% e comparing outcomes between enhanced recovery after surgery and traditional protocols in total knee arthroplasty: a retrospective cohort study (beukes je, immelman rj, venter jh, janse van rensburg c, ngcelwane mv, de vos jn) 4. enhanced recovery after surgery (eras) protocols contain which of the following interventions: a. preoperative a b. intraoperative b c. postoperative c d. a and b d e. a, b and c e 5. the following forms part of the eras protocol except: a. full diet day 0 postoperative a b. mobilisation out of room day 0 b c. benzodiazepine sedative c d. clear fluids up to 2 hours preoperative d e. standard ward postoperative e 6. eras is associated with: a. increased readmission rate a b. increased complication rate b c. general anaesthesia c d. increased reoperation rate d e. decreased length of stay e splints and immobilisation approaches used for second to fifth metacarpal fractures: a systematic review (keller mm, barnes ry, brandt c, hepworth lm) 7. according to the highest level of evidence sourced in the article, fifth metacarpal neck (boxer’s) fractures with ≤ 70° of angulation and no rotational deformities are best immobilised with which of the following? a. u-shaped gutter splint a b. hand-based palmar splint b c. plaster of paris cast c d. soft wrap and buddy strapping d e. palmar wrist extension splint e 8. select the complication following prolonged and incorrect immobilisation of extra-articular neck or shaft of fifth metacarpal fractures: a. itchiness a b. pressure sores b c. pain c d. neuropraxia d e. b and e e 9. select the outcome measures/assessments most frequently used for monitoring management for individuals who sustained second to fifth metacarpal fractures: a. pinch strength a b. joint range of motion b c. dash/quickdash c d. sensation d e. b and c e orthopaedic research in zimbabwe: a seminal bibliometric analysis (sibindi c, mageza a, socci a) 10. in this bibliometric analysis of research in zimbabwe, what nature of research collaboration was seen to yield the most productivity and is suggested for more productivity? a. established zimbabwe-based researcher working with hic researcher a b. hic/lic-based graduate student working with mentor in hic b c. established zimbabwe-based researcher working with lic researcher c d. external researchers working in zimbabwe d e. all of the above e orthopaedic journal s o u t h a f r i c a n � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � contents � � � � � � � � � � t h e s o u t h a f r ic a n o r t h o pa e d ic a s s o c ia t io n page 112 sa orthop j 2022;21(2) 11. within zimbabwean orthopaedic surgery research, what is a key distinction in the trend of research foci compared to other lowand middle-income countries (lmics)? a. trauma has the highest focus of research a b. paediatric clubfoot is a distinguished research focus b c. all research foci seem to be equally represented c d. hiv-related orthopaedic pathology dominates as a consequence of the hiv/aids pandemic d e. the zimbabwean trends follow other lmic trends with no distinction e 12. looking at this study, what, if any, is an inherent limitation of bibliometric analysis methodology? a. in a bibliography with a limited number of papers, there is severe distortion of the output limiting utility a b. for a bibliography with papers spread over an extended time period, there is incoherence of output b c. no limitation of bibliometric analysis methodology is highlighted in this paper c d. bibliometric analysis is better carried out on bibliography containing publications of a higher level of evidence d e. all of the above e modular prosthetic reconstruction for primary bone tumours of the distal tibia in ten patients (mugla w, bauer hcf, vogel j, hosking kv, campbell n, hilton tl) 13. which study has the biggest number of patients who had a distal tibial replacement? a. shekkeris et al. a b. lee et al. b c. natarajan et al. c d. abudu et al. d e. this study e 14. what is the functional outcome msts of this study? a. 90% a b. 80% b c. 50% c d. 20% d e. 63% e 15. what was the amputation rate of this study? a. 10% a b. 20% b c. 30% c d. 33% d e. 5% e current concepts on the assessment of a patient with a traumatic anterior shoulder dislocation (kauta nj, du plessis jp, de wet jj, vrettos b, roche sjl) 16. which one of the following statements is true with regard to recurrent traumatic anterior shoulder dislocation? a. a rotator cuff tear is almost always present in patients younger than 40 years of age a b. this is a common challenge in patients older than 30 years of age b c. an off-track hill–sachs lesion is associated with a recurrence rate of more than 90% in anterior shoulder dislocation c d. anteroinferior glenoid bone loss will not predispose to recurrent dislocation if the humeral head is intact d e. age younger than 30 years at the initial dislocation is the single most important predisposing factor to recurrent dislocation e 17. the clinical significance of a positive walsh sign (or test) is best described by: a. external rotation more than 90° and higher risk of shoulder instability a b. internal rotation of more than 90° and higher risk of shoulder instability b c. abduction of more than 90° and higher risk of shoulder instability c d. forward flexion of more than 90° and higher risk of shoulder instability d e. internal rotation of more than 90° and lower risk of shoulder instability e 18. the currently recommended imaging modality for glenoid bone loss measurement is: a. axial ct scan a b. coronal ct scan b c. 3d ct scan (en face view) c d. axial mri scan d e. coronal mri scan e mega-oats of the knee without specialised instrumentation: a low-cost option for large cartilage defects in a resourcerestrained environment (le roux j, von bormann r, braun s, imhoff ab, held m) 19. recommended treatment options for a large cartilage lesion in the knee in a young patient is: a. microfracture a b. arthroplasty b c. osteochondral autograft transplantation (oats) c d. fresh osteochondral allograft transplantation (oca) d e. intra-articular local anaesthetic and steroid injection e 20. the traditional mega-oats technique requires: a. donor hamstrings tendon a b. donor allograft cartilage b c. donor autograft cartilage from the contralateral knee c d. a specialised workbench d e. autologous chondrocyte culture in a laboratory e subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm. co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online. • once you have completed the answers, go back to the top of the page next to the registration option. there is another icon “find my cpd certificate”. (you will have to answer the two questions regarding your internship and last cpd audit once you have completed a questionnaire and want to retrieve your certificate). • if you click on that icon it will open your certificate which you can print or save on your system. • please call mpc helpdesk if you have any questions: 0861 111 335. medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 mdb015/137/01/2022 south african orthopaedic journal editorial doi 10.17159/2309-8309/2021/v20n1a0sa orthop j 2021;20(1) advocacy for sporting injury prevention and care stephen roche* professor of orthopaedics, university of cape town deputy head, division of orthopaedics head of adult reconstruction and of shoulder and elbow surgery, groote schuur hospital co-director orthopaedic biomechanics laboratory, university of cape town co-director orthopaedic research unit, university of cape town *corresponding author: stephen.roche@uct.ac.za the duties and responsibilities of orthopaedic surgeons obliges us to be an advocate on multiple levels within our society. the american medical association stated in 2009 that ‘physicians must advocate for the social, economic, educational, and political changes that ameliorate suffering and contribute to human wellbeing’. in our troubled south african society, exacerbated by the current covid-19 crisis, our advocacy is needed even more than ever. we should already be advocates for transformation/diversity, alleviation of hunger, access to healthcare, the eradication of the scourge of gender-based violence, reduction of road deaths and gunshots, among others. these problems not only directly affect those injured, abused, murdered or dispossessed, but indirectly affect all of us through the massive financial cost to society. the financial burden is compounded by the current economic climate of south africa which has been worsened by the covid-19 pandemic and corruption. a report in 2019 states that road accidents cost the state r164 billion, and i am not going to rehash the massive figures of corruption highlighted daily in the news. in 2017, case martin from our university published an article in the south african medical journal estimating that the cost to treat a patient sustaining an orthopaedic-related gunshot injury was close to us$ 3 000.1 moreover, m van heukelum from tygerberg hospital published in the same journal in august 2020 that the global cost to treat gunshots presenting to their department in 2017 was over r10 million.2 the global peace index for 2020 by the institute for economics & peace, as reported by the mail & guardian on 11 nov 2020, estimates that the cost of violence in south africa is about 13% of its gross domestic product (gdp). our advocacy is stretched to the limit, but we must not forget the other patients we treat. sports injuries in south africa do not receive the same attention in orthopaedic forums as the other burdens documented above. while the orthopaedic implant industry drives the improvement in surgical techniques and implants, it is not directed at injury prevention or access to care in this group of patients. we can see the effects of the injuries by merely watching our national sporting teams; for example, during the webb ellis world cup rugby final of 2019, we lost bongi mbonambi to concussion and lood de jager to a shoulder dislocation. it has been well documented that the risk of arthritis is ten times greater after a traumatic shoulder dislocation. i alone have seen more than ten of the proteas cricket players and operated on more than four in the last three years. additionally, we have seen our premier fast bowler, kagiso rabada, unable to play for three months due to an overuse injury to his lower back in 2018. the difficulty in addressing sporting injuries is multifactorial. many of these injuries present to the private sector and are therefore seen in isolation with no collective database to analyse the burden or the prevention of these injuries. in the state sector, the burden of trauma, waiting time for elective surgery, as well as lack of resources makes it difficult to collect decent data on these injuries. we undertook a student study module by third-year medical students which looked at sporting injuries presenting to the emergency unit at four hospitals in cape town in 2012. the study found large numbers presenting to these units following saturday sporting activities. another part of this study involved phoning the head of sports at the local schools to determine whether they had an insurance plan for these injuries. sadly, only one of the schools had insurance cover for their scholars. this leaves many of the scholars at the mercy of an overburdened state system where, for example, there is a waiting list of over a year for shoulder surgery in cape town. this is even harder for those scholars who are on a sporting bursary to access timely care for the injuries which are not considered an emergency, such as a reduced shoulder dislocation, and i am sure we are all faced by this in our busy clinics. a paper in the orthopaedic journal of sports medicine, titled ‘pediatric and adolescent shoulder instability: does insurance status predict delays in care, outcomes, and complication rate?’, highlights this problem in california, usa. their conclusion was as follows: ‘public insurance status affected access to care and was correlated with the development of secondary bony injury and a higher rate of postoperative dislocations. clinicians should practice with increased awareness of how public insurance status can significantly affect patient outcomes by delaying access to care – particularly if delays lead to increased patient morbidity and healthcare costs’.3 to address this, we set up the sports orthopaedic clinic at groote schuur hospital with the collaboration with sports physicians from exercise science and sport medicine (essm) at the university of cape town, and i believe there are collaborations like this occurring in other state hospitals. prevention is also important and has been shown to be effective in many sports medicine journals, as confirmed in the article titled ‘exercise-based injury prevention in child and adolescent sport: a systematic review and meta-analysis’, published in sports medicine in 2014.4 the development of stop (sports trauma and overuse prevention) sports injuries was initiated by the american orthopedic society for sports medicine (aossm) in early 2007. dr james r andrews, a shoulder and sports orthopaedic surgeon, was instrumental in this advocacy to address the issue of overuse injuries in young athletes, which they believe had become a critical issue. prevention of venous thromboembolism (vte*) in patients undergoing major orthopaedic surgery of the lower limbs.1 individualising anticoagulation reference 1. ixarola package insert. s4 ixarola® 10, 15, 20 (film-coated tablets). each film-coated tablet contains 10 mg, 15 mg or 20 mg rivaroxaban. reg. no.: ixarola® 10: 50/8.2/9017, ixarola® 15: 50/8.2/9018, ixarola® 20: 50/8.2/9019. name and business address of the holder of the certificate of registration (hcr): bayer (pty) ltd, reg. no. 1968/11192/07. 27 wrench road, isando 1609. marketed by sanofi aventis south africa (pty) ltd., reg. no.: 1996/010381/07, 2 bond street, grand central ext. 1, midrand, 1685. tel: (011) 256 3700. fax: (011) 256 3707. www.sanofi.com. pp-ixa-za-0044.1.03.0/2021 a xarelto® clone rivaroxaban s4 ixarola® other indications of the ixarola® product range: ixarola® 10 film-coated tablets are indicated for the prevention of venous thromboembolism (vte) in patients undergoing major orthopaedic surgery of the lower limbs. ixarola® 15 and ixarola® 20 are indicated for: prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation. treatment of deep vein thrombosis (dvt) and for the prevention of recurrent deep vein thrombosis (dvt) and pulmonary embolism (pe). treatment of pulmonary embolism (pe) and for the prevention of recurrent pulmonary embolism (pe) and deep vein thrombosis (dvt). *vte venous thromboembolism 40329 ixarola concept glass f.indd 440329 ixarola concept glass f.indd 4 03/03/2021 16:2803/03/2021 16:28 page 6 sa orthop j 2021;20(1) the private sector needs collaboration and data collection sharing to be able to address this problem. it thus behoves us to be part of the drive by the south african orthopaedic association in setting up and running a national registry to enable collation and analysis of injuries. the south african shoulder and elbow society has discussed the higher rates of posterior dislocation of the shoulder due to the clean out and position of the players’ arms when competing at the rugby ruck. sadly, it is anecdotal, and without evidence we cannot advocate rule changes or altering playing techniques to prevent injuries. this has been done very well in the prevention of spinal injuries in rugby with the boksmart programme. we need collaborative and translational research with our colleagues in sports medicine, but also need involvement of the community, coaches and sports administrators. this process has proven arduous, as we discovered when trying to get the schools, parents and coaches to participate in an injury-tracking study in eight schools in the cape town area. nevertheless, it can be done, as seen by the report by yale jamieson at the recent saoa congress where he presented on water polo injury factors in schoolboys in the eastern cape.5 this research collaboration with dr janine gray from the essm – which was initiated after we observed an increasing number of rotator cuff tears in adolescent water polo players – has led to presentations to water polo coaches and administrators. it has also seen the development of a coaching programme encompassing performance, training, injury prevention, emotional intelligence and coaching. we hope this will be rolled out over the next few months. another collaboration with essm has led to a paper submitted for publication and presented at the annual saoa congress 2020 by grethe geldenhuys, titled ‘return to play protocols for musculoskeletal upper and lower limb injuries in tackle-collision team sports: a systematic review of the literature’.6 the paper highlights the low level of scientific evidence available, and she will soon be sending out invitations to the saoa to ask for the members to contribute to a delphi process in improving our returnto-play protocols for our patients with contact-sport injuries. this editorial is written with the hope that all of you involved in managing sporting injuries will consider your advocacy and involvement in trying to improve the outcomes and access to care for all our patients, especially the disadvantaged and younger sportspeople. references 1. martin c, thiart g, mccollum g, roche s, maqungo s. the burden of gunshot injuries on orthopaedic healthcare resources in south africa. samj. 2017 june;107(7);626-30. 2. van heukelum m, le roux n, jakoet s, ferreira n. financial burden of orthopaedic gunshot-related injury management at a major trauma centre. samj. 2020 august;110(9):882-86. 3. hung nj, darevsky dm, pandya nk. pediatric and adolescent shoulder instability: does insurance status predict delays in care, outcomes, and complication rate? orthop j sports med. 2020 oct;8(10):2325967120959330. https://doi.org/10.1177/2325967120959330 4. rössler r, donath l, verhagen e, junge a, schweizer t, faude o. exercisebased injury prevention in child and adolescent sport: a systematic review and meta-analysis. sports med. 2014 dec;44(12):1733-48. https://doi.org/10.1007/ s40279-014-0234-2. pmid: 25129698. 5. jameson y, grey j, dutton m, roche s. identifying risk factors contributing to the development of shoulder pain and injury in male, adolescent water polo players. presented at south african orthopaedic congress 2020. paper id: 11179. 6. geldenhuys g, hendricks s, burgess t, roche s. return to play protocols for musculoskeletal upper and lower limb injuries in tackle-collision team sports: a systematic review of the literature. presented at south african orthopaedic congress 2020 paper id: 11201. page 54 sa orthopaedic journal autumn 2014 | vol 13 • no 1 uncemented primary total hip arthroplasty in patients aged 55 years or younger: results at a minimum of 5 years in a consecutive series p ryan fcs orth(sa) consultant orthopaedic surgeon prof ie goga md, frcs(edinburgh), fcs orth(sa) head of department: orthopaedic surgery inkosi albert luthuli central hospital, durban, kwazulu-natal, south africa correspondence: dr paul ryan private bag x03 mayville 4058 tel: 031 240 2160 email: paulrya@ialch.co.za introduction total hip arthroplasty is effective in the management of patients with advanced hip joint disease of variety of aetiologies. surgical management of the younger patient requiring arthroplasty remains challenging due to their increased activity levels, physical demands, and the need for longevity of implanted components. high rates of failure of cemented implants in this young, active patient group led to an expanding interest in uncemented hip arthroplasty.1 the results of first generation uncemented, and some of the second generation uncemented implants have been unacceptably poor.2 other second generation femoral components, both porous and hydroxyapatite-coated, have yielded excellent long-term results, with survivorships of up to 96.8% at 20 years.3 abstract introduction surgical management of younger patients requiring primary total hip arthroplasty is challenging due to increased activity levels, physical demands, and the need for longevity of implanted components. there is debate regarding the most suitable component type, and the optimal fixation, should a stemmed component be utilised. materials and methods we retrospectively reviewed a sequential group of patients, aged 55 years or younger at the time of surgery, who underwent uncemented primary total hip arthroplasty, and are currently at a minimum of 5 years post operation. eighty-eight primary uncemented total hip replacements were performed between january 2004 and december 2006. the patient ages ranged from 18 to 55 years with a mean of 43.1 years at time of operation. at last review, eight patients (ten hips) had demised of unrelated causes and 16 patients (20 hips) were lost before completing 5 years of follow-up. results complications included one peri-operative mortality, ten intra-operative femoral calcar fractures, two revisions for sepsis, one dislocation and one deep vein thrombosis. all stems achieved bony fixation as per engh’s criteria. at a minimum of 5 years post operation, there were no revisions for aseptic loosening. conclusion we present our radiological results, complications, and survivorship of uncemented primary total hip replacements in patients 55 years or younger. key words: total hip arthroplasty, uncemented hip, young patient, hip replacement saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:13 am page 54 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 55 however, concerns remain regarding the acetabular side, with high rates of liner wear, osteolysis and revision of sockets in certain implant types.4-7 resurfacing arthroplasty appeared to be a good solution for the young active patient, providing greater range of motion with the large heads, and bone conservation allowing for easier revision when required. due to recent concerns regarding metal debris and pseudo-tumour formation, large bearing metal-on-metal replacements, including resurfacing, are being employed less frequently. there is renewed interest in stemmed prostheses, and continued debate on component fixation. with this in mind, we retrospectively reviewed a cohort of patients who underwent uncemented total hip arthroplasty, were 55 years or younger at the time of surgery, and who were at a minimum of 5 years post operation at the time of analysis. the aims were to evaluate the radiographic outcomes, the early and late complications, and the need for revision surgery. materials and methods we performed a retrospective chart and radiographic review. patient notes were canvassed for demographic and operative details, as well as details regarding early or late complications, or revision surgery. radiographs were evaluated as described below. between january 2004 and december 2006, 88 primary uncemented total hip replacements were performed in 72 adults under the age of 55 years. the cohort included 37 men and 35 women, with a mean age 43.1 years (range 18 to 55 years). at time of analysis, eight of the 72 patients had demised and 16 were lost before 5 years of follow-up, leaving 59 hips in 48 patients. the aetiology (table i and graph 1) was avascular necrosis (avn) in 59 hips (67%) and inflammatory in eight (9%). twenty-six arthroplasties were done on the right hips, 30 on the left, and 16 bilaterally. as the surgeries were performed in an academic training hospital, they were done by a number of surgeons. the antero-lateral approach was utilised in 69 hips, the posterior in 18. the femoral component was a collarless, fully hydroxyapatite-coated, press-fit stem (corail, de puy international ltd) in 77 of the 88 hips; a tapered proximally coated stem in nine (summit, de puy international ltd); a cementless, proximally porous-coated tapered stem in one (synergy, smith and nephew); and a tapered grit-blasted stem in one (cls zimmer). the acetabular component was a hemispherical or subhemispherical, porous-coated press-fit in all cases: pinnacle 300 or duraloc 300 in 80; pinnacle sector or duraloc 1200 in six (de puy international ltd); reflection in one (smith and nephew); and durom in one (zimmer). the bearing surface was metal-on-polyethylene (marathon ultra-high molecular weight, moderately cross linked polyethylene, de puy international ltd) in 67 and metalon-metal (mom) in 21. the head size was 28 mm in all the metal-on-uhmwpe, and in the mom articulations it was 36 mm in 16, 28 mm in three, 32 mm in one and 38 mm in one. the use of metal-on-metal articulations was abandoned by the unit in 2007 due to concerns raised in the literature. the current unit protocol is the use of ceramic-on-ceramic articulations for this age group. all patients received peri-operative antibiotics and thrombo-prophylaxis as per protocol, and were mobilised on day one/two post-operatively – partial weight bearing initially, with progression to full weight bearing as tolerated. the initial post-operative x-ray was an antero-posterior view of the pelvis, centred over the pubis, including the most distal aspect of the femoral component. the 6-week x-rays included a repeat of the above view, as well as a lateral view which included the acetabular component and the distal tip of the femoral component. these served as reference for follow-up films. graph 1. aetiology avascular necrosis 59 primary osteoarthritis 5 dysplasia 4 previous tuberculous infection 2 previous infection 1 perthes’ 1 rheumatoid arthritis 6 previous trauma 5 slipped upper femoral epiphysis 3 systemic lupus erythematosus 1 ankylosing spondylitis 1 table i: aetiology of hip disease – number of hips operated avn inflammatory primary oa 2’ oa (trauma, scfe, dysplasia) previous infection resurfacing arthroplasty appeared to be a good solution for the young active patient with large bearing metal-on-metal replacements, including resurfacing, being employed less frequently. there is renewed interest in stemmed prostheses, and continued debate on component fixation saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:13 am page 55 page 56 sa orthopaedic journal autumn 2014 | vol 13 • no 1 x-rays one surgeon, not involved in the index surgeries, independently evaluated the early post-operative and most recently available radiographs. the anteroposterior radiograph taken in the early post-operative period, and the antero-posterior and lateral radiographs taken at the 6-week follow-up were used as the baseline for further comparisons. linear and angular measurements were taken using siemens magicweb software, and magnification errors were accounted for. the following radiographic assessments were made: 1. femoral component alignment classified as valgus (tip engaging the medial cortex), neutral or varus (tip engaging the lateral femoral cortex) 2. femoral component subsidence as defined by a change of more than 3 mm of the distance from the superolateral aspect of the femoral stem to the tip of the greater trochanter8 3. femoral zonal analysis as per gruen et al9 4. femoral stress shielding as per engh et al10 5. femoral component fixation and stability classified as: bone ingrowth, stable fibrous or unstable according to the criteria of engh et al10 6. femoral bone remodelling: calcar resorption, reactive bone formation or cortical hypertrophy 7. acetabular component alignment 8. acetabular migration as defined by a linear change of 3 mm or a rotational change of 8° or greater11 9. acetabular zonal analysis as per delee and charnley12 10. acetabular loosening defined as a change in position of the component or a continuous circumferential radiolucent line >2 mm on ap and lateral radiographs 11. presence of periacetabular or femoral osteolysis 12. heterotopic ossification graded according to brooker et al13 results patients at a minimum of 5 years post hip replacement, eight patients (ten hips) had demised, at an average of 3.3 years post operation. three of these patients had avn secondary to chronic alcohol abuse, one of them died from liver failure, and the other two (both smokers) suffered acute myocardial events. two patients had avn secondary to systemic conditions (sle and sarcoidosis respectively) and demised from complications of their underlying disease. one patient died from complications related to advanced immune-compromise secondary to hiv infection, one died in a motor vehicle accident, and in the last the cause of death is unknown. at time of last clinical review, none had required nor were planned for reoperation. seventeen patients (21 hips) were lost to follow-up. this was at an average of 18 months (range 0.5 to 36) post surgery. at time of last review, none had required further intervention. forty-seven patients (57 hips) had completed 5-year clinical follow-up (average 77.5 months post-operative). complications intra-operative complications included iatrogenic femoral calcar fractures in ten hips (11.4%). three required fixation with charnley wiring. all of these fractures occurred during the insertion of corail stems, and all healed uneventfully without any implant subsidence. one patient suffered an acute myocardial event intraoperatively and demised in the early post-operative period. the patient was a 55-year-old male whose only pre-operative identified risk factor for ischaemic heart disease was a 20 pack/year smoking history. there was no excessive intra-operative blood loss. there was one clinically evident deep vein thrombosis (dvt) which resolved with pharmacological therapy and without long-term sequelae. it is not the unit policy to actively screen asymptomatic post-operative patients for dvts with either doppler ultrasound or venography. one hip (figures 1 to 3) dislocated on the second postsurgical day. the indication for arthroplasty was steinberg stage 6 avascular necrosis. the avn was a consequence of open reduction and posterior column fixation performed for a fracture-dislocation 3 years prior. pre-operatively the patient was noted to have fixed flexion and external rotation deformities of 50° and 20° respectively. the hip replacement was done through a posterior approach, extensive scarring was encountered, which required significant release. the dislocation was managed by closed manipulation and immobilisation in an abduction cast. the patient later developed brooker grade 3 heterotopic ossification and chronic moderately severe pain. one patient had a transient sciatic nerve palsy, which recovered fully. superficial wound infections developed in two hips. these settled on dressings and short courses of oral antibiotic therapy. there were two cases of deep infection. the first patient, a 34-year-old male smoker, presented 5 months post replacement with peri-prosthetic infection. a cloxacillin sensitive staphylococcus aureus was grown on culture, and he was managed successfully with a two-stage revision. the second patient developed clinical symptoms and elevated inflammatory markers 5 years post hip replacement. radiographically, on the acetabular side the gaps initially seen in zones 1 and 2 had disappeared, but in zone 2 an area of washout, typical of sepsis, was noted. the femur had undergone extensive meta-diaphyseal remodelling and the femoral component had subsided (figures 4 and 5). the patient has since been diagnosed with hiv infection (cd4 of 53), and has been started on antiretroviral therapy. her prosthesis has been removed, and she awaits the second stage of her revision. microbiological specimens taken at the first stage revealed a cloxacillin-sensitive staphylococcus aureus. revisions apart from the above revisions for deep sepsis, there were no further revisions. forty-seven patients (57 hips) had completed 5-year clinical follow-up (average 77.5 months post-operative) saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:13 am page 56 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 57 radiographic outcomes of the 57 hips that had completed 5 years of clinical review, three hips had less than 4 years of radiological follow-up, and two had been revised for deep infection. these were excluded from radiological analysis. of the remaining 52 hips, the average length of radiological follow-up was 73.6 months (range 49 to 93). the femoral component was neutral in 47 (90%), varus in three (6%) and valgus in two (4%). there was one case of subsidence. in the single case in which a synergy stem was used, the component was noted on the 6-week postoperative visit to have subsided 15 mm. at last radiograph, 68 months later, the position had remained unchanged and there were no other radiographic features of loosening. on review, the femoral component was noted to be relatively undersized, leading to the initial subsidence. radiographic double line formation in zone 1 was demonstrated in 27 hips (52%), and in zones 1 and 7 in three (6%) hips. twenty-three hips (44%) had femoral cortical thickening and 42 of the 52 (81%) had developed reactive bone formation at the prosthesis tip. this reactive bone was seen to extend from the tip of the component to the medial cortex when the stem was in valgus, the lateral cortex when the stem was in varus, and was central or pancentral when the stem was neutral (figures 6 to 8). twenty-nine (56%) had developed medial calcar rounding and 23 (44%) showed evidence of further proximal stress shielding which was graded as second degree in 19 and third degree in four. all of the 52 femoral components were graded as having achieved bony fixation as per engh’s criteria. the average acetabular inclination on the anteroposterior radiograph was 46.04° (range 32 to 60°). fourteen (27%) of the hips had lateral uncoverage, with an average of 10.57° (range 4° to 23°). at last radiographic review, none of the cups had migrated. circumferential radiolucencies of less than 1 mm in all three zones were seen in three hips (6%). one of these was noted in the immediate post-operative period, and is attributed to incomplete component seating. figure 1. pre-operative radiograph figure 2. day 2 post-operative showing dislocation figure 4. septic case. day 2 post index surgery figure 5. septic case: five years post operation showing extensive meta-diaphyseal remodelling and implant subsidence figure 3. three years post operation saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:13 am page 57 page 58 sa orthopaedic journal autumn 2014 | vol 13 • no 1 a further 26 cups (50%) had radiolucent lines (of less than 1 mm thick) in one or more of the delee and charnley zones: 13 in zone a (average 12 mm), one in zone b (15 mm), seven in zone c (average 18 mm), three in zones ab (average 33 mm) and two in zones bc (average 30 mm). there were three cases (6%) of focal peri-acetabular osteolysis, graded mild (<1 cm2) in two and moderate (<2 cm2) in one. two of the cups had pegs and the other had screws. there was no evidence of liner wear in any of the above. twenty of the 52 radiographs (38%) demonstrated heterotopic ossification, brooker grade 1 in ten hips (19%), grade 2 in six (11%), and grade 3 in four (8%). discussion total hip replacement is being performed on younger patients. the finnish registry shows a progressive increase, since the late 1980s, in the proportion of primary surgeries done in the age group 49 to 59 years. in the uk national joint registry, patients under the age of 55 years account for 12% of the arthroplasty burden.14 there remains debate regarding component fixation and bearing surface in this patient population. the available options for component fixation are: all cemented, all uncemented and hybrid/reverse hybrid (acetabular cementation and uncemented femoral fixation). evolving implant technology, and improved surgical and cementation techniques have resulted in a progressive improvement in prosthesis survival in both cemented and uncemented arthroplasty, the most dramatic being uncemented. this improvement has however not been uniform across different prostheses, with certain cemented and uncemented options demonstrating unacceptably high revision rates. there has been a marked increase in the use of uncemented components, as seen in registry data. the norwegian arthroplasty register report of june 2010, and the british registry report of 2011 indicate that the most commonly used stem in primary hip arthroplasty is a fully hydroxyapatite-coated uncemented prosthesis. in the canadian registry, in 2009/2010 82.9% of the primary total hip replacements were uncemented.15 cemented stems are still considered by many to be the gold standard. burston et al, using a polished tapered stem and new generation cementing technique, reported no stem revisions for aseptic loosening or osteolysis at a minimum of ten years.16 there is, however, good long-term evidence in support of certain of the hydroxyapatite-coated stems, with survival rates of greater than 95% at 20 years.3 survival data from the norwegian arthroplasty register in patients under the age of 60 years supports the use of hydroxyapatite-coated femoral prostheses. it also supports the use of cemented acetabular components over any of the uncemented options. over the past 12 years in that register, there has been a progressive increase in the percentage of reverse hybrid arthroplasties. in a review of just under 4 000 reverse hybrid total hip replacements in patients under 60 years on the norwegian register, survival rates at 5 and 7 years (up to 10) were the same as cemented total hip replacements.17 figure 6. new bone formation towards medial cortex with stem in valgus figure 7. new bone formation towards lateral cortex with stem in varus figure 8. central bone formation with stem in neutral alignment in the uk national joint registry, patients under the age of 55 years account for 12% of the arthroplasty burden saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:13 am page 58 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 59 as noted by a number of authors, the major problem in both cemented and uncemented arthroplasty in young patients remains the acetabular component.18-20 surgery for aseptic loosening, osteolysis and liner exchange forms a large part of the revision burden. in this study, besides the two revisions for deep sepsis, none of the stems has been revised. all have shown radiographic evidence of fixation via bony ingrowth. there was a high rate of intra-operative femoral calcar fracture, which is likely due to attempts by trainee surgeons to fit larger stems, and consequently overstuffing the proximal femur. reassuringly all of these fractures healed uneventfully and without subsidence. eighty per cent of the hips demonstrated reactive bone formation at the femoral component tip, and 81% demonstrated a reactive double line formation in zone 1. these findings are in keeping with previous reports on the use of the corail stem. the double line formation is attributed to distraction forces on the proximal–lateral aspect21 (figure 10). one of the stems subsided in the early post-operative period, but was judged to have achieved bony fixation at review 5 years later. the subsidence is attributed to a technical error and undersizing of the component. the particular stem used in this case is rarely used in the unit, which may also be a contributing factor. although we report a high rate of heterotopic bone formation (20 of 52 hips), the vast majority were brooker grade 1 or 2, and not clinically significant. we report three cases of focal peri-acetabular osteolysis. as these were non-progressive, and the patients asymptomatic, no further surgery has been undertaken. notably, the patient demographics in this study differ significantly from those in other studies and in registry data. the primary indication for surgery was avascular necrosis in over two-thirds of the cases, inflammatory in 9% and primary osteoarthritis in only 5%. streit et al22 in a study of primary hip arthroplasty done in german patients under the age of 60 years had 52% osteoarthritis and only 20% avascular necrosis, while archibeck et al had 32% osteoarthritis and 20% avascular necrosis in an american population under the age of 50 years.23 identifiable risk factors for the development of avascular necrosis were noted as follows: in male patients, alcohol abuse in 65%, smoking in 62%, steroid use in 25%, trauma in 14%, and known hiv-positive status in 3%. in female patients, alcohol abuse was noted in 18%, smoking in 9%, steroid use in 28%, trauma in 14%, and known hiv-positive status in 28%. the significance of hiv status, the development of avn, and the outcomes of hip arthroplasty are currently being investigated by our unit. the significance of the difference in aetiologies and how it may influence surgical outcomes, is however unclear. radl et al evaluated stem subsidence and stem survival in patients with osteoarthritis and patients with avn. they found a significant difference in stem subsidence, and stem survivals of 74% for avascular necrosis versus 89% for osteoarthritis at a median of 6 years. they suggest the differences can be attributed to the pathological process in the proximal femur of patients with avascular necrosis.24 ince et al, however, showed no greater risk of subsidence and had no stem revisions in patients with avascular necrosis at an average of 7 years post uncemented arthroplasty with a porous-coated stem.25 this was confirmed by min et al who had a 95% stem survival at 10 years in patients with avn.4 at time of last follow-up, eight of the 88 patients (9%) had demised. although this may seem excessive, it should be taken in context. the death rate for adults aged 40 to 54 years in south africa is estimated at 15 per 1 000 per year for females and 27 per 1 000 per year for males.26 this equates roughly with the death rate seen in this cohort of patients over the study period. there are a number of limitations to this study. first, it is retrospective, and therefore reliant on information gained from previous notes. secondly, as our institution performs mainly uncemented arthroplasty in this age group, there is no matched cohort of patients with which to compare our results. thirdly, there was a high rate of attrition due to death and loss to follow-up which may have altered the analysis. conclusion we have analysed a consecutive group of patients who underwent total hip replacement, and present our radiological results and complications at a minimum of 5 years’ follow-up. our findings regarding the radiographic features are in keeping with the published literature, and we have encountered no revisions for aseptic loosening. uncemented component fixation remains a suitable option for patients under the age of 55 years requiring total hip arthroplasty. i have no conflicting interests, and received no benefits for writing this original article. references 1. dorr ld, kane tj, 3rd, conaty jp. long-term results of cemented total hip arthroplasty in patients 45 years old or younger. a 16-year follow-up study. j arthroplasty, 1994;9(5):453-56. 2. duffy gp, et al. primary uncemented total hip arthroplasty in patients <40 years old: 10to 14-year results using first-generation proximally porous-coated implants. j arthroplasty, 2001;16(8 suppl 1):140-44. 3. vidalain jp. twenty-year results of the cementless corail stem. int orthop, 2011;35(2):189-94. figure 9. reactive double line formation in zone 1 due to tensile stresses saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:13 am page 59 page 60 sa orthopaedic journal autumn 2014 | vol 13 • no 1 4. min bw, et al. second-generation cementless total hip arthroplasty in patients with osteonecrosis of the femoral head. j arthroplasty, 2008;23(6):902-10. 5. eskelinen a, et al. uncemented total hip arthroplasty for primary osteoarthritis in young patients: a mid-to long-term follow-up study from the finnish arthroplasty register. acta orthop, 2006;77(1):57-70. 6. moyer ja, et al. durability of second-generation extensively porous-coated stems in patients age 50 and younger. clin orthop relat res, 2010;468(2):448-53. 7. blacha j. high osteolysis and revision rate with the hydroxyapatite-coated abg hip prostheses: 65 hips in 56 young patients followed for 5-9 years. acta orthop scand, 2004;75(3):276-82. 8. garcia-cimbrelo e, et al. total hip arthroplasty with use of the cementless zweymuller alloclassic system. a ten to thirteenyear follow-up study. j bone joint surg am, 2003;85-a(2):296303. 9. gruen ta, mcneice gm, amstutz hc. ‘modes of failure’ of cemented stem-type femoral components: a radiographic analysis of loosening. clin orthop relat res, 1979;141:17-27. 10. engh ca, bobyn jd,glassman ah. porous-coated hip replacement. the factors governing bone ingrowth, stress shielding, and clinical results. j bone joint surg br, 1987;69(1):45-55. 11. massin p, schmidt l, engh ca. evaluation of cementless acetabular component migration. an experimental study. j arthroplasty, 1989;4(3):245-51. 12. delee jg, charnley j. radiological demarcation of cemented sockets in total hip replacement. clin orthop relat res, 1976;121:20-32. 13. brooker af, et al. ectopic ossification following total hip replacement. incidence and a method of classification. j bone joint surg am, 1973;55(8):1629-32. 14. national joint registry for england and wales 8th annual report. 2011. 15. hip and knee replacements in canada – 2011 annual statistics (clinical data) from the canadian institute for health information, 2011. 16. burston bj, et al. cemented polished tapered stems in patients less than 50 years of age: a minimum 10-year follow-up. j arthroplasty, 2010;25(5):692-99. 17. lindalen e, et al. is reverse hybrid hip replacement the solution? acta orthop, 2011;82(6):639-45. 18. kim yh, et al. comparison of total hip replacement with and without cement in patients younger than 50 years of age: the results at 18 years. j bone joint surg br, 2011;93(4):449-55. 19. wangen h, et al. hip arthroplasty in patients younger than 30 years: excellent ten to 16-year follow-up results with a hacoated stem. int orthop, 2008;32(2):203-208. 20. kim yh, et al. periacetabular osteolysis is the problem in contemporary total hip arthroplasty in young patients. j arthroplasty, 2012;27(1):74-81. 21. rokkum m, reigstad a. total hip replacement with an entirely hydroxyapatite-coated prosthesis: 5 years’ follow-up of 94 consecutive hips. j arthroplasty, 1999;14(6):689-700. 22. streit mr, et al. high survival in young patients using a second generation uncemented total hip replacement. int orthop, 2012;36(6):1129-36. 23. archibeck mj, et al. cementless total hip arthroplasty in patients 50 years or younger. j arthroplasty, 2006;21(4):476-83. 24. radl r, et al. higher failure rate and stem migration of an uncemented femoral component in patients with femoral head osteonecrosis than in patients with osteoarthrosis. acta orthop, 2005;76(1):49-55. 25. ince a, et al. no increased stem subsidence after arthroplasty in young patients with femoral head osteonecrosis: 41 patients followed for 1–9 years. acta orthop, 2006;77(6):866-70. 26. statistics-sa. adult mortality data (aged 16–64) based on death notification data in south africa. report no 03-09-05. 2006. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:13 am page 60 south african orthopaedic journal paediatric orthopaedics doi 10.17159/2309-8309/2021/v20n2a4maré ph et al. sa orthop j 2021;20(2) citation: maré ph, thompson dm, marais lc. growth modulation may decrease recurrence when used as an adjunct to osteotomy in infantile blount’s disease. sa orthop j 2021;20(2):88-92. http://dx.doi. org/10.17159/2309-8309/2021/ v20n2a4 editor: prof. ruan goller, university of pretoria, pretoria, south africa received: july 2020 accepted: november 2020 published: may 2021 copyright: © 2021 maré ph. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: ph maré has performed educational services for orthofix. dm thompson has no conflict of interest to declare. lc marais has no conflict of interest to declare. abstract background this study aimed to determine whether the addition of a lateral proximal tibial tension band plate, combined with proximal tibial dome realignment osteotomy, would decrease the recurrence rate in a group of children younger than 7 years with infantile blount’s disease (ibd) and high recurrence risk, defined as a medial physeal slope ≥60°. methods we reviewed the records of 14 children (22 limbs) under the age of 7 years with ibd and a medial physeal slope ≥60˚ that were treated with a combination of tibial osteotomy and tension band plates (group 2) to determine the recurrence rate and time to reoperation. these results were compared with a matched group of eight children (12 limbs) with ibd and a medial physeal slope ≥60˚ that were treated previously with tibial osteotomy alone (group 1). results the two groups were matched in terms of age, sex, obesity, langenskiöld stage, tibio-femoral angle and medial physeal slope. the recurrence rate was 92% (11/12) in group 1 and 77% (17/22) in group 2 (odds ratio 0.31; 95% ci 0.03–3.01, p=0.312). the mean time to reoperation was 2.4 years in group 1 and 1.9 years in group 2 (p=0.319). there were two implant-related complications: one broken screw and one case of epiphyseal fixation failure in the tension band plate group, both in cases of recurrence. conclusion the addition of a lateral tension band plate to a proximal tibial realignment osteotomy may be an option to consider in children younger than 7 years with ibd and a high risk of recurrence. further research is required to determine recurrence risk in ibd and to develop and evaluate surgical strategies to mitigate this risk with well-designed, multicentre controlled trials. level of evidence: level 4 keywords: blount’s disease, tibia vara, guided growth, tension band plate, osteotomy, recurrence growth modulation may decrease recurrence when used as an adjunct to osteotomy in infantile blount’s disease pieter h maré,¹* david m thompson,¹ leonard c marais² ¹ department of orthopaedic surgery, grey’s hospital, school of clinical medicine, university of kwazulu-natal, south africa ² department of orthopaedic surgery, school of clinical medicine, university of kwazulu-natal, durban, south africa *corresponding author: phmare@gmail.com introduction infantile blount’s disease (ibd) presents as a progressive multiplanar proximal tibial deformity with onset from the age of walking.1 the deformity is due to disordered growth in the posteromedial proximal tibial physis.2 the cause of disordered growth is likely to be multifactorial.3 once the diagnosis is confirmed, surgery is indicated.4 the risk of recurrence following proximal tibial osteotomy is high and has been reported to be between 41% and 72%.5-8 it is crucial to attempt to prevent recurrence because repeat osteotomy has been linked to worse outcomes at skeletal maturity.6,9 several authors have identified risk factors that predict recurrence. these include age at surgery, obesity, the severity of deformity, langenskiöld stage, lamont type c appearance, and a medial physeal slope (mps) ≥60°.5-16 we previously showed that an mps≥60° was the best predictor of recurrence in our population.16 despite the risk factors associated with recurrence being known, surgical strategy selection based on risk stratification has not been extensively investigated. overcorrection into valgus, medial epiphysiolysis and lateral epiphysiodesis are all strategies that have been employed in an attempt to decrease the recurrence rate.5,11,17-19 overcorrection has not been proven to be an effective strategy, medial epiphysiolysis has limited application, and there is a risk of overcorrection and loss of growth potential with permanent epiphysiodesis.18,20 guided growth has become a popular technique to correct long bone deformities in children since the development of the tension band plate.21 while reports on the use of growth modulation with tension band plates to correct the deformity caused by blount’s https://orcid.org/0000-0003-1599-7651 page 89maré ph et al. sa orthop j 2021;20(2) disease have been encouraging, the use of a tension band plates as an adjunct to proximal tibial osteotomy as a strategy to decrease the risk of recurrence has not been investigated.22-25 we aimed to investigate whether the addition of a tension band plate to a standard proximal tibial realignment osteotomy could decrease the rate of recurrence after proximal tibial osteotomy in children under 7 years of age with ibd and high recurrence risk. materials and methods we reviewed our paediatric orthopaedic database and identified all children with ibd under the age of 7 years with a high risk for recurrence treated at our tertiary hospital between 2010 and 2018 with at least 18 months follow-up. ibd was diagnosed by observing progressive proximal tibial deformity, typical changes on standing ap and lateral knee radiographs and a tibial metaphyseal diaphyseal angle (mda) >16°. high risk of recurrence was defined as a metaphyseal slope angle (mps) ≥60°.12,13,16 we excluded eight children (ten limbs) who had less than 18 months followup. we also excluded children older than 7 years because these cases were frequently complicated by knee instability due to medial plateau depression and were treated with medial elevation osteotomy and definitive lateral epiphysiodesis. in children under 7 years with ibd, it was our practice to perform multiplanar deformity correction through a metaphyseal proximal tibial dome osteotomy. we aimed to correct the coronal alignment into physiological valgus, while simultaneously correcting the internal rotation and procurvatum to normal. the normative data published by salenius and vankka were used as a reference (diaphyseal tibio-femoral angle between 5° and 6°±4°).26 pragmatically, we aimed to correct the tibio-femoral angle to between 5° and 10° valgus alignment. during the study period, our practice changed to include the use of a lateral proximal tibial eightplate (orthofix, mckinney, texas, usa), in addition to immediate proximal realignment osteotomy, in children where the mps≥60° (figure 1a–d). we compared a subgroup of the initial patients who had an mps≥60° and were treated with tibial osteotomy alone, with the latter patients who had the additional eight-plate. the two groups were compared in terms of demographics, obesity and disorder severity to ensure they were matched in terms of recurrence risk. severity was assessed by the langenskiöld stage, metaphyseal– diaphyseal angle (mda), anatomic tibio-femoral angle (tfa) and medial physeal slope (mps). radiographic measures were obtained on standing ap long cassette radiographs. if these were not available, standing ap knee radiographs that included sufficient tibial and femoral diaphysis to allow measurements were used. the postoperative measurements were obtained from supine ap knee radiographs. the outcome measures were the recurrence rate and time to repeat surgery. recurrence was defined as progressive varus ≥10° varus tfa. all recurrent cases required repeat operation. procedures that were needed to correct alignment and restore knee stability were tibial osteotomy and medial joint line elevation. if medial growth was observed, the eight-plates were removed. if there was no medial growth, a lateral proximal tibial phemister epiphysiodesis was performed. surgical technique all cases were treated by immediate multiplanar deformity correction through a low energy proximal tibial dome osteotomy.27 an oblique incision from proximal medial to distal lateral was made to access the proximal tibia. the orientation of the incision allowed easy access to the medial metaphysis should medial elevation osteotomy be required at recurrence. a section of 5–10 mm of the midshaft fibular diaphysis was resected through a longitudinal incision with a fine oscillating saw before deformity correction. the tibial osteotomy was pre-drilled in the ap plane and completed with curved and straight osteotomes. varus, internal rotation and procurvatum were corrected acutely, and we aimed to achieve an ap tibio-femoral angle of 5–10° valgus. the congruent corresponding bone surfaces at the osteotomy contributed to stability so that, with the addition of an above-knee cast, internal fixation was not necessary. closed system suction drains were used routinely, and wounds were closed with absorbable suture material. in group 2, an additional incision was made over the lateral proximal tibial physis. initially, we used a longitudinal incision but have since transitioned to a transverse incision as we found the scar to have an improved cosmetic appearance. an eight-plate of appropriate length plate and screws was selected and inserted under fluoroscopic guidance according to the standard surgical technique.28 the corrected position was assessed clinically and confirmed under fluoroscopy. the radiolucent diathermy cable spanned between the centre of the hip to the ankle was useful to assure realignment of the axis to neutral or valgus at the knee. the limb was maintained in an above-knee cast (synthetic polyester cast tape) for six to seven weeks. weight-bearing ambulation was initiated between eight and twelve weeks postoperatively. statistical analysis statistical analysis was performed using jamovi version 1.2.18.0 open-source software.29 continuous variables were reported as mean (standard deviation [sd], range) or median (interquartile range [iqr], range), and categorical variables as number and percentages. the shapiro–wilk test was used to analyse the distribution of data. normally distributed data were compared with the use of the unpaired student’s t-test, whereas the mann– whitney u test was used for non-parametric data. categorical data were analysed using the chi-squared test unless the expected value in any cell was below 5 when fisher’s exact test was used. all tests were two-sided, and the level of significance was set at p<0.05. binomial logistic regression was used to determine the odds ratio (or) and 95% confidence interval (95% ci) of the primary outcome measure. results we identified eight children (12 limbs) that were treated with a tibial osteotomy alone (group 1) and 14 children (22 limbs) that were treated with a tibial osteotomy combined with a lateral proximal tibial tension band plate (group 2). a comparison of the descriptive treatment and outcome data is summarised in table i. the followup duration for group 1 was longer than that of group 2. the groups were matched for obesity, severity as measured by the langenskiöld stage, mda, tfa and mps. in both groups, the mean tfa as measured on postoperative radiographs was within the physiological valgus range. the mean tfa on the first standing films (within 12 weeks postoperatively) was in less valgus, but still within the physiological valgus range in both groups. the recurrence rate in group 1 was 92% compared to 77% in group 2 where a tension band plate was used as an adjunct to tibial osteotomy with an or of recurrence of 0.31 (95% ci 0.03–3.01, p=0.312). the time to reoperation was similar between the two groups. there were two tension band plate-related complications: one metaphyseal screw breakage and one of epiphyseal screw pull-out. in both of these cases, recurrence occurred. there were no cases of vascular injury, peroneal nerve injury, compartment syndrome or infection. page 90 maré ph et al. sa orthop j 2021;20(2) figure 1. a) standing ap radiograph of the right knee of a 4-year-old girl – the medial physeal slope (mps) was measured as 70°; b) postoperative ap radiograph in long leg cast immobilisation; c) standing ap radiograph one year postoperatively demonstrating divergence of the tension band plate screws and mild overcorrection prior to removal of the implant – the harris line shows the extent of growth; d) bilateral standing ap radiograph three years after the initial procedure demonstrating maintenance of correction a b c d subgroup analysis in group 2 showed that the median age of the children that did not recur was 4 years (i.e., between 4 and 5 years), compared to a median age of 5 years in the children that did have recurrent deformity (p=0.177). the mean tfa of the children that did not recur was 22° (sd 13°, range 10–40), compared to a mean of 33° (sd 14°, range 15–65) in the recurrent group (p=0.121). the langenskiöld stage was a median of stage 3 in the group without recurrence, and stage 4 in the group with recurrence (p=0.292). discussion we aimed to determine whether the addition of a lateral proximal tibial tension band plate to a proximal tibial realignment osteotomy could decrease the rate of recurrence in children under the age of 7 years with ibd and a high risk of recurrence. when children under 7 years present with severe ibd, selecting a surgical strategy is challenging because while further medial growth is unlikely, growth arrest is not inevitable. three techniques have been described to decrease recurrence risk: overcorrection, medial epiphysiolysis and lateral epiphysiodesis.5,11,17-19 corrective proximal tibial realignment osteotomy aims to unload the medial physis during weight-bearing, so that the ‘sick’ physis may resume growing under normal weight-bearing loads. the aim of overcorrection beyond the physiological range is to compensate for knee instability (due to medial joint depression and lateral ligament laxity) during weight-bearing and therefore to ensure that the mechanical axis is corrected to a lateral position at the knee.19 the lateral mechanical axis deviation, in theory, decreases the compressive forces over the medial physis. there is conflicting data about the effectiveness of overcorrection in preventing recurrence. when assessing the evidence for overcorrection, it is essential to note whether authors describe the anatomic tfa (or shaft– shaft angle) or the mechanical tfa (or hip–knee angle). another complicating factor is that the immediate postoperative radiograph is non-weight-bearing after the osteotomy and does not reflect the extent of knee instability.1,8 loder and johnston recommended overcorrection to >5° of the mechanical tfa as a strategy to decrease recurrence risk.11 schoenecker et al. suggested that realignment to within 5° of neutral was sufficient.10 the only investigation specifically evaluating the effect of overcorrection was a study by eamsobhana et al. in 2014 on children with langenskiöld stage 2 ibd which failed to demonstrate an advantage to overcorrection beyond a tfa of 15° valgus alignment.20 langenskiöld advised against overcorrection of the deformity, as he stated that excessive valgus did not remodel reliably.5 therefore, we aimed to correct the limb to a valgus anatomic tfa of 5–10° in the above-knee cast as measured on an ap non-weight-bearing radiograph. medial epiphyseolysis, first reported by beck et al., is another technique that may reduce the risk of recurrence.17 andrade and johnston reported that 26% of 27 limbs treated with a combination of valgus osteotomy and medial epiphysiolysis had a normal mechanical alignment (0°±5°) at latest follow-up.18 this study was limited by selection bias, and the authors acknowledge that adequacy of epiphysiolysis may be challenging to confirm intraoperatively, as there is no well-defined bar.4,18 our previous experience with this procedure was unsatisfactory, and it was not part of our surgical strategy. lastly, definitive lateral epiphysiodesis will prevent recurrent deformity at the cost of any potential growth.5 should growth resume medially after proximal tibial realignment, progressive overcorrection would result. temporary page 91maré ph et al. sa orthop j 2021;20(2) lateral epiphysiodesis with a tension band plate was, therefore, an attractive option to potentially prevent or delay recurrence after proximal tibial realignment without the risk of permanent growth arrest or progressive overcorrection. several factors predisposed the children in both groups to recurrence; these included age >4 years, langenskiöld stage >iii or iv, and mps≥60°.6-13,16 correction was achieved through proximal tibial dome osteotomy in both groups to physiological valgus on the first postoperative radiograph. the first weight-bearing tfa, while still within the normal valgus range and comparable between the two groups, was less than that measured on the postoperative radiograph. this joint instability may be due to medial tibial plateau depression, lateral collateral ligament attenuation or a combination of the two factors. the high recurrence rate in both groups is indicative of the severe impairment of growth potential that exists in children with severe ibd. the 92% recurrence rate in the osteotomy only group was similar to the findings of kling et al. and kaewpornsawan, who both reported a 100% recurrence rate associated with an mps≥60°.12,13 with the addition of the tension band plate in group 2, the recurrence rate was 77%. because the effect size is possibly small and our patient numbers limited, our study was not sufficiently powered in terms of the recurrence rate. our study was similarly underpowered for subgroup analysis in terms of age and severity. additional research is required to further define recurrence risk in blount’s disease. we were also unable to confirm a difference in the time to reoperation between the two groups. procedures that were required at reoperation included medial elevation osteotomy, proximal tibial realignment osteotomy and lateral epiphysiodesis. these were performed in similar frequency in both groups. the recurrence rate remains very high in this patient group despite the addition of the tension band plate. for this reason, we routinely perform medial elevation osteotomy, lateral epiphysiodesis and proximal tibial realignment osteotomy as the primary procedure from the age of 7 years. before the age of 7 years, even the slim chance of preventing recurrence was deemed worthwhile when considering the inevitable loss of longitudinal growth with definitive epiphysiodesis. for this reason, we continue using the lateral tension band plate in addition to tibial osteotomy in children with an mps≥60°. besides the small size of our study and resultant insufficient power, there were several other limitations. we did not have standing long leg films that included the entire lower limb in all cases and this may have affected the accuracy of the tfa measurements. we compared the group of children treated with tension band plate combined with proximal tibial osteotomy with a historical control group where only a proximal tibial osteotomy was used, which opened the study to potential selection bias. however, our analysis revealed that the children in both groups were matched in terms of risk factors for recurrence. the numbers in this study are low, but its findings are important because these patients represent a small subgroup of children with ibd with very high recurrence risk. while it is recommended that the treatment of children with ibd is individualised, this is the first study that has attempted to risk-stratify children with ibd and evaluates a treatment strategy accordingly. it is also the first study to assess the effect of an additional tension band plate, with proximal tibial realignment osteotomy, on recurrence rate in children with ibd and high recurrence risk. despite this surgical strategy, the recurrence rate remained high, and further research is required both to quantify recurrence risk and to identify additional interventions that can reduce the risk of recurrence and the need for reoperation. conclusion the addition of a lateral tension band plate has demonstrated a low complication rate, and in the absence of another strategy that may effectively decrease recurrence rate, may be an option to consider in children younger than 7 years with ibd and a high risk of recurrence. further research is required to determine recurrence risk in children under 7 years with ibd and to develop surgical strategies to mitigate this risk accordingly. table i: comparative analysis of descriptive and treatment data of group 1 (tibial osteotomy alone) and group 2 (tibial osteotomy and tension band plate) variable group 1 tibial osteotomy 8 children (12 limbs) group 2 tibial osteotomy and eight-plate 14 children (22 limbs) p-value agea 5 (5–5) 5 (4–6) 0.398 sex 88% female (7/8) 71% female (10/14) 0.486 obesity (bmi > 95th centile) 50% (4/8) 29% (4/14) 0.440 langenskiöld stageb 4 (4–5) 4 (3–4) 0.126 mdac 38°±10° 34°±9° 0.241 tfad 32°±9° 31°±14° 0.845 mpse 70°(65°–75°) 66° (65°–70°) 0.507 postoperative tfaf 10° valgus (9°–12° valgus) 8° valgus (5°–10° valgus) 0.101 tfa weight-bearing 5° valgus (5° varus to 10° valgus) 2° valgus (5° varus to 5° valgus) 0.332 follow-upg 7 (6.2–8) 3.5 (2.2–5.7) 0.002 recurrence rate 92% (11/12) 77% (17/22) 0.389 reoperation time to reoperationh 2.4±1.4 1.9±1.0 0.319 lateral epiphysiodesis 83% (10/12) 68% (15/22) 0.439 tibial osteotomy 92% (11/12) 59% (13/22) 0.061 medial elevation 58% (7/12) 59% (13/22) 1.000 a: age in years as median and interquartile range; b: langensköld stage as median and interquartile range; c: tibial metaphyseal diaphyseal angle; d: tibio-femoral angle; e: medial physeal slope; f: post-operative tfa in cast; g: follow-up in years as median and interquartile range; h: time to reoperation in years as mean with standard deviation page 92 maré ph et al. sa orthop j 2021;20(2) ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethical approval (bca268/15) was granted by the university of kwazulu-natal biomedical research ethics committee. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions phm: study design, data capture, data analysis and interpretation, first draft preparation, manuscript revision dmt: study conceptualisation, manuscript review lcm: study design, data analysis and interpretation, manuscript preparation and revision orcid maré ph https://orcid.org/0000-0003-1599-7651 thompson dm https://orcid.org/0000-0003-2607-3999 marais lc https://orcid.org/0000-0002-1120-8419 references 1. blount wp. tibia vara. osteochondrosis deformans tibiae. j bone joint surg. 1937;19:1-29. 2. golding jsr, mcneil-smith jdg. observations on the etiology of tibia vara. j bone joint surg. 1963;45-b:320-25. 3. banwarie rr, hollman f, meijs n, et al. insight into the possible aetiologies of blount’s disease: a systematic review of the literature. j pediatr orthop b. 2019;29:323-36. 4. sabharwal s. blount disease. current concepts review. j bone joint surg (am). 2009;91-a:1758-76. 5. langenskiöld a, riska eb. tibia vara (osteochondrosis deformans tibiae) a survey of seventy-one cases. j bone joint surg (am). 1964;46:1405-20. 6. doyle bs, volk ag, smith cf. infantile blount disease. long-term follow-up of surgically treated patients at skeletal maturity. j pediatr orthop. 1996;16:469-76. 7. ferriter p, shapiro f. infantile tibia vara: factors affecting outcome following proximal tibial osteotomy. j pediatr orthop. 1987;7:1-7. 8. chotigavanichaya c, salinas g, green p, et al. recurrence of varus deformity after proximal tibial osteotomy in blount disease: long-term follow-up. j pediatr orthop. 2002;22:638-41. 9. hofmann a, jones re, herring ja. blount’s disease after skeletal maturity. j bone joint surg. 1982;64-a:1004-1009. 10. schoenecker pl, meade wc, pierron rl, et al. blount’s disease: a retrospective review and recommendations for treatment. j pediatr orthop. 1985;5:181-86. 11. loder rt, johnston ce ii. infantile tibia vara. j pediatr orthop. 1987;7:639-46. 12. kling tf, volk ag, dias l, et al. infantile blount’s disease treated with osteotomy followed to maturity. orthopaedic transactions. 1990;14:634-35. 13. kaewpornsawan k, tangsataporn s, jatunarapit r. early proximal tibial valgus osteotomy as a very important prognostic factor in thai children with infantile tibia vara. j med assoc thai. 2005;88 suppl 5:s72-79. 14. lamont le, mcintosh al, jo ch, et al. recurrence after surgical intervention for infantile tibia vara: assessment of a new modified classification. j pediatr orthop. 2019;39:65-70. 15. horn a, boskovic v. predictors of early recurrence following high tibial osteotomy for infantile tibia vara. int orthop 2020. https://doi.org/10.1007/ s00264-020-04808-2. 16. maré ph, thompson dm, marais lc. predictive factors for recurrence in infantile blount disease treated with tibial osteotomy. j pediatr orthop 2021;41(1):e36-e43. 17. beck cl, burke sw, roberts jm, johnstone ce ii. physeal bridge resection in infantile blount disease. j pediatr orthop. 1987;7:161-63. 18. andrade n. johnston ce. medial epiphysiolysis in severe infantile tibia vara. j pediatr orthop. 2006;26:652-58. 19. johnston ce. infantile tibia vara. clin orth rel res. 1990;255:13-23. 20. eamsobhana p, kaewpornsawan k, yusuwan k. do we need to do overcorrection in blount’s disease? int orthop. 2014;38(8):1661-64. 21. stevens pm. guided growth for angular correction: a preliminary series using a tension band plate. j pediatr orthop. 2007;27:253-59. 22. scott ac. treatment of infantile blount disease with lateral tension band plating. j pediatr orthop. 2012;32:29-34. 23. sabharwal s, sabharwal s. treatment of infantile blount disease: an update. j pediatr orthop. 2017;37:s26-s31. 24. griswold bg, shaw ka, houston h, et al. guided growth for the treatment of infantile blount’s disease: is it a viable option? j orthop. 2020;20:41-45. 25. danino b, rödl r, herzenberg je, et al. the efficacy of guided growth as an initial strategy for blount disease treatment. j child orthop. 2020;14:312-17. 26. salenius p, vankka e. the development of the tibiofemoral angle in children. j bone joint surg (am). 1975;57:259-61. 27. langenskiöld a. tibia vara. a critical review. clin orthop rel res. 1989;246:195-207. 28. no authors listed. guided growth system operative technique. http://web. orthofix.com/products/products/guided%20growth%20system/ep-1305opt-e0.pdf. [accessed 10 june 2020]. 29. the jamovi project (2020). jamovi (version 1.2) [computer software]. retrieved from https://www.jamovi.org. https://orcid.org/0000-0003-1599-7651 https://orcid.org/0000-0003-2607-3999 https://orcid.org/0000-0002-1120-8419 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 47 clinical anatomy of the anterior cruciate ligament and pre-operative prediction of ligament length mrs r van zyl,1,2 msc anatomy dr a-n van schoor,2 phd anatomy dr pj du toit,3 phd physiology dr em louw,4 phd statistics 1 lecturer, department of basic medical sciences, school of medicine, faculty of health sciences, university of free state, south africa 2 senior lecturer, department of anatomy, school of medicine, faculty of health sciences, university of pretoria, south africa 3 professor, department of physiology, school of medicine, faculty of health sciences, associate of the institute for food, nutrition and well-being, associate of the institute for cellular and molecular medicine, associate of the exercise smart team, university of pretoria, south africa 4 senior lecturer, department of statistics, faculty of natural and agricultural sciences, university of pretoria, south africa corresponding author: mrs reinette van zyl department of basic medical sciences (g25) faculty of health sciences university of free state po box 339 bloemfontein, 9300, south africa. tel: +27 (0)51 401 7362 fax: +27 (0)51 401 9134 email: ebersohnr@ufs.ac.za abstract background: ligament grafts used in anterior cruciate ligament (acl) reconstruction need to be the correct length for proper functioning. if the graft length is incorrect, the patient could risk knee instability, loss of range of motion, or failure of graft fixation. easier and time-efficient reconstruction will be facilitated if the length of the acl is predicted in advance. apart from examining the morphological properties of the acl, this study aimed to determine whether the epicondylar width of an individual can be used to predict acl length and thereby assist in restoring the normal anatomy of the acl. methods: ninety-one adult cadavers were studied. patellar ligament (pl) length, acl length, acl width and the maximum femoral epicondylar width (fecw) were measured. results: the morphology of the acl and pl was determined. the results revealed that fecw was the most reliable predictor of acl length. a linear regression formula was developed in order to determine acl length by measuring maximum fecw. conclusions: acl and pl morphology compared well with the results found in previous studies. an individual’s fecw can be used to predict acl length pre-operatively. these results could improve pre-operative planning of acl reconstruction. key words: anterior cruciate ligament, femoral epicondyles, ligament graft, reconstruction http://dx.doi.org/10.17159/2309-8309/2016/v15n4a7 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 47 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 48 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 49 page 50 sa orthopaedic journal summer 2016 | vol 15 • no 4 results all data were symmetrically distributed. the descriptive analysis results are shown in table i. the pearson’s correlation coefficient results can be seen in table ii. the pearson’s correlation coefficient r-value was determined to suggest which of the four independent variables demonstrated a significant positive or negative linear relationship with the dependent variable, acl length. (table ii). if the p-value of the pearson’s correlation coefficient test was p<0.05, it was considered as a statistically significant correlation. statistical inference followed after the completion of the descriptive statistics in order to predict acl length. by means of backward elimination using a multiple regression model, it was observed that both height and fecw had a statistically significant correlation to acl length. however, fecw was a more reliable predictor for estimating acl length than height (r=0.36 against r=0.31, respectively). on the basis of this estimation, no additional variables were used to compile an equation for preoperative ligament length estimation. a linear regression formula was developed for predicting acl length and, therefore, optimum final graft length to re-establish the intra-articular length of the torn acl. the following equation (equation 1) can be used to predict acl length by measuring the maximum fecw: acl length = 0.25 (fecw) + 11.18 (1) where acl=anterior cruciate ligament; fecw=femoral epicondylar width discussion the mismatch of grafts can be minimised by more accurate prediction of acl intra-articular length and the required graft length for acl reconstruction. the first aim of this study was to determine the morphology of the acl and pl. this study has shown that the mean intra-articular acl length of this sample was 32.4 mm, with a range between 22.9 and 45.1 mm. the literature has shown different results for the mean length of the acl, namely: 20 mm,24 31 mm,25 32 mm,5,7,9 38 mm,8 and 39 mm.26 the acl length has exhibited some variability, with reported ranges of 20–25 mm,13 22–41 mm,9 22–44 mm,7 25–35 mm,25 and 37–41 mm.26 the mean width of the acl calculated in the current study was 8.2 mm, ranging from 5.1–13.7 mm. this measurement differs slightly from the range of 7–12 mm as determined by bicer et al.,7 zantop et al.5 and odensten and gillquist.25 previous authors found the acl to have a mean width of 10 mm25 and 11 mm.8 the pl mean length of this sample was 45.7 mm, ranging between 31.6 mm and 59.2 mm. these measurements were similar to results from previous studies: brown et al.13 recorded a range of 45–50 mm and denti et al.24 a mean length of 45.5 mm. on average, the pl is 14 mm longer than the acl in this study and is therefore sufficient in length to allow effective fixation of the graft. variation in pl length could explain the occurrence of graft mismatch found with acl reconstructive surgery. lastly, the slight differences between both the acl and pl measurements from this sample and other reported measurements could be attributed to the respective population differences of the samples studies. the comparisons were made between the current sample (south african), an italian sample24 and a north american sample.13 the measuring technique used could also account for the dissimilarities found among the studies referred to by brown et al.13 and denti et al.24 acl length and pl length demonstrated no significant statistical correlation (p=0.92), as was the case between acl length and acl width (p=0.26). the significant correlation between acl length and height (p=0.01) was not unexpected. brown et al.13 in 2007 found a strong correlation on a large magnetic resonance imaging (mri) study sample consisting of 414 knees, and concluded that patient height can predict the required length of the btb graft used for acl reconstruction. in contrast, denti and coworkers,24 using 50 reconstructed and nine cadaver knees, were unable to confirm this relationship between acl length and patient height. acl length and fecw revealed a significant correlation of p<0.01 in this study. table i: simple descriptive statistics of the patellar ligament (pl) and anterior cruciate ligament (acl) length and the acl width measurements variables pl length (mm) acl length (mm) acl width (mm) mean 45.66 32.44 8.23 sd 5.71 4.06 1.96 minimum 31.56 22.90 5.10 maximum 59.17 45.10 13.74 acl=anterior cruciate ligament; pl=patellar ligament; sd=standard deviation table ii: correlation matrix to indicate associations between the dependent (acl length) and independent variables independent variables acl length p-value r-value height .01a 0.31 pl length 0.92 0.01 fecw 0.00a 0.36 acl width 0.26 0.14 a statistically significant correlation acl=anterior cruciate ligament; fecw= femoral epicondylar width; pl=patellar ligament saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 50 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 51 it was also statistically determined that fecw could account for the other three independent variables in predicting acl length as fecw had a strong correlation with all other variables. femoral epicondylar width was found to be the most reliable predictor of acl length (r=0.36) as opposed to height, which had an r-value=0.31. a significant model was developed for the estimation of acl length when fecw is known. the r2-value of 0.13 indicated that 13% of variation found in acl length (among the cadavers) could be accounted for by equation 1. therefore, measuring the fecw of the patient might allow for pre-operative estimation of the length of the acl by using the previously mentioned linear regression formula. these values could then be utilised to predict the required graft length to replace the torn or ruptured acl. maximum fecw was used in the current study to correlate with acl length. patient height is often unknown and fecw is a practical measurement, as it is commonly available on x-ray and mri.13,24 in this sample, fecw has also proven to be a slightly more reliable predictor than height for acl length estimation. when comparing acl length and fecw, a definite positive correlation between the measurements (p<0.05) was noticed. however, the low r2-value of the linear regression indicates that in the south african cadaver sample examined in the current study, the fecw cannot be the sole predictor of acl length. preoperative mismatch of the graft length could occur if the fecw is measured without the incorporation of additional imaging modalities. intra-operative measurements may also assist to determine acl length and therefore the required graft length. the weak positive correlation observed for predicting acl length using the maximum fecw could be explained by remnants of soft tissue covering the epicondyles after dissection, which may have led to inaccurate measurement of the maximum fecw. dissection of the acl was also problematic because the ligament coursed diagonally within the knee joint. the measurement was therefore taken blindly, which could have resulted in inaccurate measurements of the true acl length. utilising imaging modalities could allow clinicians a greater degree of accuracy in estimating acl length from measuring the fecw of the patient. future studies could therefore be designed to investigate whether the correlation between the acl length and the fecw could be improved when measured on mris. these findings should be verified in the clinical setting. conclusion the anatomy of the acl and pl of this south african cadaver sample compared favourably with results reported in previous studies conducted on other population groups. similar to some of these studies, a correlation was found between the intra-articular acl length and the height of the cadaver. it was also found that the maximum fecw of a patient can predict the length of the intra-articular acl more reliably than the height of the patient can. using fecw as a possible predictor provides an additional method for estimating the pre-operative length of the graft required for acl reconstruction and minimising the chance of graft mismatch. acknowledgements the financial assistance of the research development programme (rdp) toward this research is hereby acknowledged. opinions expressed and conclusions arrived at are those of the authors and are not necessarily attributed to the rdp. mrs joyce c jordaan is greatly thanked for her assistance with the conduction of statistical analyses. barbara english of the research office of the university of pretoria’s faculty of health sciences is thanked for her language editing. medical editor, ms theanette mulder, of the support school of medicine of the university of free state is deeply thanked. finally, the authors kindly thank all the body donors without whom this research would not have been possible. compliance with ethics guidelines • conflict of interest the enclosed manuscript has been read and approved by all authors. the authors, mrs van zyl and drs van schoor, du toit and louw, have no conflict of interest to declare. • benefits no benefits of any form have been received from a commercial party related directly or indirectly to the subject of this article. • ethics statement ethical clearance (ethics reference number 151/2013) was obtained from the research ethics committee, faculty of health sciences, university of pretoria. all cadaveric material used in this study was handled in accordance with the requirements of the south african national health act, act 61of 2003. references 1. boden bp, griffin ly, garrett we jr. etiology and prevention of noncontact acl injury. phys sportsmed 2000;28(4):53–60. 2. wipfler b, donner s, zechmann cm, springer j, siebold r, paessler hh. anterior cruciate ligament reconstruction using patellar tendon versus hamstring tendon: a prospective comparative study with 9-year follow-up. arthroscopy 2011;27(5):653–65. 3. yu b, garrett we. mechanisms of non-contact acl injuries. br j sports med 2007 aug;41:suppl 1:i47–i51. 4. moore kl, dalley af, agur amr. clinically oriented anatomy. 6th ed. philadelphia: lippincott williams & wilkins; 2009. p. 639–63. 5. zantop t, petersen w, fu fh. anatomy of the anterior cruciate ligament. oper tech orthop 2005;15(1):20–8. 6. amis aa, bull amj, lie dtt. biomechanics of rotational instability and anatomic anterior cruciate ligament reconstruction. oper tech orthop 2005;15(1):29–35. saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 51 page 52 sa orthopaedic journal summer 2016 | vol 15 • no 4 7. bicer ek, lustig s, servien e, selmi ta, neyret p. current knowledge in the anatomy of the human anterior cruciate ligament. knee surg sports traumatol arthrosc 2010;18(8):1075– 84. 8. markatos k, kaseta mk, lallos sn, korres ds, efstathopoulos n. the anatomy of the acl and its importance in acl reconstruction. eur j orthop surg traumatol 2013;23(7):747–52. 9. petersen w, zantop t. anatomy of the anterior cruciate ligament with regard to its two bundles. clin orthop relat res 2007 jan;454:35–47. 10. mcculloch pc, lattermann c, boland al, bach br jr. an illustrated history of anterior cruciate ligament surgery. j knee surg 2007;20(2):95–104. 11. miller md. knee. in: delee jc, drez d jr, miller md, editors. delee & drez’s orthopaedic sports medicine. 3rd ed. philadelphia: elsevier saunder; 2010. p. 1579–1609. 12. palmer i. on the injuries to the ligaments of the knee joint. a clinical study. acta chir scand 1938;suppl 53:1–28. 13. brown ja, brophy rh, franco j, marquand a, solomon tc, wantanabe d, mandelbaum br. avoiding allograft length mismatch during anterior cruciate ligament reconstruction: patient height as an indicator of appropriate graft length. am j sports med 2007;35(6):986–89. 14. cheung sc, allen cr, gallo ra, ma cb, feeley bt. patients’ attitudes and factors in their selection of grafts for anterior cruciate ligament reconstruction. knee 2012;19(1):49–54. 15. gerhard p, bolt r, dück k, mayer r, friederich nf, hirschmann mt. long-term results of arthroscopically assisted anatomical single-bundle anterior cruciate ligament reconstruction using patellar tendon autograft: are there any predictors for the development of osteoarthritis? knee surg sports traumatol arthrosc 2013;21(4):957–64. 16. miller md. knee and lower leg. in: miller md, chhabra ab, hurwitz s, mihalko wm, shen fh, 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reconstruction: a literature review of the anatomy, biomechanics, surgical considerations, and clinical outcomes. oper tech orthop 2005;15(1):5–19. 22. tantisricharoenkul g, linde-rosen m, araujo p, zhou j, smolinski p, fu fh. anterior cruciate ligament: an anatomical exploration in humans and in a selection of animal species. knee surg sports traumatol arthrosc 2014;22(5):961–71. 23. miles j, carrington r. soft tissue surgery of the knee. in: briggs t, miles j, aston w, editors. operative orthopaedics: the stanmore guide. london: hodder arnold; 2010. p. 200–17. 24. denti m, bigoni m, randelli p, monteleone m, cevenini a, ghezzi a, schiavone panni a, trevisan c. graft-tunnel mismatch in endoscopic anterior cruciate ligament reconstruction. intraoperative and cadaver measurement of the intra-articular graft length and the length of the patellar tendon. knee surg sports traumatol arthrosc 1998;6(3):165–68. 25. odensten m, gillquist j. functional anatomy of the anterior cruciate ligament and a rationale for reconstruction. j bone joint surg am 1985;67(2):257–62. 26. kennedy jc, weinberg hw, wilson as. the anatomy and function of the anterior cruciate ligament. as determined by clinical and morphological studies. j bone joint surg am 1974;56(2):223–35. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 52 page 34 sa orthopaedic journal autumn 2014 | vol 13 • no 1 pre-hospital antibiotics for open fractures: is there time? dr jk mccaul mbchb(uct) medical officer in orthopaedics, somerset hospital mr mg mccaul btech emc(dut), msc clin epi (stell) (c) researcher, biostatistics unit, centre of evidence-based health care, stellenbosch university correspondence: mr mg mccaul email: mmccaul@sun.ac.za tel: (021) 938-9314 introduction early administration of intravenous (iv) antibiotics providing cover against gram positive and negative organisms can be argued to be the single most important factor in reducing infection rate in patients with open (compound) fractures.1 a delay of more than 3 hours from injury (open fractures or war wounds including fractures) to antibiotic administration is associated with a significantly higher infection rate.2-4 infection is a complication of open fractures. there have been reports of osteitis in 5.7%5 and 8.2% of patients (across all grades of fractures) with up to 23.7% observed for gustilo-anderson type iiic fractures.6 early surgical debridement has also been shown to be important in preventing infection.2 however, some studies have shown that, when early prophylactic iv antibiotics and open fracture first aid had been implemented, delaying aggressive debridement and lavage up to 13 hours post injury did not adversely affect the outcome.7 in animal studies, a delay to debridement of up to 24 hours increased the risk of infection, but not significantly; rather again showing that delay in timing of antibiotic administration (to 6–24 hours instead of less than 6 hours) had the most profound effect regardless of timing of surgery.8 current practice in south africa regarding management of open fractures involves administration of iv antibiotics soon after the patient arrives at a hospital or clinic. the patient is often treated in the pre-hospital setting by emergency medical care providers (emcps) on scene and en route to hospital. if early administration of iv antibiotics is important, is there not a role for an immediate dose of iv antibiotics in the pre-hospital setting? the purpose of this study is to identify the proportion of patients in a suburban sample that experience delay in antibiotic administration after open fracture. by examining trends in the time period from injury to ultimate administration of iv antibiotics the authors aim to clarify if there would be opportunity for pre-hospital antibiotic administration to significantly shorten the delay. materials and methods a retrospective and prospective descriptive study was conducted of all patients with open fractures of the limbs or girdles arriving via ambulance at a single district hospital in a suburban area in kwazulu-natal, south africa. data collection was performed from folders of patients arriving at the hospital from may to december 2012 (inclusive). abstract early administration of intravenous (iv) antibiotics providing cover against gram positive and negative organisms can be argued to be the single most important factor in reducing infection rate in patients with open (compound) fractures. by examining trends in the time period from injury to ultimate administration of iv antibiotics, the authors aim to clarify if there would be opportunity for pre-hospital antibiotic administration to significantly shorten the delay. a retrospective and prospective descriptive study was conducted of all patients with open fractures of the limbs or girdles arriving via ambulance at a single district hospital in a suburban area in kwazulu-natal, south africa. thirty-eight patients were identified from may to december 2012. the median time from injury to antibiotics was 465 minutes (7.75 hours) (first quartile = 230 minutes, third quartile = 615). administration of antibiotics was delayed beyond 3 hours in 78.9% (95% confidence interval [ci] 65.3–92.52) of patients and beyond 6 hours in 60.5% (95% ci 44.2–76.8). although much of the delay occurred due to clinic and in-hospital delays, there is also a hypothetical window available to pre-hospital healthcare providers where antibiotics could be administered. this would potentially decrease the delay and bypass many of the difficulties encountered in-hospital. key words: pre-hospital, antibiotic, open fracture, compound fracture saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 34 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 35 prospective data was collected from september to december, supplemented with retrospective review of the previous four months. ethical approval was obtained from durban university of technology (irec reference number: rec:42/12). consent was obtained from the hospital manager to assess patient folders. patients were not approached directly for information. inclusion and exclusion criteria included: all patients with fractures of their limbs, extremities, shoulder girdles or pelvis that were classified and managed as open and who were transported to the hospital’s emergency department (ed) via an ambulance, either from the scene of trauma or from the local clinic. a fracture was classified as ‘open’ if it had a full-thickness skin wound which could conceivably communicate with the fracture site. gunshot wounds with fractures were all regarded as open. excluded: patients with open fractures of the skull or mandible, patients with incomplete or absent records where the total injury-to-antibiotic time could not be calculated, patients who came to the hospital with their own transport, and patients who had delay in seeking medical attention after injury. data gathering patients were identified from admission/transfer registers in the ed and the orthopaedic wards. data were extracted and time intervals in minutes calculated from the hospital’s copy of ambulance trip sheets kept in patients’ folders as well as doctors’ and nurses’ clinical notes in the folder. data were entered onto a pre-prepared electronic spreadsheet. circumstances resulting in delay were collected when noted in the folder. the following data were collected: age, gender, mechanism of injury, grade of fracture (gustilo-anderson and ganga hospital score); times of: injury, call-out of ambulance, arrival on scene, departure from scene, out-of-hospital iv access, arrival at emergency department, antibiotic administration; choice and dose of antibiotic; route to hospital (via clinic or direct); and selected or notable circumstances causing delay. bias a single researcher gathered the data from the folders. hospital staff was informed about the study; this could have caused increased vigilance regarding administration of antibiotics, but this was not considered to add significant bias due to the study’s focus on pre-hospital time available for administration. statistical methods the sample size was calculated for the primary outcome (binary variable) with a baseline proportion of 0.8 with 13% precision. the estimated sample size was reached. quantitative variables were recorded in excel and imported into stata 11 for analysis. basic descriptive analysis was used to describe the data, reporting medians and interquartile ranges (iqr) as the data were not normally distributed. the primary outcome variable was stratified into different time-subgroups to accommodate analysis. subgroups were examined using basic summary statistics. missing data were considered to be missing at random and analysed as missing data. all efforts were made to account for missing data. results sixty-five patients with open fractures arrived at the ed between may and december 2012 (inclusive). twenty-five were excluded as they had utilised their own private transport to the hospital. two further patients were excluded; one having first gone home before seeking medical care the next morning, while the other did not receive antibiotics at the study hospital and was transferred out without the relevant data being recorded. the final number of included patients was 38. see figure 1 for a summary of patient selection. the mean age was 28.7 years (95% confidence interval [ci] 24.9–32.5) and 73.7% of patients were male (95% ci 59.0–88.4). for further demographic and clinical characteristics of included cases see table i. the median total time from injury to antibiotics was 465 minutes (7.5 hours) (first quartile [q1] = 230 minutes, third quartile [q3] = 615). administration of antibiotics was delayed beyond 3 hours in 78.9% (95% ci 65.3–92.52) of patients and beyond 6 hours in 60.5% (95% ci 44.2–76.8). the longest delay occurred after arrival at the hospital with a median of 363 minutes (q1=171, q3=505) until antibiotic administration. a median of 164 minutes (q1=115, q3=222) was spent out of hospital with emergency medical care practitioners (emcps) being in attendance for a median of 56 minutes (q1=37, q3=64). see table ii for all timeframes. pre-hospital iv access was documented as obtained in 17.1% of patients, not obtained in 62.9% and no documentation was available for the remaining 20%. just over a quarter (26.3%) of patients were transported directly from the scene (of injury) to the hospital; they had a median time from injury to antibiotics of 170 minutes. figure 1. patient selection patients with open fractures (n=65) excluded transported via ambulance (n=40) private transport (n=25) excluded included patients (n=38) irregular cases (n=2) a delay of more than 3 hours from injury (open fractures) to antibiotic administration is associated with a significantly higher infection rate saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 35 page 36 sa orthopaedic journal autumn 2014 | vol 13 • no 1 a subgroup of 13.2% patients travelled via a clinic and received antibiotics at the clinic after a median of 230 minutes after injury. the remaining 60.6% also travelled via a clinic but were not given antibiotics at the clinic, only receiving antibiotics at the hospital a median of 570 minutes after injury. there was a statistically significant difference in median times between patients who received clinic antibiotics and patients where the clinic omitted antibiotics (p<0.05). other comparisons between routes were nonsignificant, possibly due to the small sample size. patients whose antibiotics were omitted by the clinic were 22 times more likely to experience delay greater than 3 hours (p=0.010) when compared to direct transfer from the scene, while patients who received clinic antibiotics were only 1.5 times more likely to be delayed (p=0.715). some data for time interval calculations were missing: only total time (injury to antibiotics) was available in two patients. only time of injury, arrival at ed and administration of antibiotics was available in seven patients. one patient was missing the time of callout of ambulance. in 20% of patients it was not clear whether iv access was obtained in the pre-hospital setting or not. discussion there was a delay to administration of antibiotics in a large proportion of patients in this study. this provides the opportunity to consider measures to decrease delay. pre-hospital antibiotics have been used in the military setting, where rapid evacuation to hospital is not always possible in conflict scenarios. it is suggested that antibiotics may be added to civilian pre-hospital care (consisting of control of haemorrhage, sterile dressing, reduction of gross deformity and pain management) if the transport time is anticipated to be greater than 60 minutes.3 the time intervals in this study show that the median time from injury to arrival at hospital was 100 minutes (q1=61, q3=115) for direct transfers to hospital (300 and 184 minutes for transfers via clinics with and without antibiotics, respectively). emcps were in attendance for a median of 56 minutes in the study sample. it has been suggested that pre-hospital times of up to 60 minutes are acceptable if the skill of the emcp is sufficient and the destination hospital is capable of providing definitive trauma care.9 unique protocols in civilian pre-hospital care may be worth considering in south africa, with its own unique challenges and context. this study provides a glimpse into transport times and practices in kwazulu-natal and may not be able to be generalised to other countries or even other provinces/areas within south africa. a systematic review and meta-analysis of transport times in the united states showed average ground ambulance pre-hospital times from callout to arrival at hospital for trauma patients to be 30.96, 30.97 and 43.17 minutes for urban, suburban and rural settings respectively. these included response times of 5.25, 5.21 and 7.72 minutes respectively. on-scene time contributed to 13.40, 13.39 and 14.59 minutes, while transport to the destination hospital took up 10.77, 10.86 and 17.28 minutes respectively.10 a british audit of patients requiring emergency laparotomy for liver or spleen injury found a median time from activation of the aeromedical team to arrival at the ed of 73 minutes.11 possible factors causing delay in pre-hospital time in the study sample could include delay in contacting ambulance services; a high call load causing delay in dispatching of units to the scene; travelling times as influenced by distance, traffic and road conditions; shortage of resources; and time spent on scene stabilising patients and/or extricating entrapped patients. no patients in this sample were entrapped; however, this circumstance presents a special situation where a great delay in the pre-hospital setting could be anticipated and pre-hospital antibiotics could be of value. one of the risks for delay in the study included omission of antibiotics when the patient first went to a clinic (via private transport or ambulance) before ambulance transfer to the hospital. reasons for omission of antibiotics as part of emergency care at the clinics could possibly include lack of resources at the smaller clinics, insufficient staff to cope with patient load or lack of knowledge about the significance of early antibiotic administration. administration of antibiotics soon after presentation at a clinic did lessen the risk of delay, but the lowest risk occurred when the patient was transferred directly to the hospital from the scene of injury. correct transport directly to the appropriate facility would be ideal, possibly achieved by emcp training in recognising open fractures in the pre-hospital setting and direct transport to appropriate hospitals. community awareness of services provided at various levels of care is part of batho pele principles12 and striving to achieve this ideal would assist in empowering patients to present to the appropriate facilities should they choose to use their own transport. age (years) mean min max 28.7 6 58 gender malefemale 73.7% 26.3% mechanism of injury pedestrian vehicle accident motor vehicle accident blunt trauma sharp trauma assault gunshot wound human bite 21.1% 15.8% 2.6% 5.3% 5.3% 42.1% 5.3% gustiloanderson score 1 2 3a 3b 3c 49.97 23.7 0% 26.3% 0% ganga hospital score group 1 (<6) group 2 (6–10) group 3 (11–15) group 4 (>15) 9.1% 54.5% 27.3% 9.1% out-ofhospital iv access access no access not documented 17.1% 62.9% 20% antibiotic choice cefazolin cloxacillin ceftriaxone augmentin triple antibiotics* 31.6% 34.2% 21.1% 5.3% 7.9% *cefazolin, gentamycin and metronidazole table i: characteristics of included cases saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 36 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 37 the largest proportion of total time before antibiotic administration was spent in the hospital’s ed. reasons for delay included: delay in a doctor attending to the patient when the department was very busy; antibiotics not being ordered in the ed and only commenced on arrival to the wards; antibiotics being ordered in the ed but not administered; initially missing fractures that were not clinically evident, and initially misdiagnosing fractures as ‘closed’ before re-evaluation revealed accurate classification as ‘open’. measures that could reduce these delays include: clear protocols on emergency treatment; adequate triage; and improvements in patient flow through the department. in an attempt to exclude in-hospital delay as a potential confounder causing a large proportion of patients to experience total-time delay, one could consider a hypothetical situation where no in-hospital delay is experienced, i.e. antibiotics are administered immediately on arrival to the ed. in this sample there would then still be a delay of greater than 3 hours in 54% of patients travelling via a clinic without antibiotics (0% of patients transferred directly to hospital would be delayed). choice of antibiotic is important. staphylococcus aureus and staphylococcus epidermidus are often cultured early from open fractures, while pseudomonas and enterococcus have been considered as nosocomial infections.13 benzylpenicillin is ineffective for these types of organisms, with a secondgeneration cephalosporin being more suitable.13 clostridium species have also been identified and require iv antibiotics effective against anaerobes,3 e.g. in cases of soil contamination. a wide variety of antibiotics was used in the study sample (see table i) which is perhaps due to lack of knowledge of correct protocol or inconsistencies in existing protocol; also it may reflect limited choice of antibiotic in local clinics as only ceftriaxone was administered by clinics in this study. limitations of this study include a small sample and limited observation period. no record of patient outcome (e.g. development of infection) was attempted; however, the patient database provides the possibility for follow-up in a future study to determine outcome. reasons for delay, except when mentioned in the hospital folders, were not recorded. as previously mentioned, increased vigilance in in-hospital antibiotic administration, while potentially biasing the results toward shorter total time to antibiotics, was not considered to adversely affect the purpose of the study. this is because even if antibiotics were administered immediately after arrival at the hospital it would not affect pre-hospital times but rather reflect ideal in-hospital practice. further studies are required: similar studies in other centres and provinces would help to determine if antibiotic delay is a pervasive or isolated issue. should other studies concur, considering introducing iv antibiotics to prehospital care could be of value. emcp level of expertise (basic, intermediate or advanced life support practitioners) would need to be taken into account as iv antibiotics are not without complications – such as anaphylaxis. interval median time and quartiles (q1,q3) in minutes injury to ambulance callout: direct transport to ed* ambulance called after private transport to clinic: -with clinic antibiotics -without clinic antibiotics 18 (15,52) 252 (245,252) 111 (82,129) call-out to arrival 18.5 (9,32.5) arrival to departure 32 (26,46) departure to ed 18 (12,24) ed to antibiotics 363 (171,505) total out-of-hospital time (injury to ed) via clinic with no antibiotics via clinic with antibiotics patients taken directly to hospital 164 (115,222) 184 (130, 220) 300 (278, 300) 100 (61, 115) emcp+ contact time (arrival to ed) 56 (37,64) total time (injury to antibiotics) 465 (230,615) *emergency department, + emergency medical care provider table ii: time intervals descriptive analysis the largest proportion of total time before antibiotic administration was spent in the hospital’s emergency department saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 37 page 38 sa orthopaedic journal autumn 2014 | vol 13 • no 1 advanced life support practitioners are trained and equipped to deal with this scenario; therefore it is conceivable that it would be safer to introduce iv antibiotics to the advanced scope of practice only. before considering introducing antibiotics to the emcp spectrum of care, efficacy, safety and cost-effectiveness studies would need to be undertaken. randomised controlled trials are also recommended to determine the effect of pre-hospital antibiotic administration on delay, infection rates and occurrence of adverse events. there is much room for improvement within the study hospital and its drainage clinics in preventing delay in antibiotic administration. however, although much of the delay occurred due to clinic and in-hospital delays, there is also a hypothetical window available to pre-hospital healthcare providers where antibiotics may be administered. this could decrease the time interval and bypass many of the difficulties encountered in-hospital. acknowledgements thank you to tonya esterhuizen from the biostatistics unit, stellenbosch university for her support. the authors have no conflict of interest to declare. no direct funding was received for this project. references 1. patzakis mj, wilkins j. factors influencing infection rate in open fracture wounds. clinical orthopaedics and related research. 1989;243:36-40. 2. mccaskill me, little dg. time to definitive management of open fractures of long bones. emergency medicine. 1993;5(4):272-75. 3. eardley w, brown k, bonner t, green a, clasper j. infection in conflict wounded. philosophical transactions of the royal society b: biological sciences. 2011;366(1562):204-18. 4. jackson d. soldiers injured during the falklands campaign 1982 sepsis in soft tissue limb wounds. jr army med corps. 2007;153(suppl 1):55-56. 5. khatod m, botte mj, hoyt db, meyer rs, smith jm, akeson wh. outcomes in open tibia fractures: relationship between delay in treatment and infection. the journal of trauma and acute care surgery. 2003;55(5):949-54. 6. seekamp a, köntopp h, schandelmaier p, krettek c, tscherne h. bacterial cultures and bacterial infection in open fractures. european journal of trauma. 2000;26(3):131-38. 7. harley bj, beaupre la, jones ca, dulai sk, weber dw. the effect of time to definitive treatment on the rate of nonunion and infection in open fractures. journal of orthopaedic trauma. 2002;16(7):484-90. 8. penn-barwell jg, murray ck, wenke jc. early antibiotics and debridement independently reduce infection in an open fracture model. journal of bone & joint surgery, british volume. 2012;94-b(1):107-12. 9. mcdonell ac, veitch c, aitken p, elcock m. policy and service delivery. journal of emergency primary health care (jephc). 2009;7(2):990308. 10. carr bg, caplan jm, pryor jp, branas cc. a meta-analysis of prehospital care times for trauma. prehospital emergency care. 2006;10(2):198-206. 11. henderson kim, coats tj, hassan tb, brohi k. audit of time to emergency trauma laparotomy. british journal of surgery. 2000;87(4):472-76. 12. white paper on transforming public service delivery (batho pele white paper). in: administration dopsa, editor. notice 1459 of 1997 ed. pretoria: goverment gazette; 1997. 13. vainionpää s, vasenius j, rokkanen p. benzylpenicillin ineffective for open fractures: prospective study of 60 cases. acta orthopaedica. 1990;61(2):158-60. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 38 south african orthopaedic journal arthroplasty doi 10.17159/2309-8309/2021/v20n1a7 sekeitto ar et al. sa orthop j 2021;20(1) abstract background the dual mobility cup (dmc) was initially design in 1974. it was designed to offer additional stability in total hip arthroplasty (tha) and to prevent dislocations. the dissociation of a dmc has been termed an intraprosthetic dislocation (ipd) and is a rare complication. it is defined as separation of the articulation between the polyethylene and head articulation in the dmc. as the utilisation of dmcs in orthopaedic surgery increases, we can expect an increase in this rare complication. we report a case of an ipd in the setting of revision hip arthroplasty in a 72-yearold female. case report the report is on a 72-year-old female patient who underwent revision hip arthroplasty. the articulation utilised was of the dual mobility type. some eight months later she dislocated her hip. an attempted closed reduction under general anaesthesia with muscle relaxant was unsuccessful. thereafter she was taken to surgery to perform an open reduction of the hip. intra-operatively it was found that the dual mobility head had dissociated, with the polyethylene component remaining in the metal liner. a revision of the components was performed. discussion we postulate on the mechanisms of dissociation of the dual mobility head. we review the current literature related to ipd and discuss the risk factors associated with this rare complication. conclusion the diagnosis of ipd is an indication for revision surgery of the dmc. when utilising a dmc, care should be taken to mitigate against the known risk factors for ipd. all dual mobility dislocations should be reduced under general anaesthesia with muscle relaxant. level of evidence: level 4 keywords: intraprosthetic dislocation, dual mobility cup, revision hip arthroplasty intraprosthetic dislocation after a revision hip replacement: a case report allan r sekeitto* , kaeriann van der jagt , nkhodiseni sikhauli , lipalo mokete , dick r van der jagt arthroplasty unit, division of orthopaedic surgery, charlotte maxeke johannesburg academic hospital, university of the witwatersrand, johannesburg, south africa *corresponding author: sekeitto@yahoo.com introduction the dual mobility cup (dmc) was initially designed in 1974 by bousquet to offer additional stability to the standard total hip arthroplasty (tha) and prevent dislocations.1-3 instability in tha is a common indication for revision.3-5 the literature reports that 17.3 to 22.5% revisions in tha are performed for instability.6-8 the dmc has reduced post-operative dislocation rates in both primary and revision tha.9 the risk factors for instability include patients older than 75 years, prior hip surgery, neuromuscular disease, dysplastic hips, spinal abnormalities, ligamentous laxity, small anatomy3,5 and neck of femur fractures. the incidence of instability with primary tha is up to 7% and increases up to 28% in revision tha.4,10 in addition to a dmc, the stability of tha can be further improved by technique modifications such as anterior approach, repair of the posterior soft tissue, increased offset, larger femoral head and increased abductor tension.1 citation: sekeitto ar, van der jagt k, sikhauli n, mokete l, van der jagt dr. intraprosthetic dislocation after a revision hip replacement: a case report. sa orthop j 2021;20(1):49-52. http://dx.doi.org/10.17159/23098309/2021/v20n1a7 editor: dr chris snyckers, university of pretoria, pretoria, south africa received: may 2020 accepted: september 2020 published: march 2021 copyright: © 2021 sekeitto ar. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. conflict of interest: dvj reports consultancy for smith & nephew, all outside the submitted work. lm reports consultancy for zimmerbiomet and implantcast; payment for lectures including service on speakers’ bureaus for zimmerbiomet, smith & nephew and advanced orthopaedics, all outside the submitted work. the other authors declare no conflict of interest relevant to this work. https://orcid.org/0000-0002-5402-6500 https://orcid.org/0000-0003-4748-6629 https://orcid.org/0000-0002-0862-8615 https://orcid.org/0000-0001-9227-0515 https://orcid.org/0000-0002-3301-9459 http://dx.doi.org/10.17159/2309-8309/2021/v20n1a7 http://dx.doi.org/10.17159/2309-8309/2021/v20n1a7 page 50 sekeitto ar et al. sa orthop j 2021;20(1) we present a case study of a patient with a dual mobility tha which had a dissociation of the dual mobility head. case a 72-year-old female patient had undergone five previous hip revisions. the indications for the previous revisions were polyethylene wear and loosening, a poorly fixed femoral component and malposition of the acetabular cup that led to instability. at the final revision, a cup-cage technique was used with a dualmobility component cemented into the cage due to pre-operative instability and pelvic dissociation (figure 1). the femoral stem was retained, and after the appropriate dual-mobility head was fitted, the reduction was stable (figure 2). she suffered from ongoing mobility issues associated with severe backache due to underlying thoraco-lumbar kyphoscoliosis. eight months later she dislocated her hip after a fall. in the x-ray, the lucency of the polyethylene component around the head is visible, indicating dislocation of the dual mobility head (figure 3). the attempted closed reduction was performed under general anaesthesia with full paralysis; however, it was not successful. at the open reduction, it was found that head had dissociated, with the polyethylene component found within the metal liner indicating an intraprosthetic dislocation (ipd) (figure 4). all incisions were through the same scar. the approach used in all the procedures was an antero-lateral type approach. the soft tissues were severely scarred and fibrotic. the contracted fibrotic peri-articular scar tissues held the polyethylene component in the metal shell. we propose the mechanism of ipd was due to the impingement of the polyethylene component on the soft tissues preventing its mobility and resulting in the levering out of the head during the attempted reduction. the same dmc construct was used but with a longer head to increase the abductor tissue tension. there have been no subsequent dislocations. discussion the dissociation of a dmc has been termed an intraprosthetic dislocation (ipd) or retentive failure11 and is a rare complication. it is defined as separation of the articulation between the polyethylene and head articulation, or loss of the polyethylene protective rim and escape of the femoral head from the polyethylene liner,1-3 or dissociation of the polyethylene component from the femoral head.9 the literature indicates an incidence of 1.9% to 5.2% in older generation designs.3 the older generation designs failed due to progressive wear of the capture mechanism leading to the ipd.11,12 ipd is a late complication occurring eight to 11 years post-operatively with conventional polyethylene.9 the current dual mobility designs have an ipd incidence of 0% to 2.4% with a followup period of six to nine years.3 the current designs lack a capture figure 1. ap radiograph of the pelvis demonstrating the dislocated left hip prosthesis figure 2. pelvis ap radiograph demonstrating the revision total hip replacement with the dual mobility cup cemented into the cage figure 3. ap radiograph of the left hemipelvis demonstrating the dislocated left hip prosthesis figure 4. the dissociated components of the dual mobility head page 51sekeitto ar et al. sa orthop j 2021;20(1) mechanism, with the head being press-fitted in the polyethylene component. de martino et al.9 in their systematic review found 19 early (within nine months) ipd in modern dmc designs. ipd cannot be reduced closed and requires operative management, with change of modular head and liner or revision of the acetabular cup.9,11 tabori-jensen et al.13 in their cohort of 966 dmcs observed eight ipd, six of which were related to an attempted closed reduction of dislocation. all required revision surgery with liner and femoral head replacement. they had 45 dmc dislocations and found that increased cup inclination (p=0.04) and cup retroversion (p<0.001) were risk factors in the dislocation group. although it has been suggested, dmcs are not limited to the lewinnek safe zones.14 addona et al.15 reported five cases of ipd in their single surgeon case series, all of which were secondary to an attempted closed reduction of a dmc dislocation. in addition, rotini et al.16 reported on two cases of ipd secondary to an attempted closed reduction. the review of the literature makes our case the 35th early ipd and 31st secondary to an attempted closed reduction of a dislocated dmc. biomechanics the principle of the dmc is the smaller inner femoral head which is in keeping with charnley’s low friction arthroplasty and the larger unconstrained polyethylene component within the cup.13 the dual mobility design has two articulating surfaces. the primary articulation takes place between the femoral head and the polyethylene component during activities of daily living (adl).3 the secondary articulation occurs between the polyethylene component and the acetabular shell, and is involved in activities beyond the usual adl which involve extremes of motion, resulting in contact of the neck of the femoral stem and rim of the polyethylene component,3 and allowing the secondary articulation to extend the range of movement. the design allows for a greater arc of motion,1 increased ‘jump distance’ and increased head-to-neck ratio which increases stability (mckee-farrar principle),17 and resulting reduced dislocation/subluxation risk.3,4,18 modern designs the complication of ipd has been addressed with modern designs. modern design modifications include: smooth neck surfaces, skirts on the femur, retentive rim modifications to press-fitted head, increased tolerances of external and internal diameters, modern polyethylene and alterations in fixation surfaces, cup configuration and femoral neck design.1 philippot and colleagues found in their study report of late ipd that the most common cause was secondary play of the inner head due to polyethylene wear.2 the use of highly crosslinked polyethylene has decreased wear and subsequent ipd secondary to play of the inner head.3,9 the use of skirted femoral heads has been recommended against. the risk is earlier neck–cup impingement in the arc of motion due to reduction of the head-to-neck ratio and increasing the potential dislocation risk.9,14 the available literature that was reviewed shows no cases of early ipd occurring in patients with a femoral head smaller than 28 mm or in patients in which the dmc was used in conjunction with a skirted femoral head.9 chouteau et al.19 reported no cases of ipd in their cohort of 240 fourth-generation dmcs at 7to 11-year follow-up, highlighting the rarity of the complication in modern designs and ultra-high molecular weight polyethylene. the potential for polyethylene wear with subsequent ipd still exists and may present several years after implantation.20 component pairing the literature reports off-label practice of mixing components from different manufacturers at revision procedures to minimise complications in removing well-fixed components, if the components are appropriately sized.21 de martino et al.9 indicated within their reported cases only six reported cases (32%) of early ipd occurring in patients with a femoral head and polyethylene liner manufacturers’ mismatch. there were a further nine cases (47%) in patients with no mismatch, and in four cases (21%) the components were not specified.9 component pairing is a suspected risk factor for ipd.9 in our case the components were matched. spinopelvic malalignment spinal abnormalities have been identified as a risk factor for tha instability. spinal abnormalities such as degenerative disease and spinal fusions result in reduced pelvic flexion.5 the pelvis has normal motion from standing to sitting which involves a pelvic posterior tilt arc of motion of 20 degrees and hip flexion ranging 55 to 70 degrees. the acetabular anteversion and inclination increases as the pelvis tilts posteriorly during sitting, and this facilitates the clearance of the femoral head and neck during hip flexion. the loss of this natural motion caused by stiffness of the spine results in compensatory increased hip motion which increases the risk of impingement and subsequent dislocation.22 iatrogenic ipd has been described in the setting of closed reduction of a hemiarthroplasty; this phenomenon was called the ‘bottle opener’ effect by loubignac and boissier.23 the proposed mechanism is that during closed reduction there is engagement of the polyethylene liner with the acetabular rim or in the setting of a dual mobility head on the acetabular cup. this is followed by dissociation of the inner bearing surface. this mechanism has been cited in reported early cases.2,15,21 to reduce the incidence of ipd, the reduction of dislocated dmc should not be attempted under conscious sedation and instead under general anaesthesia with muscle relaxation to prevent muscle contraction and subsequent rim impingement.14-16 in cases of dislocated dmc, care should be taken during the reduction, and it is also recommended to use intraoperative imaging to ensure both bearing surfaces are concentric after reduction.9 this described mechanism is in keeping with our presented case. classification philippot et al. proposed a classification which was mechanistic based on radiographic and intra-operative findings. type 1 is due to wear of polyethylene retentive rim and the absence of arthrofibrosis and loosening. type 2 is due to blocking of the larger polyethylene articulation resulting from arthrofibrosis or heterotopic ossification. type 3 is due to loosening.2 this classification proposed three causes of intraprosthetic dislocation based on the respective aetiology. we propose a modification of this classification to include a type 4 iatrogenic. conclusion dmc offers increased stability in tha. our case study presents the 31st reported case of early ipd as a complication of an attempted closed reduction of a dmc dislocation. the limited literature is insufficient to summarise the mechanisms of ipd. the diagnosis of ipd is an indication for revision surgery of the dmc. when utilising page 52 sekeitto ar et al. sa orthop j 2021;20(1) 16. rotini m, cianforlini m, aucone d, pacetti e, politano r. iatrogenic intraprosthetic dislocation after closed reduction of dual mobility total hip arthroplasty: report of two cases. int j surg case rep. 2020;71:225-29. https://doi.org/210.1016/j.ijscr.2020.1004.1085. 17. mckee g, watson-farrar j. replacement of arthritic hips by the mckee-farrar prosthesis. j bone joint surg br. 1966;48(2):245-59. 18. terrier a, latypova a, guillemin m, parvex v, guyen o. dual mobility cups provide biomechanical advantages in situations at risk for dislocation: a finite element analysis. int orthop. 2017;41(3):551-56. https://doi.org/510.1007/ s00264-00016-03368-z. 19. chouteau j, rollier jc, bonnin mp, et al. absence of instabilities and intra-prosthetic dislocations at 7 to 11 years following tha using a fourthgeneration cementless dual mobility acetabular cup. j exp orthop. 2020;7(1):51. https://doi.org/10.1186/s40634-40020-00265-40633. 20. you d, sepehri a, kooner s, et al. outcomes of total hip arthroplasty using dual mobility components in patients with a femoral neck fracture. bone joint j. 2020;102-b(7):811-21. https://doi.org/810.1302/0301-1620x.1102b1307. bjj-2019-1486.r1301. 21. de martino i, d’apolito r, waddell bs, et al. response to letter to the editor on ‘early intraprosthetic dislocation in dual-mobility implants: a systematic review’. arthroplast today. 2018;4(1):133-34. https://doi.org/110.1016/j. artd.2017.1011.1005. 22. hiroyuki i, dorr l, transolini n, et al. spine-pelvis-hip relationship in the functioning of a total hip replacement. j bone joint surg am. 2018;100a(18):1606-15. https://doi.org/1610.2106/jbjs.1617.00403. 23. loubignac f, boissier f. [cup dissociation after reduction of a dislocated hip hemiarthroplasty]. rev chir orthop reparatrice appar mot. 1997;83(5):469-72. pmid: 9452801 a dmc, care should be taken to mitigate against the known risk factors for ipd – notably all dual mobility dislocation should be reduced under general anaesthesia with muscle relaxant. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. the patient provided written informed consent for print and electronic publication of the case report. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions as: data analysis, first draft preparation, manuscript preparation kvj: data capture, data analysis ns: manuscript revision lm: manuscript revision dvj: study conceptualisation, manuscript revision references 1. henawy at, abdel badie a. dual mobility total hip arthroplasty in hemiplegic patients. sicot j. 2017;3:40. https://doi.org/10.1051/sicotj/2017024. 2. philippot r, boyer b, farizon f. intraprosthetic dislocation: a specific complication of the dual-mobility system. clin orthop relat res. 2013;471(3):965-70. https://doi.org/910.1007/s11999-11012-12639-11992. 3. plummer dr, haughom bd, della valle cj. dual mobility in total hip arthroplasty. orthop clin north am. 2014;45(1):1-8. https://doi.org/10.1016/j. ocl.2013.1008.1004. 4. plummer dr, christy jm, sporer sm, paprosky wg, della valle cj. dual-mobility articulations for patients at high risk for dislocation. j arthroplasty. 2016;31(9 suppl):131-35. https://doi.org/110.1016/j.arth.2016.1003.1021. 5. rowan fe, salvatore aj, lange jk, westrich gh. dual-mobility vs fixed-bearing total hip arthroplasty in patients under 55 years of age: a singleinstitution, matched-cohort analysis. j arthroplasty. 2017;32(10):3076-81. https://doi.org/3010.1016/j.arth.2017.3005.3004. 6. gwam c, mistry j, mohamed n, et al. current epidemiology of revision total hip arthroplasty in the united states: national inpatient sample 2009 to 2013. j arthroplasty. 2017;3(7):2088-92. https://doi.org/2010.1016/j. arth.2017.2002.2046. 7. bozic k, kurtz s, lau e, et al. epidemiology of revision total hip arthroplasty in the united states. j bone joint surg am. 2009;91(1):128-33. 8. haynes j, stambough j, sassoon a, et al. contemporary surgical indications and referral trends in revision total hip arthroplasty: a 10-year review. j arthroplasty. 2016;31(3):622-25. https://doi.org/610.1016/j. arth.2015.1009.1026. 9. de martino i, d’apolito r, waddell bs, et al. early intraprosthetic dislocation in dual-mobility implants: a systematic review. arthroplast today. 2017;3(3):197202. https://doi.org/110.1016/j.artd.2016.1012.1002. 10. sutter eg, mcclellan tr, attarian de, et al. outcomes of modular dual mobility acetabular components in revision total hip arthroplasty. j arthroplasty. 2017;32(9s):s220-s224. https://doi.org/210.1016/j.arth.2017.1003.1035. 11. mcarthur ba, nam d, cross mb, westrich gh, sculco tp. dual-mobility acetabular components in total hip arthroplasty. am j orthop (belle mead nj). 2013;42(10):473-78. 12. hernigou p, dubory a, potage d, roubineau f, flouzat lachaniette ch. dual-mobility arthroplasty failure: a rationale review of causes and technical considerations for revision. int orthop. 2017;41(3):481-90. https://doi. org/410.1007/s00264-00016-03328-00267. 13. tabori-jensen s, hansen tb, stilling m. low dislocation rate of saturne®/ avantage® dual-mobility tha after displaced femoral neck fracture: a cohort study of 966 hips with a minimum 1.6-year follow-up. arch orthop trauma surg. 2019;139(5):605-612. https://doi.org/610.1007/ s00402-00018-03093-00408. 14. neri t, boyer b, batailler c, et al. dual mobility cups for total hip arthroplasty: tips and tricks. sicot j. 2020;6:17. https://doi.org/10.1051/sicotj/2020018. 15. addona jl, gu a, de martino i, et al. high rate of early intraprosthetic dislocations of dual mobility implants: a single surgeon series of primary and revision total hip replacements. j arthroplasty. 2019;34(11):2793-98. https:// doi.org/2710.1016/j.arth.2019.2706.2003. 404 not found maqungo s et al. sa orthop j 2018;17(2) doi 10.17159/2309-8309/2018/v17n2a4 south african orthopaedic journal http://journal.saoa.org.za traumatrauma citation: maqungo s, swan a, naude p, held m, kruger n, mccollum g, laubscher m. the management of low velocity transarticular gunshot injuries: a pilot study. sa orthop j 2018;17(2):25–27. http://dx.doi.org/10.17159/2309-8309/2018/v17n2a4 editor: prof anton schepers, university of the witwatersrand received: february 2017 accepted: june 2017 published: may 2018 copyright: © 2018 maqungo s, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no external funding was received for this study. conflict of interest: the authors have no conflicts of interest to declare. abstract objectives: to prospectively evaluate the incidence of superficial and deep wound sepsis in a cohort of patients who sustained low velocity transarticular gunshot wounds. methods: we performed a prospective, randomised, non-blinded pilot study of all adults presenting to a single institution between november 2011 and january 2015 that sustained a transarticular gunshot injury with no definite indication for surgery. we defined indications for surgery as: retained bullet or bullet fragments that warranted surgical removal or the presence of skeletal injuries that required surgical intervention. patients were randomised into two treatment groups. the conservative treatment group received antitetanus toxoid and antibiotics alone, and the surgical treatment group received anti-tetanus toxoid and antibiotics, as well as formal arthrotomy, debridement and irrigation. setting: single level 1 university hospital trauma centre. main outcome measurements: the two groups were assessed for development of septic arthritis or superficial wound infection. results: we identified 30 transarticular gunshot wounds in 29 patients with an average age of 29.5 years (range 18–74). sixteen (53%) were treated conservatively and 14 (47%) had a formal arthrotomy and washout. the median follow-up period was 20 days (range 5–84) for the conservative group and 30 days (range 8–84) for the operative group. no wound or intra-articular sepsis was observed for any of the 30 gunshot wounds. conclusion: it can be concluded, with appropriate caution, that there may be a place for non-operative treatment of low-velocity transarticular gunshot injuries without a demonstrable increased risk of infection. level of evidence: level 2 key words: septic arthritis, wound infection, civilian gunshot wounds, transarticular injuries the management of low velocity transarticular gunshot injuries: a pilot study maqungo s¹, swan a¹, naude p¹, held m¹, kruger n², mccollum g¹, laubscher m¹ ¹ fc ortho; orthoballistics research unit, department of orthopaedic surgery, university of cape town, groote schuur hospital, cape town, south africa ² fcs sa orth; orthoballistics research unit, department of orthopaedic surgery, university of cape town, groote schuur hospital, cape town, south africa corresponding author: prof sithombo maqungo, department of orthopaedic surgery, h49 old main building, main road, observatory, groote schuur hospital; tel: +27214045108; email: sithombo@msn.com page 26 maqungo s et al. sa orthop j 2018;17(2) introduction south africa has a high incidence of interpersonal violence, including penetrating trauma. gunshot-related injuries and death form a significant portion of this.1 transarticular gunshot injuries remain uncommon, but due to an increasing number of civilian gunshot injuries, they are becoming more prevalent. the management of transarticular gunshot wounds with significant skeletal injuries as well as retention of bullet fragments in joints is well established. this involves operative fracture fixation and removal of any retained shrapnel, which can be achieved via open or arthroscopic means. the literature does not firmly dictate management of low velocity transarticular gunshot injuries that do not require skeletal fixation or shrapnel removal. the question of whether these injuries should be treated non-operatively or surgically with joint debridement and irrigation remains unanswered. the few available studies are based on high velocity injuries sustained in military conflict. there is a high degree of contamination and tissue damage that accompanies high velocity gunshot injuries and as such formal debridement and arthrotomy are deemed mandatory.2 objective the aim of this study was to prospectively evaluate the incidence of superficial and deep wound sepsis in a cohort of patients who sustained low velocity transarticular gunshot wounds not requiring internal fixation, or removal of retained intra-articular bullets or fragments. patients were managed either non-operatively or surgically. our hypothesis was that the infection rate would be low and similar in both treatment groups. methods a prospective, randomised, non-blinded pilot study was conducted on a consecutive series of patients presenting to a single level 1 trauma unit. all patients that met the inclusion criteria were recruited into the study. informed consent was obtained in all patients. the proposal was reviewed and approved by the human research ethics committee of our institution. inclusion criteria inclusion criteria were: a patient sustaining a low velocity transarticular gunshot injury with no definite indication for surgery. indications for surgery included: retained bullet or bullet fragments that warranted surgical removal or the presence of skeletal injuries that required surgical intervention. index group the index group received non-operative treatment which consisted of anti-tetanus toxoid administration and a single dose of intravenous prophylactic antibiotics (penicillin or clindamycin if allergic to penicillin). this was administered at presentation to our institution, if they had not already received a dose of antibiotics from the referral centre. control group the control group received antibiotics as per the index group protocol. in addition, they underwent surgical debridement of the bullet tract, as well as arthrotomy and irrigation of the involved joint. a routine pre-operative single dose of intravenous cephazolin or clindamycin was administered prior to surgery. a tourniquet was used when possible. outcomes the primary outcome was the development of superficial wound infection or a septic arthritis. patients were followed up for clinical signs of superficial and deep sepsis during admission and at routine clinic follow-up appointments at two, six and twelve weeks. superficial infection was defined as infection that was limited to the skin or subcutaneous tissue, not requiring surgical debridement. deep infection was defined as infection of the deep tissues or joint space requiring formal surgical debridement. if superficial sepsis was diagnosed, the protocol was to send a wound swab for microscopy, culture and sensitivity, and monitor inflammatory markers using erythrocyte sedimentation rate (esr). wounds were to be managed topically and with oral antibiotics. the type and duration of antibiotic therapy in both groups was to be recorded. if deep wound sepsis was diagnosed the protocol was again to monitor esr and perform formal debridement and irrigation of the infected wound. tissue samples were to be sent for microscopy, culture and sensitivity. randomisation simple random sampling was obtained utilising sealed envelopes. blinding the patient, attending clinician and principal investigator were not blinded to the treatment groups. statistical analysis simple descriptive statistics were to be used to describe categorical data. results thirty transarticular gunshot injuries in 29 patients met the inclusion criteria during the recruitment period from november 2011 to january 2015. one patient sustained bilateral knee gunshot injuries. sixteen (53%) injuries were randomised to the non-operative treatment group, and 14 (47%) to the operative treatment group. the mean age of patients was 30 years (range 15–59) for the nonoperative group and 30 (range 18–74) for the operative treatment group. twenty-seven of the 29 patients were males. the most commonly injured joints were knees (83%), with 13 gunshot injuries treated non-operatively, and 12 injuries treated operatively (table i). the median follow-up period was 20 days (range 5–84) for the conservative group and 30 days (range 8–84) for the operative group. no superficial or deep sepsis was observed in any of the 30 injuries across both groups. statistical significance could not be demonstrated with these limited patient numbers. table i. distribution of operative and non-operative transarticular gunshot injuries operative non-operative knee 12 13 shoulder 1 3 elbow 1 0 total 14 16 page 27maqungo s et al. sa orthop j 2018;17(2) discussion ganocy3 et al. reviewed the literature on low-velocity transarticular gunshot and identified three key factors in the management algorithm, namely: bullet or bullet fragments’ ultimate location, contamination as well as fracture configuration. based on these factors a classification system was proposed to guide the management of these injuries. in fractures not requiring internal fixation, with absence of contamination, and no intra-articular bullet or fragments, conservative management with antibiotics was proposed. it was recommended that bullet fragments lodged in bone or soft tissue that are in communication with the intra-articular space should be treated on an individualised basis, unless there had been obvious bacterial contamination of the projectile. the presence of retained intra-articular bullet or fragments mandates formal surgical debridement, irrigation and removal of the projectile.3 there is a common misconception that the heat generated in firing a projectile results in auto-sterilisation. this has been disproven in both experimental and animal models. it has been demonstrated that bacterial contamination of the wound usually occurs immediately as bacteria are sucked into the wound by the vacuum effect, or contamination of the projectile as it passes through clothing or skin.4-6 the clinical relevance of this remains disputed, and there is no firm recommendation in the literature for or against the use of prophylactic antibiotics in the management of low velocity extraarticular, or intra-articular fractures not requiring internal fixation.7,8 however, it is recommended that treatment with antibiotics for intraarticular fractures be considered on clinical grounds.7 in a retrospective case series by junkin et al.9 consisting of 18 patients with transarticular gunshot knee injuries, all patients received early intravenous cephalosporin or clindamycin. on average follow-up of 16.6 days post discharge, no sepsis was observed for four patients managed conservatively, nine who had surgical debridement, or five who had surgical debridement and internal fixation.9 long et al. in an analysis of transarticular gunshot injuries of the hip concluded that transarticular low velocity gunshot injuries to the hip without bowel penetration, minimal bone injury, and with the bullet no longer in contact with synovial fluid, could be managed conservatively.10 this is confirmed in our results with no difference in sepsis rates shown between treatment groups. one needs to be aware that these injuries may often be difficult to appreciate on plain radiographs.11 in two case series of seven and eight patients undergoing arthroscopy of the knee following transarticular gunshot injury with no definite indication for surgery, foreign material such as clothing, shrapnel and osteochondral fragments not appreciated on plain films were found in the majority of patients.12-13 tornetta et al.14 in a similar series of 33 patients identified 14 meniscal injuries, five chondral injuries and five cases of intra-articular of debris or bullet fragments not suspected on plain radiographs. it was recommended to inspect the clothing for defects when possible, as this may hint at retained foreign material in the wound tract or joint.14 other clinical parameters such as time to union, range of motion or mechanical symptoms of the affected joint were not assessed in our study. limitations a small cohort of patients, a high drop-out rate and short follow-up periods are obvious limitations of this study. these are rare injuries and this sub-group of patients is notoriously a difficult group to follow up as shown in other studies15,16 we also did not run any statistical analysis on the results as there were no clinical differences between the two groups. with an estimated infection rate of 5% extrapolated from open fracture data, power analysis meant we would require an estimated 274 patients in each arm to demonstrate the lack of statistical difference between conservative or operative management. our study is therefore underpowered. this study is best viewed as a pilot study to inspire and guide a well-designed and properly powered clinical research study. conclusion it can be concluded, with appropriate caution, that there may be a place for non-operative treatment of low-velocity transarticular gunshot injuries without a demonstrable increased risk of infection. ethics statement this study adheres to the helsinki declaration of 2008. the proposal was reviewed and approved by the human research ethics committee of our institution. references 1. seedat m, van niekerk a, jewkes r, suffla s, ratele k. violence and injuries in south africa: prioritizing an agenda for prevention. lancet 2009; 374(9694):1011-22. 2. griffiths d, clasper j. military limb injuries/ballistic fractures. curr orthop 2006;20:346-53. 3. ganocy k, ronald w. the management of civilian intra-articular gunshot wounds: treatment considerations and proposal of a classification system. injury 1998;29(1):sa1-sa6. 4. wolf aw, benson dr, shoji h, hoeprich p, gilmore a. autosterilization in low-velocity bullets. j trauma 1978;18(1)63. 5. tian hh, huang mj, liu yq, wang zg. primary bacterial contamination of the wound tract. acta chir scand suppl 1982;508:265-69. 6. tian hh, deng gg, huang mj, tian fg, suang gy, liu yg. quantitative bacteriological study of the wound track. j trauma suppl 1988;28:215-16. 7. holtom pd. antibiotic prophylaxis: current recommendations. j am acad orthop surg 2006;14:98-100. 8. simpson bm, wilson rh, grant re. antibiotic therapy in gunshot wound injuries. clin orthop relat res 2003;408:82. 9. junkin d, delong, w, lucas, j. intra-articular civilian gunshot wounds to the knee: initial management and early treatment. j orthop surg & sports med 2007;2:2-25. 10. long wt, brien ew, boucree jr jb, filler b, stark hh, dorr ld. management of civilian gunshot injuries to the hip. orthop clin north am 1995;26(1):123-31. 11. dougherty pj, vaidya r, silverton cd, barlett c, najibi s. joint and long-bone gunshot injuries. j bone joint surg am 2009;91:980-97. 12. 12. ashby me. low-velocity gunshot wounds involving the knee joint: surgical management. j bone joint surg 1974;56a(5):1047-53. 13. parasien js, esformes i. the role of arthroscopy in the management of low velocity gunshot wounds of the knee. clin orthop 1984;185:207-13. 14. tornetta p, hui rc. intraarticular findings after gunshot wounds through the knee. j orthop trauma 1997;11(6):422-24. 15. swanepoel s, leong w, kruger n, laubscher m, mccollum g, maqungo s. subtrochanteric femur fractures caused by low velocity gunshots. results of intramedullary nailing. sa orthop. j., sept 2017;16(3):46-50. 16. maqungo s, kauta n, dachs r, mccollum g, held m, roche s. early clinical outcomes of isolated low velocity gunshot radius fractures treated with closed reduction and locked intramedullary nailing. sa orthop. j., june 2016;15(2):28-31. orthopaedics vol3 no4 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 53 achilles tendinopathy part 2: surgical management dr a horn mbchb(pret) registrar dr ga mccollum mbchb(uct), fcorth(sa), mmed(uct) consultant orthopaedic surgeon department of orthopaedic surgery, groote schuur hospital, cape town corresponding author: dr anria horn postnet suite 342 private bag x18 rondebosch 7701 cape town email: anriahorn@gmail.com cell: 071 679 4228 work: 021 404 5108 introduction tendinopathy of the main body of the achilles tendon is a common condition affecting both athletes and the sedentary population. the aetiology of this painful condition is largely unknown and exhaustive research has elucidated numerous and complex contributing intrinsic and extrinsic factors. the diagnosis is clinical, although imaging modalities such as mri and ultrasound are useful in confirming the diagnosis in cases of clinical equipoise. conservative management, mostly involving an eccentric exercise regimen, is the mainstay of treatment. the various conservative treatment modalities, as well as the aetiology, pathology and diagnosis of achilles tendinopathy is discussed in part 1 of this review (see sa orthopaedic journal, spring 2015 vol 14 no 3). this article will focus exclusively on the surgical treatment of noninsertional achilles tendinopathy. some 24–45.5% of patients suffering from achilles tendinopathy will not respond to conservative management and will require surgical intervention.1-6 surgery should be considered only once conservative means have been exhausted and the patient failed to improve or comply with a supervised rehabilitation programme. the goal of surgery is to modulate the cell-matrix environment in such a way that healing is promoted by improving vascularity and stimulating the remaining viable cells to regenerate.4 this was classically achieved by excision of fibrotic peritendinous adhesions and intratendinous degenerate nodules. abstract although non-surgical management is the mainstay of treatment for non-insertional achilles tendinopathy, many patients fail to respond to conservative measures. if symptoms persist after an extended period of conservative management, usually at least six months, surgery should be considered. classically, open surgery was performed with excision of the diseased areas of the tendon. due to a high rate of complications, as much as 10%, less invasive surgical techniques have been developed and are widely employed with good surgical outcomes and far fewer complications. the reported success rates of open and minimally invasive surgery are comparable and range from 46–100%. considering the significant morbidity associated with open surgery, minimally invasive surgery is recommended as initial intervention, followed by open surgery if symptoms persist. key words: achilles tendinopathy, main body, surgery, minimally invasive surgery, tendon http://dx.doi.org/10.17159/2309-8309/2015/v14n4a7 conservative management, mostly involving an eccentric exercise regimen, is the mainstay of treatment saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 53 page 54 sa orthopaedic journal summer 2015 | vol 14 • no 4 more recently, attention has shifted towards disrupting the pathological peritendinous neoneurovascularisation that has been shown to be intimately related to the severity of the disease.7 the recent development of minimally invasive techniques has decreased the high complication rates seen with open surgery and shows promising results, although some authors express a concern regarding higher risk for certain complications such as sural nerve damage.8 the rehabilitation period is also much reduced with the use of minimally invasive procedures. open surgical management of achilles tendinopathy open tenotomy with excision of fibrotic adhesions and degenerate intratendinous lesions the patient is positioned prone and the tendon is approached through an incision medial to the medial border of the tendon to avoid damage to the sural nerve and vein. the paratenon is identified and incised. if there are dense, fibrotic adhesions found within the paratenon, these are excised leaving as many layers of normal paratenon intact as possible.9 care must be taken to avoid the anterior surface of the tendon lying adjacent to kager’s fat pad, as the majority of the tendon’s blood supply is believed to originate here.10 pre-operative imaging can guide the surgeon as to the location of any intratendinous lesions; alternatively two to three longitudinal tenotomies are made to identify areas of degeneration. these areas will lack the usual shiny appearance of normal tendon tissue and would have an appearance resembling ‘crab meat’ (figure 1).6 these degenerate nodules are sharply excised and the defect repaired by end-to-end suturing (figure 2a and 2b). if the defect exceeds 50% of the surface area of the tendon, consideration should be given to one of various augmentation procedures:4 1) a tendon turndown flap can be fashioned by dissecting out one or two strips of achilles tendon proximally at the musculotendinous junction. these strips are developed proximally but left attached distally and flipped 180 degrees to bridge the gap formed by the excised nodules.6 2) the plantaris tendon, found on the medial aspect of the tendo achilles, may be used, either as a free graft or left attached distally to augment the tendon defect.6 3) the flexor hallucis longus (fhl) tendon may be used in various ways to augment the degenerate achilles tendon (figure 3). several studies have shown good to excellent outcomes in patients over 50 years of age with fhl tendon transfers for the treatment of insertional and non-insertional tendinopathy, as well as tendon ruptures.11-13 4) the peroneus brevis14 or flexor digitorum5 tendons have also been used as autologous graft to repair and augment the achilles tendon after debridement. post-operatively, the patient is kept non-weightbearing for 2 weeks, or 6 weeks if a tendon transfer has been performed. weight bearing is initially protected in a boot or walking cast. range of motion and strengthening exercises are initiated at 4–6 weeks and return to activity is allowed when strength has been regained, usually 4–6 months after surgery.10 reported success rates following open surgery of the achilles tendon range from 46%–100%.4,5,10,15,16 in a critical review by talon et al.5 assessing 26 published papers, there was a negative correlation between study methodology and good outcomes, which partially explains the discrepancy between the favourable results published in the literature and those which are observed in clinical practice. figure 1. longitudinally incised tendon showing abnormal tendon tissue resembling ‘crab meat’ figure 2a. opening of the paratenon figure 2b. excision of diseased tendon tissue a b pre-operative imaging can guide the surgeon as to the location of any intratendinous lesions; alternatively two to three longitudinal tenotomies are made to identify areas of degeneration saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 54 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 55 in one 7-month prospective follow-up study evaluating 42 patients who had open surgery for chronic achilles tendinopathy, 67% of patients had returned to their previous level of activity and 83% of patients were asymptomatic. it was also noted that those patients who had intratendinous lesions fared worse that those who had isolated paratendinopathy.17 alfredson et al. followed up 14 patients, eight years after they had undergone surgery for achilles tendinopathy. all patients were satisfied with the outcome and experienced no activity restriction. ultrasound investigation revealed persistence of structural tendon abnormalities, as well as an increase in tendon thickness.18 saxena reviewed 27 athletes who had a variety of surgical procedures for chronic achilles tendinopathy. elite athletes returned to their previous sporting activities in 7.9 ± 4.8 weeks and non-elite athletes in 15.0 ± 6.2 weeks. three patients in this series required re-operation.19 maffulli, in an age-matched series comparing men and women, found that women had significantly worse outcomes following surgery and were far less likely to return to their previous level of activity, regardless of whether or not they were physically active prior to surgery.20 the complication rate for open achilles tendon surgery is reported to be as high as 10%, with 25% of these being major complications.9 (major and minor complications are listed in table i.) risk factors for developing complications are increased age, pre-operative steroid injections, poor attention to haemostasis intraoperatively, undermining of the skin edges and excessive stripping of the paratenon.9,17 gastrocnemius recession the concept of gastrocnemius lengthening for the treatment of resistant achilles tendinopathy was first suggested by duthon et al.21 in 2003. this was based on the premise that a contracted achilles tendon leads to altered biomechanics in the hindfoot and is a well-known aetiological factor for the development of achilles tendinopathy. they performed a gastrocnemius recession as described by strayer22 on 17 tendons in 14 patients who demonstrated gastrocnemius contracture pre-operatively, as evidenced by a positive silfverskiold test.23 all but one patient were satisfied with the outcome of surgery, and 11 of the 14 could return to their previous sporting level. mri following surgery demonstrated reduction in size and number of hyperintense lesions and tendon thickness, signifying an improvement of the tendinopathy. there were no surgical complications in this series. kiewiet et al.24 performed this procedure for 12 patients with contracted achilles tendons and chronic tendinopathy. all patients had significantly improved aofas hindfoot scores (range 75–100) and only one patient had persistent pain. there were no complications in this series. table i: complications associated with open surgery for achilles tendinopathy9 major complications minor complications re-rupture of the achilles tendon permanent ankle equinus overlengthening of the achilles tendon deep infection chronic fistula formation skin necrosis deep vein thrombosis pulmonary embolism superficial infection wound haematoma delayed wound healing adhesion of the scar sensibility disturbance (hyperaesthesia or numbness) suture granuloma reported success rates following open surgery of the achilles tendon range from 46%–100% figure 3. flexor hallucis longus tendon being prepared to use as augmentation following debridement of the achilles tendon saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 55 page 56 sa orthopaedic journal summer 2015 | vol 14 • no 4 percutaneous surgical techniques percutaneous tenotomy this technique was first described by maffulli et al.8 in the early 1990s. the patient is positioned prone with the feet hanging over the edge of the operating table. general or local anaesthesia may be used. the area of maximal swelling is identified, and ultrasound may be used if the lesions are not clinically obvious. a stab incision is made in the middle of the tendon with a size 11 blade, cutting edge pointing caudally. the ankle is then moved through a full range of plantarand dorsiflexion. the blade is then partially extracted and rotated 180 degrees so that the cutting edge points cranially and the ankle is again moved through a full range of plantarand dorsiflexion. cadaver studies have shown the resultant longitudinal tenotomy to be approximately 3 cm in length. this procedure is then repeated through stab wounds placed proximally and distally medial and lateral to the original stab wound so that the pattern resembles the number 5 on a die. post-operatively the patient is allowed full weight bearing with or without a boot and physiotherapy is begun at 2 weeks following surgery. the same group that described this procedure published the outcomes of 63 athletes who underwent percutaneous tenotomy for recalcitrant achilles tendinopathy. forty-seven of the patients reported good to excellent results. nine patients with fair or poor results underwent formal exploration and debridement of the affected tendon 7–12 months after the index operation. poorer results were associated with pan tendinopathy, multiple steroid injections preoperatively and poor compliance with the prescribed rehabilitation protocol.25 the authors concluded that percutaneous tenotomy is a good surgical option for resistant achilles tendinopathy, but patients should be aware that in the case of multinodular disease and extensive paratenon disease, open surgery will be required. minimally invasive stripping of the paratenon this technique was first described by maffuli et al.8 in 2008 but no published review of outcomes for this technique exists at present. the procedure is performed through four stab incisions, two proximally and two distally, on either side of the tendon. a size 1 suture is passed through the two proximal incisions ventral to the tendon and then extracted distally through the two distal incisions. the suture is then pulled distally with a see-saw motion, effectively freeing the tendon from the surrounding paratenon and disrupting neovascularisation. the procedure is repeated with the suture passed along the dorsal surface of the tendon. this can be combined with percutaneous tenotomies. the rationale for this procedure is based on the fact that numerous studies have shown a direct relation between neovascularisation and pain in chronic achilles tendinopathy.1,6,26,27 achilles tendoscopy endoscopic surgery for the disorders of the achilles tendon has been practised since the beginning of the century as an alternative to open surgery, in the hope of reducing c omplications seen with open procedures.27 the goal of achilles tendoscopy is to release fibrous adhesions around the tendon and paratenon, to strip pathological neovascularisation of the ventral surface of the tendon and to release the plantaris tendon.27,28 it has recently been suggested that a thickened, adherent plantaris tendon might be causative, or at least contributory in the development of mid-portion achilles tendinopathy.29-31 the tendoscopy can be performed through a proximal medial and distal lateral portal, or through two medial portals, using a 2.7 mm scope. care is taken to avoid damage to the neurovascular structures by staying on the surface of the tendon at all times. the endoscopic release can be combined with longitudinal tenotomies if intratendinous pathology is also present. preliminary results using this method are promising. steenstra et al. reported on 20 patients who underwent paratenon release only. all patients experienced pain relief and improved hindfoot scores, and most were able to return to sporting activities within 4–6 weeks.32 a few other small studies assessing outcomes following tendoscopy, with and without tenotomy, also reported good to excellent outcomes in all patients, return to previous level of activity and no complications.28,33,34 conclusion the mainstay of treatment of achilles tendinopathy is nonoperative management but for those patients who fail to respond to such measures, surgical treatment remains a feasible option. there have been many promising developments in the field of surgical management for chronic achilles tendinopathy with encouraging preliminary outcomes. extensive intratendinous disease requires open surgery with excision of the degenerate intratendinous lesions, and augmentation with tendon transfers if more than 50% of the width of the tendon has been excised. newer, minimally invasive surgeries, such as percutaneous tenotomies, are effective in treating less extensive disease and pose an attractive alternative to the classic open surgery in terms of complications and accelerated rehabilitation. current evidence is however limited to small series with short follow-up. further large prospective studies are needed to define the role of novel surgical techniques in the management of this complex condition. declaration: the content of this article is the sole work of the authors. no benefits of any form have been or are to be received from a commercial party related directly or indirectly to the subject of this article. minimally invasive stripping of the paratenon was first described by maffuli et al.8 in 2008 but no published review of outcomes for this technique exists at present saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 56 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 57 references 1. paavola m, kannus p, järvinen tah et al. achilles tendinopathy: current concepts review. j bone joint surg [am]2002;84-a(11):2062-75. 2. paavola m, kannus p, paakkala t, et al. long-term prognosis of patients with achilles tendinopathy: an observational 8-year follow-up study. am j sports med 2000;28(5):634-42. 3. maffulli n, binfield pm, moore d, king jb. surgical decompression of chronic central core lesions of the achilles tendon. am j sports med 1999;27(6):747-52. 4. rees jd, maffulli n, cook j. management of tendinopathy. am j sports med 2009;37(9):1855-67. 5. talon c, coleman b, khan m, et al. outcomes of surgery for chronic achilles tendinopathy. a critical review. am j sports med 2001;29(3):315-20. 6. longo ug, ronga m, maffulli n. achilles tendinopathy. sports med arthrosc rev 2009;17:112-26. 7. longo ug, ramamurthy c, denaro v, et al. minimally invasive stripping for chronic achilles tendinopathy. disability and rehabilitation, 2008;30(20-22):1709-13. 8. maffulli n, longo ug, francesco o, et al. minimally invasive surgery of the achilles tendon. orthop clin n am 2009;40:491-98. 9. paavola m, orava s, leppilahti j, et al. chronic achilles tendon overuse injury: complications after surgical treatment. am j sports med 2000;28(1):77-82. 10. heckman ds, gluck gs, parekh sg. tendon disorders of the foot and ankle, part 2: achilles tendon disorders. am j sports med 2009;36(6):1223-33. 11. den hartog bd. flexor hallucis longus transfer for chronic achilles tendonosis. foot ankle int 2003;24:233-38. 12. hahn f, meyer p, maiwald c, et al. treatment of chronic achilles tendinopathy and ruptures with flexor hallucis tendon transfer: clinical outcome and mri findings. foot ankle int 2008;28:294-304. 13. wilcox dk, bohay dr, anderson jg. treatment of chronic achilles tendon disorders with flexor hallucis longus tendon transfer/augmentation. foot ankle int 2000;21:2004-11. 14. pintore e, barra v, pintore r, et al. peroneus brevis tendon transfer in neglected tears of the achilles tendon. j trauma 2001;50:71-78. 15. schepsis aa, wagner c, leach re. surgical management of achilles tendon overuse injuries: a long-term follow-up study. am j sports med 1994;22:611-19. 16. vulpiani mc, guzzini m, ferretti a. operative treatment of chronic achilles tendinopathy. int orthop 2003;27:307-10. 17. paavola m, kannus p, orava s, et al. surgical treatment for chronic achilles tendinopathy: a prospective seven-month follow-up study. br j sports med 2002;36:178-82. 18. alfredson h, zeisig a, fahlström m. no normalisation of tendon structure and thickness after intratendinous surgery for chronic painful midportion achilles tendinosis. br j sports med 2009;43:948-49. 19. saxena a. results of chronic achilles tendinopathy surgery on elite and non-elite track athletes. foot ankle int 2003;24:712-20. 20. maffulli n, testa v, capasso g, et al. surgery for chronic achilles tendinopathy produces worse results in women. disability and rehabilitation 2008;30(20-22):1714-20. 21. duthon vb, lubbeke a, duc sr. noninsertional achilles tendinopathy treated with gastrocnemius lengthening. foot ankle int 2011;32:375-80. 22. strayer lm.recession of the gastrocnemicus. j bone joint surg(am) 1950;32:671. 23. silvferskiold n. reduction of the uncrossed two-joint muscles of the leg to one-joint muscles in spastic conditions. acta chir scand 1924;56:315-30. 24. kiewiet nj, holthusen sm, bohay dr. gastrocnemius recession for chronic noninsertional achilles tendinopathy. foot ankle int 2013;34:481-86. 25. testa v, capasso g, benazzo f, et al. management of achilles tendinopathy by ultrasound-guided percutaneous tenotomy. med sci sports exerc 2002;34(4):573-80. 26. zanetti m, metxdorf a, kundert h, et al. achilles tendons: clinical relevance of neovascularisation diagnosed with power doppler us. radiology 2003;227(2):556-60. 27. roche aj, calder jdf. achilles tendinopathy. a review of current concepts of treatment. bone joint j 2013;95-b:1299-07. 28. maqquirriain j, ayerza m, costa m, et al. endoscopic surgery in chronic achilles tendonopathies: a preliminary report. arthroscopy 2002;18:298-303. 29. van sterkenburg mn, kerkhoffs gmmj, kleippol rp, et al. the plantaris tendon and a potential role in mid-portion achilles tendinopathy: an observational anatomical study. journ anat 2011;218(3):336-41. 30. van sterkenburg mn, van dijk cn. mid-portion achilles tendinopathy: why painful? an evidence-based philosophy. knee surg sports traumatol arthrosc 2011;19(8):1367-75. 31. alfredson h. midportion achilles tendinosis and the plantaris tendon. br j sports med 2011;45:1023-25. 32. steenstra f, van dijk cn. achilles tendoscopy. foot ankle clin 2006;11:429-38. 33. vega j, cabestany jm, golano p, et al. endoscopic treatment for chronic achilles tendinopathy. foot ankle clin 2008;14:204-10. 34. therman h, benestos is, panelli c, et al. endoscopic treatment of chronic mid-portion achilles tendinopathy: novel technique with short term results. knee surg sports traumatol arthrosc 2009;17:1264-69. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 57 south african orthopaedic journal spinal surgery doi 10.17159/2309-8309/2021/v20n2a8ukunda fun et al. sa orthop j 2021;20(2) citation: ukunda fun. mycobacterium xenopi osteomyelitis of the spine: a case report. sa orthop j 2021;20(2):114-116. http://dx.doi. org/10.17159/2309-8309/2021/ v20n2a8 editor: prof. robert dunn, university of cape town, cape town, south africa received: january 2020 accepted: june 2020 published: may 2021 copyright: © 2021 ukunda fun. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the author declares there are no conflicts of interest that are directly or indirectly related to the research. abstract background mycobacterium xenopi (m. xenopi) osteomyelitis is an uncommon infection which is found in immunosuppressed patients. it is reported to be a slow-growing, nonchromogenic or scotochromogenic nontuberculous mycobacterium. the lungs constitute the most common site for infection and extrapulmonary manifestations, and disseminated forms of the disease are rare. only a few cases of spontaneous spinal involvement have been reported. we report a case of m. xenopi vertebral osteomyelitis of the spine. patient and methods a 41-year-old female patient, hiv reactive on antiretroviral therapy with a low cd4 count of 183 cells/mm3, presented with clinical and radiological features in keeping with thoracic spinal tuberculosis, complicated with thoracic myelopathy. she was managed surgically with costotransversectomy and drainage of the paraspinal cold abscess. the ziehl–neelsen staining was negative for acid-fast bacilli. however, the histology result revealed a necrotising granulomatous inflammation. a delayed result of polymerase chain reaction (pcr)/line probe assay for mycobacterium genus testing revealed the presence of m. xenopi, as the cause for the spine osteomyelitis and thoracic myelopathy. however, no m. xenopi susceptibility testing, and no specific photoreactivity techniques for strain identification, were performed. anti-tuberculosis therapy (att) consisting of a two-month initiation phase using rifampicin, isoniazid, ethambutol and pyrazinamide, followed by a seven-month continuation phase using rifampicin and isoniazid, was initiated according to national guidelines. she was fitted with a thoraco-lumbar-sacral orthosis, and underwent a spinal rehabilitation programme. upon receipt of the pcr result, and considering the good clinical and radiological response to att, a consensus was reached with the infectious disease unit (idu) to continue with att until 18 months due to the atypical nature of the pathogen. results the patient was successfully treated with the standard tb regimen, but for a period of 18 months, and made full clinical neurological recovery, without any back pain. furthermore, her cd4 count had also improved to 707 cells/mm3 with a viral load reported lower than 1 000 copies/ml. conclusion this case report emphasises the importance of biopsy in suspected spinal tuberculosis and highlights the concerns with laboratory testing and the prognostic and therapeutic implications of a positive strain identification. level of evidence: level 5 keywords: mycobacterium xenopi osteomyelitis, tuberculosis, anti-tuberculosis treatment mycobacterium xenopi osteomyelitis of the spine: a case report fred un ukunda* department of orthopaedic surgery, chris hani baragwanath academic hospital, johannesburg, south africa; department of orthopaedic surgery, university of the witwatersrand, johannesburg, south africa *corresponding author: fredukunda@icloud.com introduction mycobacterium xenopi (m. xenopi) was first isolated in the united kingdom in 1959 by schwabacher from skin granulomas of a south african female toad (xenopus laevis). it is reported to be a slow-growing, nonchromogenic or scotochromogenic nontuberculous mycobacterium (ntm) with optimal growth speed at 42 °c.1 the lungs constitute the most common site for infection and particularly in hiv-reactive patients with cd4 counts below 100 cells/mm3.2,3 extrapulmonary manifestations and disseminated forms of the disease are rare.4 the first case of m. xenopi infection in humans was published in 1965 and since then only a few cases of spontaneous spinal involvement have been reported.5-9 however, cases of nosocomial vertebral infections have been reported following discovertebral surgery due to contaminated surgical instruments by tap water at a mean time of 5.6 years for diagnosis.10 a positive culture for m. xenopi raises the concern as to whether it is a contaminant or true pathogen.11 the difficulties in isolating the organism and recommendations for improving culture techniques have been reported in the literature.12,13 increasingly, rrna nucleic acid probe testing for m. xenopi is performed to confirm the diagnosis.14 the american thoracic society (ats) and infectious diseases society of america (idsa) guidelines for the diagnosis https://orcid.org/0000-0002-9284-6358 page 115ukunda fun et al. sa orthop j 2021;20(2) of ntm lung disease include clinical, radiological and microbiological criteria. the microbiologic criterion requires a positive culture from at least two separate expectorated sputum samples. unfortunately, no guidelines exist for the diagnosis of extrapulmonary manifestations.15,16 the optimal treatment for m. xenopi is yet to be identified. however, a recent study on mice shows significant bactericidal effect with ethambutol/ rifampicin combination with either clarithromycin or moxifloxacin.17 we report a case of thoracic spine osteomyelitis caused by m. xenopi, destroying three contiguous midthoracic vertebrae, causing spinal stenosis and myelopathy. the patient was successfully treated with anti-tb treatment (att),18 after limited cold abscess drainage. this case highlights the concerns with laboratory testing and the increased use of pcr in mycobacterial infection diagnosis. case report a 41-year-old female presented with a four-month history of progressive thoracic back pain and walking difficulty. at the time of presentation, she was wheelchair-bound and she had bladder and bowel incontinence. she was hiv reactive and was on antiretroviral therapy (art) since 2006. her clinical evaluation revealed no obvious gibbus, but there was spastic paraplegia (american spinal injury association impairment scale [asia] a)19 with a t4 sensory level. laboratory investigations revealed a raised erythrocyte sedimentation rate (esr) of 67 mm/hr, a c-reactive protein (crp) of 50 mg/l and a cd4 count of 187 cells/mm3. the thoracic spine x-rays revealed a double heart shadow and irregularity, and collapse of the t7 and t8 vertebrae. the stir and t2 mri scans showed three-level thoracic spine involvement (t6–t9), with spinal stenosis and paraspinal fluid collection and increased cord signal (figure 1). the working diagnosis of tuberculosis (tb) of the spine was made. the differential diagnosis of an atypical mycobacterial infection, a non-mycobacterial infection (fungal) and spine neoplasm were also considered. the patient underwent drainage of pus and caseous-like material through left-sided costo-transversectomy at t7/t8 level. specimens were sent for ziehl–neelsen staining, microscopy culture and sensitivity, and histology. the ziehl–neelsen staining was negative for acid-fast bacilli. however, the histology result revealed a necrotising granulomatous inflammation. no malignant cells were seen. anti-tuberculosis therapy (att) consisting of a two-month initiation phase using rifampicin, isoniazid, ethambutol and pyrazinamide, followed by a seven-month continuation phase using rifampicin and isoniazid, was initiated according to national guidelines,18 and a thoracolumbar-sacral orthosis was fitted. the patient was in a wheelchair for spine rehabilitation. at her four-month follow-up visit, the patient’s back pain had reduced significantly, and her neurology had improved to asia c. at this stage, review of supplementary laboratory results for polymerase chain reaction (pcr)/line probe assay for mycobacterium genus testing revealed the presence of m. xenopi. however, no m. xenopi susceptibility testing, and no specific photoreactivity techniques for strain identification were performed. the culture result showed no growth. her cd4 count had also improved to 707 cells/mm3 with a viral load reported lower than 1 000 copies/ml. the thoracic spine x-rays (figure 2) showed no progression of vertebral destruction with reduction of the paraspinal shadow seen at presentation. considering the good clinical and radiological response to att, a consensus was reached with the infectious disease unit (idu) to continue with att until 18 months due to the atypical nature of the pathogen. at the next follow-up visit, the patient’s neurology had improved to asia d, she was mobilising with crutches and she had good recovery of bowel and bladder control.the att was continued until she completed 18 months. at her last follow-up visit, she had full neurological recovery without any back pain and she returned to work. a b c d figure 1. the thoracic spine x-rays showed in (a) double heart shadow and (b) irregularity and the collapse of t7 and t8 vertebrae. the stir and t2 mri scans (c) and (d) show three-levels thoracic (t6–t9) spine involvement with spinal stenosis and paraspinal fluid collection, as well as cord signal. ba figure 2. last follow-up thoracic spine x-rays show no progression of vertebral destruction with reduction of the paraspinal shadow. page 116 ukunda fun et al. sa orthop j 2021;20(2) discussion the majority of clinical cases of m. xenopi have been found in the pulmonary specimens of hiv-reactive patients. although extremely rare, kulasegaram et al.16 report that extrapulmonary spinal m. xenopi has a clinical presentation somewhat similar to m. tuberculosis, but the progression seems slower. in most case reports, treatment was conservative with variable results.2,4 our patient confirms these observations, as she had a presentation like that of spinal m. tuberculosis, was hiv reactive with low immunity (cd4 count) and she responded well to att after limited cold abscess drainage. tissue diagnosis in the form of ct-guided, percutaneous or open vertebral biopsy, is always required.16 photoreactivity testing to reveal a non-chromogen isolate and, increasingly, confirmation by rrna nucleic acid probe testing are performed.1,15 in this case, an open biopsy was undertaken. the microbiological diagnosis of m. xenopi was made from the laboratory pcr supplementary testing of the drainage specimen. in the absence of strain identification, the need for repeat biopsy was considered. however, concerns regarding the assurance of a positive yield, the invasive nature of the procedure and the good clinical and radiological response to att led us to regard the procedure as unjustified and it was not performed. currently, although the ats diagnostic criteria are designed for lung disease, many authors still recommend their awareness as a good tool for determining clinical relevance.14,15 according to the british thoracic society, the treatment in pulmonary disease is reported to be difficult with high failure, relapse and mortality rates, despite prolonged courses of rifampicin, ethambutol and isoniazid.20 the ats/idsa (american thoracic society/infectious diseases society of america) recommends a combination regimen that includes either streptomycin or clarithromycin for a duration of 18 to 24 months. ongoing trials with macrolides and quinolones are yet to produce results. other reports suggest there is no correlation between in vitro susceptibility and clinical response. this patient was successfully treated with standard tb regimen, but for a period of 18 months as recommended by the idu, and she made full clinical (neurological) recovery. the favourable response to the standard tb regimen suggests that m. xenopi was susceptible to at least one of the components of the regimen. this emphasises the unresolved debate on the exact susceptibility of m. xenopi and its value in clinical practice. therefore, greater awareness of the ats nontuberculous mycobacteria management guidelines is recommended in the literature, to optimise the clinical response.17 conclusion in the presense of hiv co-infection, atypical mycobacterial infection must be considered in the differential diagnosis. this case report emphasises the importance of biopsy in suspected spinal tb cases, not only to establish the diagnosis but also for strain identification and prognostic and therapeutic implications. acknowledgements we would like to acknowledge the support of the orthopaedic spine team at chris hani baragwanath academic hospital, south africa, and the contributions of dr a mjuza. ethics statement the study was approved by the human research ethics committee at the university of the witwatersrand (m190943), and the chris hani baragwanath hospital management granted permission for it to be undertaken. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the author declares authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions fu formulated the research aims and objectives, collected the data and prepared the manuscript. orcid ukunda fun https://orcid.org/0000-0002-9284-6358 references 1. schwabacher h. a strain of mycobacterium isolated from skin lesions of a cold-blooded animal, xenopus laevis, and its relation to atypical acid-fast bacilli occurring in man. epidemiology & infection. 1959;57(1):57-67. 2. danesh-clough t, theis j-c, van der linden a. mycobacterium xenopi infection of the spine: a case report and literature review. spine. 2000;25(5):626. 3. el-helou p, rachlis a, fong i, et al. mycobacterium xenopi infection in patients with human immunodeficiency virus infection. clinical infectious diseases. 1997;25(2):206-10. 4. donnabella v, salazar-schicchi j, bonk s, et al. increasing incidence of mycobacterium xenopi at bellevue hospital: an emerging pathogen or a product of improved laboratory methods? chest. 2000;118(5):1365-70. 5. jiva tm, jacoby hm, weymouth la, et al. mycobacterium xenopi: innocent bystander or emerging pathogen? clinical infectious diseases. 1997;24(2):225-32. 6. jones pg, schrager ma, zabransky rj. pott’s disease caused by mycobacterium xenopi. clinical infectious diseases. 1995;21(5):1352. 7. kerbiriou l, ustianowski a, johnson m, et al. human immunodeficiency virus type 1-related pulmonary mycobacterium xenopi infection: a need to treat? clinical infectious diseases. 2003;37(9):1250-54. 8. manfredi r, nanetti a, tadolini m, et al. role of mycobacterium xenopi disease in patients with hiv infection at the time of highly active antiretroviral therapy (haart). comparison with the pre-haart period. tuberculosis. 2003;83(5):319-28. 9. ormerod p. a step forward in the evidence-based treatment of opportunist mycobacteria. bmj publishing group ltd; 2001. 10. astagneau p, desplaces n, vincent v, et al. mycobacterium xenopi spinal infections after discovertebral surgery: investigation and screening of a large outbreak. lancet. 2001;358(9283):747-51. 11. prosser aj. spinal infection with mycobacterium xenopi. tubercle. 1986;67(3):229-32. 12. andréjak c, almeida dv, tyagi s, et al. improving existing tools for mycobacterium xenopi treatment: assessment of drug combinations and characterization of mouse models of infection and chemotherapy. j antimicrob chemother. 2013;68(3):659-65. 13. rahman m, phongsathorn v, hughes t, et al. spinal infection by mycobacterium xenopi in a non-immunosuppressed patient. tuber lung dis. 1992;73(6):392-95. 14. meybeck a, fortin c, abgrall s, et al. spondylitis due to mycobacterium xenopi in a human immunodeficiency virus type 1-infected patient: case report and review of the literature. j clin microbiol. 2005;43(3):1465-66. 15. van ingen j, boeree mj, de lange wc, et al. mycobacterium xenopi clinical relevance and determinants, the netherlands. emerg infect dis. 2008;14(3):385. 16. kulasegaram r, richardson d, macrae b, de ruiter a. mycobacterium xenopi osteomyelitis in a patient on highly active antiretroviral therapy (haart). int j std aids. 2001;12(6):404-406. 17. alfreijat m, ononiwu c, sexton c. pott’s disease: a case of mycobacterium xenopi infection of the spine. j community hosp intern med perspect. 2013;2(4):20150. 18. department of health. national tuberculosis management guidelines. pretoria: department of health; 2014. 19. roberts tt, leonard gr, cepela dj. classifications in brief: american spinal injury association (asia) impairment scale. clin orthop relat res. 2017;475(5):1499-504. 20. research committee of the british thoracic society. first randomised trial of treatments for pulmonary disease caused by m avium intracellulare, m malmoense, and m xenopi in hiv negative patients: rifampicin, ethambutol and isoniazid versus rifampicin and ethambutol. thorax. 2001;56(3):167-72. https://orcid.org/0000-0002-9284-6358 _hlk38812429 _hlk37964042 _hlk37436412 _hlk66991783 _hlk31280275 layout 1 page 4 south african orthopaedic journal http://journal.saoa.org.za conferences, courses & symposia 18th congress sa spine society 24-26 may 2018 elangeni hotel, durban sassh (sa society for surgery of the hand) annual congress 31 august–2 september 2018 csir, pretoria 64th congress of the south african orthopaedic association 3-6 september 2018 csir, pretoria march 2018 european pelvic course 2018 22 march 2018 24 march 2018 hamburg, germany unfallmedizinische tagung murnau: “das beste aus 25 jahren” 23 march 2018 24 march 2018 murnau am staffelsee, germany april 2018 14th world congress icrs 2018 09 april 2018 12 april 2018 macau, macao aaos orthopaedic board preparation and review course 10 april 2018 14 april 2018 chicago, united states wco-iof-esceo krakow 2018 19 april 2018 22 april 2018 krakow, poland world arthroplasty congress 2018 19 april 2018 21 april 2018 rome, italy may 2018 evidence based medicine sessions (ebm) barcelona 2018 31 may 2018 01 june 2018 barcelona, spain foot and ankle arthroscopy and sports traumatology course 31 may 2018 01 june 2018 amsterdam, netherlands june 2018 international conference “ilizarov readings” 14 june 2018 16 june 2018 kurgan, russia international research society on spinal deformities irssd 2018 14 june 2018 16 june 2018 utrecht, netherlands eurospine education week 18 june 2018 22 june 2018 strasbourg, france paediatrics course: diagnosis and functional treatment in cp gait disorders 22 june 2018 basel, switzerland local international orthopaedics vol3 no4 i think we would all agree that orthopaedics is an extremely rewarding specialty, which often returns patients to a greatly improved quality of life and productive lifestyle. huge advances have been made over the past years, which have enabled us to treat an increasing range of conditions more effectively, with reduced complications and a quicker return to function. however we are faced with a significant increase in the cost of providing this service, a more informed and demanding patient population and an exponential increase in medical litigation, which further drives up the provider costs. on the other side of the equation, funders are under increasing pressure to contain costs and we are frequently being informed that the present practice of medicine is becoming unaffordable.1 michael porter, a health economist from the harvard business school, defined value in health care as the health outcome achieved per dollar spent.2 over recent years a lot has been written about the definition of health care and what tools would be most appropriate to measure this outcome. there is no doubt that we need risk-adjusted patient-specific models and validated outcomes measures. the lack of reliable cost information remains a problem.3 one thing that has impressed me so far on my travels to our sister organisations, is how far they have progressed down the road of outcomes assessment, how much it is integrated into their practices and how far we have fallen behind in this regard. you only have to look at the programme for the forthcoming comoc congress and our international journals to see this growing international trend. i have no doubt that the vast majority of us practise costeffective medicine with appropriate indications and patientcentred care. however, and i include myself when i say this, we may overstate our successes and understate our complications without some objective measurement of our work. the implementation of outcomes measurements into our practices obviously adds time and expense to our already busy schedules. this is but one of the many challenges associated with this introduction. there are legal and regulatory challenges and the question of funding of the registries is another. however, unless we are able to critically evaluate our results objectively and compare them with our peers both locally and internationally, we won’t know how effective we really are. the whole process should lead to better patient outcomes, which must be our primary goal. it is obviously not practical at this time to evaluate all surgical procedures in this way. i would therefore like to make a plea that we all start by contributing data to the national joint registry. as with any registry, it becomes more accurate when more events are captured. the knee society and shoulder society are probably going to roll out software for outcomes studies appropriate to their areas, through the surgical outcomes solutions programme. there are additional modules, which pertain to our other special interest groups and if the roll-out is beneficial to the membership, the south african orthopaedic association will consider partnering in the extension of this. while the primary reason for engaging in this exercise should be to objectively assess our patient outcomes and thereby improve our management, we may in the foreseeable future have to justify our expertise to the funders in an increasingly competitive environment. we would then need data to justify our position. one can already see a trend of linking funding to improved patient outcomes. whether we are in private or state practice, the central tenets of outcomes measurement still apply, as does practising cost-effective medicine. there are many challenges involved in implementing outcomes-based evaluations into our practices; however, i don’t foresee that we are going to be able to avoid it. i think it is something to which we will have to give increasing attention. we should take the initiative in introducing systems which are beneficial to our practices and patients. references 1. lansky d, milstein a. quality measurement in orthopaedics. clin orthop relat res. 2009;467:2548-55. 2. porter m. what is value in health care? n engl j med 2010;363:2477-81. 3. andrawis jp, chenok ke, bozic kj. health policy implications of outcomes measurement in orthopaedics. clin orthop relat res. 2013;471:3475-81. sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 19 outcomes-based evaluations of our patients: a challenge for us all m e s s a g e f r o m t h e p r e s i d e n t dr robert fraser mbchb(uct), mmed(orth), fcs(sa)orth president: sa orthopaedic association 404 not found 404 not found orthopaedics vol3 no4 sa orthopaedic journal winter 2017 | vol 16 • no 2 page 39 the microbiology of chronic osteomyelitis in a developing world setting pg mthethwa mbbch, h diploma(ortho)sa registrar, department of orthopaedics, grey’s hospital, school of clinical medicine, university of kwazulu-natal lc marais mbchb, fc(ortho)sa, mmed(ortho), cime, phd tumour, sepsis and reconstruction unit, department of orthopaedics, grey’s hospital, school of clinical medicine, university of kwazulu-natal corresponding author: dr phakamani g mthethwa tumour, sepsis and reconstruction unit department of orthopaedic surgery grey’s hospital nelson r. mandela school of medicine university of kwazulu-natal pietermaritzburg, south africa tel: +27 33 897 3000 email: phakspg@gmail.com abstract objectives: the primary aim of this study was to identify the microorganisms that cause chronic osteomyelitis in a developing world clinical setting and to characterise the antibiotic sensitivity profile of these pathogens. furthermore, we aimed to determine whether the causative organisms vary in relation to physiological status of the host, the hiv status of the patient or the cause of the infection (post-traumatic, post-operative and haematogenous). methods: we performed a retrospective review of consecutive adult patients treated curatively for chronic osteomyelitis of long bones, over a two-year period. patient charts were reviewed and data extracted in respect of patient demographics, the cause of infection, physiological status of the host in accordance with the cierny and mader classification, hiv status, surgical treatment strategy and causative organism. results: a total of 108 organisms were identified in the 60 patients included in the study. multiple organism were cultures in 45% of patients, a single gram-positive organism in 22% and a single gram-negative organism in 26% of patients. in four cases (7%) no causative organism was cultured. the most prevalent organisms were enterobacteriaceae (34%), staphylococcus spp. (29%), pseudomonas aeruginosa (11%), and enterococcus spp. (9%). many isolates were found to be resistant to commonly used empirical anti-microbial agents. seventy per cent of enterobacteriaceae spp. were resistant to either cefuroxime and/or ampicillin-clavulanic acid. seventy-seven per cent of staphylococcus aureus isolates were susceptible to cloxacillin. more than 50% of pseudomonas aeruginosa strains were resistant to meropenem, imipenem, piperacillin-tazobactam or cefepime. there was a significant association between the aetiology of the infection and the microorganisms involved (p-value < 0.01). the bacterial pathogen profile was, however, not associated with the physiological status of the host (p=0.22) or the hiv status of the patient. conclusion: while the majority of haematogenous chronic osteomyelitis still involved a solitary gram-positive organism, the incidence of gram-negative infections was found to be higher than previously reported. contiguous chronic osteomyelitis was mostly polymicrobial in nature and solitary infections involving a gramnegative organism was most common in the post-traumatic group. the bacterial pathogen did not vary in relation to the hiv status of the patient or the physiological status of the host. key words: chronic, osteomyelitis, microbiology, antibiotics, treatment, hiv http://dx.doi.org/10.17159/2309-8309/2017/v16n2a4 page 40 sa orthopaedic journal winter 2017 | vol 16 • no 2 introduction the diagnosis of chronic osteomyelitis encompasses a range of bone infections resulting from either haematogenous bacterial seeding or direct spread from a contiguous focus.1 traditionally, the clinical entity of chronic osteomyelitis has been dominated by haematogenous disease. this form of the disease is typically associated with a narrow range of causative organisms.1 in recent times this category has been supplemented considerably by contiguous infections which are caused by a much wider range of microorganisms.2,3 posttraumatic, post-operative and implant-related infections are now encountered much more frequently, especially in developed regions.2,3 overall, infectious complications can be expected in approximately 1–5% of internally fixated closed fractures and in up to 30% of open fractures.4 irrespective of the cause, chronic osteomyelitis remains difficult to treat and treatment failure may occur in more than 10% of cases.4 treatment options for chronic osteomyelitis include curative and palliative management strategies.5,6 curative treatment protocols involve a combination of thorough debridement, dead space management, soft tissue reconstruction and adjuvant antibiotic therapy in order to achieve remission of the disease prior to reconstruction. palliative treatment strategies, may be indicated in compromised hosts who are not suitable for complex surgery.5,6 typically palliative treatment involves chronic suppressive antibiotic therapy. knowledge of the microbiology of chronic osteomyelitis may guide the selection of empiric postoperative or palliative antibiotic therapy. there is limited data available on the spectrum of causative organisms, especially in contiguous chronic osteomyelitis. previous studies have shown that the most common causative organism remains staphylococcus aureus, followed by enterobacteriaceae.1-3 few studies have been performed in the developing world. furthermore, the variation of causative organism in relation to the physiological host status, the hiv status of the patient or the cause of the infection has not previously been reported. the primary aim of this study was to identify the microorganisms that cause chronic osteomyelitis in the developing world clinical setting. in addition, we aimed to characterise the antibiotic sensitivity profile of these pathogens. furthermore, we aimed to determine whether the causative organisms vary in relation to the physiological status of the host, the hiv status of the patient or the cause of the infection (post-traumatic, post-operative and haematogenous). methods we retrospectively reviewed a cohort of consecutive patients who underwent surgical treatment of chronic osteomyelitis at our tertiary level musculoskeletal tumour and sepsis unit over the two-year period from january 2012 to december 2013. following ethical approval, eligible patients were identified from a prospectively gathered database. all patients, 14 years or older, who underwent surgical treatment for chronic osteomyelitis were included in the study. cases involving tuberculosis or fungal infection, as well as cases with insufficient data, were excluded from the study. the patients’ charts and x-rays were reviewed and data extracted in respect of patient demographics, the cause of infection (haematogenous or contiguous) and the host classification in accordance with the cierny and mader classification system.7 the patient’s hiv status, the surgical treatment strategy employed and the causative organism, along with their antibiotic sensitivity profiles, were also recorded. in all cases, formal tissue biopsy for the purposes of histology and microscopy, culture and sensitivity testing was performed at the time of the initial debridement. antibiotic treatment was discontinued at least seven days prior to tissue sampling. samples were processed by agitating them in a sterile glass ball in 10 ml of peptone water under laminar flow. samples were then plated onto blood agar (incubated aerobically and anaerobically) and lysed blood agar (incubated in air with 5% co2). extended culture, for a minimum period of seven days, was routinely performed. organisms’ antimicrobial sensitivity was determined by vitek2 technology which identifies the vast majority of routine organisms (over 300 microorganisms). for the purposes of this study chronic osteomyelitis was defined as a bone infection characterised by the presence of either necrotic bone or an implant which may serve as a nidus for biofilm formation and a duration of at least 6 weeks.8 contiguous chronic osteomyelitis was defined as post-traumatic (following open fractures) and postoperative infections, as well as bone infection resulting from direct spread from an adjacent septic focus or ulceration.9 statistical analysis was performed using stata 13.0 (stata corp. college station, texas). continuous variables were reported as mean (± sd) or median (with interquartile range) and categorical variables as number and percentages, unless otherwise stated. the fisher’s exact test was used for categorical data. all tests were two-sided and the level of significance was set at p<0.05. ethical approval was obtained from our institution’s ethics review board prior to commencement of the study (brec: be020/14). the study was conducted according to the ethical principles for medical research on human subjects as defined by the world medical association declaration of helsinki (amended at the ma general assembly, seoul, oct 2008). results a total of 60 patients, from the 64 initially identified to meet the inclusion criteria, were included in this cohort. of the four patients who were excluded, one was diagnosed with tuberculosis osteomyelitis and one with a fungal infection (cryptococcus neoformans), and two cases were excluded on the basis of insufficient data. the mean age of the remaining 60 patients was 31 years (range 14–59 years), with 47 males and 13 females. sa orthopaedic journal winter 2017 | vol 16 • no 2 page 41 a total number of 108 microorganisms were identified and multiple organisms were cultured in 45% (n=27) of patients, a single gram-positive organism in 22% and a single gramnegative organism in 26% of patients. in four cases (7%) no causative organism was cultured. the most common causative organisms was found to be from the enterobacteriaceae group (citrobacter, enterobacter, escherichia, klebsiella, morganella, pantoea, proteus and serratia spp.; 34%, n=37), followed by staphylococcus spp. (29%, n=31), pseudomonas aeruginosa (11%, n=12) and enterococcus spp. (9%, n=10) (table i). in terms of individual organisms, s. aureus was the most common isolate (n=23). seventy per cent of enterobacteriaceae were resistant to either cefuroxime and/or ampicillin-clavulanic acid. resistance to piperacillin-tazobactam and cefepime was observed in 29% and 34% of enterobacteriaceae cultures, respectively. enterobacteriaceae sensitivity to ciprofloxacin, gentamycin and meropenem was 71%, 81% and 89% respectively. fourteen (77%) of staphylococcus aureus isolates were susceptible to cloxacillin. s. aureus exhibited a similar susceptibility pattern to other common anti-staphylococcal agents, including erythromycin (84%), clindamycin (84%) and trimethoprim-sulfamethoxazole (68%). five (23%) of the s. aureus cultures and six (86%) of the other staphylococcus spp. were found to be methicillin-resistant. none of the methicillin-resistant s. aureus strains were resistant to vancomycin. we noted a high rate of resistance (≥ 50%) of pseudomonas aeruginosa strains to meropenem, imipenem, piperacillin-tazobactam or cefepime. more than 80% of p. aeruginosa strains were sensitive to gentamycin and ciprofloxacin. fifty per cent of enterococcus spp. were ampicillin-resistant. no vancomycin-resistant enterococcus spp. were cultured (table ii). the cause of chronic osteomyelitis was haematogenous in 28% (n=17) of cases. seventy-two per cent (n=43) of cases were classified as contiguous, with post-operative and post-traumatic infection comprising 17% (n=10) and 55% (n=33) of all cases, respectively. there was a significant association between the origin of the infection and the microorganism involved (p-value = 0.003). the majority of contiguous infections involved mixed organisms, while solitary infections by a gram-negative organism were most common in the post-traumatic group (table iii). twenty-one organisms were cultured in the 10 patients with post-operative infection. the most common pathogens were acinetobacter baumannii (n=5), enterobacter spp. (n=5), e. coli (n=4) and enterococci (n=3). sixty-two organisms were found in the post-traumatic group of 33 patients. the most common pathogens in this group was methicillin-sensitive staphyloccus aureus (n=7), serratia marcescens (n=7), pseudomonas aeruginosa (n=6), acinetobacter baumannii, enterobacter spp., proteus maribillis, klebsiella spp. (n=4, respectively), e. coli and mrsa (n=3), respectively. in the haematogenous group of infections, the majority of infections were caused by a solitary grampositive organism. methicillin-sensitive staphylococcus aureus was cultured in nine out of the 17 haematogenous cases, although only four of these were monomicrobial in nature. methicillin-resistant staphyloccus aureus and pseudomonas spp. were responsible for two cases respectively. four (24%) of haematogenous cases were polymicrobial in nature. when applying the cierny and mader classification system 25% (n=15) patients were classified as a-hosts, 55% (n=33) as b-hosts and 20% (n=12) as c-hosts.10 six type-a hosts had gram-positive infections, while only three had mixed infections. the majority of infections (70%) in b and c hosts were caused by multiple organisms. this difference was, however, not statistically significant (p=0.22) (table iv). eleven patients (18%) were found to be hiv-positive, with a median cd4 count of 544 cells/mm3 (range 194–1034). no significant difference was noted in terms of gram-positive, gram-negative, mixed pathogen or no growth cultures table i: microorganisms cultured in the cohort of 60 patients multiple organisms were identified in 27 (46%) of cases. microorganism n (%) acinetobacter baumannii 7 (6%) aeromonas hydrophylia 1 (1%) citrobacter amalonaticus 1 (1%) citrobacter koseri 1 (1%) escherichia coli 5 (5%) entecoccus faecalis 1 (1%) enterobacter cloacae 6 (6%) enterobacter species 1 (1%) enterococcus avium 1 (1%) enterococcus faecalis 7 (6%) enterococcus faecalis 1 (1%) klebsiella oxytoca 2 (2%) klebsiella pneumonia 5 (5%) lactococcus lactis subsp lactis 1 (1%) methicillin-resistant staphylococcus aureus 5 (5%) methicillin-sensitive staphylococcus aureus 19 (18%) morganella morganii subsp sibonii 2 (2%) no growth 4 (4%) proteus maribilis 7 (6%) pseudomonas aeruginosa 12 (11%) serratia marcescens 7 (6%) staphylococcus capitis 2 (2%) staphylococcus epidermidis 2 (2%) staphylococcus haemolyticus 1 (1%) staphylococcus hominis4 1 (1%) staphylococcus simulans 1 (1%) streptococcus mitis 1 (1%) streptococcus pneumoniae 1 (1%) streptococcus pyogenes 2 (2%) streptococcus sanguinis 1 (1%) total 108 (100%) m s s a i m r s a ii a ci n et o b a ct er b a u m a n n i e sc h er ic h ia c o li e n te ro b a ct er cl o a ca e k le b si el la p n eu m o n ia p ro te u s m a ri b il is p se u d o m o n ia a er u g in o sa s er ra ti a m a rc es ce n s n = 19 ( 18 % ) n = 5 (5 % ) n = 7 (7 % ) n = 5 (5 % ) n = 6 (6 % ) n = 5 (5 % ) n = 7 (6 % ) n = 12 ( 11 % ) n = 7 (6 % ) s en si ii r es iv s en si ii r es iv s en si ii r es iv s en si ii r es iv s en si ii r es iv s en si ii r es iv s en si ii r es iv s en si ii r es iv s en si ii r es iv n (% ) n (% ) n (% ) n (% ) n (% ) n (% ) n (% ) n (% ) n (% ) n (% ) n (% ) n (% ) n (% ) n (% ) n (% ) n (% ) n (% ) n (% ) a m o x ic il li n 2( 11 ) 14 (7 7) * 5( 10 0) * 1( 14 ) * 5( 10 0) * 5( 83 ) * 4( 80 ) * 7( 10 0) * * * 7( 10 0) a m p ic il li n 2( 11 ) 14 (7 7) * 5( 10 0) * 1( 14 ) * 5( 10 0) * 5( 83 ) * 4( 80 ) * 7( 10 0) * * * 7( 10 0) c lo x ac il li n 14 (7 7) 1( 5) 1( 20 ) 4( 80 ) 5( 83 ) 1( 16 ) * * * * * * * * * * * * a m p ic il li n -c la v u la n ic a ci d * * * 1( 20 ) * * * 5( 10 0) * 5( 83 ) 1( 20 ) 2( 40 ) 6( 86 ) * 1( 8) * * 7( 10 0) e ry th ro m y ci n 16 (8 4) 2( 11 ) 3( 60 ) 2( 40 ) * * * * * * * * * * * * * * c li n d am y ci n 16 (8 4) 2( 11 ) 3( 60 ) 2( 40 ) * * * * * * * * * * * * * * s u lb ac ta m -c ef o p er az o n e 13 (6 8) 5( 26 ) 2( 60 ) 2( 60 ) * 7( 10 0) 2( 40 ) 3( 60 ) 2( 33 ) 3( 50 ) 1( 20 ) 4( 80 ) 2( 29 ) 5( 71 ) * 12 (1 00 ) 7( 10 0) * v an co m y ci n 2( 11 ) * 4( 80 ) * * * * * * * * * * * * * * * c ip ro fl o x ac in * 1( 5) * 3( 60 ) * 7( 10 0) 1( 20 ) * 2( 33 ) 3( 50 ) 1( 20 ) 3( 60 ) 1( 14 ) * 11 (9 2) 1( 8) 7( 10 0) * c ef u ro x im e * * * 1( 20 ) * * 1( 20 ) 3( 75 ) 2( 33 ) 2( 33 ) 1( 20 ) 4( 80 ) 7( 10 0) * * 1( 8) * 6( 86 ) c et ri ax o n e * * * * * * * 1( 20 ) 2( 33 ) 3( 50 ) * 4( 80 ) 1( 14 ) * * * 7( 10 0) * g en ta m y ci n * * * * 1( 17 ) 5( 83 ) * 4( 80 ) 1( 16 ) 3( 50 ) 6( 86 ) * 11 (9 2) * 7( 10 0) * p ip er ac il li n * * * * * 6( 86 ) 1( 20 ) * 2( 33 ) 3( 50 ) 1( 20 ) 4( 80 ) * * 5( 42 ) 4( 33 ) 7( 10 0) * c ef ep im e * * * * * 6( 86 ) 1( 20 ) 2( 40 ) 2( 33 ) 2( 33 ) 1( 20 ) 1( 20 ) 2( 29 ) * 5( 42 ) 1( 8) 7( 10 0) * im ip en em * * * * * 6( 86 ) 1( 20 ) * 1( 16 ) 1( 16 ) 4( 80 ) * 1( 14 ) * 4( 33 ) 3( 25 ) 1( 14 ) * m er o p en em * * * * * 6( 86 ) 1( 20 ) * 1( 16 ) 1( 16 ) 4( 80 ) * 1( 14 ) * 4( 33 ) 1( 8) * * a m ik ac in 2( 11 ) * * * 1( 16 ) 5( 83 ) * * 1( 16 ) 1( 16 ) 4( 80 ) * 1( 14 ) * 2( 17 ) 1( 8) * * i m et h ic il li n -s en si ti v e s ta p h y lo co cc u s au re u s; ii m et h ic il li n -r es is ta n t s ta p h y lo co cc u s au re u s; ii i s en si ti v e o rg an is m s; iv r es is ta n t o rg an is m s; * n o d at a av ai la b le t a b le i i: a n ti -m ic ro b ia l se n si ti v it y a n d r es is ta n ce p a tt er n s o f th e m o st c o m m o n ly e n co u n te re d b a ct er ia page 42 sa orthopaedic journal winter 2017 | vol 16 • no 2 between hiv-positive and -negative patients (p=0.18) (table v). furthermore, when comparing individual pathogens in hiv-positive and -negative patients, no significant differences were found. while there appeared to be an increased incidence of enterococcus spp. infections in hiv-positive patients, it was not statistically significant (p=0.18). discussion the aim of this study was to characterise the organisms causing chronic osteomyelitis in a developing world setting and to compare it to existing data from other parts of the world. furthermore, we examined the anti-microbial resistance and sensitivity patterns. we also aimed to determine if the pathogen profile varied in relation to the origin of the infection, the physiological status of the host or the patient’s hiv status. while the series is small, a wide spectrum of organisms with a wide variety of antibiotic sensitivities was found. this emphasises the importance of identifying the offending bacteria by tissue culture, and tailoring therapy according to antibiotic sensitivity patterns. methicillin-sensitive staphylococcus aureus was the most commonly isolated gram-positive organism (18% of all organisms), followed by other staphylococcal species (7%), enterococcus (6%), methicillin-resistant staphylococcus aureus (5%) and streptococcus spp. (4%). the most common gramnegative organism was pseudomonas aeruginosa (11% of all organisms), followed by enterobacter, acinetobacter, serratia and proteus spp. (6%, each). our results are comparable to previous studies from other parts of the world (table vi). walvogel et al., in 1970, found staphylococcus aureus in approximately 60% of cases.1 in subsequent studies the relative incidence of staphylococcal infections decreased, possibly due to a rise in the incidence of contiguous infections.2 post-operative or post-traumatic chronic osteomyelitis has been associated with broad spectrum of organisms, including those commonly associated with hospital acquired infections like methicillinresistant s. aureus, enteric gram-negative bacilli and coagulase-negative staphylococci.2,3 however, s. aureus appears to remain the most commonly isolated organism, regardless of aetiology (table vi). trampuz et al. identified staphylococcus aureus (30% of cases) and gram-negative micro-organisms as the most common bacteria involved in infections associated with fracture-fixation devices.2 sheehy et al. found staphylococcus aureus to be the most commonly isolated pathogen among a wide range of organisms, which included gram-negative bacilli, anaerobes and coagulase negative staphylococci.3 sa orthopaedic journal winter 2017 | vol 16 • no 2 page 43 in our series, the majority of post-operative and posttraumatic infections involved gram-negative or mixed infections. we found a significant association between the aetiology of the infection (post-traumatic, post-operative or haematogenous) and the causative organism (p-value = 0.003). haematogenous infections were mostly due to gram-positive organisms, while the majority of mixed infections occurred in contiguous chronic osteomyelitis. isolated gram-negative infections were most common in the post-traumatic group of cases. in this series, the prevalence of polymicrobial infections was somewhat higher (45%) than previously reported in studies performed in the developed world setting.2,3 trampuz et al. found polymicrobial infections in 27% of patients.2 sheehy et al. reported that 29% of their cases were polymicrobial in nature.3 spellberg and lipsky reviewed publications, from 1970 to 2011, related to the use of antibiotics in chronic osteomyelitis.11 the authors emphasised the importance of surgical debridement and noted that the cure rate of chronic osteomyelitis is increased with surgical resec tion of infected and devitalised tissue in conjunction with antibiotic therapy. the important conclusions from their review were that oral antibiotic therapy with agents that have high bioavailability is comparable with parenteral therapy; improved cure rates are achieved with the addition of rifampicin; and that the duration of antibiotic therapy should be individualised based on clinical, haematological, and radiological response.11 the authors also recommended that antibiotic therapy should be tailored to local sensitivity patterns. the organisms cultured in this series exhibited a wide range of antibiotic sensitivities. many commonly employed generic antibiotic regimens may be ineffective in our setting. it is alarming that 70% of the enterobacteriaceae spp. in this series were resistant to either cefuroxime or ampicillin-clavulanic acid and 34% of these organisms were resistant to cefepime. table iii: bacterial pathogens involved (per patient) in relation to the aetiology of the infection aetiology gram-positive n (%) gram-negative n (%) mixed n (%) no growth n (%) p-valuei post-operativeii 2 (1.8%) 2 (1.8%) 5 (4.6%) 1 (0.9%) 0.003 post-traumaticii 2 (1.8%) 12 (11.1%) 18 (16.7%) 1 (0.9%) haematogenous 9 (8.3%) 2 (1.8%) 4 (3.7%) 2 (1.8%) totals 13 (12.0%) 16 (14.7%) 27 (25%) 4 (3.6%) i fisher’s exact test; ii contiguous infections table iv: bacterial pathogens in relation to the physiological status of the host, in accordance with the cierny and mader staging system for chronic osteomyelitis6 host status gram-positive n (%) gram-negative n (%) mixed n (%) no growth n (%) p-valuei a-host 6 (10%) 4 (7%) 3 (7%) 1 (2%) 0.221 b-host 6 (10%) 10 (17%) 16 (17%) 1 (2%) c-host 1 (2%) 2 (3%) 7 (12%) 2 (3%) totals 13 (22%) 16 (27%) 26 (43%) 4 (7%) i fisher’s exact test table v: bacterial pathogens in relation to hiv status of the patient hiv status gram-positive n (%) gram-negative n (%) mixed n (%) no growth n (%) p-valuei negative 13 (22%) 13 (22%) 20 (33%) 3 (5%) 0.183positive 0 (0%) 3 (5%) 7 (12%) 1 (2%) totals 13 (22%) 16 (27%) 27 (45%) 4 (7%) i fisher’s exact test table vi: organisms isolated in cases of adult chronic osteomyelitis by previous investigators study year culture positivity s. aureus e. coli klebsiella spp. proteus spp. p. aeruginosa enterobacter spp. walvogel et al.1 1970 95% 59.4% * * * * * trampuz et al.2 2005 98% 30% * * * * * sheehy et al.3 2010 72% 32% * * * 5% 5% our study 2016 96% 23% 5% 7% 6% 11% 7% * no data available page 44 sa orthopaedic journal winter 2017 | vol 16 • no 2 our findings conflict with previous data showing that cephalosporins generally have a good activity against commonly isolated enterobacteriaceae.12 in our series, enterobacteriaceae spp. exhibited reasonable sensitivity to ciprofloxacin (71%), gentamycin (81%) and meropenem (89%). this is consistent with the findings of spellberg et al. who found a high cure rate with a combination use of ciprofloxacin and trimethoprimsulfamethoxazole when given for for 8–16 weeks.11 in our series, 77% of staphylococcus aureus were susceptible to cloxacillin. jones et al. reported similar results, with more than 99% s. aureus susceptible to oxacillin.12 methicillin-resistant s. aureus was however common in our series, with 80% of strains being susceptible to vancomycin. vancomycin penetrates bone relatively poorly, with the ratio of bone to serum concentration being only approximately 20% in infected bone.13 cefazolin outperformed vancomycin in one series, despite its bone penetration being inferior to that of vancomycin (approximately 15%).14 meropenem does not appear to fare much better, with a bone penetration of approximately 17%.15 intravenous quinolone antibiotics are another option for gram-negative cover and exhibit excellent bone penetration. the bone/serum ratio of intravenous ciprofloxacin has been reported to be up to 47% in cortical bone.16 conveniently, the bone penetration of oral ciprofloxacin is also reasonable, reaching 35% at a dose of 500 mg.17 taking these results into account the generic antibiotic regimen (for use following surgery) proposed by mcnally, involving the use parenteral vancomycin and meropenem, appears to be reasonable.18 ciprofloxacin (or another quinolone) appears to be a useful alternative to meropenem for aerobic gram-negative bacilli, and previous clinical studies support its use.19 cefepime appears to remain an excellent option in gram-negative infections due to relatively low resistance and excellent bone penetration.20 in our series, the bacterial pathogen profile did not vary in relation to the patient’s hiv status. previous literature identified staphylococcus aureus as the most common organism causing osteoarticular infections in hiv patients.10,21 zalavras et al. looked at the microbiology of chronic osteomyelitis in patients living with the human immunodeficiency virus and found s. aureus in 50% of cases, polymicrobial infections in 35% and no growth in three cases.21 they also found no osseous opportunistic infection in hiv patients with immunodeficiency. busch et al. also reported staphylococcus aureus (in 8 of 19 patients) as the most common agent in hivinfected patients with chronic osteomyelitis.10 staphylococcus aureus was also shown to be the most common organism responsible for osteoarticular infections in intravenous drug abusers with immunodeficiency virus.22 information about the causative agents was available in 88 (27%) of the 330 osteomyelitis cases identified by the adult/adolescent spectrum of hiv disease project of the centers for disease control (cdc). staphylococcus aureus was the most common pathogen, comprising 48% of identified organisms. in our study, the majority of hiv-positive patients presented with polymicrobial infections and there was no association between hiv status and causative bacteria (p-value = 0.18). therefore, in our series, hiv infection does not appear to alter the microbiology of chronic osteomyelitis. there is insufficient evidence to suggest that clinicians should change their antibiotic protocol based on the hiv status of their patients, and according to the available data it does not appear necessary to add routine antibiotic coverage for opportunistic infections in hiv patients. previous studies did not stratify infective organisms in relation to the cierny and mader host status or anatomical nature of the disease. in our study shows that there is no significant association between host status (a, b and c-host) and the causative organism (p-value = 0.221). although it did not reach statistical significance, type c-hosts were found to have predominantly polymicrobial infections. the small number of cases in this series is a shortcoming and much larger studies are required before resolute recommendations can be made in terms of generic antibiotic selection. the absence of routine anaerobe cultures is a further shortcoming. in larger series, anaerobic infections have accounted for a small, but significant, number of infections. an additional shortcoming is the absence of data relating to prior antibiotic therapy and number of previous surgical attempts. prior treatment may influence the bacterial profile and thus the cultured organism may not necessarily be the original causative organism. comparative studies are required to determine the clinical efficacy of different antibiotic regimens. conclusion the causative microorganism in chronic osteomyelitis was found to be associated with aetiology of the infection. while the majority of haematogenous chronic osteomyelitis still involved a solitary gram-positive organism, the incidence of gram-negative infections was found to be higher than previously reported. contiguous chronic osteomyelitis was mostly polymicrobial in nature and solitary infections involving a gram-negative organism was most common in the post-traumatic group. the bacterial pathogen did not vary in relation to the hiv status of the patient or the physiological status of the host. compliance with ethics guidelines conflict of interest: the authors declare that they have no conflict of interests and that no financial support was received for this study. • saoj sa orthopaedic journal winter 2017 | vol 16 • no 2 page 45 ethics approval: ethical approval was obtained from our institution’s ethics review board prior to commencement of the study (brec: be020/14). the study was conducted according to the ethical principles for medical research on human subjects as defined by the world medical association declaration of helsinki (amended at the ma general assembly, seoul, oct 2008). authors’ contributions: all authors made contributions toward the conception and design of the research, acquisition of data and drafting of the manuscript. the final manuscript was read and approved by all the authors. references 1. lew dp, waldvogel fa. current concepts osteomyelitis. n eng j med 1997;336:999-1007. 2. trampuz a, zimmerli w. diagnosis and treatment of infections associated with fracturefixation devices. injury 2006;37(suppl 2):59-66. 3. sheehy sh, atkins ba, bejon p, byren i, wyllie d, athanasou na, berendt ar, mcnally ma. the microbiology of chronic osteomyelitis: prevalence of resistance to common empirical anti-microbial regimens. j infection 2010;60:338-43. 4. gustilo rb, merkow rl, templeton d. the management of open fractures. j bone joint surg am 1990;72(2);299-304. 5. walter g, kemmerer m, kappler c, hoffmann r. treatment algorithms for chronic osteomyelitis. dtsch arztebl int 2012;109(14):257-64. 6. marais lc, ferreira n, sartorius b, aldous c, le roux tlb. a modified staging system for chronic osteomyelitis. j orthop 2015;12:184-92. 7. cierny g, mader jt, penninck jj. a clinical staging system for adult osteomyelitis. clin orthop relat res 2003;414:724. 8. cierny g. surgical treatment of osteomyelitis. plast reconstr surg 2011;127(suppl1):190-204. 9. lew dp, waldvogel fa. osteomyelitis. lancet 2004;364: 369-79. 10. busch v, regez r, heere b, willems j. osteoarticular infections in hiv-infected patients: 23 cases among 1,515 hivinfected patients. acta orthop 2009;78(6):786-90. 11. spellberg b, lipsky a. systemic antibiotic therapy for chronic osteomyelitis in adults clinical infectious diseases. clin infect dis 2012;54(3):393-407. 12. jones me, karlowsky ja, draghi dc. antibiotic susceptibility of bacteria most commonly isolated from bone related infections: the role of cephalosporins in antimicrobial therapy. int j antimicrob agents 2004;23:240-46. 13. graziani al, lawson la, gibson ga, steinberg ma, macgregor rr. vancomycin concentrations in infected and non-infected human bone. antimicrob agents chemother 1988;32:1320-22. 14. williams dn, gustilo rb, beverly r, kind ac. bone and serum concentrations of five cephalosporin drugs. relevance to prophylaxis and treatment in orthopedic surgery. clin orthop 1983;179:253-65. 15. sano t, sakurai m, dohi s, et al. investigation of meropenem levels in the human bone marrow blood, bone, joint fluid and joint tissues. jpn j antibiot 1993;46:159-63. 16. meissner a, borner k. concentration of ciprofloxacin in bone tissue. aktuelle traumatol 1993;23:80-84. 17. fong iw, ledbetter wh, vandenbroucke ac, simbul m, rahm v. ciprofloxacin concentrations in bone and muscle after oral dosing. antimicrob agents chemother 1986;29:405408. 18. mcnally m, nagarajah k. osteomyelitis. orthop trauma 2010;24(6):416-429. 19. gilbert dn, tice ad, marsh pk, craven pc, preheim lc. am j med 1987;82(4a):254-58. 20. breilh d, boselli e, bel jc, chassard d, saux mc, allaouchiche b. diffusion of cefepime into cancellous and cortical bone tissue. j chemother 2003;15:134-38. 21. zalavras c, gupta n, patzakis m, holtom p. microbiology of osteomyelitis in patients infected with the human immunodeficiency virus. clin orthop relat res 2005;439;97-100. 22. belzunegui j, gonzalez c, lopez l, osteoarticular and muscle infections lesions in patients with the human immunodeficiency virus. clin rheum 1997;16(5):450-53. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. moonda z et al. sa orthop j 2020;19(4) doi 10.17159/2309-8309/2020/v19n4a2 south african orthopaedic journal http://journal.saoa.org.za arthroplasty citation: moonda z, nortje mb, dey r. does the intra-operatively measured leg length correction compare to the post-operative radiograph in total hip replacement surgery? sa orthop j 2020;19(4):206-211. http://dx.doi.org/10.17159/2309-8309/2020/v19n4a2 editor: dr david north, paarl hospital, western cape, south africa received: december 2019 accepted: march 2020 published: november 2020 copyright: © 2020 moonda z. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: this study aims to analyse the accuracy of the vertical measurement system™ (vms) in assessing the leg length correction (llc) during total hip arthroplasty (tha) by comparing the intra-operative measurements to the radiographic measurements obtained six weeks post-operatively. patients and methods: a prospective cohort study was conducted in which patients undergoing primary tha were enrolled at two centres in cape town, over a period of 19 weeks. thas were performed by four surgeons. pre-operative leg length discrepancy (lld) measurements were obtained in 92 patients. the vms was used to predict intra-operative llc, and this measurement was compared to the post-operative llc measured on the six-week follow-up x-ray. these measurements were statistically compared using the mann–whitney u test. results: the difference between the intra-operative vms calculation and the six-week radiological measurement was not significant (p>0.05), with the difference in their mean values being 0.1±3.3 mm. in the cohort, 82% of the patients (n=75) were within 5 mm of the target llc, and 96% of patients (n=88) were within 10 mm of the target llc. the mean absolute residual lld at six weeks was 3.2±3.1 mm. conclusion: the intra-operative llc measurement obtained using the vms accurately predicts the six-week post-operative radiographic llc measurement. level of evidence: level 4 keywords: total hip replacement, leg length discrepancy, leg length correction, vertical measurement system, comparative study, longitudinal study does the intra-operatively measured leg length correction compare to the post-operative radiograph in total hip replacement surgery? moonda z1 , nortje mb2 , dey r3 1 mbbch(wits), fc orth(sa); orthopaedic surgeon, arthroplasty fellow, department of orthopaedic surgery, university of cape town; vincent pallotti hospital, cape town, south africa 2 mbchb(uct), fc orth(sa), mmed(orth)(uct); consultant orthopaedic and arthroplasty surgeon, department of orthopaedic surgery, university of cape town, vincent pallotti and kingsbury hospitals, cape town, south africa 3 phd; postdoctoral fellow, faculty of health sciences, university of cape town, south africa; groote schuur hospital, cape town, south africa corresponding author: dr zaheer moonda, department of orthopaedics, university of cape town, h49 old main building, groote schuur hospital, main road, observatory, cape town, 7925: tel: (021) 404 5108; email: zmoonda@tiscali.co.za https://orcid.org/0000-0002-6481-1334 https://orcid.org/0000-0002-7737-409x https://orcid.org/0000-0002-3616-1995 page 207moonda z et al. sa orthop j 2020;19(4) introduction total hip arthroplasty (tha) is one of the most successful orthopaedic operations, with high patient satisfaction and low revision rates.1 accurate leg length correction (llc) in tha is imperative for a good clinical outcome. therefore, equalisation of leg length remains one of the primary objectives of tha. nevertheless, leg length inequality remains a recognised complication of the procedure.2,3 leg length discrepancy (lld) accounts for 5% of all medical errors, as per the joint commission on accreditation of healthcare organizations (jcaho),4 and remains one of the leading causes of litigation against orthopaedic surgeons in the usa.5 the complications of lld after tha include sciatic, femoral and peroneal nerve palsy, hip or low back pain, abnormal gait and posture, and aseptic loosening. the incidence of lld after tha has been reported to range from 1% to 27%,6 with some studies reporting values of lld from 3 mm to 70 mm (mean 3–17 mm).² small discrepancies may be a source of dissatisfaction for some patients; however, several studies have shown that up to 10 mm of lld may be well tolerated by most patients. leaving the operated leg short seems to be more acceptable to patients than lengthening the operated leg, since patients can detect relatively small increases in length, and are particularly unhappy if they have to wear a shoe raise on the contralateral, unoperated side.7 the importance of attempting to equalise leg length is recognised among all orthopaedic surgeons in all sub-specialties, not just arthroplasty surgeons. this is attested to by the large amount of literature on lld in tha. in order to mitigate the occurrence of lld after tha, various methods have been used. these include preoperative templating,8-10 a wide range of intra-operative techniques, such as measurements from a fixed point on the pelvis using a suture or ruler, to drilling steinman pins or k-wires into a point in the pelvis.11 more recently, computer navigation has been used.12,13 in order to achieve consistent llc, the surgeon needs to be familiar with the various surgical techniques and the accuracy of these in the clinical or operative setting. the objective of this study was to assess the accuracy of a method we use to quantify the llc intra-operatively, namely the vertical measurement system™ (vms), and compare it to sixweek post-operative x-rays. the basic principle of this system is that the difference in vertical height between the excised femoral head and neck, and the combined vertical height of the implants, determines the change in leg length. our hypothesis was that the llc measured using the intra-operative vms method would equal the post-operative radiological measurement. patients and methods a prospective cohort study was conducted at two hospitals in the western cape, south africa. patients who were booked for tha were invited to participate, after careful explanation of the study design and methods. informed consent for the study was obtained from all patients. inclusion criteria were all patients undergoing primary tha, as per standard protocols utilised in the arthroplasty units at the two hospitals. exclusion criteria were thas performed for trauma (fractures of the femoral neck or pelvis) and revision tha. patients were recruited between may and october 2019, over a period of 19 weeks. pre-operative assessment prior to surgery (at the routine pre-operative clinic visit), clinical assessment of the true and apparent leg length was performed to exclude other causes of lld such as hip adduction, abduction or flexion contractures, or knee flexion contractures. digital x-rays were obtained using the philips intellispace pacs enterprise system. a standard ap pelvis standing x-ray, scaled using a radiological sphere marker at the level of the greater trochanter, was used for planning. orthoview digital planning software was used for pre-operative templating, sizing and positioning of implants and calculation of the pre-operative radiological lld. the method described by woolson,8 using the distance measured between a line drawn at the inferior aspect of each acetabular teardrop (the reference line) and the medial vertex of each lesser trochanter, was used to measure lld (figure 1).8 the three possible pelvic reference points include the inferior aspect of the obturator foramen, the ischial tuberosities, and the acetabular teardrop. the teardrop is the most reproducible and accurate when calculating limb length discrepancy.9 this measurement, in combination with the clinical assessment of lld, was used to inform the intra-operative llc to be achieved. intra-operative measurement and calculation the thas were performed by four surgeons at two hospitals. each tha proceeded in the routine manner, utilising the modified hardinge or direct anterior approach. implanted components figure 1. the method used by woolson to measure lld. a reference inter-teardrop line is drawn between the most inferior aspect of each teardrop. the distance to the medial vertex of each lesser trochanter is measured (woa and won) figure 2. the measurement jig utilised by the vertical measurement system™ (vms) to measure the vertical height of the excised femoral head and neck page 208 moonda z et al. sa orthop j 2020;19(4) were mostly triloc, summit and c-stem stems with pinnacle cups (de puy synthes, warsaw, in, usa), while a small proportion were accolade stems and tritanium cups (stryker, kalamazoo, mi, usa). after the femoral neck osteotomy, the vertical height (vh) of the excised bone (resection measurement) was measured using the vms or vertical measurement system™ (peninsula orthopaedics, cape town, south africa) jig (figure 2). acetabular and femoral preparation, trial implantation and reduction were performed, and the hip tested for range of movement (rom), stability and tension. the resection measurement and implanted component data were then utilised by the available application (vms), an online calculator with a database of implant sizes and measurements that obviates the need to use multiple charts, to calculate the llc. the difference between what is resected, i.e. the height of the excised femoral head and neck (vh), and the height of the implanted components (ic) (figure 3) determines the llc.14 at this point, if it was found that the llc achieved (using the vms system) did not match what was planned (as per the pre-operative x-ray measurement), intra-operative adjustments were made to further correct the leg length, until the objective was achieved. the surgery was concluded in the normal manner. post-operative standard rehabilitation protocols were followed, and the patients were followed up at six weeks. standardised, calibrated x-rays and templating software were again utilised to measure the radiological llc achieved. this radiological llc was compared to the intraoperative llc measurement provided by the vms. statistics all data analyses were performed using ibm spss ver. 25 (armonk, new york, usa) and g*power ver. 3.1.9 (open source).15,16 the distribution of vms and x-ray measurement data were analysed using the shapiro-wilk test for normality. the two sets of measurements were compared using the mann–whitney u test for statistical significance. the cut-off for type i error (α) was set at 0.05. results for this study, 98 patients were enrolled over the period of 19 weeks. prior to the six-week follow-up, one patient died from an unrelated cause. a further four patients were later excluded from the final analysis due to incomplete data, and one patient failed to return for their six-week follow-up. this left 92 patients who completed the six-week follow-up and whose data was complete for analysis. baseline characteristics of the study group are listed in table i. the difference between the means of the vms measurements and the x-ray measurements was –0.1±3.3 mm (figure 4). the mean absolute measurement difference between the two sets of values was 2.4±2.2 mm. the difference of each patient’s values (vms and x-ray) was plotted against their mean (figure 5). the mean difference of all these values was very close to zero, which was ideal, and most measured differences were found to lie within the 95% confidence interval. when compared to the target llc decided on pre-operatively, the mean absolute residual lld post-op was 3.2±3.1 mm. of the 92 patients, 82% (n=75) had a residual post-operative lld of ≤5 mm, while 96% patients (n=88) had an lld of ≤10 mm. discussion the primary goals of tha include pain relief and the restoration of normal hip biomechanics, gait and function. however, restoring or maintaining equal leg lengths is critical for patient satisfaction and return to function. the orthopaedic literature is replete with articles on lld, the effects thereof, and methods to achieve adequate llc during tha. nevertheless, the amount of lld at which it becomes figure 3. vertical measurement system: the height of the implanted components (ic) minus the height of the excised bone (vh) determines the leg length correction (source: verticalmeasurementsystem.com, used with permission) table i: baseline characteristics of the study group variable result number of patients 92 male:female 43 (46%):50 (54%) mean age (years) 60.8 laterality (right/left) 47/46 page 209moonda z et al. sa orthop j 2020;19(4) clinically significant, or that leads to symptoms, is still debated. generally, an lld of less than 10 mm is widely accepted.11 beard et al. found patients had worse oxford hip scores at three years if lld was greater than 10 mm.17 our clinical aim was to achieve equal leg lengths since even small discrepancies are associated with functional impairment and pain.18,19 in our study, the desired llc was decided on pre-operatively, using a combination of measuring the lld on a templating pelvic x-ray and clinical measurement. we then aimed to achieve this llc intra-operatively, by using the vms. intra-operative adjustments were therefore possible (in component sizing and positioning), allowing restoration of leg length to near equal. when comparing the intra-operative vms measurements to the six-week post-operative radiographic measurement, there was no statistically significant difference (p>0.05) between the two sets of values. the mean absolute difference of 2.4±2.2 mm is very similar to the values quoted in other studies, where an intra-operative method was compared to the post-operative radiograph. barbier et al.20 utilised a mechanical measurement device (lood – length and offset optimisation device) fixed to the pelvis to correct lld, and the mean deviation from target length was 2.3 mm (range 0.04– 10.6 mm). other studies have reported post-operative radiographic lld of between 1.8 mm and 3.5 mm.21,22 using intra-operative fluoroscopy is an available option, particularly in the anterior approach where supine positioning is conducive to imaging, as discussed by austin et al., who compared two different techniques of llc.23 using a radiographic overlay technique, the lld was 4.8 mm, and their transverse rod method yielded a lld of 4.4 mm. however, this involved increased surgical time, radiation exposure and increased surgical cost. more invasive measures have been utilised, which involve fixing a reference device into the pelvis and obtaining measurements to the greater trochanter or other reference point on the femur. the reference can be iliac fixation pins, intraoperative callipers, infracotyloid pins, and fixed suture lengths. in order for these devices to work properly, the operating table must be level with the floor and the position of the hip must be reproduced precisely in all planes before and after reconstruction is performed.24 ranawat et al. used a steinman pin fixed to the ischium in the posterior acetabulum and achieved lld<6 mm in 87% of their cases.25 shiramizu et al. compared a series of patients operated on with or without the use of a calliper fixed to the anterior superior iliac crest, and found a mean post-op lld of 2.1 mm using the calliper versus 8.2 mm without.26 a plethora of other examples of similar techniques have been reported. however, due to these techniques having their own problems – inconsistent leg positions during measurement, extra skin incisions, additional invasiveness of inserting devices into the pelvis, reference pins or devices loosening during surgery, greater surgical time and greater cost – most of them are not widely used. more recently tagomori et al. proposed a simpler intra-operative technique of llc. they utilised a reference mark cut into the posterior acetabular wall with a saw and referenced this off a marking on the greater trochanter. their measurement error, as calculated by intra-operative measurement versus post-operative ct lld measurement, was 1.9±1.4 mm.27 modern advancements in arthroplasty include the use of computer-assisted navigation to enhance the accuracy of implant placement. this method of computer-assisted surgery (cas) uses two different techniques, i.e. imageless and image-based (using ct, mri or intra-operative fluoroscopy). imageless systems use a generic simulated model, whereas ct-based systems allow figure 5. bland-altman plot showing each patient’s values. the difference between the vms and x-ray measurements are plotted against their mean. the green line is the mean difference between the values, namely x-ray vs vms (very close to zero here, which is ideal). the red lines are the upper and lower limits of the 95% confidence interval of the measured differences. 20.0 10.0 0.0 -10.0 -20.0 d iff e re n c e ( in m m ) -5.0 0.0 5.0 10.0 15.0 20.0 25.0 mean (in mm) 30.0 20.0 10.0 0.0 -10.0 m e a su re d v a lu e s (i n m m ) vms prediction x-ray measurement 5.4+4.2 5.4+5.4 figure 4. the two data sets are shown: vms and x-ray measurements. depicted are their means, standard deviations and ranges. the difference between the two means was –0.1±3.3 mm. page 210 moonda z et al. sa orthop j 2020;19(4) visualisation of a patient-specific model.12 cas systems require the registration of landmarks on the pelvis and femur. this requires placement of a reference frame on the pelvis, commonly involving placement of steinman pins or similar into the iliac crest, and other landmarks on the pubis sometimes requiring mini incisions to accurately locate them. femur landmarks are registered using a dynamic sensor array, which the surgeon controls. this intraoperative method can lead to complications during surgery, including failure to calibrate the cas station and fracture of the iliac crest, greater trochanter and distal femur when inserting the pins for the sensor arrays. in a study by brown et al., where cas was compared to conventional freehand technique, no difference was found in component positioning, leg length and harris hip scores (hhs) in their series. they reported an increased operative time of 18 minutes in the cas group, increased blood loss (69 ml), and a higher cost of surgery, with no additional benefit over freehand tha.28 in contrast, ellapparajda et al. used navigation in a series of 152 thas, and produced very good results, with 96% of thas restoring the leg length to within 6 mm of the contralateral side. they also reported minimal extra surgical time or surgical cost required in the navigated thas.29 similarly, renkawitz et al. compared the intra-operative values provided by the cas system they used to the post-operative llc measured on radiographs, and found a high degree of correlation between the two measurement methods, and recommended cas as a good intra-operative tool.30 according to rajpaul and rasool, cas enables the surgeon to more accurately and reproducibly correct leg length, with fewer outliers and no major complications. however, the improved accuracy does not translate into better outcome scores, and the technique is associated with complications including fractures, pin-site infections and pain.12 longer-term studies are required to assess the effect of cas on implant longevity and revision rates. all the methods discussed here have their drawbacks. some intra-operative tools are invasive, cumbersome or expensive; many are not user-friendly or accurate enough; more modern tools have steep learning curves, are very costly to acquire and have potential complications with their use. a simple, accurate and reliable method that is easy to use, and that gives live feedback or results, allowing intra-operative adjustments to be made in order to accurately achieve the desired llc, would be the panacea of llc in tha. we found that the vms method enabled us to achieve a reliable intra-operative llc, and this correlated well to the post-operative six-week x-ray. the accuracy of the method is in keeping with that of other methods, with a mean absolute measurement difference of 2.4 mm. this is a reliable and trustworthy method, indicating that the llc calculated by vms is very close to what one will actually achieve. the residual lld measured on x-ray was 3.2±3.1 mm, which is well below what most patients would notice, and is similar to the results achieved by other authors.12,20-23,25-30 nevertheless, we analysed why the results could not be even better. in determining the desired llc, we used a combination of x-ray determination of lld, as per the woolson method,8 and clinical measurement of lld. this introduces an element of human error, which could skew the effectiveness of whatever method is used to correct lld. clinical measurement of lld at the medial malleolus is open to a margin of error and inter-observer variation.31 furthermore, the woolson method relies on measuring the difference of two lines drawn between a reference pelvic line and the vertex of each lesser trochanter (lt), to calculate the lld. determining the lowest point of the acetabular teardrop on x-ray to draw the pelvic reference line is often a bit difficult, with only moderate inter-observer correlation.31 in addition, there is interobserver difference in determining exactly where the vertex, or most medial point, of the lt is. this is due to the differing shape of the lt among individuals, and some lts having a long vertex (in the vertical plane), making the determination of the point to measure to quite inconsistent. a further variable which would influence the final outcome is the determination of the exact measurement of the height of bone excised (vh). the measurement jig is designed to measure the height from a reference point on the inner cortex of the calcar, which the surgeon needs to pay careful attention to when placing the head and neck on the jig, to avoid any errors.14 in this study, our technique was not compared to a control group, in which no measurement protocol was used, and where the surgeon used more traditional methods of estimating llc, such as comparison to the other leg by feeling the heels and knees. further studies would be required in this regard. conclusion in this study, we found that the vms method offers the surgeon a reliable, accurate, simple and inexpensive method of quantifying llc intra-operatively, where adjustments can be made to fine-tune the outcome. provided that the surgeon pays careful attention while templating and with intra-operative measurements, the vms can accurately predict the post-operative radiographic llc. ethics statement prior to commencement of the study, ethical approval was obtained from the following ethical review boards: university of cape town, faculty of health sciences, human research ethics committee, hrec ref: 117/2019; institutional review board (irb) number: irb00001938. informed written consent was obtained from all patients prior to being included in the study. the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions zm contributed to the conceptualisation, study design and data collection, performed surgeries and prepared the manuscript. mbn contributed to conceptualisation and design, performed surgeries, supervised the study and reviewed the manuscript. rd contributed to data and statistical analysis, as well preparation of graphs and manuscript review. orcid moonda z https://orcid.org/0000-0002-6481-1334 nortje mb https://orcid.org/0000-0002-7737-409x dey r https://orcid.org/0000-0002-3616-1995 references 1. rasanen p, paavoilanen p, sintonen h, et al. effectiveness of hip and knee replacement surgery in terms of quality-adjusted life years and costs. acta orthop. 2007;78(1):108-15. 2. turula kb, friberg o, lindholm ts, tallroth k, vankka e. leg length inequality after total hip arthroplasty. clin orthop relat res. 1986;202:163. 3. williamson ja, reckling fw. limb length discrepancy and related problems following total hip joint replacement. clin orthop relat res. 1978;134:135. 4. joint commission on accreditation of healthcare organisations: ambulatory care sentinel event statistics – 24 june 2003. 5. clark cr, huddleston hd, schoch ep, 3rd, thomas bj. leg-length discrepancy after total hip arthroplasty. j am acad orthop surg. 2006;14(1):38-45. https://orcid.org/0000-0002-6481-1334 https://orcid.org/0000-0002-7737-409x https://orcid.org/0000-0002-3616-1995 page 211moonda z et al. sa orthop j 2020;19(4) 6. ranawat cs, rodriguez ja. functional leg-length inequality following total hip arthroplasty. j arthroplast. 1997;12:359-64 7. maloney wj, keeney ja. leg length discrepancy after total hip arthroplasty. j arthroplast. 2004;19:108-10. 8. woolson st. leg length equalization during total hip replacement. orthopedics. 1990;13(1):17-21. 9. meermans g, malik a, witt j, haddad f. preoperative radiographic assessment of limb-length discrepancy in total hip arthroplasty. clin orthop relat res. 2011;469(6):1677-82. 10. woolson st, hartford jm, sawyer a. results of a method of leg length equalization for patients undergoing primary total hip replacement. j arthroplasty. 1999;14:159-64. 11. ng vy, kean jr, glassman ah. limb-length discrepancy after hip arthroplasty. j bone joint surg am. 2013;95(15):1426-36. 12. rajpaul j, rasool mn. leg length correction in computer assisted primary total hip arthroplasty: a collective review of the literature. j orthop. 2018;15:442-46. 13. manzotti a, cerveri p, de momi e, et al. does computer-assisted surgery benefit leg length restoration in total hip replacement? navigation versus conventional freehand. int or thop. 2011;35(1):19-24. 14. no authors listed. vertical measurement system. available from: ht tps://w w w.ver ticalmeasurementsystem.com/assets/docs/ scientific_evidence.pdf (date last accessed 07 november 2019). 15. faul f, erdfelder e, lang a, buchner a. g*power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. behav res methods. 2007;39(2):175-91. https://doi.org/10.3758/bf03193146. 16. faul f, erdfelder e, buchner a, lang a. statistical power analyses using g*power 3.1: tests for correlation and regression analyses. behav res methods. 2009;41(4):1149-60. https://doi.org/10.3758/ brm.41.4.1149. 17. beard d, palan j, andrew j, nolan j, murray d. incidence and effect of leg length discrepancy following total hip arthroplasty. physiotherapy. 2008;94(2):91-96. 18. gurney b, mermier c, robergs r, gibson a, rivero d. effects of limb-length discrepancy on gait economy and lower-extremity muscle activity in older adults. j bone joint surg am. 2001;83-a(6):907-15. 19. parvizi j, sharkey pf, bissett ga, rothman rh, hozack wj. surgical treatment of limb-length discrepancy following total hip arthroplasty. j bone joint surg am. 2003;85-a(12):2310-17. 20. barbier o, ollat d, versier g. interest of an intraoperative limb-length and offset measurement device in total hip arthroplasty. orthop & trauma. 2012;98:398-404. 21. sayed-noor as, hugo a, sjödén go, wretenburg p. leg length discrepancy in total hip arthroplasty: comparison of two methods of measurement. int orthop. 2009;33(5):1189-93. 22. ogawa k, kabata t, maeda t, et al. accurate leg length measurement in total hip arthroplasty: a comparison of computer navigation and a simple manual measurement device. clin orthop surg. 2014;6(2):153. 23. austin dc, dempsey be, kunkel st, et al. a comparison of radiographic leg-length and offset discrepancies between two intraoperative measurement techniques in anterior total hip arthroplasty. arthropl today. 2019;5:181-86. 24. desai a, dramis a, board tn. leg length discrepancy after total hip arthroplasty: a review of literature. curr rev musculoskelet med. 2013;6:336-41. 25. ranawat cs, rao rr, rodriguez ja, bherde bs. correction of limb-length inequality during total hip arthroplasty. j arthroplasty. 2001;16:715-20. 26. shiramizu k, naito m, shitama t, et al. l-shaped caliper for limb length measurement during total hip arthroplasty. j bone joint surg (br). 2004;86:966-99. 27. tagomori h, kaku n, tabata t, et al. a new and simple intraoperative method for correction of leg-length discrepancy in total hip arthroplasty. j orthop. 2019;16:405-408. 28. brown ml, reed jd, drinkwater cj. imageless computer-assisted versus conventional total hip arthroplasty: one surgeon’s initial experience. j arthroplasty. 2014;29(5):1015-20. 29. ellapparadja p, mahajan v, deakin ah, deep k. reproduction of hip offset and leg length in navigated total hip arthroplasty: how accurate are we? j arthroplasty. 2015;30(6):1002-1007. 30. renkawitz t, sendtner e, schuster t, et al. femoral pinless length and offset measurements during computer-assisted, minimally invasive total hip arthroplasty. j arthroplasty. 2014;29(5):1021-25. 31. moonda z, nortje mn. an assessment of the accuracy of measurement of leg length discrepancy and inter-observer reliability, using a digital pacs x-ray system and templating software. [abstract]. saoa congress, 2019. _hlk37169859 layout 1 abughalya ms et al. saoj 2017;16(3) south african orthopaedic journal doi 10.17159/2309-8309/2017/v16n3a1 http://journal.saoa.org.za hip the radiological outcome of uncemented femoral stems in rheumatoid patients undergoing total hip arthroplasty: results at minimum eight years ms abughalya,1 p ryan,2 ie goga3 1 hdip(ortho), fcs ortho(sa), consultant orthopaedic surgeon, department of orthopaedic surgery, university of kwazulu-natal, durban, south africa 2 mbchb(uct), hdip(orth), mmed(ortho), fcorth(sa), specialist orthopaedic surgeon at arthroplasty and sports medicine units, department of orthopaedics, inkosi albert luthuli central hospital, durban, kwazulu-natal, south africa 3 md, frcs(edin), fcs orth(sa), professor and head of department orthopaedic surgery, inkosi albert luthuli central hospital, durban, kwazulu-natal, south africa corresponding author: dr ms abughalya, email: dr.abughalya@gmail.com, tel: +27 812 711935 abstract background: rheumatoid arthritis is a multi-systemic disease which affects all synovial joints. compromised bone quality may have a negative impact on prosthesis incorporation after total hip replacement, resulting in an increased risk of aseptic loosening and early implant failure. materials and methods: between 2002 and 2007, 49 patients (age 29–80 years) underwent total hip replacement. radiographs were evaluated for signs of loosening or failure. result: of the 49 hips, there was one case of stem subsidence, and one case of aseptic loosening. there were no revisions in the current series. complications included eight (16.3%) intra-operative calcar fractures, which healed uneventfully. conclusion: we report satisfactory radiological results, and revision rate in a group of rheumatoid patients at mid-term review following total hip replacement with uncemented femoral stems. key words: rheumatoid arthritis, uncemented stem, femoral stem, hip, total hip arthroplasty, radiological assessment citation: abughalya ms, ryan p, goga ie. the radiological outcome of uncemented femoral stems in rheumatoid patients undergoing total hip arthroplasty: results at minimum eight years. saoj 2017;16(3):22-26. doi 10.17159/2309-8309/2017/v16n3a1 editor: prof anton schepers, university of the witwatersrand received: march 2016 accepted: october 2016 published: august 2017 copyright: © 2017 abughalya ms et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for the writing of this article. conflict of interest: the authors declare they have no conflicts of interest relating to this article. introduction rheumatoid arthritis (ra) is a chronic systemic inflammatory disorder characterised by multiple joint involvement. the hip joint is commonly affected (15–30% of patients).1 the disease process, medication and steroid use affect bone properties which lead to changes in bone bio-mechanics.2,3 destruction of articular cartilage, bony deformity and protrusion are commonly seen in rheumatoid hip disease. alterations to joint morphology, as well as bone quality contribute to an increased risk of intraand post-operative complications.4 there is a two-fold increase in the frequency of osteoporosis compared to the general population.5 this results in a decreased potential for bony in/on-growth to uncemented prosthesis, and a decrease in fixation strength, with early aseptic loosening. for this reason, cemented total hip replacement (thr) has been considered by many to be the gold standard for patients with ra.1 with modern cementing techniques, stem survival rates are increased as the relative risk for stem loosening decreases.6 saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:01 pm page 22 abughalya ms et al. saoj 2017;16(3) page 23 the use of uncemented prostheses for hip arthroplasty continues to rise as shown in numerous national joint registries.7,8 although there have been some disappointing results for certain uncemented femoral stem designs used in this patient group – with high rates of subsidence and loosening – others have been more encouraging. with this in mind, we set out to perform a mid-term review of the radiological outcomes of a group of rheumatoid patients who had total hip replacements at our institution. methods and materials this study was conducted at the local arthroplasty unit in durban, kwazulu-natal. from 2002 to 2007, 61 cementless primary total hip replacements were performed in 46 rheumatoid patients. at the time of review, three patients had demised, and nine were lost to follow-up. in the remaining 34 patients, 49 uncemented thrs were performed. at the time of hip arthroplasty, the patients were aged between 29 and 80 years (mean of 58.4 years) (sd=12.12) (table i). there were ten males, and 24 females (graph 1), with 70.8% of the patients being female. fifteen patients had bilateral thrs and 19 patients had unilateral thrs (graph 2). all patients were operated on through a modified harding approach. all patients had index surgery without previous hip surgery. the femoral component was a collarless fully hydroxyapatite coated stem (corail, de puy international ltd) in 34 hips and a tapered grit blasted stem (cls zimmer, warsaw) in four. follow-up ranged from 8 to 13 years (mean of 8.8 years) (sd=1.70). the hips were evaluated radiographically pre-operatively and post-operatively by standardised anteroposterior view and lateral view of the hips. all measurements were taken by using siemens syngo.plaza software, and magnification errors were accounted for. the radiological assessment was made according to the following criteria: • stem subsidence defined as a >5 mm change in distance between the top of the stem and greater trochanter9 as in figure 1 • stem position in relation to the long axis of the femoral shaft in anteroposterior view as shown in figures 2a and b, valgus or varus more than 3 degrees10 figure 1. (a) immediate post-operative and (b) most recent film showing stem subsidence, but solid stem fixation a b figure 2. (a) ap view and (b) lateral view, demonstrating reactive bone formation from the tip of the femoral prosthesis towards the medial and anterior cortices a b table i: descriptive statistics mean (sd) n=51 age (years) 58.43 (12.12) years between surgery and final follow-up 8.82 (1.70) graph 1. sex of patients female male graph 2. uni and bilateral split 20 15 10 5 0 unilateral bilateral saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:01 pm page 23 page 24 abughalya ms et al. saoj 2017;16(3) • loosening of the stem based on gruen zones11 as result of subsidence >5 mm, progressive change in the stem position >3 degrees, or continuous radiolucency more than 2 mm12 (figure 3) • stability of the femoral stem was graded as stable ingrown fixation or unstable according to engh’s criteria13 • femoral remodelling as evidenced by calcar resorption, cortical hypertrophy (figure 4) • stress shielding as evidenced by a decrease of bone quality of the trochanters due to unloading of the proximal femur (figure 5). data was analysed with stata v.12. descriptive statistics were calculated for the data, including mean and standard deviation for continuous data, and frequency and proportions for categorical data. chi-squared tests were used to identify significant associations between categorical variables. a significance level of p<0.05 was deemed significant. results the records and radiographs of 49 patients were retrospectively analysed. the stem position was central in 42 hips, varus in six hips, and valgus in one. there was one (1.9%) case of femoral subsidence (graph 3). this was noted in the six-week follow-up x-ray, and is considered to be due to undersizing of the femoral component (figure 1). there were eight cases (16.3%) of intra-operative calcar cracks, six of which were fixed with charnley wire, and two which were not. all fractures healed uneventfully, with no subsidence. reactive double line formation from bone remodelling was noted in zone 1 in five hips (figure 3), and at the distal tip of the component in 28 hips (57.14%). femoral calcar resorption was noted in two cases (graph 4), mild stress shielding was seen in 17 cases (33%), and more significant stress shielding in two hips (3.9%) (table ii). although, one hip was deemed to be radiologically loose, there were no revisions in this group. chi-squared tests (fischer’s exact) indicated a significant association between femoral calcar resorption and femoral osteolysis (p=0.001), femoral stress shielding (p=0.012) and femoral alignment (p=0.001). however, no significant association was observed between femoral osteolysis and femoral calcar rounding (p=0.12), and femoral alignment (p=0.072). the sex of the patient was not significantly associated with any of the variables. figure 5. bilateral thrs and bilateral proximal stress shielding figure 4. right hip replacement with medial calcar resorption/osteolysis figure 3. ap radiograph of right femoral stem demonstrating reactive double line formation in gruen zone 1 saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:01 pm page 24 abughalya ms et al. saoj 2017;16(3) page 25 discussion total hip replacement has been shown to be a hugely beneficial and cost-effective procedure in rheumatoid patients, improving hip function, relieving pain, and improving quality of life.14,15 however, there remain concerns regarding periarticular bone stock in the rheumatoid patient. akesson et al.16 reported that compared to patients with primary osteoarthritis, rheumatoid patients going for hip arthroplasty showed an increase in bone turnover and a greater amount of unmineralised bone. this is postulated to be the cause of early implant loosening in rheumatoid patients. reported series of the use of cemented thrs in rheumatoid patients show varying degrees of success. poss et al.17 reported results at seven years’ follow-up: 96% of the patients in this study were happy with their outcome, and were clinically improved. despite 31% femoral stem subsidence, there was only a 1.6% revision rate.17 ranawat et al.18 reported 8% femoral loosening at an average 4.3 years’ follow-up with cemented stems. severt et al.19 reviewed 75 rheumatoid patients at an average of 7.4 years, and reported three loose stems, and one revision for aseptic loosening. creighton et al.20 found that cemented prosthesis survival in ra patients is comparable, if not better, compared to other diagnoses. with the introduction of modern cementing techniques, femoral stem survival rates have improved. rasquinha21 reported on 15 thrs at 15-year follow-up, with no aseptic loosening or stem revisions. when considering cemented thr one should remain cognisant of the risk of haemodynamic instability inherent during the cementing process.22,23 deep infection rates may also be increased due to the increase in operating time, and the local deep tissue injury from cement curing.17,19,24-27 the calculated cost of utilising cemented prostheses should include the increase in theatre time, which may be as much as 20 minutes longer on average than uncemented thr.28 cementless fixation of femoral stems has become more popular, and good long-term results can be expected if there is solid biological integration. however, subsidence rates as high as 80% have been reported.29 implant loosening does not necessarily correlate with implant survival. unger et al.25 reported an overall 16.7% revision rate in ra patients at 12.1 year follow-up, with a further 15.7% prostheses being radiologically loose. according to a study from the national finnish register, uncemented prostheses performed better in both juvenile and old rheumatoid patients when compared to matched groups of patients with cemented stems.30,31 in the swedish hip arthroplasty registry between 1992 and 2007, it was shown that the risk of revision for uncemented femoral stems for any reason was lower than that for cemented stems. revision for aseptic loosening was also lower in the uncemented group, after adjusting for age, sex, and underlying diagnosis. however, reasons for revision differed between the two groups, with a higher proportion of the revisions in the uncemented hips being for fractures (17%) compared to that of cemented stems (6% of the revisions in this group).27 table ii: categorical proportions n (%) sex male 14 (29.2) female 34 (70.8) type of femoral implant corail 44 (89.8) zimmer 4 (8.2) unknown 1 (2.0) femoral alignment central 38 (79.2) valgus 1 (2.1) varus 9 (18.7) femoral reactive double line formation none 45 (91.8) superolateral 4 (8.2) femoral stress shielding none 32 (65.3) mild 16 (32.7) moderate 1 (2.0) femoral calcar rounding no 47 (95.9) yes 2 (4.1) femoral calcar resorption no 43 (87.8) mild 5 (10.2) severe 1 (2.0) femoral cortical thickening no 46 (93.9) medial 3 (6.1) femoral osteolysis no 46 (98.0) yes 1 (2.0) femoral reactive bone formation no 20 (40.8) yes 29 (59.2) subsidence no 48 (98.0) yes 1 (2.0) femoral component fixation 49 (100.0) graph 3. indication of femoral subsidence 50 45 40 35 30 25 20 15 10 5 0 no yes subsidence graph 4. indication of femoral calcar resorption 50 45 40 35 30 25 20 15 10 5 0 no yes femoral osteolysis saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:01 pm page 25 page 26 abughalya ms et al. saoj 2017;16(3) although we had one case of subsidence, and one case of femoral component loosening, there were no revisions in this series. several studies report the most common complication in uncemented total hip arthroscopy (tha) is intra-operative fracture, which may or may not need fixation. such fractures do not necessarily affect implant stability or long-term survival.32-35 in this series, there was a 16.3% fracture rate; however, none of these stems subsided, or were radiologically loose. conclusion in this current retrospective case series, we have demonstrated satisfactory radiological results at a minimum of eight years post-surgery. although, previous studies consider cemented femoral prostheses as the gold standard for rheumatoid patients, this study confirms that cementless femoral stem fixation is a safe alternative. compliance with ethics guidelines ethics clearance was approved by brec (biomedical research ethics cpmmittee) which is registered with the south african national health research ethics council (rec-290408-009) and has us office for human research protections (ohrp) federal-wide assurance (fwa678). references 1. thomason hc, lachiewicz pf. the influence of technique on fixation of primary total hip arthroplasty in patients with rheumatoid arthritis. j arthroplasty. 2001;16(5):628-34. 2. trancik t, mills w, vinson n. the effect of indomethacin, aspirin, and ibuprofen on the bone growth into a porous-coated implant. clin orthop. 1989;249:113-21. 3. wheeler dl, vander griend ra, wronski tj, et al. the shortand longterm effects of methotrexate on the rat skeleton. bone. 1995;16: 215-16. 4. zwartele re, witjes s, doets hc, stijnen t, poll rg. cementless total hip arthroplasty in rheumatoid arthritis: a systematic review of the literature. arch orthop trauma surg. 2012;132:535-46. 5. haugeberg g, uhlig t, falch ja, halse ji, kvien tk. bone mineral density and frequency of osteoporosis in female patients with rheumatoid arthritis. arthritis rheum. 2000;43:522-30. 6. onsten i, besjakov j, carlsson as. improved radiographic survival of the charnley prosthesis in rheumatoid arthritis and osteoarthritis: results of new versus old operative techniques in 402 hips. j arthroplasty. 1994;9:3-8. 7. no authors listed. the canadian joint replacement registry. http:// secure.cihi.ca (date last accessed 24 sep. 2015). 8. no authors listed. the swedish joint registry. http://www.shpr.se/ libraries/documents/annualreport_2013-04-1_1.sflb.ashx. 9. garcia-cimbrelo e, cruz-pardos a, madero r, ortega-andreu m. total hip arthroplasty with use of the cementless zweymuller alloclassic system. a ten to thirteen-year follow-up study. j bone joint surg am. 2003;85:296-303. 10. barrack rl, mulroy rd, harris wh. improved cementing techniques and femoral component loosening in young patients with hip arthroplasty. a 12-year radiographic review. j bone joint surg br 1992;74:385-89. 11. gruen ta, mcneice gm, amstutz hc. ‘modes of failure’ of cemented stem-type femoral components: a radiographic analysis of loosening. clin orthop relat res. 1979;141:17-27. 12. sanz-reig j, lizaur-utrilla a, llamas-merino i, lopez-prats f. cementless total hip arthroplasty using titanium, plasma-sprayed implants: a study with 10 to 15 years of follow-up. j orthop surg 2011;19:169-73. 13. engh ca, bobyn jd, glassman ah. porous-coated hip replacement. the factors governing bone ingrowth, stress shielding, and clinical results. j bone joint surg br. 1987;69:45-55. 14. liang m, cullen k, larson m, thompson m, schwartz j, fossel a. cost effectiveness of total joint arthroplasty in osteoarthritis. arthritis rheum 1986;29:937-43. 15. jonsson b, larsson s. functional improvements and costs of hip and knee arthroplasty in destructive rheumatoid arthritis. scand j rheumatol 1991;20:351-57. 16. akesson k, onsten i, obrant kj. periarticular bone in rheumatoid arthritis versus arthrosis: histomorphometry in 103 hip biopsies. acta orthop scand. 1994;65:135-38. 17. poss r, maloney jp, ewald fc, et al. six to 11 year results of total hip arthroplasty in rheumatoid arthritis. clin orthop. 1984;182:109-16. 18. ranawat cs, dorr ld, inglis ae. total hip arthroplasty in protrusio acetabuli of rheumatoid arthritis. j bone joint surg am 1980;62:1059-65. 19. severt r, wood r, cracchiolo iii a, amstutz hc: long-term follow-up of cemented total hip arthroplasty in rheumatoid arthritis. clin orthop 1991;265:13745. 20. creighton mg, callaghan jj, olejniczak jp, johnston rc. total hip arthroplasty with cement in patients who have rheumatoid arthritis: a minimum ten-year follow-up study. j bone joint surg am 1998;80:1439-46. 21. rasquinha vj, dua v, rodriguez ja, ranawat cs. fifteen-year survivorship of a collarless, cemented, normalized femoral stem in primary hybrid total hip arthroplasty with a modified third-generation cement technique. j arthroplasty. 2003;18:86-94. 22. ereth mh, weber jg, abel md, et al. cemented versus noncemented total hip arthroplasty embolism, hemodynamics, and intrapulmonary shunting. mayo clin proc 1992;67:1066-74. 23. nolan jp. arterial oxygenation and mean arterial blood pressure in patients undergoing total hip replacement: cemented versus uncemented components. anaesthesia 1994;49:293-99. 24. maric z, haynes rj. total hip arthroplasty in juvenile rheumatoid arthritis. clin orthop 1993;182:109-19. 25. unger as, inglis ae, ranawat cs, johanson na. total hip arthroplasty in rheumatoid arthritis: a long-term follow-up study. j arthroplasty 1987;2:191-97. 26. witt jd, swann m, ansell bm. total hip replacement for juvenile chronic arthritis. j bone joint surg br 1991;73:770-73. 27. hailer np, garellick g, kärrholm j. uncemented and cemented primary total hip arthroplasty in the swedish hip arthroplasty register. acta orthop 2010;81:34-41. 28. barrack rl, castro f, guinn s. cost of implanting a cemented versus cementless femoral stem. j arthroplasty 1996;11:373-76. 29. smilowicz m, kowalczewski jb. long-term results after total hip replacement; cemented and cementless in young rheumatic patients. chir narzadow ruchu ortop pol 2005;70:319-23. 30. eskelinen a, paavolainen p, helenius i, pulkkinen p, remes v. total hip arthroplasty for rheumatoid arthritis in younger patients. acta orthop 2006;77:853-65. 31. mäkelä kt, eskelinen a, pulkkinen p, virolainen p, paavolainen p, remes v. cemented versus cementless total hip replacement in patients fiftyfive years of age or older with rheumatoid arthritis. j bone joint surg am 2011;93:178-86. 32. turula k, savioja s, innes a, et al. early results of cementless total hip replacement in inflammatory joint disease. scand j rheumat 1987;67:61-63. 33. zwartele r, peters a, brouwers j, olsthoorn p, brand r, doets c. longterm results of cementless primary total hip arthroplasty with a threaded cup and a tapered, rectangular titanium stem in rheumatoid arthritis and osteoarthritis. int orthop 2008;32:581-87. 34. araujo j, gonzalez j, tonino a, international abg study group. rheumatoid arthritis and hydroxyapatite-coated hip prostheses. j arthroplast 1998;13:660-67. 35. arnold p, schüle b, schroeder-boersch h, jani l. review of the results of the aro multicenter study. orthopade 1998;27:324-32. saoj spring 2017 issue.qxp_layout 1 2017/08/06 2:01 pm page 26 rosin rc et al. sa orthop j 2019;18(4) doi 10.17159/2309-8309/2019/v18n4a2 south african orthopaedic journal http://journal.saoa.org.za paediatric orthopaedics citation: rosin rc, rasool mn, sibanda w, rollinson pd. antegrade flexible intramedullary nailing through the greater trochanter in paediatric femur shaft fractures. sa orthop j 2019;18(4):20-27. http://dx.doi.org/10.17159/2309-8309/2019/v18n4a2 editor: dr gb firth, university of witwatersrand, johannesburg, south africa received: april 2019 accepted: july 2019 published: november 2019 copyright: © 2019 rosin rc. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: this study received no funding. conflict of interest: all authors declare having no conflict of interest with regard to this study. abstract aims: to determine whether an antegrade approach, through the tip of the greater trochanter, in femoral shaft fractures in children, is safe, achieves adequate union and results in significant proximal femoral growth complications. patients and methods: the case records and radiographs of 23 paediatric patients aged 7 to 12 years with femur shaft fractures managed with stainless steel antegrade flexible nailing were reviewed retrospectively. pre-operative radiographs were reviewed for fracture pattern, level and comminution. post-operative radiographs were reviewed to assess for union, alignment, osteonecrosis of the femoral head and epiphysiodesis of the greater trochanter. morphological changes of the proximal femur were assessed by comparing the neck shaft angle and articulo-trochanteric distance with the opposite hip. case records were reviewed for post-operative complications, patient-reported complaints and leg length discrepancy. clinical outcomes were assessed with the criteria established by flynn. results: all patients achieved union, and none had evidence of osteonecrosis of the femoral head on follow-up. three patients had malalignment and two patients had radiographic evidence of greater trochanteric epiphysiodesis. two patients had morphological changes of the proximal femur, with one having an increased neck shaft angle and one an increased articulo-trochanteric distance. one patient had a leg length discrepancy of 2 cm. fifteen patients had excellent clinical outcomes, five had satisfactory outcomes and three had poor outcomes according the criteria established by flynn. conclusion: antegrade entry through the tip of the greater trochanter does not appear to compromise the blood supply to the femoral head or increase the risk of clinically significant morphological changes to the proximal femur. all patients achieved adequate union. furthermore, antegrade insertion avoided skin problems and prominent nail complications around the knee seen with retrograde insertion. level of evidence: level 4 keywords: paediatric, femur shaft fractures, flexible intramedullary nails, antegrade antegrade flexible intramedullary nailing through the greater trochanter in paediatric femur shaft fractures rosin rc¹ , rasool mn2 , sibanda w3 , rollinson pd4 1 mbchb(uct); orthopaedic registrar, department of orthopaedic surgery, nelson r mandela school of clinical medicine, university of kwazulu-natal, south africa 2 mbch, fcs(sa), phd; professor of paediatric orthopaedic surgery, nelson r mandela school of clinical medicine, university of kwazulu-natal 3 phd statistics (north-west university); biostatistics unit, school of nursing and public health, college of health sciences, university of kwazulu-natal, durban, south africa 4 mbchb(sheff), frcs (ed & eng); chief orthopaedic specialist, ngwelezana hospital, empangeni, kwazulu-natal, south africa corresponding author: dr rainer christian rosin, 40 halford road, musgrave, durban, 4001; tel: 0725840361; email: rainerrosin@gmail.com https://orcid.org/0000-0002-6247-4039 https://orcid.org/0000-0002-2073-8358 https://orcid.org/0000-0001-5702-2436 https://orcid.org/0000-0002-2384-7250 page 21rosin rc et al. sa orthop j 2019;18(4) introduction the incidence of femoral shaft fractures in south africa is estimated to be 0.25 per 1 000 children per year.1 the management of paediatric femoral shaft fractures includes both non-operative and operative options.2 flexible intramedullary nails (fin) are becoming increasingly popular in the 5–11 year-old age group. the standard approach for insertion of fin is retrograde, with medial and lateral entry portals. this approach avoids the greater trochanteric epiphysis and vessels supplying the femoral head. damage to these structures raises concerns regarding interruption to the blood supply of the femoral head, as well as growth disorders resulting from damage and subsequent epiphysiodesis of the greater trochanteric epiphysis. paediatric femoral shaft fractures have been managed with fin since 1999 in the orthopaedic department of a regional hospital in kwazulu-natal. being a resource-limited hospital at that time, the selection of the implant was greatly influenced by the cost. as a result, stainless steel flexible rods (rush rods) were preferred over more expensive titanium elastic nails. the orthopaedic department was staffed by relatively junior medical officers and so an antegrade approach was adopted. this approach was considered to be easier as it had the same theatre setup and patient positioning as used for adult femoral antegrade nailing, which was done on a more regular basis. this approach also avoids the distal femoral epiphysis unlike the standard retrograde approach. early experience revealed very few complications and it became the method of treatment for children from the age of 7 years. the aim of this study was to determine whether an antegrade approach with rod insertion through the tip of the greater trochanter is safe, achieves adequate union, and whether this approach results in any significant proximal femoral complications. materials and methods a retrospective study was done between june 2011 and june 2017 at a regional hospital in kwazulu-natal. a search of the operation slate database of the orthopaedic department for this period revealed 67 paediatric patients aged 7 years to 12 years with 67 femoral shaft fractures treated operatively. patients were admitted either directly or from one of 14 peripheral referring hospitals, servicing a population of 2.34 million people. the children were physiologically stabilised and were taken to theatre on the earliest available elective slate, aiming to get the fracture fixation performed within ten days of the date of injury. the patients were positioned supine on a traction table in a similar setup for antegrade nailing for an adult femur fracture but using a smaller perineal support (figure 1a). a 1 cm stab incision was made proximal to the greater trochanter and carried down to the tip of the trochanter. a 4.5 mm rush rod hand reamer was used to perforate the tip of the trochanter under fluoroscopic guidance, taking care to stay within the proximal femoral canal (figure 1b). two 3.2 mm rush rods, the length of which were determined intraoperatively, were contoured with a distal bend forming a ‘j-shape’. the first rod was advanced down to the fracture level. by rotating the rod and utilising the distal bend as well as manual manipulation, figure 1. intra-operative technique: a) patient positioned supine on traction table; b) entry through tip of trochanter with a 4.5 mm hand reamer; c) passing first rod across fracture site after reduction; d) advancing rods with aid of mallet; e) final positioning of rods a b c d e page 22 rosin rc et al. sa orthop j 2019;18(4) fracture reduction was achieved, and the rod was passed into the distal segment (figure 1c). the second rod was then introduced by carefully aligning the bent tip of the rod with the entry portal adjacent to the first rod, screening with ap and lateral views. once correctly positioned, the rod was advanced using a rod introducer and mallet (figure 1d). once across the fracture site, both rods were advanced down the distal femoral canal with the ideal configuration being to splay the rods in the medial and lateral distal metaphyses to gain rotational control of the fracture (figure 1e). the proximal ends of the rush rods were left approximately 2 cm out of the tip of the greater trochanter to facilitate future removal. post-operatively, patients with stable fracture patterns (such as transverse short oblique fractures) were mobilised immediately with partial weight-bearing. alternatively, if the fracture was classified as unstable, the patient was placed on skin traction for approximately 10 to 14 days to allow early callus formation to stabilise the fracture before allowing mobilisation on crutches. figure 2 shows an example of a fracture fixed using the above technique preoperatively, immediately post-operatively and at union. data was obtained retrospectively from case records and radiographic analysis. initial radiographs were assessed for fracture level, pattern and comminution according to the winquist and hansen classification.3 follow-up radiographs were assessed for signs of femoral head osteonecrosis, neck shaft angle difference (nsad), articulo-trochanteric distance difference (atdd), union and alignment. the articulo-trochanteric distance was defined as the distance between two lines drawn perpendicular to the femoral anatomical axis. the first line is drawn through the tip of the greater trochanter and the second line tangential to the highest level of the femoral head (figure 3). the atdd measures the growth of the greater trochanter relative to the femoral head. an increase in atdd indicates a relative undergrowth of the greater trochanter due to epihysiodesis. the normal articulo-trochanteric distance in children aged 5 to 13 years is 23 mm (±4.5 mm) and 16 mm (±3.6 mm) in males and females respectively.4 in order to account for any differences in magnification of the radiographs, the atdd was reported as an index of the affected side divided by the unaffected side. the atdd was considered abnormal if it was greater than 10 mm.5 a normal atdd index range was therefore calculated with the following formula, ‘(normal + 10)/normal’ for the upper range and ‘(normal 10)/normal’ for the lower range. thus, an atdd index range of 0.57 to 1.44 for males and 0.38 to 1.68 for females was considered normal. leg length was assessed clinically using a measuring tape. clinical outcomes were assessed according to criteria proposed by flynn et al.6 inclusion criteria included paediatric patients aged 7 to 12 years with femur shaft fractures that were managed surgically. exclusion criteria included patients whose case records lacked adequate follow-up information, patients with pathological fractures, and patients whose fractures were managed with methods other than antegrade stainless steel flexible intramedullary rods. analysis of data statistical analyses were performed using ibm spss version 25 (spss inc., chicago, il, usa). t-tests were used to determine significance for continuous data and chi-square/fisher’s exact tests were used for categorical data. a p-value <0.05 was considered statistically significant. pearson’s correlation coefficient was figure 2. a) pre-operative radiograph; b) immediate post-operative radiograph; and c) radiograph showing union after 6 months figure 3. articulo-trochanteric distance n=67 20 lost files n=47 11 retrograde nails n=36 1 pathological fracture n=35 12 inadequate notes total included in study n=23 figure 4. exclusions page 23rosin rc et al. sa orthop j 2019;18(4) used to determine the correlation between fracture pattern and comminution with the flynn outcome. results twenty-three children were selected for inclusion in the study from a total number of 67 who underwent surgery (figure 4). the majority of patients were excluded due to lost files or inadequate notes (i.e. no ap pelvis x-ray) making analysis impossible due to lack of data. the patient demographics, injury characteristics and management are presented in table i. the average age of the patients at the time of injury was 9 years (range: 7–12). three patients in the series had multiple injuries and were categorised as polytrauma. one patient had a gustilo-anderson grade ii open fracture. one fracture required open reduction; although it went on to union, it developed late sepsis with sequestrum. the sepsis later resolved following sequestrectomy. the average time to surgery was five days (range: 1–11). the average surgical time was 65 minutes (range: 35–120). the majority of patients (14) were mobilised immediately post-operatively on crutches, while the remainder required post-operative traction. the average time to removal of rods following surgery was 7.6 months (range: 3.2–36.3). the average follow-up time of the patients was 17.9 months (range: 6.8–37.5). the patients’ post-operative and radiological findings are presented in table ii. union was achieved in all patients. there was valgus malalignment in two patients of 11° and 7°, and apex anterior angulation in one patient of 11°. two patients had closure of their greater trochanteric epiphysis evident on table i: patient demographics, injury characteristics and management p a ti e n t a g e ( y e a rs ) m e c h a n is m o f in ju ry * f ra c tu re t y p e f ra c tu re l e v e l c o m m in u ti o n (w in q u is t g ra d e ) p o st -o p e ra ti v e m a n a g e m e n t t im e t o o p e ra ti o n (d a y s) o p e ra ti o n t im e (m in u te s) f o ll o w -u p (m o n th s) 1 7 fall transverse proximal third, mid third 1 mobilisation 4 80 15 2 9 fall spiral subtrochanteric 1 post-operative traction 5 45 38 3 8 gate fell on leg oblique proximal third, mid third 1 mobilisation 3 35 33 4 7 pva transverse distal third 1 mobilisation 4 75 10 5 11 mva transverse midshaft 3 post-operative traction 3 80 30 6 7 pva transverse subtrochanteric 2 mobilisation 6 120 27 7 11 pva transverse proximal third, mid third 2 post-operative traction 11 50 7 8 8 pva transverse midshaft 1 mobilisation 3 55 21 9 8 pva transverse proximal third, mid third 1 post-operative traction 8 50 15 10 8 fall transverse midshaft 1 mobilisation 13 95 11 11 9 fall oblique proximal third, mid third 1 post-operative traction 4 75 17 12 11 pva transverse proximal third, mid third 2 post-operative traction 2 60 12 13 12 mva spiral midshaft 1 mobilisation 5 35 11 14 7 mva oblique proximal third, mid third 1 mobilisation 4 90 13 15 10 fall oblique distal third 1 post-operative traction 1 45 12 16 10 fall transverse midshaft 1 mobilisation 3 50 26 17 9 mva transverse midshaft 1 mobilisation 10 45 10 18 10 gate fell on leg spiral subtrochanteric 3 post-operative traction 6 65 18 19 8 fall spiral subtrochanteric 1 mobilisation 3 80 27 20 12 fall transverse midshaft 1 mobilisation 2 40 19 21 9 fall transverse midshaft 1 mobilisation 2 110 15 22 8 pva transverse proximal third, mid third 2 mobilisation 7 75 9 23 9 fall transverse proximal third, mid third 1 mobilisation 3 50 18 * mva: motor vehicle accident; pva: pedestrian vehicle accident figure 5. evidence of epiphysiodesis of left greater trochanteric physis page 24 rosin rc et al. sa orthop j 2019;18(4) radiographs (figure 5). the average atdd index was 1.08 (range: 0.75–1.88) in males and 1.14 (range: 0.95–1.40) in females. the nsad ranged from -7° to 11°. osteonecrosis of the femoral head was not seen in any patients. flynn’s criteria are shown in table iii.6 of the three patients with poor results, two had pain, one of which also had malalignment 13° of valgus and one patient had 11° of apex anterior angulation. all patients had full range of movement of the knee. the leg length discrepancies ranged from 1.5 cm of shortening to 1.9 cm of lengthening. none of the patients had skin or prominent nail end complications. the small sample size allowed for very limited statistical analysis. no statistically significant correlation was found between age and malalignment (p=0.10). the proportion of patients with malalignment and with leg length discrepancies was statistically greater in children older than 11 years, with p-values of 0.031 and 0.005, respectively. comminution had a statistically significant association with malalignment (p=0.02). using pearson’s correlation, we found no statistically significant correlation between the fracture pattern (p=0.74) or comminution (p=0.66) and the flynn outcome. discussion the treatment of femoral shaft fractures in children lacks consensus in the literature.6 traditionally the management of paediatric femur table ii: post-operative clinical and radiological findings p a ti e n t l e n g th d is c re p a n c y ( c m ) u n io n c o ro n a l a li g n m e n t (° ) s a g it ta l a li g n m e n t (° ) a t d d # i n d e x n s a * d if fe re n c e (° ) o st e o n e c ro si s g re a te r tr o c h a n te ri c c lo su re f ly n n c ri te ri a 1 -0.5 yes 0 0 1.88 6.5 no no excellent 2 -1 yes 0 0 1.29 5 no no excellent 3 -1 yes 0 0 0.90 6 no no excellent 4 1 yes 0 0 0.96 0.5 no no excellent 5 -1 yes 0 0 1.00 -3 no no poor 6 -1 yes 13° valgus 0 1.20 5.5 no no poor 7 0 yes 0 11° apex anterior angulation 1.35 6.5 no no poor 8 0 yes 0 4° apex posterior angulation 0.85 -3 no no excellent 9 -1.5 yes 0 0 0.95 -7 no no satisfactory 10 0.2 yes 0 0 0.75 -2 no no excellent 11 -2 yes 0 0 1.40 9 no yes satisfactory 12 0 yes 0 0 1.00 -3 no no excellent 13 1.9 yes 0 5° apex posterior angulation 1.00 -4 no yes satisfactory 14 1 yes 0 0 0.95 -7 no no excellent 15 -1.5 yes 0 0 1.00 -0.4 no no satisfactory 16 0 yes 0 0 1.08 3 no no excellent 17 -0.8 yes 0 0 0.90 0 no no excellent 18 -0.2 yes 0 0 0.91 -6 no no excellent 19 -0.6 yes 0 0 1.43 11 no no excellent 20 -1.5 yes 7° valgus 0 1.30 4 no no satisfactory 21 0 yes 0 0 1.12 5 no no excellent 22 -0.3 yes 0 0 0.96 -5 no no excellent 23 -0.5 yes 5° valgus 3° apex anterior angulation 1.05 6 no no excellent # atdd: articulo-trochanteric distance difference; * nsa: neck shaft angle table iii: flynn criteria6 excellent satisfactory poor leg length discrepancy <1.0 cm <2.0 cm >2.0 cm malalignment <5° <10° >10° pain none none present complications none minor/resolved major/lasting morbidity results 15 (65%) 5 (22%) 3 (13%) page 25rosin rc et al. sa orthop j 2019;18(4) fractures involved a period of traction followed by hip spica cast immobilisation.7 there has, however, been a trend towards early operative management, especially in older children. the 2015 american academy for orthopaedic surgeons (aaos) evidencebased clinical practice guidelines for the treatment of paediatric diaphyseal femoral fractures provides a limited recommendation for the use of elastic intramedullary nails in children between the ages 5 to 11 years.8 conservative treatment inevitably resulted in prolonged immobilisation with negative effects on the child’s social development, schooling and family.9-11 increasing pressure on hospital beds lends impetus to management techniques that facilitate early mobilisation and discharge.12 operative options include external fixation, plating and flexible or rigid intramedullary nailing.7 shemshaki et al. compared hip spica casting with fin in children aged 6 to 12 years and found significant benefits with fewer complications with intramedullary nailing.13 bar-on et al. compared external fixation with fin. they recommended the use of fin as they found that there was more callus formation, as well as earlier return to full weight-bearing, full range of movement and return to school with fin.14 wani et al. reported similar results but recommended that the decision be left to the surgeon, as certain fractures, such as very distal or proximal fractures, may benefit from external fixation.15 chen et al. found that the use of fin was associated with a shorter operative time, less blood loss and shorter length of hospitalisation compared to submuscular plating.16 concerns with antegrade nailing are that the blood supply to the femoral head may be compromised and that penetration through the greater trochanteric epiphysis may lead to epiphysiodesis and proximal femoral growth deformities. it is for these reasons that a retrograde approach, or antegrade approach with an entry port distal to the greater trochanteric epiphysis has been popularised with fin insertion.17 however, some authors still consider an antegrade approach through the tip of the trochanter to be safe.18-20 the main blood supply to the femoral head is from the lateral ascending cervical artery in the piriformis fossa.21 momberger et al. believed that entry through the greater trochanter completely avoided these vessels and would decrease the incidence of osteonecrosis.22 this was further supported by the research of gordon et al., townsend et al. and elgohary et al.20,23,24 in their review of the literature macneil et al. found no evidence of osteonecrosis with a lateral greater trochanteric entry, a 1.4% rate of osteonecrosis with a tip of the greater trochanter entry and a 2% rate of osteonecrosis with a piriformis fossa entry point.25 in this study, radiographic follow-up showed no evidence of osteonecrosis. we attribute this to the small entry portal on the tip of the trochanter made with the 4.5 mm rush rod awl, thus minimising the risk of damage to the blood supply. gage et al. and herndon et al. believed that after the age of 8 years, trochanteric epiphysiodesis resulted in little or no deformity of the proximal femur, as growth was appositional.26, 27 raney et al. disagreed. they reviewed five patients who had changes to their proximal femur following epiphysiodesis secondary to reamed antegrade nailing. these changes were noted within five to eight months of the operation in four of the patients, and the fifth patient only showed changes after three years. furthermore, they believed that active growth of the physis was present in the second decade and showed that there was very little space in the proximal femur to avoid the physis. they did, however, note that although there were significant radiological changes, none of the children had functional impairment.28 gonzalez-herranz et al. found significant changes to the proximal femur in patients older than 13 years who had antegrade nails inserted. they considered these iatrogenic changes to be pre-arthritic and recommended varus osteotomies in severe cases.5 schofield et al. showed that epiphysiodesis of the greater trochanter resulted in a long valgus femoral neck.29 in contrast, elgohary et al. and gordon et al. reviewed 23 children aged 9 to 15 years, and 25 children aged 7 to 13 years, respectively, and found no proximal femur changes after reamed antegrade rigid intramedullary nails.20,23 furthermore, carey et al. reported no growth arrest following entry through the greater trochanteric epiphysis and, although there were changes with the atd and neck shaft angle, neither were clinically significant.18 galpin et al. who favoured an entry through the tip of the greater trochanter, further supported these findings. they also found no growth arrest of the greater trochanter and, therefore, suggested that a smooth unreamed nail does not affect the epiphysis.19 in this study two patients, aged 9 and 12 years, had radiographic evidence of greater trochanteric epiphysiodesis. neither of these patients, however, had significant changes in their atdd or neck shaft angle although they only achieved ‘satisfactory’ outcomes according to flynn’s clinical outcomes score. both cases were noted to lose points due to leg length discrepancies, which was more likely related to the fracture characteristics (one a spiral and the other an oblique fracture) than damage to the greater trochanteric epiphysis. two patients in this study did have morphological changes to the proximal femur. one patient had an increased atdd index and another had an increased nsad. both however, had excellent outcomes according to flynn’s clinical outcomes score, suggesting that these changes were not clinically significant. without the ability to lock fin, stability is one of the major concerns.30 length stable fractures, such as transverse fractures, lend themselves to fin. comminuted, long spiral and long oblique fractures lack inherent axial stability and are considered length unstable fracture patterns.31 in two studies by sink et al., fin was recommended for stable fracture patterns whereas alternative treatment was advised for fixation of unstable fracture patterns.30,31 alternatively, some researchers have recommended post-operative immobilisation for unstable fractures, although they were unable to substantiate this with statistically significant evidence.6,17,32 in contrast, in a mechanical study on simulated bones, lee et al. found axial stiffness in comminuted fractures to be equivalent to transverse fractures with retrograde flexible nailing.33 furthermore, fricka et al. found that antegrade flexible nailing may have a greater resistance to shortening than retrograde flexible nailing.34 none of the patients in this study had leg length discrepancies greater than 2 cm, with the majority (20) being less than 1 cm short. five patients in this study achieved a ‘satisfactory’ outcome, according to flynn’s criteria, due to a limb length discrepancy of 1–2 cm. one patient had 7° of valgus malalignment. statistical analysis of the data showed no correlation between fracture pattern and leg length discrepancy. moroz et al. showed that children older than 11 years or with bodyweight greater than 49 kg had an increased complication rate, including angular deformity.35 sink et al. made similar conclusions and suggested children over the age of 11 years should not be stabilised with flexible nails.30 heinrich et al. however, found no significant differences in angular deformities when comparing children in the age groups of 6 to 9 years and older than 10 years.36 in this study children older than 11 years had a greater proportion of malalignment and leg length discrepancies than those younger than 11. mehlmann et al., in their mechanical study, showed that retrograde nailing was superior to antegrade nailing with regard to bending stiffness in distal third fractures of the femur.37 due to its higher modulus of elasticity and a larger elastic limit, stainless nails are less flexible than their titanium counterparts. flexibility, however, is also related to the diameter of the nail, and stainless steel nails up to a diameter of 4 mm have been considered flexible in previous studies.38 hence the 3.2 mm nails used in this study may be considered flexible. wall et al. compared stainless steel versus titanium nails and reported a higher incidence of malunion page 26 rosin rc et al. sa orthop j 2019;18(4) in the titanium group.38 in children aged 6 to 10 years, 10° of coronal and 15° of sagittal angulation is acceptable and this decreases to 5° and 10° respectively in children older than 11 years.39 in this study, three patients (13%) had angular deformities not within these limits, which is similar to the malalignment reported in the reviewed literature, which ranged from 8% to 18%.6,18,19,32,35,36,40 to facilitate removal, retrograde flexible nails are deliberately left protruding from the bone entry portal and hence have a tendency to cause problems. luhmann et al. found the most significant problem they encountered with retrograde nails was pain and skin erosion from prominence of the nail at the insertion site.32 nail prominence may also result in knee pain and reduced range of movement. similar complications were found by other authors with rates ranging from 4.8% to 93% of patients, with the large range presumably due to varying length of the nail that was left prominent.6,30,31,35,38 a balance is required between cutting the nail short enough to avoid irritation and maintaining it long enough to aid removal and prevent slippage of the nail into the canal, which may compromise stability. luhmann et al. recommended the nail is trimmed and then impacted, leaving less than 2.5 cm of the nail protruding.32 in this study the nails were deliberately left protruding approximately 2 cm from the greater trochanter to aid with later removal. skin complications or complaints regarding nail prominence were not seen in this study. this study has a number of limitations. these include the retrospective nature of the study and the small sample size allowed for very limited statistical analysis and underpowered results. further limitations include the relatively short follow-up (mean of 18 months and the longest of 3.1 years) with regard to screening for osteonecrosis, as well as the morphological changes within the proximal femur. ideally these patients should be followed up longer to determine if osteonecrosis develops and if the changes to the proximal femur manifest in clinical problems. conclusion antegrade nailing using the described technique of a small entry portal through the tip of the greater trochanter does not appear to place the blood supply to the femoral head at risk or increase the risk of clinically significant morphological changes to the proximal femur. the follow-up, however, was relatively short and further follow-up is required. in this study 20 out of 23 patients achieved an excellent or satisfactory outcome according to flynn’s criteria with all fractures uniting and malalignment rates similar to the rates achieved in the reviewed literature. furthermore, antegrade insertion avoids the skin and prominent nail complications seen with retrograde insertion. the relatively low cost of this technique is useful in south africa with its high trauma burden and resource limitations in the public sector. ethics statement ethical approval was obtained from the university of kwazulu-natal brec ethics committee (be392/16), the kwazulu-natal department of health (kz_2016rp46_898) and the ngwelezana hospital ceo prior to the commencement of data collection. all participant names, information and relevant data were kept confidential. patients were assigned a number to keep their identities confidential on the data sheets and database. declarations the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. acknowledgments i would like to thank matthew foster and maureen zungu for assisting me with data collection. author contributions rcr: literature review, data collection, primary author and data interpretation and analysis mnr: paper editing and supervision sw: statistical analysis pdr: idea conception, paper editing, supervision and data collection orcid rc rosin http://orcid.org/0000-0002-6247-4039 mn rasool http://orcid.org/0000-0002-2073-8358 w sibanda http://orcid.org/0000-0001-5702-2436 pd rollinson http://orcid.org/0000-0002-2384-7250 references 1. mughal ma, dix-peek si, hoffman eb. the epidemiology of femur shaft fractures in children. sa orthop j. 2013;12(4):23-27. 2. john r, sharma s, raj gn, singh j, cv, rhh a, et al. current concepts in paediatric femoral shaft fractures. open orthop j. 2017;11:353-68. 3. winquist ra, hansen st, jr. comminuted fractures of the femoral shaft treated by intramedullary nailing. orthop clin north am. 1980;11(3):633-48. 4. langenskiold a, salenius p. epiphysiodesis of the greater trochanter. acta orthop scand. 1967;38(2):199-219. 5. gonzalez-herranz p, burgos-flores j, rapariz jm, lopez-mondejar ja, ocete jg, amaya s. intramedullary nailing of the femur in children. effects on its proximal end. j bone joint surg br. 1995;77(2):262-66. 6. flynn jm, hresko t, reynolds ra, blasier rd, davidson r, kasser j. titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. j pediatr orthop. 2001;21(1):4-8. 7. anglen jo, choi l. treatment options in pediatric femoral shaft fractures. j orthop trauma. 2005;19(10):724-33. 8. jevsevar ds, shea kg, murray jn, sevarino ks. aaos clinical practice 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management. j pediatr orthop. 2010;30(7):633-37. 31. sink el, gralla j, repine m. complications of pediatric femur fractures treated with titanium elastic nails: a comparison of fracture types. j pediatr orthop. 2005;25(5):577-80. 32. luhmann sj, schootman m, schoenecker pl, dobbs mb, gordon je. complications of titanium elastic nails for pediatric femoral shaft fractures. j pediatr orthop. 2003;23(4):443-47. 33. lee ss, mahar at, newton po. ender nail fixation of pediatric femur fractures: a biomechanical analysis. j pediatr orthop. 2001;21(4):442-45. 34. fricka kb, mahar at, lee ss, newton po. biomechanical analysis of antegrade and retrograde flexible intramedullary nail fixation of pediatric femoral fractures using a synthetic bone model. j pediatr orthop. 2004;24(2):167-71. 35. moroz la, launay f, kocher ms, newton po, frick sl, sponseller pd, et al. titanium elastic nailing of fractures of the femur in children. predictors of complications and poor outcome. j bone joint surg br. 2006;88(10):1361-66. 36. heinrich sd, drvaric dm, darr k, macewen gd. the operative stabilization of pediatric diaphyseal femur fractures with flexible intramedullary nails: a prospective analysis. j pediatr orthop. 1994;14(4):501-507. 37. mehlman ct, nemeth nm, glos dl. antegrade versus retrograde titanium elastic nail fixation of pediatric distal-third femoral-shaft fractures: a mechanical study. j orthop trauma. 2006;20(9):608-12. 38. wall ej, jain v, vora v, mehlman ct, crawford ah. complications of titanium and stainless steel elastic nail fixation of pediatric femoral fractures. j bone joint surg am. 2008;90(6):1305-13. 39. wilkins ke. principles of fracture remodeling in children. injury. 2005;36 suppl 1:a3-11. 40. ligier jn, metaizeau jp, prevot j, lascombes p. elastic stable intramedullary nailing of femoral shaft fractures in children. j bone joint surg br. 1988;70(1):74-77. _goback south african orthopaedic journal paediatric orthopaedics doi 10.17159/2309-8309/2023/v22n1a5mdingi vs et al. sa orthop j 2023;22(1) citation: mdingi vs, maré ph, marais lc. factors associated with dissemination and complications of acute bone and joint infections in children. sa orthop j. 2023;22(1):3440. http://dx.doi.org/10.17159/23098309/2023/v22n1a5 editor: prof. ruan goller, university of pretoria, pretoria, south africa received: june 2022 accepted: september 2022 published: march 2023 copyright: © 2023 mdingi vs. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background paediatric bone and joint infections remain common in lowand middle-income countries (lmics) and may have devastating long-term sequelae. there is a paucity of data from lmics where the true incidence might be underreported, and delayed presentation is common. our study aimed to determine the complication rate and incidence of disseminated infection in paediatric bone and joint infections in an lmic setting. secondly, we aimed to elucidate factors associated with complications and disseminated disease. methods we retrospectively reviewed our paediatric orthopaedic database for children that presented with bone and joint infections between september 2015 and march 2019. data were extracted from medical records, laboratory results and radiological investigations to identify factors that were associated with the development of complications and disseminated infection at a median follow-up of four months. results we analysed 49 children. the median age at presentation was 6 years (range 1 month to 12 years). locally advanced disease, with combined acute haematogenous osteomyelitis (ahom) and septic arthritis (sa), was present in 13 children (27%). the remaining 36 children were evenly divided (18/49 each, 37%) between isolated ahom and sa, respectively. disseminated disease was present in 16 children (33%) and was associated with locally advanced disease, an increase in the number of surgeries and an increased length of stay. twenty-six complications were documented in 22 (45%) children. chronic osteomyelitis developed in 15/49 (31%) cases, growth arrest in 5/49 (10%), and pathological fracture, dvt and septic shock in 2/49 (4%) each. complicated disease was associated with locally advanced disease, a higher number of surgeries, disseminated disease and an increased length of stay. staphylococcus aureus was the infecting pathogen in 65% of cases (31 mssa, 1 mrsa), while 25% (12/49) were culturenegative infections. while the median time from admission to surgery was one day, the median time from onset of symptoms to surgery was seven days. conclusion we found a high complication rate despite a short follow-up period. more than a quarter of patients had locally advanced disease, and this was associated with the development of complications and disseminated disease. further studies are needed to be able to predict which children will have poor outcomes. level of evidence: level 4 keywords: acute haematogenous osteomyelitis, septic arthritis, bone and joint infections, low-and middleincome countries, developing world, resource-constrained factors associated with dissemination and complications of acute bone and joint infections in children vuyisa s mdingi,¹* pieter h maré,² leonard c marais¹ ¹ department of orthopaedic surgery, school of clinical medicine, university of kwazulu-natal, south africa ² clinical unit: paediatric orthopaedics, grey’s hospital school of clinical medicine, university of kwazulu-natal, south africa *corresponding author: vsmdingi@gmail.com https://orcid.org/0000-0001-8867-0700 page 35mdingi vs et al. sa orthop j 2023;22(1) introduction paediatric bone and joint infections are a major burden in low and middle-income countries (lmics). acute haematogenous osteomyelitis (ahom) has been shown to have an incidence of 8 to 10 per 100 000 in high-income countries while in lmic countries the incidence is reported to be much higher at 80 per 100 000.1,2 the true incidence may still be underreported. data from the united states of america (usa) revealed a 2.8-fold increase in the incidence of ahom from 1982 to 2008, while that of sa has remained unchanged.3 according to a study from south africa by nunn and rollinson in 2007, the incidence of haematogenous pyogenic bone and joint sepsis in the ngwelezane catchment area was estimated to be 1:4 000.4 this suggests a higher incidence of musculoskeletal infections in children in south africa when compared to the international figures. some of the concerns with musculoskeletal infection include a protracted course of infection leading to severe disease and a poor outcome. popescu et al. performed a retrospective study to identify the patients with ahom who are at risk of a poor outcome. they found that a negative outcome was associated with a young age, male sex, rural residence, repeated negative cultures and delayed surgery.5 there was no statistically significant association between negative outcomes and infection entry site, organism and location of the infectious process.5 in southeast asia, investigators have found that poor outcomes are associated with a prolonged course of antibiotics (> 30 days), symptom duration of more than one week, younger age, hip joint infection, infection with methicillin-resistant staphylococcus aureus (mrsa) and delayed administration of antibiotics.6,7 in sub-saharan africa, a study by mamo et al. in ethiopia found that poor outcomes were associated with the presence of a comorbidity and the use of combination antibiotics (ceftriaxone and metronidazole).8 mue et al. in nigeria suggested that complications in their cohort of patients may be due to a long duration of symptoms and delay in treatment, underlying systemic and immunosuppressive illnesses, joint site (especially hip and shoulder), and the virulence of the organisms (e.g., staphylococcus aureus and gram-negative bacilli).9 unfortunately, no univariate analyses were performed on these proposed associations. as described earlier, the severity of the infection influences the outcomes. we, therefore, aimed to determine the complication rate and incidence of disseminated infection in paediatric bone and joint infections. secondly, we aimed to identify factors associated with complications and disseminated disease, and, by extension, the severity of infection. our results will contribute to the literature that is available in lmics. methods after obtaining approval from the relevant institutional medical research ethics board, we reviewed our paediatric orthopaedic database to identify all children who presented with acute bone and joint infections, between september 2015 and march 2019, to our paediatric orthopaedic unit. a retrospective review of case medical records, laboratory results and radiological investigations was done, and data were extracted to identify factors that were associated with the development of complications or disseminated disease. we included all children who were 12 years or younger at the time of presentation with a diagnosis of ahom and/or sa. we excluded children with acute reactivation of chronic osteomyelitis, pyomyositis without bone or joint involvement, hand infections, pre-patellar abscesses and musculoskeletal tuberculosis (tb). the following data were recorded from the folders: hiv status, immunisation status, time from onset of symptoms to presentation, length of hospital stay (los), intensive care unit (icu) admission, time from presentation to surgery, diagnosis (septic arthritis and/or acute haematogenous osteomyelitis), initial vitals, inflammatory markers (erythrocyte sedimentation rate [esr], c-reactive protein [crp], white cell count [wcc]), and the cultured organism. the number of surgeries was recorded, as well as the development of any complications (e.g., chronic osteomyelitis, pathological fracture, growth arrest, deep vein thrombosis and septic shock). all radiographs were accessed and analysed using our picture archiving and communication system (pacs). complications were defined as the development of any of the following conditions: septic shock, deep venous thrombosis, growth arrest, chronic osteomyelitis or pathological fracture. the presence of septic shock was diagnosed using the criteria of the 2005 pediatric sepsis consensus conference (pscc).10 the presence of disseminated infection was diagnosed by the involvement of an organ system other than the musculoskeletal system (e.g., pneumonia, infective endocarditis or septic shock), or another distant musculoskeletal site. (e.g., combined distal femur and proximal humerus ahom). locally advanced disease was defined as adjacent ahom and sa. management the patients were managed according to our departmental protocol on the management of musculoskeletal infection in children. a clinical diagnosis of ahom and/or sa was made by history and clinical examination. biochemical inflammatory markers (wcc, crp and esr) and x-ray imaging were obtained to confirm the suspected diagnosis and monitor the response to treatment. ultrasound was used when available to identify joint effusion and/or the location of subperiosteal or other abscess collections. initial management included empiric intravenous antibiotic treatment with either an anti-staphylococcal penicillin (cloxacillin) or a first-generation cephalosporin (cefazolin), and gentamycin was added in patients aged ≤ 12 months and younger. analgesia, splinting, emergent surgical drainage, debridement and biopsy also formed part of the initial management strategy. debridement involved draining any subperiosteal pus collections and removing infected tissues. in cases where there was no subperiosteal collection, an oval window was drilled in the bone to drain any intramedullary collections. samples (pus, periosteal tissue) were sent for gram staining, and microscopy, culture and antibiotic sensitivity analysis. directed antibiotics were started as soon as culture results became available, and intravenous antibiotics were changed to an oral equivalent depending on the clinical response and the crp level demonstrating a downward trend and dropping to below 20 mg/l.11 in uncomplicated sa and uncomplicated ahom, oral antibiotics were given for a total of three and six weeks, respectively. statistical analysis statistical analysis was performed using jamovi version 1.2.18.0 open-source software.12 normally distributed continuous variables were reported as means with standard deviations (sd) and ranges. non-parametric data were reported as medians with interquartile ranges (iqr) [q25–q75] and total ranges. continuous variables were reported as percentages and numbers. the shapiro–wilk test was used to analyse the distribution of data. normally distributed data were compared with the use of the unpaired student’s t-test, while the mann–whitney test was used for non-parametric data. categorical data were analysed using the chi-squared test unless the expected value in any cell was below 5 when fisher’s exact test was used. all tests were two-sided, and the level of significance was set at p < 0.05. page 36 mdingi vs et al. sa orthop j 2023;22(1) results we identified 66 children who were admitted and treated for ahom and/or sa at our institution during the study period. we were unable to retrieve the records of 17 children and they were excluded. we analysed the records of 49 children. thirty-two (65%) of the 49 children were male. the median age of the children was 6 years (iqr 3–9 years, range 1 month to 12 years). forty-five of the 49 children had a record of their hiv status available in the nursing charts. the recorded hiv infection prevalence was 4% (2/45). the median time between the onset of symptoms and presentation to our institution was seven days (iqr 4.5–13.8 days, range 1 to 30 days). the median crp was 104 mg/l (iqr 32–193 mg/l, range 1–315 mg/l). locally advanced disease (combined sa and osteomyelitis) was present in 27% (13/49) of children, while the remaining 36 children were evenly divided between locally isolated ahom and sa (18/49, 37% each) (table i). the median crp in children with locally advanced disease was 152 mg/l, compared to 74 mg/l in children with isolated ahom or sa (p = 0.060). disseminated disease was present in 33% (16/49) of children. the median esr was 92 mm/hr (iqr 59–108 mm/hr, range 7 to 122 mm/hr). the median wcc was 14.2 x 109/l (iqr 9.0–19.2 × 109/l, range 4.9 to 34.7 × 109/l). two (3.8%) patients met the pediatric sepsis consensus conference (pscc) criteria for septic shock. fourteen per cent (7/49) of patients were admitted to the intensive care unit (icu) with a mean icu stay of 8.1 days (sd 7.6 days, range 2–23 days). while the median time to surgery from admission was one day (iqr 0–1 day, range 0–7 days), the median time to surgery from table i: nature and anatomical distribution of musculoskeletal infections distribution n % acute haematogenous osteomyelitis tibia 9 50 femur 5 28 radius 2 10 fibula 1 6 calcaneus 1 6 total 18 100 septic arthritis knee 9 50 hip 6 33 elbow 3 17 total 18 100 locally advanced disease ilium and hip 3 22 proximal femur and hip 2 15 proximal tibia and knee 2 15 pan-femoral, hip, knee 1 8 pan-tibial, knee, ankle 1 8 distal femur and knee 1 8 distal fibula and ankle 1 8 proximal humerus and shoulder 1 8 proximal radius and elbow 1 8 total 13 100 a b c d figure 1. locally advanced and disseminated infection in a 10-year-old female patient – disseminated staphylococcal infection involving the lungs, left proximal femur and left hip. a) initial x-rays at presentation: chest x-ray (cxr) revealing bilateral pulmonary infiltrates, and endotracheal tube in situ; pelvis x-ray (pxr) shows soft tissue swelling of the left thigh with no obvious bony changes; b) one month after presentation: rarefaction involving the proximal left femoral metaphysis; c) six weeks after presentation: extensive destruction of proximal femoral metaphysis extending into the diaphysis; d) ten weeks after presentation: resolving infection, with a periosteal reaction around the left femur diaphysis and metaphysis table ii: bacteriology organism n % staphylococcus aureus (mssa) 31 63 staphylococcus aureus (mrsa) 1 2 klebsiella pneumoniae 1 2 staphylococcus lugdenusis 1 2 bacillus species 1 2 morganella morganii 1 2 no organism grown 12 24 no results 1 2 total 49 100 page 37mdingi vs et al. sa orthop j 2023;22(1) the onset of symptoms was seven days (iqr 4–14 days, range < 24 hours to 42 days). the median number of surgical procedures required was one (iqr 1–2, range 1–4). the median length of stay (los) was 12 days (q25 7 to q75 16 days, range 4–82 days). the median follow-up was four months (iqr 1–11 months, range 1–43 months). staphylococcus aureus was responsible for 32/49 (65%) of cases (table ii). there was no statistically significant associa-tion between staphylococcus aureus and complicated (p = 0.247) or disseminated disease (p = 0.343). during the hospital stay and follow-up period, 26 complications in 22/49 (45%) patients were documented. twenty patients developed a single complication, and two patients had three complications. the most common complication was chronic osteomyelitis (n = 15) (figures 1 and 2). we found a statistically significant association between complicated disease and the presence of locally advanced disease, disseminated disease and the number of surgeries performed (table iii). patients who developed complicated disease also had a longer hospital stay (median 15 vs 8 days, p = 0.004). disseminated disease was associated with locally advanced disease, a higher number of surgeries performed, as well as an increased los (table iv). discussion this study aimed to describe bone and joint infections in a cohort of paediatric patients from an lmic. furthermore, it aimed to identify factors associated with the development of complications or disseminated disease, and, by extension, the severity of infection. the median age of our patients was 6 years, similar to horn et al., but higher than the 2.5 years reported by robertson et al.13,14 we found a male predilection (65%) for bone and joint infections in our study population. although arkader et al. stated that the prevalence is equally distributed among the sexes, our finding was similar to other south african reports and international publications.4,15,16 it has been speculated that this may be due to increased exposure to microtrauma in males.16 the hiv prevalence in our study group was 4% (2/45). this was comparable to the reported hiv prevalence of 2.7% in children between 0 and 14 years in south africa in 2017.17 the rate is much lower than the 21.6% reported by robertson et al. in 2012.13 the reduced rate may be the result of an effective prevention of motherto-child transmission programme (pmtct), as the hiv prevalence reported in women of childbearing age (15–49 years) was 26.3% in 2017.17 the pmtct programme consists of antenatal hiv-testing, effective maternal viral load suppression with anti-retroviral drugs, safe childbirth practices and appropriate infant feeding. a b c d figure 2. complicated infection in a 4-year-old male patient with left ulna acute haematogenous osteomyelitis secondary to methicillin-resistant staphylococcus aureus (mrsa). a) initial x-rays at presentation with no bony changes; b) two months after presentation, showing extensive destruction of ulna shaft with sequestrum and involucrum; c) and d) five and six months after presentation, showing dense, sclerotic proximal ulna with loss of intramedullary canal and nonunion with the distal third ulna shaft table iii: factors associated with complicated musculoskeletal infection variable no complications complications p-value age 5.6 yr (1 mo–11 yr) 5.9 yr (1 mo–12 yr) 0.832 sex 63% male (17/27) 68% male (15/22) 0.703 symptom duration 7 days (range 1–21) 8 days (range 1–30) 0.194 time to surgery 7 days (range 0–22) 7.5 days (range 0–42) 0.709 surgical procedures 1 (range 1–4) 2 (range 1–4) < 0.001 crp (mg/l) 117 (range 1–315) 79 (range 5–291) 0.904 esr (mm/hr) 78 (sd 36) 87 (sd 33) 0.437 wcc 16.1 × 109/l (sd 8.23) 14.4 × 109/l (sd 6.72) 0.501 locally advanced disease 15% (4/27) 41% (9/22) 0.040 disseminated disease 19% (5/27) 45% (10/22) 0.042 length of stay 7 days (range 4–31) 15.5 days (range 4–82) 0.004 page 38 mdingi vs et al. sa orthop j 2023;22(1) the median crp on admission was 104 mg/l. this value was similar to robertson et al. but lower than the median 223.6 mg/l reported by horn et al.13,14 rosenfeld et al. found a significantly higher crp in children with sa and adjacent osteomyelitis.18 in our study, the median crp of the patients with locally advanced disease was higher than the median crp of children with isolated ahom or sa, but there was a significant overlap in the ranges, and the association was not statistically significant. roine et al. found an association between a higher crp and the occurrence of complications.19 we, together with horn et al., did not confirm this association in our study group.14 the children in our study were symptomatic for a mean of seven days prior to surgery at our institution. this was a longer period than the symptom duration of three days (range 1–7 days) and five days (range 1–42 days) in the studies by robertson et al. and horn et al., respectively.13,14 nunn and rollinson reported that in their series the majority of their patients had surgery beyond the recommended five and seven days of symptoms for sa and osteomyelitis respectively. a major finding in their study was a significantly longer duration of symptoms prior to surgery in the children with complications when compared to those without complications.4 dartnell et al. in a systematic review similarly warned against delayed treatment, reporting a study by cole et al. which showed a decreased cure rate from 92% to 25% when treatment was delayed beyond five days.20,21 this intuitively seems correct but was not corroborated by our study or by robertson et al.13 in the study by robertson et al., there were no patients that had surgery after seven days, which may have skewed their results. in our study, several of the children with prolonged symptom duration had treatment before presentation, including the prescription of oral antibiotics, which may have influenced their presentation and outcome. another consideration is that infectious disease severity is influenced by organism virulence and host defence, which may result in those children with more severe disease who present earlier having a similar complication rate to those children with moderate disease that present late. further studies with comprehensive data capturing and accurate disease severity classification are essential to study the association between symptom duration prior to treatment and outcome. despite our findings, we maintain the recommendation that efforts to improve early recognition and referral of children with suspected musculoskeletal infection for definitive treatment should be strengthened. we base this on our finding of a relatively long duration of symptoms before surgery in a condition taught to be an orthopaedic emergency. staphylococcus aureus was the pathogen found in most of our bacterial cultures (65%) with mssa predominating (97%) and only one case (3%) of community-acquired mrsa. the low rate of mrsa was similar to the previous studies from south africa (0–2.4%).13,14 this rate is much lower than the rates of 25% and 29% reported in the usa.22,23 there was a high culture-negative rate in our study (25%, 12/49). several factors could have contributed, including the fact that a blood culture was not done on admission in all cases, a failure to collect a viable bacterial sample intraoperatively, and the possibility of kingella kingae infection. literature has shown an increasing trend in the prevalence of kingella osteoarticular infections in children between 6 months and 4 years of age.24 a systematic review by wong et al. identified k. kingae in 48% of musculoskeletal infections in children aged less than 48 months.25 this is mainly due to the improvement in detection and isolation methods with real-time pcr (rt-pcr) being more sensitive and specific compared to microbiological culture. ceroni et al. identified k. kingae in 82% of cases using rt-pcr.26 notably, gram staining and traditional culturing methods were all negative. in our study, 4/12 (33%) of the culture-negative patients were aged 4 years and below. only microbiological culture was performed on the samples, and none were sent for rt-pcr. further research using improved detection methods is required to determine the true incidence of k. kingae infection in our setting. children with acute musculoskeletal infection present on a spectrum of severity.27 several attempts have been made to devise scoring systems to predict more severe infection. variations in the definition of severe infection make these difficult to interpret. copley et al. used length of stay (los) as a surrogate measure of disease severity, while mignemi et al. classified infection severity into three groups: inflammation, local infection and disseminated infection.28,29 more severe infection was associated with higher inflammatory markers and specifically the crp, increased number of surgical procedures and an increased los.29,30 disseminated infection included infection in multiple compartments (e.g. subperiosteal abscess), as well as in children with a combination of sa and osteomyelitis (defined anatomically as complex infections in their study).29 this makes this classification less applicable in our environment where most cases of osteomyelitis have subperiosteal abscess formation at presentation. the classic teaching that the physis presents a barrier to epiphyseal and articular infection spread after the age of 1 year is based on the vascular studies of trueta.31 the exception to the rule is where the metaphysis extends beyond the capsular insertion, such as in the proximal humerus, femur and radius, and the distal fibula.32 a more recent observational study based on mri investigations found that transphyseal spread is considerably more common than once thought.33 this is supported by nunn and rollinson who found a 44% (35/80) incidence of combined sa of the knee with distal femur or proximal tibial osteomyelitis.4 we found a 27% (13/49) incidence of combined sa and adjacent osteomyelitis (defined as locally advanced disease). there was a 10% (5/49) incidence of knee sa with adjacent osteomyelitis (in two of these cases the hip and ankle were respectively also affected). rosenfeld et al. table iv: factors associated with disseminated musculoskeletal infection variable no disseminated disease disseminated disease p-value age 6 yr (1 mo–11 yr) 5.5 yr (1 mo–12 yr) 0.983 sex 70% male (23/33) 56% male (9/16) 0.354 symptom duration 7 days (range 1–30) 8 days (range 3–30) 0.061 time to surgery 7 days (range 0–42) 8.5 days (range 0–31) 0.137 surgical procedures 1 (range 1–2) 2 (range 1–4) 0.004 crp (mg/l) 69 (range 1–291) 152 (range 9–315) 0.096 esr (mm/hr) 85 (range 7–120) 117 (range 20–122) 0.099 wcc 13.7 × 109/l (4.93–33.0) 20.7 × 109/l (7.9–34.7) 0.107 locally advanced disease 9% (3/33) 63% (10/16) < 0.001 length of stay 9 days (range 4–31) 18.5 days (range 6–82) < 0.001 page 39mdingi vs et al. sa orthop j 2023;22(1) developed an algorithm to predict adjacent infections in children diagnosed with sa based on age, crp, duration of symptoms and neutrophil count.18 other authors were not able to validate this algorithm in different geographic regions.20,34 we found an association between locally advanced disease and a higher rate of complications, as well as a higher rate of disseminated disease, highlighting the importance of this diagnosis as a marker of increased disease severity. a timely diagnosis of concomitant sa and osteomyelitis will assist with appropriate management of both sites at the index operation, thus reducing the bacterial burden early and potentially reducing the number of surgeries and positively impact the outcome. griswold et al. showed that routine mri investigation in children with suspected musculoskeletal infection reduced repeat surgery from 50% of cases to < 27% (p = 0.009).35 further research is required to develop indicators to predict which children are at risk of locally advanced disease to inform the appropriate use of mri investigation in a resourcelimited environment. children in our study who developed complications were more likely to have locally advanced disease, disseminated disease, a longer los and more surgical procedures. similarly, children with disseminated disease were more likely to have locally advanced disease, a longer los and a higher number of surgical procedures. further research is required to develop a locally applicable disease severity classification and to identify factors associated with increased disease severity at presentation. our study found a 45% (22/49) complication rate within a median follow-up period of four months (range 1–43 months). the most common complication was chronic osteomyelitis. this relatively high complication rate was similar to the 48% complication rate reported by horn et al.14 the follow-up period in our study was too short to detect all cases of chronic osteomyelitis, pathological fracture and growth arrest, and it is likely to have underrepresented the actual complication rate. our study had several limitations. first, we had a small sample size. contributing to the small sample size, and another limitation impacting the interpretation of our results, was the exclusion of 17 patients. we also did not analyse adolescents between the ages of 13 and 18 years with musculoskeletal infections because they were not managed by our paediatric unit. our findings may not be representative of all children with musculoskeletal infection, as only the cases referred to our institution that underwent surgical drainage were included in this study. thirdly, we were unable to record the time to the first dose of antibiotics, as antibiotics were often started at the base hospitals before referral. another limitation of our study was the short follow-up period. this was because children with an uncomplicated course of infection often failed to attend scheduled follow-up appointments. despite the short follow-up period, we reported a relatively high complication rate, emphasising the serious consequences of musculoskeletal infections and the importance of further research. conclusion septic arthritis and acute haematogenous osteomyelitis remain a relevant concern in the developing world. we found a high complication rate despite a short follow-up period. more than a quarter of patients had locally advanced disease, involving combined sa and ahom, and this was associated with the development of complications and disseminated disease. further, adequately powered, studies are still needed to be able to predict which children will have poor outcomes. acknowledgements the authors wish to thank dr yenziwe n dlamini for her contribution in assisting with collecting patient files and capturing the data. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, ethics approval was obtained from the university of kwazulu-natal biomedical research ethics committee (brec/00001084/2020). all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions vsm: study conceptualisation, data collection, data analysis, manuscript preparation and revision phm: study conceptualisation, study design, data analysis, manuscript review and revision lcm: data review and revision, manuscript review and revision orcid mdingi vs https://orcid.org/0000-0001-8867-0700 maré ph https://orcid.org/0000-0003-1599-7651 marais lc https://orcid.org/0000-0002-1120-8419 references 1. arnold jc, bradley js. osteoarticular infections in children. infect dis clin north am. 2015;29(3):557-74. 2. jaramillo d, dormans jp, delgado j, et al. hematogenous osteomyelitis in infants and children: imaging of changing disease. radiology. 2017;283:629-43. 3. gafur oa, copley lab, hollmig st, et al. the impact of the current epidemiology of paediatric musculoskeletal infection on evaluation and treatment guidelines. j pediatr orthop. 2008;28(7):777-85. 4. nunn t, rollinson p. haematogenous pyogenic bone and joint sepsis – reducing avoidable morbidity. s afr med j. 2007;97:456-60. 5. popescu b, tevanov i, carp m, ulici a. acute haematogenous osteomyelitis in paediatric patients: epidemiology and risk factors of a poor outcome. j int med res. 2020;48(4):1-9. 6. stoesser n, pocock j, moore ce, et al. the epidemiology of pediatric bone and joint infections in cambodia, 2007–11. j trop pediatr. 2013(1);59:36-42. 7. sukswai p, kovitvanitcha d, thumkunanon v, et al. acute haematogenous osteomyelitis and septic arthritis in children: clinical characteristics and outcomes study. j med assoc thai. 2011;94 suppl 3:s209-16. 8. mamo md, daba fb, beshir m, fanta k. treatment and clinical outcomes of osteoarticular infections among pediatrics admitted to jimma university medical center, ethiopia: a prospective observational study. infect drug resist. 2021:14 2933-41. 9. mue dd, salihu mn, awonusi fo, et al. the epidemiology and outcome of acute septic arthritis: a hospital-based study. j west afr coll of surg. 2013;3(1):40-52. 10. obonyo ng, schlapbach lj, fraser jf. sepsis: changing definitions, unchanging treatment. front pediatr. 2019;6:425. 11. faust sn, clark j, pallett a, clarke nmp. managing bone and joint infection in children. arch dis child. 2012;97:545-53. 12. the jamovi project (2020). jamovi (version 1.2) [computer software]. retrieved from https:// jamovi.org 13. robertson ajf, firth gb, truda c, et al. epidemiology of acute osteoarticular sepsis in a setting with a high prevalence of pediatric hiv infection. j pediatr orthop. 2012;32(2):215-19. 14. horn a, wever s, hoffman eb. complications following acute severe haematogenous osteomyelitis of the long bones in children. sa orthop j. 2019;18(3):23-29. 15. arkader a, brusalis c, warner jr wc, et al. update in pediatric musculoskeletal infections: when it is, when it isn’t, and what to do. j am acad orthop surg. 2016;24:e112-21. 16. pääkkönen m, kallio mjt, lankinen p, et al. preceding trauma in childhood hematogenous bone and joint infections. j pediatr orthop b. 2014;23:196-99. 17. human sciences research council (2018). the fifth south african national hiv prevalence, incidence, behaviour and communication surveys, 2017. 18. rosenfeld s, bernstein dt, daram s, et al. predicting the presence of adjacent infections in septic arthritis in children. j pediatr orthop. 2016;36:70-74. 19. roine i, faingezicht i, arguedas a, et al. serial serum c-reactive protein to monitor recovery from acute hematogenous osteomyelitis in children. pediatr infect dis j. 1995;14:40-44. 20. dartnell j, ramachandran m, katchburian m. haematogenous acute and subacute paediatric osteomyelitis: a systematic review of the literature. j bone joint surg br. 2012;94-b:584-95. https://orcid.org/0000-0001-8867-0700 https://orcid.org/0000-0003-1599-7651 https://orcid.org/0000-0002-1120-8419 page 40 mdingi vs et al. sa orthop j 2023;22(1) 21. cole wg, dalziel re, leitl s. treatment of acute osteomyelitis in childhood. j bone joint surg br. 1982;64(2):218-23. 22. sarkissian ej, gans i, gunderson ma, et al. community-acquired methicillin-resistant staphylococcus aureus musculoskeletal infections: emerging trends over the past decade. j pediatr orthop. apr-may 2016;36(3):323-27. 23. hamdy r, dona d, jacobs mb, gerber j. risk factors for complications in children with staphylococcus aureus bacteremia. j pediatr orthop. 2019 may;208:214-220.e2. 24. villani mc, hamilton ec, klosterman mm, et al. primary septic arthritis among children 6 to 48 months of age: implications for pcr acquisition and empiric antimicrobial selection. j pediatr orthop. 2021;41(3):190-96. 25. wong m, williams n, and cooper c. systematic review of kingella kingae musculoskeletal infection in children: epidemiology, impact and management strategies. pediatric health med ther. 2020:11 73-84. 26. ceroni d, cherkaoui a, ferey s, et al. kingella kingae osteoarticular infections in young children: clinical features and contribution of a new specific real-time pcr assay to the diagnosis. j pediatr orthop. 2010;30(3):301-304. 27. athey ag, mignemi me, gheen wt, et al. validation and modification of a severity of illness score for children with acute haematogenous osteomyelitis. j pediatr orthop. 2019;39(2):90-97. 28. copley lab, barton t, garcia c, et al. a proposed scoring system for assessment of severity of illness in paediatric acute haematogenous osteomyelitis using objective clinical and laboratory findings. pediatr infect dis j. 2014;33:35-41. 29. mignemi me, benvenuti ma, an tj, et al. a novel classification system based on dissemination of musculoskeletal infection is predictive of hospital outcomes. j pediatr orthop. 2018;38(5):279-86. 30. benvenuti ma, an tj, mignemi me, et al. a clinical prediction algorithm to stratify pediatric musculoskeletal infection by severity. j pediatr orthop. 2019;39(3):153-57. 31. trueta j. the three types of acute haematogenous osteomyelitis. j bone and joint surg. 1959;41:4. 32. montgomery co, siegel e, blasier rd, suva lj. concurrent septic arthritis and osteomyelitis in children. j pediatr orthop. 2013;33:464-67. 33. gilbertson-dahdal d, wright je, krupinski e, et al. transphyseal involvement of pyogenic osteomyelitis is considerably more common than classically taught. am j roentgenol. 2014;203(1):190-95. 34. hunter s, kennedy j, baker jf. external validation of an algorithm to predict adjacent musculoskeletal infection in pediatric patients with septic arthritis. j pediatr orthop. 2020;40(10):e999-e1004 35. griswold bg, sheppard e, pitts c, et al. the introduction of a preoperative mri protocol significantly reduces unplanned return to the operating room in the treatment of pediatric osteoarticular infections. j pediatr orthop. 2020;40(2):97-102. _ref99446262 _ref99708280 _hlk121076446 _ref99792998 south african orthopaedic journal current concepts review doi 10.17159/2309-8309/2021/v20n4a7 rachuene pa et al. sa orthop j 2021;20(4) citation: rachuene pa, du toit fj, tsolo gk, khanyile sm, tladi mj, golele ss. distal radius fractures: current concepts. sa orthop j 2021;20(4):231-239. http://dx.doi. org/10.17159/2309-8309/2021/ v20n4a7 editor: prof. leonard c marais, university of kwazulu-natal, durban, south africa received: february 2021 accepted: may 2021 published: november 2021 copyright: © 2021 rachuene pa. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract distal radius fractures (drfs) are commonly encountered in the elderly population, secondary to low-energy injury mechanisms. in the younger population, drfs are mainly secondary to highenergy trauma. stable drfs can be treated conservatively. however, in the elderly population group, drfs are often unstable and are likely to benefit from surgical intervention. they are often compounded by comorbid medical conditions requiring optimisation. when treating the elderly group, one should be aware of sarcopaenia, as this may have a bearing on return to function. recent literature reports an increasing trend in the surgical management of these fractures. current classification systems fail to consistently guide the management of these fractures. although evidence is still limited in guiding decision-making in the treatment of these fractures, one should consider the economic implications of prolonged immobilisation in young patients in addition to defined indications for surgery. improvement in implants allows safe dorsal fixation in patients with dorsal comminution, with low complication rates reported. this narrative review summarises current trends and the body of evidence. level of evidence: level 5 keywords: distal radius, fracture management, osteoporosis distal radius fractures: current concepts pududu a rachuene,¹* frederick j du toit,² gladwell k tsolo,² sivesonke m khanyile,³ makgabo j tladi,⁴ sikheto s golele⁵ 1 department of orthopaedics, shoulder and elbow unit, sefako makgatho health sciences university, dr george mukhari academic hospital, pretoria, south africa ² department of orthopaedics, sefako makgatho health sciences university, dr george mukhari academic hospital, pretoria, south africa ³ department of orthopaedics, female trauma unit, sefako makgatho health sciences university, dr george mukhari academic hospital, pretoria, south africa ⁴ louis pasteur private hospital, pretoria, south africa ⁵ department of orthopaedics, department of hands and microsurgery, sefako makgatho health sciences university, dr george mukhari academic hospital, pretoria, south africa *corresponding author: archie.pududu@gmail.co.za introduction having noted a trend of steady increase in life expectancy globally, the world health organization (who) declared the years 2020 to 2030 as a decade of healthy ageing. the main aim of this declaration is to develop and maintain the functional ability that enables the wellbeing of the elderly population. most people over the age of 60 years live in lowto middle-income countries.1 in south africa, as of mid-2020, the estimated life expectancy was 68.5 and 62.5 years for females and males respectively, showing a steady annual increase.2 distal radius fractures (drfs) are the second most common fragility fracture.3 about 1.5% of the patients treated in the emergency unit will present with drfs, of which 5–17% are due to low-energy injury mechanisms in osteoporotic patients.4-6 in an epidemiological review of the swedish registry, rundgren et al. noted a higher prevalence of drfs in females over the age of 50 years compared to males of the same age.7 the incidence of drfs in young adults is low, and usually follows high-energy trauma or sports-related injuries, often presenting with complex fracture patterns.8-10 economic burden more reconstruction options are available for the treatment of these injuries, each with cost implications. a recent review of a commercial claims database in the united states found conservative management to remain the treatment of choice throughout various demographic groups.11 more recent literature reported a shift towards surgical intervention in these fractures.12 https://orcid.org/0000-0003-4045-5301 page 232 rachuene pa et al. sa orthop j 2021;20(4) mauck and swigler reported an incidence of 634 000 drfs annually in the american elderly population, with a high financial burden ranging from 385 to 535 million us dollars annually.4 comparing treatment options for drfs in adults from the medicare dataset, shauver et al. found the cost of surgery to be almost twice the cost of closed reduction and casting. among young adults, an additional financial burden applies in the form of ‘loss of productivity’ due to the inability to perform their employment responsibilities.13 historical background abraham colles noted the deformities in patients he treated for drfs in 1814, decades before x-rays were available. he reported good functional outcomes following closed reduction and a splintage with a ‘narrow wooden-splint’.14 with the advancement in radiological investigations, fixation methods and arthroscopic skills, the understanding and management of these injuries is evolving from mostly conservative treatment methods to advanced fracture fixation methods, arthroscopic-assisted surgery and arthroplasty procedures.15,16 anatomic considerations the distal radius is functionally made up of three columns formed by osteo-ligamentous structures; it rests on a pedestal and transmits 80% of the axial load through the wrist (figure 1).17 the radial column the radial column consists of the radial styloid and the scaphoid fossa, the insertion of the brachioradialis tendon, the long radiolunate ligament and radio-scapho-capitate ligament. this column serves as a radial buttress for the carpal bones during wrist ulnar deviation and weight bearing.4,18 this column is often spared in patients with injuries secondary to axial forces. the brachioradialis is responsible for radial deviation, tilt and loss of radial height in these fractures.18 intermediate column the intermediate column is made up of the lunate facet and sigmoid notch and serves as the load transmission column.18 the ligamentous structures are the short radiolunate and volar distal radioulnar ligaments attached to the volar rim fragment; the dorsal radiocarpal ligament attached on the dorsal wall; and the dorsal distal radioulnar ligament attached to the dorsal ulnar corner. fractures of the dorsal wall, volar rims, intra-articular fragments and dorsal ulnar corner form part of the intermediate column fractures.17 the dorsal wall provides functional stability against dorsal carpal subluxation. shear force, axial loads and bending mechanisms can result in fractures of this dorsal wall.18 fractures of the ulnar corner and more than 10 mm radial height loss are associated with unstable distal radioulnar joint (druj) and triangular fibrocartilaginous complex (tfcc) injuries.19,20 reduction of the articular fragment is important for the restoration of the lunate facet. the lunate-lunate facet ratio (llfr), measured on the lateral view, can help to determine the degree of articular separation.4 articular surface congruency is best assessed with medoff’s teardrop angle (tda), formed by a line through the central axis of the teardrop and a line in the centre of the distal radius where normal is 68° on the lateral view plain x-rays.21 the pedestal the pedestal is the metadiaphyseal segment, immediately proximal to the radial and intermediate columns. fractures extending into the pedestal are seen in high-energy injuries.4,17 evaluation clinical evaluation clinical examination should include a neurovascular assessment. careful assessment of the median nerve is important, especially if there is a complaint of paraesthesia or numbness. this may indicate acute carpal tunnel syndrome (cts). acute cts has figure 1. an image and posteroanterior view plain x-ray representing the columns of the distal radius (rc: radial column, ic: intermediate column, uc: ulnar column, p: pedestal) (adapted from: rhee pc, medoff r, shin ay. complex distal radius fractures: an anatomic algorithm for surgical management. j am acad orthop surg. 2017;25(2):77-88. https://doi.org/10.5435/jaaos-d-15-00525) a b page 233rachuene pa et al. sa orthop j 2021;20(4) been reported in 5.4–8.6% of patients with drfs. it may develop rapidly, and the diagnosis is made by establishing the presence of severe paraesthesia in the median nerve distribution and sensory testing with two-point discrimination testing and semmesweinstein monofilament testing.22,23 skin puncture is common in elderly patients with thin soft tissues. care must be taken to avoid shearing of these tissues, especially during closed reductions.24 evaluation of elderly patients with drfs should include assessment of the muscle mass. the asian working group for sarcopenia recommends the evaluation of hand grip strength and gait speed to diagnose sarcopaenia.25 the presence of sarcopaenia has been reported to be prevalent in elderly patients with drfs and it is closely associated with osteoporosis. roh et al. reported 34% of men and 27% of women over the age of 50 years had sarcopaenia in a review of 264 patients with drfs.26 the presence of sarcopaenia is associated with poor functional recovery after drf surgery.27 radiographic evaluation a minimum of posteroanterior (pa) and lateral view plain x-rays is mandatory for the initial fracture evaluation.4 an additional 45° pronated oblique view can be added if deemed necessary. this view is helpful with profiling the dorsal ulnar cortex and lends insight into this biomechanically important region.9 computed tomography scan coronal and axial computed tomography (ct) images with 2 mm slices provide a detailed view for fracture configuration, in occult or complex fractures as well as an assessment of the reduction.28 in a study on the utility of radiographs, two-dimensional (2d) ct scans and three-dimensional (3d) ct scans on 30 drfs, harness et al. found 3d ct scans to be highly reliable and accurate over other studies and influenced treatment recommendations.29 a ct scan should be considered in patients undergoing open reduction and internal fixation (orif) or when information about comminution and joint depression is needed.30 classifications most drf classification systems are descriptive in nature and fail to guide on management. the mcmurty and jupiter as well as the frykman, melone and mayo classification systems focus on the amount of articular involvement, whereas those by gartland and werley, and older and jenkins emphasise the amount of comminution.31 the ao classification lacks interobserver reliability and is mainly used for research and documentation.4,32-34 the ideal classification35 is a five-factor mnemonic used to classify drfs into three broad groups which could predict stability, guide management and prognosticate. validation and reproducibility are yet to be confirmed. no classification has been proven to be superior in terms of determining prognosis or guiding management.4,31,35 table i shows a summary of the results of selected studies evaluating inter-rater reliability of the commonly used classification systems. management of distal radius fractures decision-making the aim of treating drfs should be to restore wrist anatomical alignment and function. important factors to consider in decisionmaking are patient’s age, hand dominance, fracture pattern and radiographic parameters.3,4,40,41 decision on treatment should be tailored based on patient-specific factors.42 being able to predict fracture instability and loss of reduction remains the greatest challenge to treating surgeons. a cochrane review of 60 drfs in elderly patients managed with closed reduction found loss of reduction to be at a rate of 88%, of which 75% occurred within one week.33 in 1989, lafontaine et al. proposed that unstable fractures are likely to occur in patients aged 60 years and above and a fracture with greater than 20° dorsal angulation, dorsal comminution, associated ulnar fracture and intra-articular involvement.43 these findings have been supported by other authors. mackenney et al. prospectively reviewed 4 000 drfs over a 5.5-year period with the aim of predicting early and late fracture instability and resultant fracture malunion. they found advanced patient age, fracture table i: selected studies showing reliability of the classification systems for distal radius fractures study participants (n) image modality (number of wrists) inter-rater reliability on radiographs (kappa values) interobserver reliability on radiographs and ct images (kappa values) azi, et al. 201936 orthopaedic surgeons (n = 5) plain radiographs and ct images (n = 43) ao/ota mean icc: 0.11 (poor) mean icc: 0.28 (fair) van buijtenen, et al. 201537 trauma consultants (2) radiology consultant (1) trauma registrars (2) intern (1) plain radiographs (n = 54) ao/ota mean icc: 0.49 first attempt and 0.3 (on second attempt) (fair) kleinlugtenbelt, et al. 201738 surgeons with over ten years experience (n = 4) plain radiographs and ct images (n = 51) frykman classification mean icc: 0.45 (fair) fernandez mean icc: 0.38 (poor) universal mean icc: 0.32 (poor) ao/ota mean icc: 0.46 (fair) mean icc: 0.28 (poor) mean icc: 0.44 (fair) mean icc: 0.43 (fair) mean icc: 0.40 (fair) mansu and gripp 202039 registrars (n = 4) consultants (n = 8) plain radiographs (n = 14) frykman classification mean icc: 0.36 (poor) universal mean icc: 0.48 (fair) ao/ota mean icc: 0.25 (poor) icc: interclass coefficient page 234 rachuene pa et al. sa orthop j 2021;20(4) comminution and alteration in ulnar variance to be significant predictive factors of loss of reduction.44 similarly, a more recent systematic review and meta-analysis identified dorsal fracture comminution and female patients aged over 60 years to be significant predictive factors of fracture instability.45 treatment methods non-surgical treatment closed reduction and cast immobilisation remain an acceptable treatment modality for stable fractures with reported good results in elderly patients even in the presence of intra-articular involvement.46 there was no difference in failure rate or final position at five weeks when the fracture was treated with finger trap traction or manipulation.47 appropriate splintage should be used. figure 2 shows x-rays of a patient with successful closed reduction and below-elbow cast immobilisation. there is limited evidence on the usage of above-elbow immobilisation compared to below-elbow immobilisation.48 fracture reduction quality can be assessed with x-rays in a cast. dailey et al. found no difference between the usage of a mini c-arm and taking radiographs in an orthosis when measuring the quality of reductions.49 there is a lack of reliable evidence for radiographic evaluation of drfs treated with closed reduction in the literature. the american academy of orthopedic surgeons (aaos) recommends weekly x-rays for the first three weeks and subsequent x-rays to be taken at six weeks to monitor alignment.48 the results of closed reduction and cast immobilisation were reported to be comparable to those of patients treated surgically for displaced drfs in a randomised controlled trial of 100 patients aged over 65 years at 12 months follow-up.50 in the young active population, one should remember that a displacement of the fracture in a cast will delay the return to work or sporting activities. closed reduction and percutaneous pinning stable extra-articular fractures can be treated with closed reduction and percutaneous pin fixation. several pinning techniques have been described in the literature, with the aim of achieving fracture stability and promoting early mobilisation. most techniques recommend the use of at least three pins with minimum 40° crossing angle to ensure stability.41,51,52 one should be wary of pinsite infection. a randomised multicentre trial (drafft) was done on patients (n = 461 adults, mean age 59.1 years) who underwent distal radius acute fracture fixation for dorsally displaced fractures within 3 cm of the radiocarpal joint, from 18 centres in the united kingdom. no difference was found in functional outcomes, quality of life and number of complications between the group treated with closed reduction and percutaneous k-wire fixation (n = 230) compared to those treated with volar-locking plate fixation (n = 231) at 12 months.52 a five-year follow-up of this population revealed no difference in wrist pain, function and quality of life between the two arms of treatment.53 surgical fixation indications the aaos recommend surgical fixation if post-reduction radial shortening is greater than 3 mm, dorsal tilt is greater than 10°, or intra-articular displacement or step-off is greater than 2 mm.48 unstable fractures with dorsal comminution or those with secondary loss of reduction should be treated surgically.41,54,55 surgical approaches volar approach henry’s volar approach is the most used approach for the treatment of drfs. the classic approach makes use of a safe interval between brachioradialis and radial artery, and the modified approach between flexor carpi radialis tendon and radial artery to gain access to the fracture.56,57 multiple modifications to this approach exist. it can be extended distally to allow the release of transverse carpal ligament for visualisation of complex intraarticular fractures.58 the choice of plate construct and plating technique should be individualised to the patient’s profile, fracture pattern and surgeon’s experience.59,60 volar plate fixation is the commonly used treatment method among surgeons for displaced drfs.10 fixed-angle volar plates are designed to transfer load from the intact subchondral bone through metaphysis to the diaphysis.18 locking plates have been reported to have improved fracture site stability against axial and bending forces over non-locked plates by biomechanics studies.61-63 however, their superiority over non-locked plates has not been demonstrated in practice. clinical studies reporting on fixation of displaced articular fractures treated with locked plates have reported good results.64-66 locked plates allow for polyaxial screw fixation and can address comminuted fragments through a b figure 2. plain x-ray images of a patient treated successfully with closed reduction and cast immobilisation. a) anteroposterior (ap) and lateral view x-rays showing intra-articular distal radius fracture; b) post-reduction x-rays with restored articular congruency, radial length and volar inclination page 235rachuene pa et al. sa orthop j 2021;20(4) multi-hole design.18 the choice of bicortical locked screws has not demonstrated superiority over unicortical screws.67,68 similarly, plates with multiple distal screw holes have not been shown to provide superior fracture stability over those with single-row locked screw holes.69 the use of screws has been reported to have better torsional and compressive stability over pegs by the biomechanical studies.55,70 plate failure and other complications following volar plating are not uncommon. wilson et al. reported 17% complication rates in patients (mean age 56.5 years) treated with volar-locking plate, at 17.5 weeks mean follow-up. loss of fracture reduction and cts were the two commonly reported complications.71 johnson et al. reported similar complications in their cohort of 204 patients with a mean age of 55 years. however, the complication rate following volar plating was lower (9.7%).72 flexor tendon rupture is not uncommon following volar plating. flexor pollicis longus (fpl) is the most commonly ruptured tendon (57% of cases), followed by flexor digitorum profundus (fdp) to the index finger.73 extensor tendon irritation and rupture is not uncommon, following volar plate fixation of drfs, and it has been associated with long dorsal penetrating screws, among other factors.71,74,75 dorsal approach the dorsal approach to drfs provides intra-articular visualisation and direct assessment of articular reduction. it is generally used in patients with severe metaphyseal dorsal comminution and those with dorsally angulated intra-articular fractures.76,77 historically, dorsal plating has been associated with high complications and risk of extensor tendons rupture.41,76,77 modern plate designs have been shown to reduce the risk of dorsal tendon attrition. spiteri et al. reported no tendon ruptures in 46 patients treated with modern-design low-profile dorsal plates and 17 treated with combined volar and dorsal plates at the five-year follow-up. however, 8.7% had reported extensor tendons irritation, and the plates were removed in all of them.78 external fixation external fixation is a viable option for complex intra-articular drfs and open fractures. it is commonly indicated for temporary fracture stabilisation.79 bajwa et al. reported a significantly worse mean dash score of 12.2 in patients treated with external fixator for intra-articular drfs compared to a mean dash score of 3.5 in those treated with orif.80 similarly, roh et al. reported comparable functional outcomes between external fixation and volar plate fixation in a prospective randomised trial of 92 patients with a minimum 12-month follow-up. the external fixator group had higher complication rates of 29% compared to 17% in the orif group.81 intramedullary fixation intramedullary fixation for drfs has been reported with enthusiasm as an option for treatment of drfs. tan et al. reported superior immediateand intermediate-term functional outcomes in patients treated with intramedullary nails for drfs compared to those treated in a cast.82 similarly, çalbiyik and ipek reported good results in a cohort of 68 young adults, with a mean age of 46 years treated with an intramedullary fixation for extra-articular and simple intra-articular drfs.83 arthroplasty arthroplasty procedure for wrist fracture is a fairly new phenomenon and evidence is limited to small sample size studies. vergnenègre et al. reported good functional outcomes in eight elderly patients treated with sofia wrist hemiarthroplasty system (biotech) for unreconstructable intra-articular fractures.84 arthroscopic-assisted surgery arthroscopic-assisted surgery for drfs has been used as an adjunct to drfs since the 1980s. however, it has failed to gain popularity because it is time-consuming and technically demanding, with increased risk of compartment syndrome.85 fluoroscopy has been the modality of choice for evaluation of articular stepoff. however, multiple studies have shown that arthroscopy is superior to fluoroscopy in evaluation of the articular surface.86-88 adjunct wrist arthroscopy is indicated in patients with radial styloid fractures, die-punch fractures, articular step-off of > 2 mm, flipped osteochondral fragment, central comminution as well as threeto four-part fractures.89 regional and local anaesthesia the wide awake local anaesthesia no tourniquet (walant) technique in the management of wrist and hand conditions has been a topic of interest in recent literature. prior literature could not demonstrate the benefits of walant in patients’ wrist fractures.90 however, recent literature has demonstrated walant to be tolerable during fixation of drfs without a tourniquet, with a faster recovery period and similar functional outcomes to general anaesthesia, and it is more cost-effective.91,92 adjuncts to surgery bone graft a cochrane database analysis of randomised trials concluded that there was insufficient evidence on functional outcomes and safety of the use of grafts in drfs.93 that said, in elderly patients with comminuted fractures and metaphyseal bone loss following restoration of length and alignment, bone graft substitutes are sometimes necessary. although no graft is superior, the iliac crest bone graft can be used in cases of major bone loss, and fracture non-union is recommended.94 pedestal bone loss can be managed with bone graft in closed fractures, and staged bone graft reconstruction should be considered in patients with open fractures.18,95 calcium phosphate cement calcium phosphate use in drfs has been reported to provide improved fracture stability in fractures treated with either external fixator or k-wire fixation in biomechanics studies.96-98 zimmermann et al. reported good results and cement incorporation in 26 postmenopausal women managed with injectable calcium phosphate bone cement and k-wires for intra-articular drfs with a metaphyseal void of at least 5 mm. this was compared to those treated with cast immobilisation or k-wire fixation without the use of bone cement following the reduction.99 the indications for bone cement use are not clearly defined in the literature. ozer and chung concluded that indications and choice of graft substitute should be based on the needs of the individual patient until further comparative research clarifies the indications and most appropriate material for a given fracture and clinical situation.94 pronator quadratus repair pronator quadratus repair following volar plating has not been shown to have a functional impact.100-102 some studies suggest this repair may be protective against flexor tendons rupture.103 carpal tunnel release during fracture fixation prophylactic carpal tunnel release (ctr) in patients with drfs is not recommended.104,105 acute ctr should be done in patients with persistent and progressive features of acute cts.22,23,106,107 page 236 rachuene pa et al. sa orthop j 2021;20(4) delayed release of more than 36 hours has been associated with irreversible nerve damage, whereas patients released acutely regained full nerve function.108-110 postoperative care and rehabilitation postoperative rehabilitation programmes remain controversial and centre-specific.111 postoperative care includes immobilisation, analgesia and elevation.112 postoperative immobilisation of two weeks versus six weeks after volar plate fixation has shown no difference in long-term range of motion or functional outcomes. although earlier range of motion exercises speeds up recovery in the acute setting, it did not translate into improved ultimate outcomes.113 duprat et al. illustrated that the stability of a locking volar plate enabled immediate mobilisation with similar complication rates, but resulted in improved short-term outcomes in all aspects.114 when treatment entails closed reduction and casting, immobilisation for four to six weeks is preferred, provided that evidence of healing can be confirmed.115 in the absence of comorbidities, like diabetes, fracture union will have taken place. if in doubt, radiographs can be used to confirm union. the majority of function is regained by three months, provided that good alignment was achieved, but continuous improvements up to 12 months can be expected with a slow return of grip strength.113 athletes need to be individualised. contact athletes can return to sport once they have achieved a pain-free range of motion and completed sport-specific drills and practice. sports where wrist function is not required needs to be discussed with the patient and practised at their own discretion while being well informed and made aware of the risks.113 adjuvant therapy vitamin c supplementation empiric vitamin c for the prevention of complex regional pain syndrome (crps) remains controversial. its use has been recommended since zollinger proved some benefit in 1999, but recent randomised controlled trials failed to demonstrate such benefit.116-118 vitamin d supplementation vitamin d deficiency is common in the elderly population with fragility drfs.119,120 several studies have demonstrated hypovitaminosis d in young patients, even in the south african setting.121-123 øyen et al. found that the elderly who sustain drfs had low vitamin d levels compared to those who did not have fractures.119 however, rozental et al. reported that, in israel, there was no association of low vitamin d with drfs.124 amid contrasting evidence, we propose selective patient vitamin d testing and supplementation if diagnosed with hypovitaminosis d. tladi proposed that one should use a regimen that contains high levels of vitamin d3.125 bisphosphonate therapy timing to initiation of bisphosphonates did not alter union times or rates. patients should be risk-stratified and initiated on bonesparing medication if indicated.126 molvik and khan reported significantly prolonged fracture union time in patients with drfs treated with bisphosphonates in a systematic literature review.127 however, the clinical studies reported similar radiographic and functional outcomes between patients with acute drfs treated with bisphosphonate therapy and those who were not given bisphosphonates.42,128,129 low-intensity ultrasound low-intensity ultrasound showed promise by reducing fracture healing times from 98 days to 61 days in a study by kristiansen et al., and from 40 days to 32 days in a study by liu et al. no longterm benefit could be proven in these studies, and the cost over benefit of this modality remain a concern.130,131 south african context trauma is a huge burden on an already compromised public healthcare system in south africa. the private sector treats about 16% of the general population while the government sector treats 84%.132,133 patients are waiting longer to receive elective surgery because of the limitation of theatres in state hospitals.134 the lack of resources results in delayed referrals of patients, compelling the treating surgeon to manage partially healed fractures that often result in long operating times and a high risk of complications. this ailing system has been further burdened by the covid-19 pandemic. it is our opinion that surgeons should consider nonoperative treatment of selected drfs. this could aid in relieving some of the pressure from the overburdened public health sector. conclusion distal radius fractures are common among elderly females, with increasing prevalence among all age groups. management of these injuries remains controversial with no clear guidelines and contrasting evidence in the literature. although nonoperative treatment is still a viable option in most cases with good results, the recent trend has seen an increase in surgical treatment. improvements in fixation plate design have shown promising results in the reduction of complications and restoration of function in those treated surgically. osteoporosis treatment should be initiated early in at-risk populations. high-level evidence and treatment guideline protocols are still lacking on this subject. learning points the incidence of drfs in young adults is on the rise and they often follow high-energy mechanisms of injury. classification systems demonstrate a lack of reliability, and their role in guiding treatment is limited. the majority of drfs are amenable to conservative treatment but one should be wary of the risk of fracture collapse in high-risk populations, and time taken off work or sports in young patients. drfs are often the first sign of osteoporosis and clinicians should not miss this opportunity to treat these patients accordingly. surgical management is associated with higher financial costs. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethical approval for this study was not obtained – review article. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions pr: assembled the team of reviewers, co-ordinated the review process, conducted the primary review and compiled the manuscript sk, mt, fd and gt: conducted the primary review and assisted with writing and reviewing the written submission sg: reviewed 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https://doi.org/10.1097/bpo.0000000000000607 https://doi.org/10.1017/s136898001000234x https://doi.org/10.1017/s136898001000234x https://doi.org/10.2106/jbjs.o.00313 https://doi.org/10.2106/jbjs.o.00313 https://doi.org/10.1186/1749-799x-9-45 https://doi.org/10.1186/1749-799x-9-45 https://doi.org/10.1007/s00198-014-3007-8 https://doi.org/10.1016/j.jhsa.2008.12.011 https://doi.org/10.1016/j.jhsa.2017.09.006 https://doi.org/10.1590/s0102-86502014001800012 https://doi.org/10.1590/s0102-86502014001800012 https://doi.org/10.1093/pubmed/fds008 https://doi.org/10.31021/ijcmc.20192116 _hlk70945200 _hlk83636875 _hlk83637285 _hlk65244340 page 32 sa orthopaedic journal spring 2014 | vol 13 • no 3 the management of chronic osteomyelitis: part ii – principles of post-infective reconstruction and antibiotic therapy dr lc marais mbchb, fcs orth(sa), mmed(ortho) tumour, sepsis and reconstruction unit, department of orthopaedics, grey’s hospital, university of kwazulu-natal dr n ferreira bsc, mbchb, fc orth(sa), mmed(orth) tumour, sepsis and reconstruction unit, department of orthopaedics, grey’s hospital, university of kwazulu-natal dr c aldous bsc, bsc(hons), msc, phd medical research scientist, school of clinical medicine, college of health sciences, university of kwazulu-natal prof tlb le roux mbchb, fcs orth(sa), mmed(ortho) professor and head of department, department of orthopaedics, i military hospital, university of pretoria correspondence: dr lc marais department of orthopaedic surgery grey’s hospital school of clinical medicine university of kwazulu-natal private bag x9001 pietermaritzburg 3201 email: leonard.marais@kznhealth.gov.za tel: +27 033 897 3299 fax: +27 33 897 3409 abstract over the past few decades considerable progress has been made in terms of our ability to reconstruct postinfective soft tissue and bone defects. soft tissue reconstruction is not always required and it is frequently possible to achieve a tension-free closure of well-perfused tissue following debridement. it is now generally accepted that primary closure of the wound, be it by direct suturing or tissue transfer, may be performed at the same sitting as the debridement. in cases were debridement has resulted in tissue loss, muscle or musculocutaneous flaps appear to be superior to random-pattern flaps in achieving resolution of infection. the management of bone defects is dependent on several factors including the host’s physiological status, the size of the defect, duration of the defect, quality of the surrounding soft tissue, the presence of deformity, joint contracture/instability or limb length discrepancy, as well as the experience of the surgeon. surgery remains the mainstay of treatment when a curative treatment strategy is selected. as is the case with chemotherapy for bone tumours, antibiotic therapy fulfils an adjuvant role in curative management strategies. the choice of antibiotic, in this setting, remains a very difficult one and there are many problems with the interpretation of ‘cure rate’ data. the controversy surrounding the optimal duration and route of antibiotic therapy has not been resolved. the second role of antibiotics in the management of chronic osteomyelitis is disease suppression as part of a palliative treatment strategy. further studies are required to clarify which patients may successfully be treated with antibiotics alone. key words: osteomyelitis, chronic, management, review part i of this article – diagnostic work-up and surgical principles – was published in the previous issue of the south african orthopaedic journal, winter 2014, vol 13, no 2 saoj spring 2014_orthopaedics vol3 no4 2014/07/31 12:07 pm page 32 sa orthopaedic journal spring 2014 | vol 13 • no 3 page 33 introduction the complex and heterogeneous nature of chronic osteomyelitis necessitates a multi-disciplinary approach, involving experts in the field of orthopaedic tumour, infection and limb reconstruction surgery, plastic surgery, microbiology, nursing, physiotherapy and psychology. numerous surgical techniques and adjuvant therapies have been developed during the past three decades in order to deal with the wide spectrum of pathology that falls under the heading of chronic osteomyelitis. despite these developments, the outcome of current treatment protocols remains unsatisfactory, with failure of therapy reported in up to 20% of cases.1 the preceding article in this series aimed to elucidate current concepts in the diagnostic work-up and surgical management of chronic osteomyelitis. in this paper postinfective soft tissue and skeletal reconstruction, as well as the principles of antibiotic therapy, will be addressed. there are several controversial issues related to these subjects. the optimal choice for soft tissue cover following debridement, for example, remains controversial. although several techniques have been described to deal with bone defects, a comprehensive contemporary strategy has not yet been described. in terms of antibiotic therapy, clear evidence-based guidelines are also lacking, especially in terms of the selection of the appropriate antibiotic agents, the optimal duration of treatment and the ideal route of administration. post-debridement reconstruction soft tissue reconstruction in many cases it is possible to achieve a tension-free closure of well-perfused tissue following debridement. unfortunately the excision of ischaemic tissue and sinuses frequently result in a soft tissue defect. it is now generally accepted that primary closure of the wound, be it by direct suturing or tissue transfer, may be performed at the same sitting as the debridement.2,3 cierny, however, emphasises the importance of systemic and local antibiotics, as well as a double setup in case of a single stage procedure. this involves re-scrubbing of all staff members, repeat preparation and draping of the patient, as well as the use of new instruments for the reconstructive part of the procedure.4 delayed primary closures may still be required in certain cases where, for example, a second look at the viability of remaining tissue is required, soft tissues are not amenable to closure due to swelling or induration, or where a second team is required to perform a complex free flap. in the past post-debridement soft tissue defects were often left to heal by secondary intention or dealt with through the use of open-sky techniques like papineau bone grafting. these methods have subsequently fallen out of favour, and authors like ger have promoted the principle of muscle flap coverage in order to achieve improved cure rates.5,6 this approach was justified through animal studies which showed that muscle or musculocutaneous flaps were superior to random-pattern flaps (i.e., local flaps) in achieving resolution of infection.7 in an experimental model, feng and colleagues were able to explain this phenomenon by showing increased blood flow and more consistent leukocyte mobilisation in musculocutaneous flaps when compared to random flaps. in addition, the oxygen tension in soft tissue defects covered by muscle flaps was shown to be higher than those covered through random-pattern flaps. the advantages of muscle flaps have also been illustrated in the clinical setting, although a recent review still questioned the clinical validity of the theoretical advances of muscle flaps in the setting of infection.8,9 with the advances in microsurgical techniques in the recent past, free tissue transfer has become more accessible. the success achieved with free flaps in the management of open fractures has prompted utilisation of these techniques in the management of chronic osteomyelitis. the excellent results, in terms of bony union and eradication of infection, with free muscle transfer in chronic osteomyelitis, have also been attributed to the dramatic increase in the local blood supply.10 in addition, performing a debridement and free flap in a single sitting has been shown to be reliable in achieving cure.3 recently, perforator free flaps have gained much popularity in the management of open fracture and have been suggested to be superior in the management of tibial osteomyelitis.11 although free anterolateral thigh fasciocutaneous flaps have been shown to be effective in the management of open tibia fractures, it is technically challenging and free muscleor musculocutaneous flaps are still considered the method of choice in coverage of lower leg defects.12 several other salvage techniques have emerged in the recent past. negative pressure dressing has been employed successfully in the management of many soft tissue defects. it has, however, a limited role in the management of chronic osteomyelitis as it results in the formation of dense and poorly vascularised scar tissue. the application of vacuum dressings to draining sinuses in particular is discouraged as it significantly complicates subsequent surgery.4 vacuum dressing may occasionally be considered in severely compromised hosts where tissue transfer is deemed impossible. more recently negative pressure wound therapy combined with the instillation of solution in the local area (vac instil therapy) has been proposed as a viable alternative in the management of osteomyelitis-associated soft tissue defects.13 this form of therapy is attractive as it offers the theoretical advantages of both the lautenbach technique and negative pressure wound therapy. as a last resort, in certain cases where the local soft tissue condition does not permit flap coverage, open skeletal transport (in accordance with ilizarov principles) may be considered. skeletal reconstruction cierny and mader type i, ii and iii lesions are, per definition, stable and generally do not require reconstruction of the defect left by the debridement. type iv lesions, on the other hand, are characterised by instability and routinely require stabilisation and reconstruction of osseous defects resulting from the debridement. existing classification systems for post-osteomyelitis bone defects, including those suggested by may and gordon, have failed to keep up with the modern trends in limb reconstruction surgery and have therefore lost some of their value.14,15 saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 2:50 pm page 33 page 34 sa orthopaedic journal spring 2014 | vol 13 • no 3 acute shortening, with primary docking of the bone ends, of up to 4 cm has been advocated for post-traumatic bone loss.16 unfortunately the soft tissue scarring associated with chronic osteomyelitis rarely permits acute shortening beyond 2 cm. not only does acute shortening in the presence of significant scar tissue present technical difficulties with wound closure, it also carries a particular risk of vascular compromise as a result of kinking of blood vessels which are immobilised by rigid soft tissues. acute shortening of 1–2 cm can, however, be used as part of a combined strategy, which may include the induced membrane technique along with bone grafting or bone transport. the size of a segmental bone defect which should be considered critical, and thus not suitable for autologous cancellous bone grafting, remains controversial. traditionally approximately 4 cm has been recommended as the cut-off point.17,18 the first problem with cancellous bone grafting is its dependence on the surrounding soft tissues for nourishment. large grafts may undergo central necrosis in the absence of an excellent soft tissue envelope (bone bed).19 secondly the regenerated segment is often weak and prone to fracture as a result of partial graft resorption.20 as a result, tiemann et al. recommended 2 cm as the maximum size of a segmental diaphyseal tibial defect that can be managed with autologous cancellous grafting.19 the advent of induced membrane techniques has, however, increased the potential for the use of cancellous bone graft in much larger defects. masquelet reported the successful use of this technique in 35 cases, with defects ranging from 4–25 cm.21 others have been able to reproduce these results. unfortunately the soft tissue scarring associated with chronic osteomyelitis rarely permits acute shortening beyond 2 cm figure 1. post-traumatic, contiguous chronic osteomyelitis of the tibia. following marginal resection of the necrotic bone the resulting bone defect was treated with cancellous bone graft into an induced membrane (classic masquelet technique).21 the advent of induced membrane techniques has increased the potential for the use of cancellous bone graft in much larger defects saoj spring 2014_orthopaedics vol3 no4 2014/07/31 11:50 am page 34 stafford reported a 90% union rate of defects ranging from 1–25 cm (average 5.8 cm) with the use of reamer-irrigationaspiration graft.22 although the induced membrane technique offers several theoretical and practical advantages, caution should be applied in the use of cancellous bone graft in tibial defects exceeding 4 cm, especially in the absence of periosteal new bone formation (figure 1).19 distraction osteogenesis, in accordance with the ilizarov method, remains the gold standard in the management of post-debridement bone defects of 4 cm or more.16,23 this may take the form of acute shortening with subsequent lengthening or, more commonly, bone transport into the defect. distraction osteogenesis offers several advantages in the management of chronic osteomyelitis, including the increase of regional blood flow for a period of up to 17 weeks following the corticotomy.24 large defects can be dealt with through simultaneous multifocal transport, sequential transport or cable-transport techniques. the upper limit of the size of defects which may be dealt with through distraction osteogenesis is, however, highly dependent on the surgeon’s experience with the technique (figure 2). circular fixation and bone transport is associated with its own subset of complications and a second procedure involving cancellous grafting of the docking site (formal docking) is generally recommended.25 following a comparative study, el-gammal and colleagues suggested that defects smaller than 12 cm should be reconstructed with ilizarov bone transport while free vascularised fibula grafts performed better in defects larger than 12 cm.26 although vascularised fibula grafts, fibula-pro-tibia (fibula centralisation) or fibula bypass grafting remain options for defects in excess of 12 cm these procedures involve donor site morbidity and is often complicated by non-union or fracture of the graft during the period of hypertrophy (figure 3).27 a combination of techniques is commonly used. ultimately the management of bone defects is dependent on several factors including the host’s physiological status, the size of the defect, duration of the defect (i.e. acute or chronic), quality of the surrounding soft tissue, the presence of deformity, joint contracture/instability or limb length discrepancy, as well as the experience of the surgeon. antibiotic therapy it is important to note that surgery remains the mainstay of treatment when a curative treatment strategy is selected. as is the case with chemotherapy for bone tumours, antibiotics fulfil an adjuvant role in curative management strategies. curative surgery should ideally involve a wide resection with clear margins. this goal is however frequently unachievable as it may result in unreconstructable loss of bone that is vital to the survival and function of the limb. marginal resection may, on the other hand, leave behind colonised bone or soft tissue that may serve as a nidus for recurrent infection.28 even in wide resections the remaining bone and soft tissue bed should also be considered contaminated. antibiotics are, therefore, used in wide and marginal resections (curative surgical strategies) in an attempt to sterilise the remaining bone and soft tissues. in the curative setting empirical adjuvant antibiotics are typically started immediately following the debridement, and the regimen is modified once the culture and sensitivity results become available. the first role of antibiotics in the management of chronic osteomyelitis, is adjuvant therapy as part of a curative treatment strategy. the choice of antibiotic, in this setting, remains a very difficult one and there are many problems with the interpretation of ‘cure rate’ data. firstly there are no standardised definitions for cure or failure of treatment and no universally accepted host stratification system. in addition, many of the historical studies evaluated the efficacy of antibiotics in the absence of surgical debridement or surgical implants. studies often include a heterogeneous group of patients in terms of their physiological status, the aetiological source of the infection and the anatomical/ pathological nature of the disease. finally, in vivo effect does not always mirror the high degree of efficacy predicted by in vitro investigations. empirical antibiotics should be selected on the basis of the aetiology of the infection as well as local pathogen profiles. β-lactams and vancomycin are the most commonly used antimicrobials in the medical management of osteomyelitis.29 sa orthopaedic journal spring 2014 | vol 13 • no 3 page 35 figure 2. contiguous chronic osteomyelitis following a failed open reduction of a tibial shaft fracture. wide resection of the necrotic bone segments was performed and an antibiotic-impregnated pmma spacer inserted. following removal of the spacer the resulting 8 cm bone defect was addressed with distraction osteogenesis. union was achieved after a formal docking procedure. circular fixation and bone transport is associated with its own subset of complications and a second procedure involving cancellous grafting of the docking site is generally recommended saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 2:51 pm page 35 page 36 sa orthopaedic journal spring 2014 | vol 13 • no 3 in terms of contiguous infections, the bone infection unit in the united kingdom recommends empirical parenteral vancomycin and meropenem.2 although this protocol covers a broad range of pathogens there are some potential concerns. vancomycin offers excellent activity against mrsa and ampicillin-resistant enterococci. unfortunately it has several drawbacks including poor bone penetration, increased minimal inhibitory concentrations among many s. aureus strains and has been shown to have increased recurrence rate when compared with cefazolin or ceftriaxone.30,31 β-lactam antibiotics (penicillins, cephalosporins and carbapenems) exhibit poor bone penetration, with levels reaching only approximately 5–20% of serum concentrations. fortunately serum levels of parenteral β-lactams are so high that the resulting bone levels most likely exceed the necessary minimum inhibitory concentration (mic).32 cefepime appears to be a reasonable alternative to meropenem, offering good activity against gram-negative organisms, and it has been shown to have excellent bone penetration, with bone concentration reaching 97–100% of serum levels.33 in terms of the route of administration, oral antibiotic agents which exhibit high bioavailibility are an acceptable alternative to parenteral therapy.32 several randomised clinical trials have found similar cure rates in patients treated with oral and parenteral antibiotic therapy.34,35 in addition parenteral antibiotics are associated with an increased incidence of moderate or severe side-effects.30 preferred oral agents, based on clinical and pharmacokinetic data, include fluoroquinolones and trimethoprimsulfamethoxazole (cotrimoxazole).32 studies involving fluoroquinolones have found high cure rates, although failure of treatment may occur in pseudomonas or s.aureus infections, especially when used as monotherapy.36 in addition, it is a matter of concern that fluoroquinolones have been associated with impaired bone healing and these agents may need to be avoided in cases of septic nonunion or in the setting of post-infective reconstruction.37 cotrimoxazole exhibits concentration-dependent killing, therefore higher than usual doses (7–8 mg/kg/day trimethoprim) are recommended in the treatment of chronic osteomyelitis.38 de barros et al. reported an impressive 98% cure rate with 6 months of cotrimoxazole therapy following surgical debridement, although it may be argued that the extended duration of therapy may have resulted in disease quiescence through suppression.39 rifampicin achieves bone levels equivalent to serum concentrations and when used in conjunction with other agents there appears to be a clear benefit in terms of cure rates.40,41 it should however never be used as monotherapy due to the risk of the development of resistance. sanchez et al. reported a 100% cure rate in staphylococcal infections with surgical debridement in conjunction with double the standard dose of cotrimoxazole combined with rifampicin for a mean of five weeks.42 similarly, cotrimoxazole combined with rifampicin achieved similar cure rates to both linezolid with rifampicin, as well as eight weeks of intravenous cloxacillin monotherapy, in the treatment of chronic osteomyelitis and infections associated with surgical implants.43,44 it is important to note that oral dosing of β-lactam antibiotics results in serum levels of less than 10% of parenteral administration. this pharmacokinetic characteristic raises concern regarding the ability of β-lactams to reach adequate mic in bone, despite the fact that their penetration is better in infected than in uninfected bone.45 clindamycin exhibits good bone penetration and many methicillin-resistant s. aureus strains are susceptible to the agent. despite these characteristics there are no recent studies investigating the use of clindamycin in the management of osteomyelitis. figure 3. fracture of a vascularised fibula graft which was used to manage a 20 cm bone defect. union of the fracture was achieved following gradual correction of the mechanical axis with the use of a hexapod external fixator. in terms of the route of administration, oral antibiotic agents which exhibit high bioavailibility are an acceptable alternative to parenteral therapy saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 2:51 pm page 36 sa orthopaedic journal spring 2014 | vol 13 • no 3 page 37 linezolid, the first antimicrobial in the new oxazolidinone class, was initially received with much enthusiasm as a result of its high bioavailability following oral administration and excellent activity against staphylococci, streptococci and vancomycin-resistant enterococci. unfortunately clinical studies have shown cure rates of only 60% and prolonged used has been associated with pancytopaenia, peripheral neuropathy and optic neuritis.46,47 the use of linezolid is therefore typically limited to patients with osteomyelitis resulting from vancomycin-resistant enterococci or patients who are intolerant of vancomycin.46 daptomycin, a new lipopeptide antimicrobial agent, exhibits good activity against gram-positive bacteria including methicillinresistant s. aureus and glycopeptide-resistant enterococci. it has been studied extensively in the management of osteomyelitis and has been shown to be a good salvage option in cases which failed to respond to standard therapy.48 the optimal duration of antimicrobial therapy following surgical debridement remains unknown. the traditional duration of treatment is four to six weeks. this is based on experience with the management of acute osteomyelitis in children, where extended periods of antibiotics are required, as well as the results of animal studies which illustrated that six weeks of antibiotics was effective in sterilising diseased bone.49 this traditional recommendation is also derived from the assumption that revascularisation of bone following debridement takes about four weeks.50 several studies have failed to demonstrate increased efficacy of extended duration antibiotic therapy.51 furthermore, the absence of standardised treatment algorithms makes interpretation of the data very difficult. many studies did not include surgical debridement or removal of surgical implants, and thus this form of treatment should rather be viewed as palliative intervention. because of the historical absence of standardised definitions and treatment strategies, older antibiotic treatment protocols are inconsistent with our current way of thinking. the duration of antibiotic treatment should rather be based on the treatment strategy selected, the realistic aim of treatment and the extent of the surgical margin. in theory, curative management strategies involving wide resection would only require a short period of antibiotics in order to sterilise the remaining soft tissue. in practice truly wide margins are, however, very difficult to achieve. traditional thinking dictates a minimum of six weeks treatment in curative treatment protocols involving marginal debridement. unfortunately there is insufficient evidence to make definitive recommendations and further studies are required in this respect.32 in palliative treatment strategies or in cases treated with intra-lesional debridement extended periods of antibiotics appear to remain appropriate. the second role of antibiotics in the management of chronic osteomyelitis is disease suppression as part of a palliative treatment strategy. this form of treatment appears to be justified by the successful use of suppressive antibiotics in peri-prosthetic infections of hip or knee replacements.52,53 success rates of between 60 and 75% have also been reported in cases of infection associated with osteosynthesis through the use of long-term antibiotics without surgical removal of the implants.38,54 the efficacy of suppressive treatment in chronic osteomyelitis without an implant has, however, not been determined. in addition many of the older studies looking at long-term antibiotic therapy included patients with and without surgical implants as well as surgically and nonsurgically managed patients. this lack of uniformity made comparison of results impossible and, again, illustrates the urgent need for the establishment of standardised nomenclature and treatment strategies in the management of chronic osteomyelitis. chronic suppressive antibiotic therapy forms the cornerstone of palliative management in c-hosts. this form of treatment typically involves antibiotics that are prescribed for a period six months. if quiescence or sufficient suppression is achieved the antibiotics can be stopped. if the infection recurs after discontinuation of the therapy, a lifelong suppressive regimen should be considered.50 various antibiotic regimens have been investigated. due to the inferior results reported with single agents, and the efficacy shown with the addition of a second agent in the setting of implant-related infections, most chronic suppressive regimens generally involve the combination of two agents.55,56 antibiotics used in suppressive regimens include cotrimoxazole, rifampicin, ciprofloxacin, cloxacillin, fusidic acid and clindamycin.38,45,57,58 although directed therapy according to culture and sensitivity results is the ideal, this is frequently not practical and possibly not necessary in order to achieve clinical quiescence. the available literature suggests that cotrimoxazole and rifampicin can be considered as first line chronic suppressive antibiotic therapy.33 if these agents fail to achieve clinical suppression during the first six months, second line therapy may be instituted in the form of clindamycin or cloxacillin in combination with rifampicin, ciprofloxacin or fusidic acid. conclusion over the past few decades considerable progress has been made in terms of our ability to reconstruct post-infective soft tissue and bone defects. muscle or musculocutaneous flaps appear to be superior to random-pattern flaps (i.e. local flaps) in achieving resolution of infection and it is now generally accepted that primary closure of the wound may be performed at the same sitting as the debridement. several factors need to be considered when dealing with post-infective bone defects, and the size of the defect serves as a useful guideline when selecting the appropriate treatment strategy. the soft tissue scarring associated with chronic osteomyelitis rarely permits acute shortening beyond 2 cm. good results have been reported with cancellous grafting into an induced membrane and the masquelet technique may be utilised in cases with bone loss of more than 2 cm. for bone defects larger than 4 cm distraction osteogenesis may be appropriate, while free vascularised fibula grafts may have to be considered for defects in excess of 12 cm. in terms of antibiotic therapy clear evidence-based guidelines are lacking, especially in terms of the selection of the appropriate antibiotic agents, the optimal duration of treatment and the ideal route of administration. oral antibiotic agents that exhibit high bioavailability appear to be an acceptable alternative to parenteral therapy. saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 2:52 pm page 37 page 38 sa orthopaedic journal spring 2014 | vol 13 • no 3 preferred oral agents, based on clinical and pharmacokinetic data, include fluoroquinolones, rifampicin and trimethoprim-sulfamethoxazole. in theory, curative management strategies involving wide resection would only require a short period of antibiotics in order to sterilise the remaining soft tissue. traditional thinking dictates a minimum of six weeks of treatment in curative treatment protocols involving marginal debridement. in palliative treatment strategies and in cases treated with intra-lesional debridement, extended periods of antibiotics remain appropriate. the content of this article is the sole work of the authors. the primary author has received a research grant from the south african 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birmingham mc, rayner cr, meagher ak, et al. linezolid for the treatment of multidrug-resistant, grampositive infections: experience from a compassionate-use program. clin infect dis 2003;36:159-68. 48. finney ms, crank cw, segreti j. use of daptomycin to treat drug resistant gram-positive bone and joint infections. curr med res opin 2005;21:1923-26. 49. norden cw, dickens dr. experimental osteomyelitis iii. treatment with cephaloridine. j infect dis 1973;127:525-28. 50. lazzarini l, mader jt, calhoun jh. osteomyelitis in long bones. j bone joint surg am 2004;86-a:2305-18. 51. haidar r, der boghossian a, atiyeh b. duration of postsurgical antibiotics in chronic osteomyelitis: empiric or evidence-based? int j infect dis 2010;14:e752-58. 52. goulet ja, pellicci pm, brause bd, salvati em. prolonged suppression of infection in total hip arthroplasty. j arthroplasty 1988;3:109-16. 53. segreti j, nelson ja, trenholme gm. prolonged suppressive antibiotic therapy for infected orthopedic prostheses. clin infect dis 1998;27:711-13. 54. javaloyas de morlius m, monreal portella m. oral antibiotic therapy in the adult bacterial osteomyelitis: results after two years of follow-up. med clin (barc) 1999;113:488-89. 55. zimmerli w, widmer af, blatter m, et al. role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. foreign-body infection (fbi) study group. jama 1998; 279:1537-41. 56. saengnipanthkul s, pongvivat t, mahaisavariya b, laupattarakasemw. co-trimoxazole in the treatment of chronic osteomyelitis. j med assoc thai 1988;71:186-91. 57. pontifex ah, mcnaught dr. the treatment of chronic osteomyelitis with clindamycin. can med assoc j 1973;109:105107. 58. atkins b, gottlieb t. fusidic acid in bone and joint infections. int j antimicrob agents 1999;12 (suppl 2):s79-93. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 2:52 pm page 39 orthopaedics vol3 no4 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 35 outcome of displaced supracondylar fractures in children after manipulation and backslab dr jl pretorius mbchb(stell) registrar, department of orthopaedics, university of kwazulu-natal dr p rollinson, mbchb(sheff), frcs chief orthopaedic specialist, ngwelezane hospital, empangeni, kwazulu-natal dr mn rasool mbchb(ukzn), fc(orth)sa, phd paediatric orthopaedics, nelson mandela school of medicine, university of kwazulu-natal, durban, south africa corresponding author: dr jl pretorius department of orthopaedic surgery university of kwazulu-natal email: johan.doc@gmail.com introduction supracondylar fractures of the humerus in children are the commonest elbow injuries. the treatment of these fractures is controversial. the average age at fracture is 6.7 years, and the non-dominant hand is more commonly affected. the mechanism of injury is a fall on an outstretched hand, either from a height or at ground level. ninety-eight per cent are extension-type injuries. complications include neurological deficit, vascular injury, compartment syndrome, elbow stiffness, myositis ossificans, non-union, avascular necrosis, angular deformity and rotational deformity.1 treatment of supracondylar fractures in children is generally determined by using the classification described by gartland.2 type i fractures are undisplaced. type ii fractures have partial displace ment, but a certain degree of contact is maintained between the proximal and distal fragments. type iii fractures have complete displacement with no bony contact. abstract aim: to assess the functional and cosmetic outcome of displaced supracondylar fractures in children treated by closed reduction and plaster backslab. method: we retrospectively reviewed 53 patients with gartland type ii and type iii fractures that were treated by closed reduction (blount’s technique) and immobilisation in a collar and cuff and above-elbow plaster backslab between december 2011 and may 2012. the mean age was 6.6 years. the mean follow-up time was 12 weeks (range, 6–20). all open injuries and undisplaced fractures were excluded from the study. flynn’s criteria were used to assess functional and cosmetic outcome.  results: the median loss of motion was 10 degrees and the median change in carrying angle was 4 degrees. fifty-one patients (96.2%) had satisfactory results, with 87% graded as excellent or good according to the flynn’s criteria for grading of the carrying angle. a range of motion of 100 degrees was achieved in 92.5% of patients at 12 weeks. conclusion: this method appears to produce less satisfactory results in comparison to closed reduction and fixation with kirschner wires (k-wires), but it does provide satisfactory results according to flynn criteria with regard to cosmetic deformity and range of motion at short-term follow-up. it is an acceptable and safe option with which to treat displaced supracondylar fractures. key words: supracondylar fractures, closed treatment, outcome http://dx.doi.org/10.17159/2309-8309/2015/v14n1a4 treatment of supracondylar fractures in children is generally determined by using the classification described by gartland saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 35 page 36 sa orthopaedic journal summer 2015 | vol 14 • no 4 various methods of treatment have been described and are based on the degree of displacement. they include immobilisation in an above-elbow backslab or even collar and cuff for undisplaced fractures (gartland i). in displaced fractures (gartland ii and iii) cast immobilisation in either flexion or extension,3-9 various forms of traction, including horizontal traction, vertical traction, dunlop traction,3,6,10–13 skeletal traction through an olecranon pin and traction in pre-fabricated braces have been used.3,6,14,15 the commonly accepted method involves closed reduction and kirschnerwire (k-wire) fixation, with variation in number of pins and configuration, either medial and lateral wires or only lateral wires, which can be either parallel or crossed.3,6,16–21 open reduction is generally reserved for irreducible fractures, vascular compromise and open injuries, but can also be used when attempted reduction is delayed.22,23 the use of flynn’s criteria is a widely accepted method of assessing the results of supracondylar fractures and incorporates a functional element, i.e. range of motion and a cosmetic component with change in carrying angle.24 the baumann angle after reduction, measured on plain radiograph between the long axis of the humerus and the growth plate of the capitellum, can accurately predict the final carrying angle.25 over the last 25 years a relatively simple treatment method was used in the orthopaedic department at a regional hospital, which serves as a referral centre for 14 district hospitals as well as serving as a district hospital for a local population of approximately 500 000. supracondylar fractures are commonly seen in the orthopaedic department each year, approximately 200, and many of these are referred late, often with marked swelling (48 hours). the department is generally staffed by relatively junior medical officers and registrars, and resources are limited. subsequently a treatment protocol was devised to accommodate these factors. this involves placing the fractured arm on vertical skin traction on a drip stand alongside the bed (figure 1) to distract the fracture and reduce swelling. a manipulation under anaesthesia is performed at five to six days post injury, flexing the elbow to 110 degrees, securing the reduction with a collar and cuff, and protecting it in an above-elbow backslab. patients and method this is a retrospective review of the functional and cosmetic outcome of all displaced supracondylar fractures in children younger than 13 years of age for a period of 6 months (01 december 2011–31 may 2012) treated by closed reduction, collar and cuff, and protected in an above-elbow backslab. clinical records and radiographs were reviewed for the demographic details, site and mechanism of injury, clinical and radiographic presentation, mode of treatment before presentation, duration of hospital stay, theatre time and final treatment. functional outcome was determined by comparing the range of motion and carrying angle with the unaffected arm (figures 2–5). inclusion criteria included: all displaced (gartland ii and iii) fractures admitted to the department in the six-month period. figure 1. elevated vertical traction a treatment protocol was devised which involves placing the fractured arm on vertical skin traction on a drip stand alongside the bed to distract the fracture and reduce swelling figures 2 and 3. radiographs of one of the gartland iii injuries treated by our method figures 2 figure 3 saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 36 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 37 exclusion criteria: undisplaced supracondylar fractures (gartland i), fractures that required open reduction and k-wire, open fractures, and patients with poor documentation. a total of 89 patients with unilateral supracondylar fractures were treated during the study period. forty-six patients were excluded (undisplaced [30] or needed k-wire fixation [5], or incomplete documentation [11]). there were 53 patients in the study with full documentation and a mean follow-up of 12 weeks. twenty-nine (54.7%) of the patients were from referral hospitals and the remaining 24 (45.3%) came from the local drainage area. the mean age at time of injury was 6.6 years (13 months to 13 years). forty-four were male (83%) and nine were female (17%). there were 37 (69.8%) left-sided fractures compared to the right 16 (30.2%). there were no open injuries in the study group. neurological examination was documented in all patients; six patients (11.3%) had anterior interosseous nerve palsy and one (1.9%) had a radial nerve palsy. vascular examination revealed two patients who presented with a pink pulseless hand with normal capillary refill. these were managed by frequent vascular assessments with the elbow maintained straight on traction and then with reduction and in flexion as per normal with a collar and cuff and backslab when the swelling had diminished, usually after five to six days of straight-arm traction. five patients (9.4%) had concomitant fractures; four distal radius fractures and one salter-harris ii fracture of the distal radius. fifty-two patients (98%) sustained extension-type injuries. they were classified into gartland type ii 13 (24.5%) or gartland type iii 40 (75.5%) fractures. treatment all patients received five to six days of vertical traction suspended over a drip stand to allow the swelling to subside and distract the fracture. thereafter the fracture was reduced in theatre under general anaesthesia under fluoroscopy guidance using blount’s technique, which entails positioning the child at the edge of the operating table with the arm over the image intensifier. firm traction was applied with a steady continuous force with the elbow in full extension. once the deformity in the coronal plane was corrected, the surgeon applied countertraction to the proximal fragment while the thumb reached the olecranon and applied an anterior force to the distal fragment to push back the distal fragment to restore the sagittal plane deformity. concurrently, the other hand flexed the elbow up to 110 degrees.26,27 the reduction was confirmed on jones view and lateral, a collar and cuff was applied with the elbow maintained strictly at 110 degrees of flexion and then an above-elbow plaster backslab was applied to stabilise the elbow in the flexed position. a neutral position in terms of pronation/supination was used. the radial pulse was assessed after reduction. the neurovascular status was reviewed again in the ward. reduction of the fracture was confirmed on plain radiographs, and the child was discharged on the first or second post-operative day. the collar and cuff and plaster backslab were removed after three weeks and active mobilisation of the elbow encouraged. the patients were then seen at six and twelve weeks after reduction, where the range of motion and carrying angle were measured with a goniometer and documented on a datasheet, and radiographic evaluation was done. if the results were good/excellent (according flynn’s criteria) before 12 weeks, the patients were discharged. results the mean follow-up period was 12.3 weeks (6 weeks to 20 weeks). all neurological deficits resolved by six weeks. the average theatre time was 14.8 minutes (range 3–40) and the average duration of hospital stay was 4.8 days (range 3–8 days). one patient had a failed mua and had 17 days of vertical traction. the functional and cosmetic outcome was tabulated using flynn’s criteria (table i). figure 4 figures 4 and 5. radiographs at 12-week follow-up of the same patient shown in figures 2 and 3. this patient had 130 degree range of motion (poor) and change in carrying angle by 3 degrees (excellent), giving him an overall poor result. figure 5 saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 37 page 38 sa orthopaedic journal summer 2015 | vol 14 • no 4 the median loss of carrying angle was 4 degrees. the majority of fractures drifted into varus compared to the unaffected elbow, with only five patients increasing their carrying angle (all within excellent/good range). fifty-one patients (96.2%) had satisfactory results with 87% graded as excellent or good according to the flynn criteria for the carrying angle. the two patients who had unsatisfactory results had an 8 and 10 degree varus deformity; they also had unsatisfactory results with regard to range of motion despite the fact that they still had a functional range, i.e. 125 degrees and 135 degrees respectively (table ii). the median loss of range of motion was 10 degrees. the mean arc of motion was 141 degrees for the gartland ii fractures and 126 degrees for the gartland iii fractures. in the gartland ii fractures group, 85% of the patients had a satisfactory result with a median loss of motion of 5 degrees, 76% of which were lost at the end range of extension. in the gartland iii fractures group, 55% of the patients had a satisfactory result with a median loss of motion of 10 degrees, again with the majority lost at extreme extension (74%) (table iii). when the carrying angle and loss of motion scores were combined, 60.4% of the patients had a satisfactory result (table iv). discussion the treatment of supracondylar fractures continues to stimulate interest, especially gartland iii fractures. various methods have been used to treat supracondylar fractures. closed reduction and immobilisation in flexion have been used by several surgeons.3-6 pirone et al. reviewed the results of numerous methods of treatment at a mean of 4.6 years. in the group treated with closed reduction and backslab in flexion, they found 80% satisfactory results.3 the majority of the poor results in this group were due to cubitus varus. de gheldere et al. used  blount’s technique with a cast around the wrist to immobilise the forearm in pronation with the elbow in full flexion. table i: flynn’s criteria results rating loss of carrying angle loss of motion satisfactory excellent 0°–5° 0°–5° good 5°–10° 5°–10° fair 10°–15° 10°–15° unsatisfactory poor >15° >15° table ii: carrying angle loss* results rating degrees grade ii grade iii total satisfactory excellent 0°–5° 8 23 31 good 5°–10° 4 11 15 fair 10°–15° 0 4 4 unsatisfactory poor >15° 1 1 2 (*one patient’s carrying angle could not be measured due to ffd) table iii: total range of motion loss results rating degrees grade ii grade iii total satisfactory excellent 0°–5° 8 13 21 good 5°–10° 2 8 10 fair 10°–15° 1 1 2 unsatisfactory poor >15° 2 18 20 table iv: combined flynn score satisfactory unsatisfactory excellent good fair poor gartland ii 5 5 0 3 gartland iii 10 10 2 18 total 32 21 our method yielded overall satisfactory results with regard to restoration of the carrying angle saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 3 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 39 they found that 8% of gartland iii patients had a poor result while all the gartland ii fractures had satisfactory results. they suggested that most gartland ii and iii fractures can be treated in this manner but only the postero-lateral gartland iii fractures require k-wires due to their inherent instability in pronation.4 nejad et al. investigated the effect of supination and pronation on the incidence of cubitus varus deformity after closed reduction and immobilisation in flexion and found no relationship between the position of the forearm and the incidence of deformity but suggested that it is the frac ture type and the quality of the reduction that are important.5 several authors have used various methods of skin traction.6,11–13 piggot et al.11 treated 98 children with displaced supracondylar fractures of the humerus by straight lateral traction. after a mean follow-up period of 3.5 years there were 90 satisfactory and only eight unsatisfactory results; four of these had cubitus varus at final follow-up. sadiq et al.12 treated 20 children with displaced supracondylar fractures with lateral traction in 90 degrees abduction and supination and found no cases of cubitus varus. urlus et al.13 treated 33 patients with reduction in theatre and dunlop traction for an average of 18 days followed by plaster cast for an average of 16 days; they achieved 97% acceptable results with regard to change in carrying angle. immobilisation with plaster cast/moulded gutter-shape slab in extension has also been described.7–9 chen et al.7 compared the incidence of varus in gartland iii fractures treated with either reduction and flexion or reduction and moulded gutter shape plaster slab in extension and 20–30 degrees of valgus. fifty-seven per cent of his flexion group developed cubitus varus, while none of his extension group developed cubitus varus at 4.6 year follow-up. there was no difference in range of motion in either group. babar et al.8 used chen’s technique to treat 70 patients with gartland iii fractures and found 80% acceptable results; this group had a 5 degree change in carrying angle. gandhi et al.9 treated displaced gartland iii fractures with manipulation under anaesthesia and full above-elbow pop in extension and had 69% good/excellent results according to flynn’s criteria. traction through an olecranon pin either vertically or in a pre-fabricated brace yielded 84–98% satisfactory results.3,14,15 young et al.6 showed 94% satisfactory results using various techniques including plaster casting, overhead skeletal traction and casting and manipulation and k-wires; however, this included undisplaced fractures. closed reduction and percutaneous k-wire fixation is considered the gold standard for treatment of displaced supracondylar fractures and results in 99% satisfactory outcome and only a 2% complication rate. numerous studies on k-wire configuration have been published and even though cross-pin configuration is biomechanically better fixation than lateral only pinning, satisfactory results can be obtained using either technique.3,16-21 o’hara et al.19 recommended the following conditions to prevent re-operation and malunion: 1) an experienced surgeon should be responsible for the initial management; 2) closed or open reduction of type iib and type iii fractures must be supplemented by stabilisation with k-wires; and 3) k-wires of adequate thickness (1.6 mm) must be used in a crossed configuration. neurological injury associated with supracondylar fractures of the humerus in children is a well-known complication. the incidence of traumatic nerve injury varies between 12% and 20%, commonly affecting the anterior interosseous and radial nerve. iatrogenic nerve injuries associated with this fracture have been reported as being between 2% to 6%, commonly affecting the ulnar nerve; these injuries are a result of blind k-wire placement and ulnar nerve instability in elbow flexion.  the majority of these injuries are neuropraxias, and recover between 2–3 months.28-38 the incidence is lowered by using the three lateral pinning technique instead of the cross-pinning or with a minimally open medial approach.20,21,39 a series of patients treated with closed reduction and plaster backslab immobilisation is presented. our method yielded overall satisfactory results with regard to restoration of the carrying angle. using the full flynn criteria, only 60% achieved satisfactory results but this was mainly because of the flynn’s criterion related to range of motion loss. limitations of the study are that the fractures were assessed only over a 12-week period. those with a limited range of motion would almost certainly improve and increase their range of motion and consequently their flynn grading over time. previous studies looking at return of range of motion found that only 86–92% of range of motion returns by 12 weeks which improves to 98% of uninjured range by 52 weeks.40,41 baumann’s angle, measured on the injured and compared with the uninjured arm would have been a more objective measurement of change in carrying angle, but due to the fact that the ap radiographs of both elbows were taken on the same film, the angle between actual beam and elbow was 30 degrees. this gave distorted views of the baumann’s angle and could thus not be included.25 the flynn criteria are very ‘severe’ in that a carrying angle loss of 10 degrees or more is not regarded as a good result. a neutral carrying angle of a few degrees of varus (up to 5°) is generally accepted by patients/parents and is usually not even noticed. mild varus deformity of the elbow seems to cause more anxiety to orthopaedic surgeons than to patients and parents and may not be as important as implied by flynn’s criteria. the technique has been refined over 20 years at our institution with almost 100 cases per year managed. corrective osteotomy for malunion/varus in the cases managed by this method was not indicated or demanded by the parents. saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 39 page 40 sa orthopaedic journal summer 2015 | vol 14 • no 4 conclusion closed reduction, collar and cuff and plaster backslab immobilisation under general anaesthesia in theatre is an acceptable technique to treat supracondylar fractures in children. it saves theatre time while obtaining anatomical reduction and results in a satisfactory outcome according to flynn criteria for cosmetic appearance and a functional range of motion for the majority of patients in the short term. it also avoids the possible complications of k-wire fixation including iatrogenic ulnar nerve injury and pin-tract sepsis which could be catastrophic if the patient is lost to follow-up in the rural setting. this method appears to produce slightly inferior results in comparison with closed reduction and fixation with k-wires, but it provides excellent results with regard to alignment and a range of motion that is comparable with return of motion found in other studies. it is thus a good and safe option to treat displaced supracondylar fractures. the content of this article is the original work of the authors. no benefits of any form have been or are to be received from a commercial party related directly or indirectly to the subject of this article. ethical approval was obtained. references 1. beaty jh kj. supracondylar fractures of the distal humerus. rockwood and wilkins’ fractures in children. 5th ed.; 2005. p. 577-615. 2. gartland jj. management of supracondylar fractures of 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grade iii supracondylar fracture of the humerus by straight-arm lateral traction. minternational orthopaedics (sicot) 2007(31):15558. 13. urlus m, kestelijn p, vanlommel e, demuynck m, vanden berghe l. conservative treatment of displaced supracondylar humerus fractures of the extension type in children. acta orthop belg 1991;57(4):382-89. 14. matsuzaki k, nakatani n, harada m, tamaki t. treatment of supracondylar fracture of the humerus in children by skeletal traction in a brace. j bone joint surg br 2004 mar;86(2):232-38. 15. badhe np, howard pw. olecranon screw traction for displaced supracondylar fractures of the humerus in children. injury 1998 jul;29(6):457-60. 16. skaggs dl, sankar wn, albrektson j, vaishnav s, choi pd, kay rm. how safe is the operative treatment of gartland type 2 supracondylar humerus fractures in children? j pediatr orthop 2008 mar;28(2):139-41. 17. woratanarat p, angsanuntsukh c, rattanasiri s, attia j, woratanarat t, thakkinstian a. meta-analysis of pinning in supracondylar fracture of the humerus in children. j orthop trauma 2012 jan;26(1):48-53. 18. maity a, saha d, roy ds. a prospective randomised, controlled clinical trial comparing medial and lateral entry pinning with lateral entry pinning for percutaneous fixation of displaced extension type supracondylar fractures of the humerus in children. j orthop surg res 2012 feb 15;7:6-799x7-6. 19. o’hara lj, barlow jw, clarke nm. displaced supracondylar fractures of the humerus in children. audit changes practice. j bone joint surg br 2000 mar;82(2):204-10. 20. barlas k, baga t. medial approach for fixation of displaced supracondylar fractures of the humerus in children. acta orthop belg 2005 apr;71(2):149-53. 21. skaggs dl, hale jm, bassett j, kaminsky c, kay rm, tolo vt. operative treatment of supracondylar fractures of the humerus in children. the consequences of pin placement. j bone joint surg am 2001 may;83-a(5):735-40. 22. otsuka ny, kasser jr. supracondylar fractures of the humerus in children. j am acad orthop surg 1997 jan;5(1):19-26. 23. walmsley pj, kelly mb, robb je, annan ih, porter de. delay increases the need for open reduction of type-iii supracondylar fractures of the humerus. j bone joint surg br 2006 apr;88(4):528-30. 24. flynn jc, matthews jg, benoit rl. blind pinning of displaced supracondylar fractures of the humerus in children. sixteen years’ experience with long-term followup. j bone joint surg am 1974 mar;56(2):263-72. saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 40 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 41 25. worlock p. supracondylar fractures of the humerus. assessment of cubitus varus by the baumann angle. j bone joint surg br 1986 nov;68(5):755-57. 26. blount wp. supracondylar(diacondylar, transcondylar) fractures. in: wilkins w, editor. fractures in children. 1st ed.; 1955. p. 26-42. 27. kinkpe cv, dansokho av, niane mm, chau e, sales de gauzy j, clement jl, et al. children distal humerus supracondylar fractures: the blount method experience. orthop traumatol surg res 2010 may;96(3):276-82. 28. culp rw, osterman al, davidson rs, skirven t, bora fw,jr. neural injuries associated with supracondylar fractures of the humerus in children. j bone joint surg am 1990 sep;72(8):1211-15. 29. dormans jp, squillante r, sharf h. acute neurovascular complications with supracondylar humerus fractures in children. j hand surg am 1995 jan;20(1):1-4. 30. cramer ke, green ne, devito dp. incidence of anterior interosseous nerve palsy in supracondylar humerus fractures in children. j pediatr orthop 1993 julaug;13(4):502-505. 31. campbell cc, waters pm, emans jb, kasser jr, millis mb. neurovascular injury and displacement in type iii supracondylar humerus fractures. j pediatr orthop 1995 janfeb;15(1):47-52. 32. brown ic, zinar dm. traumatic and iatrogenic neurological complications after supracondylar humerus fractures in children. j pediatr orthop 1995 julaug;15(4):440-43. 33. cheng jc, lam tp, shen wy. closed reduction and percutaneous pinning for type iii displaced supracondylar fractures of the humerus in children. j orthop trauma 1995;9(6):511-15. 34. ikram ma. ulnar nerve palsy: a complication following percutaneous fixation of supracondylar fractures of the humerus in children. injury 1996 jun;27(5):303-305. 35. royce ro, dutkowsky jp, kasser jr, rand fr. neurologic complications after k-wire fixation of supracondylar humerus fractures in children. j pediatr orthop 1991 marapr;11(2):191-94. 36. rasool mn. ulnar nerve injury after k-wire fixation of supracondylar humerus fractures in children. j pediatr orthop 1998 sep-oct;18(5):686-90. 37. birch r, achan p. peripheral nerve repairs and their results in children. hand clin 2000 nov;16(4):579-95. 38. zaltz i, waters pm, kasser jr. ulnar nerve instability in children. j pediatr orthop 1996 sep-oct;16(5):567-69. 39. green dw, widmann rf, frank js, gardner mj. low incidence of ulnar nerve injury with crossed pin placement for pediatric supracondylar humerus fractures using a mini-open technique. j orthop trauma 2005 mar;19(3):158-63. 40. zionts le, woodson cj, manjra n, zalavras c. time of return of elbow motion after percutaneous pinning of pediatric supracondylar humerus fractures. clin orthop relat res 2009 aug;467(8):2007-10. 41. spencer ht, wong m, fong yj, penman a, silva m. prospective longitudinal evaluation of elbow motion following pediatric supracondylar humeral fractures. j bone joint surg am 2010 apr;92(4):904-10. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 41 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 61 stress fracture of the femoral neck (sffn) as a consequence of an unusual occupation: a case report and review of the literature dr ss mukansi mbchb dr ej d’alton mmed(orth) prof rg golele, mbchb(natal), mfgp(cmsa), mmed(orth)medunsa, fc(orth) university of limpopo, medunsa campus correspondence: dr ss mukansi department of orthopaedics university of limpopo (medunsa campus) po box 25 medunsa 0204 tel: 012 521 4049 fax: 012 521 4284 email: leonie.strauss@ul.ac.za case report a 33-year-old male presented to dr george mukhari hospital as a transfer from a peripheral hospital. his main complaint was pain in his left hip, which had been present for a period of 3 months. the pain did not respond to conservative management which was administered prior to referral. the treatment that he initially received included paracetamol and ibuprofen and a walking stick. upon systemic enquiry, he had not been on any drugs for conditions which included epilepsy and asthma and he had no history of trauma. he had not been in any military institution and he was not an athlete or dancer. he had worked as a pneumatic drill operator for a few years. however recently since the pain started he became a car salesman which does not require long standing hours. on examination the left lower limb was 2 cm shorter than the right. there was an increased external rotation. the movements were all limited as a result of pain. all other systems which included blood pressure, chest and abdominal were normal. x-rays of the pelvis as well as ap and lateral views of the femur were done on admission. these showed a displaced left-sided fracture of the femoral neck (figure 2). investigations which included fbc, urea and electrolyte, esr and liver function enzymes were done and these were all within normal limits. two days after admission the patient was taken to theatre where a closed reduction and internal fixation was done under general anaesthesia. the fracture was fixed with three cannulated screws under fluoroscopic guidance and the screws were inserted in a triangular fashion. on post-operative x-ray controls, it was evident that an anatomical reduction had not been achieved (figure 3). the proximal screw was too close to the joint. the patient refused to be taken back to theatre. he was then instructed to start mobilising non-weight bearing on crutches. however after three days he signed refusal of hospital treatment (rht) forms. abstract stress fractures of the femoral neck are as old as mankind.1 they affect all ages, young and old. they mostly affect those who are physically active such as military recruits, athletes, especially marathon runners, as well as dancers. we are reporting a case of a femoral neck stress fracture in a 33-year-old male working as a pneumatic drill operator. see also figure 1. key words: stress fractures, unusual occupation, repetitive force, fatigue, insufficiency x-rays of the pelvis as well as ap and lateral views of the femur showed a displaced left-sided fracture of the femoral neck saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:13 am page 61 page 62 sa orthopaedic journal autumn 2014 | vol 13 • no 1 he returned to our outpatients’ department six months later. he was pain free and was walking normally. the hip was non-tender and had a full range of motion (figure 4). at 18 months post-operatively the patient was still walking without pain and without a limp. x-rays showed no progression of fracture displacement and there was bridging callus subperiosteally. there were no signs of avascular necrosis (avn) of the head of the femur (figure 5). review of the literature the incidence of femoral neck stress fracture is reported to be between 3.5% and 8% in the military population. no incidence for the civilian population is known. fresh military recruits, dancers and marathon runners are commonly affected by stress fractures of the femoral neck. this usually happens early when an abrupt increase in physical activity is experienced.2 figure 1: causes of femoral neck stress fractures six months later he was pain free and was walking normally common causes (risk factors) unknown/unusualcauses (risk factors) mechanical i.e. coxa vara sports military recruits dancing metabolic disorders hormonal imbalance osteoporosis pneumatic drill operator no yes possible cause figure 3. immediate post-operative x-rays – the fracture is not anatomically reduced and the lateral screw is too close to the joint figure 4. the picture six months post-operatively – the fracture line is still visible and no avn has developed figure 5. the x-rays 18 months post-operatively. bridging callus can be seen on the x-rays and no avn has developed figure 2. pre-operative x-rays showing the fracture saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:13 am page 62 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 63 these events occur in normal bone that is subjected to abnormal repetitive exercise. insufficiency fractures are stress fractures that occur in abnormal bone in the presence of metabolic disorders or osteoporotic bones in the elderly.3 the latter happens during normal activities of daily living and should not be confused with stress fractures that occur in normal bone during a period of abnormal activities.4-6 a typical history should result in one having a high index of suspicion: initially pain is felt after cessation of activity. subsequently the patient usually feels the pain during the activity. finally the pain is there all the time. imaging early in the disease process the x-rays may appear normal. during the advanced stage these fractures can be seen on normal x-rays. it is preferable to make a diagnosis before the stress fracture has reached this stage. magnetic resonance imaging (mri) will detect early bone changes that cannot be seen on plain x-rays. although mri is more sensitive than normal x-rays, it is very costly. ct scan is also more sensitive than plain x-rays and more costeffective than mri. nuclear bone scan is sensitive but nonspecific.1,2,5,7-10 see also table i. discussion stress fractures of the femoral neck start as an incomplete fracture, which may initially be difficult to see on standard x-rays (figure 6a and b).1,10-12 early x-ray signs include a sclerotic line transverse to the trabecular pattern.5,7 in the case where the fracture progresses there may be a fracture line that involves the femur neck partially. callus may also be seen. callus in a stress fracture may be exogenous which is subperiosteal callus formation, or endogenous which is callus formation on the inside of the bone.1,5,12 in cancellous bone the callus is often endogenous and shows a sclerotic line.5 in our patient the fracture was a complete fracture of the neck of the femur that was also displaced. we did not achieve a perfect reduction of the fracture. three cannulated screws were used in a triangular fashion percutaneously. eighteen months post-operatively the original reduction of the fracture is still maintained and the patient is walking with a normal gait and is pain-free. the fracture is united. on x-rays there is bridging callus across the fracture line. lee et al report on the surgical treatment of displaced fracture of the femoral neck in military recruits.11 a concern in these fractures is avascular necrosis (avn) of the femoral head, even after union has taken place.3,7 this may happen as late as 5 years after the initial injury was treated. in our patient there are no signs of avn 18 months after surgery (figure 5). the screw on the superior surface is too close to the joint and has to be removed, but the patient is still undecided about undergoing another operation. what is strange in our patient is that he developed a stress fracture without the usual predisposing factors. we wonder if being a pneumatic drill operator could have contributed to this. the complications of femoral neck stress fractures are progression from undisplaced to displaced fractures, nonunion, mal-union and osteonecrosis. our patient has developed a mal-union. table i is a summary of the signs and symptoms and finding on investigations. the gateway to the diagnosis is a high index of suspicion when the pain pattern and exercise pattern change. in the first two stages when mri is normal the patient may be treated by weight relief and rest. as soon as the fracture is established with a clear line orif (open reduction internal fixation) is indicated. when surgery is indicated transcervical screws is the preferred method of treatment.10,12 clinical signs and symptoms conventional x-rays mri scintigraphy ct scan time frame groin pain after activity normal oedema on stir sensitive inall 3 phases negative 48–72 hrs groin pain during activity normal moderate periosteal oedema on stir and marrow changes on t2wi sensitive in all 3 phases negative 3 weeks groin pain all the time discrete line or cloud-like area perpendicular to trabeculae positive t1w periosteal oedema and t2wi less sensitive positive >3 weeks pain incapacitating obvious fracture low signal fracture line tw1 and t2w less sensitive positive 1–3 months obvious fracture displaced fracture low signal fracture line tw1 and t2w positivephase 3 positive >3 months table i: organogram showing the relationship of clinical and imaging findings related to duration of patient presentation stress fractures of the femoral neck start as an incomplete fracture, which may initially be difficult to see on standard x-rays saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:13 am page 63 page 64 sa orthopaedic journal autumn 2014 | vol 13 • no 1 when the stress fracture is diagnosed on the superior surface, which is the tension side of the neck of femur, then urgent surgery is indicated. when the stress fracture is on the inferior side of the neck, which is the compression side, care should be taken because an incomplete stress fracture has been shown to progress to a complete fracture with marked displacement when the patient is subjected to minimal trauma.4,5,10 for this reason others recommend that cannulated screws be inserted as soon as the diagnosis is made. when the fracture is complete and displaced, very urgent treatment is indicated. when the plain x-rays are not diagnostic, mri is the investigation of choice since it is specific, non-invasive and will differentiate stress fractures from other causes of anterior hip pain. see also table i. although the history and findings in a stress fracture are almost diagnostic, one should consider osteoid osteoma/osteosarcoma round cell lesions (ewing’s sarcoma and langerhans cell histocytosis). conclusion because the sffn are rare, one should have a high index of suspicion when a young patient complains of hip pain. in these cases mri and sometimes ct scans may be diagnostic. there was no third party involved in the preparation of this work. the sole motivation was to add to the body of knowledge on the subject. references 1. devas, m. stress fractures. 1975. london churchill livingstone. 2. brockwell j, yeung y, griffith fj. stress fractures of the foot and ankle. sports med arthosc. rev sept 2009;17(3). 3. soubier m, dubost jj, biosgard s, et al. insufficiency fractures. a survey of 60 cases and review of literature. rev sept 2009;17(3). 4. pihlajamaki hk, ruohola jp, kiuru mj, visuri ti. displaced femoral neck fatigue fractures in military recruits. j bone joint surg am. sep 2006;88(9):1989-97. [medline] 5. maffulli n, longo ug, denaro v. femoral neck stress fractures. oper tech sports med 2009;17:90-93. elsevier. 6. bouchoucha s, barsaoui m, saied w, trifa m, khalifa sb, bengachem m. bilateral stress fractures of the femoral neck with no risk factor: a case report. la tunisie medicale 2011;89(3):295-97. 7. spitz dj, newberg ah. imaging of stress fractures in the athlete. radiology clin. am 2002;40:p313-331. 8. shocum ka, gorna jd, puckett mc, jones sb. resolution of abn mr sign. insensitive in patients with stress fractures of the femoral neck. ajr 1992;168:1295-99. 9. provencher tm, baldwing ja, gorman dj, gould tm and shin ya. atypical tensile-sided femoral neck stress fractures. the value of magnetic resonance imaging. american journal of sports medicine. 2004;32(6). 10. truong th, chew sf. femoral neck fracture imaging. h t t p : / / e m e d i c i n e m e d s c a p e . c o m / a r t i c l e / 3 9 0 5 9 8 overviewupdatedmay25,11 11. lee ch, huang gs, chao kh, jean jl, wu ss. surgical treatment of displaced stress fractures of the femoral neck in military recruits: a report of 42 cases. arch orthop trauma surg. dec 2003;123(10):527-33. 12. boden bp, osbahr dc. high risk stress fractures – evaluation and treatment. american academy of orthopaedic surgeons. 2000. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. figure 6a. example of a tension stress fracture (from devas m. 1975. stress fractures. london churchill livingstone) figure 6b. example of a compression fracture (from devas m. 1975. stress fractures. london churchill livingstone) • saoj saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:13 am page 64 page 52 sa orthopaedic journal winter 2014 | vol 13 • no 2 challenges and controversies in defining and classifying tibial non-unions n ferreira bsc, mbchb, hdip orth(sa), fc orth(sa), mmed(orth) tumour, sepsis and reconstruction unit, department of orthopaedics, grey’s hospital, university of kwazulu-natal lc marais mbchb, fcs orth(sa), mmed(ortho) tumour, sepsis and reconstruction unit, department of orthopaedics, grey’s hospital, university of kwazulu-natal c aldous bsc, bsc(hons), msc, phd medical research scientist, school of clinical medicine, college of health sciences, university of kwazulu-natal correspondence: dr n ferreira department of orthopaedic surgery grey’s hospital school of clinical medicine university of kwazulu-natal private bag x9001 pietermaritzburg 3201 email: drferreiran@gmail.com tel: +27 033 897 3299 fax: +27 33 897 3409 introduction non-unions are encountered frequently with multiple factors being implicated in their development.1-7 these include systemic compromise of the host, local condition of the involved limb, specific injury characteristics and iatrogenic factors relating to the management of the initial injury.1,8-11 the management of non-unions is challenging and requires more healthcare services than the initial injury.2,12-14 non-unions are almost universally associated with delays in diagnosis leading to significant loss of limb function due to muscle atrophy, joint contractures and disuse osteopaenia.10,13,15-17 these associated findings significantly complicate the management that is often protracted, expensive and may even fail in 20% of cases.2,14,18-22 the definition and classification of non-unions should limit the potential protracted course of diagnosis and management. to date, no consensus exists regarding the definition of non-unions and none of the current classifications has proven universally useful.2,10,13,14,23-25 most classifications fail to take all aspects of tibial non-union development into account, and more importantly, do not aid in the decision making as to the most appropriate treatment strategy.12,14 this may result in non-unions being managed on anecdotal evidence that could exacerbate the existing morbidity. abstract tibial non-unions not only result in significant physical impairment but also serve as a source of considerable psychological and socio-economic stress for the patient. unnecessary delays in recognising potential non-unions lead to treatment delays that further exacerbate the morbidities associated with non-unions. current definitions are not universally accepted and are considered by some to be too esoteric for general use. the lack of clear defining criteria for non-union may result in delays in diagnosis and appropriate management. the most frequently used classification systems currently are more than 30 years old and do not take new knowledge of biology and modern treatment modalities into account. key words: tibia, non-union, definition, classification, healing delays in diagnosis lead to significant loss of limb function due to muscle atrophy, joint contractures and disuse osteopaenia saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 52 sa orthopaedic journal winter 2014 | vol 13 • no 2 page 53 the ideal definition and classification is elusive and would allow early recognition of a non-union in progress, and provide guidelines to the most effective treatment strategy. defining non-unions ‘medicine is a science of uncertainty and an art of probability.’ osler26 the existing definitions of non-union are more controversial than most other definitions in orthopaedics and medicine and are not universally accepted.2,10,13,14,23-25 the majority are temporal systems that use time as the sole variable to define the presence of a non-union. the 1986 united states food and drug administration (us fda) definition, for example, defines non-unions as nine months having elapsed with no progression of union in the preceding three months.2,27 this definition was not intended for clinical use, but was specifically devised for the testing and comparison of medical devices. it does however remain the most widely used definition of nonunion in clinical practice. other proposed temporal definitions use the absence of radiographic progression of healing between the third and sixth month after injury, six to eight months having elapsed without union, or double the expected union time as a definition for an established non-union.2,24,25 the reason that temporal systems are used to define nonunions is because non-unions are regarded at the extreme end of a time scale continuum, along with normal fracture healing and delayed union. the distinction between normal fracture healing and delayed union is based on the time needed to achieve union, where delayed union occurs after the arbitrary ‘expected’ time for union. when non-union is seen in this frame of reference, one can understand why a time variable for the diagnosis of non-union is enforced on the definition. this approach is based on the assumption that all non-unions go through a delayed union phase. although this might be true for some fractures, where the treating surgeon is unsure of the healing potential, there are definite fracture scenarios where union without surgical intervention is unlikely. examples would include fractures with segmental bone loss, minimal bone contact, fractures with extensive circumferential soft tissue loss and operatively managed fracture with a fixed gap. one obvious problem with these stipulative definitions is the erroneous implication that fractures will heal over similar time frames. multiple factors affect normal fracture union and therefore a large variation in healing time can be expected.23 between individuals, for example, several host factors can affect the time to union. these include the age of the patient, where fractures in children can generally be expected to heal twice as fast as in adults.5 other host factors affecting union include smoking, malnutrition, hiv infection and pre-existing pathological bone conditions.6,28-31 even in the same individual, a wide variation in fracture healing times is considered normal. upper extremity fractures generally heal faster than lower extremity fractures. injuries with severe bony and soft tissue damage may take longer to heal, and treatment strategy, aiming for either primary, direct bone healing or secondary bone healing with callus formation also influence the healing time.6,29,32-34 an average time to union for each anatomical site, fracture configuration and method of treatment, at any given age should therefore be researched. tibial fractures in adults, for instance, may heal from anywhere between 10 and 25 weeks, depending on the fracture severity and method of treatment.35 a further drawback to temporal definitions is the inevitable delay in diagnosis and treatment they cause. it is during this period where most of the morbidity associated with non-unions arises. prolonged periods of inability to work contribute to financial hardship, which combined with chronic pain and narcotic dependency, places significant psychological stress on patients and their families.13,20 it is also during this period that most of the muscle atrophy, joint contracture, osteopaenia and complex regional pain syndrome associated with non-unions develop.18 fractures treated with internal fixation also frequently lose the race between union and implant failure during this period, resulting in broken metalware or bone destruction that contribute to the surgical difficulties associated with treating non-unions. this time, waiting for a definition to be fulfilled, could be better spent achieving union and supporting functional rehabilitation. megas defined non-union as a cessation of all reparative processes of healing without bone union, while marsh more specifically emphasised the cessation of both the periosteal and endosteal healing responses without bridging.25,36 these definitions are empiricist explanations of non-unions rather than true definitions. they are teleological and descriptive in nature, and of limited value in clinical practice. many authors have suggested more pragmatic, working definitions. harwood et al. defined non-union as symptomatic fractures with no apparent potential to heal without intervention.2 jones et al. and brinker et al. defined non-union as the point normal biological healing ceases and will not continue without intervention,9,37 while wiss et al. suggested that the designation of a non-union be made once the surgeon believes the fracture has little or no potential to heal.27 although these definitions are not limited by temporal restrictions and more directed toward clinical use, they are however dependent on surgeon experience to predict fracture healing. this drawback often contributes to delays in diagnosis and treatment, particularly when these patients are managed by junior orthopaedic surgeons without the benefit of experience to identify potential nonunions in progress. to date, no consensus exists regarding the definition of non-unions and none of the current classifications has proven universally useful multiple factors affect normal fracture union and therefore a large variation in healing time can be expected saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 53 page 54 sa orthopaedic journal winter 2014 | vol 13 • no 2 the ideal definition the ideal non-union definition should not limit or prevent appropriate and timely intervention. the time parameter, however, should not completely be neglected from a comprehensive definition. some fractures develop nonunions without any obvious predisposition and these nonunions also need to be addressed in the definition. we suggest the following definitions: • non unus potentia (potential non-union): any fracture that when taking host factors, injury severity and management into account, has little potential to heal without further intervention. • non unus certus (established non-union): any fracture that shows no clinical or radiological union in a reasonable time, for that specific injury, host and management strategy. the rationale for this distinction is the early identification of potential non-unions. early identification, referral and treatment of these patients might achieve union with simple interventions without the need for complex, expensive surgeries – a saving that is not only monetary in terms of the healthcare system and the patient’s personal finances, but also a saving in terms of morbidity, limb integrity and social dependency of the individual patient. classification classifications in orthopaedics are useful in that they assist in diagnosis, guide treatment, indicate prognosis, and/or assist with research. very few classifications can do all of these things and often only help with one aspect of management. although debatable, for the average treating surgeon a classification that prescribes treatment strategy is often the most useful. the judet and judet classification, modified by weber and cech in 1976, classified non-unions according to the vascularity of the bone ends.38,39 the distinction between avascular and hypervascular non-unions was made and a biological cause for non-union development was underlined.39 the diagnosis was based on strontium-85 uptake at the fracture site to delineate the viability of the bone ends. bone scintigraphy examinations are not widely used to diagnose non-unions today and are especially difficult to perform in the resource-restricted environment of the developing world. the amount of fracture callus visible on normal radiographs is therefore currently used as a surrogate marker for fracture site vascularity, giving rise to the current terms of atrophic and hypertrophic nonunions.11,25 although important, the radiographic appearance of a non-union should not be the only consideration when contemplating the ideal treatment strategy. non-union in an avascular setting is explained by insufficient osteogenic potential to affect healing, while hypervascular non-unions are attributed to inadequate stability to allow normal fracture union.25 many orthopaedic surgeons use this classification as the basis of non-union management, providing stability for hypervascular (hypertrophic) non-unions, and adding biology in the form of bone-graft for avascular (atrophic) non-unions. although widely used, not all researchers subscribe to this aetiogenesis of non-union formation in the avascular setting,40,41 as illustrated by the research of sun et al. who hypothesised the existence of temporally quiescent mesenchymal cells in avascular bone ends.4 this could explain why certain ‘avascular’ non-unions may unite in the ideal biomechanical environment without the addition of bone-graft.42 a further drawback to the classification proposed by weber and cech is the fact that bone loss, limb length discrepancy, angular deformities, rigidity of the non-union’s site, previous fixation used or adequacy of fixation is not considered.39 each weber and cech group, therefore, has multiple potential treatment strategies, depending on these variables. the time required before the described bone end changes are seen on x-ray is also problematic and may lead to delays in diagnosis and management of patients who could benefit from earlier intervention. the ilizarov classification attempts to facilitate the selection of the appropriate surgery for a non-union. this system is based on the non-union morphology being stiff or lax, and whether stiff non-unions have any concomitant angular deformities.43 this classification does not take the whole clinical scenario into account. host factors, limb length discrepancy and bone loss are not considered, and non-union with internal fixation in situ is not addressed. the paley classification specifically addresses tibial nonunion.44,45 it considers bone loss, fracture site mobility, angular deformities and overall tibial length. although this classification is an excellent advance on other existing classifications with regard to the mechanical attributes of a nonunion, it again fails to address non-union biology and host optimisation. an attempt to address some of these shortcomings was made by wu et al. who developed their protocol to more clearly classify non-unions.11 a novel addition to this classification was the incorporation of non-unions with internal fixation in situ. these non-unions were designated as either avascular or hypervascular depending on whether the fixation was stable or unstable. another important aspect in non-union management was also raised, namely the possibility of these non-unions potentially being infected. the active exclusion of infection was emphasised. management of each group was suggested, being either open bone-graft and intramedullary nailing, bone grafting alone, or bone grafting and implant exchange. the wu classification successfully addressed the management of non-unions with failed internal fixation, but did not incorporate bone alignment or host optimisation. automatically designating non-unions with stable fixation as avascular is also not necessarily biologically accurate as fractures fixed in distraction are not always avascular but may develop non-unions due to the healing process not being able to cross the fracture gap. the calori non-union scoring system (nuss) has recently been developed14 and validated12 to assist surgeons with the complex analysis of non-union surgery. it uses the ‘diamond concept’ where multiple elements are considered in non-union management, including the cellular environment, the growth factors, the bone matrix and the mechanical stability (table i). each individual factor is scored and then added to give a final score that guides treatment. saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 54 sa orthopaedic journal winter 2014 | vol 13 • no 2 page 55 this score is an excellent starting point to improve non-union management. it does however need to be improved in terms of factors taken into account. hiv infection and genetic predisposition has been implicated in non-union development but is omitted from the nuss system.3,7,46,47 the weight that each factor carries towards the final score is crucial in order to guide appropriate treatment and should be devised through regression analysis. with the current nuss score, the authors weighted each factors according to the opinions and experience of the senior authors who have tertiary referral non-union practices. another area that needs to be addressed is the treatment strategy that the final score proposes. the present score only proposes, in broad terms, where and how these patients should be treated. the suggested treatments include ‘standard treatment’, ‘specialised care’ and ‘specialised care and specialised treatment’. this provides an indication for junior orthopaedic surgeons of which patients to refer, but does not provide specific treatment guidelines as to what ‘specialised treatments’ should be offered. the different approaches and focal points of these classification systems complicate treatment strategy decisions and research into non-union management.14 formulating standardised treatment strategies or protocols on existing classification systems is challenging, and might not take all aspects of non-union development and management into account. the ideal classification ef schumacher said that any intelligent fool can makes things bigger, more complex, but it takes a touch of genius and a lot of courage to move in the opposite direction.48 unfortunately, we are at a point where classifications and scoring systems for non-unions are becoming more complicated. as more variables are identified that contribute to the development and negatively impact the management of non-unions, more factors are built into classifications and scoring systems. as effective treatment will depend on addressing the host, biological and mechanical factors; all of these need to be incorporated into an encompassing classification system. conclusion non-union management is resource intensive and technically demanding. inadequate definitions and suboptimal classification systems often exacerbate the existing morbidities associated with non-unions and may even cause delays in diagnosis and treatment. in order to improve non-union management, definitions that allow the early identification of potential non-unions and a classification system that incorporates all factors identified in non-union development is required. the content of this article is the sole work of the author. no benefits of any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. table i: calori non-union scoring system14 the bone score max. score bone quality good moderate poor very poor 0 1 2 3 3 primary injury – open or closed fracture closed open grade i open grade ii – iiia open grade iiib and iiic 0 1 3 5 5 number of previous interventions on the bone to procure healing none <2 2–4 >4 1 2 3 4 4 invasiveness of previous interventions minimally invasive – closed surgery internal intra-medullary nailing internal extra-medullary any osteosynthesis which include bone grafting 0 1 2 3 3 adequacy of primary surgery inadequate stability adequate stability 0 1 1 weber & cech group hypertrophic oligotrophic atrophic 1 3 5 5 bone alignment non-anatomical alignmentanatomical alignment 0 1 1 bone defect – gap 0.5–1 cm 1–3 cm >3 cm 2 3 5 5 soft tissues score max. score soft tissue status intact minor scarring previous treatment of soft tissue defect previous free flap poor vascularity presence of skin lesion / defect 0 2 3 4 5 6 6 the patient score max. score asa grade 1 or 23 or 4 0 1 1 diabetes no yes – well controlled yes – poorly controlled 0 1 2 2 blood tests: fbc, esr, crp fbc: wcc > 12 esr > 20 crp > 20 1 1 1 3 clinical infection status clean previously infected or suspicion of infection septic 0 1 4 4 drugs steroidsnsaids 1 1 2 smoking noyes 0 5 5 hiv infection and genetic predisposition has been implicated in non-union development but is omitted from the nuss system saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 55 page 56 sa orthopaedic journal winter 2014 | vol 13 • no 2 references 1. bhandari m, schemitsch e. clinical advances in the treatment of fracture nonunion: the response to mechanical stimulation. curr opin orthop. 2000;11:372-77. 2. harwood p, newman j, alr. m. an update on fracture healing and non-union. orthopaedics and trauma. 2010;24(1):9-23. 3. dimitriou r, kanakaris n, soucacos pn, giannoudis pv. genetic predisposition to non-union: evidence today. injury. 2013;44(suppl 1):s50-3. pubmed pmid: 23351872. 4. sun d, yuan d, zhang x. a new hypothesis on the mechanism of atrophic non-union. medical hypotheses. 2011;77(1):69-70. 5. gaston ms, simpson ah. inhibition of fracture healing. j bone joint surg br. 2007;89(12):1553-60. pubmed pmid: 18057352. 6. calori gm, albisetti w, agus a, iori s, tagliabue l. risk factors contributing to fracture non-unions. injury. 2007;38(suppl 2):s11-18. pubmed pmid: 17920412. 7. copuroglu c, calori gm, giannoudis pv. fracture non-union: who is at risk? injury. 2013. pubmed pmid: 24035757. 8. douglas l, benson d, seligson d. the incidence of nonunion after nailing of distal tibial and femoral fractures. curr orthop pract. 2010;21(1):49-53. 9. jones cb, mayo ka. nonunion treatment: iliac crest bone graft techniques. j orthop trauma. 2005;19(10 suppl):s11-13. pubmed pmid: 16479216. 10. perumal v, roberts c. (ii) factors contributing to non-union of fractures. curr orthop. 2007;21(4):258-61. 11. wu cc, chen wj. a revised protocol for more clearly classifying a nonunion. j orthop surg. 2000;8(1):45-52. pubmed pmid: 12468875. 12. abumunaser la, al-sayyad mj. evaluation of the calori nonunion scoring system in a retrospective case series. orthopedics. 2011;34(5):359. pubmed pmid: 21598896. 13. antonova e, kim le t, burge r, mershon j. tibia shaft fracture costly burden of nonunions.pdf. bmc musculoskeletal disorders. 2013;14:42. 14. calori gm, phillips m, jeetle s, tagliabue l, giannoudis pv. classification of non-union: need for a new scoring system? injury. 2008;39(suppl 2):s59-63. pubmed pmid: 18804575. 15. akhtar a, shami a, sarfraz m. functional outcome of tibial nonunion treatment by ilizarov fixator. annals of pakistan institute of medical sciences. 2012;8(3):188-91. 16. buijze ga, richardson s, jupiter jb. successful reconstruction for complex malunions and nonunions of the tibia and femur. j bone joint surg am. 2011;93(5):485-92. pubmed pmid: 21368081. 17. kanellopoulos ad, soucacos pn. management of nonunion with distraction osteogenesis. injury. 2006;37(suppl 1:s51-5). pubmed pmid: 16574120. 18. gershuni dh. fracture nonunion. west j med. 1989;150(6):68990. pubmed pmid: 2750154. pubmed central pmcid: 1026720. 19. kanakaris nk, giannoudis pv. the health economics of the treatment of long-bone non-unions. injury. 2007;38(suppl 2):s77-84. pubmed pmid: 17920421. 20. tay wh, gruen r, richardson m, de steiger r. self-reported health outcomes of delayed union and nonunion of femoral and tibial shaft fractures. j bone joint surg br. 2012;94-b(supp xxiii). 21. zeckey c, mommsen p, andruszkow h, macke c, frink m, stubig t, et al. the aseptic femoral and tibial shaft non-union in healthy patients an analysis of the health-related quality of life and the socioeconomic outcome. the open orthopaedics journal. 2011;5:193-97. pubmed pmid: 21686321. pubmed central pmcid: 3115668. 22. tzioupis c, giannoudis pv. prevalence of long-bone nonunions. injury. 2007;38(suppl 2):s3-9. pubmed pmid: 17920415. 23. frolke jp, patka p. definition and classification of fracture nonunions. injury. 2007;38(suppl 2):s19-22. pubmed pmid: 17920413. 24. hernigou p, poignard a, beaujean f, rouard h. percutaneous autologous bone-marrow grafting for non-union. j bone joint surg br. 2005;87(7):1430-37. 25. megas p. classification of non-union. injury. 2005;36(suppl 4):s30-37. pubmed pmid: 16291321. 26. silverman m, murray t, bryan c, editors. the quotable osler. philadelphia: acp press; 2003. 27. wiss da, stetson wb. tibial nonunion: treatment alternatives. j am acad orthop surg. 1996;4(5):249-57. pubmed pmid: 10797192. 28. adams ci, keating jf, court-brown cm. cigarette smoking and open tibial fractures. injury. 2001;32(1):61-65. pubmed pmid: 11164405. 29. bhandari m, tornetta p, 3rd, sprague s, najibi s, petrisor b, griffith l, et al. predictors of reoperation following operative management of fractures of the tibial shaft. j orthop trauma. 2003;17(5):353-61. pubmed pmid: 12759640. 30. harvey ej, agel j, selznick hs, chapman jr, henley mb. deleterious effect of smoking on healing of open tibia-shaft fractures. am j orthop. 2002;31(9):518-21. pubmed pmid: 12650537. 31. kyro a, usenius jp, aarnio m, kunnamo i, avikainen v. are smokers a risk group for delayed healing of tibial shaft fractures? annales chirurgiae et gynaecologiae. 1993;82(4):254-62. pubmed pmid: 8122874. 32. gaebler c, berger u, schandelmaier p, greitbauer m, schauwecker hh, applegate b, et al. rates and odds ratios for complications in closed and open tibial fractures treated with unreamed, small diameter tibial nails: a multicenter analysis of 467 cases. j orthop trauma. 2001;15(6):415-23. pubmed pmid: 11514768. 33. gaston p, will e, elton ra, mcqueen mm, court-brown cm. fractures of the tibia. can their outcome be predicted? j bone joint surg br. 1999;81(1):71-76. pubmed pmid: 10068007. 34. karladani ah, granhed h, karrholm j, styf j. the influence of fracture etiology and type on fracture healing: a review of 104 consecutive tibial shaft fractures. arch orthop trauma surg. 2001;121(6):325-28. pubmed pmid: 11482464. 35. ellis h. the speed of healing after fracture of the tibial shaft. j bone joint surg br. 1958 feb;40-b(1):42-46. pubmed pmid: 13513649. 36. marsh d. concepts of fracture union, delayed union, and nonunion. clin orthop relat res. 1998;355(suppl):s22-30. pubmed pmid: 9917623. 37. brinker mr, o’connor dp, monla yt, earthman tp. metabolic and endocrine abnormalities in patients with nonunions. j orthop trauma. 2007;21(8):557-70. pubmed pmid: 17805023. 38. judet j, judet r. l’osteogene et les retards de consolidation et les pseudarthroses des os longs. huitieme congress sicot1960. p15. 39. weber b, cech o, editors. pseudarthrosis. bern, switzerland: hans huber; 1976. 40. brownlow hc, reed a, simpson ah. the vascularity of atrophic non-unions. injury. 2002;33(2):145-50. pubmed pmid: 11890916. 41. volpon jb. nonunion using a canine model. arch orthop trauma surg. 1994;113(6):312-17. pubmed pmid: 7833207. 42. ilizarov g, editor. transosseous osteosynthesis. 1st ed. ed. berlin: springer; 1992. 43. catagni m, editor. treatment of fractures, non-unions, and bone loss of the tibia with the ilizarov method. 1998. [in which publication?] 44. paley d. treatment of tibial nonunion and bone loss with the ilizarov technique. instructional course lectures. 1990;39:185-97. pubmed pmid: 2186101. 45. paley d, catagni ma, argnani f, villa a, benedetti gb, cattaneo r. ilizarov treatment of tibial nonunions with bone loss. clin orthop relat res. 1989;241:146-65. pubmed pmid: 2924458. 46. aird j, noor s, rollinson p. is fracture healing affected by hiv in open fractures? j bone joint surg br. 2012;94-b(supp xix):16. 47. kamat as, govender m. the effects of hiv/aids on fracture union. j bone joint surg br. 2010;92-b(suppl 1):228. 48. schumacher e. small is beautiful: a study of economics as if people mattered. the radical humanist. 1973;37:2. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 56 404 not found south african orthopaedic journal hand doi 10.17159/2309-8309/2023/v22n1a2shah mr et al. sa orthop j 2023;22(1) citation: shah mr, shah mm, shah im. functional outcome of free fibula grafting in benign non-reconstructable bone tumours involving the hand. sa orthop j. 2023;22(1):18-23. http://dx.doi. org/10.17159/2309-8309/2023/ v22n1a2 editor: dr duncan mcguire, university of cape town, cape town received: april 2022 accepted: september 2022 published: march 2023 copyright: © 2023 shah mr. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for the purposes of performing this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background bone tumours involving hands are usually benign but can be locally aggressive. several treatments have been described. usual modalities of treatment include curettage and bone grafting. in more advanced stages when short bones of the hand are involved with more than 70% cortical destruction, or when such treatment option is not possible (as with non-contained tumours with cortical breaches, pathological fracture), only the resection or amputation of the affected segment can offer an effective cure. we studied the role of the free fibula graft (nonvascularised) in such types of benign non-reconstructable (by conventional methods) hand tumours. the aims and objectives were to study the functional outcome of free fibula grafting in benign non-reconstructable bone tumours involving the hand and to analyse the complications, if any, and assess the causes and solutions for them. methods we prospectively studied 15 patients with different types of benign, non-reconstructable bone tumours involving the hand operated by free fibula grafting. the study period ranged from january 2014 to december 2021. follow-up ranged from 2 to 8 years (average of 4.26 years). results results were analysed by the quidkdash-9 score system. there was no recurrence. one case of superficial infection was treated with antibiotics and dressing. all patients were happy with the treatment and resumed their normal duties and functional movements. conclusion use of the free fibula graft can be a good option for benign non-reconstructable bone tumours involving the hand to avoid amputation. the free fibula graft gives better results due to total excision of the lesion and strut graft support for good functional outcomes. level of evidence: level 3 keywords: benign bone tumour, free fibula graft, quickdash-9 score, bone tumour, orthopaedic oncology functional outcome of free fibula grafting in benign non-reconstructable bone tumours involving the hand manish r shah,¹* manisha m shah,² isha m shah³ ¹ department of orthopaedics, dhiraj hospital, smt bk shah medical institute and research centre, sumandeep vidyapeeth deemed to be university, waghodia, gujarat, india ² department of pathology, medical college and ssg hospital, vadodara, gujarat, india ³ gmers medical college, gotri, vadodara, gujarat, india *corresponding author: manishshah2001in@yahoo.co.in introduction bone tumours involving hands are usually benign but can be locally aggressive. of all the bone tumours, only 6% occur in the hand.1 several treatments have been described. usual modalities of treatment include curettage and bone grafting. cytotoxic adjuvant agents such as liquid nitrogen, phenol and hydrogen peroxide can be used in conjunction with curettage to enhance the area of tumour kill, although their efficacy is still controversial.2-4 in some cases, local sclerosant injections are advocated. all such methods require contained lesions. optimal treatment of bone tumours requires a careful balance of local tumour control and preservation of hand function. treatment plans are influenced by factors such as tumour size, bone destruction, risk of recurrence, proximity to joint surfaces and overall predicted function. when insufficient bone stock is available for salvage, en bloc excision with reconstruction is needed. reconstructive options include osteoarticular allograft, vascularised or non-vascularised bone graft from either local (for example, distal radius) or distant sites (for example, fibula or iliac crest), and arthrodesis. in more advanced stages when short bones of hands are involved with more than 70% destruction or when such treatment option is not possible (as in non-contained tumours with cortical breaches, pathological fracture), only the resection or amputation of the affected segment can offer an effective cure. such lesions are non-reconstructable by conventional methods. this can lead to disability, more or less pronounced, depending on which bone is involved, and the characteristics of the patient. over the years, various forms of reconstruction have been described, but it is difficult to provide a return to the previous functional level.5,6 vascularised fibula grafts are usually reserved for bigger defects, and for the site where https://orcid.org/0000-0002-9381-9095 page 19shah mr et al. sa orthop j 2023;22(1) bigger diameter vessels are available for anastomosis. in hand tumours, the length of strut graft is less and digital vessels are of narrow diameter. we studied the role of the free fibula (nonvascularised) grafts in such types of benign non-reconstructable hand tumours. our use of the term ‘non-reconstructable’ refers to lesions which cannot be filled with cancellous graft after curettage (conventional method) because of the non-contained nature of the tumour. in comparison to iliac crest graft, the fibula has the medullary canal for fixation of the graft by intramedullary wire, and the shape of the fibula can be matched to small hand bones; we therefore preferred the fibula in our study. the aims were to study the functional outcome of free fibula grafting in benign non-reconstructable bone tumours (by conventional method) involving the hand. objectives included the assessment of the functional outcome of free fibula grafting in benign non-reconstructable bone tumours involving the hand; to analyse the complications, if any, and assess the causes and solutions for them; to study the time of union of free fibula graft; to compare results with other centres; and to study different types of benign bone tumours involving the hand. methods after obtaining clearance from the ethical committee of the institute, and informed consent from the patients, work was carried out on suitable patients in this interventional study. the sampling method was purposive sampling, and the study was conducted on 15 patients with benign bone tumours involving the hand, which were non-reconstructable. inclusion criteria were all cases of benign bone tumours irrespective of patient age. the benign nature was decided as per the clinical history and examination, radiological parameters (x-ray, ct scan, and mri as required), or biopsy. biopsy was done on all cases except those cases that were clearly benign by clinical and radiological parameters. benign bone tumours are non-reconstructable-like lesions with pathological fracture, lytic expansile lesion involving more than 70% of the bone (phalanx or metacarpal), destruction or lesions with non-contained defect. exclusion criteria comprised patients who refused to participate in the programme; patients who did not have a minimum of six months follow-up; and patients with malignant bone tumours involving the hand (proved by preoperative biopsy). preoperative evaluation patients of either sex with benign non-reconstructable hand tumours were included in the study as per inclusion and exclusion criteria. biopsy was done in all except three cases. those three cases were clinically and radiologically confirmed as benign and patients were ready for final treatment. however, all three were informed about the risks and prognosis. all cases were subjected to routine pre-anaesthetic check-up and additional investigations where indicated. the procedure was explained to the patients, and that followup at four, six, 12 and 24 weeks was necessary. the chances of recurrence and other complications were made clear. operative procedure after preoperative investigations, patients were operated on with all standard sterile precautions. the fibular graft was harvested from the ipsilateral side in all cases. (as per our setup, one surgical team would operate per case, therefore an ipsilateral leg was chosen for the graft. however, if two teams are available, the contralateral leg can be used to make the procedure faster. another reason for selecting the ipsilateral leg was, from the patient’s point of view, to keep one side of the body pain-free.) for tumours involving the thumb, a lateral approach was taken; for tumours involving phalanges, a midline dorsal approach (with splitting extensor tendon) was taken. the tumour was excised as per preoperative measurements and intraoperative image intensifier television (iitv) guidance. the length of the fibula graft was decided before the excision of the tumour. thorough curettage was done as per tumour protocol using a high-speed burr, and hydrogen peroxide and povidoneiodine wash was given. intraoperative frozen section confirmed the benign nature on the table. in all except two cases, we preserved proximal and distal articular margins. in two cases of tumours involving proximal phalanges of thumb, it was not possible to preserve the proximal articular surface due to the involvement by the tumour itself. in those two cases, we attempted the cartilage grafting technique (putting pieces of articular cartilage/fascia obtained while procuring fibula between the fibula graft and proximal articular surface). the graft was fixed by k-wire in all cases. postoperative protocol intravenous antibiotics were given for three days. intravenous analgesics were given for one day followed by oral analgesics for 7–10 days. the first postoperative dressing was done on the second day and the second postoperative dressing on the fifth day. suture removal was done at roughly two weeks. x-ray of the affected hand, biopsy and immunohistochemistry (ihc) (as per the case) were done postoperatively. the patient was discharged from the hospital once the wound condition and the patient’s general condition was satisfactory. the patient was called for follow-up at four weeks, six weeks, three months, six months and after a year. x-ray of the affected hand was done at each follow-up. implant extraction (usually k-wire) was done after the radiological union of the graft. results we prospectively studied 15 patients with benign bone tumours. all patients were operated on by a single surgeon. the study period ranged from january 2014 to december 2021. of the 15 patients, four (26.7%) were male and 11 (73.3%) female. the right hand was involved in nine (60%) and the left hand in six (40%) patients (tables i and ii). age ranged from 13 to 49 years (average 24.86). table i: patient demographic data sex number (%) males 4 (26.7%) females 11 (73.3%) table ii: side of involvement side of involvement number (%) right hand 9 (60.0%) left hand 6 (40.0%) table iii: site of involvement in hand site number (%) proximal phalanx of middle finger 5 (33.3%) proximal phalanx of thumb 4 (26.7%) proximal phalanx of ring finger 3 (20.0%) first metacarpal 2 (13.3%) proximal phalanx of index finger 1 (6.7%) page 20 shah mr et al. sa orthop j 2023;22(1) a e f g b c d figure 1. aneurysmal bone cyst of the first metacarpal bone treated by free fibula grafting a) clinical photograph; b) preoperative x-ray ap view; c) preoperative x-ray oblique view; d) 3d ct scan; e) mri of part; f) postoperative x-ray oblique view; g) postoperative x-ray ap view a d e f b c figure 2. intraoperative and follow-up photographs of case shown in figure 1 a) intraoperative photo showing broken cortex (arrow); b) three months follow-up x-ray ap view showing graft incorporation; c) three months follow-up x-ray oblique view; d) four months follow up x-ray ap view (implant removed); e) four months follow-up x-ray oblique view (implant removed); f) clinical photograph showing full flexion at final follow-up page 21shah mr et al. sa orthop j 2023;22(1) a d g h e f b c figure 3. giant cell tumour involving proximal phalanx of the middle finger a) clinical photograph (swelling marked by arrow); b) preoperative x-ray ap view (lesion marked by arrow); c) preoperative x-ray oblique (lesion marked by arrow); d) preoperative mri (lesion with broken cortex marked by arrow); e) intraoperative photograph from dorsal side showing broken cortices and flexor tendon (marked by arrow); f) intraoperative photograph with fibula graft (arrow); g) immediate postoperative x-rays; h) final follow-up x-rays at one year figure 4. clinical follow-up of case shown in figure 3 with movements of middle finger a) extension; b) flexion a b page 22 shah mr et al. sa orthop j 2023;22(1) the first metacarpal was involved in two (13.3%) (figures i and 2); a proximal phalanx of the middle finger in five (33.3%) (figures 3 and 4); a proximal phalanx of the thumb in four (26.7%) (figure 5); a proximal phalanx of the ring finger in three (20%); and a proximal phalanx of the index finger was involved in one (6.7%) of the patients (table iii). preoperative and postoperative types of lesions (confirmed by biopsy) were bone cyst, aneurysmal bone cyst (abc), giant cell tumour (gct) and enchondroma. postoperative (final biopsy) lesions included abc (5/15 = 33.3%), gct (3/15 = 20%), enchondroma (3/15 = 20%) and benign histocytic lesion (4/15 = 26.7%) (table iv). in all cases, the fibula graft was fixed with one k-wire. the average length of the fibula graft was 3 cm (range: 2.8–3.2). the wire was kept till union was found in three out of four cortices in ap and oblique views radiologically. the average time of graft union was 96.86 days (range: 90–100) in our study. cases were followed up for infection and wire-related complications in the early stage and recurrence and functional range of movements (rom) in later stages. follow-up ranged from 2 to 8 years (average of 4.26 years). superficial infection was found in one case of first metacarpal tumour which healed by dressings and antibiotics over three weeks in total (figure 5). no implantrelated complications were found in our study. no recurrence was found in any case. functional rom was satisfactory in all cases. all cases were assessed by the quickdash-9 score preand postoperatively. the average preoperative score was 73.7 and the average postoperative score was 24. all patients were happy with the treatment and resumed their normal duties and functional movements. discussion we studied the results of free fibula graft in benign, nonreconstructable bone tumours. there are studies that describe the diagnostic approaches to hand tumours.1,4 several treatments have been described. usual modalities of treatment include curettage and bone grafting. cytotoxic adjuvant agents such as liquid nitrogen, phenol and hydrogen peroxide can be used in conjunction with curettage to enhance the area of tumour kill, although their efficacy is still controversial.2-4 studies compared results of curettage with or without allograft bone with the use of cement and other adjuvants. it was found that adequacy of tumour removal rather than the type of adjuvant determines the risk of recurrence.5,6 most of the studies described giant cell tumours and options for treatment with follow-up mainly finding recurrence as the main complication. averill et al. showed that curettage is not an effective method. thirteen out of 15 tumours recurred in their series treated by curettage. they recommended amputation or local resection.6 jones et al. described reconstruction of the entire metacarpal bone and metacarpophalangeal joint using osteocutaneous fibula free flap and silicone arthroplasty for gct of the third metacarpal bone. they showed that a free vascularised fibula graft is ideal for the reconstruction of defects of metacarpal bone.7 naam et al. showed recurrence after one year in their study for gct fourth and fifth metacarpal bone which was treated by pulmonary lobe resection.8 lim and babineaux showed arthrodesis as a treatment for tumours table iv: final type of lesion (as per biopsy) type of lesion number (%) aneurysmal bone cyst (abc) 5 (33.3%) giant cell tumor (campanacci grade iii) 3 (20.0%) enchondroma 3 (20.0%) benign histocytic lesion 4 (26.7%) a f g h i b c d e figure 5. benign lymphohistiocytic lesion involving proximal phalanx of thumb with pathological fracture a) preoperative x-ray ap view (pathological fracture shown by arrow); b) preoperative x-ray lateral view (pathological fracture shown by arrow); c) mri (lesion shown by arrow); d) clinical photograph (swelling at local site shown by arrow); e) intraoperative photograph (lateral approach shown by arrow); f) intraoperative photograph with graft (arrow); g) immediate postoperative x-ray ap view; h) immediate postoperative x-ray lateral view; i) follow-up showing superficial infection (arrow) page 23shah mr et al. sa orthop j 2023;22(1) involving the entire first metacarpal bone. they used a tricortical iliac crest bone graft. nine months follow-up in their study showed no recurrence.9 other authors showed the use of vascularised grafts in their studies.10-12 when insufficient bone stock is available for salvage, en bloc excision with reconstruction is needed. reconstructive options include osteoarticular allograft, vascularised or non-vascularised bone graft from either local (i.e., distal radius) or distant sites (i.e., fibula or iliac crest), and arthrodesis.11,12 saini et al., in their series, showed the use of autogenous fibula for the reconstruction of aggressive gct of distal radius campanacci grade ii/iii.13 biopsy was not done only in cases that were sure to be benign in nature by clinical and radiological parameters.14 authors have recently described case reports of gct being treated by free fibula graft with promising results.15,16 a study done by mukherjee et al. showed that up to 20 cm free fibula graft can be used in adults (with 36 cm total fibula length) and up to 10 cm free fibula graft can be taken in children (with total fibula length of 25 cm).17 furthermore, vascular fibula graft requires surgical expertise or assistance from a plastic/microvascular surgeon. harvesting vascular fibula graft takes more surgical time and requires compliance of the patient. all these factors increase the cost of surgery.18 we have studied all common types of benign bone tumours for a reasonably long period (seven years). no recurrence was found in any type of tumour. all our tumours were non-reconstructable by routine curettage and cancellous bone grafting techniques. our results matched those of published case reports. we used k-wire, which is a very common implant. the use of other implants such as plates or fixators can cause problems such as impingement of the implant and infection. no implant-related complication was found in our series. only one case of superficial infection found in the first metacarpal tumour was treated by dressing and antibiotics for three weeks. our time to graft union and graft incorporation matches other studies.16 all of our patients gained functional movements and returned to their normal professions. the variety of tumours and long-term follow-up are a strength of our study. more patients and study results from different centres would be useful to study the treatment method. conclusion the use of free fibula graft is a good option for benign nonreconstructable bone tumours involving the hand to avoid amputation. it gives better results due to total excision of the lesion and strut graft support for good functional outcomes. this treatment option provides fewer chances of recurrent tumour and prevents future re-surgeries. cosmetically it is more acceptable than amputation. though other modalities of treatment are available for contained defects in benign tumours, for tumours having more than 70% destruction of the small bone in the hand, free fibula grafting is a viable option available to the general orthopaedic surgeon. our study showed no recurrence at long-term follow-up and full patient satisfaction. acknowledgements we acknowledge the immense help received from the scholars whose articles are cited and included in the references of this manuscript. the authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. we acknowledge the patients, their family members, hospital staff, and all others who directly or indirectly participated in the study. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to the commencement of the study, ethical approval was obtained from the sumandeep vidyapeeth institutional ethics committee: sviec/med/rp/20029. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. written informed consent was obtained from all patients included in the study. consent was obtained from patients for the use of clinical photographs, and these images were adequately anonymised. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions mrs: study conceptualisation, data capture, data analysis, first draft preparation, manuscript revision mms: data analysis, manuscript preparation, manuscript revision ims: design of testing set-up, manuscript preparation orcid shah mr https://orcid.org/0000-0002-9381-9095 shah mm https://orcid.org/0000-0002-2252-9752 shah im https://orcid.org/0000-0002-7468-0278 references 1. hsu cs, hentz vr, yao j. tumours of the hand. lancet oncol. 2007;8:157-66. https://doi. org/10.1016/s1470-2045(07)70035-9 2. turcotte re. giant cell tumor of bone: giant cell tumor of bone. orthop clin north am. 2006 jan;37(1):35-51. https://doi.org/10.1016/j.ocl.2005.08.005 3. errani c, ruggieri p, asenzio ma, et al. giant cell tumor of the extremity: a review of 349 cases from a single institution. cancer treat rev. 2010 feb;36(1):1-7. https://doi. org/10.1016/j.ctrv.2009.09.002 4. payne wt, merrell g. benign bony and soft tissue tumors of the hand. j hand surg am. 2010 nov;35(11):1901-10. https://doi.org/10.1016/j.jhsa.2010.08.015 5. blackley hr, wunder js, davis am, et al. treatment of giant-cell tumors of long bones with curettage and bone-grafting. j bone joint surg am. 1999 jun;81(6):811-20. https://doi. org/10.2106/00004623-199906000-00008 6. averill rm, smith rj, campbell cj. giant-cell tumors of the bones of the hand. j hand surg am. 1980 jan;5(1):39-50. https://doi.org/10.1016/s0363-5023(80)80042-6 7. jones nf, dickinson bp, hansen sl. reconstruction of an entire metacarpal and metacarpophalangeal joint using a fibular osteocutaneous free flap and silicone arthroplasty. j hand surg am. 2012, 37:310-15. https://doi.org/10.1016/j.jhsa.2011.10.031 8. naam nh, jones sl, floyd j, memisoglu ei. multicentric giant cell tumor of the fourth and fifth metacarpals with lung metastases. hand (ny). 2014;9:389-92. https://doi.org/10.1007/ s11552-013-9574-x 9. lim s, babineaux kl. reconstruction of an entire thumb metacarpal: a case report. plast reconstr surg glob open. 2016;4:610. https://doi.org/10.1097/gox.0000000000000593 10. kotwal pp, nagaraj c, gupta v. vascularised joint transfer in the management of recurrent giant cell tumour of the second metacarpal. j hand surg eur vol. 2008; 33:314-16. https:// doi.org/10.1177/1753193408089048 11. maini l, cheema gs, yuvarajan p, gautam vk. free osteoarticular metatarsal transfer for giant cell tumor of metacarpal a surgical technique. j hand microsurg. 2011;3:8992. https://doi.org/10.1007/s12593-011-0048-5 12. malizos kn, dailiana zh, innocenti m, et al. vascularized bone grafts for upper limb reconstruction: defects at the distal radius, wrist, and hand. j hand surg am. 2010;35:1710-18. https://doi.org/10.1016/j.jhsa.2010.08.006 13. saini r, bali k, bachhal v, et al. en bloc excision and autogenous fibular reconstruction for aggressive giant cell tumor of distal radius: a report of 12 cases and review of literature. j orthop surg res. 2011;6(14). https://doi.org/10.1186/1749-799x-6-14 14. bickels j, malawer mm. biopsy of musculoskeletal tumors. in: operative techniques in orthopaedic surgical oncology. 2014. p. 25-33. 15. fernandes h, almeida m, lopes r, et al. reconstruction of the second metacarpal bone after bone tumor resection with free fibular graft. j cas rep. 2018;8:290-93. https://doi. org/10.17659/01.2018.0078 16. agrawal ac, verma s, kar b, et al. mammoth giant cell tumor of the first metacarpal: a case report and management trends. cureus. 2021;13(7):e16150. 17. mukherjee an, pal ak, singharoy d, et al. harvesting the free fibular graft: a modified approach. indian j orthop. 2011 jan;45(1):53-56. https://doi.org/10.4103/0019-5413.73657 18. devireddy sk, senthil mm, kishore krv, et al. evaluation of non-vascular fibula graft for mandibular reconstruction. j maxillofac oral surg. 2015 jun;14(2):299-307. https://doi. org/10.1007/s12663-014-0657-1 https://orcid.org/0000-0002-9381-9095 https://orcid.org/0000-0002-2252-9752 https://orcid.org/0000-0002-7468-0278 https://dx.doi.org/10.1016/s1470-2045(07)70035-9 https://dx.doi.org/10.1016/s1470-2045(07)70035-9 https://dx.doi.org/10.1016/j.ocl.2005.08.005 https://dx.doi.org/10.1016/j.ocl.2005.08.005 https://dx.doi.org/10.1016/j.ctrv.2009.09.002 https://dx.doi.org/10.1016/j.ctrv.2009.09.002 https://dx.doi.org/10.1016/j.ctrv.2009.09.002 https://dx.doi.org/10.1016/j.jhsa.2010.08.015 https://dx.doi.org/10.1016/j.jhsa.2010.08.015 https://dx.doi.org/10.2106/00004623-199906000-00008 https://dx.doi.org/10.2106/00004623-199906000-00008 https://dx.doi.org/10.2106/00004623-199906000-00008 https://dx.doi.org/10.1016/s0363-5023(80)80042-6 https://dx.doi.org/10.1016/s0363-5023(80)80042-6 https://dx.doi.org/10.1016/j.jhsa.2011.10.031 https://dx.doi.org/10.1016/j.jhsa.2011.10.031 https://dx.doi.org/10.1016/j.jhsa.2011.10.031 https://dx.doi.org/10.1016/j.jhsa.2011.10.031 https://dx.doi.org/10.1007/s11552-013-9574-x https://dx.doi.org/10.1007/s11552-013-9574-x https://dx.doi.org/10.1007/s11552-013-9574-x https://dx.doi.org/10.1007/s11552-013-9574-x https://dx.doi.org/10.1097/gox.0000000000000593 https://dx.doi.org/10.1097/gox.0000000000000593 https://dx.doi.org/10.1177/1753193408089048 https://dx.doi.org/10.1177/1753193408089048 https://dx.doi.org/10.1177/1753193408089048 https://dx.doi.org/10.1007/s12593-011-0048-5 https://dx.doi.org/10.1007/s12593-011-0048-5 https://dx.doi.org/10.1007/s12593-011-0048-5 https://dx.doi.org/10.1016/j.jhsa.2010.08.006 https://dx.doi.org/10.1016/j.jhsa.2010.08.006 https://dx.doi.org/10.1016/j.jhsa.2010.08.006 https://dx.doi.org/10.1186/1749-799x-6-14 https://dx.doi.org/10.1186/1749-799x-6-14 https://dx.doi.org/10.1186/1749-799x-6-14 https://doi.org/10.17659/01.2018.0078 https://doi.org/10.17659/01.2018.0078 https://dx.doi.org/10.7759/cureus.16150 https://dx.doi.org/10.7759/cureus.16150 orthopaedics vol3 no4 page 80 sa orthopaedic journal spring 2015 | vol 14 • no 3 stand-alone cage neck fusions: a long-term review mm maine mbchb(medunsa) orthopaedic registrar, department of orthopaedics, university of pretoria i zondagh mbchb(pret), fcs orth(sa), mmed(orth) spinal consultant, department of orthopaedics, 1 military hospital, university of pretoria corresponding author: dr mm maine department of orthopaedics university of pretoria 1 military hospital private bag x1026 0143 thaba tshwane email: motsapim@yahoo.com tel: (012) 314 0044 fax: 086 632 9182 introduction anterior cervical decompression and fusion (acdf) is a well-known treatment in the management of cervical degenerative disease causing persistent radiculopathy or myelopathy. anterior surgery of the cervical disc with fusion using iliac crest autograft was introduced in the 1950s.1 after decompression, a fusion is performed to stabilise the segment, restore the height and recreate the normal cervical lordosis. initially acdf was performed using tricortical iliac bone graft with good fusion rates. abstract background: anterior cervical decompression and fusion (acdf) is a well-known treatment for persistent cervical radiculopathy or myelopathy. fusion is performed to stabilise the segment, maintain foraminal height, and maintain the normal sagittal profile. the stand-alone cage concept, initiated by bagby, has been used in the human spine since 1988. there are some concerns with stand-alone cages regarding expulsion and migration of the cage. aim: to review the long-term outcome of stand-alone cage fusions done from 2000–2010 at 1 military hospital and describe our experience with this procedure. methods: a retrospective review of stand-alone cage neck fusion of 55 levels in 35 patients performed between january 2000 and december 2010 at 1 military hospital was done. clinical notes and x-rays were reviewed. fusion rate was assessed using standard x-rays with flexion/extension views. results: seven patients (14%) had a non-union, giving a fusion rate of 86%. five non-unions were painful. one patient had a revision for a painful non-union (ndi score: 35/50). one patient refused to have a revision at last visit despite having significant pain (ndi score: 27/50). one patient with a double level non-union has phaeochromocytoma with significant risk to revision and chose not to have the surgery (ndi score: 14/50). two patients are on the waiting list for a revision in the near future (ndi scores: 24/50 and 19/50). the two remaining patients with non-unions are asymptomatic (ndi scores: 0/50 and 7/50). conclusion: stand-alone cage fusion is a safe and effective procedure providing a favourable clinical and radiological outcome. good fusion rates can be obtained (86% in our study) with this method. key words: radiculopathy, myelopathy, anterior cervical discectomy and fusion, stand-alone cage fusion, fusion rate http://dx.doi.org/10.17159/23098309/2015/v14n3a10 sa orthopaedic journal spring 2015 | vol 14 • no 3 page 81 the use of autologous bone graft gave rise to complications, especially acute and chronic pain at the donor site. donor site morbidity favoured development of cage technology. anterior cervical plating was added to un-instrumented autograft fusion to prevent graft settling and collapse and to enhance a solid fusion. plating however has its own challenges. peek (polyether ether ketone) cervical synthetic cages have recently been used. peek has biomechanical properties similar to bone and is radiolucent allowing for post-operative radiographic fusion evaluation. the standalone cage concept was initiated by bagby and has been used in the human spine since 1988. the rectangular cages used resemble the dimensions and anatomy of the disc space and vertebral end plates. there are concerns with stand-alone cage usage regarding expulsion and migration of the cage. the purpose of the study is to review the long-term outcome of stand-alone cage fusions done from 2000 to 2010 at 1 military hospital and to describe our experience with the procedure. the impact of the study is aimed to show that standalone cage fusion is a safe and effective procedure which provides a good clinical and radiological outcome. methods a retrospective review was done on patients who underwent anterior cervical decompression and fusion using stand-alone cage at 1 military hospital between january 2000 and december 2010. patients were operated by a spinal team consisting of an orthopaedic surgeon and a neurosurgeon working together. a standard right-sided smith robinson approach was used. after discectomy and decompression the end plates were prepared and the cage, packed with either autogenous bone, allograft bone or synthetic bone substitutes, was inserted. the cage size was determined by releasing distractor pins and assessing resistance to pull-out. post-operative immobilisation in a philadelphia brace for 12 weeks was the standard of care. fusion rates were assessed using standard x-rays with flexion/extension views as shown in figure 1. trabecular continuity and bone bridging across the disc space, absence of motion with flexion/extension views and absence of a dark halo around the implant on ap and lateral views were assessed. patient clinical outcome was assessed using the neck disability index score (ndi). the ndi was developed in 1989 by vernon.2 each of the ten items is scored from 0–5. the maximum score is therefore 50 (see appendix a). the obtained score can be multiplied by 2 to produce a percentage score. the scoring intervals for interpretation are as follows: 0–4 = no disability 5–14 = mild 15–24 = moderate 25–34 = severe above 34 = complete results thirty-five patients were treated with stand-alone anterior cervical cages between january 2000 and december 2010 at 1 military hospital. seventeen patients were male and 18 were female, with an average age of 58 years. indications for surgery are shown in figure 2. follow-up was from 2 to 12 years with an average of 5 years. most patients (22) underwent c5/c6 fusion, followed by c6/7 (11) as shown in figure 3. eighteen patients had a 1-level fusion, 14 patients had a 2-level fusion and three patients had 3-level fusion (18 single level and 17 multilevel). thus a total of 55 levels were fused. the average theatre time was 195 minutes. the most frequently used cage height was 6 mm as depicted in figure 4. the graft material used was autograft in 82%, allograft in 10% and synthetic bone substitute in 8% as illustrated in figure 5. seven patients (14%) had a non-union, giving a fusion rate of 86%. of the seven non-unions, there were no nonunion in the three level fusions. in the two-level fusion group there was one patient who had non-union at both operated levels. the remaining six non-union patients were all single-level surgery. five non-unions were painful. one patient had a revision for a painful non-union (ndi score: 35/50), one patient refused to have a revision at last visit despite having significant pain (ndi score: 27/50), one patient with a double-level non-union has phaeochromocytoma with significant risk to revision and chose not to have the surgery (ndi score: 14/50). two patients are on the waiting list for a revision in the near future (ndi scores: 24/50 and 19/50). the two remaining patients are asymptomatic (ndi scores: 0/50 and 7/50).figure 1. flexion/extension views page 82 sa orthopaedic journal spring 2015 | vol 14 • no 3 appendix a this questionnaire is designed to help us better understand how your neck pain affects your ability to manage everyday life activities. please mark in each section the one box that applies to you. although you may consider that two of the statements in any one section relate to you, please mark the box that most closely describes your presentday situation. copyright: vernon h & hagino c, 1991, hvernon@cmcc.ca section 1 – pain intensity q i have no neck pain at the moment. q the pain is very mild at the moment. q the pain is moderate at the moment. q the pain is fairly severe at the moment. q the pain is very severe at the moment. q the pain is the worst imaginable at the moment. section 2 – personal care q i can look after myself normally without causing extra neck pain. q i can look after myself normally, but it causes extra neck pain. q it is painful to look after myself, and i am slow and careful. q i need some help but manage most of my personal care. q i need help every day in most aspects of self-care. q i do not get dressed. i wash with difficulty and stay in bed. section 3 – lifting q i can lift heavy weights without causing extra neck pain. q i can lift heavy weights, but it gives me extra neck pain. q neck pain prevents me from lifting heavy weights of the floor but i can manage if items are conveniently positioned, i.e. on a table. q neck pain prevents me from lifting heavy weights, but i can manage light weights if they are conveniently positioned. q i can lift only very light weights. q i cannot lift or carry anything at all. section 4 – reading q i can read as much as i want with no neck pain. q i can read as much as i want with slight neck pain. q i can read as much as i want with moderate neck pain. q i can’t read as much as i want because of moderate neck pain. q i can’t read as much as i want because of severe neck pain. q i can’t read at all. section 5 – headaches q i have no headaches at all. q i have slight headaches that come infrequently. q i have moderate headaches that come infrequently. q i have moderate headaches that come frequently. q i have severe headaches that come frequently. q i have headaches almost all the time. section 6 – concentration q i can concentrate fully without difficulty. q i can concentrate fully with slight difficulty. q i have a fair degree of difficulty concentrating. q i have a lot of difficulty concentrating. q i have a great deal of difficulty concentrating. q i can’t concentrate at all. section 7 – work q i can do as much work as i want. q i can only do my usual work, but no more. q i can do most of my usual work, but no more. q i can’t do my usual work. q i can hardly do any work at all. q i can’t do any work at all. section 8 – driving q i can drive my car without neck pain. q i can drive my car with only slight neck pain. q i can drive as long as i want with moderate neck pain. q i can’t drive as long as i want because of moderate neck pain. q i can hardly drive at all because of severe neck pain. q i can’t drive my car at all because of neck pain. section 9 – sleeping q i have no trouble sleeping. q my sleep is slightly disturbed for less than 1 hour. q my sleep is mildly disturbed for up to 1–2 hours. q my sleep is moderately disturbed for up to 2–3 hours. q my sleep is greatly disturbed for up to 3–5 hours. q my sleep is completely disturbed for up to 5–7 hours. section 10 – recreation q i am able to engage in all my recreational activities with no neck pain at all. q i am able to engage in all my recreational activities with some neck pain. q i am able to engage in most, but not all of my recreational activities because of pain in my neck. q i am able to engage in a few of my recreational activities because of neck pain. q i can hardly do recreational activities due to neck pain. q i can’t do any recreational activities due to neck pain. patient name date score [50] sa orthopaedic journal spring 2015 | vol 14 • no 3 page 83 from the seven non-unions reported, with regard to bone graft material used, six out of seven non-unions were from autograft, and for the one, non-union synthetic graft was used. in this study some complications were noted. one patient had a recurrent laryngeal nerve injury after a two-level fusion (c5–c7) and had a persistent speech problem at 9 years’ follow-up. another patient had an internal jugular vein injury which was ligated intra-operatively to control bleeding, theatre time was 390 minutes, and the patient was started on long-term anticoagulants. another patient had a fracture of end plate at c7 which needed additional plate and screw fixation. two cages were mal-positioned, one anterior and one lateral, but they did not cause any clinical problems. there were no infections, cerebrospinal fluid leaks or cage migrations in our study. fifteen of 35 patients (42%) demonstrated radiological evidence of adjacent segment disease at 5-years’ follow-up; however, only one patient required revision for adjacent segment disease (asd). discussion degenerative disease of the cervical spine can result in significant radiculopathy, myelopathy or both. the anterior approach is the preferred method for decompression of the roots because of the easy patient positioning and surgical approach by blunt dissection through anatomical planes. with an anterior approach, however, interbody fusion is often required to maintain foraminal height and prevent localised kyphosis, especially with multiple-level surgery. results of our study are comparable to other recent publications for stand-alone cage fusions. marota et al.3 in their study of 132 patients showed an 87% fusion rate at 5-years’ follow-up. dunn et al.4 had a 92% fusion rate in 34 patients at 2-years’ follow-up. fraser et al.5 did a meta-analysis of fusion rates comparing different anterior fusion methods. radiculopathy (23) radiculopathy and axial pain (9) axial pain (1) myelopathy (2) figure 2. indications for surgery 30 20 10 c3/4 c4/5 c5/6 c6/7 c7/t1 0 figure 3. levels operated 20 15 5 10 4mm 5mm 6mm 7mm 0 figure 4. cage size inserted results of our study are comparable to other recent publications for stand-alone cage fusions autograft (82%) allograft (10%) synthetic bone substitute (8%) figure 5. graft type page 84 sa orthopaedic journal spring 2015 | vol 14 • no 3 they found fusion rate to be 84.99% using anterior cervical decompression, 92.1% using anterior cervical decompression and fusion, and 97.1% using anterior cervical decompression and fusion with anterior plating. plating is however more costly, requires longer operative times, and may be associated with problems such as breakage or dislocation of the screws and perforation of adjacent structures. the use of interbody cages for anterior cervical fusion was introduced to prevent problems such as graft resorption and expulsion and therefore loss of alignment as seen with tricortical iliac bone graft.6 cho et al.7 used cages to replace plate function in multilevel cervical fusion. they demonstrated that the peek cage results are statistically better than those of the plating group in total complications, p< 0.05. they also showed that peek cage without plating and autogenous iliac crest graft with plating are good methods for interbody fusion in multilevel cervical degenerative diseases. shousha et al.8 showed that stand-alone cage fusion is an acceptable line of treatment for four-level cervical disc disease, both clinically and radiologically, though the addition of posterior instrumentation yielded better radiological results; the difference, however, did not reach the statistical significance level. clinical follow-up was attempted but the clinical information/ndi scores were only obtained in 20 patients. there was a trend in our patients with a radiological nonunion to have a higher ndi score than those with radiological union. our asd incidence is high compared to other literature (±25%), but our revision rate for asd remains low despite the radiological picture. this brings us to question the clinical relevance of asd. mccormick et al.9 studied adjacent segment disease and demonstrated that adjacent segment disease is not clinically relevant. they also support the idea that asd is the consequence of natural degeneration of the discs. conclusion almost 50% of our study group underwent multilevel fusion with one reported non-union. we feel stand-alone cage fusion is a safe and effective procedure providing a good clinical and radiological outcome for the management of cervical degenerative disease, even in multilevel disease. good fusion rates can be obtained (86%) using this method. the high incidence of adjacent segment disease seems not to be clinically relevant at long-term follow-up. this study is the authentic work of the authors. no financial benefits were received from any commercial party for this study. references 1. cloward rb. the anterior approach for removal of ruptured cervical discs. j neurosurg 1958;15:602-17. 2. vernon h, moirs s. the neck disability index: a study of reliability and validity. j manip physiol ther 1991;14(7):40915. 3. marota n, landi a, tarantino r, mancarella c, ruggeri a, delfini r. five-year outcome of stand-alone fusion using carbon cages in cervical disc arthrodesis. eur spine j 2011;20(suppl 1):s8–s12. 4. dunn rn, pretorius c. cervical peek cage standalone fusions – the issue of subsidence. sa orthopaedic journal 2011;10(1):25-29. 5. fraser jf, härti r. anterior approaches to fusion of the cervical spine: a meta-analysis of fusion rates. neurosurg spine 2007;6:298-303. 6. bohlman hh, emery se, goodfellow db, jones pk. robinson anterior cervical discectomy and arthrodesis for cervical radiculopathy. long-term follow-up of one hundred and twenty patients. j bone joint surg (am)1993;75:1298-1307. 7. cho dy, lee wy, sheu pc. treatment of multilevel cervical fusion with cages. surg neurol 2004;62:378-86. 8. shousha m, ezzati a, boehm h. four-level anterior cervical discectomies and cage-augmented fusion with and without fixation. eur spine j 2012;21:2512-19. 9. mccormick pc. the adjacent segment. j neurosurg spine 2007;6:1-4. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. we feel stand-alone cage fusion is a safe and effective procedure providing a good clinical and radiological outcome • saoj page 60 south african orthopaedic journal http://journal.saoa.org.za editorial in 2009, a survey of 7 905 surgeons in america noted that 40% had signs of burnout, 30% depression, 20% a mental quality of life score >0.5 sd below the population mean, and 7% suicidal ideation.1 professional burnout is a syndrome characterised by loss of enthusiasm for work, depersonalisation and a low sense of personal accomplishment.2 the hallmarks include emotional and physical exhaustion, as well as feelings of cynicism, guilt and ineffectiveness. sounding familiar? i am not surprised. forty-five per cent of physicians in the us were reported to have burnout symptoms in 2012.2 physicians were also significantly more likely to have burnout and a dissatisfaction with work–life balance than the general population. furthermore, while a higher level of education had a protective effect in the general population, the opposite is true for physicians.3 and things may be getting worse. shanafelt and co-workers repeated the survey in 2015, reporting a burnout rate of close to 55% and a reduction in job satisfaction from 49% to 41% across all specialities.4 how did orthopaedics fare? not great, with a burnout rate of 60%. this was the fifth highest behind emergency medicine, urology, family medicine and radiology.4 burnout has consequences on several levels. the personal costs are significant. it adversely affects relationships and results in an increase in alcohol use, depression and cognitive impairment.2,5-7 the medscape national physician burnout & suicide report of 2020 reported that 23% of respondents have either thought about or attempted suicide (and a further 9% preferred not to answer).8 on an occupational level, it results in decreased effectiveness at work, it erodes professionalism and increases staff turnover, absenteeism, presenteeism (being at work when one should be off sick) and early retirement.9,10 it also impacts patient care with a decrease in quality of care and patient satisfaction, an increase in medical errors and erosion of the doctor–patient relationship.9,10 at an organisational level, the cost to the healthcare system cannot be disregarded. in the us it is estimated that the annual national costs associated with burnout is in the region of about $4.6 billion.11 it was recently described as ‘a global crisis’ by the lancet.12 there are numerous factors that play a role in the development of burnout. personal factors that contribute include female sex, being a racial minority or being from generation x.8,10 financial concerns and work–family conflict add to this burden, while time for hobbies, high self-efficacy, parenthood and strong familial support systems have a protective effect.10 the second major category is work environment-related factors, such as excessive workload, long working hours, stress in workplace relationships, loss of autonomy, lack of a sense of community and insufficient reimbursement.10 other negative factors in this sphere include too many bureaucratic tasks, increased computerisation and government regulations.8 the third group of factors relate to the physician’s career. negative factors include being a registrar, regret about career choice, competition with colleagues and anxiety about competence. job satisfaction and being later in your career may have a positive effect10 – except if you are in a leadership position, in which case there is an increased risk of burnout, particularly in the emotional exhaustion and depersonalisation sub-scales.13 the statistics are alarming and there is certainly cause for concern. it would be reasonable to expect that funders, organisations, hospitals or healthcare system managers would therefore take heed and implement preventative and curative strategies. however, in south africa there seems to be a great vacuum in this space. while universities and the department of health have employee wellness programmes, i am not aware of a programme dedicated to physicians. private hospitals and private healthcare funders surely have a great deal to benefit by ensuring that their doctors are fully effective. yet, an internet search and discussion with my private counterparts failed to provide any information of a physician wellness programme offered by these organisations. thus, it seems we might be on our own with this one. the problem is that only about 13% of clinicians seek professional help.8 in fact the top coping mechanism in the 2020 medline survey was: ‘isolate myself from others’.8 we are in a vicious cycle. if i see my colleagues suffering in silence and simply getting on with the work, who am i to complain? and i certainly don’t want to be seen as the physician suggesting that i may not always be able to place the needs of my patient or student first. it is therefore understandable that surgeons with burnout often isolate themselves and internalise their struggles. the problem is that many of the physician wellness programmes currently implemented in other countries, such as mindfulness training, volunteer days and social events, are not addressing the underlaying cause and have been described as simply ‘putting the proverbial lipstick on a pig’.14 drozdowicz suggests that the problem should be addressed at its roots with widespread healthcare system reform on multiple levels.14 what action then needs to be taken? the consensus study report by the national academy of medicine in the us provides some more comprehensive guidelines.15 in brief the goals are to create a positive work and learning environment, reduce the administrative burden placed on clinicians, enable technology solutions to support clinicians, provide support for clinicians and learners, and invest in research. so where are we going here in south africa in terms of the prevention and management of burnout? and once we have the necessary programmes in place, do we have adequate knowledge physician wellness in south africa ‘where are we going? and if we get there, will there be a place to park?’ marais lc mbchb, fc orth sa, mmed(ortho), phd department of orthopaedics, school of clinical medicine, university of kwazulu-natal, durban, south africa corresponding author: maraisl@ukzn.ac.za leonard marais page 62 south african orthopaedic journal http://journal.saoa.org.za and resources to deal with the problem? the south african orthopaedic association (saoa) has undertaken to engage with this issue. as a stepping-stone, the association has initiated research to characterise both the extent and the cause of the problem among orthopaedic surgeons and trainees. it is crucial that our community participates. it seems that if we do not start looking after ourselves, our colleagues and our trainees, no-one else will. references 1. shanafelt td, balch cm, bechamps gj, et al. burnout and career satisfaction amongst american surgeons. annals surg. 2009;250(3):463-70. 2. shanafelt td, boone s, tan l, et al. burnout and satisfaction with work-life balance among us physicians relative to the general us population. arch intern med. 2012;172(18):1377-85. 3. shanafelt td, sinsky c, dyrbye ln, et al. burnout among physicians compared with individuals with a professional degree in a field outside of medicine. mayo clin proc. 2019;94(3):549-51. 4. shanafelt td, hasan o, derbye ln, et al. changes in burnout and satisfaction with work-life balance in physicians and the general population between 2011 and 2014. mayo clin proc. 2015;90(12):1600-603. 5. jackson er, shanafelt td, hasan o, et al. burnout and alcohol abuse/dependence among us medical students. acad med. 2016;91(9):1251-56. 6. haskins j, carson jg, chang ch, et al. the suicide prevention, depression awareness, and clinical engagement program for faculty and residents at the university of california, davis health system. acad psychiatry. 2016;40(1):23-29. 7. sandström a, rhodin in, lundberg m, olsson t, nyberg l. impaired cognitive performance in patients with chronic burnout syndrome. biol psychol. 2005;69(3):271-79. 8. medscape national physician burnout, depression & suicide  report  2020. available from: https://www.medscape.com/ slideshow/2020-lifestyle-burnout-6012460#1. (date accessed: 5 march 2020) 9. ames se, cowan jb, kenter k, et al. burnout in orthopaedic surgeons: a challenge for leaders, learners, and colleagues. j bone joint surg. 2017;99:e78(1-6). 10. hui rwh, leung kc, ge s, et al. burnout in orthopaedic surgeons: a systematic review. j clin orth traum. 2019;10:s47-52. 11. shanafelt td, goh j, sinsky c. the business case for investing in physician well-being. jama int med. 2017. doi:10.1001/ jamainternmed.2017.4340 12. editorial: physician burnout: a global crisis. lancet 2019;394:93. 13. saleh kj, quick jc, conaway m, et al. the prevalence and severity of burnout among academic orthopaedic departmental leaders. j bone joint surg am. 2007;89(4):896-903. 14. drozdowicz l. physician wellness programs are lipstick on a pig. 2017. available from: https://www.kevinmd.com/blog/2017/11/ physician-wellness-programs-lipstick-pig.html (date accessed: 6 march 2020). 15. national academies of sciences, engineering, and medicine.  taking action against clinician burnout: a systems approach to professional well-being. washington, dc: the national academies press, 2019. https://doi.org/10.17226/25521 maku mm et al. sa orthop j 2018;17(2) doi 10.17159/2309-8309/2018/v17n2a3 south african orthopaedic journal http://journal.saoa.org.za trauma citation: maku mm, ngcelwane mv, olorunju sas. open tibial fractures: risk factors for infection in conversion of external fixator to intramedullary nail at a tertiary academic hospital. sa orthop j 2018;17(2):20–24. http://dx.doi.org/10.17159/2309-8309/2018/v17n2a3 editor: prof anton schepers, university of the witwatersrand received: september 2017 accepted: january 2017 published: may 2018 copyright: © 2018 maku mm, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no external funding was received for conducting this study. conflict of interest: there is no conflict of interest. none of the authors have any relation to the companies whose implants were used in this study. abstract aim: to determine the rate of infection in open tibial fractures treated by conversion of an external fixation into an intramedullary nail, and to identify the factors contributing to the infections. methods: the study included a total of 52 patients. multiple variables were assessed as risk factors that could lead to infection in open tibial fractures treated primarily with an external fixator and later converted into an intramedullary nail. the factors looked at were: age, average time taken from injury to debridement, average time taken from admission to debridement, antibiotics administration, facility that admitted the patient before intramedullary nail, average time for conversion of external fixator into intramedullary nail insertion, type of soft tissue management, initial gustilo and anderson classification and retrospective re-classification of fractures, existence of superficial sepsis or pin-tract infection, radiologic evidence of infection, the injury severity score and the type of external fixator used. a p value < 0.05 was used as the threshold for level of significance. results: the average follow-up was 37 weeks (median 24 weeks). we had a 40% infection rate ci [27%, 55%]. factors that were found to be the most statistically significant (p≤0.05) were amount of soft tissue injury and fracture comminution; this is after the fractures were retrospectively re-classified. all other factors looked at were not statistically significant as risk factors for infection (p>0.05). conclusion: the study suggests that correct classification of open tibial fractures, with recognition of soft tissue injury and bone comminution, is important in reducing infection rates and in ensuring proper initial management of these fractures. treatment should be based on the classification done in theatre during the initial debridement, rather than on presentation in the trauma unit. level of evidence: level 4 key words: open tibial fractures, external fixation, intramedullary nailing, infection rate open tibial fractures: risk factors for infection in conversion of external fixator to intramedullary nail at a tertiary academic hospital maku mm¹, ngcelwane mv², olorunju sas3 ¹ bsc, mbchb(ufs); consultant orthopaedic surgeon, department of orthopaedic surgery, steve biko academic hospital, university of pretoria ² mbchb, fcs(sa)orth, msc(orth)london; consultant orthopaedic surgeon, department orthopaedic surgery, steve biko academic hospital, university of pretoria ³ bsc, msc, phd; biostatistician, south african medical research council, pretoria corresponding author: prof mv ngcelwane, department of orthopaedic surgery, steve biko academic hospital, university of pretoria; email: mthunzi.ngcelwane@up.ac.za, tel: (012) 354 2851; fax: (012) 354 2821 page 21maku mm et al. sa orthop j 2018;17(2) background open tibia fractures are common long bone fractures, often resulting in extensive bone and soft tissue damage.1 the subcutaneous location of the tibia as well as its poor blood supply makes it susceptible to non-unions and infections.2 injuries to the neurovascular structures are also a known complication.1 currently, the management of open tibial fractures comprises thorough wound debridement, immediate bone stabilisation with an external fixator, and coverage of bone with soft tissue. this aids in enabling early mobilisation and restoration of limb function. because of the complications of external fixators, such as pin-tract sepsis and non-union, there is a trend to convert the external fixator into an intramedullary fixation device.2 this treatment is also not without its complications, infection being a major one. yokoyama et al. mention factors found to influence infection rates post-operatively.2 they include the patient’s age, sex, severity of the fracture as classified by gustilo and anderson (ga),3 the fracture site, injury severity score (iss), time to debridement, reamed versus unreamed nailing, the duration of external fixation, interval between external fixation and intramedullary nail, time taken to achieve closure of skin, and the existence of superficial or pin-tract infection.2 in their original classification, gustilo and anderson classified open tibial fractures into three types:3 • type i – an open fracture with a wound less than 1 cm long, clean wound • type ii – an open fracture with a wound more than 1 cm long without extensive soft-tissue damage, flaps or avulsions • type iii – an open fracture with extensive soft-tissue damage, or a traumatic amputation type iii fractures were subsequently further subdivided into three subtypes, because of the problems that were observed in their management, notably high infection rates and amputations:4 • type iiia – adequate soft-tissue coverage of a fractured bone despite extensive soft-tissue laceration or flaps, or high-energy trauma irrespective of the size of the wound • type iiib – extensive soft-tissue injury with periosteal stripping and bony exposure. this is usually associated with massive contamination. • type iiic – open fracture-associated arterial injury requiring repair type iii ga fractures pose a special challenge to the orthopaedic surgeon because of their soft tissue component, degree of contamination and fracture configuration. types iiib and iiic present with periosteal stripping, muscle contusions, contamination and neurovascular structure damage. it is therefore not recommended for these types of injuries to be nailed primarily. irrigation, debridement, external fixator, antibiotics and consultation with the plastic surgeon for the method of closing the defect are recommended steps in the management of the types iii b and c fractures.1,2 the literature on this topic shows that infection rates are still a concern regardless of the form of intervention.2,5,6 at the orthopaedic outpatient clinic in steve biko academic hospital, there has been a number of patients presenting with nail sepsis after secondary intramedullary nailing of open tibial fractures. the contributing factors for sepsis in these patients are however not clear, and this prompted the undertaking of this study. aim to determine the rate of infection in open tibial fractures treated by conversion of an external fixator into an intramedullary nail, and to identify the factors contributing to the infections. patients and methods we reviewed the clinical records of all patients treated at steve biko academic hospital for open fractures of the tibia during the period january 2009 to december 2013. convenience sampling was used to include patients into this retrospective, observational study.7 we included all skeletally mature patients with open diaphyseal fractures of the tibia, treated with an external fixator and later converted to a nail. we identified 66 patient records. after excluding all patients with metaphyseal fractures, patients with diabetes and peripheral vascular diseases, pregnant patients, and patients with inadequate clinical records (total 14 patients), we were left with 52 patients, and these formed the basis of this study. there were 46 male patients and six females. their age range was 18–58 years, with a mean age of 34 years. the mean follow-up duration was 37 weeks, with a median of 24 weeks. the standard protocol in our hospital is that in patients who present with open tibia fractures, the wound is covered with a sterile dressing and the limb is immobilised with a temporary back slab in casualty. antibiotics are commenced in casualty. the attending surgeon grades the fracture using the ga grading.3 for ga i and ii open fractures, cefazolin 2 g stat is given intravenously, followed by 1g 8 hourly intravenously for 24–72 hrs. for ga iii open fractures, intravenous amoxicillin clavulanate 2.4 g loading dose, followed by 1.2 g intravenously 8 hourly, till soft tissue closure (7–10 days). patients who are allergic to penicillin are given clindamycin 600 mg intravenously. in this study, no patients were identified to have a penicillin allergy. patients are given three doses of antibiotics for simple fractures post-operatively, extending to seven days for complex fractures. wound management entails primary debridement of the wound, removing all contaminating foreign material, all necrotic tissue and all loose bone fragments. the wound is then temporarily covered with a hydrogel wound dressing mixed with gentamycin, the dressing being the vector for the gentamicin and to keep the wound moist. if the treating surgeon assesses the injury to be a ga type i, primary wound closure is done. the fracture is stabilised with an external fixator device (predominantly a hoffman external fixator, smith and nephew). the patient is taken back to theatre in 48–72 hours for re-assessment of the soft tissues and removal of the hydrogel dressing. fractures with minimal comminution associated with soft tissues that can be treated with secondary closure, undergo secondary internal fixation with an intramedullary nail (trigen nail, smith and nephew, memphis, tennessee). the 52 patients in this study belong to this group. in ga types iiia-iiic, the temporary external fixator is converted to a definitive external fixator, that is, they do not undergo intramedullary nail insertion. these patients may also require other means of soft tissue cover, and as such require consultation with plastic surgeons. the following data was collected from the files of the study patients: age, sex, ga classification recorded initially by the treating doctor, fracture site, iss, time interval from injury to debridement, time interval from admission to debridement, type of external fixator used, duration in external fixator, type of soft tissue management, interval between external fixator and intramedullary nail, clinical and radiological evidence of infection. we used the criteria described by fukushima et al.6 to define wound infection. in superficial wound infection, the infection lies entirely above the fascia with associated erythema and tenderness, which requires antibiotics and opening of the wound. deep infection is defined as an infection involving bone, as well as the tissue below the fascia. pin-tract sepsis is defined as persistent drainage from a pin site that requires intervention or positive bacterial cultures from the site.6 the following radiologic features were used as indicators of infection: periosteal thickening, page 22 maku mm et al. sa orthop j 2018;17(2) lytic lesions, endosteal scalloping and new bone apposition, implant loosening as indicated by lucency around the intramedullary tibial nail associated with cortical thinning, cortical irregularity and subperiosteal new bone formation.8 during data collection, when looking at the description of the wound, soft tissue damage and periosteal stripping, and reviewing the extent of comminution of the fractures on x-ray (xr), we found some fractures that were initially classified as ga i which were actually ga ii , some that were classified as ga ii fractures which were actually ga iiia and some ga iiia whose severity of injury was also underestimated. we did not have any ga iiic in the study. the data was recorded onto a data-capturing sheet, which was used to perform statistical analysis. variables collected were tested against each other to determine their level of significance in being a risk factor for infection. statistical analysis stata 14.1 statistical software was used to analyse the data.9 the analysis presented descriptive statistics by demographic characteristics, including proportions, standard errors and associated 95% confidence intervals. an independent t-test for comparing proportions was used to compare various categories between infected and non-infected groups. chi-square analysis was used to determine the association between the rates of infection and the associated factors. testing was done at the 0.05 level of significance (p < 0.05). results the patients were divided into two groups. group a comprised those that were assessed as being not infected at final follow-up. group b comprised those that were complicated by infection. the results are summarised in table i. out of the 52 fractures, 21 (40%) were complicated by infection. the average time from injury to debridement was 27 hrs in group a and 22 hrs in group b. the time spent in hospital before theatre was 18 hrs in group a and 17 hrs in group b. after initial debridement, most of the patients were nursed in the orthopaedic ward (28 in group a and 20 in group b). a few of the patients, because of associated injuries, were managed in icu (two in group a and one in group b) and one from group a was managed in a high care ward. in 14 patients primary wound closure was performed; six of these became septic. secondary wound closure was performed in 28 patients; nine of these became septic. six patients had split skin graft; four of them became septic. four patients had gastrocnemius/soleus flap; two of them became septic. the average time to conversion of table i: variables tested as contributors to infection in open tibial fractures variable non-infected fractures (group a) (n=31) infected fractures (group b) (n=21) p-values average time from injury to debridement 27 hours (3–84 hrs) 22 hours (7–120 hrs) ns average time from admission to debridement 18 hours (0.6–48 hrs) 17 hours (2–72 hrs) ns type of external fixator used hoffman ex-fix = 27 dispofix = 1 orthofix = 2 jet-x = 1 hoffman ex-fix = 17 dispofix = 2 orthofix = 2 jet-x = 0 ns admitting facility between external fixator and intramedullary nail ward = 28 icu = 2 high care = 1 ward = 20 icu = 2 high care = 0 ns wound coverage primary closure secondary cover split skin graft flap (gastrocnemius/soleus) 8 19 2 2 6 9 4 2 ns average time to conversion of external fixator to an intramedullary nail 5.7 days (2–19) median 3 days 3.4 days (1–9) median 4.3 days ns injury severity score n=17 (5–36) n=19(9–27) ns *ns = not statistically significant table iia: gustilo and anderson classification of fractures as contributor to infection ga classification non-infected (group a) (n=31) infected (group b) (n=21) p-values i (n=8) 4/8 4/8 p=0.01 ii (n=35) 22/35 13/35 p>0.05 iiia (n=8) 3/8 5/8 p>0.05 iiib (n=1) 1/1 0/1 p>0.05 iiic (n=0) 0/0 0/0 – table iib: gustilo and anderson classification as contributor to infection after reclassifying the fractures ga classification non-infected (group a) (n=31) infected (group b) (n=21) p-values i (n=4) 4/4 0/4 p=0.005 ii (n=26) 22/26 4/26 p=0.000 iiia (n=20) 3/20 16/20 p=0.000 iiib (n=2) 2/2 1/2 p=1.0 iiic (n=0) 0/0 0/0 – page 23maku mm et al. sa orthop j 2018;17(2) external fixator to intramedullary nail was 5.7 days for group a, and 3.4 days for group b. as seen in table i, the following factors were not significant in causing sepsis, as indicated by p-values exceeding 0.05: average time from injury to debridement, average time from admission to debridement, average time to conversion of external fixator to an intramedullary nail, type of external fixator used, type of ward to which patient is admitted between the external fixator and intramedullary nail period, and wound coverage. table ii looks at the results after re-classifying the fractures. the treating surgeons had initially classified 43 patients as being ga types i and ii, and nine patients as being type iii. on re-classifying the fractures, we found that 30 patients were types i and ii, and 22 were type iii. figure 1 is an example of a fracture that was initially graded as ga i, on the basis of a small skin wound of less than a centimetre. the theatre notes described that there was periosteal stripping. the xr showed a comminuted fracture. combining all these we re-classified this injury as ga iiia. on the initial classification of the fractures, there was no significant difference in infection rates between the ga types of the fractures, as seen in table iia. however, upon re-classification of these fractures, there was a significant difference in infection rates between the various ga types of fractures, as seen in table iib. discussion open tibia fractures continue to have a high infection rate, reported to be 10–50% in the literature,4,5 despite advances in wound care, soft tissue cover and types of internal and external fixator devices. this study shows an infection rate of 40%, which is comparable to the literature. according to bashir et al.,1 the treatment of choice for ga types i to iii open tibia fracture is an external fixator. with the advent of the interlocking nail, intramedullary nailing has become a very popular treatment choice in tibia fracture. the success of the intramedullary nail is related to the high union rates, reduced requirements for bone grafting, decreased hospital stays, low incidences of mal-union, and rapid return to normal function. our hospital follows a similar protocol when managing open tibial fractures. there is no consensus that debriding open fractures within 6 hours helps to reduce infection rates.10,11 there is however literature that shows that late debridement, beyond 6 hours, does increase infection rates.10,12 in this study, the average time from injury to debridement was 27 hours and 22 hours in group a and group b respectively. however, this was not statistically significant. the average time from admission to debridement was 18 hours and 17 hours for group a and b respectively. this was not statistically significant, despite the long wait the patients had in hospital before debridement. we attribute this result to our pre-debridement antibiotic policy. this is well documented by other authors who show that early administration of antibiotics is vital in preventing infection.5,10,13 the time interval between external fixation and intramedullary nail insertion varies in the literature.14 it is also dependent on the type of fracture that the surgeon is faced with. various authors recommend waiting an average of 9–11 days before introducing the nail to the medullary canal, and then using specific clinical indicators such as waiting for granulation tissue circumscribing the pin tract sites before intramedullary nailing.12,14 for the type iiia fracture, a waiting period of 15 days has been shown to be beneficial after debridement and systemic antibiotic administration.12 in this study there was a mean waiting period of 5.7 days for the non-infected group, and 3.4 days for the infected group (p>0.05). the infected group was taken to theatre for a definitive intramedullary nail insertion a day and a half earlier than the non-infected group. there was no statistical significance in this result. the type of temporary external fixator used did not prove to be a significant risk factor for the increased incidence of infection. trampuz and zimmerli state that microbial contamination occurs in delayed wound closure.15 early wound coverage and bone grafting forms part of aggressive soft tissue management, which plays a major role in open tibia fracture treatment.16 yokoyama found that skin closure within one week reduces the incidence of deep infections when treating open tibial fractures with an intramedullary nail.2 the definition of pin-tract sepsis entails any persistent drainage from a pin site that will require an intervention, or a positive bacterial culture from the pin site.2 the use of external fixators is associated with a high incidence of pin-tract sepsis. the incidence of infection is then increased when sequential nailing is undertaken, even if adequate antibiotic coverage is provided.6 wheelwright and courtbrown found that if sequential nailing is undertaken after granulation tissue has formed along the pin-tract, the incidence of infection may be reduced.12 in this study 44 patients had superficial sepsis and pin-tract infection. they did not, however, progress to osteomyelitis. eight patients progressed to osteomyelitis after a superficial sepsis and pin-tract infection. the iss has been suggested as a predictor for deep infection in open tibia fractures.17 in the study done by yokoyama et al.2, it was found that there was no significant difference among patients with a high or low iss in the incidence of deep infection. this corresponds with the results of our study, where we also found that the iss was not a statistically significant factor in contributing to deep infection in open tibia fractures. this study provides evidence that soft tissue injury and comminution of open tibia fractures are the leading factors in determining the outcome of infection in open tibial fractures treated initially with an external fixator and converted to an intramedullary nail. this amount of soft tissue injury and bone comminution was statistically significant (p=0.05). when the treating surgeons classified the fracture, they classified them into ga i, ii and iii without taking account of the comminution and soft tissue injury. this showed no statistical relevance in the figure 1. an example of a comminuted tibial fracture that was initially graded as ga i on the basis of a small puncture wound, and retrospectively re-graded to ga iiia. the fracture subsequently developed osteomyelitis. page 24 maku mm et al. sa orthop j 2018;17(2) cause of infection, as shown in table iia. in this study, we re-classified the fractures4 taking into account the amount of soft tissue injury and periosteal stripping as detailed in the operation notes, and the comminution of the fracture as seen on the radiographs. this then showed a statistically significant relationship between the ga classification and the rate of deep infections in these open tibial fractures as seen in table iib. this has also been shown by different authors in the literature.17-20 the extent of soft tissue injury, periosteal stripping and bone comminution is an indication of the amount of energy transferred to the limb during the injury. we consider it a significant finding that this correlates much more with infection than other factors we examined in this study. in particular, it is important to note that the amount of energy transferred to the patient in general as shown by the iss does not correlate very well to infection in this study. this suggests that the interruption of blood supply to the bone as evidenced by the amount of soft tissue injury and periosteal stripping may be the main factors responsible for infection. limitations of the study being a retrospective study, we lost some patients because of inadequate records. conclusion the study shows that the main factor contributing to infection in open fractures of the tibia is the extent of energy transferred to the limb, as expressed by periosteal stripping and comminution of the fracture as seen on the xr. treatment should be based on the gustilo and anderson classification done during the initial surgery of wound debridement, and not on presentation in the trauma unit. ethical consideration no benefits of any form have been received by any of the authors from a commercial party related to the subject of this study. ethical approval was obtained from the ethics committee of health sciences of the university of pretoria (ethics ref no: 112/2016). references 1. bashir a, dar ta, badoo ar, ganie ma. secondary intramedullary nailing after primary external fixation in the treatment of tibial fractures. the internet journal of orthopedic surgery. 2009;12(1):1-3. 2. yokoyama k, et al. risk factors for deep infection in secondary intramedullary nailing after external fixation for open tibial fractures. injury, int j care injured. 2006;37:554-60. 3. gustilo rb, anderson jt. prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analysis. j bone joint surg [am]. 1976;58(a):453-58. 4. gustilo rb, mendoza rm, williams dn. problems in the management of type iii (severe) open fractures: a new classification of type iii open fractures. j trauma.1984;24(8):742-46. 5. shorin hr, et al. antibiotic prophylaxis in bacterial infection of type iiia open fracture of tibial shaft with or without fibula fracture. ravazi int j med. 2016 june;4(2):1-7. 6. fukushima, et al. immediate versus delayed intramedullary nailing for open fractures of the tibial shaft; a multivariate analysis of factors affection deep infection and fracture healing. indian journal of orthopaedics. 2008;42(4):410-17. 7. golafshani n. understanding reliability and validity in qualitative research. the qualitative report. december 2003;8(4):597-604. 8. bhat v, gupta h. the radiological diagnosis of infection. orthopaedics and trauma. 2014;28(6):409-16. 9. statacorp. stata: release 14. statistical software. texas: college station, statacorp lp. 2014. 10. penn-barwell jg, murray ck, wenke jc. early antibiotics and debridement independently reduce infection in an open fracture model. j bone joint surg [br] 2012;94(b):107-12. 11. crowley dj, kanakaris nk, giannoudis pv. debridement and wound closure of open fractures: the impact of the time factor on infection rates. injury, int j care 2007;38:879-89. 12. wheelwright ef, court-brown cm. primary external fixation and secondary intramedullary nailing in the treatment of tibial fractures. injury. 1992;23(6):373-76. 13. sharr pj, buckley re. current concepts review: open tibial fractures. arch orthop trauma surg. 2014;81:95-107. 14. vikas k. incidence of infection after early intramedullary nailing of open tibial shaft fractures stabilized with pinless external fixators. indian journal of orthopaedics. 2008;42(4):401-407. 15. trampuz a, zimmerli w. diagnosis and treatment of infections associated with fracture-fixation devices. injury, int j care injured. 2006;37:s59-s66. 16. sienbenrock ka, gerich t, jakob rp. sequential intramedullary nailing of open tibial shaft fractures after external fixation. arch orthop trauma surgery 1997;116:32-36. 17. metsemakers wj, handojo k, reynders p, sermon a, vanderschot p, nijs s. individual risk factors for deep infection and compromised fracture healing after intramedullary nailing of tibial shaft fractures: a single centre experience of 480 patients. injury, int j care injured. 2015;46:740-45. 18. roussignol x, sigonney g, potage d, ettienne m, duparc f, dujardin f. secondary nailing after external fixation for tibial shaft fracture: risk factors for union and infection. a 55 case series. orthopaedic and traumatology; surgery and research 2015;101:89-92. 19. papakostidis c, et al. prevalence of complications of open tibial shaft fractures stratified as per the gustilo-anderson classification. injury, int j care injured. 2011;42:1408-15. 20. khatod, et al. outcomes in open tibia fractures; relation between delay in treatment and infection. journal of trauma and injury, infection, and critical care. 2003;55:949-54. south african orthopaedic journal orthopaedic oncology and infections doi 10.17159/2309-8309/2021/v20n2a6brown o et al. sa orthop j 2021;20(2) citation: brown o, van rooyen drm, aldous c, marais lc. culturally competent patient– provider communication with zulu patients diagnosed with osteosarcoma: an evidence-based practice guideline. sa orthop j 2021;20(2):98-105. http://dx.doi. org/10.17159/2309-8309/2021/ v20n2a6 editor: dr thomas hilton, university of cape town, south africa received: october 2020 accepted: november 2020 published: may 2021 copyright: © 2021 brown o. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this work. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background this guideline was developed as a response to patients with osteosarcoma presenting late for treatment thereby significantly affecting their prognoses. healthcare providers recognised the role of culture and the importance of culturally competent communication in addressing this problem. the aim of this guideline is to present healthcare providers treating zulu patients diagnosed with osteosarcoma with evidence-based recommendations that can facilitate culturally competent communication regarding the diagnosis, treatment and prognosis of osteosarcoma. methods the agree ii (appraisal of guidelines, research and evaluation) appraisal instrument was used as a guide for developing the evidence-based practice guideline. an integrative literature review, focus groups with healthcare providers, and in-depth interviews with zulu patients were conducted to gather the evidence for the evidence-based practice guideline. the guideline was reviewed by four content and methodological experts using the agree ii tool. results the guideline specifies generic aspects such as the awareness, knowledge, skills and provider attitudes required for culturally competent communication as well as the type of healthcare system that can support and cultivate such communication. specific recommendations for communicating the diagnosis, treatment and prognosis of osteosarcoma to zulu patients were also included. conclusion healthcare providers will require cultural competence and communication training in order to facilitate the implementation of the guideline. some of the challenges identified in the focus group interviews are not addressed in this guideline, leaving room for further development of the guideline. evidence-based practice can contribute to improving culturally competent communication with cancer patients receiving treatment at culturally discordant healthcare facilities. level of evidence: level 5 keywords: evidence-based practice guideline, cancer, osteosarcoma, cultural competence, patient–provider communication, cross-cultural clinical settings culturally competent patient–provider communication with zulu patients diagnosed with osteosarcoma: an evidence-based practice guideline ottilia brown,¹* dalena rm van rooyen,² colleen aldous,¹ leonard c marais³ ¹ school of clinical medicine, university of kwazulu-natal, durban, south africa ² school of clinical care sciences, nelson mandela university, port elizabeth, south africa ³ department of orthopaedic surgery, school of clinical medicine, university of kwazulu-natal, durban, south africa *corresponding author: ottiliabrown1978@gmail.com https://orcid.org/0000-0003-2862-1733 page 99brown o et al. sa orthop j 2021;20(2) introduction communicating the diagnosis and prognosis of cancer is known to be challenging.1-10 furthermore, ensuring that patients understand their treatment options is considered good practice.11 performing these communication tasks in cross-cultural clinical settings complicates patient–provider communication.12 culture plays a significant role in how patients’ health-related values, beliefs and behaviours are shaped, and affects how patients and communities approach the diagnosis and treatment of cancer as well as their trust in healthcare providers and institutions.13,14 culture also affects providers’ and institutions’ approach to minority patients and contributes substantially to disparities in access to healthcare for minority and underprivileged patients.14,15 an evidencebased practice guideline (hereafter referred to as ‘guideline’) would contribute significantly to improving culturally competent communication with cancer patients receiving treatment at culturally discordant healthcare facilities. a guideline of this nature does not exist in the south african context. this guideline was developed for healthcare providers communicating with adult zulu patients diagnosed with osteosarcoma. the zulu people are indigenous and reside in the predominantly rural south african province of kwazulu-natal. they speak isizulu, one of south africa’s 11 official languages. this province has an overall population of 11.5 million (of a total south african population of 59.6 million), the majority of which is classified as zulu.16 the focus on osteosarcoma resulted from observations in clinical practice of the significant role that cultural factors play including extensive familial, ancestral and/or traditional healing consultations and rituals before agreeing to certain treatment options in the management of osteosarcoma. in addition, research findings indicated that most patients presenting at the study site already have locally advanced or metastatic disease.17 other observations in clinical practice related to delayed presentation included denial and/or underestimation of the seriousness of the condition. our research with healthcare providers and zulu patients at the study site confirmed that cultural considerations were paramount when treating zulu patients diagnosed with osteosarcoma.18-21 despite advances in treatment of osteosarcoma, survival is dependent on diagnosis prior to progression beyond localised disease.22 the late presentation of patients therefore limits treatment options and results in poor prognosis.17,23-26 the treatment options are closely related to patients’ understanding of their prognosis and the outcomes resulting from various approaches to treatment. healthcare providers in this setting are therefore expected to simultaneously inform patients of the diagnosis of osteosarcoma, the significant limitations with regard to treatment options, and prognostic considerations in a culturally sensitive manner that engenders cooperation in the patient while allowing them the opportunity to fulfil their cultural obligations. healthcare encounters at the study site are largely culturally discordant. methods the agree ii (appraisal of guidelines, research and evaluation) appraisal instrument was used as a guide for developing the guideline.27 the agree ii is a 23-item tool comprising six domains. scope and purpose the aim of the developed guideline is to present healthcare providers treating adult zulu patients diagnosed with osteosarcoma with evidence-based recommendations that can facilitate culturally competent communication regarding the diagnosis, treatment and prognosis of osteosarcoma. the review question read: how is culturally competent patient–provider communication best delivered by healthcare providers to adult zulu patients diagnosed with osteosarcoma? the targeted patient population are adult zulu patients diagnosed with osteosarcoma. stakeholder involvement the guideline was developed by one of the members of the multidisciplinary team working with zulu patients diagnosed with osteosarcoma. the developer is a content expert with methodological experience in both quantitative and qualitative research. furthermore, the healthcare providers working in a multidisciplinary team context with zulu patients diagnosed with osteosarcoma participated in three focus groups, and four zulu patients’ views and preferences were investigated using in-depth interviews. the evidence-based practice guideline was developed for use among healthcare providers (doctors, nurses and allied health professionals) working with zulu patients diagnosed with osteosarcoma. the doctors working in the orthopaedics department are the first port of call for these patients. nurses working in orthopaedic and oncology outpatient clinics and wards have the most contact with zulu patients diagnosed with osteosarcoma. allied health professionals working with this patient group include physiotherapists, clinical psychologists, social workers, occupational therapists and dieticians. rigour of development an integrative literature review was conducted to review the existing evidence. details of the integrative literature review process are available in brown et al.28 in addition, focus groups with healthcare providers18-21 and in-depth individual interviews with zulu patients22 were conducted in order to contextualise the guideline. the approach taken therefore reflects the general consensus in the literature that evidence-based practice typically includes three key components, namely, research-based evidence available from the literature, clinical expertise and patient preferences.29,30 the recommendations included in the guideline were developed using content analysis. the guideline development process was supervised by content and methodological experts. in addition, the guideline was also reviewed by expert reviewers comprising four content and methodological experts. their reviews showed consensus. guideline recommendations the recommendations are based on levels 4 and 5 evidence from the integrative literature review, focus groups with healthcare providers and patient interviews. a comprehensive and frequently used hierarchy system was used to rate the evidence.31 cultural competence has varied definitions but seems to require the acquisition, integration and application of awareness, knowledge, skills and attitudes regarding cultural differences in order to effectively deliver expert care that meets the unique cultural needs of patients; to manage and reduce cross-cultural misunderstanding in discordant medical encounters; and to successfully negotiate mutual treatment goals with patients and families from different cultural backgrounds.15,33-41 the guideline first specifies generic aspects such as the awareness, knowledge, skills and provider attitudes required for culturally competent communication as well as the type of healthcare systems that can support and cultivate such communication. the guideline then page 100 brown o et al. sa orthop j 2021;20(2) details specific recommendations for communicating the diagnosis, treatment and prognosis of osteosarcoma to zulu patients. results the guideline includes findings that encompass generic recommendations for culturally competent communication and specific recommendations communicating about osteosarcoma. generic requirements for culturally competent communication evidence-based rationale: generic requirements for engaging in culturally competent communication include the development of awareness, the acquisition of knowledge, the acquisition and implementation of skills and strategies, and fostering certain attitudes.15,33,34 the development and practice of culturally competent communication by individual practitioners and multidisciplinary teams is best fostered in the context of culturally competent healthcare systems. culturally competent healthcare systems provide linguistically and culturally appropriate services and supportive policies, strategies and resources that promote culturally competent communication.42 generic recommendation 1: healthcare provider awareness different types of healthcare provider awareness are required for working in cross-cultural oncology settings. it is recommended that healthcare providers develop contextual awareness of: • the country’s socio-political history41 • the socio-cultural factors that affect the patient–provider relationship42 • patient demographics in the service area43,44 • the role of gender in culture44,45 • the role of religion in culture45,46 • patients’ level of education46,47 • patients’ experiences of discrimination in clinical settings48 • dominant cultural narratives regarding health and illness49 • culturally constructed myths about cancer50 • cancer patients possibly combining allopathic and traditional medicine49 it is recommended that healthcare providers develop selfawareness of own: • culture51 • cultural beliefs52 • belief systems53 • spirituality54 • cultural assumptions, biases, and stereotypes14,42,51,53,55 it is recommended that healthcare providers develop interpersonal awareness of: • inherent power differentials between patient and provider41 • interaction between patient and provider’s culture51,56 • communication differences between cultures45,57 it is recommended that healthcare providers develop awareness of cultural expectations in the healthcare setting related to the: • level of family involvement required53,58 • role of family in cross-cultural clinical settings15,44,58,59 generic recommendation 2: healthcare provider knowledge culturally competent communication requires the acquisition, integration and application of knowledge regarding the context, the self and the patient’s culture. it is recommended that healthcare providers acquire knowledge of broader contextual factors pertaining to: • racism, sexism, ageism52,60 • socio-political barriers to accessing healthcare14,55,61 • the impact of past and present racism55 • the role of gender in the communication process14 • the role of age in the communication process14 • patients’ role expectations in the communications process14 • socio-historical cultural context14 • socio-cultural differences between self and patient55 it is recommended that healthcare providers acquire contextspecific knowledge of: • the cultural groups attending services in the provider’s clinical setting43,55,57,59,61,62 • the serviced population’s disease profiles, health disparities and treatment outcomes38,57 • cultural health-related needs and health-seeking behaviours55 • cultural approaches to illness and treatment42 • cultural meanings of cancer14 • patients’ perception of their illness57 • influence of culture on how patient interacts with healthcare system53 it is recommended that healthcare providers acquire selfknowledge of own: • culture49,55,57,61 • belief system55 • biases and stereotypes14,53,55,61 it is recommended that healthcare providers acquire knowledge of the patient’s culture, specifically: • the patient’s health belief systems18,48,58,61 • the patient’s traditional health system18,58 • the role of gender in decision-making43,58 • the role of family in decision-making19,43,59 • preferences regarding language used to discuss cancer15 • nonverbal communication standards15 generic recommendation 3: healthcare provider skills the healthcare provider is expected to acquire, integrate and apply a variety of skills in order to successfully deliver culturally competent patient–provider communication. it is recommended that healthcare providers deliver culturally and linguistically sensitive services by acquiring and applying the following cross-cultural communication skills: • engage in culturally sensitive communication recognising the values, beliefs and practices of the patient and presenting the communication accordingly14,15,50,63 • engage in culturally congruent communication which recognises that cultural variations exist between patient and healthcare professional and engages in culturally sensitive and competent communication accordingly14,61 • observe culturally appropriate nonverbal communication etiquette14 • use congruent verbal and nonverbal communication14,61 page 101brown o et al. sa orthop j 2021;20(2) it is recommended that healthcare providers ensure patient understanding by acquiring and applying the following communication skills and strategies: • provide clear,58,61 accurate,58,61 open,47,48,54,64 flexible47 and transparent54 communication • provide information in the patient’s language58 • learn the language58 • develop a vocabulary of terms familiar to the patient58 • include some basic isizulu phrases in conversations18 • use language that patients can understand18 • use simple language18,41,46,48 • encourage the patient to ask questions18,45 • repeat information several times18,41 • check patient understanding of information18,41,49,56-58,63 • check what patients remember from previous explanations18 • do not use medical jargon18 it is recommended that healthcare providers manage differences in the patient–provider encounter: • avoid stereotyping and generalisations14,19,38,42,55,57,58,61 • do not make assumptions about patient race, nationality and language15,19,21 • treat patients equally46,47 • encourage patients to raise concerns about discrimination48 • create a culturally safe and caring environment41,64 • individualise patient care42,64 it is recommended that healthcare providers build the patient– provider relationship: • invest time in the beginning43,57,65 • engage the patient61 • build rapport41,45 • gain patient trust32,45,47,50,61 • respond to patients’ emotions18-21 • actively engage patients in decision-making19,45,57,63 • encourage and empower patients to raise trust issues48 • address patients according to cultural preference61 • recognise inherent power differentials61 • be open about own cultural frame of reference49 • acknowledge own cultural background to patients15 • respond skilfully to cultural discordance61 it is recommended that healthcare providers conduct a comprehensive patient assessment: • assess patients’ specific communication needs65 • conduct a cultural assessment by actively exploring patients’ culture54,56,65 • invite patients to describe their cultural backgrounds62 • explore views on family and community in the healthcare context62 • explore cultural61 and health beliefs53 • explore family expectations, feelings and concerns54 • explore level of family involvement required53 • determine who the main decision-makers are (patient or family?)19,21,42,43 • explore preferences for truth disclosure15,53,57 • explore patients’ spiritual and religious beliefs15,54 • ask patients about their disease process19,20 • use kleinman’s eight questions32,62 it is recommended that healthcare providers acquire and apply the skill of accommodating the patients’ family: • invest in and gain family trust46,61 • communicate with extended family as per patient’s directive19,61 • afford the family maximum control possible if this is a patient need54 it is recommended that healthcare providers instil and maintain hope regardless of the disease stage by:18 • emphasising what can be done • informing patients that a palliative amputation could help with pain management • reassuring patients of continued involvement of the multidisciplinary team • differentiating the different problems that would be addressed • explaining how the different problems would be addressed ▫ avoiding the provision of false hope ▫ do not inform patients that amputation could cure due to the possibility of disease recurrence generic recommendation 4: healthcare provider attitudes it is recommended that healthcare providers cultivate and integrate the following attitudes in order to facilitate culturally competent communication: • take responsibility for cultural aspects of health and illness42 • take responsibility for combating discrimination in healthcare settings42 • take responsibility for learning about the zulu culture18 • be willing to learn from patients61 • be open to change and growth64 • be culturally sensitive15,42,64 • be willing to listen64 • develop and demonstrate respect for cultural diversity, for the patient’s culture and their cultural values15,42,47,48,53,59-61 • demonstrate respect for patients’ spiritual and religious beliefs46 • develop an appreciation of different health belief systems60 • be willing to explore culture with individual patients57 • validate different cultures62 • engage in continual self-examination and self-reflection to examine one’s own values and assumptions52,55,64 • be willing to adjust behaviours and attitudes57 • reflect on own interaction with cultural groups in the clinical setting57 generic recommendation 5: culturally competent healthcare systems culturally competent healthcare systems are a requirement for the delivery of culturally competent communication. it is recommended that healthcare systems cultivate the following characteristics: • respond to individual needs and to how cultures are perceived50,55 • promote and facilitate effective patient-centred communication55 • respect cultural differences, and support effective care for diverse populations54 • provide ethnic-specific services14 • convert an awareness of disease prevalence into practices and policies38 • develop and implement policies to support effective crosscultural communication55,64 • link with culturally competent agencies and community organisations that provide bilingual and bi-cultural navigation, promotions and community health outreach services14 page 102 brown o et al. sa orthop j 2021;20(2) • have adequate support services64 • include traditional healers in patient care19 it is recommended that healthcare systems employ the following cultural competence strategies: • use patient navigators36,43,45,61,66,67 • use experienced and professional interpreters14,15,32,42,45,48,49,53,58,62 • use culturally sensitive print, visual and audio-visual media and electronic communication45,49,63 • use images to assist providers when discussing cancer with patients18,41 • monitor patient characteristics48 • translate written communications42 • provide language-concordant encounters48 • provide patient-centred care66 • consult communities on cultural needs41 • integrate community resources into cancer care14 • display images of people from cultural groups attending the service41 • have ethnically similar staff visible41 specific recommended strategies for communicating the diagnosis, treatment and prognosis of osteosarcoma the focus groups and patient interviews revealed specific strategies for communicating the diagnosis of osteosarcoma to zulu patients. general recommendations for discussing treatment as well as proposed strategies for managing cultural factors that affect treatment are outlined. prognosis discussion recommendations are less extensive but still provide some guidance on how to approach this challenging task. specific recommendations 1: strategies for communicating the diagnosis of osteosarcoma to zulu patients evidence-based rationale: communicating the diagnosis of cancer in cross-cultural clinical settings is documented as a challenging task.1-4,68 results from the focus group interviews with healthcare providers highlighted distinctive factors that complicate communicating the diagnosis of osteosarcoma to zulu patients. the zulu people generally view the cancer diagnosis as an ancestral punishment or resulting from witchcraft and have been socialised to associate a cancer diagnosis with a poor prognosis. the isizulu word for cancer reflects these cultural health beliefs and presents a significant barrier as the meanings associated with this word significantly complicate the diagnosis discussion especially when a good prognosis is possible. the isizulu word for cancer is umdlavuza and refers to something that ravages, destroys or cannot be stopped. furthermore, language barriers present a significant challenge in this cross-cultural setting. the lack of availability of medical terms in isizulu and the limitations with regard to the translatability of words into the patient’s language significantly impacts patient understanding. language barriers further manifest in the lack of access to professional interpreters. communicating the diagnosis of osteosarcoma to zulu patients therefore requires an understanding of cultural and health beliefs and incorporating this knowledge into diagnostic conversations. it is recommended that healthcare providers provide patients with factual information about their condition including:21 • its name • prevalence • causes it is recommended that healthcare providers set the stage for truthtelling by: • starting the diagnosis discussion right from the beginning18 • assessing how much the patient knows18 • warning patients a few times about a possible cancer diagnosis18,21 • giving patients incremental information as the diagnostic process unfolds18 • informing patients of the reasons for diagnostic tests18,21 • warning patients before delivering bad news when the diagnosis is confirmed18,21 • warning patients by reminding them of earlier conversations of possible diagnosis18 • checking patients’ readiness to receive the diagnosis21 • offering privacy when communicating the diagnosis21 • confirming diagnosis only once patient has been warned18,21 it is recommended that healthcare providers engage in patientcentred communication by: • building a relationship with the zulu patient18 • spending time with the patient18 • offering the patient support18 • demonstrating a personal interest in the patient18 • assessing and addressing patient needs, emotions, and coping18,21 • responding to patient questions about the diagnosis18 • assessing patients’ reactions to the diagnosis18 • responding appropriately to patients’ reactions to the diagnosis18 • managing the response of denial by18 ▫ acknowledging that the diagnosis is difficult to accept ▫ reinforcing the diagnosis ▫ helping patients to accept the diagnosis • mobilising support by having a psychologist present when patients are informed of the diagnosis18 it is recommended that healthcare providers engage in culturecentred communication by: • taking responsibility for improving communication18 • demonstrating an understanding of zulu cultural health beliefs18 • reassuring patients that their diagnosis is:18 ▫ not due to anything that they have done ▫ not a punishment ▫ not due to bewitchment • demonstrating a genuine interest in the zulu culture by:18 ▫ asking patients questions about ▪ their cultural practices ▪ their religious practices ▪ their understanding of the aetiology of the condition ▪ how they want to manage the condition ▪ their cultural health beliefs ▫ offering patients the best care possible regardless of language discordance18 it is recommended that healthcare providers facilitate understanding of the diagnosis by:18 • using visual aids ▫ use images, pictures and information brochures • explaining the stages of cancer ▫ educate patients regarding their stage of the disease ▫ educate patients about the effects of cancer in every stage • using metaphors page 103brown o et al. sa orthop j 2021;20(2) ▫ use metaphors to explain concepts like cells, organs, tumours and metastases ▫ use patient-initiated metaphors specific recommendation 2: strategies for communicating the treatment of osteosarcoma to zulu patients evidence-based rationale: owing to the late presentation of patients for treatment at the study site,17 treatment options are limited, and prognoses are often poor. healthcare providers consequently must simultaneously inform patients of the diagnosis of osteosarcoma as well as the significant limitations regarding treatment options. several cultural factors have been identified about discussing the treatment option of amputation with zulu patients. healthcare providers reported in the focus group interviews that zulu patients’ cultural beliefs dictate that they cannot become an ancestor if they have an amputation because their body is incomplete. the issue of post-amputation community exclusion was also raised. the patient interviews also revealed that cultural considerations become important when treatment, specifically amputation, is discussed. focus groups and patient interviews further indicated other zulu cultural and health beliefs that affect treatment such as the belief in traditional healing and the need to consult with cultural decision-makers before agreeing to treatment. the recommendations on how to communicate with zulu patients regarding the treatment of osteosarcoma therefore take these cultural beliefs and practices into account. it is recommended that healthcare providers provide patients with factual information pertaining to:19,21 • surgical treatment options ▫ limb salvage is explained if this is an option ▫ amputation is discussed if it is the only option or in the case of borderline tumours • chemotherapy ▫ its purpose ▫ when and how it will be used ▫ side-effects of chemotherapy (emphasised in patient interviews) • treatment of metastases (metastasectomies and/or chemotherapy) it is recommended that healthcare providers follow this process when discussing treatment with patients: • delay providing treatment information until staging investigations are completed19 • inform patients about the prognostic consequences of not treating the tumour, e.g. metastases, shortened life-span19,21 • balance hope and honesty19 by: ▫ communicating the urgency of intervening21 ▫ offering patients reassurance21 • ensure patient understanding by:19 ▫ using analogies ▫ using the stages of cancer to explain disease progression and realistic treatment options • explore and manage patients’ emotions associated with amputation and chemotherapy21 it is recommended that healthcare providers use these strategies for responding to cultural factors associated with amputation:19 • time the treatment discussion to prevent the patient from signing refusal of hospital treatment before diagnostic testing is complete • when patients refuse amputation, offer patients other treatment options such as chemotherapy and refer patients to other services like oncology, psychology, social work and dietetics • mobilise support by having a psychologist present when patients are informed that an amputation is required • expose patients to veteran osteosarcoma patients who have successfully adjusted to amputation • show newly diagnosed patients a video of patients with successful outcomes it is recommended that healthcare providers use these strategies for responding to cultural and health beliefs that affect treatment: • initiate cultural discussions in order to fast track decisionmaking19 • demonstrate an understanding of patients’ cultural beliefs by: ▫ acknowledging patients’ need to discuss treatment with their family19 ▫ encouraging patients to engage in their cultural traditions and rituals19 ▫ encouraging patients to combine western and traditional approaches19,21 ▫ respecting patients’ cultural health beliefs and their desire to consult a traditional healer19,21 • liaise directly with family and cultural decision-makers where possible19 • negotiate with patients to not go home and to rather invite a family member(s) to the hospital19 specific recommendation 3: strategies for communicating prognostic information pertaining to osteosarcoma with zulu patients evidence-based rationale: given the late presentation of patients at the study site, healthcare providers must communicate diagnostic and treatment information urgently. the treatment options are closely related to patients’ understanding of their prognosis and the outcomes resulting from various approaches to treatment. it is recommended that healthcare providers assess patient emotions and knowledge by: • enquiring about patients’ thoughts, fears and impressions of the future20 it is recommended that healthcare providers inform patients of the prognostic consequences of not treating the osteosarcoma:20,21 • inform patients of the likelihood of metastases if the osteosarcoma is not treated • inform patients of the effect on survival if the osteosarcoma is not treated it is recommended that healthcare providers inform patients of treatment limitations: • explain the nature of osteosarcoma to patients and inform patients that this type of cancer is not curable20 • inform patients that even with surgery the cancer could recur20,21 • inform patients that they must return within six months and then annually to check for cancer recurrence20,21 when patients have metastases, it is recommended that healthcare providers inform patients that: • they have metastases20,21 • the condition is not curable, but that amputation could help with pain20 • treatment options are limited due to the metastases20 it is recommended that healthcare providers inform patients of poor prognoses: page 104 brown o et al. sa orthop j 2021;20(2) • inform patients about the terminal nature of the disease if the osteosarcoma is reasonably expected to result in the death of the patient within a short period of time20 • normalise death20 • do not inform patients of the life expectancy20 it is recommended that healthcare providers use a staged approach to communicating about prognosis.20 given the late presentation of patients at this tertiary hospital, a staged approach may be more useful for patients that present with localised or metastatic disease that is amenable to surgical management. • communicate about immediate treatment goals and if the disease progresses, communicate about adjustments in treatment goals to, for example, palliative care • if treatment is working and cancer is remitting, communicate with patients about rehabilitation and resuming normal everyday activities. conclusion communicating with patients about cancer in cross-cultural clinical settings is widely recognised as a challenging task. this guideline offers guidance about approaching this daunting task. the limitations of the body of evidence are noted and should be considered when this guideline is reviewed. some of these limitations include the mostly low-level evidence (level 5) in the integrative literature review; the lack of availability of some of the healthcare providers at the time of data collection; patients’ retrospective accounts of their experiences as the interviews were conducted at one point in time; and challenges experienced with regard to locating participants thereby limiting the size of the sample. this guideline included research with the healthcare providers and patients thus providing higher levels of evidence for some of the recommendations. further development of this guideline needs to address the remaining limitations. furthermore, the guideline has not been piloted with the target group as this task was beyond the scope of the current research study. however, implementing the guideline and conducting research to investigate its effectiveness will also facilitate further development of the guideline. acknowledgements the guideline reviewers are acknowledged for their significant contribution to the end product presented here. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study ethics approval for the phd study was obtained from the biomedical research ethics committee (brec) of the university of kwazulunatal (ukzn) (reference no: be051/15) where the phd study was registered. this guideline refers to findings obtained from studies with healthcare providers and patients done as part of the phd study. informed consent was always obtained from both these groups in a language that was preferable to the participants, namely english or isizulu. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ob made substantial contributions to the conception and design of the work; the acquisition, analysis, and interpretation of data for the work; drafting the work; final approval of the version to be submitted to the journal; and has agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. rmvr made a substantial contribution to the conception and design of the work, revising it critically for important intellectual content; final approval of the version to be published; and has agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. ca made a substantial contribution to the conception and design of the work, revising it critically for important intellectual content; final approval of the version to be published; and has agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. lcm made a substantial contribution to the conception and design of the work, revising it critically for important intellectual content; final approval of the version to be published; and has agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately 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key to cultural competence. ann oncol. 2012;23(3):iii33–iii42. https://www.annalsofoncology.org/article/ s0923-7534(19)38890-8/fulltext. 63. kreps gl. communication and racial inequities in health care. am behav sci. 2006;49(6):760-74. https://journals.sagepub.com/doi/ abs/10.1177/0002764205283800. 64. huang y, yates p, prior d. factors influencing oncology nurses’ approaches to accommodating cultural needs in palliative care. j clin nurs. 2009;18:3421-29. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2702.2009.02938.x. 65. cohen m z, palos g. culturally competent care. semin oncol nurs. 2001;17(3):153-58. https://pubmed.ncbi.nlm.nih.gov/11523481/. 66. moore ad, hamilton jb, knafl gj, et al. patient satisfaction influenced by interpersonal treatment and communication for african american men: the north carolina–louisiana prostate cancer project (pcap). am j men’s health. 2012;6(5):409-19. https://pubmed.ncbi.nlm.nih.gov/22833311/. 67. murphy mm, tseng jf, shah sa. disparities in cancer care: an operative perspective. surgery. 2010;147(5):733-37. https://pubmed.ncbi.nlm.nih. gov/19962161/. 68. gao g, burke n, somkin cp, pasick r. considering culture in physician– patient communication during colorectal cancer screening. qual health res. 2009;19(6):778-89. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2921881/. _heading=h.gjdgxs _heading=h.30j0zll south african orthopaedic journal knee doi 10.17159/2309-8309/2021/v20n3a4 le roux j et al. sa orthop j 2021;20(3) citation: le roux j, dey r, deichl as, torney o, laubscher m, graham sm, held m. correlation of the squat-and-smile test against other patient-reported outcome scores in knee pathology. sa orthop j 2021;20(3):157-161. http://dx.doi.org/10.17159/23098309/2021/v20n3a4 editor: dr david north, paarl hospital, western cape, south africa received: september 2020 accepted: january 2021 published: august 2021 copyright: © 2021 le roux j. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was obtained for this study. conflict of interest: the authors confirm there are no conflicts of interest, financial or otherwise, to declare. abstract background the use of patient-reported outcome measures (proms) for knee pathology may be affected by socioeconomic factors, language barriers and time constraints in busy outpatient clinics. the squat-and-smile test (sst) is an example of such a test that has previously been validated for femur fractures. the aim of this study was to validate the sst against other proms in patients with knee pathology. methods patients presenting to a subspecialist knee clinic in a large hospital in sub-saharan africa were approached to participate. they were asked to squat and the depth of the squat as well as the need to support themselves were classified into four categories. to describe their pain, participants also selected one of three smiley faces (unhappy, neutral, smiling). these test scores were correlated to the patient’s knee injury and osteoarthritis outcome score (koos), tegner lysholm score and eq-5d scores. results seventy patients (median age 53.4 years) were included. the squat depth correlated moderately with the koos score (r=0.56) and poorly with the eq-5d and lysholm scores (r=0.46; r=0.43). the need for squat support had poor correlations with the koos, eq-5d and lysholm scores (r=0.29; r=0.31; r=0.31), as did the smiley face component (r=0.40; r=0.32; r=0.30). conclusion for patients with knee pathology, the squat depth correlates moderately with other proms. it could therefore be used in settings for which conventional proms have limited application. support needed to squat, and a visual analogue scale of smiley faces, had poor correlation when compared to other knee proms and should not be used for the assessment of knee pathology. level of evidence: level 4 keywords: squat and smile, koos, prom, smiley faces, outcome score correlation of the squat-and-smile test against other patient-reported outcome scores in knee pathology johan le roux,1 roopam dey,1,2 andrea s deichl,1 oscar torney,3 maritz laubscher,1 simon m graham,1,4 michael held1* ¹ orthopaedic research unit, department of orthopaedic surgery, groote schuur hospital, university of cape town, south africa ² department of human biology, division of biomedical engineering, university of cape town, south africa ³ charité universitätsmedizin berlin ⁴ liverpool school of tropical medicine, liverpool, united kingdom *corresponding author: michael.held@uct.ac.za introduction patient-reported outcome measures (proms) are crucial to determine functional deficits and monitor clinical improvement as well as scientific outcomes.1 however, proms can be timeconsuming and, especially in developing countries, language barriers as well as the use of translators may lead to an incorrectly reported outcome.2 for knee pathology in particular, a multitude of measures are available to reliably test functional status and monitor improvement after treatment, but no specific proms have been developed for a resource-limited setting.3-5 proms assess, among other criteria, the patient’s ability to perform activities of daily living (adls). the need to squat to complete adls differs across cultural and socioeconomic groups. a lower socioeconomic background has been linked to an increase in squatting requirements, and likewise the presence of fewer chairs and tables in a household.6 in countries like malawi, nigeria, zambia, india and pakistan, squatting has been shown to be associated with praying, food preparation, eating and using pit latrines.6-10 therefore, in these cultures squatting is a critical function. the squat-and-smile test (sst) was developed to assess union in femur shaft fractures in low-resource settings10 and could potentially be useful to assess knee pathology. the original sst consisted of asking a patient to squat, and then assessing and grading three components: the depth of the squat, the need for hand support to steady oneself during the squat, and the facial expression during the squat (unhappy, neutral or happy). our primary aim of the study was therefore to validate the sst against other commonly used knee proms. https://orcid.org/0000-0002-5658-6827 https://orcid.org/0000-0002-0671-0439 page 158 le roux j et al. sa orthop j 2021;20(3) methods recruitment and demographics participants presenting to a knee unit of a large public university hospital in sub-saharan africa were recruited via a cluster random sampling process. patients above the age of 18 years and patients with knee pain were included. patients who were unable to walk and had visual impairment were excluded from the study. demographic information was recorded, as well as the level of education, which was graded as either high (completed tertiary education), intermediate (completed secondary schooling such as high school) or low education (did not complete secondary schooling) or none (did not complete basic schooling). after consultation with an orthopaedic surgeon, the diagnosis was recorded based on history, clinical examination and radiological investigation. institutional approval and written consent were obtained. squat-and-smile test the sst consisted of testing three separate components based on the patient performing a squat in the clinic: the depth of the squat itself, the need to support oneself during the squat, and the patient afterwards selecting an emoticon or ‘smiley face’ that best conveyed how they experience squatting. the depth of the squat was divided into four different levels (table i) based on the height of the patient’s hips. the squat was performed between two chairs, and the amount of support needed was also subclassified into four levels. for the smile component, patients were then asked to select one of three emoticons (figure 1) which best described their pain during squatting. this test is, therefore, a modification of the original sst which was described previously,10,11 highlighting the influence of squatting activities of daily living.7,8 the same domains were used in this study; however, the ability to smile while squatting was replaced using the visual analog score of smiley faces.10 scores apart from the sst, the knee injury and osteoarthritis outcome score (koos), lysholm score, and the eq-5d score were recorded. knee injury and osteoarthritis outcome score (koos) physical short form (ps) the koos assesses daily living and function, sports and recreational activity as a seven-item questionnaire. the measure is scored by converting this raw sum of the items to a rasch-based interval score provided in the koos-ps user guide to range from no difficulty (0) to extreme difficulty (100). it assesses the functional status of patients with knee arthritis or ligament injuries, and responses are coded from 0 to 4, none to extreme.5 the questionnaire is scored by summing the raw response (range 0–28) and then converted using a nomogram to a true interval score. each question must have a response (i.e., no missing data). the smallest detectable difference is 18.6.12 the koos score has been validated for multiple languages, for traumatic knee injuries and for osteoarthritis.13 tegner lysholm score the tegner lysholm score4 is one of the most commonly used knee scores in studies for multiligament knee injuries and proposed by experts as a patient-specific outcome metric for knee dislocations.14 it has various questions on knee function regarding limping, pain, locking, stair-climbing, support, instability, swelling and squatting, which can be rated. an overall score is given and less than 65 is poor, 65–83 is fair, 84–90 is good, and more than 90 points represents excellent knee function. in the normal population the average lysholm score is 94 (range 43–100), and the average tegner activity level is 5.7 (range 1–10). the minimum detectable change for lysholm is 8.9 and for tegner is 1. both the lysholm (intraclass correlation coefficient = 0.9) and tegner (intraclass correlation coefficient = 0.8) scores have an acceptable test-retest reliability.15 eq-5d the eq-5d was designed by euroqol, a network of researchers of measurements of health status.16 this short questionnaire measures the generic health status and is applicable for clinical as well as economic evaluation of the delivery of healthcare.17 it can be self-completed and accurately evaluates change after an orthopaedic intervention.18 although it is not a knee-specific outcome score, it has comparable practicality and construct validity to other knee scores and is appropriate to assess interventions which are designed to alleviate knee pain.19 the minimal clinically important difference for this score is 0.074.20 the score can be compared to mean population ratings. statistical analysis and sample size a sample size calculation prior to the study showed that 19 participants would achieve 80% power to detect a mean of paired differences of 4.5, with a known standard deviation (sd) of differences of 7.0 and with a significance level (alpha) of 0.05 using a two-sided paired z-test. we recruited a higher number of participants to enable a potential subgroup analysis. internal consistency for the koos-ps, eq-5d, and lysholm score was calculated using cronbach’s alpha. the sst responses were correlated with the other standardised scores and spearman rank correlation coefficient (rs) was calculated. this result was interpreted as follows: poor correlation (less than 0.3), fair or moderate correlation (0.3–0.5), moderately strong correlation (0.6–0.8) and a very strong correlation (0.8 and above).21 the table i: the three components of the squat-and-smile test squat depth component points unable to squat at all 0 squats with hips above knees 1 squats with hips to level of knees 2 squats with hips below level of knees 3 support component   unable to squat 0 requires support with both hands 1 requires support with one hand 2 does not require support while squatting 3 smile component   selected ‘unhappy’ face 0 selected ‘neutral’ face 1 selected ‘happy’ face 2 figure 1. smiley face (yellow), neutral face (green) and unhappy face (blue) as emoticons patient could select to rate their pain during squatting page 159le roux j et al. sa orthop j 2021;20(3) standardised test scores and each category of the sst were compared using kruskal–wallis test for which the condition for statistical significance was kept at p<0.05, post bonferroni correction, and a post-hoc power (1-β error) calculation was performed. the statistical analyses were performed in g* power v.3.1.9.22,23 and ibm spss v.26 (armonk, ny: ibm corp). results demographics seventy patients (median age of 53.4 years, iqr: 27.25 years) were included in the study. forty-five (64%) were female and 25 male (36%). their demographic information and knee pathology are summarised in table ii. three patients with incomplete questionnaires were excluded. squat depth of the 70 participants, 12 (17%) were able to squat with their hips lower than their knees, 15 (21%) with the hips at the level of the knees, 34 patients (49%) with their hips above the knees, and nine patients (43%) were unable to squat. the squat depth had moderate correlation with the koos score, and poor correlation with the eq-5d and the tegner lysholm score. (table iii). the correlation between the modified sst and the koos score increased with squat depth (p<0.05) (figure 2). squat support fifty-two of the 70 participants were able to perform a squat without any support (74%), and 18 required support (26%). of these, nine patients (13%) were unable to perform a squat, four required a single arm support (6%) and five required the support of both arms (7%). squat support correlated poorly with the koos, lysholm and eq-5d scores (table iii) (figure 3). smiley face component a happy face was selected by 28 (40%) participants, a neutral face by 17 (24%), and an unhappy face by 25 (36%) to describe their pain during squatting (figure 1). the face selection correlated poorly with the koos, lysholm and eq-5d (figure 4). discussion this study showed that there was a moderate to poor correlation of the index score to the koos (r-value=0.56), lysholm (r=0.38) and eq-5d (r=0.44), although the correlation with the koos score increased with squat depth. among the koos, lysholm and eq5d scores, there was moderate to good correlation (r=061; r=0.71; r=0.62). barriers to the use of proms have previously been reported as the time spent on completing the score, patient health literacy, and socioeconomic status.2,24 these barriers were also present in our table ii: patient demographics age (yr, sd) 54.4 (17.3) sex (n, %) male 29 (41.4) female 41 (58.6) first language (n, %) english 38 (54.3) afrikaans 23 (32.9) isixhosa 9 (12.9) income unemployed 30 (42.9) <$5 260 p.a. 19 (27.1) $5 260–$1 8410 p.a. 7 (10) >$1 8410 p.a. 6 (8.6) unavailable 8 (11.4) side (n, %) right 32 (45.7) left 23 (32.9) bilateral 15 (21.4) knee pathology (n, %) arthropathy 43 (61.4) ligamentous injury 18 (25.7) meniscus/cartilage 7 (10) unknown 2 (2.9) table iii: correlation between squat-and-smile components and outcome scores displayed in r-value variables koos eq-5d lysholm sst squat sst support sst smile koos 1.00 0.61 0.71 0.56 0.29 0.40 eq-5d 0.61 1.00 0.62 0.46 0.31 0.32 lysholm 0.71 0.62 1 0.43 0.31 0.30 koos: knee injury and osteoarthritis outcome score; sst: squat-and-smile test; squat: depth of squat; support: support needed to squat; smile: facial expression score figure 2. the correlation of the squat depth with the knee injury and osteoarthritis outcome score (koos), the eq-5d and the lysholm scores, as displayed in r-value. the squat depth had a fair correlation with the koos score, and a poor correlation with the eq-5d and lysholm scores. k o o s eq -5 d ly sh ol m squat level page 160 le roux j et al. sa orthop j 2021;20(3) study population. sixty-four patients (74%) did not complete their secondary schooling, 32 patients (46%) did not speak english as their first language, and at least 49 patients (70%) had a household income of less than $5 260 per annum. this was one of our main drivers to establish a simple, acceptable and valid outcome measure tool. wu et al.10 described the sst for a similar setting to assess healing in femur fractures, but we could not achieve similar results for our patients assessing knee pathology. although the inability to squat has previously been associated with hip and knee injuries and surgery,8,25,26 the squat component of this test had fair correlation with the koos and poor correlation with the lysholm and eq-5d scores.21 the squat support, although previously found to have good correlation with femur shaft nonunion, had a poor correlation when assessing knee pathology.10 rating of knee pain with smiley faces also correlated poorly with the other proms, also noted by wu et al.10 using a similar ‘smilewhile-squatting’ component. although a single examiner captured the data and there was consistency in the examination and observation techniques, this study has limitations. concomitant pathology in the ipsilateral lower limb or contralateral knee pathology could possibly have confounded the scores. the body mass index (bmi) was also not recorded for the participants. however, these would also reflect in reference proms and should therefore not affect the correlation of the sst to these scores. as previously mentioned, the requirement to squat has been shown to be an important activity of daily living in some lowand middle-income countries, where the squatting position may be used while cooking, praying, using pit latrines and eating,7 and requires almost full range of motion of the hips and knees.27 the activities for daily life might be affected differently with the cultural need for squatting. as such, we did not test a specific patient cohort regarding the cultural need for squatting. conclusion although the squat component of the sst had a moderate correlation with other proms, squat support and a visual analogue scale based on smiley faces had weak correlation. a graded scale of squatting can therefore be used as an outcome measure for knee pathology when the collection of conventional proms is challenging. future research should focus on validating proms in cultural groups with varying needs for squatting to perform adls and validating the sst for other lower limb pathology. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study ethical approval was obtained from the university of cape town human research ethics committee (hrec), no. 144/3030. written consent was obtained from the patients included in this study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions jlr: primary author; design, data contribution, manuscript preparation rd: design, data analysis, manuscript preparation figure 3. the correlation of the squat support with the knee injury and osteoarthritis outcome score (koos), the eq-5d and the lysholm scores, as displayed in r-value. the squat support had poor correlation with the prom scores. k o o s eq -5 d ly sh ol m squat support figure 4. the correlation of the smile-while-squatting component with the knee injury and osteoarthritis outcome score (koos), the eq-5d and the lysholm scores, as displayed in r-value. the smile-while-squatting had poor correlation with the prom scores. k o o s eq -5 d ly sh ol m squat face page 161le roux j et al. sa orthop j 2021;20(3) asd: conceptualisation, design, manuscript preparation ot: conceptualisation, design, data collection ml: conceptualisation, design, manuscript preparation smg: conceptualisation, design, manuscript preparation mh: supervisor, conceptualisation, design, data collection, manuscript preparation orcid le roux j https://orcid.org/0000-0002-5658-6827 dey r https://orcid.org/0000-0002-3616-1995 deichl as https://orcid.org/0000-0003-2016-0709 torney o https://orcid.org/0000-0003-4348-532x laubscher m https://orcid.org/0000-0002-5989-8383 graham sm http://orcid.org/0000-0002-4091-7548 held m https://orcid.org/0000-0002-0671-0439 references 1. patrick dl, burke lb, powers jh, et al. patient-reported outcomes to support medical product labeling claims: fda perspective. value health. 2007;10(suppl 2):s125-37. https://doi.org/10.1111/j.1524-4733.2007.00275.x. 2. schamber em, takemoto sk, chenok ke, bozic kj. barriers to completion of patient reported outcome measures. j arthroplasty. 2013;28(9):1449-53. https://doi.org/10.1016/j.arth.2013.06.025. 3. wang d, jones mh, khair mm, miniaci a. patient-reported outcome measures for the knee. j knee surg. 2010;23(3):137-51. https://doi.org/10.1055/s-0030-1 268691. 4. tegner y, lysholm j. rating systems in the evaluation of knee ligament injuries. clin orthop relat res. 1985;198:43-49. 5. roos em, roos hp, lohmander ls, et al. knee injury and osteoarthritis outcome score (koos) development of a self-administered outcome measure. j orthop sports phys ther. 1998;28(2):88-96. https://doi. org/10.2519/jospt.1998.28.2.88. 6. gibson t, hameed k, kadir m, et al. knee pain among the poor and affluent in pakistan. br j rheumatol. 1996;35(2):146-49. https://doi.org/10.1093/ rheumatology/35.2.146. 7. grimason am, davison k, tembo kc, et al. problems associated with the use of pit latrines in blantyre, republic of malawi. j r soc promot health. 2000;120(3):175-82. https://doi.org/10.1177/146642400012000307. 8. singh u, wason ss. multiaxial orthotic hip joint for squatting and cross-legged sitting with hip-knee-ankle-foot-orthosis. prosthet orthot int. 1988;12(2):101102. https://doi.org/10.3109/03093648809078207. 9. lubega n, mkandawire nc, sibande gc, et al. joint replacement in malawi: establishment of a national joint registry. j bone jt surg ser b. 2009;91(3):341-43. https://doi.org/10.1302/0301-620x.91b3.21706. 10. wu hh, liu m, challa st, et al. development of squat-and-smile test as proxy for femoral shaft fracture-healing in patients in dar es salaam, tanzania. j bone jt surg. 2019;101(4):353-59. https://doi.org/10.2106/jbjs.18.00387. 11. eliezer en, haonga bt, morshed s, shearer dw. predictors of reoperation for adult femoral shaft fractures managed operatively in a sub-saharan country. j bone jt surg. 2017;99(5):388-95. https://doi.org/10.2106/jbjs.16.00087. 12. collins nj, prinsen cac, christensen r, et al. knee injury and osteoarthritis outcome score (koos): systematic review and meta-analysis of measurement properties. osteoarthr cartil. 2016;24(8):1317-29. https://doi. org/10.1016/j.joca.2016.03.010. 13. roos em, lohmander ls. the knee injury and osteoarthritis outcome score (koos): from joint injury to osteoarthritis. health qual life outcomes. 2003;1(64):1-8. 14. moatshe g, dornan gj, ludvigsen t, et al. high prevalence of knee osteoarthritis at a minimum 10-year follow-up after knee dislocation surgery. knee surgery, sport traumatol arthrosc. 2017;23:3914-22. https://doi. org/10.1007/s00167-017-4443-8. 15. briggs kk, lysholm j, tegner y, et al. the reliability, validity, and responsiveness of the lysholm score and tegner activity scale for anterior cruciate ligament injuries of the knee: 25 years later. am j sports med. 2009;37(5):890-97. https://doi.org/10.1177/0363546508330143. 16. hurst np, kind p, ruta d, et al. health-related quality of life in rheumatoid arthritis: validity, responsiveness and reliability of euroqol (eq-5d). br j rheumatol. 1997;36(5):551-59. https://doi.org/10.1093/rheumatology/36.5.551. 17. payakachat n, ali mm, tilford jm. can the eq-5d detect meaningful change? a systematic review. pharmacoeconomics. 2015;33(11):1137-54. https://doi. org/10.1007/s40273-015-0295-6. 18. jansson kå, granath f. health-related quality of life (eq-5d) before and after orthopedic surgery. acta orthop. 2011;82(1):82-89. https://doi.org/10.3109/174 53674.2010.548026. 19. barton gr, sach th, avery aj, et al. comparing the performance of the eq-5d and sf-6d when measuring the benefits of alleviating knee pain. cost eff resour alloc. 2009;7(1):12. https://doi.org/10.1186/1478-7547-7-12. 20. walters sj, brazier je. comparison of the minimally important difference for two health state utility measures: eq-5d and sf-6d. qual life res. 2005;14(6):1523-32. https://doi.org/10.1007/s11136-004-7713-0. 21. chan yh. biostatistics 104: correlation analysis. singapore med j. 2003;44(12):614-19. 22. faul f, erdfelder e, buchner a, lang a-g. statistical power analyses using g*power 3.1: tests for correlation and regression analyses. behav res methods. 2009;41(4):1149-60. https://doi.org/10.3758/brm.41.4.1149. 23. faul f, erdfelder e, lang ag, buchner a. g*power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. behav res methods. 2007;39(2):175-91. https://doi.org/10.3758/bf03193146. 24. philpot lm, barnes sa, brown rm, et al. barriers and benefits to the use of patient-reported outcome measures in routine clinical care: a qualitative study. am j med qual. 2018;33(4):359-64. https://doi. org/10.1177/1062860617745986. 25. roos pe, button k, van deursen rwm. motor control strategies during double leg squat following anterior cruciate ligament rupture and reconstruction: an observational study. j neuroeng rehabil. 2014;11(1):1-8. https://doi. org/10.1186/1743-0003-11-19. 26. charlton pc, bryant al, kemp jl, et al. single-leg squat performance is impaired 1 to 2 years after hip arthroscopy. pm & r. 2016;8(4):321-30. https:// doi.org/10.1016/j.pmrj.2015.07.004. 27. mulholland sj, wyss up. activities of daily living in non-western cultures: range of motion requirements for hip and knee joint implants. int j rehabil res. 2001;24(3):191-98. https://orcid.org/0000-0002-5658-6827 https://orcid.org/0000-0002-3616-1995 https://orcid.org/0000-0003-2016-0709 https://orcid.org/0000-0003-4348-532x https://orcid.org/0000-0002-5989-8383 http://orcid.org/0000-0002-4091-7548 https://orcid.org/0000-0002-0671-0439 _hlk68842322 _hlk74231536 _hlk71878404 ole_link1 ole_link2 orthopaedics vol3 no4 page 58 sa orthopaedic journal summer 2015 | vol 14 • no 4 the accessory soleus muscle causing tibial nerve compression neuropathy: a case report dr p reddy mbchb, hdip orth(sa), fcorth(sa) department of orthopaedic surgery, grey’s hospital, nelson r mandela school of medicine, university of kwazulu-natal, pietermaritzburg, south africa dr ga mccollum mbchb, fcorth(sa) mmed(uct) department of orthopaedic surgery, university of cape town, groote schuur hospital, cape town, south africa corresponding author: dr p reddy department of orthopaedic surgery grey’s hospital nelson r mandela school of medicine university of kwazulu-natal 3201 pietermaritzburg, south africa tel: +27 33 897 3000 email: praven.reddy@kznhealth.gov.za introduction the accessory soleus muscle is an uncommon anatomical variant with a reported incidence of between 0.7–5.5%.1 it may be unilateral or bilateral and although congenital, it is usually asymptomatic and may only present in the second to third decade of life, possibly due to the increased muscle mass and activity during this period.2 it may mimic a soft tissue tumour of the lower leg3 and present with painful syndromes of the calf, ankle and foot.4 we present a case report of a patient with a unilateral accessory soleus associated with neurological symptoms of his foot. case report a 37-year-old male presented with complaints of intermittent paraesthesia on the plantar aspect of his left foot. he was an avid cyclist and the symptoms only developed during and after a bike ride, typically starting after approximately 20 minutes of riding and was relieved by rest. he reported no occurrence of the symptoms during other activities such as walking or running and had no pain or cramping to suggest an exertional compartment syndrome. he reported that the symptoms began approximately 6–8 months prior to presentation when he began to increase the intensity of his cycling regimen. he had no other symptoms to suggest a pathological origin of the pain. abstract the accessory soleus muscle is a rare anatomic variant which may present as a mass in the posteromedial aspect of the ankle, causing compression of the tibial nerve or an exertional compartment syndrome. it should be considered in the differential diagnosis of all soft tissue masses in this area. treatment options include conservative treatment, excision of the whole muscle and fasciotomy. we report a case of an accessory soleus in a cyclist presenting with activity-related paraesthesia in the foot and discuss the pathology and management of this condition. key words: accessory soleus, mri, tumour, compression neuropathy, fasciotomy http://dx.doi.org/10.17159/2309-8309/2015/v14n4a8 the accessory soleus muscle is an uncommon anatomical variant with a reported incidence of between 0.7–5.5% saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 5 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 59 physical examination revealed fullness in the posteromedial aspect of the ankle. he had a normal range of ankle movement, with no features of ankle impingement or instability. there were subtle features of achilles tendinitis but his achilles tendon was otherwise normal. he had normal motor and sensory function of the ankle and foot, a negative tinel test and his symptoms were not reproducible during examination, although the reported paraesthesia was in the typical distribution of the medial and lateral plantar nerves. a contrasted mri of the foot and ankle was performed, identifying a posterior mass with the same signal intensity as normal muscle in all of the sequences performed. the muscle was located posterior to the deep posterior compartment and anterior to the achilles tendon in close proximity to the posterior neurovascular bundle (figure 1), and showed attachment to the posterior tuberosity of the calcaneus (figure 2). the tibial nerve was flattened and showed intraneural oedema. a small fluid collection was noted around the achilles tendon suggestive of subtle inflammatory changes. the above findings confirmed the diagnosis of an accessory soleus muscle, and the patient’s symptoms were attributed to being caused by a compression neuropathy rather than an exertional compartment syndrome. a conservative management plan was initially pursued, which included avoidance of cycling for a period of 6 weeks. however, being an enthusiastic cyclist, the patient was not accepting of this course of treatment and the decision was then made to proceed to surgical excision of the accessory soleus muscle. figure 1. axial mri, showing the relationship of the accessory soleus (white arrow) between the deep posterior compartment of the leg and the achilles tendon and its relationship to the posterior neurovascular structures (red arrow) figure 2. sagittal mri, t1 and t2 weighted images showing the accessory soleus (white arrow) having the same signal intensity as normal muscle and its attachment to the calcaneus (green arrow) findings confirmed the diagnosis of an accessory soleus muscle, and the patient’s symptoms were attributed to being caused by a compression neuropathy rather than an exertional compartment syndrome saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 59 page 60 sa orthopaedic journal summer 2015 | vol 14 • no 4 under a general anaesthetic with the use of a tourniquet, the muscle was approached through a longitudinal incision posteromedial to the distal tibia and ankle. the accessory soleus was noted to be enclosed in its own fascial sheath (figure 3a) with attachment to the calcaneus via a micro tendon (figure 3b). it was closely apposed to the tibial nerve which lay on its anterior surface (figure 3c). the anomalous muscle was mobilised and excised completely, after which haemostasis was achieved and the skin closed in layers. the patient’s ankle was splinted in a below-knee backslab for 10 days to allow adequate wound healing. he was thereafter not restricted and returned to cycling after 4 weeks. he reported no recurrence of paraesthesia after returning to pre-surgery activity level and was still symptom free at 1-year follow-up. discussion and literature review the accessory soleus muscle presents as a posteromedial soft tissue mass in the lower leg. it may simulate a soft tissue tumour with a differential diagnosis that includes lipoma, ganglion, haemangioma, synovioma and sarcoma.3,4 it may also be a cause of recurrent tarsal tunnel syndrome, and failure of tarsal tunnel decompression has been shown to be due to the presence of an undiagnosed accessory soleus.5 the anatomical variants have been described by sookur et al.6 this accessory muscle may originate from the anterior fascia of the soleus muscle; the posterior aspect of the head and upper shaft of the fibula; the soleal line of the tibia; and the middle third of the medial border of the tibia. it inserts on the achilles tendon or on the superior or medial aspect of the calcaneus with either a muscular or tendinous insertion.7,8 it is usually enveloped within its own fascia and derives its neurovascular supply from branches of the posterior tibial artery and tibial nerve.8 patients may present with muscular or neuropathic pain associated with paraesthesia and radiation into the posteromedial ankle and plantar aspect of the foot. this is commonly exacerbated by physical activity. theories that may explain the origin of pain include a localised compartment syndrome caused by an increase in the size of the anomalous muscle during exercise, a compression neuropathy caused by the proximity of the accessory soleus to the tibial nerve or a claudication of the muscle due to a tenuous and insufficient blood supply from the posterior tibial artery during exercise.8 partial tears and strains to the accessory muscle, as well as an association between an accessory soleus and achilles tendinopathy have also been described.9 diagnostic imaging begins with plain radiographs, which will rule out bony pathology and may demonstrate an increased opacity in the retrocalcaneal space (kager’s triangle) and a posterior soft tissue shadow. mri should be considered essential in diagnosis and decision-making, to confirm the benign nature of the mass, describe in detail the anatomy of the anomalous muscle for surgical planning and rule out any of the differential diagnoses as described above.10 conservative management remains the first step in the treatment of a symptomatic accessory soleus in athletic and sedentary patients, and is effective in a large number of reported cases. these measures include activity modification, rest, elevation, the use of nsaids and physical therapy which includes massage, stretching and eccentric muscle training typically over a 12-week period.10 figure 3. intra-operative photos showing a) the accessory soleus enclosed within its own fascial layer, b) being mobilised from its attachment, and c) post excision, its relationship overlying the tibial nerve (white arrow) a b c patients may present with muscular or neuropathic pain associated with paraesthesia and radiation into the posteromedial ankle and plantar aspect of the foot saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 60 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 61 surgery should be considered when conservative measures fail, especially in athletic patients. surgical treatments previously reported include debulking of the muscle, fasciotomy, total excision and even ligation of the accessory muscle’s blood supply.11 the largest case series of 21 patients by kouvalchouk et al.12 suggested that complete resection is the most reliable treatment in symptomatic patients. however other smaller series have shown fasciotomy and excision to be equally effective.1,13 there does seem to be a trend in the literature towards complete excision of the accessory soleus in athletic patients and in general, fasciotomy can be considered for patients with a small accessory soleus or with low activity level and excision for patients with a large accessory muscle and those involved in high level sporting activities. summary the accessory soleus muscle should be considered as a cause of compression neuropathy of the tibial nerve, especially in the presence of a posteromedial lower leg mass. clinical examination and mri scans form the basis of diagnosis. treatment should include an attempt at conservative management; however, surgical intervention has shown good results with minimal complications. the content of this article is the original work of the authors. no benefits of any form have been or are to be received from a commercial party related directly or indirectly to the subject of this article. references 1. brodie jt, dormans jp, gregg jr, et al. accessory soleus muscle. a report of 4 cases and review of literature. clin orthop 1997;337:180-86. 2. romanus b, lindahl s, stener b. accessory soleus muscle: a clinical and radiological presentation of eleven cases. j bone joint surg am 1986;68:731-34. 3. palaniappan m, rajesh a, rickett a, kershaw cj. accessory soleus muscle: a case report and review of the literature. pediatr. radiol. 1999;29(8):610-12. 4. dunn aw. anomalous muscles simulating soft-tissue tumors in the lower extremities. report of three cases. j bone joint surg am.1965;47(7):1397-400. 5. dosremedios et, jolly gp. the accessory soleus and recurrent tarsal tunnel syndrome: case report of a new surgical approach. j. foot ankle surg 2000;39(3):194-97. 6. sookur pa, naraghi am, bleakney rr, jalan r, chan o, white lm. accessory muscles: anatomy, symptoms, and radio-logic evaluation. radiographics 2008;28:481-99. 7. lorentzon r, wirell s. anatomic variations of the accessory soleus muscle. acta radiol 1987;28:627-29. 8. yu js, resnick o. mr imaging of the accessory soleus muscle appearance in six patients and a review of the literature. int skeletal soc. 1994;525-28. 9. luck md, gordon ag, blebea js, dalinka mk. high association between accessory soleus muscle and achilles tendonopathy. skeletal radiol 2008;37(12):1129-33. 10. rossi r, bonasia de, tron a. accessory soleus in the athletes: literature review and case report of a massive muscle in a soccer player. knee surg sports traumatol arthrosc 2009;17:990-95. 11. trosko jj. accessory soleus: a clinical perspective and report of three cases. j foot surg 1986;25:296-300. 12. kouvalchouk jf, lecocq j, parier j, fischer m. the accessory soleus muscle: a report of 21 cases and a review of the literature. rev chir orthop reparatrice appar mot 2005;91(3):232-38. 13. chittaranjan bs, babu nv, abraham g. accessory soleus muscle: a problem of awareness. aust n z j surg 1994;64:503-505. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 61 bakkai a et al. sa orthop j 2018;17(2) doi 10.17159/2309-8309/2018/v17n2a5 south african orthopaedic journal http://journal.saoa.org.za trauma citation: bakkai a, hardcastle tc, sibanda w. fracture patterns and complications related to pedestrian–vehicle collision victims in a public level-1 trauma centre icu population. sa orthop j 2018;17(2):28–34. http://dx.doi.org/10.17159/2309-8309/2018/v17n2a5 editor: prof anton schepers, university of the witwatersrand received: february 2017 accepted: october 2017 published: march 2018 copyright: © 2018 bakkai a, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no financial support was received for this study. conflict of interest: the authors have no conflicts of interest to declare. abstract introduction: death and injury associated with road traffic collisions are global phenomena that require urgent attention. approximately 1.2 million people worldwide are killed each year. pedestrian collisions remain one of the single largest causes of injury, disability, and death in the developing world and contribute significantly to trauma centre activity, especially in urban areas. materials and methods: the study aim was to describe the fracture patterns in pedestrians, and to highlight the epidemiology, spectrum, and outcomes of orthopaedic injuries identified in pedestrian vehicle collision (pvc) victims admitted to a major trauma intensive care unit (ticu). this retrospective analysis of 405 pvc victims, retrieved from an ethics approved trauma registry (be360/13 and be207/09) admitted to the ticu at inkosi albert luthuli central hospital, durban, south africa, spans a six-year period from 2007 to 2012. results: four hundred and five pedestrian–vehicle collision patients were admitted over the six-year study period. missing data were found in two patients. the mean age was 25.8 ± 17.49 years, with 135 (33.3%) female patients and 270 (66.7%) males. one hundred and eleven patients were referred directly from the scene; the others were inter-hospital transfers. two hundred and eighty-five patients had fractures and from this group, 63 (22%) patients died in icu. the most common fracture site was femur (122), followed by tibia (112) and pelvis (95). the mortality was related mainly to the age of the victims; none of the fractures were found to be associated directly with increased mortality. conclusion: diverse fracture patterns are seen in pvc patients. the leading cause of death is head injury, followed by chest injury. increased age of the patients was associated with increased mortality. the predominance of specific fractures, in specific sex and age groups, were noted, and some fractures were found to be associated with more complications; however, none of the fractures were linked directly to mortality. level of evidence: level 4 key words: trauma, pedestrian, fracture, icu outcome, complications fracture patterns and complications related to pedestrian–vehicle collision victims in a public level-1 trauma centre icu population bakkai a1, hardcastle tc2, sibanda w3 1 mbchb, hdiporth(sa), fcorth(sa); registrar, orthopaedics, university of kwazulu-natal 2 mbchb(stell), mmed(chir)(stell), phd(ukzn), fcs(sa); trauma(hpcsa) trauma icu, inkosi albert luthuli central hospital; honorary senior lecturer, department of surgery, university of kwazulu-natal 3 phd(it)(nwu); biostatics unit, school of nursing and public health, college of health science, university of kwazulu-natal, durban, south africa corresponding author: dr ali bakkai, 27 nordbury, 130 gladys mazibuko road, essenwood, durban, 4001; email: alibakkai@yahoo.com; tel: 0812701076, 0312075555 page 29bakkai a et al. sa orthop j 2018;17(2) introduction death and injury associated with road traffic crashes are global phenomena that require urgent attention.1 approximately 1.2 million people worldwide are killed each year resulting from road traffic crashes.2 pedestrian collisions are noted to be one of the single largest causes of injury, disability and death in the developing world.2-4 pedestrian–vehicle collisions (pvcs) contribute significantly to trauma centre activity, especially in urban areas.1 epidemiologic studies may allow for further understanding of risk factors involved in roadside pedestrian injuries.5 previous studies have demonstrated the impact of geographical and demographic factors on pvcs in specific cities, mainly in the usa, by using the age as a predictor of the outcome of the patients.5-7 the aim of this study was to investigate the fracture patterns, epidemiology, spectrum and clinical outcomes of pedestrians involved in pvcs. the outcomes in this study were death or survival following admission to a trauma intensive care unit (ticu) at inkosi albert luthuli central hospital (ialch). it has been previously reported that up to 50% of patients admitted to the ticu at ialch are as a result of pedestrian collisions.8 materials and methods the study was performed in the ticu (level 1 centre) at ialch, durban, south africa. the target group for this study was pvc victims admitted to ticu (or those who died in the resuscitation bay), in the period march 2007 until december 2012. after obtaining ethical approval (ukzn brec be360/13), a retrospective chart review was undertaken, using the data from the brec class approved (be207/09) electronic patient record system. study design the pedestrian data obtained included: age, sex, fracture pattern, the length of stay, other non-orthopaedic injuries, complications and whether the patient was transferred directly from the accident scene or from another hospital. the severity of injuries was assessed using the injury severity score (iss).9 almost all patients had ct scan angiograms, except patients who died in the resuscitation room. all fractures identified were reviewed and included, irrespective of whether they were single or multiple fractures. the study analysed the epidemiology and fracture patterns. in-hospital morbidity and mortality associated with orthopaedic injuries were the main outcome measures, with the intent to identify fractures associated with a higher risk of death. statistical analyses data analysis was performed using ibm spss version 24 (armonk, ny, usa) and sas version 9.0 (sas institute, cary, nc). continuous variables were summarised using mean ± standard deviation (sd), and medians and interquartile ranges (iqr) were used for highly skewed data. categorical variables were summarised using proportions and percentages. proportions and categorical variables were compared using pearson’s chi-square test and fisher’s exact test as appropriate. a multivariate logistic regression model was used to assess the association between different predictor variables and clinical outcome and to identify potential risk factors. an odds ratio for each variable was calculated. a p-value < 0.05 was accepted as indicative of statistical significance. results between march 2007 and december 2012, 405 patients were admitted as pvc victims in the trauma unit at ialch. missing data were found in two participants (0.5%). a total of 403 patients were included in the logistic regression. one hundred and thirty-five (33.3%) of the patients were female (95% confidence interval [ci] 28.0–37.9) and 270 (66.7%) were male (95% ci 62.11–71.29%). a total of 94 (23.2%) patients died due to their injuries (95% ci 19.09–27.31), 309 (76.3%) survived (95% ci 72.16–80.44) and in two (0.5%) their ankle 0 92 (97.9) 292 (94.5) 2 (100) 1 2 (2.1) 17 (5.5) 0 (0) total 94 (100) 309 (100) 2 (100) 405 (100) 0.177 foot 0 94 (100) 307 (99.4) 2 (100) 1 0 (0.0) 2 (0.6) 0 (0) total 94 (100) 309 (100) 2 (100) 405 (100) 0.434 spine 0 80 (85.1) 279 (90.3) 2 (100) 1 14 (14.9) 30 (9.7) 0 (0) total 94 (100) 309 2 (100) 405 (100) 0.158 *chi-squared test figure 1. age group-based mortality per injury 0,0 0,3 0,5 0,8 1,0 1,3 1,5 1,8 2,0 2,3 clavicle scapula humerus radius ulna hand pelvis femur tibia ankle foot spine pe rc en ta ge m or ta lit y pe r to ta l n um be r of in ju ri es ≤20 21-30 31-40 41-50 51-60 ≥61 figure 1. age group-based mortality per injury page 30 bakkai a et al. sa orthop j 2018;17(2) clinical outcome was not recorded (95% ci 0.19–1.19). the median iss among all patients was 29 (iqr: 18–36), and the mean age was 25.8±17.49 years. one hundred and eleven (27.4%) patients were transferred directly from the scene, and the rest (n=294, 72.6%) from other hospitals for advanced care post-resuscitation. all the patients had either ct angiogram or a combination of trauma x-rays and ct scan, to evaluate multiple organ injuries, except patients who died in the resuscitation room. the median hospital stay was eight days (iqr: 9–15). the number of patients found to have orthopaedic injuries was 285, of whom 63 demised, with a mortality rate of 22%. in this group, table i: descriptive statistics independent variables clinical outcome total n (%) *p-valuedied n (%) alive n (%) na n (%) gender female 29 (30.9) 105 (34) 1 (50) male 65 (69.1) 204 (66) 1 (50) total 94 (100) 309 (100) 2 (100) 405 (100) 0.573 age ≤20 33 (35.1) 122 (39.5) 0 (0) 21-30 23 (24.5) 100 (32.4) 1 (50) 31-40 9 (9.6) 45 (14.6) 1 (50) 41-50 10 (10.6) 22 (7.1) 0 (0) 51-60 8 (8.5) 11 (3.6) 0 (0) >61 11 (11.7) 9 (2.9) 0 (0) total 94 309 2 (100) 405 (100) 0.0121 clavicle 0 88 (93.6) 293 (94.8) 1 (50) 1 6 (6.4) 16 (5.2) 1 (50) total 94 (100) 309 (100) 2 (100) 405 (100) 0.652 scapula 0 91 (96.8) 297 (96.1) 2 (100) 1 3 (3.2) 12 (3.9) 0 (0) total 94 (100) 309 (100) 2 (100) 405 (100) 0.756 humerus 0 87 (96.6) 281 (90.9) 2 (100) 1 7 (7.4) 28 (9.1) 0 (0) total 94 (100) 309 (100) 2 (100) 405 (100) 0.626 radius 0 88 (93.6) 292 (94.5) 2 (100) 1 6 (6.4) 17 (5.5) 0 (0) total 94 (100) 309 (100) 2 (100) 405 (100) 0.747 ulna 0 89 (94.7) 288 (93.2) 2 (100) 1 5 (5.3) 21 (6.8) 0 (0) total 94 (100) 309 (100) 2 (100) 405 (100) 0.610 hand 0 93 (98.9) 307 (99.4) 2 (100) 1 1 (1.06) 2 (0.6) 0 (0) total 94 (100) 309 (100) 2 (100) 405 (100) 0.681 pelvis 0 73 (77.7) 235 (75.1) 2 (100) 1 21 (22.3) 74 (23.9) 0 (0) total 94 (100) 309 (100) 2 (100) 405 (100) 0.748 femur 0 65 (69.1) 216 (69.9) 2 (100) 1 29 (30.9) 93 (30.1) 0 (0) total 94 (100) 309 (100) 2 (100) 405 (100) 0.889 tibia 0 68 (72.3) 223 (72.2) 2 (100) 1 26 (27.7) 86 (27.8) 0 (0) total 94 (100) 309 (100) 2 (100) 405 (100) 0.974 ankle 0 92 (97.9) 292 (94.5) 2 (100) 1 2 (2.1) 17 (5.5) 0 (0) total 94 (100) 309 (100) 2 (100) 405 (100) 0.177 foot 0 94 (100) 307 (99.4) 2 (100) 1 0 (0.0) 2 (0.6) 0 (0) total 94 (100) 309 (100) 2 (100) 405 (100) 0.434 spine 0 80 (85.1) 279 (90.3) 2 (100) 1 14 (14.9) 30 (9.7) 0 (0) total 94 (100) 309 2 (100) 405 (100) 0.158 *chi-squared test page 31bakkai a et al. sa orthop j 2018;17(2) head injury was present in 36 patients (57%), while chest injury was noted in 13 patients (20%). nineteen of those patients died during resuscitation (6.6%). using the chi-square test, age was the only independent variable with a statistically significant association with the clinical outcome (p-value = 0.0121). however, no bone injuries had a statistically significant association with the outcome (p>0.05) in all fracture groups as illustrated in table i. using a binary logistic regression model, the odds of dying from injuries for older patients were 1.35 times higher than younger patients (or 1.35, 95% ci 1.148–1.589), and the odds ratio (or) was statistically significant (p-value = 0.0003). the ors for some fractures were not statistically significant with a wide ci indicating a low level of precision. on the other hand, the or of injuries to spine, clavicle, and femur resulted in 1.515, 1.266 and 1.178 times the likelihood of dying. though the 95% cis (0.721–3.063, 0.425–3.354, and 0.686–1.998) respectively indicate high precision in or, these or were not statistically significant (table ii). the mortality rate in males was 24% and in females 22%. the most common fracture identified was femur fracture (n=122, 23.4%), followed by tibia (n=113, 21.7%), and pelvis (n=95, 18.2%). those fractures involved almost all age groups with notable predominance of the femur and tibia below the age of 30 years as illustrated in figure 1. the sex-related injuries (figure 2) show that females with fractured clavicle, scapula or pelvis have a slightly higher mortality, whereas in males, only those with fractured spine were noted to have higher mortality. the most common cause of death, according to hospital records, among all pedestrians was head injury (n=56, 60%), followed by chest injury (n=17, 18%), while others included pulmonary embolism, retroperitoneal haematoma, crush injury to the pelvis, septic shock, figure 2. sex-grouped injuries table ii: odds ratio for all variables odds ratio of living after accident odds ratio of dying after accident independent variable odds ratio 95% confidence interval pvalue independent variable odds ratio 95% confidence interval pvalue age 0.741 0.629–0.871 0.0003 age 1.350 1.148–1.589 0.0003 sex 0.961 0.564–1.613 0.8806 sex 1.041 0.620–1.773 0.8806 clavicle 0.790 0.298–2.352 0.6491 clavicle 1.266 0.425–3.354 0.6491 scapula 1.425 0.390–6.914 0.6190 scapula 0.702 0.145–2.562 0.6190 humerus 1.490 0.605–4.152 0.4113 humerus 0.671 0.241–1.654 0.4113 radius 0.446 0.095–2.028 0.2885 radius 2.243 0.493–10.48 0.2885 ulna 2.588 0.594–14.35 0.2362 ulna 0.386 0.070–1.685 0.2362 hand 0.567 0.051–12.70 0.6520 hand 1.765 0.079–19.63 0.6520 pelvis 1.153 0.653–2.10 0.6311 pelvis 0.867 0.477–1.531 0.6311 femur 0.849 0.501–1.46 0.5477 femur 1.178 0.686–1.998 0.5477 0 1 2 3 4 5 6 7 8 0 2 4 6 8 10 12 14 16 18 20 pe rc en ta ge m or ta lit y pe r to ta l i nj ur ie s pe rc en ta ge s ur vi va l p er to ta l i nj ur ie s manalive femalealive mandied femaledied figure 2. sex-grouped injuries table ii: odds ratio for all variables odds ratio of living after accident odds ratio of dying after accident independent variable odds ratio 95% confidence interval p-value independent variable odds ratio 95% confidence interval p-value age 0.741 0.629–0.871 0.0003 age 1.350 1.148–1.589 0.0003 sex 0.961 0.564–1.613 0.8806 sex 1.041 0.620–1.773 0.8806 clavicle 0.790 0.298–2.352 0.6491 clavicle 1.266 0.425–3.354 0.6491 scapula 1.425 0.390–6.914 0.6190 scapula 0.702 0.145–2.562 0.6190 humerus 1.490 0.605–4.152 0.4113 humerus 0.671 0.241–1.654 0.4113 radius 0.446 0.095–2.028 0.2885 radius 2.243 0.493–10.48 0.2885 ulna 2.588 0.594–14.35 0.2362 ulna 0.386 0.070–1.685 0.2362 hand 0.567 0.051–12.70 0.6520 hand 1.765 0.079–19.63 0.6520 pelvis 1.153 0.653–2.10 0.6311 pelvis 0.867 0.477–1.531 0.6311 femur 0.849 0.501–1.46 0.5477 femur 1.178 0.686–1.998 0.5477 tibia 1.078 0.629–1.89 0.7880 tibia 0.928 0.530–1.589 0.7880 ankle 2.990 0.808–19.46 0.1557 ankle 0.334 0.051–1.238 0.1557 spine 0.660 0.327–1.39 0.2569 spine 1.515 0.721–3.063 0.2569 page 32 bakkai a et al. sa orthop j 2018;17(2) myocardial infarction, ruptured uterus, liver and spleen injuries, aortic arch injury, and ruptured diaphragm (n=21, 22%). among the fatalities, the oldest was 82 years of age, who died during resuscitation, while the youngest was 2 years old, who died due to a head injury. the fracture combinations that were seen included femur and tibia (21 injured, 6 dead), pelvis and femur (14 injured, 3 dead). using a fisher’s exact test to determine whether there is an association between combined fractures without head and chest injuries and the same combined fractures with head and chest injuries, a conclusion was that the combined fractures (with and without head and chest injuries) are independent of clinical outcome (mortality), i.e. there was no association between femur and tibia injuries in isolation or with head injury, chest injury, and both head and chest injury (p-value=0.1322, 0.7063, 0.2507) respectively. a similar observation was made for pelvis and femur alone, or with a head injury, chest injury and both head and chest injury (p-value=0.8658, 0.4795, 0.8298) respectively (table iii). however, using a two-sample test to compare the differences in proportions of deaths among femur and tibia injuries (femur+tibia (12%) vs femur+tibia+head (50%), femur+tibia (12%) vs femur+tibia+chest (20%), femur+tibia (12%) vs femur+tibia+head+ chest (50%), the result indicated statistically significant differences at p <0.0001, which means that including head or chest or both tended to result in increased mortality. the commonest complications noted among survivors (table iv) included: amputations (n=9, 3%), nosocomial pneumonia (n=5, 1.6%), line sepsis (n=3, 1%), acute kidney injury (n=3, 1%), compartment syndrome (n=3, 1%), and small bowel obstruction (n=1, 0.3%). the commonest fracture noticed to be associated with those complications was the tibia, i.e. all patients who had compartment syndrome, two patients with acute kidney injury, all patients with line sepsis, two patients with nosocomial term ln fk lm ck c dn cn be ce d ek h ah an ak al b a bj kn fn l el en fg cl kl cd ac ab 2.52.01.51.00.50.0 k femur l tibia m ankle n spine a age_1 b gender c clavicle d scapula e humerus f radius g ulna h hand j pelvis factor name standardized effect 1.967 pareto chart of the standardized effects (response is outcome(1=alive,0-dead), α = 0.05, only 30 effects shown) figure 3. combined factors effect table iii: fractures combinations, associations with head and chest injuries injury combination outcome: alive dead p-value femur+tibia 7(88%) 1(12%) 0.1322 femur+tibia+head 3(50%) 3(50%) femur+tibia 7(88%) 1(12%) 0.7063 femur+tibia+chest 4(80%) 1 (20%) femur+tibia 7(88%) 1(12%) 0.2507 femur+tibia+head+chest 1(50%) 1(50%) pelvis+femur 3(75%) 1(25%) 0.8658 pelvis+femur+head 4(80%) 1(20%) pelvis+femur 3(75%) 1(25%) 0.4795 pelvis+femur+chest 2(100) 0(0%) pelvis+femur 3(75%) 1(25%) 0.8298 pelvis+femur+head+chest 2(67%) 1(33%) *fisher’s exact test pareto chart of the standardised effects standardised effect page 33bakkai a et al. sa orthop j 2018;17(2) pneumonia, six patients who had amputations, initially had a tibia fracture. using a pareto chart (figure 3), to distinguish the few most important factors from the many unimportant predictive variables, indicated that the following two-factor interactions accounted for 80% of the observed clinical outcomes: sex*age, age*clavicle, clavicle*scapula, femur*tibia, clavicle*tibia, and radius*ulna. none of the individual main effects constituted the 20% that resulted in the 80% of the observed clinical outcomes. in general, a pareto chart provides an illustration of the pareto principle, which asserts that 80% of the observed outcome is produced by 20% of the input variables. discussion this epidemiological retrospective study investigates the patterns of fractures and complications observed among pvcs admitted to a tertiary ticu. it also highlights the effects of other factors including age and sex. furthermore, it describes the predominance of specific fractures in different age groups. pvcs are responsible for a substantial portion of overall road traffic accidents, with the highest fatality percentage among all road users attributed to pedestrians.10 many studies have looked at the demographics and prevention aspects of pedestrian injuries in both developed and developing countries.11-13 the present study describes in depth different fracture patterns seen in pvc victims, starting from the clavicle to the foot. from this study, a diversity of fractures is noted among the pedestrians, with different patterns in each age and sex groups. of note is the presence of femur and tibia fractures in all age groups with specific predominance among the victims younger than 30 years, and notably higher mortality in females with pelvis fracture. an important finding from our study is that none of the fractures, either isolated or combined, has a direct effect on mortality, but when head and chest are added together, a trend towards mortality is noticed. however, some fractures are noted to be associated with a higher morbidity, an example is the association between tibia fracture and in-hospital complications. the findings of this study and previous reports show that fracture patterns in pedestrians involve mainly the lower extremity, specifically femur, followed by tibia and pelvis, which is attributed to the position of the knee joint, level of the pelvis and in relation to what part of the vehicle collides with the pedestrian.7,14,15 the present study confirmed the finding of previous studies about the effect of age on mortality, relating that to the anatomical and physiological changes associated with an increase in age, as well as comorbidities and osteoporosis making the elderly more fragile with a subsequent high death rate.16 head injury is confirmed by this study (60%) to be in concordance with previous research as the main cause of fatality among pedestrians and is followed by chest injuries at 18%.15,17-19 additionally, the mortality rate (23.2%) in our cohort is consistent with a previous study.20 however, in the current cohort, with 67% male and 33% female, the mortality rate among men was 24% which is different from previous reports.21,22 reith et al. reported in their study of 4 435 pedestrian victims, similar findings in some aspects, including the association between pedestrian trauma and body parts involved, higher iss, and subsequently higher mortality in pvc victims. epidemiological studies may allow for a better understanding of the injury pattern, length of stay, complications, as well as the mortality in roadside pedestrian victims. furthermore, this type of study can be used for educational efforts, triggering the trauma team to expect the injury profile, or predicted severity associated with pvcs, which may improve the initial trauma management, and the outcome. such studies can be used to modify the physical and social environments of the transportation system and to prevent further escalation of the pedestrian collision pandemic. this study has limitations considering it is a retrospective study, and does not include a comparison with injury patterns and outcomes of vehicle-occupant admissions. however, the strength of the study results from the large sample size, derived from a legible electronic database with all clinical detail captured on standardised templates. it is also the first study to describe in detail the fracture patterns in those patients with severe injury. conclusion in conclusion, this study described in detail all fracture patterns seen in pvc victims, including single and combined fractures, and it validated a clinically known fact, namely the effect of age on the outcomes of this group. the mortality is related mainly to head injury followed by chest injuries. lower limb fractures are more frequent, but no specific fractures are associated with increased mortality. ethical approval ethical approval was obtained from the university brec ethics committee and the kwazulu-natal department of health prior to the commencement of data collection. table iv. complications among survivals complication number fracture small bowel obstruction 1 fracture femur compartment syndrome 3 fracture tibia, pelvis fracture tibia, scapula fracture tibia acute kidney injury 3 fracture pelvis fracture femur, tibia fracture tibia line sepsis 3 fracture tibia, clavicle, spine fracture tibia fracture tibia nosocomial pneumonia 5 fracture tibia, pelvis fracture spine, pelvis, scapula fracture radius fracture tibia, clavicle fracture clavicle amputation 9 six patients with fracture femur and tibia, one patient with foot fracture, one patient with femur fracture, one patient with femur and pelvis fracture page 34 bakkai a et al. sa orthop j 2018;17(2) references 1. martin nd, grabo dj, tang l, sullivan j, kaulback kr, weinstein ms, et al. are roadside pedestrian injury patterns predictable in a densely populated, urban setting? j surg res. 2010;163(2):323-26. 2. aidoo en, amoh-gyimah r, ackaah w. the effect of road and environmental characteristics on pedestrian hit-and-run accidents in ghana. accid anal prev. 2013;53:23-27. 3. hijar m, trostle j, bronfman m. pedestrian injuries in mexico: a multi-method approach. soc sci med (1982). 2003;57(11):2149-59. 4. sullman mj, gras me, font-mayolas s, masferrer l, cunill m, planes m. the pedestrian behaviour of spanish adolescents. j adolesc. 2011;34(3):531-39. 5. lascala ea, gerber d, gruenewald pj. demographic and environmental correlates of pedestrian injury collisions: a spatial analysis. accid anal prev. 2000;32(5):651-58. 6. harruff rc, avery a, alter-pandya as. analysis of circumstances and injuries in 217 pedestrian traffic fatalities. accid anal prev. 1998;30(1):11-20. 7. kong lb, lekawa m, navarro ra, mcgrath j, cohen m, margulies dr, et al. pedestrian-motor vehicle trauma: an analysis of injury profiles by age. j am coll surg. 1996;182(1):17-23. 8. cheddie s, muckart dj, hardcastle tc, den hollander d, cassimjee h, moodley s. direct admission versus inter-hospital transfer to a level i trauma unit improves survival: an audit of the new inkosi albert luthuli central hospital trauma unit. s afr med j. 2011;101(3):176-78. 9. copes ws, champion hr, sacco wj, lawnick mm, keast sl, bain lw. the injury severity score revisited. j trauma. 1988;28(1):69-77. 10. toroyan t. global status report on road safety. inj prev. 2009;15(4):286. 11. fredriksson r, zhang l, bostrom o, yang k. influence of impact speed on head and brain injury outcome in vulnerable road user impacts to the car hood. stapp car crash j. 2007;51:155-67. 12. zhang g, cao l, hu j, yang kh. a field data analysis of risk factors affecting the injury risks in vehicle-to-pedestrian crashes. ann adv automot med. 2008;52:199-214. 13. al-shammari n, bendak s, al-gadhi s. in-depth analysis of pedestrian crashes in riyadh. traffic inj prev. 2009;10(6):552-59. 14. maki t, kajzer j, mizuno k, sekine y. comparative analysis of vehicle-bicyclist and vehicle-pedestrian accidents in japan. accid anal prev. 2003;35(6):927-40. 15. toro k, hubay m, sotonyi p, keller e. fatal traffic injuries among pedestrians, bicyclists and motor vehicle occupants. forensic sci int. 2005;151(2-3):151-56. 16. johnson cl, margulies dr, kearney tj, hiatt jr, shabot mm. trauma in the elderly: an analysis of outcomes based on age. am surg. 1994;60(11):899-902. 17. takahashi y, kikuchi y, konosu a, ishikawa h. development and validation of the finite element model for the human lower limb of pedestrians. stapp car crash j. 2000;44:335-55. 18. al-ghamdi as. pedestrian-vehicle crashes and analytical techniques for stratified contingency tables. accid anal prev. 2002;34(2):205-14. 19. pruthi n, ashok m, kumar vs, jhavar k, sampath s, devi bi. magnitude of pedestrian head injuries & fatalities in bangalore, south india: a retrospective study from an apex neurotrauma center. indian j med res. 2012;136(6):1039-43. 20. brainard bj, slauterbeck j, benjamin jb, hagaman rm, higie s. injury profiles in pedestrian motor vehicle trauma. ann emerg med. 1989;18(8):881-83. 21. reith g, lefering r, wafaisade a, hensel ko, paffrath t, bouillon b, et al. injury pattern, outcome and characteristics of severely injured pedestrian. scand j trauma resusc emerg med. 2015;23:56. 22. zhao h, yin z, yang g, che x, xie j, huang w, et al. analysis of 121 fatal passenger car-adult pedestrian accidents in china. j forensic leg med. 2014;27:76-81. page 50 sa orthopaedic journal autumn 2014 | vol 13 • no 1 a possible role of synovial fluid in bone healing sl biddulph mbbch(rand), fcs(sa), frcs(eng), frcs(edin) department of orthopaedic surgery, johannesburg hospital, university of the witwatersrand sj nayler bsc(rand), mbbch(rand), fcpath(sa), mmed(rand) division of anatomical pathology, school of pathology, faculty of health sciences, university of the witwatersrand mbe sweet mbchb(cape town), phd(rand) department of orthopaedic surgery, johannesburg hospital, university of the witwatersrand ad barrow fcs(sa)orth department of orthopaedic surgery, johannesburg hospital, university of the witwatersrand lg biddulph mbbch(rand), fcs(sa)orth hand unit, chris hani baragwanath hospital, university of the witwatersrand correspondence: prof sl biddulph po box 1270 2041 houghton south africa tel: +27 11 640 3005 fax: +27 11 640 3007 e-mail: biddulph@webafrica.org.za introduction it is widely believed that the presence of a layer of synovial fluid at the fracture line may inhibit the healing of intra-articular fractures. on the other hand, osteochondral loose bodies do survive within synovial fluid and grow to a considerable size.1 abstract background the aim of the study was to study the rate of intra-articular fracture healing in baboons. it is postulated that this could correlate with fracture healing in the human model of the scaphoid, as this fracture healing takes place in an intra-articular environment. methods five baboons were used. segments of iliac crest were divided along the cancellous zone and fixed together by means of cerclage wire with the cancellous surfaces facing each other. the conjoined blocks of bone were sutured into the joint capsule of the suprapatellar pouch of the animal from which they were obtained. control specimens were fixed submuscularly to the outer cortex of the iliac crest. specimens were harvested at two, three and four weeks. after decalcification, samples were examined histologically. results all specimens were found to be viable. a firm union was noted at two weeks, a greater union at three weeks, and a substantial union at four weeks. some of the specimens had a covering of synovial membrane, due to the fact that the specimen was sutured into the joint lining. it appeared to have no effect on bone survival or the rate of union. conclusion the results suggest that synovial fluid may nourish bone and promote union. this is in contradiction to the theory that synovial fluid may hamper bone healing, specifically in the scaphoid model in humans. key words: synovial fluid, bone healing, intra-articular fractures research suggests that synovial fluid might support bony union saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 50 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 51 in 1989 mass and tuel showed that tenocytes could survive and proliferate in a medium consisting entirely of synovial fluid.2 in their work on intra-articular tendon healing, lundborg and rank placed two segments of tendon sutured together within rabbit knee joints.3 they demonstrated that tenocytes could survive in synovial fluid, retaining the capacity to heal. the results of the above research suggested that synovial fluid might support bony union. this work describes the use of a primate model to study the role of synovial fluid in bone healing. materials and methods five baboons (papio papio), each weighing about 40 kg, were selected for the study. we chose primates for this research because of their evolutionary and genetic proximity to man (animal ethics screening committee certificate no. 98.95.5). segments of iliac crest measuring 5 cm × 1 cm were harvested and divided into five fragments of 1 cm. samples were divided into two along the central cancellous zone. the cortical fragments were held together with wire so that the cancellous surfaces faced each other (figure 1 a, b, c). a control specimen was attached submuscularly to the outer cortex of the iliac crest and the wound was closed in layers. two of the bony units were inserted into the suprapatellar pouch of each knee. a total of five units, each consisting of two pieces of bone wired together with the cancellous surfaces facing each other, were used in each baboon. a dacron stitch through the wire loop anchored each to the joint capsule to prevent mechanical locking. all the baboons recovered uneventfully and by the next day were moving normally. no haematomata were noted. skin wounds healed well. specimens were harvested from two baboons at two weeks, from one at three weeks, and from the remaining two, at four weeks after insertion. the partial synovial covering, when present, and the wire loops were removed and the specimens fixed in 10% buffered formalin before being prepared for histological examination. each specimen was evaluated in terms of five parameters: the presence of bone necrosis; medullary cavity new bone formation; periosteal new bone formation; degree of remodelling; and the extent and nature of granulation tissue formation. the extent of these parameters was determined semiquantitatively (figure 2). the criteria for new bone formation were the presence of trabeculae of osteoid or mineralising osteoid with osteoblastic rimming. figure 1a. segment of iliac crest figure 1b. crest split into two along the cancellous zone figure 1c. fragments wired together with cancellous bone facing each other figure 2. there was no statistically significant difference in the criteria considered between the control and synovial groups, keeping in mind the relatively small series. we chose primates for this research because of their evolutionary and genetic proximity to man saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 51 remodelling was assessed on the presence of new bone formation and osteoclastic resorption. osteoclastic activity was noted in most specimens and was part of the remodelling process. new bone was observed both in the periosteum and subperiosteum where there are most uncommitted mesenchymal cells and better nutrition. osteoblasts are thought to develop from either uncommitted stem cells or native osteocytes. the age of granulation tissue was assessed on the degree of extracellular myxoid matrix (younger granulation tissue) versus the extent of dense relatively acellular collagen deposition (older granulation tissue). there was no evidence of samples having drawn a physical blood supply from synovium. histological sections were reviewed by the pathologist and senior colleagues in the micropathology department. results the control specimens were found to be tightly attached to the outer cortex of the ilium by what appeared to be very gritty calcified callus. ten specimens were removed after two weeks of insertion and five after three weeks. specimens removed from the supra-patellar pouch at two and three weeks had no synovial covering. some of the ten specimens removed at four weeks had a covering of synovial membrane that varied from 0% to 50% (figure 3). the fact that the specimens were anchored into the synovial pouch enhanced the tendency for synovial encapsulation. there was a moderate effusion in three knees and a small haemarthrosis in one. all specimens were totally viable and showed no evidence of bone necrosis. the degree of bony union varied according to the time at which the specimens were harvested, with obvious bony union present at two weeks and greater union at three weeks. there was substantial union at four weeks (figure 4). comparing the control specimens with the intraarticular specimens, we found no difference in the rate of bony union. union was unaffected by the presence or absence of synovial membrane. discussion the fact that intra-articular loose bodies may grow to considerable size and remain viable suggests that synovial fluid has a nourishing role according to duthie and bentley.1 the work of bird and sweet suggests that in the normal knee synovial fluid plays an important role in nutrition of the meniscus and intra-articular ligaments.4 mass and tuel showed that tenocytes could survive and proliferate in synovial fluid alone.2 when lundborg and rank (1978) placed tendon segments into rabbit knee joints they also demonstrated the continued ability of tenocytes to survive within synovial fluid.3 these results suggested that synovial fluid might support bony union. the scaphoid is entirely intra-articular and more often than not poorly vascularised. a bone graft, which has no source of nutrients except for synovial fluid, is used to treat non-union of the scaphoid. this procedure carries a success rate of 90%.5-8 figure 4. the sections were decalcified and stained with haematoxylin and eosin. slide a shows prominent osteoclastic activity in existing cancellous bone indicating remodelling. slide b shows prominent new bone formation. a b page 52 sa orthopaedic journal autumn 2014 | vol 13 • no 1 figure 3. specimen a was the control removed from the iliac crest. it was tightly bound to the cortex by gritty calcified fibrous tissue. specimen b was taken from the knee four weeks after insertion. some of its surface was covered by synovial membrane. a b union was unaffected by the presence or absence of synovial membrane saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:13 am page 52 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 53 the high rate of union may be due to the nourishing role of synovial fluid. (in a consecutive personal series of 95 cases of scaphoid non-union and a success rate of 95% treated between 1980 and 2004, there was an absence of synovial membrane covering or proliferation at the fracture site – biddulph, unpublished work). conclusion our results show that excellent repair, remodelling, new bone formation and bony union occur in specimens of bone joined together and placed within a synovial joint. these data support the theory that synovial fluid may play a role in bony union. synovial covering influenced neither the rate of healing nor specimen survival. in the clinical context, the treatment of non-union of scaphoid fractures provides a good example of this phenomenon. the content of this article is the sole work of the authors, and no benefit of any form has been received or will be received from any commercial party. references 1. duthie rb, bentley g. loose bodies. in: duthie rb, bentley g (eds). mercer’s orthopaedic surgery 9th edition. arnold. 1973:1179. 2. mass dp and tuel r. human flexor tendon participation in the in vitro repair process. journal of hand surgery 1989;14a:64-71. 3. lundborg g and rank f. experimental intrinsic healing of flexor tendons based upon synovial nutrition. journal of hand surgery 1978;3(1):21-31. 4. bird mdt and sweet mbe. a system of nutrient canals in the semi-lunar menisci. south african bone and joint surgery 2002;12(1):36-37. 5. tsuyuguchi y, murase t, hidaka n, ohno h, kawai h. anterior wedge-shaped bone graft for old scaphoid fractures or non-unions. journal of hand surgery (br and european volume) 1995;20b(2):194-200. 6. barton nj. experience with scaphoid grafting. journal of hand surgery (br and european volume) 1997;22b(2):153-60. 7. shah j and jones wa. factors affecting the outcome in 50 cases of scaphoid non-union treated with herbert screw fixation. journal of hand surgery (br and european volume) 1998;23b(5):680-85. 8. eggli s, fernandez dl and beck t. unstable scaphoid fracture non-union: a medium-term study of anterior wedge grafting procedures. journal of hand surgery (br and european volume) 2002;27b:1:36-41. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:13 am page 53 page 22 sa orthopaedic journal autumn 2014 | vol 13 • no 1 the classification of chronic osteomyelitis lc marais mbchb, fcs orth (sa), mmed (orth) tumour, sepsis and reconstruction unit, department of orthopaedics, grey’s hospital, university of kwazulu-natal n ferreira bsc, mbchb, fc orth (sa), mmed (orth) tumour, sepsis and reconstruction unit, department of orthopaedics, grey’s hospital, university of kwazulu-natal c aldous bsc, bsc (hons), msc, phd medical research scientist, school of clinical medicine, college of health sciences, university of kwazulu-natal tlb le roux mbchb, fcs orth (sa), mmed (orth) professor and head of department, department of orthopaedics, i military hospital, university of pretoria correspondence: dr lc marais department of orthopaedic surgery grey’s hospital school of clinical medicine university of kwazulu-natal private bag x9001 pietermaritzburg 3201 email: leonard.marais@kznhealth.gov.za tel: +27 33 897 3299 fax: +27 33 897 3409 introduction chronic osteomyelitis, as a clinical entity, encompasses a wide array of clinical scenarios, including chronic haematogenous osteomyelitis, post-traumatic osteomyelitis, periprosthetic infections and contiguous osteomyelitis. owing to the heterogeneous nature of disease, the wide variety of patients affected and the multitude of factors that need to be considered during the formulation of a treatment strategy, more than ten classification systems of chronic osteomyelitis have been published over the past 40 years. none of these classifications is universally accepted. some of the systems simply classify the nature of the disease while others attempt to guide the treating surgeon on certain aspects of the management of chronic osteomyelitis or enable comparison of the outcome of different treatment strategies.1 formulating the appropriate management strategy, albeit palliative or curative, is a complex task. the decisionmaking process requires consideration of multiple factors including the impairment resulting from the disease, the patient’s functional requirements, local and systemic risk factors, the anatomic nature of the disease and the realistic goals of therapy. when considering the risk–benefit ratio of any proposed management strategy, the host’s physiological status remains the main determinant of the risk involved with a specific intervention. this is illustrated by previous studies which have identified the physiological status of the host as the most important predictor of treatment failure.2 the significant impact of inadequate or incorrect host stratification and risk assessment is epitomised by the fact that failure of a curative (limb reconstruction) strategy often results in the inevitable amputation of the involved limb. abstract as a result of the heterogeneous nature of chronic osteomyelitis and the complexity of management strategy formulation, more than ten classification systems have been published over the past 40 years. historical systems, used in the classification of chronic osteomyelitis, remain useful in terms of the description of the nature and origin of the disease. they fail, however, to provide the user with sufficient information in order to select the appropriate treatment strategy. as a result, more comprehensive classifications have subsequently been proposed. accurate host stratification, in particular, is considered to be essential. the physiological status of the host serves as the primary indicator of the patient’s ability to effect healing of bone and soft tissues, as well as their ability to launch an effective immune response in conjunction with antibiotic therapy. despite the development of more comprehensive classification systems, many shortcomings remain within the domain of disease classification and host stratification. key words: osteomyelitis, chronic, classification saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 22 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 23 this article aims to review the available classification systems for chronic osteomyelitis and highlight some of their shortcomings. furthermore we will evaluate how the existing classification systems relate to new and evolving principles and techniques utilised in the management of chronic osteomyelitis. historical perspectives traditionally, osteomyelitis has been classified according to the system described by waldvogel in 1970.3 this was a descriptive classification system incorporating the source of the infection (haematogenous or contiguous), the presence of generalised vascular disease and the duration of the infection (acute, sub-acute and chronic). haematogenous chronic osteomyelitis of long bones typically presents as recurrence at a previous site of acute haematogenous osteomyelitis, while haematogenous periprosthetic infections involve seeding from a distant infective focus. contiguous osteomyelitis may be the result of either direct inoculation (as is the case in post-traumatic and postoperative infections) or, alternatively, continuous spread from an adjacent septic focus (pressure sore or vascular ulcer, for example). as the frequency of surgical intervention increased, so did our need to classify contiguous osteomyelitis. kelly subsequently published an aetiological classification which distinguished haematogenous from post-surgical and post-traumatic causes (with or without the presence of non-union).4 ger’s classification, published in 1977, recognised that the condition of the soft tissues plays an important role in the surgical decision-making process. according to this system the condition of the soft tissue is classified as a simple sinus, chronic superficial ulcer, multiple sinuses or multiple skinlined sinuses.5 in 1984 weiland et al. introduced an anatomical classification system based on the nature of skeletal involvement in order to guide the utilisation of free tissue transfers during the reconstruction process. type i lesions were defined as soft tissue infection with exposed bone. type ii lesions were characterised as circumferential endosteal and cortical infection, while type iii lesions involved endosteal and cortical infection in the presence of a segmental bone defect. although the abovementioned classification systems are useful in terms of describing the nature and origin of the disease, they fail to provide the treating physician with guidance regarding the management of the patient. may and jupiter addressed these shortcomings in 1989 through the publication of their classification system, which focused on the status of the tibia and ipsilateral fibula as a guide during the selection of the appropriate reconstruction procedure (table i).6 gordon et al. simplified the approach to post-infective reconstruction by condensing the classification of tibial defects into three groups, namely, no significant bone loss, <3 cm of bone loss and >3 cm bone loss.7 this classification system was, however, specifically designed to prognosticate patients following free muscle transfers. romanò et al. subsequently proposed a more extensive classification system for bone defects, which included defects frequently seen following periprosthetic infections. according to this system, type 1 lesions were defined as cavitatory defects within a stable bone segment, type 2 lesions represented epiphyseal lesions with joint involvement and type 3 lesions involved a segmental bone defect. type 3 bone defects were sub-classified as either less than 1cm, between 1 and 3 cm, or more than 3 cm.8 prior to 2006 there was no published classification for infections following osteosynthesis. romanò et al. responded to this omission with the publication of the ics (infection, callus, stability) classification. according to this system, type i infection occurs in the presence of stable internal fixation and progression of union on serial x-rays. in terms of the management of type i infections, they suggested conservative measures until union was achieved. type ii infections were defined as infections in the presence of stable osteosynthesis without the progression of callus. the authors suggested managing this type of infection with control of the infection (as for type i), acceleration of bone healing through physical stimulation (low-intensity pulsed ultrasound, for example), biological factors (bone morphogenetic protein, platelet-rich plasma, etc.) and limited surgical procedures (e.g. dynamisation of intra-medullary nail fixation). for type iii infections, involving unstable fixation and the absence of callus formation, revision surgery was recommended. type characteristics reconstructive options i intact tibia capable of withstanding functional loads none required ii intact tibia requiring bone graft for structural support anterior bone graft and flap posterolateral bone graft papineau open bone graft iii tibial defect <6 cm, intact fibula posterolateral bone graft and tibio-fibular synostosisdistraction osteogenesis iv tibial defect >6 cm, intact fibula posterolateral bone graft and tibio-fibular synostosis distraction osteogenesis fibula-pro-tibia (ipsilateral fibula transfer) free vascularised bone graft allograft replacement v tibial defect >6 cm as for type ivconsider amputation table i: classification and reconstruction options as suggested by may and jupiter6 saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 23 page 24 sa orthopaedic journal autumn 2014 | vol 13 • no 1 the abovementioned classification systems are all useful, especially in terms of the description of the nature and origin of the disease. with exception of the ics classification system they fail, however, to provide the user with sufficient information to formulate a treatment strategy. the need had thus arisen to develop a more comprehensive classification system which incorporated several criteria and was able to guide the treating orthopaedic surgeon towards the correct management strategy. comprehensive classification systems cierny and mader revolutionised our approach to osteomyelitis in 1984 through the publication of a classification system which emphasised a more holistic approach to the patient, recognising the importance of immune competency and the physiological ability of the host to effect healing.9 this system involved classification according to the host’s physiological status and the anatomic nature of the disease (table ii). the importance of the consideration of the physiological host status of patients with osteomyelitis was validated through cierny and mader’s study involving 189 patients. the host classification facilitated the decision-making process in terms of offering the patient the alternatives of amputation or limb salvage surgery. forty-six patients required amputation in order to achieve cure, while arrest of disease was achieved in 93.6% of patients in the limb salvage group.10 in our opinion the anatomical sub-section of the cierny and mader classification remains applicable today, although the definition of the subtypes has been refined over the years. type i lesions imply infection limited to the medulla, while type ii lesions refer to infection limited to the cortex. type iii and iv infections involve both medullary and cortical bone, with type iv being differentiated by the presence of instability prior to or following the debridement. although initially included as an anatomic type iv infection, peri-prosthetic infection has subsequently also been allocated its own classification system.11 the cierny and mader classification however failed to provide specific, objective criteria according to which the c-host, whom they deemed unsuitable for surgery, should be defined. mcpherson et al. attempted to address the shortcomings of the cierny and mader host classification system by modifying it to include specific objective criteria (table iii).12 the mcpherson system divides patients into three classes, a, b or c, based on the number of comorbid conditions that a patient has in common with a list of 14 immune-compromising factors. patients with no compromising factors are in class a, while patients in class b have fewer than three compromising factors. patients in class c have three or more compromising factors and/or one of the following conditions: an absolute neutrophil count less than 1  000; a cd4 count less than 100; intravenous drug abuse; chronic active infection of another site; or dysplasia or a neoplasm of the immune system. this classification system was, however, developed specifically for use in terms of planning for second stage revision arthroplasty in patients with infection following total hip replacement. the criteria suggested by them are conservative in terms of their numerical values and may not be appropriate when applied to chronic osteomyelitis in the south african clinical setting. several criteria have been omitted, with specific reference to physical impairment, the state of the soft tissue, arterial and venous sufficiency, age, diabetic control (hba1c), albumin and haemoglobin values, which may play a critical role in the decision-making process in the case of chronic osteomyelitis. the mcpherson modification of the cierny and mader host classification system has, nevertheless, also been used in other clinical settings. bowen and widmaier looked at the incidence of infection following open fractures in three cohorts of patients, who were classified according to the mcpherson modification.13 they found that type b hosts were 2.86 times, and type c hosts 5.72 times more likely than type a hosts to develop infection following open fractures. lautenbach developed a staging system that integrates clinical, laboratory and radiological features in an incremental manner.14 this classification is based on the severity of the disease and describes certain characteristic laboratory abnormalities which may be utilised to confirm the presence underlying infection in equivocal cases. cierny and mader in 1984 published a classification system which emphasised a more holistic approach to the patient anatomic type type characteristics i medullary osteomyelitis ii superficial osteomyelitis iii localised osteomyelitis iv diffuse osteomyelitis physiological class class characteristics a good immune system and delivery b compromised locally (bl) or systemically (bs) c requires suppressive or no treatment; minimal disability; treatment worse than disease; not a surgical candidate factors affecting physiological class systemic factors (s) local factors (l) malnutrition renal, liver failure alcohol abuse immune deficiency chronic hypoxia malignancy diabetes mellitus extremes of age steroid therapy tobacco abuse chronic lymphedema venous stasis major vessel compromise arteritis extensive scarring radiation fibrosis table ii: cierny and mader classification system9 saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 24 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 25 the classification system consists of eight escalating grades of severity (three grades of acute and five grades of chronic osteomyelitis), which are each defined by characteristic clinical and laboratory features (table iv). as the grades of chronic osteomyelitis increase in intensity we see progressive abnormalities of the laboratory findings, especially in terms of iron studies, which may then be utilised in the diagnosis and stratification of disease severity. recently romanò et al. again highlighted the shortcomings of the cierny and mader host stratification system as a subjective evaluation of the host’s physiological ability to deal with infection.15 their seven-item comprehensive classification system (siccs) of bone and joint infections for adults is based on the clinical presentation, aetiopathogenesis, anatomo-pathological characteristics (incorporating the cierny and mader anatomical sub-section for long bones), the mcpherson modification of host classification (further subdivided according to age as less than 2 years, less than 14 years and more than 14 years of age), causative microorganism, the bone defect (in accordance with romanò’s earlier classification system), as well the state of the soft tissues (table v). the siccs is descriptive in nature, incorporating existing classification systems. in contrast with the cierny and mader classification system it was not designed to guide management, but is rather intended for didactic and scientific purposes in order to compare results from different clinical trials. importance of accurate host stratification the clinical manifestations of osteomyelitis are the result of the complex interplay between the host’s immune defence system and the causative organisms’ attempts to establish a biofilm-based colony on a sequestrum, surgical implant or foreign body. the host’s physiological status in particular, has been identified as a crucial factor, determining the course and clinical manifestations of the disease. the host status also serves as the primary indicator of the patient’s ability to effect healing of bone and soft tissues, as well as their ability to launch an effective immune response in conjunction with antibiotic therapy. without a competent immune response from the host, any attempt at surgical eradication of the infection may be futile. the physiological host status does not only determine the suitability of a treatment strategy for the patient, be it curative or palliative, it also guides the surgeon in terms of the appropriate surgical margin during debridement. traditional teaching regarding the surgical management of chronic osteomyelitis advocates the excision of all necrotic and ischaemic bone and soft tissue, to a clean, well-perfused surgical margin.16 the importance of the extent of debridement has been investigated in both normal and compromised hosts. compromised patients (b-hosts) treated with marginal resection (clearance margin of <5 mm) had a higher rate of recurrence than normal patients (a-hosts), whereas a marginal resection may be acceptable in normal hosts.17 thus, compromised hosts are theoretically best treated with a wide resection and subsequent limb reconstruction. these reconstruction procedures, involving bone transport or extensive bone grafts, are however fraught with danger, and failure invariably results in the amputation of the limb. systemic factors local factors age >80 years immunosuppressive medication alcoholism malignancy pulmonary insufficiency chronic indwelling catheter renal failure requiring dialysis chronic malnutrition systemic inflammatory disease current nicotine use systemic immune compromise diabetes hepatic insufficiency active infection >3–4 months multiple previous incisions with skin bridge soft tissue loss from prior trauma subcutaneous abscess >8 cm3 synovial cutaneous fistula prior peri-articular fracture prior local irradiation vascular insufficiency table iii: systemic and local compromising factors according to the mcpherson classification of infected total hip arthroplasty12 grade characteristic clinical grades acute grade 1 grade 2 grade 3(a) grade 3(b) chronic grade 4 grade 5 grade 6 grade 7 grade 8 acute fulminating sub-acute acute with insidious onset acute exacerbation of chronic chronic overwhelming chronic diffuse with inflammation chronic low grade extensive without inflammation chronic localised lesion non-infective pathology laboratory findings chronic grade 4 grade 5 grade 6 grade 7 grade 8 increased wbc, neutrophilia, left shift and toxic granulation, decreased transferrin, procalcitonin >2, increased platelets, abnormal rbc corpuscles decreased hb mcv and mch, rouleaux formation increased ferritin, decreased iron, decreased iron saturation, increased esr ferritin:iron ratio >7 normal radiological features definite infection probable infection equivocal probable cure or absence of infection definite cure or absence of infection new bone lysis or sequestrum new periosteal reaction no change sclerosis only normal bone architecture table iv: the lautenbach classification system14 in our opinion the anatomical sub-section of the cierny and mader classification remains applicable today saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 25 page 26 sa orthopaedic journal autumn 2014 | vol 13 • no 1 the decision-making process is further complicated by that fact that many patients should not receive surgery because the risk of surgery may outweigh the benefit thereof. for example, patients may have little pain and minimal disability, with only intermittent drainage from a sinus. embarking on major limb reconstruction surgery may be inappropriate in such a case, due to the risk of ablation. thus, further consideration should also be given to the patient’s current functional status and the realistically achievable goals of treatment. in south africa the high prevalence of immune compromise, malnutrition and other risk factors present unique challenges during host stratification. classifications previously devised in developed countries have been found to be either inadequate or inappropriate in a resource-poor clinical setting. in stark contrast with the south african public sector, where approximately one-third of patients are classified as c-hosts, developed countries deal with a much lower percentage. in a review of 2 207 patients seen over approximately 30 years, cierny reported an incidence of only 4% type c-hosts in his american practice.18 clinical experience in south africa has therefore revealed the need for accurate and objective host stratification to enable the selection of a safe, appropriate and patient-specific treatment plan. ultimately the patient’s physiological status should be considered as a critical factor during the formulation of the appropriate treatment strategy for an individual. shortcomings of existing classification systems the first major shortcoming of existing classification systems relates to host stratification. the stratification strategies currently available have failed to determine specific objective criteria whereby which patients who are unsuitable for a curative management strategy (a type c-host) can be identified. according to cierny type chosts should not be offered definitive care, but rather palliated or simply treated expectantly.18 the type c-host, as defined by cierny and mader, is a patient in whom the risk or morbidity of treatment outweigh the benefits thereof or, in other words, the treatment or results of treatment of chronic osteomyelitis are more compromising to the patient than the disability caused by the disease itself. this definition encompasses a large group of patients, including patients with minimal disability as a result of the disease as well as patients who are not suitable candidates for complex bone and/or soft tissue reconstruction. the limitation of this definition is the fact that it is subjective (with a poor inter-observer reliability), case dependent and susceptible to widely varying interpretation depending on the surgeon’s experience. the second limitation of existing chronic osteomyelitis classification systems lies in the patho-anatomical characterisation of lesions. there is currently no universally accepted classification system for either bone or soft tissue defects. the problem is further confounded by the fact that the magnitude of a bone defect that should be considered as critical and thus not manageable with cancellous bone graft, remains controversial.19 older classifications systems have failed to keep up with contemporary reconstruction techniques. the classifications proposed by may and jupiter, for example, fail to mention the induced-membrane technique popularised by masquelet.20 furthermore, the classification of bone defects varies widely in terms of cut-off points and each system reflects the unique preferences and abilities of the authors. while some surgeons, for example, feel comfortable transporting bone for a defect in excess of 6 cm, others would prefer the use of a vascularised fibula graft. a problematic decision commonly faced when utilising the cierny and mader classification’s anatomical subsection, is whether a specific lesion should be graded as a type iii or type iv lesion. this decision is complicated by the fact that the distinction between the two grades is defined as instability following debridement. item characteristic clinical presentation acute/sub-acute/chronicearly/delayed/late aetiopathogenesis haematogenous vasculopathy/neuropathy temporary implant ics classification type i type ii type iii permanent implant anatomo-pathology rachis hand long bones type 1 type 2 type 3 type 4 foot joint host type/age a/b/c<2 yr/<14 yr/>14 yr microorganism gram + gram − mixed or multi-resistant mycobacterium negative bone defect type i type ii type iii a/b/c soft tissue defect no soft tissue defect soft tissue defect (cm3) with or without exposed bone table v: the seven-item comprehensive classification system proposed by romanò, et al.15 many patients should not receive surgery because the risk of surgery may outweigh the benefit thereof saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 26 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 27 the classification of a lesion as either type iii or iv is, therefore, completely subjective and arbitrary, depending on the surgeon’s choice of resection margin. if an infected section of bone is critical for axial stability, the surgeon has two choices: either resection of the bone with subsequent destabilisation of the limb (which will require complex reconstruction procedures), or leaving the infected bone behind and attempting to suppress the infection. the former type of wide resection with ‘clear’ margins (resecting any avascular material) remains the ideal, but it is frequently unachievable as it may involve resecting bone or soft tissue that is vital to the survival and function of the limb. on the other hand marginal resections may leave behind soft tissue or bone which contains bacteria and may serve as a nidus for recurrence of infection. the major limitation of the cierny and mader system is that it unfortunately does not provide any guidelines regarding the selection of the appropriate surgical margin. the most prominent inadequacy of existing classification systems rests in the fact that they fail to guide the user in selecting the appropriate treatment strategy from the myriad of contemporary treatment options available. although the seven-item comprehensive classification system, proposed by romanò et al., is useful when describing the nature of the infection, it is complex and does not offer any guidelines for the selection of the applicable treatment strategy. in fact, the authors conclude that the classification system should find application in the comparison of outcomes, rather than being used as a guide to management. this problem is not unique to the siccs and is a feature common to the other classification systems. the treatment guidelines offered by cierny and mader have failed to keep up with modern trends in the surgical management of chronic osteomyelitis.10 although the basic premise remains sound, some of the modalities suggested in the original publication has fallen out of favour. the use of open-sky (papineau) bone grafting, for example, has been all but abandoned. this point is further illustrated by the fact that cierny abandoned the original guidelines in a more recent publication, opting for a more generic approach to management.21 the final limitation of existing classification systems lies in the structure of the decision-making process. while there are three host types described there are only two major treatment options, namely cure or palliation.22 in order to appear logical and aid in the therapeutic decision-making process each host group should ideally be matched with its own unique management strategy. this will require revision of existing systems and the establishment of a new unified classification which incorporates all the relevant selection criteria, as well as all contemporary interventional strategies and techniques. conclusion as stated by cierny, the selection of patient-matched treatment options (for example low risk treatment in high risk patients) closes the gap in successful outcomes between health-compromised patients (bor c-hosts) and patients without compromise (a-hosts).23 ultimately the patient’s physiological status is considered to be the single most important factor that needs to be considered when stratifying patients and during the formulation of the appropriate treatment strategy for any individual. despite the development of comprehensive classification systems, many shortcomings remain within the domain of disease classification and host stratification. the failure of existing classification systems to keep pace with contemporary management philosophies and modern reconstructive techniques has resulted in the need for the development of a new classification system which allows integration of host factors with the oncological-oriented approach which is currently being popularised in the surgical management of chronic osteomyelitis. the content of this article is the sole work of the author. the primary author, lc marais, has received a research grant from the south african orthopaedic association for research relating to chronic osteomyelitis. references 1. mader jt, shirtliff m, calhoun jh. staging and staging application in osteomyelitis. clin inf dis 1997;25:1303-309. 2. haas dw, mcandrew mp. bacterial osteomyelitis in adults: evolving considerations in diagnosis and treatment. am j med 1996;101:550-61. 3. waldvogel fa, medoff g, swartz mn. osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects. n engl j med 1970;282:198-206. 4. kelly pj. infected nonunion of the femur and tibia. orthop clin north am 1984;15:481-90. 5. ger r. muscle transposition for treatment and prevention of chronic traumatic osteomyelitis of the tibia. j bone joint surg am 1977;59-a:784-91. 6. may jw, jupiter jb, weiland aj, et al. clinical classification of post-traumatic tibial osteomyelitis. j bone joint surg am 1989;71a(9):1422-28. 7. gordon l, chiu ej. treatment of infected non-unions and segmental defects of the tibia with staged microvascular muscle transplantation and bone-grafting. j bone joint surg am 1988;70a:377-86. 8. romanò cl, meani e. il difetto osseo nelle infezioni: proposta di classificazione e opzioni di trattamento. arch ortop reumatol 2006;117:14-15. 9. cierny g, mader jt. adult chronic osteomyelitis. orthopedics 1984;7:1557-64. 10. cierny g, mader jt, penninck jj. a clinical staging system for adult osteomyelitis. contemporary orthopaedics 1985;10:17-37. 11. cierny g, dipasquale d. periprosthetic total joint infections. staging, treatment, and outcomes. clin orthop relat res 2002;403:23-28. 12. mcpherson ej, woodson c, holtom p, et al. periprosthetic total hip infection. outcomes using a staging system. clin orthop relat res 2002;403:8-15. 13. bowen tr, widmaier jc. host classification predicts infection after open fractures. clin ortho rel res 2005;433:205-11. the most prominent inadequacy of existing classification systems rests in the fact that they fail to guide the user in selecting the appropriate treatment strategy from the myriad of contemporary treatment options available saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 27 page 28 sa orthopaedic journal autumn 2014 | vol 13 • no 1 14. lautenbach eeg. calibrating the systemic effects of infection with laboratory investigations. european bone and joint infection society congress, s11.2, september 2009,vienna, austria. j bone joint surg br 2011; 93-b:supp iii s333. 15. romanò cl, romanò d, logoluso n, drago l. bone and joint infections in adults: a comprehensive classification proposal. eur orthop traumatol 2011;1:207-17. 16. rao n, ziran, bh, lipsky ba. treating osteomyelitis: antibiotics and surgery. plast reconst surg 2011;127(1):177s187s. 17. simpson ah, deakin m, latham jm. chronic osteomyelitis. the effect of the extent of surgical resection on infection-free survival. j bone joint surg br 2001;83:403-407. 18. cierny g. surgical treatment of osteomyelitis. plast reconstr surg 2011;127(1)suppl:190s-204s. 19. tiemann ah, hofmann go. principles of the therapy of bone infection in adult extremities. strat traum limb recon. 2009;4:5764. 20. masquelet ac, begue t. the concept of induced membrane for reconstruction of long bone defects. orthop clin n am 2010;41:27-37. 21. cierny g, dipasquale d. treatment of chronic infection. j am acad orthop surg 2006;14:s105-s110. 22. walter g, kemmerer m, kappler c, hoffmann r. treatment algorithms for chronic osteomyelitis. dtsch arztebl int 2012;109(14):257-64 23. cierny g. patient selection in osteomyelitis. osteomyelitis.com 2009; available from: http://www.osteomyelitis.com/public/ blog/wp-content/uploads/2009/11/treatment-modification3. jpg this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 28 404 not found 404 not found sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 39 giant cell tumour of the tendon sheath (gct-ts) in the foot: a case report z mayet bsc, mbchb, fc orth(sa), mmed orth(wits) m street mbbch, registrar t noble mbbch, intern, chris hani baragwanath academic hospital skm magobotha fc orth(sa), deputy head of department (chbah) division of orthopaedics, university of the witwatersrand, johannesburg correspondence: dr z mayet division of orthopaedics po bertsham 2013 tel: (011) 933-8914 email: dr.z@webmail.co.za introduction giant cell tumour of the tendon sheath (gct-ts) is a benign, solitary, proliferative tumour that arises from the complex of the tendon sheath of small joints in the hands and feet.1 gct-ts occurs most commonly in the fourth to fifth decades, but can occur between 10 and 60 years.2 the female to male ratio is 3:2 and there is no racial preponderance.2,3 gct-ts has been described as the most common tumour of the hand after ganglion cysts.2,4 in contrast it is much rarer in the foot, with only 3–10% of gct-ts being described in the foot,2 and is reported to make up 0.8% of foot and ankle masses.5 this equates to a condition that is not rare, but is uncommon. the case presented here shows the typical findings of gct-ts, which grew to a considerable size due to its long history. it crossed the anatomically confined spaces of the forefoot and midfoot. we further present a review of the topic. case report a 42-year-old male presented with a painful mass in the third web space of his left foot. it was a slow-growing mass, which was first noticed many years earlier. approximately 12 years prior to presentation, a biopsy was performed from the dorsal aspect of the foot at a peripheral hospital. no clinical notes or histology results were available to us. at the time of presentation to our unit, the patient complained that the mass had increased in size considerably over the last year, and he felt as if he was walking on a stone. despite the use of orthotics and shoe-wear modifications, he was experiencing a lot of pain on weight bearing and he complained of numbness in the third and fourth toes. examination of the foot revealed a healed surgical incision in the third web space. there was a fullness visible in the area on the dorsum and plantar aspects, and the third and fourth toes were splayed. palpation revealed a large mass that was more prominent on the plantar aspect of the foot (figure 1), and its full extent could not be felt. the mass was non-tender, but there was pain when the metatarsals were compressed to perform a mulder’s test. sensation was altered in the third web space and on the third and fourth toes. he had an antalgic gait and he preferred heel walking because of the pain. his general examination was unremarkable and he was in good health. there were no lymph nodes palpable. abstract giant cell tumour of the tendon sheath (gct-ts) has been described as the most common tumour of the hand following ganglion cysts. in contrast it is much rarer in the foot, with only 3–10% of gct-ts being described in the foot. a pubmed and medline search of the topic has revealed two case series and 12 case studies. it is therefore an uncommon condition, but should be considered as part of a differential diagnosis for a mass in the foot. we present the case of a 42-year-old male who presented with a large painful mass in in the third web space of his left foot, which was 7 cm in length in vivo. it crossed the anatomical compartments of the forefoot and midfoot. our case report showed the typical findings of a gct-ts. along with this we also present a review of the literature. key words: giant cell tumour of the tendon sheath, gct-ts, benign tumours, foot tumours saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 39 page 40 sa orthopaedic journal autumn 2014 | vol 13 • no 1 his x-rays showed a soft tissue mass in the third intermetatarsal space, with splaying of the adjacent rays. there were no bony erosions, and no calcifications in the mass. serology was unremarkable. our differential diagnosis at this point was giant cell tumour of the tendon sheath, synovial sarcoma and morton’s neuroma. we also considered tuberculosis and pigmented villonodular synovitis, but these were thought to be less likely. an mri scan of the lesion revealed a well circumscribed mass in the third intermetatarsal space, which extended into the plantar aspect. it was homogenous and showed a low intensity on the t1 and t2 images. it enhanced on the gadolinium images of the mri. the proximal aspect of the mass could not be well visualised on the available films or on the computer, but was thought to be around the level of the tarsometatarsal joints. the size measured on mri was 33 mm × 26 mm × 27 mm (figures 2 and 3). the mass was excised in its entirety. this was achieved through a primary dorsal incision which spanned the intermetatarsal space (figure 4). the distal end was blindending, and no flexor tendons were seen distally to the third and fourth toes. proximally a second incision was needed on the plantar aspect. the mass was found to originate from the tendon, and a tenotomy was performed proximal to the mass through healthy tendon. a large, yellowish-tan, rubbery-hard mass was removed. it measured 7 cm in length in vivo, which was larger than that seen on mri (figure 5). its length in situ appeared to be much longer, which is probably due to the elasticity of the tendon and mass. the wound was found to have no residual traces of the mass. digital nerves were not seen in the intermetatarsal space. closure was done on a portavac drain, and compression dressings were applied in an attempt to close down the splaying of the rays. macroscopic examination of the specimen showed a lobulated mass with no areas of calcification, haemorrhage or necrosis. it had a yellowish-tan colour. microscopic examination showed a spindle cell neoplasm arranged in fascicles. interspersed between the spindle cells were osteoclast-like giant cells (figure 6). there was a background chronic inflammation, and haemosiderin pigment was seen. two mitoses were seen per 10 hpf. the periphery of the specimen was covered in adipose tissue and skeletal muscle. a final diagnosis of gct-ts was made. the post-operative period was uneventful and the patient did very well. he has no problems with weight bearing or footwear and the splaying has disappeared. he reports normal sensation and no pain. there are no signs of recurrence after 1 year of follow-up. discussion a pubmed and medline search of the topic for articles in the english language has revealed two case series, and 12 case studies. the first series of 17 patients was collected retrospectively over 17 years.1 the second was also a retrospective study of 20 patients treated over 5 years.6 this is in keeping with gct-ts being an uncommon condition. figure 1. visible mass on the dorsum of the left foot figure 2. homogenous mass in the third intermetatarsal space extending into the plantar aspect on coronal t1 image the post-operative period was uneventful and the patient has no problems with weight bearing or footwear and the splaying has disappeared. figure 3. axial fat sat image showing a homogenous mass with enhancement at the periphery saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 40 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 41 the most common site of occurrence was originally described as the great toe.2 wang et al however presented a group of 30 patients presenting for ultrasound of gct-ts, of which seven (23.3%) were foot cases. most of these occurred in the forefoot.4 a review of the articles in the orthopaedic literature gave us 49 cases to evaluate the anatomic site of origin1,3,4,7,8-15 (figure 7). the forefoot had 32 cases (65%), of which 81% occurred on the medial side. the midfoot had four cases (8%) and the hindfoot 11 cases (22%). there were a further two cases that crossed anatomical boundaries. the first is our case which involved the flexor digitorum longus tendon and crossed the forefoot and midfoot with a 12-year history. the second case involved a longstanding large tumour reported in the extensor digitorum longus tendon which crossed anatomical boundaries of the hindfoot, midfoot and forefoot.9 figure 4. mass dissection in the third intermetatarsal space figure 5. lobulated mass measuring almost 7 cm in length figure 6. histology slide showing spindle cells and osteoclast-like giant cells figure 7. anatomical sites of origin of gct-ts (the figures in red show large tumours that usually cross anatomical boundaries of the foot) patients will generally present with a painless mass that gives discomfort on weight-bearing or difficulty with footwear saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 41 page 42 sa orthopaedic journal autumn 2014 | vol 13 • no 1 figure 7 also shows a case of a tumour in the fourth toe. this was a case report of a large tumour in the form of a macrodactyly after an 11-year history.11 table i presents a comprehensive differential diagnosis for foot and ankle masses and gct-ts. as is usual with such long lists, most conditions will be excluded by clinical presentation, including site of the lesion.5,16 the few remaining conditions are usually difficult to exclude, even after radiology, and a diagnosis has to be made histologically. pre-operative diagnostic accuracy in the two case series was 20% and 17.6%, which highlights the difficulty clinicians have with making a diagnosis.1,4 patients will generally present with a painless mass that gives discomfort on weight-bearing or difficulty with footwear.1 occasionally there is an associated sensory deficit secondary to compression of the digital nerves. there are also two reports of patients with gct-ts presenting with hallux valgus deformities.8,12 plain radiology may show a soft tissue mass or swelling which may cause splaying and erosion of the adjacent bone.3 however to make a diagnosis using radiology, an ultrasound or mri is needed. gct-ts is seen as a hypo-echoic nodule with ultrasonography. the mass could have either homogenous or heterogenous echogenicity. under doppler imaging, 71% of lesions also show substantial flow, while the rest show minimal flow. a finding of hypervascularity is typical of gct-ts; however, it is not specific. this hypervascularity has led to a misdiagnosis of haemangioma.1 it will however exclude ganglions, which are typically avascular or anechoic.4,17 mri is considered an important diagnostic tool, and has very typical features. gct-ts has a low intensity signal on t1 and t2 weighted images, and has homogenous enhancement on gadolinium-enhanced images.6,18 these findings, although typical, are not absolute or specific. most lesions are said to be hypointense as compared to muscle; however, some are isointense. these low signal images also occur in pigmented villonodular synovitis, densely mineralised tumours and tumours with large amounts of fibrous tissue. a gradient-echo sequence is helpful to be able to differentiate haemosiderin from fibrous tissue.6,17,18 a definitive diagnosis however can only be made on tissue samples. this is routinely done by histology. stromal cells can either be spindle-shaped or polygonal. the nuclei of stromal cells are a source of much debate in microbiology, but are now said to be of variable morphology. giant cells which resemble osteoclasts are also seen. mitoses vary considerably from 0–9 per 10 hpf. lastly, xanthomatous change is present and haemosiderin-laden macrophages can be seen. fineneedle aspiration can also be considered, with venkateswaran et al stating that cytodiagnosis is now possible. cytology findings generally mirror the features on histology as he found in a 20-case series.19 treatment takes the form of a marginal excision. recurrence rates are quoted as 0% at 85 months and 20% at 5 years in the two available case series.1,6 none of the case studies reported any recurrences, and complete local excision is stated as the only method of preventing recurrence.1,3,4,7-9,20 recurrence is treated by marginal excision in the case of the localised forms that occur in gct-ts of the foot. radiotherapy is used as an adjunct in other forms of the disease outside the hand and foot.20 there was no mention of any malignant transformation in any of the literature for masses appearing in the foot and ankle. conclusion gct-ts is an uncommon condition in the foot and ankle, with most orthopaedic surgeons seeing only one case in a career. it presents as a mass in the foot and ankle, and making a definitive diagnosis is difficult without histology. clinical features are usually of a slow-growing mass that causes compressive symptoms. findings on mri are typically of low signal intensity on t1 and t2 images. our case report showed the typical features. however, because of the longstanding nature of the case, our patient presented with an unusually large mass, which crossed the confined anatomical spaces of the forefoot and midfoot. the content of this article is the sole work of the authors, and no benefit of any form has been received or will be received from any commercial party. tissue precursor lesion 1. adipose lipomaspindle lipoma 2. cartilage/bone chondroma subungual exostosis osteophyte osteoid osteoma 3. fibrous plantar fibromatosis fibroma fibrin fibrous tissue 4. fibrohistiocytic plexiform fibrohistiocyticfibrous histiocytoma 5. neural neuroma neurofibroma schwannoma 6. smooth muscle angioleiomyoma 7. vascular haemangioma 8. synovial fibrovascular tissuegiant cell tumour 9. miscellaneous ganglion cyst adventitious bursa gouty tophus calcific tendonitis connective tissue histiocytic reaction 10. tumour-like benign intradermal naevus rheumatoid nodule mucoid cyst epidermal inclusion cyst viral wart keratinous horn 11. infectious tuberculous granulomas table i: differential diagnosis of foot and ankle masses saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 42 sa orthopaedic journal autumn 2014 | vol 13 • no 1 page 43 references 1. gibbons clmh, khwaja ha,cole as,cooke ph, athanasou na. giant-cell tumour of the tendon sheath in the foot and ankle. jbjs-b 2002;84-b(7):1000-1003. 2. giant cell tumor of tendon sheath foot and ankle http:// www.bonetumor.org/tumors-foot-and-ankle/giant-celltumor-foot-and-ankle 3. occhipinti e, heinrich sd, craver r. giant cell tumor of tendon sheath arising in the toe. fetal and pediatric pathology 2004;23:171-79. 4. zhang y, huang j, ma x, wang x, zhang c, chen l. giant cell tumor of the tendon sheath in the foot and ankle: case series and review of the literature. j foot ankle surg 2013;52(1):24-27. 5. macdonald djm, holt g, vass k, marsh a, kumar cs. the differential diagnosis of foot lumps : 101 cases treated surgically in north glasgow over 4 years. ann r coll surg engl 2007;89:272-75. 6. yuexiang wang,jie tan, yukun luo. the value of sonography in diagnosing giant cell tumors of the tendon sheath. j ultrasound med 2007 26:1333-40. 7. findling j, lascola nk, groner tw. giant cell tumor of the flexor halluces longus tendon sheath. j am podiatr med assoc 2011;101(2):187-89. 8. kuo cl, yang sw, chou yj, wong cy. giant cell tumor of the edl tendon sheath : an unusual cause of hallux valgus. foot ankle int 2008;29(5):534-37. 9. guryel e, coleridge s, bendall s. unusual presentation of a giant cell tumor of the tendon sheath in a foot. j surg orthop adv 2004 13(2):110-11. 10. muramatsu k, mine t, ichihara k. atypical tenosynovial giant cell tumor of the extensor hallucis longus tendon. j am podiatr med assoc. 2006 jul-aug;96(4):359-61. 11. skaliczki g, mády f. giant cell tumor of the tendon sheath of the toe imitating macrodactyly: case report. foot ankle int. 2003 nov;24(11):868-70. 12. young kw, lee kt, kwak jj, lee yk, park yu. mass-induced unilateral hallux valgus. orthopedics. 2010 dec 1;33(12):927. 13. vasconez hc, nisanci m, lee ey. giant cell tumour of the flexor tendon sheathof the foot. jpras 2008;61:815-18. 14. ming xie bm, kai xiao mm, zhen-hua fang mm, jing-jing zhao mm, wu-sheng kan bm. giant cell tumor of the tendon sheath of the toe. orthopaedic surgery 2011;3(3):211-15. 15. goni v, gopinathan nr, radotra bd, viswanathan vk, logithasan rk. giant cell tumour of peroneus brevis tendon sheath a case report and review of the literature. bmj case rep 2012;13. 16. bos gd, esther rj, woll ts. foot tumors : diagnosis and treatment. jaaos 2002;10(4):259-70. 17. ganguly a, aniq h, skiadis b. lumps and bumps around the foot and ankle: an assessment of frequency with ultrasound and mri. skeletal radiol 2013;42:1051-60. 18. llauger j, palmer j, monill jm, franquet t, bague s, roson n. mr imaging of benign soft tissue masses of the foot and ankle. radiographics 1998 nov-dec;14(6):1481-98. 19. venkateswaran k, kusum k,kusum v. fine-needle aspiration cytology of giant cell tumor of tendon sheath. diagnostic cytopathology 2003;29(2):105-10. 20. van der heiden l, max cl. gibbons h, bass hassan a, kroep jr, gelderblom h, van rijswijk csp, nout ra, bradley km, athanasou na, sander dijkstra pd, hogendoorn pcw, van de sande maj. a multidisciplinary approach to giant cell tumors of tendon sheath and synovium – a critical appraisal of literature and treatment proposal. journal of surgical oncology 2013;107:433-45. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj autumn 2014_orthopaedics vol3 no4 2014/02/18 9:12 am page 43 404 not found orthopaedics vol3 no4 page 30 sa orthopaedic journal summer 2014 | vol 13 • no 4 a unique case of a radius shaft fracture with proximal radio-ulnar joint dislocation s maqungo mbchb(natal), fcortho(sa), mmed(uct) consultant, orthopaedic trauma surgeon w nkomo mbchb(uct) medical officer orthopaedic trauma service, groote schuur hospital, university of cape town, cape town correspondence: dr s maqungo 4 granula place 7441 sunset beach e-mail: sithombo@msn.com tel: +27 (0) 21 4045108 fax: 0866922718 introduction displaced diaphyseal forearm fractures in adults associated with dislocation of either the proximal or distal radio-ulnar joints are inherently unstable, and plate fixation plus joint reduction of these injuries is the current gold standard. these injury combinations are respectively known by their eponymous names: monteggia and galeazzi fractures.1-3 we present a unique case of a fractured proximal radius with associated proximal radio-ulnar joint dislocation. to our knowledge this injury pattern has not been described before. ethics approval was obtained from our institution and the patient consented to the study. case summary we treated a 21-year-old male patient who was involved in a motor vehicle accident as a driver. he sustained blunt chest trauma with rib fractures but no head or intraabdominal injuries. his right forearm was neurovascularly intact and he had no open wounds. he had no tenderness over the distal radio-ulnar joint so an essexlopresti lesion was excluded.4 radiographs (figures 1a and 1b) revealed a displaced transverse fracture in the proximal third of the right radius with an associated posterior dislocation of the right proximal radio-ulnar joint (pruj). compression plating via the thompson approach was performed and closed reduction of the pruj was attained; this was stable throughout the forearm and elbow range of movement arc.5 the elbow joint was stable with no apparent ligament injury. at one-year follow-up he had united fully and had a full range of movement of the forearm and elbow (figures 2a and 2b). the calcification noted at the proximal aspect of the forearm may represent localised injury to the interosseous membrane but this patient did not have an essex-lopresti injury clinically. abstract we present a previously undescribed lesion of a fractured proximal radius associated with a proximal radio-ulnar joint dislocation. compression plating was performed via the thompson approach and closed reduction of the proximal radio-ulnar joint (pruj) was attained. at one-year follow-up he had united fully and regained full use of his arm. clinicians need to be aware of this possible variation when confronted with proximal radius fracture. key words: galeazzi fracture, proximal radio-ulnar joint dislocation, monteggia fracture compression plating via the thompson approach was performed and closed reduction of the pruj was attained saoj summer 2014_orthopaedics vol3 no4 2014/11/05 11:57 am page 30 sa orthopaedic journal summer 2014 | vol 13 • no 4 page 31 conclusion missed pruj dislocations may result in disabling complications such as limited forearm and elbow range of movement, chronic pain and chronic pruj instability. a vigilant eye for dislocation of both the proximal and distal radio-ulnar joints dislocation should be maintained when dealing with displaced diaphyseal radius fractures. references 1. sebastin sj, chung kc. a historical report on riccardo galeazzi and the management of galeazzi fractures. j hand surg am 2010;35(11):1870-77. 2. bado jl. the monteggia lesion. clin orthop 1967;50:71-76. 3. boyd hb, boals jc. the monteggia lesion: a review of 159 cases. clin orthop 1969;66:94-100. 4. essex-lopresti p. fractures of the radial head with distal radio-ulnar dislocation; report of two cases. j bone joint surg br. 1951 may;33b(2):244-37. 5. anderson ld, sisk d, tooms re, park wi 3rd. compressionplate fixation in acute diaphyseal fractures of the radius and ulna. j bone joint surg am. 1975;57a:287-97. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. figure 1a and b. anteroposterior and lateral radiograph showing a proximal radius fracture and dislocation of the proximal radio-ulnar joint figure 2a and b. anteroposterior and lateral radiograph of the forearm at one-year follow-up showing a wellunited fracture at one-year follow-up he had united fully and had a full range of movement of the forearm and elbow • saoj saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 31 page 32 sa orthopaedic journal summer 2014 | vol 13 • no 4 the shelf life of sterile medical devices ta du plessis, msc(physics), dsc(chem) gammatron (pty) ltd, modimolle, limpopo reprint requests: dr ta du plessis po box 1271 kokanje 0515 email: gammatron@mweb.co.za introduction manufacturers of sterile medical devices often give an expiry (‘use by’) date on the package, generally five years from the date of sterilisation. the question arises as to what limits the duration of the sterility of such devices? why is the shelf life limited by manufacturers, and if so, why specifically five years and not three or ten years – probably relating to the accelerated or real-time testing of the packaging material? this becomes particularly relevant in the case of medical implants such as prostheses. if the implant is specified by the manufacturer to have a shelf life of five years prior to implantation, how does this relate to the in vivo performance of the device? it should be clearly pointed out that in this discussion the emphasis is put on the sterility of the implant and not on the mechano-clinical performance of such a device. in order to get perspective on this issue, it is necessary that we clearly understand the underlying principles of the particular sterilisation technique and the associated packaging of sterile medical devices. the concepts of sterile, sterilisation and sterility assurance levels in many authoritative books in the field of sterilisation, the concept sterile is referred to as a state completely free of any viable microorganisms, and sterilisation is defined as the process which will destroy all viable microorganisms.1-3 these concepts are thus used in the absolute sense where no viable microorganisms exist. however, an inherent problem is that it is impossible in practice to prove either the complete absence or the destruction of these microorganisms.4 this will be discussed in more detail later. the fact that the destruction of microorganisms through physical (radiation and steam) and chemical (ethylene oxide) sterilisation methods shows an exponential dependence on the various process parameters, clearly implies that the absence of microorganisms on a medical device following a properly validated sterilisation process can only be described in terms of a probability function.4-5 this exponential nature of sterilisation means that, although the probability may reach a very low value, it can never be lowered to a zero level in the absolute sense of the word.5-7 this probabilistic approach to sterility leads to the concept of sterility levels – a view which no doubt may have little room in the ‘classical’ approach to sterility. such a probabilistic approach also implies the existence of certain ‘sterility assurance levels’ (sals) – a concept that plays an important role in this field and is being used to quantify the level or probability of sterility achieved through a certain sterilisation process.8 abstract the issues of the shelf life of sterile medical devices and the concept of end-product sterility testing of a sample of devices to prove the sterility of a batch of sterile devices are discussed against the background of the probabilistic approach to sterility and sterilisation. the particular role that the sterilisation technique and the packaging materials used play in maintaining sterility are discussed against the background that sterility and the maintenance thereof is eventand not time-related, and the implications thereof on the shelf life of sterile medical devices. key words: sterile medical devices, sterility maintenance, shelf life what limits the duration of the sterility of sterile medical devices? saoj summer 2014_orthopaedics vol3 no4 2014/11/05 11:58 am page 32 sa orthopaedic journal summer 2014 | vol 13 • no 4 page 33 the sal indicates the expected probability of finding a viable microorganism on a medical device after subjecting such a device to an acceptable and properly validated sterilisation process in which all process specifications are strictly adhered to, and is usually expressed as an exponential function – 10-n.6 the use of sals improves the understanding of the efficacy of a sterilisation process and its practical significance. field of application as a determinant of the required sterility assurance level (sal) the association for the advancement of medical instrumentation (aami) in the usa in the early seventies recognised that different sals can be specified for medical devices, depending on the locality of their application.9 in the iso codes on sterilisation a similar distinction is made between two different medical device categories, depending on the intended field of application of such a device: with this approach, the contamination risk to the patient is the determining factor in selecting an sal for a particular device. those devices that are of an invasive nature will require a lower sal than those that are non-invasive. both categories will still be considered and classified as ‘sterile’ and appropriately labelled as such. end-product sterility testing the probabilistic approach to sterility and sterilisation has led to the concept and common practice of end-product sterility testing as proof of efficiency of a sterilisation process after completion. however, sterilisation is internationally recognised as an example of a process for which the efficacy cannot be verified by retrospective inspection and testing of the end product.6 this implies that sterility testing of the end product cannot be applied to verify a sal of smaller than about 10-2, because the number of devices required as a representative sample for the sterility testing becomes both impractical and uneconomical. to perform end product sterility testing to uniquely ‘prove’ an sal of 10-6 will require the sterility testing of one million devices. to further complicate matters, it is accepted that the inherent limitations of sterility testing typically leads to ‘false positives’ at a level of about 10-3, which prevents end-product sterility testing to low sal values.10-11 it clearly follows that end-product sterility testing of a few medical devices following sterilisation to ‘demonstrate’ or ‘prove’ that the entire batch is sterile, without a proper prior process validation, is without scientific foundation and can lead to erroneous conclusions with regard to the sterility of the batch as a whole. however, it should be pointed out that the use of dosimeters (radiation) or biological indicators (steam and ethylene oxide) with a known accuracy and properly calibrated to monitor a properly validated sterilisation process, is completely acceptable and indeed essential, but they are employed to monitor the process parameters and not to prove the sterility of the resulting product. the impact of sterilisation technique and packaging on the maintenance of sterility based on the basics of sterility and sterilisation, we return to our initial question on the shelf life of sterile medical devices – thus the maintenance of sterility prior to implantation. the sterilisation technique employed obviously plays a very important role on the nature and type of packaging that can be used.12,13 in the case of ethylene oxide gas sterilisation (eto), the packaging material for both the primary and secondary packaging has to be selected to permit penetration by the sterilising gas to sterilise the devices, and its later removal at the end of the cycle. for this reason the polymer laminate packaging commonly used for radiation sterilisation cannot be used for gas sterilisation. in the case of radiation sterilisation the device is hermetically sealed in double laminate pouches (polyethylene/polyester) – in general with a double seal and in the case of polymeric orthopaedic prostheses blanketed under ultra-pure nitrogen gas – the latter to protect the device or its polymeric components from radiation oxidative degradation during the radiation sterilisation cycle and subsequent storage. radiation sterilisation has the advantage that the packaging integrity of these laminate pouches is particularly high and the author is not aware of any of such laminate pouches having failed during storage prior to use. sal 10-6: surgically implanted devices sterile fluid paths other products transgressing natural tissue barriers; implying that not more than one device in a million shall be non-sterile. sal 10-3: topical products mucosal devices non-fluid path surfaces of sterile devices; implying that not more than one device in a thousand shall be non-sterile. radiation sterilisation has the advantage that the packaging integrity of these laminate pouches is particularly high saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 33 page 34 sa orthopaedic journal summer 2014 | vol 13 • no 4 provided a properly validated sterilisation process is used, and the integrity of the packaging is maintained, there is no reason to limit the shelf life of a sterile medical device – especially so in the case of radiation sterilisation. this clearly underlines the concept that sterility as a property of a medical device is recognised as event-related and not time-related. should the packaging of a sterile medical device be compromised, it could lose its sterility directly after sterilisation. similarly, if the packaging integrity is not compromised, the device will remain sterile. the entire concept of the shelf life of medical devices is clearly still a topic that is hotly debated as follows from the international literature on the internet, with the role of the packaging materials and the sterilisation techniques employed being the major points of discussion. accelerated ageing of the packaging materials and seals that are generally used by manufacturers to set the shelf life are topics with their own inherent uncertainties. no benefits of any form have been received from a commercial party related directly or indirectly to the subject of this article. references 1. medical microbiology, ed. r cruickshank, p 680, e&s livingstone limited, london, 1968. 2. dorland’s illustrated medical dictionary, 24th edition, p 1440, wb saunders company, london, 1965. 3. sykes g. disinfection and sterilization, second edition, p 6, e and f n spon limited, london, 1967. 4. whitby jl. resistance of microorganisms to radiation and experience with dose setting, in sterilization of medical products, volume 5, p 346, polyscience publications inc., canada, 1991. 5. medical devices – validation and routine control of ethylene oxide sterilization, draft international standard iso/dis 11135, p 2, international organization for standardization, 1992. 6. sterilization of health care products – methods for validation and routine control gamma and electron beam radiation sterilization. iso/tc 198 wg 2 n16, pp 1 and 5, international organization for standardization, 1991. 7. tallentire a, khann aa. the sub process in defining the degree of sterility assurance, in sterilization by ionizing radiation, volume 2, pp 65 66, multiscience publications limited, montreal, 1978. 8. ibid, p 5. 9. masefield j, et al. a north american viewpoint on selection of radiation sterilization dose, in sterilization by ionizing radiation, volume 2, pp 322-325, multiscience publications limited, montreal, 1978. 10. sterilization of health care products – methods for validation and routine control gamma and electron beam radiation sterilization. iso/tc 198 wg 2 n16, p 99, international organization for standardization, 1991. 11. iso 11137-1: sterilization of health care products – radiation – part 1: requirements for development, validation and routine control of a sterilization process for medical devices (2006). 12. iso 11607-1: packaging for terminally sterilized medical devices – part 1: requirements for materials, sterile barrier systems and packaging systems (2007). 13. iso 11607-2: packaging for terminally sterilized medical devices – part 2: validation requirements for forming, sealing and assembly processes (2007). this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. sterility as a property of a medical device is recognised as event-related and not time-related • saoj saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 34 niemoller hg et al. sa orthop j 2018;17(2) doi 10.17159/2309-8309/2018/v17n2a2 south african orthopaedic journal http://journal.saoa.org.za trauma citation: niemoller hg, greyling p, birkholtz f, goller r, suleman f, postma tc. ability of the schatzker classification to predict posteromedial fragmentation in tibial plateau fractures. sa orthop j 2018;17(2):16–19. http://dx.doi.org/10.17159/2309-8309/2018/v17n2a2 editor: prof anton schepers, university of the witwatersrand received: may 2017 accepted: october 2017 published: may 2018 copyright: © 2018 niemoller hg, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: this study did not require major funding. minimal costs incurred for stationery were covered by the first author. conflict of interest: the authors have no conflicts of interests with respect to this article. abstract background: the schatzker classification is the most widely accepted system used to classify tibial plateau fractures. the presence of posteromedial fragments in the more severe fracture types is known, but the presence of posteromedial fragmentation in the less severe fracture types is unknown. the ability of the schatzker classification to predict posteromedial fragmentation was evaluated. methods: two hundred patients were reviewed of which only 67 met the inclusion criteria. the x-rays were reviewed by three independent orthopaedic surgeons and classified according to the schatzker classification. a radiologist reviewed the ct scans and noted the presence or absence of a posteromedial fragment and if present, the largest diameter of the fragment was measured. results: the mean age of the sample was 44.79 (sd: 14.03) years. seventy-five per cent of the females (n=33) presented with posteromedial fragmentation compared to 65.20% of the males (n=44) (chi²-test, p=0.399). the incidence of posteromedial fragmentation varied between 15.8 and 26.3% for schatzker 1 and 2 fractures and 73.7 and 84.2% for schatzker 3 to 6 (chi2-test, p<0.001) based on the three independent assessments. the mean length of the posteromedial fragmentation ranged from 41.87 to 47.77 mm for schatzker 1 and 2 fractures, and 44.74 to 46.12 mm for schatzker 3 to 6 for the three assessors (statistically not significant [t-test, p=0.536, p=0.551 and p=0.652]). conclusion: the schatzker classification by itself is not adequate to identify all fractures with posteromedial fragmentation. there is a higher association of posteromedial fragmentation with fracture types 3 to 6. there is a high probability of missing a significantly sized posteromedial fragment in schatzker type 1 and 2 fractures if a ct scan is not performed which might influence and compromise fracture stability, joint congruency and the ability to rehabilitate optimally. level of evidence: level 4 key words: tibial plateau fracture, schatzker classification, ct scan, posteromedial fragmentation ability of the schatzker classification to predict posteromedial fragmentation in tibial plateau fractures niemoller hg1, greyling p², birkholtz f³, goller r2, suleman f4, postma tc5 ¹ bsc(uv), mbbch(wits); orthopaedic surgeon in training, kalafong hospital, pretoria ² mbchb(pret), mmed(orth)(pret), fcs(orth)(sa); orthopaedic surgeon, steve biko academic hospital, pretoria ³ mbchb(pret), mmed(orth)(pret), fcs(orth)(sa); orthopaedic surgeon, unitas hospital, walk-a-mile centre of excellence 4 mbchb(pret), mmed(radiology)(pret), fcs(rad)(sa); radiologist, professor, steve biko academic hospital, pretoria postma tc6 5 mchd, dhsm, phd; associate professor and head of clinical unit and statistician. orthopaedic surgery, department of orthopaedic surgery, steve biko hospital, university of pretoria corresponding author: dr h niemoller, second avenue, menlopark, pretoria; email: heinrichniemoller@gmail.com page 17niemoller hg et al. sa orthop j 2018;17(2) introduction tibial plateau fractures represent approximately 1.2% of all fractures and are therefore relatively uncommon. these fractures have a bimodal distribution: younger individuals with high-energy injuries and lower energy elderly patients who fall due to osteopaenia.1 classifying the injury is important for pre-operative planning and prognosis. the range of tibial plateau injuries present across a full spectrum, including open or closed and displaced or non-displaced fractures. the more severe the comminution, the higher the chance of soft tissue compromise and neurovascular complications.2 the goals of treatment for intra-articular fractures are three-fold: the achievement of a stable fixation, the anatomical reduction of the joint surface and the preservation of a range of motion.3 the two most common systems that are used to classify fractures and dislocations are the ao/ota system and the schatzker system. of these two systems, the schatzker system is the most reliable and widely accepted classification system, internationally.3 figure 1 highlights the important components of the schatzker classification.3 bicondylar tibial plateau fracture management remains therapeutically challenging. a study done by david et al. evaluated the frequency and morphology of the posteromedial fragment in this injury pattern. they concluded that the ao classification system missed 6% of posteromedial fragments on x-rays.4 in an attempt to increase the sensitivity of these classification systems, martijn et al. researched whether the addition of a computer tomography (ct) scan would increase interand intra-observer agreement or not. the study also aimed to evaluate inter-observer agreement for fracture classification according to the schatzker classification as well as the treatment of tibial plateau fractures using x-rays alone in comparison to using both x-rays and ct scans. they concluded that ct scans are not advised for all tibial plateau fractures.5 this, however, is in contrast with what zhu et al. found when they compared the schatzker classification (x-ray-based classification) with the three-column classification system (ct scan-based classification). the reproducibility and the reliability of the two systems were compared. in the study it was found that there were 14 cases that could not be classified by the schatzker classification system. the three-column classification system demonstrated a higher interobserver reliability and can therefore be used as a supplement to the conventional schatzker classification, especially in cases of complex fractures with posterior comminution.6 the final aspect of the study was to look at whether threedimensional computed tomography increased the reliability of classification systems for tibial plateau fractures. hu concluded that three-dimensional computed tomography improved intra-observer and inter-observer reliability of classification systems for tibial plateau fractures when compared to plain radiographs and two-dimensional ct images.7 the aim of this study is to determine the ability of the schatzker classification to predict the presence of posteromedial fragmentation in tibial plateau fractures and to determine the incidence of posteromedial fragmentation in the lower group (schatzker type 1 and 2) as well as in the higher group (schatzker type 3 to 6). method the research ethics committee of the faculty of health sciences, university of pretoria provided ethical clearance for this study (protocol october/2016). two hundred patients treated at the steve biko hospital complex and eugene marais hospital during the period january 2006 to december 2015 were identified for possible inclusion in the study. digital radiographs and records of these cases were retrieved to confirm whether inclusion criteria were met. to be included in the study, patients had to be older than 18 years of age with a tibial plateau fracture and an adequate view of the affected knee on an antero-posterior radiograph. moreover, a ct scan of the affected area was a necessity. the researcher assigned a unique case number to each of the cases that met the inclusion criteria. personal details were kept anonymous. three independent trauma orthopaedic surgeons reviewed the antero-posterior radiographs. they were requested to classify fractures according to the schatzker classification.3 a radiologist examined the ct scans for posteromedial fragmentation and measured the fragment with the largest diameter in millimetres by means of a single measurement, using the most adequate ct view available. it should be noted that lateral radiographs were not used in this study as the schatzker classification is a system based on antero-posterior view only. identifying the origin of a posterior fragment on a lateral x-ray is difficult as the fragment could be located medially or laterally. in such circumstances the ideal is rather to revert to ct scans to delineate the one from the other as was done in this study. the statistical analysis was conducted with ibm spss statistics for windows, version 23.0 armonk, ny.ibm corp. the demographic traits of the sample were determined for descriptive purposes. percentage distributions were calculated for the fractures according the schatzker classification system according to the categorisation of the three independent orthopaedic surgeons. the kappa statistic8 was calculated to indicate the level of agreement between the categorisation of the three independent orthopaedic surgeons. posteromedial fragmentation prevalence and mean diameter (in millimetres) per schatzker type were descriptively reported in relation to the corresponding schatzker categorisations. the mean age for cases with and without posteromedial fragmentation was compared using an independent sample’s t-test. one-way analysis of variance was used to compare the mean diameter of the posteromedial fragmentation (widest measurement) per schatzker type. figure 1. a brief explanation of the schatzker classification3 page 18 niemoller hg et al. sa orthop j 2018;17(2) results sixty-seven of the 200 identified hospital cases met the inclusion criteria, of which 44 were males and 33 females. the mean age of the included cases was 44.79 (standard deviation [sd]: 14.03, 95% ci (confidence interval: 41.37–48.21; range 24–93) years. table i shows the percentage distribution of fractures classified, according to the schatzker classification system, by the three independent orthopaedic surgeons. all three surgeons classified the majority of fractures as either schatzker type 1 or 2. type 1 and 2 fractures constituted the majority, ranging between between 53.70 and 61.20 for the three independent assessments. the inter-rater reliability test yielded kappa statistics of 0.49, 0.51 and 0.54 when comparing the agreement between orthopaedic surgeons 1 and 2, 1 and 3, and 2 and 3, respectively, which constituted ‘weak’ agreement9 between the surgeons for the above-mentioned classification. according to the ct scan assessment, a posteromedial fragment was present in 19 cases. the mean age where this occurred was 48.78 (sd: 17.33) years as opposed to the mean age of 43.21 (sd: 12.34) years for the cases where posteromedial fragmentation was not prevalent (independent samples t-test, p=0.143, 95% ci of the difference: −13.11 to 1.95 years). furthermore, 75% of the females in the sample presented with posteromedial fragmentation compared to 65.20% of the males (chi2-test, p=0.399). table i also indicates the prevalence of posteromedial fragmentation in relation to the schatzker types. according to the three independent assessments, posteromedial fragmentation occurred in 84.2%, 84.2% and 73.7% of type 3 to 6 cases compared to 15.8%, 15.8% and 26.3% in type 1 and 2 cases. these differences were statistically significant (chi2-test:p<0.001). the mean posteromedial fragmentation length was 45.22 mm (sd: 10.22; 95% ci: 40.29–50.15). the average size of the posteromedial fragment in males overall was 39.18 (sd: 10.78) mm and 49.65 (sd: 7.45) mm in females (p=0.022; 95% ci of the mean difference: −19.31 to −1.71). the mean length of the posteromedial fragmentation ranged from 41.87 to 47.77 mm for schatzker 1 and 2 fractures and 44.74 to 46.12 mm for schatzker 3 to 6 for the three assessors (statistically not significant (table ii) [t-test, p=0.536, p=0.551 and p=0.652]). discussion the schatzker classification is the most widely used and internationally known classification system for tibial plateau fractures.3 it has the best inter-observer reliability and is taught at most government institutions as the way to quantify the severity of these injuries. it is also mainly an anteroposterior view-based system whereby a lateral view plays no role in this classification system. all tibial plateau fractures, however, cannot be reliably classified by using the schatzker classification and hence the role of a ct scan in these fractures to delineate the extent is important. the use of a ct scan in all types of tibial plateau fractures is controversial as it is costly to scan every patient with this fracture. the association between posteromedial fragmentation and types 3 to 6 is known as all these fracture types are further investigated by a ct scan to delineate the fragmentation and configuration. type 1 and 2 fractures in some institutions do not routinely get a ct scan and hence the exact incidence of posteromedial fragmentation is not known. overall, posteromedial fragmentation was more common in females than males in all categories, although not statistically significant. based on the assessment of the three orthopaedic surgeons in this study it appears as if a substantial number (15.8%– 26.3%) of posteromedial fragmentation may be missed in the lower categories if a ct scan is not done. a range of 41.87–47.77 mm in the widest diameter of the fragment was noted in schatzker 1 and schatzker 2 fractures. there were no studies that evaluated this table ii: posteromedial fragmentation length differences according to a schatzker classification dichotomy (class 1 and 2 versus 3 to 6) schatzker classification orthopaedic surgeon 1 orthopaedic surgeon 2 orthopaedic surgeon 3 mean (x) fracture length (mm) mean (x) fracture length (mm) mean (x) fracture length (mm) n x sd n x sd n x sd 1 and 2 3 47.77 9.25 3 41.87 18.86 5 42.70 13.95 3 to 6 16 44.74 10.60 16 45.85 8.67 14 46.12 9.03 95% ci of the mean difference −10.86 to 16.90 −17.78 to 9.83 −14.85 to 8.01 p 0.652 0.551 0.536 table i: percentage distribution of fractures categorised according to the schatzker classification system in relation to ct confirmation of posteromedial fragmentation schatzker classification orthopaedic surgeon 1 orthopaedic surgeon 2 orthopaedic surgeon 3 all cases posteromedial fragmentation all cases posteromedial fragmentation all cases posteromedial fragmentation n % n % n % n % n % n % 1 11 16.4 1 5.3 9 13.4 1 5.3 10 14.9 1 5.3 2 25 37.3 2 10.5 28 41.8 2 10.5 31 46.3 4 21.1 3 4 6.0 1 5.3 6 9.0 2 10.5 4 6.0 1 5.3 4 7 10.4 3 15.8 5 7.5 3 15.8 8 11.9 5 26.3 5 7 10.4 5 26.3 2 3.0 2 10.5 7 10.4 3 15.8 6 13 19.4 7 36.8 17 25.4 9 47.4 7 10.4 5 26.3 1 and 2 subtotal 36 53.7 3 15.8* 37 55.2 3 15.8* 41 61.2 5 26.3* 3 to 6 subtotal 31 46.3 16 84.2* 30 47.8 16 84.2* 26 38.8 14 73.7* total 67 19 67 19 67 19 *chi2 test: p<0.001 page 19niemoller hg et al. sa orthop j 2018;17(2) correlation and hence a clear comparison could not be made to compare to known literature. we found an incidence of posteromedial fragmentation in the higher categories (schatzker 3 to 6) of between 73.7%–84.2% which is higher than reported in current literature where a percentage of between 59% and 74% is noted. this can be attributed to the small sample size of our study. cuellar et al. state that the posteromedial fragment in tibial plateau fractures is considered unstable and hence proceeded to provide biomechanical evidence in this regard. they reviewed the effect of the size of the posteromedial fragment and the effect on stability of the knee. they found that for fragments the size of 10 mm, medial femoral condyle displacement was only unaffected when the knee was taken to a range of 30 degrees of flexion. beyond this measurement there was medial femoral condyle displacement. fragments larger than 20 mm added to medial femoral condyle displacement in all ranges of flexion from baseline to 90 degrees of flexion. this was a biomechanical study done in cadavers. during non-weightbearing knee range of motion exercises such as compression, flexion, torque and varus-valgus stress, the size of the posteromedial fragment is important and can lead to subsequent fracture instability. the correlation between the exact fragment size and need for fixation is unknown, but the biomechanical disadvantage of not addressing the fragment is present.9 the standard approach to the fixation of a tibial plateau fracture is most often laterally or medially depending on the fracture characteristics. if there is a significantly sized posteromedial fragment, a posterior approach is preferable to address and buttress the fragment from posterior. in this case a standard approach might not suffice to provide and maintain adequate alignment, reconstruct an anatomical joint surface and provide early range of motion. yoram et al. described a posteromedial approach to address the posteromedial fragment, which is a variation of the conventional medial approach. the importance is that one needs to anticipate fixing the posteromedial fragment before using this approach.10 the limitation of our study is that it is a retrospective study with a small sample size of 67 patients. a larger sample size will contribute to better statistical significance with regard to the fracture lengths as well as inter-relater correlation. conclusion the schatzker classification by itself is not adequate to identify all fractures with posteromedial fragmentation. there is a higher incidence of posteromedial fragmentation with fracture types 3 to 6 tibial plateau fractures. there is a high probability of missing a significantly sized posteromedial fragment in schatzker type 1 and 2 fractures that might influence and compromise fracture stability, joint congruency and the ability to rehabilitate optimally. ethics statement the research ethics committee of the faculty of health sciences, university of pretoria, provided ethical clearance for this study (protocol october/2016). references 1. cole p, levy b, schatzker j, watson jt. tibial plateau fractures. skeletal trauma: basic science management and reconstruction. philadelphia: saunders elsevier. 2009;2201-87. 2. bare dp, nork se, mills wj, coles cp, henley mb, benirschke sk. functional outcomes of severe bicondylar tibial plateu fractures treated with dual incisions and medial and lateral plates. j bone joint surg. 2006 aug;88(8):1713-21. 3. david w, zeltser md, seth s, leopold md. classification in brief. schatzker classification of tibial plateau fractures. clin orthop relat res. 2013 feb;471(2):371-74. 4. david p, barei tj, o’mara la, taitsman rp, dunbar se. frequency and fracture morphology of the posteromedial fragment in bicondylar tibial plateau fracture patterns. j orthop trauma. 2008 april;22(4):176-82. 5. martijn aj, te stroet hm, biert j, van kampoen a. the value of ct scan compared to plain radiographs for the classification and treatment plan in tibial plateau fractures. emergency radiology. 2011 aug;18(4):279-83. 6. zhu y, yang g, luo c-f, smith wr, hu c-f, gao h, zhong b, zeng b-f. computed tomography-based three column classification in tibial plateau fractures: introduction of its utility and assessment of its reproducibility. j trauma acute care surg. 2012 dec;73(6):731-37. 7. hu y, ye f-g, ji a-y, qiao g-x, liu h-f. three-dimensional computed tomography imaging increases the reliability of classification systems for tibial plateau fractures. injury. 2009 dec;40(12):1282-85. 8. mchugh ml. interrelated reliability. the kappa statistic. biochem med 2012 oct;22(3):276-82. 9. ceullar vg, martinez d, immerman i. a biomechanical study of posteromedial tibial plateau fracture stability: do they all require fixation? j orthop trauma 2015 july;29(2):325-30. 10. yoram a, gardner mj, helfet dl. posteromedial supine approach for reduction and fixation of medial and bicondylar tibial plateau fractures. j orthop trauma 2008 may;22(5):357-62. page 15south african orthopaedic journal http://journal.saoa.org.za editorial orthopaedic surgeons, particularly trauma surgeons, spend a considerable amount of time trying to get bone to heal. while it is certainly a natural process, we aim to guide and manipulate the process to ensure that it is achieved as fast as possible, with the lowest chance of complications and the best long-term functional outcome for the patient. although we have made huge strides in our understanding of bone healing, much remains to be discovered. and, as is the case in nature, the answer to some of our questions are often somewhat obscure. a case in point is the fact that we only discovered the reason for zebras having stripes in 2014.1 white and black stripes are certainly not good camouflage in the african savannah. it turns out that tsetse flies and horse flies (the vector of various equid diseases) avoid black-and-white striped surfaces. while the answer seems obvious now, it eluded scientists for years. similarly, there are aspects of bone healing which we have thought of as ‘just the way things are’. the diamond concept of bone healing, introduced by giannoudis et al., illustrates the complex interplay between growth factors, osteoinductive scaffolds, osteogenic cells and the mechanical environment.2 the gaps in our knowledge, however, lie in the finer details and particularly at sub-microscopic level. maybe more importantly, translating this knowledge into clinical practice remains a major challenge. the ‘mechanical environment’ element serves as good example of this. while orthopaedic surgeons have long recognised the interaction between physical stimuli (or lack thereof) and biology, the exact mechanisms involved were not well understood. mechanobiology is an emerging scientific field that explores how physical factors, such as forces and mechanics, influence biological systems at the molecular, cellular and tissue level. the fundamental process which drives this is mechanotransduction, the ability of cells to convert mechanical stimuli into biochemical signals. in the 1960s pauwels recognised that compressive and deformation forces drive the differentiation of mesenchymal tissue.3 carter et al. expanded on the theory underlying the relationship between stress and strain and bone formation. they postulated that intramembranous bone formation dominates at low stress and strain levels.4 claes and heigele took the theory one step further, quantifying the stress and strain levels required for the formation of different types of tissue.5 for example, it was postulated that endochondral ossification predominates when local hydrostatic pressures are less than -0.15 mpa and strain in the region of -15 to 15%. prendergast and colleagues encapsulated the concept with the description of the so-called ‘mechano-regulatory’ pathway which describes the differentiation of mesenchymal stem cells (msc) where the emergence of a specific extracellular matrix can favour a divergence in phenotype.6 thus, the synthesis of extracellular matrix by differentiating mscs is linked to the predominant mechanical and perfusion characteristics of the local environment. the authors also recognised the temporal and reciprocal nature of this relationship with change occurring within the differentiation tissues (and resulting extracellular matrix) over time, which in turn also impacts the mechanical environment during loading throughout the healing process. the question then arose: how does the mechanical environment influence tissue generation? basically, stem cells detect and respond to the stiffness of their environment. these external mechanical forces thus tune stem cell fate, driving differentiation towards a certain phenotype.7 the major problem with stem cells is however the maintenance of this differentiation. this requires the creation of a ‘mechano-niche’, which is determined by the mechanical properties of the cells themselves, the extracellular matrix stiffness and finally external mechanical cues.8 this process is mediated by the mechano-sensing apparatus of the stem cells, which is different from those found in the final differentiated cells.9 stem cells sense the nano-features of their dynamic scaffold (the surrounding extracellular matrix), including its so-called motion-tenso-elastic properties.7 within this context, scientists have demonstrated the ability of cells to express ‘vibrational’ (nano-mechanical) signatures of their health and differentiating potential.10 furthermore, we now have the ability to gather information about the nano-mechanical properties of cells with the aid of atomic force microscopy.11 this all sounds very theoretical, and it is, but we are starting to see some experimental work being done in the field. glatt and co-workers, for example, have shown that reverse dynamisation, involving very low initial stiffness of the initial external fixator followed by an increase in stiffness, resulted in improved healing of osseous defects in a rat model.12 the authors, however, cautioned that care is required in terms of the selection of stiffness parameters. the translation of mechanobiology into clinical practice is, however, in its infancy. we now have some evidence that it is possible to treat oligotrophic or atrophic non-unions without necessarily bone grafting them.13 furthermore, there seems to be growing support for the principle that non-unions will heal, if the optimal mechanical environment can be provided, without the need for biological augmentation (like autologous bonegraft).14 it is thus thought that the biological potential to effect union always remains in the local mscs. we just need to create and maintain an optimal ‘mechanoniche’ in order to tune stem cell fate towards the tissue we desire for healing. many questions remain and there are endless opportunities for experimental research in this area. how can we measure the stress and strain at a fracture/osteotomy site? how do we determine the optimal mechanical environment for individual fractures? can tuning stem cells leonard marais phd, editor-in-chief, south african orthopaedic journal page 16 south african orthopaedic journal http://journal.saoa.org.za we develop an implant or external fixator that can allow accurate optimisation of the mechanical environment after application? perhaps most exciting is the prospect of external stimulation of mscs. magneto-mechano stimulation of bone marrow mesenchymal stem cells, for example, through the manipulation of magnetic nanoparticles attached to cell membrane mechanoreceptors has been shown to possess the ability to upregulate gene expression involved in osteoand chondrogenesis.15 however, as we are now entering this ‘nanosphere’, we are left wondering if there is a sufficient scientific platform for the creation and development of these ideas, which may eventually have an enormous clinical impact. references 1. caro t, izzo a, reiner rc, et al. the function of zebra stripes. nature communications 2014;5:3535. 2. giannoudis pv, einhorn ta, marsh d. fracture healing: the diamond concept. injury. 2007;38:s3-6. 3. pauwels df. a new theory concerning the influence of mechanical stimuli on the differentiation of the supporting tissues. z anat entwicki gesch 1960;121:478-515. 4. carter dr, beaupre gs, giori nj, helms ja. mechanobiology of skeletal regeneration. clin orthop relat res 1998;355:s41-55. 5. claes le, heigele ca. magnitudes of local stress and strain along bony surfaces predict the course and type of fracture healing. j biomech 1999;32:255-66. 6. prendergast pj, huiskes r, søballe k. biophysical stimuli on cells during tissue differentiation at implant interfaces. j biomech 1997;30:539-48. 7. ventura c. tuning stem cell fate with physical energies. cytotherapy 2013;15:1441-43. 8. lee da, knight mm, campbell jj, bader dl. stem cell mechanobiology. j cell biochem 2011;112:1-9. 9. wolf cb, mohammad rk. mechano-transduction and its role in stem cell biology. in: baharvand h, editor. trends in stem cell biology and technology. totowa (nj): humana press; 2009. p. 389e403. 10. gimzewski jk, pelling a, ventura c. international patent: international publication number wo 2008/105919 a2, international publication date 4 september 2008. title: nanomechanical characterization of cellular activity. 11. cross se, jin ys, rao j, gimzewski jk. nanomechanical analysis of cells from cancer patients. nat nanotechnol. 2007;2:780e3. 12. glatt v, bartnikowski n, quirk n, et al. reverse dynamization: influence of fixator stiffness on the mode and efficiency of large-bone-defect healing at different doses of rhbmp-2. j bone joint surg 2016;98(8):677-87. 13. ferreira n, marais lc, aldous c. mechanobiology in the management of mobile atrophic and oligotrophic tibial nonunions. journal of orthopaedics 2015;12(suppl 2):s182-7. doi: 10.1016/j. jor.2015.10.012 14. elliot ds, newman kjh, forward dp, et al. a unified theory of bone healing and nonunion. bone joint j 2016;98-b;884-91. 15. kavand h, rahaie m, haghighipour n, et al. magneto-mechanical stimulation of bone marrow mesenchymal stromal cells for chondrogenic differentiation studies j comp app mech 2018;49(2):386-94. _goback south african orthopaedic journal paediatric orthopaedics doi 10.17159/2309-8309/2021/v20n1a3 de jager lj et al. sa orthop j 2021;20(1) citation: de jager lj, maré ph, thompson dm, marais lc. short-term comparison of the use of static and expandable intramedullary rods in the lower limbs of children with osteogenesis imperfecta. sa orthop j 2021;20(1):27-32. http://dx.doi.org/10.17159/23098309/2021/v20n1a3 editor: dr greg firth, london, england received: july 2020 accepted: october 2020 published: march 2021 copyright: © 2021 de jager lj. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background children with osteogenesis imperfecta suffer from frequent fractures and deformities due to skeletal fragility. stabilisation of fractures, correction of deformity and intramedullary rodding result in decreased pain and improved function. modern expandable intramedullary rods aim to provide lasting stability during growth, without an increase in complications. the aim of our study was to determine and compare the outcome of static rush rods and expandable fassier-duval rods in terms of complications and reoperation rate. methods we reviewed the records of a cohort of 17 children (seven female) with osteogenesis imperfecta (11 sillence type iii, six sillence type iv) who were treated with intramedullary rods in the lower limb between 2011 and 2017. they had 64 rodding (38 femoral and 26 tibial) procedures (26 rush rods and 38 fassier-duval rods). these were a primary procedure in 46, and a revision procedure after previous rush rodding in 18 cases. results the overall complication rate was 66% (n=42). there was a higher complication rate in the rush rod group (81%, n=21) when compared to the fassier-duval group (55%, n=21)(p=0.035). the most frequent complication in the rush rod group was distal deformity as the rod is outgrown (69%, n=18). the most frequent complication in the fassier-duval rod group was intramedullary migration due to a failure to expand (45%, n=17). factors that were associated with increased risk of complications included younger age (p=0.031), type of rod (p=0.035), and deformity as an indication for surgery (77% complications, p=0.033). at a mean follow-up of 3.1 years, the reoperation rate in the rush rod group was 58% (n=15). comparatively, at a mean of 3.7 years follow-up, there were no reoperations in the fassier-duval group. conclusions despite the numerous innovations, the surgical management of lower limb deformities and fractures in children with osteogenesis imperfecta remains challenging with a relatively high complication rate. the use of fassier-duval rods may result in a lower reoperation rate when compared to rush rods, in the short term. level of evidence: level 4 keywords: osteogenesis imperfecta, intramedullary rod, rush rod, fassier-duval rod, fracture, deformity short-term comparison of the use of static and expandable intramedullary rods in the lower limbs of children with osteogenesis imperfecta louis j de jager1* , pieter h maré2 , david m thompson2 , leonard c marais3 ¹ rk khan hospital, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa ² grey’s hospital, nelson r mandela school of medicine, university of kwazulu-natal, pietermaritzburg, south africa ³ department of orthopaedics, nelson r mandela school of medicine, university of kwazulu-natal, durban, south africa *corresponding author: louisdejager2@gmail.com http://dx.doi.org/10.17159/2309-8309/2021/v20n1a3 http://dx.doi.org/10.17159/2309-8309/2021/v20n1a3 https://orcid.org/0000-0003-3625-3483 https://orcid.org/0000-0003-1599-7651 https://orcid.org/0000-0003-2607-3999 https://orcid.org/0000-0002-1120-8419 page 28 de jager lj et al. sa orthop j 2021;20(1) introduction osteogenesis imperfecta (oi) is a rare disorder characterised by a spectrum of skeletal fragility and associated features due to collagen abnormality. children who are affected commonly present with progressive long bone deformities or fractures. surgical interventions in these patients are challenging due to the combination of poor bone quality and severity of deformity. several studies have shown a high rate of complications and reoperations associated with surgery.1-5 surgery typically involves deformity correction and/or fracture fixation using either static or expandable intramedullary rods.6-8 intramedullary rodding in children with severe oi has been shown to prevent pain, fractures and deformity.6 when combined with bisphosphonates, intramedullary rod fixation results in improved ambulation, gross motor function, self-care and mobility.9 static and expandable rods share some of the same risks: external rod migration, infection, physeal injury, rod breakage and rotational malunion. expandable rods have the potential benefit of lengthening as the patient grows. while this potentially reduces the risk of subsequent fracture or deformity, the use of these expandable rods can be associated with certain design-specific complications. these include failure to expand due to epiphyseal fixation failure and intra-articular penetration.2,8 the use of expandable rods results in a longer interval before reoperation is required (from 2–2.5 years to 4–5 years).2,6,10,11 while the complication rates of expandable rods remain high, this has decreased with advances in implant design. reported complication rates of the fassier-duval (fd) rod (pega medical, quebec, canada) are lower than those of earlier implants.7,9 there are few reports describing the surgical management of oi from south africa.3,12 oduah et al. described the results of surgery using static rods without a comparative analysis.3 we see a high proportion of children who are severely affected, and our practice has included both the use of expandable and static intramedullary rods. the aim of this study was to determine and compare the reoperation and complication rates of static rush rods (rr) and expandable fd rods in the treatment of lower limb long bone fracture and deformity in children with oi. materials and methods non-probability purposive sampling was used to identify a cohort of 17 consecutive patients (64 cases) with oi under the age of 18 years who had intramedullary rod fixation (expandable or rigid) for the treatment of lower limb long bone fracture or deformity at our tertiary paediatric orthopaedic unit between november 2011 and december 2017. all oi patients younger than 18 years who received surgical treatment of a lower limb fracture or deformity were included. cases with less than 12-month follow-up, or that required plate or locked nail intramedullary nail fixation, were excluded. each surgical procedure was regarded as a separate case. if a previously operated limb segment required revision surgery, this was recorded as a new case and the indication for surgery recorded as a revision. follow-up was calculated from the date of the procedure for all cases and thus all revision cases were handled as new cases. reoperation was defined as the need for repeat surgery in each case. following ethical approval, clinical data was extracted from the paediatric orthopaedic database, together with the radiological records stored in our picture archiving and communication system (pacs). data points included type of oi (according to the sillence classification system), sex, mobility, age at surgery, site, indication for surgery, rod type, rod diameter, follow-up period, complications and whether reoperation was performed. reoperation and complications were the primary outcome variables. possible complications included infection, growth arrest, periprosthetic fracture, rod breakage, rod bending, transcortical rod migration, migration due to limited expansion and deformity (>10°) adjacent to an outgrown rod. reoperation was defined as an unplanned repeat surgical event necessary to obtain the goals of the index procedure or to prevent a secondary disorder. treatment strategy the surgical technique of deformity correction and intramedullary rod placement followed the description by sofield and fassier.6,13 the tibia and femur on one side were operated in the same setting when multiple rods were required. the decision whether to use static (rr) or expandable (fd) intramedullary rods was based on an estimation of the rod size required and growth remaining. we preferred rrs when 3.2 mm diameter or smaller rods were required (although we did insert two 3.2 mm fd rods). this was due to the high likelihood that rod revision would be required in younger children and that the revision of rrs was likely to be simpler. if less than two years of growth remained rrs were favoured as well, as revision was unlikely to be necessary in these cases and rrs were significantly more cost effective. the diameter of the fd rods ranged from 3.2 mm to 5.6 mm (3.2, 4, 4.8 and 5.6 mm). the diameter of rrs was either 3.2 or 4.8 mm (we did not have 4 mm rrs available). intravenous zoledronic acid (0.05 mg/kg diluted in normal saline) was given as an infusion over 30 minutes after oral calcium supplementation at six-monthly intervals at our metabolic bone clinic. statistical analysis statistical analysis was performed using stata 15.0 (statacorp. college station, texas). continuous variables were reported as mean (± standard deviation [sd] and ranges) and categorical variables as number and percentages. the primary dependent outcome variables were complication and reoperation. the shapiro–wilk test was used to analyse the distribution of data. normally distributed data (age, follow-up duration) were compared with the use of the unpaired t-test, whereas the wilcoxon rank-sum test was used for non-parametric data (rod diameter). categorical data (sex, oi type, rod type, surgical indication) were compared using the fisher’s exact test if the expected value in any cell was below 5, or alternatively the pearson’s chi-squared test. all tests were two-sided and the level of significance was set at p<0.05. results the study cohort included 17 patients (seven females). two femoral rrs were revised to locked intramedullary nails and excluded from further analysis. one case was excluded due to a follow-up duration of less than 12 months. this left us with 64 cases (rodding procedures) that were included in the analysis. the breakdown per segment was as follows: nine patients required rodding of all four lower limb segments, six patients of bilateral femurs, one patient of three segments (bilateral tibias and one femur) and one patient a single femur. there were 46 (72%) primary procedures and 18 (28%) revision procedures (15 fd rods and three rrs were inserted at revision surgery). of the 18 procedures that were revisions, 13 were done following rrs that were also included in our series as new fd cases. the other five revisions were required following rrs that were done elsewhere before presenting to our unit and the original procedures were not included in our series as primary cases. page 29de jager lj et al. sa orthop j 2021;20(1) descriptive data are summarised in table i. the mean age at surgery was 6.9 years. there were 26 rrs and 38 fd rods inserted during the study period. more femoral (59%, n=38) than tibial (41%, n=26) rods were inserted. the indications for surgical procedure were deformity correction (55%, 35/64), stabilisation of fractures (17%, 11/64) and revision surgery for complications after a previous rr procedure (28%, 18/64). these complications were mostly recurrent deformity when the rod was outgrown (17/18), and one case of proximal rod migration. the mean follow-up was 3.6 years (standard deviation [sd] 1.5, range 1 to 6.4 years). a comparison of descriptive data between the rr and the fd rod group is summarised in table ii. there was no difference between the two groups in terms of age, sex, type of oi, site (tibia or femur), or follow-up duration. while the number of cases performed for fractures and deformities was comparable, there were more revision procedures performed in the fd group (40% vs 12%, p=0.022) the complication rate in the rr group was 81% (n=21). the most common complication (69%, n=18) was distal deformity when the rod was outgrown (figure 1). in addition, there was one fracture of the rod and femur, one tibia fracture distal to an outgrown rod, and one case of proximal migration into the gluteal region of an rr in the femur. the reoperation rate for rrs during the study period was 58% (n=15). the mean time to reoperation was 22 months (sd 9 months, range 1–36 months). the complication rate in the fd group was 55% (n=21). the most common complication (45%, n=17) was limited rod expansion (figure 2), associated with a bent rod in 41% (n=7, four femurs and three tibia) of cases. there were three instances (8%) of distal articular penetration of the obturator segment of the fd rod (two involving the ankle joint and one the knee). the articular penetration in the ankles were both in a patient with small, distorted distal tibial epiphysis. she was wheelchair-bound pre-operatively and asymptomatic post-operatively, and replacement of the rod table i: summary of the descriptive characteristics of our patients measurement n (%) mean (years) sd range patients 17 procedures 64 male 44 (69%) 6.6 3.1 2–14 female 20 (31%) 7.6 3.1 4–16 age (years) 64 6.9 3.0 2–16 sillence type type iii 11 (65%) type iv 6 (35%) rush rods age at surgery (years) 26 6.6 3.7 2–16 follow-up 26 3.1 1.4 1.3–4.8 complication rate 21 (81%) outgrown rod with deformity 18 (69%) outgrown rod with fracture 1 (4%) fractured rod and femur 1 (4%) proximal migration 1 (4%) reoperation rate 15 (58%) fassier-duval rods age at surgery 38 7.1 2.5 2–11 follow-up 38 3.7 1.5 1–6.4 complication rate 21 (55%) failure to expand 17 (45%) joint penetration 3 (8%) proximal cut-out 1 (3%) reoperation rate 0 (0%) table ii: descriptive data reported for the rush rod and fassier-duval (fd) rod groups variable rush rod n=26 (41%) fd rod n=38 (59%) p-value age (mean years ± sd) 6.6±3.7 7.1±2.5 0.149 sex male 19 (73%) 25 (38%) 0.537 sillence classification type iii 19 (46%) 22 (54%) 0.214 type iv 7 (30%) 16 (70%) location femur 13 (50%) 25 (66%) 0.207 tibia 13 (50%) 13 (34%) indication for surgery deformity 17 (65%) 18 (47%) 0.155 fracture 6 (23%) 5 (13%) 0.331 revision 3 (12%) 15 (40%) 0.022 implant size rod diameter 3.9±0.1 4.7±0.6 <0.001 follow-up (mean years ± sd) 3.1±1.4 3.7±1.5 0.246 figure 1. ap radiograph of the right femur of a 6-year-old boy. the rod is outgrown, and distal deformity is evident. page 30 de jager lj et al. sa orthop j 2021;20(1) was not attempted. the articular penetration in the knee was also asymptomatic and, as it subsequently moved to a subcortical position during growth, did not require revision. in another case a subtrochanteric proximal femur stress fracture, with an fd rod in situ, resulted in varus deformity with proximal lateral transcortical migration. she was asymptomatic and declined further surgery (figure 3). there was no case of infection or growth arrest observed. there were no reoperations in the fd rod group. comparative data relating to the development of complications are described in table iii. factors that were associated with increased risk of complications included younger age (mean age 6.3±3 vs 8±3.1 years, p=0.031), type of rod (rr 81% vs fd rod 54%, p=0.035), and deformity as an indication for surgery (77% complications, p=0.033). comparative data relating to the need for reoperation is described in table iv. male sex correlated with an increased risk of reoperation (male 32%, female 5%, p=0.025). we could not detect any confounders in terms of severity of oi, age at surgery, indication or implant choice that could explain this. revision figure 2. standing ap radiograph of a 12-year-old boy six years after deformity correction and fassier-duval rod insertion. limited expansion is present in all four rods with proximal migration of the obturator segment. distal migration of the sleeve segment is present only in the tibial rods. figure 3. ap radiograph of the left hip and proximal femur in a 12-year-old girl. lateral transcortical migration of the proximal fassier-duval rod due to a subtrochanteric proximal femur stress fracture and varus deformity is evident. table iii: comparative data related to the development of complications variable no complication complication p-value age (mean years ± sd) 8±3.1 6.3±3.0 0.031 sex male 14 (32%) 30 (68%) 0.523 female 8 (40%) 12 (60%) sillence type type iii 15 (36%) 26 (64%) 0.619 type iv 7 (30%) 16 (70%) location femur 14 (37%) 24 (63%) 0.615 tibia 8 (31%) 18 (69%) indication for surgery deformity 8 (23%) 27 (77%) 0.033 fracture 6 (55%) 5 (45%) 0.166 revision 8 (44%) 10 (66%) 0.289 implant rush rod 5 (19%) 21 (81%) 0.035 fassier-duval rod 17 (46%) 21 (54%) implant size rod diameter 4.5±0.70 4.2±0.78 0.116 rush rod diameter 3.5±0.71 4.0±0.82 0.280 fassier-duval diameter 4.8±0.33 4.5±0.64 0.053 page 31de jager lj et al. sa orthop j 2021;20(1) procedures had a lower risk of subsequent reoperation (6% vs 30% in primary cases). other variables that were associated with a decreased need for reoperation included larger implant diameter (p=0.007) and the type of rod (rr 58% vs fd rod 0%, p<0.001). discussion the surgical management of long bone deformities and fractures in oi was pioneered by sofield and millar in 1959.6 they described deformity correction through multilevel osteotomies along with intramedullary rod fixation. the static rods protected the long bone from deformity and refracture in the post-operative period. with subsequent growth, however, the segments distal or proximal to the rods were prone to deformity or fracture, necessitating reoperation. this led to the invention of expandable (or telescoping) rods, designed by bailey and dubow.7 these rods could potentially delay reoperation when compared to solid rods but added complexity and had their own unique set of complications.2 specifically, the t-piece that provided epiphyseal fixation was susceptible to articular displacement. the sheffield rod, where the t-piece was fixed, reduced the risk of displacement.7 the fd rod was the first single entry expandable rod system, preventing the need for distal arthrotomy during insertion.8 the fd rod has threaded epiphyseal portions on both the obturator and sleeve sections that stabilise the rod during expansion with growth. while the system allows for epiphyseal locking of the obturator segment, we did not utilise this option. short-term follow-up of this device reports a reoperation rate of 13%.8 the aim of our study was to determine and compare the complication and reoperation rates in a cohort of children treated with static and elongating intramedullary rods for lower limb deformities and fractures due to oi. our patient cohort consisted of children with sillence type iii and iv in similar proportions to other studies that reported the surgical outcomes in children with oi.3,11,14 the mean age at initial surgery (6.9 years), similarly, is comparable to that of other reports on the subject.2,3,14 during the study period there was a higher complication rate in the rr group (81%) when compared to the fd rod group (55%) (p=0.035). this confirms the findings of previous studies showing higher complication rates with the use of static rods.2,9,15-17 the main complication in the rr group was distal deformity, which occurred when the rod was outgrown (86% of complications in this group). this occurred despite bisphosphonate therapy. our complications in the fd rod group consisted mainly of rods that failed to expand with growth (45%, n=17). in comparison, expansion failure was reported in 33% (n=5) by birke et al., and in 16% (n=28) of cases by azzam et al.8,11 lee et al. reported a 32% (n=13) failure rate due to rod bending in 41 fd rods. the mean time to rod bending was 4.0 years (range 0.9–8.2 years).17 we confirmed this mode of failure, as we found that 41% (n=7) of the 17 rods that failed to expand had bent. transcortical migration due to proximal femur deformity, normally described in rrs with progressive deformity, occurred with one fd rod after initial central placement subsequent to proximal femur stress fracture.2 intra-articular penetration of the obturator segment of fd rods has previously been reported.8,11 this occurred in three cases in our series. birke et al. described a combined insertion technique to prevent articular penetration where bone quality is poor and the epiphysis is narrow and distorted, which might be useful in selected cases.8 we found that children who developed complications were operated at a younger age (6.3 vs 8 years, p=0.031). previous authors have also noted this association.1,3 during our study period, with a mean follow-up of 3.6 years, there had been no reoperations in the fd group. contrastingly, the reoperation rate was 58% in the rr group, with a mean time to revision of 22 months. the expected time to reoperation after deformity correction and static intramedullary rod fixation is 2–2.5 years.6 expandable rods are expected to delay this interval to 4–5 years.2,10 initial studies on fd rods reported a reoperation rate of 13–14% at short-term follow-up.8,9 azzam et al. reported a reoperation rate of 46% at a mean 4.3 years in a large cohort of 179 lower extremity fd rods.11 most recently, spahn et al. reported a higher probability of survival for fd rods when compared to static rods over the first 48 months (88.1% [95% ci 68–96%] vs 41% [95% ci 25–56%]).14 our results corroborate the expected improved survival of fd rods in comparison to rrs. despite the high rate of limited expansion seen in the fd rod group, there was still a lower reoperation rate when compared to the rr group. there are several limitations to our study. our indications for whether to use a static or expandable rod predisposed the study to selection bias. despite this, our study groups were comparable in terms of type of oi, age at operation, site and follow-up duration. documentation of mobility and functional status prior to surgery and at the end of the study period was incomplete, limiting our ability to evaluate the combined effect of intramedullary rodding and bisphosphonate therapy. while longer follow-up would have shed light on the expected survival of fd rods, we were able to confirm the short-term difference in reoperation rate between rrs and fd rods. with ongoing follow-up, monitoring of reoperations will enable us to calculate the survival rate of the fd rods in our study group. the small sample size prohibited the development of a regression model to identify factors associated with complications. a larger prospective series is required to shed further light on the subject. conclusion despite the numerous innovations, the surgical management of lower limb deformities and fractures in children with oi remains challenging. the complication rates of intramedullary rods are relatively high. the most common complication of rrs was table iv: comparative data relating to the need for a reoperation variable no reoperation reoperation p-value age (mean years ± sd) 7.1±2.85 6.27±3.73 0.361 sex male 30 (68%) 14 (32%) 0.025 female 19 (95%) 1 (5%) sillence type type iii 31 (76%) 10 (24%) 0.810 type iv 18 (78%) 5 (22%) location femur 29 (74%) 9 (26%) 1.000 tibia 20 (77%) 6 (23%) indication for surgery deformity 31 (76%) 10 (24%) 1.000 fracture 7 (64%) 4 (36%) 0.268 revision 17 (94%) 1(6%) 0.048 implant rush rod 11 (42%) 15 (58%) <0.001 fassier-duval rod 38 (100%) 0 (0%) implant size diameter 4.5±0.69 3.8±0.81 0.007 page 32 de jager lj et al. sa orthop j 2021;20(1) deformity at the distal end of the rod during growth, which frequently necessitated reoperation. the most common complication of fd rods was failure to expand during growth. despite this complication, the use of fd rods may result in a lower reoperation rate when compared to rrs in the short term. ethics statement ethics approval was obtained from the biomedical research ethics committee (bca268-15). the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was not required for inclusion in the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ljj: study design, data collection, manuscript preparation phm: study design, data collection, statistical analysis, manuscript review dmt: study design, manuscript review lcm: study design, statistical analysis, manuscript review references 1. zionts le, ebramzadeh e, stott sn. complications in the use of the baileydubow extensible nail. clin orthop rel res. 1998;348:186-95. 2. luhmann sj, sheridan jj, capelli am, et al. management of lower-extremity deformities in osteogenesis imperfecta with extensible intramedullary rod technique: a 20-year experience. j pediatr orthop. 1998;18(1):88-94. 3. oduah go, firth gb, pettifor jm, et al. management of osteogenesis imperfecta at the chris hani baragwanath hospital. s afr orthop j. 2017;16(2):19-25. 4. scollan jp, jauregui jj, jacobsen cm, et al. the outcomes of non-elongating intramedullary fixation of the lower extremity for pediatric osteogenesis imperfecta patients. j pediatr orthop 2017;37(5):313-16. 5. zeitlin l, fassier f, glorieux fh. modern approach to children with osteogenesis imperfecta. j pediatr orthop b. 2003;10:77-87. 6. sofield ha, millar ea. fragmentation, realignment and intramedullary rod fixation of deformities of the long bones in children. a ten-year appraisal. j bone joint surg. 1959;41-a(8):1371-91. 7. burnei g, vlad c, stefan i, et al. osteogenesis imperfecta: diagnosis and treatment. j am acad orthop surg. 2008;16:356-66. 8. birke o, davies n, latimer m, et al. experience with the telescopic rod: first 24 consecutive cases with a minimum of 1 year follow up. j pediatr orthop. 2011;31(4):458-64. 9. ruck j, dahan-oliel n, montpetit k, et al. fassier-duval rodding in children with osteogenesis imperfecta receiving bisphosphonates: functional outcomes at one year. j child orthop. 2011;5:217-24. 10. joseph b, rebello g, kant cb. the choice of intramedullary devices for the femur and the tibia in osteogenesis imperfecta. j pediatr orthop b. 2005;14:311-19. 11. azzam ka, rush et, burke br, et al. mid-term results of femoral and tibial osteotomies and fassier-duval nailing in children with osteogenesis imperfecta. j pediatr orthop. 2018;38:331-36. 12. robertson a, george a. a surgical technique for coxa vara in osteogenesis imperfecta. s afr orthop j. 2005;4(1):16-18. 13. fassier f. fassier-duval telescopic system: how i do it? j pediatr orthop. 2017;37(6):s48-s51. 14. spahn km, mickel t, carry pm, et al. fassier-duval rods are associated with superior probability of survival compared with static implants in a cohort of children with osteogenesis imperfecta deformities. j pediatr orthop. 2019;39:e392-e396. 15. harrison w, rankin c. osteogenesis imperfecta in zimbabwe: a comparison between treatment with intramedullary rods of fixed-length and self-expanding rods. j r coll surg edinb.1998;43:328-32. 16. el-adl g, khalil ma, enan a, et al. telescoping versus non-telescoping rods in the treatment of osteogenesis imperfecta. acta orthop belg. 2009;72(2):200-208. 17. lee rj, paloski md, sponseller pd, et al. bent telescopic rods in patients with osteogenesis imperfecta. j pediatr orthop. 2016;36(6):656-60. 404 not found south african orthopaedic journal message from the president sa orthop j 2021;20(2) ‘the art of war’ brian bernstein president: south african orthopaedic association corresponding author: brian.bernstein@vincentpallotti.com the period 2020/2021 has been an extremely interesting time. the concerns around the ‘rise of pseudoscience’ referred to in my inauguration address last november have turned out to be prophetic to say the least, with my screenshot taken off the tv of the ‘shaman of q-anon’ being superseded by his public involvement in the storming of the capitol in january and his subsequent imprisonment. among the noise, my concern about how we will practise our craft of healing in this environment of mistrust, distrust and the proliferation of the ‘instant expert’ may have been lost or misunderstood. please pay attention to this! things have really seemed to only accelerate with the vaccine development and rollouts being challenged, the treatment protocols for covid-19 being influenced by the media and internet, and signs that global mental health has been negatively impacted by the lockdowns and restrictions, which seem to have polarised communities across the world. all we can do is ‘carry on’ as normally as possible, and hope this influences those around us to do the same. to do this we need to have accurate and reliable data to support our decisions. ‘the hottest places in hell are reserved for those who maintain their neutrality in a period of moral crisis.’ – dante alighieri many of the decisions made by some eminent scientists over the last year have been flawed, and we have to acknowledge that nobody really knew, or knows, what to expect. the initial literature from wuhan advising against surgery during the pandemic was based on 33 patients, only three having had orthopaedic surgery for hip arthroplasty, with the bulk having procedures for abdominal surgery and neoplasms. although there have been follow-up papers with more ‘statistical power’ concluding that major surgery and covid-19 are not a good mix, those of us doing trauma emergency work, as limited as it was, did not seem to experience this anecdotally. i am sure that the longer-term trials and experiences will clarify this conclusion in the coming years as we live with the virus and its variants. another example is the decision to stop the oxford-astrazeneca vaccine rollout, after the vaccine had landed in sa, based on the analysis of a study involving approximately 2 000 patients but, actually, only 40 odd having had the genome sequencing for the ‘newer variant’, and a 20/20 split between the placebo arm and the vaccine arm. that means the decision was made on the basis of the immune response of approximately 20 patients. clearly, these decisions may turn out to have been good ones, and time will tell, but the application of the scientific process was not always, in my opinion, well served by these events. it is for this reason i would like to reinforce my plea to our membership to register with and submit their data to the south african orthopaedic registry (saor). the saor remains a world first – the only attempt to host a comprehensive registry of all orthopaedic procedures performed in a country, independent of the hospital groups’ and funders’ data. the registry is gaining traction, and we are starting to generate reports which will be useful for our negotiations, and will enable us to challenge the funders’ and hospital groups’ data interpretations. in addition, they will assist in comprehensively and intelligently planning for the provision of national orthopaedic excellence and implementing our mentor programmes. ten per cent of our membership is actively participating, and despite the lockdown restrictions over the last year, we have close to 3 000 patients registered. we need this number to increase so that we can honestly and accurately represent all our membership. ‘if you know your enemy, and know yourself, you need not fear the result of a hundred battles.’ sun tzu – the art of war discussions with our fellow associations and specialties, locally and across the world, are met with envy, and indicate that we are way ahead of the game. let us remain leaders. please engage with the registry, register on the website, load your patients, and use the operation note functionality and patient-reported outcome measures (prom) opportunity to help us to help you. finally, as we plan for the saoa annual congress in september, please be assured that we have heard the members and will plan another hybrid type of event, with enhanced virtual offerings and hopefully enhanced face-to-face events that will comply with the regulations of the day. stay safe, get vaccinated and carry on! south african orthopaedic journal current concepts review doi 10.17159/2309-8309/2021/v20n3a6 garrett br et al. sa orthop j 2021;20(3) citation: garrett br, grundill ml. patella dislocations and patellofemoral instability: a current concepts review. sa orthop j 2021;20(3):167-177. http://dx.doi. org/10.17159/2309-8309/2021/ v20n3a6 editor: prof. michael held, university of cape town, cape town, south africa received: december 2020 accepted: april 2021 published: august 2021 copyright: © 2021 garrett br, grundill ml. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract lateral patellar dislocation affects young, active patients with an incidence rate of 5.8 per 100 000. the management of first episode dislocations is non-surgical in the majority of cases, unless associated pathology dictates surgical intervention. approximately 40% of cases that are treated non-surgically will develop recurrent patellofemoral instability. evidence supports surgical intervention in these cases; however, the best approach is debatable. most research and consensus statements agree that medial patellofemoral ligament reconstruction (mpflr) should be performed in most cases. additional procedures can be used ‘a la carte’ according to certain conditions or pathology. a tibial tubercle osteotomy (tto) is usually indicated in patients with maltracking and/or patella alta, but the direction and degree of correction must be carefully considered. trochleoplasty is technically demanding and should be reserved for a select few patients with severe trochlear dysplasia. it should be performed by an experienced knee surgeon due to the high risk of inadvertent complications. level of evidence: level 5 keywords: patellofemoral instability, patellar dislocation patella dislocations and patellofemoral instability: a current concepts review benjamin r garrett, michael l grundill* department of orthopaedic surgery, livingstone tertiary hospital, port elizabeth, south africa *corresponding author: mlgrundill@gmail.com introduction patellofemoral instability is defined as symptomatic deficiency of the soft tissue, muscular and bony constraints maintaining the patella within the trochlear groove, such that the patella may escape either partially or completely from its asymptomatic position as the knee flexes.1 patellar dislocation is a relatively common problem, with an incidence of 5.8 per 100 000 affecting young, active patients with an increased risk in adolescent females.2,3 it is best described by direction of instability with degree of flexion. as such, lateral instability in early flexion <45°, lateral instability in late flexion >45°, medial instability and multidirectional instability can be differentiated. this article will focus on lateral instability in early flexion.1 the aetiology of instability and dislocation can be attributed to an initial traumatic event or to underlying bone and soft tissue abnormalities4 (table i). the recurrence rate after nonoperative management may be higher than 40%,2 and literature suggests that up to 55% of patients with first-time dislocations do not return to sport after an initial dislocation.5 management is aimed at preventing recurrent dislocations. however, despite substantial evidence on the topic, the ideal strategy for first-time lateral patellar dislocation remains controversial.6 following conservative treatment for a first-episode dislocation, one-third of patients have good outcomes, one-third will have recurrent instability and require surgical intervention, and onethird of patients will not have recurrence – but will have persistent symptoms of pain and instability.7 since the landmark work in 1994 by dejour et al.,8 which identified four anatomical risk factors (trochlear dysplasia, patella alta [caton-deschamps index ≥1.2], patellar tilt ≥20° and tibial tuberosity–trochlear groove [tt-tg] distance ≥20 mm), two schools of thought have emerged in the management of these patients. the first approach is to deal with each of the underlying anatomical abnormalities on an ‘à la carte’ basis,8 as compared to a standardised surgical approach, which involves performing an isolated mpfl reconstruction.9 despite low-level evidence supporting either strategy, a combination approach has evolved, which involves performing an mpfl reconstruction along with correcting additional major risk factors.10,11 the difference between this method and the initial ‘a https://orcid.org/0000-0002-0478-8136 page 168 garrett br et al. sa orthop j 2021;20(3) la carte’ approach, is the addition of an mpfl reconstruction along with selective correction of major associated anatomical problems. an isolated mpfl reconstruction has been shown to be sufficient for low magnitude and low number of risk factors. however, the point at which this isolated procedure will fail and correction of additional factors is required is not fully understood.12 in skeletally immature patients there are additional considerations due to open physes. regardless of the treatment strategy, the initial assessment remains critically important and involves a thorough history, clinical examination as well as imaging to quantify the problem and guide decision-making. pathoanatomy the biomechanics of the patellofemoral joint (pfj) rely on the interplay between bony congruence and associated soft tissue static and dynamic constraints, to achieve joint stability throughout the range of motion. the mechanism of traumatic lateral patellar dislocation usually occurs with the knee in slight flexion with an associated valgus force, or by direct medial force to the patella.13 the pfj is most unstable in full extension, and stability improves as the patellar engages the femoral trochlea during flexion under normal circumstances. during the first 30° of flexion the mpfl has been shown to be important in preventing lateral translation. a recent anatomical study has shown the potential importance of associated medial structures, namely the medial patellotibial ligament (mptl), and medial patellomeniscal ligament (mpml). the mean failure load for the mpfl, mptl and mpml was 178 n, 147 n and 105 n, respectively. no significant difference was found between the mpfl and mptl or between the mptl and mpml. however, a significant difference was found between the mpfl and mpml. interestingly the vast majority of failures occurred midsubstance. both the semitendinosus and gracilis tendons would be appropriate graft options as their load failures exceed that which is described above (1 216 n and 838 n respectively).14 the effects of the mpfl on pfj stability has been widely investigated and is thought to be mostly isometric during the flexion arc of the knee joint. work by amis et al. showed that the mpfl is tightest when in full extension and early flexion.15 its origin is on the medial femur, approximately 4 mm distal and 2 mm anterior to the adductor tubercle, and inserts onto the proximal half of medial patella.16,17 lateral tightness can also contribute to instability and is usually as a result of a tight iliotibial band and/or capsule. beyond 30° of flexion, the congruence between the patella and trochlea becomes the primary restraint. for this reason, patella alta (high-riding patella) can lead to lateral instability by increasing the distance travelled before engaging the trochlea.4 trochlear dysplasia and its variants may result in loss of the guiding effect on the patella beyond 30° of flexion causing lateral instability.4 the aetiology of trochlear dysplasia is largely unknown; however, it is postulated to have both genetic and developmental origins.18,19 dejour et al. found that 96% of patients with a history of a true patellar dislocation had evidence of trochlear dysplasia.8 the position of the tibial tubercle determines the force vector of the patellar tendon on the patella; therefore, a laterally based tubercle can cause lateral pull resulting in instability. the alignment and rotational profile of the lower limb may have a contributing effect on pfj stability. external tibial torsion and/or internal femoral torsion will result in an increased lateral force vector, especially during terminal extension, which is accentuated by the screw-home mechanism of the knee.4 valgus coronal plane deformity will also contribute to this effect. the vastus medialis oblique (vmo) is often the first quadriceps muscle to weaken during functional impairment and can result in muscular imbalance causing lateral instability.20 clinical evaluation a detailed history should include the age, sex, skeletal maturity, level of sport and expectation to return to competitive activity. the mechanism of injury and position of limb during dislocation should be noted as this may identify underlying pathology in subtle cases. subsequent episodes need to be recorded and the presence of pain, deformity and disability needs to be identified. there is often an overlap of pain and instability symptoms which need to be evaluated independently. a thorough gait and alignment examination may reveal valgus knees with potential thrusting. rotational profile must be carefully checked to exclude femoral and/or tibial torsional problems. a particular combination of deformities was described by james et al.21 as the ‘miserable malalignment syndrome’. these include valgus knees, increased femoral anteversion, pronation of the foot and external tibial torsion. the quadriceps should be evaluated for vmo wasting and the q angle determined by measuring the angle between the line connecting the anterior superior iliac spine and the patella with the line connecting the patella and tibial tuberosity in extension.22 overall, the reliability of the q-angle measurement has been questioned and evidence suggests that it should not be used.23-26 examine the knee for possible haemarthrosis. patellar dislocation is the most common cause of traumatic haemarthrosis in children, and the second most common in adolescents after anterior cruciate ligament injuries.27 tenderness (bassett sign) over the medial femoral condyle should be elicited. anterior knee pain and/or positive patellofemoral grind (clarke’s test) may indicate underlying osteochondral damage. patellar tracking should be noted along with a possible j-sign (lateral subluxation of the patella when actively moving knee from flexion into extension).28 lateral glide (sage sign) of the patella should not exceed two quadrants (compare to contralateral side).29 the most sensitive (100%) and specific test (88.4%) for patellar instability is the moving patellar apprehension test as described by ahmad et al. (a two-part test performed by taking the knee from full extension into flexion with a laterally directed force on the patella, resulting in apprehension and involuntary quadriceps activation to prevent further knee flexion. the second component again involves taking the knee from extension to flexion, this time with a medially directed force on the patella. a positive test shows no apprehension in this phase and the patient allows the knee to be fully flexed30). features of connective tissue disorders such as ehlers–danlos and marfan syndromes should be sought, along with a general ligamentous laxity beighton score if indicated.31 radiographic evaluation basic evaluation begins with four standard x-ray views, including an anteroposterior (ap), lateral, rosenberg weight-bearing table i: factors associated with patellofemoral instability soft tissue bony malalignment • medial laxity (e.g. incompetent medial patellofemoral ligament, vastus medialis obliquus weakness) • lateral tightness (e.g. iliotibial band) • global laxity (e.g. marfan syndrome, ehlers-danlos syndrome) • trochlea dysplasia • patella alta • lateralised tibial tubercle • increased q-angle • increased femoral anteversion • increased tibial torsion page 169garrett br et al. sa orthop j 2021;20(3) bent-knee posteroanterior (pa) and a sunrise (bent-knee axial) as per the seminal paper by dejour et al.8 should there be any concern about coronal alignment, long-leg standing views of the legs should be performed. a lateral view of the knee in 30° flexion allows evaluation of the trochlea, as well as the patellar height. three lines are evaluated on the lateral view, and include the two most anterior lines which represent the superimposed femoral condyles, followed by the third line which represents the trough of the trochlea groove. in a normal knee, the line representing the trochlea groove does not intersect the lines representing the femoral condyles. evidence of trochlear dysplasia is thus demonstrated by the third line crossing the femoral condyles, the so-called crossing sign32 (figure 1). evidence of a trochlear bump/ spur is evaluated with a line drawn along the anterior cortex of the femur, where the trochlea groove may either be anterior, posterior or neutral to this line. a trochlear groove line >3 mm anterior to this line represents a pathological spur/bump which may act like a ramp pushing the patella laterally33,34 (figure 2). the double contour sign is represented by a line below the trochlear groove line on lateral view, representing a hypoplastic medial condyle. these findings form the basis of the dejour classification of trochlear dysplasia, which is divided into four types (figure 3).33,35 the dejour classification system helps to guide management, and patients with types b and d may benefit from trochleoplasty.33,36 recently a new mri classification system, the oswestrybristol classification, has emerged and appears to have improved interand intra-observer reliability as compared to the dejour classification. this classification grades trochlea dysplasia as normal, mild, moderate and severe, with severe cases requiring trochleoplasty according to the suggested algorithm37 (figure 4). axial views of the knee are also very useful in identifying trochlear dysplasia, patellar tilt and subluxation. on the sunrise view, patellar tilt (laurin’s angle) and subluxation (merchant’s congruence angle) can be quantified. the merchant congruence angle view requires knee flexion of 45° with the x-ray beam angled at 30° caudally, and is usually 6–11° medial.38 the sulcus angle can be calculated by measuring the angle between the intercondylar trough and the femoral condyles. an angle greater than 145° is diagnostic of trochlear dysplasia. a patellar tilt angle less than 5° is normal.8 patellar alta can be assessed on lateral radiographs using various ratios between the patella and the tibia/tibial tubercle. these include the blackburne-peel ratio,39 insall-salvati ratio,40 koshino ratio41 and the caton-deschamps ratio42,43 (figure 5). most surgeons prefer to use the catondeschamps ratio as it is less reliant on the flexion position of the knee and better reflects the articulating portion of the patellofemoral joint.44 a caton-deschamps ratio greater than 1.2 indicates patella alta. advanced imaging in the form of computed tomography (ct) and/or magnetic resonance imaging (mri) is recommended for assessment of the underlying pathology prior to any surgical intervention and to exclude associated injuries in acute patella dislocations. high-resolution, cross-sectional imaging using ct figure 2. trochlear bump: yellow line represents anterior femoral cortex; blue line represents the floor of the trochlea (adapted from batailler c, neyret p. trochlea dysplasia: imaging and treatment options. efort open rev. 2018;3(5):240-47. used with permission from corresponding author philippe neyret) figure 1. radiographic features of patellofemoral dysplasia a) normal; b) crossing sign; c) double contour sign (adapted from zaffagnini et al. the patellofemoral joint: from dysplasia to dislocation. efort open rev. 2017;2(5):204-14. use permitted under creative commons licence cc-by-nc 4.0) a b c shallow trochlea > 145º supra trochlear spur supra trochlear spur flat trochlea cliffdouble contour double contour lateral convexity medial hypoplasia crossing sign dysplasia type a dysplasia type b dysplasia type c dysplasia type d d. dejour d. dejour d. dejour d. dejour figure 3. dejour classification. type a: crossing sign on the lateral view, shallow trochlea, sulcus angle >145° on the axial view (shallow trochlea). type b: crossing sign, supratrochlear spur/bump on lateral radiographs (flat or convex trochlea). type c: crossing sign, double contour sign (asymmetry of trochlear facets with a hypoplastic medial condyle). type d: crossing sign, supratrochlear spur/bump, double contour sign (asymmetry of trochlear facets plus vertical join and cliff pattern) (reproduced with permission from david dejour. original article: dejour d, reynaud p, lecoultre b. douleurs et instabilite rotulienne. essai de classification. med hyg. 1998;56:1466-71) page 170 garrett br et al. sa orthop j 2021;20(3) accurately demonstrates trochlear dysplasia and rotational abnormalities of the tibia and femur. furthermore ct imaging is used to calculate the tibial tubercle–trochlear groove (tt-tg) distance, and when more than 20 mm is associated with patellar instability8,45 (figure 6). it is important to note that knee flexion influences the measurement significantly, with the tt-tg distance shortening by 1 mm for every 5° of flexion, as described by tanaka et al.46 if there are any clinical suspicions of associated soft tissue and cartilage injuries, or concerns over radiation exposure, an mri may be better indicated. mri demonstrated 85% sensitivity and 70% specificity in identifying associated mpfl injuries.47 cartilage injuries can be expected in 70–90% of acute and recurrent dislocations.48-50 patellar height can also be assessed using the mri-derived patella–trochlear index which measures the ratio of trochlea cartilage to patellar cartilage on a mid-sagittal view with the knee in extension. a measurement of 12.5% indicates patella alta, whereas a measurement of >50% indicates patella baja.24 the tt-tg distance can also be measured using mri imaging; however, it has been shown to underestimate the distance by 3.8 mm when compared to ct.51 furthermore, some clinicians believe that the position of the tibial tubercle is affected by knee rotation and therefore a more accurate measurement should reference from tibial structures alone. thus the tibial tubercle– posterior cruciate ligament distance has been developed to assess lateralisation of the tibial tubercle which is independent of knee flexion.52,53 other mri-based measurements include the sagittal patellofemoral engagement index which acts as a supplementary assessment of patellar height, and the axial engagement index which indicates lateral patellar displacement.54,55 mri has also been used to accurately measure trochlea depth, sulcus angle and facet asymmetry.56 mri may be more accurate in grading trochlear dysplasia when compared to the x-ray-based dejour classification.57 quantifying risk of dislocation in order to predict the risk of recurrence and guide management, attempts have been made to quantify the cumulative effect of risk factors. according to lewallen et al., the risk of recurrence in young patients (<25 years) is 27%, whereas if the patient has trochlear dysplasia the risk is 23%. on an individual basis, one might not consider surgery for either of the above situations after a primary dislocation; however, if these individual risk factors are combined, the exponential cumulative risk is 60% and the threshold for surgery is lower.58 steensen et al.4 showed that 60% of recurrent dislocations had two or more associated risk factors and this was validated by a finite element model by fitzpatrick et al.59 which used a prediction algorithm based on variable weighting of risk factors showing a 90% sensitivity and 87.5% specificity respectively. hiemstra et al. grouped their patients into either warps (weak, atraumatic, risky anatomy, pain and subluxation) or staid (strong, traumatic, anatomy normal, instability and dislocation) categories which allows a relatively simple approach to prognostication and management.60 balcarek et al. introduced the patellar instability severity score (iss), which identifies six risk factors: age (<16 years), bilateral instability and four anatomic risk factors measured on mri (trochlear dysplasia, patellar height, tt-tg distance and patellar tilt). an iss of more than 4 has a five times higher odds ratio of recurrence.61 there is a good correlation between the warps/staid system and the iss.60 management guidelines the correct treatment of primary and recurrent lateral patellar dislocation may be a dilemma and should be determined on an individual basis. there are many potential surgical procedures, used in various combinations, which make direct comparisons in the literature difficult. figure 5. radiographic methods for evaluating patella alta on lateral x-ray of the knee (adapted from: mayer c et al. patellar tendon tenodesis in association with tibial tubercle distalization for the treatment of episodic patellar dislocation with patella alta. am j sports med. 2012;40(2):346-51. used with permission from the corresponding author, robert magnussen) figure 6. tt-tg distance measurement: axial image of the deepest portion of the trochlear groove is marked and superimposed onto an axial image where the tibial tubercle can be marked. the distance between these two points is then measured. (adapted from zaffagnini et al. the patellofemoral joint: from dysplasia to dislocation. efort open rev 2017;2(5):204-14. use permitted under creative commons licence cc-by-nc 4.0) normal mild trochlear dysplasia moderate trochlear dysplasia severe trochlear dysplasia figure 4. author’s diagrammatic representation of the oswestry-bristol classification adapted from sharma et al. the oswestry-bristol classification: a new classification system for trochlear dysplasia. bone jt j. 2020;102(1):102-107 figure 4. author’s diagrammatic representation of the oswestry-bristol classification (adapted from sharma et al. the oswestry-bristol classification: a new classification system for trochlear dysplasia. bone jt j. 2020;102(1):102-107) page 171garrett br et al. sa orthop j 2021;20(3) the initial aim is to decrease swelling which can hinder quadriceps muscle activity. adequate assessment is required to confirm that the correct diagnosis is made (not cruciate or collateral ligament or meniscus injury); to exclude associated injuries (osteochondral fracture of the lateral femoral condyle or patella) which may require mri and early surgery; to assess risk factors for recurrence with appropriate imaging modalities (young age, sports-related injury, patella alta, skeletal immaturity and trochlear dysplasia) and to counsel appropriately. nonoperative management conservative treatment is supported in most cases of first-time acute lateral patellar dislocations without associated osteochondral fractures. reported recurrence rates vary between 15% and 44%, and 50–60% of patients report residual limitations to activity after conservative treatment. there is also growing evidence showing that the rate of re-dislocation is significantly lower following early operative reconstruction.2,5,6,62-72 indications for surgery after a first episode dislocation may be influenced by using predictive tools as described above. this may result in cases being treated operatively which otherwise may have been treated nonoperatively. immobilisation and bracing most commonly, a period of three to six weeks of immobilisation is followed by progressive increase in mobility over time. longer periods of immobilisation in a cast or posterior splint can cause stiffness, weakness and loss of proprioception.73-78 a position of 20° of knee flexion places the least amount of strain on the injured mpfl.15 knee braces (hinged or lateral stabilisation) may decrease patients’ subjective feeling of patellar instability and improve patella tracking while allowing earlier free range of motion.79-83 physical therapy physiotherapy is recommended for regaining early range of motion, quadriceps/gluteal strengthening and vastus medialis oblique (vmo) conditioning, specifically following closed-chain exercises and core stability exercises.82 gait re-education and landing technique in sports may be important.76,77,79,82 there is little difference between non-, partial and full weight-bearing status. mcconnell taping may help to control excessive patella motion during therapy and increase quadriceps muscle torque and activate vmo earlier than vastus lateralis during stair ascent and descent. it allows earlier functional rehabilitation, is easy to apply and is cheap.78,84-86 return-to-sports guidelines follow the same principles of recovery as most knee injuries and occur in a stepwise manner as described by ménétrey et al. and respizzi and cavallin.87,88 surgical management patella stabilisation is indicated for those with recurrent instability that are symptomatic with continued apprehension despite conservative treatment.2,89 early stabilisation may also be considered for those with significant anatomic abnormalities. many authors recommend that the correct procedure is performed in a specialised unit with a multidisciplinary team and governance systems in place to review practice. lateral patellar instability in early flexion (0–30°) is the most common problem warranting early surgery, and the restoration of a medial constraint (mpfl) is considered to be the most important surgical factor.1,90-92 the principle of surgical management with recurrent instability is to address the primary abnormal anatomical factor or interacting factors contributing to the instability, without resulting in excessive abnormal loads on the articular cartilage. however, addressing each risk factor, often with potential complications and unproven long-term side effects on the articular cartilage, is not currently supported by definitive evidence in the literature. it is not always straightforward, and many different operations have been described and various combinations used to address the abnormal anatomical factors. an mpfl or medial stabilisation procedure is typically performed in conjunction with the other bony procedures (table ii). this makes evaluation and comparisons of the literature difficult. an algorithmic approach is commonly recommended (figures 7–9). surgical options include medial repair or reefing, lateral release, mpfl reconstruction, tibial tubercle osteotomy (with medialisation or distalisation), trochleoplasty and derotational osteotomies. lateral release an isolated lateral retinacular release is no longer recommended and has shown to be ineffective in the treatment of patellar instability. it may be indicated in combination when there is pathologic retinacular tightness, i.e. when manual correction to neutral is not possible on physical examination (and not only evidenced by excessive patella tilt on imaging).2,93-96 excessive lateral release may be complicated by medial instability.95 table ii: the principles of surgical intervention based on the pathoanatomy of pfji pathoanatomy surgical options instability without malalignment mpfl reconstruction instability with malalignment tibial tuberosity medialisation + mpflr instability with patella alta tibial tuberosity distalisation + mpflr trochlear dysplasia trochleoplasty + mpflr rotational problems derotation osteotomy acute primary dislocation (history and physical examination, x-rays, mri scan) conservative treatment high risk of recurrence (features of patella alta, trochlear dysplasia, etc.) follow guidelines for recurrent dislocation associated osteochondral lesion treatment of osteochondral lesion + reconstructive procedures as indicated figure 7. suggested management algorithm for first episode patellofemoral dislocations page 172 garrett br et al. sa orthop j 2021;20(3) medial repair and imbrication repair may be considered in certain rare cases without evidence of dysplasia, malalignment and hypermobility, and with a clearly identifiable femoral avulsion injury. there is a high reported rate of recurrent instability due to the difficulty in visualising the exact location of the mpfl injury.65,71,97-99 in the paediatric and adolescent populations, medial imbrication has evolved from insall’s extensive technique to a multitude of newer less invasive techniques involving medial reefing with or without arthroscopic lateral release, reporting good/excellent results.100 these techniques avoid injury to the physis and do not need soft tissue grafts. mpfl reconstruction the mpfl is the most important restraint to lateral patella displacement from 0–30° of flexion.90-92 it dramatically reduces subjective instability and frank dislocations.101-105 it is indicated as an isolated procedure when recurrent instability is present without associated major anatomical abnormalities, i.e. tt-tg distance <20 mm, normal/mild trochlear dyplasia (dejour type a), absence of patella alta (caton-deschamps index <1.2), and a patella tilt <20°.24,106 various autografts and allografts have been used, e.g. gracilis tendon. different patella attachment techniques have been described, e.g. bone tunnels, suture anchors and interference screws. all of these methods approach or exceed the load-to-failure of the native mpfl.107-109 there are also many options of fixation to the femur, e.g. docking tunnels with interference screws or anchors. in a meta-analysis of 1 065 mpfl reconstructions in 31 studies, it was found that autograft was better, and double-limbed reconstructions had better outcomes.110 the most important aspect is determining the correct anatomic location using anatomic landmarks as well as radiographic parameters ensuring correct graft isometry and reproduction of normal tension during knee range of motion.16,111,112 radiographic parameters which can be used intraoperatively include distal femoral percentage measurements as described by stephen et al. more commonly, schottle point is utilised which is 1.3 mm anterior to the tangent of the posterior femoral cortex, 2.5 mm distal to the perpendicular of the superior border of the femoral condyle, and immediately proximal to a perpendicular line from the supero-posterior aspect of blumensaat line (figure 10). this reproducibly locates the femoral tunnel within a 5 mm isometric point for fixation.16,111,113 malpositioning can lead to excessive load on the medial patella facet.114 overtensioning can lead to increased patellofemoral contact pressures.115 other complications are patella fracture, loss of motion and arthrofibrosis.116,117 the optimal amount of knee flexion to fix the graft has not been definitively determined, but fixation in >60° will exacerbate any malpositioned femoral fixation.118 thaunat and erasmus introduced the concept of favourable anisometry, or graft isometry from 0–30° flexion.119 graft tension can be measured intraoperatively but should be compared to the contralateral knee. stephen et al.113 reported that only 2 n of graft tension accurately restored contact pressure and patellar tracking. koh and stewart suggested that there should be recurrent patellar instability (skeletally mature patients) evaluate anatomical abnormalities (dejour/ oswestry-bristol classification) anatomic parameters within normal limits patella alta (cdi>1.2) tt-tg>20 mm, tt:pcl>24 mm trochlea dysplasia (severe/ dejour b or d) consider trochleoplasty mpflr +/tto medialise tt (+mpflr) distalise tt (+mpflr) mpfl reconstruction figure 8. suggested management algorithm for recurrent patellofemoral instability in skeletally mature patients recurrent patellar instability (skeletally immature patients) coronal malalignment (genu valgum >10) rotational malalignment (excessive femoral anteversion or tibial external rotation) guided growth hemiepiphysiodesis derotational osteotomy anatomic mpfl reconstruction physeal sparing/ non-anatomic reconstruction mpfl injury figure 9. suggested management algorithm for recurrent patellofemoral instability in skeletally immature patients page 173garrett br et al. sa orthop j 2021;20(3) 1 cm of lateral translation in full extension or the equivalent of two quadrants lateral deviation with a firm endpoint.120 placement of the femoral tunnel too proximally will result in a graft that is too tight in flexion, and too distal will make it too loose in flexion.121 overall, mpfl reconstruction results in appropriate patellar stability with <10% redislocation rates, and numerous studies show good or excellent clinical outcomes.119,122-128 this is a technically demanding procedure with complication rates as high as 26%, and up to 15.8% reoperation rate.116,129 distal realignment procedures/tibial tubercle transfer osteotomies for patellofemoral instability fall into three groups:130,131 1. fulkerson anteromedialisation (amz) of the tibial tubercle 2. medial tibial tubercle transfer as described by emslie-trillat et al. 3. distalisation using a step-cut or feathered distal cut the fulkerson amz, which was originally described for patella chondrosis, is most commonly used as it can unload the distal and lateral articular cartilage and improve patella maltracking. the oblique osteotomy allows customising the individual deformity. a long, hinged osteotomy fixed with a minimum of two screws with flat headed low-profile screws is preferred.132 the preferred magnitude of medialisation varies; however, most researchers agree that the postoperative tt-tg goal should be 9–15 mm.33,133-135 when assessing the role of patella alta in the instability, various indices can be used as discussed previously. no absolute cut-off value for increased tt-tg has been defined and the measurements are less than ideally reproducible.128 indications for distal realignment include a tt-tg>15–20 mm52 and a caton-deschamps >1.2–1.4.24,136-138 an elevated tt-pcl or a patellotrochlear index (pti) <15–20% (<0.32) or sagittal patellofemoral engagement (spe) <0.45 can also assist decision-making.24,54 distalisation of roughly 6–7 mm using a feathered shingle can be used if cdi>1.2, and if cdi>1.4, a step-cut tto is performed.24,54,132 distalisation is indicated for patellar instability in the setting of patella alta. this may be combined with an amz in selected cases. isolated anteriorisation as described by maquet is not indicated for patellofemoral instability.139 isolating clinical outcomes is difficult because most studies have cohorts of patients with multiple contributory factors and have required concomitant procedures, but distal realignment procedures have been shown to result in low redislocation rates62,135,140-142 and patient satisfaction has been rated to be good or excellent for 63–90%.62,142-144 the overall risk of complications has been found to be between 4.6% and 7.4%, although removal of hardware is required in 36–50% of cases.134,145 in a recent systematic review of outcomes after concomitant mpfl and tibial tubercle transfer (ttt), these procedures were found to be effective in the setting of malalignment.146 consensus groups are hesitant to universally recommend the use of medialisation or patellar instability.1,147-149 trochleoplasty the aim is to create a recentralised groove, correcting the trochlear depth abnormality and thus stabilising the patella by an improved entrance into the trochlear groove.150 several types of trochleoplasty have been described including a lateral facet-elevating albeetype;151 a sulcus-deepening trochleoplasty (described by masse and later modified by dejour35,150 and bereiter152); and a proximal recession wedge trochleoplasty described by goutallier.153 according to dejour, trochleoplasty is indicated for severe trochlear dysplasia (dejour types b and d).35 and according to the oswestrybristol classification, indications are severe dysplasia as indicated by a convex/domed trochlea on mri.37 contraindications include an open physis and patellofemoral arthritis. most cases will also need an mpfl reconstruction, but the need for a ttt should be decided on a case-by-case basis.149,154 it is a technically challenging procedure and should be limited to surgeons experienced and trained in its use. trochleoplasty is often not performed, despite good basic science and clinical data, as there are concerns regarding the long-term effects on articular cartilage, arthrofibrosis (2–46%) and arthritis.1,151,155,156 the failure rates with recurrent instability are varied (0.8–10.5%) and the reoperation rates are high (14–25%).157-160 in a systematic review by longo et al., 40% of patients who had a trochleoplasty had complications, including increased pain in 11% of cases; 6.7% reduction in range of motion; and 12% developed oa.157 clinical outcome reviews describe a reduction in patella apprehension of 80%, and improved kujala scores postoperatively, with up to 92% patient satisfaction.157,158,161 skeletally immature patients in the skeletally immature population there is an especially high incidence in females aged between 10 and 17 years.5,162,163 the child typically presents with vague symptoms, and a high index of suspicion should be maintained. management is usually nonoperative except in cases of large displaced osteochondral fragments; however, recent trends suggest acute surgical intervention may be warranted in certain situations with high risk factors for recurrence.164 hinton and sharma classified adolescent primary dislocators into two groups to guide decision-making (table iii). there is a shift from non-anatomic procedures to techniques that restore normal anatomy, and special attention is focused on avoiding physeal injury. no evidence of growth table iii: classification of adolescent primary dislocators laacs tones laxity and younger traumatic/sports-related atraumatic and chronic older age abnormal patellofemoral architecture normal alignment and architecture contralateral side equal sex distribution single occurrence conservative management mri and consider early stabilisation (adapted from hinton ry, sharma km. patellar instability in childhood and adolescence. in: insall jn, scott wn, editors. surgery of the knee. 4th ed. london: churchill livingstone; 2006) figure 10. schottle point determined by line along posterior cortex (red line), then perpendicular lines through origin of medial condyle and blumensaat line (blue and orange lines respectively). insertion point 1.3 mm anterior to red line and 2.5 mm distal to blue line (yellow dot) (produced by author ml grundill) page 174 garrett br et al. sa orthop j 2021;20(3) disturbance was found when using physeal-sparing techniques.165 an important consideration is that the femoral origin of the mpfl is located 5–6 mm distal to the open physis in the young patient.166,167 anatomic fixation of the epiphyseal femoral origin is important to avoid proximalisation of the mpfl insertion and thus tightening of the ligament during growth.168 patellar stabilisation procedures are grouped into two main categories: proximal realignment and distal realignment procedures. distal soft-tissue procedures or proximal-only procedures should be used when the tibial physis is open. medial imbrication has evolved from insall’s extensive technique to a multitude of newer, less-invasive techniques involving medial reefing with or without arthroscopic lateral release, reporting good/excellent results.100 an mpfl reconstruction as performed in adults has become the treatment of choice in most active adolescent patients.169 many other mpflrs have been described using different graft options such as: 1. semitendinosus autograft with an mcl pulley170 2. autologous quadriceps tendon171 3. adductor magnus tendon172 4. semitendinosus around an adductor sling173 combined proximal and distal procedures like the modified galleazi, grammont and roux-goldthwait have also been described, the details of which are beyond the scope of this article.169,174-177 in summary, when performing an mpflr in skeletally immature patients, ries and bollier recommends wrapping the free ends of the graft around the adductor tendon in younger patients, and using fluoroscopy while creating the femoral epiphyseal tunnel in older adolescents. distal realignment can be achieved with soft tissue procedures but ttt should only be considered in skeletally mature patients.100 conclusion patellofemoral dislocation occurs in young, active patients and can lead to recurrent instability unless it is appropriately managed. nonoperative management is still the mainstay of treatment for most first-episode dislocations, unless there is associated osteochondral pathology requiring surgical intervention. using this approach approximately 40% of patients will experience recurrent instability and require surgical intervention. despite abundant evidence on the topic, there is no consensus on which surgical approach is most appropriate for recurrent dislocation. a reasonable approach, supported by evidence, includes performing an mpfl reconstruction in most cases of recurrent instability, with additional procedures (e.g. tto/trochleoplasty) tailored to the individual as indicated. this serves to maximise the benefit to the patient, while limiting the risk of complications. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethical approval for this study was not obtained – review article. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions both authors contributed to the conception and design of the work, literature review, analysis, drafting of the work; and final approval of the version to be published. orcid garrett br https://orcid.org/0000-0002-0478-8136 grundill ml https://orcid.org/0000-0002-4308-4051 references 1. post wr, fithian dc. patellofemoral instability: a consensus statement from the aossm/pff patellofemoral instability workshop. orthop j sport med. 2018;6(1):1-5. 2. fithian dc, paxton ew, stone m lou, et al. epidemiology and natural history of 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instability. orthop clin north am. 2015;46(1):14757. https://doi.org/10.1016/j.ocl.2014.09.011. 121. burrus mt, werner bc, cancienne jm, et al. mpfl graft fixation in low degrees of knee flexion minimizes errors made in the femoral location. knee surg sports traumatol arthrosc. 2017;25(10):3092-98. 122. hinterwimmer s, imhoff ab, minzlaff p, et al. anatomical two-bundle medial patellofemoral ligament reconstruction with hardware-free patellar graft fixation: technical note and preliminary results. knee surg sports traumatol arthrosc. 2013;21(9):2147-54. 123. song sy, kim is, chang hg, et al. anatomic medial patellofemoral ligament reconstruction using patellar suture anchor fixation for recurrent patellar instability. knee surg sports traumatol arthrosc. 2014;22(10):2431-37. 124. kita k, tanaka y, toritsuka y, et al. factors affecting the outcomes of double-bundle medial patellofemoral ligament reconstruction for recurrent patellar dislocations evaluated by multivariate analysis. am j sports med. 2015;43(12):2988-96. 125. steiner tm, torga-spak r, teitge ra. medial patellofemoral ligament reconstruction in patients with lateral patellar instability and trochlear dysplasia. am j sports med. 2006;34(8):1254-61. 126. watanabe t, muneta t, ikeda h, et al. visual analog scale assessment after medial patellofemoral ligament reconstruction: with or without tibial tubercle transfer. j orthop sci. 2008;13(1):32-38. 127. deie m, ochi m, adachi n, et al. medial patellofemoral ligament reconstruction fixed with a cylindrical bone plug and a grafted semitendinosus tendon at the original femoral site for recurrent patellar dislocation. am j sports med. 2011;39(1):140-45. 128. weber ae, nathani a, dines js, et al. an algorithmic approach to the management of recurrent lateral patellar dislocation. j bone jt surg am vol. 2016;98(5):417-27. 129. seeley ma, knesek m, vanderhave kl. osteochondral injury after acute patellar dislocation in children and adolescents. j pediatr orthop. 2013;33(5):511-18. 130. fulkerson jp. anteromedialization of the tibial tuberosity for patellofemoral malalignment. clin orthop relat res. 1983;177:176-81. 131. fulkerson jp, becker gj, meaney ja, et al. anteromedial tibial tubercle transfer without bone graft. am j sports med. 1990;18(5):490-97. 132. laidlaw ms, diduch dr. current concepts in the management of patellar instability. indian j orthop. 2017;51(5):493-504. page 177garrett br et al. sa orthop j 2021;20(3) 133. camp cl, stuart mj, krych aj, et al. ct and mri measurements of tibial tubercle-trochlear groove distances are not equivalent in patients with patellar instability. am j sports med. 2013;41(8):1835-40. 134. servien e, verdonk pc, neyret p. tibial tuberosity transfer for episodic patellar dislocation. sports med arthrosc. 2007;15(2):61-67. 135. tecklenburg k, feller ja, whitehead ts, et al. outcome of surgery for recurrent patellar dislocation based on the distance of the tibial tuberosity to the trochlear groove. j bone jt surg ser b. 2010;92(10):1376-80. 136. caton jh, dejour d. tibial tubercle osteotomy in patello-femoral instability and in patellar height abnormality. int orthop. 2010;34(2 special issue):305-309. 137. duchman k, bollier m. distal realignment: indications, technique, and results. clin sports med. 2014;33(3):517-30. https://doi.org/10.1016/j.csm.2014.03.0 01. 138. magnussen ra, de simone v, lustig s, et al. treatment of patella alta in patients with episodic patellar dislocation: a systematic review. knee surg sports traumatol arthrosc. 2014;22(10):2545-50. 139. sherman sl, erickson bj, cvetanovich gl, et al. tibial tuberosity osteotomy: indications, techniques, and outcomes. am j sports med. 2014;42(8):2006-17. 140. barber fa, mcgarry je. elmslie-trillat procedure for the treatment of recurrent patellar instability. arthrosc j arthrosc relat surg. 2008;24(1):77-81. 141. koëter s, diks mjf, anderson pg, wymenga ab. a modified tibial tubercle osteotomy for patellar maltracking. j bone jt surg ser b. 2007;89(2):180-85. 142. tjoumakaris fp, forsythe b, bradley jp. patellofemoral instability in athletes: treatment via modified fulkerson osteotomy and lateral release. am j sports med. 2010;38(5):992-99. 143. wang cj, chan ys, chen hh, et al. factors affecting the outcome of distal realignment for patellofemoral disorders of the knee. knee. 2005;12(3):195-200. 144. pritsch t, haim a, arbel r, et al. tailored tibial tubercle transfer for patellofemoral malalignment: analysis of clinical outcomes. knee surg sports traumatol arthrosc. 2007;15(8):994-1002. 145. payne j, rimmke n, schmitt lc, et al. the incidence of complications of tibial tubercle osteotomy: a systematic review. arthrosc j arthrosc relat surg. 2015;31(9):1819-25. https://doi.org/10.1016/j.arthro.2015.03.028. 146. burnham jm, howard js, hayes cb, lattermann c. medial patellofemoral ligament reconstruction with concomitant tibial tubercle transfer: a systematic review of outcomes and complications. arthrosc j arthrosc relat surg. 2016;32(6):1185-95. https://doi.org/10.1016/j.arthro.2015.11.039. 147. drexler m, dwyer t, dolkart o, et al. tibial rotational osteotomy and distal tuberosity transfer for patella subluxation secondary to excessive external tibial torsion: surgical technique and clinical outcome. knee surg sports traumatol arthrosc. 2014;22(11):2682-89. 148. matsushita t, kuroda r, oka s, et al. clinical outcomes of medial patellofemoral ligament reconstruction in patients with an increased tibial tuberosity–trochlear groove distance. knee surg sports traumatol arthrosc. 2014;22(10):2438-44. 149. nelitz m, dreyhaupt j, reichel h, et al. anatomic reconstruction of the medial patellofemoral ligament in children and adolescents with open growth plates: surgical technique and clinical outcome. am j sports med. 2013;41(1):58-63. 150. batailler c, neyret p. trochlear dysplasia: imaging and treatment options. efort open rev. 2018;3(5):240-47. 151. duncan st, noehren bs, lattermann c. the role of trochleoplasty in patellofemoral instability. sports med arthrosc. 2012;20(3):171-80. 152. von knoch f, böhm t, bürgi ml, et al. trochleaplasty for recurrent patellar dislocation in association with trochlear dysplasia: a 4to 14-year follow-up study. j bone jt surg ser b. 2006;88(10):1331-35. 153. koh jl, stewart c. patellar instability. clin sports med. 2014;33(3):461-76. https://doi.org/10.1016/j.csm.2014.03.011. 154. banke ij, kohn lm, meidinger g, et al. combined trochleoplasty and mpfl reconstruction for treatment of chronic patellofemoral instability: a prospective minimum 2-year follow-up study. knee surg sports traumatol arthrosc. 2014;22(11):2591-98. 155. donell st, joseph g, hing cb, marshall tj. modified dejour trochleoplasty for severe dysplasia: operative technique and early clinical results. knee. 2006;13(4):266-73. 156. faruqui s, bollier m, wolf b, amendola n. outcomes after trochleoplasty. iowa orthop j. 2012;32:196-206. 157. longo ug, ciuffreda m, locher j, et al. treatment of primary acute patellar dislocation: systematic review and quantitative synthesis of the literature. clin j sport med. 2017 nov;27(6):511-23. 158. testa ea, camathias c, amsler f, et al. surgical treatment of patellofemoral instability using trochleoplasty or mpfl reconstruction: a systematic review. knee surg sports traumatol arthrosc. 2017;25(8):2309-20. 159. mcnamara i, bua n, smith to, et al. deepening trochleoplasty with a thick osteochondral flap for patellar instability. am j sports med. 2015;43(11):2706-13. 160. metcalfe aj, clark da, kemp ma, eldridge jd. trochleoplasty with a flexible osteochondral flap. bone jt j. 2017;99b(3):344-50. 161. utting mr, mulford js, eldridge jdj. a prospective evaluation of trochleoplasty for the treatment of patellofemoral dislocation and instability. j bone jt surg ser b. 2008;90(2):180-85. 162. boden bp, pearsall aw, garrett wej, et al. patellofemoral instability: evaluation and management. j am acad orthop surg. 1997 jan;5(1):47-57. 163. seeley ma, knesek m, vanderhave kl. osteochondral injury after acute patellar dislocation in children and adolescents. j pediatr orthop. 2013;33(5):511-18. 164. hinton r. primary, traumatic patella dislocation: surgical indications. sports medicine update. 2010 sep/oct:2-6. 165. vavken p, wimmer md, camathias c, et al. treating patella instability in skeletally immature patients. arthrosc. 2013 aug;29(8):1410-22. 166. kepler ck, bogner ea, hammoud s, et al. zone of injury of the medial patellofemoral ligament after acute patellar dislocation in children and adolescents. am j sports med. 2011 jul;39(7):1444-49. 167. nelitz m, dornacher d, dreyhaupt j, et al. the relation of the distal femoral physis and the medial patellofemoral ligament. knee surg sports traumatol arthrosc. 2011 dec;19(12):2067-71. 168. hensler d, sillanpaa pj, schoettle pb. medial patellofemoral ligament: anatomy, injury and treatment in the adolescent knee. curr opin pediatr. 2014 feb;26(1):70-78. 169. hennrikus w, pylawka t. patellofemoral instability in skeletally immature athletes. j bone joint surg am. 2013 jan;95(2):176-83. 170. deie m, ochi m, sumen y, et al. reconstruction of the medial patellofemoral ligament for the treatment of habitual or recurrent dislocation of the patella in children. j bone joint surg br. 2003 aug;85(6):887-90. 171. noyes fr, albright jc. reconstruction of the medial patellofemoral ligament with autologous quadriceps tendon. arthrosc. 2006 aug;22(8):904.e1-7 172. sillanpää pj, mäenpää hm, mattila vm, et al. a mini-invasive adductor magnus tendon transfer technique for medial patellofemoral ligament reconstruction: a technical note. knee surg sports traumatol arthrosc. 2009 may;17(5):508-12. 173. gomes je. comparison between a static and a dynamic technique for medial patellofemoral ligament reconstruction. arthrosc. 2008 apr;24(4):430-35. 174. fondren fb, goldner jl, bassett fh 3rd. recurrent dislocation of the patella treated by the modified roux-goldthwait procedure. a prospective study of forty-seven knees. j bone joint surg am. 1985 sep;67(7):993-1005. 175. marsh js, daigneault jp, sethi p, polzhofer gk. treatment of recurrent patellar instability with a modification of the roux-goldthwait technique. j pediatr orthop. 2006;26(4):461-65. 176. grannatt k, heyworth be, ogunwole o, et al. galeazzi semitendinosus tenodesis for patellofemoral instability in skeletally immature patients. j pediatr orthop. 2012 sep;32(6):621-25. 177. kraus t, lidder s, švehlík m, et al. patella re-alignment in children with a modified grammont technique. acta orthop. 2012 oct 1;83(5):504-10. https:// doi.org/10.3109/17453674.2012.736168. _hlk68842322 404 not found 404 not found strydom s et al. sa orthop j 2020;19(2) doi 10.17159/2309-8309/2020/v19n2a6 south african orthopaedic journal http://journal.saoa.org.za paediatric orthopaedics citation: strydom s, hattingh c, ngcelwane m, ngcoya n. epidemiology of paediatric and adolescent fractures admitted to a south african provincial hospital. sa orthop j 2020;19(2):92-96. http://dx.doi.org/10.17159/2309-8309/2020/v19n2a6 editor: dr greg firth, royal london hospital, london, england received: october 2019 accepted: january 2019 published: may 2020 copyright: © 2020 strydom s. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background: there are limited studies available that examine the epidemiology of children and adolescents admitted with orthopaedic injuries in developing countries. several unique factors in south africa, such as a large socio-economic divide and a public health sector with limited resources, are suggested to influence injury patterns and fracture management. the data emanating from this study may play a role in identifying potential preventative measures. the aims of the study were to determine the age, sex, duration of admission, aetiology and management regimen of paediatric and adolescent patients admitted with fractures in a south african provincial hospital. patients and methods: we did a cross-sectional review of medical records for the period 1 january 2016 to 31 december 2017 at a south african provincial hospital. convenience sampling was done, and demographic and clinical data was collected from patient records. all patients younger than 18 years at the time of injury who were admitted with fractures of the limbs, pelvis or spine were included. patients with incomplete clinical records were excluded. results: a total of 731 patients were admitted during this period. after excluding patients with incomplete records, 526 (72%) were included in the study. from these records we found a higher percentage of males admitted (73%) and the average age was 7.72 years. the average duration of admission was 8.59 days. a fall on ground level was the most common mechanism of injury (70.0%), followed by pedestrian vehicle accidents (12.2%). the most frequently fractured regions were the forearm (36.4%), humerus (26.5%) and femur (18.9%). multiple fractures were sustained by 2.4% and additional non-skeletal injuries were sustained by 2.9%. there was one fatality: a patient who presented with gunshot trauma. conclusion: despite fall-related injuries being the most common cause for admission, pedestrian vehicle accident prevention can have the greatest effect on admissions. they require significantly longer hospitalisation and present more frequently with additional injuries. by implementing safety strategies and improving road infrastructure, we can theoretically decrease the number of serious paediatric admissions. level of evidence: level 4 keywords: epidemiology, paediatric, adolescent, fracture, admission, management epidemiology of paediatric and adolescent fractures admitted to a south african provincial hospital strydom s¹ , hattingh c² , ngcelwane m³ , ngcoya n4 1 mbchb(pret); orthopaedic registrar, department of orthopaedics, university of pretoria, kalafong tertiary hospital, pretoria, south africa ² mbchb(pret); department of orthopaedics, university of pretoria, steve biko academic hospital, pretoria, south africa 3 fcs(sa)orth, msc orth(london); department of orthopaedics, university of pretoria, steve biko academic hospital and department of orthopaedics, faculty of health sciences, university of pretoria, pretoria, south africa 4 fcs(sa)orth; department of orthopaedics, university of pretoria, tembisa provincial tertiary hospital, tembisa, south africa corresponding author: dr sven strydom, postnet suite 169, private bag x8, elarduspark, 0047; tel: +27 82 778 9475; email: svenstrydom@gmail.com https://orcid.org/0000-0002-6288-4388 https://orcid.org/0000-0002-8477-4657 https://orcid.org/0000-0001-7564-3308 https://orcid.org/0000-0001-7122-0287 page 93strydom s et al. sa orthop j 2020;19(2) introduction trauma remains a leading cause of death and disability in children worldwide.1 the management of fractures in low-income countries is often sub-optimal due to resource limitations, predisposing patients to an increased risk of physical disability.2 south africa has an injury-related mortality rate that is six times greater than the global average, with the number of road traffic accident injuries being double the global average.3 fractures during childhood are common, with studies showing incidence ranging from 25% to 34%.2,4 other studies found boys had an increased risk of sustaining a fracture.5,6 paediatric fractures strongly relate to lifestyle and environment, making risk assessment and incidence studies vital to monitor trends and plan for the future.7 in developing countries like south africa most parents are required to work, but cannot afford or do not have access to safe day-care facilities, therefore children are often left unsupervised.8 the incidence of fractures requiring admission appears to be on the rise; one study reported an increase of 38% over a nine-year period.7 hospital care remains the most expensive component of any healthcare system.9 galano et al.1 highlighted that understanding the patterns of traumatic injuries is vital in establishing effective injury prevention programmes and adjusting treatment protocols to optimise patient outcome. thus, we may be able to better weigh the cost of prevention against the cost of treatment to optimise resource management. the majority of studies investigating the epidemiology of fractures in a local community are from american and eurasian countries. there are currently no south african studies nor are there any trauma databases in gauteng on injury surveillance to facilitate predictions on trends in fracture patterns. this makes it difficult for local government to identify high risk areas where safety programmes need to be instituted to prevent childhood injuries or provide guidance for resource planning and allocation. patients and methods we did a cross-sectional review of medical records at tembisa provincial tertiary hospital, a south african provincial hospital which services an estimated population of 1.2 to 1.4 million in gauteng. all children and adolescents aged less than 18 years at the time of injury and admitted with a fracture of the limbs, pelvis or spine were included in our study. we did convenience sampling of the period 1 january 2016 to 31 december 2017. standard demographic data was analysed. the mechanism of injury was taken from the history given on presentation and the fractures sustained were grouped according to the region of the body involved. data on the admission duration, definitive treatment of the fracture received, and additional non-orthopaedic injuries sustained were collected from the clinical notes. incomplete files were excluded from the study. data analysis was done on the software suite sas v9.4 and descriptive statistics were used to describe the data. results during the two-year study period, 731 patients were admitted with fractures meeting our criteria. a total of 526 (72%) had complete files and were included in the study. we noted a high male-tofemale ratio, with 73% of fractures occurring in males. the mean (standard deviation – sd) age at the time of injury was 7.7 (4.5) years; with an interquartile range (iqr) of 4 to 11 years. the mean age for males to sustain a fracture was 8.3 years, while females had a mean age of 6.1 years. admissions according to age group are demonstrated in figure 1. the mean duration of admission was 8.6 days, with an iqr of 3 to 10 days. figure 2 demonstrates the admission duration trend. patients with multiple fractures remained in hospital for a mean of 13.5  days. those admitted with femur fractures were admitted for the longest duration on average (18.8 days), followed by pelvis fractures (13.0 days) and tibia/fibula fractures (8.8  days). the mechanisms of injury resulting in the longest average duration of admission were railroad injuries (27.0 days) and pedestrian vehicle accidents (pvas) (14.7 days). patients with additional nonorthopaedic injuries were admitted on average for 22.3 days. a breakdown of the admissions based on the five commonest mechanisms of injury is provided in table i. of those injured in pvas, 76.6% were aged 12 years or younger. less common mechanisms were motor vehicle accidents (1.7%), gunshot and railroad injuries (both 0.4%). there were no confirmed or suspected non-accidental causes of injury, defined as deliberate injury caused by a parent/ caregiver. a total of 539 fractures were diagnosed, with 13 (2.4%) children sustaining fractures to multiple regions and six (1.1%) children having multiple admissions during the study period for both refractures and new fractures involving different bones. the most common region fractured was the forearm, accounting for 36.4% of the fractures. this was followed by the humerus (26.5%), femur (18.9%), leg (12.2%), pelvis and foot (both 1.9%), hand (1.1%), spine (0.6%) and clavicle and scapula (0.6%). additional non-musculoskeletal injuries were sustained in 15 (2.9%) of the admissions. with the exception of one patient, these were all due to high energy trauma. there was one mortality: a patient who sustained gunshot injuries resulting in fractures of his forearm and spine and abdominal trauma. figure 1. admissions per age group 37.6% 0 5 n u m b e r o f p a ti e n ts age groups in years 250 200 150 100 50 0 6 12 13 17 43.5% 18.8% < 1 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 > 2 1 80 70 60 50 40 30 20 10 0 days n u m b e r o f p a ti e n ts figure 2. admission duration trend page 94 strydom s et al. sa orthop j 2020;19(2) table i: admission breakdown based on the commonest mechanisms of injury mechanism n (%) m:f n (%) mean age (years) mean admission duration (days) fracture n (%) additional injuries n (%)b management n (%) fall (ground level) 368 (70) 276:92 (75:25) 7.6   7.3 hand 2 (<1) 1 (7) bed rest 1 (<1) forearm 172 (44)   sling 2 (1)       humerus 117 (30)   traction 35 (10)       clavicle/scapula 1 (<1)   plaster only 94 (26)       spine 1 (<1)   manipulation and plaster 121 (33)       pelvis 1 (<1)   manipulation and k-wire 81 (22)       femur 56 (14)   orif (plate and screws) 23 (6)       leg 21 (5)   intramedullary nail 3 (1)       foot 21 (5)   transfer to private 7 (2)           absconded 1 (<1)           multiple fracturesa 4 (31)       pedestrian vehicle accident 64 (12) 41:23 (64:36) 8.4 14.7 forearm 4 (6) 10 (67) bed rest 3 (5)     humerus 1 (2)   sling 2 (3)       clavicle/scapula 2 (3)   traction 7 (11)       pelvis 5 (7)   plaster only 21 (32)       femur 19 (28)   manipulation and plaster 12 (18)       leg 33 (49)   manipulation and k-wire 5 (8)       foot 4 (6)   soft tissue procedure and plaster 1 (2)           orif (plate and screws) 5 (8)       multiple fracturesa 4 (31)   intramedullary nail 6 (9)           external fixator 1 (2)           primary amputation 1 (2)             transfer to private 2 (3) fall (>1 m) 35 (7) 26:9 (74:26) 6.4 8.0 forearm 11 (31) 0 traction 2 (6)   humerus 17 (49)   plaster only 5 (14)       spine 1 (3)   manipulation and plaster 15 (43)       femur 4 (11)   manipulation and k-wire 10 (29)       leg 2 (6)   orif (plate and screws) 2 (6)           transfer to private 1 (3)       multiple fracturesa 0       crush injury 32 (6) 21:11 (66:34) 6.7 11.4 hand 3 (9) 0 bed rest 2 (6)   forearm 4 (11)   traction 11 (34)   humerus 4 (11)   plaster only 11 (34)   pelvis 3 (9)   manipulation and plaster 3 (9)   femur 12 (34)   manipulation and k-wire 1 (3)   leg 6 (17)   soft tissue procedure and plaster 1 (3)   foot 3 (9)   intramedullary nail 3 (9)   multiple fracturesa 3 (23)       assault 10 (2) 9:1 (90:10) 10.1 5.9 hand 1 (10) 0 plaster only 4 (44)     humerus 3 (30)   manipulation and plaster 2 (22)       femur 2 (20)   manipulation and k-wire 2 (22)       leg 4 (40)   orif (plate and screws) 1(11)       multiple fracturesa 0       a percentage calculated from total number of patients with multiple region fractures (n=13) b percentage calculated from total number of patients with non-orthopaedic injuries (n=15) orif: open reduction internal fixation page 95strydom s et al. sa orthop j 2020;19(2) our research shows the following results related to the 539 fractures: 57.5% received definitive management in theatre and 39.9% received conservative management in the ward. definitive treatment with plaster was the most frequently used method of treatment (56.1%), while hardware was used in 28.2% of patients taken to theatre. figure 3 provides a breakdown of the management received. patients who received plaster only were admitted due to transport difficulties at night or for monitoring of perfusion due to swelling. those who received closed reduction were managed in theatre under general anaesthesia. discussion there is limited data on the number of children and adolescents admitted with fractures in developing countries like south africa. while there are numerous international studies, their findings have limited application to our population due to different socio-economic circumstances, an increased trauma burden and a unique disease profile that strain a healthcare system with limited resources. even though we found a higher male-to-female ratio admitted with fractures, the mean age for admission with a fracture was in keeping with previous publications. the greatest number of admissions occurred among the 5to 6-year-old age groups. this highlights that children at this age have developed independent mobility and explorative behaviour, yet still lack sufficient cognitive awareness of environmental hazards and avoidance skills.8,10 similar to other publications, we also found a fall on ground level to be the most common mechanism of injury.2,8 approximately one out of 18 children with a fall-related fracture required admission in a hong kong-based study.9 what is distressing is that pvas were the second most common (12.2%) cause of injury which results in admission, with the majority occurring in children aged 12 years or younger. we found that these patients presented more frequently with lower limb fractures, accounting for 50% of tibia/fibula fractures and 18.9% of all the femur fractures admitted. hitosugi et al.10 noted that patients injured in a pva are more likely to require admission as they tend to suffer more severe injuries. this was confirmed in our study with a large number of the patients with multiple fractures and 66.7% of additional non-skeletal injuries being present in the group injured in pvas. they were also admitted for 6.1 days longer than the average. most children involved in pvas are from lowerincome communities, where a major risk factor is the absence of usable sidewalks,11 which is the norm in communities such as the one under discussion. the incidence of pvas has been found to increase with age,7 with the majority occurring in children walking to school.8 this emphasises the need for environmental modification in high risk areas, such as adequate speed breakers, sidewalks in local communities and safe public transport to schools.8 several studies have also recommended educational programmes directed at both children and parents,8,10-12 while others have shown a significant reduction in road traffic-related injuries after implementation of such prevention strategies.5,13 it is evident that this is one area where we can have a great impact on the number of children admitted with fractures, thus reducing the associated morbidity and strain on healthcare resources. clinicians should always maintain a high index of suspicion for non-accidental injuries. the incidence of confirmed non-accidental injuries ranges from 1% to 7.7% in children presenting with musculoskeletal injuries,8,14,15 with the highest incidence among children less than 2 years of age.14 risk factors for child abuse include multiple fractures in different stages of healing, femur fractures in children less than 1 year old, unemployed parents, unplanned pregnancies and children less than 3 years old.15 in a low-income community such as ours, a number of these risk factors may be present. clinicians can miss the subtle signs of non-accidental injuries, especially in public hospitals where patient volumes can often overwhelm the limited number of healthcare workers. in our study, 12 of the 13 children aged less than 1 year were admitted with femur fractures. also, none of the injuries caused by physical assault were suspected to be abuse-related. 0.8% 1.3% 10.7% 26.8% type of management n u m b e r o f p a ti e n ts 29.3% 19.0% 6.3% 2.7% 0.8% 0.2% 0.2% 2.3% 180 160 140 120 100 80 60 40 20 0 s lin g b e d r e st tr a c ti o n p la st e r o n ly c lo se d r e d u c ti o n & p o p c lo se d r e d u c ti o n & k -w ir e o r if ( p la te & s c re w s) in tr a m e d u lla ry n a il s o ft t is su e o p e ra ti o n & p la st e r e xt e rn a l f ix a to r p ri m a ry a m p u ta ti o n n o n e figure 3. summary of definitive management received page 96 strydom s et al. sa orthop j 2020;19(2) since none of the patients were suspected of being victims of nonaccidental injuries, this may indicate that we are not recognising these victims. we can thus recommend that all healthcare workers be regularly re-educated on the signs of abuse; even easily visible educational posters may assist with identification of individuals at risk. femur fractures remain one of the fractures requiring a longer hospitalisation period due to the large number treated conservatively,1,2 as was also confirmed in our study. reducing the duration of admission has a direct impact on the cost of care, and guifo et al.2 described the use of home traction to achieve this reduction in admission duration. this is however not practical in our setting, as parents often lack the funds necessary for frequent hospital visits, and staff shortages prevent home visits. our study is reliant on diligent note-keeping by treating healthcare providers and accurate data capturing by clerks. a total of 205 (28%) patients were excluded due to incomplete records or missing files. additionally, as there is no set protocol on which patients need admission; it is left to the discretion of the on-duty doctor. this could result in an inexperienced doctor admitting minor injuries, while a more experienced doctor would have treated a similar patient on an out-patient basis. because of staff turnover, the average level of experience remains fairly constant through the years. therefore, the results should still reflect the amount of resources required to adequately manage these patients annually. however, to better understand the epidemiology of paediatric and adolescent fractures, the number of patients managed on an outpatient basis should also be considered. unfortunately, the records were insufficient to allow us to trace these patients’ files to include them in our study. further limitations include lack of information on specific locations of humerus fractures and how many open fractures were included in the cohort. conclusion the need to provide safer environments for children has already been recognised in south africa. however, trauma-related injuries remain a leading cause of death and disability in children, continuing to place a burden on hospitals. despite a fall on ground level being the most common cause of admission, effective pva prevention could have the greatest effect on trauma admissions. this is the second commonest mechanism of injury in our communities, with the majority occurring in young children. they require significantly longer hospitalisation and present more frequently with additional injuries. by implementing safety strategies and improving road infrastructure, we can theoretically decrease the number of serious paediatric admissions and so reduce the burden on our healthcare system. in an already resource-strained system, any reduction in patient load or unnecessary wastage of resources can improve quality of healthcare for all in the community. ethics statement prior to commencement of the study ethical approval was obtained from the following ethical review boards: university of pretoria’s health science research ethics committee (ref: 357/2019) and the national heath research database (ref: gp_201906_038). this article does not contain any studies with humans or animals. for this study formal consent was not required. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ss contributed to the conceptualisation, design, data collection, data analysis and manuscript preparation. ch contributed to data collection, data analysis and manuscript preparation. mn contributed to the design and manuscript preparation. nn contributed to the design and manuscript preparation. orcid strydom s https://orcid.org/0000-0002-6288-4388 hattingh c https://orcid.org/0000-0002-8477-4657 ngcelwane m https://orcid.org/0000-0001-7564-3308 ngcoya n https://orcid.org/0000-0001-7122-0287 references 1. galano g, vitale m, kessler m, hyman j, vitale m. the most frequent traumatic orthopaedic injuries from a national pediatric inpatient population. j pediatr orthop, 2005;25(1):39-44. http:// dx.doi.org/10.1097/00004694-200501000-00010. 2. guifo m, tochie j, oumarou b, et al. paediatric fractures in a sub-saharan tertiary care centre: a cohort analysis of demographic characteristics, clinical presentation, therapeutic patterns and outcomes. pan afr med j. 2017;27:46. http://dx.doi. org/10.11604/pamj.2017.27.46.11485. 3. norman r. the high burden of injuries in south africa. bull world health organ. 2007;85(09):695-702. http://dx.doi.org/10.2471/ blt.06.037184. 4. hedström e, svensson o, bergström u, michno p. epidemiology of fractures in children and adolescents. acta orthop. 2010;81(1):148-53. http://dx.doi.org/10.3109/17453671003628780. 5. mäyränpää m, mäkitie o, kallio p. decreasing incidence and changing pattern of childhood fractures: a population-based study. j bone miner res. 2010;25(12):2752-59. http://dx.doi.org/10.1002/ jbmr.155. 6. ferrari s, chevalley t, bonjour j, rizzoli r. childhood fractures are associated with decreased bone mass gain during puberty: an early marker of persistent bone fragility? j bone miner res. 2005;21(4):501-507. http://dx.doi.org/10.1359/jbmr.051215. 7. issin a, kockara n, oner a, sahin v. epidemiologic properties of pediatric fractures in a metropolitan area of turkey. medicine. 2015;94(43):e1877. http://dx.doi.org/10.1097/ md.0000000000001877. 8. hussain s, dar t, beigh a, et al. pattern and epidemiology of pediatric musculoskeletal injuries in kashmir valley, a retrospective single-center study of 1467 patients. j pediatr or thop b. 2015;24(3):230-37. http://dx.doi.org/10.1097/ bpb.0000000000000146. 9. lee j, tung k, li t, et al. fall-related attendance and associated hospitalisation of children and adolescents in hong kong: a 12-year retrospective study. bmj open. 2017;7(2):e013724. http:// dx.doi.org/10.1136/bmjopen-2016-013724. 10. hitosugi m, kawato h, gomei s, mizuno k, tokudome s. severity of child pedestrian injuries due to bonnet-type-vehicle collision. pediatr int. 2013;55(5):624-28. http://dx.doi.org/10.1111/ ped.12140. 11. calhoun a, mcgwin g jr, king w, rousculp m. pediatric pedestrian injuries: a community assessment using a hospital surveillance system. acad emerg med. 1998;5(7):685-90. http:// dx.doi.org/10.1111/j.1553-2712.1998.tb02486.x. 12. pasco j, lane s, brennan-olsen s, et al. the epidemiology of incident fracture from cradle to senescence. calcif tissue int. 2015;97(6):568-76. http://dx.doi.org/10.1007/s00223-015-0053-y. 13. ferraz-torres m, belzunegui-otano t, martínez-garcía o, iriartecerdán l, salgado-reguero e. epidemiological characteristics and overall burden of accidental injuries in navarra, spain. j trauma nurs. 2016;23(4):231-36. http://dx.doi.org/10.1097/ jtn.0000000000000222. 14. servaes s, brown s, choudhary a, et al. the etiology and significance of fractures in infants and young children: a critical multidisciplinary review. pediatr radiol. 2016;46(5):591-600. http:// dx.doi.org/10.1007/s00247-016-3546-6. 15. fong c, cheung h, lau p. fractures associated with non-accidental injury – an orthopaedic perspective in a local regional hospital. hong kong med j. 2005;11(6):445-51. https://orcid.org/0000-0002-6288-4388 https://orcid.org/0000-0002-8477-4657 https://orcid.org/0000-0001-7564-3308 https://orcid.org/0000-0001-7122-0287 _goback 404 not found south african orthopaedic journal orthopaedic oncology and infections doi 10.17159/2309-8309/2021/v20n3a7wadee r et al. sa orthop j 2021;20(3) citation: wadee r, linda z, ismail a. phosphaturic mesenchymal tumour, ‘nonphosphaturic’ variant: a case report and review of the literature. sa orthop j 2021;20(3):178-182. http://dx.doi.org/10.17159/23098309/2021/v20n3a7 editor: dr thomas hilton, university of cape town, cape town, south africa received: april 2020 accepted: august 2020 published: august 2021 copyright: © 2021 wadee r. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was required for this case report. conflict of interest: the authors have no conflicts of interest to declare. abstract background phosphaturic mesenchymal tumours are uncommon neoplasms, usually associated with tumourinduced osteomalacia, that occur in middle-aged adults but have been reported at the extremes of age. the ‘non-phosphaturic’ variant is even rarer. methods herein, we describe the non-phosphaturic variant in a 12-year-old male who presented to the department of orthopaedic surgery with a six-month history of painful progressive swelling of his right forearm in the absence of trauma. he had no other significant symptoms. results the patient had normal serum calcium and phosphate levels on biochemical analysis. an incisional biopsy was performed and a histopathological diagnosis of a phosphaturic mesenchymal tumour, non-phosphaturic variant, was rendered. six weeks later, he underwent surgical excision of a 15×15 cm soft tissue mass from his right forearm. he had an uneventful postoperative period and was discharged. he has been followed up at the outpatient department and has been free of tumour recurrence for over 18 months since his surgery with no evidence of osteomalacia and no other tumours. conclusion phosphaturic mesenchymal tumours are rare mesenchymal neoplasms and their microscopically identical counterpart without phosphaturia, known as the ‘non-phosphaturic’ variant, is even more uncommon and may prove a greater diagnostic challenge. while the diagnosis may be confirmed by hypophosphataemia and phosphaturia secondary to the paraneoplastic phenomenon of tumour-induced osteomalacia, there may be instances, such as with our patient, where tumourinduced osteomalacia is absent. this case underscores the importance of clinicopathological correlation together with a wide differential diagnosis required to arrive at a correct diagnosis to facilitate appropriate patient management. level of evidence: level 5 keywords: phosphaturic mesenchymal tumours, non-phosphaturic variant phosphaturic mesenchymal tumour, ‘non-phosphaturic’ variant: a case report and review of the literature reubina wadee,¹* zwelithini linda,² abdullah ismail¹ ¹ department of anatomical pathology, university of the witwatersrand/national health laboratory service (nhls), johannesburg, south africa ² department of orthopaedic surgery, university of the witwatersrand, johannesburg, south africa *corresponding author: reubinawadee@gmail.com introduction phosphaturic mesenchymal tumours (pmts) are rare neoplasms that are usually associated with renal phosphate loss and tumourinduced osteomalacia (tio).1 clinically, patients may have symptoms of hypophosphataemia and on thorough examination, small soft tissue or intraosseous masses in the extremities or the jaw may be identified.2,3 tio occurs secondary to excessive production of tumour-associated fibroblast growth factor-23 (fgf23).4 this hormone is secreted by osteocytes and causes phosphaturia by inhibiting renal phosphate reabsorption and, by inhibiting activity of the 1α hydroxylase enzyme, results in decreased production of 1,25-hydroxyvitamin d.4,5 occasionally, cases of pmt may not demonstrate tio and as such, are referred to as ‘non-phosphaturic’ variants.5 a histological diagnosis in these circumstances may be confirmed by a comprehensive immunohistochemical panel excluding other tumours and by the detection of fgf23 transcripts using reverse transcription-polymerase chain reaction (rt-pcr) or in-situ hybridisation.5 herein, we present a case of a 12-year-old patient who was diagnosed with this rare non-phosphaturic variant of pmt. case report a 12-year-old male presented to the department of orthopaedic surgery with a six-month history of painful progressive swelling of his right forearm. he reported no history of trauma to his forearm and had no other significant symptoms. on examination, he was clinically well and did not have any other masses. there was no neurological deficit in the right forearm. local examination revealed a 15×15 cm mass on his right proximal forearm that was tender, https://orcid.org/0000-0002-5981-4450 page 179wadee r et al. sa orthop j 2021;20(3) non-pulsatile and immobile. overlying skin changes in the form of prominent veins were noted (figure 1). plain radiographs showed a large lesion with an osteoid matrix abutting the ulna (figure 2). magnetic resonance imaging (mri) showed a large mixed cystic mass with foci of calcification and fluid-fluid levels. the mass covered the anteromedial aspect of the ulna and was in close association with the proximal ulna (figure 3). relevant laboratory investigations showed the following: • calcium: 2.51 mmol/l (n=2.17–2.54 mmol/l) • magnesium: 0.87 mmol/l (n=0.66–0.91 mmol/l) • inorganic phosphate: 1.42 mmol/l (n=1.05–1.85 mmol/l) the clinical differential diagnosis included juxtacortical osteochondroma, chondrosarcoma, synovial sarcoma, soft tissue sarcoma and traumatic myositis with cystic changes. the patient initially underwent an incisional biopsy which was submitted for histopathological evaluation. microscopically, the specimen consisted of fibrous connective tissue together with spicules of bone and a cellular, neoplastic infiltrate. the blood vessels had a haemangiopericytic appearance. the tumour was composed of small, hyperchromatic cells which had a spindled to stellate appearance with moderate amounts of eosinophilic cytoplasm. there was no mitotic activity or hypercellularity and areas of necrosis were absent. foci of hyalinisation together with distinctive ‘grungy’6,7 or flocculant-appearing calcified matrix, typical of pmts, were seen. in areas, the tumour infiltrated surrounding skeletal muscle fibres (figure 4). both tio-associated pmts and non-phosphaturic variants show the same histological features.5 table i summarises the special stains and immunohistochemical stains which were negative and thus excluded other mesenchymal tumours in the differential diagnosis. focal, weak positive staining was noted on a cd99 stain. bcl2 was positive in tumour cells while scattered histiocytes were identified on a cd68 stain. these stains are not diagnostic of a particular tumour. tissue was submitted for assessment of the syt-ssx1/2 transcripts which yielded a negative result, thus excluding a synovial sarcoma. in addition, fluorescence in-situ hybridisation (fish) for 22q12 re-arrangement of the ewsr1 gene was performed and was negative, excluding ewing’s sarcoma. a diagnosis of a phosphaturic mesenchymal tumour, non-phosphaturic variant, was made. six weeks later, once a definitive diagnosis was made and theatre time was available, the patient underwent excision of the mass which was performed by a consultant orthopaedic surgeon. intraoperatively, a fluid-filled mass was found (figure 5). the tumour was firmly attached to the underlying muscles and focally figure 1. right proximal forearm mass showing venous engorgement and the previous biopsy site figure 2. lateral radiograph showing a large soft tissue-based mass abutting the ulna with areas of calcification figure 3. mri scan coronal and axial views showing a large mixed cystic mass with foci of calcification and fluid levels. the mass covered the anteromedial aspect of the ulna and was in close association with the proximal ulna. table i: a summary of stains used to exclude other mesenchymal tumours negative special stains and immunohistochemical stains tumours excluded periodic acid-schiff and diastase ewing’s sarcoma cytokeratins mnf116, ae1/3, epithelial membrane antigen (ema), cytokeratin (ck)7 synovial sarcoma stat6 solitary fibrous tumour myogenin and myo-d1 rhabdomyosarcoma cd34, cd57 and s100 malignant peripheral nerve sheath tumour synaptophysin, mnf116, ae1/3 neuroendocrine tumour hmb45, s100 and microphthalmia transcription factor (mitf) malignant melanoma page 180 wadee r et al. sa orthop j 2021;20(3) to the periosteum of the ulna, but there was no bony erosion (figure 5). during resection, the tumour ruptured, and white chalklike fluid extruded from the tumour. macroscopically, the specimen consisted of a soft tissue mass which measured 80×60×30 mm. numerous cystic areas and calcified regions were seen on the cut section of the tumour. microscopic examination revealed identical features to the incisional biopsy. viable tumour was identified at the peripheral margins of excision. the patient had an uneventful postoperative course and was discharged. he has been followed-up on an outpatient basis for over 18 months and has no evidence of local recurrence on clinical examination (figure 6). his follow-up included clinical examination a c d b figure 4. haematoxylin and eosin photomicrographs of the patient’s tumour are shown: a) the blood vessels have a haemangiopericytic appearance (arrows); b) ‘grungy’-appearing matrix is shown (arrows); c) tumour cells are permeating between skeletal muscle fibres (arrows); d) small hyperchromatic tumour cells are shown (original magnification a−c: ×100, d: ×400) figure 5. the tumour protruding from the incision site figure 6. a) an anteroposterior radiograph showing no residual tumour in the soft tissue of the forearm; b) the surgical scar is seen with no appreciable tumour a b page 181wadee r et al. sa orthop j 2021;20(3) together with serial chest x-rays and x-rays of his limbs at each follow-up visit, but he has not had additional mri/ct scans or biochemical investigations. discussion pmts are uncommon tumours with fewer than 500 cases reported to date, most of which have been diagnosed in middle-aged adults.6 tumours occurring at the extremes of age have, however, been documented.6 pmts are neoplasms of uncertain histogenesis which may arise in bone or soft tissue.1,7 soft tissue pmts have a propensity to develop in the extremities while pmts of bone tend to arise in the cranium, sinuses or appendicular skeleton.6 patients often present with nonspecific symptoms and signs of tio such as muscle pain, generalised weakness and pathological fractures due to excessive fgf23 production.7,8 fgf23 is a peptide that has an important role in phosphate reuptake in the kidneys via fgf receptor and a co-receptor (a-klotho).6,9,10 increased tumourassociated fgf23 results in phosphate wasting by decreased renal uptake of phosphate and increased renal excretion. phosphate is required for several cellular metabolic functions such as energy production and intracellular signal transduction.10 as such, hypophosphataemia may result in nonspecific symptoms. the rare occurrence of pmt together with the insidious onset of symptoms often results in a delayed diagnosis of approximately three years.3,8 microscopically, other mesenchymal neoplasms such as chondroblastoma, chondromyxoid fibroma, giant cell tumour of bone, solitary fibrous tumour, tenosynovial giant cell tumours, osteosarcomas and mesenchymal chondrosarcomas may be considered in the differential diagnosis of a pmt.4 in the present case, however, the other mesenchymal tumours noted above were excluded morphologically and immunohistochemically. soft tissue ewing’s sarcoma and synovial sarcoma were excluded by immunohistochemical and molecular tests. the present nonphosphaturic variant of pmt did not show histological features of malignancy such as hypercellularity, nuclear pleomorphism, increased mitotic activity and necrosis, which have been table ii: a summary of clinical, radiological and pathological findings in phosphaturic mesenchymal tumours1,2,4,6,7,10-14 clinical radiology pathology age sex usually middle-aged adults no sex predilection ct osteolytic bone lesions with narrow zones of transition morphology macroscopy microscopy 1. most are less than 5 cm 2. minimal calcification 3. tan to yellow cut surface 1. bland spindled to stellate cells with variable cellularity 2. low mitotic activity 3. chondromyxoid/hyalinised matrix that calcifies in a typical ‘grungy’ or flocculant manner 4. haemangiopericytic branching vessels 5. rare cases show malignant features such as hypercellularity, nuclear pleomorphism, increased mitotic activity and necrosis site any soft tissue (acral sites and extremities are preferred locations) or bone (cranium, sinuses or appendicular skeleton) mri 1. t2 hyperintense, solidly enhancing. regions of dark t2 signal may be noted 2. most are t1 isointense differential diagnosis 1. chondroblastoma 2. chondromyxoid fibroma 3. giant cell tumour of bone 4. solitary fibrous tumour 5. tenosynovial giant cell tumour 6. osteosarcoma 7. mesenchymal chondrosarcoma 8. synovial sarcoma 9. ewing’s sarcoma presentation 1. longstanding muscle pain and increasing weakness 2. symptoms of chronic hypophosphataemia 3. bone pain and fractures due to tumour induced osteomalacia (tio) 4. small tumours radionuclide scans useful in identifying occult soft tissue tumours. these include: 68ga-dotatate pet/ ct, 99mtc-sestamibi scintigraphy, 18f-fdg pet/ct and 111 in-pentetreotide scintigraphy immunohistochemistry 1. most routine immunohistochemical stains are used to exclude other tumours 2. fgf23 immunohistochemical stain does not have a high level of specificity biochemistry 1. hypophosphataemia and phosphaturia 2. decreased production of 1,25-hydroxyvitamin d 3. raised serum fgf23 molecular studies 1. fgf23 may be detected using reverse transcriptase polymerase chain reaction (rt-pcr), chromogenic in-situ hybridisation (cish), or fluorescent in-situ hybridisation (fish) 2. fn1-fgfr1 and fn1-fgf1 gene fusions can be detected by rt-pcr prognosis 1. most are benign 2. symptoms usually resolve with resection 3. local recurrence may occur in cases with positive tumour margins 4. malignant tumours may metastasise and cause death page 182 wadee r et al. sa orthop j 2021;20(3) described in current literature.6 pmts do not have a specific immunohistochemical profile and as such, a broad panel of stains may be used to exclude other possible mesenchymal neoplasms, such as in the present case. biochemically, raised serum fgf23 levels together with hypophosphataemia may suggest a pmt if a patient has normal renal function. however, serum fgf23 levels may be compensated for or may not be sufficiently elevated for detection.11 this test is, however, not widely available globally. gene fusions between fibronectin-1 (fn1) and fibroblast growth factor receptor-1 (fgfr1) as well as fusions between fn1 and fibroblast growth factor-1 (fgf1) have been identified by reverse transcriptase polymerase chain reaction (rt-pcr). while fgf23 may be detected in most pmts, including non-phosphaturic variants, using rt-pcr, chromogenic in-situ hybridisation (cish), or fluorescent in-situ hybridisation (fish), thus confirming the histopathological diagnosis, these tests are often not available in most routine histopathology departments. it has been noted that fish has demonstrated less sensitivity on archived material.1,12 while immunohistochemistry, however, is accessible to most pathology laboratories, the fgf23 immunohistochemical stain has not demonstrated a high level of specificity and is therefore not widely used. thus, a multidisciplinary team approach including clinical, radiological and pathological findings are required to arrive at a definitive diagnosis.1 table ii summarises clinical, radiological and pathological findings of pmts.1,2,4,6,7,10-14 wu et al. and honda et al. have documented that for patients with tio, complete excision of the tumour with negative margins is the preferred treatment.8,13 while the patient in the present case report did not have tio, he did have a positive surgical excision margin which is known to increase the likelihood of local recurrence.7 he is, therefore, being followed up on an outpatient basis with clinical examination and serial chest and limb x-rays. it has been noted that patients who have tumours demonstrating uptake of octreotide on imaging studies may derive benefit from octreotide replacement therapy. furthermore, early-stage clinical trials have suggested that antibodies to fgf23 may be advantageous for patients with tio.8 additional research is, however, required in this regard. conclusion pmts are rare mesenchymal neoplasms and their microscopically identical counterpart without phosphaturia, known as the ‘nonphosphaturic’ variant, is even more uncommon and may prove a greater diagnostic challenge. while the diagnosis may be confirmed by hypophosphataemia and phosphaturia secondary to the paraneoplastic phenomenon of tio, there may be instances, such as with our patient, where tio is absent. these tumours require thorough clinicopathological and radiological correlation together with a broad differential diagnosis to ensure accurate diagnosis and appropriate, timeous management of the patient. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethical clearance (certificate number m190753) was obtained through the human research ethics committee (medical) of the university of witwatersrand, following signed written consent from the patient’s parent for use of the clinical history, clinical photographs, histological tissue sections, photomicrographs, diagnosis and treatment plan. signed written consent from the patient’s mother for use of his clinical history, clinical photographs, histological tissue sections, photomicrographs, diagnosis and treatment plan were obtained for use in this case report. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. acknowledgements the authors thank dr e ncube for his assistance with the mri report. colleagues within the department of anatomical pathology are acknowledged for their agreement of our diagnosis of this unusual case. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions rw: reviewed the histology slides, took photomicrographs of the histology slides, contributed to write-up and revision of the manuscript zl: took the clinical photographs, provided the radiograph images and their descriptions, contributed to the clinical write-up of the manuscript ai: reviewed the histology slides, contributed to write-up of the manuscript, assisted with photomicrographs of the histology slides orcid wadee r https://orcid.org/0000-0002-5981-4450 ismail a https://orcid.org/0000-0001-8635-7630 references 1. agaimy a, michal m, chiosea s, et al. phosphaturic mesenchymal tumors: clinicopathologic, immunohistochemical and molecular analysis of 22 cases expanding their morphologic and immunophenotypic spectrum. am j surg pathol. 2017 oct;41(10):1371-80. 2. yavropoulou mp, poulios c, foroulis c, et al. distant lung metastases caused by a histologically benign phosphaturic mesenchymal tumor. endocrinol diabetes metab case rep. 2018;2018:18-0023. https://doi.org/10.1530/ edm-18-0023. 3. ghorbani-aghbolaghi a, darrow ma, wang t. phosphaturic mesenchymal tumor (pmt): exceptionally rare disease, yet crucial not to miss. autopsy case rep. 2017;7(3):32-37. 4. shiba e, matsuyama a, shibuya r, et al. immunohistochemical and molecular detection of the expression of fgf23 in phosphaturic mesenchymal tumors including the non-phosphaturic variant. diagn pathol. 2016 dec;11(1):26. 5. bahrami a, weiss sw, montgomery e, et al. rt-pcr analysis for fgf23 using paraffin sections in the diagnosis of phosphaturic mesenchymal tumors with and without known tumor induced osteomalacia. am j surg pathol [internet]. 2009;33(9):1348-54. available from: https://journals.lww.com/ ajsp/fulltext/2009/09000/rt_pcr_analysis_for_fgf23_using_paraffin_ sections.11.aspx. 6. folpe al. phosphaturic mesenchymal tumors: a review and update. paraneoplastic syndr. 2019 jul 1;36(4):260-68. 7. folpe al. phosphaturic mesenchymal tumour. in: fletcher cdm, bridge ja, hogendoorn pcw, mertens f, editors. who classification of tumours of soft tissue and bone. 4th ed. lyon: iarc press; 2013. p. 211-12. 8. wu h, bui mm, zhou l, et al. phosphaturic mesenchymal tumor with an admixture of epithelial and mesenchymal elements in the jaws: clinicopathological and immunohistochemical analysis of 22 cases with literature review. mod pathol. 2019 feb;32(2):189-204. 9. carter jm, caron bl, dogan a, folpe al. a novel chromogenic in situ hybridization assay for fgf23 mrna in phosphaturic mesenchymal tumors. am j surg pathol. 2015 jan;39(1):75-83. 10. chande s, bergwitz c. role of phosphate sensing in bone and mineral metabolism. nat rev endocrinol. 2018 nov;14(11):637-55. 11. sent-doux kn, mackinnon c, lee j-c, folpe al, habeeb o. phosphaturic mesenchymal tumor without osteomalacia: additional confirmation of the ‘nonphosphaturic’ variant, with emphasis on the roles of fgf23 chromogenic in situ hybridization and fn1-fgfr1 fluorescence in situ hybridization. hum pathol. 2018 oct 1;80:94-98. 12. lee j-c, su s-y, changou ca, et al. characterization of fn1–fgfr1 and novel fn1–fgf1 fusion genes in a large series of phosphaturic mesenchymal tumors. mod pathol. 2016 jul 22;29:1335-46. 13. honda r, kawabata y, ito s, kikuchi f. phosphaturic mesenchymal tumor, mixed connective tissue type, non-phosphaturic variant: report of a case and review of 32 cases from the japanese published work. j dermatol. 2014 sep;41(9):845-49. 14. qari h, hamao-sakamoto a, fuselier c, et al. phosphaturic mesenchymal tumor: 2 new oral cases and review of 53 cases in the head and neck. head neck pathol. 2015 nov 14;10(2):192-200. https://orcid.org/0000-0002-5981-4450 https://orcid.org/0000-0001-8635-7630 _hlk74654785 _hlk37320867 _hlk42247923 _hlk74243549 _hlk42779977 _hlk45547450 _hlk74654514 page 40 sa orthopaedic journal spring 2014 | vol 13 • no 3 intraneural lipoma of the common peroneal nerve: a case report and review of the literature dr p ryan mbchb(uct), hdip(orth), mmed(orth), fcorth(sa) orthopaedic surgeon dr m ter haar mbchb, fcorth(sa) orthopaedic surgeon dr a rocher mbchb, fcorth(sa) orthopaedic surgeon prof i goga md, rfcs(edinburgh), fcs(orth)(sa) professor and head of arthroplasty and reconstruction unit department of orthopaedic surgery, inkosi albert luthuli central hospital, durban, kwazulu-natal correspondence: dr p ryan arthroplasty unit department of orthopaedic surgery inkosi albert luthuli central hospital private bag x03 mayville, kzn, 4058 tel: +27 (31) 240 2160 email: paullisa.ryan@gmail.com introduction benign fatty lesions of peripheral nerves are uncommon, and when they occur, typically affect the nerves of the upper limb. there are only a handful of reports describing cases in the lower limb, and these are mostly confined to distal branches of the superficial peroneal nerve at the foot and ankle. due to its rare occurrence, we report a case of an intraneural lipoma associated with the common peroneal nerve (cpn), presenting as a compression neuropathy. case report a 25-year-old female patient presented with a 12-month history of progressive pain in the lateral aspect of her right leg. she had associated numbness over the fourth toe running proximally up to the fibula head for five months. there were no associated constitutional symptoms, and she was otherwise well. clinical examination demonstrated full, painless movement of her lumbar spine and hip. straight leg raise test was negative, and there was no gross lower limb malalignment. local examination of the knee revealed no skin abnormalities. a vague swelling around the lateral aspect of the knee was noted, extending 5 cm below the level of the fibular head. it was tender over the area of the fibular head and slightly more distally. local percussion along the common peroneal nerve reproduced her neurological symptoms. there was some paraesthesia in an area extending from the fibula head down to the fourth toe. there was very mild weakness with power graded 4+ in the right tibialis anterior and extensor hallucis longus muscles. neurological examination of the upper limbs and the left lower limb revealed no abnormality. abstract intraneural lipomas are rare hamartomas, encompassed within the spectrum of fatty lesions associated with peripheral nerves. more commonly associated with nerves of the upper limb, there are few reports of intraneural lipomas associated with nerves of the lower limb. in these cases they are usually found around the foot and ankle, or more proximally in the upper thigh or hip. we report a case of an intraneural lipoma associated with the common peroneal nerve: the presenting features, diagnosis and subsequent management. we give a concise review of fatty lesions associated with peripheral nerves, and in particular, intraneural lipomas. key words: lipoma, intraneural lipoma, common peroneal, compression neuropathy, fibrolipoma saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 2:53 pm page 40 sa orthopaedic journal spring 2014 | vol 13 • no 3 page 41 plain radiographs of the affected limb (figure 1) revealed a slight increase in the local soft tissue shadow with no underlying bony abnormality. magnetic resonance imaging (mri) (figures 2 to 4) revealed a benign-appearing tumour, most likely a lipoma, with iso-intensity to normal fat on t1 and fat-suppressed sequences. the lesion originated at the level of the knee joint, and followed the common peroneal nerve distally, around the neck of the fibula and into the antero-lateral calf. in view of the progressive nature of her symptoms, and the radiological appearance of an evolving compressive neuropathy, the patient was offered operative intervention. at surgery, a curvilinear incision was utilised, beginning 7 cm above the knee joint line on the lateral side, and extending to the antero-lateral aspect at the upper-calf level. the common peroneal nerve was identified proximally under the hamstring tendon (figure 5), and followed distally. the proximal extent of the lesion was identified intraneurally (figure 6), and an interfascicular dissection of the tumour from the nerve was continued distally (figure 7) to below the level of the fibular neck, with care taken not to injure branches of the cpn (figure 8). the excised tumour measured 11 cm × 6 cm × 3 cm, and macroscopically resembled lipomatous tissue, with a homogenous yellow colour, firm consistency and lobulation (figure 9). histological evaluation showed features consistent with a benign fatty lesion with well-encapsulated mature adipose tissue. there were no associated chondroid elements, and a histological diagnosis of a benign lipoma was made. the patient had an uneventful post-operative course. there was no neurological complication, and at nine-week follow-up, the patient had regained full strength in the antero-lateral calf musculature, and normal sensation had returned to the antero-lateral calf and toe. discussion while adipose tissue is a normal constituent of epineural and perineural tissue, lipomatous lesions associated with peripheral nerves are rare. they may be classified according to their location: intraneural versus extraneural; their pathological activity: infiltrating (lipomatous) or not (lipoma); and by their histological contents: whether they contain fibrous or chondroid elements. lipomatous lesions associated with peripheral nerves are rare figure 1. ap x-ray of knee demonstrating mild soft tissue swelling lateral to fibula figure 2. coronal t1 weighted mri demonstrating lipoma along common peroneal nerve figure 3. sagittal t1 weighted mri showing lobulation of lipoma figure 4. axial t1 weighted mri. note the individual nerve fascicles which have been separated and displaced towards the periphery of the lesion. saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 2:53 pm page 41 page 42 sa orthopaedic journal spring 2014 | vol 13 • no 3 lipomatosis refers to an infiltration of fatty tissue intimately involved with a nerve. it may be associated with a local increase in mesenchymal growth, or focal gigantism. in these cases the term ‘macrodystrophia lipomatosa’ may be used. in extreme cases it may be more generalised and associated with syndromes such as proteus and klippel-trenaunay.1-3 surgical excision of the lipomatous tissue inevitably involves damage to, or excision of the associated nerve, and surgical debulking of distal hypertrophied tissues may be required. in contrast, lipomas have a much more benign clinical course. they are hamartomas arising from the normal epineural fat tissue, and may be intraneural or extraneural. they are focal, well demarcated and tend to displace rather than invade or surround nerve fascicles,3 as seen in this case. they are not associated with local bone and tissue overgrowth. historically the terminology for these lesions has had little conformity. terms included intraneural lipoma, neural fibrolipoma, lipofibromatous hamartoma, perineural lipoma, macrodystrophia lipomatosa, lipomatosis of nerve, fibrolipomatous hamartoma, and fatty infiltration of nerve. figure 6. proximal extent of lipoma seen to occupy an intraneural positionfigure 5. common peroneal nerve identified proximally figure 8. post excision with the branches of cpn intactfigure 7. interfascicular dissection of the lipoma fromsurrounding nerve fascicles figure 9. macroscopic appearance of the excised lipoma lipomas have a benign clinical course saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 2:54 pm page 42 sa orthopaedic journal spring 2014 | vol 13 • no 3 page 43 recently, in an attempt to clarify the nomenclature, spinner et al.3 divided the lesions into two groups: • group 1 included the basic lesions of lipomas and lipomatosis as separate entities, which could occupy either an intraneural or extraneural position. • group 2 contained combined lesions. these combined lesions could be: • a single basic lesion (e.g. lipoma or lipomatosis) in both an intraneural and extraneural position. • both basic lesions in a single position, e.g. intraneural lipoma with associated intraneural lipomatosis • combined lesions in differing positions. the authors further emphasised the concept that these adipose lesions form a broad yet interrelated spectrum of pathology. intraneural lipomas most commonly affect the nerves of the upper limb. the median nerve4-9 is the most frequent, but they have been described in the ulnar,8,10 radial,11 musculocutaneous,8 and axillary nerves,8 as well as in the brachial plexus.8,12 in the lower limb, the majority arise from small branches of the common peroneal nerve around the ankle and foot,13,14 and others arise more proximally from the sciatic nerve.8,15,16 there are few reports of intraneural lipomas affecting the cpn. one paper describes an intraneural chondroid lipoma of the cpn17 which had similar clinical and mri features, but varying histological characteristics, and a single other case in the italian literature describes a giant lipoma of the sciatico-popliteal nerve.18 three papers report on cases of compression of the cpn by extraneural lipomas,19-21 i.e. the origin of the fat cells was not of neural tissue. diagnosis of intraneural lipoma may be suspected on clinical grounds. sabapathy et al.14 highlight the features of mass consistency, association with a cord-like structure, free medial to lateral mobility with little longitudinal mobility, and no association with tendon movement as key clinical features. they do, however, suggest further imaging by mri scan should the diagnosis be less clear, or on the suspicion of possible malignancy. severe pain should be a warning sign, as intraneural lipomas are typically painless, or cause only minor discomfort.6,10,13 typical mri findings include tissue with signal characteristics identical to subcutaneous fat: bright signal on t1 and dark signal on fat-suppressed images. two reports19,20 highlight the usefulness of ultrasound imaging over mri scanning in the diagnosis of compression neuropathies of superficial nerves by lipomas. however, despite this and other advantages such as cost and availability, operator dependence still remains a concern. in most instances, surgical management yields excellent results, and recurrence or malignant change are rare.13 preservation of distal neurologic function may be achieved with careful dissection of neural structures. this may, however, not be necessary in cases where the involvement is that of a distal sensory nerve alone, where sacrifice of the nerve and en-bloc resection is an acceptable option.14 in our case, the position of the lipoma within the cpn resulted in the splaying of the numerous nerve divisions over the mass. this required meticulous dissection aided by magnification. fortunately, there was no neurological complication; however, pre-operative patient counselling regarding potential neurological fallout cannot be overemphasised. summary intraneural lipomas are rare lesions, but should be considered in the differential diagnosis of patients presenting with compressive neurological symptoms. clinical suspicion aided by relevant investigations make diagnosis relatively straightforward. surgical excision with care taken of neurological structures gives excellent results. the content of the article is the sole work of the authors. no benefits of any form have been or are to be received from a commercial party related directly or indirectly to the subject of the article. the patient gave consent for the use of clinical records and radiographic materials. references 1. meirer r, huemer gm, shafighi m, kamelger fs, hussl h, piza-katzer h. sciatic nerve enlargement in the klippeltrenaunay-weber syndrome. br j plast surg 2005;58(4):565-68. 2. biesecker lg. the multifaceted challenges of proteus syndrome. jama 2001;285(17):2240-43. 3. spinner rj, scheithauer bw, amrami kk, wenger de, hebert-blouin mn. adipose lesions of nerve: the need for a modified classification. j neurosurg 2012;116(2):418-31. 4. abu jamra fn, rebeiz jj. lipofibroma of the median nerve. j hand surg am 1979;4(2):160-63. 5. morley gh. intraneural lipoma of the median nerve in the carpal tunnel. report of a case. j bone joint surg br 1964;46:734-35. 6. rusko ra, larsen rd. intraneural lipoma of the median nerve—case report and literature review. j hand surg am 1981;6(4):388-91. 7. watson-jones r. encapsulated lipoma of the median nerve at the wrist. j bone joint surg br 1964;46:736. 8. kim dh, murovic ja, tiel rl, moes g, kline dg. a series of 146 peripheral non-neural sheath nerve tumors: 30-year experience at louisiana state university health sciences center. j neurosurg 2005;102(2):256-66. 9. carvi y nievas mn, archavlis e, unkel b. delayed outcome from surgically treated patients with benign nerve associated tumors of the extremities larger than 5 cm. neurol res 2010;32(6):563-71. 10. balakrishnan c, saini ms, demercurio j. intraneural lipoma of the ulnar nerve: a case report and review of literature. can j plast surg 2006;14(1):49-50. severe pain should be a warning sign, as intraneural lipomas are typically painless, or cause only minor discomfort saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 2:54 pm page 43 page 44 sa orthopaedic journal spring 2014 | vol 13 • no 3 11. balakrishnan c, bachusz rc, balakrishnan a, elliot d, careaga d. intraneural lipoma of the radial nerve presenting as wartenberg syndrome: a case report and review of literature. can j plast surg 2009;17(4):e39-41. 12. chatillon ce, guiot mc, jacques l. lipomatous, vascular, and chondromatous benign tumors of the peripheral nerves: representative cases and review of the literature. neurosurg focus 2007;22(6):e18. 13. terrence jose jerome j. superficial peroneal nerve lipoma. rom j morphol embryol 2009;50(1):137-39. 14. sabapathy sr, langer v, bhatnagar a. intraneural lipoma associated with a branch of the superficial peroneal nerve. j foot ankle surg 2008;47(6):576-8. 15. chiao hc, marks ke, bauer tw, pflanze w. intraneural lipoma of the sciatic nerve. clin orthop relat res 1987(221):267-71. 16. godquin b, brunelli m, basso m. [giant lipoma of the sciatic nerve (author’s transl)]. chirurgie 1978;104(3):22124. 17. park se, lee ju, ji jh. intraneural chondroid lipoma on the common peroneal nerve. knee surg sports traumatol arthrosc 2011;19(5):832-34. 18. crescente d, cucco d. [giant lipoma of the external sciaticopopliteal nerve]. chir organi mov 1981;67(3):357-60. 19. hsu yc, shih yy, gao hw, huang gs. subcutaneous lipoma compressing the common peroneal nerve and causing palsy: sonographic diagnosis. j clin ultrasound 2010;38(2):97-99. 20. vasudevan jm, freedman mk, beredjiklian pk, deluca pf, nazarian ln. common peroneal entrapment neuropathy secondary to a popliteal lipoma: ultrasound superior to magnetic resonance imaging for diagnosis. pm r 2011;3(3):274-79. 21. seki n, okada k, miyakoshi n, shimada y, nishida j, itoi e. common peroneal nerve palsy caused by parosteal lipoma of the fibula. j orthop sci 2006;11(1):88-91. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj spring 2014_bu_orthopaedics vol3 no4 2014/07/30 2:55 pm page 44 south african orthopaedic journal review dippenaar jm sa orthop j 2023;22(1) funding: no funding was received for this study. conflict of interest: the author declares no conflict of interest. republished from: south afr j anaesth analg. 2023;29(1):43-48 abstract cost-effective care amidst the rapidly rising cost of medical services necessitates the implementation of a standardised multimodal analgesia plan to aid patient care. this review aims to address the physiology and pharmacological management of postoperative pain following musculoskeletal surgery. keywords: multimodal analgesia, musculoskeletal pain, postoperative management the management of postoperative pain after musculoskeletal surgery – a narrative review jm dippenaar department of anaesthesiology, university of pretoria, south africa *corresponding author: tinus.dippenaar@up.ac.za introduction the healthcare environment functions on cost-effective care, and the rapidly rising cost of medical services is fast becoming a major consideration in patient management.1 the implementation of a standardised multimodal analgesia plan can streamline planned patient care since all role players know what to expect after a surgical procedure. this review will focus on strategies for use in the management of postoperative pain following musculoskeletal surgery. the pathophysiology of musculoskeletal pain no discussion of the treatment of pain is complete without a review of the physiology of nociception. ascending tracts whenever an injury occurs, peripheral nociceptors are activated.2 these receptors comprise i) high threshold mechanoreceptors (htm) and ii) polymodal nociceptors (pnm – stimulated by serotonin, histamine, h+ ions, cytokines, bradykinins, prostaglandins and leukotrienes). inflammatory mediators sensitise nociceptors and lower threshold for firing. nociceptors are free nerve endings from which impulses are carried via primary afferent aδ and c fibres. the release of glutamate and substance p here activates the second order neurons in the substantia gelatinosa of the dorsal horn of the spinal cord. these neurons, after crossing the midline, proceed to the brain via the spinothalamic tract which eventually terminate in the thalamus – the primary somatosensory processing area. from here, tertiary order neurons project to the primary and secondary somatosensory cortexes, the insula, anterior cingulate cortex (acc) and the prefrontal cortex for conscious perception of pain, as well as interacting with the cerebellum and basal ganglia.3 activation of the acc, for instance, leads to processing of emotionally related stimuli4 which may go some way as to explain many of the psychological components of pain. descending tracts the purpose of the descending pathways is in modulation of pain. neurons from the higher centres as well as projections from the spinothalamic tract connect to the peri-aqueduct grey matter (pag – with noradrenaline as transmitter) and from there to the nucleus raphe magnus (nrm – with serotonin as transmitter). from here, it proceeds down via the ipsilateral inhibitory dorsolateral columns to synapse with the substantia gelatinosa to accomplish three objectives: i) block transmission of nociceptive stimuli via the primary neurons, ii) direct inhibition of dorsal horn cells and iii) activate inhibitory dorsal horn neurons. each step of neurotransmission can be accessed and modified by the use of pharmacological agents in the management of pain. muscle pain besides the normal pain pathways, muscle pain is commonly associated with both abnormal muscle tension and trigger points.5 understanding myofascial pain relates to these two concepts of trigger points and muscle tension (the product of viscoelastic tone and contractile activity). viscoelastic tone is the elastic stiffness (related to the distance the contractile elements move) and viscoelastic stiffness (effect of velocity on the contractile elements) in the absence of electromyographic activity. contractile activity is the sum of three elements: contracture (muscle activity independent of electromyographic action), electrogenic spasm (pathological contractions arising from electrical activity in the alpha motor neurons and endplates) and electrogenic stiffness (muscle tension derived from normal electrogenic muscle contracture in individuals who are not relaxed). trigger points are taut bands of muscle fibres producing pain in specific designated zones in a muscle group and can be identified as active or latent trigger points. other physiological mechanisms contributing to muscle pain may include (but is not limited to) increased metabolism and/or decreased perfusion in the muscle fibres contributing to ischaemia, peripheral and central sensitisation, autonomic hyperactivity as well as psychological influences. since pain after muscle injury is transmitted via the same pathways as other somatic pain, the altered sensory and sympathetic excitability due to the secreted peptides sensitise nociceptive receptor thresholds in a process called peripheral sensitisation. this is experienced as spontaneous pain and https://orcid.org/0000-0002-2338-2975 page 56 dippenaar jm sa orthop j 2023;22(1) tenderness after injury. further repetitive stimulation of second and higher order neurons may contribute to the development of central sensitisation. it has been shown that muscle injury contributes the major portion of summation of the central sensitisation process. central sensitisation is implicated in chronic muscle pain syndromes and development of referred pain. deep tissue pain does not have the plethora of scientific literature as seen with cutaneous pain models. patients often describe it as a poorly localised, deep cramp-like pain. the convergent afferent inputs from skin, joints and viscera to the spinothalamic and other ascending tracts cause misinterpretation of information having their origin in aδ and c fibres, resulting in referred pain. hyperalgesia is much more likely to occur in smaller muscles or groups. it should be considered that a specific pain syndrome may have multiple origins (tmd may be myofascial or arthrogenic in origin).3 perioperative pain management it is safe to say that multimodal analgesia (mma) has become the norm at most institutions. the multimodal approach consists of the use of different analgesia medication to target different receptors along the pain pathway1 to maximise analgesia but minimise side effects of any one group. currently, the focus is on opioidsparing techniques given the fact that opioid addiction has taken on epidemic proportions in large parts of the world. postoperative musculoskeletal pain is a combination of pain subtypes (i.e. somatic sympathetic, neuropathic, psychogenic)6 for which a single agent will not be effective. therefore, mma is the best approach to manage the variety of patients.7 the advantage of mma is that it standardises treatment across an institution based on current best practice while allowing flexibility for individual tailoring according to specific patient needs (e.g. allergies). regional analgesic techniques there are many advantages to employing techniques before or during the procedure that can be continued into the postoperative period. regional anaesthesia by means of nerve blocks is the first part of this approach. by interrupting the conduction of noxious stimuli, most of the debilitating effects of pain are averted before the damage begins. regional analgesia benefits many physiological processes, including respiration, bowel function, coagulation and the hormonal stress response.8 other advantages include superior analgesia, decreased postoperative nausea and vomiting (ponv), and earlier discharge from post anaesthesia care units (pacu). clinically relevant doses of opioids during and after cancer surgery are thought to suppress natural killer cell function, which, with release of tumour promoting substances in turn will facilitate tumour growth. decreased opioid consumption may favourably influence patient survival.9 regional anaesthesia for analgesia in breast cancer surgery,10 prostate cancer11 and colon resection12 have all shown favourable outcomes. for musculoskeletal surgery, upper and lower limb surgery is eminently suited for regional analgesia and can decrease reliance on opioids tremendously. the addition of dexamethasone or dexmedetomidine has been shown to increase the duration of nerve blocks considerably.13,14 prolonging regional analgesia by continuous peripheral block by means of indwelling catheter is another option. it is safe if staff is trained to manage it and if the resources to maintain staffing is available. although the addition of some adjuvants to nerve blocks have been shown to cause nerve damage in animal models, this has not been seen in human studies.15 local anaesthesia infiltration into wound edges has been shown to be of benefit in caesarean section and laparoscopic cholecystectomy.16 the opioid-sparing effect, however, is short lived and of little clinical relevance. where other regional techniques are not an option, infiltration is advantageous when used as part of an mma plan. injection into joint spaces provide analgesia comparable with regional techniques, albeit shorter lived.17 periarticular cocktails differ from institution to institution but may include diluting local anaesthetics, steroids, opioids, nonsteroidal anti-inflammatory drugs (nsaids) and adrenaline.18 intravenous lignocaine plays a role in mma protocols at many institutions practicing according to the enhanced recovery after surgery (eras) guidelines. recovery of bowel function, decreased opioid use and increased analgesia are seen after spinal surgery where intravenous (iv) lignocaine was part of the mma protocol.19,20 the mechanism of action is thought to be that lignocaine attenuates the effect of a number of pro-inflammatory mediators. the most obvious postoperative advantage of the use of regional nerve blocks are that mobilisation of the operated limb may commence within hours of the procedure.21 though benefit is demonstrated in the immediate postoperative period, there seems to be little influence on later outcome, mostly due to a paucity of clinical studies. permanent incapacity due to neurological injury is the main fear in preventing the use of regional techniques in the perioperative period. yet, permanent nerve damage after peripheral nerve block is extremely rare.22 the incidence of damage is 7.6:10 000 for epidural, 0–4.2:10 000 for spinals,23 and 0:1 416 for peripheral blocks.24 the advent of ultrasound-guided needle and catheter placement, as well as the use of nerve stimulation during placement has gone a long way in reducing the complication rate. patient safety also relies on care and follow-up in the ward, in order to be alerted to the development of complications. a recognised postoperative analgesia protocol must be implemented to ensure safety at all time. systemic non-opioid analgesics systemic non-opioid analgesics remain the cornerstone of any mma protocol. the opioid side effect profile is avoided and the effectiveness of these agents allow for faster mobilisation and rehabilitation. table i summarises the commonly used non-opioid analgesic agents. table i: commonly used non-opioid agents drug route* preoperative dose intraoperative dose postoperative dose paracetamol iv/po 1 000 mg (> 50 kg) 1 000 mg 1 000 mg 6 hourly celecoxib po 400 mg n/a 200 mg 12 hourly gabapentin po 300–1 200 mg n/a 300–800 mg/8 hourly ketamine iv n/a 0.25–0.5 mg/kg 0.25 mg/kg/h iv ibuprofen po 600–800 mg n/a 600 mg 6–8 hourly pregabalin po 75–150 mg n/a 75 mg 12 hourly iv – intravenous, po – orally, n/a – not applicable page 58 dippenaar jm sa orthop j 2023;22(1) paracetamol paracetamol is included in most mma protocols because of its impressive safety profile (unless when administered in overdose), its cost and its opioid-sparing effect.25 oral administration may cause bioavailability to vary (63–87%) and influence onset and duration of action. this is overcome by iv administration where onset of action is within 5 minutes and peak effect is achieved within 40–60 minutes. current evidence, however, do not universally support the routine ward use of intravenous acetaminophen over oral paracetamol, unless the duration of surgery precludes the effective use of the oral preparation.26 paracetamol does not decrease tissue inflammation and is therefore not a classic nsaid.27 the mechanism of action is twofold. what is referred to as cyclooxygenase (cox) is more appropriately called prostaglandin h2 synthase. this enzyme has two active sites – the cox and the peroxidase (pox) sites. arachidonic acid is converted by cox to an unstable intermediate hydro peroxide prostaglandin, pgg2, which is then converted by pox to the stable pgh2 – the precursor to other prostaglandins (pg), leukotrienes and thromboxane. paracetamol acts as a reducing agent on the pox site, decreasing the oxidising of cox needed for pg production. the peroxide dependant cox inhibition explains why paracetamol has a differential activity in the brain (where peroxide is low) and in the periphery (where peroxide levels are high due to cellular destruction). a second mechanism may be its direct inhibition on the cox-3 (thought to be a cox-1 splice variant) isoenzyme, which is present in the central nervous system (cns).28 this may explain the analgesic and antipyretic properties in the absence of anti-inflammatory effects. activation of the descending serotoninergic pathway and inhibition of endocannabinoid reuptake is further postulated in the actions of paracetamol.4 nonsteroidal anti-inflammatory drugs nsaids are the most frequently used pharmacological agents in the treatment of postoperative musculoskeletal pain. their ability to inhibit cox, thereby interrupting the peripheral production of pgs from arachidonic acid, makes them suitable as analgesic drugs. pgs sensitise peripheral nociceptors so that even a small stimulus will now produce adequate pain impulse propagation to the cns.29 the development of cox2-specific inhibitors were touted to be safer in that it circumvents the gastric mucosa erosion, potential renal impairment and platelet inhibition caused by inhibition of pg production via cox1, but the increased incidence of cardiac thrombotic events associated with long-term use has tempered its use (apart from patients with gastric ulcer disease).30 it is important to remember that many cox2 inhibitors are contra-indicated in patients with an allergy to sulphas.31 concerns regarding nsaids increasing postoperative bleeding seem unfounded.32 in a recent meta-analysis examining inhibition of nsaids on bone healing, short-term nsaid use (< 2 weeks) had no increased risk of nonunion when compared to longer treatment periods (< 4 weeks).33 indomethacin seemed to have the greatest risk with an odds ratio (or) of 1.66 to 9.03. the predominant site of action for nsaids are peripheral, so unsurprisingly, topical administration of this group of drugs are very effective.34-36 nsaids have specific anti-nociceptive effects on painful conditions that involve muscles.37 gabapentinoids gabapentin and pregabalin is often included in mma protocols. developed as anticonvulsants, these agents exert their effect by interaction with the α2 δ subunit in the voltage-gated ca++ channel and thus decreasing glutamate release in peripheral and central neurons.38 they are particularly effective in patients with neuropathic pain. a number of studies have shown it to be effective as part of an mma protocol; unfortunately, its use is often associated with drowsiness, dizziness, fatigue, nystagmus and weight gain.39,40 n-methyl-d aspartate antagonists ketamine and magnesium have received much attention as adjuvants in mma protocols. as antagonists at the n-methyl-d aspartate (nmda) receptor, the analgesic effects of these agents are mediated via inhibition of glutamate enabled ca++ influx into neurons in the brain and spinal cord. ketamine has the potential for psychomimetic effects (hallucinations), although this side effect is not reported in pain literature.41 the analgesic benefits seem most prominent in painful surgery (such as total knee replacement) or patients with opioid tolerance.42 magnesium has not produced consistent results as adjuvant in all mma studies, but is synergistic to morphine and ketamine.43 since it seems more effective when used intrathecally, it is thought that analgesia is (in part) due to direct nmda blockade of the spinal nerves. magnesium is a cheap addition to an mma plan, especially when contraindications to the use of other analgesics are present. alpha-2 agonists dexmedetomidine and clonidine have been investigated as part of mma protocols. these agents act as agonists on α2 receptors in peripheral and central neuronal connections. dexmedetomidine is an ideal opioid replacement agents since it has no respiratory depression effects. a number of studies have shown benefit in the use of dexmedetomidine as part of patient-controlled analgesia, decreasing reliance on opioids for pain relief while providing analgesia on par with opioids.44 systemic opioids opioids have been the mainstay of postoperative analgesia for various reasons; including, simplicity of use, predictability and clinical familiarity. the presence of opioid receptors in the periphery is well documented but the efficacy of opioids are still attributed to actions within the cns. recently, the opioid epidemic and heightened awareness of opioid side effects have shifted the focus away from opioids. although the updated world health organization (who) ladder for pain management reserve opioids for moderate to severe pain, or where more simple analgesics have failed, it cannot be eliminated completely from an mma plan for procedures like hip or knee arthroplasty.45 oral opioid preparations include hydrocodone and oxycodone – both available in a variety of combination preparations. tramadol is a binary analgesic in that it possesses both opioid and nonopioid-related mechanisms of action. it binds to mu receptor with an affinity of about 1/6 000 of morphine, but also acts as serotonin and noradrenaline reuptake inhibitors. the total analgesic effect is due to the summation of these effects.46 serotonin syndrome is a life-threatening drug interaction when tramadol is administered with mono-amine oxidase (mao-i) inhibitors, selective serotonin reuptake inhibitor (ssri) and serotonin noradenaline reuptake inhibitor (snri) antidepressants. the incidence of nausea and vomiting is increased, and in caucasians, 10% of patients will have reduced effect due to an inherited enzyme defect (needed to activate the prodrug). furthermore, tramadol use is associated with increased opioid dependence and emergency unit attendance.47 skeletal muscle relaxants muscle relaxants are classified into two groups: antispastics (dantrolene and baclofen) and antispasmodics (benzodiazepines, cyclobenzaprine, tizanidine, carisoprodol). the mechanism of action of antispasmodics (apart from benzodiazepines) is not fully page 59dippenaar jm sa orthop j 2023;22(1) understood – central nmda blockade has been suggested for cyclobenzaprine, while tizanidine had α2 agonist properties. there is precious little evidence to suggest the efficacy of any of the antispasmodics in acute settings, but cyclobenzaprine has been incorporated in a few mma protocols as a preoperative adjuvant.48 antispastics have not been used in the acute setting. studies has shown cyclobenzaprine to be an effective adjuvant in the management of acute lower back pain49,50 while being the least sedative of all the muscle relaxants. there is however a notable paucity in evidence for its efficacy in the acute postoperative setting (apart from incorporation into preoperative mma protocols). since it is structurally related to tricyclic antidepressants, its side effect profile and contra-indications are similar to these agents. facing the challenge the implementation of clinical guidelines can go a long way to standardise practice. these guidelines should follow established evidence-based strategies to be able to champion this burden. lin et al.51 reviewed how clinical practice guidelines (cpg) may benefit patients and the healthcare service providers in the management of musculoskeletal pain conditions. they suggested 11 recommendations and their best practice of care for musculoskeletal pain.51 although the recommendations aim to encompass both acute and chronic pain management, the suggestions applicable to the acute setting, are listed below: 1. care must be patient-centred. it needs to speak to the specific patient context, and allow shared decision making and effective communication. 2. assessment of psycho-social factors are important. 3. a physical exam including complete neurological exam with assessment of mobility and muscle strength is important. 4. patients should be educated and informed about their condition and available management options. conclusion the need for postoperative analgesia following musculoskeletal surgery is a given. although the ideal pharmacological management programme is not quite established, a multidisciplinary multimodal analgesia plan may go a long way in making the surgical experience far more satisfying for the patient. orcid jm dippenaar https://orcid.org/0000-0002-2338-2975 references 1. schwenk es, mariano er. designing the ideal perioperative pain management plan starts with multimodal analgesia. korean j anesthesiol. 2018;71(5):345-52. https://doi.org/10.4097/ kja.d.18.00217. 2. steeds ce. the anatomy and physiology of pain. surgery. 2009;27(11):508-11. https://doi. org/10.1016/j.mpsur.2009.10.013. 3. perl er. pain mechanisms: a commentary on concepts and issues. prog neurobiol. 2011;94:20-38. 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https://doi.org/10.1001/archinte.161.13.1613 https://doi.org/10.1136/bjsports-2018-099878 https://doi.org/10.1136/bjsports-2018-099878 404 not found south african orthopaedic journal paediatric orthopaedics doi 10.17159/2309-8309/2021/v20n1a2 vajapey s et al. sa orthop j 2021;20(1) citation: vajapey s, horn a. tuberculosis of the extra-axial skeleton in paediatric patients. sa orthop j 2021;20(1):21-26. http://dx.doi.org/10.17159/23098309/2021/v20n1a2 editor: prof. jacques du toit, stellenbosch university, cape town, south africa received: march 2020 accepted: october 2020 published: march 2021 copyright: © 2021 vajapey s. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background musculoskeletal tuberculosis (msk tb) is a disease entity that often mimics other orthopaedic conditions in its radiographic and clinical presentation, which can delay diagnosis and treatment. the purpose of this study is to examine the clinical and radiographic presentation as well as the accuracy of various diagnostic tests, treatment, complications and outcome in paediatric patients diagnosed with msk tb. we aim to provide insight into typical presenting features in order to expedite diagnosis in this perplexing disease. methods we retrospectively reviewed 77 consecutive patients with extra-axial msk tb treated at our institution over a ten-year period from 2008 to 2018. we collected data on initial clinical presentation, laboratory values, radiographic findings, diagnostic testing, treatment and outcomes. we performed quantitative and qualitative analysis to look for patterns in presentation that can help with diagnosis and factors affecting the clinical outcomes. results the most common clinical presentation was pain of the affected limb. constitutional symptoms were uncommon. our patients presented with thrombocytosis and anaemia, but normal white cell counts. inflammatory markers were mildly elevated. of diagnostic tests employed, the mantoux skin test yielded the most positive results (70%) followed by tissue pcr (53%). the hip was most frequently involved, followed by the knee and elbow. most patients presented with normal appearing x-rays. we had a medical compliance rate of 94% with all patients followed up to completion of treatment having resolution of active disease. thirty-nine per cent of our patients had residual joint stiffness or deformity following completion of treatment, ranging from ankylosis to mildly decreased joint range. conclusion patients with msk tb usually present with non-specific symptoms and signs, and a high index of suspicion should be maintained in endemic areas. typical haematological findings are an elevated esr and crp accompanied by anaemia and thrombocytosis. radiographs at presentation are non-specific in more than 50% of patients. a combination of diagnostic modalities should be employed as no single test is 100% sensitive or specific. compliance with medical treatment reliably leads to resolution of the disease. residual joint pathology is common and needs to be addressed secondarily. level of evidence: level 4 keywords: musculoskeletal tuberculosis, paediatric tuberculosis, joints, anti-tuberculosis treatment, deformity, genexpert tuberculosis of the extra-axial skeleton in paediatric patients sravya vajapey¹ , anria horn²* 1 department of orthopaedic surgery, the ohio state university, columbus, ohio, united states of america 2 department of orthopaedic surgery, university of cape town, cape town, south africa *anria.horn@uct.ac.za http://dx.doi.org/10.17159/2309-8309/2021/v20n1a2 http://dx.doi.org/10.17159/2309-8309/2021/v20n1a2 https://orcid.org/0000-0001-7245-320x https://orcid.org/0000-0002-4159-6520 page 22 vajapey s et al. sa orthop j 2021;20(1) introduction musculoskeletal tuberculosis (msk tb) is a disease entity that often mimics other orthopaedic conditions in its radiographic and clinical presentation, which can delay diagnosis and treatment. while msk tb accounts for 9.7% of all extra-pulmonary cases in the united states, this percentage is much higher in endemic regions like india and south africa.1 approximately 20 children each year are diagnosed with and treated for msk tb at our institution.2 fifty per cent of msk tb involves the extra-axial skeleton in the form of tuberculous arthritis, osteomyelitis, bursitis, subcutaneous abscess or tenosynovitis.3,4 diagnosing msk tb in children is particularly challenging due to vague presenting symptoms like joint pain, fatigue and history of minor trauma, which can often obscure the underlying pathology.5 the purpose of this study is to examine the initial presentation of patients diagnosed with msk tb to determine the characteristic clinical and radiographic features of this disease, as an aid to expedient diagnosis. we also examine the accuracy and value of the various diagnostic tests utilised, the medical and surgical treatment offered and the outcome of treatment. materials and methods a retrospective review was performed on records and radiographs of all patients diagnosed with extra-axial msk tb from january 2008 to september 2018. approval was obtained from the institutional human research ethics committee. we included all patients aged 14 years or less with laboratory confirmed diagnosis of msk tb. we included five patients that were lost to follow-up or defaulted treatment, in order to assess their presenting and diagnostic features. there were 77 patients of whom 38 were males. mean age at presentation was 6.7 years (5 months to 14 years) and mean follow-up was 17 months (0–38 months). data was collected on demographic variables, clinical presentation, special investigations and radiological features, treatment compliance and clinical outcome. routine investigations performed were hiv testing, full blood count (fbc), c-reactive protein (crp) and erythrocyte sedimentation rate (esr). standard diagnostic tests performed were the mantoux skin test, microscopy, culture and sensitivity (mcs) of sputum or gastric washings in younger patients, synovial or bone biopsy for tissue pcr (genexpert mtb/ rif [cepheid, usa]) and tissue mcs. synovium was routinely sent for histological analysis. not all patients had results for all the abovementioned tests, therefore analysis was performed on the available results. plain x-rays at presentation were evaluated for radiographic features of tb. x-rays were then classified according to the system described by shanmugasundaram6 (figure 1a-g) for tb of the hip, and that of kerri and martini for tb of the knee and elbow (table i).7 chest x-ray was routinely performed as part of the diagnostic work-up. following diagnosis of msk tb and initiation of anti-tuberculous drugs, patients were typically admitted to a long-stay facility associated with our unit. in cases where compliance was questionable due to socio-economic factors, patients remained admitted for the duration of treatment. response to treatment was monitored with serial esr measurements and radiographs. duration of medical treatment was nine months, but would be prolonged if incomplete resolution of disease was noted after nine months of treatment. statistical analysis was performed using the stattools tool pack in microsoft excel. descriptive data was presented in the form of means and standard deviations for continuous variables, and proportions for categorical variables. independent sample t-tests (for continuous variables), and chi-squared tests (for categorical variables) were used to assess the relationship between various independent variables. where appropriate, statistical significance was set at p<0.05. a d ge f b c figure 1. the system described by shanmugasundaram to classify tb of the hip:⁶ a) type 1 ‘normal’; b) type 2 ‘travelling acetabulum’; c) type 3 ‘dislocating’; d) type 4 ‘perthes’; e) type 5 ‘protrusion’; f) type 6 ‘atrophic’; g) type 7 ‘mortar and pestle’ table i: the system described by kerri and martini to classify tb of the knee and elbow7 stage description appearance 1 normal osteopaenia and soft tissue swelling with or without epiphyseal hypertrophy 2 osteomyelitic epihyseal or metaphyseal cysts, normal joint space 3 arthritic narrow joint space without gross anatomical disorganisation 4 arthritic gross anatomical disorganisation page 23vajapey s et al. sa orthop j 2021;20(1) results all patients had symptoms or signs localised to the involved joint, such as pain, inability to bear weight, swelling, limp and deformity. the mean duration of symptoms prior to presentation was four months (one day to three years). seventy-six patients presented with pain and tenderness localised to an extremity. the one patient who did not have pain presented with a painless deformity of the distal tibia. presenting features are summarised in table ii. of the 77 patients included, hiv status at time of presentation could be determined for 34 patients, of whom four were hivpositive. this is 5% of the total study population and 12% of those whose results were available. the hip was the most frequently involved joint (n=29), followed by the knee (n=22), the foot and ankle (n=15), the elbow (n=18) and clavicle (n=1). the results of the haematological investigations are presented in table iii. our patients generally demonstrated a mild anaemia, thrombocytosis and elevated inflammatory markers. of the 29 patients diagnosed with tb of the hip, the most common radiographic presentation was a type 1 hip (‘normal’ hip) according to the shanmugasundaram classification.6 the frequency of the different types of radiographic presentation for tb of the hip in our population is illustrated in figure 2. the most common stage at presentation for tb of the knee and elbow was stage 1 according the kerri and martini staging system.7 the frequency of the different stages at presentation is illustrated in figure 3. chest x-ray demonstrated hilar adenopathy or other features of pulmonary tb in 22 patients out of 71 for whom these x-rays were available (31%). of the array of diagnostic tests performed for each patient, the mantoux skin test yielded the highest number of positive results (55/67 tested; 82%) followed by tissue culture and/or histology (41/73 available results; 56%), tissue pcr (39/73 tested; 53%), tissue microscopy (33/74 available results; 45%) and sputum/ gastric washings (11/59 available results; 19%). necrotising or caseating granulomas on histology were considered diagnostic of tb. seventy-four out of 77 patients included in the study underwent open biopsy. the most common intra-operative finding in all surgical cases was synovial hypertrophy. frank purulence was uncommon and only seen in nine cases. the rest had either serous or straw-coloured synovial fluid. one patient underwent an open reduction of a dislocated hip at initial presentation. three years table ii: presenting features in patients diagnosed with extra-axial msk tb in order of frequency presenting feature frequency tenderness or pain 99% gait abnormalities 77% decreased range of motion 75% swelling or effusion 66% tb contact (relative or person living in the same house) 22% history of trauma 14% constitutional symptoms (malaise, loss of weight, loss of appetite) 13% joint contracture 8% hiv co-infection 7% limb length discrepancy 4% table iii: haematological findings in patients diagnosed with extra-axial msk tb haematological parameter n* normal range study population mean (range) p-value white cell count (wcc) 71 4–12 × 109/l 10.61 × 109/l (4.59–30.45) 0.766 haemoglobin (hb) 60 11.8–14.6 g/dl 11.15 g/dl (7–13.1) 0.01 platelet count (plt) 46 180–440 × 109/l 458 × 109/l (192–807) 0.003 crp 40 <10 mg/l 29.2 mg/l (1–219) <0.001 esr 67 0–10 mm/hr 42.1 mm/hr (40–121) <0.001 *n designates the number of patients for whom results were available for the specific blood parameter type 1 53% type 2 14% type 3 4% type 4 11% type 5 7% type 6 7% type 7 type 7 4%4% figure 2. the frequency of radiographic type, as described by shanmugsundaram,⁶ at initial presentation for patients diagnosed with tuberculosis of the hip stage iv stage iii stage ii stage i 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% knee elbow 0% 41% 59% 50% 25% 13% 13% figure 3. frequency of radiographic stages, as described by kerri and martini,7 at initial presentation for patients diagnosed with tuberculosis of the knee and elbow page 24 vajapey s et al. sa orthop j 2021;20(1) following the open reduction, he has near full range of motion in the hip, a 1 cm leg length discrepancy and a slight trendelenburg limp (figure 4a-d). one patient had an intralesional curettage and bone grafting of a proximal femoral lesion thought to be a unicameral bone cyst. the biopsy results revealed sensitive tb and the lesion healed with medical treatment. three patients received medical treatment only. medical treatment consisted of nine months of four-drug therapy (rifampicin, isoniazid, pyrazinamide and ethambutol). five patients demonstrated isolated inh resistance (resistance to isoniazid), which did not alter the medical treatment as per our institution’s infectious diseases protocol. compliance with medical treatment was 94%. three patients were lost to follow-up immediately following diagnosis, and two patients underwent partial treatment before defaulting. secondary surgery consisted of hip arthrodesis in two patients for persistent pain and severe deformity (figure 5). one patient developed proximal tibial growth arrest and progressive valgus deformity, for which a high tibial osteotomy was performed (figure 6). further reconstructive surgery is planned for this patient. no patient had persistent active disease following completion of medical treatment. thirty patients (39%) had some loss of range a c d b figure 4. a) left hip dislocation in a 7-year-old male with associated tb meningitis; b) mri in the same patient showing large intra-articular abscess, surrounding oedema and deformity of the femoral head; (c, d) x-rays at three-year follow-up. there is residual proximal femoral deformity but a congruent joint and near normal range of motion. note the vp-shunt in situ. figure 6. a) left knee of a 5-year-old male showing a lytic lesion involving the lateral epiphysis and metaphysis of the proximal tibia; b) x-rays of the same patient after completion of medical treatment with growth arrest and progressive valgus deformity of the lower limb a b figure 5. a) pelvic x-ray of a 13-year-old male with a destroyed hip secondary to advanced tb; b) hip arthrodesis was performed for persistent pain and severe deformity leading to resolution of symptoms a b page 25vajapey s et al. sa orthop j 2021;20(1) of motion, ranging from ankylosis to mildly decreased range, or deformity of the affected joint/limb at the final follow-up. discussion tb is one of the top ten causes of death worldwide and the leading cause of mortality among hiv-positive patients.8 extrapulmonary tb can account for up to 20% of all tb cases, with msk tb accounting for 10–35% of these.9 the purpose of this retrospective study was to provide the most common clinical presentation of msk tb in the paediatric patient to provide recommendations for diagnostic workup and treatment. in our population, the most common presenting symptom was, not surprisingly, pain. this was closely followed by gait abnormalities if tb involved the lower extremity, and decreased range of motion if it involved a joint. unlike the study by mulleman et al. that showed that fever or weight loss was present in up to 42% of patients with spinal tb, constitutional symptoms were present in only 13% of the patients with extra-axial tb in our study.10 no other presenting symptom or sign was found to be specific to msk tb, or to aid in differentiating msk tb from other msk conditions. msk tb may, on rare occasions, present with symptoms and signs mimicking acute bacterial infection as noted by lee et al.11 it is therefore routine practice at our institution to send samples for tb culture, microscopy and pcr in all patients that undergo biopsy for suspected acute septic arthritis or osteomyelitis. patients in our population were prone to thrombocytosis and anaemia with mean values being significantly different from normal values in children. the association between thrombocytosis and msk tb has been described in tb of the spine,12 but not to our knowledge in msk tb in children. our patients had raised esr and crp values but normal wcc. the esr is widely used as a diagnostic and prognostic tool in tb infections,12,13 and is our preferred investigation to monitor treatment response. the mean crp in our patients was 29.2 mg/dl. though higher than the maximum normal value of 10 mg/dl, it was low compared to the mean crp in patients presenting with acute pyogenic osteomyelitis in our population, which is 223.6 mg/dl.14 this finding may be helpful in distinguishing pyogenic infections from tuberculous infections, as also proven by niu et al. in the setting of pneumonia.15 of the available diagnostic tests specific for mycobacterium tuberculosis (mtb), the mantoux skin test had the highest positive rate in our study population (82%) followed by tissue culture and/or histology (56%), tissue pcr (53%), tissue microscopy (45%), and sputum/gastric washings (19%). a positive mantoux test should be interpreted with caution as false positives may occur in the setting of prior bcg vaccination, which forms part of our national vaccination programme. children who have latent tb, but no active disease, may also demonstrate a positive mantoux test, and the test may be falsely negative in patients who are immunocompromised due to, for example, hiv infection. tissue pcr has been shown to have a sensitivity and specificity for tb of 92.3% and 99.1% respectively in a series including spinal tb from our institution.16 the reason for the lower diagnostic sensitivity in our series may be the quality of our samples and the absence of frank pus in most of our patients. lee et al. demonstrated a sensitivity of 17.6% for pcr in their study and found the sensitivity to be much improved if necrotic tissue was present.17 only four out of 77 patients (5%) were known to be hiv-positive at time of presentation. results could only be found for 34 of our patients but even then, the incidence is 12%. in a study examining extra-axial msk tb in children, firth et al. reported a prevalence of 33.3% of hiv co-infection.18 the reason for the low hiv co-infection rate in our patients remains elusive, but tb is endemic in our region, as is demonstrated by the four-times higher number of cases in our study than in that by firth et al.18 over the same time period, and may be ascribed to different epidemiology and disease trends in our population. the systems described by shanmugasundaram6 and kerri and martini7 for msk tb are helpful in recognising typical radiological presentations. the most common radiographic presentation of tb of the hip in our population was type 1, which is ‘normal’, followed by type 2, the travelling type. it should be noted that type 1 hips are seldom completely normal and may demonstrate generalised osteopaenia and/or displacement of the soft-tissue planes, if an effusion is present. these results were similar to results from a retrospective study of 27 patients by agarwal et al.19 all seven radiographic stages were represented in our population, even though there was only one case each of type 3 (dislocating) and type 7 (pestle and mortar). this differs from other studies where certain types were not seen.19,20 in the case of knee-and-elbow tb, the most common stage at presentation was stage 1. the treatment of msk tb is primarily medical and, depending on the stage of disease at presentation, surgery may be avoided completely.21 msk tb can usually be diagnosed clinically, particularly in areas where the disease is endemic. despite this, biopsy is recommended, if not mandatory, to exclude other pathology as well as to determine sensitivity due to the rise in drug resistant tb.22 all but three patients in our study underwent open biopsy in order to confirm the diagnosis. in cases where a large cold abscess was present, this was drained and the joint debrided. no patient required a synovectomy to control active disease, although this has been reported in other literature.21 all our patients that were followed up to completion of treatment had complete resolution of active disease, as demonstrated by a healed lesion on x-ray and normal esr levels. compliance with the intensive and prolonged medical treatment regimen is paramount to treatment success and avoidance of recurrence or resistance.23 we had a 94% compliance rate as many of our patients were hospitalised for the duration of treatment. a recent study looking at factors influencing adherence to tb treatment by gebreweld et al. showed that short distances to health facilities, good communication with and health education of families, and strengthening of social structures can enable better adherence to tb treatment.24 these factors should be considered by physicians lacking the facilities or resources to admit patients to the inpatient ward for the duration of tb treatment, to improve compliance. residual deformity and joint stiffness are common following successful treatment of msk tb. only three of our patients have required orthopaedic surgery to address residual pain and deformity, but we anticipate that many will require surgery in future for early onset osteoarthritis of the involved joint. there are several limitations to our study. as it is a retrospective study, it is subject to biases inherent to its design, such as selection bias. investigations were not necessarily performed systematically in all patients, and treatment initiation was at the discretion of the treating physician. our follow-up was short, and we cannot comment on the long-term outcomes of patients with msk tb. despite these limitations, the major strengths of this paper are the large number of patients and data points collected for each patient in the sample. this allowed us to investigate patterns in laboratory values, imaging findings, demographics, treatments and outcomes, and provide a comprehensive review of how a patient with msk tb might be diagnosed and treated appropriately. page 26 vajapey s et al. sa orthop j 2021;20(1) 16. held m, laubscher m, workman l, et al. diagnostic accuracy of genexpert mtb/rif in musculoskeletal tuberculosis: high sensitivity in tissue samples of hiv-infected and hiv-uninfected patients. s afr med j. 2017;107(10):854-58. 17. lee yj, kim s, kang y, et al. does polymerase chain reaction of tissue specimens aid in the diagnosis of tuberculosis? j pathol transl med. 2016;50(6):451-58. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5122730/. 18. firth gb, lescheid j, camacho m, et al. extraspinal osteoarticular multidrug-resistant tuberculosis in children: a case series. s afr med j. 2017;107(11):983-86. https://doi.org/10.7196/samj.2017.v107i11.12577. 19. agarwal a, suri t, verma i, et al. tuberculosis of the hip in children: a retrospective analysis of 27 patients. indian j orthop. 2014;48(5):463-69. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4175859/#ref8. 20. campbell jab, hoffman eb. tuberculosis of the hip in children. j bone joint surg (br). 1995;77-b(2):319-26. 21. tuli sm. general principles of osteoarticular tuberculosis. clin orthop relat res. 2002;398(1):11-19. 22. dunn r. the medical management of spinal tuberculosis. sa orthop j. 2010;9(1):37-41. 23. dick j, lombard c. shared vision – a health education project designed to enhance adherence to anti-tuberculosis treatment. int j tuberc lung dis. 1997 apr;1(2):181-86. 24. gebreweld fh, kifle mm, gebremicheal fe, et al. factors influencing adherence to tuberculosis treatment in asmara, eritrea: a qualitative study. j health popul nutr. 2018;37:1. https://www.ncbi.nlm.nih.gov/pmc/articles/ pmc5756387/. conclusion msk tb should always be considered as part of the differential for bone and joint pain in children, especially in endemic areas. certain clinical, radiological and haematological patterns are typical, though not diagnostic; diagnostic testing should include a variety of modalities including an open biopsy, as no individual test is 100% sensitive or specific. initial treatment is medical and will lead to resolution of disease in nearly all patients that complete the full treatment course. orthopaedic surgery may be indicated for residual deformity or disability once medical treatment is complete. ethics statement approval as obtained from the institutional human research ethics committee (hrec ref 183/2019). the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was not obtained from all patients for being included in the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions sv: study design, data capturing and analysis, preparation of manuscript ah: study design, data capturing and analysis, editing of manuscript, supervision references 1. united states centers for disease control and prevention. reported tuberculosis in the united states, 2016. https://www.cdc.gov/tb/statistics/ reports/2016/pdfs/2016_surveillance_fullreport.pdf. 2. held mfg, hoppe s, laubscher m, et al. epidemiology of musculoskeletal tuberculosis in an area with high disease prevalence. asian spine j. 2017;11(3):405-11. 3. kramer n, rosenstein ed. rheumatologic manifestations of tuberculosis. bull rheum dis. 1997 may;46(3):5-8. 4. vohra r, kang hs, dogra s, saggar rr, sharma r. tuberculous osteomyelitis. j bone joint surg (br). 1997;79(4):562. 5. rasool mn. tuberculosis-the masquerader of bone lesions in children. sa orthop j. 2009;8(1):21-25. 6. shanmugasundaram tk. bone and joint tuberculosis. madras: kothandaram and co; 1983. 7. kerri o, martini m. tuberculosis of the knee. int orthop. 1985;9(3):153-57. https://www.ncbi.nlm.nih.gov/pubmed/4077334. 8. who media center. tuberculosis. who. 2018. available from: http://www.who. int/mediacentre/factsheets/fs104/en/. 9. held m, bruins mf, castelein s, et al. a neglected infection in literature: childhood musculoskeletal tuberculosis – a bibliometric analysis of the most influential papers. int j mycobacteriology. 2017;6(3):229-38. 10. mulleman d, mammou s, griffoul i, et al. characteristics of patients with spinal tuberculosis in a french teaching hospital. joint bone spine. 2006 jul;73(4):424-27. 11. lee as, campbell jab, hoffman eb. tuberculosis of the knee in children. j bone joint surg (br). 1995;77-b:313-18. 12. daniel k, dunn r. comparison of platelet count in tuberculosis spine to other spine pathology. europ spine j. 2013;22(12):2810-14. 13. tengku muzaffar tms, shaifuzain ar, imran y, noor haslina mn. hematological changes in tuberculous spondylitis patients at the hospital universiti sains malaysia. southeast asian j trop med public health. 2008;39(4):686-89. 14. horn a, wever s, hoffman eb. complications following acute severe haematogenous osteomyelitis of the long bones in children. sa orthop j. 2019;18(3):23-29. 15. niu w-y, wan y-g, li m-y, et al. the diagnostic value of serum procalcitonin, il-10 and c-reactive protein in community acquired pneumonia and tuberculosis. eur rev med pharmacol sci. 2013;17:3329-33. orthopaedics vol3 no4 abstract study design: retrospective review aim: to identify factors affecting surgeons’ management decisions regarding acute cervical distraction-flexion dislocation reduction and the consequences thereof. summary of background data: there is clinical benefit when early (<24 hours) decompression in distraction-flexion dislocation (df) injuries with cord injury is performed. the risk of secondary cord injury during awake closed reduction is low. the need for mri scanning prior to reduction is controversial but it may identify patients with an uncontained herniated ‘disc at risk’ that may be drawn into the spinal canal during reduction, causing further cord injury. surgeons’ belief regarding the importance of pre-reduction mri varies. thus in many clinical scenarios, treatment algorithms are chosen individually by the surgeon on the merits of each case as well as limited access to mri facilities in the remoter areas of this large country. methods: analysis was performed on 110 consecutive patients with a mean age of 37.1 years with df dislocation injuries of the cervical spine. pre-reduction mri scans were assessed by two independent, blinded teams to determine patients with a ‘disc at risk’. this subgroup was then investigated as to the management decisions, neurological status and outcome. results: nineteen patients (21%) were identified to have a perceived ‘disc at risk’. six of these patients underwent anterior surgery. initial closed reduction was attempted in the other 13. none deteriorated neurologically. presenting neurological status was found to have a large impact on surgeons’ choice of reduction. of the nine asia a patients, seven had initial closed reduction, while in the three asia e group only one had closed reduction. conclusion: patients with agreed mri features of a perceived ‘disc at risk’ had no increased risk of secondary cord injury. the presence of these disc lesions only influenced our surgeons to choose open reduction in four cases (21%). neurological status had a much greater effect on surgical decision-making in that those with neurological deficit (most to gain) were reduced closed and asia e (most to lose) tended to open reduction. early reduction need not wait for mri imaging and should be performed as soon as possible in cord-injured patients. key words: cervical, mri, distraction-flexion, unifacet, bifacet, surgeon behaviour page 42 sa orthopaedic journal summer 2015 | vol 14 • no 4 http://dx.doi.org/10.17159/2309-8309/2015/v14n4a5 saoj summer 2015_press_orthopaedics vol3 no4 2015/11/02 12:06 pm page 42 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 43 introduction cervical spine dislocation carries an inherent risk of cord injury. although we have little influence over the primary injury, we can improve outcome by limiting the secondary effects of ongoing compression and physiological circumstances which lead to ischemia and cellular changes of the cord.1,2 animal models confirm that persistent cord compression has time-related adverse effects on the ability to recover.2,3 clinical benefit has been demonstrated with cervical reduction performed earlier than 24 hours following injury.4 the safety of closed reduction has been questioned with sporadic case reports of secondary cord injury occurring with unrecognised cervical disc prolapse.5-9 eismont and green concluded that pre-reduction mri will identify cervical disc prolapse thus allowing the surgeon to avoid secondary cord injury during reduction. evidence of a prolapsed disc might change clinical management by dictating an immediate anterior decompression. although the incidence of disco-ligamentous lesions in distractive flexion injuries has been reported to be as high as 18%–80%,10-12 the incidence of secondary cord injury following closed reduction is considered low.13 thus a discrepancy exists between identifiable disc lesions on mri and clinical significance. reporting of disc lesions does not carry a high interrater reliability.12 mri is often not readily available due to distances involved between district hospitals and academic centres with mri facilities and competition for resources. these factors may result in delay to cervical reduction with possible reduced neurological outcome. treatment pathways chosen by surgeons have been demonstrated to be inconsistent.14 some surgeons perform pre-reduction mri scans on all df dislocation injuries, whereas others perform closed reduction on selected patients based on neurological status and stage of df injury. for this reason we performed this study to identify our surgeons’ behaviour as regards the reduction decisionmaking process and clinical consequences thereof. aim this retrospective review evaluates the management behaviour of our surgeons when faced with decisionmaking in acute df dislocation injuries of the cervical spine, particularly with reference to the impact of mri features, and the presenting neurological status of the patients. methods following local institutional ethics approval (hrc ref: 091/2011), 110 consecutive df injuries were identified from the senior author’s database. all were managed at a single tertiary hospital over a ten-year period. an initial study12 was performed to assess the interrater agreement of mri variables between radiologists and orthopaedic surgeons. the highest agreement was found on the presence of posterior disc herniation (based on defined posterior, inferior and corner-to-corner lines) and containment variables. these variables were then used to define the perceived ‘disc at risk’ – a herniated uncontained disc that may cause secondary cord injury during cervical reduction techniques. both teams were blinded to patients’ clinical data and worked completely independently. nineteen of the 110 mri df dislocation injuries satisfied both teams that there was the presence of a ‘disc at risk’. clinical data of this subgroup was then assessed. case notes were reviewed, noting the management algorithm chosen and reasons for doing so. when employed, closed reduction involved skeletal traction applied with skull tongs to the awake patient. sequential weights were added while visualising the cervical spine in a slightly flexed position with an image intensifier. the patient was monitored clinically for onset of neuralgia or weakness. once the facets had been distracted sufficiently the head was gently repositioned in extension; the weights were reduced when the facets were visualised to be reduced. following reduction, the patient was kept in the extended position in skeletal traction until definitive surgical fixation was performed. should open reduction be performed, an anterior smith-robinson cervical approach was utilised and a discectomy performed prior to reduction.15,16 frequently skull traction was combined with a levering manoeuvre using a macdonald or cobb instrument in the inter-body space on the side of the dislocation (cloward/reverse-cloward manoeuvre). a cage or structural allograft was placed in the disc space and anterior locked plating performed.17,18 chronic injuries are not applicable to closed reduction. patients who presented with a delay of more than three weeks from time of injury (n=15) and patients whose clinical notes were missing (n=6) were excluded from data analysis. data was collected and entered utilising a double-entry method thereby reducing entry error.19 epidata and stata statistical software was used. results ‘disc at risk’ cases nineteen patients (21%) had a perceived ‘disc at risk’ based on uncontained, posteriorly herniated intervertebral disc based on independent, blinded assessment by both radiologists and orthopaedic surgeons (figure 1). of these 19 patients, six had anterior discectomy and reduction performed primarily. four of these were operated upon due to the surgeon recognising mri features of a disc prolapse. one was done due to the surgeon finding the patient to be neurologically intact and thus being concerned over the possibility of neurological deterioration, and one patient for an undocumented reason. saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 43 page 44 sa orthopaedic journal summer 2015 | vol 14 • no 4 the remaining 13 patients had an attempted closed reduction despite the presence of the ‘disc at risk’ on mri. six (46%) of these failed to reduce, at which point attempts were aborted in favour of open reduction. there was no secondary cord injury in any of these patients. when assessing neurological status against the management chosen, there was a strong correlation between initial neurological impairment and the likelihood of the surgeon initially choosing closed reduction (figure 2). of the nine patients who were neurologically complete (asia a), seven had attempted closed reduction. of the seven who were neurologically incomplete (asia b/c/d), five had attempted closed reduction. of the three patients who were neurologically intact, two had initial open discectomy and reduction. neurological deterioration of the 89 patients included in the total data analysis (early presenting cases/with notes available), 54 had an initial attempted closed reduction. one patient deteriorated following aborted closed reduction (1.8%); this patient was assessed as motor-sensory complete (asia a) prior to attempted reduction. during the procedure the patient lost two mrc grades in the c8 myotome (5/5 to 3/5). this patient had a unifacet dislocation and did not have agreed features of a ‘disc at risk’. discussion with evolving evidence that the risk of secondary cord injury during awake reduction for distraction flexion injuries is low, there has been a resurgence of intent to reduce these injuries closed acutely.7,10,11,20–22 fehlings et al. reported significant neurological improvement six months after spinal cord injury, if adequately decompressed within 24 hrs of injury.4 these authors consider closed reduction, demonstrated with mri scanning, as adequate decompression. mri scanning consumes time that could be spent decompressing the cervical spine. the interpretation of the mri may at times be a source of disagreement and may steer orthopaedic surgeons towards operative reduction, if relying on radiologists’ reporting exclusively12 which may introduce delays to conclusive reduction. mri may demonstrate disc lesions well; however, the relevance of these disc lesions with regard to the risk of secondary cord injury is thrown into question by our findings and others.23 figure 1. nineteen patients of the 110 patients investigated had features of a herniated uncontained cervical disc. 13/19 (68%) had attempted closed reduction. a large portion (6/13, or 46%) failed and progressed to open reduction in theatre. ‘disc at risk’ open reduction n=6 closed reduction attempt n=13 68% successful closed n=7 failed closed n=6 46% n=19 figure 2. this box diagram demonstrates the treatment algorithm initially chosen by the surgeon relating to presenting neurological status. what is noteworthy is that with increasing neurological impairment the surgeon was far more likely to choose early closed reduction – this is independent of mri features. neurological status open reduction n=2 closed reduction n=1 normal neurology n=3 open reduction n=2 closed attempted reduction n=5 (71%) incomplete n=7 open reduction n=2 closed attempted reduction n=7 (77%) complete n=9 data was collected and entered utilising a double-entry method thereby reducing entry error saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 44 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 45 despite agreed features of a ‘disc at risk’, 13 patients underwent attempted closed reduction and none deteriorated neurologically. what we may conclude from our findings is that these ‘disc at risk’ injuries predict a high likelihood of failed closed reduction(46%), as opposed to 2.6% failed reduction rate in other studies.13 we also note the high incidence of presenting neurological impairment in this subgroup. patients with df dislocation injuries and uncontained herniated discs had an 89% incidence of neurological compromise on presentation. this is in keeping with the understanding that the original injury was more severe with greater initial displacement when disc herniations are present. this finding is in keeping with recent level 3 evidence linking poorer neurological outcomes with an increasing stage of df injuries.24 in this study we find that our surgeons’ choice to attempt closed reduction initially was influenced greatly by the presence of initial neurological deficit and far less by the presence of a ‘disc at risk’ lesion. the principle of continued compression in an injured swelling cord steers our surgeons to choose early closed reduction. this may be based on the neurologically impaired being assessed as those with the ‘most to gain’ with early reduction (indirect decompression) and the neurologically normal, the ‘most to lose’. closed reduction is performed in the emergency room as described above. the need to perform pre-reduction mri is questioned, especially when it risks causing a delay to reduction in areas where mri is relatively inaccessible. mri may be best performed following reduction to confirm decompression.4 this remains a difficult question to answer in wellresourced environments where mri is immediately available and the costs of routine pre-reduction mri is compared to the rare post-reduction neurological deterioration. acknowledgments gen chang – clerical work, department of radiology, groote schuur hospital henri carrara – statistical advice, university of cape town no disclosures are pertinent to this study. institutional ethics approval was obtained from the uct ethics committee. references 1. tator ch, fehlings mg. review of the secondary injury theory of acute spinal cord trauma with emphasis on vascular mechanisms. j. neurosurg 1991;75:15–26. 2. carlson gd, gorden cd, oliff hs, et al. sustained spinal cord compression part i: time-dependent effect on long-term pathophysiology. j bone joint surg am. 2003;85:86-94. 3. tarlov im. spinal cord compression studies iii. time limits for recovery after gradual compression in dogs. neurol psychiatry 1954;71:588–97. 4. fehlings mg, vaccaro a, wilson jr, et al. early versus delayed decompression for traumatic cervical spinal cord injury: results of the surgical timing in acute spinal cord injury study (stascis). plos one 2012;7(2):e32037. doi:10.1371/journal.pone.0032037 5. eismont fj, arena mj, green ba, et al. extrusion of an intervertebral disc associated with traumatic subluxation or dislocation of cervical facets . case report traumatic of an intervertebral subluxation disc associated of cervical with facets or dislocation of five. j bone joint surg am 1991;73:1555–60. 6. berrington n, staden j., willers j, van der westerhuizen j. cervical intervertebral disc prolapse associated with traumatic facet dislocations. surg neurol 1993;40:395–99. 7. lee as, maclean jcb, newton da. rapid traction for reduction of cervical spine dislocations. j bone joint surg br. 1994;76(3):352–56. 8. mahale y, silver j, henderson n. neurological complications of the reduction of cervical spine dislocations. j bone joint surg (br) 1993;75:403–409. 9. olerud c, jónsson h. compression of the cervical spine cord after reduction of fracture dislocations. report of 2 cases. acta orthop scand 1991;62:599–601. 10. rizzolo sj, piazza mr, cotler jm, balderston ra, shaefer dfa . intervertebral disc injury complicating cervical spine trauma. spine (phila pa 1976) 1991;16(6 suppl):s187–89. 11. vaccaro ar, falatyn sp, flanders ae, et al. magnetic resonance evaluation of the intervertebral disc, spinal ligaments, and spinal cord before and after closed traction reduction of cervical spine dislocations. spine (phila pa 1976) 1999;24:1210–17. 12. fleming m, westgarth-taylor t, candy s, dunn r. interobserver reliability in determining the presence of hazardous disc disruption in flexion distraction injuries of the c-spine: an mri study. sa ortho j 2014:13(4):14–18. 13. grant ga, mirza sk, chapman jr, et al. risk of early closed reduction in cervical spine subluxation injuries. j neurosurg 1999;90:13–18. 14. grauer jn, vaccaro ar, lee jy, et al. the timing and influence of mri on the management of patients with cervical facet dislocations remains highly variable: a survey of members of the spine trauma study group. j spinal disord tech 2009;22:96–99. 15. toit ab, dunn r, town c. bifacet dislocations of cervical spine: acute management and outcome. sa ortho j. 2008;7(4):30–36. 16. storm m, surgery o, dunn r, et al. management of unilateral cervical facet dislocations – a review of 49 cases. sa ortho j 2007;6(3):14–22. the principle of continued compression in an injured swelling cord steers our surgeons to choose early closed reduction saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 45 page 46 sa orthopaedic journal summer 2015 | vol 14 • no 4 17. kwon bk, beiner j, grauer jn, albert tj. anterior/posterior operative reduction of cervical spine dislocation: techniques and literature review. curr opin orthop 2003;14:193–99. doi: 10.1097/00001433-200306000-00012. 18. wiseman db, bellabarba c, mirza sk, chapman j. anterior versus posterior surgical treatment for traumatic cervical spine dislocation. curr opin orthop 2003;14:174–81. doi: 10.1097/00001433-200306000-00009. 19. gliklich re, dreyer na. data collection and quality assurance. agency for healthcare research and quality. outcome sciences, inc., d/b/a outcome rockville (md): agency for healthcare research and quality (us); 2010 sep.publication no.: 10-ehc049. 20. grant ga, mirza sk, chapman jr, et al. risk of early closed reduction in cervical spine subluxation injuries. j neurosurg spine 1999;90:13–18. doi: 10.3171/spi.1999.90.1.0013. 21. rizzolo sj, piazza mr, cotler jm, et al. intervertebral disc injury complicating cervical spine trauma. spine (phila. pa. 1976). 1991;16:187–89. 22. cotler jm, herbison gj, nasuti jf, et al. closed reduction of traumatic cervical spine dislocation using traction weights up to 140 pounds. spine (phila pa 1976) 1993;18:386–90. 23. benzel ec, hart bl, ball pa, et al. magnetic resonance imaging for the evaluation of patients with occult cervical spine injury. j neurosurg 1996;85:824–29. doi: 10.3171/jns.1996.85.5.0824. 24. wilson jr, vaccaro a, harrop js, et al. the impact of facet dislocation on clinical outcomes after cervical spinal cord injury: results of a multicenter north american prospective cohort study. spine (phila pa 1976) 2013;38:97–103. doi: 10.1097/brs.0b013e31826e2b91. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 46 south african orthopaedic journal current concepts review doi 10.17159/2309-8309/2022/v21n4a7blair nr et al. sa orthop j 2022;21(4) citation: blair nr, van der merwe jf, matshidza s. truth or dair? a review of debridement, antibiotics and implant retention. sa orthop j. 2022;21(4): 228-235. http://dx.doi.org/10.17159/ 2309-8309/2022/v21n4a7 editor: dr jurek pietzrak, university of the witwatersrand, johannesburg, south africa received: may 2022 accepted: october 2022 published: november 2022 copyright: © 2022 blair nr. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract debridement, antibiotics and implant retention (dair) is a viable treatment option in early postoperative and acute haematogenous periprosthetic joint infections (pjis) with a stable implant. despite lower success rates compared to oneand two-stage revisions, dair maintains satisfactory outcomes in selected patient groups and, if successful, has similar functional outcomes to primary arthroplasty. dair remains an attractive treatment option, providing satisfactory outcomes with decreased healthcare costs, reduced surgical burden on the patient and shorter hospital stays. with success rates of 37–90%, various factors need to be considered when deciding on dair as the appropriate treatment option for pji. the risk of dair failure needs to be weighed against the potential benefits of dair success. factors that increase success rates include an open dair procedure performed for a low-virulence, antibiotic-sensitive organism, within a short duration between symptom onset and/or index surgery and dair. the procedure involves intraoperative exchange of mobile components and copious wound irrigation, followed by an appropriate antibiotic regimen for a minimum of six weeks that can be administered either intravenously or orally in a well-optimised host, without significant soft tissue defects or contraindications to surgery. factors increasing the risk for dair failure include chronic/late pjis with resistant organisms, especially methicillin-resistant staphylococcus aureus (mrsa) in poor hosts with significant comorbidities, such as chronic obstructive pulmonary disease (copd), liver cirrhosis, rheumatoid arthritis, advanced age > 80 years, patients with fracture indications for arthroplasty and those who cannot tolerate rifampicinand fluoroquinolone-based antibiotic regimens. unfortunately, there is no definitive factor to serve as an indication of whether dair will be successful, but with recent data showing that a failed dair procedure does not lower success in future staged revisions, then even in the face of a 50% success rate, dair can maintain its role as an initial treatment option in the management of pjis. level of evidence: level 5 keywords: dair, debridement, antibiotics, implant retention, periprosthetic joint infection, pji, arthroplasty truth or dair? a review of debridement, antibiotics and implant retention neill r blair,* johan f van der merwe, steven matshidza department of orthopaedic surgery, school of clinical medicine, faculty of health sciences, university of the free state, bloemfontein, south africa *corresponding author: neillrblair@gmail.com introduction total joint arthroplasty is a common intervention to relieve pain from advanced joint disease. with improvements in joint replacement surgery and increasing life expectancy, total joint arthroplasties are expected to increase with time.1,2 with escalating joint arthroplasty procedures, increased periprosthetic joint infections (pjis) are expected.3 the incidence of pji is estimated at 0.5–2%, with knee arthroplasty at 0.8–1.9% and hip arthroplasty at 0.3–1.7%.4,5 pji is a devastating complication of total joint arthroplasty and significantly increases the burden on the patient, the surgeon and the healthcare system. prolonged hospitalisation, multiple surgical procedures, psychological stressors of progressive disease, increased healthcare costs, loss of income and physical disability all add to the burden of pji and reflect as diminished patient outcomes concerning morbidity, quality of life and mortality rates.2,4,6 pji is a leading cause of revision arthroplasty, as the management of the condition frequently requires a combination of surgical and medical intervention.7 eradicating a pji while retaining a viable and functional prosthesis remains a challenge due to multiple variables, including patient condition, the infective organism, surgical approach and antimicrobial use.3 debridement, antibiotics and implant retention (dair) has been identified as a viable treatment choice in pji when applied to selected patients, and its use has shown a significantly increasing trend of approximately 0.9–3.4% over a ten-year period.8 this review discusses the use of dair for pji and highlights its potential benefits and pitfalls. defining periprosthetic joint infection diagnosing pji with the decision to perform additional surgical procedures and selecting which one of the multiple available interventions to conduct is often difficult. differentiating superficial wound infection from deep joint infection can be challenging in early presentations, whereas only subtle signs of infection can be present in late pji, often leading to a delay in diagnosis. parvizi et al.9 released revised guidelines for the diagnosis of pji in 2018. the scoring system uses major and minor criteria to confirm pji in patients where infection is suspected. the new criteria have demonstrated a sensitivity of 97.7% and specificity https://orcid.org/0000-0002-7468-9969 page 229blair nr et al. sa orthop j 2022;21(4) of 99.5%.9 the criteria to take into consideration are illustrated in figure 1. once pji is diagnosed, it can be classified as either early/acute postoperative, late postoperative/chronic or acute haematogenous. various authors have suggested specific time cut-off values paired with these definitions. tsukayama et al. propose four types of pji: type i – positive intraoperative cultures; type ii – early postoperative infection within four weeks of index surgery; type iii – acute haematogenous infection that presents acutely after an asymptomatic period, with a suspected haematogenous origin; and type iv – late chronic infection presenting more than four weeks after the index procedure.10 zimmerli et al. defined pjis as early (within three months of surgery), delayed ( 3 to 24 months after surgery) and late (more than 24 months after surgery).11 in 2021, tarity et al. defined chronicity as acute postoperative (less than six weeks after surgery), chronic (more than six weeks after surgery and more than six weeks of symptoms) and acute haematogenous (less than six weeks of symptoms in a previously well-functioning prosthesis, more than six weeks after surgery).12 classification of pji assists with decision making when considering dair, as acute postoperative and acute haematogenous infections are more likely to be successful than chronic infections.13 treatment options the treatment goals in pjis are to eradicate infection and maintain pain-free joint function.3,14 options include prolonged suppressive antibiotics, dair, oneand two-stage revisions, resection arthroplasty, arthrodesis and amputation. chronic suppressive antibiotic therapy is a conservative approach to pji, usually reserved for patients who are unfit for or refuse further surgical management, and has poor success rates.5,15,16 oneand twostage revision arthroplasties show the highest success rates for pji eradication but are paired with more significant patient burden, prolonged hospitalisation, soft tissue and bony defects, and higher costs.4,8,14,15,17 resection arthroplasty can be considered in low-functioning, non-ambulatory patients with bony or soft tissue defects, those with resistant organism infections, and patients with failed two-stage revisions where antibiotic suppression and further implant intervention are unlikely to be successful.7 arthrodesis and amputation may be considered as last resort options for patients due to the severe impairment of functionality and quality of life, and are reserved for patients where other surgical options have failed.15 dair as a treatment option will be discussed in detail in this article. rationale behind dair two-stage revision arthroplasty is considered the most effective procedure for infection eradication and prevention of infection relapse. despite its success, it is not without challenges for both patient and surgeon. two-stage revisions require two extensive surgical procedures, each placing significant strain on the patient, who may already be frail or systemically compromised due to the infection. increased theatre time, blood loss, surgical difficulty and bone loss associated with implant removal and potential damage to surrounding soft tissues add to a procedure with significant morbidity, prolonged hospitalisation and costs to both patient and healthcare systems.3,14,18 when applied to selective patients, dair has shown itself as a cost-effective option in treating pji while maintaining implants and the surrounding soft tissue envelope. dair is associated with an overall decreased surgical demand on both the surgeon and patient, reduced hospital stay and improved functional outcomes when successful. it is regarded as similar to primary arthroplasty in uninfected cohorts with better results compared to two-stage revisions.4,6,15,17,19-21 major criteria (at least one of the following) intraoperative diagnosis (inconclusive preop score or dry tap) minor criteria (preoperative diagnosis) the same organism isolated from two separate positive cultures preoperative score 2–5 possible pji; ≥ 6 pji positive purulence score: 3 ↑ crp or d-dimer score: 2 ↑ synovial wbc count or le score: 3 ↑ synovial pmn (%) score: 2 sinus tract with observed link to the joint or the prosthesis visible on examination positive histology score: 3 single positive culture score: 2 ↑ esr score: 1 positive alpha-defensin score: 3 ↑ synovial crp score: 1 conclusion pji present conclusion pji present with score ≥ 6 inconclusive with score 4–5 no pji with score equal to or less than 3 conclusion pji present with score ≥ 6 possible pji with score 2–5 no pji with score 0–1 serum synovial fluid figure 1. criteria for the diagnosis of periprosthetic joint infections (pjis) crp: c-reactive protein; esr: erythrocyte sedimentation rate; wbc: white blood cell; le: leukocyte esterase; pmn: polymorphonuclear page 230 blair nr et al. sa orthop j 2022;21(4) dair approach although dair is considered less invasive than two-stage revision procedures, it is not to be thought of as a simple washout, and it is suggested that a senior surgeon perform the surgery.4 preand postoperative optimisation of the patient is required to minimise operative risks. dair is performed via the index surgery’s approach in open procedures. arthroscopic dair has been described and will be discussed later in the article. dair is a radical debridement of all potentially infected tissue from the skin to the prosthesis. previous scar tissue, sinus tracts and inflammatory tissue superficial and deep to the fascia are excised. debridement of the capsule, synovium and any sequestrum is required, with or without exchange of modular components. three to five wound samples are collected for microbiological culture, and empirical antibiotic therapy is started until the antimicrobial susceptibility profile of the causative organism has been determined. wound irrigation with normal saline or an antiseptic solution is advised and meticulous closure is undertaken with or without a suction drain. postoperative antibiotics and infection monitoring are continued until a satisfactory clinical response is achieved.18,20-22 success rates varying success rates for dair have been reported, while several confounding variables are at play. heterogeneity of cohorts, length of follow-up, inclusion and exclusion criteria, and definitions of success and failure are all factors adding to the overall rates of success reported.4 table i summarises the success rates for dair reported in the literature, but whether a success rate of 50% should discourage dair is debatable, as it should be decided on a caseby-case basis whether the potential benefits for a successful dair outweigh the consequences of failure.19 indications for dair debridement, antibiotics and implant retention is indicated in early postoperative and acute haematogenous infections with a stable, well-fixed prosthesis. some sources regard early postoperative infections as occurring within one to three months of the index procedure29,36 and acute haematogenous infections with symptoms no longer than three to four weeks,3,19 while others suggest dair is a viable option in all cases of pji with a well-fixed prosthesis, regardless of implant age,28 that is susceptible to anti-biofilm agents.35 contraindications the only absolute contraindication to performing dair is a loose implant. despite this, the procedure is discouraged when the odds of failure outweigh the potential benefit.19 therefore, dair is discouraged in chronic pji, patients with poor soft tissue cover where wound closure problems are expected, and virulent infections where antibiotic susceptibility is uncertain.36 current concepts in dair current concepts in dair are discussed under surgical and nonsurgical factors. these factors play a role in evaluating the risk of success/failure with dair, and despite the varying opinions raised, a pattern of successful traits and practices can be identified in the literature. surgical factors timing it is widely agreed in the literature that timing plays an essential role in determining the success of dair. many attempts have been made to determine a time cut-off when dair is no longer a viable option. however, the decision should not be solely based on the implant or symptom duration but rather on implant stability, organism virulence, the patient’s condition and soft tissue viability.37 three factors need to be considered when assessing the rate of success in dair. these factors include the type of pji, symptom duration and implant age or time from index surgery. table ii summarises the current literature. acute postoperative pjis have the best success rates for dair, followed by acute haematogenous infections. dair is often discouraged in late/chronic pji due to high rates of failure.1,12-14 a shorter duration of symptoms has also shown more favourable outcomes following dair, with some articles advising dair in patients with symptoms less than one week,4,33 while others say outcomes remain favourable if dair is performed within four weeks of symptom onset.15,37 despite varying time frames proposed, most authors agree that the sooner dair is performed after symptoms have developed, the greater the success rate can be expected to be. nevertheless, dair remains a favourable option in patients with an average duration of symptoms of less than three weeks.7,16,19,31 the time from index surgery or implant age is a heavily debated topic, with some literature suggesting that dair should only be performed if the duration from the index surgery is less than one month,7 whereas others have suggested that this time frame could be extended to three months3,8,16,19,34 or even a year.18 it has been suggested that when the implant is well fixed and the pji is caused by a less virulent organism in an otherwise viable joint, the implant age is not significant.4,33,37 again, when summarising the literature, the highest success rates in dair are seen with an implant age of less than three months. table ii summarises timing recommendations by various authors cited in this review. table i: reported success rates for dair published in the literature publication reported success rate bolduc et al., 20214 72.2% barros et al., 20196 89.5% boyle et al., 20208 37–88% (average of 50%) chalmers et al., 202123 21–36% failure rate chaussade et al., 201724 69.0% chung et al., 201925 86.7% deijkers et al., 202026 82.0% deng et al., 202121 67.3% gerritsen et al., 202127 67.0% grammatopoulos et al., 201728 84.0% horriat et al., 201813 34.1% failure rate kunutsor et al., 20181 61.4% lesens et al., 201816 76.0% lora-tamayo et al., 201729 57.0% ottesen et al., 201930 84.0% qu et al., 201931 57.11% rodríguez-pardo et al., 201432 68.0% tarity et al., 202112 47.6% failure rate tsang et al., 201733 64.7% van der ende et al., 202134 20.0% failure rate wouthuyzen-bakker et al., 201935 45% failure rate zhu et al., 202118 53.9% page 231blair nr et al. sa orthop j 2022;21(4) urgency dair is considered an urgent procedure but not an emergency. all efforts should be made to optimise the patient’s general condition prior to surgery without significantly delaying the procedure.1,4,8,19,20 number of surgeries consensus seems to have been achieved regarding the appropriateness of follow-up dair procedures, from the perspective that if an initial dair has failed, a second procedure is unlikely to improve the success rate.19 it has been shown in the literature that follow-up dair procedures have similar outcomes to the initial debridement, if not worse. the recommendation is that after one failed dair procedure, additional debridement procedures should be avoided and revision or resection arthroplasty considered.19,20,31 of note is that previous researchers have published a ‘double dair’ protocol, where a planned two-stage dair procedure was performed on all patients, with a planned re-examination at five days to maximise infection control.25,38 this protocol relied heavily on the short-term use of high-dose antibiotic-loaded beads and modular component exchange, with success rates of 86.7% and an average follow-up of 41.8 months.25,38 component exchange the practice of exchanging all mobile components and liners is considered to theoretically improve infection eradication by two means; first, to improve the exposure of the joint to aid debridement of all areas where a potential infectious focus is present, especially posterior aspects of the knee;19 and second, replacing mobile parts to remove a potential site of bacterial adherence that cannot always be achieved by debridement and irrigation, limiting the bacterial load present in the joint.15 despite some research showing that replacing mobile components does not relate to improved outcomes,27,30 a notable amount of literature reports significant improvements in implant survivability4,19,28 and infection eradication in both early and late pji.18,28 exchange of mobile components is an independent factor related to dair success.2,14,20,29,33,35 besides cost implications, the exchange of mobile components has no adverse effects. therefore, if possible, all mobile components should be exchanged.5 irrigation irrigation with normal saline with or without the addition of an antiseptic solution is strongly recommended by most sources, and the volume recommended ranges between six and nine litres.4,15,19 the addition of antiseptic solutions such as diluted povidone-iodine, chlorhexidine, peroxide and antibiotics to irrigation fluid has been described, but the concentrations used and efficacy over standard irrigation are unclear.19 pulsed lavage is practically convenient but has comparable efficacy to conventional irrigation.20 direct antibiotics direct intra-articular antibiotic loading using catheters or pumps, antibiotic-loaded beads, sponges and cement spacers has been described, but insufficient evidence supports the routine application of these methods.4 although antibiotic spacers can provide highdose local availability of a selected drug, it does not supply a consistent amount to remain therapeutic, and often concentrations fall to subtherapeutic levels within 72 hours, therefore reducing its efficacy.19 table ii: timing recommendations for the performance of dair published in the literature publication description of cases index surgery duration of symptoms additional comments argenson et al., 201919 < 3 months < 21 days the shorter duration between index surgery and symptom onset related to the best results bolduc et al., 20214 < 6 weeks < 1 week no limit in time from index surgery if the implant is well fixed boyer & cazorla, 202120 < 15 days boyle et al., 20208 < 90 days elkins et al., 201937 < 4 weeks < 4 weeks no time interval for a well-fixed prosthesis. implant, soft tissue, organism and patient health factors of more relevance grammatopoulos et al., 201728 < 13 weeks dair is viable in all pji regardless of duration from index surgery lesens et al., 201816 < 3 months < 3 weeks less dependent on duration, more dependent on the organism involved and implant stability lora-tamayo et al., 20213 < 3 months < 21 days the shorter duration between index surgery and symptom onset related to the best results. dair can still be of benefit in patients with a longer duration lora-tamayo et al., 201729 < 3 months osmon et al., 20137 < 1 month < 3 weeks ottesen et al., 201930 < 42 days qu et al., 201931 < 3 weeks tsang et al., 201733 < 4 weeks < 7 days duration from index surgery is less significant van der ende et al., 202134 < 3 months xu et al., 202015 < 4 weeks zhu et al., 202118 < 1 year duration of symptoms unreliable, especially in haematogenous infections horriat et al., 201813 acute postoperative pji > acute haematogenous > late/chronic pji kunutsor et al., 20181 acute postoperative pji > acute haematogenous > late/chronic pji qasim et al., 201714 acute postoperative pji > acute haematogenous > late/chronic pji tarity et al., 202112 acute postoperative pji > acute haematogenous > late/chronic pji page 232 blair nr et al. sa orthop j 2022;21(4) sinus tract a sinus tract is a pathognomonic feature of a pji,37 and many authors suggest that its presence is an independent risk for dair failure,20 or dair is contraindicated in patients with a draining sinus.14,15 one source has reported no difference in outcome between patients with or without the presence of a sinus tract, and that meticulous debridement and component exchange improved infection control in these patients.21 there is no consensus to suggest that a sinus tract is an absolute contraindication to dair. drain wound drains left in situ postoperatively are recommended in dair to prevent fluid accumulation and decrease potential dead space.4,14 some authors suggest high negative pressure drains, reporting improved outcomes, but they need to be used selectively due to increased hospital stay, costs and impaired mobility.15 stability the radical nature of soft tissue debridement in dair can contribute to postoperative instability. a thorough evaluation of joint stability intraoperatively is required, and when modular components are exchanged, more constrained components can be substituted to mitigate such issues. postoperative precautions, including patient education, splinting and structured physiotherapy, can also be implemented.28 arthroscopic dair arthroscopic dair without component exchange has been described, but many authors discourage arthroscopic dair, identifying it as a risk for failure with lower infection control rates.2,4,20,31 part of the rationale is that the arthroscopic approach does not allow for sufficient debridement or replacement of mobile components.14,15 dair in uniand mega-prosthesis the use of dair is supported in both uniand mega-prosthesis patients with pji. the unique feature of pji in a uni-knee arthroplasty is that both prosthesis and native cartilage are present, and in the event of failure, conversion to a total knee arthroplasty is required. mega-prosthesis pji is often a complex problem, and as revision options are usually limited, dair remains a viable initial approach.19 dair in revision arthroplasty debridement, antibiotics and implant retention should be considered carefully in pjis with prior revisions. poorer outcomes have been reported and revision surgery has been identified as an independent risk factor for failure in dair, with failure rates of 12–22% higher than in primary joint infections.4,15 dair effect on salvage two-stage revision despite its high rate of failure, the debate remains on whether dair is a viable option for patients with pji. a salvage two-stage exchange is often warranted when dair fails and opinions in the literature are still divided. some authors suggest no difference in functional outcomes between patients undergoing a direct twostage procedure versus those having first undergone dair, then a subsequent salvage two-stage procedure,3,19 leaving dair a promising initial option in managing pji. inferior outcomes of salvage two-stage procedures have also been reported, but more data are required to make a definitive decision.14 non-surgical factors organism involved identification of the organism involved in pji is not only valuable to guide antimicrobial therapy but may determine success rates in dair. staphylococcus aureus is the most common organism responsible and represents 27% of all pjis.16 s. aureus has been associated with early and late pji and is recognised as an independent risk factor for dair failure, independent of infection chronicity.12,14 infections with methicillin-resistant s. aureus (mrsa) bears the worst prognosis, with success rates reported as low as 30%. some authors discourage dair in cases of mrsa infection.4,14,19,24 following mrsa, enterococcal and fungal infections also carry a significant risk for dair failure due to its high virulence and frequent presentation with early treatment failure.3,20 mixed cultures or polymicrobial infections pose a moderate risk for failure.20 coagulase-negative staphylococcal (cons) infections are associated with late pji and due to their non-invasive nature and low virulence, present with a good overall prognosis.14 streptococci and fluoroquinolone-sensitive gram-negative bacteria present the best prognosis in pjis managed with dair, but the success rates decrease significantly once antibiotic-resistant gram-negative bacteria are cultured.1,32 when attempting dair in patients with mrsa, resistant gram-negative and fungal infections, careful consideration of the potential risks should be taken into account when deciding whether to perform the procedure. organism identification prior to dair laboratory-based identification of the causative organism in pji is a valuable tool to determine if dair is an appropriate treatment modality and estimate the probability of success, especially when highly virulent organisms, e.g. mrsa, are responsible for the infection.20 recommendations are to attempt identification of the organism prior to dair, as long as it does not delay definitive treatment.19 when requesting an urgent investigation, commonly used basic laboratory tests and microscopy can assist with a preliminary indication of the causative organism within a reasonably short period of time. choice of antimicrobial treatment microbial culture and sensitivity results are the basis on which antibiotic therapy in dair is based and should be tailored according to the causative organism’s antimicrobial susceptibility profile as soon as possible.2 knowledge of the organism preoperatively limits the transition time between empiric and organism-specific regimens.35 for staphylococcal infections, the addition of rifampicin to the treatment regimen is associated with higher success rates, especially in combination with fluoroquinolones.19,20,28 studies have shown that a fluoroquinolone and rifampicin combination decreases failure rates by up to 20% in staphylococcal infections.16,35 fluoroquinolones are also associated with higher success rates in gram-negative infections.3,19 beta-lactam antibiotics are the preferred treatment for streptococcal infections.29 in polymicrobial infections, a combination regimen directed against all cultured organisms is used.28 antimicrobial duration three schools of thought prevail in the literature regarding the duration of antibiotic therapy in dair, which include chronic suppressive antibiotics, intermediate course antimicrobial therapy and short-course antimicrobial therapy. after a dair procedure, chronic suppressive antibiotic therapy remains an appropriate option to prevent infection remission. however, treatment intolerances, potential resistance, and poor prognoses limit chronic suppression as an option for patients who either decline further surgery or are not medically fit to undergo revision surgery.4,14,19 intermediate course antimicrobial therapy has long been accepted as the ideal duration of therapy. many authors still recommend this approach which involves an initial course of page 233blair nr et al. sa orthop j 2022;21(4) intravenous therapy for two to six weeks, followed by three to six months of oral antibiotics.4,7,16,20 newer literature indicates that the duration of treatment does not influence the outcome of dair, with long-term treatment failing to show improved outcomes over short treatment schedules. furthermore, extended duration of antimicrobial therapy masks infective symptoms and postpones the diagnosis of treatment failure.1,15,19 newer recommendations advise a minimum of six weeks of antimicrobial therapy, with six to eight weeks of therapy being sufficient following the performance of dair. an initial course of intravenous therapy and conversion to appropriate oral therapy are proposed if allowed by the causative organism’s susceptibility profile.1,19,35,39 implant factors regarding implant indications, dair performed for pji in fracture arthroplasty showed a 20–30% increased failure risk compared to pji in primary joint arthroplasty.4,19 along with this trend, dair for revision arthroplasties also showed a 12–22% increased risk of failure, with revision arthroplasty being identified as an independent risk factor for dair failure.19,20 no consensus has been reached over cemented versus uncemented implants, with some sources citing cemented implants as having a greater failure risk.19,34 hip arthroplasty shows higher success rates for dair over knee arthroplasty,1,20 but shoulder arthroplasty shows a dair success rate of 75%, in keeping with hip and knee cohorts.20 patient factors despite optimal surgical and microbial conditions, the general condition of the host also plays a role in the success of dair. all efforts should be made to optimise host status prior to treatment. reversible conditions such as anaemia (haemoglobin < 10 mg/dl), malnutrition, coagulopathy and tobacco use should be addressed before attempting dair without causing a significant delay between presentation and treatment.19 chronic conditions such as rheumatoid arthritis, liver cirrhosis, renal failure, copd, diabetes mellitus and active malignancy should be considered prior to dair, as these conditions significantly increase failure rates, and alternative revision options may be more appropriate.16,19,31 patient factors such as advanced age (> 80 years), male sex, obesity (body mass index [bmi] > 30 kg/m2) and compromised immune status secondary to disease or steroid use have also been identified as risk factors for dair failure.15,19,26,34 lastly, a high american society of anaesthesiology (asa) score, elevated esr (> 40 mm/h) and elevated c-reactive protein (crp); (> 65 mg/l) on presentation are also predictors of failure.2,15,18,26,35 a multidisciplinary team, ideally including specialist nurses, therapists, infectious disease physicians and plastic surgeons in addition to the orthopaedic team, is recommended to treat the pji, optimise any associated comorbidities, manage reversible conditions, exclude any concurrent extrinsic infections and assist with postoperative rehabilitation.4 staging tools once surgical, microbial, implant and patient factors have been considered, the difficulty remains to decide whether dair is an appropriate treatment option and whether it will be successful. no system is available to take all these factors into account and most cases have to be assessed individually. however, staging tools are available to assist in decision making and the use of a scoring system is associated with improved outcomes.20 as summarised in table iii, the klic score (kidney, liver, index surgery, cemented prosthesis and crp value), ranging from 0 to 9.5, was developed to predict dair failure in acute postoperative infections.4,36 taking negative prognostic factors such as chronic renal failure, liver cirrhosis, fracture or revision index surgery, cemented prosthesis and an elevated crp (> 115 mg/l) into consideration, a score of 4 already suggests a success rate of less than 45%, which can aid in determining an alternative procedure for the patient.4,19,20,36 researchers have attempted to validate the klic scoring system and found that it shows reasonable sensitivity and specificity at higher scores (> 3.5) and facilitates the identification of high-risk patients, but its value at lower scores is uncertain.3,4,23,36 the crime80 score (based on the presence of specific predictive factors, namely copd and an elevated crp level of > 150 mg/l, table iii: summary of the klic and crime80 preoperative risk scores to predict failure following debridement, antibiotics and implant retention (dair) klic score: preoperative risk score development to predict failure following dair for early acute periprosthetic joint infections (pjis) klic score parameter individual parameter score total score failure rate (%) k chronic renal failure (kidney) 2 ≤ 2 4–5 l liver cirrhosis 1.5 2–3.5 19 i index surgery: indication: prosthesis: fracture or revision prosthesis 1.5 4–5 55 c cemented prosthesis 2 5.5–7 71 c-reactive protein (crp) > 115 mg/l 2.5 ≥ 7 100 crime80 score: preoperative risk score development to predict failure following dair for acute haematogenous periprosthetic joint infections (pjis) crime80 score parameter point(s) allocated per parameter total score failure rate (%) c chronic obstructive pulmonary disease (copd) 2 –1 22 c-reactive protein (crp) > 150 mg/l 1 r rheumatoid arthritis 3 0 28 i indication prosthesis: fracture 3 1–2 40 m male sex 1 3–4 64 e exchange of mobile components –1 ≥ 5 79 80 age ≥ 80 years 2 reproduced with minor changes under the terms of the creative commons attribution non-commercial no derivatives 4.0 international licence (cc by-nc-nd 4.0) (https:// creativecommons.org/licenses/by-nc-nd/4.0/) from tables 3 & 4 in bolduc et al.4 page 234 blair nr et al. sa orthop j 2022;21(4) rheumatoid arthritis, fracture-related indication for surgery, male sex, exchange of mobile components and more than 80 years of age) was developed as a prognostic tool for acute haematogenous infections.4 out of 12 points, a score of 3 or more is associated with a less than 40% success rate. the only positive predictive factor was the exchange of mobile components.19,20,35 the crime80 score showed an acceptable predictive value for dair failure on external validation.23 conclusion debridement, antibiotics and implant retention (dair) is a feasible treatment option in acute postoperative and acute haematogenous periprosthetic joint infections in healthy hosts with a well-fixed prosthesis. despite lower infection eradication rates compared to oneand two-stage revisions, dair provides a low-cost option with good functional outcomes and decreased surgical burden, limiting morbidity and mortality. with improvements in surgical techniques, antimicrobial therapy and a multidisciplinary approach, success rates for dair have been increasing with time and could continue to improve. any patient presenting with an acute pji who has a well-fixed prosthesis, culturing a low-virulence organism with adequate soft-tissue coverage and no significant comorbidities is eligible for dair with a mobile component exchange. as it is a far less invasive procedure and does not preclude revision surgery, an ideal treatment algorithm would primarily include dair, followed by a staged revision in unsuccessful cases. acknowledgement dr daleen struwig, medical writer/editor, faculty of health sciences, university of the free state, for technical and editorial preparation of the manuscript. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions nrb: contributed to the conception and design of the work, literature review and analysis, drafting of the manuscript, and final approval of the version to be published jfvdm: contributed to the conception and design of the work, revising it critically for important intellectual content, and final approval of the version to be published sm: contributed to the conception and design of the work, revising it critically for important intellectual content, and final approval of the version to be published orcid blair nr https://orcid.org/0000-0002-7468-9969 matshidza s https://orcid.org/0000-0003-0128-0385 references 1. kunutsor sk, beswick ad, whitehouse mr, et al. debridement, antibiotics and implant retention for periprosthetic joint infections: a systematic review and meta-analysis of treatment outcomes. j infect. 2018;77(6):479-88. 2. kuiper jw, willink rt, moojen djf, et al. treatment of acute periprosthetic infections with prosthesis retention: review of current concepts. world j orthop. 2014;5(5):667-76. 3. lora-tamayo j, mancheño-losa m, lumbreras c. to dair or not to dair: decision-making in the management of acute prosthetic joint infection – a narrative review. span j med. 2021;1(2):119-31. 4. bolduc m, fischman d, kendrick b, et al. contemporary outcomes of debridement, antibiotics and implant retention (dair) in hip arthroplasty. ann joint. 2021;6:34. https://doi. org/10.21037/aoj-20-87. 5. bezel p, fucentese s, burkhard j, et al. mini review on the impact of mobile parts’ exchange during the dair procedure (debridement, antibiotics, irrigation, retention) for infected total joint arthroplasties. j infectiol. 2019;2(4):13-17. 6. barros lh, barbosa ta, esteves j, et al. early debridement, antibiotics and implant retention (dair) in patients with suspected acute infection after hip or knee arthroplasty – safe, effective and without negative functional impact. j bone joint infect. 2019;4(6):300-305. 7. osmon dr, berbari ef, berendt ar, et al. diagnosis and management of prosthetic joint infection: clinical practice guidelines by the infectious diseases society of america. clin infect dis. 2013;56(1):e1-e25. 8. boyle kk, kapadia m, landy dc, et al. utilization of debridement, antibiotics, and implant retention for infection after total joint arthroplasty over a decade in the united states. j arthroplasty. 2020;35(8):2210-16. 9. parvizi j, tan tl, goswami k, et al. the 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. j arthroplasty. 2018;33(5):1309-14. 10. tsukayama dt, estrada r, gustilo rb. infection after total hip arthroplasty. a study of the treatment of one hundred and six infections. j bone joint surg am. 1996;78(4):512-23. 11. zimmerli w, trampuz a, ochsner pe. prosthetic joint infections. n engl j med. 2004;351(16):1645-54. 12. tarity td, gkiatas i, nocon aa, et al. irrigation and debridement with implant retention: does chronicity of symptoms matter? j arthroplasty. 2021;36(11):3741-49. 13. horriat s, ayyad s, thakrar rr, haddad fs. debridement, antibiotics and implant retention in management of infected total knee arthroplasty: a systematic review. semin arthroplasty. 2018;29(3):244-49. 14. qasim sn, swann a, ashford r. the dair (debridement, antibiotics and implant retention) procedure for infected total knee replacement – a literature review. sicot j. 2017;3:2. 15. xu y, wang l, xu w. risk factors affect success rate of debridement, antibiotics and implant retention (dair) in periprosthetic joint infection. arthroplasty. 2020;2(1):4-9. 16. lesens o, ferry t, forestier e, et al. should we expand the indications for the dair (debridement, antibiotic therapy, and implant retention) procedure for staphylococcus aureus prosthetic joint infections? a multicenter retrospective study. eur j clin microbiol infect dis. 2018;37(10):1949-56. 17. fisman dn, reilly dt, karchmer aw, goldie sj. clinical effectiveness and cost-effectiveness of 2 management strategies for infected total hip arthroplasty in the elderly. clin infect dis. 2001;32(3):419-30. 18. zhu mf, kim k, cavadino a, et al. success rates of debridement, antibiotics, and implant retention in 230 infected total knee arthroplasties: implications for classification of periprosthetic joint infection. j arthroplasty. 2021;36(1):305-10. 19. argenson jn, arndt m, babis g, et al. hip and knee section, treatment, debridement and retention of implant: proceedings of international consensus on orthopedic infections. j arthroplasty. 2019;34(2s):s399-s419. 20. boyer b, cazorla c. methods and probability of success after early revision of prosthetic joint infections with debridement, antibiotics and implant retention. orthop traumatol surg res. 2021;107(1s):102774. 21. deng w, li r, shao h, et al. comparison of the success rate after debridement, antibiotics and implant retention (dair) for periprosthetic joint infection among patients with or without a sinus tract. bmc musculoskelet dis. 2021;22(1):895. 22. zhang c, he l, fang x, et al. debridement, antibiotics, and implant retention for acute periprosthetic joint infection. orthop surg. 2020;12(2):463-70. 23. chalmers bp, kapadia m, chiu yf, et al. accuracy of predictive algorithms in total hip and knee arthroplasty acute periprosthetic joint infections treated with debridement, antibiotics, and implant retention (dair). j arthroplasty. 2021;36(7):2558-66. 24. chaussade h, uçkay i, vuagnat a, et al. antibiotic therapy duration for prosthetic joint infections treated by debridement and implant retention (dair): similar long-term remission for 6 weeks as compared to 12 weeks. int j infect dis. 2017;63:37-42. 25. chung as, niesen mc, graber tj, et al. two-stage debridement with prosthesis retention for acute periprosthetic joint infections. j arthroplasty. 2019;34(6):1207-13. 26. deijkers rl, elzakker, pijls bg. debridement, antibiotics, and implant retention with the direct anterior approach for acute periprosthetic joint infection following primary tha. j bone joint surg open access. 2020;5(2):e0062. 27. gerritsen m, khawar a, scheper h, et al. modular component exchange and outcome of dair for hip and knee periprosthetic joint infection. bone joint open. 2021;2(10):806-12. 28. grammatopoulos g, kendrick b, mcnally m, et al. outcome following debridement, antibiotics, and implant retention in hip periprosthetic joint infection – an 18-year experience. j arthroplasty. 2017;32(7):2248-55. 29. lora-tamayo j, senneville é, ribera a, et al. the not-so-good prognosis of streptococcal periprosthetic joint infection managed by implant retention: the results of a large multicenter study. clin infect dis. 2017;64(12):1742-52. 30. ottesen cs, troelsen a, sandholdt h, et al. acceptable success rate in patients with periprosthetic knee joint infection treated with debridement, antibiotics, and implant retention. j arthroplasty. 2019;34(2):365-68. 31. qu gx, zhang ch, yan sg, cai xz. debridement, antibiotics, and implant retention for periprosthetic knee infections: a pooling analysis of 1266 cases. j orthop surg res. 2019;14(1):358. 32. rodríguez-pardo d, pigrau c, lora-tamayo j, et al. gram-negative prosthetic joint infection: outcome of a debridement, antibiotics and implant retention approach. a large multicentre study. clin microbiol infect. 2014;20(11):o911-9. 33. tsang stj, ting j, simpson ahrw, gaston p. outcomes following debridement, antibiotics and implant retention in the management of periprosthetic infections of the hip: a review of cohort studies. bone joint j. 2017;99-b(11):1458-66. https://orcid.org/0000-0002-7468-9969 https://orcid.org/0000-0003-0128-0385 page 235blair nr et al. sa orthop j 2022;21(4) 34. van der ende b, van oldenrijk j, reijman m, et al. timing of debridement, antibiotics, and implant retention (dair) for early post-surgical hip and knee prosthetic joint infection (pji) does not affect 1-year re-revision rates: data from the dutch arthroplasty register. j bone joint infect. 2021;6(8):329-36. 35. wouthuyzen-bakker m, sebillotte m, lomas j, et al. clinical outcome and risk factors for failure in late acute prosthetic joint infections treated with debridement and implant retention. j infect. 2019;78(1):40-47. 36. duffy sd, ahearn n, darley es, et al. analysis of the klic-score; an outcome predictor tool for prosthetic joint infections treated with debridement, antibiotics and implant retention. j bone joint infect. 2018;3(3):150-55. 37. elkins jm, kates s, lange j, et al. general assembly, diagnosis, definitions: proceedings of international consensus on orthopedic infections. j arthroplasty. 2019;34(2s):s181-5. 38. mcquivey kd, bingham j, chung a, et al. the double dair: a 2-stage debridement with prosthesis-retention protocol for acute periprosthetic joint infections. jbjs essent surg tech. 2021;11(1):e19.00071. 39. lora-tamayo j, euba g, cobo j, et al. shortversus long-duration levofloxacin plus rifampicin for acute staphylococcal prosthetic joint infection managed with implant retention: a randomised clinical trial. int j antimicrob agents. 2016;48(3):310-16. orthopaedics vol3 no4 page 14 sa orthopaedic journal summer 2015 | vol 14 • no 4 e d i t o r i a l expanding the orthopaedic training programme to improve the management of lower extremity trauma in these lower extremity injuries, a number of tissues get injured, each requiring specialised care. these tissues are bone, nerve, tendon, blood vessels and other soft tissues. as orthopaedic surgeons we are adequately trained in managing the skeletal injuries. we have in our armamentarium intramedullary nails, anatomical contoured locking plates and external fixation devices that can provide fixation in high energy fractures with minimal additional insult to bone. with the amount of training offered by our academic departments, and the numerous courses we have all over the country on these devices, we are able to use these devices appropriately by the time we complete our training. we are also well trained in managing injuries to the nerves; from primary nerve repair, secondary nerve repair, nerve grafting, and even closing nerve gaps with interposition vein conduits. the same can be said about tendon injuries. with regard to injuries to blood vessels, the vascular surgeons throughout the country respond promptly to a call for a threatened limb. in areas where there is no vascular surgeon, the local general surgeons are able to manage vascular trauma to the limbs. once the vascular repair has been done, the orthopaedic surgeon is usually left alone to continue managing the limb, and the patient. the next tissue is the soft tissues. this is where our problems currently lie and it is where we can improve our training to achieve better results in lower extremity injuries. it has been shown that early soft tissue cover reduces infection and non-union in these injuries.1 the plastic surgeons are traditionally trained to take care of the soft tissues. in practice however in this country, the orthopaedic surgeon performs the initial debridement. even when the orthopaedic surgeon thinks he needs input from plastics, in the middle of the night the response one often gets is; ‘debride the wound, we will see it in the morning’. off course the wound will not be reviewed the following morning, as it is not usual to open these types of wounds in the ward on day 1 post-operatively. the timing of the second debridement at 48 hours may not be suitable for the plastic surgeon, as they may not have seen the wound so as to plan further management. this then delays the soft tissue cover to the exposed structures. the practical scenario outlined above is compounded by the fact that we do not have enough plastic surgeons to help us cope with the amount of lower extremity trauma that we have to manage. the figures at the colleges of medicine of south africa show that in the five years from 2011 to 2015, the college of plastic surgeons qualified 30 plastic surgeons. during the same period 151 candidates passed the exams of the college of orthopaedic surgeons. if this situation continues, we will continue to have very few plastic surgeons available to help the orthopaedic surgeons with the management of these injuries. plastic surgeons are invaluable in the management of these injuries. what makes plastic surgeons even more important is that the soft tissue cover often requires continued supervision. their input is often required for much longer periods than that of vascular surgeons, who usually are no longer involved with the management once the leg is vascularised. recognising the value of plastic surgeons in managing these injuries has resulted in some countries forming orthoplastic centres.2 these are centres where plastic surgeons work together with orthopaedic surgeons from initial stage to conclusion of treatment, in order to provide a better service for these patients. in our country we have only seven teaching centres that would be able to create orthoplastic units. even in these teaching centres, we may not have enough plastic surgeons dedicated to musculoskeletal trauma, because of competition from cosmetic surgery. open fractures of the tibia continue to be a challenging problem in orthopaedics. this is particularly so in ourcountry because of the high incidence of motor vehicle accidents. the results of the management of these injuries are not universally good, with non-unions and infections being the major complications. at the recent south african orthopaedic association congress (2015), we learned that in some centres in our country the infection rate is as high as 40%. saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 14 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 15 we therefore need a different solution to the orthoplastic units. the solution for south africa is to train orthopaedic trainees in procedures for soft tissue cover in lower extremity trauma. we do not have to climb to the top of the ladder of soft tissue reconstruction.3 the first few steps are already covered during the medical officer training in the departments of general surgery. these are primary wound suture, delayed primary suture, secondary suture and split-skin grafting. we need to climb a little higher up the ladder to local flaps and free flaps. this is where plastics can help us. orthopaedic trainees need to rotate through plastics to learn the principles of local flaps. we do not have to learn all the flaps. the commonest flaps used to cover exposed bone and other structures in the proximal lower limb are the gastrocnemius flap and the soleus flap. the sural flap has become more reliable in routine management of large soft tissue defects of the distal lower limb, because of its wide area of rotation and constant anatomical features and blood supply.4 if more complex flaps are required, these can be performed by plastic surgeons. of course our trainers will guide us on which of these flaps can be done routinely by non-specialist surgeons. what is encouraging is that we do not have to do the free flaps. in an interesting review of the use of flaps in lower extremity trauma, parrett et al.3 report that over the years there has been a decrease in the number of free flaps required for closing lower limb soft tissue defects. the plan of rotating through plastics will make it possible for orthopaedic surgeons working in any part of the country to be able to provide soft tissue cover for most open fractures of the lower extremity. the goal of early soft tissue cover in open tibia fractures would be universally achievable, except perhaps in a few patients who will require more specialised flaps by plastic surgeons. will we not be encroaching into the domain of another speciality? i do not think so. the aim is to provide early skin cover, which is not happening at the moment. besides, training in skills across the specialities is not unfamiliar. any self-respecting orthopaedic hand surgeon can do a groin flap. they make sure that they are trained and able to do this type of flap. any self-respecting gynaecological surgeon should be able to repair an uncomplicated small bowel perforation. besides, these trainees will be trained on a programme supervised by plastic surgeons. they are not simply going to an overseas course on flaps for a few days. do we have time to do this training? a number of orthopaedic training programmes in our country are for 60 months. those that are for 48 months have a lot of orthopaedic training time outside the 48 months. i believe that in the 60 months we have enough time to rotate through plastics and learn the principles and techniques of soft tissue cover in lower extremity trauma. the duration of the training can be discussed with the trainers. we have to look for a local solution to our local problem. if we do not, we will continue having suboptimal results for lower extremity trauma because of delay in getting adequate soft tissue cover. references 1. norris bl, kellani jf. soft tissue injuries associated with high energy extremity trauma: principles of management. jaaos 2007;5:37-46. 2. editorial. orthoplastics: an integral evolution within comprehensive trauma care. injury, int.j. care injured 2011;42:969-71. 3. parrett b, matros e, pribaz j, orgill d. lower extremity trauma: trends in the management of soft tissue reconstruction of open tibia-fibula fractures. plastic and reconstructive surgery 2006;117:1315. 4. nayagam s, graham k, pearse m, nanchahal j. reconstructive surgery in limbs. the case of orthoplastic approach. annals of plastic surgery 2011;66:6. prof ‘mthunzi ngcelwane head: department of orthopaedics, university of pretoria the solution for south africa is to train orthopaedic trainees in procedures for soft tissue cover in lower extremity trauma saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 15 south african orthopaedic journal basic sciences doi 10.17159/2309-8309/2022/v21n4a6 pretorius hs et al. sa orthop j 2022;21(4) citation: pretorius hs, burger mc, ferreira n. the mechanical testing of a novel interlocking forearm nail. sa orthop j. 2022;21(4):223-227. http:// dx.doi.org/10.17159/2309-8309/2022/ v21n4a6 editor: prof. leonard c marais, university of kwazulu-natal, durban, south africa received: april 2022 accepted: june 2022 published: november 2022 copyright: © 2022 pretorius hs. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: all research related to the design and manufacture of the intramedullary nail system was done in conjunction with implantcast gmbh (buxtehude, germany). prototypes were produced and provided for research purposes at no cost. all research-related costs were borne by stellenbosch university. a royalty agreement between stellenbosch university and implantcast gmbh (buxtehude, germany) was negotiated in the event of the design eventually being used commercially. abstract background mechanical testing of newly designed implants provides valuable insight into their mechanical properties. this provides surgeons with information about implant choice for the treatment of fractures and the effect of the implant’s mechanical properties on fracture healing. methods a novel interlocking forearm nail was subjected to standardised mechanical testing according to the standard specification and test methods for intramedullary fixation devices (atsm 126416), using static and dynamic four-point bending and static torsion (astm stp 588). three nails were used for the static bending and torsion and nine for the dynamic bending tests. all nails were catalogued, numbered and photographed before testing. results the mechanical testing results showed a mean force yield (fy) of 566 ± 20 n, a moment of yield (my) 10.75 ± 0.37 nm, a stiffness of 67.10 ± 2 n/mm and structural stiffness of 1.53 ± 0.50 m². the torsional stiffness of the nail was 0.088 ± 0.002 nm/°. the four-point dynamic bending test showed a fatigue strength of 5.23 nm. this value was determined using the semi-log moment/ number of cycles (m-n) diagram and showed a 50% failure at a million cycles. if the moment were reduced to 4.4 nm, mathematically, the survival rate would improve to 90%. conclusion the results from this mechanical testing show that this novel intramedullary forearm nail can resist mechanical forces experienced during fracture healing and could potentially be used in future clinical studies. level of evidence: level 4 keywords: mechanical testing, astm, load, yield, stiffness, fatigue strength the mechanical testing of a novel interlocking forearm nail henry s pretorius,* marilize c burger, nando ferreira division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa *corresponding author: hsp359@sun.ac.za introduction the mechanical properties of implants are one of many factors that contribute to the mechanobiological environment for fracture healing. mechanical testing of newly designed implants provides valuable insight into their mechanical properties. this provides surgeons with information about implant choice and the effect of the implant’s mechanical properties on fracture healing.1 although not weight-bearing, radius and ulna fracture fixation are still exposed to significant in vivo forces, including pronation/ supination rotational and bending moments created when carrying objects. the ability of an implant to withstand these forces is considered when these devices undergo mechanical testing prior to clinical use. compression plate fixation of the forearm provides absolute stability with no fragment movement while bridge plating and nail fixation will provide relative stability with some movement between fragments. restoration of length and alignment and the ability to control rotation make intramedullary nail fixation ideal for managing long bone fractures. comminuted and segmental fractures, which are frequently seen in high-energy gunshot wounds, are particularly well suited to intramedullary fixation as the intramedullary nail provides load-sharing mechanics, restores anatomy and fragment stability and has a minimal invasive insertional approach which can be important when soft tissue injuries are involved. with nail fixation of simple forearm fractures, the bone provides some mechanical support, but with comminuted or segmental fractures, https://orcid.org/0000-0002-7419-0885 page 224 pretorius hs et al. sa orthop j 2022;21(4) the nail provides most of the support, so any implant must have the mechanical properties to maintain stability until fracture union. a novel interlocking forearm nail was designed to address both length and rotational stability in forearm fractures. the implant design was based on findings from a computed tomography scan anatomical study.2 in the design process, the biomechanical properties of bone, the modulus of elasticity of metals and the mechanical testing process of similar products in the literature were used to inform the process.1,3,4 the modulus of elasticity of bone ranges from 10–28 gpa (gigapascals or kn/mm2), and for the radius specifically 10–17 gpa.5 titanium specifically has a modulus closest to bone and better fatigue than stainless steel; after taking this into account, titanium (ti6ai4v iso 5832-3) was utilised.6-8 the nail is machined to the correct specifications instead of being cast or 3d printed. the base material, a solid tube, is made by additive manufacturing (am), an advanced manufacturing technology using 3d cad by adding materials in a layer-by-layer fashion that allows products with geometric complexities as simple as solid tube structures or complex shapes like replacement mandible bones to be made.9 this study reports the results of standardised mechanical testing of a novel forearm nail to ascertain whether the implant would withstand physiological load during fracture healing. methods standardised mechanical testing to ascertain the clinical applicability of the new nail design was conducted. implants are generally exposed to between 150 000 and 200 000 cycles of repeated strain over three months until fracture union.4 to simulate the upper limit of expected cycles until union, fatigue testing is performed at a standard amount of one million cycles.4 the fourpoint bending with static and dynamic tests and static torsion tests are the implants’ prescribed tests. saka et al. showed a mean bending test force of 539.75 n and a mean torsional force of 0.028 nm/°.10 gardner et al. used 250 n force represented by partial weight-bearing to evaluate femur fracture intramedullary nails as an idea of mechanical strength needed for specific orthopaedic products.1 with the evaluation of plate constructs by roberts et al., the locked hybrid model showed anterior bending stiffness of 194 n/mm, a lateral stiffness of 430 n/mm and torsional stiffness of 0.42 nm/°.11 mechanical testing according to the standard specification and test methods for intramedullary fixation devices (imfd) (atsm 1264-16) was undertaken by ima materialforschung und anwendungstechnik gmbh (dresden, germany 01109).4 this refers to static and dynamic four-point bending and static torsion testing. all testing and statistical analysis was performed according to industry standards (astm stp 588). all nails were catalogued, numbered and photographed before testing. three nails were used for the static bending and torsion, and nine nails were used for the dynamic bending tests. the test device specifications are shown in table i. the nails for four-point bending were placed on the hydraulic rig (mts 858 mini bionix) with a 38 mm centre span, and the distance to the loading points was also 38 mm (figures 1 and 2). a constant force at a rate of 0.1 mm/s was applied until failure. in this test, failure was defined as permanent deformation, breakage or buckling. the test was stopped, and the maximum force was measured in newtons (n) (figure 3). the results are reported as yield force, moment of yield, stiffness and structural stiffness. dynamic testing was performed in a wpn servo-hydraulic test rig and followed a sinusoidal cyclic load waveform at a frequency of 5 hz and programmed for 1 million cycles or until failure. the results were plotted on a moment/number of cycles (m-n diagram) graph to determine the fatigue strength that 50% of the specimens will survive at one million cycles. figure 1. illustration showing the distance between four points for the four-point bending test figure 2. picture of the nail placed in the four-point testing rig figure 3. picture of the nail placed in the rotational testing rig figure 4. picture of the nail at maximum deformation on the four-point rig figure 5. semi-logarithmic graph illustrating the survival probability points for the nail figure 6. the nails after failure to see the exact position of the break s = 38 c = 38 s = 38 225 mm l = 114 m om en t ( n m ) number of cycles (n) 10% probability of survival 90% probability of survival 4.4 nm figure 1. illustration showing the distance between four points for the four-point bending test figure 2. nail placed in the four-point testing rig table i: testing device specifications test device ima identification no. used for mts 858 mini bionix pmk-no a4_2 static tests wpn servo hydraulic test rig pmk-no a4_7 bending fatigue calliper (300 mm) mnk-no a4-l16 distance measurement angle gauge mnk-no a4-w-4 angle measurement page 225pretorius hs et al. sa orthop j 2022;21(4) the test setup for the dynamic torsional test has the nail clamped between a base plate and hydraulic rotation device (figure 4). the system rotates at a fixed rate of 5° per minute until failure. the results are reported as torsional stiffness. results following the atsm 1264-16 guidelines, a report was supplied showing photos of the setup, the results and photographs of breakages. a summary of the testing parameters is shown in table ii. the mechanical testing results showed a mean force yield (fy) of 566 ± 20 n, a moment of yield (my) 10.75 ± 0.37 nm, a stiffness of 67.10 ± 2 n/mm and structural stiffness of 1.53 ± 0.50 m2 (table iii). the torsional stiffness of the nail was similar in the three specimens, with a mean result of 0.088 ± 0.002 nm/° (table iv). the four-point dynamic bending test showed a fatigue strength of 5.23 nm. this value was determined using the semi-log m-n diagram and showed a 50% failure at one million cycles. due to the large numbers used for the cycles and the small numbers used for the moment, the graphs are presented as cycles in a logarithmic scale on the x-axis and the moment in a linear scale on the y-axis. if the moment was reduced to 4.4 nm, mathematically, the survival rate improved to 90% (figure 5). the force applied can be calculated mathematically with the forearm as the lever arm: moment [nm] = force [n] × lever arm [m]. if the forearm from elbow to palm measures 0.2 m, the force would be 22 n or 2.2 kgf (kilogram-force). all the samples used for dynamic testing were tested until failure, and the place of failure was then noted. to this end, photos of figure 3. nail at maximum deformation on the four-point rig table ii: summarised testing parameters parameter astm f1264-16 a1 astm f1264-16 a2 astm f1264-16 a3 test type four-point bending (static) static torsion four-point bending (dynamic) loading displacement controlled angle-controlled sinusoidal cyclic load waveform number of specimens 3 3 9 rate/frequency 0.1 mm/s 5°/min 5 hz y0.2%=s(l+2c)/(1500) difmd 1.07 mm ratio (mmin/mmax) 0.1 number of cycles (run out) 1 000 000 results yield force moment of yield stiffness structural stiffness torsional stiffness semi-log m-n diagram test environment ambient condition ambient condition ambient condition table iii: results for static bending specimen yield force fy (n) moment at yield my (nm) stiffness fy (n/mm) structural stiffness ele (nm 2) f022/20-1 559 10.62 67.4 1.54 f022/20-2 550 10.45 64.9 1.48 f022/20-3 588 11.17 69.0 1.58 mean 566 10.75 67.1 1.53 standard deviation 20 0.37 2.0 0.05 figure 4. nail placed in the rotational testing rig page 226 pretorius hs et al. sa orthop j 2022;21(4) the broken nails were supplied to show where each nail failed (figure 6). in this example, the nails broke in the shaft and not through the locking holes. discussion mechanical testing of newly designed implants provides valuable insight into their mechanical properties and ability to withstand expected physiological forces during fracture healing. this provides surgeons with information about implant choice for fractures and the effect of the implant’s mechanical properties on bone and fracture healing. bone is anisotropic, indicating different tolerances to forces applied from different directions. normal bone can withstand axial forces of approximately 15 000 n and tangential forces of 6 000 n.5 the human upper limb seldom generates forces exceeding 200 n.12,13 halilaj et al. and putnam et al., in various tests of the wrist function for jar twist and grip, showed that the maximum force generated was 47–65 n.14,15 horii used 140 n when testing wrist strength and transfer of mechanical loads to the carpus.16 peine et al. tested dorsal plates for distal radius fractures and applied a maximum force of 400 n for testing plate strength.17 implants are expected to withstand up to 200 n forces to allow fracture healing. the human forearm is rarely exposed to forces exceeding 200 n, but any implant is expected to survive this threshold tolerance. in an article by saka et al., the yield strength of the radial nail had a mean of 539 n and torsional strength of 0.028 nm/°.3 the yield strength in the current study was 566 n and a higher torsional strength of 0.080 nm/°. as this is a locked nail, the amount of comminution of the fracture affects how much of the torsional forces are transferred to the prosthesis. with loadsharing nails, the length of cortical contact is reduced in severely comminuted fractures and a higher torque resistance is therefore beneficial.18 this shows the proposed implant to have results equivalent to contemporary forearm nails in clinical use. dynamic testing showed a moment strength of 5.2 nm is 50% survival with one million cycles. with extrapolation from the graph to 4.4 nm, the survival of the implant improves to 90%. this is equivalent to exposing the nail to a 2.2 kg weight held in the hand. as the lever arm or forearm, in this case, gets longer, the force will reduce. this will allow the clinician to allow mobilisation of the forearm while allowing functional activities with a weight limit until union of the fracture. the standardised testing of implants by independent companies provides integrity for the results. these standard tests limit the number of implants needed for testing that may result in slightly different results and could help make the semi-logarithmic graphs more accurate. conclusion the results from the study’s mechanical testing show that this novel intramedullary forearm nail can resist mechanical forces experienced during fracture healing and could potentially be used in future clinical studies. table iv: results for torsional stiffness specimen torsional stiffness (nm/°) f022/20-1 0.088 f022/20-2 0.090 f022/20-3 0.086 mean 0.088 standard deviation 0.002 figure 1. illustration showing the distance between four points for the four-point bending test figure 2. picture of the nail placed in the four-point testing rig figure 3. picture of the nail placed in the rotational testing rig figure 4. picture of the nail at maximum deformation on the four-point rig figure 5. semi-logarithmic graph illustrating the survival probability points for the nail figure 6. the nails after failure to see the exact position of the break s = 38 c = 38 s = 38 225 mm l = 114 m om en t ( n m ) number of cycles (n) 10% probability of survival 90% probability of survival 4.4 nm m om en t ( n m ) number of cycles (n) figure 5. semi-logarithmic graph illustrating the survival probability points for the nail figure 6. the nails after failure, to see the exact position of the break page 227pretorius hs et al. sa orthop j 2022;21(4) ethics statement the author/s declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, ethical approval was obtained from the following ethical review board: stellenbosch university health research ethics committee, s20/04/100 (phd). declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions hsp: study conceptualisation, first draft preparation, data analysis and manuscript revision mcb: data analysis and manuscript revision nf: data analysis and manuscript revision orcid pretorius hs https://orcid.org/0000-0002-7419-0885 burger mc https://orcid.org/0000-0003-2831-4960 ferreira n https://orcid.org/0000-0002-0567-3373 references 1. gardner mj, silva mj, krieg jc. biomechanical testing of fracture fixation constructs: variability, validity, and clinical applicability. j am acad orthop surg. 2012;20:86-93. 2. pretorius hs, ferreira n, burger mc. a computer tomography-based anthropomorphic study of forearm osteology: implications for prosthetic design. sa orthop j. 2021;20(3):162-66. 3. saka g, saglam n, kurtulmuş t, et al. new interlocking intramedullary radius and ulna nails for treating forearm diaphyseal fractures in adults: a retrospective study. injury. 2014;45(suppl 1):s16-23. 4. astm. standard specification and test methods for intramedullary fixation devices 1. annual book on astm standards. 2003. p1-22. 5. bosisio mr, talmant m, skalli w, et al. apparent young’s modulus of human radius using inverse finite-element method. j biomech. 2007;40(9):2022-28. 6. niinomi m, nakai m. titanium-based biomaterials for preventing stress shielding between implant devices and bone. int j biomech. 2011;2011:1-10. 7. koh j, berger a, benhaim p. an overview of internal fixation implant metallurgy and galvanic corrosion effects. j hand surg am. 2015;40(8):1703-10. http://dx.doi.org/10.1016/j. jhsa.2015.03.030 8. hayes js, richards rg. the use of titanium and stainless steel in fracture fixation. expert rev med devices. 2010;7(6):843-53. 9. liu s, shin yc. additive manufacturing of ti6al4v alloy: a review. mater des. 2019 feb;164:107552. https://doi.org/10.1016/j.matdes.2018.107552 10. saka g, saglam n, kurtulmus t, et al. treatment of isolated diaphyseal fractures of the radius with an intramedullary nail in adults. eur j orthop surg traumatol. 2014;24(7):1085-93. 11. roberts jw, grindel si, rebholz b, wang m. biomechanical evaluation of locking plate radial shaft fixation: unicortical locking fixation versus mixed bicortical and unicortical fixation in a sawbone model. j hand surg am. 2007;32(7):971-75. 12. rikli da, honigmann p, babst r, et al. intra-articular pressure measurement in the radioulnocarpal joint using a novel sensor: in vitro and in vivo results. j hand surg am. 2007 jan;32(1):67-75. https://doi.org/10.1016/j.jhsa.2006.10.007 13. kuhn s, burkhart kj, schneider j, et al. the anatomy of the proximal radius: implications on fracture implant design. j shoulder elb surg. 2012;21(9):1247-54. http://dx.doi. org/10.1016/j.jse.2011.11.008 14. halilaj e, moore dc, patel tk, et al. early osteoarthritis of the trapeziometacarpal joint is not associated with joint instability during typical isometric loading. j orthop res. 2015;33(11):1639-45. 15. putnam md, meyer nj, nelson ew, et al. distal radial metaphyseal forces in an extrinsic grip model: implications for postfracture rehabilitation. j hand surg am. 2000;25(3):469-75. 16. horii e, garcia-elias m, an kn, et al. effect on force transmission across the carpus in procedures used to treat kienböck’s disease. j hand surg am. 1990;15(3):393-400. 17. peine r, rikli da, hoffmann r, et al. comparison of three different plating techniques for the dorsum of the distal radius: a biomechanical study. j hand surg am. 2000;25(1):29-33. 18. marcus re. practical biomechanics, techniques in orthopaedics. 1998 jan;13(1):1-8. https://orcid.org/0000-0002-7419-0885 https://orcid.org/orcid-search/0000-0003-2831-4960 http://orcid.org/0000-0002-0567-3373 _hlk111559673 404 not found page 122 south african orthopaedic journal http://journal.saoa.org.za doi 10.17159/2309-8309/2020/v19n3a0 editorial authorship is often considered to be an academic currency funding several aspects of an academic career.1 academic institutions are placing more pressure on academics, regardless of discipline or expertise, to author and co-author research outputs. authorship currency funds promotions, travel opportunities, academic esteem, and some institutions even provide a cash incentive for publishing original research. it is therefore not surprising that phrases like ‘publish or perish’ and ‘i should be writing’ are of similar importance as ‘i need coffee’ and ‘when is the deadline’, in the vocabulary of most academics, whether they are primarily researchers or clinicians. it comes as no surprise that this sought-after commodity is often misused, misinterpreted and abused, leading to widespread plagiarism and authorship misconduct. a pubmed search with ‘authorship’ in the title listed 778 articles in 2012;2 a similar search at the time of writing lists 1 366 articles, highlighting that issues surrounding authorship are on the increase. at the same time authorship conflicts are also on the increase and have become one of the main areas within academia requiring mediation or arbitration.3 two of the main culprits in authorship misconduct include ghost and guest/gift authorship.4 ghost authors are those contributing to a research study and subsequent manuscript, without being acknowledged as an author. the prevalence of ghost authorships has been reported to range between 2 and 75%, with the higher prevalence predominantly being in industry-initiated clinical trial protocols, with statisticians in particular being omitted from the author list.1,5 gift, guest or honorary authorship is the exact opposite, where individuals are added to publications regardless of their not meeting authorship criteria. gift authorships are typically granted to an individual in the hopes that it will increase the probability of being accepted by a journal, as a favour to a colleague or friend, or as a result of that individual’s position in the direct environment,6 with especially junior and emerging investigators being susceptible to being taken advantage of, given their inexperience and vulnerability in their environment.7 an increased number of authors on a manuscript has been associated with an increased likelihood of gift authorship,6 which could potentially serve as a warning sign to journal editors. however, using this warning sign in isolation could potentially be problematic, especially in the complex structure of multi-disciplinary collaboration or multi-site investigations, where multiple authors would be expected. to try and prevent unethical publishing practices, most medical journals, higher education and research institutions in south africa subscribe to the guidelines of the international committee of medical journal editors (icmje) which has published and refined specific guidelines to define the role of authors and contributors on scientific publications.8 the icmje guidelines state that authorship is warranted only if the individual has fulfilled all the following criteria: 1. ‘the author has made substantial contributions to the conception and/or design of the work. this includes the acquisition, analysis or interpretation of data for the work; and 2. has drafted the work or revised it critically for important intellectual content; and 3. has approved the final version that is to be published; and 4. agrees to be held accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.’ these guidelines however leave considerable room for interpretation where specifically points 1–3 can be argued extensively, as to a) what constitutes a ‘substantial contribution’; b) how much scientific input and how many drafts of review constitutes ‘critical revision’; and c) whether skimming over a final version constitutes ‘approval of the final version’. these points are open to interpretation and can be extensively motivated and debated. point 4 is the one that is arguably the most important factor to consider, and has received criticism in the past for being ambiguous,9 considering the reality and harshness of its potential implications. as it stands, point 4 is widely interpreted to mean that each author takes responsibility for what every other author does, regardless of the level of their involvement. the trachea implant scandal in sweden, where severe repercussions, and professional and reputational harm was suffered by co-authors for the misconduct of one surgeon, shows that the responsibility associated with co-authorship should not be taken lightly.9,10 a recent study from spain highlighted that research misconduct accounts for 65% of retractions,11 and although research misconduct does not always harbour equally severe consequences as illustrated in the swedish scandal, an investigation into the effect of a single retraction has reported a lasting penalty of citation losses to the author and their citation network.12 the reputational damage of being associated with a paper retracted for misconduct therefore remains significant, and accepting gift authorship should be discouraged, if not from an integrity point of view, then from a reputational one. a simple recommendation to prevent or resolve potential authorship issues includes open communication regarding authorship caught between a ghost and a gift: navigating authorship issues burger mc bsc, b(med)sc hons, m(med)sc, phd scientific research coordinator/lecturer: surgical sciences; division of orthopaedic surgery, faculty of medicine and health sciences, stellenbosch university, south africa corresponding author: mcburger@sun.ac.za dr marilize c burger page 124 south african orthopaedic journal http://journal.saoa.org.za at the onset and throughout the execution of studies. although easy in theory, research studies naturally evolve over time, with new investigators being included and additional expertise being sought; therefore, it may become difficult to assign authorship while satisfying all involved. additionally, workplace and collaborative environments are even more complex to navigate, making prevention of future conflict no easy task. it is clear that, although many guidelines, recommendations and indices are available to guide decision-making processes on authorship, the final judgement ultimately rests on the integrity of those involved in the research process. references 1. marusic a, bosnjak l, jeroncic a. a systematic review of research on the meaning, ethics and practices of authorship across scholarly disciplines. plos one. 2011;6(9):e23477 1-17. https:// doi.org/10.1371/journal.pone.0023477. 2. brand ra. further thoughts on authorship: gift authorship. clin orthop relat res. 2012;470(10):2926-29. https://doi.org/10.1007/ s11999-012-2504-3. 3. faulkes z. resolving authorship disputes by mediation and arbitration. res integr peer rev. 2018;3(12):16-18. 4. teixeira da silva j, dobranszki j. multiple authorship in scientific manuscripts: ethical challenges, ghost and guest/gift authorship. sci eng ethics. 2016;22:1457-72. https://doi.org/0.1007/s11948 015-9716-3. 5. gøtzsche pc, hrobjartsson a, johansen hk, et al. ghost authorship in industry-initiated randomised trials. plos one. 2007;4(1 e19):47-52. https://doi.org/10.1371/journal. pmed.0040019. 6. bavdekar sb. authorship issues. lung india. 2012;29(1):76-80. https://doi.org/10.4103/0970-2113.92371. 7. kwok ls. the white bull effect: abusive coauthorship and publication parasitism. j med ethics. 2005;31:554-56. https://doi. org/10.1136/jme.2004.010553. 8. international committee of medical journal editors. recommendations for the conduct, reporting, editing, and publication of scholarly work in medical journals. 2019; (updated december):1-19. available from: http://www.icmje.org/icmje recommendations.pdf. 9. helgesson g, eriksson s. revise the icmje recommendations regarding authorship responsibility! learn publ. 2018;31:267-69. https://doi.org/10.1002/leap.1161. 10. herold e. a star surgeon left a trail of dead patients — and his whistleblowers were punished. leapsmag. 2018:1-21. available from: https://leapsmag.com/a-star-surgeon-left-a-trail-of-deadpatients-and-his-whistleblowers-were-punished/. 11. campos-varela i, ruano-ravi a. misconduct as the main cause for retraction. a descriptive study of retracted publications and their authors. gac sanit. 2019;33(4):356-60. https://doi.org/10.1016/j. gaceta.2018.01.009. 12. lu sf, jin gz, uzzi b, jones b. the retraction penalty: evidence from the web of science. sci rep. 2013;3(nov):3146(1-5). https:// doi.org/10.1038/srep03146. erratum there is an amendment to the authors of an article published in the previous issue, south african orthopaedic journal 2020;19(2): 79-83. the correct version is as follows: the use of three-dimensional models to improve the reliability of tibial plateau fracture classification and their influence on surgical management authors: joubert ja¹, matshidza s², d’alton ej³ ¹ mbchb, fc orth(sa), mmed(orth); orthopaedic surgeon, department of orthopaedics, sefako makgatho health sciences university, ga-rankuwa, south africa; orcid: https//orcid.org/0000-0001-6502-9806 ² mbchb, fc orth (sa), mmed(orth); head of clinical, department of orthopaedic surgery, university of the free state, and orthopaedic consultant, universitas academic hospital, bloemfontein, south africa; orcid: https//orcid.org/0000-0003-0128-0385 ³ mbchb(up), mmed(orth); department of orthopaedics, sefako makgatho health sciences university, ga-rankuwa, south africa; orcid: https//orcid.org/0000-0001-7588-1496 it has been changed accordingly on the digital version. south african orthopaedic journal trauma and general orthopaedics doi 10.17159/2309-8309/2023/v22n1a3kauta nj et al. sa orthop j 2023;22(1) citation: kauta nj, owolabi eo, salence b, swanepoel s, roche s, chu km. a survey on the educational value of an mhealth referral app for orthopaedics in south africa. sa orthop j. 2023;22(1):24-27. http:// dx.doi.org/10.17159/2309-8309/2023/ v22n1a3 editor: dr franz birkholtz, stellenbosch university, cape town, south africa received: june 2022 accepted: september 2022 published: march 2023 copyright: © 2023 kauta nj. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background a whatsapp orthopaedic referral group (org) was created in 2017 by orthopaedic specialists at a district hospital to provide support to primary healthcare doctors in order to manage traumatic fractures and dislocations. this study assessed the educational value and user satisfaction of the org platform. methods an online, cross-sectional survey was conducted among org users from may to june 2021. demographic information, user satisfaction, the educational value of org, and perceived improvement in managing closed fractures and dislocations were captured using descriptive and inferential statistics. results there were 80 respondents, with 50% females. the median age was 30 (interquartile range [iqr] 28–35) years, duration of practice was 5 (iqr 3–10) years, and length of org use was 10 (iqr 5–24) months. seventy-two (90%) reported that org enabled them to receive timely advice for orthopaedic case management and 75 (93.8%) considered it an easy referral facilitation tool. most (76.3%) felt that the advice, pictures, and videos shared on org helped novice doctors successfully complete fracture reduction. the percentage of participants who felt very capable in managing the following fractures increased after org membership: extra-articular distal radius fracture (12.5% to 45.0%, p < 0.001); bimalleolar ankle fractures (16.3% to 43.8%, p < 0.001) and shoulder dislocation (35.0% to 61.3%, p = 0.001). conclusion org is an easy-to-use and well-accepted platform for the management, referral facilitation and teaching of acute orthopaedic conditions. similar platforms can be introduced in other settings where surgical specialists are scarce. additional studies should measure the feasibility and effectiveness of these mhealth platforms. level of evidence: level 3 keywords: mhealth, whatsapp, orthopaedics, south africa a survey on the educational value of an mhealth referral app for orthopaedics in south africa ntambue j kauta,¹ eyitayo o owolabi,²,³* bijou salence,¹ stefan swanepoel,¹ stephen roche,⁴ kathryn m chu²,⁵ ¹ department of orthopaedic surgery, mitchell’s plain district hospital, university of cape town, south africa ² centre for global surgery, department of global health, faculty of medicine and health sciences, stellenbosch university, cape town, south africa ³ edson college of nursing and health innovation, arizona state university, phoenix, arizona, usa ⁴ department of orthopaedic surgery, groote schuur hospital, university of cape town, south africa ⁵ department of surgery, university of botswana, gaborone, botswana *corresponding author: owolabiomolara101@gmail.com introduction the burden of trauma and injury is significantly higher in lowand middle-income countries, yet access to timely and quality injury care is limited.1 this is partly due to the shortage and maldistribution of surgical care providers, especially those with orthopaedic training.2 mhealth, defined as the provision of healthcare services using mobile devices, is increasingly being used to bridge access gaps by improving communication between providers and enabling virtual patient consultations.3,4 in addition to improving clinical care, mhealth can also be a teaching and learning platform for healthcare providers through shared communication between specialists and healthcare providers.5 the ability of mhealth to facilitate consultations and efficient referrals in various surgical specialities, including neurosurgery, plastic and reconstructive surgery, orthopaedic surgery and paediatric surgery has been highlighted.6-9 whatsapp is an encrypted smartphone app that is widely used in mhealth.10 the clinical benefits of whatsapp groups have been demonstrated in several studies.8,11,12 a 2018 study showed that communications and patient triage via whatsapp effectively reduced outpatient visits for paediatric burns and prevented unnecessary admissions.13 the whatsapp platform can also facilitate medical teaching and learning.14-16 a study among resident doctors showed an improvement in knowledge of postoperative pain management following whatsapp discussions.14 another study conducted among medical students documented the https://orcid.org/0000-0002-7099-2506 https://orcid.org/0000-0001-5575-7842 page 25kauta nj et al. sa orthop j 2023;22(1) potential of whatsapp as a learning tool for community medicine.15 there is, however, limited information on the educational value of whatsapp in orthopaedics. south africa (sa) has a very high acute orthopaedic trauma burden.17 only 5% of the orthopaedic surgeons in sa work at public health facilities which serve 86% of the population.18 also, the orthopaedic surgeons in the public sector are hospitalbased while many patients with acute fractures and dislocations present to primary healthcare clinics which are staffed by general practitioners and family physicians with variable orthopaedic training. in 2017, a whatsapp orthopaedic referral group (org) was created by orthopaedic specialists at a first-level hospital in cape town, south africa, to support primary healthcare doctors in managing closed traumatic fractures. org was shown to improve patient management, with 15 minutes referral response times and 42% of cases definitively managed through advice alone;8 however, its impact on users has not been explored. the primary objectives of this study were to assess the educational value and user satisfaction of the org platform. methods study design, population and setting this was a cross-sectional survey conducted with org users from may to june 2021. org was created in 2017 by orthopaedic surgeons at mitchell’s plain hospital (mph), a first-level hospital in cape town, south africa, as an acute orthopaedic trauma platform for primary care doctors from five referring community health centres (chcs) to make referrals and receive advice from orthopaedic providers. chc doctors join org voluntarily and discussions are visible to all org users.8 at the time of this study, the specialist team responding to queries on org included two consultant orthopaedic surgeons and five orthopaedic medical officers. sample and sampling technique all org users were purposively recruited. these were medical interns, community service doctors, medical officers, family physicians and emergency medicine physicians who treated traumatic orthopaedic conditions at the chc level. as of november 2020, there were 157 org users. to survey at least 50% of the study population, the minimum sample size was 80. an invitation to an online survey was posted on org weekly throughout the sixweek enrolment period. individual invitations were not sent. data collection the survey comprised 17 questions in three categories: user demographics, org platform usefulness/usability, and perceived clinical competence in managing selected orthopaedic trauma cases. demographic variables included age, sex, medical qualification, duration of clinical practice and the duration of participation on org. a previous study demonstrated that the three most common conditions managed without onward referral (through advice only) on the org platform were extra-articular distal radius fracture, bimalleolar ankle fracture and shoulder dislocation. clinical competencies in the management of these conditions before and after joining org were self-assessed using a six-point likert scale. the scale ranged from grossly inadequate (1), knew the approach in theory but never practised (2), had tried before but not confident (3), still not confident (4), reasonably capable but needed supervision (5), to very capable (6). data analysis the google docs online survey was imported into stata se version 15 (college park, tx, usa) for statistical analysis. descriptive and inferential statistics were performed. continuous variables were presented as median and interquartile ranges (iqrs), and categorical data as counts and frequency. selfreported competency was coded as a binominal variable (yes/no). the proportion of respondents that felt competent was then determined by those that felt competent/total respondents. change in perceived clinical competence was determined using the two-sample proportion test. p-values < 0.05 were considered statistically significant. results a total of 80 (51%) of 157 users completed the survey. the median age of participants was 30 years (iqr 28–35) and the median duration of org use was 10 months (iqr 5–24). there were 40 (50%) females. half (n = 44, 55.0%) were medical officers (table i). user satisfaction with org seventy-two (90.0%) reported that org enabled them to receive timely advice for orthopaedic case management, and 75 (93.7%) perceived it as an easy referral tool. only a few, 14 (17.5%), felt overburdened with the frequency of clinical queries and responses posted on org (table ii). educational value of org fifty-four (68.0%) felt that org was a good platform to keep up to date with current principles of fracture management and for table i: participant demographics frequency % age; median (iqr) years 30 (28–35) duration of clinical practice; median (iqr) years 5 (3–10) duration of org use; median (iqr) months 10 (5–24) sex female 40 50.0 male 39 48.8 non-binary 1 1.2 medical qualification intern 11 13.8 community service doctor 14 17.5 medical officer 44 55.0 family physician 8 10.0 emergency physician 3 3.8 table ii: satisfaction with org use yes don’t know no i receive responses on org soon enough to process my case in a timely manner 72 (90.0) 5 (6.2) 3 (3.8) i find it is easy to refer my patients to mitchell’s plain hospital on org 75 (93.7) 3 (3.8) 2 (2.5) i feel overburdened with the number of clinical queries and responses posted on org or receiving org notifications 14 (17.5) 8 (10.0) 58 (72.5) page 26 kauta nj et al. sa orthop j 2023;22(1) on-the-job continuous medical education. the majority (n = 75; 95%) felt that org offered educational value and 61 (76.3%) of the participants felt that the advice, pictures and videos shared on org are sufficient to allow novice doctors to attempt fracture reduction (table iii). perceived competence in managing orthopaedic cases the proportion of participants who felt very capable of managing extra-articular distal radius fracture increased from 10 (12.5%) to 36 (45.0%) (p < 0.001) after becoming org users. for the management of bimalleolar ankle fracture, the proportion of competent users increased from 13 (16.3%) to 35 (43.8%) (p < 0.001), and for the management of shoulder dislocation increased from 28 (35.0%) to 49 (61.3%) (p = 0.001) (figure 1). discussion the org platform was created to provide support to primary healthcare doctors in south africa to manage acute orthopaedic trauma at chcs. we have previously shown that org improves timely referral and management advice.8 this study demonstrated that org is also an easy-to-use platform and provides educational value for improving clinical competency. for instance, ankle and wrist fractures were the most common fractures treated in chcs in our study settings.8 we found a significantly increased proportion of self-reported competence for nonoperative management of extra-articular distal radius and ankle fractures, after an average of ten months of org use. likewise, three-quarters of the study participants felt that the advice provided on the platform was sufficient to enable them to perform their first closed fracture reduction. our results support the educational value of mobile health platforms such as whatsapp for passive medical e-learning and clinical management.19-21 orthopaedic trauma management is particularly amenable to telehealth education because post-fracture reduction x-rays are an objective method of evaluating manipulation and reduction. given the shortage of orthopaedic trainers in africa, mhealth platforms can provide e-learning through shared messages with clinical photos, videos and case descriptions visible to all users.18 non-orthopaedic doctors using the platform can learn through the advice given for all the cases, not just those they post. whatsapp is ubiquitous in sub-saharan africa and requires low bandwidth, sometimes even free, making it easily accessible to doctors without the need to download additional phone apps.22 however, the educational value of group posting of clinical information must be weighed against ethical issues such as confidentiality, privacy and consent of individual patients. whatsapp has end-to-end encryption. in addition, org requires membership to join, and clinicians not involved in the direct care of a patient are not privy to their identifying information. cases are posted without patient identifiers such as names or medical record numbers. if it is decided on org that a particular case needs to be referred to the district hospital, the referring doctor communicates patients’ details directly to the receiving doctor by private messaging. verbal consent to discuss clinical information and images on org was obtained from the patients. in the future, we may need to consider written consent to discuss patient information, even anonymously, given the more stringent privacy laws rolled out in south africa in 2020.23 in addition, other mhealth platforms can be considered that restrict case discussions to only two clinicians. vula mobile is a referral mhealth app endorsed by the south african national department of health and used to refer orthopaedic patients between levels table iii: educational value of org educational value n % written advice, pictures and videos received on org to describe reduction techniques for traumatic fractures are sufficient to allow a doctor to attempt reduction for the first time in their career 61 76.3 org is a good way to keep up to date with current principles of fracture management 54 67.5 org provides on-the-job continuous medical education 54 67.5 org is a platform where new orthopaedic fracture management skills can be acquired 50 62.5 the learning environment is non-judgemental 46 57.5 org offers no educational value 5 5.0 closed reduction and casting of extra-articular distal radius fracture closed reduction and casting of bimalleolar ankle fracture closed relocation of an acute anterior shoulder dislocation p < 0.001 10 (12.5%) 36 (45.0%) 13 (16.3%) 35 (43.8%) 28 (35.0%) 49 (61.3%) p < 0.001 p = 0.001 before org before org figure 1. changes in perceived clinical orthopaedic competence page 27kauta nj et al. sa orthop j 2023;22(1) of care.24 this application is only accessible to registered medical practitioners, and patient information is only shared between the referring doctor and the receiving specialist. however, the platform does not allow a larger group of non-specialist providers to learn by reading the case discussion. a platform that allowed only one user and one specialist to see the active case but archived anonymous inactive case discussions visible to the larger membership could both allow better patient privacy as well as facilitate learning. the study has certain limitations. first, clinical competence was self-reported and not independently assessed by an orthopaedic surgeon. responses were not stratified by medical qualification, years of clinical experience, or time as an org user. finally, the response rate was only 50%, so these results may not be representative of all the users. conclusion this study demonstrates that a clinical mhealth platform created to improve acute orthopaedic trauma management by non-orthopaedic surgeons also has the added value of being an educational modality for its users. cases can be reviewed asynchronously, allowing medical doctors to learn at their own pace. with anonymised patient details, this can become an effective form of continuing medical education. in other resourcelimited settings where surgeons are scarce, this type of platform can expand access to nonoperative injury management through task-sharing. additional studies are needed to measure the feasibility and effectiveness of these mhealth platforms. ethics statement ethics approval for this study was obtained from the university of cape town human research ethics committee (hrec ref: 199/2021). a participation information sheet was provided in the preface of the online survey, and consent was given through completion of the survey. participation was voluntary and did not influence the ability to continue to use org. responses were anonymised. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions njk: study conceptualisation, data management and analysis, first draft of manuscript, approval of final version of manuscript eoo: study conceptualisation, data management and analysis, substantial contributions to the manuscript revision, approval of final version of manuscript bs: data collection, approval of final version of manuscript ss: study conceptualisation, approval of final version of manuscript sr: approval of final version of manuscript kmc: study conceptualisation, data management and analysis, substantial contributions to the manuscript revision, approval of final version of manuscript orcid kauta nj https://orcid.org/0000-0002-7099-2506 owolabi eo https://orcid.org/0000-0001-5575-7842 salence b https://orcid.org/0000-0001-6296-9915 swanepoel s https://orcid.org/0000-0003-2553-4343 roche s https://orcid.org/0000-0002-5695-2751 chu km https://orcid.org/0000-0002-8923-7447 references 1. world health organization. road traffic injuries 2021 [cited 2022 24 february]. available from: https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries. 2. chokotho l, jacobsen kh, burgess d, et al. a review of existing trauma and musculoskeletal impairment (tmsi) care capacity in east, central, and southern africa. injury. 2016;47(9):1990-95. 3. free c, phillips g, watson l, et al. the effectiveness of mobile-health technologies to improve health care service delivery processes: a systematic review and meta-analysis. plos medicine. 2013;10(1):e1001363. 4. odine m. south africa’s mobiles deliver healthcare services. j emerg trends educ res policy stud. 2015;6(2):182-88. 5. littman-quinn r, mibenge c, antwi c, et al. implementation of m-health applications in botswana: telemedicine and education on mobile devices in a low resource setting. j telemed telecare. 2013;19(2):120-25. 6. joshi ss, murali-krishnan s, patankar p, choudhari ka. neurosurgical referral service using smartphone client whatsapp: preliminary study at a tertiary referral neurosurgical unit. br j neurosurg. 2018;32(5):553-57. 7. den hollander d, mars m. smart phones make smart referrals: the use of mobile phone technology in burn care–a retrospective case series. burns. 2017;43(1):190-94. 8. kauta nj, groenewald j, arnolds d, et al. whatsapp mobile health platform to support fracture management by non-specialists in south africa. j am coll surg. 2020;230(1):37-42. 9. bertani a, launay f, candoni p, et al. teleconsultation in paediatric orthopaedics in djibouti: evaluation of response performance. orthop traumatol-sur. 2012;98(7):803-807. 10. a m. business insider french. whatsapp is the most popular chat app in more than half the world internet 2016 [cited 2022 24 february]. available from: http://www.businessinsider.fr/ us/whatsapp-is-the-most-popular-chat-app-in-more-than-half-the-world-2016-5/. 11. ellanti p, moriarty a, coughlan f, mccarthy t. the use of whatsapp smartphone messaging improves communication efficiency within an orthopaedic surgery team. cureus. 2017;9(2). 12. wani sa, rabah sm, alfadil s, et al. efficacy of communication amongst staff members at plastic and reconstructive surgery section using smartphone and mobile whatsapp. indian j plast surg. 2013;46(03):502-505. 13. martinez r, rogers ad, numanoglu a, rode h. the value of whatsapp communication in paediatric burn care. burns. 2018;44(4):947-55. 14. bakshi sg, bhawalkar p. role of whatsapp-based discussions in improving residents’ knowledge of post-operative pain management: a pilot study. korean j anesthesiol. 2017;70(5):542. 15. dyavarishetty pv, patil dc. an interventional study to assess the effectiveness of ‘whatsapp’as a teaching learning tool in community medicine. int j community med public health. 2017;4(7):2564-69. 16. khanna v, sambandam sn, gul a, mounasamy v. ‘whatsapp’ ening in orthopedic care: a concise report from a 300-bedded tertiary care teaching center. eur j orthop surg traumatol. 2015;25(5):821-26. 17. marszalek j, de villiers pjt. morbidity profile of admissions to gf jooste hospital, manenberg, cape town. s afr fam pract. 2006;48(6):15-e. 18. dell aj, gray s, fraser r, et al. orthopaedic surgeon density in south africa. world j surg. 2018;42(12):3849-55. 19. gon s, rawekar a. effectivity of e-learning through whatsapp as a teaching learning tool. mvp j med sci. 2017:19-25. 20. maske ss, kamble ph, kataria sk, et al. feasibility, effectiveness, and students’ attitude toward using whatsapp in histology teaching and learning. j educ health promot. 2018;7. 21. woods j, moorhouse m, knight l. a descriptive analysis of the role of a whatsapp clinical discussion group as a forum for continuing medical education in the management of complicated hiv and tb clinical cases in a group of doctors in the eastern cape, south africa. south afr j hiv med. 2019;20(1):1-9. 22. j c. number of monthly active whatsapp users worldwide from april 2013 to march 2020 (in millions). available from: https://www.statista.com/statistics/260819/ number-of-monthly-active-whatsapp-users/ 23. protection of personal information act. available from: https://popia.co.za 24. morkel rw, mann tn, du preez g, du toit j. orthopaedic referrals using a smartphone app:uptake, response times and outcomes. s afr med j. 2019;109(11):859-64. https://orcid.org/0000-0002-7099-2506 https://orcid.org/0000-0001-5575-7842 https://orcid.org/0000-0001-6296-9915 https://orcid.org/0000-0003-2553-4343 https://orcid.org/0000-0002-5695-2751 https://orcid.org/0000-0002-8923-7447 _hlk103340306 _hlk118283230 _hlk75374182 orthopaedics vol3 no4 page 72 sa orthopaedic journal autumn 2016 | vol 15 • no 1 background an accurate definition of a knee dislocation is subject to on-going discussions as the description of a knee injury as a dislocation does not clearly define the injury or guide management.1 radiologic evidence of a dislocation is not available in about 20%–50% of the patients, as the knee often reduces spontaneously or is reduced by emergency staff at the scene. thus, many authors define knee dislocations as the disruption of three or more of the four major knee ligaments. yet, it has been argued that the disruption of only two ligaments is sufficient for a knee dislocation to occur such as in dislocations with an intact posterior cruciate ligament.2 this lack of a commonly accepted definition makes a comparison of incidences of associated injuries challenging and reports of popliteal artery injuries in knee dislocations vary widely between 7% and 64%.3-8 abstract background: knee dislocations are reported to have an incidence of popliteal artery injuries between 7% and 64%. the purpose of this study was to determine the incidence of injuries to the popliteal artery as well as early limb loss in knee dislocations at a level-1 trauma hospital in south africa. methods: twenty-eight patients with popliteal artery injuries were selected from a prospectively collected database of 96 patients with acute knee dislocations. the incidence of vascular injuries, compartment syndromes and limb loss was determined retrospectively. results: of 96 knee dislocations 28 had a popliteal artery injury (29.1%). seven of 28 patients with popliteal artery injuries needed an amputation. of the 28 patients, ten were documented as a threatened limb. five of these ten patients (50%) needed an amputation. the documented median delay to revascularisation of patients who presented with threatened limbs was 10 hours. conclusion: overall, one-third of knee dislocations presented with a vascular injury. the prevalence of amputations in knee dislocations with associated popliteal artery injuries was 25% and increased to more than 50% in patients who presented with a threatened limb. key words: knee dislocation, popliteal artery injury, amputation, limb loss http://dx.doi.org/10.17159/2309-8309/2016/v15n1a8 high rate of popliteal artery injuries and limb loss in 96 knee dislocations m held* fc orth(sa), mmed(ortho) m laubscher* fc orth(sa) r von bormann* fc orth(sa) j walters* fc orth(sa) s roche* fc orth(sa) a banderker** fcs(sa), mmed(surg) p navsaria** fcs(sa) a nicol** fcs(sa), phd s maqungo* fc orth(sa) *orthopaedic research unit **trauma centre, department of surgery groote schuur hospital, university of cape town corresponding author: dr michael held h49 old main building groote schuur hospital 7925 observatory south africa tel: 0027 -214066157 fax: 0027 -21472709 email: michael.held@uct.ac.za sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 73 a recent study has described popliteal artery injury rates as low as 1.6% with only 0.1% of patients needing an amputation.9 indisputably, each multidirectional knee injury with an adequate history of trauma and presentation should be regarded as a knee dislocation until proven otherwise.1 the mechanism of injury in knee dislocations can range from high energy injuries due to road accidents and falls from a height to low energy injuries such as sports injuries and even ultra-low-velocity injuries such as simple falls, especially in obese patients.10-13 the energy level of the injury can affect the injury pattern itself, which varies from ligamentous disruption only, to knee dislocations with severe soft tissue damage, compartment syndrome, open wounds and fractures, all of which are risk factors for adverse limb outcomes.14,15 in its most severe presentation a knee dislocation can be associated with popliteal artery injuries resulting in a threatened limb and subsequent limb loss if not treated urgently. the specific anatomy of the popliteal artery makes it susceptible to damage during trauma. it is fixed to the distal femur in the adductor canal, and is tethered distally under the soleus muscle and inbetween the two heads of the gastrocnemius muscles. with its tenuous collateral supply, the arterial flow is very rarely sufficient to guarantee adequate distal perfusion to the limb during a complete disruption of the popliteal artery. the purpose of this study was to determine the frequency of popliteal artery injuries in knee dislocations and evaluate the incidence of early limb loss. methods twenty-eight of 96 consecutive knee dislocations admitted to the trauma unit of a tertiary care hospital in south africa over a period of 12 years (2000–2012) were included in this study and were analysed retrospectively. the data was collected prospectively. included were all patients with knee dislocations diagnosed radiologically or, in patients who presented with a reduced joint, in the presence of multidirectional, gross instability. children were excluded. the viability of the limb on presentation was documented according to the rutherford classification into ‘viable’, ‘threatened’ and ‘non-viable’ limbs.2 in accordance with the protocol of the local trauma unit the vascular status was assessed via an angiogram in all patients (figure 1). a hybrid procedure room for simultaneous computer tomography with angiogram (cta) in the operating room was not available and therefore, in threatened limbs with vascular hard signs, arterial contrast was injected into the femoral artery and the popliteal artery injury was visualised under fluoroscopy either in the emergency room or on the operating table prior to the intervention (‘on-table’ angiography). a ct angiogram with venous contrast or digital subtraction angiogram with arterial contrast was obtained in patients, in which a threatened limb was excluded. all vascular injuries were managed by a dedicated trauma team. serial neurovascular checks for 48h algorithm knee dislocation revascularization positive negative on-table angiogram formal angiogram noyes threatened limb? knee dislocation figure 1. algorithm used for the assessment and management of knee dislocations figure 2. angiogram; injury to the popliteal artery page 74 sa orthopaedic journal autumn 2016 | vol 15 • no 1 the musculoskeletal pathology was assessed and treated by a specialised orthopaedic unit. all popliteal artery injuries were repaired through a medial approach with end-to-end suturing or grafted with a reverse saphenous vein graft if direct repair was not possible. the knee dislocations were reduced and stabilised with an external fixation device prior the vascular repair. a joint spanning configuration of two 5 mm half pins each, proximal and distal to the joint, was used. the duration of external fixation was not documented. capsular structures were not repaired at the initial sitting. a lower leg compartment release was carried out in limbs assessed to have a compartment syndrome. this was a clinical diagnosis with examinations done pre-operatively and at regular 2-hour intervals for 48 hours after surgery and was not confirmed by intra-compartmental pressure measurements. the delay from injury to revascularisation, viability of the limb, type of vascular injury and repair, mechanism of injury, associated compartment syndrome, and limb loss were documented. ethics approval for the study was obtained. results in the study period 96 knee dislocations were identified. twenty-eight (29.1%) patients (14 males) had evidence of a popliteal artery injury (figure 2). this was confirmed by formal digital subtraction angiography in ten cases and by cta in eight cases. in ten patients an ‘on-table’ angiogram was performed. in the remaining 68 patients vascular injuries were excluded by angiography. in two cases the diagnosis of a knee dislocation had not been made primarily but only after a popliteal artery injury was detected. seven patients of the 28 patients (25%) with popliteal artery injuries needed an amputation at an average of 9.3 days after the initial assessment (range: 0–42). the mechanisms of injury included 14 falls (50%), 11 motor vehicle crashes (39.3 %), and three soccer injuries (10.7%). on documentation no distinction was made regarding falls from height or lowenergy falls. three of the 11 patients (27.3%) who injured their knee during a motor vehicle crash needed an amputation. four of the 14 patients (28.6%) who dislocated their knee during a fall were amputated; none of the three sport-related injuries needed an amputation (table i). an associated popliteal vein injury was found in three patients, two of which needed an amputation (66.7%); in the remaining 22 patients (13.6%) without an associated popliteal vein injury, three needed an amputation. a compartment syndrome was present in four limbs, of which two were amputated compared to two amputations of the remaining 24 patients (8.3%), who did not have a compartment syndrome (table ii). of the 28 patients, 18 presented with a ‘viable’ limb and ten were documented as a threatened limb. five of the ten patients (50%) who presented with a threatened limb needed an amputation (table ii). the documented median delay to revascularisation of patients who presented with threatened limbs was 10 hours (interquartile range [iqr]: 13.2). two patients who were revascularised after 12 hours of ischaemic time developed acute kidney injury with myoglobinuria and abnormally high serum potassium levels. one patient was able to undergo delayed amputation at day 10; the other patient succumbed seven days postoperatively due to multi-organ failure. in both cases the knee dislocation was missed as the joint had reduced prior to admission to the emergency unit. two cases in the ‘viable’ limb group of 18 patients needed an amputation on day 16 and day 42 post-operatively. in one patient a late compartment syndrome was missed; the other patient refused relook surgery once a diagnosis of primary graft failure was made. restitution of the vascular supply was by direct repair in nine patients (32.1%). all limbs in this group were salvaged. seventeen patients needed a reverse saphenous vein graft (60.7%). of these patients five (29.4%) had an amputation (table iii). the popliteal artery was found transected in nine patients (32.1%) and thrombosed in six (21.4%), and an intimal flap was seen in 11 patients (27.3%). percutaneous transarterial repair during arteriography was not performed. discussion the rate of popliteal artery injuries and amputations in knee dislocations in our patient population remains alarmingly high. missing knee dislocations and associated injuries poses a high risk of limb loss and can be life-threatening. table i: mechanism of injury mechanism n (%) limb loss fall 14 (50%) 4/14 (28.6%) mvc 11 (39.3%) 3/11 (27.3%) soccer 3 (10.7%) 0 total 28 7 (25%) n = number; mvc = motor vehicle crash table ii: associated conditions and injuries associated conditions n (%) limb loss popliteal vein 3/28 (10.7%) 2/3 (66.7%) compartment syndrome 4/28 (14.3%) 2/4 (50%) threatened limb 10/28 (35.7%) 5/10 (50%) table iii. vascular repair type of repair n (%) limb loss direct 9/28 (32.1%) 0 rsvg 17/28 (60.7%) 5/17 (29.4%) rsvg = reverse saphenous vein graft sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 75 therefore, the most severe form of knee dislocation should be assumed until further examination and special investigations have ruled out associated injuries. in two patients of our study a knee dislocation was missed as the joint had reduced prior to admission to the emergency unit and a multidirectional instability of the knee was overlooked. this might point to a much larger number of knee dislocations without vascular injuries, which are missed on admission. in our study 28 of 96 knee dislocations were found to have a popliteal artery injury (29.1%). this incidence is comparable to above-mentioned studies although a finnish population-based study has reported popliteal artery injury rates as low as 1.6% with only 0.1% of limb loss.9 forty-six per cent of knee dislocations were caused by falls on the same level and the lower rate of popliteal artery injury might be a consequence of this predominantly low-energy injury pattern. our study was done in a cohort recruited from a single centre and subspecialised level 1 trauma unit, rather than being a population-based study and with this we might have selected more severe injury patterns. yet, we also acknowledge our numbers could be lower if missed knee dislocations were to be taken into account. it remains controversial whether distal perfusion should be assessed by means of physical examination (with or without the measurement of ankle-brachial index), or routine arteriography.16 most cases with threatened limbs present with vascular hard signs or symptoms described by de bakey17 such as active haemorrhage, expanding haematoma, bruit or thrill, and distal ischaemia with symptoms like absent pulses, pain, paraesthesia, paralysis and paleness. but often only subtle signs such as a diminished pulse amplitude and pain can be found, so that a high index of suspicion is needed to avoid missing vascular damage. many authors agree that patients with a viable limb and patent distal pulses should be reviewed regularly for 48 hours and treated conservatively unless deterioration is evident.18 with adequately trained staff and appropriate facilities, acceptable results have been reported with serial neurovascular examinations including ankle-brachial index (abi) measurements for at least 24 hours.18 this seems advisable since the presence of normal pulses on admission does not rule out a clinically significant vascular injury.16,19,20 cases in which a viable limb shows an abi of less than 0.90 warrant further vascular imaging and reperfusion. other options such as duplex ultrasonography (100% sensitivity and 97% specificity for clinically significant arterial injury) or ct angiography (95–100% sensitivity and 97–98% specificity) have also been described.21-23 even though, serial neurovascular examinations have shown equal sensitivity and specificity compared to obtaining a formal angiographic study, we have adopted a policy that ensures angiographic examination of all knee dislocations. despite these efforts our amputation rate remains at 25% (seven of 28 patients) of diagnosed vascular injuries. a conservative approach to non-occlusive popliteal artery injuries with serial neurovascular examinations have been proposed by some centres with an adequate set-up. this seems to be more cost effective and has less morbidity for the patient than surgical exploration and repair of the artery with a similar outcome.24 contrary to this, all of the patients who presented with a vascular injury to our unit, occlusive or non-occlusive, underwent vascular repair. although no clear evidence is available yet, the authors feel that serial examinations are often of insufficient quality, and the costs and morbidity of an early exploration of the popliteal artery outweighs the risk taken if the patient deteriorates unnoticed. one of the most influential factors for limb salvage is the delay from injury to reperfusion. it is reported that if reperfusion is achieved within 6 hours, amputation rates can be kept below 10%. the amputation rate increases to more than 80% if the ischaemic time reaches 8 hours.24 in our series, five of ten threatened limbs could be salvaged even after an ischaemic time of 10.8 hours (median, iqr: 9.2), but with five patients the sample size was too small to make conclusions on time to revascularisation without bias. a delay to revascularisation will most likely lead to a high risk of reperfusion injury and subsequent multi-organ dysfunction. the exact point of transition from a threatened pulseless limb with strong vascular hard signs to a non-viable limb cannot be measured clinically and it is therefore extremely challenging for the surgeon and the patient to agree on the indication for amputation. factors such as overall trauma load, associated injuries to bone and soft tissue as well as age of the patient and comorbidities add to the complexity of this decision. two of our patients who were revascularised after 10 hours developed acute kidney injury. one of these patients died seven days post-operatively due to multi-organ failure, highlighting the danger of this endeavour. a shortcoming of our study is that we might have missed more knee dislocations and therefore are overreporting the incidence of popliteal artery injuries and amputations. although we report on one of the highest number of knee dislocations for a single centre, the small number of amputations makes it impossible to reach strong conclusions on associated injuries and reasons for amputations. we also note that we have not differentiated falls into high-energy, low-energy and even ultralow energy falls and cannot assess differences here. conclusion the incidence of vascular injuries in knee dislocations reached nearly 30%. the risk of amputations in knee dislocations with associated popliteal artery injuries was 25% and increased to more than 50% in patients who presented with a threatened limb. • saoj page 76 sa orthopaedic journal autumn 2016 | vol 15 • no 1 conflict of interest statement all authors declare that they do not have conflict of interest. the study was approved by the appropriate ethics committee and has therefore been performed in accordance with the ethical standards laid down in the 1964 declaration of helsinki and its later amendments. references 1. liow r, mcnicholas m, keating j, nutton r. ligament repair and reconstruction in traumatic dislocation of the knee. journal of bone & joint surgery, british volume. 2003;85(6):845-51. 2. cooper de, speer kp, wickiewicz tl, warren rf. complete knee dislocation 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marin el, bifulco ss, fast a. obesity: a risk factor for knee dislocation. american journal of physical medicine & rehabilitation. 1990;69(3):132-34. 13. peltola ek, lindahl j, hietaranta h, koskinen sk. knee dislocation in overweight patients. american journal of roentgenology. 2009;192(1):101-106. 14. farber a, tan tw, hamburg nm, kalish ja, joglar f, onigman t, et al. early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: a review of the national trauma data bank. injury. 2012;43(9):1486-91. epub 2011/07/02. doi: 10.1016/j.injury.2011.06.006. pubmed pmid: 21719009; pubmed central pmcid: pmcpmc3777619. 15. hafez hm, woolgar j, robbs jv. lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss. journal of vascular surgery. 33(6):1212-19. doi: 10.1067/mva.2001.113982. 16. stannard jp, sheils tm, lopez-ben rr, mcgwin jr g, robinson jt, volgas da. vascular injuries in knee dislocations: the role of physical examination in determining the need for arteriography. the journal of bone & joint surgery. 2004;86(5):910-15. 17. debakey me, simeone fa. battle injuries of the arteries in world war ii: an analysis of 2,471 cases. annals of surgery. 1946;123(4):534. 18. hollis jd, daley bj. 10-year review of knee dislocations: is arteriography always necessary? journal of trauma and acute care surgery. 2005;59(3):672-76. 19. rose sc, moore ee. trauma angiography: the use of clinical findings to improve patient selection and case preparation. journal of trauma and acute care surgery. 1988;28(2):240-45. 20. snyder wh, thal er, bridges ra, gerlock aj, perry mo, fry wj. the validity of normal arteriography in penetrating trauma. archives of surgery. 1978;113(4):42428. 21. fry wr, smith rs, sayers dv, henderson vj, morabito dj, tsoi ek, et al. the success of duplex ultrasonographic scanning in diagnosis of extremity vascular proximity trauma. archives of surgery. 1993;128(12):1368-72. 22. inaba k, potzman j, munera f, mckenney m, munoz r, rivas l, et al. multi-slice ct angiography for arterial evaluation in the injured lower extremity. journal of trauma and acute care surgery. 2006;60(3):502-507. 23. soto ja, múnera f, cardoso n, guarín o, medina s. diagnostic performance of helical ct angiography in trauma to large arteries of the extremities. journal of computer assisted tomography. 1999;23(2):188-96. 24. green ne, allen bl. vascular injuries associated with dislocation of the knee. the journal of bone & joint surgery. 1977;59(2):236-39. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. page 9south african orthopaedic journal http://journal.saoa.org.za editorial trauma continues to be a major epidemic in our country. our hospital emergency departments are overflowing with trauma patients. a large part of this trauma involves the musculoskeletal system. this has a negative effect on orthopaedic service delivery, especially elective orthopaedics. time and again we have to turn away patients we have booked for elective hip replacement, because all the beds are occupied by the weekend’s trauma admissions. injuries in general are the major cause of death all over the world. in 2010 there were 5.1 million deaths from injuries, which was much greater than the number of deaths from hiv-aids, tuberculosis and malaria combined (3.8 million).1 motor vehicle accidents are the major cause of the injuries.2 the road transport management corporation (rtmc) reported 12 944 road fatalities in 2015. this figure increased by 22% in 2016, and is continuing to rise.3 the rtmc reports that it is committed to improving these figures by making roads and roadsides safer, strengthening traffic enforcement, setting appropriate speed limits, and encouraging road users to behave in a more responsible manner. despite these commitments, our annual road deaths remain high at 25 per 100 000 population. this figure is much higher than australia’s at 5/100 000, and a very populous india, with figures of 12/100 000.3 the problem with figures from traffic authorities is that they mainly report on deaths at the scene of the accident or soon thereafter, and not on those who die in hospital from the injuries.4 the figures also do not report on the number of patients that come to our emergency departments, which is our main concern as clinicians treating these patients. figures from the trauma unit in cape town show road traffic accidents accounting for 18.8% of the patients they treat, second to assault by sharp objects at 20.9%.5 parkinson et al. in pietermaritzburg calculated the cost of treating motor vehicle accident victims admitted over a ten-week period to be 698 850 usd.6 there is no publication that talks to the burden of orthopaedic trauma in our country that i could find. at steve biko academic hospital in pretoria, statistics for 2017 show that of the 3 968 operations performed by the orthopaedic department, 69.9% were for trauma. this leaves very little room for us to do non-trauma orthopaedics. various methods have been tried by orthopaedic units to make it easier to manage this trauma load. we have divided the orthopaedic departments into various units, trauma being one of them. unfortunately, because of the sheer number of patients, the trauma patients overflow to the non-trauma beds. and so does theatre time – the patient coming into hospital for a knee arthroscopy following an old sports injury simply cannot compete for theatre time with a patient with a grade iii open fracture of the tibia from a motor vehicle accident. the next thing we could do is to have separate hospitals for trauma. this would ensure that trauma is managed without interfering with the non-trauma orthopaedics. this, however, will take a long time to implement. commissioning of new hospitals is a complex process. the idea of separate hospitals for trauma would happen much quicker in situations where there are already two hospitals in close proximity to each other, where one of the two could be converted to a trauma-only hospital. there are quite a few towns in the country where there are two hospitals nearby each other. knowing the challenges we currently experience in the department of health, it might be better to look at tackling the problem of the burden of trauma from motor vehicle accidents from other fronts. a lot has been done in south africa (sa) to control hiv and malaria. the successes in these two diseases have involved dedicated work outside the hospitals. public awareness of the disease through programmes like love life and khomanani in the case of hiv, and involvement of other government departments in the case of malaria, have helped in reducing the burden of these diseases on the health system. paniker et al. support the idea that the response to the burden of road traffic injuries should be a multipronged one.7 this response should include: • increasing awareness and improving trauma data collection • involvement of international organisations and governments • individual and small-scale responses transferring these three points to our sa situation, this is how we could approach the problem of managing road traffic accidents. increasing awareness with improved data collection improving data collection is already underway in the main trauma units. we need to make it more uniform, as currently they are collecting different sets of data. we also need to expand it to all the emergency medicine departments in the country. the major impact we need to be making is on public awareness of the effect of motor vehicle accidents on health care delivery. the public knows that road accidents kill, but we have not stressed enough how they prevent us from delivering health services. to this end, we as the orthopaedic fraternity through our association, could approach the departments of transport or health to flight, for example, a tv advert of an elderly patient who is being turned new frontiers in the battle against the burden of musculoskeletal trauma from motor vehicle accidents prof mthunzi ngcelwane faculty of health sciences, head: department of orthopaedics, steve biko academic hospital, university of pretoria page 10 south african orthopaedic journal http://journal.saoa.org.za away from hospital admissions for a total hip replacement because a young man caught driving recklessly over the weekend is occupying the bed that was reserved for the old man. involvement of international organisations and governments the world health organisation (who) has declared 2011 to 2020 as the decade of action for road safety. sa is a signatory to this accord. the who hopes that by 2020 their action will have decreased road accident deaths by 5 million lives.8 currently, low and middle-income countries account for 90% of the deaths from road traffic accidents.9 sa is classified as a middle-income country by the world bank. unfortunately, as people at the forefront this trauma epidemic, we have not seen any changes as yet in the number of road trauma patients that reach our emergency departments. yes, there are new legislations that have been promulgated in the last few years aimed at reducing road fatalities, but their effect has yet to be seen. what we need to do, as the orthopaedic community, is to approach the department of transport about a need for tougher sanctions for transgressions of the rules of the road. this does not mean increasing the severity of the penalties, but ensuring there is a specific penalty for all types of motor vehicle offences. the department of transport should ensure that for each traffic offence, there is a consequence. emphasis can be just on the common offences, like exceeding the speed limit, beating a red robot, not stopping at a stop sign, and driving above the legal alcohol limit. we have to impress on the department of transport to adopt the attitude of the former mayor of new york, rudolph guiliani, in reducing crime in that city, by getting tough on minor crimes, in a policy referred to as ‘broken window’ policy.10 this is one way of making sure that outside the hospitals, we are taking action that will prevent the filling up of our wards with road accident trauma patients. individual and small-scale responses in the uk, the global health partnership was set up to assist with health care in developing countries. an example is the training they provide, and the support they give, to the college of surgeons of eastern, central and southern africa (cosecsa) in training health workers in these countries in trauma management.7 through our own outreach committee at the saoa, we could do the same, where those of us who work in the ‘medium-income’ sa could reach out to the ‘low-income’ sa, thus reducing the effect of the debilitation caused by the neglected trauma in the outlying hospitals. to reduce the burden of trauma from motor vehicle accidents in our public hospitals, we have to look beyond the confines of our hospitals and look at other frontiers for solutions. references 1. norton r, kobusingye o. injuries. n engl j med. 2013;368(18): 1723-30. 2. parkinson f, kent s, aldous c, oosthuizen g, clarke d. road traffic crashes in south africa: the burden of injury to a regional trauma centre. samj. 2013;103(11):850-82. 3. road traffic management corporation. annual report 2016. www. arrivealive.co.za (searched march 2018). 4. laing gl, skinner dl, bruce jl, aldous c, oosthuizen gv, clarke dl. understanding the burden and outcome of trauma care drivers a new trauma systems model. world journal of surgery. 2014;38(7):1699-706. 5. nicol a, knowlton lm, schuurman n, matzopoulos r, zargaran e, cinnamon j, fawcett v, taulu t, hameed m. trauma surveillance in cape town, south africa. an analysis of 9236 consecutive trauma centre admissions. jama surg. 2014;149(6):549-56. 6. parkinson f, kent sjw, aldous c, oosthuizen g, clarke d. the hospital cost of road traffic accidents at a south african regional trauma centre: a micro-costing study. injury, int j care injured. 2014;45:342-45. 7. paniker j, graham sm, harrison jw. global trauma: the great divide. sicot j. 2015;1(19). 8. who. the global burden of disease. 2012. geneva. world health organization. 9. global road safety facility. transport for health: the global burden of diseases from motorized road transport. 2014. washington, dc. the world bank. 10. the national bureau of economic research. www.nber.org. (searched april 2018). orthopaedics vol3 no4 page 22 sa orthopaedic journal summer 2015 | vol 14 • no 4 subclinical hypoperfusion in trauma patients and its influence on surgical fracture fixation: systematic review and meta-analysis dr b grey mbchb, hdip orth(sa), fcorth(sa), mmed(orth) orthopaedic surgeon, edendale hospital, pietermaritzburg and department of orthopaedics, nelson r mandela school of medicine, university of kwazulu-natal dr g oosthuizen mbchb, fcs(sa) clinical head: pietermaritzburg metropolitan trauma service, department of surgery, nelson r mandela school of medicine, university of kwazulu-natal, south africa dr r rodseth mbchb, fca, mmed, msc, phd head clinical unit: anaesthesia, grey’s hospital and perioperative research group, pietermaritzburg, university of kwazulu-natal and department of outcomes research, cleveland clinic, cleveland, ohio corresponding author: dr b grey department of orthopaedic surgery grey’s hospital private bag x9001 pietermaritzburg, south africa, 3201 tel: +27 338973299 email: bcgrey@gmail.com abstract introduction subclinical hypoperfusion (sch) is present when cellular hypoxia persists in the presence of normal vital signs. its presence, as well as duration, is associated with poor patient outcomes. different terminology and various definitions exist for sch. methods a systematic review was performed on the terminology and definitions used for sch. meta-analysis was performed on patients presenting with sch. primary study outcomes were mortality, icu length of stay, and hospital length of stay. when surgical fracture fixation was performed, we compared the incidence of postoperative ventilation, respiratory complications and infective complications in sch patients to patients without sch. results eight observational studies were eligible for systematic review and meta-analysis. sch is more commonly known as occult hypoperfusion, and lactate ≥ 2.5 mmol/l has been used most commonly to define hypoperfusion. patients presenting with sch had an increased mortality risk ratio of 4.02 (ci 2.62, 6.16). there was a non-significant increase in the standard mean difference for hospital length of stay for patients with sch (1.21 days, 95% ci [−0.22, 2.64]). when haemodynamically stable trauma patients underwent surgical fracture fixation prior to correction of sch they were at increased risk for post-operative ventilation (rr 2.54, 95% ci [1.56, 4.12]) as well as respiratory (or 3.88, 95% ci [1.38, 10.89]) and infective complications (or 5.54, 95% ci [2.02, 15.15]). conclusions trauma patients appearing haemodynamically stable should be screened for sch, especially when early surgical fracture fixation is required. key words: subclinical hypoperfusion, occult, lactate, meta-analysis http://dx.doi.org/10.17159/2309-8309/2015/v14n4a2 saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 22 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 23 background the resuscitation of hypotensive trauma patients has traditionally been based on clinical markers such as heart rate and blood pressure. for the majority of patients this strategy is highly effective; however, recent studies have suggested that a subset of patients will present with normal heart rate and blood pressure while still having a substantially elevated lactate, indicative of cellular hypoxia.1 this phenomenon has been termed subclinical or occult hypoperfusion (sch) and its presence, as well as duration, is correlated with poor patient outcomes.2-5 recent publications have suggested that patients with subclinical hypoperfusion, who undergo surgery in this state, experience worse outcomes.6,7 in this study we aimed to: 1) investigate the terminology and definitions used for sch; 2) undertake a systematic review and meta-analysis to determine the impact of sch in haemodynamically stable trauma or polytrauma patients on the outcomes of mortality, intensive care unit (icu) stay, and hospital stay; and 3) determine whether patients with sch, who undergo surgical fracture fixation, experience a higher rate of serious intraand postoperative complications. methods first, to identify the terminology and definitions used for sch, we conducted a systematic review, identified all studies dealing with this concept, and presented the results in a narrative fashion. second, to determine the impact of sch in haemodynamically stable trauma or polytrauma patients, we extracted those studies that identified patients with sch within a population of haemodynamically stable trauma patients. using data from these studies we then conducted meta-analyses to examine the impact of sch on the outcomes of mortality, icu length of stay, and hospital length of stay. third, to determine the impact of sch on patients who subsequently underwent surgical fracture fixation, we compared the incidence of ventilatory requirement, respiratory complications, and infective complications in sch patients who underwent surgery to those patients without sch who underwent surgery. study eligibility for this analysis we included all papers regardless of language, study design, sample size, publication status or date of publication. studies were excluded if they were non-clinical or if they included septic patients. for inclusion, studies had to define haemodynamic stability using both blood pressure and heart rate. study identification on 5 may 2013 we searched six databases (embase, ovid health star, ovid medline, cochrane central register of controlled trials, cochrane database of systematic reviews, proquest dissertations and theses a&i), consulted with experts, reviewed reference lists from identified articles, and searched for cited references of key publications in web of science. the search terms and databases used are listed in appendix 1. no language filters were used. eligibility assessment the title and abstract of each citation was independently screened by both bg and rr to identify potentially eligible studies. if either reviewer felt the citation might contain a relevant study, the article was retrieved to undergo full text evaluation. full texts of all citations identified as being potentially relevant were then independently evaluated by both bg and rr to determine eligibility. disagreements were solved by consensus. chance corrected interobserver agreement for study eligibility was tested using kappa statistics. appendix 1. search strategy and databases database searches were conducted on 5 may 2013 using the ovidsp search engine (ovid technologies, inc., new york, ny 2009) for the following databases: 1. embase 1980 to 2013 week 18 2. ovid health star (1966 to march 2013) 3. ovid medline(r) in-process & other non-indexed citations and ovid medline(r) 1946 to may 5 2013 4. cochrane central register of controlled trials (may l 2013) 5. cochrane database of systematic reviews (may l 2013) 6. proquest dissertations and theses a&i (may l 2013) example of search conducted in ovid search terms 78 1. occult hypoperfusion.mp. 78 2. occult hypoperfusion.mp. 78 3. subclinical hypoperfusion.mp. 4 4. subclinical shock.mp. 2 5. occult shock.mp. 34 6. cellular shock.mp. 16 7. cellular dysoxia.mp. 15 8. 2 or 3 or 4 or 5 or 6 or 7 148 9. remove duplicates from 8 70 subclinical or occult hypoperfusion (sch) and its presence, as well as duration, is correlated with poor patient outcomes saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 23 page 24 sa orthopaedic journal summer 2015 | vol 14 • no 4 data collection and assessment of study quality data was extracted to an excel spreadsheet recording: principle author, study design, total number of study patients, number of patients with sch, number of patients without sch, mortality, icu length of stay, hospital length of stay, respiratory complications and infective complications. authors were contacted to provide original patient data when it was insufficient for meta-analysis. study quality was evaluated using the newcastle ottowa scale.8 statistical analysis meta-analysis was conducted using a random effects model in review manager version 5.1. (copenhagen: the nordic cochrane centre, the cochrane collaboration, 2011). heterogeneity was assessed using i2 and chi-squared analysis. pooled dichotomous outcomes were reported as risk ratios (rr), odds ratios (or) and 95% confidence intervals (ci). continuous outcomes were reported as standard mean difference and 95% ci. we constructed a funnel plot to assess the possibility of publication bias. results after having reviewed the results from our systematic review, in addition to articles identified in study reference and by experts, we present a narrative review of the terminology and definitions used for sch. when cellular hypoperfusion is present in patients with normal vital signs, a state of sch exists. sch has previously been referred to as occult hypoperfusion or occult shock and when caused by severe sepsis is commonly known as cryptic shock.9 however, we believe sch is a more appropriate term for this pathophysiological process as the hypoperfusion is not occult, but rather subclinical, and can easily be detected by the presence of raised lactate or base deficit. sch has been well described in elderly trauma patients. this is due in part to the presence of medical comorbidities and the concurrent use of medications such as β-blockers that may mask the conventional signs of shock in these populations.1,4,5,10–12 it has also been described in younger trauma patients when vital signs have been restored back to normal, but where persistent cellular hypoperfusion and oxygen debt remain.1 table i: varying definitions of subclinical hypoperfusion (sch) study terminology definition of haemodynamic stability method of sch diagnosis blow, 19992 occult hypoperfusion sbp > 100 mmhg, heart rate < 120 bpm, urine output > 1 ml/kg/h la > 2.5 mmol/l claridge, 20003 occult hypoperfusion sbp > 100 mmhg, heart rate < 120 bpm, urine output > 1 ml/kg/h la ≥ 2.5 mmol/l crowl, 20006 occult hypoperfusion sbp > 100 mmhg, heart rate < 120 bpm, urine output > 1 ml/kg/h la ≥ 2.5 mmol/l schulman, 200427 occult hypoperfusion n/a la ≥ 2.5 mmol/l ikossi, 200635 occult shock, occult under-resuscitation map ≥ 70 mmhg, heart rate ≤ 110 bpm pmo2 ≤ 25 for at least 2 hours jansen, 200813 occult shock sbp ≥ 100 mmhg la ≥ 3.5 mmol/l callaway, 200912 occult hypoperfusion sbp ≥ 90 mmhg la ≥ 2.5 mmol/l or bd > 0 meq/l martin, 20104 occult hypoperfusion sbp ≥ 90 mmhg, heart rate < 120 bpm la > 2.2 mmol/l or bd < −2 meq/l thom, 201015 occult hypoperfusion sbp ≥ 100 mmhg, heart rate ≤ 110 bpm, temperature > 35 °c ci < 2.6 l/minute/m² or be ≤ 3 meq/l or si ≥ 0.9 or rope ≥ 3.0 corradi, 201116 occult haemorrhagic shock sbp ≥ 90 mmhg, urine output ≥ 30 ml/h la ≤ 2 mmol/l no vasoactive drug support sch not identified renal doppler ri used to predict haemorrhagic shock corradi, 201217 occult haemorrhagic shock sbp ≥ 90 mmhg, no vasoactive drug support sch not identified splenic doppler ri used to predict haemorrhagic shock grey, 20137 subclinical hypoperfusion map ≥ 60 mmhg, heart rate < 110 bpm la ≥ 2.5 mmol/l salottolo, 20135 occult hypoperfusion sbp ≥ 90 mmhg, heart rate < 120 bpm venous la ≥ 2.5 mmol/l zakrison, 201314 occult shock sbp > 100 mmhg, heart rate < 110 bpm bd ≥ 4 mmol/l sbp = systolic blood pressure; map = mean arterial pressure; la = lactate; bd = base deficit; be = base excess; pmo2 = licox polarographic tissue oxygen monitor; ci = cardiac index; si = shock index; rope = rate over pressure evaluation; ri = resistive index saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 24 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 25 various definitions and modalities have been used to define both haemodynamic stability and sch (table i). haemodynamic stability definitions have generally included both systolic blood pressure (sbp) as well as heart rate while some have included mean blood pressure (map) and urine output in the definition. for the most part cellular hypoperfusion has been defined as a lactate ≥ 2.5 mmol/l but some studies have used a higher lactate threshold,13 base deficit,4,12,14 markers of impaired cardiac output15 or organ hypoperfusion.16,17 to address our second objective we reviewed the 188 articles that met our search criteria (181 identified through the electronic database search; seven articles identified in references) and identified 33 articles for full text review. the chance corrected inter-observer agreement was excellent (kappa = 0.78). of these 33 articles, 25 were excluded after full text review as: sch was not identified in 12 studies;10,16–26) four did not include vital signs or pulse rate in their definition of haemodynamic stability;11–13,27 two included patients with sepsis;28,29 the patient population in one study was similar to another study;5,30 one study did not investigate the outcome of patients with sch;14 two citations were editorials or letters to the editor;31,32 and one citation was a review article.1 we were unable to obtain two articles as they did not provide correspondence details.33,34 eight studies were therefore eligible for meta-analysis (figure 1). these were all observational studies and their study quality and population characteristics are summarised in tables ii and iii. seven of the eight studies included in the meta-analysis reported mortality, providing a total of 678 patients with sch (figure 2, supplementary data). patients presenting with sch had an increased mortality risk ratio of 4.02 (ci 2.62, 6.16). the pooled results were homogenous (i2 = 0%) and no publication bias was evident on the funnel plot (figure 3, supplementary data). only four of the studies provided data for hospital length of stay (figure 4, supplementary data). there was a non-significant increase in the standard mean difference for hospital length of stay for patients with sch (1.21 days, 95% ci [−0.22, 2.64]) and this result showed considerable heterogeneity (i2 = 99%). insufficient data were available to analyse icu length of stay as it was only reported on by two articles.3,4 table ii. newcastle-ottawa scale assessment of study quality8 study study design selection of study group (maximum = 4 stars) comparability of groups (maximum = 2 stars) ascertainment of outcome (maximum = 3 stars) blow2 retrospective cohort hhhh hh hhh claridge3 prospective cohort hhhh h hhh crowl6 retrospective cohort hhh hh hhh ikossi35 prospective cohort hhhh nil hhh martin4 retrospective cohort hh h hhh thom15 prospective cohort hhhh h hhh grey7 retrospective cohort hhh hh hhh salottolo5 retrospective cohort hh hh hhh figure 1. study selection process sch = subclinical hypoperfusion articles identified through electronic database search (n = 181) additional articles identified through references (n = 7) abstracts screened (n = 188) articles excluded during screening process (n = 155) full-text articles assessed for eligibility (n = 33) full-text articles excluded (n = 25) studies included in qualitative synthesis: 8 eligible studies 12 – sch not identified 4 – sch not well defined 2 – studies included patients with septic shock 1 – similar study population as another study 2 – editorial/letter to the editor 1 – review 1 – study did not investigate outcome of patients with sch 2 – studies not available in sch, the hypoperfusion is subclinical, and can easily be detected by the presence of raised lactate or base deficit saoj summer 2015_press_orthopaedics vol3 no4 2015/11/02 11:57 am page 25 page 26 sa orthopaedic journal summer 2015 | vol 14 • no 4 for our third objective we identified only two studies that investigated outcomes in patients undergoing surgical fracture fixation in the presence of sch.6,7 crowl et al. reported on the incidence of post-operative complications among patients with sch undergoing intramedullary nailing of femur fractures in the first 24 hours post admission.6 different systemic complications were noted, including respiratory, cardiac, haematologic, neurologic, gastrointestinal, musculoskeletal and infectious. patients with sch had significantly more post-operative complications. thirty-five complications were encountered in the 20 patients with sch, compared with 11 complications in the control group of 27 patients. ventilation requirement was also reported. thirteen patients with sch required ventilation, compared with only five patients from the control group. the study by grey et al. reported on the outcome of polytrauma patients with sch undergoing early surgical fracture stabilisation.7 their primary findings were higher inotrope requirements in the first 24 hours post-operatively (p = 0.02) and higher sequential organ failure assessment (sofa) scores on day three (p = 0.003) in the sch group. for the purposes of this meta-analysis the original data from grey’s study were used to investigate the outcomes of ventilation requirement, respiratory complications and infective complications. when haemodynamically stable trauma patients underwent surgical fracture fixation prior to correction of sch they had an increased likelihood for ventilation postoperatively (rr 2.54, 95% ci [1.56, 4.12]) and a higher incidence of respiratory (or 3.88, 95% ci [1.38, 10.89]) and infective complications (or 5.54, 95% ci [2.02, 15.15]) (figures 5–7, supplementary data). discussion statement of principle findings first, our systematic review of the literature identified a wide range of definitions for sch, the majority of which included a lactate measurement ≥ 2.5 mmol/l in the presence of normal haemodynamic parameters (table i). secondly, meta-analysis found patients with sch were at increased risk of mortality (rr 4.02; 95% ci 2.62–6.16; i2 = 0%) and showed a non-significant increase in hospital length of stay (mean difference 1.21 days; 95% ci −0.22–2.64; i2 = 99%). finally, patients with sch who underwent surgical fracture fixation within the first 24 hours of presentation required more ventilation (rr 2.54, 95% ci 1.56–4.12; i2 = 0%), and were at a higher risk of respiratory (or 3.88, 95% ci 1.38–10.89; i2 = 0%) and infective complications (5.54, 95% ci 2.02–15.15, i2 = 0%). table iii. study characteristics study population total population of stable patients (mean, sd) sch patients (mean, sd) no sch (mean, sd) size (n) age iss size (n, %) age iss age iss blow, 19992 polytrauma patients: iss ≥ 20 79 43 (19) 28 (6.4) 58 (73.4) 44.7 (19.9) 29.2 (6.1) 42 (14.6) 26 (4.2) claridge, 20003 trauma patients admitted to icu 364 43.7 (2.0) 23.8 (1.1) 246 (67.6) 43.2 (2.1) 24.9 (1.2) 45.1 (1.9) 20.3 (1) crowl, 20006 trauma patients with femur fractures fixed < 24 hours 47 n/a 19.21 (8.2) 20 (42.6) n/a 21 (10.66) n/a 17.42 (6.34) ikossi, 200635 trauma patients admitted to icu, ais ≥ 3 in any body region 14 40 (18) n/a 4 (28.6) n/a n/a n/a 29 (10) martin, 20104 geriatric trauma patients > 65 years 72 n/a 8.18 28 (38.9) n/a 10.5 n/a 6.7 thom, 201015 polytrauma patients: iss > 15 or significant injury to ≥ two body regions 62 52 (21) 19 (11) 7 (11.3) 58 (20) 29 (9) 49 (21) 17.7 (11.3) grey, 20137 polytrauma patients: niss > 16 36 35.8 (14.9) 24.67 (10.871) 19 (52.8) 37.3 (15.37) 32.1 (8.42)* 34.2 (14.37) 28 (9.55)* salottolo, 20135 geriatric trauma patients ≥ 65 years 1416 79 9 300 (21.2) n/a n/a n/a n/a iss = injury severity score; ais = abbreviated injury scale; *niss = new injury severity score saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 26 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 27 strengths and weakness of this review there were several limitations to this meta-analysis. there has been very little published on sch and the eight studies included in the meta-analysis were all observational studies. however, these studies were all of good quality as measured by the newcastle–ottowa scale (table ii). the study populations in the eight papers were all trauma patients with variable injury severity and age groups. three papers investigated sch in polytrauma patients2,7,15 and different definitions of polytrauma were used; blow et al. defined polytrauma as iss > 20; thom et al. defined polytrauma as iss > 15 or significant injury to two or more body regions; and grey et al. used the new injury severity score (niss) > 16 to define polytrauma. two papers included trauma patients admitted to intensive care units but did not score the injury severity.3,35 the study by crowl et al. investigated trauma patients with femur fractures that were fixed with intramedullary nails within the first 24 hours.6 twelve out of the 20 patients with sch had iss > 18. two studies focused on sch in the elderly (> 65 years) trauma population but did not select patients based upon their iss.4,5 only two studies with small patient numbers were available for the third objective of this meta-analysis to determine the impact of sch on trauma patients going for surgical fracture fixation.6,7 figure 2. forest plot comparing risk ratios for mortality in patients presenting with subclinical hypoperfusion (sch) m–h = mantel–haenszel; ci = confidence interval figure 3. funnel plot showing distribution of treatment effect of studies investigating mortality in patients presenting with sch figure 4. forest plot comparing standard mean difference in hospital length of stay in days for patients presenting with subclinical hypoperfusion (sch) ci = confidence interval these studies were all of good quality as measured by the newcastle–ottowa scale saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 27 page 28 sa orthopaedic journal summer 2015 | vol 14 • no 4 interpretation and implication of findings this analysis highlights a few key points with regard to sch in the trauma population. various definitions have been used to describe haemodynamic stability and sch (table i). the target systolic blood pressure and mean arterial pressure in trauma patients is debatable, and is influenced by the patient’s age, cardiovascular conditioning and other medical comorbidities. the systolic blood pressures or mean arterial pressures used in the included studies were adequate in selecting clinically apparent haemodynamically stable patients, provided the pulse rate was also normal. to allow for the normal sympathetic response to trauma and pain, the maximum heart rate used to define haemodynamic stability in all the studies was either 110 or 120 beats per minute. our study emphasises the use of cellular hypoperfusion markers rather than traditional vital signs in the assessment of shock and resuscitation. the most common marker used to identify sch was lactate. most authors chose a minimum value of 2.5 mmol/l to define cellular hypoperfusion. in the presence of normal vital signs this was accurate in identifying sch. more direct ways to detect hypoperfusion have been investigated such as the licox polarographic tissue oxygen monitor that measures partial pressure of oxygen in deltoid muscle35 as well as renal – and splenic doppler resistive indices.16,17 these indices should be investigated further as possible markers for sch. this study affirms other studies that show that trauma patients presenting with sch have worse outcomes. even though these patients appeared haemodynamically stable, they still had a four-fold higher mortality than patients without sch. all trauma patients and especially polytrauma patients need to be screened for sch by having lactate or base deficit measured. a recent survey among canadian traumatologists revealed that even though 78% of respondents were aware of sch, only 8% were screening for sch.36 a further 88% felt that they should be screening for sch. figure 5. forest plot comparing ventilation requirement for patients with sch undergoing surgery m–h = mantel–haenszel; ci = confidence interval figure 6. forest plot comparing the incidence of respiratory complications among patients with sch undergoing surgery m–h = mantel–haenszel; ci = confidence interval figure 7. forest plot comparing the incidence of post-operative infective complications among patients with sch m–h = mantel–haenszel; ci = confidence interval our study emphasises the use of cellular hypoperfusion markers rather than traditional vital signs in the assessment of shock and resuscitation saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 2 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 29 our study also showed that surgical fracture fixation in the presence of sch was associated with increased perioperative morbidity. even though only two studies with small patient numbers were available for this part of the meta-analysis, both studies were of good quality. both these studies investigated fracture fixation in the presence of sch. the timing and the type of fracture fixation in the trauma patient is influenced by the haemodynamic state of the patient. early definitive fracture fixation, also known as ‘early total care’, has been advocated in haemodynamically stable polytrauma patients.37–39 this has been shown to reduce fat embolism syndrome (fes), acute respiratory distress syndrome (ards), pneumonia and icu length of stay. we advocate delaying early definitive fracture fixation in haemodynamically stable trauma patients with sch until resuscitation is complete. while aiming to do early definitive fixation in the first 24 hours, o’toole et al. safely delayed femoral nailing in polytrauma patients (iss > 17) until resuscitation was complete as evidenced by a normalising lactate.40 femoral nailing started more than 8 hours after admission to theatre in 48% of their patients and this approach was associated with an ards rate of 1.5% and a mortality rate of 2%. future research very little research has been done into sch and no randomised controlled trials have been conducted on the subject. we know that both the presence of sch and surgery in the presence of sch is detrimental, but prospective randomised controlled trials are required to prove that patients presenting with sch have improved outcomes when surgery is delayed until lactate normalises. conclusion sch is most commonly defined as serum lactate ≥ 2.5 mmol/l in the presence of normal vital signs. the presence of sch in clinically stable trauma patients was associated with a four-fold increase in mortality risk as well as a non-significant increase in hospital length of stay. trauma patients should therefore be screened for sch. trauma patients who underwent surgical fracture fixation in the presence of sch required more ventilation and were at a higher risk of respiratory and infective complications. when possible, fracture fixation should be delayed until sch is corrected. prospective randomised controlled trials are needed to investigate this further. the content of this article is the original work of the authors. no benefits of any form have been or are to be received from a commercial party related directly or indirectly to the subject of this article. references (underlined references included in meta-analysis) 1. barbee rw, reynolds ps, ward kr. assessing shock resuscitation strategies by oxygen debt repayment. shock. [review]. 2010 february;33(2):113-22. 2. blow o, magliore l, claridge ja, butler k, young js. the golden hour and the silver day: detection and correction of occult hypoperfusion within 24 hours improves outcome from major trauma. j trauma. 1999 nov;47(5):964-69. 3. claridge ja, crabtree td, pelletier sj, butler k, sawyer rg, young js. persistent occult hypoperfusion is associated with a significant increase in infection rate and mortality in major trauma patients. j trauma. 2000 jan;48(1):8-14; discussion -5. 4. martin jt, alkhoury f, o’connor ja, kyriakides tc, bonadies ja. ‘normal’ vital signs belie occult hypoperfusion in geriatric trauma patients. am surg. 2010 jan;76(1):65-69. 5. salottolo km, mains cw, offner pj, bourg pw, bar-or d. a retrospective analysis of geriatric trauma patients: venous lactate is a better predictor of mortality than traditional vital signs. scand j trauma resusc emerg med. 2013;21:7. 6. crowl ac, young js, kahler dm, claridge ja, chrzanowski ds, pomphrey m. occult hypoperfusion is associated with increased morbidity in patients undergoing early femur fracture fixation. j trauma. 2000 feb;48(2):260-67. 7. grey b, rodseth rn, muckart dj. early fracture stabilisation in the presence of subclinical hypoperfusion. injury. 2013 feb;44(2):217-20. 8. newcastle-ottawa quality assessment scale. ottawa health research institute; [1 january 2014]; http://www.ohri.ca/programs/clinical_epidemiology/n osgen.doc]. 9. puskarich ma, trzeciak s, shapiro ni, heffner ac, kline ja, jones ae. outcomes of patients undergoing early sepsis resuscitation for cryptic shock compared with overt shock. resuscitation. 2011 oct;82(10):1289-93. 10. scalea tm, simon hm, duncan ao, atweh na, sclafani sj, phillips tf, shaftan gw. geriatric blunt multiple trauma: improved survival with early invasive monitoring. j trauma. 1990 feb;30(2):129-34; discussion 34-6. 11. schulman am, claridge ja, young js. young versus old: factors affecting mortality after blunt traumatic injury. am surg. 2002 nov;68(11):942-47; discussion 7-8. 12. callaway dw, shapiro ni, donnino mw, baker c, rosen cl. serum lactate and base deficit as predictors of mortality in normotensive elderly blunt trauma patients. j trauma. 2009 apr;66(4):1040-44. 13. jansen tc, van bommel j, mulder pg, rommes jh, schieveld sj, bakker j. the prognostic value of blood lactate levels relative to that of vital signs in the prehospital setting: a pilot study. critical care (london, england). 2008;12(6):r160. 14. zakrison t, mcfarlan a, wu yy, keshet i, nathens a. venous and arterial base deficits: do these agree in occult shock and in the elderly? a bland-altman analysis. journal of trauma and acute care surgery. 2013 march;74(3):936-39. saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 29 page 30 sa orthopaedic journal summer 2015 | vol 14 • no 4 15. thom o, taylor dm, wolfe re, myles p, krum h, wolfe r. pilot study of the prevalence, outcomes and detection of occult hypoperfusion in trauma patients. emergency medicine journal. 2010 june;27(6):470-72. 16. corradi f, brusasco c, vezzani a, palermo s, altomonte f, moscatelli p, pelosi p. hemorrhagic shock in polytrauma patients: early detection with renal doppler resistive index measurements. radiology. 2011 jul;260(1):112-18. 17. corradi f, brusasco c, garlaschi a, santori g, vezzani a, moscatelli p, pelosi p. splenic doppler resistive index for early detection of occult hemorrhagic shock after polytrauma in adult patients. shock. 2012 nov;38(5):46673. 18. bradburn e, rogers fb, krasne m, rogers a, horst ma, beelen mj, miller ja. high-risk geriatric protocol: improving mortality in the elderly. j trauma acute care surg. 2012 aug;73(2):435-40. 19. chytra i, pradl r, bosman r, pelnar p, kasal e, zidkova a. esophageal doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial. crit care. 2007;11(1):r24. 20. guyette fx, gomez h, suffoletto b, quintero j, mesquida j, kim hk, hostler d, puyana jc, pinsky mr. prehospital dynamic tissue oxygen saturation response predicts inhospital lifesaving interventions in trauma patients. j trauma acute care surg. 2012 apr;72(4):930-35. 21. rogers a, rogers f, bradburn e, krasne m, lee j, wu d, edavettal m, horst m. old and undertriaged: a lethal combination. am surg. 2012 jun;78(6):711-15. 22. abramson d, scalea tm, hitchcock r, trooskin sz, henry sm, greenspan j. lactate clearance and survival following injury. j trauma. 1993 oct;35(4):584-88; discussion 8-9. 23. manikis p, jankowski s, zhang h, kahn rj, vincent jl. correlation of serial blood lactate levels to organ failure and mortality after trauma. am j emerg med. 1995 nov;13(6):619-22. 24. lipsky am, gausche-hill m, henneman pl, loffredo aj, eckhardt pb, cryer hg, de virgilio c, klein sl, bongard fs, lewis rj. prehospital hypotension is a predictor of the need for an emergent, therapeutic operation in trauma patients with normal systolic blood pressure in the emergency department. j trauma. 2006 nov;61(5):1228-33. 25. morshed s, corrales la, lin k, miclau t. femoral nailing during serum bicarbonate-defined hypo-perfusion predicts pulmonary organ dysfunction in multi-system trauma patients. injury. 2011 jul;42(7):643-49. 26. guyette f, suffoletto b, castillo jl, quintero j, callaway c, puyana jc. prehospital serum lactate as a predictor of outcomes in trauma patients: a retrospective observational study. j trauma. 2011 apr;70(4):782-86. 27. schulman am, claridge ja, carr g, diesen dl, young js. predictors of patients who will develop prolonged occult hypoperfusion following blunt trauma. journal of trauma injury, infection and critical care. 2004 october;57(4):795800. 28. yu m, morita sy, daniel sr, chapital a, waxman k, severino r. transcutaneous pressure of oxygen: a noninvasive and early detector of peripheral shock and outcome. shock. 2006 nov;26(5):450-56. 29. lawniczak ra, jones-bamman c, dugas a, giberson t, cocchi mn, donnino m. 313 evaluation of the management and outcome of patients with occult hypoperfusion in the emergency department. annals of emergency medicine. 2011;58(4):s283. 30. bar-or d, salottolo km, orlando a, mains cw, bourg p, offner pj. association between a geriatric trauma resuscitation protocol using venous lactate measurements and early trauma surgeon involvement and mortality risk. j am geriatr soc. 2013 aug;61(8):1358-64. 31. honore pm, joannes-boyau o, boer w, collin v. regional occult hypoperfusion detected by lactate and sequential organ failure assessment subscores: old tools for new tricks? critical care medicine. [editorial]. 2009 august;37(8):2477-78. 32. kepros jp. occult hypoperfusion and long-bone fixation. j trauma. 2002 jan;52(1):189. 33. zakrison tl, soklaridis s, rizoli s. ‘we train our jewelers better than our trauma surgeons’ how global trauma surgeons recognize occult shock. the journal of surgical research. 2013;179(2):344. 34. rodriguez a, vetere l, egurrola a, hernandez m, chiacchiara d, pusajo j. significance of different levels of gastric intramural ph. [spanish] significacion de diferentes niveles de ph intramural gastrico. medicina intensiva. 1998 february;22(2):55-59. 35. ikossi dg, knudson mm, morabito dj, cohen mj, wan jj, khaw l, stewart cj, hemphill c, manley gt. continuous muscle tissue oxygenation in critically injured patients: a prospective observational study. journal of trauma injury, infection and critical care. 2006 october;61(4):780-88. 36. zakrison t, leung e, mccredie v, nathens a, diez c, rizoli s, namias n. canadian traumatologists and the recognition of occult shock: results of a national survey. panam j trauma critical care emerg surg. 2013;2(1):33-36. 37. johnson kd, cadambi a, seibert gb. incidence of adult respiratory distress syndrome in patients with multiple musculoskeletal injuries: effect of early operative stabilization of fractures. j trauma. 1985 may;25(5):375-84. 38. seibel r, laduca j, hassett jm, babikian g, mills b, border do, border jr. blunt multiple trauma (iss 36), femur traction, and the pulmonary failure-septic state. ann surg. 1985 sep;202(3):283-95. 39. bone lb, johnson kd, weigelt j, scheinberg r. early versus delayed stabilization of femoral fractures. a prospective randomized study. j bone joint surg am. 1989 mar;71(3):336-40. 40. o’toole rv, o’brien m, scalea tm, habashi n, pollak an, turen ch. resuscitation before stabilization of femoral fractures limits acute respiratory distress syndrome in patients with multiple traumatic injuries despite low use of damage control orthopedics. j trauma. 2009 nov;67(5):1013-21. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 30 404 not found 404 not found saoj autumn 2017.qxp_orthopaedics vol3 no4 2017/02/27 7:42 pm page 15 orthopaedics vol3 no4 page 18 sa orthopaedic journal autumn 2015 | vol 14 • no 1 private practice (rwops) and overtime for state-employed specialists letter to the editor limited private practice (lpp) for state-employed specialists was introduced in 1994 to compensate for the poor salaries paid by government, at a time when the country was unable to afford appropriate salary increases. around the same time, a fixed overtime allowance replaced the professional allowance previously paid to professionals in the public service in recognition of their higher qualifications and irregular working hours. in 2001 the lpp system was modified and re-named ‘remuneration for work outside the public service’ or rwops. from the beginning the concept of private practice was a necessary evil. it was evil because it was open to blatant exploitation by some participants, but necessary because it was the only way to keep competent specialists working in the unsatisfactory conditions of the public health system. recently, dissatisfaction with rwops at national and provincial government level has led to it being labelled as fraudulent, with the possibility of it being severely limited or banned. the questions are whether conditions in the public service have improved to the extent that rwops can be dispensed with, and what the implications might be if it were stopped. the arguments in favour of rwops being continued are professional and financial: 1. government considers that the occupational specific dispensation (osd) has removed the need for additional income for specialists; in fact osd has not brought state salaries anywhere near the income of private specialists. this is aggravated by failure to award deserved promotions and bonuses to many specialists in state hospitals. their careers have stalled with no hope of further progress and no incentive to continue working for the state. 2. academic/provincial practice is too restricted to allow surgeons to grow in their speciality. the collapse of the state hospital system with inadequate beds and theatre time, combined with obsolete equipment and underfunding for implants and procedures, all cause enormous frustration among our specialists. this dissatisfaction is relieved by private work, allowing them to continue to work in the public service. the skills so acquired are fed back into the state system to the benefit of patients and trainees. 3. the spectrum of procedures we can perform in academic/state practice is inadequate for training registrars in modern surgery. we need access to the private sector for registrar-training opportunities. 4. without rwops, no expenses such as congress and professional society fees, books, travel, etc., are tax deductible for a state-employed specialist. sars’ position is that the employer is responsible for these costs, many of which are essential to gain the cpd points needed to maintain registration with the hpcsa, a prerequisite for state employment. however the department of health is not prepared to finance these expenses. 5. income from private work is taxed at the maximum rate, at present 40%. so the rwops specialist subsidises his own state salary to a significant extent by the tax he pays. with the tax on rwops income of r1.87 million/year a senior specialist will repay his own after-tax salary, including overtime, and his services to the state cost the government nothing. 6. rwops specialists offer a valuable service to the community, usually in cooperation with their private colleagues; obvious examples are unusual skills such as transplant surgery or the after-hours orthopaedic trauma service in private hospitals which is often run largely by academic specialists. if rwops is stopped or curtailed there will predictably be a mass exodus from the public service, with a further decline in the already abysmal standard of health care for the majority of this country’s population. equally important would be the threat to our training centres at a time when the government accepts the need to dramatically increase our numbers of preand post-graduate medical trainees. over the past few years, rwops (remuneration for work outside the public service) has been blamed for much of the failure of service delivery in public hospitals with allegations that doctors spend more time in their private practices than performing their duties in state hospitals. the reality is that rwops has been one of the main factors retaining specialists and their valuable skills in the decaying public hospital system, and that withdrawal or curtailment of rwops will potentially cripple the public health system at secondary and tertiary levels. recently, dissatisfaction with rwops at national and provincial government level has led to it being labelled as fraudulent, with the possibility of it being severely limited or banned saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 18 sa orthopaedic journal autumn 2015 | vol 14 • no 1 page 19 less attention has been paid to the implications for the private sector: 1. competition for already inadequate private hospital facilities and beds by specialists leaving the state for private practice will put the private hospital groups in a position where they can dictate their own terms for access to their limited facilities. 2. competition for work when there is pressure to reduce medical costs will diminish specialists’ bargaining power with the medical schemes about appropriate tariffs. 3. the result is that private specialists will lose their independence, being forced into managed health care systems and the potential compromise of professional standards. we shall lose our voice in the decision-making levels of health care, being relegated to the status of employees participating only by courtesy of the administrators of hospital and funding groups. 4. many specialists will simply emigrate. inevitably they will be the younger and most employable people – the specialists we can least afford to lose. the pool of specialists is already ageing, and within a decade the country may well be left without a corps of experienced specialists, leaders and teachers. 5. it may not be paranoid to see this as the first step towards a privatised national health insurance system with lucrative contracts awarded to private sector managed health care. it is unlikely that the state can afford to rebuild the hospitals and service systems it has allowed to collapse; investment by private hospital groups would be an obvious solution, and if doctors could be forced into working in these hospitals for financial reasons, staffing problems would also be solved. i believe medicine should be a socially responsible profession, but realistically it has also become a business; if so, doctors should be able to compete for their rewards on equal terms and not be dominated by other commercial interests, namely the private hospitals and medical aid groups. clearly abolition of rwops could easily cause irreversible damage to all levels of health delivery and training in this country. it is in the interests of all specialist groups to support the retention of rwops, or to suggest practical alternatives to keep specialists in state hospitals. the biggest single problem in the present form of rwops is the difficulty in controlling the amount of private practice performed by a specialist, and there are many areas of uncertainty about this issue. 1. should rwops be time-based, or should it be unrestricted provided the quality of service provided to the state is satisfactory irrespective of hours worked? in other words is the specialist being paid a salary for his time or for a defined service? 2. where should rwops be performed? if capacity or conditions in public hospitals are inadequate, can rwops be denied? if rwops is practised in private hospitals, how can it be controlled? 3. how should each doctor be monitored and by whom? 4. what would be appropriate penalties for exceeding agreed limits of practice? 5. would specialists accept employment in 5/8 posts or sessions with unlimited rwops outside these hours, and would this provide an adequate service level? 6. rwops and overtime may be seen as conflicting commitments. would specialists be prepared to choose one of two options: overtime payment with no rwops or alternatively being allowed rwops while still providing an unpaid after-hours service? 7. would it not be easiest to simply cap earnings from rwops and let sars be the monitor? it is vital that the department of health debates these and related aspects with the specialist groups, and not attempt to impose a unilateral decision which will certainly be challenged legally. government must understand that any authoritarian curtailment of rwops will probably lead to a mass exodus of specialists, and the collapse of the state hospital and training systems. it is encouraging that sama has already started to prepare itself for negotiations, and i believe that every doctor should be a member of our legal trade union, and not just our specialist associations. in the long term, the whole question of specialist services in public hospitals needs to be reviewed. it must be remembered that although financial gain from rwops is important, it is far from the only issue for most state-employed doctors. rwops also provides enormous personal and professional satisfaction that is sadly lacking in the overloaded, under-resourced public hospitals, and could provide valuable training opportunities for registrars. academic and secondary hospitals urgently need improved financing and revitalisation programmes to make a public service career more attractive to specialists. south africa should perhaps consider a system like new zealand’s, where all specialists are in private practice, but also work part-time for the state. should rwops be stopped, realistic financial compensation would be needed – say 50% of salary – guaranteed to be increased annually in line with the reference price list or its replacement. this, of course, would bring us back to the original reason for rwops, and would still not improve the unsatisfactory working conditions of a public service specialist. until conditions in the public service improve, rwops remains a necessary evil. but it must be better controlled and used for teaching. ja shipley acting head: department of orthopaedics university of the free state saoj autumn 2015_orthopaedics vol3 no4 2015/03/11 5:56 pm page 19 page 53south african orthopaedic journal http://journal.saoa.org.za saoj south african orthopaedic journal. cpd questionnaire. may 2019 vol 18 no 2 posterior based circumferential spinal cord decompression in paediatric patients with the vertebral column resection (vcr) technique spares the anterior approach in severe kyphosis (dunn rn, horn a) 1. posterior vertebral column resection in paediatric patients does not: a. obviate intra-operative re-positioning and draping a b. require nerve root sacrifice b c. involve rib resection c d. expose the lung d e. allow circumferential thecal decompression e 2. posterior vertebral column resection in kyphotic myelopathic paediatric patients will: a. improve neurological status in most cases a b. allow sagittal plane correction b c. allow resolution of syringomyelia c d. lengthen the spinal column and increase cord tension d e. reduce operative time in comparison to dual approaches e 3. posterior vertebral column resection does not involve: a. laminectomy a b. extensive thecal retraction b c. bilateral costotransversectomies c d. preferably transcranial motor evoked potential monitoring d e. nerve root sacrifice e a survey of the use of traction for the reduction of cervical dislocations (workman mi, kruger n) 4. a rugby player is referred by your emergency room 2 hours after injury with a c5/6 bifacet cervical dislocation diagnosed on x-rays, motor complete (frankel a). your immediate management is: a. closed cervical skeletal traction reduction without mri a b. closed cervical skeletal traction reduction after mri b c. urgent open reduction in theatre without mri c d. urgent open reduction in theatre after mri d e. reduction on next available theatre slate e 5. in a cervical dislocation with normal or partial neurology, what is the risk of causing permanent neurological deterioration during closed cervical traction reduction? a. >75% a b. 50%–75% b c. 25%–50% c d. 1%–25% d e. <1% e 6. what is the time frame, as stipulated by the constitutional court, in which a cervical spine reduction should be performed following a facet dislocation? a. within 4 hours of arrival at the emergency rooms a b. within 4 hours of being assessed by an orthopaedic surgeon or neurosurgeon b c. within 4 hours of diagnosis by ct or mri scan of cervical dislocation c d. within 4 hours of injury d e. within 4 hours of neurological deterioration e epidemiology and injury severity of 294 extremity gunshot wounds in ten months: a report from the cape town trauma registry (engelmann ewm, maqungo s, laubscher m, hoppe s, roche s, nicol a, navsaria p, held m) 7. which statement is true regarding the referrals of gunshotrelated injuries? a. most injuries required tertiary care a b. time to admission was shorter in patients with higher injury severity b c. most patients with lower injury severity were transferred during the day time c d. most patients were from the drainage area of the treating hospital d e. few patients had an interfacility transfer e 8. which statement is not true regarding injury severity in orthopaedic ballistic injuries? a. patients with upper extremity injury had higher injury severity a b. most patients were not severely injured b c. lower limb extremities were injured more frequently c d. upper extremity fractures had a lower association with nerve injuries d e. lower limb fractures had a higher incidence of vascular injuries e 9. which is true regarding the patient demographics and occurrences of the gunshot injuries? a. most injuries occurred at home a b. sixteen per cent of victims were underage b c. most victims were shot by people known to them c d. most injuries occurred on weekends d e. more than half of the patients were victims of gang-related violence e page 54 south african orthopaedic journal http://journal.saoa.org.za subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm.co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online • once you have completed the answers, go back to the top of the page next to the registration option. there is another icon “find my cpd certificate”. (you will have to answer the two questions regarding your internship and last cpd audit once you have completed a questionnaire and want to retrieve your certificate). • if you click on that icon it will open your certificate which you can print or save on your system. • please call mpc helpdesk if you have any questions: 0861 111 335. management of complex proximal humerus fractures in the elderly: what is the role of open reduction and internal fixation? (bernstein bp, du plessis jp, laubscher m, maqungo s) 10. a 67-year-old woman, who is an avid tennis player, falls onto her dominant shoulder during a tennis match. examination reveals tenderness and swelling in the shoulder region, but no neurovascular deficits. radiographs and ct scan reveal a three-part proximal humerus fracture with significant displacement of the greater tuberosity as a part. combined cortical thickness is 4.2 mm. what is the most appropriate treatment option? a. closed reduction and sling immobilisation for six weeks a b. closed reduction and sling immobilisation for two weeks followed by early active range of motion exercises b c. open reduction and internal fixation c d. hemiarthroplasty d e. reverse total shoulder arthroplasty e 11. prolonged sling immobilisation should be used with caution due to the following negative aspects: a. causes pain a b. compromises hygiene b c. confuses caregivers c d. affects balance d e. promotes stiffness e 12. proximal humerus fragility fractures in the elderly are: a. are uncommon a b. are more common than vertebral fractures b c. are more common than wrist fractures c d. are more common than hip fractures d e. never occur e 13. the profher study investigated the outcomes of proximal humerus fractures managed operatively and non-operatively and found: a. threeand four-part fractures had improved outcomes if managed operatively a b. no difference in clinical outcomes between those managed operatively or non-operatively b c. no difference in clinical outcomes at six months but improved clinical outcome scores in those managed operatively at 12 and 24 months c d. a higher rate of revision surgery in the group managed nonoperatively d e. a lower rate of revision surgery in the group managed nonoperatively e proximal fibular resections for primary bone tumours: oncological and functional results of a case series (hilton tl, wiese kr, hosking kv, hoffman eb) 14. in patients with high grade osteosarcoma of the proximal fibula, which is the most correct option? a. an amputation is the safest oncological procedure to ensure the best prognosis for the patient a b. if the tumour involves multiple compartments, a malawar type ii procedure is advised but the peroneal nerve should be preserved at all costs b c. a malawar type ii procedure is a safe oncological procedure but has poor functional results c d. a malawar ii procedure is indicated to safely resect the tumour with or without sparing of the peroneal nerve to give good functional results d e. none of the above e 15. common complications after a malawar ii resection of the proximal fibular include the following, except: a. synovial fluid leak a b. knee instability b c. superficial and deep wound infection c d. foot drop d e. none of the above e 16. a malawar ii procedure includes resection of the following structures: a. proximal fibula, shark-bite osteotomy of the tibia, peroneal nerve, anterior neurovascular bundle a b. proximal fibula only b c. proximal fibula, anterior compartment, posterior tibial artery and vein c d. proximal fibula, peroneal nerve, anterior and lateral compartments, lateral collateral ligament d e. none of the above e 17. contraindications for a malawar ii procedure include: a. involvement of the anterior and posterior tibial vessels, peroneal nerve and tibial nerve a b. involvement of the tibiofibular joint b c. involvement of the anterior, lateral and posterior compartments of the leg c d. involvement of the peroneal nerve d e. none of the above e intraosseous terminal phalanx epidermoid inclusion cyst: a first case of late recurrence (kruger n, de villiers a-l, mcguire dt, solomons mw) 18. the most common tumour that mimics an epidermoid inclusion cyst of the distal phalanx is? a. giant cell tumour a b. aneurysmal bone cyst b c. enchondroma c d. osteoid osteoma d e. ewing sarcoma e 19. the radiological feature of an epidermoid inclusion cyst that distinguishes it from infection is: a. an absence of periosteal reaction a b. the presence of intralesional calcification b c. the presence of a pathological fracture c d. significant intralesional sclerosis such as that seen with an osteoid osteoma d e. the absence of surrounding soft tissue swelling e 20. the definitive treatment most frequently undertaken to treat a symptomatic epidermoid inclusion cyst is: a. initial biopsy, followed by definitive curettage and a second sitting a b. terminal ablation, as there is a risk of metastasis b c. symptomatic pain management as it recedes over time and will resolve on its own c d. excision biopsy through curettage, with or without bone graft as determined by defect size d e. needle aspiration and bone cement injection to cause thermal necrosis e medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 anley c et al. sa orthop j 2019;18(3) doi 10.17159/2309-8309/2019/v18n3a8 south african orthopaedic journal http://journal.saoa.org.za traumacurrent concepts review citation: anley c, vrettos bc, rachuene p, roche sjl. proximal humerus fractures. part 1: conservative management sa orthop j 2019;18(3):63-71. http://dx.doi.org/10.17159/2309-8309/2019/v18n3a8 editor: prof lc marais, university of kwazulu-natal, durban, south africa received: july 2019 accepted: july 2019 published: august 2019 copyright: © 2019 anley c, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received by any of the authors for this review. conflict of interest: the authors declare that there is no conflict of interest regarding the publication of this paper. abstract fractures of the proximal humerus are common, especially in osteoporotic females. despite this, there remains significant debate around their preferred treatment. the difficulties when considering treatment options is the wide array of fracture patterns and multiple patient factors which play an important role in the outcome of the management of these fractures. fortunately, the vast majority of these fractures can be treated conservatively. the challenge, however, is the 15% of patients in which surgery may be required such as displaced threeand four-part fractures, and fractures in young and active patients. although various recent studies and review papers show acceptable results with conservative treatment, especially in elderly patients, the decision on when to operate and when to consider conservative treatment remains challenging. the goal of this current concepts paper is to highlight important aspects of the conservative management of patients with proximal humerus fractures, from initial assessment through to treatment, including possible complications. level of evidence: level 5 key words: fracture, proximal humerus, conservative, osteoporosis proximal humerus fractures part 1: conservative management anley c¹ , vrettos bc², rachuene p³, roche sjl4 1 mbchb(stell), fcs(sa)orth, mmed (ortho)(stell); consultant, shoulder and elbow unit, tygerberg hospital, division of orthopaedics, stellenbosch university ² mbchb(zim), frcs(eng), fcs(sa)orth, mmed(orth)(uct); associate professor and honorary consultant, shoulder and elbow unit, groote schuur hospital, division of orthopaedics, university of cape town; vincent pallotti hospital ³ mbchb(ul-medunsa), fcs(sa)orth, mmed ortho (smu); fellow, shoulder and elbow unit, groote schuur hospital, division of orthopaedics, university of cape town 4 mbchb(uct), fcs(sa)orth; associate professor, shoulder and elbow unit, groote schuur hospital, orthopaedic research unit and orthopaedic biomechanics laboratory, division of orthopaedics, university of cape town corresponding author: dr cameron anley, medisuites 7, 9 paul kruger street, durbanville, 7550; tel: 021 9752890; email: drcameronanley@gmail.com https://orcid.org/0000-0002-5983-3520 page 64 anley c et al. sa orthop j 2019;18(3) introduction proximal humerus fractures (phfs) are common, accounting for 4–6%1-3 of all fractures, and more common in females over the age of 60 years due to the influence of osteoporosis.4,5 many authors have suggested that up to 85% do not require surgery.4,6-8 despite this, there appears to be a trend towards increased surgical intervention which has been attributed to newer designs of plating systems, as well as the promotion of the reverse shoulder replacement as a treatment option.6,7,9-12 the ideal outcome for a patient with a phf is a pain-free shoulder with an acceptable range of motion according to the individual’s specific functional requirements. the decision about when to operate in order to achieve an acceptable outcome remains challenging, especially in older patients.6,7,10,11 olerud has published results in which surgical outcome was superior;13 however, recent literature,9,14-17 including the well-publicised profher trial,9 continues to promote the conservative management of phfs. this discrepancy continues to create more questions than answers. although there is criticism of these studies, they are changing the way that these fractures are approached. the goal of this review is to try and clarify some of the current aspects related to the conservative management of phfs. a second current concepts review article exploring the surgical options will be published in a later issue of this journal. patient workup and classification clinical assessment a detailed history should be obtained to establish the mechanism of injury and to gain further information regarding comorbidities, social habits and previous functional status of the patient. poor outcomes and increased risk of complications are associated with severe osteoporosis, smoking, drug and alcohol abuse, diabetes mellitus, rheumatoid arthritis, immunocompromise including steroid medication and concurrent neoplasm.4 a thorough assessment should be performed to exclude other injuries. older patients are at risk of other common osteoporotic fractures of the neck of femur, distal radius and vertebra. younger patients, whose injuries are more often the result of a significant trauma, are at risk of associated injures to the cervical spine, brachial plexus and the chest. vascular injuries may be masked by collateral circulation4,5 and further imaging should be considered if there is concern. nerve injuries have been shown to be common (up to 67%) with a previous study showing axillary nerve and the suprascapular nerve most commonly affected. in this study, these were diagnosed on electromyography (emg) and the sensory fallout was noted to be low. fortunately, most injuries did not have a clinical significance as they recovered but the authors did highlight that these patients had increased stiffness, possibly due to difficulties with the active aspect of their rehabilitation.18 radiological work-up three x-ray views (figure 1) should be routinely obtained to gain an understanding of the fracture configuration and prevent missing fragments which overlap with the humeral head or glenoid. a true shoulder ap (taken in line with the glenohumeral joint) can be used to assess the valgus or varus angulation of the head on the shaft, displacement of the shaft, a head split fracture, and to assess superior migration of a greater tuberosity fracture. on the lateral or scapular-y view, a dislocation should be excluded, tuberosity fractures can be identified (especially posteriorly displaced fragments) and shaft displacement can be identified. finally, an axillary view is essential. this is often poorly done due to the pain. in this situation, a modified axillary view or valpeau view can be used to assess for a head split fracture, to exclude a dislocation and assess the displacement of the tuberosities which may be overlapping with the glenoid or humeral head on other views. an impression of the bone quality can be obtained on a plain x-ray (figure 2). the tingart measurement was first described in 2003.19 on the ap view of the shoulder, the combined cortical thickness is calculated as the sum of the means of the medial and lateral cortical thickness at two levels and adjusted for the magnification factor. level 1 is the most proximal level of the humeral diaphysis where the endosteal borders of the lateral and medial cortices are parallel to each other, with level 2 being 20 mm distal to level 1. according to tingart, a measurement of <4 mm suggests poor bone quality.19 more recently spross introduced the deltoid tuberosity index (dti) on the ap view of the shoulder.20 the dti is measured proximal a b c figure 1. suggested trauma series showing (a) ap view, (b) axillary view and (c) lateral view allowing excellent assessment of the fracture fragments and a demonstration of the how the x-rays are taken [please could you assist with blocking out the eyes] a b c figure 1. suggested trauma series showing (a) ap view, (b) axillary view and (c) lateral view allowing excellent assessment of the fracture fragments and a demonstration of the how the x-rays are taken [please could you assist with blocking out the eyes] a b c figure 1. suggested trauma series showing (a) ap view, (b) axillary view and (c) lateral view allowing excellent assessment of the fracture fragments and a demonstration of the how the x-rays are taken [please could you assist with blocking out the eyes] a b c figure 1. suggested trauma series showing (a) ap view, (b) axillary view and (c) lateral view allowing excellent assessment of the fracture fragments and a demonstration of the how the x-rays are taken page 65anley c et al. sa orthop j 2019;18(3) to the deltoid tuberosity where the outer cortical border becomes parallel. at this level, the outer cortical diameter is divided by the inner endosteal diameter. a dti <1.4 correlates to low bone mineral density of the humeral head.20 the advantages of the dti are that, unlike the tingart measurement, no adjustment for magnification is required and the area where the measurement is performed is not commonly affected by the fracture. this study suggested an improved sensitivity of the tingart measurement if 5 mm was used as the cut-off.20 the indications for obtaining a computerised tomography (ct) scan for phfs have not been well established. a recent study set out to establish indications but rather vaguely concluded that a ct should be obtained when sufficient information regarding the fracture pattern or extent cannot be obtained on good quality radiographs.21 although there is no direct correlation with the fracture classification and the need for a ct, more complex fractures will most commonly require a ct to assess fragment displacement (especially the tuberosities), assess the joint surface (especially with head split fractures), to assess the amount of comminution, and to exclude associated glenoid fractures. although a ct can be used to assist with the decision when not to operate and possibly allow for better fracture classification, it plays a very important role in pre-operative planning when surgery is suggested. a ct allows the surgeon to appropriately assess the displaced fragments to ensure they are appropriately reduced during surgery. in addition, the benefit of 3d printing is being explored with promising results in assisting with pre-operative surgical planning.22 classification an ideal classification is one that is reproducible, best describes the pathology, and provides guidance on management of fractures. codman first described phf patterns by using anatomic drawings and it was from his work that the neer and hertel classifications were established.23,24 the neer classification is the most widely used for evaluation of phfs. his fracture descriptions coupled plain radiographs and intra-operative findings. he based his description on codman’s four-segment theory, dividing the proximal humerus into four important anatomical aspects, namely greater tuberosity, lesser tuberosity, humeral articular segment and the humeral shaft. neer defined a part as displacement of either 1 cm or 45° angulation. the fractures were then grouped into six groups depending on the displacement. based on his classification system, neer described associated soft tissue injuries and guided the management of phfs. various studies have demonstrated poor interand intra-observer reliability of the neer classification.24-26 other limitations of this system have been attributed to difficulty in defining and estimating the extent of displacement.24 results of the neer classification on 3d ct images are mixed.24,25,27 in an attempt to improve on the neer classification, multiple other classification systems have been published. the ao group described a more detailed classification system in 1990 with more fracture configurations than neer’s. hertel has been the biggest critique of the neer classification and recently he described a classification system based on codman’s original drawings to describe fracture planes and impact on humeral head perfusion.28 resch et al. described a classification based on the pathomorphological analysis of phfs on 3d ct scans. once again studies showed poor interobserver reliability in more complex fractures.29 these systems have failed to improve on limitations of the neer classification in clinical practice and their use seems to be purely academic.25,26 the ability of artificial intelligence (ai) to accurately diagnose and classify phfs has been explored with excellent results (96% accuracy) in diagnosing a fracture and promising results (65–86% accuracy) with regard to classification of the fractures when using the neer classification.30 these results were similar to those obtained by specialist shoulder surgeons. the authors suggest that the ai results will continue to improve with time. unfortunately, ai does not yet address the management of phfs. management as with most fractures in orthopaedics, the decision whether to operate or not is multifactorial considering both patient factors and fracture configuration. a lack of large sample comparative studies makes decision-making difficult. current trends show increases in surgical management of phfs6,11,12 and confirms a lack of consensus on choice of treatment among surgeons.7,31 this is illustrated in a recent study7 in which three experienced shoulder surgeons only unanimously agreed on treatment in 51% of 274 cases. in the cases in which unanimous agreement was achieved, the patients underwent the selected treatment 63.5% of the time. finally, they concluded the successful management of displaced phfs requires not only the technical ability to adequately perform surgical treatment but also, perhaps more importantly, the critical ability to decide when patients should undergo conservative or operative treatment. a variety of newer studies and review articles have advocated the use of conservative management of phfs,9,14-17,32 showing no significant difference in outcome between surgery and conservative management even in threeand four-part fractures.33,34 it is important to note, however, that the average age in most of these studies is older than 65 years, and thus there remains a risk that these conclusions are applied across the board, including to a younger population of patients, who will naturally have higher physical demands and expectations. this was highlighted in the 2015 cochrane review17 as well as a recent meta-analysis on phfs.16 the profher trial has recently published the five-year results of the initial trial, in which 250 patients were randomly assigned into conservative or surgical treatment. patients were eligible for inclusion if they were aged 16 years or older and presented within three weeks of sustaining a displaced fracture of the proximal humerus that involved the surgical neck.9 the majority of patients had twoor three-part fractures. the degree of displacement had to be sufficient for the treating surgeon to consider surgical intervention. the original trial concluded that there was no significant figure 2. showing the tingart measurement (2 mm + 2.45 mm = 4.5 mm) and deltoid tuberosity index (1.82 cm/1.35 cm = 1.35) page 66 anley c et al. sa orthop j 2019;18(3) figure 3a. ct scan of patient of a patient with a proximal humerus fracture figure 3a. ct scan of patient of a patient with a proximal humerus fracture figure 3a. ct scan of a patient with a proximal humerus fracture figure 3c. clinical pictures to show range of motion and a successful outcome following conservative management (with above ct scan) figure 3b. x-rays at union figure 3b. x-rays at union figure 3b. x-rays at union figure 3b. x-rays at union page 67anley c et al. sa orthop j 2019;18(3) difference in patient-reported clinical outcomes between surgical treatment compared with non-surgical treatment over two years following fracture occurrence in patients with displaced proximal humeral fractures involving the surgical neck. these results were sustained at the five-year follow-up.32 the average age in the two groups was similar (surgical: 66.60 years vs non-surgical: 65.43 years) with a standard deviation (sd) of 11.80 and 12.03 respectively, implying that most patients included were older than 55 years. a variety of other limitations of the profher trial have been highlighted including high exclusion rate, the bias introduced by surgeons by excluding patients who they deemed definitely required surgery, small numbers treated by each centre with various levels of expertise, and surgical treatment being not specific with either open reduction and internal fixation (orif) or arthroplasty being done. one of the difficulties with any research in phfs is the array of different fracture patterns leading to small numbers of certain fracture types in trials such as the profher trial. a more recent meta-analysis16 pooled the data of 22 studies (both randomised control studies and observational studies) resulting in a metaanalysis of 1 743 patients with displaced phfs (including the patients from the profher trial): 910 treated operatively and 833 non-operatively. the results showed there was no difference in physical function as measured with the constant-murley score when comparing operative and non-operative treatment. the authors acknowledge the limitations of a meta-analysis but this well-conducted review again recommends the non-operative treatment for the average elderly patient (aged >65 years) with a displaced phf.16 from these two papers and a 2015 cochrane review it now seems clear that there is justification to consider conservative treatment in patients over the age of 65 years. this is demonstrated in figure 3. two important questions remain: the preferred treatment of displaced threeand four-part fractures in elderly patients and the management of phfs in young patients. the use of the reverse shoulder replacement has been advocated for management of displaced neer threeand four-part fractures in elderly patients.35,36 once again, however, this is debated in the literature. the previously cited meta-analysis included a reasonable number of four-part fractures (21%). a subgroup analysis of neer threeand four-part fractures showed no difference in outcome. this is supported in a paper comparing the outcome of reverse total shoulder versus conservative treatment (patients who refused surgery) for threeand four-part fractures, concluding that there was no difference in outcome at one year. this is now the topic of the profher 2 trial which has recently started recruiting. this involves patients over the age of 65 years with neer three and four-part fractures being randomised into conservative, hemiarthroplasty or reverse shoulder replacement. a second concern which is highlighted is the management of phfs in younger, active patients. the lack of research related to the management of this group of patients has been highlighted in the literature.16,17 the amount of acceptable displacement or angulation is often based on small sample studies, author opinion or biomechanical studies and has not been specifically demonstrated in clinical trials. the dilemma we currently have is trying to predict who may be left with a symptomatic malunion. the absolute indications for surgery (in any age group) are fairly universally accepted and include threeand four-part fractures in conjunction with a dislocation, head splitting fractures, pathological (other than osteoporosis) fractures, open fractures, and fractures associated with a vascular injury.4,5 relative indications are not as clearly defined and are more commonly applied to younger and more active patients. current relative indications include displaced tuberosity fractures, an unstable configuration of the surgical neck (disengagement of the head due to displacement, >50% displacement or comminution) and varus or valgus angulation of >30° from the normal 130°.4,5 valgus deformity has been shown to have a worse outcome.37 the acceptable displacement of the tuberosities varies among authors ranging from 3 mm to 1 cm4,38-40 and differs between superior and posterior displacement. the majority of authors appear to have reduced the original guidelines of 1 cm described by neer to 5 mm displacement in all directions. this is supported by small clinical trials showing better outcomes38 and biomechanical evidence demonstrating a significant difference in the force required to abduct the arm with a 5 mm change in position of the tuberosity.41 a recent review article suggested surgical intervention for more than 5 mm of superior displacement and concluded that there are no clear guidelines for posterior displacement but notes poor outcomes if left untreated.40 spross et al. have recently published a new algorithm (figure 4) which differentiates between patients based on age (65 years) and activity level after which the fracture pattern and displacement is considered. these authors have published the results of 160 patients treated according to their proposed treatment algorithm with very satisfying overall results with low complication and revision rates.42 although further verification is required, this algorithm highlights important aspects to consider when treating a patient with a phf. currently most outcome scores focus on pain, sleep and function. a recent study looking into the importance of these factors in older patients with phfs concluded that improved function is less important than reduced pain and better sleep.43 this paper highlights that maybe we are measuring the wrong outcomes when assessing the outcomes of fractures. this will require further investigation going forward. conservative management once conservative management has been decided upon, important factors to consider are the type of sling and the length of immobilisation time. a simple sling has shown to be adequate along with appropriate analgesia for comfort. there is no benefit to a hanging cast as they have been shown not to improve the alignment and they may in fact increase the risk of a non-union by causing distraction at the fracture site.4,44-46 if there is uncertainty about the need for surgery, a common practice is to give a trial of conservative treatment for a week or two to allow for reassessment. an x-ray should be considered at one to two weeks to ensure there has not been further displacement of the fracture. various studies have confirmed that prolonged immobilisation is not required and thus a short period of two to three weeks immobilisation followed by physiotherapy is suggested as improved recovery has been shown when physiotherapy commences early.4,5,46-49 a recent meta-analysis showed a better patient quality of life score for the first three to six months with early mobilisation.50 no specific physiotherapy programme has proven to be superior. when treating phfs, all patient factors should be assessed and factored into the management particularly paying attention to the fact that phfs are the fourth most common osteoporotic fractures. any patient presenting with a phf should therefore be seen as an opportunity to make the diagnosis of osteoporosis and initiate the appropriate management. the literature shows poor initiation of treatment for osteoporosis following a phf,51 which is worrying given that a recent study of over 1 million fragility fractures (13.1% page 68 anley c et al. sa orthop j 2019;18(3) figure 4. the algorithm as presented by spross et al.42 (adapted from the original and used with permission) + young and active patients with good bone quality (healthy worker <65 years) one-part fracture + + orif or arthroscopic rif nonoperative one-third tubular plate orif locking plate orif aim: maximal shoulder function hemiarthroplasty stable and anatomical reconstruction possible >5mm displacement of the greater or lesser tuberiosity valgus impacted 2-, 3-, 4-part and fracture dislocations elderly patient > 65 years active and autonomous fx dislocationlow local bone quality: dti <1.4 one-part fracture two-part fracture varus/ valgus impacted sn valgus impacted <70 y anatomical reduction possible no lp orif no no ha aim: pain relief persistent pain and/or no unison rotation at 3 weeks aim: maximal shoulder function ha (<70y) rtsa (<70y) <1 cm dispacement of gt/lt to head three-part fracture four-part fracture fracture-dislocations and head-split see graphic 1: rtsa instead of ha in patients >70 years + + + + + + + + + page 69anley c et al. sa orthop j 2019;18(3) of which were phfs) reported a 13.2% chance of a second fragility fracture within three years of a phf. this second fragility fracture was most likely to be a neck of femur fracture with a 21.3% mortality rate at one year’.52 it has been shown that a well-run screening and treatment programme can reduce the risk of a primary phf fragility fracture by 45%, and that anti-osteoporosis treatment started after a fragility fracture can decrease the ageand sex-adjusted risk of a subsequent fracture by 52% in patients with a phf as the index fracture.53,54 complications of conservative treatment the most common and important complications associated with conservative treatment of phfs are avascular necrosis (avn), symptomatic malunion and non-union (1.1–10%).45,55 avn the physiology around the development of avn remains poorly understood.4 hertel initially tried to quantify the risk of avn suggesting that fractures with a metaphyseal head extension of <8 mm and medial hinge disruption >2 mm correlated strongly with humeral head ischaemia.28 he later acknowledged in a followup article that this ischaemia did not necessarily predict avn.56 in addition, there is little evidence to show that surgical realignment reduces the risk of avn;16 in fact, poor technique and excessive surgical periosteal stripping may increase the risk.4 the most common treatment of symptomatic avn is arthroplasty. non-union the risk of non-union following a phf is low, reported as 1.1%, increasing to 8% with metaphyseal comminution and 10% with significant displacement of the surgical neck.57 although surgery might slightly reduce the chance of non-union, comparative studies have not shown a significant reduction related to surgery. factors which are likely to predispose to non-union include: patient factors like malnutrition, poorly controlled medical comorbidities, smoking and alcohol abuse; fracture factors including severe comminution and severe displacement of the humeral head; and treatment factors such as distraction due to a hanging cast or extensive shoulder mobilisation.4,57-60 the treatment of patients presenting with pain and loss of function should be individualised, but both orif with bone grafting and a reverse shoulder arthroplasty have been advocated.4,61,62 the absence of arthritis or avn, adequate humeral bone stock, and absence of malunion of the tuberosities are required before considering orif.4 a few small studies have reported the use of the reverse shoulder arthroplasty as a salvage procedure for phf non-unions. although good results have been reported, a high complication rate, especially dislocation, was noted.62 malunion the degree of acceptable malunion has not been fully defined hence the uncertainty around the acceptable parameters for conservative treatment. an important factor is the age and expectations of the patient; as expected, older patients will tolerate a malunion better than younger patient.4 concerns related to malunion are cuff dysfunction and impingement which can be difficult to address post union. a ct should be obtained (ideally including elbow cuts to fully assess rotational malunion) if surgical intervention is required. treatment options such as osteotomies and arthroplasty (including the new stemless prosthesis) have been described depending on the type and extent of the malunion.63 mortality osteoporotic fractures are associated with mortality rates above those of the general population ranging from 1% during the initial admission to 10% at a year following the fracture.64,65 patients who live at nursing homes are at higher risk of mortality than those who live in their own homes.65 although no specific protocols exist, the early involvement of a physician is recommended on admission to assist with the medical care of patients with phfs. delayed vs early reverse total shoulder replacement an important question related to the treatment of phfs is whether the results of a salvage arthroplasty procedure, particularly a reverse shoulder replacement, are equivalent to a primary reverse arthroplasty at time of fracture. we have to rely on reviews and metaanalysis, as the published studies are small case series. a recent meta-analysis suggests that there is no difference in outcome; in fact, there was improved external rotation in the delayed group.66 this would imply that it is not detrimental to try a conservative approach initially, knowing that it remains possible to obtain as good a result if a reverse total shoulder replacement needs to performed as a salvage procedure.66 this approach potentially subjects patients to a longer period of pain and immobility with delayed surgery, and this should be discussed with the patient. this was slightly contradictory to a previous paper which showed improved tuberosity healing and external rotation when a reverse is performed for an acute fracture.67 the newer stemless implants have been advocated as a possible solution for the challenges of an arthroplasty in the face of a malunion; however, long-term follow-up is still required for this indication. conclusion and summary in conclusion, despite being a common fracture the treatment remains widely debated. the majority of phfs can be managed conservatively. the current literature supports the conservative management in older patients, even in threeand four-part fractures. in these patients, a reverse shoulder replacement appears be available as a salvage procedure. a more aggressive approach is generally advocated for younger patients. relative indications are displaced tuberosity fractures, an unstable configuration of the surgical neck, and varus or valgus angulation. conservative management, when advocated, consists of a simple master sling and early mobilisation with physiotherapy. complications are rare; once again the reverse shoulder replacement appears to be available as a salvage procedure. learning points the majority of proximal humerus fractures can be treated conservatively with an acceptable outcome. proximal humerus fractures are common osteoporotic fractures and should be an opportunity to confirm the diagnosis and start treatment of osteoporosis. the treatment of threeand four-part proximal humerus fractures in elderly patients remains challenging but conservative treatment may be acceptable. a more aggressive approach remains advocated for younger patients. conservative management, when advocated, consists of a simple master sling and early mobilisation with physiotherapy. page 70 anley c et al. sa orthop j 2019;18(3) declarations the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ca was the primary author. bv reviewed the written submission. pr assisted with the writing and reviewed the written submission. sr assisted with the writing and reviewed the written submission. orcid c anley https://orcid.org/0000-0002-5983-3520 references 1. court-brown cm, caesar b. epidemiology of adult fractures: a review. injury. 2006;37(8):691-97. 2. palvanen m et al. update in the epidemiology of proximal humeral fractures. clin orthop related research 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1;27(3):470-77. 8. roche sj, vrettos bc. surgery for displaced three-and four-part proximal humeral fractures: the rationale for our approach. sa orthopaedic journal. 2008 sep;7(3):16-21. 9. rangan a, handoll h, brealey s, jefferson l, keding a, martin bc, goodchild l, chuang lh, hewitt c, torgerson d. surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the profher randomized clinical trial. jama. 2015 mar 10;313(10):1037-47. 10. spross c, meester j, mazzucchelli ra, puskás gj, zdravkovic v, jost b. evidence-based algorithm to treat patients with proximal humerus fractures—a prospective study with early clinical and overall performance results. journal of shoulder and elbow surgery. 2019 jun 1;28(6):1022-32. 11. khatib o, onyekwelu i, zuckerman jd. the incidence of proximal humeral fractures in new york state from 1990 through 2010 with an emphasis on operative management in patients aged 65 years or older. journal of shoulder and elbow surgery. 2014 sep 1;23(9):1356-62. 12. huttunen tt, launonen ap, pihlajamäki h, kannus p, mattila vm. trends in the surgical treatment of proximal humeral fractures–a nationwide 23-year study in finland. bmc musculoskeletal disorders. 2012 dec;13(1):261. 13. olerud p, ahrengart l, ponzer s, saving j, tidermark j. internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. journal of shoulder and elbow surgery. 2011 jul 1;20(5):747-55. 14. rabi s, evaniew n, sprague sa, bhandari m, slobogean gp. operative vs non-operative management of displaced proximal humeral fractures in the elderly: a systematic review and meta-analysis of randomized controlled trials. world j orthop 2015;6:838-46. 15. xie l, ding f, zhao z, chen y, xing d. operative versus non-operative treatment in complex proximal humeral fractures: a meta-analysis of randomized controlled trials. springerplus. 2015 dec;4(1):728 16. beks rb, ochen y, frima h, smeeing dp, van der meijden o, timmers tk, van der velde d, van heijl m, leenen lp, groenwold rh, houwert rm. operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. journal of shoulder and elbow surgery. 2018 aug 1;27(8):1526-34. 17. handoll hh, brorson s. interventions for treating proximal humeral fractures in adults. cochrane database syst rev 2015;(11):cd000434. 18. visser cp, coene ln, brand r, tavy dl. nerve lesions in proximal humeral fractures. journal of shoulder and elbow surgery. 2001 sep 1;10(5):421-27. 19. tingart mj, apreleva m, von stechow d, zurakowski d, warner jj. the cortical thickness of the proximal humeral diaphysis predicts bone mineral density of the proximal humerus. the journal of bone and joint surgery. british volume. 2003 may;85(4):611-17. 20. spross c, kaestle n, benninger e, fornaro j, erhardt jb, zdravkovic v, et al. deltoid tuberosity index: a simple radiographic tool to assess local bone quality in proximal humerus fractures. clin orthop relat res 2015;473:3038-45. 21. bahrs c, rolauffs b, südkamp np, schmal h, eingartner c, dietz k, pereira pl, weise k, lingenfelter e, helwig p. indications for computed tomography (ct-) diagnostics in proximal humeral fractures: a comparative study of plain radiography and computed tomography. bmc musculoskeletal disorders. 2009 dec;10(1):33. 22. you w, liu lj, chen hx, xiong jy, wang dm, huang jh, ding jl, wang dp. application of 3d printing technology on the treatment of complex proximal humeral fractures (neer 3-part and 4-part) in old people. orthopaedics & traumatology: surgery & research. 2016 nov 1;102(7):897-903. 23. neer cs2. displaced proximal humerus fractures: part i. classifications and evaluation. j bone joint surg am. 1970; 52(223): p. 1077-89. 24. carofino bc, leopold ss. classifications in brief: the neer classification for proximal humerus fractures. clin orthop relat res. 2013;471:39-43. 25. bernstein ja, adler lm, dalsey rm, williams gr, iannotti jp. evaluation of the neer system of classification of proximal humerus fractures with computerized tomographic scans and plain x-rays. j bone joint surg am. 1996;78:1371-75. 26. majed a, macleod i, bull am, zyto k, resch h, hertel r, et al. proximal humeral fracture classification systems revisited. j shoulder elbow surg. 2011 oct;20(7):1125-32. 27. brunner a, honigmann p, treutmann t, babst r. the impact of stereo-visualisation of three-dimensional ct datasets on the inter and intraobserver reliability of the ao/ota and neer classifications in the assessment of fractures of the proximal humerus. j bone joint surg br. 2009;91:766-71. 28. hertel r, hempfing a, stiehler m, leunig m. predictors of humeral head ischaemia after intracapsular fracture of the proximal humerus. j shoulder elbow surg. 2004 jul/aug;13(4):427-33. 29. resch h, tauber m, neviaser rj, neviaser aa, majed a, hasley t, et al. classification of proximal humeral fractures based on a pathomorphologic analysis. j shoulder elbow surg. 2016 march;25(3):455-62. 30. chung sw, han ss, lee jw, oh ks, kim nr, yoon jp, kim jy, moon sh, kwon j, lee hj, noh ym. automated detection and classification of the proximal humerus fracture by using deep learning algorithm. acta orthopaedica. 2018 jul 4;89(4):468-73. 31. floyd sb, campbell j, chapman cg, thigpen ca, kissenberth mj, brooks jm. geographic variation in the treatment of proximal humerus fracture: an update on surgery rates and treatment consensus. journal of orthopaedic surgery and research. 2019 jan;14(1):22. 32. handoll hh, keding a, corbacho b, brealey sd, hewitt c, rangan a. five-year follow-up results of the profher trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus. the bone & joint journal. 2017 mar;99(3):383-92. 33. roberson ta, granade cm, hunt q, griscom jt, adams kj, momaya am, kwapisz a, kissenberth mj, tolan sj, hawkins rj, tokish jm. nonoperative management versus reverse shoulder arthroplasty for treatment of 3-and 4-part proximal humeral fractures in older adults. journal of shoulder and elbow surgery. 2017 jun 1;26(6):1017-22. https://orcid.org/0000-0002-5983-3520 https://orcid.org/0000-0002-5983-3520 page 71anley c et al. sa orthop j 2019;18(3) 34. li y, zhao l, zhu l, li j, chen a. internal fixation versus nonoperative treatment for displaced 3-part or 4-part proximal humeral fractures in elderly patients: a meta-analysis of randomized controlled trials. plos one. 2013 sep 16;8(9):e75464. 35. jobin cm, galdi b, anakwenze oa, ahmad cs, levine wn. reverse shoulder arthroplasty for the management of proximal humerus fractures. jaaos-journal of the american academy of orthopaedic surgeons. 2015 mar 1;23(3):190-201. 36. mata-fink a, meinke m, jones c, kim b, bell je. reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review. journal of shoulder and elbow surgery. 2013 dec 1;22(12):1737-48. 37. foruria am, de gracia mm, larson dr, munuera l, sanchezsotelo j. the pattern of the fracture and displacement of the fragments predict the outcome in proximal humeral fractures. j bone joint surg br. 2011 mar;93(3):378-86. 38. platzer p, kutscha-lissberg f, lehr s, vecsei v, gaebler c: the influence of displacement on shoulder function in patients with minimally displaced fractures of the greater tuberosity. injury 2005;36(10):1185-89. 39. rath e, alkrinawi n, levy o, debbi r, amar e, atoun e: minimally displaced fractures of the greater tuberosity: outcome of non-operative treatment. j shoulder elbow surg 2013;22(10):e8-e11. 40. rouleau dm, mutch j, laflamme gy. surgical treatment of displaced greater tuberosity fractures of the humerus. jaaos-journal of the american academy of orthopaedic surgeons. 2016 jan 1;24(1):46-56. 41. bono cm, renard r, levine rg, levy as: effect of displacement of fractures of the greater tuberosity on the mechanics of the shoulder. j bone joint surg br 2001;83(7):1056-62. 42. spross c, meester j, mazzucchelli ra, puskás gj, zdravkovic v, jost b. evidence-based algorithm to treat patients with proximal humerus fractures—a prospective study with early clinical and overall performance results. journal of shoulder and elbow surgery. 2019 jun 1;28(6):1022-32. 43. sabharwal s, archer s, cadoux-hudson d, griffiths d, gupte cm, reilly p. exploring elderly patients’ experiences of recovery following complex proximal humerus fracture: a qualitative study. journal of health psychology. 2019 may 30:1-12. 44. leyshon rl. closed treatment of fractures of the proximal humerus. acta orthop scand 1984;55:48-51. 45. rasmussen s, hvass i, dalsgaard j, christensen bs, holstad e. displaced proximal humeral fractures: results of conservative treatment. injury 1992;23:41-43. 46. vachtsevanos l, hayden l, desai as, dramis a. management of proximal humerus fractures in adults. world journal of orthopedics. 2014 nov 18;5(5):685-93. 47. kancherla vk, singh a, anakwenze oa. management of acute proximal humeral fractures. jaaos-journal of the american academy of orthopaedic surgeons. 2017 jan 1;25(1):42-52. 48. kristiansen b, angermann p, larsen tk. functional results following fractures of the proximal humerus. a controlled clinical study comparing two periods of immobilization. arch orthop trauma surg 1989;108:339-41. 49. lefevre-colau mm, babinet a, fayad f, fermanian j, anract p, roren a, kansao j, revel m, poiraudeau s. immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. a randomized controlled trial. j bone joint surg am 2007;89:2582-90. 50. punnoose a, fisk r, triggs f, gibbins n, harvey-hyde m. rehabilitation of conservatively managed proximal humerus fractures: a systematic review of the literature. physiotherapy. 2019 jan 1;105:e15. 51. viprey m, caillet p, canat g, jaglal s, haesebaert j, chapurlat r, schott am. low osteoporosis treatment initiation rate in women after distal forearm or proximal humerus fracture: a healthcare database nested cohort study. plos one. 2015 dec 2;10(12). 52. dang dy, zetumer s, zhang al. recurrent fragility fractures: a cross-sectional analysis. jaaos-journal of the american academy of orthopaedic surgeons. 2019 jan 15;27(2):e85-91. 53. singh a, adams al, burchette r, dell rm, funahashi tt, navarro ra. the effect of osteoporosis management on proximal humeral fracture. journal of shoulder and elbow surgery. 2015 feb 1;24(2):191-98. 54. bawa hs, weick j, dirschl dr. anti-osteoporotic therapy after fragility fracture lowers rate of subsequent fracture: analysis of a large population sample. jbjs. 2015 oct 7;97(19):1555-62. 55. cadet er, yin b, schulz b, ahmad cs, rosenwasser mp. proximal humerus and humeral shaft nonunions. j am acad orthop surg 2013;21:538-47. 56. bastian jd, hertel r: initial post-fracture humeral head ischemia does not predict development of necrosis. j shoulder elbow surg 2008;17(1):2-8. 57. court-brown cm, mcqueen mm. nonunions of the proximal humerus: their prevalence and functional outcome. j trauma. 2008;64:1517–21. 58. healy wl, jupiter jb, kristiansen tk, white rr. nonunion of the proximal humerus: a review of 25 cases. j orthop trauma 1990;4:424-31. 59. scheck m. surgical treatment of nonunions of the surgical neck of the humerus. clin orthop 1982;167:255-59. 60. volgas da, stannard jp, alonso je. nonunions of the humerus. clin orthop 2004;419:46-50. 61. quadlbauer s, hofmann gj, leixnering m, rosenauer r, hausner t, reichetseder j. open reduction and fixation with a locking plate without bone grafting is a reasonable and safe option for treating proximal humerus nonunion. international orthopaedics. 2018 sep 1;42(9):2199-209. 62. zafra m, uceda p, flores m, carpintero p. reverse total shoulder replacement for nonunion of a fracture of the proximal humerus. the bone & joint journal. 2014 sep;96(9):1239-43. 63. duparc f. malunion of the proximal humerus. orthopaedics & traumatology: surgery & research. 2013 feb 1;99(1):s1-1. 64. clement nd, duckworth ad, mcqueen mm, court-brown cm. the outcome of proximal humeral fractures in the elderly: predictors of mortality and function. the bone & joint journal. 2014 jul;96(7):970-77. 65. van eck cf, klein cm, rahmi hea. morbidity, mortality and cost of osteoporotic fractures-should proximal humerus fractures be taken as seriously as hip fractures? ann joint. 2019;4(3):1-7. 66. torchia mt, austin dc, cozzolino n, jacobowitz l, bell je. acute versus delayed reverse total shoulder arthroplasty for the treatment of proximal humeral fractures in the elderly population: a systematic review and meta-analysis. journal of shoulder and elbow surgery. 2019. april (28)4:765-73. 67. seidl a, sholder d, warrender w, livesey m, williams g, abboud j, namdari s. early versus late reverse shoulder arthroplasty for proximal humerus fractures: does it matter? archives of bone and joint surgery. 2017 jul;5(4):213-19. _goback _hlk14356639 orthopaedics vol3 no4 page 62 sa orthopaedic journal winter 2016 | vol 15 • no 2 expert opinion on published articles the treatment of displaced supracondylar fractures of the humerus in children continues to stimulate interest in the literature. closed reduction and percutaneous pinning with crossed k-wires has gained support as the preferred method of treatment. iatrogenic ulnar nerve injury remains a concern. an incidence of 2%–3% has been reported in a few studies in the literature. the dynamic changes that occur in the cubital tunnel during flexion and extension of the elbow are worthwhile knowing as these changes may help to prevent injury to the ulnar nerve during medial pinning. yildrum et al. studied the position of the ulnar nerve relative to the medial epicondyle in healthy children (4–12 years), bilaterally, with high resolution ultrasonography, with elbow flexion and rotation manoeuvres which are commonly performed during routine reduction of supracondylar fractures. the elbow was gradually flexed, and the forearm was alternately placed in pronation and supination. the medial epicondyle–ulnar nerve distance was measured with various positions of the elbow and forearm. seventy-six elbows were studied (mean age ± 8 years). the ulnar nerve translated anteriorly towards the medial epicondyle with increasing elbow flexion. using specially designed angle adjustment orthotics, the increments in flexion were recorded. the mean medial epicondyle–ulnar nerve distance that was 3.7 mm in an extended elbow decreased to 1.1 mm with full elbow flexion. placement of the forearm in either supination or pronation did not produce a statistically significant difference. the authors concluded that flexion of the elbow brings the ulnar nerve close to the medial epicondyle independent of forearm rotation. the decrease in medial epicondyle–ulnar nerve distance up to 1.1 mm in a fully flexed elbow might be a factor that endangers the nerve during medial pinning in supracondylar fractures. the above article adds knowledge to the dynamic changes in the position of the ulnar nerve in the cubital tunnel which is crucial to prevent injury following medial pin placement. biomechanical studies with the elbow in flexion and extension have been shown in previous reports to alter the capacity of the cubital tunnel. with the elbow in flexion, the aponeurosis overlying the ulnar nerve (cubital tunnel retinaculum) is stretched, thereby decreasing the capacity of the cubital tunnel. placing a medial k-wire through the retinaculum in this position constricts the nerve thereby preventing the nerve from returning to its relaxed position on extension of the elbow. the possibility of a subluxing or hypermobile ulnar nerve should also be considered before pinning, by examining the opposite elbow. the subluxed nerve can be pinned during flexion of the elbow. ulnar nerve injury can be prevented by using lateral pins, visualisation of the nerve through a small incision, avoiding placement behind the medial epicondyle, acute angulation of the pin and skin tethering with the wire. with the anterior translation of the nerve in flexion, some authors have suggested placing the lateral pin first and then extending the elbow fully to place the medial wire. others suggest pinning the fracture in 50°–70° of flexion. we have used 90° of flexion with crossed k-wires, the medial pin at 45°, slightly anteriorly on the medial epicondyle, successfully. the above article admits that the study was not done on injured elbows and clinical studies are required to verify the accuracy of sonography in the fractured elbow. sonography permits dynamic observation of the ulnar nerve intra-operatively before placement of the medial pin to prevent iatrogenic injury. a thorough clinical examination before and after pinning should be emphasised. the medial epicondyle – ulnar nerve relation with various elbow positions in healthy children y yildrum, m bawameh, t balikci and h bal h journal of pediatric orthopaedics 2014;34:437–40 reviewer: dr mn rasool department of orthopaedics university of kwazulu-natal tel: (031) 260 4297 page 64 sa orthopaedic journal winter 2016 | vol 15 • no 2 an increasing trend to treat clavicle fractures in adolescents by open reduction and internal fixation has recently been documented in the literature.1 this probably follows reports that advocate the operative treatment of certain middle third clavicle fractures in adults.2 in keeping with these trends, i am sometimes asked what my approach is to clavicle fractures in older children and adolescents. the article under review is the most recent outcome study in this respect and has offered some insight. as the title suggests, the purpose of the study was to determine the long-term outcome after a clavicle fracture in older children and adolescents. the study has merit in that it was a patient-reported outcome study. the authors conducted a retrospective review of 185 patients aged 10 to 18 years (median age 14.4 years) treated at their institution with an isolated clavicle fracture. thirteen had lateral fractures and 172 had midshaft fractures. outcomes were assessed using the oxford shoulder score (oss), the quick version of the disability of arm, shoulder and hand questionnaire (quick-dash score) and a visual analog score for pain, cosmesis and overall satisfaction. of the midshaft fractures, 122 patients (70.9%) responded to the questionnaires. of the lateral fractures, 8 patients (61.5%) responded to the questionnaires. the mean age of the respondents was 18.7 years and this was at an average of 4.7 years after injury. sixty-five midshaft fractures were displaced. nine of these displaced midshaft fractures were treated surgically. seven were operated on as primary treatment; however, the actual indication for surgery in these cases was not stated. an additional patient was operated at 23 days for increasing pain and displacement, and another because of symptomatic nonunion at 163 days. the nine operated fractures did not have any difference in terms of initial shortening, displacement or angulation compared to the non-operative group. of the nine operated patients, six had local irritation which prompted plate removal. one had a disfiguring scar and one complained of decreased sensation distal to the incision. no patient with a lateral fracture was treated surgically. of the lateral fracture group of patients at follow-up, one complained of general shoulder discomfort and one of pain while carrying a backpack. with respect to the overall patient-reported outcomes, 95 per cent of the respondents with conservatively managed fractures reported good to excellent outcomes on both the oss and quick-dash score. however, in the group of midshaft fractures managed non-operatively, shortening of the fracture had a small but statistically significant negative effect on the oss, cosmetic and overall satisfaction scores. the degree of angulation and displacement had no effect on the outcome scores in this group. the authors’ opinion was that the overall functional result after non-operatively treated clavicle fractures was good to excellent for most patients. the inferior result associated with shortening was small and most likely of limited clinical significance. the authors also note that nonunion of the clavicle at this age is very rare and therefore cannot be used as an argument to justify operative treatment. the level of evidence in this study is low, with a high rate of non-responders. the number of operative cases was too small to provide an acceptable comparative group. however, the results support earlier literature3,4 with regards to good functional outcomes of non-operatively treated clavicle fractures in children and adolescents. we must take cognisance of the available literature, and it is for this reason that i continue to advocate non-operative management as the mainstay of treatment in this age group. i support the authors’ recommendation to reserve operative treatment for fractures with absolute indications such as threatened skin integrity, open fractures or associated neurovascular injuries. whether other selected cases will benefit from operative treatment still needs to be defined. references 1. yang s, werner bc, gwathmey fw, jr. treatment trends in adolescent clavicle fractures. j pediatr orthop. 2015;35(3): 229-33. 2. canadian orthopaedic trauma s. nonoperative treatment compared with plate fixation of displaced midshaft clavicular fractures. a multicenter, randomized clinical trial. j bone joint surg am. 2007;89(1):1-10. 3. schulz j, moor m, roocroft j, bastrom tp, pennock at. functional and radiographic outcomes of nonoperative treatment of displaced adolescent clavicle fractures. j bone joint surg am. 2013;95(13):1159-65. 4. bae ds, shah as, kalish la, kwon jy, waters pm. shoulder motion, strength, and functional outcomes in children with established malunion of the clavicle. j pediatr orthop. 2013;33(5):544-50. reviewer: dr icm robertson dept of orthopaedics tygerberg hospital private bag x3 tygerberg, cape town tel: 021 938 5458 long-term patient-reported outcome after fractures of the clavicle in patients aged 10 to 18 years ph randsborg, hf fuglesang, jh rotterud, ol hammer, ea sivertsen journal of pediatric orthopaedics 2014;34(4):393-99 page 66 sa orthopaedic journal winter 2016 | vol 15 • no 2 the article under review is a new addition to the ongoing debate on the controversial topic of operative versus non-operative management of the ‘high grade’ or complete dislocation of the acromio-clavicular joint. the canadian orthopaedic trauma society undertook a therapeutic level i, prospective, randomised and multi-centre study over a period of 24 months. the study was spread over 11 hospitals with a total of 83 patients being randomised. this study took place against the backdrop of the previous numerous reports that suggested that there was not much difference in the final outcome between the surgical and non-surgical treatment of the rockwood types iii, iv and v injuries. the gaps that inspired the replication of this study were identified as: 1. the reviewed orthopaedic literature that was found to be limited to surgeon-based outcomes instead of validated outcome measures. 2. most studies used outdated and inferior surgical fixation methods. 3. they also lacked statistical power. 4. some of the research methods used were flawed. for the purposes of this study, the modern and superior biomechanically proven ‘hook plate’ fixation was used in the 40 operated patients. the rest were treated conservatively with a sling support and analgesics, and followed by physiotherapy rehabilitation. a proper study design with appropriate ethics committee approvals, informed consent, sample size calculation, independent radiographs assessor and patients’ randomisation with clear inclusion and exclusion criteria was employed. the goals of this research were seen as the following: 1. to define predictive factors for both conservative and surgical care 2. to define the role of surgery 3. to provide the practising orthopaedic surgeon with evidence-based decision-making tools the outcome measures used included: 1. the dash score – disabilities of the arm, shoulder and hand 2. constant score 3. radiographic evaluation all the above were assessed at 6 weeks and 3, 6, 12 and 24 months. the outcome of this research revealed the following: 1. the patients’ demographics and mechanisms of injury were similar. 2. the dash and constant scores were almost similar. 3. the x-rays were much better in the operated group with the best anatomical reduction – assessed from the acromio-clavicular joint reduction and the coracoclavicular distance. 4. the re-operation rate was more prevalent in the operated group. 5. the non-operated group returned to work earlier. 6. the persistently displaced distal clavicle in the nonoperated group was cosmetically unacceptable. the identified complications in the surgical group were: plate loosenings, acromial erosions, clavicular fracture, stiff shoulder, deep wound infection and numbness. the conservative group showed the persistent lateral clavicular end protrusion with soft tissues tethering as well as heterotopic ossification. a list of key conclusions emerged from this study, namely: 1. the treatment of the high-grade acromio-clavicular joint disruption remains controversial. 2. the study provided valuable insight into the natural history of acute acromio-clavicular dislocations. 3. the modern hook plate design was found to result in good anatomical reductions with horizontal and vertical stability and good shoulder function. it is also a reproducible technique. 4. surgery was however not superior to non-operative treatment in many respects. the conservative group rehabilitated much earlier. this study has added more substance to the better understanding and reinforcement of the current approach and treatment of this common, often difficult and controversial injury. the main criticism, also conceded by the authors, is that the sample size may be too small to make very firm conclusions. however, it is heartening in that the study is a follow-up to the previous reputable cochrane (2010) and knut beitzel et al. systematic reviews (2013) that reached similar conclusions on the approach and treatment of the injuries under discussion. the cochrane reviews identified the three relevant and critical clinical trials that involved a larger grouping of 174 patients. two of those trials were randomised and the one was quasi randomised. none of them used the validated measures for assessing the functional outcomes. reviewer: dr mt ramokgopa department of orthopaedic surgery university of the witwatersrand tel: 011 717-1000 multicenter randomized clinical trial of non-operative versus operative treatment of acute acromio-clavicular joint dislocation the canadian orthopaedic trauma society journal of orthopaedic trauma november 2015;29(11) page 68 sa orthopaedic journal winter 2016 | vol 15 • no 2 furthermore, the lesser superior methods of fixation in the form of coraco-clavicular screws, acromio-clavicular pins and slings were used. the clinical evidence was found to be insufficient. the 20 studies subjected to beitzel et al.’s systematic review identified the 162 different techniques for the surgical treatment of the acromio-clavicular joint dislocation matched against the conservative measures. three considerations regarding treatment were made. these were operative versus non-operative (14), early versus late treatment (4) and anatomic versus non-anatomic (2) treatment. again, the authors concluded that there was lack of evidence to support the treatment options for the patients with acromio-clavicular joint dislocation. emilio calvo et al. (2006) reported a retrospective analysis of 43 patients in which he identified acromio-clavicular joint anatomic reduction-related osteoarthritis and coracoclavicular joint ossification in some of the 32 patients treated operatively. the group recommended conservative management. there are several other concurring published reviews regarding this same topic that are worth reading such as imatani (1975), bannister (1983), hootman (2004), bäthis (2000), ceccarelli (2008). the opposing spectrum would include horn (1954) who raised the problem of shoulder fatigue from the nonattached muscles whereas kessel (1982) on the other hand alluded to the painful subluxation in the non-operated patient. from the article under review and backed by the papers quoted and especially cochrane reviews in particular, there are both clinical and research implications. first the implications for clinical practice are the following: 1. there is no proof that there are long-term benefits from surgery. 2. surgery is associated with complications. 3. there is concern about the long stay from work following surgery. 4. there is a hospitalisation factor with surgery. 5. conservative management seems to be the preferred option. 6. selected patients may benefit from surgery, such as professional athletes and labourers. treatment must be adapted to the patient’s demands. for the research the implications are: 1. further well-designed research in this area is justified. 2. larger, multicentre trials with better standardisation, especially with the appropriate outcome measures, are required. 3. comparison between conservative treatment and minimally invasive arthroscopic surgery or other modern fixation methods is needed. • saoj south african orthopaedic journal editorial doi 10.17159/2309-8309/2021/v20n3a0sa orthop j 2021;20(3) antibiotic resistance netflix, hal 9000 and the $100 billion question leonard c marais* head of department: orthopaedics, school of clinical medicine, university of kwazulu-natal, durban, south africa *corresponding author: lcmarais@saoj.co.za with yuval noah harari’s ‘i told you so’ still ringing in our ears and the battlefield still ablaze, one cannot help but wonder what the next microorganism assault on humankind is going to involve.1 while we are still fully engaged on our main front, another old enemy is gathering strength on our flanks. bacterial resistance has been described as the single most important threat to public health in the 21st century.2 the united nations interagency group on bacterial resistance estimates that drug-resistant disease could rise from a current figure of around 700 000 deaths per annum to around 10 million a year by 2050, if we don’t act.3 the six most common bacterial pathogens in orthopaedics are currently all on the cdc (centers for disease control and prevention) ‘urgent’ or ‘serious’ threat list.4 a meta-analysis estimated that 39% to 51% of surgical site infection in the usa was caused by bacteria that are resistant to the standard prophylactic antibiotics.5 our primary tool against resistance is antibiotic stewardship programmes. but will it solve the problem? traditionally, resistance was thought of as a real-world example of evolution by natural selection.3 we now know that this type of vertical transmission of resistance genes represents only a small part of the picture. horizontal transmission, with the sharing of genetic information among the same generation of bacteria, drives the process. and the information can also be shared with bacteria from other species. thus, exposure to antibiotics may induce resistance in our native commensal bacteria, which can then serve as a library of resistance genes for invading pathogens.6 with this understanding, the emphasis on antibiotic stewardship and rational prescription is certainly sensible. in particular, the use of prophylactic antibiotics has come under fire. a recent example from our field is the recommendation that gram-negative antibiotic prophylaxis should not be used routinely in grade iii open fractures.7 the authors state that while most infections are admittedly caused by gram-negative organisms, there is insufficient evidence to suggest that the use of aminoglycosides makes a difference. it seems that having a placebo arm in future randomised controlled trials might be prudent. however, the problem goes beyond simply rationalising medical use of our available agents. around 73% of all antimicrobials sold on the planet are used in agriculture and in animals raised for food.8 the increased global demand for dietary protein has translated into a rapid growth expansion of intensive animal production, with africa seeing a 64% growth over the past 20 years. there has been a dramatic increase in the number of resistant pathogens in animals, and evidence suggests that this trend also contributes to increased antibiotic-resistant infections in humans. in this context, antibiotic stewardship in the medical fraternity is not enough. there needs to be a global awareness of the threat, and all communities need to get involved to address the issue at the level of our entire ecosystem.3 the optimist might say: ‘don’t worry, look what the guys in r&d did with the covid vaccines, we will just get some new antibiotics.’ maybe not. the estimated cost of developing a new antibiotic agent was estimated around us$1.5 billion in 2017.9 on the other hand, the estimated yearly income from an antibiotic’s sale is in the region of $45 million – so, a possible return on investment in about 33 years, if resistance does not develop. and typically, the company is only given about five to ten years of exclusive rights; then the generics enter the fray. profit depends on volume and price, but neither is controlled by the pharmaceutical company. stringent antibiotic stewardship programmes control volume, while government establishments regulate the price based on the reasonable cost-benefit ratio principle. this is the chief reason why many large pharmaceuticals companies are abandoning the fight and looking at other more lucrative product lines. musculoskeletal drugs are estimated to be around 11 times more profitable.2 astrazeneca announced that they were halting the development of new antibiotics in 2016; novartis and sanofi followed suit in 2018.2 in december 2018, there were only around 11 antibiotics in development for the treatment of pathogens in the who critical threat list.10 considering that only about 3% to 5% of antibiotics in the pre-clinical phase of development make it to the marketplace, the situation certainly seems dire. the future of our primary weapon against bacteria may now be in the hands of healthcare economists trying to convince funders and policy makers. this has yielded a few finance programmes aimed at stimulating the antibiotic development pipeline. the carb-x programme, led by boston university and funded by several governmental organisations in the us, uk and germany as well as charities like the bill and melinda gates foundation, has invested $325 million in 86 innovation projects around the world. the international federation of pharmaceutical manufacturers and associations’ amr action fund is backed by over 20 major pharmaceutical companies. it is expected to invest us$1 billion in antibiotic development and hopes to bring two to four new antibiotics to the clinical platform by 2030. however, the fundamental factors that make antibiotic discovery such an unattractive option for investors remain unchanged. alternative funding models are therefore being considered. the so-called ‘netflix model’ involves healthcare providers, like national health departments, paying a subscription fee for the development and then use of new antibiotics. the uk is aiming to award two contracts to pharmaceutical companies using this model and the first instalments will already be paid during the expensive research and development phase. page 127sa orthop j 2021;20(3) another possible solution could be to reduce the cost of the research and development phase. the data scientists have now entered the race, causing a major paradigm shift by creating a new pipeline for antibiotic discovery. traditionally, antibiotics were found testing soil samples containing bactericidal compounds produced by other microbes.11 stokes and colleagues recently used machinelearning algorithms in the search for novel antibiotic compounds. they trained a deep neural network capable of predicting molecules with antibacterial activity and searched chemical compound libraries comprising more than 100 million molecules. their artificial intelligence (ai) model was able to identify eight antibacterial compounds that are structurally distant from known antibiotics.12 they named the most promising candidate molecule halicin, after the sentient computer ‘hal 9000’ in arthur c clarke’s 2001: a space odyssey. ‘in silico’ (i.e., an experiment performed on a computer) drug discovery is not a new idea, but until now the predictive models were not sufficiently accurate. previously, molecules were represented as vectors (the basic unit used for computational arithmetic in ai) reflecting only the presence or absence of certain chemical groups. however, the new neural networks can learn these representations automatically, mapping molecules into continuous vectors which are subsequently used to predict their properties.13 in simpler terms, it could possibly be thought of as adding an n-dimensional space to the vectors representing coordinates. other scientists are exploring alternatives to antibiotics that target either the bacteria themselves or the processes they use to attack their host. the wellcome trust recently commissioned a portfolio review of antibiotic alternatives. they identified 19 possible approaches for systemic use that justify further investigation.14 tier 1 approaches were defined as options in the clinical phase of development. antibodies, targeting either the pathogen or their toxins, have considerable basic science backing and were the top contender for making a clinical impact. the development of prophylactic vaccines is also relatively far advanced (phase 2 and 3 trials ongoing) but have not yielded the much-expected benefits. vaccination against staphylococcus aureus infections, for example, have mostly failed in human trials.15 probiotics might provide some protection against antibiotic-associated diarrhoea, but might also be useful as an adjunct to other therapies (like phages). bacteriophages (phages, either wild-type or engineered) are the natural enemy of bacteria and have the potential to make a high impact as an antibiotic alternative. their versatility of application and antibiofilm activity make them an attractive option and their use has already found some traction in orthopaedics. onsea and colleagues have described their protocol and experience with bacteriophage treatment in four cases with severe difficult-to-treat musculoskeletal infections.16 the procedure is quite complex and involves intraoperative and postoperative administration through an irrigation system (reminiscent of the lautenbach method) three times a day for seven to ten days. as bacteriophages are hostspecific, a cocktail of several different phages was used. after a single course of phage therapy with concomitant antibiotics, there was no recurrence because of the original causative strains. several therapeutic and preventative strategies are also being investigated in periprosthetic joint infection.17 phage lysins are the enzymes produced by bacteriophages to break down the target bacterial cell wall. they are currently considered to have the greatest potential of all the antibiotic alternatives due to their anticipated clinical impact and feasibility as a therapeutic approach. a phase 3 trial of a lysin acting on s. aureus (aptly entitled disrupt) is currently underway and could be eligible for registration by 2022.18 phage lysins also have great potential as adjunctive agents due to their potent biofilm eradication ability, synergistic effect with antibiotics, and low propensity for the development of resistance. antibiotics depend on an appropriate host-immune response for success. immune stimulation has been proposed as an adjunct to shift the balance in favour of the antibiotics. currently, the focus is on repurposed drugs and bacterial extracts to induce the expression of innate antibacterial peptides. with a high potential for side-effects and response varying among different individuals, this development pathway will probably be more complicated. tier 2 antibiotic alternatives were defined by the expert group as approaches in the pre-clinical phases of development.14 here, antimicrobial peptides, host defence peptides and antibiofilm peptides are leading the chase. antimicrobial peptides (amps) are found in most organisms, including fungi, plants and animals, and form an indispensable component of our own immune response.19 they depend on the fundamental differences between prokaryotic and eukaryotic cells, and the typical mechanism of action is thought to involve integration of the peptide into the bacterial cell membrane thereby disrupting it, causing cell lysis.20 amps have been investigated in clinical trials, with disappointing results, and many projects have been abandoned. originally thought to exhibit broad-spectrum activity against gram-positive and -negative bacteria, new evidence seems to suggest a somewhat more intricate model. amps are now known to exhibit high levels of specificity, genetic variability and functional diversity. this complexity results in an estimated price tag of approximately £600 million to get one successful product to clinical practice.14 then there are some outside contenders.14 much of the morbidity resulting from bacterial infections is a result of the host’s inflammatory response, and selective immune suppression might curtail that. gene therapy is theoretically an option. anti-resistance or anti-bacterial nucleic acids could possibly be delivered by transmissible genetically modified vectors inducing altered gene expression in the bacterial targets. other novel approaches include custom-made rna-guided nucleases (rgns) targeting specific dna sequences delivered by bacteriophage or plasmids and liposome decoys for bacterial toxins. however, these approaches are still viewed as somewhat speculative in nature. during the second world war, penicillin was introduced to treat infections, both in the field and in hospitals across europe. its widespread success earned it the title of ‘the wonder drug’ and alexander fleming a share of the nobel prize for medicine in 1945.21 aside from the antibiofilm peptides which were discovered in 2013, the rest of the top 10 current antibiotic alternatives candidates have all been around for more than 15 years.14 funding, again, seems to be the major stumbling block. the wellcome trust review panel fittingly captured the level of commitment needed in their closing remarks by recommending an investment somewhere between that of the large hadron collider (£6 billion) and the international space station (£96 billion) in antimicrobial therapy. let’s say roughly $100 billion... where is the money going to come from? if we move towards the ‘netflix model’, it may put pressure to invest on other countries who will not want to get left behind. but where would this leave us in middleand lower-income countries? it is essentially the same problem we are currently facing with the covid vaccines. on the positive side, this global challenge is spurring on innovation and creative thinking. and it appears that science will be responsible for the solution. however, this time, it seems highly unlikely that we are going to find it on someone’s messy desk. references 1. homo deus. a brief history of tomorrow. harari yn. london: vintage; 2017. 2. malik b, bhattacharyya s. antibiotic drug-resistance as a complex system driven by socioeconomic growth and antibiotic misuse. scientific reports. 2019;9:9788. 3. plackett b. no money for new drugs. nature. 2020;586:s50-s52. page 128 sa orthop j 2021;20(3) 4. siddiqua a, scholl e, bhandari m, silburt j. antimicrobial resistance: implications for orthopaedic surgery. orthoevidence. 2021:80. 5. teillant a, gandra s, barter d, et al. potential burden of antibiotic resistance on surgery and cancer chemotherapy antibiotic prophylaxis in the usa: a literature review and modelling study. lancet infect dis. 2015;15(12):1429-37. 6. mcinnes rs, mccullkum ge, lamberte le, van schaik w. horizontal transfer if antibiotic resistance genes in the human gut microbiome. curr opin microbiol. 2020;53:350-43. 7. hand tl, hand eo, welborn a, zelle ba. gram-negative antibiotic coverage in gustilo-anderson type-iii open fractures. j bone joint surg. 2020;102:1468-74. 8. van boeckel tp, pires j, silvester r, et al. global trends in antimicrobial resistance in animals in lowand middle-income countries. science. 2019;365 (6459):eaaw1944. 9. towse a, hoyle ck, goodall j, et al. time for a change in how new antibiotics are reimbursed: development of an insurance framework for funding new antibiotics based on a policy of risk mitigation. health policy. 2017;121(10):1025-30. 10. carb-x. the global antibiotics pipeline is precariously thin. available from: https://carb-x.org/about/global-threat/. accessed 10 may 2021. 11. svoboda e. antimicrobial resistance. research round-up. nature. 2020;586;s58-9. 12. stokes jm, yang k, swanson k, et al. a deep learning approach to antibiotic discovery. cell. 2020;180:688-702. 13. trafton a. artificial intelligence yields new antibiotic. a deep-learning model identifies a powerful new drug that can kill many species of antibiotic-resistant bacteria. mit news; 2020. available from: https://news.mit.edu/2020/artificialintelligence-identifies-new-antibiotic-0220. accessed 10 may 2021. 14. czaplewski l, bax r, clokie m, et al. alternatives to antibiotics – a pipeline portfolio review. lancet infect dis. 2016;16:239-51. 15. miller ls, fowler vg, shukla sk, et al. development of a vaccine against staphylococcus aureus invasive infections: evidence based on human immunity, genetics and bacterial evasion mechanisms. fems microbiology reviews.. 2020;44:123-53. 16. onsea j, soentjes p, djebera s, et al. bacteriophage application for difficult-to-treat musculoskeletal infections: development of a standardized multidisciplinary treatment protocol. viruses. 2019;11:891. 17. van bellegham jd, manasherob r, miedzybrodski r, et al. the rationale for using bacteriophage to treat and prevent periprosthetic joint infections. front microbiol. 2020;11:591021. 18. clinicaltrials.gov. direct lysis of staph aureus resistant pathogen trial of exebacase (disrupt). available from: https://clinicaltrials.gov/ct2/show/ nct04160468. accessed 21 may 2021. 19. brogden ka. antimicrobial peptides: pore formers or metabolic inhibitors of bacteria. nature reviews microbiology. 2005;3:238-50. 20. lazzaro bp, zasloff m, rolff j. antimicrobial peptides: application informed by evolution. science. 2020;368(6490):eaaau5480. 21. microbiology society. the history of antibiotics. available from: https:// microbiologysociety.org/members-outreach-resources/outreach-resources/ antibiotics-unearthed/antibiotics-and-antibiotic-resistance/the-history-ofantibiotics.html. accessed 12 may 2021. 404 not found south african orthopaedic journal general orthopaedics doi 10.17159/2309-8309/2022/v21n1a2van marle a et al. sa orthop j 2022;21(1) citation: van marle a, acho p-m, chepape co, mahlaba rm, dlamini p, magugu s, mahlohla kk, teis n, kachelhoffer am, joubert g, coetzee mj. a retrospective file audit of preoperative anaemia in patients referred to an anaesthesiology clinic before elective orthopaedic surgery. sa orthop j 2022;21(1):16-20. http://dx.doi.org/10.17159/23098309/2022/v21n1a2 editor: prof. michael held, university of cape town, cape town, south africa received: november 2020 accepted: october 2021 published: march 2022 copyright: © 2022 van marle a. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: local departmental resources. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background preoperative anaemia has been shown to be associated with increased postoperative morbidity and mortality, prolonged hospital stay, and increased allogeneic blood transfusions. with elective surgery there is time to manage preoperative anaemia. the aim was to determine the prevalence of preoperative anaemia and evaluate how anaemia was investigated and managed in adult patients who were referred from the orthopaedic clinic to the universitas academic hospital anaesthesiology clinic between january 2016 and december 2018. methods the retrospective file audit included patient demographics, comorbidities and chronic medication, indication for elective surgery, haemoglobin level at first clinic visit, laboratory investigations done for anaemia, dates of clinic visits and surgery, whether the anaemia was corrected before surgery, and if there were any perioperative red cell transfusions. results a total of 178 patients were included. the cut-off value for anaemia was 13 g/dl in both sexes. forty-four patients (25%, 95% ci 19–32%) had preoperative anaemia with a median haemoglobin of 12.25 g/dl (iqr 11.2; 12.7). their mean age was 63.3 (sd ± 10.0) years. fifteen patients (34%) were booked for knee arthroplasty and 24 patients (55%) for hip replacement surgery. no workup was done for the anaemia, and only 15/44 (34%) anaemic patients received any form of treatment. eighteen anaemic patients (41%) received perioperative red cell transfusions. eight of the transfused patients (44%) developed postoperative sepsis, while five were still anaemic postoperatively. conclusion the prevalence of preoperative anaemia before elective orthopaedic surgery (25%) was the same as that reported before patient blood management was introduced internationally. none of the anaemic patients had a diagnostic workup and therefore did not receive therapy targeted at the cause of the anaemia. perioperative red cell transfusions could have been significantly reduced. the clinic now focuses on managing preoperative anaemia. level of evidence: level 3 keywords: preoperative anaemia, elective orthopaedic procedures, patient blood management, preoperative care, blood transfusion a retrospective file audit of preoperative anaemia in patients referred to an anaesthesiology clinic before elective orthopaedic surgery anne-cecilia van marle,¹ petra-marie acho,² christine o chepape,² reitumetse m mahlaba,² precious dlamini,² samkelisiwe magugu,² kamogelo k mahlohla,² nicole teis,² anna m kachelhoffer,³ gina joubert,⁴ marius j coetzee²* 1 department of haematology and cell biology, school of pathology, faculty of health sciences, university of the free state and national health laboratory service, bloemfontein, south africa ² department of haematology and cell biology, school of pathology, faculty of health sciences, university of the free state, bloemfontein, south africa ³ department of anaesthesiology, school of clinical medicine, faculty of health sciences, university of the free state, bloemfontein, south africa ⁴ department of biostatistics, school of basic medical sciences, faculty of health sciences, university of the free state, bloemfontein, south africa *corresponding author: coetzeemj@ufs.ac.za https://orcid.org/0000-0002-6569-4061 https://orcid.org/0000-0003-2762-0966 page 17van marle a et al. sa orthop j 2022;21(1) introduction preoperative anaemia has been shown in systematic reviews to be associated with increased morbidity and mortality in general surgery, cardiovascular surgery and orthopaedic surgery.1-3 patient blood management emphasises the diagnosis and treatment of anaemia and prevention of blood loss, rather than the use of allogeneic red cell transfusions.4,5 the south african surgical outcomes study showed that preoperative anaemia was independently associated with in-hospital mortality (odds ratio 1.657) and admission to critical care (odds ratio 1.487).6 the prevalence of preoperative anaemia was 1 727/3 610 (47.8%) in that study. jadhunandan et al. showed preoperative anaemia was associated with a three-fold higher risk of postoperative mortality in open abdominal surgery.7 conradie et al. reported that the prevalence of preoperative anaemia was 28% in 375 adult patients presenting for elective non-cardiac, non-obstetric surgery in the western cape.8 in that study, 37% of the anaemic patients had iron deficiency, but only 9% of these patients received iron before surgery. there is sufficient evidence that preoperative anaemia is a significant problem in south africa that requires active management to improve patient outcomes. it is estimated that 17.8 million south africans are anaemic.9,10 at least two general international guidelines emphasise the need for the identification and prevention of preoperative anaemia.11,12 palmer et al. and goodnough et al.provide international guidelines for the management of preoperative anaemia in orthopaedic surgery.5,13 the south african society of anaesthesiologists (sasa) published their perioperative patient blood management guidelines in 2020.14 palmer et al. and the sasa guidelines both recommend that the cut-off level for anaemia in both sexes is 13 g/dl.5,14 women have a smaller blood volume than men, even though they may lose the same amount of blood for a given procedure. women with a preoperative haemoglobin of 12 g/dl often require perioperative red cell transfusions.5,7,15 the current world health organization definitions of anaemia of 12 g/dl in women and 13 g/dl in men are being revisited.16 preoperative anaemia screening clinics can manage preoperative anaemia in patients before elective surgery.17 the anaesthesiology clinic at universitas academic hospital (uah) evaluates patients before elective surgery, especially orthopaedic surgery. spahn’s systematic review of 2010 reported preoperative anaemia in 25% of patients undergoing elective total hip or knee arthroplasty, and 50% of patients undergoing surgical hip fracture repair.18 that review also showed that preoperative anaemia was associated with a blood transfusion rate of 45 ± 25% and postoperative infections in 44 ± 15%, poorer physical functioning and recovery, and increased length of hospital stay and mortality. meybohm et al. showed that in 10 017 german patients, the preoperative anaemia rate was 14.8% for elective knee joint arthroplasty, 22.9% for elective hip joint arthroplasty and 45.0% for duo-prosthesis implantation.19 patients with anaemia had a prolonged hospital stay and increased mortality. our primary aim was to assess the prevalence of anaemia in patients referred to the uah anaesthesiology clinic for preoperative assessment and management prior to elective orthopaedic surgery. secondary objectives were to document i) in how many of these patients the underlying cause for the anaemia was investigated; ii) in how many of these patients the anaemia was corrected prior to surgery; and iii) which of these patients required blood transfusions perioperatively. the information would help to improve the management of preoperative anaemia. patients and methods the retrospective audit included all adult patients who were referred to the uah anaesthesiology clinic from the orthopaedic clinic before elective orthopaedic surgery between january 2016 and december 2018. we identified patients from the attendance list of the uah anaesthesiology clinic. a total of 178 adult patients were included. patients younger than 18 years, and those who required emergency orthopaedic surgery, were excluded. information was collected from patient notes and hospital, pharmacy and laboratory table i: demographic and clinical characteristics (n = 178) risk factor anaemic (n = 44) non-anaemic (n = 134) p-value age (years) (mean ± sd) 63.3 ± 10.0 62.2 ± 12.3 0.557 sex (male/female) (% female) 7/37 (84) 54/80 (60) 0.003 haemoglobin (g/dl) (median, iqr) 12.25 (11.2; 12.7) 14.3 (13.7; 15.5) < 0.001 comorbidities hypertension 34 (72%) 97 (77%) 0.524 ischaemic heart disease 28 (64%) 76 (57%) 0.419 obesity 16 (36%) 49 (37%) 0.981 copd/smoking 13 (30%) 46 (34%) 0.559 diabetes mellitus type 2 5 (11%) 19 (14%) 0.635 peptic ulcer disease 8 (18%) 12 (9%) 0.104 hypothyroidism 6 (13.6%) 17 (13%) 0.871 alcohol abuse 4 (9%) 24 (18%) 0.163 chronic medication nsaids 29 (66%) 89 (66%) 0.951 aspirin 22 (50%) 83 (62%) 0.162 paracetamol 12 (27%) 37 (28%) 0.956 haematinic treatment oral iron 6 (14%) 7 (5%) 0.090 folate 8 (18%) 16 (12%) 0.293 vitamin b compound 8 (18%) 16 (12%) 0.293 sd: standard deviation; iqr: interquartile range; copd: chronic obstructive pulmonary disease; nsaids: nonsteroidal anti-inflammatory drugs page 18 van marle a et al. sa orthop j 2022;21(1) information systems. the pseudoanonymised data included basic patient demographics, comorbidities and chronic medications, the indication for elective surgery, haemoglobin level at first clinic visit, laboratory investigations done to determine the cause of anaemia, whether anaemia was corrected before surgery, the dates of the clinic visits and surgery, the postoperative haemoglobin levels, whether any perioperative red cell transfusions were given, as well as any documented postoperative complications. for all 178 patients, information relating to the study objectives was available and therefore no patients were excluded due to missing data. the data was captured on a microsoft excel spreadsheet. the cut-off level for anaemia was 13 g/dl in both sexes.14 the design followed the strengthening the reporting of observational studies in epidemiology (strobe) guidelines for observational studies.20 data was analysed by the department of biostatistics at the university of the free state using sas version 9.4 (sas institute inc, cary nc, usa). age was summarised by mean and standard deviation. other numerical variables were summarised by medians and percentiles due to skew distributions. categorical variables were summarised by frequencies and percentages. comparison of subgroups regarding categorical variables were done using contingency tables with chi-squared or fisher’s exact tests. numerical variables were compared using mann–whitney tests. results a hundred and seventy-eight patients were included. forty-four patients (25%, 95% ci 19–32%) were found to be anaemic during their preoperative anaesthesiology clinic assessment (table i). their mean age was 63.3 years (sd ± 10.0), and 84% were female (compared to 60% of non-anaemic patients, p < 0.001). the median haemoglobin in the anaemic subgroup was 12.25 g/dl (iqr 11.2; 12.7) compared to that of the non-anaemic subgroup which was 14.3 g/dl (p < 0.001). of the anaemic patients, 29 (66%) regularly used nonsteroidal anti-inflammatory drugs (nsaids). unexpectedly, apart from screening tests for renal function, no laboratory investigations for the anaemia were done. among the anaemic patients, the most common comorbidities were hypertension (72%), followed by ischaemic heart disease (64%). none of the comorbidities, chronic medication or haematinic treatment differed significantly between the anaemic and nonanaemic subgroups. of the 44 anaemic patients, three were booked for knee arthroscopy, 15 (34%) for total knee replacement, one for shoulder acromioplasty, one for tibial osteotomy, and the remaining 24 (55%) for hip replacement surgery. the median time between the clinic visit and surgery for the anaemic patients was 76.5 days (range 1–488). the flow diagram in figure 1 summarises the patients’ clinical course. only 15/44 (34%) anaemic patients received some treatment for anaemia, which consisted of a varying combination of vitamin b complex, folic acid and oral iron. the anaemia was corrected before surgery in only three of these patients. eighteen (41%) of the 44 anaemic patients received perioperative red cell transfusions. one patient received three units, nine patients received two units each and the remaining eight patients received one unit of red cell concentrate each. seven of the 18 patients who received blood transfusions were on some form of haematinic treatment. the median preoperative haemoglobin level of transfused patients was 11.5 g/dl (range 9.2–12.7). fourteen of the patients who received blood transfusions were among the 32 anaemic patients who were also regularly using nsaids and aspirin. eight of the 18 patients (44%) who received perioperative blood transfusions developed postoperative sepsis. ten patients (10/44 = 23%), five of whom had been transfused, were anaemic following surgery. however, this may be an underestimate as a postoperative haemoglobin level was only documented in 13 of the 44 anaemic patients. discussion the prevalence of anaemia in our study was 25%. this is similar to the 20% reported by saleh et al. in 2007.21 it is also in the range reported in spahn’s meta-analysis of patients undergoing elective orthopaedic surgery before 2010.18 transfusion rates in arthroplasty surgery are currently decreasing, but the rates depend on the specific hospital setting.22 recently, bolz et al. reported that the michigan arthroplasty collaborative quality initiative managed to reduce the transfusion rate from 14.82% in 2011 to 1.12% in 2017 by introducing patient blood management education.23 of concern is that no attempt was made to diagnose the cause of the anaemia in the 44 anaemic patients, even though there was often enough time to investigate and correct the anaemia, with a median time of 76.5 days between the first clinic visit and surgery. the use of nsaids by 66% of the anaemic patients might have contributed to their anaemia. the society for the advancement of patient blood management recommends that tests be done to diagnose the common causes of anaemia: iron deficiency anaemia, anaemia of inflammation, preoperative assessment of patients for elective orthopaedic surgery n = 178 no anaemia n = 134 some treatment n = 15 transfused n = 6 anaemia n = 44 no treatment n = 29 transfused n = 11 anaemia corrected n = 3 transfused n = 1 anaemia not corrected n = 12 figure 1. strobe flowchart of patients for elective orthopaedic surgery seen at the anaesthesiology clinic page 19van marle a et al. sa orthop j 2022;21(1) anaemia of chronic renal disease, and folate or vitamin b12 deficiency.24 the australian blood authority guidelines simply recommend a full blood count, iron studies including ferritin, c-reactive protein and renal function tests.25 the aetiology of any anaemia needs to be established to guide therapy. despite documented anaemia, 29 of 44 patients (66%) received no treatment. the treatment for the other 15 anaemic patients was haphazard and mostly inadequate, as the anaemia was only corrected in time for surgery in three of the anaemic patients (figure 1). iron deficiency is the most common nutritional deficiency that contributes to preoperative anaemia.8,21,26 with sufficient time interval (≥ 6 weeks) before surgery, oral iron supplementation is appropriate. intravenous iron should be considered if oral iron is poorly tolerated, ineffective (inadequate haemoglobin response), in cases of ongoing blood loss or functional iron deficiency and when the planned surgery is fairly urgent.15,27 iron deficiency can be rectified within a month by administering intravenous iron.21,22 where appropriate, an erythropoietin can be combined with intravenous iron to manage anaemia of chronic disease, another common cause of anaemia among surgical patients.28 this combination therapy is also endorsed by the sasa 2020 perioperative patient blood management guidelines to reduce postoperative transfusions in patients with non-iron deficiency (e.g. erythropoietin, vitamin d or folate acid deficiency) undergoing elective surgery.14 the routine use of erythropoietin is, however, discouraged due to its potential increased thrombotic risk.27 these measures correct anaemia more safely, and mostly cost far less, than equivalent red cell transfusions. it is not certain why the one patient whose anaemia had been corrected received a red cell transfusion. in our study population, 44% of the 18 anaemic patients who received blood transfusions developed postoperative sepsis. as we did not collect exhaustive clinical information, we could not exclude other contributing factors to the infections. however, everhart et al. report that in hip and knee arthroplasty, the odds ratio for surgical site infections increases from 1.97 when one unit of red cells is transfused, to 7.40 when more than three units are transfused.29 the sample of patients was not very large and consisted only of patients referred to the anaesthesiology clinic because they needed optimisation of their clinical condition before elective surgery. as a result, the patient cohort consisted mainly of older patients with comorbidities. regarding the prevalence of preoperative anaemia, this patient cohort is probably not representative of the general population undergoing elective orthopaedic surgery. most (84%; p < 0.001) of the patients with preoperative anaemia were women. this female preponderance has been noted previously.26 considering their smaller blood volume, this puts them at greater risk of postoperative complications.14 in retrospect, we did not take into account that bloemfontein is 1 387 m above sea level, and therefore our cut-off levels should probably have been increased by 0.5 g/dl.30,31 the clinic had mainly focused on comorbidities other than anaemia in the past. barrett et al. previously demonstrated the need to improve training and knowledge of basic transfusion principles and perioperative anaemia management at our hospital.32 following this study, the clinic now follows the sasa perioperative patient blood management guidelines in order to reduce the rate of transfusions in elective orthopaedic surgery.14,33 this retrospective file audit primarily focused on the prevalence of preoperative anaemia in patients referred to the uah anaesthesiology clinic. only if patients were found to be anaemic at the first clinic visit was additional information regarding anaemia investigation and management before surgery, as well as perioperative blood transfusions and associated complications, collected. as a result, true comparisons with the non-anaemic cohort, especially with regard to the frequency of perioperative blood transfusions and postoperative complications, cannot be made. some conclusions should therefore be interpreted with caution. because an estimated 17.8 million south africans are anaemic, there is an urgent need for better management of preoperative anaemia.9,10 in a period when the covid-19 pandemic has strained our blood supply even further, the era of preoperative red cell transfusions in elective surgery should be something of the past.5,34 the world health organization has recently issued a policy brief about the urgent need to implement patient blood management.35 conclusion despite our small cohort, we were able to demonstrate that preoperative anaemia is prevalent, but often missed or neglected, and contributes to unnecessary blood transfusions and postoperative complications. our study illustrates the urgent need for multidisciplinary teams or clinics that screen patients for anaemia before elective surgery, as well as for the implementation of clear treatment guidelines for preoperative anaemia.17 acknowledgements the authors would like to thank the finance and it departments of universitas academic hospital for the provision of data about blood usage. we would also like to thank the nurses at the universitas academic hospital orthopaedic and anaesthesiology clinics. we would like to acknowledge the contribution of our fellow author, prof. anna m kachelhoffer (1935–2021) who worked so hard to collect all the patient files and information, but unfortunately passed away before being able to see this publication. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, ethics approval was obtained from the university of the free state health sciences research ethics committee (ufs-hsd2019/0372/3007) as well as from the free state department of health (fs_fs201904-002). all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was not obtained from patients for being included in the study as the study was retrospective and the research data was pseudoanonymised. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions avm: suggested the topic, was a study leader who supervised the students and wrote the final draft manuscript pma, cc, rm, pd, sm, km and nt: wrote the protocol, did the data collection and wrote the first draft report amk: supervised the collection of data gj: helped to plan the study, performed the analysis, and assisted with the write-up of the manuscript mjc: was a study leader who supervised the students and wrote the final draft manuscript orcid van marle a https://orcid.org/0000-0002-6569-4061 acho p-m https://orcid.org/0000-0003-0982-9926 chepape co https://orcid.org/0000-0002-5943-3308 mahlaba rm https://orcid.org/0000-0001-7986-8774 dlamini p https://orcid.org/0000-0002-0527-9501 magugu s https://orcid.org/0000-0001-6033-2750 mahlohla kk https://orcid.org/0000-0001-9966-3178 teis n https://orcid.org/0000-0002-0240-926x kachelhoffer am https://orcid.org/0000-0003-0418-7493 joubert g https://orcid.org/0000-0002-3728-6925 coetzee mj https://orcid.org/0000-0003-2762-0966 https://orcid.org/0000-0002-6569-4061 https://orcid.org/0000-0003-0982-9926 https://orcid.org/0000-0002-5943-3308 https://orcid.org/0000-0001-7986-8774 https://orcid.org/0000-0002-0527-9501 https://orcid.org/0000-0001-6033-2750 https://orcid.org/0000-0001-9966-3178 https://orcid.org/0000-0002-0240-926x https://orcid.org/0000-0003-0418-7493 https://orcid.org/0000-0002-3728-6925 https://orcid.org/0000-0003-2762-0966 page 20 van marle a et al. sa orthop j 2022;21(1) references 1. fowler aj, ahmad t, phull mk, et al. meta-analysis of the association between preoperative anaemia and mortality after surgery. br j surg. 2015;102(11):1314-24. https://doi. org/10.1002/bjs.9861. 2. padmanabhan h, siau k, curtis j, et al. preoperative anemia and outcomes in cardiovascular surgery: systematic review and meta-analysis. ann thorac surg. 2019;108(6):1840-48. https://doi.org/10.1016/j.athoracsur.2019.04.108. 3. potter lj, doleman b, moppett ik. a systematic review of pre-operative anaemia and blood transfusion in patients with fractured hips. anaesthesia. 2015;70(4):483-500. https://doi. org/10.1111/anae.12978. 4. thomson j, hofmann a, barrett ca, et al. patient blood management: a solution for south africa. s afr med j. 2019;109(7):471-76. https://doi.org/10.7196/samj.2019.v109i7.13859. 5. palmer 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long-term sustainability of a quality initiative program on transfusion rates in total joint arthroplasty: a follow-up study. j arthroplasty. 2020;35(2):34046. https://doi.org/10.1016/j.arth.2019.08.056. 24. sabm. sabm administrative and clinical standards for patient blood management programs, 5th ed. society for the advancement of blood management; 2019. 25. national blood authority. patient blood management guidelines: module 2 perioperative. canberra: national blood authority; 2012. 26. muñoz m, laso-morales mj, gómez-ramírez s, et al. pre-operative haemoglobin levels and iron status in a large multicentre cohort of patients undergoing major elective surgery. anaesthesia. 2017;72(7):826-34. https://doi.org/10.1111/anae.13840. 27. munting ke, klein aa. optimisation of pre-operative anaemia in patients before elective major surgery why, who, when and how? anaesthesia. 2019;74 suppl 1:49-57. https://doi. org/10.1111/anae.14466. 28. pagano d, milojevic m, meesters mi, et al. 2017 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vitamin and mineral nutrition information system. geneva, world health organization; 2011. (who/nmh/nhd/mnm/11.1). 32. barrett c, mphahlele k, khunou i, et al. the knowledge of transfusion and related practices among doctors at universitas academic complex, bloemfontein, south africa. transfus apher sci. 2020;59(3):102739. https://doi.org/10.1016/j.transci.2020.102739. 33. newman c, tran p, mcgregor s, bramley d. patient blood management strategies in total hip and knee arthroplasty. curr orthop pract. 2018;29(1):31-36. https://doi.org/10.1097/ bco.0000000000000577. 34. wise rd, gibbs mw, louw vj. lockdown and our national supply of blood products. s afr med j. 2020;110(5):12904. https://doi.org/10.7196/samj.2020.v110i5.14749. 35. world health organization. the urgent need to implement patient blood management: policy brief. geneva: world health organization; 2021. available from: https://apps.who.int/iris/ handle/10665/346655. accessed 20 october 2021. hhttps://doi.org/10.1002/bjs.9861 hhttps://doi.org/10.1002/bjs.9861 https://doi.org/10.1016/j.athoracsur.2019.04.108 https://doi.org/10.1111/anae.12978 https://doi.org/10.1111/anae.12978 https://doi.org/10.7196/samj.2019.v109i7.13859 https://doi.org/10.2106/jbjs.19.01417 https://doi.org/10.2106/jbjs.19.01417 https://doi.org/10.7196/samj.2018.v108i10.13148 https://doi.org/10.7196/samj.2018.v108i10.13148 https://doi.org/10.36303/sajaa.2020.26.1.2250 https://doi.org/10.7196/samj.2019.v110i1.14051 https://doi.org/10.1182/blood-2013-06-508325 https://doi.org/10.1182/blood-2013-06-508325 https://doi.org/10.1016/j.hoc.2015.11.002 https://doi.org/10.1111/bjh.13623 https://doi.org/10.1001/jama.2019.055 https://doi.org/10.1093/bja/aeq361 https://doi.org/10.36303/sajaa.2020.26.6.s1 https://doi.org/10.2450/2017.0296-16 http://dx.doi.org/10.1016/s2352-3026(18)30004-8 https://doi.org/10.1182/hematology.2019000061 https://doi.org/10.1097/aln.0b013e3181e08e97 https://doi.org/10.1097/aln.0b013e3181e08e97 https://doi.org/10.1055/a-0974-4115 https://doi.org/10.1136/bmj.39335.541782.ad https://doi.org/10.1093/bja/aem299 https://doi.org/10.5435/jaaos-d-18-00205 https://doi.org/10.1016/j.arth.2019.08.056 https://doi.org/10.1111/anae.13840. https://doi.org/10.1111/anae.14466 https://doi.org/10.1111/anae.14466 https://doi.org/10.1093/ejcts/ezx325 https://doi.org/10.2106/jbjs.17.00237 https://www.ufs.ac.za/docs/librariesprovider22/physics-documents/boyden-documents/all-documents/boyden-history-1087-eng.pdf?sfvrsn=42af921_0 https://www.ufs.ac.za/docs/librariesprovider22/physics-documents/boyden-documents/all-documents/boyden-history-1087-eng.pdf?sfvrsn=42af921_0 https://doi.org/10.1016/j.transci.2020.102739 https://doi.org/10.1097/bco.0000000000000577 https://doi.org/10.1097/bco.0000000000000577 https://doi.org/10.7196/samj.2020.v110i5.14749 https://apps.who.int/iris/handle/10665/346655 https://apps.who.int/iris/handle/10665/346655 _1v1yuxt _4f1mdlm _2u6wntf _19c6y18 _3tbugp1 _28h4qwu _nmf14n _37m2jsg _1mrcu09 _46r0co2 _2lwamvv _111kx3o _vx1227 _3l18frh _1hmsyys _206ipza _4k668n3 _2zbgiuw _3fwokq0 _1egqt2p _3ygebqi _2dlolyb _sqyw64 _3cqmetx _1rvwp1q _4bvk7pj _2r0uhxc _1664s55 _3q5sasy _25b2l0r _hlk87966915 orthopaedics vol3 no4 page 54 sa orthopaedic journal winter 2017 | vol 16 • no 2 the radial nerve danger zone: a cadaver study aj paterson mbchb, mmed(family med), msc(sports med) senior lecturer n navsa bsc(uwc), bsc(hons)(wits), bsc(physt)(wits), phd(pret) senior lecturer department of anatomy, school of medicine, faculty of health sciences, university of pretoria corresponding author: dr andrew j paterson department of orthopaedics faculty of health sciences university of pretoria private bag x323, arcadia, 0007 tel: +27 823731322 fax: +27 012 3798512 email: patersonaj1@gmail.com introduction distal humerus fractures are uncommon, comprising 2% of all fractures and a third of all humerus fractures.1 open fractures, comminuted fractures and fracture dislocation of the elbow are often accompanied by severe soft tissue damage. external fixation of the humerus is indicated when severe soft tissue damage or the presence of infection warrants initial alternative immobilisation of the fractures around the elbow.2 external fixation allows for easy access for wound cleaning and dressing,3 stabilises fractures where vascular and nerve repair was done4 and allows for frame adjustments to improve alignment. external fixation allows for early mobilisation of adjacent joints and mobilisation of the patient.5 external fixation can cause pin tract sepsis,6 and injury to nerves and blood vessels and the surrounding soft tissue.7 the radial nerve is situated close to the humerus, and placing external fixation around the distal humerus may lead to nerve damage. the upper limb is innervated by a plexus of nerves arising from the ventral rami of the c5–t1 nerve roots. the ventral rami of the upper, middle and lower trunks divide into anterior and posterior divisions. the posterior divisions of all three trunks form the posterior cord.8 in the axilla, the radial nerve is located posterior to the axillary artery from where it runs inferiorly along the medial aspect of the proximal humerus. the radial nerve then descends along the radial groove to pierce the lateral intermuscular septum proximal to the lateral epicondyle where it runs between the brachialis and brachioradialis muscles. abstract certain distal humerus fractures and elbow fracture dislocations warrant early fixation with an external fixator. the distal humerus is close to the radial nerve and a hazardous area for the placement of an external fixator. no known safe zone for the placement of an external fixator has been identified on the lateral border of the humerus. we record the incidence of radial nerve damage following external pin fixation and note the relation of the radial nerve to each pin. a total of 39 cadavers were dissected for this study. two 4 mm pins were placed with a multi-pin clamp into the lateral border of the right and left humerus at 100 mm and 70 mm proximal to the lateral epicondyle. we dissected the upper limbs and recorded the incidence of radial nerve damage and the position of the nerve in relation to the two pins. data for right and left sides were combined. the radial nerve was damaged by the proximal and distal pin in 56.4% and 20.5% respectively. the radial nerve was located anterior to the proximal pin (41%) and distal pin (79.5%). the radial nerve was located posterior to the proximal pin (2.6%) and distal pin (0.0%). we were unable to identify a safe zone from this study. we propose that pins should be placed less than 100 mm proximally from the lateral epicondyle and as posterior as possible to minimise the risk of radial nerve damage. key words: radial nerve, external fixation, humerus fractures http://dx.doi.org/10.17159/2309-8309/2017/v16n2a7 sa orthopaedic journal winter 2017 | vol 16 • no 2 page 55 as the radial nerve approaches the lateral epicondyle it divides into the superficial radial and posterior interosseous nerves.8 the highest risk of injury to the radial nerve is at the point where the nerve pierces the lateral intermuscular septum.9 bodner et al.10 identified the radial nerve at 100 mm proximal to the epicondyle using ultrasonography. artico et al.11 performed a study on fresh cadavers and found that the mean distance between the lateral epicondyle and the point where the nerve pierces the lateral intermuscular septum was 110 mm.11 kamineni et al.12 described the safe zone for placing pins in relation to the trans-epicondylar distance. they concluded that 100% of the trans-epicondylar distance along the lateral border of the humerus was a safe zone for external fixation.12 clement et al.13 stated the risk of radial nerve damage by external fixation may be due to the variation in the course of the nerve and that wide incision and blunt dissection to the cortex was necessary to prevent nerve damage. our study aims to identify a safe zone for the surgical placement of pins and records the location of the radial nerve in relation to the two pins placed. method our sample consisted of 39 cadavers (28 male and 11 female), between 18 and 99 years of age. cadavers were dissected by second year medical students in the department of anatomy at the university of pretoria. the use of cadavers for research is covered under the south african national health act 41 of 2003. the cadavers were positioned supine with the palms of both hands facing up. the lateral epicondyle was palpated and the two half pins (4 mm in diameter) were inserted at 100 mm (proximal pin) and 70 mm (distal pin) to the epicondyle. a hand drill and a multi-pin clamp (figures 1a and 1b), similar to those used in most external fixators around the elbow, was used to insert the pins. once the pins were placed, the upper limbs were dissected. the radial nerve was identified at the lateral border of the humerus and the incidence of nerve damage caused by the pins and the relation of the nerve to the pins was recorded. statistical analysis was done using the chi-square and mixed model test estimated along a 95% confidence interval. the overall results adjusted dependence between left and right sides and this proportion, together with its confidence interval was analysed using the statistical software stata. testing was carried out at the 0.05 level of significance. a fisher’s exact test was used to identify the incidence of radial nerve damage relative to pin insertion. results the radial nerve was damaged by the proximal pin in 56.4% of cases and by the distal pin in 20.5% of cases (table i). results of bilateral radial nerve damage by the proximal and distal pin for males and females are shown in table ii. the radial nerve was anterior to the proximal pin on the left humerus (43.5%) compared to the right (38.5%) for both males and females. the radial nerve was anterior to the proximal pin more often in male cadavers (50.0%) than in females (27.3%). these findings were not statistically significant (p=0.29). the radial nerve was anterior to the distal pin in 79.5% of cases irrespective of side. the radial nerve was damaged by the proximal pin more often in female right sides (81.8% of cases) figure 1a. multi-pin clamp. the pin on the right is used as a marker, thus making the pin of the left the proximal pin situated at 100 mm proximal to the lateral epicondyle and the middle pin would be situated 30 mm distal to the proximal pin. figure 1b. insertion of the proximal and distal pin with the use into the left arm of a cadaver table i: incidence (%) of radial nerve damage in a south african cadaver sample (n = number of cases out of total sample) pin nerve hit % (n) nerve non-hit % (n) proximal 56.41 (44) 43.59 (34) distal 20.51 (16) 79.49 (62) n=78 (total sample) n=number of cases page 56 sa orthopaedic journal winter 2017 | vol 16 • no 2 compared to male right sides (53.6% of cases). the right sides of both males and females had more nerve damage (61.5% of cases) than the left sides (51.3% of cases) although not statistically significant. direct nerve damage by the distal pin on both the left and right sides of males and females was 20.5% irrespective of side. male cadavers had more nerve damage on the right sides (17.9% of cases) than left sides (10.7% of cases), but female cadavers had more damage on the right sides (27.2% of cases) compared to left (45.5% of cases). the radial nerve was posterior the proximal pin on the left side more often in females (9.1%) compared to males (3.6%), in 5.1% of cases on the left sides only. the radial nerve was never encountered posterior to the distal pin. table iii indicates the location of the radial nerve in relation to the proximal and distal pin bilaterally. discussion in the present study, the incidence of nerve damage at the proximal pin (100 mm) was significantly higher than the distal pin (70 mm). this suggests that the risk of radial nerve damage is greater at 100 mm than at 70 mm. the lower incidence of nerve damage at the distal pin relates to the anterior course of the nerve. clement et al.13 inserted pins into 20 cadaver arms at 50 mm and 30 mm proximal to the lateral epicondyle. the proximal pin (50 mm) damaged the radial nerve in five out of 20 cases (25.0%).13 the distal pin damaged the radial nerve in four out of 20 cases (20.0%).13 according to our results and those of clement et al.,13 the radial nerve is more likely to be damaged if the pin is inserted between 70 and 100 mm proximal to the lateral epicondyle. although not clinically significant, we found nerve damage caused by the proximal pin in more female than male cadavers and more on the right than left side. no other studies have reported sex or bilateral differences. the higher incidence of nerve damage on the right side indicates that the proximal pin position is crucial to avoid hitting the nerve. the nerve was anterior to both pins in most cases but more so to the distal pin. the nerve changes course as it travels distally, eventually wrapping around the lateral epicondyle. the radial nerve was found at distances (our study) similar to artico et al.,11 who examined the topographical relation of the radial nerve to different anatomical landmarks in 20 fresh cadavers. they reported that the mean distance between the entry point of the nerve in the lateral intermuscular septum and the lateral epicondyle was 110 (±23) mm. our findings reinforce that the high-risk area for pin insertion is 100 mm proximal to the lateral epicondyle. clement et al.13 similarly placed pins in upper limbs and after dissection found that the radial nerve was anterior to the proximal pin in 13 cases and anterior to the distal pin in 14 cases. in three arms the nerve was posterior to the distal pin. we found similar results and conclude that pins should be placed more posteriorly as the radial nerve runs more anteriorly. table ii: comparison of the incidence (%) of radial nerve damage (hit) versus not damage (non-hit) relative to pin placement for males (m) and females (f) using the fisher’s exact test pin relation of nerve arm male hit % (n) female hit % (n) male non-hit % (n) female non-hit % (n) total hit % (n) total non-hit % (n) p-value proximal anterior right 46.43 (13) 18.18 (2) 53.57 (15) 81.82 (9) 38.46 (15) 61.54 (24) 0.15 left 50.00 (14) 27.27 (3) 50.00 (14) 72.73 (8) 43.59 (17) 56.41 (22) 0.29 direct right 53.57 (15) 81.82 (9) 46.43 (12) 18.18 (2) 61.54 (24) 38.46 (15) 0.15 left 46.43 (13) 63.64 (7) 53.57 (15) 36.36 (4) 51.28 (20) 48.72 (19) 0.48 posterior right 0.00 (0) 0.00 (0) 100.00 (28) 100.00 (11) 0.00 (0) 100.00 (39) 0.00 left 3.57 (1) 9.09 (1) 96.43 (27) 90.91 (10) 5.13 (2) 94.87 (37) 0.49 distal anterior right 17.86 (5) 27.27 (3) 82.14 (23) 72.73 (8) 20.51 (8) 79.49 (31) 0.66 left 10.71 (3) 45.45 (5) 89.29 (25) 54.55 (6) 20.51 (8) 79.49 (31) 0.03 direct right 17.86 (5) 27.27 (3) 82.14 (23) 72.73 (8) 20.51 (8) 79.49 (31) 0.66 left 10.71 (3) 45.45 (5) 89.29 (25) 54.55 (6) 20.51 (8) 79.49 (31) 0.09 posterior right 0.00 (0) 0.00 (0) 100.00 (28) 100.00 (11) 0.00 (0) 100.00 (39) 0.00 left 0.00 (0) 0.00 (0) 100.00 (28) 100.00 (11) 0.00 (0) 100.00 (39) 0.00 n=78 (total sample) n=number of cases table iii: incidence (%) of radial nerve position relative to pin placement in the right and left arm, using the fisher’s exact test pin relation of nerve to pin right arm (n) left arm (n) total (n) proximal anterior 38.46 (15) 43.59 (17) 41.03 (32) direct 61.53 (24) 51.28 (20) 56.41 (44) posterior 0.00 (0) 5.13 (2) 2.57 (2) distal anterior 79.49 (31) 79.49 (31) 79.49 (62) direct 20.51 (8) 20.51 (8) 20.51 (16) posterior 0.00 (0) 0.00 (0) 0.00 (0) n=78 (total sample) n=number of cases sa orthopaedic journal winter 2017 | vol 16 • no 2 page 57 kamineni et al.12 concluded that radial nerve damage is due to three causes: lack of anatomical knowledge and awareness of anatomical variations; surgical methods used; and clearly defined restricted areas for placement of external fixators. chaundry et al.14 performed a study on cadavers and concluded that the variations in the course of the radial nerve may account for damage. conclusion no defined safe zone could be established from this study. the authors propose that pin placement at 100 mm from the lateral epicondyle is avoided and that pins should be positioned as posterior as possible to minimise the risk of radial nerve damage. wide incision and blunt dissection is still recommended to minimise the risk of radial nerve damage. compliance with ethics guidelines we confirm there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. we confirm that the manuscript has been read and approved by all named authors and that there are no other persons who satisfied the criteria for authorship but are not listed. we further confirm that the order of authors listed in the manuscript has been approved by all the authors. we confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. in so doing we confirm that we have followed the regulations of our institutions concerning intellectual property. we confirm that dr paterson has contributed in the writing of the protocol as well as the literature research and placing of the pins. he also contributed with writing the final draft of the article. dr navsa contributed in the writing of the protocol and final draft of the article as well as the data collection. the study was approved by the faculty of health sciences research ethics committee. the use of cadavers for research is covered under the south african national health act 41 of 2003. references 1. egol ka, koval kj, zuckerman jd. handbook of fractures. 2010. p214-29. 2. hoppenfeld s, de boer p, buckley r. surgical exposures in orthopaedics: the anatomical approach. 4th ed. 2009. p69698. 3. hoppenfeld s, murphy vl. treatment and rehabilitation of fractures. 2000.lippincott williams & wilkins. 4. sala f, talamont t, agus ma, capitani d. 2010. sequential reconstruction of complex femoral fractures with circular hybrid sheffield frame in polytrauma patients. musculoskelet surg. 2010 dec;94(3):127-36. 5. ruland wo.2000. is there a place for external fixation in humeral fractures? injury 31: 27-34. 6. el-rosasy ma. non-united humerus shaft fractures treated by external fixator augment by intermedullary rod. indian journal of orthopaedics 2012;46:58-64. 7. epps ch (ed). complications in orthopaedic surgery volume 1. 1994. jb lippincott, philadelphia. 8. moore kl, dalley af, agur amr. clinically oriented anatomy. 6th ed. 2010. lippincott williams & wilkens. awolters kluwer business. 9. bono c, grossman m, hochwald n, torentta p. radial and axillary nerves, anatomical consideration for humeral fixation. clinical orthopaed rel res. 2000;373:259-64. 10. bodner g,buchberger w, et al. radial nerve palsy associated with humerus shaft fractures: evaluation with us-initial experience. radiology 2001;219(3): 811. 11. artico m, telera s, tiengo c, steggo c, macchi v, et al. surgical anatomy of the radial nerve at the elbow. surg radiol anat 2009;31:101-106. 12. kamineni s, ankem h, patten dk. anatomical relationship of the radial nerve to the elbow joint: clinical implications of safe pin placement. clinical anatomy 2009;22:684-88. 13. clement h, pichler w, tesch np, heidari n, grechenig w. anatomical basis of the risk of radial nerve injury related to the technique of external fixation applied to the humerus. surg radiol anatomy 2010;32:221-24. 14. chaundry t, noor s, maher b, bridger j. the surgical anatomy of the radial nerve and the triceps aponeurosis. clinical anatomy 2010;23:222-26. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj sa orthopaedic journal winter 2014 | vol 13 • no 2 page 31 atlanto-axial fusion: magerl transarticular versus harms instrumentation techniques rn dunn mbchb, mmed, fcs(sa) orth pieter moll and nuffield chair of orthopaedic surgery h stander mbchb(stell), fcorth(sa) registrar (at time of study) department of orthopaedic surgery, university of cape town correspondence: prof robert dunn email: robert.dunn@uct.ac.za tel: 021 404 5108 introduction atlanto-axial instability may occur following indirect trauma resulting in transverse ligament disruption or dens fracture. it may also occur insidiously in inflammatory conditions such as rheumatoid arthritis with progressive attenuation of the transverse ligament. less frequently it may be associated with dysplasias such as achondroplasia, down’s syndrome with a small dens or mucopolysaccharidosis such as morquio syndrome. traditional wiring techniques such as the gallie and brookes are technically simple but provide poor biomechanical control necessitating concomitant rigid external orthosis application and unacceptable non-union rates.1 magerl’s transarticular screw fixation offers high fusion rates but is not possible in 18% of patients due to a high riding vertebral artery.2 it also requires pre-instrumentation anatomical reduction which is not always possible. access can also be a problem due to thoracic kyphosis hindering drill direction. abstract transarticular screw fixation offers acceptably high fusion rates but is not possible in 18% of patients due to a high riding vertebral artery. it also requires pre-operative anatomical reduction which is not always possible. the harms technique utilises a posterior c1 lateral mass and c2 pedicle screw. this allows easier access due to the angle of drilling and has become an increasingly popular surgical technique. aim the aim of this study is to review and compare the above techniques with regard to surgery, complications and outcome. methods a retrospective case note and radiographic review of 42 patients undergoing posterior c1–2 fusion in a single institution during the period 2003 to 2011, identified on a prospectively maintained database, was performed. the indication for surgery was atlanto-axial instability with post-traumatic and rheumatoid arthritis the commonest aetiologies. there was no difference in age and gender between the two groups. results the harms method had a slightly higher mean blood loss compared to the transarticular method. the surgical time was no different. the transarticular technique was abandoned in three cases due to inability to place the screw safely. the harms technique was successfully completed in all cases. there were four unilateral vertebral artery injuries in the transarticular group and one in the harms group. there were three intra-operative unintentional durotomies in the transarticular group with one in the harms. all but one transarticular case fused, with five transarticular cases taking more than 9 months. conclusion although the harms technique had an increased blood loss, the incidence of vertebral artery and dura injury was lower. fusion was similar in both groups with the only non-union occurring in the transarticular group. the harms technique offers the advantage of intra-operative reduction and a smaller exposure due to the direction of access but at a higher instrumentation cost. key words: atlanto-axial fusion, harms, transarticular saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 31 page 32 sa orthopaedic journal winter 2014 | vol 13 • no 2 the harms technique utilises a posterior c1 lateral mass and c2 pedicle screw.3 this allows easier access due to the more perpendicular direction of drilling and has become an increasingly popular surgical technique. the aim of this study is to compare the above techniques with regard to surgery, complications and outcome. material and methods following institutional research ethics committee approval, a retrospective case note and radiographic review was performed on all patients undergoing posterior c1–c2 fusion by the senior author. forty-two consecutive patients were identified from a prospectively maintained database. twenty-seven underwent transarticular fusion and 15 the harms technique. this largely represented a change in the surgeon’s choice of procedure, initially performing the transarticular technique as the default operation with transition to the harms procedure. the two groups were similar in terms of age and gender. the median age was 43 years (21–69 ± 15.7) in the transarticular group and 35 (12–74 ± 20.7) in the harms group. the difference was not statistically significant (p=0.14). there were 18 males and nine females in the transarticular compared to nine males and seven females in the harms group (p=0.53) in both techniques the patient was positioned prone on a relton hall frame with the skull held with a mayfield clamp. the neck was positioned to optimise access by slight flexion at the occiput but extended in the sub-axial spine. an attempt was made to reduce the c1–2 articulation during this positioning process. both procedures were performed with lateral fluoroscopy only. a midline incision was made over c1–2 but extended distally in the transarticular group to allow the required drill angulation. sub-periosteal exposure of the c1 arch and c2 posterior elements was done. a right-angled hook was used to run on the inner cortex of the c2 lamina in a lateral direction to palpate the medial isthmus, and thus the medial border of the screw placement. in the transarticular group, a starting point was based about 2–3 mm lateral to this medial isthmic palpation, inferiorly on the c2 lamina, directed in a cephalad direction and neutral in terms of medial–lateral angulation. this was done under lateral image guidance. the c1–2 joint was crossed and anterior c1 lateral mass perforated. titanium 3.5 mm cortical screws were placed (figure 1). in the harms group, the posterior aspect of the c1 lateral mass was visualised after sub-periosteal exposure of the posterior arch and a plane developed inferiorly onto the lateral mass. a watson-cheyne was placed into the c1–2 joint, after penetrating the capsule, to allow inferior retraction of the c2 root and improve access to the entry point. a burr was used to create a cortical breach in the lateral mass as it joins the arch superiorly. this allowed stable initial placement of the 2.7 mm drill bit. the path was drilled parallel to the arch with 10–15° convergence. this was observed on lateral image while drilling. a screw was placed with the tulip at the level of the arch, i.e. part of the proximal screw shaft remained visible. c2 pedicle screws were then placed under lateral image after medial isthmic/pedicle palpation (figure 2). cortico-cancellous bone graft was harvested from the iliac crest in all cases and placed from the c1 arch to c2 lamina. patients were managed in a philadelphia collar when up, for 6 weeks. patient demographics, surgical indications, intra-operative variables, complications and radiographic outcome were assessed. x-rays pre-op, post-op, and follow-up at 6 weeks, 3 months, 6 months, 12 months and 24 months were evaluated for successful instrumentation and subsequent fusion. results trauma predominated over aetiology by accounting for half the cases. the remainder was due to rheumatoid arthritis, os odontoidium, a pathological fracture from tuberculosis and neurofibromatosis-related destruction. this is tabulated in table i. there was a small statistically significant difference in blood loss between the two groups with a median of 150 ml in the transarticular group and 250 ml in the harms group. when considering the number of cases that bled more than 500 ml, it was clearly more frequent in the harms group (p=0.016). the cases that bled excessively were two rheumatoid cases (one converted from an aborted transarticular screw), two dens non-unions and the tuberculosis pathological fracture. there was no difference in surgical time between the two techniques (table ii). the transarticular technique was abandoned in three cases due to inability to place the screw safely. the harms technique was successfully completed in all cases. figure 1. ap and lateral x-ray of a well-fused transarticular instrumented fusion figure 2. ap and lateral x-rays of the harms technique saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 32 sa orthopaedic journal winter 2014 | vol 13 • no 2 page 33 there were five unilateral vertebral artery injuries, four in the transarticular group and one in the harms group. these were easily controlled with screw placement in the former group but the other side not drilled. the harms injury occurred while tapping for the c1 screw and lacerating the artery as it passes on the c1 arch. the patients suffered no clinically evident effect from the single vertebral artery injuries (table iii). there were four intra-operative unintentional durotomies with csf leaks. three were in the transarticular group. these were successfully dealt with at the time of surgery with surgical, muscle and/or duroseal. there was one case of instrumentation failure with bilateral screw fracture in the transarticular group. despite this the patient went onto successful fusion. there were no cases of neurological deterioration or sepsis. median time to union was similar in both groups at around 5 months (table iv). all harms patients were fused by 9 months, with 18% of the transarticular group taking longer than this and one requiring revision for an established non-union. discussion atlanto-axial instability is a concern due to the risk of myelopathy and sudden death from proximal spinal cord compression.4 the decision to arthrodese the joint is based on the appreciation of this risk and the expectation that stabilisation will not occur spontaneously with conservative means. in the case of trauma, transverse ligamentous rupture recognised by an atlanto-dens interval of more than 5 mm on the lateral x-ray, is a clear indication as it is not expected to heal.5 dens fractures however may heal with restriction of motion but older patients, with marked displacement or angulation are recognised as a high non-union risk. theoretically, anterior dens osteosynthesis allows stabilisation without rotational motion sacrifice but this is often not the case due to spontaneous loss of motion.5,6 this may be due to associated c1–2 joint injury or the period of postoperative immobilisation and local inflammatory response to injury and surgery. in addition, reverse oblique fractures are not amenable to screw fixation. in non-compliant patients, rigid posterior fusion is the better option in our opinion. historically, uninstrumented and posterior wiring techniques (gallie and brookes) have been employed.7 although simple they provide poor biomechanical control of translation and necessitate rigid external orthoses and have a high non-union risk. magerl described the transarticular technique.2 it offers a stable construct which can be augmented with a posterior tension band between the c1 arch and c2 spine with socalled three-point fixation. this technique is demanding as it requires passage of the drill bit and screw medial and superior to the vertebral artery as it exits c2. up to 18% of patients have a high riding artery precluding this technique. we have also anecdotally noted that advanced rheumatoid patients tend to have enlarged vertebral artery foramina leaving less bone available for safe screw passage. the risk of vertebral artery injury is 5% per case.8 although a single vertebral artery injury is usually not clinically significant, it creates surgeon distress and necessitates an alternative technique if it occurs with the first screw as the second artery cannot be risked. the technique also demands anatomical reduction of c1 and c2 to allow a safe trajectory of the drill and subsequent screw. this is not always possible and can be difficult to maintain once reduced.9 the harms technique is initially more challenging to the surgeon as it requires visualisation of the c1 lateral masses which are a least a centimetre deep to the arch.3 the access can be difficult and excessive epidural bleeding can be encountered, which obliterates the surgeon’s view and prevents safe drill placement. this is due to the extensive venous plexus or epidural mesh of veins over the c2 root and posterior thecal sac. it is difficult to control with bipolar as once cauterised, the venous walls become hard and crack easily with further dissection increasing the bleeding. through trial and error, we have found the most efficient access is by sub-periosteal dissection on the inferior half of the c1 arch. the sharp side of the watson cheyne is used to lift to the periosteum inferiorly, creating a path on the posterior aspect of the c1 lateral mass. aetiology transarticular harms total trauma-related 52% transverse ligament rupture 5 2 7 acute odontoid fracture 5 1 6 odontoid non-union 6 2 8 atlanto-axial rotatory subluxation 1 1 inflammatory spondylopathy 38% rheumatoid arthritis 11 5 16 other 10% os odontoidium 2 2 tuberculosis with c2 fracture 1 1 neurofibromatosis 1 1 table i: aetiology of atlanto-axial instability table ii: blood loss and surgical time transarticular harms p-value blood loss (median) 150 ml (25–800 ± 153) 250 ml (50–800 ± 242.1) 0.02* surgical time (median) 90 min (45–150 ± 32.9) 95 min (70–225 ± 38.1) 0.22 blood loss > 500 ml 1 5 0.016* * indicates statistical significance the harms technique is initially more challenging to the surgeon as it requires visualisation of the c1 lateral masses saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/06 12:12 pm page 33 page 34 sa orthopaedic journal winter 2014 | vol 13 • no 2 the watson-cheyne is then punctured into the c1–2 joint capsule bearing in mind the oblique nature form supero-medial to infero-lateral. this is then levered inferiorly by the assistant to retract the c2 root and create space over the c1 lateral mass. usually the surgeon retracts the space medially or laterally with a small sucker tip and creates a cortical notch under vision with a burr at the apex of the lateral mass where it joins the arch. there may be venous bleeding from laterally around the vertebral artery which can be controlled with a small patty. the drill is then placed in the starter hole and directed parallel to the c1 arch, assisted with lateral imaging. bicortical drilling is done to facilitate bicortical screw engagement. any residual bleeding can be controlled with small quantities of surgicel®. this is an extremely powerful screw and allows intraoperative reduction of c1 to c2. the c2 screws should be locked first, rods bent in lordosis and even a tool applied to the c2 screw head during reduction to ensure maximum c1 retro-translation without forward tilt of the rods at the c2 screw–rod interface. the downside of the harms is the increased expense of four polyaxial screws versus two cortical screws but the advantages outweigh this. the incision is smaller due to the required trajectories being less steep than the transarticular screws. the risk of increased blood loss is present, but with experience can be avoided with the aforementioned techniques. in our experience, the blood loss is minimal in most cases but if encountered, can be extensive due to the venous plexus over the screw insertion area. this was confirmed by hu in his review of manual screw position. their average blood loss was 450 ml but encountered a maximum of 1 200 ml. they had no vascular or neurological complications and post-op ct confirmed adequate placement of the freehand-inserted screws.10 conclusion although the harms technique had an increased blood loss, the incidence of vertebral artery and dural injury was lower. fusion was similar in both groups with the only non-union occurring in the transarticular group. the harms technique offers the advantage of intraoperative reduction and a smaller exposure due to the direction of access but at a higher instrumentation cost. the content of this article is the sole work of the authors, and no benefit of any form has been received or will be received from any commercial party. references 1. bransford rj, lee mj, reis a. posterior fixation of the upper cervical spine: contemporary techniques. the journal of the american academy of orthopaedic surgeons [internet]. 2011 feb;19(2):63–71. available from: http://www.ncbi.nlm.nih. gov/pubmed/21292929 2. magerl f, seeman p. stable posterior fusion of the atlas and axis by transarticular screw fixation. in: kehr p, weidner a, editors. cervical spine. 1st ed. wien, new york, springer verslag.; 1987. p. 322–27. 3. harms j, melcher r. posterior c1-c2 fusion with polyaxial screw and rod fixation. spine (phila pa 1976). 2001;26(22):2467–71. 4. dreyer sj, boden sd. natural history. clinical orth. 1999;(366):98–106. 5.. hsu wk, anderson pa. odontoid fractures: update on. j am acad orthop surg. 2010;18(7):383–94. 6. bormann rpb von, uct m. dens screw fixation: is it all it ’ s cut out to be? sa orthopaedic journal 2007 winter: 18–24. 7. santavirta s, konttinen y, laasonen e, honkanen v, anttipoika i, kauppi m. ten year results of operations spine for rheumatoid cervical disorders. j bone joint surg br 1991;73b:116–20. 8. low h, redfern r. c1-c2 transarticular screw fixation for atlantoaxial instability: a 6-year experience, and c1-c2 transarticular screw fixation-technical aspects. neurosurgery. 2002;50(5):1165–66. 9. dunn r, ombachi r. transarticular screw fixation of the atlanto-axial spine: a safe and effective option. saoj. 2006;(august):1–6. 10. hu y, kepler ck, albert tj, yuan z-s, ma w-h, gu y-j, et al. accuracy and complications associated with the freehand c-1 lateral mass screw fixation technique: a radiographic and clinical assessment. j neurosurg spine 2013 apr;18(4):372–7. available from: http://www.ncbi.nlm.nih.gov/pubmed/ 23373564 this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. transarticular screws harms technique abandoned procedures 3 0 vertebral artery injuries 4 1 csf leaks 3 1 instrumentation failure 1 0 sepsis 0 0 neurological deterioration 0 0 table iii: summary of complications transarticular fixation harms technique p-value time to union (median) 5 (3–12 ± 3.2) months 4.5 (3–6 ± 1.5) months 0.04* delayed union 5 0 0.14 non-union 1 0 1.0 * indicates statistical significance table iv: time to union • saoj saoj winter 2014 bu_orthopaedics vol3 no4 2014/05/05 9:51 pm page 34 page 9south african orthopaedic journal http://journal.saoa.org.za editorial the word ‘paradigm’, derived from the greek paradeigma, refers to a ‘framework’ or ‘a very clear and typical example of something’.1 a paradigm shift thus signifies a change in the demand for certain competencies and/or expertise within a specific framework. this certainly applies to patients affected by cerebral palsy (cp) in a developed world context. the domain of childhood cp has entered a new paradigm which entails significant changes regarding patient profile, treatment approach, outcomes and expectations. after an initially slow uptake, the developed world has now successfully adjusted to a broader biopsychosocial approach. most of the developing world, however, still lacks a structured framework with the ability to accommodate and address the needs of this changing cohort of patients. so, what exactly has changed? a significant number of cp patients have reached adulthood. a meta-analysis, conducted by oskoui et al. between 1985 and 2011, concluded a global cp prevalence of 2.11 per 1 000 live births,2 which is in keeping with the most commonly quoted global prevalence of 2–3 per 1 000 live births.3,4 it is generally acknowledged that developing countries would have a higher prevalence of cp, but multiple confounding factors, along with a lack of relevant literature, make an accurate estimation difficult. south africa3 reports a prevalence of 10/1 000 live births, india and china5 1.5–2.5/1 000 and uganda 1.8–2.3/1 000.6 these statistics, along with the encouraging trend that death due to cp has become a much rarer occurrence,7 contribute to the startling revelation that we will soon be treating large groups of patients with cp in the unique categories of adolescent, young adult, mature and even geriatric populations. currently, there is a paucity of literature regarding the prevalence of adult cp. in sweden, a highly developed country, the prevalence of cp in the adult population is 1.14 per 1 000.8 although this number is slightly lower than the childhood prevalence for the same group, i.e. 1.7 per 1 000 at birth, it is clear that most of these children are, in fact, reaching adolescence and adulthood.8 mortality in children with cp is centred on infancy. eventual life expectancy, or progression into adulthood, shows a linear relationship with the number of major disabilities which co-occur in an infant, or young child, with cp.9 children with cp and no major disability have a 99% probability of surviving to the age of 30 years and beyond. however, only 33% of children will survive into adulthood if they have four or more co-occurring disabilities.7,9 the survival of 47 259 children receiving cp care in california was evaluated over a 20-year period (1983–2002). researchers ascertained that life expectancy recorded in earlier studies should be increased by approximately 5 years and that mortality in children with severe disabilities should be decreased by 3.4% per year.10 unfortunately, very few studies have evaluated the survival and mortality of cp patients in developing countries. the higher prevalence of cp in south africa, however, strongly suggests that we can expect a large adult cp population group. why is this important? the profile of the adult cp patient should take note of comorbidities, above and beyond motor disorders, which could affect these individuals. these factors may include depression, anxiety, intellectual disability, visual impairment, eating and swallowing disorders, language and speech disorders, dysarthria, gastrointestinal disorders, urinary disorders, auditory limitations as well as cardiovascular problems. when compared to the general population, an adult with cp might display a significant increase in general pain, premature symptoms of ageing, spinal deformities and back pain, osteoporosis and arthritis, sarcopenia, cardio-metabolic and pulmonary morbidity, nutritional challenges (such as dysphagia and general malnutrition) as well as global functional limitations.11 up to 70% of young adults with cp struggle to perform activities associated with daily living.12 these individuals experience a slow and progressive decline in their functional reserve and overall strength.13 in addition, psychological issues and depression are also more commonly found in adults with cp.14 it is, unfortunately, abundantly clear that cp patients’ healthrelated quality of life consistently rates lower than that of the general population, and that the factors which impact upon these individuals extend far beyond motor disabilities.15 why do we need to shift our paradigm? ‘i suppose it is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail’ – abraham maslow (1966) children with cp are traditionally cared for by a multidisciplinary team. the paediatric orthopaedic surgeon constitutes an integral cog within this framework as we are called on to mainly address the motor abnormalities of these children. unfortunately, the care of cp adolescents, young adults, adults and geriatric patients becomes much more fragmented and, as a result, in most cases the individualised approach is once again adopted. for example, when an adult cp patient presents with osteoarthritis of the hip, more often than not the arthroplasty surgeon will address this problem. said arthroplasty surgeon will frequently, and without addressing the numerous additional problems as previously noted, perform a total hip replacement. the additional problems may involve other musculoskeletal (biopsychosocial) as well as the so called ‘soft’ (biopsychosocial) aspects of comprehensive care for an adult with cp. the next consultation may be with a spinal surgeon, and so the individualised and fragmented cycle repeats itself. this cyclical repetition of fragmented care can, primarily, be ascribed to insufficient multidisciplinary support for the adult cp cerebral palsy care in south africa: a paradigm shift j du toit mbchb (stellenbosch university), fc orth sa, mscclinepi (stellenbosch university); associate professor, stellenbosch university, south africa page 10 south african orthopaedic journal http://journal.saoa.org.za patient and his/her treating orthopaedic surgeon, and should not be attributed to the treating physician’s lack of attention to detail. what should we do about the status quo? in an effort to fully understand the outcomes of different treatment options we should rethink our traditional approach to measuring said outcomes. in 1980 the world health organization (who) proposed the international classification of impairments, disabilities and handicaps (icidh) which classified consequences of disease. this comprehensive classification was developed to address a wide range of various health aspects and was consequently revised and adjusted in the early 1990s. after nine years of intensive research and input, the who published a new classification system, the international classification of functioning, disability and health, or icf.16 the icf emphasises components of health rather than consequences of disease and has proven to be an extremely useful classification and model to adopt when dealing with cp patients. the icf model, as per figure 1, provides a balanced perspective within which the spectrum of functioning and disability across the patient’s lifespan can be appreciated. it seeks to identify and classify abnormalities across two components, namely: 1) body function and structure; and 2) activities and participation. these components can be defined as follows: • body structures: anatomical parts of the body such as organs, limbs and their components • body functions: physiological functions of body systems including psychological functions • activities: execution of a task or action by an individual • participation: involvement in a life situation in addition, the icf recognised the importance of contextual factors, including personal and environmental factors which may obstruct, or facilitate, the level of functioning and disability. environmental factors denote the physical, social and attitudinal environment in which people live, while personal factors describe factors unique to the individual (e.g. education, social background, life events, lifestyle and race/ethnicity) which impact upon his/her functioning. the icf model thus provides a biopsychosocial framework according to which clinical identification and quantification can take place while considering body function/structure and activities/ participation as well as other relevant contextual data. this approach has proven useful in the cp domain, especially in the case of adolescents transferring into adulthood, as well as the adult cp patient.17-19 if we wish to successfully implement this line of action, we need to reinvent our approach by creating different multidisciplinary groups which function within the broader scope of healthcare for adults with cp. in addition, groups within south africa which are already utilising this approach should be embraced to facilitate knowledge transfer. our aim should be to include a paediatric orthopaedic surgeon, well versed in cp care, to reassess general mobility, supply institutional memory, and treat reversible aspects that would normally have been addressed in childhood. active participation of an upper limb, spinal, arthroplasty and foot and ankle surgeon will add immense value by facilitating a balanced approach to addressing the motoric abnormalities in addition to promoting an earlier recognition of the sequence and effect of one type of surgery on another, e.g. spinal and arthroplasty surgery. the psychosocial team will re-emphasise those day-to-day challenges which affect these individuals most, thus imbuing the orthopaedic surgeon with deeper insight regarding the possible implications of surgery as well as treatment plan options. how should we approach cp care in the future? to render appropriate and balanced care for this emerging patient group, we need to: • better understand the prevalence of adults with cp in south africa. we need to seriously contemplate the question: how large is this cohort of patients? • identify the unique challenges which will be experienced by the adult population of cp patients in the south african developed/ developing country context • avail ourselves with the current structures which care for this group within south africa • reinvent and implement a multidisciplinary team which can address the unique challenges of this cohort • utilise and implement the icf • set up research avenues that will assess, address and audit our past, present and future initiatives with regard to adults with cp • become champions for the cause of this vulnerable group of patients. this shifting landscape creates a unique opportunity to develop what can arguably be considered the first multidisciplinary team within south africa, and africa, to address the needs of a very special, and ever-growing group of patients, thus enabling us to render global and balanced care within an evidence-based framework. references 1. cambridge university press. cambridge online dictionary. 2008. 2. oskoui m, coutinho f, dykeman j, jetté n, pringsheim t. an update on the prevalence of cerebral palsy: a systematic review and meta-analysis. dev. med. child neurol. 2013;55:509-19. 3. donald ka, samia p, kakooza-mwesige a, bearden d. pediatric cerebral palsy in africa: a systematic review. semin. pediatr. neurol. 2014;21:30-35. 4. moreno-de-luca a, ledbetter dh, martin cl. genetic [corrected] insights into the causes and classification of [corrected] cerebral palsies. lancet neurol. 2012;11:283-92. 5. gladstone ma. review of the incidence and prevalence, types and aetiology of childhood cerebral palsy in resource-poor settings. ann. trop. paediatr. 2010;30:181-96. 6. kakooza-mwesige\, a. et al. prevalence of cerebral palsy in uganda: a population-based study. lancet glob. heal. 2017;5:e1275-e1282. 7. haak p, lenski m, hidecker m-j, li m, paneth n. cerebral palsy and aging peterson. dev med child neurol. 2009;51:16-23. 8. jonsson u, eek mn, sunnerhagen ks, himmelmann k. cerebral palsy prevalence, subtypes, and associated impairments: a population-based comparison study of adults and children. dev health conditions (e.g., cp, asd) activity environmental factors personal factors participationbody structure and function figure 1. international classification of functioning, disability and health (icf) (policyoptions.irpp.org-source world health organization 2001) page 11south african orthopaedic journal http://journal.saoa.org.za med child neurol. 2019 oct;61(10):1162-1167. doi: 10.1111/ dmcn.14229. 9. hutton jl. cerebral palsy life expectancy. clin. perinatol. 2006;33:545-55. 10. strauss d, shavelle r, reynolds r, rosenbloom l, day s. survival in cerebral palsy in the last 20 years: signs of improvement? dev. med. child neurol. 2007;49:86-92. 11. yi yg, jung sh, bang ms. emerging issues in cerebral palsy associated with aging: a physiatrist perspective. ann. rehabil. med. 2019;43:241-49. 12. nieuwenhuijsen c, donkervoort m, nieuwstraten w, stam hj, roebroeck me. experienced problems of young adults with cerebral palsy: targets for rehabilitation care. arch. phys. med. rehabil. 2009;90:1891-97. 13. verschuren o, et al. determinants of muscle preservation in individuals with cerebral palsy across the lifespan: a narrative review of the literature. journal of cachexia, sarcopenia and muscle. 2018;9(3):453-464. doi: 10.1002/jcsm.12287.. 14. van der slot wma, et al. chronic pain, fatigue, and depressive symptoms in adults with spastic bilateral cerebral palsy. dev. med. child neurol. 2012;54:836-42. 15. roebroeck me, jahnsen r, carona c, kent rm, chamberlain am. adult outcomes and lifespan issues for people with childhoodonset physical disability. dev. med. child neurol. 2009;51:670-78. 16. peden m, oyegbite k, ozanne-smith j, hyder aa, branche c, et al. (eds world health organization, geneva.) world report on child injury prevention. 2008. (https://www.who.int/ violence_injury_prevention/child/injury/world_report/report/en/) 17. liptak gs. health and well being of adults with cerebral palsy. curr. opin. neurol. 2008;21:136-42. 18. majnemer a, mazer b. new directions in the outcome evaluation of children with cerebral palsy. semin. pediatr. neurol. 2004;11:11-17. 19. rosenbaum p, stewart d. the world health organization international classification of functioning, disability, and health: a model to guide clinical thinking, practice and research in the field of cerebral palsy. semin. pediatr. neurol. 2004;11:5-10. erratum the article, ‘proximal humerus fractures – part 1: conservative management’ by anley c, vrettos bc, rachuene p and roche sjl, published in the south african orthopaedic journal august 2019 vol 18 no 3 pp 63–71, inadvertently contained the incorrect version of an algorithm regarding the treatment of proximal humerus fractures, as well as the incorrect reference (figure 4, page 68). these have both now been updated on the online version of the article. _goback _hlk18082073 404 not found page 246 sa orthop j 2021;20(4) cpd questionnaire. november 2021 vol 20 no 4 impact of correctable mediolateral tibiofemoral subluxation on unicompartmental knee arthroplasty implant survival in patients with anteromedial osteoarthritis (oosthuizen cr, maposa i, magobotha s, pandit h) 1. which knee is most suitable for medial unicompartmental knee arthroplasty? a. isolated medial osteoarthritis without mediolateral subluxation a b. isolated medial osteoarthritis with mediolateral subluxation b c. isolated medial osteoarthritis with anterior cruciate ligament rupture c d. isolated medial osteoarthritis with patellofemoral joint osteoarthritis d e. dominant medial osteoarthritis with intact ligaments e 2. how do you confirm the correct diagnosis of medial osteoarthritis on x-ray evaluation? a. anteroposterior and lateral view radiographs a b. anteroposterior, lateral view and skyline view radiographs b c. anteroposterior, lateral view, skyline view and 45° posteroanterior radiographs c d. anteroposterior, lateral view, skyline view and 15° posteroanterior radiographs d e. anteroposterior, lateral view, skyline view, 15° posteroanterior and stress views radiographs e 3. unicompartmental knee arthroplasty is indicated for patients: a. > 40 years a b. > 50 years b c. > 60 years c d. > 70 years d e. any age conforming to the clinical and x-ray indications e preoperative asymptomatic bacteriuria in patients undergoing total joint arthroplasty in south africa (maharaj z, pillay t, mokete l, pietrzak jrt) 4. the prevalence of asymptomatic bacteria in patients undergoing total joint arthroplasty is: a. 22% in a single institution in gauteng, south africa a b. 22% in rural south africa b c. 39% in an academic institution in south africa c d. 39% in a multicentre study in gauteng d e. 22% worldwide e 5. what is the five-year mortality rate for pji following total joint arthroplasty? a. 12.5% a b. 5.4% b c. 27.6% c d. 21.12% d e. 1.4% e patient-reported outcomes following plantar incisions in foot surgery (alexander an, saragas np, ferrao pnf) 6. which comment below is true regarding incisions made parallel to the rstls? a. the incision runs parallel to collagen bundles a b. it lessens the chance of painful hypertrophic scar formation b c. the incision runs perpendicular to the axis of muscle contraction c d. it results in finer and stronger scars d e. all of the above e 7. which statement regarding plantar fibromatosis is incorrect? a. it is a benign condition a b. it has a low recurrence rate b c. it is a locally aggressive fibrous tissue tumour c d. the presence of skin adherence is a poor prognostic sign d e. indications for surgery include pain and local aggressiveness e 8. for which pathology/procedure is a plantar incision not indicated? a. medial sesamoiditis a b. morton’s neuromas b c. metatarsal head resection c d. ledderhose disease d e. turf toe e do anatomical contoured plates address scapula body, neck and glenoid fractures? a multi-observer consensus study (de wet jj, dey r, vrettos b, du plessis jp, anley c, rachuene pa, haworth lc, yimam hm, sivarasu s, roche sjl) 9. when addressing intra-articular glenoid fractures and associated glenoid rim and/or neck fractures, which of the following do the authors prefer as first-line treatment of these fractures? a. cannulated screws a b. buttressing plates b c. bone grafting (coracoid/iliac crest) c d. cerclage wiring d e. suture anchors e 10. isolated scapula fractures are rare and account for what percentage of upper limb fractures? a. 1–2% a b. 3–5% b c. 7–8% c d. 9–10% d e. 10% e orthopaedic journal s o u t h a f r i c a n � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � contents � � � � � � � � � � t h e s o u t h a f r ic a n o r t h o pa e d ic a s s o c ia t io n page 248 sa orthop j 2021;20(4) the short-term outcomes of hip arthrodesis in children and adolescents with end-stage hip disease (mniki ta, maré ph, marais lc, thompson dm) 11. the commonest cause for symptomatic end-stage hip disease in children and adolescents is: a. trauma a b. post-infective sequala b c. metabolic/systemic disease c d. neuromuscular disorders d e. developmental hip disorders e 12. careful patient selection for hip arthrodesis is important and indicated in children and adolescents presenting with: a. active septic arthritis a b. polyarticular inflammatory disease b c. monoarticular non-inflammatory end-stage hip disease c d. bilateral developmental dysplasia of the hip (ddh) d e. ipsilateral knee fixed flexion contracture e incidence of radius shortening following intramedullary nail fixation for gunshot fractures: a retrospective radiological audit (abramson m, maqungo s, dey r, laubscher m) 13. what is the most accurate way of assessing radial shortening? a. using evans rule a b. ulnar variance on x-ray b c. clinical examination of radial styloid c d. circle x-ray method d e. using the watson’s shift test e 14. what is considered a normal ulnar variance? a. 0.9 mm a b. 1.5 mm b c. −0.9 mm c d. −1.5 mm d e. −2.0 mm e 15. common complications of radial shortening include all of the following except: a. reduced pro-supination a b. reduced wrist flexion/extension b c. reduced grip strength c d. ulnar abutment syndrome d e. early-onset arthrosis e distal radius fractures: current concepts (rachuene pa, du toit fj, tsolo gk, khanyile sm, tladi mj, golele ss) 16. which of the following is true regarding acute carpal tunnel syndrome in patients with distal radius fractures (drfs)? a. prophylactic carpal tunnel release should be performed in all patients with drfs a b. delayed carpal tunnel release of more than 6 hours is associated with irreversible nerve damage b c. delayed carpal tunnel release of more than 16 hours is associated with irreversible nerve damage c d. delayed carpal tunnel release of more than 36 hours is associated with irreversible nerve damage d e. delayed carpal tunnel release of more than 26 hours is associated with irreversible nerve damage e 17. with regard to stable extra-articular distal radius fractures, which of the following is true? a. closed reduction with minimum two k-wire fixation and 40° crossing angle is considered a stable fixation a b. closed reduction with minimum three k-wires fixation and 40° crossing angle is considered a stable fixation b c. closed reduction with minimum three k-wires fixation and 20° crossing angle is considered a stable fixation c d. closed reduction with minimum two k-wires fixation and 90° crossing angle is considered a stable fixation d e. orif is the only recommended choice in these patients e 18. sarcopaenia is a disorder associated with loss of muscle mass; in patients with distal radius fractures (drfs) which of the following statements is false? a. sarcopaenia is prevalent in elderly patients a b. sarcopaenia is closely related to osteoporosis b c. sarcopaenia is associated with poor functional outcomes in patients with distal radius fractures c d. sarcopaenia affects females only d e. literature reports slightly higher prevalence of sarcopaenia in male patients with drfs compared to females e minimally invasive subcutaneous anterior fixation of pelvic fractures in the elderly: case report and literature review (strydom s, snyckers ch) 19. what is the most common complication with minimally invasive subcutaneous anterior pelvis fixation? a. patient discomfort a b. surgical site infection b c. symptomatic heterotropic ossification c d. lateral femoral cutaneous nerve impingement d e. significant intraoperative blood loss e 20. which statement regarding minimally invasive subcutaneous anterior pelvis fixation techniques is false? a. it allows for easier nursing compared to ex-fix a b. patients need to remain non-weight-bearing for six weeks postoperatively b c. it should not be used in isolation for combined anterior and posterior instability c d. it can be used in patients with osteoporosis d e. they combine the low-profile benefits of internal plate fixation with ex-fix principles e subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm.co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online. • once you have completed the answers, go back to the top of the page next to the registration option. there is another icon “find my cpd certificate”. (you will have to answer the two questions regarding your internship and last cpd audit once you have completed a questionnaire and want to retrieve your certificate). • if you click on that icon it will open your certificate which you can print or save on your system. • please call mpc helpdesk if you have any questions: 0861 111 335. medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 404 not found south african orthopaedic journal shoulder and elbow doi 10.17159/2309-8309/2022/v21n4a4rachuene ap et al. sa orthop j 2022;21(4) citation: rachuene ap, dey r, de villiers s, berry k, mulder m, du plessis j-p, roche s. retrospective audit of serum vitamin d levels in patients who underwent latarjet procedure for anterior shoulder instability. sa orthop j. 2022;21(4):212-216. http://dx.doi. org/10.17159/2309-8309/2022/ v21n4a4 editor: dr cameron anley, stellenbosch university, cape town, south africa received: november 2021 accepted: may 2022 published: november 2022 copyright: © 2022 rachuene ap. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: this study was funded by johnson & johnson (depuy synthes) and smith & nephew, through a sponsored fellowship training. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background the aim of this study was to review vitamin d levels in patients who underwent latarjet procedures at a tertiary teaching hospital and a private clinic. methods a retrospective review of clinical and radiological records was performed for 22 patients who underwent latarjet procedure between november 2017 and june 2019. postoperative vitamin d levels were retrieved and classified into sufficient (> 75 nmol/l), insufficient (25–75 nmol/l), and deficient (< 25 nmol/l) groups. two observers assessed radiographic images of the patients at six weeks and three months after surgery. any bone resorption, fracture and nonunion were reported, and interobserver reliability was analysed using the intraclass correlation coefficient (icc). results the median age was 20.5 years and was predominantly male. a little more than two-thirds (68.1%) of the patients were found to have insufficient or deficient levels of vitamin d. one patient from the insufficient group had postoperative bone resorption. good interobserver reliability was observed with the icc value being 0.86. conclusion this study found a prevalence of insufficient/deficient vitamin d levels in young patients undergoing a latarjet procedure. this study serves as a reminder to orthopaedic surgeons that vitamin d deficiency is prevalent among patients undergoing latarjet. level of evidence: level 4 keywords: vitamin d, retrospective audit, bone-block resorption, modified latarjet, low-resource setting retrospective audit of serum vitamin d levels in patients who underwent latarjet procedure for anterior shoulder instability archie p rachuene,1 roopam dey,1,2* shaun de villiers,1 kirsty berry,1 mike mulder,1 jean-pierre du plessis,1 stephen roche1 ¹ department of surgery, division of orthopaedic surgery, groote schuur hospital, cape town, south africa ² department of human biology, division of biomedical engineering, university of cape town, south africa *corresponding author: roopam.dey@uct.ac.za introduction anterior shoulder dislocation is common, and nearly 50% of these patients are younger than the age of 30 years.1,2 about 85% of all anterior shoulder dislocations have an associated bankart lesion, and hill–sachs lesion is present in all of the cases with recurrent dislocations.2 recurrent shoulder dislocations have been reported to develop within two years of the initial injury and the risk of recurrence is higher in the younger patient population group, usually males and those who participate in contact sports or repeated overhead activities.2,3 soft tissue repair (bankart repair) and bone-block reconstruction procedures such as latarjet are commonly performed stabilisation procedures for anterior shoulder instability.4 the risk of re-dislocation following an arthroscopic bankart repair increases with glenoid bone loss of more than 20%.5 the modified latarjet procedure has become the treatment of choice in patients with associated significant anterior glenoid bone loss and contact athletes.6-8 a high rate of complication has been reported, with 4–10% of cases undergoing revision surgery.8,9 prevalence of coracoid bone resorption is high following latarjet procedure, with up to 90% reported by ct scan-based studies; however, this appears to be of minimal clinical significance.10 https://orcid.org/0000-0003-4045-5301 https://orcid.org/0000-0002-3616-1995 page 213rachuene ap et al. sa orthop j 2022;21(4) vitamin d deficiency is a problem that commonly affects postmenopausal females and it is estimated to affect over 1 billion people globally.11 vitamin d has been reported to play a critical role in bone formation and bone healing; therefore, its deficiency can affect bone healing and bone-block incorporation post latarjet.11-13 the role of vitamin d in shoulder pathologies has been described before. oh et al. found vitamin d deficiency to be associated with high-grade fatty infiltration in patients with rotator cuff tears.14 reports of serum vitamin d levels in patients undergoing latarjet surgery does not exist in current literature. this study aims at assessing vitamin d levels of patients undergoing latarjet at clinical centres. materials and methods after obtaining approval from the institutional review board, a retrospective review of the surgical database at a tertiary teaching hospital and of a private clinic was conducted. consecutive patients who underwent the modified latarjet procedure from 2017 to 2019 were considered for this study. these patients were operated by a single shoulder surgeon or by an associate under his direct supervision. patients had vitamin d levels tested following surgery. for this study, the serum vitamin d levels of these patients were retrieved. those patients whose vitamin d levels were unavailable were excluded from the study. the serum vitamin d levels were classified into normal, insufficient and deficient, according to the canadian institute of medicine recommendations.15 normal serum vitamin d level was set as > 75 nmol/l, suboptimal or insufficient vitamin d level was set as 25–75 nmol/l, and deficient vitamin d level was set as < 25 nmol/l. vitamin d levels were only done on patients we felt had possibly had softer bone when preparing the coracoid graft. if the patient had deficient or insufficient serum vitamin d levels, they were supplemented with vitamin d 50 000 iu weekly for three months. as a part of this study, we wanted to find the effect this supplementation had on the postoperative bone healing. therefore, a radiological review of the routine six-week and threemonth postoperative x-rays was performed by two independent observers. the anteroposterior, lateral outlet, and modified axillary view of the x-rays were reviewed for presence of screw osteolysis (defined as radiolucency around the screws), bone-block fracture, bone-block resorption and/or bone-block nonunion (defined as clear uninterrupted lucent line between the bone block and native glenoid on at least two views at minimum three months follow-up). statistical analysis all the statistical tests were done in ibm spss v.26 (armonk, ny, usa). interobserver reliability was tested using the intraclass correlation coefficient (icc) which was calculated using the absolute agreement two-way mixed model. icc values were reported according to the guidelines present in the literature.16 chi-square tests were performed to find the dependency between patients’ vitamin d levels, patients’ age, and coracoid graft healing. the condition for statistical significance was set at p < 0.05. results the retrospective review of patient records found 64 patients who had undergone a modified latarjet procedure between january 2017 and april 2019. twenty-two patients satisfied the inclusion criteria and were included in the study (table i). the median age of this cohort was 20.5 years (range: 16–49 years), and 20 were male. insufficient vitamin d levels were found in 12 patients (54.5%) and three patients (13.6%) had deficient vitamin d levels. seven patients (31.8%) had sufficient vitamin d levels (figure 1). by categorising the patients above and below the median age of 20.5 years, we found age and vitamin d levels to be independent of age (p = 0.80). patients with healed grafts had a higher average age (p = 0.6) compared to those without healing (figure 2). table i: demographic distribution and vitamin d levels of the study population case no. sex age (years) 25-hydroxy (oh) vitamin d level (nmol/l) 1 male 16 70.8 2 male 19 69.8 3 male 17 63.5 4 male 49 64.8 5 male 20 28 6 female 44 55.6 7 male 27 21 8 male 20 27 9 male 16 26 10 male 21 27 11 male 18 40 12 male 20 67.5 13 male 43 39.6 14 male 27 18 15 male 23 18 16 male 20 76.9 17 male 19 82.4 18 male 18 90 19 female 17 122.5 20 male 16 82.5 21 male 36 87.5 22 male 28 85 vit d insufficient deficient sufficient figure 1. prevalence of different vitamin d levels in the study cohort 36.4% 50.0% 13.6% page 214 rachuene ap et al. sa orthop j 2022;21(4) inter-rater reliability between the observers was good as suggested by the icc value of 0.86 (95% confidence interval: 0.67 to 0.94; p < 0.0001). one patient, 27 years of age, among the vitamin d-insufficient group showed signs of bone resorption. in the sufficient group, two patients, with ages 18 years and 28 years, showed signs of graft resorption (figure 3). postoperative healing and vitamin d categories were found to be independent of each other (p = 0.35). discussion the 22 patients believed to have a soft bone block at the time of their shoulder stabilisation procedure using a latarjet procedure were selected for serum vitamin d testing. this retrospective study found a high prevalence of hypovitaminosis d in young adults undergoing latarjet procedures. in this study, we found a high rate of bone graft healing in the vitamin d deficient and insufficient patients, which may be attributed to the vitamin d supplementation. a systematic review of vitamin d status among populations from 44 countries reported vitamin d insufficiency, with levels of < 75 nmo/l to be 88.1% of the samples presented. hilger et al. reported that african and the middle east children and adolescents had higher vitamin d levels compared to older adults.17 vitamin d synthesis is reduced among people with dark skin pigmentation.18,19 there is a prevalence of vitamin d deficiency in 50% of african-american and hispanic adolescents compared to 48% among white preadolescent girls in the reported literature.20 low dietary intake, poor sunlight exposure, obesity, and disorders of vitamin d metabolism remain common risk factors.18 among orthopaedic patients, stoker et al. reported a high prevalence of vitamin d deficiency in patients undergoing spinal fusion, with 57% of 313 patients having hypovitaminosis d. in their study, although the vitamin d-deficient patients were supplemented with oral vitamin d, the authors did not evaluate the rate of failed bone fusions.21 vitamin d deficiency in south africa has been reported to affect 41% of the general population. among ethnic groups in the country, 28.6% of south african indians had deficient vitamin d levels compared to 5% black africans who had vitamin d deficiency.22 prevalence in south african children is reported to be lower than the general population. lisenda et al. reported a 16% vitamin d a ge (i n ye ar s) healing groups healed not healed 50 40 30 20 10 0 24.5 + 8.98 21.0 + 4.12 13 22 33 6 figure 2. distribution of age for the patients whose bone grafts healed postoperatively compared to the patients whose bone grafts were not found to be healed a b c d figure 3. postoperative x-rays of patients who underwent latarjet procedure: a) showing bone-block resorption around the screw heads; b) showing bone-block nonunion represented by clear radiolucent line; and c) & d) ap and lateral view x-rays showing bone-block fracture with screw breakage page 215rachuene ap et al. sa orthop j 2022;21(4) deficiency in children with blount’s disease.23 similarly, poopedi et al. reported 19% low vitamin d levels among urban south african children.24 in our study, consisting of patients who have shoulder instability, it was observed that younger patients often have lower vitamin d levels, and we would recommend surgeons to be cognitive of this fact. the authors would also recommend measuring serum vitamin d levels in patients undergoing latarjet procedure especially for those individuals whose bones appear to be softer than normal. laboratory rat studies have shown vitamin d, calcium and phosphorus deficiency impairs graft healing and is associated with higher infection rates.25 a systematic review of 153 articles on the cellular effects of vitamin d in fractures has shown that vitamin d improves cellular production of growth factors like the plateletderived growth factor (pdgf) and the vascular endothelial growth factor (vegf) necessary for bone healing and bone remodelling. vitamin d supplementation also showed improved callus formation during fracture healing, when compared to those who did not receive vitamin d.13 vitamin d supplementation in postmenopausal females has shown to reduce fracture risk.19,20 kwiatek et al. observed a correlation between peri-implant bone formation and serum vitamin d level in 122 healthy adults undergoing mandible implantation for missing molar teeth. evaluation of bone loss or gain was evaluated using radiovisiography on the day of implantation compared to findings at six weeks and 12 weeks.26 the role of vitamin d in bone metabolism and bone healing cannot be ignored in clinical practice. we believe it possibly has an impact on bone-block union incorporation and the degree of resorption in patients undergoing anterior shoulder stabilisation. bone-block shoulder stabilisation procedures have high complication rates which range between 15 and 30%.8,27 willemot et al. reported a 42.3% nonunion rate and 26% graft resorption rate among 26 young patients who presented with failed bristow or latarjet procedures.28 it would have been beneficial if these studies had reported on their patients’ vitamin d levels. supplementing our patients with vitamin d, postoperatively, might have been the reason for their rate of bone healing. further research must be performed to investigate the effect of deficient and insufficient vitamin d levels on bone healing. the retrospective nature of this study is a limitation because vitamin d levels were only available for those patients the surgeons subjectively felt to have softer coracoid at time of preparation. we acknowledge that intervention with vitamin d supplementation also prevents the ability to assess the effect of hypovitaminosis on graft healing and resorption. we could not ethically withhold treatment. despite the limitations, we were able to shed light on the fact that younger patients undergoing latarjet procedure suffer from low serum vitamin d levels. further, attention should be paid to treating these patients with adequate supplementation to reduce postoperative coracoid complications, and we recommend routine testing for patients undergoing a bony procedure for instability in countries with a high prevalence of deficiency. our standard of care is to x-ray patients six weeks and three months post surgery to evaluate for bone-block union and osteolysis. due to financial constraints and the potential for radiation exposure, we do not routinely assess these parameters using a ct scan. when compared to countries with more resources, this is a study limitation.29 in our context, ct scans are used when there is a complication, and it is necessary to assess the bone block. conclusion vitamin d deficiency is common among young patients with anterior shoulder instability who undergo latarjet surgery. future studies should be focused on establishing the relationship between serum vitamin d levels and postoperative bone graft healing. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, ethics approval was received from the university of cape town faculty of health sciences human research ethics committee: hrec585/2019. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was not obtained from all patients included in the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions apr: study conceptualisation, data capture, first draft preparation rd: data analysis, first draft preparation, manuscript revision sdv: data capture, manuscript revision kb: data capture, study design mm: data capture, manuscript preparation jpdp: study design, manuscript revision sr: study conceptualisation, study design, manuscript revision orcid rachuene ap https://orcid.org/0000-0003-4045-5301 dey r https://orcid.org/0000-0002-3616-1995 de villiers s https://orcid.org/0000-0003-0023-5152 berry k https://orcid.org/0000-0001-8747-8995 du plessis j-p https://orcid.org/0000-0001-6469-7765 roche s https://orcid.org/0000-0002-5695-2751 references 1. hasebroock aw, brinkman j, foster l, bowens jp. management of primary anterior shoulder dislocations : a narrative review. sport med open. 2019;5(1):31. https://doi.org/10.1186/ s40798-019-0203-2%0a. 2. youm t, takemoto r, park bkh. acute management of shoulder dislocations. j am acad orthop surg. 2014;22(12):761-71. https://doi.org/10.5435/jaaos-22-12-761 3. streubel pn, krych aj, simone jp, et al. anterior glenohumeral instability: a pathologybased surgical treatment strategy. j am acad orthop surg. 2014;22(5):283-94. https://doi. org/10.5435/jaaos-22-05-283 4. bah a, lateur gm, kouevidjin bt, et al. chronic anterior shoulder instability with significant hill–sachs lesion: arthroscopic bankart with remplissage versus open latarjet procedure. orthop traumatol surg res. 2018;104(1):17-22. https://doi.org/10.1016/j.otsr.2017.11.009 5. gupta a, delaney r, petkin k, lafosse l. complications of the latarjet procedure. curr rev musculoskelet med. 2015;8(1):59-66. https://doi.org/10.1007/s12178-015-9258-y 6. bessiere c, trojani c, pélégri c, et al. coracoid bone block versus arthroscopic bankart repair: a comparative paired study with 5-year follow-up. orthop traumatol surg res. 2013;99(2):123-30. https://doi.org/10.1016/j.otsr.2012.12.010 7. burkhart ss, de beer jf. traumatic glenohumeral bone defects and their relationship to failure of arthroscopic bankart repairs: significance of the inverted-pear glenoid and the humeral engaging hill–sachs lesion. arthroscopy. 2000;16(7):677-94. https://doi.org/10.1053/ jars.2000.17715 8. du plessis j-p, lambrechts a, mcguire d, et al. early and medium-term complications of the modified latarjet procedure. sa orthop j. 2014;13(3):50-56. 9. hovelius l, sandström b, olofsson a, et al. the effect of capsular repair, bone block healing, and position on the results of the bristow–latarjet procedure (study iii): long-term follow-up in 319 shoulders. j shoulder elb surg. 2012;21(5):647-60. https://doi.org/10.1016/j. jse.2011.03.020 10. zhu ym, jiang cy, lu y, et al. coracoid bone graft resorption after latarjet procedure is underestimated: a new classification system and a clinical review with computed tomography evaluation. j shoulder elb surg. 2015;24(11):1782-88. https://doi.org/10.1016/j. jse.2015.05.039 11. salovaara k, tuppurainen m, kärkkäinen m, et al. effect of vitamin d3 and calcium on fracture risk in 65to 71-year-old women: a population-based 3-year randomized, controlled trial the ostpre-fps. j bone miner res. 2010;25(7):1487-95. https://doi.org/10.1002/ jbmr.48 12. gaston ms, simpson ahrw. inhibition of fracture healing. j bone jt surg ser b. 2007;89(12):1553-60. https://doi.org/10.1302/0301-620x.89b12.19671 13. gorter ea, hamdy nat, appelman-dijkstra nm, schipper ib. the role of vitamin d in human fracture healing: a systematic review of the literature. bone. 2014;64(2014):288-97. https:// doi.org/10.1016/j.bone.2014.04.026 https://orcid.org/0000-0003-4045-5301 https://orcid.org/0000-0002-3616-1995 https://orcid.org/0000-0003-0023-5152 https://orcid.org/0000-0001-8747-8995 https://orcid.org/0000-0001-6469-7765 https://orcid.org/0000-0002-5695-2751 page 216 rachuene ap et al. sa orthop j 2022;21(4) 14. oh jh, kim sh, kim jh, et al. the level of vitamin d in the serum correlates with fatty degeneration of the muscles of the rotator cuff. j bone jt surg ser b. 2009;91(12):1587-93. https://doi.org/10.1302/0301-620x.91b12.22481 15. hanley da, cranney a, jones g, et al. vitamin d in adult health and disease: a review and guideline statement from osteoporosis canada. cmaj. 2010;182(12):e610-8. https://doi. org/10.1503/cmaj.080663 16. koo tk, li my. a guideline of selecting and reporting intraclass correlation coefficients for reliability research. j chiropr med. 2016;15(2):155-63. https://doi.org/10.1016/j. jcm.2016.02.012 17. hilger j, friedel a, herr r, et al. a systematic review of vitamin d status in populations worldwide. br j nutr. 2014;111(1):23-45. https://doi.org/10.1017/s0007114513001840 18. parva nr, tadepalli s, singh p, et al. prevalence of vitamin d deficiency and associated risk factors in the us population (2011–2012). cureus. 2018;10(6):e2741. https://doi.org/10.7759/ cureus.2741 19. rosen cj, abrams sa, aloia jf, et al. iom committee members respond to endocrine society vitamin d guideline. j clin endocrinol metab. 2012;97(4):1146-52. https://doi.org/10.1210/ jc.2011-2218 20. holick mf, binkley nc, bischoff-ferrari ha, et al. evaluation, treatment, and prevention of vitamin d deficiency: an endocrine society clinical practice guideline. j clin endocrinol metab. 2011;96(7):1911-30. https://doi.org/10.1210/jc.2011-0385 21. stoker ge, buchowski jm, bridwell kh, et al. preoperative vitamin d status of adults undergoing surgical spinal fusion. spine (phila pa 1976). 2013;38(6):507-15. https://doi. org/10.1097/brs.0b013e3182739ad1 22. du plessis m. vitamin d overview. ampath chat. 2017;(44):1-10. available from: www.\ ampath.co.za. accessed 23 november 2019. 23. lisenda l, simmons d, firth gb, et al. vitamin d status in blount disease. j paediatr orthop. 2016;36(5):e59-e62. https://doi.org/10.1097/bpo.0000000000000607 24. poopedi ma, norris sa, pettifor jm. factors influencing the vitamin d status of 10-year-old urban south african children. public health nutr. 2010;14(2):334-39. https://doi.org/10.1017/ s136898001000234x 25. cantorna mt, hullett da, redaelli c, et al. 1,25-dihydroxyvitamin d3 prolongs graft survival without compromising host resistance to infection or bone mineral density. transplantation. 1998;66(7):828-31. https://doi.org/10.1097/00007890-199810150-00003 26. kwiatek j, jaroń a, trybek g. impact of the 25-hydroxycholecalciferol concentration and vitamin d deficiency treatment on changes in the bone level at the implant site during the process of osseointegration: a prospective, randomized, controlled clinical trial. j clin med. 2021;10(3):526. https://doi.org/10.3390/jcm10030526 27. gupta a, thussbas c, koch m, seebauer l. management of glenoid bone defects with reverse shoulder arthroplasty—surgical technique and clinical outcomes. j shoulder elb surg. 2018;27(5):853-62. https://doi.org/10.1016/j.jse.2017.10.004 28. willemot l, de boey s, van tongel a, et al. analysis of failures after the bristow–latarjet procedure for recurrent shoulder instability. int orthop. 2019;43:1899-1907. https://doi. org/10.1007/s00264-018-4105-6 29. kordasiewicz b, kicinski m, małachowski k, et al. comparative study of open and arthroscopic coracoid transfer for shoulder anterior instability (latarjet)—computed tomography evaluation at a short term follow-up. part ii. int orthop. 2018;42(5):1119-28. https://doi.org/10.1007/s00264-017-3739-0 _heading=h.gjdgxs _heading=h.30j0zll _hlk111542934 _hlk111551192 404 not found south african orthopaedic journal orthopaedic trauma doi 10.17159/2309-8309/2022/v21n1a1pretorius hs et al. sa orthop j 2022;21(1) citation: pretorius hs, burger mc, ferreira n. evaluating the design modifications of an intramedullary forearm nail system: a cadaver study. sa orthop j 2022;21(1):12-15. http://dx.doi. org/10.17159/2309-8309/2022/ v21n1a1 editor: dr frans birkholtz, university of pretoria, pretoria, south africa received: june 2021 accepted: october 2021 published: march 2022 copyright: © 2022 pretorius hs. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare no conflict of interest. all research related to design and manufacture of the intramedullary nail system was done in conjunction with implantcast gmbh (buxtehude, germany). prototypes were produced and provided for research purposes at no cost. all research-related costs were borne by stellenbosch university. a royalty agreement between stellenbosch university and implantcast gmbh (buxtehude, germany) was negotiated in the event of the design eventually being used commercially. abstract background current orthopaedic practice requires a forearm nail that is length and rotationally stable and which can restore functional anatomy. a forearm nailing system was designed based on clinical need. this nailing system features unique designs and locking holes that offer a larger approach and escape angle for ease of interlocking. the aim of the present study was to test the prototype and evaluate the design changes in cadaver bones. methods a cross-sectional cadaveric study, including ten cadavers with normal forearm anatomy (n = 20 forearms) was conducted. both forearms of the cadavers were used to evaluate the locking times and exposure time during i) insertion; ii) locking; and iii) removal of the nails, resulting in the evaluation of a total of 40 procedures. all nails were assessed for insertions of interlocking screws. results the nail was successfully inserted into 38 bones. inserted nails were available for locking (n = 38), and all locking attempts at both driving ends (n = 38, 100%), as well as the non-driving ends (n = 76, 100%), were successful. freehand locking at the non-driving end of the nail (38 cases, 76 locking holes) took a median of 44.5 seconds (interquartile range [iqr] 33.0–59.0), while the number of exposures ranged from 2 to 12 with a median of 5.5 exposures (iqr 4.0–8.0). the freehand locking procedure’s exposure time was 0.09 minutes (iqr 0.07–0.23). conclusion the proposed forearm intramedullary nail design modifications allowed for successful implantation, interlocking and removal of nails in both radius and ulna cadaver bones, with acceptable radiation exposure. level of evidence: level 5 keywords: radius and ulna intramedullary nail, locked forearm nail, forearm fractures evaluating the design modifications of an intramedullary forearm nail system: a cadaver study henry s pretorius,* marilize c burger, nando ferreira division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa *corresponding author: hsp359@sun.ac.za introduction current orthopaedic practice requires a forearm nail that is length and rotationally stable and which can restore functional anatomy. restoring forearm motion is vital to regaining full upper limb function following radius and ulna fractures. the anatomical relationship of the radius and ulna allows the forearm to function as a joint, and this motion contributes significantly to the versatility of the human hand. to maintain this motion and restore forearm function, most fractures involving either bone or involving the proximal or distal radioulnar joint will usually need surgical fixation.1,2 the gold standard of management in adult forearm fractures is compression plate fixation for simple fractures and bridge plating for comminuted fractures.3 locked intramedullary nails have been shown to have comparable results but have mostly fallen out of favour and have been removed from the market for various reasons, including difficulty with the placement of interlocking screws.4-7 the problem with traditional forearm nails is the freehand locking at the non-driving end of the nail that may be challenging to execute. the interlocking hole size, soft tissue envelope and proximity of the radial nerve make this a challenging procedure, even in experienced hands. in a recent study by blažević et al., good results have been reported with a https://orcid.org/0000-0002-7419-0885 page 13pretorius hs et al. sa orthop j 2022;21(1) locking forearm nail, but the publication failed to describe the nondriving end locking, which appears to have been performed from lateral in the radius as per the clinical pictures.8 locking in the proximal radius is performed through the supinator muscle, in close proximity to where the posterior interosseous nerve transverses the muscle. it can either be penetrated, entangled or suffer thermal damage, which will result in nerve fallout that may be temporary or permanent. several authors reported up to an 11% incidence of radial nerve damage during proximal radius locking.8-10 köse et al., in their nail design, omitted locking at the non-driving end of the radius due to the perceived risk of injury to the radial nerve.11 bansal showed no damage to the radial nerve in 19 cases by using a different approach to the radius neck depending on the locking hole position.12 fluoroscopy exposure times for the locking of intramedullary devices is another concern and vary widely in published reports.13-18 during interlocking of femoral nails, suhm et al. reported exposure times of 108 seconds, while müller et al. noted screening times in excess of 4 minutes during freehand locking for the same procedure.19,20 in turn, weckbach and bansal reported forearm fluoroscopy times for locking at between 4.4 and 14 minutes and 3.5 minutes, respectively.12,21 currently, only one forearm nailing system is commercially available in our geographic area; as this nail is only locked at the driving end, these devices lack rotational stability. the nail has some design features that make it impractical for use in specific fracture configurations. the nail diameter is too small and lacks the internal cortical grip to stabilise the radius of curvature of the forearm bones. this may lead to an anatomically straight radius which subsequently increases the risk of non-union.21 the 20 mm nail length increments also make the accurate restoration of length unstable fracture patterns challenging, as the surgeon must rely on subchondral abutment to provide length stabile fixation. we undertook the challenge of designing a modified forearm nailing system that improves nail insertion and interlocking ergonomics. unique design features include longitudinal surface flutes that allow pressure release during nail insertion and newly designed locking holes that offer a larger approach and escape angle for ease of interlocking and potentially reducing radiation exposure. the length increments were also reduced to 10 mm with a nail size of 4.5 mm (figure 1). this study aimed to evaluate the design modifications of this forearm nailing system in ten cadavers. specific objectives were to: i) assess the number of attempts to achieve locking, which is relevant to the ease of locking; ii) measure the screening time required during locking, and evaluate exposure; iii) measure the total screening time; and iv) assess the ease of removal of the nail. material and methods a cross-sectional cadaveric study was conducted to evaluate the design modifications of the forearm nail. ethical approval was obtained prior to the commencement of this study. two experienced orthopaedic trauma surgeons performed all insertion procedures. interlocking was done for all inserted nails, with both surgeons locking an equal number of nails. ten formaldehyde-preserved cadavers were included, with specific inclusion criteria being skeletal maturity (> 18 years) and previously uninjured forearm bony anatomy. the forearms were x-rayed with the image intensifier to preclude previous trauma. the forearm bones of both upper limbs were used to evaluate the insertion, locking and removal of the nails, resulting in the evaluation of a total of 40 procedures. the ability to open the canal, ream and complete insertion of the nail was documented. radius nails were pre-bent to a radius of curvature of 569 mm, while ulna nails were pre-bent to 10°.23 the entry point for all the radius nails was the distal ridge of lister’s tubercle, and the radial canal was opened with a 6 mm entry drill. the medullary canal was reamed with a 5 mm hand reamer to accommodate the 4.5 mm diameter nail. the nail was attached to the jig and advanced with the forearm in supination to a depth where the locking holes were in the radial neck proximal to the biceps tuberosity. an anterior incision was made over the radial neck in supination, and blunt dissection was used to reach the bone. a radiolucent plastic drill sleeve was used to protect the soft tissue during drilling. freehand locking was done through both holes using a fluoroscopic image intensifier (figure 2). all nails were locked, through the jig, at the driving end (figure 3). ulna nails used the entry point at the olecranon’s posterior aspect, using a 6 mm drill. the canal was prepared with a 5 mm reamer followed by nail insertion to the distal ulnar metaphysis depth. a dorsal incision was made over the distal ulna with the forearm in pronation, and a radiolucent plastic drill sleeve was used to protect the soft tissue during drilling. freehand locking was done through both holes using a fluoroscopic image intensifier. all nails were locked, through the jig, at the driving end (figures 2 and 4). the time for each locking attempt was recorded. a preliminary image intensifier scout view was taken, and an incision was made over the locking holes. the drill was placed onto the bone, and another image intensifier view was taken to ascertain the drill tip’s position. the timer for locking was then started, and all exposures, 35°35° jig-screw locking peg radius of curvature 569 mm ulna curve 10° size 1 2 3 4 5 length 225 mm 235 mm 245 mm 255 mm 265 mm head ø 6.5 mm 6.5 mm 6.5 mm 6.5 mm 6.5 mm stem ø 4.5 mm 4.5 mm 4.5 mm 4.5 mm 4.5 mm length head ø stem ø figure 1. novel nail design illustrating product sizes, flutes, screws and non-driving end locking with 35° approach angle as well as nails bent to the correct curvature for each bone figure 2. jig locking in radius and ulna page 14 pretorius hs et al. sa orthop j 2022;21(1) including the second scout view, were recorded. the timer was only stopped once the drill was passed through the opposite cortex and confirmed with fluoroscopy (figure 3). the number of locking attempts was recorded, and the timer continued until the locking was successfully accomplished. screws were passed through the nail for confirmation of locking (figure 4). the number of exposures and total screening time of each attempt was recorded in minutes. all nails were removed after insertion, with the ability to remove the nail being recorded. statistical analysis data was analysed using statistica (v13, tibco software). data is described as means ± standard deviations with 95% confidence intervals or medians with interquartile ranges (iqr). categorical data is described as frequencies, with the count indicated in parentheses. no hypothesis testing was performed considering the proof-of-concept nature of this investigation. results the entry point was exposed, and the 6 mm drill was successfully inserted in all cases (n = 40, 100%) (table i). the shaft was reamed successfully in 95% of cases (n = 38), and the nail was successfully inserted into these bones. complications arose in two cases (5%), where the medullary canal was too narrow in one case, and the reamer broke inside the canal in the other. all nails that were successfully inserted were available for locking (n = 38). all locking attempts at both the driving end (n = 38, 100%) as well as the non-driving end (n = 76, 100%) were successful (table i). in three instances (4%), comprising two ulna locking holes and one radial locking hole, two attempts were required to achieve locking. nails were successfully removed in all cases (n = 38, 100%) (table i). freehand locking at the non-driving end of the nail (38 cases, 76 locking holes) took a median of 44.5 seconds, while the number of exposures required ranged from 2 to 12 with a median of 5.5 exposures (table ii). the median total exposure time for the freehand locking procedure was 0.09 minutes (table ii). discussion designing a forearm nail that is length and rotationally stable and can restore functional anatomy is challenging, and many aspects must be considered. contemporary forearm nail design has no reliable way to control rotation or length, and the restoration of the native anatomy can be challenging. this study aimed to evaluate the design modifications of a forearm nailing system in a cadaver study. the successful implanting of nails in all cases where the bones could be reamed shows an acceptable implant diameter. this will require further testing in patients to establish if this is true for the broader population. the two cases where the canal of the radius was not amenable for the procedure included only a single case where the radius canal was too small for the reamer. this may be due to normal anatomical variations or dominance as the contralateral side was nailed easily. the other case was amenable to a nail, but the reamer broke, and the nail could not be inserted. this may be related to design issues for the reamer which have been addressed. considering the small sample size (n = 10 cadavers) where the anatomy of both forearms is expected to be symmetrical, this was not an unusual finding. this study has shown that the nail size might potentially fit into most trauma patients; if the nail does not fit into the patient’s radius or ulna, an alternative treatment will be required. locking of both holes at the non-driving end was achieved in all cases where insertion of the nail was possible, highlighting that the new screw hole design may make insertion of these screws easier. the screw hole has a wider recess on the outside of the nail, pushing the drill towards the hole. evaluating the locking attempts helps to establish if the hole was missed and does not relate to the time as a careful surgeon may spend more time selecting the spot for drilling and only have one attempt. the complexity of locking is clinically so relevant that the noticeable absence of its description by blažević et al. of his locking procedure or direction is concerning, table ii: overview of time and exposure of freehand locking attempts   median (iqr) (n = 76) range time (s) 44.50 (33.00–59.00) 14.00–112.00 exposures (n) 5.5 (4.0–8.0) 2.00–12.00 exposure (minutes) 0.09 (0.07–0.13) 0.03–0.23 iqr: interquartile range table i: overview of procedure success procedure (n) successful unsuccessful entry point (40) 100.0 (40) 0.0 (0) shaft ream (40) 95.0 (38) 5.0 (2) jig locking (38) 100.0 (38) 0.0 (0) free locking (76) 100.0 (76) 0.0 (0) nail removal (38) 100.0 (38) 0.0 (0) figure 3. proximal radius locking with drill successfully traversing the bone and the locking hole figure 4. locking screws placed at the non-driving end of the ulna and radius shown in an ap and lateral plane. screws are placed from volar in full supination for the radius and from dorsal in a fully pronated ulna. page 15pretorius hs et al. sa orthop j 2022;21(1) with only one minor radial nerve injury when the literature reports at 11%.8 contemporary available nail designs do not afford the ability to interlock at the non-driving end of the nail, potentially resulting in fractures fixed in a shortened position or intraoperative length being lost if the nail does not abut the subchondral bone at the non-driving end. rotational control may also be insufficient with the currently available implants. iatrogenic radial nerve injury is another concern,8-12,22 specifically with the insertion of locking screws in the neck of the radius. the use of radiolucent drill sleeves worked well to mitigate any soft tissue incarceration during drilling. in the clinical setting, this may help prevent radial nerve injury. limiting radiation exposure is an increasingly important consideration during orthopaedic procedures.14,15,17 investigations by kim et al. reported fluoroscopy times between 240 and 840 seconds for nails, and 78 to 162 seconds for plating of forearm fractures.23 in this series, cases included both locking nails and non-locking nails, and screening time was measured for the entire procedure. similarly, screening time for femoral or tibial nails has been reported to range between 180 and 360 seconds.16,18,19 in the current series, a maximum exposure time during locking was 0.23 minutes (13 seconds), mostly in agreement with the previous reports. the relatively short locking times in the current study could be attributed to the surgeons’ experience in performing this procedure and the dimensions of the new locking hole, including a wide entry and exit angle, both of which may have added to the ease of locking. the exposures ranging between 2 and 12 seconds indicates the difficulty in accurately aligning the drill with the interlocking hole. the aim was to lock the nail with acceptable exposure times knowing that further exposure would occur for the rest of the procedure. all the nails were removed successfully after the procedure was done and the jig disengaged. the locking bolt was easily inserted into the nail and the nail was easily removed. this is important as, if there is an issue with the nail, the instrumentation can be used to remove the nail. the study’s main strength was the ability to illustrate that the forearm nail fits into most forearms in the present study and that the locking can be achieved in a timeous fashion without excessive radiation exposure. a limitation of this study was the inability to test the radius of curvature of the nail and its ability to restore the anatomy of a fractured radius with the use of intact forearms. in addition, the nature of a cadaver study does not lend itself to investigate injury to the nerve and vascular structures, the stability of the bones for union and functional outcome. furthermore, the fact that anatomically normal bones were used in this study naturally lends itself to easier procedures, which might result in reduced time requirements. we have been able to evaluate 76 potential locking holes, but the limited number of cadavers is also a limitation that can be corrected with a clinical study. therefore, clinical evaluation is recommended for future research investigating the use of this nail in forearm fractures to evaluate efficacy in terms of providing length and rotational stability and union and function in radius and/ or ulna fractures. conclusion the proposed forearm intramedullary nail design modifications allowed for successful implantation, interlocking and removal of nails in both radius and ulna cadaver bones, with acceptable radiation exposure. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, ethical approval was obtained from the following ethical review board: stellenbosch university health research ethics committee, (n19/09/097). declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions hsp: study conceptualisation, data capture, data analysis, manuscript preparation, manuscript revision and final draft preparation mcb: data analysis, manuscript revision nf: study conceptualisation, manuscript revision and final draft preparation orcid pretorius hs https://orcid.org/0000-0002-7419-0885 burger mc https://orcid.org/0000-0003-2831-4960 ferreira n https://orcid.org/0000-0002-0567-3373 references 1. rehman s, sokunbi g intramedullary fixation of forearm fractures. hand clin. 2010;26(3):391-401. https://.doi.org/10.1016/j.hcl.2010.04.002. 2. moss jp, bynum dk. diaphyseal fractures of the radius and ulna in adults. hand clin. 2007;23(2):143-51. https://doi.org/10.1016/j.hcl.2007.03.002. 3. bizzarro j, regazzoni p. 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surg. 2006;23(3):235-43. https://doi.org/10.5505/tjtes.2016.66267. 23. kim sb, heo ym, yi jw, lee jb, lim bg. shaft fractures of both forearm bones: the outcomes of surgical treatment with plating only and combined plating and intramedullary nailing. clin orthop surg. 2015;7(3):282-90. https://doi.org/10.4055/cios.2015.7.3.282. https://orcid.org/0000-0002-7419-0885 https://orcid.org/0000-0003-2831-4960 https://orcid.org/0000-0002-0567-3373 https://.doi.org/10.1016/j.hcl.2010.04.002 https://doi.org/10.1016/j.hcl.2007.03.002 https://aotrauma.aofoundation.org https://doi.org/10.1007/s00268-016-3753-1 https://doi.org/10.1016/j.injury.2013.10.040 https://.doi.org/10.1016/j.injury.2020.11.012 https://.doi.org/10.1016/j.injury.2020.11.012 https://doi.org/10.1016/j.otsr.2015.11.019 https://doi.org/10.1007/s00264-017-3460-z https://doi.org/10.1007/s00264-017-3460-z https://doi.org/10.1007/s00402-014-2058-9 https://doi.org/10.1007/s00402-014-2058-9 https://doi.org/10.4103/0019-5413.83760 https://doi.org/10.1007/s00590-017-2020-y https://doi.org/10.7196/sajs.965. https://doi.org/10.3944/aott.2015.14.0250 https://doi.org/10.1007/s00402-004-0743-9 https://doi.org/10.1016/s0020-1383(03)00312-7 https://doi.org/10.1016/s0020-1383(98)00088-6 https://doi.org/10.1007/s00402-006-0122-9 https://dx.doi:10.5505/tjtes.2016.66267 https://doi.org/10.4055/cios.2015.7.3.282 _hlk90392761 404 not found davis jh et al. sa orthop j 2020;19(1) doi 10.17159/2309-8309/2020/v19n1a3 south african orthopaedic journal http://journal.saoa.org.za traumaspine citation: davis jh, burger mc, pienaar g, lamberts rp. 18f-fdg pet/ct as a modality for the evaluation of persisting raised infective markers in patients with spinal tuberculosis. sa orthop j 2020;19(1):23-27. http://dx.doi.org/10.17159/2309-8309/2020/v19n1a3 editor: prof. r dunn, university of cape town, south africa received: march 2019 accepted: october 2019 published: march 2020 copyright: © 2020 davis jh, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare no conflict of interest with respect to this study. abstract aims: the aim of the study was to investigate the differences in participant characteristics between positive and negative, positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-d-glucose integrated with computed tomography (18f-fdg pet/ct) activity at the spinal tuberculosis (tb) site following 12 months of the appropriate chemotherapy therapy for spinal tb. a secondary aim of the study was to determine whether erythrocyte sedimentation rate (esr) levels could be used as a reliable marker of tb activity and/or treatment success of spinal tb, especially in a high hiv-positive population. patients and methods: all patients who were treated for spinal tb and underwent an 18f-fdg pet/ct scan were considered for inclusion. pet/ct positive patients underwent a spinal biopsy which was sent for microscopy, gram staining, gene xpert (gxp) polymerase chain reaction (pcr) and histology. patients in the pet/ct positive group underwent a repeat mri scan and biopsy at the completion of treatment to investigate the potential presence of resistance or ongoing active spinal tb. results: a total of 18 patients were included in the study: five patients were allocated to the pet/ct positive group and 13 to the pet/ct negative group. the pet/ct negative group was significantly older (p=0.016) and had significantly fewer tb-infected vertebrae (p=0.010) than the pet/ct positive group. two patients, one in each group, were found to have drug-resistant spinal tb. at the 12-month follow-up visit, two patients (40%) in the pet/ct positive group and three patients (30%) in the pet/ct negative group were still complaining of back pain. all smear microscopy results of the pet/ct positive patients who underwent a repeat biopsy were negative after the conclusion of treatment; culture results (n=4/4) were also negative. gxp pcr results were positive in four and negative in one case. only one of four samples showed classic tb signs on histology. conclusion: this study is the first to report on biopsies done from a pet/ct positive site, after 12 months of anti-tubercular treatment. it is not unlikely that pet/ct is over-sensitive and can show metabolic activity in areas of sterile inflammation, and future studies are necessary to evaluate this. level of evidence: level 3 keywords: pet/ct, spinal tuberculosis, gene xpert, histology, tuberculosis 18f-fdg pet/ct as a modality for the evaluation of persisting raised infective markers in patients with spinal tuberculosis davis jh1 , burger mc2 , pienaar g3 , lamberts rp4 1 mbchb, fc orth(sa), mmed(orth)(sa); consultant orthopaedic surgeon, spinal surgery ² bsc, b(med)sc hons (med virol), m(med)sc (med virol), phd (exercise science); lecturer/scientific research coordinator 3 mbchb, fc orth(sa), mmed(orth)(sa); consultant orthopaedic surgeon 4 msc (med hms), phd (exerc physiol), fecss; professor and head of research division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, tygerberg, south africa corresponding author: dr johannes h davis, division of orthopaedic surgery, department of surgical sciences, stellenbosch university, tygerberg campus, po box 19063, tygerberg, 7505, south africa; tel: +27 (0)21 938 9266; email: johanhdavis@gmail.com https://orcid.org/0000-0002-1909-7629 https://orcid.org/0000-0003-2831-4960 https://orcid.org/0000-0003-3925-1264 https://orcid.org/00000-0003-1112-2604 page 24 davis jh et al. sa orthop j 2020;19(1) introduction the diagnosis of spinal tuberculosis (tb) can be very challenging, with no single test being available that provides 100% sensitivity in detecting either lung or musculoskeletal tb.1 due to its insidious onset, late presentation and late diagnosis ranging from weeks to years, spinal tb often results in significant levels of morbidity and mortality.2-4 besides having a high index of suspicion of tb spine and performing a thorough clinical assessment, several haematological, microbiological and radiological investigations can be performed to confirm the diagnosis of tb spine. in addition to these investigations, several blood markers can be used to aid in the diagnosis of tb infection. a popular blood marker which is used for this purpose is the erythrocyte sedimentation rate (esr), which is an inexpensive and simple blood test that is able to reflect a chronic inflammation state of the human body.5 however, the use of esr as a screening test in asymptomatic persons is limited by its low sensitivity and specificity,5,6 and esr levels can be raised in many other chronic disease processes. a good example of this is in patients with hiv infection, who, due also to a weaker immune system, have a 20-fold increased risk of contracting tb.7 other cytological, microbiological and dna-based tests are also used in the diagnosis of tb spine. to confirm the diagnosis of spinal tb, it is necessary to either demonstrate acid-fast bacilli (afb) on microscopy, grow bacilli in culture or have histological evidence of granulomatous inflammation.8 tissue is obtained from diseased vertebrae using a percutaneous needle biopsy or open surgery with the diagnosis of tb spine through histological studies being positive in approximately 60% of patients.9 additional laboratory tests include gene xpert (gxp) polymerase chain reaction (pcr) which is utilised in the molecular testing for tb and which allows direct detection, identification and susceptibility testing, with a reduction in the diagnostic time from weeks to hours.10 because this is a dna-based test, a false-positive result may be obtained from a repeated biopsy from a site of previous infection. it does, however, confirm that the tissue collected in a repeat biopsy for example, was taken from an area with previously diseased bone. studies have reported sensitivity of pcr ranging from 61 to 96% and a specificity of 80 to 98%.9,11 in addition, hiv status can affect this testing method by decreasing its sensitivity.11 in terms of radiological assessments, plain film radiographs are the initial investigation for patients suspected of having tb spine. compared to plain film x-rays, computer tomography (ct) is superior in showing the pathological bony changes12 while magnetic resonance imaging (mri) is regarded as the gold standard imaging modality for spinal infections, with a sensitivity of 96% and specificity of 94%.5 abscess collections, together with granulation tissue adjacent to the vertebral body, are highly suggestive of spinal tb,9 but there is no pathognomonic finding on mri that reliably distinguishes tb from other spinal infections or from a possible neoplasm.9 in addition to this, walled-off sterile fluid collections can persist in previously diseased bone, following on completion of anti-tuberculous therapy. apart from minimal oedema and reaction in the adjacent bone, it is very difficult to distinguish from active disease and is not necessarily indicative of on-going tb infection.13 finally, 18-fluorodeoxyglucose positron emission tomography/computer tomography (18f-fdg pet/ct) scan has emerged as a significant molecular imaging technique in clinical oncology and cancer research.14 further, recent literature suggests that the 18f-fdg pet/ct scan can be used as a functional imaging technique to evaluate the extent of spinal tb, and can also be used to assess response to treatment.7,15 zinn et al.7 concluded in their work that 18f-fdg pet/ct appears to be a very promising imaging modality in spinal tb, especially for identifying the most appropriate biopsy site, evaluating the disease extent, predicting possible multidrug resistance and monitoring the response to treatment. current standard operating procedures prescribe a 12–18 month treatment regimen for spinal tb, which should be monitored through a serial investigation with radiographs and changes in esr levels and subjective clinical parameters.16 in the setting of an hiv pandemic, we are often faced with patients still showing a persisting raised esr near completion of treatment, posing the question of persisting/resistant spinal tb, hiv co-infection contributing to elevated esr levels or an alternate diagnosis. therefore, the aim of the study was to investigate the differences in participant characteristics between positive and negative 18f-fdg pet/ct activity at the spinal tb site following 12 months of the appropriate chemotherapy therapy for spinal tb. a secondary aim of the study was to determine whether esr levels could be used as a reliable marker of tb activity and/or treatment success of spinal tb, especially in a high hiv-positive population. patients and methods general characteristics all patients who were treated for spinal tb at the orthopaedic spinal unit at tygerberg hospital and underwent an 18f-fdg pet/ct scan between january 2012 and december 2014 were considered for inclusion in this retrospective study. patient records were reviewed and all patients who were a) older than 18 years with spinal tb; b) hiv negative or hiv positive with a cd4 count >200; and had c) confirmed spinal tb by means of tissue biopsy were included in this study. patients with incomplete data sets or who were lost to follow-up were excluded. patient records were reviewed, and general and clinical characteristics were recorded for each patient. clinical characteristics clinical characteristics from each patient’s first presentation to the unit were recorded and all patients underwent an 18f-fdg pet/ct scan. results were recorded as being pet/ct positive if the scan showed increased metabolic activity at the site of previous spinal tb, considered suggestive of ongoing active spinal tb. scans that showed no activity were recorded as pet/ct negative. all patients with a pet/ct positive result underwent a repeat mri scan done to plan the repeat spinal biopsy. biopsies were sent for microscopy, gram staining, gxp pcr and histology. the biopsy method used, and results from smear microscopy, culture, gxp pcr and histology were recorded. patients in the pet/ct positive group underwent a repeat mri scan and biopsy at the completion of treatment to investigate the potential presence of resistance or ongoing active spinal tb. treatment all patients were treated with a four-drug anti-tubercular chemotherapy regimen for the complete remainder of the course, without de-escalating after two months. dose was given as per body weight, and patients were referred to their local clinics to continue their treatment. data collection from each three-monthly follow-up visit to our spinal clinic included: presence of pain, neurological function score (frankel grade) and esr level (using the westergren method). statistical analysis the data was analysed using statistica version 12.0 (statsoft inc, tulsa, ok, usa). the kolmogorov-smirnov test was used to test the distribution of the data. due to the small sample size, data is page 25davis jh et al. sa orthop j 2020;19(1) expressed as medians with interquartile ranges for continuous data while categorical data is expressed as frequencies with the number of participants indicated. differences between pet/ct positive and pet/ct negative patients were analysed with a mann-whitney u test for any statistical significance (p<0.05 was considered to be significant). results general characteristics a total of 18 patients were included in the study, with five patients allocated to the pet/ct positive group and 13 to the pet/ct negative group. the pet/ct negative group was significantly older (p=0.016) and had significantly fewer tb-infected vertebrae (p=0.010) than the pet/ct positive group (table i). eight patients (44%) had previous pulmonary tuberculosis (ptb), of which three patients were in the pet/ct positive group and five patients in the pet/ct negative group. of those with previous ptb, five (63%) were on anti-tubercular treatment when the spinal tb was diagnosed, with an average treatment duration of three months. a difference in the neurological function between the two groups at the time of spinal tb diagnosis was observed: all pet/ct positive patients were ambulatory, with four of five (80%) having no neurological fallout (frankel grade e) compared to four out of 12 (31%) of pet/ct negative patients who presented ambulatory (frankel grade d/e), with the rest (69%) presenting with neurological fallout that prevented mobilisation. pre-treatment outcomes all patients underwent an initial biopsy to confirm spinal tb, and biopsy test results from smear microscopy, culture and gxp pcr are described in table ii. two patients, one in each group, were found to have drug-resistant spinal tb. treatment outcomes at the 12-month follow-up visit, two patients (40%) in the pet/ct positive group and three patients (30%) in the pet/ct negative group were still complaining of back pain. esr values decreased from onset of treatment until completion of treatment but no correlation between the two groups was observed (figure 1). all patients in the pet/ct positive group were neurologically intact both at 12 months and at completion of treatment (mean duration of 24 [range 23–28] months). in the pet/ct negative group, 92% of patients (n=12/13) could ambulate at both 12 months and completion of treatment (mean duration of 15 [range 12–18] months). only one patient was non-ambulatory at completion of treatment (frankel grade c). all smear microscopy results of the pet/ct positive patients who underwent a repeat biopsy were negative after the conclusion of treatment and all culture results (n=4/4) were also negative. gxp table i: general characteristics of patients in the pet/ct positive and pet/ct negative groups variable pet/ct positive (n=5) pet/ct negative (n=13) age (years) 29 (26–37)* 49 (40–54)* sex (male / female) 2 (40%) / 3 (60%) 2 (15%) / 11 (85%) hiv status (positive / negative) 4 (80%) / 1 (20%) 8 (62%) / 5 (38%) cd4 count (hiv+ patients) 491 (316–561) 249 (155–491) complaints of back pain before the diagnosis (months) 4 (3–6) 4 (3–6) number of infected vertebra with tb 6 (4–7)** 2 (2–3)** location of infection (thoracic / lumbar) 2 (40%) / 3 (60%) 5 (38%) / 8 (62%) data is presented as median (interquartile ranges) or frequency with the number of participants in parentheses; *p=0.016; **p=0.010 table ii: biopsy results of pet/ct positive and pet/ct negative patients variable pet/ct positive (n=5) pet/ct negative (n=13) positive negative positive negative smear microscopy 2 (40%) 3 (60%) 3 (23%) 10 (77%) culture 4 (80%) 1 (20%) 9 (69%) 4 (31%) gene xpert pcr 5 (100%) 0 (0%) 10 (100%)* 0 (0%)* sensitive resistant sensitive resistant dst 1 4 (80%) 1 (20%) 9 (90%)* 1 (10%)* *only performed in 10 of the 13 patients pcr: polymerase chain reaction; dst 1: drug susceptibility testing figure 1. change in esr values from admission (esr – 0), at 12 months (esr – 12 months) and at completion of treatment (esr – completion) between pet/ct positive (light bars) and pet/ct negative (dark bars) groups. the shaded area represents the range of normal esr values. dotted line: 29 mm/hr e s r b a s e lin e e s r 1 2 m o n t h s e s r c o m p le t io n 0 2 0 4 0 6 0 8 0 1 0 0 s e d im e n ta ti o n r a te ( m m /h r) p e t /c t p o s itiv e p e t /c t n e g a tiv e 1 0 0 9 5 8 0 7 0 3 9 5 6 e s r b a s e lin e e s r 1 2 m o n t h s e s r c o m p le t io n 0 2 0 4 0 6 0 8 0 1 0 0 s e d im e n ta ti o n r a te ( m m /h r) p e t /c t p o s itiv e p e t /c t n e g a tiv e 1 0 0 9 5 8 0 7 0 3 9 5 6 page 26 davis jh et al. sa orthop j 2020;19(1) pcr results were positive in four cases and negative in one. finally, only one of four samples showed classic tb signs on histology (table iii). discussion the primary aim of this study was to investigate differences in participant characteristics between patients with a positive and negative 18f-fdg pet/ct scan at the spinal tb site following 12 months of appropriate chemotherapy. eighteen patients who underwent an 18f-fdg pet/ct scan between january 2012 and december 2014 were included in this study. the main finding of this study was that participants with a positive pet/ct scan were significantly younger, and had significantly more tb-infected vertebrae than those with a negative result. the latter finding is in agreement with the literature which reports that increased fdg uptake is recorded in active tb in various anatomical locations.17 it has further been reported that patients with three or more vertebral lesions affected demonstrated intense fdg uptake, almost three times more that of a single spinal lesion.7 additionally, in the present study, most participants (80%) in the positive pet/ct scan group were hiv positive, with the majority (60%) having had a history of previous ptb. the relationship between hiv and tb is well known and often described as a co-epidemic, and in 2014 the who estimated the risk of contracting tb to be 26 to 31 times greater in hiv-positive individuals.18 early diagnosis of spinal tb and appropriate treatment, as per drug sensitivity testing, are the fundamentals in preventing complications. the diagnosis of spinal tb is, however, frequently missed due to insidious onset of the disease and slow development of clinical features. the delay in making the diagnosis spans several months, but can take from several weeks up to years from the onset of symptoms.19,20 spinal tb has been called the great mimicker due to its ability to mimic neoplasms and other atypical infections, especially in hiv-exposed patients.21,22 for this reason, microbiological and/or histological confirmation is mandatory for the final diagnosis. the international figures of a positive m. tuberculosis culture yield through a percutaneous core needle biopsy is between 50 and 83%, with an average time period of four weeks to obtain the results.23,24 held et al., using the new, rapid molecular diagnostic test (gxp), reported a sensitivity of 95.6% and specificity of 96.2%, with these results available in 48 hours.23 biopsy results in the present study showed a culture yield in line with international figures while the gxp test was 100% sensitive in our study, with 10% of pet/ct negative participants having a positive gxp result. all pet/ct positive patients underwent a repeat spinal biopsy at the site dictated by an mri scan, to exclude possible new, resistant or on-going infection. none of these showed any tb on microscopy or culture; however, gxp was positive in four of five cases. considering that gxp is a dna-based test, it is important to keep in mind that it can lead to false positives, indicating either ongoing active or previous disease. the only way of diagnosing ongoing disease would be through histology showing necrotising granulomatous formation. in the present study, histology of only one repeat biopsy revealed classic necrotising granulomatous inflammation while three cases were suggestive of tb, showing non-necrotising granulomatous inflammation, typically seen in hivpositive patients. we further report multi-drug resistant tb (mdr-tb) in both pet/ct groups that gives an overall resistance rate of 13% for this study compared to other cape town-based studies published by held et al.23 and watt et al.24 which reported mdr-tb in 5.8% and 12% of patients, respectively. though overall esr levels in the present study decreased from diagnosis to 12 months and eventually to completion of treatment, they were still on average above 40 mm/hr at the final measurement. a prospective observational study performed in india between 2009 and 201325 reported no significant correlation between the esr levels over time, as measured at presentation and then again at 6, 12 and 18 months, and concluded that esr does not provide any objective evidence of response to treatment. this is in agreement with the findings of the current study, which highlights that this blood marker is unreliable when used as a response monitoring tool, especially in patients with hiv co-infection. neurological complications in spinal tb have a prevalence of between 10 and 42%.26 the spinal cord and cauda equina are more tolerable to compression as encountered in tb infection, especially if it happens gradually, and up to 76% of canal compromise can be tolerated without any neurological compromise. however, paraplegia can develop at lesser canal compromise if mechanical instability or vascular ischaemia is present.27 we report half of all the patients being non-ambulatory before the start of treatment. interestingly these non-ambulatory patients were all in the pet/ct negative group. at the completion of treatment, 92% of all participants were able to mobilise, without crutches. this finding is echoed in the literature: an average improvement in neurological function by two frankel grading scores was reported after completion of anti-tubercular treatment.28 the duration of treatment was considerably long in both groups, which is concerning considering the risk of drug resistance, patient compliance and drug-related side-effects. the most common reported side-effects are nausea/vomiting, abdominal pain and gastric upset, which disappear after prolonged drug use; however, we saw two cases of optic neuritis due to ethambutol treatment which only partially recovered after changing the drug regimen. logistical reasons, mainly long waiting periods for appointments for pet/ct scans and follow-up consultations, are likely to blame for the prolonged treatment in the pet/ct negative group. the main limitation of the study is the retrospective study design. poor data collection during patient follow-up led to incomplete datasets for several patients, who had to be excluded, subsequently leading to a small sample size. in addition, patients were not all screened for hypo-albuminaemia or anaemia, which could potentially have an effect on the esr levels. conclusion this study is the first to report on biopsies done from a pet/ct positive site, after 12 months of anti-tubercular treatment. it might well be that pet/ct is over-sensitive and can show metabolic activity in areas of sterile inflammation, and future studies are necessary to evaluate this. ethics statement the author/s declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement table iii: repeat biopsy results of initial pet/ct positive patients variable pet/ct (n=5) positive negative smear microscopy 0 (0%) 5 (100%) culture* 0 (0%) 4 (80%) gene xpert pcr 4 (80%) 1 (20%) classic tb signs suggestive of tb histology** 1 (20%) 3 (60%) data is presented as count with frequency indicated in parentheses *one sample not sent for culture; **one sample not sent for histology page 27davis jh et al. sa orthop j 2020;19(1) of the study ethical approval was obtained from the following ethical review board: stellenbosch university health research ethics committee, s15/08/174). formal consent was not required for this study. all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions jhd conceptualised the work and contributed to design, interpretation and drafting of the work. further contributions include critical revision and expression of intellectual content, as well as final approval of the version submitted to the journal. mcb contributed to design of the work, analysis and interpretation of the data, drafting as well as revision and final approval. gp contributed through design of the work and acquisition of data. interpretation of the data was a further contribution, with final approval of the work prior to submission. rpl contributed to interpretation of the data and statistical analysis as well as approval of the final version. orcid davis jh http://orcid.org/0000-0002-1909-7629 burger mc http://orcid.org/0000-0003-2831-4960 pienaar g http://orcid.org/0000-0003-3925-1264 lamberts rp http://orcid.org/0000-0003-1112-2604 references 1. watt jp, davis jh. percutaneous core needle biopsies: the yield in spinal tuberculosis. south african med j. 2014;104(1):29-32. 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patwardhan sa, joshi s. laboratory diagnosis of spinal tuberculosis : past and present. argospine news j. 2011;23(sep):120-21. doi:10.1007/s12240-011-0023-9. 9. garg rk, somvanshi ds. spinal tuberculosis: a review. j spinal cord med. 2011;34(5):440-54. doi:10.1179/20457723 11y.0000000023. 10. soini h, musser jm. molecular diagnosis of mycobacteria. clin chem. 2001;47(5):809-814. 11. boehme cc, nabeta p, hillemann d, et al. rapid molecular detection of tuberculosis and rifampin resistance. n engl j med. 2010;363(11):1005-1015. 12. burrill j, williams fcj, bain fg, conder fg, hine fal, rakesh r. tuberculosis : a radiologic review 1. radiographics. 2007 sep-oct;27(5):1255-74. 13. chaudhary k, dhawale a, chaddha r, laheri v. spinal tuberculosis – an update. j clin orthop. 2017;2(1):31-42. doi:10.13107/jcorth.2456-6993.189. 14. sobhani i, tiret e, lebtahi r, et al. early detection of recurrence by 18 fdg-pet in the follow-up of patients with colorectal cancer. br j cancer. 2008;98:875-80. doi:10.1038/sj.bjc.6604263. 15. özmen ö, gökçek a, tatcı e, biner i̇, akkalyoncu b. integration of pet/ct in current diagnostic and response evaluation methods in patients with tuberculosis. nucl med mol imaging. 2014;48:75-78. doi:10.1007/s13139-013-0236-2. 16. jain ak. tuberculosis of the spine: a fresh look at an old disease. j bone jt surg. 2010;92(7):905-13. doi:10.1302/0301-620x.92b7.24668. 17. harkirat s, anana ss, indrajit lk, dash ak. pictorial essay: pet/ct in tuberculosis. indian j radiol imaging2. 2008;18(2):141-47. 18. who. global tuberculosis report 2015. doi:who/htm/ tb/2014.08. 19. rivas-garcia a, sarria-estrada s, torrents-odin c, casas-gomila l, franquet e. imaging findings of pott’s disease. eur spine j. 2013;22:567-78. doi:10.1007/s00586-012-2333-9. 20. arciniegas w, orjuela dl. extrapulmonary tuberculosis: a review of 102 cases in pereira, colombia. biomedica. 2006;19:71-80. 21. d’souza mm, mondal a, sharma r, jaimini a, khanna u. tuberculosis the great mimicker: 18f-fludeoxyglucose positron emission tomography/computed tomography in a case of atypical spinal tuberculosis. indian j nucl med. 2014;29(2):99-101. doi:10.4103/0972-3919.130294. 22. dunn r. the medical management of spinal tuberculosis. sa orthop j. 2010;9(1):37-41. 23. held m, laubscher m, zar hj, dunn rn. gene xpert polymerase chain reaction for spinal tuberculosis: an accurate and rapid diagnostic test. bone joint j. 2014;96-b(10):1366-1369. doi:10.1302/0301-620x.96b10.34048. 24. watt jp, davis jh. percutaneous core needle biopsies: the yield in spinal tuberculosis. south african med j. 2014;104(1):29-32. doi:10.7196/samj.6868. 25. dureja s, sen ib, acharya s. potential role of f18 fdg pet-ct as an imaging biomarker for the noninvasive evaluation in uncomplicated skeletal tuberculosis: a prospective clinical observational study. eur spine j. 2014;23(11):2449-54. doi:10.1007/s00586-014-3483-8. 26. adendorff jj, boeke ej, lazarus c. pott’s paraplegia. south african med j. 1987;71(7):427-28. 27. jain ak, aggarwal a, mehrotra g. correlation of canal encroachment with neurological deficit in tuberculosis of the spine. int orthop. 1999;23(2):85-86. doi:10.1007/s002640050313. 28. dunn r, zondagh i, candy s. spinal tuberculosis: magnetic resonance imaging and neurological impairment. spine (phila pa 1976). 2011;36(6):469-73. http://orcid.org/0000-0002-1909-7629 http://orcid.org/0000-0003-2831-4960 http://orcid.org/0000-0003-3925-1264 http://orcid.org/0000-0003-1112-2604 _goback _hlk27145046 _goback _goback _goback _goback 404 not found page 187sa orthop j 2022;21(3) cpd questionnaire. august 2022 vol 21 no 3 high burnout among the south african orthopaedic community: a cross-sectional study (o’connor m, ferreira n, smith m, webster p, venter rg, marais lc) 1. in this research paper there was a significant association with burnout in which demographic group? a. women a b. respondents of an older age b c. registrars c d. respondents with a greater number of calls d e. respondents with a greater number of children e 2. which self-reported management strategy to cope with burnout was found to be associated with an increase in the measured burnout rate of respondents? a. drinking alcohol a b. cannabis use b c. smoking c d. exercising d e. participation in hobbies e 3. match the correct percentages of burnout and professional fulfilment among respondents in this study: a. burnout 27%, professional fulfilment 84% a b. professional fulfilment 84%, burnout 72% b c. burnout 72%, professional fulfilment 48% c d. professional fulfilment 48%, burnout 27% d e. burnout 27%, professional fulfilment 27% e triceps-off transfascial sleeve approach, functional outcomes and surgical technique in distal humerus fractures (nkomo wb, rachuene pa, dey r, maqungo s, roche s, solomons m) 4. regarding the prophylactic use of non-steroidal antiinflammatory drugs (nsaids) following elbow surgery, the evidence suggests which of the following in relation to the reduction of heterotopic ossification formation? a. there is convincing evidence to support their use following elbow surgery a b. there is more convincing evidence supporting the use of nsaids following elbow surgery compared to hip surgery b c. the evidence is equally supportive of the use of nsaids following elbow and hip surgery c d. there is more convincing evidence supporting the use of nsaids following hip surgery compared to elbow surgery d e. the evidence does not support the use of nsaids following elbow surgery e 5. distal humerus fractures in adults make up which proportion of fractures? a. 2–7% a b. 20–30% b c. 50–60% c d. 70–75% d e. 75–80% e 6. which statement is invalid? the treatment of distal humerus fractures is complex due to the following: a. low fracture line of one or both columns a b. metaphyseal fragmentation of one or both columns b c. inadequate surgical exposure c d. articular comminution d e. poor bone quality e halo-external fixator frame-assisted correction to treat severe kyphotic deformity in children younger than 4 years old (cetinkaya m, gezengana v, mann tn, du toit j, davis jh) 7. what is the main purpose of halo-pelvic traction when managing severe spinal deformity? a. to avoid the need for corrective surgery a b. to improve vital capacity prior to corrective surgery b c. to improve deformity prior to corrective surgery c d. to maintain deformity correction after surgery d e. to avoid spinal cord compression during surgery e 8. which of the following complications did not occur among the patients treated with the halo-external fixator frame? a. pin-site infection a b. injury to the cranial nerves b c. respiratory arrest c d. hospital-acquired pneumonia d e. dislodgement of the fixator frame e 9. what are some of the potential benefits of halo-pelvic traction versus halo-gravity traction? a. gradual, controlled distraction a b. greater distraction strength b c. independent mobilisation for patients c d. a and b only d e. a, b and c e orthopaedic journal s o u t h a f r i c a n � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � contents � � � � � � � � � � t h e s o u t h a f r ic a n o r t h o pa e d ic a s s o c ia t io n page 188 sa orthop j 2022;21(3) short-term outcomes of one-stage bilateral total hip arthroplasty in a south african setting (mia sm, rajpaul j, goga ie) 10. regarding the bilateral hip arthroplasty study, which of the following statements are correct? a. the 30-day mortality rate in the study was 50% a b. eighteen per cent of patients requested a disability grant application postoperatively b c. the 30-day mortality rate in the study was 0% c d. thirty-six per cent of patients in this study were hiv positive d e. when the one-stage btha was performed at a highvolume arthroplasty centre, the complication rate was also reduced e 11. the advantages of a one-stage btha include: a. theoretical reduction in anaesthetic risk a b. prolonged rehabilitation period b c. decreased costs to the healthcare system c d. earlier return to work d e. shorter rehabilitation period e epidemiology of primary bone tumours in nigeria: a systematic review (koyejo tt, olusunmade oi, olufemi ot) 12. what is the estimated annual incidence rate of bone tumours in nigeria, per 100 000 population? a. 0.5–0.7 a b. 1–3 b c. 0.1–0.3 c d. 1.1–1.3 d e. 4–7 e 13. what is the most common benign primary bone tumour in nigeria, according to this study? a. benign giant cell tumour a b. osteochondroma b c. chondroblastoma c d. osteoid osteoma d e. benign fibrous histiocytoma e 14. malignant primary bone tumours in nigeria were most commonly found in what location in this study? a. radius and ulna a b. femur b c. pelvis c d. craniofacial bones d e. tibia and fibula e wide awake local anaesthesia no tourniquet: a review of current concepts (rocher agl, o’connor m, koch o) 15. select the correct ratio, concentration and volume of constituents to formulate a standard 1% lignocaine 10 ml walant solution: a. 5 ml of 2% lignocaine, 1 ml of 1:1 000 adrenaline, 1 ml of 8.5% sodium bicarbonate, 3 ml saline a b. 5 ml of 1% lignocaine, 1 ml of 1:1 000 adrenaline, 1 ml of 8.5% sodium bicarbonate, 3 ml saline b c. 5 ml of 2% lignocaine, 1 ml of 1:1 000 adrenaline, 1 ml of 8.5% sodium bicarbonate, 3 ml saline c d. 5 ml of 1% lignocaine, 0.1 ml of 1:1 000 adrenaline, 1 ml of 8.5% sodium bicarbonate, 4 ml saline d e. 5 ml of 2% lignocaine, 0.1 ml of 1:1 000 adrenaline, 1 ml of 8.5% sodium bicarbonate, 4 ml saline e 16. select the fracture for which walant has not been utilised as the anaesthetic for surgical fixation: a. phalangeal plating a b. metacarpal plating b c. distal radius plating c d. distal humerus plating d e. ankle fracture plating e 17. which of the following is not a technique described in the text to reduce the pain of injection? a. warming the walant solution a b. injecting the solution at an acute angle to the skin b c. buffering the solution with sodium bicarbonate c d. pinching or raising the skin of the initial injection site d e. cognitive distraction of the patient during injection e a clinician-run 3d-printing laboratory for orthopaedic preoperative planning: an illustrative case series (venter rg, kotze l, ferreira n) 18. during the study period, the median ‘total cost’ to manufacture anatomical 3d-printed models at our lab, per patient, was: a. r325.76 a b. r3 257.62 b c. r4 951.00 c d. r7 177.09 d e. r12 632.62 e 19. during the study period, the mean ‘total manufacturing time’ for anatomical 3d-printed models, per patient, was: a. 8 hours a b. 33 hours b c. 62 hours c d. 1 week d e. 2 weeks e 20. the materials used in this study for the manufacturing of anatomical 3d-printed models did not include: a. polylactic acid (pla) a b. acrylonitrile butadiene styrene (abs) b c. polyethylene terephthalate glycol (petg) c d. nylon d e. titanium e subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm. co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online. • complete the questionnaire and click on submit. • your points are automatically submitted to the relevant authority. • please call mpc helpdesk if you have any questions: 0861 111 335. medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 mdb015/137/01/2022 south african orthopaedic journal trauma and general orthopaedics doi 10.17159/2309-8309/2022/v21n4a5 thikhathali nd et al. sa orthop j 2022;21(4) citation: thikhathali nd, ngcelwane mv. the burden of road traffic accident-related trauma to orthopaedic healthcare and resource utilisation at a south african tertiary hospital: a cost analysis study. sa orthop j. 2022;21(4):217-222. http:// dx.doi.org/10.17159/2309-8309/2022/ v21n4a5 editor: prof. sithombo maqungo, university of cape town, cape town, south africa received: july 2021 accepted: july 2022 published: november 2022 copyright: © 2022 thikhathali nd. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background road traffic accidents (rtas), the second commonest cause of trauma in south africa (sa), are on the rise. it is therefore important to study and understand the burden of rta-related injuries on our orthopaedic healthcare and healthcare in general, in order to devise new prevention strategies to minimise the number of rtas. methods a retrospective analysis of data from orthopaedic trauma intake records was done for patients admitted with rta-related injuries to the orthopaedic department at a south african tertiary hospital between february 2019 and january 2020. hospital records and the pac (picture archiving and communication) system were analysed for radiological studies done. the uniform patient fee schedule (upfs) was analysed for individual costing of all variables being studied. results there were 642 patients seen and managed with rta-related injuries included in this study. seventy-one per cent of them were males, with an average age of 35 years. the majority (76.2%) were motor vehicle occupants, whereas 17% were pedestrians. seventeen per cent of them had polytrauma. four hundred and sixty-two (76%) patients required some form of surgical intervention and spent an average of 171 minutes in theatre per procedure. ten per cent of these patients required icu/hcu admission for an average of 13 days. the total length of hospital stay was an average of 21.8 days. the majority of patients (67%) had some form of orthopaedic implant inserted, with an average of 1.3 implants per patient. the average cost per patient was r92 737.39. the major cost drivers were hospital stay, icu/hcu stay, implant cost, radiological studies and theatre utilisation, respectively. conclusion management of rta-related trauma puts a significant burden on orthopaedic healthcare management and resource utilisation. while we may not be able to directly influence other contributing factors to high costs, reducing the use of temporary external fixators may help reduce the cost of managing rta victims. these findings provide scientific data which will help support the implementation of preventative measures aimed at minimising the numbers of rtas we see on our roads, thereby minimising the burden this puts on our healthcare system. level of evidence: level 3 keywords: road traffic accident, burden, implant cost, theatre time, length of hospital stay, polytrauma the burden of road traffic accident-related trauma to orthopaedic healthcare and resource utilisation at a south african tertiary hospital: a cost analysis study ndivhoniswani d thikhathali,* mthunzi v ngcelwane department of orthopaedics, university of pretoria, steve biko academic hospital, pretoria, south africa *corresponding author: ndivho@gmail.com introduction road traffic accidents (rtas) are one of the commonest causes of trauma globally, and are ranked the ninth leading cause of mortality worldwide.1-4 rtas have become a neglected global epidemic and they continue to rise, mostly in lowand middle-income countries (lmics) like south africa (sa).1,2,5 rtas are the second most common cause of trauma in sa, the most common being interpersonal violence (ipv).2 many patients with trauma-related injuries sustain musculoskeletal injuries.6-8 these injuries increase the workload for orthopaedic surgeons who treat the majority of these patients.7 the majority of patients affected are pedestrians, cyclists and passengers in commercial vehicles.2,6,9 rtas mostly cause high-energy injuries and the majority of the patients have polytrauma, sustaining long bone fractures and lifethreatening head, blunt chest and abdominal injuries.9,10 they are prioritised for emergency theatre management and intensive care unit (icu) or high care unit (hcu) admission because they have lifeor limb-threatening conditions which require emergency procedures.7,9,11-13 https://orcid.org/0000-0002-8208-5153 page 218 thikhathali nd et al. sa orthop j 2022;21(4) they utilise more theatre time on initial theatre visits with orthopaedic and non-orthopaedic lifesaving, damage control surgical/orthopaedic procedures being performed. up to 26% of them will have second theatre visits for definitive management with some form of orthopaedic implants. these implants play a major role in driving the financial burden of managing musculoskeletal trauma.8,9 the severity of the injury plays a big role in influencing the length of icu stays as well as the overall length of hospital stay.6,7,11,12 many musculoskeletal injuries have increased risks of developing complications which will require multiple theatre visits, multiple radiological studies and a subsequent prolonged length of hospital stay.14 there is a big discrepancy in reporting the number of rtarelated injuries in our country. only the rta-related fatalities are reported on national statistics, while non-fatal injuries, said to be three to eight patients per reported accident, are unreported.15,16 these patients are seen and managed at our healthcare facilities, which increases the disease burden both financially and in terms of resource utilisation in orthopaedic healthcare.15,16 it is difficult to quantify the impact of managing these patients on our healthcare systems due to lack of quantifiable data.11 despite there being literature reports showing increased rates of musculoskeletal injuries among these patients, there is still a paucity of literature locally and abroad that addresses the impact of managing these patients on orthopaedic healthcare.6,7,15 the question about the burden of managing patients with rta-related injuries with musculoskeletal injuries to an orthopaedic department remains unanswered. the aim of our study was to determine the overall burden of managing patients with rta-related injuries, both financially and in terms of resource utilisation, on the orthopaedic surgery department at steve biko academic hospital. this information will help direct policy on funding prevention strategies or methods of minimising rtas. our study objectives were to determine the proportion of rta patients compared to the total trauma load seen at orthopaedics in the study period. methods a retrospective, single centre study was conducted to determine the burden of rta-related injuries treated at steve biko academic hospital, a south african tertiary hospital, over a 12-month period from february 2019 to january 2020. the departmental daily admission records were analysed for all patients assessed with trauma-related injuries during the study period. the patient population in the study included all patients who sustained trauma from rtas. these were patients of all ages and both sexes. the proportion of this study population was compared to the total number of trauma patients seen at the orthopaedic department during the same study period. these were further subdivided according to the modes of rtas into motor vehicle accidents (mvas), motorbike accidents (mbas) and pedestrian-vehicle accidents (pvas). we recorded the patients’ demographic data, injuries sustained, injury severity, mechanism of injury, and length of hospital stay, including length of icu/hcu stay, from the hospital records. the injury severity score (iss) was used to differentiate between polytrauma and multiply injured patients. the iss is a score used to assess the severity of the trauma sustained by the patient and it is helpful in determining if the patient’s injuries are severe. it is directly related to the length of hospital stay as well as the morbidity and mortality after the injury. polytrauma was defined as injury to two or more major systems with an associated iss > 15, whereas a multiply injured patient was defined as a patient with multiple injuries to different systems with minimal severity and an iss < 15. radiological investigations were analysed and recorded from the patient archiving and communication system (pacs). theatre register records were analysed for procedures performed, orthopaedic implants, number of procedures, frequency of theatre visits and duration of procedures. duration of a procedure was calculated from the patient’s sign-in time to their sign-out time. the procedures were classified into major procedures (for which orthopaedic implants were utilised) and minor procedures, including soft tissue procedures such as tendon repairs, debridement and wound closure. the micro-costing (bottom-up) method of direct data costing was utilised for the study variables per patient. this kind of study includes calculating detailed individual costs for each patient to obtain an individual’s total cost. although it is time consuming, it gives the most accurate results compared to the top-bottom method which only takes institution average costs, dividing it by the number of patients in the study to get an average cost per patient. the costs of radiological studies, theatre utilisation per procedure, icu/hcu and general orthopaedic ward stays were obtained from the finance department, uniform patient fee schedule (upfs) and road accident fund (raf) offices in the hospital. all recorded costs included facility utilisation and specialist fee for each procedure or service rendered. the costs of implants were taken from individual patients’ invoices, from the implant suppliers and the government tender pricing system. all other consumables and medication were part of the facility fee as described by the upfs, except for a few things such as vacuum-assisted closure (vac) wound dressings and machines, braces and other forms of orthosis. the total cost of treating rta-injured patients from time of admission to time of discharge was derived from the total costs of emergency department (ed) consultation, the radiological studies performed, the cost of icu and hcu utilisation, theatre utilisation costs, costs of implants and general ward admission costs per day. all the data was analysed and recorded in a microsoft excel spreadsheet. all the patient identifiers were removed from the data collection sheet to ensure anonymity. results a total of 3 237 patients with trauma-related injuries were assessed at the orthopaedic department during the study period. the study cohort consisted of 642 (20%) patients who sustained rta-related injuries. the average age of the study population patients was 35.7 years (range 1–82), with 462 (72%) patients between 19 and 45 years of age (figure 1). figure 2 shows there were 458 (71.3%) 500 450 400 350 300 250 200 150 100 50 0 1–18 years 41 139 462 19–45 years 46–82 years figure 1. age distribution page 219thikhathali nd et al. sa orthop j 2022;21(4) males and 184 (28.7%) females. mvas were the most common modes of rta, responsible for 76.2% of injuries, compared to pvas (17%) and mbas (6.8%), as shown in figure 3. a total of 560 (87.2%) patients were admitted for further management, while 82 (12.8%) were assessed and discharged on the day of presentation. of the admitted patients, 124 (22%) were treated nonoperatively while ten (1.8%) patients died in hospital after admission. one hundred and twelve patients had polytrauma, 57 were multiply injured and the remainder had isolated injuries. our 642 patients sustained a total of 870 (mean: 1.4) orthopaedic injuries. the injuries included lower limb (ll) injuries (54.5%), upper limb (ul) injuries (36.6%) and spine injuries (9.0%) (figures 4 and 5). one hundred and thirty patients had open injuries, 63.9% of which were open long bone fractures. ninety-one patients had associated non-orthopaedic injuries. four hundred and thirty-two (67.3%) patients were treated operatively, and 22.9% of them went to theatre more than once. a total of 565 (mean: 1.3) orthopaedic procedures were performed. of the 565 procedures, 362 patients had major procedures utilising 431 (mean: 1.2) orthopaedic implants. eighty-one patients had two major operations, while 13 had three major procedures (figure 6). the remaining 90 patients had minor procedures performed in theatre. eight patients required more than one theatre visit. of the 431 implants, 80 (18.6%) were external fixators used for either temporary or permanent fracture stabilisation. the total cost spent on orthopaedic implants was r8 065 494.87, an average of r19 820.15 per patient. this amounts to 28.8% of the total hospital budget for all surgical implants, including for other orthopaedic sub-specialities. the most expensive implants were external fixators, accounting for 42% of the total implant costs utilised in the current study period. the surgical procedures required a total surgical time of 96 854 minutes (mean: 171). this translates to 265.35 minutes, an equivalent of 4.4 hours per day. six patients blocked theatre for an average 622.50 minutes (range: 240–1 885 minutes), while awaiting icu/hcu bed availability. the cumulative cost of theatre utilisation was r3 363 070.00, an average of r5 952.34 per procedure and r4 578.72 per patient. a total of 45 patients required an average icu admission of 13 days (range: 2–50), while 71 patients required an average hcu admission of seven days (range: 2–32). of the icu and hcu patients, 52 patients had polytrauma with associated lifethreatening non-orthopaedic injuries. the total cost of icu stay was male 29% 71% female figure 2. sex distribution mva 71% mba pva figure 3. mechanism of injury 76% 17% 7% upper limb 1 upper limb 2 upper limb 3 lower limb 1 lower limb 2 lower limb 3 spine 1 spine 2 450 400 350 300 250 200 150 100 50 0 285 3 2 407 59 8 38 40 figure 4. number of injuries per body region 400 350 300 250 200 150 100 50 0 isolated upper limb injuries isolated lower limb injuries spine injuriescombined upper and lower limb injuries 219 346 77 78 figure 5. injury pattern per body region page 220 thikhathali nd et al. sa orthop j 2022;21(4) r12 455 820.00, an average r276 796.00 per patient, whereas total hcu costs were r4 983 808.00, an average of r70 336.00 per patient. the initial assessment cost at the ed for the study patients was r418 584.00. all patients required at least one form of radiological study on initial assessment, whereas more studies were done during their admission period. a total of 4 920 plain radiographs, 219 skeletal survey radiographs, 75 ultrasounds, 603 ct scans, 23 mris and 2 677 fluoroscopic imaging were done. the total cost of radiological investigations was r4 330 613.00, an average of r6 745.50 per patient. the admitted patients had an average length of in-hospital stay of 21.8 days. the total cost of hospital stay was r25 916 165.00, translating to r46 278.86 per patient. total cost of treating rta-injured patients requiring orthopaedic intervention was r59 533 555.87, which equates to r92 731.39 per patient. the biggest cost driver for this study was hospital stay contributing 43.5%, followed by icu/hcu costing 29.3% of the total costs (figure 7). discussion this is the first study to assess the burden of rta injuries with specific reference to orthopaedic healthcare in south africa. the burden was determined by assessing financial burden as well as time and resource utilisation. this tertiary hospital is one of the three public tertiary hospitals which receive trauma patients in pretoria. we found a high male-to-female ratio of 7.1:2.9, with an average age of 35 years. this is comparable to previous studies which reported that patients in this age group and sex engaged more in high-risk behaviour on the road.17-19 more significantly, however, we found that 72% of patients were between the ages of 19 and 45 years. these are the economically active people with musculoskeletal injuries, which take a minimum of six weeks to heal. the patients are off-duty for a significant amount of time and are unable to contribute to the economy.1 previous studies in africa and abroad have highlighted the disproportionate involvement of vulnerable road users such as pedestrians in rtas. prakash et al. found that 53% of the rta victims were pedestrians, whereas in a south african study, parkinson et al. reported 41% of pedestrian victims.18,20 unlike the other studies reporting high rates of pvas, our study found only 17% pedestrians who sustained road traffic injuries. while previous literature reported high rates of in-patient mortality ranging between 5.6% in south africa to 38.8% in ethiopia following rtas, our study found a remarkably low inpatient mortality rate of 1.78% following rta injuries.21,22 almost all rta-injured patients sustain high-energy injuries, with patients having high iss, severe musculoskeletal injuries and other life-threatening non-orthopaedic injuries. our study found a high admission rate of 87%, 77% of whom required surgical intervention, with 21% of them having open fractures. these patients had an average of 1.3 procedures per patient, and 81 of them required more than one theatre visit. they spent an average of 171 minutes per procedure in theatre. the average theatre utilisation for rta trauma management was 265.35 minutes (4.4 hours), an equivalent of 18.3% theatre time per day. although our institution runs a 24-hour emergency theatre, this is still a significant amount of time given that our emergency theatre caters for other trauma and non-trauma emergencies alike. the amount of time and frequency of theatre visits is influenced by many modifiable and non-modifiable factors. these factors include a high iss, multiple fractures, open fractures, life-threatening non-orthopaedic injuries and development of complications, which has a big influence on theatre utilisation, as well as on length of hospital stay. most haemodynamically unstable patients and those with open fractures require initial debridement and temporary stabilisation before definitive management; they will therefore require more than one theatre visit. other factors influencing theatre times are the surgeons, anaesthetists and nursing team’s experience. most of these emergency operations are performed at night when mostly junior registrars are on call. the quality of initial debridement and 400 350 300 250 200 150 100 50 0 major 1 major 2 major 3 minor 1 minor 2 minor 3 362 51 4 90 7 1 figure 6. type of surgery performed implants hospital stay icu stay hcu stay emergency department radiology theatre utilisation 30.0 25.0 20.0 15.0 10.0 5.0 0.0 c os t ( m ill io n ra nd ) figure 7. major cost drivers page 221thikhathali nd et al. sa orthop j 2022;21(4) fracture stabilisation will determine the subsequent frequency of theatre visits. our tertiary hospital as a training institution has many surgeons and anaesthetists at different levels of training. this has an impact on the anaesthesia time as well as quality of debridement and surgical time. the above factors also have an influence on icu, hcu and length of hospital stays. our patients had long icu/hcu and hospital stays. this was in keeping with the injury severity, open fractures and associated life-threatening non-orthopaedic injuries reported in the current study. these findings were similar to those reported by parkinson et al.9 many patients also spend long periods of time in the wards for bed rest or rehabilitation before they can be safely discharged home or to rehabilitation facilities. the long periods of hospital stay and multiple theatre visits with prolonged surgical time have an impact on orthopaedic healthcare. these patients are occupying hospital beds for protracted periods, and as a result, block the admission of other non-trauma or elective patients who require orthopaedic interventions. prolonged theatre durations limit available theatre time for other non-trauma and nonrta trauma patients who utilise the same theatre. resource utilisation, such as theatre, icu or hcu availability and utilisation, by these patients also has a significant impact on other orthopaedic patient care. patients with severe lifeor limbthreatening injuries will always be prioritised for theatre occupancy. these patients are haemodynamically unstable and require icu management postoperatively. an icu/hcu bed is, on its own, a precious resource which is never readily available. these unstable patients cannot be transferred to general wards for further management. they will essentially block the theatre while awaiting icu bed availability. one patient blocking theatre has an enormous negative impact on other non-trauma or non-rta orthopaedic emergency patient care. fifty-four patients in our study blocked theatre. it took an average of 622.50 minutes, ranging between 240 minutes and 1 885 minutes. this is a significant amount of time for no operations to be done in an emergency theatre. radiological investigations play an integral role in the diagnosis and management of musculoskeletal injuries. these investigations contributed significantly to the resource utilisation in the patient care during their hospital stay. the majority of these patients received an average of 13.3 radiological investigations, the majority of which were ordered from the icu/hcu complex throughout the admission period. these amounted to an average cost of r6 745.50 per patient. with a majority of our patients sustaining high-energy injuries and multiple fractures, we recorded that 87.8% of the operated patients required an average of 1.2 orthopaedic implants. approximately 19% of these implants were external fixators used either for temporary or permanent fracture stabilisation. the other implants included plates, screws and intramedullary devices. implants such as k-wires were recorded as minor as they are considered part of the orthopaedic sets in hospital and are therefore classified with other theatre consumables. of the orthopaedic implants utilised, external fixators accounted for only 18.6% of all the implants and they were utilised in treating only 21% of the patients; however, they were responsible for 42% of the total implant costs. these findings highlight external fixators as one of the major cost drivers in orthopaedic trauma management. although most previous literature directs us to utilise temporary external fixation for most initial open fracture management, recent evidence supports early definitive fracture fixation which allows primary nailing for open fractures up to gustilo-anderson grade iiia.23-25 as surgeons we need to start adopting new protocols which allow for early fracture fixation where possible, in order to minimise implant costs. the tibia intramedullary nail costs r8 500.00 on tender, while a temporary external fixator costs r40 000.00. the total cost of cases in this study was r59 533 555.87, which translates to an average cost of r92 731.39 per patient and 4.4 hours in theatre per day. this cost is still high despite implementation of government tender prices for orthopaedic implants used in government institutions. limitations of the study include that it is a retrospective, single centre study. polytrauma patients have other associated lifethreatening injuries which influence the length of hospital stays, theatre time and management costs. we were unable to include costs of other consumable items like blood transfusions and vac wound dressings that were utilised in the study period. the radiographs done in icu influence the costs spent in treating these patients. the amount of theatre time in the study reflected different levels of experience, mostly including junior doctors with minimal experience. this has a bearing on the amount of time spent in theatre, and in some cases the number of times a patient goes to theatre. conclusion road traffic accidents place a significant burden on orthopaedic patient care. there is a major financial, time and resource utilisation burden placed on orthopaedic patient care, and this has a negative impact on other non-trauma orthopaedic patients. minimising the use of temporary external fixation may help reduce the cost of management. acknowledgements the author would like to thank the department of orthopaedic surgery, steve biko academic hospital and university of pretoria for research support. special thanks to prof. mv ngcelwane for all the guidance provided throughout the study, and steve biko academic hospital for allowing me to access patients’ records in order to make this study a success. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. the study was approved by the research ethics committee, faculty of health sciences, university of pretoria with ethics reference number: 474/2020. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was not obtained from patients for being included in this retrospective study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ndt: conception and design, data collection, data analysis and interpretation, drafting the article, critical revision, final approval of article mvn: conception and design, drafting the article, critical revision, final approval of article orcid thikhathali nd https://orcid.org/0000-0002-8208-5153 ngcelwane mv https://orcid.org/0000-0001-7564-3308 references 1. sakran jv, greer se, werlin e, mccunn m. care of the injured worldwide: trauma still the neglected disease of modern society. scand j trauma resusc emerg med. 2012;20:64. 2. saggie j. trauma: south africa’s other epidemic. samj. 2013;103:589-90. 3. adeloye d, thompson jy, akanbi ma, et al. the burden of road traffic crashes, injuries and deaths in africa: a systematic review and meta-analysis. bull world health organ. 2016;94(7):510-21a. 4. paniker j, graham sm, harrison jw. global trauma: the great divide. sicot j. 2015;1:19. 5. norton r, kobusingye o. injuries. n engl j med. 2013;368(18):1723-30. https://orcid.org/0000-0002-8208-5153 https://orcid.org/0000-0001-7564-3308 page 222 thikhathali nd et al. sa orthop j 2022;21(4) 6. parkinson f, kent s, aldous c, et al. road traffic crashes in south africa: the burden of injury to a regional trauma centre. s afr med j. 2013;103(11):850-52. 7. stinner dj, edwards d. surgical management of musculoskeletal trauma. surg clin north am. 2017;97(5):1119-31. 8. martin c, thiart g, mccollum g, et al. the burden of gunshot injuries on orthopaedic healthcare resources in south africa. s afr med j. 2017;107(7):626-30. 9. parkinson f, kent sj, aldous c, et al. the hospital cost of road traffic accidents at a south african regional trauma centre: a micro-costing study. injury. 2014;45(1):342-45. 10. hoogervorst p, shearer dw, miclau t. the burden of high-energy musculoskeletal trauma in high-income countries. world j surg. 2020;44(4):1033-38. 11. hardcastle tc, oosthuizen g, clarke d, lutge e. trauma, a preventable burden of disease in south africa : review of the evidence, with a focus on kwazulu-natal. south african health review. 2016;2016(1):179-89. 12. gnass i, ritschel m, andrich s, et al. assessment of patient-reported outcomes after polytrauma: protocol for a systematic review. bmj open. 2018;8(3):e017571. 13. laing gl, skinner dl, bruce jl, et al. understanding the burden and outcome of trauma care drives a new trauma systems model. world j surg. 2014;38(7):1699-706. 14. aizpuru m, staley c, reisman w, et al. determinants of length of stay after operative treatment for femur fractures. j orthop trauma. 2018;32(4):161-66. 15. beveridge m, howard a. the burden of orthopaedic disease in developing countries. j bone joint surg am. 2004;86(8):1819-22. 16. norman r, matzopoulos r, groenewald p, bradshaw d. the high burden of injuries in south africa. bull world health organ. 2007;85(9):695-702. 17. lutge ee, muirhead d. the epidemiology and cost of trauma to the orthopaedic department at a secondary-level hospital. s afr j surg. 2005;43(3):74-77. 18. prakash i, neves o, cumbe e, et al. the financial burden of road traffic injuries in mozambique: a hospital-related cost-of-illness study of maputo central hospital. world j surg. 2019;43(12):2959-66. 19. turner c, mcclure r. age and gender differences in risk-taking behaviour as an explanation for high incidence of motor vehicle crashes as a driver in young males. inj control saf promot. 2003;10(3):123-30. 20. parkinson f, kent s, aldous c, et al. patterns of injury seen in road crash victims in a south african trauma centre. s afr j surg. 2013;51(4):131-34. 21. woyessa ah, heyi wd, ture nh, moti bk. patterns of road traffic accident, nature of related injuries, and post-crash outcome determinants in western ethiopia a hospital based study. afr j emerg med. 2021;11(1):123-31. 22. saidi hs, macharia wm, ating’a jeo. outcome for hospitalized road trauma patients at a tertiary hospital in kenya. eur j trauma. 2005;31(4):401-406. 23. poletti f, macmull s, mushtaq n, mobasheri r. current concepts and principles in open tibial fractures part ii management and controversies. moj orthop rheumatol. 2017;8. 24. diwan a, eberlin kr, smith rm. the principles and practice of open fracture care, 2018. chin j traumatol. 2018;21(4):187-92. 25. manjra m, basson t, du preez g, et al. current concepts in the management of open tibia fractures. sa orthop j. 2019;18(4):52-62. _hlk113971546 _hlk70201202 _hlk70199066 orthopaedics vol3 no4 page 16 sa orthopaedic journal summer 2015 | vol 14 • no 4 cell signalling and bone remodelling: the skeleton as an endocrine relay organ part 1 ej raubenheimer phd, dsc hd hendrik msc metabolic bone disease unit, faculty of health sciences, smu, south africa corresponding author: prof ej raubenheimer pathology: metabolic bone disease unit faculty of health sciences 0204 smu email: ejraub@fox5.co.za tel: +27 12 5214838 fax: +27 12 5215274 introduction until recently the functions of the skeleton were believed to be limited to the maintenance of the vital ionised blood calcium (ca2+) concentration, provision of rigid attachments for muscles, protection of vital organs and hosting of the haemopoietic system. mapping of the human genome paved the way for the study of rare genetic skeletal diseases, which uncovered signalling pathways involved in bone remodelling. several of these pathways link systemic health to bone metabolism and the skeleton is now firmly established as an endocrine relay organ. the preventative and corrective management of generalised skeletal deficiency states will increasingly be oriented towards manipulation of cell signalling and, depending on the desired clinical outcome, it is now possible to control the induction or inhibition of bone formation. space does not permit a detailed review and readers are referred to the voluminous literature on each cytokine mentioned in this manuscript for more detail. this overview is aimed at providing practitioners with insight into cell signalling during bone remodelling and the systemic metabolic implications thereof. bone remodelling the skeleton undergoes remodelling throughout life. the cycle involves resorption of bone through osteoclast action and the substitution of resorbed bone through osteoblast action, resulting in replacement of the entire skeleton every decade.1 in broad terms, this process is aimed at the stabilisation of blood calcium (ca2+), repair of damaged bone, removal of old bone and enabling the skeleton to meet changing mechanical demands. during the last decade genetic technology unravelled the pathogenesis of several metabolic bone diseases, and important systemic pathways linked to bone were uncovered. this added significantly to our understanding of the role bone plays in systemic health. the homing of precursor cells to sites of bone remodelling, their differentiation and actions are tightly controlled through autocrine, paracrine and endocrine mechanisms mediating an effective and coordinated cycle of resorption, followed by bone formation. abstract as knowledge on the signalling pathways involved in bone remodelling unfolds, maintenance of skeletal health and the management of skeletal diseases will increasingly focus on the manipulation of the autocrine, paracrine and endocrine mechanisms involved in the process. this overview is aimed at providing practitioners with an update on recent advances on cell signalling in bone remodelling and highlights the role of the skeleton in systemic metabolism. key words: bone metabolism, cell signalling, skeletal remodelling during the last decade genetic technology unravelled the pathogenesis of several metabolic bone diseases, and important systemic pathways linked to bone were uncovered http://dx.doi.org/10.17159/2309-8309/2015/v14n4a1 saoj summer 2015_press_orthopaedics vol3 no4 2015/11/02 11:54 am page 16 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 17 the sites at which this occurs are referred to as bone metabolic units or bmus. although not yet clearly understood, it is suggested that osteocytes in the early stage of programmed cell death release cytokines which stimulate the initiation of a bmu.2 this is a feasible explanation for the initiation of bone remodelling along fracture lines or at sites of bone necrosis where osteocytes invariably lose their vitality. the bone remodelling compartment (or brc) the first morphological evidence of a developing bmu is elevation of the cells lining the bone surface and the creation of a canopy which separates the bone marrow from the bmu. through the release of angiopoietin3 and vascular endothelial growth factor (vegf),4 a dedicated blood supply is established and monocytes and lymphocytes (supplied by the blood) and undifferentiated mesenchymal cells (which are concentrated around the blood vessel5) enter the site of remodelling, which is now referred to as a bone remodelling compartment or brc2 (figure 1). among other factors, parathyroid hormone (pth) plays an important role in attracting osteoclast precursors to the brc either through stimulation of the production of sphinosine-1-phosphate (s1p), a potent chemo-attractant for monocytes produced by resident osteoclasts6 or elaboration of the inflammatory cytokine, macrophage colony stimulating factor (m-csf) by t-lymphocytes.7 the structure of a brc in cortical bone differs from that in trabecular bone, which provides a partial explanation for the dissimilar reactions of these two bone compartments to metabolic demands. trabecular bone is remodelled on its surface, whereas cortical bone remodelling occurs subperiosteally and within the haversian systems. paracrine and autocrine control of the bmu differentiation of monocytes into osteoclasts and undifferentiated mesenchymal cells into osteoblasts within a brc are linked and tightly controlled. osteoclasts are subjected to paracrine signalling by osteoblasts and are active for approximately 3 weeks.2 one of the most elaborately studied effectors of osteoclast differentiation and activation is rank-ligand (rankl) which is produced by osteoblasts. this binds to rank receptors on the cell surface of osteoclast precursors to activate cytoplasmic kinases which neutralise the inhibition of nuclear factor κb (nf-κb). nf-κb regulates the genes for osteoclast differentiation.8 this signal requires interleukin-1 (il-1), produced by osteoblasts, for activation.9 the process is balanced by osteoprotegerin (opg) production by osteoblasts. opg acts as a decoy receptor for rankl antagonising its osteoclastogenic effect.10 other factors released by osteoblasts and which have an effect on osteoclasts, include parathyroid hormone related protein (pthrp) and interleukin-1 (il-1). the latter was previously known as osteoclast activation factor (oaf). pthrp binds to the same receptors as pth, activates osteoclasts and mobilises skeletal ca2+.11 il-1 enhances osteoclast formation and survival, rankl expression by osteoblasts and induces il-6 production in the presence of 1,25(oh)2vit d (vit d3). il-6 is an inflammatory cytokine known for its resorptive effect on bone.12 for resorption to take place, osteoclasts must bind to specific receptors on the bone surface. 25(oh) vit d (vit d2) reduces the resorptive capacity of osteoclasts by affecting their adhesive properties to bone.13 the specialised ruffled cytoplasmic borders of osteoclasts enlarge the contact area with bone, and the lowered ph, established through the release of h+ ions, creates an acidic environment that is conducive to the release of minerals. the collagen matrix is degraded through the release of cathepsin k and tartrate-resistant acid phosphatases (trap).14 several proteins with systemic metabolic effects are released during bone resorption, establishing an important role for the skeleton in systemic metabolism. the microscopic manifestation of an active site of bone resorption is a resorptive cavity (or howship’s lacuna) containing osteoclasts (figure 2). figure 1. brc (b) in trabecular bone associated with a micro-fracture (white arrow). note the canopy of cells (black arrows) which separates the brc from the bone marrow (h&e stain, ×1000). for resorption to take place, osteoclasts must bind to specific receptors on the bone surface saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 17 page 18 sa orthopaedic journal summer 2015 | vol 14 • no 4 undifferentiated mesenchymal cells, which are progenitors for several mesenchymal cell types, are programmed to differentiate into osteoblasts through the binding of wnt ligands to cell-surface wnt receptors (frizzled family receptors and co-receptor lrp5).15 the cytoplasmic reaction resulting from wnt triggering in the mesenchymal stem cells can be β-catenin dependent (canononical pathway) or β-catenin independent (non-cananonical pathway). in the canononical pathway, several cytoplasmic kinases which neutralise β-catenin preventing its nuclear translocation, are inactivated. the cytoplasmic concentration of β-catenin subsequently increases promoting the nuclear signal for osteoblast differentiation and bone formation. wnt ligands include members of the transforming growth factor β (tgf-β) family (bone morphogenetic proteins bmp7, bmp6 and bmp3),16 cardiotrophin-1 (produced by osteoclasts)6 and bmp2. bmp7 (also known as osteogenic protein-1) plays a key role in the differentiation of mesenchymal cells into osteoblasts through the phosphorylation of smad1 and smad5, which activate the transcription of osteogenic genes.17 wnt antagonists like dickkopf (dkk1), sostdc1 and sclerostin are produced by osteocytes and suppress osteoblast function through blocking of the wnt receptors.18-20 bmp2 is produced by osteoblasts and signals through an autocrine loop for the elaboration of alkaline phosphatase which hydrolyses pyrophosphate (an inhibitor of mineralisation) into phosphate (a promoter of mineralisation).21 several steps in the wnt pathway are unique to bone and are currently exploited by industry for the production of monoclonal antibodies and drugs that guide bone remodelling in order to achieve a desirable bone phenotype (see part 2 – to be published in the sa orthopaedic journal autumn 2016 vol 15 no 1). carboxylated osteocalcin released by osteoblasts increases the affinity of the protein matrix for minerals.22 bone sialoprotein production by osteoclasts is facilitated by mechanical stress and stimulates osteoblast-induced growth of the hydroxyapatite crystal.22 osteopontin, a non-collagenous protein deposited in the matrix of bone by osteoblasts, provides a direct mechanical link (through the cell surface receptor integrin) with the cytoskeleton of bone cells. mechano-transduction through the integrin receptor plays a role in the maintenance of bone mass during skeletal loading23 and is an important consideration in disuse osteopaenia. the activities of osteoblasts last for 3–4 months2 and after deposition of immature (woven) bone, which restores the resorbtive facet (figure 3), the majority undergo apoptosis and those that are incorporated in newly formed bone become osteocytes. slender processes communicate between neighbouring osteocytes and osteoblasts. this provides a cellular network involved in post formation mineral exchange, transduction of mechanical forces and lamellation of the newly formed bone. the latter mechanism remains one of the enigmas of bone maturation. irregular cemental lines in lamellar bone, imparting a jigsaw puzzle appearance microscopically (figure 4), are the only historical record of a restored brc in mature bone. endocrine control of bone remodelling most of the endocrine factors influencing bone remodelling were described centuries ago. the effects of pth on the brc are summarised in table i and vit d (which is more aptly described as a hormone) in table ii. prostaglandins e2 and e4, which are widely produced in the body, bind to receptors on the osteoblast, stimulate bone formation and improve fracture healing.29 nuclear factor κb (nfκb), the ‘ageing’ hormone produced by the hypothalamus, stimulates the differentiation of osteoclasts and is partially responsible for the reduction of skeletal mass during ageing.30 epidermal growth factor (egf) binds to a receptor on osteoblasts and stimulates bone formation.31 figure 2. resorptive facet on the surface of bone. note the active osteoclasts (black arrows) attached to the bone surface and the canopy demarcating the brc (open arrow). undifferentiated mesenchymal cells are visible between the two osteoclasts (h&e stain, ×1000). figure 3. resorptive facet on the surface of bone showing a residual osteoclast (black arrow) and osteoid (black star) associated with a single layer of osteoblasts (white arrow). the white star indicates mineralised bone with osteocytes in lacuna (h&e stain, ×1000). saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 1 sa orthopaedic journal summer 2015 | vol 14 • no 4 page 19 the role of thyroidal calcitonin (tct) in bone remodelling remains speculative.32 oestrogen binds to estrogen receptor alpha (erα) on cortical osteoblasts and maintains cortical bone volume (possibly through the suspension of sclerostin production). erα of cortical osteoblast progenitors also stimulate wnt signalling and cortical bone formation in response to mechanical strain, independent of oestrogen. androgen receptors on mature osteoblasts facilitate the maintenance of trabecular bone mass in males, but are not required for the anabolic effects of androgen on cortical bone.33 the only endocrinologic functions of pthrp, produced by lactating mammary glands and the placenta, are mobilisation of skeletal calcium for milk production and regulation of maternal placental ca2+ transport for foetal skeletal growth respectively.11 figure 4. cemental lines (white arrows) in a hypermetabolised bone trabeculum. note the lamellar nature of the bone (von kossa stain, non-demineralised section, ×600). table i: targets, mode of action and effects of pth in bone remodelling target mode of action effect osteoblast and cd40l t lymphocytes24 continuous pth administration as in hyperparathyroidism stimulate rankl and m-csfand supress opg production in the presence of t cells catabolic: recruit active osteoclasts which resorb bone and elaborate ca2+ and other noncollagenous proteins osteoblast and cd8+ t lymphocytes24 intermittent pth administration activate t cell wnt production which stimulates canonical signalling in osteoblasts anabolic: osteoblast differentiation osteoblast6 stimulate angiopoetin-1 production vascularise the brc osteoclast6 suppress production of sclerostin pro-osteogenic osteoclast6 stimulate production of s1pr facilitate osteoclast precursor migration to bone osteoclast6 stimulate production of bmp6 pro-osteogenic osteocyte25 potentiates ion channels for influx of ca2+, regulates apoptosis, amplifies bone formation during loading maintains functions of osteocyte: communication, mineral exchange, response to loading and apoptosis endothelium6 stimulate vegf production vascularisation of the brc t-lymphocyte7 release of m-csf promote osteoclast differentiation and survival table ii: targets, mode of action and effects of of vit d2 and vit d3 on bone remodelling target mode of action effect osteoblast and osteocyte26 stimulate production of fgf-23 induces phosphaturia and decreases vit d3 synthesis osteoblast27 enhance osteocalcin production promote bone mineralisation osteoclast13 vit d2: reduce adhesive properties reduce resorbtive capacity monocyte (osteoclast precursor)28 vit d3: suppress s1pr production inhibit migration to bone nuclear factor κb (nfκb), the ‘ageing’ hormone produced by the hypothalamus is partially responsible for the reduction of skeletal mass during ageing saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 19 page 20 sa orthopaedic journal summer 2015 | vol 14 • no 4 the skeleton as an endocrine relay organ the skeleton is now firmly established as an organ influencing peripheral sugar homeostasis. insulin produced by pancreatic β-cells inhibits opg production by osteoblasts thereby effectively promoting resorption of bone. during resorption, the elaboration of osteocalcin (which is decarboxylated in the acidic environment of active osteoclasts) stimulates the release of pancreatic insulin in a forwardfeed loop,34 increases tissue insulin sensitivity and promotes male fertility by stimulating testosterone synthesis by leydig cells.34 leptin, a hormone produced by adipocytes, binds to receptors in the sympathetic nervous system and suppresses serotonin production. this suspends the serotonin-associated inhibition of osteoblasts and promotes bone formation,35 providing a feasible explanation for the increased skeletal strength of obese individuals. fibroblast growth factor 23 (fgf23) released by bone cells and elaborated during bone resorption binds to klotho-fgf23r1 receptors in the renal tubules, induces phosphaturia and decreases vit d3 synthesis,36 thus regulating ca2+ and p homeostasis. conclusion recent revelations in the signalling pathways of bone remodelling propelled the functions of the skeleton from mechanical ambiguity to a key organ in systemic metabolism. a thorough understanding of the signalling pathways involved in bone remodelling is required in order to understand bone disease and master recent developments in the manipulation of bone health, which are discussed in part 2. the authors have no conflict of interest to declare, and received no direct funding for the writing of the article. references 1. parfitt a. morphological basis of bone mineral measurements: transient and steady effects of 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munoz j et al. fgf23 and mineral metabolism, implications in ckd-mbd. nefrologia 2012;32:275-78. 27. cantore fp, corrado a, grano m et al. osteocalcin synthesis by human osteoblasts from normal and osteoarthritic bone after vitamin d3 stimulation. clin rheumatol 2004;23:490-95. 28. sphinosine-1-phosphate-mediated osteoclast precursor monocyte migration is a critical point of control in antibone-resorptive action of active vitamin d. proc natl acad sci usa 2013;110:7009-13. 29. li m, thompson dd, paralkar vm. prostaglandin e2 receptors in bone formation. int orthop 2007;31:767-72. 30. zhang g, li j, purkayastha s et al. hypothalamic programming of systemic ageing involving ikk-[bgr], nf-[kgr]b and gnrh. nature 497;211-16. 31. zang x, tamasi j, lu x et al. epidermal growth factor plays a positive role in bone metabolism in vivo. j bone miner res 2011:26: 1022-34. 32. wookey pj. a review of calcitonin expression in embryonic, foetal and adult tissues, with a hypothesis on the connection between expression during foetal development and disease. open zool j 2009:2:53-61. 33. manolagas sc, o’brien ca, almeida m. the role of estrogen and androgen receptors in bone health and disease. nat rev endocrinol 2013;9:699-712. 34. hinoi e. the sympathetic tone mediates leptin’s inhibition of insulin secretion by modulating osteocalcin bioactivity. j cell biol 2008:183:1235-42. 35. lee nk, sowa h, hinoi e et al. endocrine regulation of energy metabolism by the skeleton. cell 2007;130:456-69. 36. kuro-o m. overview of the fgf23-klotho axis. pediatr nephrol 2010;25:583-90. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2015_press_orthopaedics vol3 no4 2015/10/27 9:56 pm page 21 south african orthopaedic journal orthopaedic oncology and infections doi 10.17159/2309-8309/2022/v21n3a5 koyejo tt et al. sa orthop j 2022;21(3) citation: koyejo tt, olusunmade oi, olufemi ot. epidemiology of primary bone tumours in nigeria: a systematic review. sa orthop j. 2022;21(3):167171. http://dx.doi.org/10.17159/23098309/2022/v21n3a5 editor: dr thomas hilton, university of cape town, cape town, south africa received: september 2021 accepted: december 2021 published: august 2022 copyright: © 2022 koyejo tt. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for the purposes of performing this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background primary bone tumours, although rare, are an important rising cause of morbidity and mortality in africa. late presentation, delayed diagnosis and failure to obtain consent for surgical procedures are important causes of loss of limb and life especially in the west african subregion. existing data on primary bone tumours in nigeria have been based on studies performed at various regional levels. the aim of this study is to determine the epidemiological pattern of primary bone tumours in nigeria in general, including demographics, predominant tumour types and predominant skeletal location by reviewing existing data. methods a search of the following databases: university of edinburgh library, pubmed, cinahl and scopus from 2000 till january 2021 following prisma guidelines was conducted to identify studies conducted in nigeria with relevant epidemiological data on primary bone tumours in nigeria. results the search yielded a total of 952 hits from which seven hospital-based retrospective studies met the inclusion criteria for review. the estimated incidence rate of primary bone tumours ranged from 0.08 to 0.31 per 100 000 population. all studies showed a male preponderance. the peak age group of individuals presenting with both benign and malignant primary bone tumours was 11–20 years. overall, benign tumours were more common. osteochondromas were the most common benign tumours, while the commonest malignant tumours identified were osteosarcomas. the most common location for both benign and malignant tumours were the tibia and fibula. conclusion nigeria shares some similar epidemiological characteristics of primary bone tumour with other countries; however, some peculiar differences have been identified in this study. populationbased studies are required to obtain more accurate epidemiological data about this disease. level of evidence: level 2 keywords: epidemiology, primary bone tumours, nigeria epidemiology of primary bone tumours in nigeria: a systematic review temitayo t koyejo,¹* opeyemi i olusunmade,² olukemi t olufemi³ ¹ department of orthopaedics and trauma, national orthopaedic hospital, igbobi, lagos, nigeria ² orthopaedic oncology unit, department of orthopaedics and trauma, national orthopaedic hospital, igbobi, lagos, nigeria ³ arthroplasty unit, department of orthopaedics and trauma, national orthopaedic hospital, igbobi, lagos, nigeria *corresponding author: tayokoyejo@gmail.com introduction the human bone consists of various cell types which are capable of proliferating and giving rise to an array of tumours.1 bone tumours mainly arise from somatic mutations; however, some risk factors have been implicated which include irradiation, chemotherapy, foreign bodies and pre-existing bone lesions.2 globally, bone sarcomas account for 0.2% of all malignancies with a five-year overall survival rate of 67.9%.3 the incidence of benign bone tumours is higher than primary malignant bone lesions which are usually asymptomatic and less likely to be clinically detected.3 in the united kingdom, around 560 new cases of bone sarcomas are diagnosed yearly.4 in italy, an average of 1.3 new malignant bone tumours are diagnosed per 100 000 males/ year and 1.1 per 100 000 females/year.3 the overall incidence rate for bone and joint malignancy in the united states is 0.9 per 100 000 persons per year.3 trinidad and tobago has an incidence of 1.125 per 100 000 population annually, while cameroon has an average incidence of 27 tumours a year, or two per one million inhabitants.5,6 nigeria has an estimated population of over 210 million people, making it the most populous country in africa and the sixth most populous in the world.7 patients with bone tumours in nigeria usually present late as a result of poverty, ignorance and cultural beliefs.8 in a study by dauda et al. at the jos university teaching hospital, nigeria, 13 cases of primary bone tumours were seen per year.2 obalum et al. saw an average of ten new cases per year at the lagos university teaching hospital, nigeria.9 primary bone tumours are classified according to their biological behaviour and form of differentiation. globally, non-ossifying fibroma is the most common benign tumour of the bone usually https://orcid.org/0000-0002-8976-8467 page 168 koyejo tt et al. sa orthop j 2022;21(3) found in the metaphyses of long bones, while osteosarcoma is the most common primary malignant tumour of bone with predilection for the metaphysis of long bones.10,11 osteochondroma was identified as the most common benign bone tumour, while osteosarcoma was shown to be the most common primary malignant bone tumour in the study by bahebeck et al. in cameroon, and this was also observed in the study by obalum et al. in lagos, nigeria.6,9 in the united kingdom, osteosarcomas affects individuals mainly within the age group 10–25 years, with males constituting a larger proportion.11 the major skeletal locations of the tumours are the distal femur and proximal tibia.11 a study conducted in ibadan, nigeria revealed osteosarcoma as the most common malignant primary bone tumour affecting predominantly individuals younger than 20 years and being more common in males.12 the major skeletal location of the tumours were the femur and mandible.12 the epidemiological patterns of bone tumours in nigeria in general has not been ascertained, as only retrospective hospital-based studies in different regions have been performed. the aim of this study was to determine the epidemiology of primary bone tumours in nigeria and compare the epidemiological patterns of primary bone tumours in nigeria to those in other parts of the world. materials and methods literature search and eligibility criteria a systematic review was conducted following the preferred reporting items for systematic reviews and meta-analyses (prisma), identifying nigerian studies conducted on primary bone tumours. the data for this study were obtained following an extensive literature search of the university of edinburgh library, pubmed, scopus and cinahl electronic databases and looking through the reference lists of articles identified for relevant articles not indexed in the databases. no language limits were applied to the search strategy. the following search terms were used to search all databases: epidemiology, incidence, prevalence, pattern, ‘primary bone tumours’, nigeria. the search was limited to studies published from january 2000. the limit ‘nonhuman’ was included in the search strategy to exclude all articles conducted in nonhumans. studies were included if they: 1) were conducted in nigeria between january 2000 to january 2021; 2) were studies on histologically confirmed primary bone tumours in all age groups and both sexes; 3) published data on demographic variables, tumour type and tumour location. studies were excluded if they: 1) were not conducted in nigeria; 2) were published prior to january 2000; 3) did not include histological confirmation of primary bone tumours; 4) were lacking data on demographic variables, tumour type and tumour location; 5) were not specific for primary bone tumours alone. data extraction two reviewers independently screened the publications to determine those to be included in the study based on the eligibility criteria. the process of study selection and extraction is presented in a prisma flow chart (figure 1).13 data was extracted by two reviewers independently including study design and year of publication, location of study, number of participants, demographic description, tumour type and tumour location. data analysis the main purpose of the systematic review was to critically appraise the available data to give a broad understanding of the epidemiology of primary bone tumours in nigeria. a quantitative synthesis of the results of the included studies (meta-analysis) was not conducted due to the retrospective nature of the studies which lacked sufficient data on key variables, but a narrative synthesis was performed. data extracted from the selected studies which met the eligibility criteria were analysed. individual assessment of key variables was performed. graphs and charts were drawn for illustration of key findings. inferences and conclusions were made based on findings from the selected studies. results description of studies seven hospital-based retrospective studies involving 773 cases of primary bone tumours were included in this systematic review.1,2,9,14-17 the studies were published between 2007 and 2018 involving four of the six geopolitical zones in nigeria. the characteristics of the studies are shown in table i. id en tif ic at io n s cr ee ni ng in cl ud ed el ig ib ili ty records identified through database searching (n = 952) records after duplicates removed (n = 756) studies included in systematic review (n = 7) records screened (n = 756) records excluded: 732 irrelevant to study aims and objective: 730 full text could not be obtained: 2 five articles were older than 20 years twelve articles were not specific for primary bone tumours full text articles assessed for eligibility (n = 24) figure 1. study selection and data extraction process table i: highlights of selected studies study no. author year of publication location total number of patients 1 abdulkareem et al.15 2007 lagos 77 2 mohammed & isa1 2007 kaduna 127 3 obalum et al.9 2009 lagos 242 4 lasebikan et al.16 2014 enugu 68 5 ugezu et al.17 2018 anambra 31 6 aina et al.14 2018 osun 100 7 dauda et al.2 2018 plateau 128 page 169koyejo tt et al. sa orthop j 2022;21(3) incidence of primary bone tumours the number of new cases of primary bone tumour per year varied widely across the institutions. lagos university teaching hospital (luth), with ten cases per year, had the lowest incidence rate of 0.08 per 100 000 population, while national orthopaedic hospital, igbobi (nohil), lagos, had the highest incidence with 15.4 cases per year, representing an incidence rate of 0.12 per 100 000 population.9,15 nnamdi azikiwe university teaching hospital (nauth), anambra, diagnosed 6.2 cases per year representing an incidence rate of 0.11 per 100 000 population (figure 2).17 sex distribution all studies showed a male preponderance. the lowest male:female ratio was obtained from the study at nauth, anambra, with a ratio of 1.1:1, while the highest ratio was from the study in nohil, lagos, with a ratio of 2:1.15,17 the male:female ratio of other studies included in this systematic review are shown in figure 3. age distribution in most of the studies, the peak age group of individuals presenting with both benign and malignant primary bone tumours was 11–20 years. however, the study by ugezu et al. in anambra revealed the peak age group of patients with primary bone tumours to be 21–30 years with a mean age of 38.8 ± 1.2 years.17 at oauthc, osun state, the peak age group for patients with benign tumours and tumour-like lesions was 21–30 years, while for malignant tumours was 11–20 years.14 tumour type overall, benign tumours were the most common, accounting for 79% of cases in nohi, lagos, and 64.8% of cases in juth, plateau.2,15 in studies performed at luth, lagos, and noh, enugu, benign tumours accounted for 53.7% and 41.2% of cases respectively.9,16 however, in the studies performed at osun, kaduna and anambra, malignant tumours were found to be more common than benign tumours accounting for 50%, 39.4% and 58.1% of cases respectively.1,14,17 among the benign tumours, osteochondroma was found to be the most common, accounting for 32.1%, 55.7% and 40.8% of cases in studies performed at osun, lagos (nohil) and kaduna respectively.1,14,15 in plateau, lagos (luth), enugu and anambra, osteochondroma accounted for 27.7%, 27.7%, 75% and 30.8% of benign bone tumours respectively.2,9,16,17 giant cell tumour was the next most common benign tumour, accounting for 17.9%, 29.5%,16.3% and 12% of cases in studies done in osun, lagos (nohil), kaduna and plateau respectively.1,2,14,15 in studies performed at lagos (luth), enugu and anambra, giant cell tumour represented 21.5%, 14.3% and 23.1% of cases respectively.9,16,17 osteosarcoma was identified as the most common malignant tumour responsible for 42%, 43.8%, 34% and 55.6% of cases in studies performed at osun, lagos (nohil), kaduna and plateau states.1,2,14,15 while in lagos (luth), enugu and anambra, osteosarcoma represented 58.9%, 81%% and 50% of cases respectively.9,16,17 chondrosarcoma was next most common malignant bone tumour responsible for 12%, 6.3%, 6% and 20% of cases in studies performed at osun, lagos (nohil), kaduna and plateau respectively.1,2,14,15 while in lagos (luth), enugu and anambra, chondrosarcoma represented 21.4%, 14.3% and 16.7% of cases respectively.9,16,17 for tumour-like lesions, fibrous dysplasia was the most common accounting for 36.3%, 92.8% and 57.8% of cases in studies performed at osun, kaduna and enugu states.1,14,17 tumour location the most common malignant tumour location from the studies available were the tibia and fibula, accounting for 47.6%, 26.7% and 2.2% of cases in studies performed in enugu, plateau and kaduna respectively.1,2,16 craniofacial bones accounted for 58.7%, 6.7% and 4.8% of cases in studies done in kaduna, plateau and enugu respectively.1,2,16 osteosarcoma, the most common malignant tumour, was found to occur more commonly in the tibia and fibula accounting for 52.9%, 36%, 28.6% and 5.9% of cases in enugu, plateau, osun and kaduna studies respectively.1,2,14,16 the femur accounted for 47.6%, 36%, 17.6% and 11.8% of cases in osun, plateau and enugu respectively.2,14,16 benign tumours were found mainly in the tibia and fibula responsible for 60.7%, 18% and 2% of cases in studies performed in enugu, plateau and kaduna.1,2,16 craniofacial bones accounted for 32.7%, 30.1% and 3.6% of cases in studies done in kaduna, plateau and enugu respectively.1,2,16 tumour-like lesions were found mostly in the craniofacial bones, accounting for 71.4% and 66.7% of cases in studies performed in kaduna and enugu respectively.1,16 among the benign bone tumours, osteochondroma was found mostly in the tibia accounting for 33.3%, 21.7%, 52.4% of cases in osun, plateau and enugu.2,14,16 the humerus was the next most common site, accounting for 26%, 14.3% and 10% of cases in plateau, enugu and kaduna studies respectively.1,2,16 fibrous dysplasia, the most common tumour-like lesion, was found mainly in the craniofacial bones in 73% and 63.6% of cases in kaduna and enugu studies respectively.1,16 incidence rate per 100 000 population incidence rate s ta te lagos (luth) anambra enugu plateau kaduna lagos (nohil) osun 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 figure 2: incidence of primary bone tumour hospital male female n um be r o f c as es 200 150 100 50 0 oauthc nohi abuth juth luth nohe nauth oauthc: obafemi awolowo teaching hospital complex, osun state nohil: national orthopaedic hospital, igbobi, lagos state abuth: ahmadu bello university teaching hospital, kaduna state juth: jos university teaching hospital, plateau state luth: lagos university teaching hospital, lagos state nohe: national orthopaedic hospital, enugu state nauth: nnamdi azikiwe university teaching hospital, anambra state figure 3. sex distribution page 170 koyejo tt et al. sa orthop j 2022;21(3) discussion the estimated annual incidence rate from this study ranged from 0.11 to 0.31 per 100 000 population. the variation in incidence may be due to the population difference across the states and patterns of health-seeking behaviour among the populace in that state.17 in cameroon, bahebeck et al. revealed an annual incidence of 27 tumours a year, while the study by negash et al. in ethiopia revealed an annual incidence of 41 tumours a year.6,18 in italy, the annual incidence rate for bone tumours is 1.3 per 100 000 per year for males, while females have an incidence rate of 1.1 per 100 000 per year.3 worldwide, the annual incidence rate of primary bone tumours is 0.9 per 100 000 persons per year.3 the figures obtained for the incidence rate for this systematic review are hospital based and may not reflect the true incidence in the population. patients with bone tumours in this environment may not seek medical attention due to ignorance about the disease, poverty, religious beliefs, patronage of traditional bone setters and fear of ablative surgery.19 the seven selected studies for the systematic review showed a male preponderance. a similar study by baena-ocampo et al. in mexico also showed a male preponderance, with males accounting for 54% and females 46% of cases with a male:female ratio of 1.16:1.20 deka and talukdar in india also revealed a male preponderance with a male to female ratio of 1.36:1, while ramdass et al. in trinidad and tobago showed a male:female ratio of 2:1.5,21 globally, the incidence of bone tumours is marginally higher in males than females, though no reason has been adduced.10 from this study, the adolescent age group was found to be most at risk of developing both benign and malignant primary bone tumours with a peak age incidence of 11–20 years. the peak age incidence for both benign and malignant bone tumours was 11–20 years in a study by deka and talukdar in india, which is similar to what was deduced by this study.21 the study by solooki et al. in shiraz, iran, revealed a peak frequency of malignant tumours in patients aged between 5 and 25 years while benign tumours were more commonly seen in those younger than 25 years.22 worldwide, primary malignant bone tumours have a bimodal distribution with the first peak occurring in the second decade of life and the second peak in patients over 60 years.23 however, the life expectancy of 60 years in nigeria may be responsible for the lack of bimodal distribution of bone tumours seen.7 the pubertal growth spurt that occurs in adolescence has been linked to the increased incidence of osteosarcoma seen in that age group.24 benign tumours were the most common among patients diagnosed with bone tumours in this study accounting for 41.2–79% of cases in four of the studies.2,9,15,16 a study by niu et al. in china also revealed a higher incidence of benign tumours, accounting for 58.7% of all cases in a hospital-based retrospective study.25 benign bone tumours were also found to be more common in a study by bahebeck et al. in cameroon accounting for 48.1% of cases. among the benign tumours, osteochondroma was found to be the commonest, followed by benign giant cell tumour.6 in a similar study in mexico by baena-ocampo et al., osteochondroma was the most common benign bone tumour representing 43.7% of cases, followed by benign giant cell tumour accounting for 14.6% of cases.20 a study in minnesota, united states of america, also revealed osteochondroma as the most common benign bone tumour followed by benign giant cell tumour.25 however, niu et al. showed benign giant cell tumour as the most common benign tumour followed by osteochondroma.25 three centres, namely oauthc, abuth and nauth, had a higher incidence of malignant bone tumours. this may be due to more patients presenting as a result of pain, swelling, restriction of limb movement and pathological fractures that occur more commonly in malignant bone tumours.26 osteosarcoma was identified as the most common malignant tumour, while chondrosarcoma was the next most common malignant tumour in this study. however, bahebeck et al. revealed osteosarcomas as the most common malignant tumour followed by non-hodgkin’s bone lymphoma, while ramdass et al. in trinidad and tobago also had osteosarcoma as the commonest malignant tumour, followed by fibrosarcoma and plasmacytoma.5,6 in the netherlands, osteosarcoma was identified as the most common malignant bone tumour, followed by chondrosarcoma from data derived from the netherland cancer registry.27 benign tumours were found mainly in the tibia and fibula, followed by craniofacial bones in this study. whereas the study by baenaocampo et al. revealed most benign tumours arose in the femur (37%) followed by the tibia (20%), similar to the results obtained by niu et al. in china, bahebeck et al. reported the tibia, followed by the femur and spine as the commonest location for benign primary bone tumours.6,20,25 the femur, tibia and bones of the hands were the most common location in the study by solooki et al.22 however, the skull and femur were identified as the commonest location for benign tumours by ramdass et al.5 the most common malignant tumour location from the studies available were the tibia and fibula followed by craniofacial bones. these figures are different from those reported by baenaocampo et al. in mexico which showed the femur (47.8%) as the commonest location for malignant bone tumours followed by the vertebrae (18%).20 niu et al., in their study in china, revealed the femur followed by the tibia and pelvis as the most common location for malignant primary bone tumours.25 bahebeck et al. in cameroon showed the tibia, followed by the femur and spine, as the commonest location for malignant primary bone tumours.6 the femur, humerus and tibia were the most common site for malignant tumours in the study by solooki et al. in iran.22 among the benign bone tumours, osteochondroma was found mostly in the tibia, followed by the humerus. in the united kingdom, the most common site for osteochondroma was the distal femur and proximal tibia, followed by the proximal humerus and proximal fibula.28 osteosarcoma, the most common malignant tumour, was found to occur mostly in the tibia and fibula, followed by the femur. however, this contrasts with the figures in the united kingdom where osteosarcoma is commonly found in the metaphyses of long bones, affecting the femur (40%, usually distal), tibia (20%), humerus (10%) and pelvis (8%).26 the study by pillay et al. in south africa showed that osteosarcoma involved the distal femur in 44.7% of cases, with the proximal tibia accounting for 34.2% of cases.29 the study was limited due to the hospital-based nature of the studies which may not reflect the true epidemiological nature of disease in the nigerian population. the studies used were retrospective studies and information obtained by individual studies may have been incomplete due to missing records, poor documentation and inaccurate data entry. conclusion nigeria shares some similar epidemiological characteristics of primary bone tumour with other countries; however, some peculiar differences have been identified in this study. population-based studies are required to obtain more accurate epidemiological data about this disease. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. this article does not contain any studies performed by any of the authors on human participants or animals. for this study, formal consent was not required. page 171koyejo tt et al. sa orthop j 2022;21(3) 22. solooki s, vosoughi ar, masoomi v. epidemiology of musculoskeletal tumors in shiraz, south of iran. indian j med paediatr oncol. 2011;32(4):187-91. https://doi. org/10.4103/0971-5851.95138 23. dorfman h, czerniak b, kotz r, et al. tumours of bone: introduction. who classification of tumours of soft tissue and bone. 2013. p. 226-32. 24. ottaviani g, jaffe n. the epidemiology of osteosarcoma. in: cancer treatment and research [internet]. kluwer academic publishers; 2009. p. 3-13. available from: http://www. ncbi.nlm.nih.gov/pubmed/20213383 accessed 22 march 2022. 25. niu x, xu h, inwards cy, et al. primary bone tumors: epidemiologic comparison of 9200 patients treated at beijing ji shui tan hospital, beijing, china, with 10 165 patients at mayo clinic, rochester, minnesota. arch pathol lab med. 2015;139(9):1149-55. https://doi. org/10.5858/arpa.2014-0432-oa 26. freeman ak, sumathi vp, jeys l. primary malignant tumours of the bone. surg (united kingdom). 2018;36(1):27-34. https://doi.org/10.1016/j.mpsur.2017.10.001 27. goedhart lm, ho vky, dijkstra spds, et al. bone sarcoma incidence in the netherlands. cancer epidemiol. 2019;60:31-38. https://doi.org/10.1016/j.canep.2019.03.002 28. perera jr, saifuddin a, pollock r. management of benign bone tumours. orthop trauma. 2017;31(3):151-60. https://doi.org/10.1016/j.mporth.2017.03.008 29. pillay y, ferreira n, marais l. primary malignant bone tumours: epidemiological data from an orthopaedic oncology unit in south africa. sa orthop j. 2016;15(4):12-16. http://dx.doi. org/10.17159/2309-8309/2016/v15n4a1 declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions ttk: study conceptualisation, data capture, data analysis, first draft preparation, manuscript preparation, manuscript revision oio: study design, data capture, data analysis, manuscript revision oto: study design, data analysis, manuscript revision orcid koyejo tt https://orcid.org/0000-0002-8976-8467 olusunmade oi https://orcid.org/0000-0002-2999-3638 olufemi ot https://orcid.org/0000-0002-9014-8142 references 1. mohammed a, isa ha. pattern of primary tumours and tumour-like lesions of bone in zaria northern nigeria: a review of 127 cases. west afr j med. 2007;26(1):37-41. https://doi. org/10.4314/wajm.v26i1.28301 2. dauda am, akpa po, barka kv, et al. primary bone tumours at a tertiary health centre in north central nigeria: a ten year retrospective review. asian j orthop res. 2018;1(december 2015):1-8. 3. franchi a. epidemiology and classification of bone tumors. clin cases miner bone metab. 2012;9(2):92-95. 4. bone sarcoma statistics | cancer research uk [internet]. available from: https://www. cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/ bone-sarcoma#heading-zero accessed 3 september 2019. 5. ramdass mj, 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trauma. boca raton: crc press taylor & francis group; 2018. 11. macduff e, reid r. bone tumour pathology. surgery [internet]. 2009;27(2):55-62. https://doi. org/10.1016/j.mpsur.2008.12.012 12. omololu ab, ogunbiyi jo, ogunlade so, et al. primary malignant bone tumour in a tropical african university teaching hospital. west afr j med. 2002;21(4):291-93. https://doi. org/10.4314/wajm.v21i4.28001 13. moher d, liberati a, tetzlaff j, altman dg. preferred reporting items for systematic reviews and meta-analyses: the prisma statement. ann intern med. 2009;151(4):264. https://doi. org/10.7326/0003-4819-151-4-200908180-00135 14. aina oj, adelusola ka, orimolade ae, akinmade a. histopathological pattern of primary bone tumours and tumour-like lesions in ile-ife, nigeria. pan afr med j. 2018;29:1-9. https:// doi.org/10.11604/pamj.2018.29.193.13111 15. abdulkareem fb, eyesan su, akinde or, et al. pathological study of bone tumours at the national orthopaedic hospital, lagos, nigeria. west afr j med. 2007;26(4):306-11. https:// doi.org/10.4314/wajm.v26i4.28332 16. lasebikan oa, nwadinigwe cu, onyegbule ec. pattern of bone tumours seen in a regional orthopaedic hospital in nigeria. niger j med. 2014;23(1):46-50. 17. ugezu ai, ofiaeli ro, ihegihu c, imo c. pattern of presentation of primary bone tumors in nnewi , south-east nigeria. orient j med. 2018;30:81-85. 18. negash be, admasie d, wamisho bl, tinsay mw. pattern of bone tumours seen at addis ababa university, ethiopia. east cent african j surg. 2009;14(2):25-32. available from: http://www.bioline.org.br/request?js09030 accessed 12 september 2019. 19. salawu o, babalola o, ibraheem g, et al. musculoskeletal tumors of the extremities: challenges and outcome of management in a nigeria tertiary hospital. african j med heal sci. 2018;17:20-25. 20. baena-ocampo l del c, ramirez-perez e, linares-gonzalez lm, delgado-chavez r. epidemiology of bone tumors in mexico city: retrospective clinicopathologic study of 566 patients at a referral institution. ann diagn pathol. 2009;13(1):16-21. https://doi. org/10.1016/j.anndiagpath.2008.07.005 21. deka mk, talukdar a. a retrospective analysis of bone tumors and tumor like lesions: a hospital based study of 76 cases. int j res med sci. 2017;5(11):4915. https://doi.org/10.4103/0971-5851.95138 https://doi.org/10.4103/0971-5851.95138 http://www.ncbi.nlm.nih.gov/pubmed/20213383 http://www.ncbi.nlm.nih.gov/pubmed/20213383 https://doi.org/10.5858/arpa.2014-0432-oa https://doi.org/10.5858/arpa.2014-0432-oa https://doi.org/10.1016/j.mpsur.2017.10.001 https://doi.org/10.1016/j.canep.2019.03.002 https://doi.org/10.1016/j.mporth.2017.03.008 http://dx.doi.org/10.17159/2309-8309/2016/v15n4a1 http://dx.doi.org/10.17159/2309-8309/2016/v15n4a1 https://orcid.org/0000-0002-8976-8467 https://orcid.org/0000-0002-2999-3638 https://orcid.org/0000-0002-9014-8142 https://doi.org/10.4314/wajm.v26i1.28301 https://doi.org/10.4314/wajm.v26i1.28301 https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bone-sarcoma#heading-zer https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bone-sarcoma#heading-zer https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/bone-sarcoma#heading-zer https://doi.org/10.1016/j.amsu.2015.10.009 https://doi.org/10.1016/j.amsu.2015.10.009 https://doi.org/10.1007/s00264-003-0480-7 https://doi.org/10.1007/s00264-003-0480-7 https://www.cia.gov/library/publications/the-world-factbook/geos/ni.html https://doi.org/10.1016/j.mpsur.2008.12.012 https://doi.org/10.1016/j.mpsur.2008.12.012 https://doi.org/10.7326/0003-4819-151-4-200908180-00135 https://doi.org/10.7326/0003-4819-151-4-200908180-00135 https://doi.org/10.11604/pamj.2018.29.193.13111 https://doi.org/10.11604/pamj.2018.29.193.13111 https://doi.org/10.4314/wajm.v26i4.28332 https://doi.org/10.4314/wajm.v26i4.28332 https://doi.org/10.1016/j.anndiagpath.2008.07.005 https://doi.org/10.1016/j.anndiagpath.2008.07.005 _hlk37884313 _hlk36275621 page 6 south african orthopaedic journal http://journal.saoa.org.za conferences, courses & symposia international january 2020 american association for hand surgery annual meeting lauderdale 2020 08 january 2020 – 11 january 2020 fort lauderdale, united states american society for reconstructive microsurgery annual meeting lauderdale 2020 10 january 2020 – 14 january 2020 fort lauderdale, united states 12th annual icjr winter hip and knee course 16 january 2020 – 19 january 2020 vail, united states 8th advanced course in knee surgery – val d’isere 2020 19 january 2020 – 23 january 2020 val d’isere, france canadian paediatric orthopaedic trauma course 23 january 2020 – 25 january 2020 whistler, canada dgooc spine course berlin 2020 23 january 2020 – 25 january 2020 berlin, germany february 2020 joint arthroplasty mountain meeting (jamm) presented by the hip society, the knee society and aaos 02 february 2020 – 05 february 2020 park city, utah, united states ors 2020 annual meeting 08 february 2020 – 11 february 2020 phoenix, united states paris shoulder symposium 2020 13 february 2020 – 15 february 2020 paris, france 34th german-austrian-swiss congress for sports traumatology & sports medicine orthopedic aspects in sports 14 february 2020 – 22 february 2020 seefeld in tyrol, austria the edinburgh hand course 2020 19 february 2020 edinburgh, united kingdom sports orthopedics on the knee 20 february 2020 – 22 february 2020 munich, germany 13th international conference on arthroplasty paris 2020 21 february 2020 – 22 february 2020 paris, france 21st annual aaos/aossm/aana sports medicine course keeping patients active through biologics, rehabilitation 23 february 2020 – 27 february 2020 park city, utah, united states page 4 south african orthopaedic journal http://journal.saoa.org.za conferences, courses & symposia sassh (sa society for surgery of the hand) refresher course 23-25 february 2018 pretoria 18th congress sa spine society 24-26 may 2018 elangeni hotel, durban 64th congress of the south african orthopaedic association 3-6 september 2018 csir, pretoria january 2018 2nd international consensus meeting on orthopaedic infections 25 january 2018 26 january 2018 philadelphia, united states focus on arthroplasty symposium: unicondylar knee replacement 26 january 2018 27 january 2018 frankfurt am main, germany 19th annual aaos/aana/aossm sports medicine course 31 january 2018 04 february 2018 park city, united states february 2018 bernese hip symposium 2018 01 february 2018 03 february 2018 bern, switzerland paris shoulder symposium 2018 01 february 2018 03 february 2018 paris, france scandinavian hand surgical dissection course 05 february 2018 06 february 2018 copenhagen, denmark endoprosthetics congress berlin 2018 22 february 2018 24 february 2018 berlin, germany march 2018 aaos 2018 annual meeting 06 march 2018 10 march 2018 new orleans, united states kiel arthroscopy course 2018 09 march 2018 10 march 2018 kiel, germany utrecht spine course: complex paediatric spine 09 march 2018 10 march 2018 utrecht, netherlands annual meeting of the orthopaedic research society – ors 2018 10 march 2018 13 march 2018 new orleans, united states 12th international congress of sports medicine society of greece / 12th hellenic-cypriot conference 16 march 2018 18 march 2018 thessaloniki, greece 12th international meeting of the austrian foot society 22 march 2018 24 march 2018 going am wilden kaiser, austria european pelvic course 2018 22 march 2018 24 march 2018 hamburg, germany local international 404 not found geurts j et al. sa orthop j 2018;17(2) doi 10.17159/2309-8309/2018/v17n2a7 south african orthopaedic journal http://journal.saoa.org.za orthopaedic oncology and infections citation: geurts j, vranken t, gabriels f, arts jj, moh p. contemporary treatment of chronic osteomyelitis: implementation in lowand middle-income countries. sa orthop j 2018;17(2):40–43. http://dx.doi.org/10.17159/2309-8309/2018/v17n2a7 editor: dr lc marais, university of kwazulu-natal received: july 2017 accepted: november 2017 published: may 2018 copyright: © 2018 geurts j, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: the following benefits have been received from a commercial party: bonalive® 1.0–2.0 mm granules, provided in kind by bonalive biomaterials ltd, turku, finland. conflict of interest: none to report. abstract aim: chronic osteomyelitis is still a difficult problem to treat in the developed world, but even more so in lowand middle-income countries. contemporary treatment options result in satisfying outcomes in a setting with abundant resources, but the question is whether these treatment options can be translated to other, less supported health care systems and if they obtain the same results. methods: eighteen patients with established chronic osteomyelitis (eight type iii, ten type iv) were prospectively enrolled and treated in a one-stage procedure with radical debridement and dead space management using bioactive glass s53p4 granules, together with adjuvant antibiotic therapy. results: thirteen patients were assessed at 24 months. infection control was achieved in five patients (38%). eight patients (61.5%) had persistence or recurrence of infection. loss to follow-up was substantial (five patients, 28%). conclusion: due to specific challenges treating chronic osteomyelitis in lowand middle-income countries, contemporary treatment options cannot be ‘copy-pasted’ with the same results in these settings. level of evidence: level 4 key words: osteomyelitis, bio-active glass, biomaterial, low and middle-income countries contemporary treatment of chronic osteomyelitis: implementation in lowand middle-income countries geurts j1, vranken t2, gabriels f3, arts jj4, moh p5 1 md; attending orthopaedic surgeon, department of orthopaedic surgery, caphri school of public health and primary care, maastricht university, maastricht, the netherlands 2 msc; medical student, department of orthopaedic surgery, caphri school of public health and primary care, maastricht university, maastricht, the netherlands 3 msc; department of orthopaedic surgery, caphri school of public health and primary care, maastricht university, maastricht, the netherlands; orthopaedic biomechanics group, department of biomedical engineering, eindhoven university of technology (tu/e), the netherlands 4 phd; department of orthopaedic surgery, caphri school of public health and primary care, maastricht university, maastricht, the netherlands; associate professor, orthopaedic biomechanics group, department of biomedical engineering, eindhoven university of technology (tu/e), the netherlands 5 md; attending orthopaedic surgeon, st john of god hospital, duayaw nkwanta, ghana corresponding author: dr j geurts, department of orthopaedics, maastricht university medical centre, po box 5800, 6202 az maastricht, the netherlands; tel +31-43-3875038; email: j.geurts@mumc.nl page 41geurts j et al. sa orthop j 2018;17(2) introduction chronic osteomyelitis is still a difficult problem to treat in the developed world, but even more so in developing, lowand middleincome countries (lmics). musculoskeletal infections in general can be the reason for hospital admission in as much as 14.5% of cases in these countries.1 contemporary treatment options, such as the use of bioactive glass in a one-stage setting, result in satisfying outcomes in a setting with abundant resources, but the question is whether these treatment options can be translated to other, less supported health care systems and if they obtain the same results. specific challenges come particularly with the treatment of chronic osteomyelitis in the setting of lowand middle-income countries: lack of good diagnostic tools (imaging as well as microbiology), availability of proper antibiotics and the possibility of administering these intravenously and for the proper length of time, conditions of surgery and adequate follow-up possibilities.2 this often results in misdiagnosis and/or under-treatment.3 treatment often requires long hospitalisation which can lead to financial problems for the affected patients and their families as well as the health care system of the country concerned. recurrence rates in the most ideal conditions can still be around 30%, but are of unknown magnitude in lmics.4 the aim of this study was to evaluate if a favourable outcome could be obtained using a treatment protocol from a european dedicated infection unit (maastricht university medical centre, the netherlands) in a setting with much fewer resources. patients and methods a series of 18 consecutive patients with chronic osteomyelitis was treated in ghana over a two-week period in march 2014. this occurred in a 150-bed district hospital which serves as a local referral centre for orthopaedic surgery. x-ray and ultrasound services are also provided. all patients were diagnosed with chronic osteomyelitis, half of which were post-traumatic in origin. the group included 15 men and three women. the average age was 26 years (range 10–70 years). only patients with implant-associated osteomyelitis and spinal infections were excluded. data was collected on demographics, comorbidities, clinical features and diagnostic tests, after consent by the individual patient and with the agreement of the hospital’s ethical committee. grading according to cierny-mader, which describes the bone involvement as well as the host status, was done at the time of surgery.5 all patients had pre-operative x-rays of the affected limb. these were made with a classic x-ray machine (philips, eindhoven, the netherlands), producing hard-copy images (figure 1). at followup in 2016, the hospital had acquired a modern digital system (digimedx, medex loncin sa, liège, belgium). all patients were operated by the two senior authors (jg & pm). surgical debridement consisted of thorough bony debridement with removal of all known sequestrae, saucerisation of the hypertrophic cortex until punctate bleeding was observed (paprika sign), lavage with at least 3 l of ringers lactate, curettage of all fistula and removal of abscessed soft tissue. finally, bony defects were filled with bioactive glass granules (bonalive® 1.0–2.0 mm granules, bonalive biomaterials ltd, turku, finland) in order to obliterate the dead space. all wounds were closed primarily without need for plastic surgery involvement. fistulae were curetted but never closed primarily. during surgery, deep tissue cultures were taken using the standard surgical sampling technique (oxford protocol: separate instruments for each sample, no-touch technique, minimum of three samples, no suction until samples are taken)6-8 and iv amoxicillin-clavulanic acid started and adjusted to the result of the cultures when they became available. patients received antibiotics for a total time of two weeks. description of the treatment above is identical to our local dutch protocol, except for the fact that patients receive a total of six weeks of antibiotics. this was, however, not possible due to the restricted financial resources of patients. after discharge, patients were reviewed at regular intervals and at one and two years post-operatively. the last outpatient review was done in march 2016. results nineteen osteomyelitic locations were operated in 18 patients (one patient with humeral and femoral osteomyelitis). localisation was tibia in ten cases, femur in seven, humerus in two. according to the cierny-mader classification, eight were type iii (localised) and ten type iv (diffuse). hosts were ten grade a and eight grade b. there were no exclusion criteria. five patients were sickle-cell positive. average preoperative sedimentation rate was 58 mm/h (range 9–100 mm/h), and average leucocyte count 7 028/ mm3 (range 5 400– 10 000/mm3). the volume of the bony defect, filled with bioactive glass granules, was 48 cc on average (range 10–100 cc). tissue cultures revealed s. aureus in six cases, proteus species in six, s. epidermidis in two, pseudomonas in one, enterobacter in one, and no organism was cultured in two (table i). unfortunately, we were not able to get antibiotic sensitivities in all cases, but the majority in which we did, did not show multi-resistant patterns. at one-year follow-up, only seven patients (38%) were able to be assessed in person at the outpatient clinic. of the other 11, four were able to be contacted by mobile phone. all but one were infectionfree at that time (55%). the other seven were lost to follow-up. figure 2 shows a one-year post-operative image of a defect filled with bioactive glass granules. extra effort was made to see all patients back at the two-year follow-up in march 2016 by reaching out to them in different ways (telephone, mail, community hospitals); we were able to get 13 patients (72%) back to the clinic and five were lost to follow-up (could not even be contacted by phone). recurrence (fistula at other than the operated site, but in the same bone) or persistence of infection occurred in eight of those 13 (61.5%). five were still infection-free after two years (38%). figure 1. radiograph of a diffuse tibial osteomyelitis. note the suboptimal quality, making the identification of sequestrae very difficult. table i: cultured micro-organisms in cohort of 18 patients micro-organism n (%) staphylococcus aureus 6 (33%) proteus mirabilis 6 (33%) staphylococcus epidermidis 2 (11%) pseudomonas aeruginosa 1 (5%) enterobacter 1 (5%) no growth 2 (11%) page 42 geurts j et al. sa orthop j 2018;17(2) discussion lowand middle-income countries have a high burden of chronic osteomyelitis patients.9-11 often it is the continuation of an acute osteomyelitis in childhood, or the result of open trauma. predisposing factors are diabetes, sickle cell anaemia and vascular disease.4,12 as the affected population is young, hospitalisation is long and lower limbs are the preferred location, chronic osteomyelitis has an important socio-economic impact on the patient and their family. depending on the state of the health system in these countries, patients often have to pay for the surgery and the medication themselves. this puts an enormous strain on the patient and his or her family and often results in suboptimal treatment (for instance, antibiotic treatment that is not prolonged beyond a couple of days).13,14 it is also an important reason why many patients don’t seek appropriate medical attention. standard surgical treatment includes thorough debridement of all devitalised bone and soft tissue, removal of sequestrae, saucerisation and dead space management. if structural integrity is compromised, the affected limb must be stabilised either externally (external fixation or traction) or with plaster of paris splinting. plain radiographs are of no value in the acute stage of osteomyelitis, but do give information about the extent and presence of sequestrae in later stages. ct scans are superior for identifying sequestrae and mri for soft tissue involvement, bone marrow abnormalities and evaluation of the extent of the disease.15,16 the latter two are more often than not unavailable in the majority of rural and community hospitals in lmics, thereby complicating work-up before surgery. although we attempted to treat these patients in a similar way to how we would in developed countries (by following our own institutional protocol for surgery, microbiology and adjuvant antibiotic therapy), we had significantly more relapses or unsuccessful treatments. several reasons were identified for why this happened. first, low-quality x-rays, often underor overexposed, hard-copy films, made accurate pre-operative diagnostic work-up very difficult (evaluation of the extent of the osteomyelitis and the presence of sequestrae) (figure 1). at the one-year follow-up, the hospital had acquired a digital pacs system which improved the quality of the x-rays significantly. in almost all of the relapsed cases, we located other sequestrae, not seen on initial x-rays, that were not removed at the time of initial surgical debridement. this, in itself, was in our opinion one of the main causes of recurrence. luckily, more and more hospitals are getting access to better imaging, which will undoubtedly improve diagnostic accuracy, although in some developing countries more than half of all rural hospitals still lack basic imaging services.17 scarcity of radiologists and trained medical imaging technologists adds to this problem.18 secondly, a lot of these patients have very longstanding chronic osteomyelitis, due to delayed presentation (the result of lack of transportation but also lack of insight by the patient), treatment by self-proclaimed traditional medicine men and the natural course of chronic osteomyelitis with periods of relative quiescence.19-21 this results in enormous cortical hypertrophy and as a consequence in the presence of intracortical abscesses.22,23 saucerisation was done very aggressively, but likely resulted in several of these intracortical abscesses not being removed, again resulting in incomplete eradication of the bony infection. all patients in our study were either cierny grade iii or iv, reflecting the extent and severity of the osteomyelitis. the average size of the bony defect (and thus dead space) to be filled is also significantly higher than what is commonplace in the western world (authors’ own experience). thirdly, access to microbiology is key in adequate antibiotic treatment. we were able to take culture specimens of all patients, but this is not possible in many rural hospitals with limited resources. this can result in inadequate adjuvant antibiotic therapy and persistence of the infection, but also the induction of antibiotic resistance over time.24,25 also, the duration of the course of antibiotics is generally recommended to be six weeks 26,27 which is often impossible in lmics due to financial restraints, thereby also compromising a favourable outcome.27 being financially compromised also influences the possibility of using (often expensive) state-of-the-art biomaterials. in our study, patients received two weeks of antibiotics; longer would have been preferred, but at the time, there was no remuneration scheme in the country, so people had to pay upfront for their own medication, which resulted in patients lacking the required antibiotics. finally, follow-up is very difficult in lmics because patients often have to travel long distances and do not come back to the clinic for review, unless some financial or other incentives can be offered to them. if not, some are forced to live with their persisting infection due to poverty, get treated in another hospital, migrate or die. this makes management of postoperative complications and monitoring of medication compliance almost impossible.20,28 often, people can be tracked by phone, but this is often insufficient to assess and monitor the clinical course of the treatment. also, the high rates of loss to follow-up have the perverse effect that a lot of well-performed studies in these countries will not be published in high level journals. other contemporary methods of treating chronic osteomyelitis in a one-stage setting have been described, such as resorbable calcium sulphate pellets loaded with tobramycin (osteoset®-t, wright medical technology, memphis, tennessee, usa). humm et al. report one recurrence (5%) of infection in a series of 21 patients with an average follow up of 1.3 years.29 ferguson et al. describe a larger series of 193 patients, followed up for a mean of 3.7 years, with 18 patients suffering from recurrence (9%).30 most authors describe wound leakage issues with this biomaterial. unfortunately, no such studies performed in the setting of low-and middle-income countries could be identified. the same applies for the gentamicin-loaded calcium-sulphate/hydroxyapatite bio-composite known as cerament g (bonesupport, lund, sweden). very good results were reported by mcnally et al., with a recurrence rate of only 4% at a mean followfigure 2. post-operative (1 y) image showing tibial defect filled with bioactive glass granules. granules in the soft tissues dissolve over time. also note improved quality of the pacs image. page 43geurts j et al. sa orthop j 2018;17(2) up of 19.5 months, in a setting of one of the top referral centres for osteomyelitis in europe.31 the manufacturer reported on a series of patients treated in the butare university teaching hospital in rwanda in 2013 with this biomaterial in a press release, but no publication on the follow-up was ever published. finally, herafill g, gentamicinloaded calcium sulphate pellets (heraeus medical, werheim, germany) have been reported to be used in a one-stage setting in nigeria by bafor et al.32 in their study, 15 patients were treated (46.7% type iii, 13.3% type iv) resulting in infection eradication in 66.7% with a mean follow-up of 14.7 months (8–26 months). in this study, no microbiology was performed and no adjuvant antibiotic therapy administered. limitations of this study are the high number of patients lost to follow-up, limited and often suboptimal adjuvant antibiotic treatment, and the absence of a control group. we aim to repeat this study in the future as a randomised control trial with adequate follow-up. conclusion in this paper we conclude that it is currently very difficult to implement state-of-the-art strategies for treating chronic osteomyelitis with modern biomaterials in a setting with often insufficient resources and expect the same outcome. there are a lot of conditions that have to be met, like proper imaging, access to microbiology, availability of adequate antibiotics and follow-up. the concept of treating osteomyelitis in a one-stage setting with modern biomaterials is, however, very attractive in these settings and further research should focus on optimising the implementation thereof, decreasing the need for antibiotic administration and reducing costs in order to offer these treatments to many more patients. ethics statement before the commencement of this study, consent was obtained from the individual patients, and with the agreement of the hospital’s ethical committee. references 1. bickler sw, sanno-duanda b. epidemiology of paediatric surgical admissions to a government referral hospital in the gambia. bulletin of the world health organization. 2000;78(11):1330-6. 2. ozgediz d, riviello r. the ‘other’ neglected diseases in global public health: surgical conditions in sub-saharan africa. plos medicine. 2008;5(6):e121. 3. museru lm, mcharo cn. 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21. ciampolini j, harding kg. pathophysiology of chronic bacterial osteomyelitis. why do antibiotics fail so often? postgraduate medical journal. 2000;76(898):479-83. 22. scott ml, robert el, catherine np. cortical lesions of the tibia: characteristic appearances at conventional radiography. radiographics. 2003;23(1):157-77. 23. gold rh, hawkins ra, katz rd. bacterial osteomyelitis: findings on plain radiography, ct, mr, and scintigraphy. american journal of roentgenology. 1991 2017;157(2):365-70. 24. van boeckel tp, gandra s, ashok a, caudron q, grenfell bt, levin sa, et al. global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data. the lancet infectious diseases. 2017;14(8):742-50. 25. ashley ea, lubell y, white nj, turner p. antimicrobial susceptibility of bacterial isolates from community acquired infections in sub-saharan africa and asian low and middle income countries. tropical medicine & international health. 2011;16(9):1167-79. 26. calhoun jh, manring mm. adult osteomyelitis. infectious disease clinics. 2005;19(4):765-86. 27. lazzarini l, lipsky ba, mader jt. antibiotic treatment of osteomyelitis: what have we learned from 30 years of clinical trials? international journal of infectious diseases. 2005;9(3):127-38. 28. ologunde r, rufai sr. surgical follow-up in low-income and middleincome countries. the lancet global health. 2013;1(3):e132. 29. humm g, noor s, bridgeman p, david m, bose d. adjuvant treatment of chronic osteomyelitis of the tibia following exogenous trauma using osteoset®-t: a review of 21 patients in a regional trauma centre. strategies in trauma and limb reconstruction. 2014;9(3):157-61. 30. ferguson jy, dudareva m, riley nd, stubbs d, atkins bl, mcnally ma. the use of a biodegradable antibiotic-loaded calcium sulphate carrier containing tobramycin for the treatment of chronic osteomyelitis. bone joint j. 2014;96(6):829-36. 31. mcnally ma, ferguson jy, lau ack, diefenbeck m, scarborough m, ramsden aj, et al. single-stage treatment of chronic osteomyelitis with a new absorbable, gentamicin-loaded, calcium sulphate/hydroxyapatite biocomposite. bone joint j. 2016;98(9):1289-96. 32. bafor a, akpojevwe e. one stage treatment of chronic osteomyelitis using antibiotic impregnated bone graft substitute: a preliminary report. annals of biomedical sciences. 2017;16(1):1-9. south african orthopaedic journal paediatric orthopaedics doi 10.17159/2309-8309/2022/v21n4a1phala mp et al. sa orthop j 2022;21(4) citation: phala mp, rachuene pa, socutshana b, bila ks. access gaterelated lower limb fractures in children and adolescents: a review of injury patterns and evaluation of associated injuries. sa orthop j. 2022;21(4):198201. http://dx.doi.org/10.17159/23098309/2022/v21n4a1 editor: dr jacques du toit, stellenbosch university, cape town, south africa received: april 2022 accepted: august 2022 published: november 2022 copyright: © 2022 phala mp. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background lower limb fractures occurring in and around the home environment and caused by collapsing access gates present frequently to our emergency unit. there is currently limited literature evaluating injuries resulting from access gate accidents. the aim of this study was to evaluate the patterns of lower limb fractures, management options offered and concomitant injuries in children as well as adolescents presenting with access gate-related lower limb traumas. methods a retrospective cross-sectional review of 43 children with 46 lower limb fractures was conducted between 1 january 2017 and 31 december 2020. hospital records and radiology archives of all children and adolescents under 12 years of age (24 males and 8 females) with lower limb fractures sustained following an access gate injury were reviewed and included for analysis. data was analysed descriptively using sas (sas institute inc, carey, nc, usa), release 9.4. results the prevalence of access gate-related injuries for all lower limb fractures in children and adolescents treated during the four-year period was 11%. the findings revealed that femur fractures are more common, accounting for 50.0% of the cases. the majority of cases were of patients younger than 6 years (71.9%), and predominantly affecting males (3:1). the fractures occurred in a home environment and were commonly related to non-motorised gates, in 93.8% of cases. the oblique fracture patterns comprised 40.6% of the fractures, and 68.8% of the fractures were located in the diaphysis. open fractures constituted 50.0% of the tibia fractures. mild head injuries associated with lower limb fractures were observed in 12.5% of the cases. conclusion the results demonstrated the prevalence of lower limb fractures above all injuries related to access gates. the majority of the injuries observed in this study occurred in manually operated gates, and commonly affected younger patients. in light of these findings, further studies are required into the reasons for these injuries and preventative measures. level of evidence: level 4 keywords: access gate, lower limb fractures, children, adolescents access gate-related lower limb fractures in children and adolescents: a review of injury patterns and evaluation of associated injuries mashupse p phala,¹ pududu a rachuene,²* bongani socutshana,¹ khetani s bila³ ¹ department of orthopaedics, sefako makgatho health sciences university, dr george mukhari academic hospital, pretoria, south africa ² department of orthopaedics, shoulder and elbow unit, sefako makgatho health sciences university, dr george mukhari academic hospital, pretoria, south africa ³ department of orthopaedics, paediatric orthopaedic unit, sefako makgatho health sciences university, dr george mukhari academic hospital, pretoria, south africa *corresponding author: archie.pududu@gmail.com introduction fenced yards and access gates are a common security feature in most homes in middleto low-income countries, due to high levels of crime and house break-ins (figure 1). it is the norm to find this kind of security measure in suburban and rural homes in these countries. the gates in these societies are often automatically operated (motorised) or manually operated (non-motorised). the accidental derailment and collapse of these gates may result in injuries during the operation (closing or opening) or climbing of the gate. numerous injury mechanisms are described in childhood fractures which can occur at home or the surrounding environment. figure 1. an example of a non-motorised sliding access gate in a semisuburban home https://orcid.org/0000-0002-8013-8290 https://orcid.org/0000-0003-4045-5301 page 199phala mp et al. sa orthop j 2022;21(4) the majority of these injuries occur at home. these include falls, non-accidental injuries (nai) and crush injuries resulting from falling objects.1,2 injuries related to access gates are not extensively reported in literature. studies have shown that children and adolescents from deprived socio-economic areas have a three to eight times higher risk of sustaining femur fractures compared to those in well-off areas.3,4 falling objects are reported to be responsible for about 10% of paediatric femur fractures.2,4 mughal et al. found that the median age of patients struck by falling objects was 4.8 years.4 the fracture patterns observed in the study are often related to the causative injury mechanism and have an impact on the treatment modality and outcomes of the fracture. this study was conducted to assess the prevalence of lower limb fractures, demographic distribution, fracture and injury patterns, and concomitant injuries in these population groups after observing a high number of cases presenting with access gate-related lower limb injuries. we believe that this research is critical in informing the public and clinicians about the dangers of access gates. methods this study is a retrospective review of the hospital records of 403 paediatric and adolescent patients with lower limb fractures treated at our unit during the four-year period 1 january 2017 to 31 december 2020, with the objective to identify those with access gate-related lower limb fractures. forty-three patients with lower limb fractures following access gate accidents from this cohort were identified. we included all children and adolescents (aged 12 years and below) with lower limb fractures sustained following an access gate accident or any other incident. patients with incomplete records were excluded (n = 11) from the final analysis. incomplete records included lost radiological images and clinical notes. the data collected from the clinical records and radiology archives included demographic characteristics (age, sex and geographical location of residence), mechanisms of injury, diagnosis, site of fracture, anatomical location (diaphyseal, epiphyseal or metaphyseal), descriptive fracture patterns (transverse, oblique, spiral or comminuted), concomitant injuries, methods of treatment and complications (figures 2 and 3). the accounts on mechanisms of injury were recorded in the clinical notes of these patients. the picture archiving and communication system (pacs, carestream health vue motion inc 2022) was used to retrieve and evaluate the x-ray images of all the participants. this evaluation was conducted by a single observer on one occasion and the patients had a minimum of three months follow-up. the patients were also assessed for clinical and radiological complications related to the treatment methods used to treat their injuries. a complication was defined as a worsening of the patient’s outcome on clinical and radiological evaluation or intervention-related adverse events following the intervention. the anatomical axis of the affected bone was measured on two-view x-rays using computer software, and shortening was determined by the degree of fracture ends overlap. this was further correlated with findings recorded in the clinical notes. the potential for bone remodelling and catch-up growth were not evaluated because they were outside the scope of this study. the accounts of the depth of infection were taken from the clinical notes due to the retrospective nature of the study, and the treating surgeons’ criteria were not specified. the data collected were compiled in a microsoft excel spreadsheet for analysis. demographic and clinical characteristics of the patients were summarised descriptively. continuous variables (e.g., age) were summarised by mean (± standard deviation [sd]), and/or median (interquartile range [iqr]) with the minimum and maximum values. categorical variables (e.g., sex, mechanism of injury, fracture patterns, fracture site, head injuries, etc.) were summarised by frequency counts and percentage calculations. statistical tests were two-sided and p-values ≤ 0.05 were considered significant. all the statistical procedures were performed on sas (sas institute inc, carey, nc, usa), release 9.4 or higher, running on microsoft windows for a personal computer. the study sample consisted of patients from predominantly lowincome communities. the collation and transcription of medical information and x-ray results from medical records to the data collection form was carried out by the researcher. collected data was stored in a secured database and anonymised data prepared for final analysis. results demographic distribution and mechanisms of injury the lower limb fractures related to access gate accidents accounted for 11.0% (n = 43) of all lower limb fractures in children and adolescents admitted during the study period. the male proportion of patients with lower limb fractures was higher than the female proportion at a ratio of 3:1. the median age of the cohort was 4.5 years (iqr 3–8 years). the youngest and the oldest patients were 1 year and 12 years respectively. children were categorised into two age groups of 0–6 and 7–12 years for description purposes. seventy-two per cent of the patients in this study were aged between 0 and 6 years of age. the gate falling on the child was a predominant mechanism of injury and occurred in 93.8% of the study sample. only 6.3% of the entire whole cohort reported being knocked by the gate (table i). manually operated gates accounted for the majority of the injuries (table ii). 18 16 14 12 10 8 6 4 2 0 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% [1, 4, 4] [7, 8, 11, 12] [4, 4, 7, 8] [11, 2, 14, 6] figure 2. the baseline age distribution of patients with access gaterelated lower limb fractures oblique spiral transverse comminuted oblique & spiral 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 40.6% 25.0% 15.6% 15.6% 3.1% figure 3. a baseline distribution of fracture patterns in patients with access gate-related lower limb fractures page 200 phala mp et al. sa orthop j 2022;21(4) fracture patterns and distribution femur fractures were the most commonly observed injuries (50%), followed by tibia/fibula (12.5%) and ankle fractures respectively (9.4%) (table iii). open fractures mostly involved the tibia/fibula whereas all the ankle fractures involved the physis. table iv indicates that the fractures of the diaphyseal segment was significantly more common (68.8%) than other bone segments. the involvement of both the metaphysis and diaphysis was found in a setting of a single patient with two fractures. all physeal fractures involved the ankle and were type ii salter–harris fractures. the majority of the fractures had an oblique fracture pattern, 40.6% (n = 13), followed by a spiral fracture pattern at 25.0% (n = 8). the prevalence of transverse and comminuted fracture patterns was the same at 15.6% (n = 5). mild head injury was the only associated injury found in this study. femur fractures were present in 75% (n = 3), while tibia/fibula fractures were present in 25% (n = 1) of the study participants with head injuries. interventions and complications surgical treatment was offered to 93.8% (n = 30) of the patients. the titanium elastic nail system (tens) was the most common treatment method used in 53% (n = 17) of the patients with length unstable diaphyseal femur fractures, followed by close reduction (c/r) and plaster of paris (pop) in 22% (n = 7). cerclage wire was used as an adjunct in one case whereas the k-wires were used in the treatment of metatarsal fractures of the foot. the non-surgical treatment in the form of skin traction was offered to only 6.3% (n = 2). the study shows a complication rate of 12.5%. the types of complications encountered were shortening, implant migration plus shortening and infection. these were seen in length unstable and open fractures respectively. discussion lower limb fractures are less common than those affecting the upper limb in children and adolescents. this is related to the prevalence of mechanisms of injury in these population groups, with falls being the most common and sports-related injuries noted in adolescence.3,4 among those with lower limb fractures, femur fractures are reported to be the commonest. access gate-related injuries are commonly observed in our setting, accounting for 11% of all lower limb injuries in children and adolescents treated at our unit. these are commonly associated with non-motorised, manually operated gates (94%). while this remains under-reported in the literature, similar observations have been reported by some authors with similar injury mechanisms. cheng et al. reported an annual rate of 1 794 baby gate-related injuries in children aged < 2 years between the years 1990 and 2010.5 sex distribution in our study was similar to those reported in the literature with a male-to-female ratio of 3:1.4,6,7 comparable to other studies, boys were more likely to sustain femoral fractures.8,9 the behavioural difference related to the sex of the child is thought to explain the male predominance, with high-risk playing activities being more common in boys than in girls.8,10,11 the majority (72%) of the children in our cohort were younger, aged between 0 and 6 years of age. this is consistent with findings by mughal et al., who found that the median age of patients struck by falling objects was 4.8 years.4 however, other researchers reported bimodal age distribution.2 in addition to the increased mobility in younger children, their femurs have decreased cortical thickness due to a higher ratio of woven bone compared to lamellar bone, which explains why a low-energy mechanism can easily result in femur fracture.12 additionally, toddlers have not yet fully developed their physical capabilities, and outpace judgment skills and protective reflexes.11 the majority of the fractures in this study occurred in a home or neighbourhood environment, similar to published literature.2,13 we posit this is due to inadequate supervision of these children at home or lack of safe playing areas, such as public parks, in these poor communities. ng’ang’a et al. noted that most children from low-income households are looked after by older siblings or unqualified nannies as parents go to work.2 fracture distribution in this study involved the femur more commonly (n = 16), followed by tibia/fibula fractures at 18.8% (n = 6). the diaphyseal segment of the bone is more commonly affected, representing 68.8% (n = 22) of cases, and aligning with the literature.2,4 lower limb fractures in these age groups often follow a torsional force resulting in an oblique or a spiral table iii: distribution of the fractures in patients with access gaterelated injuries fractures frequency per cent cumulative frequency cumulative per cent femur 16 50.0 16 50.0 tibia and fibula (open) 4 12.5 20 62.5 ankle (physeal injury) 3 9.4 23 71.9 open metatarsal 2 6.2 25 78.1 tibia and fibula (closed) 2 6.2 27 84.4 femur and ankle 1 3.1 28 87.5 femur and tibia (open) 1 3.1 29 90.6 femur and metatarsal 1 3.1 30 93.8 tibia 1 3.1 31 96.9 traumatic amputation toe 1 3.1 32 100.0 table iv: anatomical distribution of the fractures in patients with access gate-related lower limb fractures fracture location frequency per cent cumulative frequency cumulative per cent diaphysis 22 68.8 22 68.8 metaphysis 5 15.6 27 84.4 physis 4 12.5 31 96.9 diaphysis and metaphysis 1 3.1 32 100.0 table i: frequency of the injury mechanisms in patients with access gate-related lower limb fractures mechanisms of injury frequency per cent cumulative frequency cumulative per cent gate fell on child 30 93.8 30 93.8 knocked by the gate 2 6.3 32 100.00 table ii: relationship between gate operational mechanisms and risk of injury type frequency per cent cumulative frequency cumulative per cent motorised 30 93.8 30 93.8 non-motorised 2 6.3 32 100.0 page 201phala mp et al. sa orthop j 2022;21(4) fracture pattern.3,14 this has a bearing on the choice of fracture treatment, despite the most common injury mechanism being a direct force from the falling gate. similar fracture patterns were, however, commonly observed in this study. hedström et al. and ng’ang’a et al. respectively found that 14.8% and 12% of fractures in children involved the growth plate.2,15 this is comparable to the 12.5% (n = 4) that was observed in our study. these were all type ii salter–harris ankle fractures. open fractures were observed in 50% (n = 4) of the tibia fractures. this is comparable to the observations of the other authors.15,16 in their review of the 37 673 cases of access gate-related injuries, cheng et al. found head injuries to be the commonest presenting injury following gate-related events.5 we observed head injury in 12.5% (n = 4) of the study population. these observations did not vary significantly from the usual patterns of associated injuries reported in paediatric and adolescent lower fractures. however, a high association of abdominal injury followed by closed head injury is often reported.17-19 our findings are consistent with those of a local study by setati et al., reported in their unpublished master of medicine in orthopaedics dissertation. setati and colleagues found that access gates were the cause of accidental head injury in 9.3% of children.20 surgical treatment was offered in 93.8% (n = 30) of patients, mostly with length unstable fractures. a quarter of the patients who underwent surgery had minor complications not requiring further surgery. this study has several limitations. because of the retrospective design, we had to rely on hospital records to collect data. therefore, this is subject to recording error. we also acknowledge that a significant number of patients (25.6%) qualifying for inclusion criteria were excluded from this study due to incomplete records. this may have an impact on the results. furthermore, because these incidents included children and toddlers, the mechanisms of injury narratives were gathered through the narration of parents or caregivers who would not have been present when the injury occurred, making it prone to reporting and interpretation problems. this study was conducted in a single centre and it involves a small sample group, thus affecting the validity of our results. furthermore, we did not investigate whether the injuries were caused by sliding or swinging gates. it is, however, important to note that the results of this study potentially highlight a public health hazard posed by the access gates. conclusion access gate-related lower limb fractures are less commonly observed compared to other injury mechanisms in children and adolescents. however, they are still commonly seen in our setting. most of these fractures are isolated diaphyseal length unstable injuries, commonly affecting younger children. manually operated gates are likely to result in lower limb fractures compared to motorised gates. the use of motorised gates and appropriate child supervision at home may reduce the chance of these injuries. acknowledgement we would like to acknowledge and thank dr gezani freeman mabasa for his involvement in the early phases of this project. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, ethics approval was obtained from the postgraduate studies, research development, integrity & ethics sefako makgatho research ethics committee: smurec/m/53/2021: pg. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. informed written consent was not obtained from the participants due to the retrospective nature of this study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions mpp: study conceptualisation, manuscript review, revisions and production of final manuscript par: literature review, data collection and compilation of first draft, manuscript review, revisions and production of final manuscript bs: literature review, data collection and compilation of first draft, manuscript review, revisions and production of final manuscript ksb: study conceptualisation, manuscript review, revisions and production of final manuscript orcid phala mp https://orcid.org/0000-0002-8013-8290 rachuene pa https://orcid.org/0000-0003-4045-5301 socutshana b https://orcid.org/0000-0003-2845-5122 bila ks https://orcid.org/0000-0001-7130-7307 references 1. ong meh, ooi sbs. a review of 2,517 childhood injuries seen in a singapore emergency department in 1999 – mechanisms and injury prevention suggestions. available from: https://www.researchgate.net/publication/10746286. accessed 10 january 2022. 2. ng’ang’a e, mutiso vm, mwangi jc. pattern of long bone fractures in a paediatric population at kenyatta national hospital. east african orthop j. 2018;11(2):54-60. 3. menon mrg, walker jl, court-brown cm. the epidemiology of fractures in adolescents with reference to social deprivation. j bone jt surg ser b. 2008;90(11):1482-86. https:// doi.org/10.1302/0301-620x.90b11.21163 4. mughal ma, dix-peek si, hoffman eb. the epidemiology of femur shaft fractures in children. sa orthop j. 2013;12(4):23-27. 5. cheng yw, fletcher en, roberts kj, mckenzie lb. baby gate-related injuries among children in the united states, 1990–2010. acad pediatr. 2014;14(3):256-61. https://doi. org/10.1016/j.acap.2013.12.006 6. loder rt, o’donnell pw, feinberg jr. epidemiology and mechanisms of femur fractures in children. j pediatr orthop. 2006;26(5):561-66. https://doi.org/10.1097/01. bpo.0000230335.19029.ab 7. von heideken j, svensson t, blomqvist p, et al. incidence and trends in femur shaft fractures in swedish children between 1987 and 2005. j pediatr orthop. 2011;31(5):512-19. https://doi.org/10.1097/bpo.0b013e31821f9027 8. joeris a, lutz n, wicki b, et al. an epidemiological evaluation of pediatric long bone fractures a retrospective cohort study of 2716 patients from two swiss tertiary pediatric hospitals. bmc pediatr. 2014;14(1):1-11. https://doi.org/10.1186/s12887-014-0314-3/ tables/6 9. capra l, levin av, howard a, shouldice m. characteristics of femur fractures in ambulatory young children. emerg med j. 2013;30(9):749-53. https://doi.org/10.1136/ emermed-2012-201547 10. cooper c, dennison em, leufkens hg, et al. epidemiology of childhood fractures in britain: a study using the general practice research database. wiley online libr. 2004;19(12):197681. https://doi.org/10.1359/jbmr.040902 11. hinton ry, lincoln a, crockett mm, et al. fractures of the femoral shaft in children. j bone jt surg. 1999;81(4):500-507. 12. beaty jh, kasser jr. rockwood and wilkin’s fractures in children. philadelphia: lippincott, williams & wilkins; 2010. p. 1076-76. 13. valerio g, gallè f, mancusi c, et al. pattern of fractures across pediatric age groups: analysis of individual and lifestyle factors. bmc public health. 2010;10(1):1-9. https://doi. org/10.1186/1471-2458-10-656/tables/6 14. pierce mc, bertocci ge, vogeley e, moreland ms. evaluating long bone fractures in children: a biomechanical approach with illustrative cases. child abus negl. 2004;28(5):50524. https://doi.org/10.1016/j.chiabu.2003.01.001 15. hedström em, svensson o, bergström u, michno p. epidemiology of fractures in children and adolescents. acta orthop. 2010;81(1):148-53. https://doi.org/10.3109/1745 3671003628780 16. tandon t, shaik m, modi n. paediatric trauma epidemiology in an urban scenario in india. j orthop surg (hong kong). 2007;15(1):41-45. https://doi.org/10.1177/230949900701500110 17. dodd a, paolucci eo, parsons d. paediatric femoral shaft fractures: what are the concomitant injuries? injury. 2013;44(11):1502-06. https://doi.org/10.1016/j. injury.2013.02.012 18. liu h, wang h, shao b, et al. epidemiological evaluation of traumatic lower limb fractures in children variation with age, gender, time, and etiology. medicine. 2019;98(38):e17123. https://doi.org/10.1097/md.0000000000017123 19. rewers a, hedegaard h, lezotte d, et al. childhood femur fractures, associated injuries, and sociodemographic risk factors: a population-based study. pediatrics. 2005;115(5):e54352.https://doi.org/10.1542/peds.2004-1064 20. setati s, lekgwara pl, kelly a. an audit of the epidemiology of head injuryin children (post-graduate thesis) at dr george mukhari academic hospital, sefako makgatho health sciences university, pretoria, south africa. 2017. https://orcid.org/0000-0002-8013-8290 https://orcid.org/0000-0003-4045-5301 https://orcid.org/0000-0003-2845-5122 https://orcid.org/0000-0001-7130-7307 _hlk70529656 _hlk115082631 orthopaedics vol3 no4 sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 77 changes in short-term cognitive function following a hip fracture in the elderly and the effect of cognitive function on early post-operative function s adam bsc physio, msc physio(wits) l godlwana bsc physio(uct), msc physio, phd(wits) d maleka bsc physio, mph, phd(wits) physiotherapy department, faculty of health sciences, university of the witwatersrand, south africa corresponding author: miss saadiya adam physiotherapy department faculty of health sciences school of therapeutic sciences university of the witwatersrand 7 york road 2193 parktown johannesburg, south africa email: adam.saadiya@gmail.com tel: +2782 947 4268 abstract objective: to evaluate the changes in short-term cognitive function and the relation between cognition and early post-operative functional outcome in the elderly following a hip fracture. design: prospective pre-test–post-test observational study. setting: two public hospitals in johannesburg, south africa. participants: ninety elderly patients with a first time unilateral hip fracture over the age of 60 years were consecutively sampled. patients with polytrauma and those with co-morbidities affecting mobility (stroke, parkinson’s disease or a spinal cord injury) were excluded. patients re-admitted with complications of a previous surgery or those managed conservatively were also excluded. seventy-two participants completed the study. data collection: pre-operative (baseline), discharge and six weeks post discharge assessments were carried out. cognitive function was established using the six-item cognitive impairment test (6cit) at each of the three assessment periods. the participants’ post-operative functional level was assessed using the elderly mobility scale (ems) and the lower extremity functional scale (lefs) at discharge and at six weeks post discharge. results: this study revealed significant advances in cognition from baseline to six weeks post discharge (z-statistic −5.04, p=0.000). after adjusting for pre-fracture functional mobility and pre-existing co-morbidities, a multivariate regression analysis revealed that cognitive function is also a strong predictor of early post-operative functional outcome (β= −0.14, p=0.036). conclusion: cognitive function in elderly individuals with a hip fracture does improve over time. cognitive function is a strong predictor of early post-operative functional outcome, when adjusted for pre-fracture functional mobility and pre-existing co-morbidities. key words: hip fracture, elderly, cognitive function, early post-operative functional outcome, six-item cognitive impairment test http://dx.doi.org/10.17159/2309-8309/2016/v15n1a9 page 78 sa orthopaedic journal autumn 2016 | vol 15 • no 1 introduction hip fracture is a common, serious injury that occurs predominantly in the elderly.1 hip fractures are a major cause of morbidity and mortality and occur in 20% to 30% of older people who fall.2 cognitive function has been reported to be an important prognostic factor associated with rehabilitation success of older patients with a hip fracture. impaired cognitive function may negatively affect functional recovery in disabled elderly patients with a hip fracture.3 elderly patients with a hip fracture who present with cognitive impairments and depressive symptoms have poorer rehabilitation outcomes, which is due to poor participation during therapy.4 there are no studies available in south africa that have evaluated the changes in short-term cognitive function, from a pre-operative state to discharge and six weeks post discharge, and the relation between cognition and early post-operative functional outcome in the elderly following a hip fracture prior to this study. the aim of this study was to establish these changes in cognitive function and determine the relation between cognitive function and the early post-operative functional outcome in elderly patients with a hip fracture. determining the effect of cognitive function on early post-operative functional outcome in elderly patients with a hip fracture in a selected public health setting in south africa will help identify those patients who are especially at risk of not regaining independence in basic mobility. evaluating the changes in cognitive function over time will assist practitioners in understanding elderly patients and exploring how best to motivate these patients, thus attempting to improve the medical management of these patients. method study design a prospective pre-test–post-test observational study was conducted. details of the study design are mentioned in the procedure section below. participants and sampling elderly patients with a first time unilateral hip fracture over the age of 60 years were consecutively sampled from the orthopaedic wards of two public health care hospitals in johannesburg, south africa. the exclusion criteria consisted of patients with polytrauma and those with comorbidities affecting mobility (stroke, parkinson’s disease or a spinal cord injury). patients re-admitted with complications of a previous surgery or those managed conservatively were also excluded. in total, ninety (n=90) subjects were consecutively entered into the study. this figure was determined using a power calculation on stata version 12. the power was set at 90% and alpha at 5%. a loss to follow-up ratio was taken into consideration and was set at 20%. standard deviations and the minimal clinical important difference for each outcome measure were used.5-7 ethical clearance was granted by the human research ethics committee of the university of the witwatersrand (m110403); institutional approval was also obtained and participants gave informed consent. pilot study a pilot study was conducted to determine the intra-rater reliability of the first author, to enable her to familiarise herself with the tools that were used in the main study, and to establish the time taken to implement these tools. twenty-seven patients were used in the pilot study; the patients were divided into three groups, and each group consisted of nine patients (10% of the number of participants in the main study). each group was assessed preoperatively, at discharge and six weeks post discharge. data of patients participating in the pilot study were not included in the main study. outcome measures the six-item cognitive impairment test (6cit) comprises six questions that take three to four minutes to complete. the scoring system uses weighting techniques and is thus slightly more complicated than previous tests. the total score is 28; scores of 0 to 7 are considered normal while scores of above 8 are significant in confirming a cognitive impairment. at the 7 to 8 cut-off the 6cit gives a specificity of 100% and a sensitivity of 78.57%.5 one of the most commonly used tools for screening for cognitive impairment, as well as being regarded as the ‘gold standard’ is mini mental state examination (mmse).8 the 6cit was validated against the mmse and its suitability as a screening tool for dementia was established.5 the 6cit was confirmed to be a short and simple test of cognition.5 the 6cit correlates well with the mmse (r2 = −0.911 p < 0.01) but fares better when screening for milder dementia; the mmse when used as a screening test for dementia is of little value. hence the 6cit was the outcome measure decided upon in the study. the elderly mobility scale (ems) is a physical assessment of function and has a score out of 20. the ems provides a physiotherapy-oriented measure for frail elderly people.9 the scale assesses seven dimensions of functional performance. these include: locomotion, balance and key position changes, all of which are skills required for the performance of activities of daily living. the maximum score is 20, with higher scores indicating better performance. latent class analysis of the ems showed strong inter-rater (r2=0.0037 ρ=1.00) and intrarater reliability (r2=0.0035 ρ=0.72). a high correlation between the ems and modified rivermead mobility index was established (spearman’s ρ=0.89), thus demonstrating concurrent validity.6 sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 79 the lower extremity functional scale (lefs) is used to evaluate the functional activity level of a patient with a disorder of one or both lower extremities.7 the lefs is a questionnaire containing 20 questions about a person’s ability to perform everyday tasks. the questionnaire starts off by asking the patient: ‘today would you have any difficulty with …’ followed by a list of functional activities. these activities are scored from zero (extreme difficulty) to four (no difficulty). the maximum score is 80. the lower the score, the greater the disability. the lefs has shown to be both reliable and valid.7 construct validity was determined by comparing the lefs to the physical function subscale [r=0.80 (95% ci=0.73)] and the physical component score [r=0.64 (95% ci=0.54)] of the 36-item short form health survey (sf-36). intra-rater reliability was r=0.86 (95% ci=0.80).7 the lefs was modified for cultural appropriateness in this study, as not all elderly south africans may relate to the activity description ‘walking a mile’. procedure pre-operative assessment following a successful pilot study, participants (n=90) were evaluated pre-operatively for the main study. cognitive function was assessed using the 6cit. table i summarises the outcome measures used and at which point they were performed. discharge and six weeks post discharge assessment post-operatively cognitive function was assessed using the 6cit, and functional outcomes were assessed using the ems and lefs at discharge (n=82) and six weeks post discharge (n=72) respectively. at six weeks post discharge, one participant had dropped out, six participants had been lost to follow-up and 11 had demised since the beginning of the study. the six participants lost to follow-up could not be reached physically or telephonically. the ems was carried out in the physiotherapy gym. lying to sitting and sitting to lying were the first two activities that participants performed. these two tests were performed on a standard plinth. thereafter, the participants were assessed on their ability to rise to standing from a 47 cm (19 in) chair in less than three seconds allowing the use of upper limbs. the ability to maintain an upright standing position with or without the use of upper limbs to steady yourself was also assessed. participants were then instructed to mobilise; the scoring for gait was based on the type of assistance required to walk, not the distance walked.9 the participant was then timed walking over a distance of 6 metres, at their normal speed, using their usual walking aid. a maximum score was given for a time of under 15 seconds.9 finally the participant was required to reach forward beyond an arm’s length while maintaining a fixed base of support. a maximum score was attained for a functional reach of 20 cm.9 data analysis data were analysed using ibm spss version 19. descriptive statistics were used to deduce the participants’ demographic data. the mcnemar statistical test analysing inferential data was presented using frequency tables, means and standard deviation or medians and interquartile ranges depending on the distribution of the data. wilcoxon signed-rank tests were used to test whether there was a median difference in paired data. spearman’s rank correlation coefficient (r) was used to test if a linear relationship existed between cognitive function and postoperative functional outcome. a multivariate regression analysis was used to determine associations between variables. the study was set at p≤0.05 level of significance and 95% confidence interval (ci). results of the 90 participants studied, n=50 (69.4%) participants were female and n=22 (30.6%) were male. the mean age of the participants was 75.7 years (sd ± 9.54). the minimum age was 60 years and the maximum was 95 years. final analysis was carried out on the participants (n=72) who completed the study. a comparison between the baseline median 6cit scores of deceased participants (median 6cit score of 24) and participants who completed the final assessment (median 6cit score of 11.5) revealed that those participants who demised during the study, originally presented with poor cognitive impairment at baseline. a mann-whitney u score of 203 was calculated with a corresponding p-value of 0.01. participants aged 80 years and over and female participants presented with poorer cognitive scores compared to their younger and male counterparts. the kruskal-wallis h test is a non-parametric test that determines significant changes between two or more groups with ordinal data. a comparison between participants aged 80 and over and those participants between 60 and 79 years revealed a kruskal wallis h-statistic value of 14.8 and a corresponding p-value of 0.00. the result for male versus female was 1.3 (p=0.26). table ii presents the frequency of 6cit scores and the percentages of each total score (n=72). the results indicate that participants found it much easier to answer questions relating to the year and month, with approximately 80% of participants answering correctly. table i: outcome measures and period at which they are administered assessment periods pre-operative (baseline) discharge six weeks post discharge 6cit 6cit 6cit ems ems lefs lefs page 80 sa orthopaedic journal autumn 2016 | vol 15 • no 1 questions that involved memory and reverse listing were more difficult. more than half of the participants made one or more errors when asked to say the months of the year in reverse and 36.1% of participants could not remember any component of the address phase they were asked to memorise and repeat later on at the pre-operative assessment. this result improved at discharge and six weeks post discharge. table iii indicates that many participants presented with moderate cognitive impairments pre-operatively (mean 6cit score of 10.5), but these impairments resolved and improved leading up to the final assessment at six weeks post discharge (mean 6cit score of 6). there were also significant advances in cognition from baseline to six weeks post discharge (z-statistic −5.04, p=0.000). cognitive function is indirectly related to post-operative functional outcome. the correlation between cognitive function and early post-operative functional outcome is shown in table iv. a multivariate regression analysis using the data collected at discharge revealed that the 6cit (β= −0.14, p=0.036) assessed pre-operatively is a strong predictor of early post-operative functional outcome using only the ems at discharge (table v). table ii: percentages of each individual score obtained using the 6cit pre-operatively, at discharge and six weeks post discharge (n=72) 6cit variable pre-operative n (%) discharge n (%) 6 weeks post discharge n (%) what year is it? correct 60 (83.3%) 62 (86.1%) 65 (90.3%) incorrect 12 (16.7) 10 (13.9%) 7 (9.7%) what month is it? correct 57 (79.2%) 59 (81.9%) 63 (87.5%) incorrect 15 (20.8%) 13 (18.1%) 9 (12.5%) about what time is it? correct 36 (50%) 46 (63.9%) 52 (72.2%) incorrect 36 (50%) 26 (36.1%) 20 (27.8%) count backwards from 20 to 1 correct 31 (43.1%) 39 (54.2%) 40 (55.6%) 1 error 20 (27.7%) 20 (27.7%) 17 (23.6%) more than 1 error 21 (29.2%) 13 (18.1%) 15 (20.8%) say the months of the year in reverse correct 20 (27.8%) 26 (36.1%) 27 (37.5%) 1 error 17 (23.6%) 18 (25%) 21 (29.2%) more than 1 error 35 (48.6%) 28 (38.9%) 24 (33.3%) repeat address phrase correct 14 (19.4%) 15 (20.8%) 21 (29.2%) 1 error 7 (9.7%) 13 (18.1%) 12 (16.7%) 2 errors 15 (20.8%) 11 (15.3%) 13 (18.1%) 3 errors 7 (9.7%) 9 (12.5%) 8 (11%) 4 errors 3 (4.2%) 6 (8.3%) 5 (6.9%) all wrong 26 (36.2%) 18 (25%) 13 (18.1%) mean (±sd) 12.44 (±9.53) 10.40 (±9.33) 8.93 (±9.03) median (iqr) 10.5 (17) 8 (17) 6 (15) table iii: median 6cit scores and statistical changes from baseline to six weeks post discharge (n=72) 6 cit wilcoxon signed ranks test baseline discharge medians 10.5 8 z-statistic −4.74 p-value 0.003 discharge six weeks post discharge medians 8 6 z-statistic −3 p-value 0.003 discharge six weeks post discharge medians 10.5 6 z-statistic −5.04 p-value 0.000 table iv: correlations with functional outcome (n=72) assessment period spearman correlations elderly mobility scale lower extremity functional scale 6cit (r) 6cit (r) discharge −0.554** −0.550** six weeks post discharge −0.692** −0.596** **correlation is significant (p≤0.01) sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 81 a multivariate regression analysis further revealed that the 6cit assessed pre-operatively is a strong predictor of early post-operative functional outcome using the ems (β= −0.22, p=0.002) and lefs (β= −0.60, p=0.001), at six weeks post discharge. table vi depicts the results of the multivariate regression analysis using the ems and lefs at six weeks post discharge. in summary, cognitive impairment is a relatively strong predictor of early post-operative functional outcome. there is an interesting trend in the relationships between cognitive impairment at the three levels of functional outcome. the relationship gets stronger as you move through the different levels (i.e. from pre-operatively to six weeks post discharge). the relationship between preoperative cognition and functional outcome at six weeks post discharge is stronger, thus indicating that preoperative cognition is a stronger predictor of functional outcome at six weeks post discharge compared to functional outcome at discharge. discussion a cognitive impairment in the context of this study includes the presence of any acute confusion states or the development of incident cognitive impairment during hospital admission. a cognitive impairment was diagnosed according to the score obtained on the 6cit. the current study revealed that the presence of a cognitive impairment pre-operatively has a negative influence on the post-operative functional level at discharge and six weeks post discharge. these findings of this study are consistent with another study that examined the adverse effects of cognitive impairment (mini-mental state examination [mmse]) in elderly hip fracture patients receiving inpatient rehabilitation.4 fifty-seven elderly participants were recruited from a rehabilitation hospital in pittsburgh, usa. it was concluded that poor cognitive function predicted poorer functional outcomes and these patients presenting with poor cognitive function were unable to participate as well in their therapy sessions.4 participants’ level of participation in therapy was evaluated using a newly developed rehabilitation participation scale.4 this scale was found to have a ceiling effect and was modified later. results similar to those of the current study were reported by two other studies.10,11 however, the final number of participants included in one of the studies was relatively small (n=59)11 and the mean age of participants included in the other study was 84 years, nine years older than the mean age of participants included in the current study.10 improvement of cognitive function occurred during the course of this study. at six weeks post discharge only 19.4% of participants presented with a severe cognitive impairment compared to 30.6% pre-operatively. these results are consistent with those of a study that demonstrated that the incidence of acute confusion (measured by the neecham confusion scale) after sustaining a hip fracture in the elderly population was 32% on admission and the day after surgery, and 14% the day before discharge.12 despite the use of varying outcome measures used to determine the incidence of a cognitive impairment, fairly similar results were obtained. an interesting strength was the use of a self-reported measure to identify cognitive impairments.12 table vi: regression analysis (six weeks post discharge assessment) (n=72) six weeks post discharge model specification regression results model fit dependent variable independent variable regression coefficient 95% confidence interval for b standardised regression coefficient regression anova results β β t-statistic p-value f-statistic p-value adj r-sqr elderly mobility scale 6cit (pre-op) −0.22 −0.35 to −0.09 −0.35 −3.27 0.002 25.05 0.000 0.50 lower extremity functional scale 6cit (pre-op) −0.60 −0.94 to −0.27 −0.40 −3.60 0.001 21.36 0.000 0.46 table v: regression analysis (discharge assessment) (n=72) model specification regression results model fit dependent variable independent variable regression coefficient 95% confidence interval for b standardised regression coefficient regression anova results β β t-statistic p-value f-statistic p-value adj r-sqr elderly mobility scale 6cit (pre-op) −0.14 −0.27 to −0.01 −0.24 −2.14 0.036 21.46 0.000 0.46 lower extremity functional scale 6cit (pre-op) −0.28 −0.54 to −0.02 −0.24 −2.13 0.037 21.51 0.000 0.46 page 82 sa orthopaedic journal autumn 2016 | vol 15 • no 1 conclusion the results of this prospective pre-test–post-test observational study indicate that improvements in cognitive function do occur in the short term in elderly patients who sustain a hip fracture. the presence of cognitive impairments in elderly patients with a hip fracture does negatively influence the early post-operative functional outcome. implications for practice education and preventative measures to protect elderly patients from the trauma associated with a fall and subsequently a hip fracture is vital. for those patients who do sustain a hip fracture, intensive rehabilitation is especially necessary for the patient that presents with poor cognitive function. more importantly, determining that cognitive impairments do improve significantly in the short term assists medical practitioners in developing systematic approaches and interventions in the rehabilitation of these frail, elderly individuals. those patients who adopt a sedentary lifestyle or remain bedridden following surgical fixation of a hip fracture impact on the financial burden of health care. therefore, those patients presenting with poorer cognitive function should be especially encouraged to participate in intensive rehabilitation. conflict of interest statement ethical approval: human research ethics committee of the university of the witwatersrand (m110403). funding: no funding was received for this research. conflict of interest: none no benefits of any form have been received from a commercial party related directly or indirectly to the subject of this article. references 1. holt g, smith r, duncan k, hutchison jd, gregori a. outcome after surgery for the treatment of hip fracture in the extremely elderly. j bone joint surg am 2008;90:18991905. 2. kalula s. prevalence and problem of falls in older persons. institute of ageing in africa 2012; university of cape town (unpublished). 3. hershkovitz a, kalandariov z, hermush v, weiss r, brill s. factors affecting short-term rehabilitation outcomes of disabled elderly patients with proximal hip fracture. arch phys med rehabil 2007;88:916-21. 4. lenze ej, munin mc, dew ma, rogers jc, seligman k, mulsant bh, reynolds iii cf. adverse effects of depression and cognitive impairment on rehabilitation participation and recovery from hip fracture. int j geriatr psychiatry 2004;19:472-78. 5. brooke p, bullock r. validation of a 6 item cognitive impairment test with a view to primary care usage. int j geriatr psychiatry 1999;14:936-40. 6. nolan js, remilton le, green me. the reliability and validity of the elderly mobility scale in the acute hospital setting. internet j. allied health sci. pract. 2008; http://ijahsp.nova.edu volume 6 no. 4 issn 1540-58x accessed 01/03/2011. 7. binkley jm, stratford pw, lott sa, riddle dl. the lower extremity functional scale (lefs): scale development, measurement properties, and clinical application. phys ther 1999;79(4):371-82. 8. folstein mf, folstein se, mchugh pr. ‘mini-mental state’ a practical method for grading the cognitive state of patients for the clinician. j psychiatr res 1975;12:189-98. 9. smith r. validation and reliability of the elderly mobility scale. physiotherapy 1994;80(11):744-47. 10. soderqvist a, miedel r, ponzer s, tidermark j. the influence of cognitive function on outcome after a hip fracture. j bone joint surg 2006;88-a:2115-23. 11. horgan nf, cunningham cj. impact of cognitive impairment on hip fracture outcome in older people. int j ther rehabil 2003;10(5):228-32. 12. johansson i, baath c, wilde-larsson b, hall-lord ml. acute confusion states, pain, health, functional status and quality of care among patients with fracture during hospital stay. int j of orthop trauma nurs 2012; doi:10.1016/j.ijotn.2012.07.002 published online 10 september 2012. accessed 10/11/2012. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj sa orthopaedic journal summer 2016 | vol 15 • no 4 page 31 meta-analysis: everything you wanted to know but were afraid to ask dr r rodseth mbchb, fca(anaes), cert crit care, mmed(anaes), msc(hrm), phd department of anaesthetics, university of kwazulu-natal, pietermaritzburg, south africa dr lc marais mbchb, fc(orth)(sa), mmed(orth), cime, phd department of orthopaedics, university of kwazulu-natal, pietermaritzburg, south africa corresponding author: dr lc marais department of orthopaedic surgery grey’s hospital private bag x9001 3201 pietermaritzburg email: maraisl@ukzn.ac.za tel: +27 033 897 3424 fax: +27 33 897 3409 introduction systematic reviews and meta-analyses have exploded into prominence in the medical literature. while traditional narrative reviews remain informative, they are prone to bias as the author is free to select only those articles they believe are important. systematic reviews are specifically aimed at reducing bias by identifying, appraising and synthesising all relevant studies. a systematic review becomes the basis for the next step where all data is synthesised into a single estimate or summary of effect. this process is called a metaanalysis. the perceived ability of systematic reviews and meta-analyses to concisely and definitively summarise existing literature regarding a specific medical question or issue has made them the most highly read and cited form of academic literature.1 however, systematic review and metaanalyses are not without their critics.2,3 this paper will provide an overview of systematic review and meta-analysis and will: 1) examine the rationale for conducting such a study, 2) overview the methodology, and 3) highlight pitfalls and weaknesses inherent in the process. why conduct a systematic review and meta-analysis? we have all experienced the medical equivalent of the mexican standoff. one consultant quotes a study from a prominent orthopaedic journal, showing that bipolar hip arthroplasty is superior to unipolar hemiarthroplasty in femoral neck fractures, only to be rebutted by another consultant who cites more recent research from another journal showing that there is no difference in outcome. in the aftermath the trainees, patients and even the consultants themselves remain unsure about which implant they should use and even more confused about how to make clinical decisions when faced with disparate trial results. the field of systematic review and meta-analysis had been developed as a tool to deal with this problem. this research tool is also invaluable in understanding the current state of the literature with regard to a specific question. a good systematic review is able to determine whether the literature has already answered the question you are asking, or whether more research is needed. for this reason, abstract the perceived ability of systematic reviews and meta-analyses to concisely and definitively summarise existing literature regarding a specific medical issue has made them the most highly read and cited form of academic literature. however, the evidence they provide is only as good as the data evaluated and the methodology followed when doing them. in order to conduct a rigorous systematic review, all the elements of the research question should be clearly stated, all relevant studies should be identified, the inclusion criteria should be appropriate and the included studies valid, heterogeneity should be identified, and finally the results of the meta-analyses should be appropriately presented. this paper aims to provide an overview of systematic reviews and meta-analyses. furthermore, we examine the rationale for conducting such a study, overview the methodology, and highlight pitfalls and weaknesses inherent in the process. key words: systematic review, meta-analysis, review http://dx.doi.org/10.17159/2309-8309/2016/v15n4a4 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 31 page 32 sa orthopaedic journal summer 2016 | vol 15 • no 4 conducting a meta-analysis before embarking on a big research trial is essential. clinical research generally aims to identify the best treatment for a specific group of patients and the randomised controlled trial is the tool most commonly used to do this. two groups of patients randomly receive two different treatment options (e.g. unipolar vs bipolar hip arthroplasty). the researcher then compares outcomes in the two groups to determine which option is best. the basic assumption in all randomised controlled trials is that the two patient groups are identical to each other and that all the outcome differences are due only to the treatment being compared. but this is clearly not always the case. clinical trials occur in the real world with real people who are not identical. one group may have more smokers, or exercise less, or may have a higher incidence of chronic diseases – all factors that will affect the trial outcome. small trials, which are cheaper and easier to do, are very vulnerable to imbalances between study groups and can give wildly disparate results driven solely by imbalance between patient groups. increasing the number of patients in a trial decreases the impact that individual patients have on the outcome and so large trials provide more robust and reliable findings. meta-analysis tries to pool all available trials, irrespective of size or date of publication, into one big patient pool. this dramatically increases the patient population of this combined ‘trial’ and hopefully determines the ‘true’ effect of the intervention. at its heart meta-analysis is an attempt to increase the statistical power of clinical trials studying an intervention. how it’s done as the name suggests there are two parts to a systematic review and meta-analysis. at the outset it is important to realise that both of these parts have become highly standardised. where in the past you could do your literature review in any way that seemed good to you, now a highly structured and transparent process must be followed. similarly, the processes by which studies are identified and evaluated, and data extracted and finally pooled has become very rigid. these rules, encompassed in the prisma guidelines, have been developed to ensure that published metaanalyses, much like clinical trials, conform to best practice and are of a high standard.4 the prisma guidelines provide a checklist that can be used by both authors and journals to ensure that a meta-analysis meets the required level of rigour. more and more journals are insisting that authors comply with these guidelines. so how do you begin? the clinical question the first step is to begin with a clinical question that you want answered. for example – should we be using unipolar or bipolar implants in femur neck fractures? this question should then be carefully honed using the picot framework (table i).5 typically a reworked question will read something like this: in patients ≥ 55 years of age requiring hip replacement due to a displaced femoral neck fracture, does a cemented unipolar hip replacement provide better functional outcomes at 2 years after replacement, as measured by activities of daily living, as compared to a cemented bipolar hip replacement? this question clearly defines the study population, the intervention and comparison arms, as well as the time frame at which outcomes will be assessed. rather than focusing only on one outcome as is done in a clinical trial, a meta-analysis should try to identify all clinically important outcomes that have been reported in individual studies. this includes common events such as readmissions and infections, but also rare events such as cardiovascular collapse, anaphylaxis and death. a second important aspect, unique to meta-analysis, is to define the type of research that will be analysed. will you only be looking at randomised controlled trials, or are you going to be looking at observational studies? your question should now read, ‘in randomised controlled trials of patients ≥ 55 years of age requiring …’ conduct a quick literature search to find major clinical trials dealing with this topic and then review the question to make sure it is correctly focused. also take this time to search for meta-analyses that may already have been conducted on the topic. finding a recent meta-analysis on the topic does not automatically mean that you need to terminate yours. the existing analysis might have a different focus, have used an inferior methodology, or be outdated. the protocol at this point a formal protocol, using the structure provided by the prisma guidelines, should be written to guide the meta-analysis. the protocol has the same function as that of a protocol written for a clinical trial. it ensures that investigators adhere to a predetermined process and ensures transparency. this step is critically important. a succinct well-structured protocol with a carefully considered description of the study methodology is invaluable as a guide during a long and complex review and analysis. failure to write a protocol will detract from the rigour of the study and may also leave the researcher confused 6 months down the line when the primary aims table i: the picot framework for the development of the research question for systematic literature review factors example p population in question femoral neck fractures i intervention of interest bipolar hemiarthroplasty c comparator unipolar hemiarthroplasty o outcome measure functional outcome t timeframe short-term (at 2 years) saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 32 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 33 and methods of the study become blurred. once written it is strongly recommended that the review be registered with prospero (http://www.crd.york.ac.uk/prospero/ search.asp) and the protocol published. this again ensures transparency. the literature search the foundation of a high quality systematic review is the literature search. as already mentioned this search must be structured and logical, and each step must be recorded so that the process can be duplicated. work in conjunction with someone experienced in searching medical databases or with your librarian. take key words from your research question and then combine these to form search terms but take care to cast your net as wide as possible. using search terms that are too restrictive at the start of the search runs the risk of excluding eligible trials. using our example – the key words could be hip replacement / hip arthroplasty and randomised controlled trial. it is not sufficient to only search a single database such as pubmed or medline. pubmed only indexes a fraction of the world’s medical research and it is essential to find all trials that have examined this topic. at a minimum databases such as embase or scopus should be included, but the cochrane database, web of science and proquest should also be considered. an attempt should then be made to search the grey literature. there are a significant number of trials that never make it to formal publication in the medical literature and many can be identified by searching the abstracts of conference proceedings. it is important not to include any outcome terms in your initial search as this will exclude trials that might have recorded the outcome of interest but did not report it as their main finding. your search terms must be recorded and an example reported in the study findings. screening for trial eligibility a wide search of this nature will often identify thousands of abstracts. these must now be screened in duplicate by two or more investigators. first round screening is done by reading only the study title and the abstract. abstracts that do not address the research question are then excluded. in our example this would exclude all letters to the editor, review articles, trials conducted in animals, trials conducted in patients < 55 years of age, traumatic hip replacements, and all observational studies. all abstracts thought to be eligible by any investigator after first round screening are then included in the second round. second round screening is again done in duplicate but this time using the full paper rather than the abstract only. papers are only excluded once both investigators agree that they are not eligible. at the end of this sifting process you should be left with all available research pertinent to your research question. during this whole process careful record must be kept of the number of excluded abstracts and trials as well as the reasons for their exclusion. transparency and repeatability are key components of a well performed meta-analysis.6 a flow diagram, illustrating the study selection process, must be included in the report (figure 1). data extraction from these trials pertinent data must now be extracted. there are three parts to this process. the first is extracting demographic data. what did each study population look like in terms of age, gender and co-morbidities? also record the number of cases in each treatment arm. the second phase is to determine the quality of the trials. each trial contributing data to your meta-analysis must be critically evaluated to determine how well the trial was conducted and what its risk of bias was (table ii).7 figure 1. an example of a trial inclusion flow diagram, which illustrates the study selection process followed during the systematic review studies identified from databases (n=175) embase (n=97) scopus (n=62) cochrane (n=12) web of science (n =4) excluded: duplicate titles (n=77) studies for review (n=98) excluded: studies unrelated to research question (n=43) abstracts reviewed (n=55) excluded: studies not meeting inclusion criteria (n=33) full articles reviewed (n=22) excluded: studies not meeting inclusion criteria (n=17) studies included in meta-analysis (n=5) saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 33 page 34 sa orthopaedic journal summer 2016 | vol 15 • no 4 was the trial randomised, were the participants blinded, were there excessive dropouts and were the results reported consistently. the cochrane data base and the review manager (revman) provide a risk of bias tool that allows these aspects to be recorded and visually presented.8,9 as described by the cochrane collaboration, the emphasis should be on the assessment of internal validity of the trial results. this should then be recorded as low, unclear or high risk of bias for each trial. finally, the outcome data you are interested in must be extracted for analysis purposes. analysis the primary outcome for this research question is function at 2 years, as measured by activities of daily living. but what about other important outcome measures such as quality adjusted life years, or pain scores. one of the strengths of the systematic review is that because of the wide net it casts many adverse outcomes, not often identified in single trials or in narrative reviews, can be captured. examples of adverse outcomes that may be considered are need for reoperation, infection rates or mortality rate. the unit, or type of data, that is used to compare the outcome of interest is important to understand. outcomes can be expressed as dichotomous data – such as mortality or number of infections. this would then be analysed as the number of deaths or infections in the one arm as compared to the number of deaths in the other. the risk comparison is then reported either as an odds ratio or a risk ratio. outcomes can also be presented as continuous data. in this analysis the outcome is activities of daily living and is expressed with a score ranging from 4 (totally independent) to 18 (totally dependent). we now need to compare the average score, across all eligible studies, between patients who have received cemented unipolar as compared to cemented bipolar hip replacements. this is done by comparing the mean difference between the two arms. if different instruments have been used to measure the same type of patients then these can be compared using a standardised mean difference, but this can be difficult to interpret. the actual pooling and analysis of the data is done using a statistical software package such as revman (cochrane collaboration), comprehensive meta-analysis (nih), stata or r. data is not just simply averaged but rather each trial is assigned a weighting based on its size and the precision of the study findings (measured by the confidence interval). two statistical methods can be used: a fixed effects or a random effects method. fixed effects models assume that the intervention has the same size of effect across all the studies, and results using this model tend to have narrower confidence intervals. random effects models assume that this effect size may vary between trials and produce results with wider confidence intervals. in most cases though the summed effects differ very little. reporting results meta-analysis reporting follows a standardised pattern. first, the number of citations screened and the results of this screening process are reported in the text as well as in a flow diagram. then, for each of the included trials, patient demographics and details of what was done in each trial must be reported – this data should also be reported in a table. after this, details regarding the quality of the trials must be reported in a second table. the results of a meta-analysis are commonly reported in a forest plot. an example of a forest plot is shown in figure 2. the forest plot provides the reader with a visual representation of the trials included in the analysis and the results for each of the trials. for each trial the forest plot shows the treatment effect (the mid-point of the square box), the size of the trial (represented by the size of the box) and the trial precision as measured by the confidence intervals (represented by the horizontal lines). in the middle of the forest plot you will find a vertical line that represent a relative risk of one. this point represents no difference between the two arms of the trial. at the bottom of the plot you will find a diamond that represents the summary of the pooled treatment effect. the size of the diamond represents the total size of the pooled study population, the mid-point of the diamond is the point estimate of the treatment effect, and the horizontal corners of the diamond represent the width of the confidence intervals. pooling many precise large trials will result in a large long thin diamond (precise estimate of effect) while a meta-analysis that contains few small and imprecise trials will result in a small wide diamond (imprecise estimate of effect). but how reliable are these results? can they be trusted? there are two tools that are used to answer this question – heterogeneity tests and funnel plots. tests of heterogeneity include the the chi2 and the i2 tests. both these tests ask the question whether the difference seen between the individual trial results are due to chance or if the difference is due to a true effect. in low heterogeneity meta-analyses there is not much difference in trial results between the different studies. in high heterogeneity table ii: examples of bias that need to be considered during the systematic review, as described by the cochrane collaboration’s tool for assessing risk of bias in randomised trials8 type of bias source of bias selection enrolment of patients into different cohorts inherently different performance improper blinding of participants or personnel in terms of intervention detection improper blinding of outcome assessment in relation to the intervention attrition incomplete outcome data due to exclusions or loss to follow-up reporting selective reporting of results other study design bias, chronological bias, recall bias, citation bias saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 34 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 35 meta-analyses there is a large difference and this is cause for concern. in this example (figure 1) both tests show that there is high heterogeneity (individual trial results are very different) with the chi2 test showing a probability of p<0.000001 that these result are due to chance only. thus, the chance that the difference in results occurred by accident is less than 1 out of a million. an i2 of 30% to 60% suggests moderate heterogeneity while values above 70% suggest considerable heterogeneity. in this example the i2 is 99% – very high heterogeneity. the second tool commonly used is the funnel plot that tries to capture the effectiveness and reliability of the intervention. the plot looks like an inverted funnel with precise trials (small confidence interval) plotted at the top of the funnel and less precise trials (larger confidence interval) plotted at the bottom. the x-axis of the plot represents the treatment effect as determined by the trial (figure 3). journals generally tend to publish articles that show a difference and ignore articles that don’t. a funnel plot that is asymmetrical may be an indicator that the meta-analysis is at risk of publication bias. the more pronounced the asymmetry, with gaps in the bottom right-hand corner of the plot, the more likely that the meta-analysis will be over-estimating the effect of the intervention.10 weaknesses and pitfalls oxford university’s centre for evidence-based medicine (cebm) provides useful guidelines for the critical appraisal of systematic reviews.11 to determine if the results of a meta-analysis are valid, six aspects have to be assessed (table iii). bhandari et al. found that, prior to the year 2000, 88% of meta-analyses in orthopaedics had methodological flaws that could limit their validity.12 in order to maximise the potential value of a meta-analysis several factors need to be considered. the first point to be aware of is that a meta-analysis is only as good as the underlying trials that have been conducted in the field. poorly designed trials will result in unreliable results. it is therefore important to evaluate the underlying methodology and bias in the individual trials. in this same vein it is important to keep in mind that a meta-analysis can only reflect the research that has been done in the field. this means that if insufficient trials have been conducted the meta-analysis, instead of providing a definitive result, will demonstrate that more needs to be done in the field. the second point to keep in mind is that a systematic review and meta-analysis is a tool for analysing data and deriving summary results. and in the same way that tools can be abused so too meta-analysis can be abused. common mistakes are searching only in english, using incorrect or incomplete search terms, searching in only one database and choosing outcomes that are not clinically important. when it comes to synthesising the data and doing a meta-analysis some judgment is called for. figure 3. an example of a funnel plot; a scatter plot of the intervention effect (on the x-axis) against some measure of the study’s size or precision (on the y-axis)10 figure 2. an example of a forest plot, which allows visual representation of the results of a meta-analysis saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 35 page 36 sa orthopaedic journal summer 2016 | vol 15 • no 4 if there are fewer than three trials and the outcomes used in the trials are very different, does it make clinical sense to merge them into a single analysis? there are undoubtedly cases where it is wiser not to conduct a metaanalysis and to leave it at a systematic review. finally, keep in mind that in many cases a single large trial is the primary contributor to the signal seen in the meta-analysis result. in cases like this it may be better to evaluate the dominant trial rather than trying to do a meta-analysis. abdullah et al. recently illustrated that 28% of orthopaedic randomised controlled trials (rct) reporting a negative finding were underpowered.13 as stated by these authors, if an rct is statistically underpowered to show a clinically relevant absence of a difference in outcome between the two groups, it would be inappropriate to declare the two procedures equivalent. conclusion while systematic reviews and meta-analyses are traditionally considered higher level evidence, the evidence they provide is only as good as the data it evaluates and the methodology that was followed. in order to satisfy the criteria for a well performed systematic review all the elements of the research question should be clearly stated; all relevant studies should be identified; the inclusion criteria should be appropriate; included studies must be valid; heterogeneity should be identified; and finally, the results of the meta-analyses should be appropriately presented. compliance with ethics guidelines • conflict of interest statement the authors declare that they have no conflict of interests and that no financial support was received for this study. • authors’ contributions all authors made contributions toward the conception and design of the research, acquisition of data and drafting of the manuscript. the final manuscript was read and approved by all the authors. • funding the study was funded by departmental resources. • disclosure dr rr is supported by an incentive grant from the south african national research foundation. references 1. patsopoulos na, analatos aa, ioannidis jp. relative citation impact of various study designs in the health sciences. jama 2005;293:2362-66. 2. meta-analysis under scrutiny [editorial]  lancet 1997;350:675. 3. bailar jc. the promise and problems of meta-analysis [editorial] n engl j med 1997;337:559-61. 4. moher d, shamseer l, clarke m, et al. preferred reporting items for systematic review and meta-analysis protocols (prisma-p) 2015 statement. systematic reviews 2015;4:1. 5. thabane l, thomas t, ye c, paul j. posing the research question: not so simple. can j anaesth 2009;56:71-79. 6. lefaivre ka, slobogean gp. understanding systematic reviews and meta-analyses in orthopaedics. j am acad orthop surg 2013;21:245-55. 7. pannucci cj, wilkins eg. identifying and avoiding bias in research. plast reconstr surg 2010;126(2):619-25. 8. higgins jpt, altman dg, gotzsche pc, et al. the cochrane collaboration’s tool for assessing risk of bias in randomised trials. bmj 2011;343:d5928 doi:1136/bmj.d5928. 9. available from: http://tech.cochrane.org/revman/ download. date last accessed: 27 may 2016. 10. higgins jpt, green s (editors). cochrane handbook for systematic reviews of interventions version 5.1.0 [updated march 2011]. the cochrane collaboration, 2011. available from www.cochrane-handbook.org. 11. avalaible from: http://www.cebm.net/criticalappraisal/. date last accessed: 30 may 2016. 12. bhandari m, morrow f, kulkarni av, tornetta p. metaanalyses on orthopaedic surgery. a systematic review of their methodologies. j bone joint surg am 2001;83(1):15-24. 13. abdullah l, davis de, fabricant pd, et al. is there truly ‘no significant difference’? underpowered randomized controlled trials in the orthopaedic literature. j bone joint surg am 2015;97(24):2068-73. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj table iii: the aspects that need to be assessed during the critical appraisal of a meta-analysis, according to the centre for evidencebased medicine (cebm)11 questions to ask in order to determine if the results of a systematic review are valid 1. has the main research question (picot framework) been clearly stated? 2. is it unlikely that important relevant studies were missed? 3. were the inclusion and exclusion criteria appropriate? 4. were the included studies valid in terms of the research question being asked? 5. was the heterogeneity of studies identified and adequately explored? 6. were the results adequately presented? saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:08 page 36 manjra ma et al. sa orthop j 2019;18(4) doi 10.17159/2309-8309/2019/v18n4a7 south african orthopaedic journal http://journal.saoa.org.za current concepts review citation: manjra ma, basson t, du preez g, du toit j, ferreira n. current concepts in the management of open tibia fractures. sa orthop j 2019;18(4):52-62. http://dx.doi.org/10.17159/2309-8309/2019/v18n4a7 editor: prof lc marais, university of kwazulu-natal, durban, south africa received: september 2019 accepted: october 2019 published: november 2019 copyright: © 2019 manjra ma, et al. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: there are no funding sources to declare. conflict of interest: all authors confirm that there are no conflicts of interest to declare. abstract open tibia fractures are associated with an increased risk of infection, delayed union, non-union and wound complications. management is aimed at mitigating the risk of infection while optimising the biological and biomechanical environment to encourage soft tissue and bone healing. with ongoing clinical trials and research, our knowledge around best clinical practice continues to evolve. multiple consensus documents and protocols have been formulated, yet some controversy exists around the ideal management for high risk grade iii injuries. early antibiotic therapy has become a cornerstone in the management of these injuries. however, some controversy remains around the type and duration of antibiotic therapy. emergent debridement and lavage is a critical factor in treatment success. intramedullary nailing is a viable fixation option for most open tibia fractures while circular external fixation has gained prominence in the management of high energy grade iii injuries, especially in the presence of bone and soft tissue loss. the timing of the various treatment interventions continues to provoke debate and controversy. considering the available literature, the local context needs to be considered. inadequate access to theatre, shortage of staff, resources and expertise are frequently encountered. we aim to elucidate current literature with regard to the management of open tibia fractures guided in part by various consensus documents and protocols. level of evidence: level 5 keywords: open fracture, tibia, debridement, antibiotics, external fixation, internal fixation current concepts in the management of open tibia fractures manjra ma¹ , basson t² , du preez g³ , du toit j4 , ferreira n5 1 mbbch, fc orth (sa), mmed(orth); tygerberg arthroplasty fellow* ² mbchb, fc orth (sa); registrar* ³ mbchb, fc orth (sa); consultant and head of trauma unit* 4 mbchb, fc orth (sa), mscclinepi; consultant and head of department* 5 bsc, mbchb, fc orth (sa), mmed (orth), phd; consultant and head of tumour, sepsis and limb reconstruction unit* * division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, 7505, south africa. corresponding author: dr ma manjra, division of orthopaedics, tygerberg hospital, cape town, western cape, 7505, south africa; tel: +27 (21) 938 5456; email: m.manjra@ymail.com https://orcid.org/0000-0002-4411-5921 https://orcid.org/0000-0003-1686-9862 https://orcid.org/0000-0003-2760-7307 https://orcid.org/0000-0002-0958-5450 https://orcid.org/0000-0002-0567-3373 page 53manjra ma et al. sa orthop j 2019;18(4) introduction tibia fractures are among the most common long bone fractures, occurring at a rate of between 8.1 to 37.0 per 100 000 patients.1-3 the superficial location of the tibia leaves it particularly susceptible to open fractures and potential loss of soft tissue and bone.4,5 compared to closed injuries, open fractures have a significantly higher risk of infection, non-union, and wound healing complications, and often require multiple surgeries for definitive care.6 a multidisciplinary approach that includes orthopaedic, trauma and plastic surgeons is frequently required in the management of open fractures. the literature does not provide strong conclusions regarding the best treatment for open tibia fractures; evidence to support best treatment practices for the less prevalent and more devastating ‘severe’ open fractures is even less conclusive.7 the primary objectives in the management of open tibia fractures include early antibiotic therapy, emergent debridement of all devitalised soft tissue and bone, early soft tissue cover and skeletal stabilisation.2,5 failure to adhere to these principles may result in significant morbidity, cost and even loss of the injured limb. the aim of this paper is primarily to review current concepts in the management of open tibia fractures, and secondarily to assess these treatment strategies considering our south african context. classification the most widely used systems in open tibia fractures include the gustilo-anderson, ganga hospital and the ao (arbeitsgemeinschaft für osteosynthesefragen) orthopaedic trauma association open fracture classification (ota–ofc) systems.8-10 ramon gustilo and john anderson, in 1976, first classified open long bone fractures into grade i to iii injuries.11 subdivision of type iii injuries (a–c) was necessitated after they identified the high rate of complications associated with this group.12 this classification system is practical, aids in prognostication and treatment, and is widely implemented in clinical practice and research. however, since the initial description, many modifications have taken place, leading to a loss of uniformity and poor interobserver reliability.10,13,14 primary assessment effective management of open tibia fractures begins in the emergency department. trauma patients are assessed and managed according to the advanced trauma life support (atls) guidelines, after which attention can be focused on the injured limb during the secondary survey. systemic antibiotic therapy intravenous antibiotic therapy has been shown to be the single biggest predictor of infection in open tibia fractures.15,16 a cochrane review by gosselin reviewing 913 patients confirmed the efficiency of prophylactic antibiotics vs placebo in open fractures, citing a pooled relative risk reduction of 59% for acute infection in patients with open fractures treated with prophylactic antibiotics.17 it was concluded that for every 13 patients treated with prophylactic antibiotics, one acute infection would be circumvented.17 in addition to systemic antibiotics, tetanus prophylaxis should be administered according to local guidelines. prophylactic antibiotic therapy should be considered an adjunct to, and not a substitute for, a systematic open fracture management protocol that includes early debridement and irrigation, fracture stabilisation, and wound coverage.18 nonetheless, prophylactic antibiotics are essential because, in their absence, infection can be expected to occur in 20% of open fractures.19 sufficient data has concluded that an intravenous antibiotic such as a firstor second-generation cephalosporin (in most cases cefazolin) should be used for antimicrobial prophylaxis.20,21 in patients with beta-lactam allergy, clindamycin is the best alternative.21 the addition of gram-negative cover (gentamycin) for grade iii fractures, and penicillin for fecal or possible clostridial contamination, has been propagated throughout the literature, but is controversial.6,20,22 gustilo and mendoza initially suggested the addition of an aminoglycoside, after reporting that up to 77% of infections were a result of gram-negative bacteria.12 however, gustilo did not subsequently investigate whether the addition of an aminoglycoside decreased the risk of infection in type iii fractures.6 the effectiveness of this strategy was reported in a retrospective study by patzakis et al., who showed a decreased risk of infection compared with cephalosporin alone; however, several flaws were noted in the study with regard to duration of antibiotic therapy and inconsistencies in the timing of wound closure.6,19 sufficiently powered trials with large sample sizes are still needed to provide unequivocal guidance on the optimal antibiotic regimen for type iii open fractures.23 considering the available evidence, a combined regimen consisting of an aminoglycoside in conjunction with a first-generation cephalosporin appears to be adopted by most authors and guidelines.23 the eastern association for the surgery of trauma (east) guidelines recommend this combination of a first-generation cephalosporin plus an aminoglycoside, with the addition of penicillin to prevent clostridium infection in farmyard injuries.6,24 carver et al. in a 2017 review further suggested that a third-generation cephalosporin (ceftriaxone) or piperacillin/tazobactam as a good alternative to the above combination, although further research is still required.21 the ao and boa/bapras standards for trauma (boast4) guidelines are currently the most implemented guidelines on which management is based. the current ao guidelines for antibiotic prophylaxis in open fractures are as follows:9 • type i and ii: 24 hours, firstor second-generation cephalosporin • type iii: five days amoxicillin/clavulanic acid or ampicillin sulbactam or five days third-generation cephalosporin • in the case of fecal contamination (farmyard injury or open pelvic fracture) use piperacillin/tazobactam or a carbapenem or thirdgeneration cephalosporin plus metronidazole the current boast4 guidelines are as follows:25,26 1. co-amoxiclav 1.2 g eight-hourly or a cephalosporin such as cefuroxime 1.5 g eight-hourly iv as soon after the injury as possible and continued until debridement 2. co-amoxiclav/cephalosporin and gentamicin 1.5 mg/kg at the time of debridement and co-amoxiclav/cephalosporin continued until definitive soft tissue closure, or for a maximum of 72 hours, whichever is sooner 3. gentamicin 1.4 mg/kg and either vancomycin 1 g or teicoplanin 800 mg on induction of anaesthesia at the time of skeletal stabilisation and definitive soft tissue closure. these should not be continued post-operatively. the vancomycin infusion should be started at least 90 minutes prior to surgery. for patients with penicillin allergy, clindamycin can be given in place of co-amoxiclav/cephalosporin. since the landmark paper by patzakis and wilkins et al., studies have consistently shown an association between delay of intravenous antibiotic administration and an increased risk of page 54 manjra ma et al. sa orthop j 2019;18(4) infection.1,16,27 in their case-control study of more than 1 100 open fractures, administration of antibiotics more than three hours after injury was associated with a 1.63 times greater odds of infection in comparison with treatment within the first three hours after injury.16 the risk of infection increases significantly beyond this period due to changes in circulation and multiplication of bacteria.27 however, limitations of this study include antibiotic timing that was not examined against the grade of injury, the evolved and advanced nature of our modern trauma systems, and only 36% patients receiving antibiotics within three hours. a more recent retrospective study by lack et al. examining the relationship between antibiotic timing and deep infection in grade iii open tibia fracture put forward a stronger case for antibiotic timing.28 they found that wound coverage beyond five days and antibiotics beyond 66 minutes independently predicted infection. immediate antibiotics and early coverage limited the infection rate relative to delay in either factor or delay in both factors. age, smoking, diabetes, injury severity score, grade iiia versus iiib/c injury, and time to surgical debridement were not associated with infection. routine antibiotic therapy beyond the initial post-operative period is not beneficial in any open fracture.15 a prospective randomised controlled trial by dellinger et al. examining the relationship between timing and duration of antibiotic therapy with infection, concluded that on presentation to the emergency department, one-day antibiotic administration is equally efficacious as fiveday administration in preventing infections.29 antibiotics should be discontinued 24 hours after wound closure in grade i and ii fractures, and continued for 72 hours following grade iii fractures – but not more than 24 hours after tissue coverage of the open wound.15,20 with increasing use of antibiotics in the general population, we are faced with a new concern that was probably not present in clinical trials from prior decades, namely antibiotic resistance.18 among four level i trials studying antibiotic prophylaxis in open fractures, all highlighted a prevalence of staphylococcus aureus as the number one cause of surgical site infection, and one reported the rate of methicillin-resistant s aureus (mrsa) as being nearly one-third of the total staphylococcal infections.27,30-32 vancomycin may be appropriate for first-line treatment if the patient has a significant, documented beta-lactam allergy, has a history of mrsa colonisation, or is hospitalised in an area with recent mrsa outbreaks.22 clinicians should also be cognisant of the associated risk for selection of resistant organisms such as mrsa that are associated with cephalosporins, particularly in patients who may require prolonged hospitalisation.33 fluoroquinolones offer no advantages compared with a combination of cephalosporin and gentamicin and may actually have a detrimental effect on fracture healing and increase the infection rate in type iii fractures.24 wound cultures wound cultures obtained at debridement immediately post injury must not be used to direct choice of agent for antimicrobial prophylaxis, as the infecting pathogens do not typically correlate to pathogens initially cultured after injury.15,20 most infections from open fracture wounds result from nosocomial organisms.32,34 in contrast, while pre-debridement cultures are not recommended, post-debridement cultures may be useful.6 positive cultures at time of closure do not predict the infecting organism but correlate with the development of infection.32 this has led to some units adopting the practice of performing post-debridement cultures in delayed cases (>24 hours).6 local antibiotic therapy local antibiotic-laden polymethylmethacrylate beads (apb) have been shown to produce high antibiotic concentrations at the wound site in open tibia fractures while minimising systemic exposure, thus decreasing the risk of systemic adverse effects.35 in addition to providing a high dose of local antibiotics to the area of highest risk, which may not be well perfused or reached by systemic antibiotics, they serve to eliminate potential dead space.36 local antibiotic therapy cannot replace the use of intravenous therapy but may be a useful adjunct in severe injuries where the tissues are not amenable to immediate closure.35 osterman et al. in the largest series of 1 085 patients on apb efficacy in open tibia fractures, demonstrated a significant decrease in the rates of acute and chronic osteomyelitis with the use of tobramycin-impregnated cement beads in conjunction with systemic antibiotics in the management of grade iii fractures (infection rate, 6.5% versus 20.6%, respectively; p=0.001); but the same benefit was not demonstrated in lower grade injuries.37 however, the decision to use apb was not randomised and was rather a matter of surgeon preference or bead availability. secondly, soft tissue management differed between the groups, with patients receiving apb having their wounds closed earlier than the control group. keating et al. and moehring et al. did not find a statistical difference comparing systemic versus local antibiotic therapy; however, there are limitations in both studies.38,39 a recent metaanalysis by craig et al. of 21 studies demonstrated a significantly lower deep-infection risk with use of local antibiotic administration as an adjunct to systemic antibiotics across all types of open tibia fractures treated with intramedullary nailing.40 the effect was most pronounced for type iii injuries, in keeping with osterman’s findings, which demonstrated a pooled infection risk of 2.4% (95% ci: 0.0% to 9.4%) with an adjunct local antibiotic as compared with 14.4% (95% ci: 10.5% to 18.5%) with systemic prophylaxis alone (odds ratio, 0.17; p value not reported).23,40 the skin should ideally be closed over the beads which can be removed on the second or third day post-surgery without a second operation, if threaded through the incision on insertion.36 wahlig and dingeldein showed that the highest concentration of elution from the gentamicin beads takes place in the first several days after implantation, with detectable levels still present at day 80.41 these elution characteristics are ideal for short-term use in open fractures.36 the use of negative pressure wound therapy (npwt) in conjunction with antibiotic beads has been reported, but there is a concern that negative pressure reduces antibiotic concentration at the wound site.42,43 bioabsorbable mediums which have recently been investigated include calcium sulfate, polycaprolactone (pcl), collagen sponges and gels.36 these mediums have the advantage of not requiring removal; however, they present a significant problem if the development of infection necessitates their removal.36 since bioabsorbable beads require cellular activity to degrade the implants, when there is a recurrence of infection the absorption process stops, and the beads simply float in the purulence.36 learning points • administer intravenous antibiotic therapy as soon as possible according to local guidelines. • be aware of local antibiotic resistance patterns. • local antibiotic beads are a useful and effective adjunct to intravenous therapy. • wound cultures are not useful in acute injuries. page 55manjra ma et al. sa orthop j 2019;18(4) surgical principles debridement the quality of the initial debridement represents a key point in the treatment of open fractures and infection prevention.44 the technique of debridement of open fractures is guided in part from the boa/bapras working party on the management of open tibia fractures.18,45 this step-by-step protocol for removal of all dead tissue at the initial debridement is followed nationwide across the united kingdom. systematic debridement occurs in the following sequence: 1. initial cleaning of the limb with a soapy solution 2. preparation of the limb with a chlorhexidine alcohol solution, avoiding direct contact of the chlorhexidine with the open wound 3. wound extension, ideally following potential fasciotomy incisions 4. systematic assessment of the tissues, from superficial to deep, and from the periphery to the centre of the wound radical excision of necrotic tissue, as proposed by godina, should be performed so that all nonviable tissue, including bone, is removed.46,47 muscle viability is assessed using the four cs: colour, consistency, contractility and capacity to bleed. it is important to note that an inflated tourniquet might interfere with this assessment. a tourniquet should be applied but only inflated when required. loose bone fragments are assessed via the tug test and all segments with no bleeding edges, or loose fragments without attachment to soft tissue, should be removed.18 this is then followed by wound lavage. at this juncture an accurate assessment of the grade of injury can be made. boa/bapras guidelines recommend longitudinal wound extensions for debridement along fasciotomy incisions to preserve the longitudinal running neurovascular structures and perforating arteries medially and laterally that form the basis of local flap reconstructive options in the leg (figure 1).25,45 conversely, salih et al. recently published a case series of 31 patients with open tibia fractures which were treated with acute bony debridement and shortening with a transverse wound extension that enabled tension-free soft tissue coverage, and either primary closure or split skin grafting.48 fracture stabilisation was usually obtained with a monolateral external fixator and converted to a circular ilizarov frame that then allowed correction of leg length discrepancy or deformity. the reasoning given for choosing a transverse incision was a wound that could be closed more easily (than the rhomboid wounds created by longitudinal incisions) with the avoidance of soft tissue flaps and associated complications. all but one patient achieved bony union with the initial circular fixator, and all wounds figure 1. recommended incisions for fasciotomy and wound extensions. (a) margins of the subcutaneous border of the tibia are marked in green, fasciotomy incisions in blue, and the perforators on the medial side arising from the posterior tibial vessels in red; (b) line drawing depicting the location of the perforators; (c) montage of an arteriogram. the 10 cm perforator on the medial side is usually the largest and most reliable for distally based fasciocutaneous flaps. in this patient, the anterior tibial artery had been disrupted following an open dislocation of the ankle; hence the poor flow evident in this vessel in the distal one-third of the leg. the distances of the perforators from the tip of the medial malleolus are approximate and vary between patients. it is essential to preserve the perforators and avoid incisions crossing the line between them. b ca page 56 manjra ma et al. sa orthop j 2019;18(4) were closed either primarily or with a split thickness graft. the decision to perform a transverse incision was done on a case-bycase basis in conjunction with the plastic surgical team. factors that were considered to guide the decision included: a transverse wound, a wound not amenable to local flap coverage, a high-energy injury with bone loss that would result in shortening, and a patient who would be unsuitable for a free flap. hence this option should not be the standard of care, but rather an option for carefully selected patients. also contrary to the boa/bapras guidelines is the technique described by marecek et al. when extension of the traumatic wound may compromise the soft-tissue envelope and necessitate a rotational or free tissue transfer, they suggest that debridement may instead be performed through a ‘defined surgical approach’, distant to the traumatic wound.49 in this technique an anterolateral or posteromedial surgical approach is used to visualise the zone of injury and perform debridement. they compared 47 patients who had direct extension of the traumatic wound with 21 patients who were debrided using an anterolateral approach. the decision on what approach to use was at the discretion of the consultant surgeon, and the groups had similar proportions of gustiloanderson grades. the average number of surgeries, including index procedure, per patient was 1.96 in the direct extension group and 1.29 in the defined approach group (p=0.026). flap coverage was needed in nine patients in the direct extension group and no patients in the defined approach group (p=0.048). however, the authors noted the absence of grade iiib injuries in the defined surgical approach group. it was unclear if any patients successfully avoided a flap based on the choice of approach for debridement. timing of debridement the timing of debridement has been the subject of many studies. it was initially advocated that the surgical debridement should not be delayed for more than six hours. this ‘six-hour rule’ is believed to originate from a rodent study in the pre-antibiotic era.50 in 1989 patzakis et al. found that the time to antibiotic prophylaxis was more important than time to surgical debridement.16 this has been corroborated by many authors, with the most recent stating that, due to the risk associated with after-hours surgery, the debridement of open fractures can be safely postponed to an urgent elective theatre slate without increasing the risk of infection.25,50,51 when the primary debridement was done by an experienced surgical team, the outcomes were also found to be better.51-53 steeby et al. confirmed this when they compared the outcome of open tibia fractures managed during daylight hours in a dedicated orthopaedic operating room (dotor) versus being managed on an urgent basis in an on-call operating theatre (ocor). although they found similar infection rates, the dotor group had fewer unplanned surgeries and an uncomplicated fracture union.54 the boast4 guidelines state that:45 • surgery to achieve debridement, fixation and cover of open fractures of the long bone, hindfoot or midfoot should be performed concurrently by consultants in orthopaedic and plastic surgery (a combined orthoplastic approach). • perform debridement: ▫ immediately for highly contaminated open fractures ▫ within 12 hours of injury for high-energy open fractures (likely gustilo-anderson classification type iiia or type iiib) that are not highly contaminated ▫ within 24 hours of injury for all other open fractures. lavage wound irrigation as an adjuvant to surgical debridement is essential to minimise infection.7,8,23,55 the ideal composition and irrigation pressure have been long been the subject of controversy.23,55-63 high pressure may be more effective in removing particulate matter and bacteria, but at the expense of bone damage.58-62 low pressure may avoid bone damage and resultant delays in bone healing but is thought to be less effective at removal of foreign bodies and bacteria.64 the fluid lavage in open wounds (flow) trial, a multicentre randomised trial examining the effect of normal saline vs castor soap and high (15–35 psi or higher) vs low pressure (5–10 psi) lavage vs very low pressure (1 or 2 psi) in open fractures, has shed light on previously held notions on the delivery and composition of the ideal lavage solution.64 it is important to note that the study included open fractures of all extremities defined as arm, wrist, leg, ankle, foot, clavicle or scapula, with the exclusion of the pelvic ring, axial skeleton and hand.64 the primary endpoint was reoperation after 12 months from the index surgery for promotion of bone healing and wound infection.64 the reasons cited for the decision to use soap as opposed to other enhanced irrigation solutions (containing antiseptics or antibiotic agents) include: less cost, toxicity and risk of antibiotic resistance.7,8,23,55-58,65,66 no significant differences were found in the rates of secondary end points (nonoperatively managed infection, wound-healing problem or bonehealing problem) between the two irrigation solutions or among the three irrigation pressures. however, castor soap did demonstrate a significantly higher incidence of reoperation.64 subgroup analysis of open tibia fractures suggested that very low pressure was superior to low or high pressure.64 given our context of budget constraints and sometimes scarce resources in peripheral government centres, low pressure saline is an acceptable and cost-effective solution. wound closure primary wound coverage has been considered critical to achieving favourable outcomes.53,67 wounds that can be closed primarily should be closed.18 however, some studies have suggested that delayed wound closure with the use of npwt also results in favourable outcomes.68,69 delayed wound closure is believed by some authors to reduce the risk of deep infection.70,71 russel et al. reported that early wound closure may result in pathogenic organisms remaining encased in the wound, hence increasing the risk of infection, and suggested there is no place for primary wound closure in open tibia fractures.72 this is supported by data from military injuries, where authors suggest that the wound should initially be left open, serial debridements performed as needed, and the wound closed after it is deemed clean.73 this notion has been challenged by more recent literature which suggests that pathogenic organisms were secondarily acquired via nosocomial routes.74,75 this is supported by studies which showed a poor correlation between organisms cultured at initial debridement and resultant infecting pathogens.15,20 furthermore, advances in the field of wound care, antibiotic therapy as well as internal fixation have vastly improved infection rates, challenging earlier studies examining the early in vitro response of bacteria to metals.67,73,76 it is generally accepted that grade i and ii open fracture wounds can be safely closed after initial debridement, provided the patient received adequate antibiotic prophylaxis. there is no concern about ongoing tissue necrosis or contamination, and that a tensionfree closure of the soft tissues can be achieved.6,23 however, controversy exists regarding the optimal closure or coverage of grade iii open fracture wounds. page 57manjra ma et al. sa orthop j 2019;18(4) rajesakeran et al. published a prospective series of 173 patients with grade iiia and iiib open tibia fractures treated with primary closure. they reported ‘excellent’ results in 87% of patients assessed by bony union, wound healing with no marginal necrosis and absence of infection at five years.77 strict criteria for closure required included: no skin loss, debridement within 12 hours of injury, stable skeletal fixation during primary surgery, skin apposition without tension, and no sewage or organic contamination.23,77 for wounds requiring flap coverage, location of the injury, size of the defect, and zone of injury must collectively be assessed to determine if rotational or free-flap coverage is optimal.23 generally, wounds in the proximal two-thirds of the tibia can be adequately managed with rotational gastrocnemius and/or soleus flaps, while fractures of the distal third require free muscle or fasciocutaneous flaps.78 learning points • debridement should be done on an emergent basis. • while it is preferable for debridement to be done by an experienced team, this is not always possible in public hospitals where these cases need to be done as theatre becomes available. • low pressure saline is acceptable and cost effective as a lavage solution. • primary wound closure should be performed where this can be done safely. the role of npwt/vac negative pressure wound therapy (npwt) or vacuum-assisted closure (vac) should be seen as an adjunctive modality in the management of the soft tissue component of open tibia fractures. it involves the application of subatmospheric pressure to a wound via a sealed sponge or foam dressing, removing fluid and exudate, and encouraging blood flow to the wound site.6,18,79 this environment decreases tissue bacterial levels, increases tissue perfusion and rapidly promotes granulation tissue formation, thus improving wound healing.79-81 in cases of immediate closure, these conditions promote wound healing, and in cases of delayed closure, the promotion of granulation tissue formation prepares the wound bed for subsequent coverage and may reduce the need for soft tissue transfer and muscle flaps.67,82 they have been shown to effectively reduce bacterial counts in wounds until definitive soft tissue coverage.81,83 the utility of npwt in orthopaedic surgery has seen an increase in recent years, particularly in the management of infection and open fractures.18,84 after open fractures specifically, npwt is commonly used as a temporary dressing between operative interventions. in a prospective, randomised study, stannard et al. examined infection rates in 62 patients with open fractures who received soft tissue management with either npwt or standard gauze dressings between the initial debridement and definitive soft tissue closure.80 they found a significantly decreased infection rate (28% vs 5.4%; p=0.02) in favour of the npwt. more recently, blum et al. reported similar results: 20% infection in the standard dressing group and 8% in the npwt group.85 as expected, the open fracture grade correlated with the infection rate. caution should however be raised against the use of npwt as a definitive soft tissue management strategy. a 2011 international expert panel attempted to provide consensus statements regarding the use of npwt in traumatic wounds and reconstructive surgery.86 a 98% agreement was obtained for a recommendation on the use of npwt for soft tissue trauma. in this regard the panel recommended that ‘npwt may be used when primary closure is not possible after or in between debridements as a bridge to definitive closure’.86 skeletal stabilisation stabilisation of open fractures restores length, alignment and rotation, protecting the soft tissues around the zone of injury from further damage, and decreases dead space.87 these factors have been shown to decrease the rate of infection in multiple studies.88-90 early fixation allows improved access to soft tissues surrounding the injury and facilitates the patient’s early return to normal function.8 the choice of fixation depends on the fracture location (intraarticular, metaphyseal, diaphyseal), the extent of the soft tissue injury, and the degree of contamination and physiologic status of the patient.46 intramedullary nails dominate the most commonly used fixation method following open tibia shaft fractures and are associated with low overall infection rates, high union rates, and high levels of patient satisfaction.4 intramedullary nails remain the fixation method of choice for gustilo-anderson i to iiia open injuries, but utilisation of these devices in gustilo-anderson iiib injuries are coming under increased scrutiny and is the topic of multiple ongoing trials.7,70,91-94 temporary external fixation plays an important role in the acute management of severely contaminated open tibia fractures.23 this is usually in the form of monolateral external fixation providing stability to the fracture, while allowing resuscitation of the soft tissues, and in the case of the multiply injured polytrauma patient, stabilisation of the patient’s physiological state before more extensive reconstructive surgery bhandari et al. conducted a systemic review of tibial and femoral fractures converted to intramedullary nailing following external fixation. they found a significant relative risk reduction for infection if conversion was done in less than 14 days, and that lack of pinsite infections was the most important factor in prevention of infections.95 other key factors in this scenario cited by yokoyama et al. include: flap coverage by well-vascularised tissue within one week after trauma; short duration of external fixation; debridement of the screw hole at the pin site; early unreamed intramedullary nailing; and slightly prolonged interval between removal of the external fixator and intramedullary nailing until complete healing of the pin site.96 circular external fixation has demonstrated its effectiveness in the management of complex open tibia fractures in both civilian and war injuries.97-100 they utilise indirect reduction techniques with fine wires and/or half pins and small incisions, which ensure minimal soft-tissue damage and soft-tissue footprint.4 treatment with circular external fixation, which does not place any hardware at the fracture site, may reduce infections and hospital readmissions.101 circular external fixators consist of two distinct systems: the original ilizarov technique and hexapod systems. limited literature regarding the use of hexapod external fixation in open tibia fractures shows promising results, suggesting that the hexapod design can play a significant role in managing complex tibia fractures.102,103 dickson et al. recently reported on the surgical and functional outcome of 22 patients with grade iii open tibia fractures treated with circular external fixation at a minimum one-year follow-up.4 clinical scores were either good or excellent in over half of the patients in all knee and ankle scores, with good functional outcome in most cases. all fractures united without further surgery, and no refractures. the deep infection rate was low at 4.5%, adding to the growing body of evidence for managing these complex injuries with a circular frame. nieuwoudt et al. reported excellent short-term results with low infection and non-union rates on 94 consecutive grade iii open tibia fractures treated with circular external fixation followed up for a period of 12 months.100 the majority of patients were treated in traditional ilizarov fixators. hexapod external fixators were used in 12 patients. deep infection developed in four out of page 58 manjra ma et al. sa orthop j 2019;18(4) 94 (4.25%) cases. two patients united in the presence of sepsis and two developed infected non-unions. there was no statistically significant difference between infection rates in grade iiia and iiib injuries (p=0.617). two of the four deep infections occurred in hiv-positive individuals. there was no statistically significant association between hiv status and the development of deep infection (p=0.601). no superficial infection cases were reported. non-union occurred in three out of 94 (3.2%) patients, all with grade iiib injuries. circular external fixation is especially useful in the setting of significant segmental bone loss, where the defect can be managed with ilizarov bone transport.53 the ilizarov bone transport technique, known as distraction osteogenesis for restoration of limb length, is well described in the literature.48,104-107 advocates of this technique use it to treat large bone defects by creating an osteotomy at a site away from the fracture and transporting the existing bone into the defect.91 new bone forms at the osteotomy site, thus maintaining the length of the limb and avoiding bone grafting procedures.91 hutson et al. reviewed 19 grade iiib injuries treated with a protocol of multiple aggressive debridements followed by soft tissue reconstruction with rotational or free flaps, utilising monolateral halfpin external fixation.98 bone loss was managed with a temporary antibiotic spacer, followed by definitive fixation and bone transport with ilizarov circular external fixation. flap coverage was achieved on an average of 34 (range 12–77) days, and the ilizarov fixator was applied at an average of 23 (range 2–43) weeks post injury. there were no cases of non-union, infection or failed treatment with internal fixation. similarly, hohmann et al. reported good outcomes using a staged ‘road to union’ protocol in their management of complex and acute complex tibial fractures.108 a modification of this technique, which is well described by multiple authors, is the intentional shortening and/or deformation of the limb to achieve bony apposition as well soft tissue closure, decreasing or negating the need for soft tissue flaps.48,104,105,109,110 the length and/or deformity is then gradually corrected utilising either conventional ilizarov external fixation or hexapod external fixation. in most cases shortening is achieved after bony debridement of devitalised bone; however, the decision can be made to excise healthy bone to achieve soft tissue apposition and negate the need for a soft tissue flap, as described in the case series by nho et al.104 internal fixation vs external fixation intramedullary nailing (imn) and external fixation currently represent the most widely used methods of fixation after open fractures, with the use of plate fixation declining since the 1970s.111 giovannini et al. performed a meta-analysis of five randomised controlled trials comparing intramedullary nailing with external fixation in the management of open tibia fractures.111 the authors concluded that imn was more effective due to the lower rate of infection; however, the results of this analysis should be treated with caution as only five studies that included less than 250 patients were reviewed, monolateral and circular fixators were grouped together, and the description of fracture subtypes and complications was not uniform. bhandari et al. conducted a systemic review and meta-analysis on the treatment of open tibia fractures comparing various methods of skeletal fixation: plate fixation, external fixators, unreamed tibial nails and reamed tibial nails.70 they concluded that their study provided ‘compelling evidence’ that unreamed nails reduced the incidence of reoperations, superficial infections and malunions, when compared with external fixators. however, no mention was made of whether monolateral or circular external fixation was used, limiting the applicability of this evidence. it is well reported in the literature that monolateral external fixation results in a significantly higher rate of delayed union in open tibia fractures.92 foote et al. conducted a network meta-analysis using evidence from randomised trials, on the risk of unplanned reoperation of open fractures of the tibial diaphysis treated with various stabilisation devices.7 the secondary study endpoints included malunion, deep infection and superficial infection. they found that unreamed nail fixation was associated with a lower risk of reoperation compared with external fixation, and this was independent of the gustilo classification of the fracture. no conclusions could be drawn with regard to secondary endpoints. they noted that limitations of the 14 studies included a high risk of bias and poor precision in the conduct of the studies. inan et al. conducted a prospective study comparing unreamed tibial nailing (utn) with ilizarov external fixation in patients with grade iiia tibial fractures.92 their results showed that the ilizarov technique had a notable incidence of pin-site infection, joint contracture and shortening related to delayed union. the utn technique had the disadvantage of post-traumatic osteomyelitis and delayed union requiring additional surgery. the rate of union of ilizarov circular external fixation was similar to that of unreamed tibial nails. no further conclusion could be drawn with regard to which modality was superior. it is important to note that the type of tibial nail used in the study was not standardised, and that all the nails used were solid nails. the leap study group has been fundamental in expanding our understanding of the surgical and functional outcomes of open and closed tibia fractures. they reported a significantly higher rate of non-union and infection with external fixation compared to unreamed tibial nails, leading to unreamed tibial nails becoming the ‘gold standard’ for open tibia fractures.93 however, the leap study (similar to other studies mentioned previously) only included monolateral external fixators, which have very different biomechanical properties, and therefore different outcomes to circular frames.4 an important systematic review of the literature conducted by dickson et al. revealed that circular frames have higher union rates, and lower deep infection and reoperation rates, compared to other treatment modalities in open tibia fractures.4 at the recent international consensus meeting for musculoskeletal infections. a consensus statement regarding the optimal fixation method for open tibia fractures in terms of infection was released and stated that: ‘there is little to no difference in terms of infection rates for gustilo-anderson type i–ii treated with either circular external fixator, unreamed intramedullary nail or reamed intramedullary nail. for gustilo-anderson iiia–b fractures, circular external fixation appears to provide the lowest infection rates when compared to all other fixation methods’.94 this statement achieved the strongest consensus and was unanimously accepted by all attending delegates.94 to date no randomised control trial has been undertaken to compare circular external fixation with internal fixation in the management of these injuries. the modern ring external fixators versus internal fixation (fixit) study, is a prospective multicentre randomised control trial which will compare one-year outcomes after treatment of severe open tibia shaft fractures with modern external ring fixation versus internal fixation among men and women of ages 18–64 years.91 the primary outcome is rehospitalisation for major limb complications. secondary outcomes include infection, fracture healing, limb function, and patient-reported outcomes including physical function and pain. one-year treatment costs and patient satisfaction will be compared between the two groups, and the percentage of gustilo iiib fractures that can be salvaged without soft tissue flap among patients receiving external fixation will be estimated. the results of this study will shed further light on the preferred management of open tibia fractures. page 59manjra ma et al. sa orthop j 2019;18(4) timing of soft tissue management and definitive fixation although many authors tend to study these two treatment modalities in isolation, they are intricately entwined and should be seen as a single treatment entity. in the lower grade injuries, both these steps can and should be completed at the initial debridement. with higher-grade injuries, these modalities cannot be completed at initial debridement and temporary fixation with soft tissue dressings is utilised. these include monolateral external fixation and npwt. the current boast4 guidelines stipulate soft tissue closure within 72 hours and definitive fixation only when it can be followed immediately by soft tissue closure.45 this was based on the evidence report of the national institute of health and care excellence (nice).26 the literature used in this report to determine the timing of soft tissue cover and fracture stabilisation is, by their own admission, of very low quality. the main driver for their recommendation of early reconstruction was the theoretical reduction in hospital-acquired infections and tissue necrosis induced by prolonged wound exposure.69 the earliest proponent of this early (<3 days) definitive soft tissue closure was godina in his landmark study.47 he achieved an infection rate of 1.5% in a group of 134 patients where soft tissue reconstruction was achieved in less than 72 hours. other supporters of soft tissue reconstruction within 72 hours include hertel et al., gopal et al. and naique et al. with their ‘fix and flap’ protocol.51,53,69 other authors supported a more conservative approach where definitive soft tissue management can be delayed up to seven days after injury without adverse effects. cierny et al. compared infection rates in type iii injuries that had wound closure before or after seven days.112 they reported rates of 4% and 50% respectively. similar findings were also made by caudle and fischer et al.113,114 reporting on patients from the leap study, webb et al. and pollak et al. found no difference in infection rate patients with wound coverage less than three, four to seven or greater than seven days; however, there was a 32% incidence in flap complications in wounds covered after seven days.93,115 this finding was complemented by a study by d’alleyrand et al. who reported that the complication rate increased by 11% per day, and the infection risk by 16% per day after seven days, even after controlling for known risk factors for complications (such as injury severity), in patients treated with flap coverage for grade iiib open tibia fractures.101 in their study, mathews et al. made the same observation and directly commented on the boast4 guideline of completing the definitive management within 72 hours post injury.116 they found much improved rates of deep infection where definitive soft tissue and skeletal management was completed at the same surgical setting rather than both being completed within the 72-hour guideline (4.2% vs 34.6%). learning points • grade i, ii and iiia injuries can be safely treated with reamed or unreamed intramedullary nailing. • grade iii (b and c) injuries should rather be treated with circular external fixation to mitigate the risk of infection. • circular external fixators can be used to aid in soft tissue cover/ healing to avoid the use of soft tissue flaps. • temporary external fixation when used should be limited to less than 14 days. • aim to obtain soft tissue cover within seven days. south african context: issues to consider results and recommendations from international studies need to be adapted to our local context. orthopaedic units within public hospitals manage a large trauma burden. this, in conjunction with a constrained resource pool, does not always lend itself to the ideal management pathway for open tibia fractures. despite literature indicating that emergency theatre debridement is not needed, limited resources often prevent patients from receiving their first debridement within 24 hours of their injury. because of this, patients must utilise theatre when it becomes available. this means that open fracture debridement sometimes happens after hours, by an inexperienced surgeon. due to an even greater shortage of plastic surgeons in south africa, orthoplastics units dedicated to the management of musculoskeletal injuries, do not exist. south africa has one of the highest prevalence of hiv infection in the world. hiv infection causes a decline in the cd4 (t helper cell) count, resulting in impaired immunity, hence one would expect to see a higher rate of infection in hiv-positive patients.117 harrison et al. conducted three studies relevant to this topic: a prospective study of open tibia fractures comparing hiv-positive and -negative patients; a prospective study of internal fracture fixation including cases in open fractures comparing wound infection for hivpositive and -negative patients; and a prospective study of pin-tract sepsis comparing hiv-positive and -negative patients.117,118 they found that rates of infection were higher in hiv-positive patients; internal fixation of open tibias was associated with a higher risk of infection; hiv was associated with delayed union; and that hivpositive patients had a higher rate of pin-tract sepsis with the use of external fixation.118 however, there are a number of factors limiting the validity of their findings: the presence of confounding factors such as smoking, nutrition, small patient number in all the studies and, probably most importantly, cd4 count. these studies were undertaken long before the advent of antiretroviral therapy, and it is plausible that an hiv-infected patient with a normal cd4 may be treated as immune competent.118 recent evidence indicates there is no association between hiv status and surgical outcome unless the cd4 count is below 350 cells/ml.119-122 it is therefore suggested that hiv status should not influence the management of open tibia fractures.120 patient demographics, and specifically home circumstances, are important factors to consider especially when deciding the optimal form of skeletal fixation. patients with poor socioeconomic circumstances may not be able to cope with labour-intensive circular fixators or may not be able to return timeously for follow-up. a peculiar circumstance is patients not being able to access public transport either logistically from not being able to fit into a crowded taxi, or not being allowed onto a taxi due to misunderstanding and the stigma associated with the fixator. this can be overcome by prolonged inpatient stays; however, this contributes to overcrowded public hospital wards and rising inpatient expenses. in the private sector, surgeons working in remote areas may not have immediate access to the same devices and implants as central areas, or may not deal with a sufficient volume of cases to be familiar with them. the availability of plastic surgical cover in these areas, as in the public sector, is also variable. devices available to surgeons in the private sector may also be governed in part by funders/medical aids. conclusion open tibia fractures remain challenging injuries to treat. early intravenous antibiotic therapy continues to be one of the most important modifiable risk factors for infection. local antibiotic beads are an effective adjunct, particularly in grade iii injuries. the importance of a thorough and meticulous debridement cannot be overstated. while the traditional method of longitudinal extension of the traumatic wound along fasciotomy lines remains standard page 60 manjra ma et al. sa orthop j 2019;18(4) practice, the use of a transverse incision or a defined surgical approach can be equally effective in select cases. costly highpressure lavage modalities have no benefit over low-cost irrigation with saline and should be avoided, especially in the context of a cost-conscious public health system. soft tissue closure should not be unnecessarily delayed if the soft tissues are amenable. definitive soft tissue coverage should aim to be completed within seven days of injury. negative pressure wound dressings are a valuable adjunct in soft tissue management prior to definitive wound coverage. while imn is effective in grade i and ii injuries, strong consideration should be given to the use of circular external fixation in high energy grade iii injuries, especially in the setting of bone and soft tissue loss. while awareness of the best clinical practice and protocols is essential, adaptation to the local context is equally important. large trauma loads, coupled with constrained resources and personnel, often make internationally accepted time frames for treatment unrealistic. public hospitals are forced to utilise theatre time at whatever time it becomes available. fixation devices need to be adapted to these possibly delayed treatment time frames as well as to patient demographics, and cultural and socioeconomic circumstances. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. ethical approval for this study was not obtained – review article. declarations the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. orcid m manjra http://orcid.org/0000-0002-4411-5921 t basson http://orcid.org/0000-0003-1686-9862 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observational case series of hiv-positive patients treated with open reduction internal fixation for a closed lower extremity fracture. eur j orthop surg traumatol. 2015;25(5):815-19. 122. phaff m, aird j, rollinson pd. delayed implants sepsis in hiv-positive patients following open fractures treated with orthopaedic implants. injury. 2015;46(4):590-94. _goback 404 not found orthopaedics vol3 no4 sa orthopaedic journal winter 2017 | vol 16 • no 2 page 19 management of osteogenesis imperfecta at the chris hani baragwanath hospital go oduah mbbs, fc orth(sa), mmed(orth)(wits) honorary lecturer, division of orthopaedic surgery gb firth mbbch, fcs orth(sa), mmed(orth)(rand) division of orthopaedic surgery, chris hani baragwanath academic hospital jm pettifor mbbch, fc paed(sa), phd(med) department of paediatrics and mrc/wits developmental pathways for health research unit, chris hani baragwanath academic hospital k thandrayen mbbch, fcpaed(sa), mmed, phd, certificate in endocrinology and metabolism (paeds) department of paediatrics, chris hani baragwanath academic hospital all of the faculty of health sciences, university of the witwatersrand, johannesburg, south africa corresponding author: dr go oduah po box 30728 2017 braamfontein johannesburg south africa tel: +27 834 700 912 email: george.oduah@gmail.com abstract background: osteogenesis imperfecta (oi) is a genetically inherited metabolic bone disorder that results in multiple fractures and deformities in children. the treatment of oi has undergone tremendous improvement in the last two decades worldwide. aims: to review the clinical presentation and management of fractures in children with oi. methods: a retrospective audit of patients treated for oi at chris hani baragwanath academic hospital (chbah), from january 2000 to december 2011 was performed. results: seventy-eight patients with oi were reviewed. the male to female ratio was 1:1.1. the median age at presentation was 20 months. the patients were classified according to the sillence classification. thirty-four patients were type iii and 22 were type iv. twenty patients (26%) had a first degree relative with oi. the majority of patients received bisphosphonate (88%) and of these patients, 69 (93%) received intravenous bisphosphonate therapy; the remaining 7% received oral bisphosphonates. the most common long bone fractures were of the femur (93 fractures) and tibia (60 fractures). sixty-six long bones (49 patients) received intramedullary rodding (im). the mean age at time of surgery was 7 years. the indication for osteotomy and im rodding was fracture of the long bones. fifty-one long bones out of the 66 long bones rodded (77%) underwent revision surgery for complications – 49% (25/51) had rod migration, 39% (20/51) had peri-implant fractures and 12% (6/51) had rod breakage. of 27 patients with type iii oi, 14 (52%) were walking at final follow-up – eight were walking with assistive devices and six (22%) were walking independently. of 19 patients with type iv oi, 16 (84%) were walking at final follow-up – four were walking with an assistive device and 12 (63%) were walking independently. conclusion: an ongoing multidisciplinary approach to the management of children with oi is of paramount importance. there is an urgent need to improve the level of awareness of this rare condition among health professionals in order to facilitate prompt diagnosis and early referral. key words: osteogenesis imperfecta, south africa, intramedullary rodding, fractures, mobility http://dx.doi.org/10.17159/2309-8309/2017/v16n2a1 page 20 sa orthopaedic journal winter 2017 | vol 16 • no 2 introduction the first scientific description of osteogenesis imperfecta (oi) was provided by the swedish army surgeon olaus jakob ekman in 1788.1 in his doctoral thesis entitled ‘congenital osteomalacia’, ekman described hereditary bone fragility in three family generations.2 vrolik in 1849 was the first to coin the term ‘osteogenesis imperfecta’ meaning abnormally formed bone.1,3 the presence of wormian bone mosaic of the skull, abnormal teeth colourations and bowed legs in an egyptian mummy from 1000 bc suggests that the disease has been with man since ancient times.3 oi has been described in every race and continent of the world. the prevalence of oi is approximately 16 cases per million index patients.3 the major clinical manifestations of oi are frequent, multilevel fractures that cause limb deformities. frequent fractures resulting from bone fragility lead to malunion and bowing, which render the bone more prone to recurrent fractures. the bowing of bone may occur even in the absence of a fracture or in the presence of multiple microfractures. musculoskeletal abnormalities are typically as a result of defects in types ia1 or ia2 collagen, which is the primary component of the protein matrix in bone, tissues and organs. bone tissue anomalies are the most visible manifestation of oi.3 a recent study has shown the importance of the compromised metabolic pathway of collagen, thus highlighting the heterogeneity of the different types of oi described.1,4 the main objectives of the surgical treatment of oi are to reduce disability and correct deformity, to enable the child to achieve relative independence in activities of daily living, and to attain the greatest degree of mobility possible.3 the aims of this study were to assess the clinical presentation, fracture incidence, and medical and surgical management of these patients at the chris hani baragwanath academic hospital (chbah), soweto, south africa. materials and methods a retrospective audit of patients treated for oi was done using an existing cohort of patients in the paediatric department (metabolic bone clinic) at chbah, from january 2000 till december 2011. all the information was retrieved from the hospital files and from the stored radiographs of each patient. the information that was gathered from the hospital file included demographic data, clinical presentation, age at initial fracture, total number of fractures, type of treatment received, and mobility status at final follow-up. the data collection sheet also included details of the complications of surgical interventions such as rod migration, re-fracture and re-operations. the diagnosis of oi was made based on clinical and radiological features assessed by consultants in the field of paediatric metabolic bone disease and confirmed by the paediatric orthopaedic surgical team. two patients with insufficient medical records were excluded from further data analysis. data was entered into microsoft excel spreadsheets and subsequently imported into statistica statistical software version 10.0 (statsoft, usa). parametric, continuous variables were described using means and standard deviations. medians and interquartile ranges were used for non-parametric data. student-t tests or mann-whitney u tests were used to detect significant differences. categorical variables were described using frequencies and percentages. p values were obtained using chi-square or fisher’s exact tests. the study was approved by the university of the witwatersrand’s human research ethics committee (ethics approval number: m120415). results a total of 78 patients were seen within the period under review. the majority of patients were of black (90%) ethnicity followed by white (5%), mixed ancestry (4%) and indian (1%). the median age at presentation was 20 months (iqr 0–48). the male to female ratio was 1:1.1 (37 males and 41 females). twenty patients (26%) had a positive family history of a first degree relative with oi of which one of the patients was from a consanguineous marriage. the majority of the patients (59%) were from gauteng. three patients came from other southern african countries. thirty-seven patients (48%) were referred by local and regional clinics, 14 (18%) by paediatricians and 11 (14%) by orthopaedic surgeons. the referring health care professionals were not documented in 16 (20%) of the patients’ records. most of the patients in our series presented with the typical features of oi. these included blue sclerae in 52.6% (41 patients). figure 1 illustrates blue sclera in a two-year-old female child with type iii oi. dentinogenesis imperfecta was seen in 26.7% (21 patients). triangular facies were seen in 50.0% (39 patients). the other features included recurrent fractures (figure 2) and lower limb deformities in 66.7% (52 patients). figure 1. photograph illustrates blue sclera and triangular face in a two-year-old female child with type iii osteogenesis imperfecta sa orthopaedic journal winter 2017 | vol 16 • no 2 page 21 the patients were classified clinically using the original sillence classification, and the number and percentages of each type of oi are shown in table i. the majority of patients in this study were classified as type iii and type iv: 38 (48.7%) and 23 (29.5%) patients respectively. thus, the more severe types of oi were seen at the metabolic bone clinic. there were no patients with type ii oi as the patients were collected from the metabolic bone clinic and did not include patient records of those seen as inpatients in the neonatal wards. at presentation 49% of the patients had achieved ageappropriate milestones. of the different types of oi, only type iii had a smaller number of patients (33%) that had achieved age-appropriate milestones (p=0.03) while 50%, 52% and 100% of patients with bruck syndrome, type iv and type i oi respectively had achieved age-appropriate milestones. the mean duration of follow-up was lower in type i (1.8 years [sd ±1.2]) and type iii (2.6 years [sd ±1.8]) oi patients compared to type iv (4.2 years [sd ±2.4]) and patients with bruck syndrome (4.9 years [sd ± 2.7], p<0.05 between type i and iv; p<0.01 between type i and bruck syndrome). patients with bruck syndrome had the longest duration of follow-up and this was significantly greater compared to type i (p<0.01) and type iii (p<0.01) oi patients. the total number of fractures from first reported fracture to the last clinic visit assessed by the researchers, was available for 65 patients. the average number of fractures from the first reported fracture till the last clinic visit differed according to the type of oi (table i), and the duration of follow-up for individual patients also varied. the average fracture rate over the first 18 years of life for all types of oi patients was 174.6 fractures/year per 1 000 persons and for types iii and iv, the rates were 201.4 and 175.9 fractures/year per 1 000 persons. figure 3 shows the fracture rates per year for all types of oi and type iii and type iv oi only. fracture rates were highest in the first 6 years of life. as shown in table ii, type iii oi patients had the highest average number of fractures compared to the other types of oi, and this was significantly greater compared to type iv and bruck syndrome (p<0.05 and p<0.01 respectively). the greatest number of fractures occurred in the long bones of the lower extremities. the femur was the most frequent site of fracture followed by the tibia/fibula, then the upper extremities combined, and thereafter the ribs and lastly the spine (figure 4). the majority (88%) of the patients received bisphosphonates. the indications for bisphosphonates were at least two or more long bone fractures and/or at least one vertebral fracture. sixty-nine patients (93%) received intravenous bisphosphonate therapy and only five patients received oral bisphosphonates (alendronate or fosamax). figure 2. radiograph of a five-year-old child with type iii oi illustrating a transverse fracture of the right femur and bowing deformity of both femurs. note the malunited fractures of both femurs and the transverse dense metaphyseal bands (‘zebra lines’) as a result of bisphosphonate use. table i: frequency of the various types of osteogenesis imperfecta type of oi frequency (n=78) type i 9 (11.5%) type ii 0 (0%) type iii 38 (48.7%) type iv 23 (29.5%) bruck syndrome 8 (10.3%) 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 age of fracture 0 200 400 600 800 1000 1200 1400 1600 1800 2000 a nn ua l f ra ct ur e r at es p er 1 00 0 pe rs on s all groups type iii type iv figure 3. annual fracture rates for types iii, iv and all types of oi page 22 sa orthopaedic journal winter 2017 | vol 16 • no 2 aredia or pamidronate was the intravenous bisphosphonate therapy available for patients from 2005 until 2007 and thereafter zoledronic acid or zometa was readily available. there was only one adverse event reported in one patient of severe myalgia that occurred post intravenous administration of zometa. all the patients received non-operative treatment (plaster of paris [pop], longitudinal skin traction, and gallows’ traction) at some stage during their fracture management, either temporarily pre-operatively or definitively if surgery was contraindicated. sixteen patients received only non-operative treatment (figure 5). sixty-six long bones (49 patients) received intramedullary rodding. the mean age at time of surgery was 7 (sd ±2.6) years. the youngest age at rodding was 3 years and the oldest child was aged 14 years. the indications for im rodding were repeated fractures of the same long bone and osseous deformities or a combination of osseous deformities and acute fractures. the complications of im rodding seen in our series included rod migration (proximal and distal migration with or without tenting of the skin), rod breakage (with or without associated fractures) and peri-implant fractures. there were no infections. a total of 51 long bones out of the 66 long bones rodded underwent single or repeated revisions for different indications. in 25 (49%) of these long bones, surgery had to be repeated because of rod migration. another 20 (39%) of these long bones had peri-implants fractures and in six (12%) rod breakage occurred. a summary of rod revision is shown in figure 6. further analysis on a subset of these patients was performed to identify specific factors associated with the final mobility status of the patients. fifty-eight patients were analysed for mobility. the following factors were recorded: whether they were walking (assisted or independent) or not, whether surgery was performed, and the type of oi. there were only three patients with type i oi and they were all walking independently at final follow-up. of 27 patients with type iii oi, 14 (52%) were walking at final follow-up – eight were walking with assistive devices and six (22%) were walking independently. of 19 patients with type iv oi, 16 (84%) were walking at final follow-up – four were walking with an assistive device and 12 (63%) were walking independently. table ii: average number of fractures in the different types of oi type of oi average number of fractures (sd)† type i (n=6) 2.2 (0.75) type iii (n=36) 3.2 (1.5) type iv (n=16) 2.3 (1.0)* bruck syndrome (n=5) 1.3 (0.7)** * <0.05 between type iii and iv and ** p<0.01 between type iii and bruck syndrome † average number of fractures is calculated based on the number of fractures in each child from the first time of a recorded fracture till last recorded visit and divided by the duration of follow-up (in years) during that time period. thereafter the average number of fractures for each group/type of oi was calculated. figure 4. illustration of the number of fractures in various parts of the body ribs spine humerus radius/ ulna femur tibia/ fibula 100 90 80 70 60 50 40 30 20 10 0 n u m b er o f fr ac tu re s site of fractures figure 5. flow diagram for fractures and intramedullary rodding n=78 65 data available 13 data inavailable 49 patient (66 long bones) intramedullary rodding 16 patients non-operative treatment total number of patients reviewed availability of fracture data fracture treatment figure 6. flow chart of reasons for rod revision 66 long bones 51/66 (77%) revisions 15/66 (23%) no revisions 25/51 rod migration 20/51 peri-implant fracture 6/51 rod breakage total number of inital im rodding revisions vs no revisions ccomplications/ reason for revision sa orthopaedic journal winter 2017 | vol 16 • no 2 page 23 of seven patients with bruck syndrome, only one (14%) was walking with an assistive device at final follow-up. there was no statistically significant association between all types of oi and walking whether surgery was performed or not. the age at first fracture was also not found to be significant regarding the final ability to walk or not as most patients were type iii or iv. finally, the number of total fractures was not associated with whether the patient was able to walk or not at final follow-up. discussion to our knowledge, this study is the first to investigate the clinical presentation and surgical management of children with oi in south africa. this study has one of the largest numbers of patients in a single series comprising a total of 78 patients. the majority of patients (59%) were from gauteng where the study was conducted while three patients came from the neighbouring countries of malawi and zimbabwe, highlighting the scarcity of specialist clinics treating oi. the health care sectors in these countries are plagued with lack of geographic and financial accessibility and in some cases non-availability of quality health care.5 the male to female ratio of oi was 1:1.1 (37 male and 41 female), indicating no gender predilection. lin et al. reported a male to female ratio of 1:2 (15 male and 33 female).6 patel et al.7 and plotkin et al.8 showed similar sex ratios to the current study with 1:1.3 and a 1:0.9 male to female ratio respectively. twenty patients (26%) in the current study had a positive family history of a first degree relative with oi. other studies have reported a higher percentage of a positive family history (40.3% and 46%).7,9 the majority of patients in this study were type iii compared to the other studies where the majority of patients were type iv (9) and type i (7). the median age at presentation was 20 months and less than 11% of cases were diagnosed in the first year of life. greeley et al. reported that 25% of infants were diagnosed before one year of age at the shriners children’s hospital in canada, an international orthopaedic referral centre which is a large referral centre for large parts of canada, us and mexico; thus, they are likely to be referred the severe forms presenting early.9 all the patients in this study were diagnosed and classified according to the sillence classification by the presence of clinical characteristics. greeley et al. in 2013 diagnosed 72% of their patients from clinical characteristics9 and suggested that special tests such as genetic and fibroblast testing are not necessary for the diagnosis of the majority of patients.9 in south africa, genetic testing is not readily available and the diagnosis of oi is based on the family history, clinical presentation and radiological findings. the majority of the patients in the current series were type iii (48.7%) and type iv (29.5%). in the study done by greeley et al., the majority of their patients were type i (34%) and type iv (35%),9 similar to findings in taiwanese children with oi (type i [40%] and type iv [40%]).6 a recent crosssectional multi-centre study of oi revealed that type i was the most prevalent type (49%), followed by types iv (27%) and iii (18%).7 it is possible that the smaller number of patients with type i oi presenting to chbah reflect the fact that the diagnosis is missed in many of these individuals who are mildly affected and are more likely to be seen at primary and secondary health care facilities in south africa where an inadequate medical and family history is obtained without referral to the specialist oi clinic. more fractures occurred in the long bones of the lower extremities. the femur and tibia comprised more than 60% (93 femur fractures and 60 tibia fractures) of the total fractures. this is expected in the ambulant oi child, as these are the major weight-bearing bones of the body. greeley et al. noted that the most common fractures at diagnosis were extremity fractures seen in 32% of patients.9 the average number of fractures was highest in type iii oi patients, which was significantly higher than in type iv (p<0.05) and bruck syndrome (p<0.01) patients. a meaningful comparison could not be made between types i and iii due to the small number of patients in the type i group of patients. these findings are similar to the crosssectional multicentre study of oi in north america.7 since all the patients were on bisphosphonate therapy, it was not possible to demonstrate the efficacy of bisphosphonates in this study, as there was no control group for comparisons. sixty-six long bones (49 patients) received intramedullary rodding. of these, the majority (96%) were william’s rods and the remaining 4% were fassier-duval (fd) telescoping rods. the smaller number is due to the recent introduction of fd rods for selected cases of femur fractures in children with good growth potential who were walking prior to the fracture. zionts et al. reported that elongating nails in the tibia were associated with a higher incidence of major complications compared with those of the femur,10 thus elongating rods at chbah are the choice of im rod for femurs only. in this study, the mean age at time of im rodding surgery was 7 years. long bone fractures in children younger than two years of age were treated non-operatively because of the technical difficulties associated with the procedure. the incidence of complications has been shown to be higher by zionts et al. in children less than five years of age when im rods are implanted.10 in the current study, only 16% of patients were under five years of age at the time of surgery and they have all had at least a single revision at the time of this report. the complications of im rodding seen in the current series was 77%. if followed up for long enough non-lengthening rods in growing children will result in complications in most if not all patients that will necessitate revision surgery. most of the complications of im rodding documented in the literature are on extensible rods therefore a direct comparative analysis with our study is not possible as only 4% of patients in the current study received fassier-duval rods. nonetheless the documented complication rates for these extensible rods remain equally high. zionts et al. documented a 100% complication rate with bailey-dubow page 24 sa orthopaedic journal winter 2017 | vol 16 • no 2 extensible rods.10 lang-stevenson and sharrard11 and gamble et al.12 reported complication rates of 64% and 69% respectively with use of bailey-dubow extensible rods. recent reports by lee k et al. highlight the risk of proximal rod migration in 14% of 50 cases using a telescopic rod13 and, in another paper, lee rj et al. highlight the problem of telescopic rod bending being an early sign of impending rod failure in 33% of 51 telescopic rods.14 despite the high rate of revision surgery, long-term benefits of im rodding outweigh the risks. it is difficult to evaluate the apparent benefits as it is considered unethical to deny patients im rodding if surgically and medically indicated and thus no comparative group was available. mobility in oi children after treatment is not very well documented in the literature. in 1985 shapiro showed that the age at initial fracture determined final mobility status in these children for all types of oi.15 in the current study, we found no difference in age at initial fracture and the final mobility status. this reflects the current cohort consisting of a homogenous group of mainly types iii and iv. ruck et al. showed that the use of the fassier-duval rod combined with bisphosphonates in a group of 60 children with oi improved ambulation, gross motor function, selfcare and mobility at one year follow-up.16 hoyer-khun et al. showed that a specialised rehabilitation approach, which included whole body vibration training, physiotherapy, resistance and treadmill training, improved mobility in these children.17 montpetit et al. used the pediatric evaluation of disability inventory to highlight the importance of improving the functional status of patients with type iii oi who were often dependent for all areas at final follow-up in comparison to patients with type iv who were more often independent.18 this study was unable to show significant differences in independent walking between the different types of oi patients whom were operated on or not as the majority of these patients were type iii and iv oi patients presenting with more severe disease. the importance of quality of life (qol) in oi patients was highlighted by dahan-oliel et al. who reviewed ten studies and found that mental and social qol was unaffected in these populations but that qol was affected by pain, scoliosis activity limitations and participation restrictions.19 all of these studies highlight the importance of achieving maximal mobility at final follow-up by means of a multi-disciplinary approach. the main limitation of this study was that it was a retrospective cohort study with the associated inherent problems of a retrospective study. the strength of the study is the large number of patients that were studied from a large geographic region, treated with the same protocol. conclusion this paper consists of a group of more severe oi patients, namely type iii (48.7%) and type iv (29.5%) who received bisphosphonates and surgery. despite the severity of the patients in this cohort, 52% of patients with oi type iii and 84% of patients with oi type iv were walking at final follow-up. there is an urgent need to improve the level of awareness of this rare condition among health professionals in order to facilitate prompt diagnosis and early referral. acknowledgements we wish to acknowledge and thank professor ajf robertson, head of paediatric orthopaedics, charlotte maxeke johannesburg academic hospital, for his ongoing surgical input and intellectual support in the management of these oi patients, and valuable comments to the final draft of this paper. in addition, we are very thankful to the staff of the paediatric metabolic bone unit of chris hani baragwanath academic hospital for their continuous support and management of these patients with oi. compliance with ethics guidelines the study was approved by the university of the witwatersrand’s human research ethics committee (ethics approval number: m120415). no benefits of any form have been received from a commercial party related directly or indirectly to the subject of this article. references 1. burnei g, vlad c, georgescu i, gavriliu ts, dan d. osteogenesis imperfecta: diagnosis and treatment. j am acad orthop surg 2008;16(6):356-66. 2. peltier lf. the classic: congenital osteomalacia. ekman oj. clin orthop rel res 1981;159:3-5. 3. kocher ms, shapiro f. osteogenesis imperfecta. j am acad orthop surg 1998;6(4):225-36. 4. forlino a, marini jc. osteogenesis imperfecta. lancet, 2016. 387(10028):1657-71. 5. peters dh, garg a, bloom g, walker dg, brieger wr, rahman mh. poverty and access to health care in developing countries. ann n y acad sci 2008;1136:161-71. 6. lin hy, lin sp, chuang ck, chen mr, chang cy, niu dm. clinical features of osteogenesis imperfecta in taiwan. j formos med assoc 2009;108(7):570-76. 7. patel rm, nagamani sc, cuthbertson d, campeau pm, krischer jp, shapiro jr, et al. a cross-sectional multicenter study of osteogenesis imperfecta in north america – results from the linked clinical research centers. clin genet 2015;87(2):133-40. 8. plotkin h, rauch f, bishop nj, montpetit k, ruck-gibis j, travers r, et al. pamidronate treatment of severe osteogenesis imperfecta in children under 3 years of age. j clin endocrinol metab 2000;85(5):1846-50. 9. greeley cs, donaruma-kwoh m, vettimattam m, lobo c, williard c, mazur l. fractures at diagnosis in infants and children with osteogenesis imperfecta. j pediatr orthop 2013;33(1):32-36. 10. zionts le, ebramzadeh e, stott ns. complications in the use of the bailey-dubow extensible nail. clin orthop rel res 1998;(348):186-95. sa orthopaedic journal winter 2017 | vol 16 • no 2 page 25 11. lang-stevenson ai, sharrard wj. intramedullary rodding with bailey-dubow extensible rods in osteogenesis imperfecta. an interim report of results and complications. j bone joint surg br 1984;66(2):227-32. 12. gamble jg, strudwick wj, rinsky la, bleck ee. complications of intramedullary rods in osteogenesis imperfecta: bailey-dubow rods versus nonelongating rods. j pediatr orthop 1988;8(6):645-49. 13. lee k, park ms, yoo wj, chung cy, choi ih, cho tj. proximal migration of femoral telescopic rod in children with osteogenesis imperfecta. j pediatr orthop 2015;35(2):178-84. 14. lee rj, paloski md, sponseller pd, leet ai. bent telescopic rods in patients with osteogenesis imperfecta. j pediatr orthop 2015 [epub ahead of print]. 15. shapiro f. consequences of an osteogenesis imperfecta diagnosis for survival and ambulation. j pediatr orthop. 1985 jul-aug;5(4):456-62. 16. ruck j, dahan-oliel n, montpetit k, rauch f, fassier f. fassier–duval femoral rodding in children with osteogenesis imperfecta receiving bisphosphonates: functional outcomes at one year. j child orthop. 2011 jun;5(3):217-24. doi: 10.1007/s11832-011-0341-7. epub 2011 may 8. 17. hoyer-kuhn h, semler o, stark c, struebing n, goebel o, schoenau e. a specialized rehabilitation approach improves mobility in children with osteogenesis imperfecta. j musculoskelet neuronal interact 2014;14(4):445-53. 18. montpetit k, palomo t, glorieux f, fassier f, rauch f. multidisciplinary treatment of severe osteogenesis imperfecta: functional outcomes at skeletal maturity. arch phys med rehabil. 2015;96(10):1834-39. 19. dahan-oliel n, oliel s, tsimicalis a, montpetit k, rauch f and dogba mj. quality of life in osteogenesis imperfecta: a mixed-methods systematic review. am j med genet a. 2016;170a(1):62-76. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj uct clinical fellowships the uct department of orthopaedic surgery offers saoa-accredited clinical fellowshipson an annual basis. these 12-month fellowships are for orthopaedic surgeons (and neurosurgeons in the case of spine) who have completed their postgraduate training and achieved the fcs orth. they are offered in spine, upper limb, lower limb arthroplasty and trauma. the trauma fellowship is focused on the fellow’s particular area of interest. all fellowships are based on both public and private experience. the fellows are integrated into the department with service, research and teaching expectations. for more information please contact mrs priest, email: bernadette.priest@uct.ac.za or tel: 021 4045108 wood l et al. sa orthop j 2018;17(2) doi 10.17159/2309-8309/2018/v17n2a8 south african orthopaedic journal http://journal.saoa.org.za paediatric orthopaedics citation: wood l, firth gb, potterton j. short-term outcomes of single event multilevel surgery for children with diplegia in a south african setting. sa orthop j 2018;17(2):44–48. http://dx.doi.org/10.17159/2309-8309/2018/v17n2a8 editor: dr lc marais, university of kwazulu-natal received: may 2017 accepted: october 2017 published: may 2018 copyright: © 2018 wood l. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: this study was partially funded by a grant awarded to joanne potterton by the national research foundation of south africa (nrf). conflict of interest: all authors declare that they have no conflict of interest with respect to the writing of this article. abstract background: although single event multilevel surgery (semls) is well supported in the literature for walking children with cerebral palsy (cp) there is little evidence to show the outcomes in developing countries with limited resources. further there is no literature reporting on the use of semls in walking children with hiv encephalopathy (hive). the primary aim of this study was to investigate whether semls can have good short-term outcomes in a south african setting, and the secondary aim was to compare the outcomes of semls in children with diplegia secondary to cp and hive. methods: a prospective cohort study of ten children with spastic diplegia was enrolled (six with cp, four with hive) and followed up for 12 months. all children underwent semls and received peri-operative therapy at a local clinic, hospital or a special-needs school. the primary outcome measures were the edinburgh visual gait score (evgs), gross motor function measure-66 (gmfm-66) and the functional mobility scale (fms) measured pre-operatively (t1), at six months (t2) and at one year (t3). results: there was an overall mean improvement of 6.4 in the evgs and 3.2% in the gmfm-66 at the one-year follow-up assessment. the fms revealed an initial deterioration in function at six months, with return to pre-operative function at the one-year assessment. improvements in the gmfm-66 were found to be clinically significant. when comparing children with cp to those with hive the improvements were similar. conclusion: the results of this study indicate that the early outcomes of semls in a south african setting, with scarce resources, are similar to those seen in developed countries. it may also be possible to use the same semls treatment principles seen in the management of children with cp for children with static hive. further follow-up is however needed in both of these areas level of evidence: level 4 key words: short-term outcomes, single event multilevel surgery, children, diplegia short-term outcomes of single event multilevel surgery for children with diplegia in a south african setting wood l¹, firth gb², potterton j³ 1 bsc physio (wits), msc physio (wits); department of physiotherapy, university of the witwatersrand 2 mbbch, fcs(orth)sa, mmed(orth); orthopaedic surgeon, chris hani baragwanath academic hospital, department of orthopaedic surgery, university of the witwatersrand 3 phd; associate professor, department of physiotherapy, university of the witwatersrand corresponding author: dr gb firth, university of the witwatersrand, 7 york road, johannesburg, 2193, gauteng, south africa; email: greg.firth@gmail.com; tel: +27826633299 page 45wood l et al. sa orthop j 2018;17(2) introduction single event multilevel surgery (semls) is the current preferred orthopaedic management of ambulant children with cerebral palsy (cp) in developed countries.1-4 semls by definition is when two or more orthopaedic procedures are being performed on the musculoskeletal system, at more than one level, at the same time.2,5,6 the benefits of semls include one hospital admission, one rehabilitation period and the prevention of further secondary deformities.6 bearing in mind that the natural progression for the walking child with cp is a regression in gross motor function,7,8 the aim of semls is to improve gait efficiency and appearance, gross motor function, independence and quality of life9 and to maintain the child’s ability to walk into adulthood. semls does not improve the gross motor function classification system (gmfcs) of the child but attempts to maintain it into adulthood.1,2 current literature reveals that the gait, functional ability and quality of life does improve at a oneand fiveyear follow-up after semls9,10 despite an initial regression in gmfcs level at three months post-surgery.11 with the majority of the research being conducted in developed countries there is little evidence to support the value of semls in children with cp in developing countries. the discrepancy in resources, namely financial, skills and therapy, available in developing countries in comparison to developed countries leads to the need to investigate the effect that this paucity of resources has on the outcomes of the surgery. the lack of resources can lead to the late diagnosis and treatment of children with cp resulting in an altered clinical picture with increased contractures and secondary complications.12 the evidence for successful outcomes of semls in developing countries is limited.12 the high prevalence of human immunodeficiency virus (hiv) in sub-saharan africa13-15 and the subsequent development and use of antiretroviral therapy (art) has resulted in a population of children with associated sequelae who have previously not been treated and managed. hiv encephalopathy (hive) is the most commonly seen neurological complication in hiv.16 hiv is neurotrophic, and infected monocytes are able to cross the immature blood brain barrier. the central nervous system (cns) may be infected in utero, perinatally or postnatally. unlike cp, damage to the cns is then progressive as the virus replicates. the most clinically useful definition of hive is the failure to gain milestones, or the loss of previously acquired milestones or cognitive abilities verified by standardised developmental and neuropsychological scales.17 children with hive frequently present with bilateral hyperreflexia.17 many children with hive on art present with a static encephalopathy, and clinically present very similarly to those with spastic diplegic cp.13 these patients with hive are often weaker and present with a jump gait pattern in our experience. despite the similar clinical presentation between the two groups there is no evidence showing the appropriate surgical management of children with hive using semls techniques. the primary aim of this study was to investigate whether semls could have good short-term outcomes in a south african setting, and the secondary aim was to compare the outcomes of semls in children with diplegia secondary to cp and hive. taking into account the high prevalence of hive in the population of children presenting with spastic diplegia at large academic hospitals in south africa, we determined that this population needed to be included in the study in order to get a true reflection of the population served by the hospital and to see what the outcomes of semls were for this population of children presenting with similar clinical features to the children with cp diplegia. materials and methods the parents of all the children gave their consent for them to participate in the study. ethics approval was granted by the human research and ethics committee and the local hospital board (clearance number m120907). all children and their parents were given information sheets with an attached consent and assent form. a cohort of the first ten patients was included in the study. participants all children referred by the surrounding clinics, special needs schools and primary health care facilities in different districts presenting with spastic diplegic cp or spastic diplegia as a result of hive with gmfcs level ii or iii, were assessed for inclusion in the study. children were included if they were between the ages of 6 and 18 years, were able to follow two-part instructions and could walk at least 10 m with or without an assistive device. furthermore, they were required to be able to attend weekly follow-ups at their regular place of therapy post surgery. children were excluded if they presented with hemiplegic or quadriplegic cp, if they had an unconfirmed diagnosis or if they had received orthopaedic surgery or botulinum toxin within the previous six months. children were also excluded if they were hiv positive, and had not been receiving art for at least one year, or if they their cd 4 count was less than 300, or if they had high viral loads, above 1 000 copies/ml. pre-operatively six children were gmfcs level ii (one hiv positive) and four children were gmfcs level iii (three hiv positive). the mean age at the time of surgery was nine years ten months (sd = two years four months, range 6–14 years). there were 5.8 surgical procedures per patient on average. fifty-eight procedures were performed, which included 14 proximal femur derotation osteotomies, two psoas lengthenings, eight adductor releases, 18 medial hamstring lengthenings, eight semi-tendinosis transfers, six strayer procedures and two metatarsophalangeal joint fusions. outcome measures assessments on all children were done at three time intervals: preoperatively (t1), at six months (t2) and one year post-operatively (t3). the edinburgh visual gait score (evgs), which is valid and reliable,18,19 was used to assess the gait. the tool is scored according to the deviation of the gait pattern from normal. the gait pattern is assessed on videos taken from both the coronal and sagittal views. a greater evgs score indicates a larger deviation from normal gait. the videos were copied onto a disk and given to a second orthopaedic surgeon, with more than five years’ experience, to score according to the evgs guidelines. the date at which the video was taken was concealed and the videos were not in chronological order. the gross motor function measure (gmfm-66) was selected as it is the gold standard for the assessment of gross motor function in children with cp.20 the more functional the child is, the higher their gmfm score will be. it is valid, reliable, and able to detect change after an intervention.8,20,21 all assessments were done by the same physiotherapist with more than five years experience at t1, t2 and t3. the functional mobility scale (fms) was used to assess the daily functional mobility of the children. as with the gmfm, a high score indicates greater function. it was scored according to parental report by the same physiotherapist at t1, t2 and t3. it has been proven to have good construct validity and is able to detect change after an intervention.11 statistical analysis due to the small sample size the data was analysed descriptively, using the minimum clinically important difference (mcid) as per the literature to determine whether the results showed clinical significance for each of the outcome scoring tools. mcid is a threshold for determining when meaningful changes occur.22 although the original article on the evgs gave an improvement of 4 as significant, we used page 46 wood l et al. sa orthop j 2018;17(2) the mcid for the evgs as described by gupta et al. they showed that a figure of 11 at the six-month post-operative assessment and 15 at the one-year post-operative assessment (t3) was a more significant mcid.23,24 the mcid in the gmfm-66 after intervention is 1.5.21 results there were ten participants in this prospective cohort study (six females, four males). six children had spastic diplegic cp and four children had hive. all children with hive were receiving art, and were adherent with treatment. the mean baseline cd4 count was 1 757.25 cells/mm3 (range 795–3 024). two of the baseline viral loads were not detectable, one specimen was rejected, and one was 540 copies. five children attended physiotherapy within the government health care setting, either at a clinic or at a hospital, four children attended local special needs schools where they received physiotherapy, and one child received therapy from a volunteer physiotherapist in the community. all children received the same additional homebased exercise programme. children receiving physiotherapy at the schools had weekly physiotherapy, except during school holidays. children receiving therapy in the government health care setting or the community received weekly physiotherapy initially for six weeks, then monthly therapy thereafter. there was one adverse event noted from the surgery. the child’s left femoral nerve was partially cut which resulted in a partial loss of sensation in the leg, generalised weakness, especially with regard to hip flexion and knee extension, and severe pain. a repair was done and she was given a tens machine to manage her pain. at the oneyear follow-up period her pain was being fully managed with a tens machine and some of her sensation had returned to her leg. she still had generalised weakness in her leg and was using a brace to assist with ambulation. due to this she was unable to ambulate 10 m at both the six-month and one-year post-operative assessments and therefore her evg scores were not included in the data. the evgs showed a mean improvement from t1 to t2 of 6.8, with a final improvement of 6.5 at t3. as illustrated in table i the greatest improvements in the gait pattern were seen at the foot and knee, with smaller improvements occurring at the hip, pelvis and trunk. deterioration from t2 to t3 occurred at the knee, pelvis and trunk with the improvement continuing at the foot and hip at t3. although the original article on the evgs gave an improvement of 4 as a significant mcid, the mcid for the evgs as described by gupta et al. is 11 at six months and 15 at one-year post-operative assessment (t3).23,24 the change in evgs in the current study, although an improvement, was not clinically significant. a summary of the gmfm-66 scores can be seen in table ii. the gmfm-66 scores ranged from 44.56 to 92.05 over the three assessments. there was a 1.87 (2.77%) decrease in the mean gmfm-66 scores at t2. there was, however, an overall mean improvement of 2.18 (3.23%) from t1 to t3. in six patients the gmfm-66 scores improved between t1 and t3, and four scores decreased (one of these was hiv positive). the changes seen in the gmfm-66 were clinically significant as the reported mcid for the gmfm-66 is 1.5.21 the overall change in the fms at t2 and t3 is illustrated in figure 1. at t2, there was an overall decline in functional mobility, with two to three children needing more assistance during gait for each distance. at the one-year follow-up period, two children were mobilising with less assistance for each distance. the changes in functional gait using the fms score corresponded with the changes seen in the gmfm-66. regarding the fms at 500 m at one-year follow-up, two children were worse (one with the femoral nerve injury), two were better and the remaining six were unchanged. table iii summarises differences between the children with cp and those with hive at baseline. the children with cp were more functional than those with hive. the gmfcs levels correspond with the pre-operative evgs and gmfm-66 scores. the children with cp had mean scores of 30.66 and 79.14 for the evgs and gmfm-66 respectively, whereas the mean scores for the hive group were 41 and 69.3. the overall changes post-operatively seen in children with cp and those with hive were very similar. the children with hive showed table i: summary of the changes in the evgs change from t1 to t2 change from t2 to t3 change from t1 to t3 total 6.8 −0.3 6.5 foot 1.2 0.9 2.2 knee 3.4 −0.9 2.5 hip 0.9 0.3 1.2 pelvis 0.3 −0.3 0.0 trunk 0.9 −0.3 0.6 table ii: gmfm-66 scores at each assessment gmfm-66 t1 t2 t3 1 69.63 72.16 74.16 2 80.93 79.11 92.05 3 50.09 44.56 46.5 4 82.99 89.7 92.05 5 71.22 61.51 65.33 6 76.75 69.63 74.16 7 72.63 69.63 70.04 8 52.09 53.38 55.15 9 50.85 50.62 53.86 10 69.63 67.75 75.34 mean 67.68 65.81 69.86 sd 12.35 13.65 15.24 12 10 8 6 4 2 0 5 5 0 5 0 0 5 5 0 5 0 0 six month assessment one year assessment the same worse better figure 1. summary of the change seen in the fms table iii: demographics of the children with cp and hive age mean (sd) sex gmfcs level cp (n=6) 10 yrs 11 months (26.97) f=3 m=3 ii=5 iii=1 hive (n=4) 8 yrs 4 months (32.71) f=3 m=1 ii=1 iii=3 page 47wood l et al. sa orthop j 2018;17(2) less functional deterioration at t2, with respect to both the gmfm-66 and the fms. the children with hive did have a greater improvement in the fms at t3. with regard to gait as measured by the evgs, the gait continued to improve in the children with hive from t2 to t3; however, the children with cp showed a small deterioration in gait leading up to t3. table iv shows a summary of these results. discussion semls is widely used in the orthopaedic management of children with cp. there is substantial research showing positive outcomes in these children in developed countries. the aim of this study was to gain insight into the outcomes of children post semls in a developing country where the resources and population differ immensely from the developed world. gait analysis to determine outcomes post semls shows an improvement in gait up to the one-year follow-up period.22 these results have been found to be maintained up to the five-year followup period.1 this study yielded similar results with an improvement of the mean evg scores at the one-year follow-up. in the current study, the mean change in evgs was 6.5 from t1 to t3, with a deterioration of 0.3 from t2 to t3. however, results were not clinically significant as the recorded mcid for the evgs for six-month and one-year followup are 11 and 15 respectively.25 this could be due to the limited supervised rehabilitation received post-surgery, with the majority of the children receiving weekly therapy for the first six weeks, then only monthly check-ups thereafter by different physiotherapists with varying experience. an initial deterioration in function was seen at t2 with an overall improvement at t3 of 2.13. the mcid for the gmfm-66 of a large effect size (0.8) is 1.5,24 therefore it can be determined that the change seen was clinically significant. greater improvement was seen in the gmfm-66 in the current study in contrast to the prospective study done by thomason et al.,1 where the mean change in gmfm-66 at one year was only 0.2. this result could be due to the fact that the children in developing countries are often diagnosed late, receive limited physiotherapy and have more secondary complications. this may lead to them not reaching their full functional potential prior to surgery, which in turn may result in a greater potential to change post-operatively. the results yielded by the fms were very similar to those of the gmfm-66. there was an initial functional deterioration seen at t2 and there was minimal change from t1 to t3. although this differs slightly from the gmfm-66 results, it coincides with the literature. it was found that the changes in the fms could also have been attributed to incorrect prescription of walking aids prior to surgery. this is applicable in poor resource settings, where there are limited funds available for devices such as wheelchairs that will only be used occasionally. the sample size was too small to directly compare the outcomes of the children with cp to those with hive. however, as the first study of its kind, including children with hive into the sample of a group of children with spastic diplegia it does open the door for further research in this area. an aspect to consider when looking at the two different causes of spastic diplegia is that the children with hive fall into a very new subset of children for whom the appropriate treatment practices are relatively unknown. this could have resulted in limited management initially, with a greater potential to change once intervention occurred. overall there were some differences with regard to the amount of functional change and the change in gait pattern at t2, but the outcomes at t3 were very similar. further research will need to be done directly comparing the two groups, in a larger study, to truly understand the differences in the outcomes. the main limitation of the study was the small sample size. one of the factors contributing to this is that semls is a relatively new management approach for children with spastic diplegia accessing health care at a large academic hospital in south africa. as the service continues to be offered at the hospital, the service will grow and the study can be broadened. the study was the first of its kind in this setting, therefore the aim was not to change the current service but to determine whether the current service was appropriate. the physiotherapy received was not standardised and it is difficult to determine what effect this had on the outcomes. further limitations were the omission of a quality of life outcomes measure as well as the short follow-up period, ideally at least two years. conclusion the results of this study indicate that the early outcomes of semls in a south african setting, with scarce resources, are similar to those seen in developed countries. it may also be possible to use the same semls treatment principles seen in the management of children with cp for children with static hive. further follow-up is, however, needed in both of these areas. compliance with ethical standards informed consent from the ethics committee of the university of the witwatersrand was obtained prior to commencement of this project (clearance number m120907). references 1. thomason p, selber p, graham k. single event multilevel surgery in children with bilateral spastic cerebral palsy: a 5 year prospective cohort study. gait and posture 2013;37:23-38. 2. harvey a, rosenbaum p, hanna s, et al. longitudinal changes in mobility following single-event multilevel surgery in ambulatory children with cerebral palsy. journal of rehabilitation medicine 2012;44:137-43. 3. rutz e, tirosh o, thomason p, et al. stability of the gross motor function classification system after single-event multilevel surgery in children with cerebral palsy. developmental medicine and child neurology 2012;54:1109-13. 4. godwin e, spero cr, nof l, et al. cerebral palsy and single-event multilevel sugery; is there a relationship between level of function and intervention over time? journal of paediatric orthopaedics 2009;29:910-15. 5. narayanan u. management of ambulatory cerebral palsy: an evidence-based review. journal of pediatric orthopaedics 2012;32:172-81. 6. bischof f. single event multilevel surgery in cerebral palsy: a review of the literature. south african orthopaedic journal 2010:30-33. 7. hannah se, bartlett dj, rivard lm, et al. reference curves for the gross motor function measure: percentiles for clinic description and tracking over time for children with cerebral palsy. physical therapy 2008;88:98-607. 8. beckung e, carlsson g, carlsdotter s, et al. the natural history of gross motor development in children with cerebral palsy aged 1 to 15 years. developmental medicine and child neurology 2007;49:751-56. table iv: summary of changes seen in each assessment tool for children with cp and hive evgs gmfm-66 fms (5m/50m/500m) change from t1 to t2 cp 7.40 −2.49 −2/−1/−2 hive 6.00 −0.95 −1/−1/0 change from t2 to t3 cp −1.00 4.60 1/0/0 hive 0.50 3.25 3/1/2 change from t1 to t3 cp 6.40 2.11 −1/−1/−2 hive 6.50 2.30 2/0/2 page 48 wood l et al. sa orthop j 2018;17(2) 9. thomason p, baker r, dodd k, et al. single-event multilevel surgery in children with spastic diplegia; a pilot randomised controlled trial. the journal of bone and joint surgery 2011;93:451-60. 10. rodda j, graham k, nattrass g, et al. correction of severe crouch gait in patients with spastic diplegia with the use of multilevel orthopaedic surgery. journal of bone and joint surgery 2006;88:2653-64. 11. harvey a, graham k, morris me, et al. the functional mobility scale: ability to detect change following single event multilevel surgery. developmental medicine and child neurology 2007;49:603-607. 12. khan ma. outcome of single-event multilevel surgery in untreated cerebral palsy in a developing country. journal of bone and joint surgery [br] 2007;89:1088-91. 13. donald ka, walker kg, kilborn t, et al. hiv encephalopathy: pediatric case series description and insights from the clinical coalface. aids research and therapy 2015;12:1-10. 14. lowenthal ed, bakeera-kitaka s, marukutira t, et al. perinatally acquired hiv infection in adolescents from sub-saharan africa: a review of emerging challenges. lancet infectious diseases 2014;14:627-39. 15. baillieu n, potterton j. the extent of delay of language, motor, and cognitive development in hiv-positive infants. jnpt 2008;32:118-21. 16. govender r, eley b, walker k, et al. neurologic and neurobehavioral sequelae in children with human immunodeficiency virus (hiv-1) infection. journal of child neurology 2001;26:1355-64. 17. hilburn n, potterton j, stewart. paediatric hiv encephalopathy in sub-saharan africa. physical therapy reviews 2010;15:410-17. 18. viehweger e, zurcher pfund l, helix m, et al. influence of clinical and gait analysis experience on reliability of observational gait analysis. annals of physical and rehabilitation medicine 2010;53:535-46. 19. ong am, hillman sj, robb je. reliability and validity of the edinburg visual gait score for cerebral palsy when used by inexperienced observers. gait and posture 2008;28:323-26. 20. debuse d, brace h. outcome measures of activity for children with cerebral palsy: a systematic review. pediatric physical therapy 2011;23:222-31. 21. russel dj, rosenbaum pl, avery lm, lane m. gross motor function measure (gmfm-88 & gmfm-66) user’s mannual 2002. plymouth: mac keith press. 22. oeffinger d, bagley a, rogers s, et al. outcome tools used for ambulatory children with cerebral palsy: responsiveness and minumum clinically important differences. developmental medicine and child neurology 2008;50:918-25. 23. gupta s, raja k. responsiveness of edinburgh visual gait score to orthopaedic surgical intervention of the lower limbs in children with cerebral palsy. american journal of physical medicine and rehabilitaton 2012;91:761-67. 24. read hs, hazlewood me, hillman sj et al. edinburgh visual gait score for use in cerebral palsy. j pediatr orthop 2003;23:296-301. 25. gorton iii ge, abel mf, oeffinger dj, et al. a prospective cohort study of the effects of lower extremity surgery on outcome measures in ambulatory children with cerebral palsy. journal of paediatric orthopaedics 2009;29:903-909. orthopaedics vol3 no4 sa orthopaedic journal summer 2014 | vol 13 • no 4 page 43 glenoid hypoplasia: a case series of ten shoulders p ryan mbchb(uct), fc(orth)(sa), mmed(orth)ukzn department of orthopaedic surgery, university of kwazulu-natal p jordaan mbchb(us) jp du plessis, mbchb(uct), fc(otho)(sa), mmed(orth)uct b vrettos mbchb(zim), frcs(eng), fcs(sa)orth, mmed(orth)uct s roche mbchb(uct), lmmc, fcs(sa)orth department of orthopaedic surgery, university of cape town correspondence: dr p ryan email: paullisa.ryan@gmail.com patients and methods from january 2002 to may 2013, nine patients (ten shoulders) with radiological signs of glenoid hypoplasia were identified. there were eight male and one female patients. the mean age at presentation was 37.2 years (range 23–77) and the mean symptom duration was 11.7 months (range 1–48). six shoulders were managed conservatively. the four shoulders that underwent surgical management were for labral tears/pathology, one patient of whom suffered from multidirectional instability. results table i summarises the clinical data, including management, follow-up and subjective shoulder scores. concerning the non-surgically managed patients, the diagnosis was impingement and tendonitis in three, calcific tendonitis in one, adhesive capsulitis in one and a labral tear in one. one patient was not contactable. in the remaining five, the mean follow-up was 27 months (range 5 to 60) and the mean oxford shoulder score was 47. all were subjectively very satisfied with their shoulder function. of the four surgically managed patients, one (patient 5, posterior labral tear) was not contactable. of the remaining three, all had labral pathology. the patient with a slap lesion and anterior labral extension was doing well at 23 months post surgery with an oss of 47. one patient with a posterior labral tear was doing well with an oss of 45 at 3 months post surgery, while the other had a slightly lower oss of 43 at 15 months post-op. this patient has multidirectional instability, and was found at the time of surgery to have a posterior labral tear, a reverse hillsacks and early cartilage eburnation. the summary of the radiographic evaluation is seen in table ii. according to the wirth classification, one shoulder was graded as mild, five graded as moderate, and four graded as severe. additional radiological features of lateral clavicular hooking were seen in three, acromial enlargement in four, humeral changes of hypoplasia and varus in four, and coracoid hypoplasia in two. introduction the terms ‘glenoid hypoplasia’, ‘glenoid dysplasia’ and ‘dentate glenoid’ refer to an uncommon developmental abnormality of the lower glenoid and scapular neck. the presenting symptoms are variable depending on the age at presentation, and in many cases the diagnosis is made incidentally on x-ray. the exact incidence is unknown, but is estimated in cadaveric and mri studies to be in the region of 14.3% to 35% depending on the ethnic population studied.1,2 current orthopaedic literature consists of case reports and small case series, with some of the more recent papers focusing on the arthroplasty management and implications.3-5 key words: glenoid hypoplasia, glenoid dysplasia, dentate glenoid although rare, glenoid hyperplasia may be more common than previously recognised saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 43 page 44 sa orthopaedic journal summer 2014 | vol 13 • no 4 discussion glenoid hypoplasia, first described by valentine in 1931,6 is a rare developmental abnormality, which affects the osseous development of the inferior glenoid. it has also been termed ‘glenoid dysplasia’, ‘posterior glenoid rim deficiency’, and ‘dentate glenoid’. the incidence is largely unknown as many cases are asymptomatic and discovered incidentally on radiographs. symptomatic dysplasia accounts for around 0.5% of patients seen in some shoulder units.7 two articles report on the incidence of glenoid hypoplasia in a general population. edelson2 evaluated dry bone specimens and reported an incidence of between 19% and 35% for different ethnic groups. the highest incidence was seen in alaskan eskimo and northern chinese populations. in an mri study of 103 consecutive mr arthrograms, harper et al.1 report an incidence of 14.3% for moderate to severe glenoid dysplasia. most series of symptomatic dysplasia report a male predominance.7-9 table i: clinical details of ten patients with primary glenoid hypoplasia age at presentation (years) symptom duration (months) arm affected handedness diagnosis management follow-up period (months) oss 1 77 48 l r impingement and biceps tendonitis conservative 28 48 2 50 16 r r impingement/ tendonitis conservative 3 35 2 r r impingement/ tendonitis conservative 5 48 4 38 3 r r calcific tendonitis conservative 30 46 5 33 2 l r slap with antero-sup extension surgical 27 47 6 23 4 r r posterior labral tear surgical 7 35 5 r r adhesive capsulitis conservative 12 45 8 30 1 r r slap conservative 60 48 9 26 24 l r mdi, labral tear surgical 15 43 10 25 12 r r posterior labral tear surgical 3 45 table ii: radiological findings diagnosis humerus acromion clavicle coracoid wirth grade management oss 1 impingement and biceps tendonitis hypo varus hooked ok moderate conservative 48 2 impingement/tendonitis ok mild conservative 3 impingement/tendonitis varus increased hooked ok severe conservative 48 4 calcific tendonitis hypo moderate conservative 46 5 slap with antero-sup extension hypo varus increased hypo severe surgical 47 6 posterior labral tear ok moderate surgical 7 adhesive capsulitis ok moderate conservative 45 8 slap varus increased hooked ok severe conservative 48 9 mdi, labral tear ok moderate surgical 43 10 posterior labral tear increased ok severe surgical 45 saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 44 sa orthopaedic journal summer 2014 | vol 13 • no 4 page 45 although the exact aetiology is unknown, familial occurrence has been noted in a few case reports10-13 and a spontaneous mutation, resulting in an autosomal dominant pattern with low penetrance, has been suggested.7,14 in a review of the genetics of scapular anomalies, williams et al.15 conclude that the various parts of the scapula develop under different genetic control genes, and that the scapula has a different embryonic origin and genetic control than the rest of the upper limb. similar bony abnormalities are seen in apert syndrome,16 and in cases secondary to other primary pathologies, such as obstetric brachial plexus trauma, muscular dystrophy, avitaminosis a and c, childhood bone and joint infection, haemophilic arthropathy and trauma.7 the scapula forms from at least eight ossification centres. the glenoid fossa forms from an inferior and a superior (or subcoracoid) centre (figure 1). the coracoid has primary, secondary and tertiary centres, and the acromion has a further two centres. in utero, part of the body of the scapula is ossified. at birth, the majority of the lateral aspect of the scapula including the glenoid, coracoid, lateral scapular border and acromion are cartilaginous, and ossification of these scapular processes, including the glenoid, is complete by mid-adolescence. the superior or subcoracoid centre fuses at around age 15 years, and the inferior, horse shoe-shaped epiphysis fuses after this. it is suggested that glenoid hypoplasia results from abnormal ossification of either or both the upper and lower glenoid centres. clinical presentation the clinical presentation of patients with symptomatic dysplasia is variable. smith et al.7 evaluated 12 patients, and divided them into two groups based on their age at presentation and symptoms. the first group was patients who presented prior to adulthood with symptoms of instability and clicking, while the second group (after the age of 40 years) presented with symptomatic early onset osteoarthritis. wirth et al.,8 in their evaluation of 16 patients, divided them into three groups. group 1 included patients with bilateral dysplasia without instability. group 2 were patients with bilateral dysplasia and instability. group 3 had unilateral hypoplasia with associated humeral head deformity. they too recognise the association of dysplasia with early onset glenohumeral arthrosis. both pettersson et al.17 and wirth et al.8 demonstrated an inverse relationship between the degree of dysplasia and the resultant shoulder range of motion. in our series, five patients presented with labral pathology at an average age of 27.4 years (23–30 years) and four patients presented with tendonitis/impingement at an average age of 50 years (35–77 years). there were no cases of early onset glenohumeral arthrosis. the association of posterior labral tears with glenoid dysplasia has been evaluated by harper et al.1 who report a 64.3% incidence of labral tears seen on mri scans in patients with moderate to severe dysplasia. impingement and tendinopathy are thought to occur due to the relatively large and inferiorly sloping acromion, and the mechanical disadvantage of a more medialised centre of rotation and relatively shortened rotator cuff musculature. radiographic features the radiographic features of glenoid hypoplasia have been well documented7-9,18 and include a shallow, irregular, elongated, retroverted glenoid with increased inferior joint space; an enlarged and infero-lateral tilted acromion; a prominent coracoid; and a hooked clavicle (figures 2 to 4). although the classical feature is that of relative coracoid prominence, we found two shoulders (figures 5 and 6) with hypoplasia of the process. this is thought to have resulted from a more diffuse dysplastic process which has affected the coracoid ossification centres. figure 1. upper (or subcoracoid) and lower glenoid ossification centres figure 2. radiographic features of a shallow, irregular, elongated, retroverted glenoid with increased inferior joint space figure 3. radiographic features of an enlarged, inferiorly sloping acromion and a relatively enlarged coracoid saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 45 page 46 sa orthopaedic journal summer 2014 | vol 13 • no 4 the above features are present to varying degrees depending on the severity of the dysplasia, and have been graded by wirth et al. (table iii) into mild, moderate and severe.8 mri features include rounding or truncation of the posterior glenoid rim, and hypertrophied low and medium signal intensity posterior labral tissues. despite significant bony abnormality, both mri and ct arthrography may show a smooth articular surface which is congruent with the humeral head (figure 7). on mri, the hypoplastic area is seen to be replaced with tissue which has similar signal characteristics to fibrocartilage or fat (figure 8), supporting the theory that failure of ossification is the causes of the pathology. associated secondary labral changes such as tears, degeneration, detachment and ganglion cysts may also been seen (figure 8).9 figure 4. prominent lateral clavicular hooking table iii: radiographic grading of glenoid dysplasia as per wirth et al.8 mild glenoid shallow, slightly irregular, occasionally dentate. part of inferior rim and scapular neck present moderate more irregular and elongated glenoid, loss of inferior rim and glenoid neck severe marked hypoplasia, inferior glenoid confluent with scapular border. associated humeral changes of hypoplasia, varus angulation of head. associated scapular changes of enlarged inferiorly tilted acromion, prominent coracoids and lateral clavicular hooking figure 5. ap view of relative coracoid hypoplasia figure 6. axillary view of relative coracoid hypoplasia figure 7. ct arthrogram demonstrating posterior glenoid deficiency, replaced with fibrocartilage and labral hypertrophy. the humeral head remains centered and congruent with the abnormal tissues figure 8. posterior glenoid truncation and associated labral tear saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 46 sa orthopaedic journal summer 2014 | vol 13 • no 4 page 47 harper et al.1 grade the severity of the dysplasia on the axial mri cuts into mild, moderate or severe depending on the degree of postero-inferior glenoid truncation and posterior sloping. in our series, plain radiographs were obtained for all patients, mri in one and ct arthrography in one. one glenoid was graded as mild, five as moderate and four as severe. associated bony changes were seen as follows: hooking of the clavicle in three, coracoid hypoplasia in two shoulders which demonstrated more severe upper glenoid hypoplasia, acromial enlargement in four, and humeral varus and hypoplasia in four. in the two cases of relative coracoid hypoplasia, the upper glenoid and coracoid changes are thought to represent a more diffuse affectation of the relevant ossification centres. management the management of glenoid hypoplasia has been described in a few papers. in their series of 12 patients, smith et al.7 report symptom resolution with physiotherapy and rehabilitation in their younger patients with presenting complaints of minor instability or pain. one patient with multidirectional instability underwent surgery in the way of posterior glenoid augmentation and capsular shift, with an unfavourable outcome. in their group of patients over the age of 40, all five had early onset osteoarthritis which responded poorly to non-operative management. three patients underwent hemiarthroplasty, which they report as technically difficult and with relatively disappointing outcomes. in a review of 16 patients, wirth et al.8 managed all patients with a tailored rehabilitation programme, and report that at a mean of five years follow-up, the majority had returned to their previous activity level with symptom resolution. however, they allude to hemiarthroplasty possibly playing a role in certain patients with unremitting symptoms. there are conflicting reports regarding the place and results of hemi and total arthroplasty in the management of secondary osteoarthritis with underlying glenoid hypoplasia. bonnevialle et al.5 report satisfactory results, at a mean of 71 months follow-up (28–126), in ten shoulders treated with hemarthroplasty. one patient underwent revision surgery for instability secondary to subscapularis insufficiency. contradicting this, sperling et al.4 in their study of seven patients (four hemiarthroplasties and three total shoulder arthroplasties), revised three of their hemiarthroplasties to total shoulder replacements for continued symptoms. the one hemiarthroplasty that was not revised had the glenoid addressed at the time of hemiarthroplasty, with a posterior re-directional osteotomy. of the three shoulders that had glenoid components inserted, two demonstrated loosening; however, none needed revision. they conclude that the glenoid deficiency and cartilage wear should be addressed at the time of surgery. the indications for reverse total shoulder arthroplasty continue to expand to include pathologies other than rotator cuff tear arthropathy. a number of recent articles highlight the use of the reverse prosthesis in cases of severe glenoid bone loss.19-22 hyun et al.22 describe a case of glenoid dysplasia secondary to kniest syndrome which was managed with a reverse total shoulder arthroplasty. they report satisfactory radiographic appearance at sixmonth follow-up. in our study, none of the patients presented with symptomatic early degeneration of the gleno-humeral joint. all patients were managed initially with nonoperative measures based on the presenting pathology, with good clinical outcomes in six, as evident by the subjective shoulder scores. of the patients that required surgical intervention, all were for labral pathology. two patients did well with oxford shoulder scores of 47 and 45, while one did less well with an oss of 43. this patient was noted at the time of surgery to have degenerative cartilaginous changes secondary to instability. conclusion we present a case series of patients with glenoid hypoplasia and associated shoulder pathologies. we confirm the male predominance, association with labral pathology and the poor clinical outcome when associated with multidirectional instability. in addition, we present a number of other patients who presented with pathologies other than labral tears, instability or early onset arthrosis. these were managed successfully with routine nonoperative means. although glenoid hypoplasia is rarely seen in clinical practice, it appears the abnormality may be more common than previously recognised. shoulder symptoms should be treated on their merits and on an individual case basis. should reconstructive arthroplasty surgery be embarked upon, the caveats should include: this is technically demanding, it may have inferior results to that performed on the normal shoulder, and one should consider addressing the glenoid deficiency at the time of surgery. references 1. harper kw, et al. glenoid dysplasia: incidence and association with posterior labral tears as evaluated on mri. ajr am j roentgenol, 2005;184(3):984-88. 2. edelson jg. localized glenoid hypoplasia. an anatomic variation of possible clinical significance. clin orthop relat res, 1995(321):189-95. reconstructive arthroplasty surgery is technically demanding, may have inferior results to that performed on the normal shoulder, and one should consider addressing the glenoid deficiency at the time of surgery saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 47 page 48 sa orthopaedic journal summer 2014 | vol 13 • no 4 3. edwards tb, et al. shoulder arthroplasty in patients with osteoarthritis and dysplastic glenoid morphology. j shoulder elbow surg, 2004;13(1):1-4. 4. sperling jw, cofield rh, steinmann sp. shoulder arthroplasty for osteoarthritis secondary to glenoid dysplasia. j bone joint surg am, 2002;84-a(4):541-46. 5. bonnevialle n, et al. hemiarthroplasty for osteoarthritis in shoulder with dysplastic morphology. j shoulder elbow surg, 2011;20(3):378-84. 6. valentine b. die kongenitale schulter-luxation. orthop chir, 1931(55):229. 7. smith sp, bunker td. primary glenoid dysplasia. a review of 12 patients. j bone joint surg br, 2001;83(6):868-72. 8. wirth ma, lyons fr, rockwood ca jr. hypoplasia of the glenoid. a review of sixteen patients. j bone joint surg am, 1993;75(8):1175-84. 9. theodorou sj, theodorou dj, resnick d. hypoplasia of the glenoid neck of the scapula: imaging findings and report of 16 patients. j comput assist tomogr, 2006;30(3):535-42. 10. kozlowski k scougall j. congenital bilateral glenoid hypoplasia: a report of four cases. br j radiol, 1987;60(715):705706. 11. samilson rl. congenital and developmental anomalies of the shoulder girdle. orthop clin north am, 1980;11(2):219-31. 12. stanciu c, morin b. congenital glenoid dysplasia: case report in two consecutive generations. j pediatr orthop, 1994;14(3):389-91. 13. weishaupt d, zanetti m, exner gu. familial occurrence of glenoid dysplasia: report of two cases in two consecutive generations. arch orthop trauma surg, 2000;120(5-6):349-51. 14. andrews sb, smithson sf. dominant inheritance of primary glenoid dysplasia. shoulder and elbow, 2007;7:13-15. 15. williams ms. developmental anomalies of the scapula-the ‘omo’st forgotten bone. am j med genet a, 2003;120a(4):58387. 16. murnaghan lm, et al. a clinicoradiologic study of the shoulder in apert syndrome. j pediatr orthop, 2007;27(7):83843. 17. pettersson h. bilateral dysplasia of the neck of scapula and associated anomalies. acta radiol diagn (stockh), 1981;22(1):81-84. 18. suryawanshi a, et al. unilateral glenoid hypoplasia: a case report and review of the literature. case rep orthop, 2011;article id 412721. 19. sears bw, et al. glenoid bone loss in primary total shoulder arthroplasty: evaluation and management. j am acad orthop surg, 2012;20(9):604-13. 20. mizuno n, et al. reverse total shoulder arthroplasty for primary glenohumeral osteoarthritis in patients with a biconcave glenoid. j bone joint surg am, 2013;95(14):1297-304. 21. macaulay a, levine w. reverse total shoulder replacement in patients with severe glenoid bone loss. operative techninques in orthopaedics, 2011;21(1):86-93. 22. hyun ys, et al. uncommon indications for reverse total shoulder arthroplasty. clin orthop surg, 2013;5(4):243-55. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2014_orthopaedics vol3 no4 2014/11/04 7:56 pm page 4 page 184 sa orthop j 2021;20(3) cpd questionnaire. august 2021 vol 20 no 3 positive patient experience of wide awake local anaesthesia no tourniquet (walant) hand surgery in the government setting: a prospective descriptive study (naude jj, koch o, schmidt lw, le roux tlb) 1. techniques to decrease pain on injection include: a. pausing after 0.5 ml injection a b. staying within 10 mm of the indurated area with following injections b c. using a 27or 30-gauge needle c d. adding 8.4 bicarbonate to the infiltration d e. all of the above e 2. select the false statement below: a. procaine usage in the 1950s caused isolated cases of finger ischaemia due to a low ph a b. clinical epinephrine can be used without inducing infarction b c. phentolamine, an alpha-blocker, reliably reverses epinephrine vasoconstriction in the finger c d. lignocaine and epinephrine infiltration in the finger has a high probability of causing finger infarction and necrosis d e. in walant procedures, 1:100 000 epinephrine is used e 3. select the false statement below: a. leblanc et al. had a superficial infection rate of 0.4% and deep infection rate of 0% following minor hand surgical procedures outside of theatre in 1 504 patients a b. outpatient minor hand procedures have an improved efficiency compared to in-theatre procedures b c. patients are given a resting period of 10 minutes to give the infiltration time to take effect c d. outpatient procedures may have a positive environmental impact by decreasing long-term refuse d e. the safe limit of lignocaine injection is 7 mg/kg e the prevalence of vascular injury utilising the lateral parapatellar approach for malignant distal femoral tumour resections: a case series (van der watt np, koch o, le roux tlb, meijer jg, mcloughlin h) 4. which one of the following malignancies does not occur frequently in the distal femur? a. chondrosarcoma a b. ewing’s sarcoma b c. conventional osteosarcoma c d. fibrosarcoma d e. telangiectatic osteosarcoma e 5. which of the following surgical approaches has been considered to be the gold standard for distal femoral tumour resections? a. anteromedial a b. direct anterior b c. posteromedial c d. direct lateral d e. lateral parapatellar e 6. with regard to the lateral parapatellar approach for distal femur tumour resections, which of the following is not true? a. theoretical increased risk for vascular complications a b. decreased risk for inadequate soft tissue cover b c. potential to increase exposure to the greater trochanter c d. the cruciate and collateral ligaments are spared d e. an elliptical resection of the lateral biopsy site is performed e the surgical management of metastatic lesions of the femur (saini ak, ferreira n) 7. what is the most common long bone destination of metastatic disease? a. humerus a b. femur b c. radius c d. tibia d e. ulna e 8. simultaneous nailing of two or more long bones in the context of metastatic disease: a. can be performed safely if the medullary canals have been adequately reamed a b. can be performed safely if the patient has been receiving chemical thromboprophylaxis b c. is associated with a significant risk of intraoperative mortality c d. is associated with a significant risk of late postoperative death d e. is cost effective and allows for early mobilisation e 9. which primary malignancy is associated with the worst five-year prognosis once bone metastasis has been diagnosed? a. lung a b. breast b c. thyroid c d. renal d e. prostate e correlation of the squat-and-smile test against other patient-reported outcome scores in knee pathology (le roux j, dey r, deichl as, torney o, laubscher m, graham sm, held m) 10. the following score was not correlated with the squat-andsmile test: a. tegner lysholm score a b. eq-5d b c. koos score c d. womac score d e. none of the above e orthopaedic journal s o u t h a f r i c a n � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � contents � � � � � � � � � � t h e s o u t h a f r ic a n o r t h o pa e d ic a s s o c ia t io n page 186 sa orthop j 2021;20(3) 11. the squat-and-smile test was originally developed to assess: a. knee pathology a b. hip pathology b c. femur shaft fracture union c d. tibia shaft fracture union d e. ankle pathology e 12. the individual component of the squat-and-smile test that showed the best correlation with the koos score was: a. depth of squat a b. need for arm support during squat b c. ‘smiley face’ during squat c d. duration of squat d e. none of the above e a computer tomography-based anthropomorphic study of forearm osteology: implications for prosthetic design (pretorius hs, ferreira n, burger mc) 13. the radius of curvature refers to which structure in the anatomy of the radius? a. the length of the radius (w) in the formula a b. the height of the radius arc (h) b c. the radius of the circle that the arc of the radius is a portion of c d. the angle of the proximal radius d e. the radial head size from side to side e 14. the proposed nail design will have a diameter of 4.5 mm, which is related to the: a. distal width of the radius for implantation a b. proximal ulna width for implantation b c. cortical thickness of the radius and ulna combined c d. combined minimum radius and ulna shaft diameter d e. radius of curvature of the radius e 15. the mean height of the distal radius is 23 mm and the max 95% ci is 24. this has implications for: a. distal radius styloid screw length a b. distal radius maximum screw length for locking plates b c. shaft screw length for radius plates c d. correction of volar tilt in distal radius fixation d e. correction of radial height distal radius fixation e patella dislocations and patellofemoral instability: a current concepts review (garrett br, grundill ml) 16. the mpfl is tightest in which position? a. deep flexion a b. full extension into early flexion b c. mid-flexion c d. completely isometric d e. 30–60° flexion e 17. when using a lateral radiograph to access for patella alta, which ratio is least affected by the flexion position of the knee? a. blackburne-peel ratio a b. insall-salvati ratio b c. koshino ratio c d. caton-deschamps ratio d e. blumensaats line e 18. a 19-year-old netball player presents with recurrent episodes of patellofemoral dislocations. after detailed assessment, her radiographic findings are as follows: tt-tg distance <20 mm, dejour type a trochlear dysplasia, caton-deschamps index <1.2, and a patella tilt <20°. which management strategy would be most appropriate? a. aggressive physiotherapy and re-assessment a b. isolated mpfl reconstruction b c. mpfl reconstruction with associated tibial tubercle transfer c d. mpfl reconstruction with associated trochleoplasty d e. isolated trochleoplasty e phosphaturic mesenchymal tumour, ‘non-phosphaturic’ variant: a case report and review of the literature (wadee r, linda z, ismail a) 19. which of the following is false regarding phosphaturic mesenchymal tumours? a. they are rare neoplasms that are usually associated with renal phosphate loss a b. tumour-induced osteomalacia (tio) occurs secondary to excessive production of tumour-associated fibroblast growth factor-23 (fgf23) b c. patients often present with nonspecific symptoms and signs of tumour-induced osteomalacia c d. the majority of these tumours have been diagnosed in middle-aged adults d e. phosphaturic mesenchymal tumours are commonly diagnosed tumours e 20. which of the following is correct? a. fibroblast growth factor-23 (fgf23) is a peptide that has an important role in phosphate reuptake in the kidneys a b. phosphaturic mesenchymal tumours are rare neoplasms that are never associated with renal phosphate loss b c. the histogenesis of phosphaturic mesenchymal tumours is well-documented c d. pmts have a specific immunohistochemical profile d e. fibroblast growth factor-23 (fgf23) is a hormone that is only secreted by fibroblasts e subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm.co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online • once you have 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(you will have to answer the two questions regarding your internship and last cpd audit once you have completed a questionnaire and want to retrieve your certificate). • if you click on that icon it will open your certificate which you can print or save on your system. • please call mpc helpdesk if you have any questions: 0861 111 335. medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 verhoef h et al. sa orthop j 2020;19(2) doi 10.17159/2309-8309/2020/v19n2a7 south african orthopaedic journal http://journal.saoa.org.za traumahand citation: verhoef h, marais lc, rollinson pd, ryan pv. the risk of early complications in patients with hand infections. sa orthop j 2020;19(2):97102. http://dx.doi.org/10.17159/2309-8309/2020/v19n2a7 editor: prof. theo le roux, university of pretoria, south africa received: july 2019 accepted: january 2019 published: may 2020 copyright: © 2020 verhoef h. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare that they have no conflicts of interest that are directly or indirectly related to the research. abstract background: the aim of this study was to identify the risk factors associated with the development of early complications in patients with hand infections. a secondary objective was to describe the bacteriology and resistance profile in our study population. methods: this retrospective observational descriptive study was performed at a regional referral centre in south africa. all primary hand infection cases treated over a period of one year were reviewed. children under 18 years, cases with incomplete primary outcome data and post-operative infections were excluded. clinical and demographic data was extracted from clinical records. amputation, re-debridement and tissue loss requiring skin grafting were regarded as early complications. bacteriological analysis comprised identification of causative organisms as well as evaluation of their resistance profiles. risk factors that were found to be significant for development of early complications were entered into a multivariate regression analysis. results: after inclusion and exclusion criteria were applied, 78 patients were deemed eligible for inclusion to the study. the patientassociated risk factors that were found to be associated with the development of early complications after univariate analysis were increasing age and poorly controlled diabetes mellitus. human bites and polymicrobial infections were the only aetiological factors that were identified to be significant on a univariate level. initial presentation to a private sector general practitioner (gp) was the only management factor to reach significance on univariate analysis. human immunodeficiency virus (hiv) infection, cd4 count, viral load and duration of arv treatment were not found to be significantly associated with the development of early infections. on multivariate logistic regression analysis, poorly controlled diabetes mellitus, human bites and first presentation to a private gp were the only risk factors that remained significant for the development of early complications. the culture yield was 68%. staphylococcus aureus (s. aureus) was the most frequently isolated organism (37%), followed by polymicrobial infections (10%). s. aureus encountered in our study population remained mostly sensitive to cloxacillin; however, high levels of resistance (50%) to ampicillin were observed. klebsiella sp. and acinetobacter sp. were the most frequently observed gram-negative organisms. conclusion: after multivariate regression analysis, hand infections in poorly controlled diabetic patients, infections occurring after human bites as well as those affected by polymicrobial infections were identified as independent risk factors for development of early complications in patients with hand infections. hiv infection was not found to be a significant risk factor. our bacteriological profile is in keeping with trends demonstrated in the literature where s. aureus infections seem to be declining in frequency while polymicrobial infections seem to be encountered more frequently. level of evidence: level 4 keywords: hiv, diabetes mellitus, hand infection, complication, risk factor the risk of early complications in patients with hand infections verhoef h1 , marais lc2 , ryan pv3 , rollinson pd4 1 mbchb(up); orthopaedic registrar, department of orthopaedic surgery, nelson r mandela school of clinical medicine, university of kwazulu-natal, durban, south africa 2 mbchb, fc orth sa, mmed(orth), phd; head of department, department of orthopaedic surgery, school of clinical medicine, university of kwazulu-natal, durban, south africa 3 mbchb(uct), h dip orth(sa); fcs orth(sa); mmed(sa); hod orthopaedic surgery, inkosi albert luthuli central hospital; university of kwazulu-natal, durban, south africa 4 mbchb(sheff), frcs (ed & eng); chief orthopaedic specialist, ngwelezana hospital corresponding author: dr hein verhoef, unit 19 el torero, 86 lewis drive, amanzimtoti, durban, 4126; tel: 082 929 544; email: heinkvkp@hotmail.com https://orcid.org/0000-0002-6164-4892 https://orcid.org/0000-0002-1120-8419 https://orcid.org/0000-0002-0957-6482 https://orcid.org/0000-0002-2384-7250 page 98 verhoef h et al. sa orthop j 2020;19(2) introduction acute hand infections are common and despite the advances in antibiotic therapy and surgical interventions, remain a challenging clinical entity to treat.1 hand infections can be associated with significant morbidity and may result in marked permanent physical impairment, especially if appropriate management is not initiated timeously.1-3 a multitude of factors have been suggested to influence the development, bacteriology and outcomes of hand infections. predisposing factors for the development of hand infections that have been identified include intravenous drug use, diabetes mellitus, steroid use and other immune-compromising conditions.4 attempts have been made to study the association between human immunodeficiency virus (hiv) and hand infections, but these studies either had small numbers of hiv-positive patients or cd4 counts were not routinely performed or available.2,5-7 diabetes mellitus has been shown to predispose to the development of infectious conditions and has also been associated with poor outcomes in infections of the hand.8 other factors that have been suggested to alter the course and outcome of hand infections include the employment status; nature of occupation; the aetiology, nature and site of infection; metabolic and nutritional status; as well as the age and sex of patients.2,9 the variability of reported factors suggests that multiple factors may be interacting in individual patients; however, multivariate analyses seem to indicate shortcomings in many of the reported studies including the most frequently cited publications.10 intravenous antibiotic therapy is an important component of early management and initially this takes the form of generic treatment based on the most likely causative organisms. historically staphylococcus aureus (s. aureus) was the most commonly isolated organism, but more recent literature suggests that this trend may be changing.11 furthermore, the bacteriology may also vary in different patients with different risk factors. therefore, knowledge of local microorganism and antibiotic resistance profiles may be useful in determining an optimal initial antibiotic strategy. the aim of this study was to identify the risk factors associated with the development of early complications in patients with hand infections. a secondary objective was to describe the bacteriology and resistance profile in our study population. methods this retrospective observational study was performed in a regional hospital which is a referral centre for 15 district level hospitals in a predominantly rural and semi-rural area of kwazulu-natal. all patients treated for primary hand infections between july 2016 and july 2017 were deemed eligible for inclusion in the study. patients younger than 18 years, cases with incomplete primary outcome data and cases involving post-operative infections were excluded. patients who presented initially with clean traumatic hand wounds or fractures requiring open reduction and internal fixation, tendon repair, nerve repair, external splinting in the form of plaster cast or external fixator, who subsequently developed hand infections were also excluded. data relating to the following demographic and clinical variables were extracted from clinical records: age, sex, hand dominance, diabetic and hiv status, hba1c levels in diabetic patients, cd4 counts and viral load in hiv-positive patients, source of infection, onset and presentation, occupation, surgical procedures performed and duration of hospital stay. pus swabs were analysed to identify the causative organism and to determine patterns of sensitivity to antibiotics. the need for re-operation, amputation and need for skin grafting due to tissue loss were regarded as complications. the standard management protocol included facilitation of prompt transfer for patients with suspected hand infections from referring hospitals. hiv elisa testing was performed on all patients unless the patient was known to be hiv-positive and already on anti-retroviral (arv) treatment. cd4 count and hiv viral load was performed on all hiv-positive patients and hba1c level on all diabetic patients. pus swabs were taken in theatre for microscopy, culture and sensitivity (mcs) testing. empiric antibiotic administration included intravenous (iv) cloxacillin 1 g 8 hourly (or second-generation cephalosporin if cloxacillin was not available) for all patients. gentamycin 240 mg iv daily and metronidazole 500 mg iv 8 hourly were added for hiv-positive and diabetic patients. empiric intravenous antibiotics were commenced on admission and continued until the culture and sensitivity results became available, and then culture-directed antibiotic therapy was instituted. daily paraffin gauze or absorbent dressings were done throughout admission. patients were discharged on oral antibiotics once the drainage had sufficiently decreased and further surgical intervention in the form of re-debridement, amputation or skin grafting was deemed unlikely. patients were referred to occupational therapists for rehabilitation once pain and wound drainage allowed. daily dressings and rehabilitation continued on an outpatient basis at our institution, or at the referral hospital. statistical analysis was performed using stata 15.0 (statacorp. college station, texas). continuous variables were reported as mean (± standard deviation [sd]) or median (with interquartile range [iqr]) and categorical variables as numbers and percentages, unless otherwise stated. differences in continuous variables were compared with the use of the mann-whitney test. categorical data was compared using the fisher’s exact test (if any cell count was below 5) or the chi-squared test (if no cell count below 5). all tests were two-sided and the level of significance was set at p<0.05. in addition, reverse stepwise logistic regression analysis was performed and factors that were significantly associated with early complications were then used in the multivariate regression model. results a total of 105 cases of primary hand infection cases were identified over the study period. two cases with incomplete primary outcome data and 25 cases involving patients under the age of 18 years were excluded from the study. therefore, 78 cases were included in the analysis. the demographic information of the study population is summarised in table i. the median age of patients was 38.8±15.6 years (range 18–90 years) of which 44 (56%) were males. the majority of patients (60%) were unemployed and 22% were manual labourers. sixty-eight patients (91%) were right-handed and the dominant hand was affected in 54% of all patients. in terms of the aetiology, 39 (50%) of hand infections developed spontaneously, 23 (30%) following penetrating injuries and seven (9%) as the result of human bites. risk factors for early complications thirty per cent of patients developed early complications with 14 (18%) cases requiring re-debridement, 12 (16%) needing amputation and eight (10%) patients having tissue loss requiring skin graft. increasing age was associated with a risk for the development of an early complication (p=0.040). the mean time from onset to presentation at the hospital was 6.4±5.6 days (range 0–29) and a delay in presentation was not associated with an increased risk for complications (p=0.810). patients whose first healthcare contact was with a private general practitioner (gp) were, however, at risk for early complications (p=0.013). only five (45%) of these cases were referred for surgical management page 99verhoef h et al. sa orthop j 2020;19(2) at the time of initial presentation, with the number of healthcare provider contacts prior to formal surgical treatment ranging from one to six. three patients were given antibiotics and were not referred for surgery, while another three received informal incision and drainage at initial contact. early complications were seen in four out of the six patients who were not referred at initial contact. seven (64%) complications were seen in patients who were initially treated by a private gp, including five (45%) amputations, one repeat debridement, and one patient requiring skin grafting due to tissue loss. all three patients who had informal incision and drainage subsequently required an amputation. thirty-four (43%) patients were hiv positive, with a mean cd4 count of 400±218 cells/mm3 and 41% of cases were on anti-retroviral (arv) therapy for longer than three months at the time of presentation. the median viral load was 50 copies/ml (iqr 0–90  000) and 27% of cases had an undetectable viral load. hiv-positive status was not associated with an increased risk for early complications (p=0.565). neither cd4 count, viral load nor arv therapy were associated with an increased risk of complications (table ii). eighty per cent of diabetic hiv-positive patients developed early complications (p=0.025). nineteen per cent of the entire cohort was diabetic with a mean hba1c 10.7±4.3% (range 6.6–15.6%). forty-three per cent of diabetic patients developed early complications (p=0.012). infections resulting from a human bite were more likely to develop an early complication than spontaneous cases or cases resulting from penetrating injuries (p=0.018). polymicrobial infections were also associated with early complications (p=0.045). backwards stepwise logistic regression analysis found diabetes mellitus (odds ratio [or] 4.4, 95% confidence interval [ci] 1.12–17.38), human bites (or 7.6, 95% ci 1.15–49.92) and first healthcare contact with a private gp (or 6.7, 95% ci 1.52–29.21) to be associated with an increased risk for early complications (table iii). these factors remained significant on multivariate regression analysis. a post-hoc power analysis revealed that the study had a 95% power for human bites but was insufficiently powered for diabetes mellitus and first contact with private general practitioner. bacteriology and resistance profiles our culture yield was 68% (n=53). forty-five swabs (58%) cultured a single organism, while no organism was cultured in 25 (32%) patients. two organisms were identified in three swabs and one swab cultured three organisms. on four occasions, culture results were reported as mixed growth, and were not further reported. in 29 (37%) cases, s. aureus was identified as a causative pathogen (table iv). the s. aureus organisms cultured showed high levels of resistance to ampicillin (50%) and only one instance of resistance to cloxacillin was observed. this specific organism also showed intermediate resistance to ciprofloxacin. another s. aureus organism showed intermediate resistance to vancomycin, but the majority of s. aureus cultures remained sensitive to the tested antibiotics. four infections were caused by other gram-positive organisms, three being enterococcus spp. and one staphylococcus lentus. nine infections involved enterobacteriaceae (klebsiella pneumonia, klebsiella oxycota, proteus mirabilis, enterobacter cloacae and serratia marcescens). the remaining three gram-negative infections involved pseudomonas spp., acinetobacter spp. and citrobacter spp. resistance was most frequently observed among klebsiella and acinetobacter spp. the klebsiella spp. showed the widest range of resistance and were resistant to ampicillin in all instances. both acinetobacter spp. and klebsiella spp., however, remained mostly sensitive to gentamycin and ciprofloxacin in our study population (table iv). discussion this study aimed to identify risk factors for the development of early complications after hand infections. the only patient factor that increased the risk for the development of early complications was table i: description of the study population n (%) mean (±sd) total 78 (100%) age (years) 38.8 (±15.6) male sex 44 (56%) employment status unemployed 47 (60%) manual labourer 17 (22%) other 14 (18%) right hand dominant 68 (91%) dominant hand affected 42 (54%) hiv positive 34 (43%) cd4 count cells/mm3 400.0 (±218.3) cd4 count <350 cells/mm3 13 (38%) viral load undetectable 9 (27%) arv treatment >3 months 14 (41%) diabetes mellitus (dm) 15 (19%) hba1c (%) 10.69 (±4.3) patients on therapy 12 (80%) hba1c >6% 15 (100%) hiv and dm 5 (6%) corticosteroid therapy 0 (0%) cigarette smoking 13 (17%) chronic renal failure 1 (1%) aetiology spontaneous onset 39 (50%) penetrating trauma 23 (30%) blunt trauma 9 (11%) human bite 7 (9%) causative organisms staphylococcus aureus 29 (37%) other gram positives 4 (5%) gram negatives 12 (16%) polymicrobial 8 (10%) no growth 25 (31%) initial healthcare contact public clinic 45 (58%) public hospital 20 (26%) private gp 11 (14%) other 1 (1%) onset to presentation (days) 6.4 (±5.6) length of hospital stay (days) 6.9 (±6.1) any complication 23 (30%) re-debridement required 14 (18%) amputation 12 (16%) tissue loss requiring skin graft 8 (10%) page 100 verhoef h et al. sa orthop j 2020;19(2) table ii: risk factors associated with early complications in hand infections risk factor no complication n (%) any complication n (%) p-value patient factors age 55 (70%) 23 (30%) 0.040 male sex 34 (77%) 10 (33%) 0.136 unemployed 30 (64%) 17 (36%) 0.111 dominant hand affected 28 (67%) 14 (33%) 0.391 hiv positive 22 (67%) 11 (33%) 0.565 cd4 count 23 (67%) 11 (33%) 0.755 viral load 22 (76%) 7 (24%) 0.836 arv therapy <3 months 12 (85%) 2 (15%) 0.390 diabetes mellitus 6 (43%) 9 (57%) 0.012 hba1c 6 (43%) 8 (57%) 0.747 hiv positive and diabetes mellitus 1 (20%) 4 (80%) 0.025 cigarette smoking 9 (69%) 4 (31%) 1.000 aetiological factors spontaneous onset 31 (82%) 7 (18%) 0.052 penetrating trauma 17 (70%) 6 (30%) 0.753 human bite 2 (29%) 5 (71%) 0.018 staphylococcus aureus 25 (86%) 4 (14%) 0.078 other gram-positive organisms 2 (50%) 2 (50%) 0.577 gram-negative organisms 9 (75%) 3 (25%) 1.000 polymicrobial infections 3 (37%) 5 (63%) 0.045 no growth 17 (68%) 8 (32%) 0.738 management factors initial healthcare contact public clinic 35 (78%) 10 (22%) 0.100 initial healthcare contact public hospital 14 (70%) 6 (30%) 0.953 initial healthcare contact private gp 4 (36%) 7 (64%) 0.013 delay in presentation 55 (71%) 23 (29%) 0.810 table iii: multivariate regression analysis of risk factors associated with the development of early complications risk factor odds ratio p-value 95% ci diabetes mellitus 4.4 0.034 1.12–17.38 human bite 7.6 0.035 1.15–49.92 first healthcare contact private gp 6.7 0.012 1.52–29.21 table iv: bacteriology and antibiotic resistance profiles (percentages indicate the fraction of all organisms found to be either sensitive or resistant to the antibiotics in question; eight infections [10%] involved multiple organisms; pathogens not listed here) pathogen n (%) antibiotic sensitivity (%) antibiotic resistance (%) staphylococcus aureus 29 (37%) 97% – cloxacillin 100% – clindamycin 50% – ampicillin staphylococcus lentus 1 (<1%) 100% – cloxacillin, gentamycin, ciprofloxacin 100% – tetracycline enterococcus sp. 3 (4%) 100% – ampicillin 33% – clindamycin 67% – erythromycin, tetracycline klebsiella sp. 5 (6%) 80% – gentamycin, ciprofloxacin, cefuroxime 20% – ciprofloxacin, gentamycin, amoxicillin/ clavulanic acid, all cephalosporins, piperacillin/ tazobactam 100% – ampicillin proteus sp. 2 (3%) 100% – ampicillin, ciprofloxacin, gentamycin, amoxicillin/ clavulanic acid 100% – tigecycline, colistin serratia sp. 1 (<1%) 100% – ciprofloxacin, gentamycin 100% – ampicillin, nitrofurantoin, chloramphenicol enterobacter sp. 1 (<1%) 100% – ciprofloxacin, gentamycin, amoxicillin/clavulanic acid 100% – cefuroxime, cefoxitin pseudomonas sp. 1 (<1%) 100% – amoxicillin/clavulanic acid, ciprofloxacin, gentamycin 100% – colistin acinetobacter sp. 1 (<1%) 100% – ciprofloxacin, gentamycin 100% – all cephalosporins, piperacillin/ tazobactam, meropenem citrobacter sp. 1 (<1%) 100% – ciprofloxacin, gentamycin, amoxicillin/clavulanic acid, piperacillin/tazobactam nil resistance found no growth 25 (32%) polymicrobial 8 (10%) page 101verhoef h et al. sa orthop j 2020;19(2) the presence of diabetes mellitus (or 4.4). neither hiv infection nor a low cd4 count was associated with early complications. patients with infections resulting from human bites had a seven times higher risk for early complications. patients who were initially treated in the private sector by a gp also had an increased risk for early complications (or 6.7). hiv is a retrovirus that causes immune suppression through suppression of cd4 t-lymphocytes. these cells release cytokines that activate macrophages in response to bound antigens and also stimulate b lymphocytes to divide, differentiate and produce antibodies.10 the burden of hiv infection in south africa is among the highest in the world, with 19% of the adult population being affected,12 and as much as 40% in certain regions.12,13 there are few publications with original data relating to the effect of hiv on hand infections. ching et al. suggested that hiv-positive patients required higher numbers of surgical procedures and longer admission.10 the authors also found that low cd4 counts were associated with more complications.10 both gonzales et al. and mcaulliffe et al., on the other hand, suggested that hiv infection had little bearing on the outcomes of hand infections.5,6 wynn et al., however, acknowledged that multiple factors could be contributing to the outcomes of hand infections in hiv-positive patients.14 although our study included higher numbers of hivpositive patients and cd4 counts than previous publications, with the addition of viral load and arv treatment data, these factors did not seem to have a significant influence on the development of early complications. taking the small difference in event rates into account, it appears that far greater numbers of hiv-positive patients would be required in order to adequately power a multivariate analysis of all contributing factors. chronic poor glycaemic control in diabetic patients leads to impaired cellular immunity, peripheral neuropathy and peripheral microvascular disease.15 elevated serum glucose may impair neutrophil phagocytosis and chemotaxis. loss of protective sensory perception to heat, pain and pressure means that diabetic patients may have an altered perception of the severity of trauma or may not notice the effects of repetitive microtrauma such as repetitive manual labour. a breach of the skin’s protective barrier may thus not be initially noticed. altered sensory perception may also cause diabetic patients to tolerate the symptoms of early infection for longer before seeking help.9 impaired peripheral vascularity further compounds the effects of impaired immunity. the abovementioned factors place diabetics at risk for developing infections and predisposes diabetic patients to a six times greater risk of experiencing complications.11 our finding that poorly controlled diabetes mellitus is a significant independent risk factor for the development of early complications (or 4.4; 95% ci 1.12–17.38) is in agreement with current literature and remained significant after multivariate analysis.8 the frequency of complications seen in patients presenting to private gps is noteworthy, but with the small number of cases involved it is difficult to draw any conclusions in terms of this finding. a number of the cases that developed complications involved an informal incision and drainage in the consulting rooms, which raises questions around the adequacy of the surgical debridement in this setting. although simple lancing may decompress superficial collections and relieve pain to some extent, incomplete drainage and recollection is common. sub-optimal debridement may lead to persistence of an infective nidus and continued soft tissue compromise. underestimation of the extent of infection, especially in tenosynovitis and deep space infections, may also contribute to the development of complications. furthermore, the oral antibiotics which would typically be prescribed on an outpatient basis may not have the necessary bioavailability in comparison to parenteral treatment. the finding of increased complications after initial outpatient management emphasises the potential value of optimal surgical conditions, in-patient care, parenteral antibiotics and a surgeon experienced in surgical management of complex hand infections. infections resulting from human bites were associated with the development of early complications in our study population and resulted in amputation in three cases. although the literature suggests that eikenella corrodens is the most common organism isolated in human bites,3 we did not encounter this organism. polymicrobial infections were seen in 29% of the human bites in this series, which was comparable to previous studies.11 a high index of suspicion should be maintained for the presence of associated tendon injury and intra-articular penetration when human bites are encountered.3,4 prompt administration of broad spectrum, parenteral antibiotics and surgical debridement followed by splinting and a low threshold for re-debridement at 48 hours is advised to limit complications.3 the bacteriology and antibiotic sensitivity profiles of the causative organisms may vary between institutions and regions; however, the findings in our study are in keeping with those that have previously been reported in the literature. historically, s. aureus was reported to be responsible for up to 86% of hand infections.3,16 more recent international and local literature suggest that polymicrobial infections are becoming more frequent.2,3,11 this trend is also reflected in our data with more than a quarter of infections involving gram-negative or polymicrobial infections. existing data suggests that diabetics and hiv-positive patients are more commonly affected by polymicrobial, gram-negative and anaerobic infections.2,5 klebsiella sp. was the most frequently isolated gram-negative organism in our study, and most (67%) of these cultures were obtained from diabetic patients who were particularly poorly controlled (hba1c 14.4–15.6). it is important to recognise that there was no growth in 31% of our cases and factors such as pre-operative antibiotic administration and the quality of specimens taken may have contributed to this. taking tissue samples for culture, for example, could potentially have increased the yield compared to pus swabs. the existing literature suggests a multitude of factors that appear to have an influence on complications in hand infections when they are viewed in isolation (on univariate level). to our knowledge this is the first study including hiv-positive and diabetic patients with hand infections that also incorporated a multivariate analysis. this showed that many of the risk factors which are considered to be significant on a univariate level may not remain significant in a multivariate model. some frequently cited publications may have been underpowered for the reported outcomes and may also fail to account for the complex interplay between multiple risk factors. there are, however, several limitations to this study, principally among which is the relatively small sample size. there was a very small difference in the complication rate between the hiv-positive patients and the control group and thus the study was insufficiently powered to assess hiv as a risk factor for the development of early complications. while the study was sufficiently powered to assess human bites, a larger number of cases would also be required to confirm diabetes as a risk factor. the second important shortcoming is the focus on early complications, the lack of long-term followup and functional outcome data. while functional outcomes were available for a small number of cases, the data was not sufficient to allow analysis. patients were often followed up at their nearest hospital due to the long distances between referral centres and transport restraints. this may have contributed to inconsistencies in patient attendance and recording of functional outcomes. future studies involving the prospective enrolment and long-term followup of patients, including the assessment of functional outcomes, are needed to determine all other risk factors for complications following hand infections. page 102 verhoef h et al. sa orthop j 2020;19(2) conclusion hand infections resulting from human bites and those occurring in diabetic patients with poor glucose control appear to be more prone to the development of early complications. hiv infection was not found to be a significant risk factor in this series. while the majority of infections were still caused by s. aureus, a number of gram-negative and polymicrobial infections were identified. the addition of empiric gram-negative antibiotic cover should be considered, particularly in high risk patients. acknowledgement the authors would like to thank prof reitze rodseth for his contributions. ethics statement ethical approval was obtained from the university of kwazulu-natal brec ethics committee (beo14/17), the kwazulu-natal department of health (kz_2017rp27_823) and the ngwelezana hospital ceo prior to the commencement of data collection. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions hv proposed the study concept, study design, data collection, data analysis and manuscript preparation. lcm contributed to study design, data analysis and manuscript preparation. pvr contributed to study design, manuscript preparation and co-supervised the study. pdr contributed to conceptualisation, study design, manuscript preparation and supervised the study. orcid verhoef h https://orcid.org/0000-0002-6164-4892 marais lc https://orcid.org/0000-0002-1120-8419 ryan pv https://orcid.org/0000-0002-0957-6482 rollinson pd https://orcid.org/0000-0002-2384-7250 references 1. koshy jc, bell b. hand infections. j hand surg am. 2019 jan;44(1):46-54. 2. greyling jf, visser e, elliot e. bacteriology and epidemiology of hand infections. sa orthop j. 2012;11(1):57-62. 3. mcdonald ls, bavaro mf, hofmeister ep, kroonen lt. hand infections. j hand surg am. 2011;36(8):1403-12. 4. osterman m, draeger r, stern p. acute hand infections. j hand surg am. 2014;39(8):1628-35. 5. gonzalez mh, nikoleit j, weinzeig n, pulvirenti j. upper extremity infections in patients with the human immunodeficiency virus. j hand surg am. 1998;23(2):348-52. 6. mcauliffe ja, seltzer dg, hornicek fj. upper-extremity infections in patients seropositive for human immunodeficiency virus. j hand surg am. 1997;22(6):1084-90. 7. glickel sz. hand infections in patients with acquired immunodeficiency syndrome. j hand surg am. 1988;13(5):770-75. 8. schmidt g, piponov h, chuang d, gonzalez m. hand infections in the immunocompromised patient: an update. j hand surg am. 2019;44(2):144-49. 9. abbas zg, gill gv, archibald lk. the epidemiology of diabetic limb sepsis: an african perspective. diabet med. 2002;19(11):895-99. 10. ching v, ritz m, song c, et al. human immunodeficiency virus infection in an emergency hand service. j hand surg am. 1996;21(4):696-99. 11. houshian s, seyedipour s, wedderkopp n. epidemiology of bacterial hand infections. int j infect dis. 2006;10(4):315-19. 12. statistics south africa [internet]. statistical release p0302 – mid-year population estimates. pretoria: statistics south africa; [updated 25 aug 2016; cited 16 oct 2016]. available from: http:// www.statssa.gov.za/publications/p0302/p03022016.pdf. 13. south african national aids council, national department of health [internet]. global aids response progress report 2012. [updated 29 feb 2012; cited 16 oct 2016]. available from: http:// files.unaids.org/en/dataanalysis/knowyourresponse/countryprogres sreports/2012countries/ce_za_narrative_report.pdf. 14. wynn sw, elhassan bt, gonzalez mh. infections of the hand in the immunocompromised host. j hand surg am. 2004;4(2):121-27. 15. mandel ma. immune competence and diabetes mellitus: pyogenic human hand infections. j hand surg am. 1978;3(5):458-61. 16. stone nh, hursch h, humphrey cr, boswick ja jr. empirical selection of antibiotics for hand infections. j bone joint surg am. 1969;51(5):899-903. https://orcid.org/0000-0002-6164-4892 https://orcid.org/0000-0002-1120-8419 https://orcid.org/0000-0002-0957-6482 https://orcid.org/0000-0002-2384-7250 _goback _goback _goback _goback south african orthopaedic journal editorial doi 10.17159/2309-8309/2021/v20n4a0sa orthop j 2021;20(4) mentorship: a two-way street cameron m anley* orthopaedic consultant, division of orthopaedics, tygerberg hospital, stellenbosch university, cape town, south africa *corresponding author: camley@sun.ac.za throughout our orthopaedic training and subsequent careers, we interact with many teachers and colleagues who help us develop our surgical skills and orthopaedic knowledge. some may become personal role models, from whom we learn more than the basics of orthopaedics. they help to mould our orthopaedic ‘character’, influencing among other aspects, our bedside manner, compassion towards patients and their families, how we interact with colleagues and how we maintain a healthy work–family balance. mulcahey et al. clarified these concepts by highlighting that a teacher shares knowledge with a learner while a role model demonstrates behaviour patterns in a passive manner and without conscious effort.1 although the ability to teach and set a positive example as a role model are considered crucial characteristics of a mentor, these roles should not be confused with mentorship. the precise definition of mentorship varies widely in the literature. taking key aspects from various definitions, mentorship can be described as where a senior respected and knowledgeable colleague (mentor) offers their time to coach, teach and guide a younger colleague (mentee) regarding personal aspects, professional attitudes and education. this requires dynamic, active involvement from both the mentor and the mentee and should enhance both of their careers.1-3 the importance of mentorship seems to be underestimated by many orthopaedic surgeons. a recent survey conducted on south african orthopaedic surgeons demonstrated that 72% of those who responded face burnout.4 one of the strategies commonly highlighted to combat burnout is participation in a dedicated mentorship programme.5,6 at present, there are few formal mentorship programmes for orthopaedic surgeons in south africa, in either the state sector, academic setting or private hospital groups. a formal mentorship programme is not just teaching young surgeons but offering a dedicated mentor to guide the process. various guidelines have been proposed to assist with the development of such a programme. training units and hospital groups should embrace the opportunity to develop these programmes to help registrars and newly qualified orthopaedic surgeons through the stressors of starting their careers. the excitement and relief of completing one’s training or fellowship should not be tainted by the stress of starting a new practice. the loneliness of private practice, ethical coding practices, financial pressures, being the sole decision-maker in complex situations, and maintaining the correct balance between work and personal life are all challenges faced by the newly qualified surgeon. the guidance of an experienced mentor is invaluable as the mentee navigates this new environment. although various mentorship models have been developed, the most productive and commonly encouraged method is one-to-one mentorship (dyadic method).3 the success of dyadic mentoring relies on willing mentees and qualified mentors. the first phase of mentorship is initiation.3 during this phase, the mentorship relationship is established. various methods have been suggested to match a mentee with a mentor. however, many articles have highlighted that the majority of successful outcomes rely on a mentee choosing their mentor.1,2,7-9 the relationship’s success depends upon the commitment of both parties to attend regular meetings during which they establish goals for the mentee and monitor their progress. these goals will vary according to the mentee’s needs and can be personal, work or research related. after discussion with their mentor, a mentee may also consider having more than one mentor. the importance of the respective roles and responsibilities of the mentee and mentor is highlighted in various articles.1-3,8 in essence, the mentee must respect the time that the mentor is offering and should thus be prepared for meetings, achieve the agreed goals, and demonstrate a willingness to learn and develop. regarding being a mentor, one of the major impediments commonly recognised is the time commitment required to be a mentor.8 once this has been overcome, several specific traits have been identified as essential to being a good mentor. these include, but are not limited to, being available and reliable with regard to meetings; allowing the mentee to express themselves and listening attentively before offering unbiased advice; not allowing their ego to prevent celebrating the success of the mentee’s achievements; and eventually acknowledging the development of the mentee into a colleague.1-3,9 the programme’s second or cultivation phase is the most fruitful to both parties as the mentorship develops. the third phase is the separation phase, where the mentorship has achieved its goals, and the relationship becomes more collegial than mentorial. the final redefinition stage can be indefinite, where the hierarchical order no longer exists between the mentee and mentor.3 an essential aspect of mentorship is the benefit derived by both the mentee and mentor. much research has shown a significant benefit to the mentor, including personal fulfilment (‘giving back’), development of leadership and coaching skills, and renewed interest in personal career.10 senior colleagues should be encouraged to develop the necessary skills to become mentors. unfortunately, teaching and demonstrating brilliant surgical skills and knowledge does not always translate into being a great mentor. specific courses have been developed, and there are multiple online resources available that can guide potential mentors through the process. page 194 sa orthop j 2021;20(4) from a personal point of view, i first met my current mentor in his role as a teacher in the mid-2000s. he was a great teacher, passionate and enthusiastic about his field of expertise. through my interaction with him, due to the humbleness and absolute respect he demonstrated to his patients and colleagues, he became a role model to me. about 18 months, ago he started assisting me as my mentor. i was honoured that he could offer me the time, given his extensive workload. our first meeting was extremely productive, and together, we formulated a plan for the way forward. importantly, he made me accountable to him to take certain actions we had agreed upon, and the benefits to me have been immense. together, we have rekindled my enjoyment of orthopaedics. vincent pellegrini jr, as the president of the american orthopaedic association, eloquently summarised being a mentor and mentorship as follows:11 ‘an effective mentor is the guardian and promoter of the young physician’s personal and professional development. so, mentoring is the act of nurturing the emotional and intellectual growth of another person to the point that, and here comes the hard part, he or she is your peer and equal and, ideally, has eclipsed your own accomplishments with the tools and opportunities that you have provided. this requires a special person, with just the right balance of self-confidence and humility, which may be a challenge for any one of us to achieve on any particular day.’ references 1. mulcahey mk, waterman br, hart r, daniels ah. the role of mentoring in the development of successful orthopaedic surgeons. j am acad orthop surg. 2018 jul 1;26(13):463-71. 2. aiyer aa, mody ks, dib ag, et al. medical student mentorship in orthopaedic surgery. j am acad orthop surg. 2021 aug;29(16):681-90. https://doi.org/10.5435/jaaos-d-20-01274. 3. burgess a, van diggele c, mellis c. mentorship in the health professions: a review. clin teach. 2018 jun;15(3):197-202. 4. o’connor m, ferreira n, venter r, webster p, marais l. burnout amongst the south african orthopaedic community: a cross-sectional study. saoa congress presentation 2021. 5. perumalswami cr, takenoshita s, tanabe a, et al. workplace resources, mentorship, and burnout in early career physician-scientists: a cross sectional study in japan. bmc med educ. 2020 dec;20:178. https://doi.org/10.1186/s12909-020-02072-x. 6. leung vw, konci x, meterissian s. is there a role for formal mentorship programs in reducing burnout in surgical residency? a literature review. int j surg. 2021 july. 7. pololi l, knight s. mentoring faculty in academic medicine. j gen intern med. 2005 sep;20(9):866-70. 8. entezami p, franzblau le, chung kc. mentorship in surgical training: a systematic review. hand. 2012 mar 1;7(1):30-36. 9. hart ra, eltorai ae, yanney k, et al. update on mentorship in orthopaedic resident education: a report from the american orthopaedic association. jbjs. 2020 mar 4;102(5):e20. 10. salazar dh, schiff ap, light tr. the value of senior mentorship among orthopaedic surgeons. j am acad orthop surg. 2019 dec 1;27(23):861-67. 11. pellegrini jr vd. mentoring: our obligation … our heritage. jbjs. 2009 oct 1;91(10):2511-19. https://doi.org/10.5435/jaaos-d-20-01274 https://doi.org/10.1186/s12909-020-02072-x _hlk81987558 page 63south african orthopaedic journal http://journal.saoa.org.za saoj south african orthopaedic journal cpd questionnaire. november 2019 vol 18 no 4 assessment of elbow functional outcome after closed reduction and percutaneous pinning of displaced supracondylar humerus fractures in children (rutarama a, firth gb) 1. regarding functional outcomes of closed reduction and percutaneous pinning of gartland grade 3 supracondylar humerus fractures in children, most children gain good functional outcome and range of motion by: a. 3 weeks a b. 6 weeks b c. 12 weeks c d. 24 weeks d e. 36 weeks e 2. in uncomplicated as opposed to complicated supracondylar humerus fractures in children, the role of physiotherapy versus no physiotherapy on functional outcome after closed reduction and percutaneous pinning at one-year follow-up is as follows: a. better outcome a b. poor outcome b c. same outcome c d. guarded outcome d e. early to assess outcome e 3. the paediatric outcome data collection instrument (podci) to assess functional outcomes after closed reduction and percutaneous pinning of supracondylar humerus fracture in children is important because: a. anatomical outcome is less important than clinical outcomes a b. anatomical outcomes do not necessarily equate to clinical outcomes b c. anatomical outcomes equate to clinical outcomes c d. anatomical outcomes are more important than clinical outcomes d e. anatomical outcomes somehow equate to clinical outcomes e antegrade flexible intramedullary nailing through the greater trochanter in paediatric femur shaft fractures (rosin rc, rasool mn, sibanda w, rollinson pd) 4. the incidence of femoral shaft fractures in south africa is estimated to be: a. 0.50 per 100 children per year a b. 0.45 per 100 children per year b c. 0.30 per 100 children per year c d. 0.25 per 100 children per year d e. 0.10 per 100 children per year e 5. the articulo-trochanteric distance is defined as the distance between two lines perpendicular to the anatomical axis of the femur through the following points: a. the tip of the greater trochanter and the tip of the lesser trochanter a b. the tip of the greater trochanter and the highest extent of the femoral head b c. the tip of the greater trochanter and the lateral border of the acetabulum c d. the tip of the greater trochanter and the contralateral tip of the greater trochanter d e. the tip of the greater trochanter and the centre of the femoral head e 6. it is recommended that flexible intramedullary nailing should not be used in children older than: a. 13 years a b. 6 years b c. 10 years c d. 15 years d e. 11 years e ‘out with the old and in with the new’ – a retrospective review of paediatric craniocervical junction fixation: indications, techniques and outcomes (swan ak, dunn rn) 7. which of the following screw fixation options is not commonly used for the c2 vertebra? a. c2 translaminar screw fixation a b. c2 lateral mass screw fixation b c. c2 pars screw fixation c d. c2 pedicle screw fixation d e. none of the above e 8. which of the following biomechanical statements is true? a. primary motion at the occipitocervical joint is rotation a b. primary motion at the atlanto-axial joint is in the sagittal plane b c. the craniocervical junction is the most significant transitional zone in children younger than 8 years c d. the sublaminar wiring technique is biomechanically superior to magerl's tasf in resisting rotation d e. the cervical facet joints are more vertically oriented in paediatric patients e 9. which statement regarding magerl's tasf and the harms techniques is true? a. magerl's tasf has a significantly higher risk of vertebral artery injury than the harms technique a b. the c2 nerve root is encountered during the surgical approach for the harms technique b c. obesity, barrel chest and kyphosis are relative contraindications for the harms technique c d. the risk of vertebral artery injury is approximately 7% for both techniques d e. the harms technique requires the reduction of the c1–c2 joints to be used e page 64 south african orthopaedic journal http://journal.saoa.org.za subscribers and other recipients of saoj visit our new cpd portal at www.mpconsulting.co.za • register with your email address as username and mp number with seven digits as your password and then click on the icon “journal cpd”. • scroll down until you get the correct journal. on the right hand side is an option “access”. this will allow you to answer the questions. if you still can not access please send your name and mp number to cpd@medpharm.co.za in order to gain access to the questions. • once you click on this icon, there is an option below the title of the journal: click to read this issue online • once you have completed the answers, go back to the top of the page next to the registration option. there is another icon “find my cpd certificate”. (you will have to answer the two questions regarding your internship and last cpd audit once you have completed a questionnaire and want to retrieve your certificate). • if you click on that icon it will open your certificate which you can print or save on your system. • please call mpc helpdesk if you have any questions: 0861 111 335. circular frames of the humerus: salvage surgery case series (pretorius hs, strauss k, ferreira n, lamberts rp) 10. what method was used in this case to minimise pin loosening with insertion? a. 90° orthogonal drilling a b. water cooling with drilling b c. pin inserted on power c d. touch technique applied d e. drill sleeves not used due to cumbersome design e 11. of the 12 cases that are described, 83% went on to union. what adjunct was used to facilitate union? a. bone grafting a b. distraction b c. stable frame fixation c d. compression d e. concertina technique e 12. the classification system for pin-site infection that is used to evaluate and manage all pin and wire complications is known as the: a. olsen criteria a b. checketts and otterburn classification b c. cierny and mader classification c d. gustilo and anderson classification d e. henderson classification e grip strength following total wrist arthrodesis using the same hand as reference: a prospective study (koch o, alexander an, olorunju s, mcloughlin ha, le roux tl) 13. standard grip strength measurement is done with a jamar dynamometer in which unit(s)? a. kg a b. mmhg b c. cm3 c d. lb d e. kg and lb e 14. aetiology contribution to a decrease in grip strength is: a. snac a b. slac b c. primary oa of the wrist c d. secondary oa after infection of the wrist joint d e. all of the above e 15. a total wrist fusion: a. improves power grip from the starting value a b. is a suitable option for a high demand patient with oa of the wrist b c. provides pain relief c d. should remain in the skill set of the orthopaedic surgeon d e. all of the above e communicating about prognosis with regard to osteosarcoma in a south african cross-cultural clinical setting: strategies and challenges (brown o, goliath v, van rooyen rm, aldous c, marais lc) 16. at the study site, healthcare professionals are expected to: a. allow sufficient time for cultural practices to be completed before discussing prognosis a b. communicate diagnostic, treatment and prognostic information urgently b c. communicate diagnostic and prognostic information in a staged approach c d. always respect patients’ occasional need for ambiguity about prognosis d e. allow patients sufficient time to come to terms with the diagnosis of osteosarcoma before communicating prognosis e 17. the limitations of this study include the following: a. the researcher could have triangulated the data-gathering procedure a b. the sample was too big to make meaningful interpretations b c. the researcher could have mixed the professionals across cultural groups c d. the researcher should have used random sampling d e. a and c e 18. participants found the following most challenging: a. disclosing a palliative amputation a b. disclosing prognosis b c. feeling incompetent with regard to disclosing prognosis despite adequate training c d. deciding who should disclose prognosis d e. giving patients time frames for survival e current concepts in the management of open tibia fractures (manjra ma, basson t, du preez g, du toit j, ferreira n) 19. choose the most correct answer with regard to the management of open tibial fractures: a. negative pressure wound therapy is an excellent strategy for definitive wound therapy a b. the single biggest predictor of infection in open tibia fractures is the use of gram-negative antibiotic cover b c. antibiotic cover should be continued for five days post wound coverage c d. wound cultures obtained at debridement should guide antibiotic therapy d e. low pressure saline is effective as a lavage solution e 20. all the statements below regarding open tibial fractures are correct except: a. local antibiotic beads are a useful and effective adjunct to intravenous therapy a b. primary wound closure should be performed where this can be done safely b c. hiv status guides management irrespective of cd4 count c d. for gustilo-anderson iii fractures, circular external fixation appears to provide the lowest infection rates when compared to intramedullary nailing d e. definitive soft tissue management should be achieved within seven days e medical practice consulting: client support center: +27121117001 office – switchboard: +27121117000 maré ph et al. sa orthop j 2020;19(3) doi 10.17159/2309-8309/2020/v19n3a8 south african orthopaedic journal http://journal.saoa.org.za traumacurrent concepts review citation: maré ph, thompson dm. infantile blount’s disease. sa orthop j 2020;19(3):173-182. http://dx.doi.org/10.17159/2309-8309/2020/v19n3a8 editor: prof. nando ferreira, stellenbosch university, cape town, south africa received: april 2020 accepted: may 2020 published: august 2020 copyright: © 2020 maré ph. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was secured for this research. conflict of interest: ph maré has received honoraria from orthofix and smith & nephew for teaching and training. dm thompson has no conflict of interest to declare. abstract infantile blount’s disease results in multi-planar proximal tibial deformity consisting of varus, procurvatum, internal rotation and shortening. the deformity is attributed to disordered growth of the posteromedial proximal tibial physis. the aetiology is multifactorial. it is associated with childhood obesity and african ethnicity. the ability to differentiate between infantile blount’s disease and physiological bowing depends on the findings of focused clinical examination, x-ray appearance, tibial metaphyseal-diaphyseal angle and tibial epiphyseal-metaphyseal angle. the gold standard of treatment is proximal tibial metaphyseal corrective osteotomy before the age of 4 years. the limb should be realigned to physiological valgus. the recurrence rate after realignment osteotomy is high. recurrence is associated with age at osteotomy, obesity, higher langenskiöld stage and medial physeal slope ≥60°. the surgical management of severe, recurrent or neglected infantile blount’s disease is challenging. comprehensive clinical examination and multi-planar deformity analysis with standing long leg x-rays are essential to identify all aspects of the deformity. distal femur coronal malalignment and significant rotational deformity should be excluded. knee instability due to intra-articular deformity should be corrected by elevation of the medial tibial plateau. lateral epiphysiodesis should be done at the same time as medial plateau elevation and when medial growth arrest is certain to prevent recurrence. level of evidence: level 5 keywords: blount’s disease, tibia vara, genu varum, recurrence, obesity infantile blount’s disease maré ph1 , thompson dm2 1 mbchb, fcorth(sa); head clinical unit: paediatric orthopaedics, grey’s hospital, nelson r mandela school of medicine, university of kwazulu-natal, pietermaritzburg, south africa 2 mbchb, fcs(glasgow); specialist orthopaedic surgeon, grey’s hospital, nelson r mandela school of medicine, university of kwazulu-natal, pietermaritzburg, south africa corresponding author: dr ph maré, po box 351, msunduzi, 3231; tel: +27 33 897 3050; cell: +27 83 294 8375; email: phmare@gmail.com https://orcid.org/0000-0003-1599-7651 https://orcid.org/0000-0003-2607-3999 page 174 maré ph et al. sa orthop j 2020;19(3) introduction blount’s disease is an abnormality of growth of the metaphysis, epiphyseal cartilage and osseous centre of the epiphysis.1 the consequence is abrupt angulation of the proximal tibia into varus,2 in association with procurvatum and internal tibial torsion. associated deformities may occur in the femur and hindfoot. the disorder was first described by erlacher in 1922.1 blount was the first to provide a detailed description of the clinical features, x-ray findings and treatment of 28 cases of tibia vara. subsequently the disorder is most commonly known as blount’s disease or alternatively as tibia vara.2 it is classified according to age at onset. infantile blount’s disease (ibd) or early-onset blount’s disease is recognised as progressive tibial bowing with onset before the age of 4 years.3 thompson and carter divided late-onset blount’s disease into juvenile (onset 4–10 years) and adolescent blount’s disease (onset ≥11 years).4 the disorder is relatively common in south africa and it is frequently treated by general orthopaedic surgeons. recurrent deformity and repeat surgery are associated with worse outcome at skeletal maturity.5 the aim of this narrative review is to highlight key principles related to the diagnosis, evaluation, assessment of recurrence risk, and treatment strategy selection for children with ibd. a literature search on google scholar, medline, lww, scopus and sciencedirect was performed using the keywords ‘infantile or early-onset tibia vara’, ‘infantile or early-onset blount disease’, ‘infantile or early-onset blount’s disease’. retrieved studies and other articles (identified from references and textbooks) were reviewed. studies relevant to these principles were selected for this narrative review. diagnosis it may be difficult to diagnose the cause of bow-leg deformity between the ages of 1 and 3 years. lower limb bowing may be apparent, physiological or pathological. apparent bowing is easily identified as due to an immature gait pattern (hip flexion and external rotation) where knee flexion is perceived as varus due to the rotation out of the plane of gait progression.6 causes of pathological bowing include blount’s disease, rickets, focal fibrocartilaginous defect (ffcd), skeletal dysplasia, or the result of trauma or infection. differentiation between causes of pathological bowing is easily made on clinical and radiological evaluation and beyond the scope of this review. physiological bowing and ibd is often indistinguishable clinically and radiologically before the age of 36 months. ibd is diagnosed when progressive pathological bowing of the proximal tibia is associated with medial metaphyseal lucency as well as sclerosis, fragmentation and delayed ossification of the medial epiphyseal ossific nucleus.7 these classic radiographic features as described by langenskiöld and riska appear between 18 and 36 months. early diagnosis is important as earlier treatment is associated with improved outcomes.5 several methods should be used to make the diagnosis. as the deformity is diaphyseal in physiological bowing, the clinical ‘coverup’ test is useful. this test is performed by obscuring the middle of the tibial diaphysis with the examiner’s hand perpendicular to the limb axis, while the other hand holds the ankle with the limb rotated so that the patella is facing directly upward. the alignment of the proximal tibia is assessed in relation to the thigh.6 a positive test results if normal valgus proximal tibial alignment is absent. it has been shown to have a sensitivity of 1.00 (95% ci [0.97, 1.03]), specificity of 0.86 (95% ci [0.75, 0.97]), positive predictive value (ppv) of 0.72 (95% ci [0.52, 0.92]) and negative predictive value (npv) of 1.0 (95% ci 0.99, 1.01).6 calculating the likelihood (+) and likelihood (–) ratios from these findings, this test ranks between ‘excellent’ and ‘very good’ in terms of impact on likelihood.8 other findings indicating pathological bowing is unilateral, severe and progressive bowing with the apex of deformity located at the proximal tibial metaphysis. radiological features of physiological bowing (figure 1) include diaphyseal bowing of both the femur and tibia, medial distal femoral and proximal tibial metaphyseal beaking, and thickening of the medial cortices of both the femur and tibial diaphysis. delayed medial ossification of the distal femoral and proximal tibial epiphyseal ossification centres results in a triangular appearance.9 several radiographic features have been identified to aid in diagnosing ibd. these include the metaphyseal-diaphyseal angle (mda), epiphyseal-metaphyseal angle (ema) (figure 2) and relative contribution to varus from distal femur and proximal tibia.10 feldman and schoenecker found that the mda averaged 9°±3.9° in patients with physiological bowing and 19°±5.7° for patients with blount’s disease. they reported a >5% false positive and false negative rate if the mda was between 9° and 16° and cautioned against using the mda in isolation.11 a combination of mda and ema, using the cut-off values of ≥10° and >20° respectively, resulted in positive prediction for ibd with a sensitivity of 1.00 (95% figure 1. a: ap standing x-ray of a 30-month-old infant presenting with classic physiological bow-leg deformity; b: six-month follow-up showing marked improvement; c: one-year follow-up showing almost complete correction of the deformity page 175maré ph et al. sa orthop j 2020;19(3) ci [0.80, 1.00] and specificity 0.80 (95% ci [0.68, 0.98]) in a study by davids et al.12 park et al. determined the rate of spontaneous correction in a cohort of 174 children with physiological bowing (mda≥9°; mean age 17.3 [12–30 months]) to be 3° at 6 months and 6° at 12 months. as expected, there was no corresponding spontaneous correction of mda in 32 children with ibd.13 consideration of all these factors should inform the management strategy. close observation (clinical and x-ray) in borderline cases is essential to avoid delayed surgical treatment of children with ibd. aetiology and pathogenesis the cause of blount’s disease is likely to be multifactorial.14 several factors have been implicated and investigated. these include a mechanical aetiology (due to its association with obesity and reported early walking), as well as genetic factors. aetiological factors in blount’s disease are often investigated and reported for mixed cohorts of ibd, juvenile and adolescent blount’s disease.14 obesity has been associated with blount’s disease since the original reports by blount and langenskiöld. heuter-volkmann law dictates that compressive forces over the growth plate will inhibit growth while the delpech law states that tensile forces will result in a growth increase.15 cook et al. using finite element analysis of the proximal tibia, demonstrated that 30° varus corresponds with a seven-fold increase in compressive forces on the medial side of the proximal tibial growth plate. lateral tensile forces were similarly increased above normal. single leg stance in a 5-year old obese child with 10° varus resulted in compressive forces sufficient to inhibit growth. in a 5-year old with 10° varus and normal weight, these forces (while resulting in a two-fold increase compared to normal alignment) were not sufficient to inhibit growth.16 scott et al. found that body mass index (bmi) and bmi percentile were significantly (p<0.001 and p=0.003 respectively) associated with a diagnosis of ibd in a cohort of 69 children (between 2 and 4 years of age) who presented with idiopathic bow legs. (when combined with an mda cut-off of ≥10°, bmi>22 kg/m2 had a sensitivity of 0.95, specificity of 1.00, ppv of 1.00 and npv of 0.98.)17 dietz et al. found a significant correlation (r=0.75, p<0.01) between the magnitude of varus (as measured by the femoral-tibial shaft angle) and body weight in children with blount’s disease.18 similarly, sabharwal et al. found a significant correlation (r=0.74, p<0.0001) between mechanical axis deviation (mad) and bmi in ibd.19 this clear association between obesity and blount’s disease does, however, not explain why the disorder also occurs in children with normal weight (often with severe deformity) or occurs unilaterally in approximately 50% of cases. early walking has been proposed as a risk factor associated with ibd.10 in contrast to obesity, no robust evidence exists to support this. on the contrary, bathfield found normal (average 13 months) age of walking in a cohort of 110 children with blount’s disease.20 more recently, mehtar et al. confirmed this finding in a cohort of 108 children with blount’s disease from the same area (johannesburg, south africa).21 vitamin d plays multiple roles in the musculoskeletal system, and its association with blount’s disease has been investigated. one study in a cohort of patients attending an obesity clinic found 12 children with blount’s disease, and an association with low levels of vitamin d.22 this finding was referenced in recent literature reviews.23,24 in a well-designed south african study, lisenda et al. contradicted this by reporting the prevalence of vitamin d deficiency in a cohort of 50 children with blount’s disease to be similar to that of healthy children living in the same area.25 it is clear that the aetiology of blount’s disease is multifactorial. further research into environmental, nutritional and genetic factors is needed to identify at-risk children, as well as potentially modifiable factors. clinical assessment patient profile ibd is defined as pathological genu varum with onset before the age of 4 years. in the south african context, children may present late with severe deformity. a thorough history is important to determine age at onset of deformity. based on meta-analysis, children with ibd are more likely to have bilateral disease (53% or=4.30 95% ci [2.27–8.17], p<0.0001) and less likely to be male (61% or=0.32 95% ci [0.13–0.78], p=0.01) when compared to adolescent blount’s disease.26 mehtar et al. confirmed these findings with 82% being female and 64% having bilateral disease from a cohort of 108 children with blount’s disease (44 with ibd).21 measuring and plotting the bmi percentile for age and sex is essential to identify children at risk for obesity and to initiate early intervention. deformity clinical assessment of the extent of proximal tibial varus, internal tibial torsion and procurvatum is essential. varus instability at 15° of knee flexion (siffert-katz sign) is the first sign of intra-articular deformity due to posteromedial depression of the tibial plateau.27 late presentation results in significant varus instability during the stance phase of gait as well as during full extension when the knee is examined in the supine position. figure 2. ap image of the knee of a girl aged 3 years 8 months a: the epiphyseal-metaphyseal angle (ema) is formed between a line parallel to the distal surface of the proximal tibial epiphyseal ossification centre and a line connecting the midpoint of the epiphyseal ossification centre and the most distal point of the medial metaphyseal beak.12 b: the metaphyseal-diaphyseal angle (mda) is formed between a line connecting the most distal points of the medial and lateral proximal tibial metaphyseal beak and a line perpendicular to a line parallel to the lateral tibial cortex (or the anatomic axis of the tibia).12 page 176 maré ph et al. sa orthop j 2020;19(3) the lower limb rotational profile is assessed by the method described by staheli et al.28 internal tibial torsion is universally present, but internal femoral torsion may also contribute to intoeing, as described by aird et al.29 a careful assessment of proximal tibial procurvatum should be made ensuring the patella is facing forward. this component of the deformity may be underestimated and should be correlated with x-ray measurements.23 imaging plain x-ray standardised standing long films including the hip and ankle should be obtained in the anteroposterior (ap) and lateral (lat) plane. several authors have emphasised the importance of ensuring the patella is facing forward for coronal plane deformity analysis.30,31 a common error is placing the limb with the foot facing forward. this leads to external rotation of the knee due to internal tibial torsion. procurvatum in this position appears as increased varus alignment. overlap at the proximal medial tibia obscures radiographic features and prevents accurate langenskiöld staging. in addition, rotation will result in incorrect assessment of the tibiofemoral angle (tfa) and mda, making the differentiation between physiological bowing and ibd difficult. in order to ensure analysis is accurate (as the patella may not yet be ossified), it is critical to ensure that no more than 60% of the proximal fibula should overlap with the proximal tibia on the ap x-ray.30 the classic x-ray features of ibd were described in detail by langenskiöld as progressive changes during skeletal maturation (figure 3 and table i). lateral physeal widening in association with blount’s disease has also been described.32 in what could be seen as a progression of this, sanghrajka et al. described the ‘slipped upper tibial epiphysis’ in three children with ibd. this entity consists of a dome-shaped metaphysis, open physis with dissociation of the lateral borders of the epiphysis and metaphysis, with infero-medial epiphyseal displacement (figure 4). it may be associated with severe obesity.33 these features were not described by the langenskiöld classification and may have implications for management. multi-planar deformity analysis of long leg films is essential to ensure comprehensive deformity correction. distal femoral frontal plane deformity has been described in association with ibd by several authors. standing standardised long leg films provide accurate data for pre-operative planning. gordon et al. showed that the distal femur is either normal or has mild varus deformity.34 figure 3. diagram of the x-ray changes seen in blount’s disease with progressive maturation of the skeleton2 table i: descriptive classification of the x-ray changes seen in blount’s disease with progressive maturation of the skeleton2 stage 1 2 3 4 5 6 age (years) 2–3 2.5–4 4–6 5–10 9–11 10–13 epiphysis delayed medial maturation more pronounced wedge shape and poorly developed wedge shaped medial borderline less clear with islands of calcification progressive ossification occupies the ‘stair-shaped depression’ medial border irregular greatly deformed epiphysis articular surface slopes medially from the intercondylar eminence progressive ossification of both branches of the double physis fairly normal growth continues laterally physis irregular medial and distal slope thin line between epiphysis and metaphysis in the shape of a stair marked difference between pathological medial and lateral physis partially double physis frequently seen irregular medially metaphysis beak in distal and medial direction abrupt varus angulation cartilage occupies a portion of the juxta-physeal medial metaphysis to form a ‘depression’ marked deepening of the medial ‘depression’ in the shape of a stair ‘stair-shaped depression’ ‘stair-shaped depression’ page 177maré ph et al. sa orthop j 2020;19(3) others have noted compensatory distal femoral valgus associated with late presentation.24 firth et al. demonstrated in a comparative study between infantile, juvenile and adolescent blount’s disease that distal femoral varus may be present in all groups.35 a limitation of this study was that long leg films were not available for all cases. in a detailed description of multi-planar deformity analysis with long leg films, sabharwal et al. found no significant difference in distal femur, proximal femur or distal tibial frontal plane alignment in either ibd or late-onset blount’s disease.36 evaluation of these studies reveals that, while the average distal femoral alignment may be normal to slight varus, a wide range of distal femoral deformity exists. distal femoral alignment should be assessed in each individual case. sabharwal et al. also emphasised the importance of the sagittal plane. they showed that proximal tibial procurvatum is routinely underestimated clinically and x-ray assessment is essential.36 the aim of x-ray classification in ibd is to inform prognosis (to prevent recurrence the first step is to identify the child at risk), guide management and categorise patients reliably to facilitate communication, records and research. no such classification exists for blount’s disease. early stages of the langenskiöld classification have been shown to not differentiate between physiological bowing and ibd.37 recurrence has been associated with either langenskiöld stage ≥338 or ≥4.39 unfortunately, reliability and reproducibility of the intermediate stages of the langenskiöld classification have been brought into doubt,40 limiting its use to predict recurrence. while more recently erkus et al. showed excellent interand intraobserver reliability, separate assessment of the intermediate grades was not done.41 in contrast, du plessis et al. from johannesburg showed only fair reliability (k=0.24) and reproducibility (k=0.38) and cautioned against its use for prognostication, management planning and research.42 lamont et al. simplified the langenskiöld classification into three grades in an attempt to better predict the risk of recurrence. their classification is based on the morphology of the metaphyseal/ epiphyseal slope. langenskiöld stages 4, 5, 6 and some stage 3 fall into group c. they described a recurrence rate of 22.5%, 20.7% and 71.7% in groups a, b and c respectively.43 kling et al. measured the medial physeal slope (mps) (figure 5) and demonstrated an association with recurrence when this is greater than 60°.44 kaewpornsawan et al. confirmed an mps angle ≥60° to be the most significant factor associated with recurrence by using multivariate logistic regression analysis.45 in a paper presented at the combined meeting of the orthopaedic associations in 2016, maré et al. showed in a group of 20 children with 35 limbs that an mps≥60° was a highly significant predictor of recurrence (or=1.4 95% ci [1.11–1.82], p=0.005) with a sensitivity of 0.79, specificity of 0.95, ppv of 0.92 and npv of 0.87.46 figure 4. ap x-ray image of the knee of a 5-year-old girl with severe obesity, ibd and features of ‘upper tibial physeal slip entity’33 figure 5. ap image of the knee of a 5-year-old girl with the medial physeal slope (mps) indicated as the angle (x) between a line drawn along the lateral physis (a) and a line drawn along the slope of the medial ‘depressed’ proximal tibial metaphysis (b)44 figure 6. arthrogram of the left knee demonstrating depression of the medial tibial plateau, delayed ossification of the medial proximal tibia, and hypertrophy of the medial meniscus page 178 maré ph et al. sa orthop j 2020;19(3) arthrogram ossification of the medial proximal tibia is delayed in younger children with ibd. subsequently the extent of the depression of the medial tibial plateau may be overestimated on plain x-ray (figure 6). arthrogram is useful intra-operatively to accurately determine the extent of depression of the medial plateau as well as to confirm adequate elevation. magnetic resonance imaging (mri) the first mri study focused on the intra-articular features of blount’s disease confirmed the depression of the medial plateau as well as delayed ossification of the cartilaginous epiphysis.47 an abnormally large medial meniscus with abnormal signal intensity is also a key feature.48 other features include cartilage intrusion into the medial metaphysis, widening and depression of the medial physis, widening of the lateral physis and osteochondral injury of the medial femoral condyle.49 mukai et al. attempted to differentiate between physiological bowing and ibd with mri investigation of 13 children at an average age of 18 months.50 they demonstrated high signal on t2-weighted images in all cases in the epiphysis, but also in the physis and perichondral region of those more likely to develop ibd (as determined by mda). mri investigation is not routine practice for the assessment of ibd disease due to availability, expense and possible need for sedation.24 further research is required to define its role in the diagnosis and assessment of ibd. management bracing several studies have shown promising results, while others have questioned these findings due to methodology, and the difficulty in differentiating physiological bowing from ibd in this young age group.10 doubt exists about its ability to alter the natural course of ibd.24 children with physiological genu varum will improve without treatment. bracing is therefore unnecessary, difficult and expensive. bracing a child with confirmed ibd may result in a delay in obtaining surgical deformity correction, which will predispose to recurrent deformity. further research is required to evaluate the role of bracing on the natural history of ibd. proximal tibial osteotomy and acute correction once the diagnosis of ibd is confirmed, corrective proximal tibial osteotomy before the age of 4 years decreases the risk of recurrent deformity.10 several techniques have been described, including the dome (curved proximal tibial osteotomy first described by langenskiöld in 1929)3, spike, oblique (described by rab)51, serrated w/m osteotomy,52 transverse, open or closing wedge osteotomies.10 no superiority of one technique over another has been demonstrated. when performed early, the aim is to overcorrect varus to 5–10° of valgus2,3,53 while simultaneously correcting procurvatum and internal tibial torsion. the corrected position may be maintained by casting, internal fixation, a combination of the two, or by external fixation.10 the complication rate of tibial osteotomies is low.54 incision placement is important as recurrence rate is high. an oblique incision from proximal medial to distal lateral is ideal, as it facilitates easy exposure of the medial tibial condyle through the same scar should elevation be required in the future. possible complications include transient or permanent peroneal nerve palsy, pin-track infection, delayed union, overor under-correction, compartment syndrome or vascular injury. prophylactic anterior compartment fasciotomy and drain insertion is strongly recommended.10 normal growth following realignment is re-established in the proximal tibia in only 50–60% of cases.3,5,38,53,55 if growth resumes symmetrically, no further treatment is necessary. if normal growth does not resume, the deformity will recur, which is associated with worse outcome.5,39 risk factors for recurrence following proximal tibial osteotomy age at osteotomy langenskiöld and riska reported that if osteotomy and deformity correction is performed before the age of 8 years, recurrence is unlikely.3 this has not been the experience of most other authors. ferriter and shapiro found the watershed age to be 4 years and 6 months,38 while schoenecker et al. reported the age to be 5 years.56 kaewpornsawan et al. recommended surgery before the age of 3 years to prevent recurrence.45 thompson et al. in a study on 58 south african children (100 limbs) found that age ≥4 years at treatment (p<0.001) is significantly associated with recurrence.55 obesity ferriter and shapiro showed an increased risk of recurrence in children with bmi>97th centile.38 thompson et al. confirmed the association between bmi>95th centile and recurrence (p=0.007).55 langenskiöld stage higher langenskiöld stage is associated with increased risk of recurrence. ferriter and shapiro reported that all children with stage 5 and 6 recurred, with an increase in recurrence rate from stage 2 to 4.38 doyle et al. found that all cases with langenskiöld 4 x-ray appearance recurred.5 thompson et al. confirmed significance (p<0.001) of the association between advanced langenskiöld stage and recurrence risk.55 the poor inter-observer reliability for intermediate langenskiöld stages limits the prognostic value of this finding. ideally a new classification system is required that will accurately stratify patients according to risk for recurrence in order to better guide treatment. medial physeal slope (mps) the measurement of slope of mps is a quantifiable assessment of the severity of the distortion of the morphology of the medial proximal tibia in ibd. several authors have emphasised the significance association of mps≥60° with risk of recurrence following corrective osteotomy.44,45,55 these factors have only been studied as part of retrospective studies of relatively small, diverse patient groups. further study to elucidate their relative and collective value as part of a predictive scoring system is required. measures to decrease risk of recurrence following osteotomy correction into physiological valgus alignment several authors have recommended correction to physiological valgus alignment.1-3,38,53 while it is clear that under-correction should be avoided,53 several authors have cautioned against excessive valgus correction, as this may not remodel if normal medial growth resumes.1-3 eamsobhana et al. showed no difference in recurrence between limbs overcorrected to >13° valgus versus those corrected to normal alignment.57 page 179maré ph et al. sa orthop j 2020;19(3) medial epiphysiolysis excision of the posteromedial proximal tibial physis/area of disordered growth has been described as an adjunctive procedure to proximal tibial realignment osteotomy in an attempt to restore symmetrical growth.58 andrade and johnstone reported their experience with this procedure in 24 children (27 limbs).59 they reported favourable results in children younger than 7 years, but did not recommend the procedure for older children. these authors noted that complete resection was challenging. unlike post-traumatic growth arrest, there is no well-defined physeal bar in blount’s disease.10 further research to identify the role of this additional procedure is required. lateral epiphysiodesis recurrent deformity is certain when no medial growth potential remains. langenskiöld and riska recommended lateral proximal tibial and fibular epiphysiodesis (in addition to proximal tibial and fibula osteotomy) in children older than 9 years when the medial physis was closed.3 epiphysiodesis may be achieved by percutaneous drilling, open phemister technique or transphyseal screw fixation.60 the challenge remains to predict which patients have no medial growth potential. an error in this assessment will result in progressive overcorrection, necessitating further surgery (medial epiphysiodesis and deformity correction) and loss of longitudinal growth potential. further research to improve risk stratification in terms of recurrence is of critical importance to improve outcomes in the treatment of ibd. guided growth paediatric deformity correction by reversible hemi-epiphysiodesis has several advantages. stevens reignited enthusiasm for this technique with the publication of his results with the tension-band plate in 65 femoral and tibial deformities.61 success of guided growth in ibd relies on three variables: medial proximal tibial growth potential, magnitude of deformity, and growth remaining. scott published an encouraging report of 89% effective correction in 14 children (18 limbs) with ibd treated with tension-band plates.62 the average age at treatment was 4.8 years (2.8– 8.7 years). the bmi percentile was ≥93rd centile in all but one child. complications included wound infection and screw breakage. correction of tibial rotation was noted to occur slower than correction of varus. persistent in-toeing was associated with increased femoral anteversion. all but one child presented before the age of 5 years and the authors stated that success is likely to be related to early treatment.62 griswold et al. in 2020 reported on 11 children (17 limbs) with ibd treated with tension-band plates.63 cases were divided into two groups according to langenskiöld stage (stage ≤2 or ≥3). the median ages were 3.2 years (±1.4) and 4.36 years (±2.16) for the groups with langenskiöld stage ≤2 and ≥3 respectively. they reported a 100% correction rate in children with langenskiöld stage ≤2 and a 33% recurrent deformity rate (treated with repeat tension-band plating). this correction rate fell to 40% in children with langenskiöld stage ≥3 with a 100% recurrence or incomplete correction rate. complications included surgical site infection, screw breakage and overcorrection. the authors cautioned against the use of tension-band plating in children with langenskiöld stage ≥3 ibd.63 stevens noted anecdotally that rotational deformity may correct together with coronal plane deformity during treatment with tension-band plating.64 cobanoglu et al., in an animal study, showed that rotational long bone deformity could be corrected with oblique placement of a tension-band plate.65 further study is required to determine the efficacy of guided growth to correct internal tibial torsion in ibd. adherence to follow-up appointments is essential to monitor for both overcorrection due to delayed removal and recurrent deformity as a result of rebound growth after removal. as age at deformity correction through osteotomy is a critical factor associated with recurrence,10 and evidence from studies on guided growth confirms an association between success and earlier treatment, guided growth should be used with caution in children with ibd older than 4 years or langenskiöld stage ≥3. the role of guided growth in children with ibd is yet to be defined. factors associated with risk of failure should be investigated. welldesigned randomised studies comparing guided growth and standard deformity correction techniques are needed. gradual correction with external fixation excellent correction can be achieved with external fixator-assisted gradual deformity correction. a major advantage is that the tibia may be lengthened at the same time as multi-planar deformity correction. the ilizarov fine-wire circular fixator has been shown to be a safe and effective technique to correct deformity while allowing early mobilisation and weight bearing.66 computer-assisted hexapod circular fixators utilise a ‘virtual hinge,’ thereby allowing all aspects of the deformity to be corrected with a single frame. this allows for complex deformity correction, especially when previous surgery for severe deformity resulted in mechanical axis translation. another significant advantage is the ability to fine-tune deformity correction without the need to return to the operating room. several authors reported safe and effective deformity correction.67,68 a systematic review and meta-analysis analysing acute vs gradual correction (mono-lateral, hexapod as well as ilizarov external fixators) reported no robust evidence to support superiority in terms of accuracy of correction or complication rates. the studies analysed were mostly small, retrospective cases series with heterogenous techniques and reporting. the complication rate of either technique was low.69 feldman et al. specifically compared computer-assisted hexapod deformity correction with acute correction. they demonstrated better correction of sagittal plane deformity and axis translation with hexapod-assisted deformity correction.70 hexapod-assisted deformity correction has specific advantage in late-presenting or recurrent ibd or where severe obesity complicates fixation, especially in unilateral cases where leg-length discrepancy can be corrected at the same time. where significant joint instability exists due to medial plateau depression, elevation can be performed at the same time. several authors reported safety and efficacy of this technique based on small, retrospective case series.71-73 larger series are required to confirm a low complication rate. pin-track infection is a common complication of fine-wire circular fixator-assisted deformity correction. this is especially common on the tension side (medially) on the proximal tibia. major pin-track infection could theoretically result in deep infection at the elevation site, catastrophically resulting in osteomyelitis and septic arthritis (if joint penetration inadvertently occurred at the time of elevation). staged elevation and subsequent gradual deformity correction may be a safer alternative. neglected infantile blount’s disease medial elevation combined with lateral epiphysiodesis if ibd is not identified and treated early, medial articular depression can occur (figure 6), together with worsening proximal tibial varus, procurvatum and internal rotation.74 this defines neglected ibd. blount recognised knee instability in three cases that page 180 maré ph et al. sa orthop j 2020;19(3) was responsible for part of the varus deformity.1 langenskiöld attributed this to the sloping of the medial tibial condyle in neglected cases.3 siffert and katz confirmed the presence of the depression of the medial tibial plateau with direct visualisation at arthrotomy and described the pathoanatomy of this deformity in detail. they advocated elevation of the medial tibial plateau as an essential part of treatment.27 medial articular elevation is normally combined with lateral epiphysiodesis of the proximal tibia and fibular and metaphyseal proximal tibial osteotomy to correct residual varus, procurvatum and internal rotation. van huyssteen et al. emphasised the importance of concomitant lateral proximal tibial epiphysiodesis at the same time as medial joint line elevation to prevent recurrence.74 the existence of medial articular depression has been brought into question in a small study of ten children (17 limbs) with arthrogram and mri investigation. these authors speculated that delayed ossification of the medial proximal tibial structures were responsible for the appearance of depression.75 other authors, by direct visualisation, arthrogram and mri investigation, have since confirmed the presence of true posteromedial depression in addition to delayed ossification of the medial structures in neglected ibd cases.74,76 the age from which medial elevation and lateral epiphysiodesis is indicated is controversial. langenskiöld originally suggested 9 years when medial growth arrest and articular depression is confirmed.9 currently, medial elevation is indicated for children older than 6 years with ibd, langenskiöld stage 5 or 6 and significant medial articular depression.10,74 controversy hinges on concern for loss of growth potential if the procedure is performed before medial proximal tibial growth arrest is confirmed. further research is essential to improve our ability to predict medial growth potential, as well as the long-term outcome of the surgical management of neglected ibd. concomitant femoral deformity correction significant distal femoral frontal plane malalignment will result in joint line obliquity if the mechanical axis is restored through proximal tibial deformity correction alone. schoenecker et al. were the first to report on the surgical treatment of distal femur in ibd. they performed concomitant corrective osteotomy for >10° distal femoral valgus in four cases.77 the long-term effect of joint line obliquity is uncertain. no robust evidence exists to predict when concomitant distal femoral and proximal tibial deformity correction is indicated to improve outcome. further research is also required to assess the incidence of symptomatic femoral rotational deformity in ibd and to determine the threshold for surgical correction. long-term outcome several authors have reported on the long-term outcome after treatment of ibd. ingvarsson et al. found 11/89 knees with signs of arthrosis.78 zayer found a much higher rate of arthritis (11/27 knees in patients older than 30 years).79 doyle et al. followed 17 children to skeletal maturity. they found 9/28 knees to be symptomatic at a mean age of 20 years. symptomatic knees all demonstrated ligamentous, meniscal or bony pathology on mri and arthroscopy. there was a significant association between repeat osteotomy and a symptomatic knee at skeletal maturity.5 hofmann et al. followed 12 children (19 limbs) to skeletal maturity. symptomatic knees (12/19) had degenerative changes at arthroscopy or arthrotomy.39 both doyle and hofmann recommended early osteotomy before permanent physeal damage occurred on the basis of their findings. total knee replacement after blount’s disease may be complex. natoli et al. recommended that surgeons be prepared to address posteromedial tibial bone defects and consider constrained arthroplasty at the index procedure.80 conclusion and future direction decision-making in ibd is complex. discriminating between ibd and physiological bowing may be difficult. meticulous clinical and x-ray follow-up is essential to prevent a delay in corrective osteotomy beyond 4 years if ibd is confirmed. once a child presents with neglected ibd or recurrent deformity, it is essential to identify all aspects of the deformity to ensure comprehensive correction and prevent recurrence by lateral epiphysiodesis. future research should focus on developing risk stratification tools to predict medial growth potential. the role of medial epiphysiolysis and guided growth requires further definition. treatment strategies should aim to achieve lasting deformity correction by decreasing recurrence risk while avoiding unnecessary growth ablation. follow-up until skeletal maturity and beyond is essential to optimise outcome and inform our understanding of the prognosis in ibd. ethics statement the author/s declare that this submission is in accordance ethical guidelines. institutional review board (irb) ethical approval was not required as this was a literature review. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions dmt contributed to the conceptualisation of the article and performed manuscript review. phm performed the literature review, contributed to the conceptualisation, preparation and revision of the manuscript. orcid maré ph https://orcid.org/0000-0003-1599-7651 thompson dm https://orcid.org/0000-0003-2607-3999 references 1. blount wp. tibia 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medial epiphysiolysis in severe infantile tibia vara. j pediatr orthop. 2006;26(5):652-58. 60. campens c, mousny m, docquier pl. comparison of three surgical epiphysiodesis techniques for the treatment of lower limb length discrepancy. acta orthop belg. 2010;76(2):226-32. 61. stevens pm. guided growth for angular correction: a preliminary series using a tension band plate. j pediatr orthop. 2007;27:253-59. 62. scott ac. treatment of infantile blount disease with lateral tension band plating. j pediatr orthop. 2012;32:29-34. page 182 maré ph et al. sa orthop j 2020;19(3) 63. griswold bg, shaw ka, houston h, bertrand s, cearley d. guided growth for the treatment of infantile blount’s disease: is it a viable option? j orthop. 2020;20:41-45. 64. stevens pm. guided growth for deformity correction. oper tech orthop. 2011;21:197-202. 65. cobanoglu m, cullu e, kilimci fs, ocal mk, yaygingul r. rotational deformities of the long bones can be corrected with rotationally guided growth during the growth phase: a study in rabbits. acta orthop. 2016;87(3):301-305. 66. alekberov c, shevtsov vi, karatosun v, günal i, alici e. treatment of tibia vara by the ilizarov method. clin orthop relat res. 2003;409:199-208. 67. feldman ds, madan s, koval kj, et al. correction of tibia vara with six-axis deformity analysis and the taylor spatial frame. j pediatr orthop. 2003;23:387-91. 68. maré p, thompson dm. the use of gradual correction with the tlhex external fixator in blount’s disease. orthopaedic proceedings. 2014;96-b suppl 19:11. 69. gilbody j, thomas g, ho k. acute versus gradual correction of idiopathic tibia vara in children. a systematic review. j pediatr orthop. 2009;29:110-14. 70. feldman ds, madan s, ruchelsman de, sala da, lehman wb. accuracy of correction of tibia vara. acute vs gradual correction. j pediatr orthop. 2006;26:794-98. 71. hefny h, shalaby h, el-kawy s, thakeb m, elmoatasem e. a new double elevating osteotomy in management of severe neglected infantile tibia vara. j pediatr orthop. 2006;26:233-37. 72. bar-on e, weigl dm, becker t, katz k. treatment of severe early onset blount's disease by an intra-articular and a metaphyseal osteotomy using the taylor spatial frame. j child orthop. 2008;2:457-61. 73. fitoussi f, ilharreborde b, lefevre y, et al. fixator-assisted medial tibial plateau elevation to treat severe blount’s disease: outcomes at maturity. orthop & traumatol: surg & res. 2011;97:172-78. 74. van huyssteen al, hastings cj, olesak m, hoffman eb. doubleelevating osteotomy for late-presenting infantile blount’s disease. j bone joint surg (br). 2005;87-b:710-15. 75. stanitski d, stanitski cl, trumble s. depression of the medial tibial plateau in early-onset blount disease: myth or reality? j pediatr orthop. 1999;19(2):265-69. 76. ho-fung v, jaimes c, delgado j, davidson rs, jaramillo d. mri evaluation of the knee in children with infantile blount’s disease: tibial and extra-tibial findings. pediatr radiol. 2013;43:1316-26. 77. schoenecker pl, johnston r, rich mm, capelli am. elevation of the medial plateau of the tibia in the treatment of blount disease. j bone joint surg (am). 1992;74:351-58. 78. ingvarsson t, hägglund g, ramgren b, jonsson k, zayer ml. long-term results after infantile blount’s disease. j pediatr orthop b. 1998;7(3):226-29. 79. zayer m. osteoarthritis following blount’s disease. int orthop. 1980;4:63-66. 80. natoli rm, nypaver cm, schiff ap, hopkinson wj, rees hw. total knee arthroplasty in patients with blount disease or blount-like deformity. j arth. 2016;31(1):124-27. _ref37164653 _ref37164737 _ref37165817 _ref37168106 _ref37164979 _ref37165437 _ref37165363 _ref37165484 _ref37165508 _ref37187597 _ref37168247 _ref37187298 _ref37167392 _hlk37169859 page 4 south african orthopaedic journal http://journal.saoa.org.za conferences, courses and symposia local august 2020 66th south african orthopaedic association (saoa) congress 31 august 2020 – 4 september 2020 venue: cticc 2 (cape town 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course 2018 22 march 2018 24 march 2018 hamburg, germany local international south african orthopaedic journal hip doi 10.17159/2309-8309/2022/v21n3a4 mia sm et al. sa orthop j 2022;21(3) citation: mia sm, rajpaul j, goga ie. short-term outcomes of one-stage bilateral total hip arthroplasty in a south african setting. sa orthop j. 2022;21(3):160-166. http://dx.doi. org/10.17159/2309-8309/2022/ v21n3a4 editor: dr chris snyckers, eugene marais hospital, pretoria, south africa received: october 2021 accepted: march 2022 published: august 2022 copyright: © 2022 mia sm. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for the purposes of performing this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background total hip arthroplasty (tha) is one of the most successful orthopaedic surgical procedures that dramatically improves function, pain relief and quality of life for the patient. in south africa, we have a high prevalence of osteonecrosis of the femoral head (onfh) and inflammatory arthropathy affecting a young population. this subgroup of patients is usually between the ages of 30 and 50 years (young) and they require bilateral total hip replacements (btha) to allow them to return to their previous level of function and employment. the study aimed to assess the short-term outcomes and complications in patients with bilateral hip pathology managed surgically with a one-stage btha. methods we retrospectively reviewed a series of 33 patients who underwent a one-stage btha at a high-volume arthroplasty unit in a central hospital in south africa between january 2016 and december 2018. the mean age was 38 years (standard deviation [sd] 9 years), and the most common diagnosis was onfh (76%). in this cohort, 12 patients (36%) tested hiv positive. we assessed patient folders for diagnosis, perioperative details, postoperative follow-up and complications. radiographic analysis was also performed. results there were no revisions or planned surgical interventions for any of the patients at a median follow-up of 22 months (interquartile range [iqr] 11–45 months). thirty patients reported no hip pain and walked unaided at their most recent follow-up visit. two patients reported groin pain and continued to walk with a single crutch. one patient demised from unrelated causes approximately one year post-surgery. the only perioperative complication was a urinary tract infection (uti) in one patient. the median postoperative length of stay was six days (iqr 4–7 days), and no other medical or surgical complications were reported. radiographic analysis revealed four patients (12%) with brooker grade 1 heterotopic ossification in six hips. conclusion our results suggest that surgical treatment with a one-stage btha is a good alternative to a two-stage btha when performed in a high-volume arthroplasty centre and carefully selected patients. the 30-day mortality rate was 0%, and the complication rate was low. level of evidence: level 4 keywords: one-stage bilateral total hip arthroplasty, two-stage bilateral total hip arthroplasty, simultaneous bilateral total hip arthroplasty, bilateral osteonecrosis of the femoral head short-term outcomes of one-stage bilateral total hip arthroplasty in a south african setting sayed m mia,¹* jitesh rajpaul,¹ ismail e goga² ¹ department of orthopaedic surgery, inkosi albert luthuli central hospital, university of kwazulu-natal, durban, south africa ² orthopaedic surgeon, nu shifa hospital, durban, south africa *corresponding author: sayedmmia@gmail.com introduction total hip arthroplasty (tha) is one of the most successful orthopaedic surgical procedures that dramatically improves function, pain relief and quality of life for the patient. a wide range of pathology affects the hip joint in our population, including osteoarthritis, osteonecrosis of the femoral head (onfh), inflammatory arthropathy and infection. in south africa, we have a high prevalence of onfh affecting a young population, and the aetiology is varied. one of the postulated causes is the chronic use of antiretroviral drugs; however, it is unclear whether antiretroviral medication or the human immunodeficiency virus (hiv) itself is responsible for the pathogenesis of onfh.1 despite the significant progress in the rollout of antiretroviral drugs, south africa has one of the highest incidences of hiv globally.2 we treat many patients with advanced bilateral onfh (steinberg stage iv–vi disease3). this subgroup of patients is usually between 30 and 50 years (young) and they require bilateral total hip replacements (btha) to allow them early return to their previous level of function and employment.4 a two-stage btha encompasses a lengthy period of morbidity and rehabilitation for the patient, which can sometimes span up to five years in our public healthcare system due to the high burden of disease and limited theatre time. staged btha involves an initial admission where a unilateral hip replacement is performed https://orcid.org/0000-0002-3834-2730 page 161mia sm et al. sa orthop j 2022;21(3) on the most severely affected hip. due to the pain, disability and contracture of the opposite unoperated hip, rehabilitation is usually slow. the contralateral tha is often performed after six months to one year, and the patient must undergo further rehabilitation to regain their function. due to this prolonged treatment method, patients often do not return to work and depend on the state for a disability grant to support their families. a one-stage btha is performed during a single admission, whereby tha is performed on both hips at the same theatre setting. the advantage of this method of treatment is a faster recovery and an earlier return to previous function.4,5 with this in mind, we retrospectively reviewed a cohort of patients who underwent a onestage btha with the aims to evaluate the perioperative details; the early in-hospital complications; the early clinical outcomes; the radiographic outcomes; and the need for revision surgery. materials and methods following ethical approval, we identified all patients presenting for tha at an arthroplasty unit in a hospital in south africa, over two years (january 2016 to december 2018). all patients who underwent a unilateral tha or a two-stage btha were excluded. we included a total of 33 patients who underwent a one-stage btha and assessed patient folders for demographics, diagnosis, perioperative details, postoperative follow-up and complications. the cohort (table i) included eight females and 25 males, with a mean age of 38 years (sd ± 9 years). the aetiology was onfh (figure 1) in 25 patients (76%) and inflammatory arthritis (figure 2) in eight patients (24%). the anaesthesiologist graded all 33 patients as american society of anesthesiologists (asa) class i or ii. surgical workflow all surgical procedures were performed using the posterior hip approach in the lateral decubitus position. two senior fellowshiptrained arthroplasty surgeons were the primary and assistant surgeons in all cases. general anaesthesia (ga), regional anaesthesia (epidural), regional nerve blocks or a combination of the above were used depending on the case’s complexity. all patients received a collarless, fully hydroxyapatite-coated, pressfit stem (corail, de puy international ltd.) and a hemispherical porous-coated press-fit acetabular cup (de puy international ltd.). intravenous antibiotic prophylaxis (1 g cefazolin) was administered preoperatively and three doses on the first day postoperatively. the thromboprophylaxis protocol included postoperative subcutaneous low molecular weight heparin (enoxaparin 0.5 mg/kg) until discharge from the hospital and aspirin 150 mg to take home for a total duration of four weeks. full weight-bearing was allowed from the day after surgery, and the patient initially mobilised with a walker with progression to crutches as tolerated. clinical follow-up was expected at six weeks, six months and yearly after that. an anteroposterior pelvis x-ray was taken on day one post-surgery and at the six-week follow-up visit. these radiographs served as a reference for follow-up films. radiographs the authors independently evaluated the early postoperative and most recently available anteroposterior x-rays. linear and angular measurements were taken using siemens syngo.plaza picture archiving and communication system (pacs), and the following radiographic features were recorded: 1. acetabular component position: measured as the angle between the inter-teardrop line and the inclination of the cup in degrees. outliers were identified according to the safe zone defined by lewinnek et al.6 2. limb length discrepancy (lld): the difference in perpendicular distance between the inter-teardrop line to the corresponding tip of the lesser trochanter of both hips were measured in millimetres. 3. heterotopic ossification graded according to brooker et al.7 patient data we reviewed all patient’s electronic medical records on the hospital software meditech health care information system to extract the following data: diagnosis, age, sex, length of stay (los), hiv status, cd4 cell count, preoperative haemoglobin, postoperative haemoglobin, operative time, anaesthetic details, and complications (such as urinary tract infection [uti], deep vein thrombosis [dvt], pulmonary embolism [pe], myocardial infarction [mi], surgical site infection [ssi], dislocation, heterotopic ossification [ho] and revision). statistical methods statistical analysis was performed using jamovi version 2.0 (the jamovi project [2021]. retrieved from https://www.jamovi. org). continuous variables were reported as mean (± standard table i: demographics of patients number percentage of total patient total 33 100% age (years) 20–30 6 18% 30–40 13 40% 40–50 11 33% 50–60 3 9% sex male 25 76% female 8 24% diagnosis osteonecrosis of the femoral head (onfh) 25 76% inflammatory arthritis 8 24% hiv status positive 12 36% negative 21 64% figure 1. case example of an hiv-positive patient with steinberg stage vi bilateral onfh page 162 mia sm et al. sa orthop j 2022;21(3) deviation [sd]) if normally distributed, or median (interquartile range [iqr]) if skewed, and categorical variables as numbers and percentages, unless otherwise stated. p-values of less than 0.05 were considered significant. results patients a one-stage btha was performed on 33 patients (a total of 66 total hip arthroplasties) over two years (january 2016 to december 2018). the median follow-up period was 22 months (iqr 11–45 months). twenty-four patients had completed a minimum of 12 months of clinical follow-up, and of these, 22 remained painfree and walked unaided on their last follow-up visit. in this subgroup, one patient diagnosed with ankylosing spondylitis (figure 2) complained of persistent groin pain with no radiographic or haematological changes to suggest loosening or infection (figure 3). another patient reported acute onset right hip pain after lifting a heavy object at work. his radiographs at his fiveyear follow-up visit revealed no change in position of the implants and the formation of brooker grade 1 heterotopic ossification. his symptoms resolved after a short course of non-steroidal antiinflammatory medication. the remaining nine patients did not complete a minimum of one-year follow-up period, and of this group, seven reported no complications, were pain-free and walked without assistance. one patient (eight months post-surgery) complained of left hip pain and was using a single crutch to mobilise; however, he defaulted his subsequent follow-up appointment, suggesting that he did not have any further complications. one patient demised from unrelated causes approximately one year post-surgery. thirty-six per cent of patients were hiv positive (n = 12 of 33) with a median cd4 cell count of 497 cells/mm3 (iqr 422–650 cells/mm3). all the hiv-positive patients were operated on for a diagnosis of onfh with no other identifiable risk factors, and there were no complications reported. despite good pain relief and restoration of function in most cases, six patients (18%) requested a state disability grant application at their most recent follow-up visit. perioperative period eighteen patients (55%) received a combined ga and epidural while the remainder received either a ga (21%), epidural (12%) or a combined ga and a regional nerve block (12%). there were no anaesthetic complications reported. the mean theatre time (anaesthesia and surgical procedure time) was 182 minutes (sd ± 30 minutes), and the mean surgical procedure time (skin incision on the first hip to skin closure on the second hip) was 143 minutes (sd ± 26 minutes). the mean preoperative haemoglobin level was 13.60 g/dl (sd ± 1.57 g/dl). seven patients (21%) received an average of two units of blood transfusion postoperatively, and the mean post-surgery haemoglobin level was 9.86 g/dl (sd ± 1.67 g/dl). the median postoperative length of stay (los) was six days (iqr 4–7 days). the longest postoperative los of 16 days was in a patient with severe ankylosing spondylitis (figure 2) due to multiple joint involvement and prolonged rehabilitation. another patient with severe inflammatory arthritis (figure 4) had a prolonged hospital stay of 14 days post-surgery due to a uti, which resolved with intravenous antibiotic therapy. this patient was bedridden for several months prior to surgery with severe contracture and deformity. he was admitted on skin traction at a peripheral hospital before he could receive his one-stage btha. at the patient’s most recent clinical assessment (five-year followup), he remains pain-free, walks unaided, and his implant position remains unchanged (figure 5). in all other patients, no other medical or surgical complications were reported (table ii). there were no perioperative (30-day mortality) deaths. radiographs of the 25 patients with onfh, 20 were graded as steinberg stage vi, and five patients as steinberg stage v. the median acetabular inclination angle of the right hip on the anteroposterior radiograph was 40° (iqr 38–45°) and of the left hip 41° (iqr 39−46°). on follow-up radiographs, none of the cups had migrated, and there was no periacetabular osteolysis evident. a total of seven hips in seven patients had an increased acetabular inclination angle outside the safe zone (> 50°) as described by lewinnek et al.; however, none of these patients had an episode of hip instability.6 the mean lld was 0.49 mm (sd ± 0.32 mm), and there was no evidence of femoral osteolysis around the femoral component in all patients. four radiographs (12%) demonstrated heterotopic ossification in six hips, all classified as brooker grade 1. figure 3. postoperative follow-up radiograph of the patient in figure 2 at five years figure 2. case example of a patient with ankylosing spondylitis (inflammatory arthropathy) page 163mia sm et al. sa orthop j 2022;21(3) revision at the last clinical review, none of the patients had undergone revision surgery or required further surgical intervention. discussion a unilateral tha has been shown to provide good pain relief, improve function, and be reliably performed with minimal complications. when performing a two-stage btha, patients have a prolonged rehabilitation period after their first surgical procedure as they await their second procedure with a painful and stiff hip. the advantages of a one-stage btha include a theoretical reduction in anaesthetic risk (single anaesthetic versus two), a shorter rehabilitation period, decreased costs to the healthcare system and an earlier return to work.8-10 despite this, there are several concerns regarding the safety of a one-stage btha due to the reported increase in complication rates and the lack of evidence in the literature.10-12 in the united states, over 2 million thas were performed between 2002 and 2010, and only less than 1% was a one-stage btha.13 the annual incidence of primary tha is increasing exponentially. it is forecast that about 500 000 procedures will be performed in the united states in 2030.8 it is essential to risk-stratify patients for a one-stage btha to improve the efficiency and outcomes of the arthroplasty service worldwide. this is especially pertinent in a developing country due to the limited resources and the long waiting periods for elective arthroplasty surgery. the decision as to which patients to perform a one-stage btha on is controversial due to the historical reporting of increased medical complications such as thromboembolic events, myocardial infarction (mi) and chest infections. data obtained between 2005 and 2014 from england’s national health service (nhs) revealed an overall more significant risk of pulmonary embolism, mi, renal failure, chest infection and mortality. when they performed a subgroup analysis, patients younger than 60 years with no comorbidities had a comparable complication rate in both groups. when the one-stage btha was performed at a high-volume arthroplasty centre, the complication rate was also reduced. the authors recommended a rigorous patient selection process and preferably high-volume surgeons to perform the procedure to minimise the risks for the patient.10 flick et al. reported low complication rates in a group of 730 patients, and they considered the use of a simultaneous btha a safe and effective procedure in patients with appropriate comorbidities.14 a retrospective cohort study by guo et al. showed an increased complication rate in their staged group compared to their simultaneous btha group, particularly for superficial infection and dislocation.15 only one patient suffered an acute complication (uti) postsurgery in our study, which resolved with antibiotic therapy. lowrisk, young patients (asa i and asa ii) were selected for a onestage btha, which is in keeping with the above recommendations. thirty-six per cent of patients in this study were hiv positive; however, in this subgroup, we did not find any perioperative complications or an increase in the incidence of surgical site infection. similar results between hiv-positive and -negative patients are in keeping with a recent study by ngwazi et al.16 several authors have highlighted a similar mortality rate between one-stage btha and two-stage btha. kim et al. reported a figure 4. patient with severe inflammatory arthritis, contractures and deformity figure 5. five-year follow-up radiograph of the patient in figure 4 table ii: summary of results number percentage of total mortality 30-day mortality 0 0% death after one year 1 3% complications urinary tract infection 1 3% deep vein thrombosis 0 0% pulmonary embolism 0 0% myocardial infarction 0 0% surgical site infection 0 0% dislocation 0 0% reoperation 0 0% revision 0 0% heterotopic ossification 4 12% final follow-up single crutch 2 6% no walking aids 30 91% page 164 mia sm et al. sa orthop j 2022;21(3) perioperative mortality rate of 0.31% (three patients out of 978) in their simultaneous group compared to 0.18% (three patients out of 1 666) in their two-stage group.17 experience from the australian orthopaedic association national joint replacement registry revealed a higher mortality rate in the one-stage group (0.18%) versus the two-stage group (0.06%); however, they recommend simultaneous btha as the absolute incidence of 30-day mortality is low.11 the 30-day mortality rate in our study was 0%, and only one patient demised from unknown causes one year post-surgery. this highlights the safety of this procedure in young, medically fit patients with severe bilateral hip pathology, especially when performed in a high-volume arthroplasty centre. many studies have demonstrated a reduced cost to the healthcare system when performing a one-stage btha.5,10,12,18,19 rolfson et al. calculated both direct medical and indirect non-medical costs for a one-stage btha and a two-stage btha. their study, which was carried out in sweden, compared 32 patients in both groups and the authors used the eq-5d questionnaire as a health-related quality of life (hrqol) instrument. the average cost per patient in the one-stage group was 14 470 euros compared to 9 060 euros per hip for the two-stage group. the one-stage btha was approximately 3 650 euros cheaper (25%), and the authors noted a significant increase in the hrqol. sick-leave cost reduction was also calculated to be roughly 30%.12,18 micicoi et al. also estimated a total hospital cost reduction of 25–30%.18 a contrasting study by phillips et al. showed no difference in the total episode-of-care cost between a one-stage and a twostage bilateral total joint replacement (btja) at 90 days. the more significant inpatient costs associated with two hospital admissions were offset by the greater post-acute care costs in the one-stage btja group. they cautioned against simultaneous btja in older patients with a history of stroke, cardiac disease or liver disease.20 in our cohort, the median postoperative length of stay of six days (iqr 4–7 days), the low complication rate, and the reduction in the number of patient hospital visits (post-acute care costs), suggests that the overall cost was reduced; however, we did not have a comparison group, and a cost data analysis was not performed. due to a lack of resources in the south african public healthcare system, several of the patients in this study were required to travel from outlying rural areas to access the arthroplasty service. in our opinion, the one-stage btha reduced the direct costs to the patient, the waiting period for surgery and the inconvenience associated with travel. further cost data analysis needs to be performed. despite being pain-free and independent ambulators, 18% of patients requested a disability grant application postoperatively at their first follow-up visit. it is therefore assumed that the rest of the patients (82%) attempted to return to work or their previous level of employment as most patients were the primary breadwinners in their families. the current employment status data was not available in the patient records. patients subjectively reported improved quality of life (pain-free and independent ambulators post-surgery); however, no instrument was used to measure hrqol in the electronic records. there are several limitations to this study. it is retrospective, hence reliant on information gained from the electronic patient records. the low sample size is due to the recent introduction (january 2016) of the one-stage btha protocol into the arthroplasty unit and there were strict selection criteria for patients (asa stage i or ii). we could not include a scoring system to assess clinical outcomes due to the inadequacy of data in the patient notes and there was a varied follow-up period due to the lack of resources to attend the hospital regularly, which may have altered the analysis. conclusion we have performed an analysis on retrospective records of 33 patients who underwent a one-stage bilateral total hip replacement (btha), and present the short-term outcomes at a median followup of 22 months (iqr 11–45 months). our results suggest that surgical treatment with a one-stage btha is a good alternative to a two-stage btha when performed in a high-volume arthroplasty centre and carefully selected patients. the 30-day mortality rate was 0%, and the complication rate was low. the level of evidence of this retrospective study is low with a low sample size and no comparison group; therefore, randomised controlled studies on this subject are recommended. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to the commencement of the study ethical approval was obtained from the following ethical review board: ukzn brec, reference number brec/00003168/2021. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions smm: study conceptualisation, data capture, data analysis, first draft preparation, manuscript revision jr: data analysis, final draft preparation ieg: language and grammar correction, data analysis orcid mia sm https://orcid.org/0000-0002-3834-2730 rajpaul j https://orcid.org/0000-0001-8950-4878 references 1. youngman tr, riepen dw, rinehart db, et al. complications of primary total hip arthroplasty in human immunodeficiency virus-positive patients with femoral head osteonecrosis. hip int. 2021:11207000211005750. https://doi. org/10.1177/11207000211005750 2. vandormael a, cuadros d, kim hy, et al. the state of the hiv epidemic in rural kwazulunatal, south africa: a novel application of disease metrics to assess trajectories and highlight areas for intervention. int j epidemiol. 2020;49(2):666-75. https://doi.org/10.1093/ ije/dyz269 3. steinberg me, hayken gd, steinberg dr. a quantitative system for staging avascular necrosis. j bone joint surg br. 1995;77(1):34-41. 4. kim sc, lim yw, jo wl, et al. surgical accuracy, function, and quality of life of simultaneous versus staged bilateral total hip arthroplasty in patients with osteonecrosis of the femoral head. bmc musculoskelet disord. 2017;18(1):266. https://doi.org/10.1186/ s12891-017-1605-2 5. saini r, powell j, sharma r, et al. one-stage versus 2-stage bilateral total joint arthroplasty: a matched cohort study. can j surg. 2020;63(2):e167-73. https://doi.org/10.1503/cjs.001019 6. lewinnek ge, lewis jl, tarr r, compere cl, zimmerman jr. dislocations after total hip-replacement arthroplasties. j bone joint surg am. 1978;60(2):217-20. 7. brooker af, bowerman jw, robinson ra, riley lh, jr. ectopic ossification following total hip replacement. incidence and a method of classification. j bone joint surg am. 1973;55(8):1629-32. 8. taheriazam a, saeidinia a. short-term outcomes of one-stage bilateral total hip arthroplasty in young patients (< 30 years old). orthop rev (pavia). 2018;10(2):7542. https://doi. org/10.4081/or.2018.7542 9. tan z, cao g, wang g, et al. total hospital cost, length of stay, and complications between simultaneous and staged bilateral total hip arthroplasty: a nationwide retrospective cohort study in china. medicine (baltimore). 2019;98(11):e14687. https://doi.org/10.1097/ md.0000000000014687 10. partridge tcj, charity jaf, sandiford na, et al. simultaneous or staged bilateral total hip arthroplasty? an analysis of complications in 14,460 patients using national data. j arthroplasty. 2020;35(1):166-71. https://doi.org/10.1016/j.arth.2019.08.022 11. calabro l, yong m, whitehouse sl, et al. mortality and implant survival with simultaneous and staged bilateral total hip arthroplasty: experience from the australian orthopedic https://orcid.org/0000-0002-3834-2730 https://orcid.org/0000-0001-8950-4878 https://doi.org/10.1177/11207000211005750 https://doi.org/10.1177/11207000211005750 https://doi.org/10.1093/ije/dyz269 https://doi.org/10.1093/ije/dyz269 https://doi.org/10.1186/s12891-017-1605-2 https://doi.org/10.1186/s12891-017-1605-2 https://doi.org/10.1503/cjs.001019 https://doi.org/10.4081/or.2018.7542 https://doi.org/10.4081/or.2018.7542 https://doi.org/10.1097/md.0000000000014687 https://doi.org/10.1097/md.0000000000014687 https://doi.org/10.1016/j.arth.2019.08.022 page 166 mia sm et al. sa orthop j 2022;21(3) association national joint replacement registry. j arthroplasty. 2020;35(9):2518-24. https:// doi.org/10.1016/j.arth.2020.04.027 12. rolfson o, digas g, herbert p, et al. one-stage bilateral total hip replacement is cost-saving. orthop muscul syst. 2014;3:4. https://doi.org/10.4172/2161-0533.1000175 13. houdek mt, wyles cc, watts cd, et al. single-anesthetic versus staged bilateral total hip arthroplasty: a matched cohort study. j bone joint surg am. 2017;99(1):48-54. https://doi. org/10.2106/jbjs.15.01223 14. flick tr, ofa sa, patel ah, et al. complication rates of bilateral total hip versus unilateral total hip arthroplasty are similar. j orthop. 2020;22:571-78. https://doi.org/10.1016/j. jor.2020.11.010 15. guo sj, shao hy, huang y, et al. retrospective cohort study comparing complications, readmission, transfusion, and length of stay of patients undergoing simultaneous and staged bilateral total hip arthroplasty. orthop surg. 2020;12(1):233-40. https://doi.org/10.1111/ os.12617 16. ngwazi m, ryan p, goga i, marais lc. the association between hiv infection and periprosthetic joint infection following total hip replacement in young adults. sa orthop j. 2021;20(2):76-80. https://doi.org/10.17159/2309-8309/2021/v20n2a2 17. kim yh, kwon or, kim js. is one-stage bilateral sequential total hip replacement as safe as unilateral total hip replacement? j bone joint surg br. 2009;91(3):316-20. https://doi. org/10.1302/0301-620x.91b3.21817 18. micicoi g, de dompsure rb, micicoi l, et al. one-stage bilateral total hip arthroplasty versus unilateral total hip arthroplasty: a retrospective case-matched study. orthop traumatol surg res. 2020;106(3):577-81. https://doi.org/10.1016/j.otsr.2020.02.003 19. hou jf, hu c, zhang y, et al. cost analysis of staged versus simultaneous bilateral total knee and hip arthroplasty using a propensity score matching. bmj open. 2021;11(3):e041147. https://doi.org/10.1136/bmjopen-2020-041147 20. phillips jlh, rondon aj, gorica z, et al. no difference in total episode-of-care cost between staged and simultaneous bilateral total joint arthroplasty. j arthroplasty. 2018;33(12):360711. https://doi.org/10.1016/j.arth.2018.08.035 https://doi.org/10.1016/j.arth.2020.04.027 https://doi.org/10.1016/j.arth.2020.04.027 https://doi.org/10.4172/2161-0533.1000175 https://doi.org/10.2106/jbjs.15.01223 https://doi.org/10.2106/jbjs.15.01223 https://doi.org/10.1016/j.jor.2020.11.010 https://doi.org/10.1016/j.jor.2020.11.010 https://doi.org/10.1111/os.12617 https://doi.org/10.1111/os.12617 https://doi.org/10.17159/2309-8309/2021/v20n2a2 https://doi.org/10.1302/0301-620x.91b3.21817 https://doi.org/10.1302/0301-620x.91b3.21817 https://doi.org/10.1016/j.otsr.2020.02.003 https://doi.org/10.1136/bmjopen-2020-041147 https://doi.org/10.1016/j.arth.2018.08.035 south african orthopaedic journal hip doi 10.17159/2309-8309/2023/v22n1a1fourie pj et al. sa orthop j 2023;22(1) citation: fourie pj, erasmus rd, botha t, jacobs hw. low dislocation rate one year after total hip arthroplasty at a tertiary hospital in south africa. sa orthop j. 2023;22(1):10-17. http://dx.doi. org/10.17159/2309-8309/2023/ v22n1a1 editor: prof. michael held, university of cape town, cape town received: november 2021 accepted: june 2022 published: march 2023 copyright: © 2023 fourie pj. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background total hip arthroplasty (tha) is one of the most performed and most researched procedures worldwide, and there is an ever-growing demand for tha in an already resource-constrained system in south africa. early dislocation after tha remains a serious and costly problem; however, few tha outcome studies have been performed locally. this study therefore aimed to calculate the incidence of dislocation after tha and to identify risk factors for dislocation after tha in a south african academic hospital. methods in this retrospective cohort review, files and radiographs of 543 patients were reviewed for dislocation during the first year after primary tha. the reason for the tha, the surgical data, the implant data, and whether and when dislocation occurred were recorded for each patient. fisher’s exact tests and independent t-tests were done to analyse the association between variables and a patient’s odds of experiencing a dislocation after tha. results twenty (3.7%) out of 543 thas dislocated during the first year, 17 of these within the first three months. the surgical approach used was not shown to be a significant risk factor (p = 0.650) for dislocation, although the hardinge approach had been used for all 20 cases of dislocation. similar dislocation rates (p = 0.967) were found for thas done for displaced neck of femur (nof) fractures (3.6%) and for elective thas (3.7%). trauma thas made up more than half (55%) of our study population. femoral head sizes ≤ 32 mm (p = 0.390 for neck of femur tha and p = 0.451 for elective tha) and a single mobility design (p = 0.494) both produced a higher dislocation rate, although this was not statistically significant. surgeon experience did not prove to be significant for our study population (p = 0.570). conclusion the dislocation rate after tha at our institution is lower than rates reported in the literature for nof tha and similar to rates reported for elective tha. this was found despite the dislocation rate for the hardinge approach being nearly eight times higher than expected. minimal surgeon experience, implant coupling and smaller femoral head size did not prove to be significant risk factors for dislocation after tha. level of evidence: level 4 keywords: total hip replacement, dislocation, south africa low dislocation rate one year after total hip arthroplasty at a tertiary hospital in south africa pieter j fourie,¹* raoul d erasmus,¹ tanita botha,² hans w jacobs³ ¹ department of orthopaedic surgery, university of pretoria, pretoria, south africa ² biostatistics unit, south african medical research council, pretoria, south africa ³ department of orthopaedic surgery, steve biko academic hospital, university of pretoria, pretoria, south africa *corresponding author: p.fourie@yahoo.com introduction total hip arthroplasty (tha) is widely considered to be one of the most successful surgical procedures in orthopaedics and the most successful surgery of the 20th century. it is associated with high satisfaction rates in relieving pain and restoring function.1-4 according to the australian arthroplasty registry, there was an increase of 109% in the number of thas performed between 2003 and 2016 and an increase of 170% internationally by 2030 is projected. despite a registry-proven 93% 13-year survivorship rate for tha and more than 20-year survivorship of implants, complications can arise with tha. the second most common complication of tha is dislocation (with aseptic loosening being the most common). dislocation rates vary from 1% to 5% for elective surgery to as high as 22% for neck of femur (nof) fractures.4-6 most dislocations occur shortly after surgery: up to 60% of dislocations occur in the first five weeks and more than 75% in the first year after the index procedure.6-8 a review of revision tha databases suggests that patient-, surgery and implant-related factors can contribute to the dislocation rate after tha. important patient factors include neuromuscular disorders, alcohol abuse, advanced age, female sex and increased body mass index (bmi).2,9 analysis of indications for tha found a higher https://orcid.org/0000-0002-5362-4197 page 11fourie pj et al. sa orthop j 2023;22(1) incidence of instability when tha was performed for avascular necrosis, rheumatoid and inflammatory arthritis, and trauma, compared with degenerative osteoarthritis.2,6,7 the surgical approach used has a definite influence on the dislocation rate. the most used approaches for tha include the posterior approach, direct lateral approach and direct anterior approach, with the posterior approach being the most used approach worldwide. the dislocation risk has been quoted as 3.23% for the posterior approach, 2.18% for the anterolateral approach, 1.27% for the transtrochanteric approach and 0.55% for the direct lateral (hardinge) approach.10 more recently, the anterior approach has become popular, achieving dislocation rates of 0.6% to 1.3%.6 another important surgical factor is implant size. larger femoral heads have been shown to improve stability by increasing jumping distance and range of motion until impingement.7,11-13 this has led to the use of larger femoral heads internationally. implant coupling design also needs consideration, as implants with dual mobility coupling significantly reduce dislocation risk compared with single mobility coupling even in high-risk patients.14 surgeon experience is paramount to the success of tha. surgeons who have performed fewer than 30 procedures have a markedly increased dislocation rate compared with more experienced and better-trained surgeons.2,6 dislocation is a dire complication after tha that leads to increased morbidity, mortality and cost of care. limited data regarding tha in south africa is available, as most research has been conducted in a developed world setting.15 this study therefore aimed to calculate the incidence of dislocation after tha and to identify risk factors for dislocation after tha in a south african academic hospital. methods this was a retrospective cohort review of all patients who had undergone a primary tha at a single tertiary level hospital, steve table i: demographic data and variables investigated for dislocation risk tha (n) no dislocation (n) dislocated (n) dislocation rate p-value 543 523 20 age (years) 0.591 mean (sd) 62.4 (12.6) 62.3 (12.6) 63.9 (11.6) range 22–91 22–91 41–83 sex 0.812 male 192 (35.4%) 186 (35.6%) 6 (30.0%) female 351 (64.6%) 337 (64.4%) 14 (70.0%) side 0.824 left 260 (47.9%) 251 (48.0%) 9 (45.0%) right 283 (52.1%) 272 (52.0%) 11 (55.0%) indication 0.967 elective 241 (44.4%) 232 (44.4%) 9 (45.0%) 3.7% oaa 122 (22.5%) 117 (22.4%) 5 (25.0%) 4.1% avnb 109 (20.1%) 105 (20.1%) 4 (20.0%) 3.7% dysplasia 6 (1.1%) 6 (1.1%) 0 (0.0%) 0.0% acetabular protrusion 4 (0.7%) 4 (0.8%) 0 (0.0%) 0.0% nof fracturec 302 (55.6%) 291 (55.6%) 11 (55.0%) 3.6% approach 0.650 lateral (hardinge) 509 (93.7%) 489 (93.5%) 20 (100.0%) 3.9% anterior 32 (5.9%) 32 (6.1%) 0 (0.0%) 0.0% posterior (southern) 2 (0.4%) 2 (0.4%) 0 (0.0%) 0.0% femoral head size (mm) 0.175 22 16 (2.9%) 16 (3.1%) 0 (0.0%) 0.0% 28 97 (17.9%) 93 (17.8%) 4 (20.0%) 4.1% 32 315 (58.0%) 303 (57.9%) 12 (60.0%) 3.8% 36 113 (20.8%) 110 (21.0%) 3 (15.0%) 2.7% 40 2 (0.4%) 1 (0.2%) 1 (5.0%) 50.0% implant design 0.494 single mobility cup 479 (88.2%) 460 (88.0%) 19 (95.0%) 4.0% dual mobility cup 64 (11.8%) 63 (12.0%) 1 (5.0%) 1.6% surgeon experience 0.570 cond/rege 175 (32.2%) 168 (32.1%) 7 (35.0%) 4.0% reg/con 147 (27.1%) 140 (26.8%) 7 (35.0%) 4.8% reg/reg 221 (40.7%) 215 (41.1%) 6 (30.0%) 2.7% a osteoarthritis; b avascular necrosis; c neck of femur; d consultant; e registrar page 12 fourie pj et al. sa orthop j 2023;22(1) biko academic hospital, from january 2009 to december 2019 and who had at least one year of follow-up. the endpoint of the review was hip dislocation after primary tha. tha patients were identified from the arthroplasty theatre register (name, hospital number, date of the procedure, size of implants). preoperative radiographs were reviewed by the authors to exclude extracapsular fractures and patients who had undergone surgery prior to the tha. the patients’ files were then retrieved from the records department and reviewed by the author and co-author. patient files and radiographs on the pacs system were used to confirm non-dislocation after tha. patients who had incomplete clinical follow-up at one year were contacted telephonically to confirm non-dislocation during the first year after tha. exclusion criteria included extracapsular fracture and failed acetabular or proximal femur open reduction and internal fixation. patients with less than one-year follow-up, missing files and incomplete follow-up who could not be contacted were also excluded from the study. the indication for surgery, surgical approach, implant size, implant design (dual mobility coupling vs single mobility coupling), incidence of dislocation and number of days after tha that it occurred, surgical team’s rank (consultant or registrar) and patient comorbidities were recorded. data was captured directly into an electronic database using microsoft excel. the data analysis consisted of analytical statistical investigations which aimed to determine the dislocation rate after tha. these consisted of descriptive statistics such as mean (standard deviation) and the range for the quantitative variables and frequencies with percentages to describe the categorical results. fisher’s exact test and the independent t-test were used to evaluate the difference between outcomes. the dislocation rate was measured against the indication for tha, the surgical approach used and surgeon experience to identify risk factors for dislocation after tha. results a total of 624 patients were identified for review, and 543 patients with a complete one-year follow-up were included. eighty-one patients were excluded: 59 patients had missing files and could not be contacted, and 22 patients had incomplete files or followup and could not be contacted telephonically. the mean age of the population was 62.4 years (range 22–91), and there were 351 female patients (64.6%) and 192 male patients (35.4%). there was an even distribution of left-sided (260; 47.9%) and right-sided replacements (283; 52.1%) (table i). this study did not find age (p = 0.591), sex (p = 0.812) or side of tha (p = 0.824) to have any influence on dislocation after tha (table i). more than half of the patients (302; 55.6%) presented with nof fractures. other indications were osteoarthritis (122; 22.5%), avascular necrosis (109; 20.1%), dysplasia (6; 1.1%) and acetabular protrusion (4; 0.7%) (table i). the vast majority of thas (509; 93.7%) were done using the hardinge (lateral) approach, as is dictated by the departmental protocol. the anterior approach was used in 32 (5.9%) cases: the anterior minimally invasive technique in 30 cases (5.5%) and the smith-petersen with conventional technique in two cases (0.4%). the southern approach (posterior) was used twice (0.4%; table i). the median femoral head size used was 32 mm (315 thas; 64.6%), with sizes ranging from 22 mm to 40 mm. four hundred and seventy-nine thas (88.2%) were done using single mobility cups and 64 (11.8%) using dual mobility cups. surgeon experience was documented according to the highest qualification of the surgeon, as experience could not be controlled for – this was not a significant risk factor for dislocation. twenty (3.7%) of the patients had confirmed dislocations during the first year after surgery. dislocation occurred after one of the 64 thas performed with dual mobility cup implants (1.5%) and 19 of the 479 thas performed with single mobility cup implants (3.9%) (tables ii and iii). we first compared the ≤ 32 mm group to the ≥ 36 mm group (table iv), since there was no ≤ 28 mm head dislocation in the elective group to which to compare (table iii). although not statistically significant, the ≤ 32 mm group had a higher dislocation rate compared with the ≥ 36 mm group for both the elective tha group (p = 0.451) and total sample (p = 1.000). table ii: dislocations after total hip arthroplasty for neck of femur fractures sex age (years) indication approach femoral head size (mm) surgeon experience implant design days to dislocation year of dislocation comorbidity 1 f 62 nof fracturea lateral 40 conb/regc single mobility cup 6 2010 not documented 2 m 69 nof fracture lateral 32 reg/reg single mobility cup 7 2015 epilepsy 3 f 77 nof fracture lateral 28 con/reg single mobility cup 7 2017 mdd,d parkinson’s, dementia 4 m 56 nof fracture lateral 36 con/reg single mobility cup 7 2013 smoker, hpt,e etoh,f sepsis after thag 5 m 64 nof fracture lateral 36 reg/reg single mobility cup 21 2018 hpt 6 m 71 nof fracture lateral 28 reg/reg dual mobility cup 24 2019 asthma, hpt 7 f 55 nof fracture lateral 28 reg/reg single mobility cup 28 2009 not documented 8 f 59 nof fracture lateral 28 con/reg single mobility cup 32 2015 hpt, hyperthyroidism 9 f 53 nof fracture lateral 32 reg/con single mobility cup 140 2015 hpt 10 f 77 nof fracture lateral 32 con/reg single mobility cup 275, 350 2016 2017 hpt, hypothyroidism 11 f 83 nof fracture lateral 32 con/reg single mobility cup 300 2011 nil a neck of femur; b consultant; c registrar; d major depressive disorder; e hyperparathyroidism; f ethanol abuse; g total hip arthroplasty page 13fourie pj et al. sa orthop j 2023;22(1) in the nof fracture group, femoral head size had a greater influence on dislocation risk (p = 0.079; table v). contradictory to the elective group and most literature, the outcome for the ≥ 36 mm group was worse, having a dislocation rate of more than 6.25%. of note is that all three ≥ 36 mm heads in the nof fracture group dislocated within 21 days of the index procedure, indicating that there were factors besides head size that contributed to dislocation. patient 1 (table ii) in the dislocated group, with a 40 mm femoral head, suffered dislocation after six days, and this was due to acetabular component mispositioning – an apparent inclination of > 70° and anteversion of > 30°. patient 4 (table ii), a smoker and ethanol abuser, suffered dislocation after seven days, and this was attributed to sepsis. the third dislocation, in patient 5 (table ii), was attributed to poor patient compliance and an immature scar. of note: patient 10 (32 mm head – single mobility design) dislocated twice. we then compared the ≤ 28 mm femoral head group to the ≥ 32 mm group (table vi). the dislocation rate was higher in the ≤ 28 mm group for the total sample and the nof fracture group, but this was not statistically significant (p = 0.520). forty-nine of the 113 heads in the ≤ 28 mm group were part of a dual mobility coupling implant, and this could explain the lack of significance for this analysis. after exclusion of the dual mobility couplings, the dislocation rate for heads ≤ 28 mm was 7.89% for nof fracture thas, more than double that of the ≥ 32 mm group. this demonstrates the benefit of using larger femoral heads. post-hoc power analysis revealed that all calculations were underpowered. this was due to the small dislocation group, resulting in effect sizes of less than 0.5 for all variables. for categorical variables the cramer’s vs were calculated and for age the cohen’s d was used to calculate the effect size. table iii: dislocations after elective total hip arthroplasty sex age (years) indication approach femoral head size (mm) surgeon experience implant design days to dislocation year of dislocation comorbidity 12 f 69 oaa lateral 32 conc/regd single mobility cup 3 2011 not documented 13 m 57 oa lateral 36 reg/con single mobility cup 14 2009 not documented 14 f 67 avnb lateral 32 reg/reg single mobility cup 14 2018 hpt,e dm,f melanoma 15 f 74 oa lateral 32 reg/con single mobility cup 16 2017 hpt, triple bypass 16 f 63 avn lateral 32 con/reg single mobility cup 27 2013 not documented 17 f 79 oa lateral 32 reg/con single mobility cup 58 2011 not documented 18 m 60 oa lateral 32 reg/reg single mobility cup 65 2018 hpt 19 f 41 avn lateral 32 con/reg single mobility cup 72 2018 hpt, dyslipidaemia, pudg 20 f 41 avn lateral 32 con/reg single mobility cup 278 2019 not documented a osteoarthritis; b avascular necrosis; c consultant; d registrar; e hyperparathyroidism; f diabetes mellitus; g peptic ulcer disease table iv: comparison of ≤ 32 mm and ≥ 36 mm femoral heads tha (n) no dislocation (n) dislocation (n) dislocation rate p-value thaa population 1.000 543 523 20 3.7% ≤ 32 mm 428 (78.8%) 412 (78.8%) 16 (80.0%) 3.7% ≥ 36 mm 115 (21.2%) 111 (21.2%) 4 (20.0%) 3.5% ≤ 32 mm excl. dmb 364 (76.0%) 349 (75.9%) 15 (78.9%) 4.0% 1.000 elective tha 0.451 241 232 9 3.7% anterior approach 11 (4.6%) 11 (4.7%) 0 (0.0%) 0.0% lateral approach 230 (95.4%) 221 (95.3%) 9 (100.0%) 4.0% ≤ 32 mm 174 (72.2%) 166 (71.6%) 8 (88.9%) 4.6% ≥ 36 mm 67 (27.8%) 66 (28.4%) 1 (11.1%) 1.5% ≤ 32 mm excl. dm 159 (70.4%) 151 (69.9%) 0 (0.0%) 0.0% 0.287 nofc fracture tha 0.390 302 291 11 3.6% anterior approach 21 (7.0%) 21 (7.2%) 0 (0.0%) 0.0% lateral approach 279 (92.4%) 268 (92.1%) 11 (100.0%) 3.9% ≤ 32 mm 254 (84.1%) 246 (84.5%) 8 (72.7%) 3.2% ≥ 36 mm 48 (15.9%) 45 (15.5%) 3 (27.3%) 6.3% ≤ 32 mm excl. dm 205 (81.0%) 198 (81.5%) 7 (70%) 3.4% 0.406 a total hip arthroplasty; b dual mobility; c neck of femur page 14 fourie pj et al. sa orthop j 2023;22(1) discussion internationally, tha is a widely researched topic on which much has been published and for which registry data is readily available. malawi is the only sub-saharan african country with a national joint registry, and publications and systematic reviews with regard to a south african tha population are scarce.15-17 tha patient, implant, outcome and revision data are vital for efficiently managing limited resources in a public healthcare sector faced with a massive demand for tha. advanced age, sarcopaenia and associated fall risk, and insufficient rehabilitation are recognised risk factors for dislocation.2,6,9,18 gender is a controversial risk factor for dislocation, with older publications claiming an almost twofold higher risk for female patients. recent reviews have, however, not been able to prove a significant difference between male and female patients.6,19 cognitive and neuromuscular disorders, dementia and alcohol abuse constitute a fourfold risk of dislocation, mostly owing to poor compliance after tha. a bmi above 30 kg/m2 does increase dislocation risk but to a lesser extent.6 incomplete and missing patient records prevented analysis of bmi and other comorbidities in this study. a review article by kunutsor et al., and the only available subsaharan african systematic review by davies, both showed avascular necrosis, inflammatory arthritis and osteoarthritis to make up almost 80% of the indications for tha in their respective literature reviews.6,16,19 this is in contradiction to our study, in which more than 50% of the thas were performed for a nof fracture (table i). avascular necrosis and osteoarthritis did, however, constitute most of the elective thas (42%). this high percentage of nof fracture patients also explains the long waiting lists for elective tha at most public hospitals in south africa. avascular necrosis has been shown to be a higher risk factor for dislocation than osteoarthritis.6,20 dislocation was 200% more likely when tha was performed for avascular necrosis, 400% more likely for nof fractures and almost 500% more likely in nonunions, malunions and previous thas. hermansen et al. found a true cumulative dislocation rate of 3.5% in the first two years after tha performed for osteoarthritis in the danish national patient register.21 we found a combined elective tha dislocation rate of 3.7% in our study, and a dislocation rate of 4.1% for osteoarthritis patients and of 3.7% for avascular necrosis patients. the results from our study further contradict the findings in the international literature with regard to nof fracture tha. several international studies have shown nof fracture tha to be associated with a higher dislocation rate compared with elective tha.2,7,20,22,23 the dislocation rate for nof fracture tha (3.6%) in our study was lower than for the elective tha patients (3.7%). the indication for surgery (nof fracture vs elective) did not, however, table v: total hip arthroplasties for neck of femur fractures and variables for dislocation risk thaa (n) no dislocation (n) dislocated (n) p-value 302 291 11 age (years) 0.913 mean (sd) 65.6 (11.1) 65.6 (11.2) 66.0 (10.1) range 22–91 22–91 53–83 sex 0.754 female 203 (67.2%) 196 (67.4%) 7 (63.6%) male 99 (32.8%) 95 (32.6%) 4 (36.4%) side 1.000 left 149 (49.3%) 144 (49.5%) 5 (45.5%) right 153 (50.7%) 147 (50.5%) 6 (54.5%) dislocation rate approach 1.000 lateral (hardinge) 279 (92.4%) 268 (92.1%) 11 (100.0%) 4.0% anterior 21 (6.9%) 21 (7.2%) 0 (0.0%) 0.0% posterior (southern) 2 (0.7%) 2 (0.7%) 0 (0.0%) 0.0% femoral head size (mm) 0.079 22 16 (5.3%) 16 (5.5%) 0 (0.0%) 0.0% 28 71 (23.5%) 67 (23.0%) 4 (36.4%) 5.6% 32 167 (55.3%) 163 (56.0%) 4 (36.4%) 2.3% 36 46 (15.2%) 44 (15.1%) 2 (18.2%) 4.4% 40 2 (0.7%) 1 (0.3%) 1 (9.1%) 50.0% implant design 1.000 single mobility cup 253 (83.8%) 243 (83.5%) 10 (90.9%) 4.0% dual mobility cup 49 (16.2%) 48 (16.5%) 1 (9.1%) 2.0% surgeon experience 0.673 conb/regc 75 (24.8%) 71 (24.4%) 4 (36.4%) 5.3% reg/con 86 (28.5%) 83 (28.5%) 3 (27.3%) 3.5% reg/reg 141 (46.7%) 137 (47.1%) 4 (36.4%) 2.8% a total hip arthroplasty; b consultant; c registrar page 15fourie pj et al. sa orthop j 2023;22(1) prove to be a significant risk factor (p = 0.967) for dislocation (table i). along with the indication for surgery, another important factor is the surgical approach preferred by the surgeon. the posterior approach remains the most used approach for tha worldwide despite the slightly higher dislocation risk.4,24,25 this risk can be mitigated with adequate capsular repair and produces dislocation rates of around 1%, similar to the anterolateral and direct lateral approaches.10,24,26,27 the anterior approach is gaining popularity because of its superior stability: muscle attachment around the hip is not disrupted and dislocation rates of 0% to 1% have been reported.28,29 our results are in keeping with those in the literature for the anterior and posterior approaches, there having been no dislocations for either group. in contrast we found a dislocation rate of 3.9% for the hardinge approach – nearly eight times higher than expected. although all 20 detected dislocations were of thas done through the hardinge approach, surgical approach was not found to be a statistically significant risk factor for dislocation. all anterior and posterior approach thas were performed by a consultant orthopaedic surgeon. tha performed with dual mobility implants has a reported 0% to 5% dislocation risk irrespective of surgical approach, and this does not increase with time or with component wear.30 recent studies have even shown 0% dislocations at one-year follow-up.17,31,32 dual mobility cups have also been proved to have a lower dislocation rate in primary tha done for osteoarthritis.31 our research results were in line with those of international publications and showed a dislocation rate of 1.6% for dual mobility implants compared with the 4.0% dislocation rate for single mobility implants (p = 0.494). although dual mobility implants were used previously in our institution, this design has only been included in our protocol for use in nof fractures since early 2019, hence the low numbers in this group. we had one dual mobility dislocation in our study sample, and it was from the nof fracture group. it was an early dislocation attributed to poor patient compliance. larger femoral heads (e.g. ≥ 36 mm) allow a wider mechanical range of motion compared with smaller head diameters (e.g. ≤ 28 mm) before the neck of the prosthesis strikes the rim of the acetabular component.9 this larger jumping distance that a larger femoral head must move away from the centre of the acetabular component before it can dislocate over the rim of the cup offers better protection against dislocation.11-13 the accepted use of larger femoral heads (> 32 mm) reduced the dislocation rate by 35% to 43%.7 howie et al. found increased risk of dislocation in 28 mm heads compared with sizes 32 mm and larger.11 zijlstra et al. concluded that 32 mm heads provided more stability than did 22 and 28 mm heads in all approaches and that stability in the posterior approach could be improved by using 36 mm heads.32 it is therefore not surprising to see an increase in the use of larger heads worldwide.12,33 the median head size in our study population was 32 mm. this finding is in line with international registries.34 in addition to femoral head size, another important implantrelated and surgical factor for tha stability is acetabular and femoral component placement.19 placement of the acetabular component in too much anteversion or retroversion can cause anterior or posterior dislocation, respectively.3 similarly, too much abduction can result in lateral dislocation.3 cup anteversion of 20° ± 5° and abduction of 40° ± 10° are suggested as the optimal zone of lowest dislocation risk.35 placement outside this safety zone can increase dislocation risk fourfold. although implant position is an important factor to consider, measuring and assessing implant position were not part of the aims of this study. surgeon volume and experience in terms of the approach and implants used have a definite influence on dislocation risk.6,35,36 the best outcomes are often obtained with the approach and procedure the surgeon is most comfortable with.26 to keep up with the growing demand for tha, the definition of ‘high-volume surgeon’ had to be adapted from a surgeon who performed more than ten cases a year (the definition in the late 1990s) to a surgeon who had table vi: comparison of ≤ 28 mm and ≥ 32 mm femoral heads tha (n) no dislocation (n) dislocation (n) dislocation rate p-value thaa population 1.000 543 523 20 3.7% ≤ 28 mm 113 (20.8%) 109 (20.8%) 4 (20.0%) 3.5% ≥ 32 mm 430 (79.2%) 414 (79.2%) 16 (80.0%) 3.7% ≤ 28 mm excl. dmb 50 (10.4%) 47 (10.2%) 3 (15.8%) 4.7% 0.435 elective tha 0.603 241 232 9 3.7% anterior approach 11 (4.6%) 11 (4.7%) 0 (0.0%) 0.0% lateral approach 230 (95.4%) 221 (95.3%) 9 (100.0%) 3.9% ≤ 28 mm 26 (10.8%) 26 (11.2%) 0 (0.0%) 0.0% ≥ 32 mm 215 (89.2%) 206 (88.8%) 9 (100.0%) 4.2% ≤ 28 mm excl. dm 12 (5.3%) 12 (5.5%) 0 (0.0%) 0.0% 1.000 nofc fracture tha 0.520 302 291 11 3.7% anterior approach 21 (7.0%) 21 (7.2%) 0 (0.0%) 0.0% lateral approach 279 (92.4%) 268 (92.1%) 11 (100.0%) 3.9% posterior approach 2 (0.7%) 2 (0.7%) 0 (0.0%) 0.0% ≤ 28 mm 87 (28.8%) 83 (28.5%) 4 (36.4%) 4.6% ≥ 32 mm 215 (71.2%) 208 (71.5%) 7 (63.6%) 3.3% ≤ 28 mm excl. dm 38 (15.0%) 35 (14.4%) 3 (30.0%) 7.9% 0.177 a total hip arthroplasty; b dual mobility; c neck of femur page 16 fourie pj et al. sa orthop j 2023;22(1) performed more than 30 to 35 cases in recent years.37,38 malik et al. also postulated that arthroplasty fellows trained in ‘high-volume centres’ may be better skilled and thus achieve better surgical outcomes.36 contradictory to this, erasmus et al. demonstrated excellent results by inexperienced arthroplasty surgeons in their study on dual mobility implant thas: a 0% dislocation rate.17 the majority of cases (58.5%) in that study were treated by registrars without any consultant supervision, and only 12% of cases had a consultant as the lead surgeon.17 surgeon experience did not appear to be significant in our total study population (p = 0.570) or the higher risk nof fracture group (p = 0.673) (table i). in both groups, however, the registrar/registrar teams, that is, low-volume surgeons, achieved the best dislocation rates. close to 40% of cases were done without a consultant in the surgical team. the difference in dislocation rate is most likely due to the more challenging or high-risk cases being treated by more senior surgeons. our study had some limitations. owing to incomplete and often missing files, patient biometrics (weight, bmi) and comorbidities could not be obtained and adequately analysed. eighty-one patients (13%) eligible for the study were excluded due to incomplete/incorrect contact details – 57 of these patients were emergency (nof) admissions. an attempt was made to contact all patients who had incomplete follow-up and incomplete files. this factor could have led to an underreporting of complications in the trauma group. patients who had presented to a different facility with an acute dislocation are also more likely to default further follow-up appointments compared to patients who had no dislocations. this study looks at the dislocation rate in the first 12 months following surgery, the period in which 75% of early dislocations occur. the incidence in our study could therefore possibly only reflect 75% of expected dislocations in this cohort. the sample size of the different surgical approaches, as well as of the two implant designs used, was unbalanced and may not be an accurate reflection. because of the high p-values obtained, and wide confidence intervals, we could not perform further regression analysis, as this would be an inaccurate representation of the data. the predominance of the hardinge approach (92%) negates any meaningful comparison of surgical approach as a risk factor. also, implant malplacement was not assessed in this study and is an important limitation. post-hoc power analysis revealed that all calculations were underpowered. this was due to the small dislocation group, resulting in effect sizes of less than 0.5 for all variables.39 there is also a high likelihood for independent risk factors being underpowered. the cause of any dislocation is often multifactorial and not solely due to the approach, implant design, size of the femoral head or surgeon experience; therefore, results should be interpreted within the context. conclusion the dislocation rates after tha at our institution is lower than literature-reported rates for nof fracture tha and similar to rates reported for elective tha. this was found despite the dislocation rate of 4.0% for the hardinge approach being nearly eight times higher than expected. south african academic centres can offer outcomes comparable to those reported internationally. although surgeon experience, single mobility couplings and smaller femoral head sizes were shown to be associated with dislocation risk, these were not found to be statistically significant risk factors for dislocation after tha. it is important to consider technical advances in tha. the anterior approach offers promising results and could herald in a new era of tha. dual mobility coupling and larger femoral head size are literature-proven risk-mitigating factors in high-risk patients and should always be considered. given the high percentage of thas done for nof fractures, preventive strategies can and should be considered to reduce this fracture burden. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. prior to the commencement of the study, ethical approval was obtained from the following ethical review board: university of the pretoria’s human research ethics committee and reference number 332/2020. informed written consent was not obtained from all patients for being included in the study. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions pjf: primary author, study conceptualisation, data capture, data analysis rde: co-author, data collection tb: data analysis hwj: conceptualisation, manuscript revision, supervision orcid fourie pj https://orcid.org/0000-0002-5362-4197 erasmus rd https://orcid.org/0000-0001-6206-6687 references 1. goldstein wm, gleason tf, kopplin m, branson jj. prevalence of dislocation after total hip arthroplasty through a posterolateral approach with partial capsulotomy and capsulorrhaphy. j bone joint surg am. 2001;83-a suppl 2(pt 1):2-7. 2. lu y, xiao h, xue f. causes of and treatment options for dislocation following total hip arthroplasty (review). exp ther med. 2019 sep;18(3):1715-22. 3. ullmark g. the unstable total hip arthroplasty. efort open rev. 2016;1(4):83-88. 4. zahar a, rastogi a, kendoff d. dislocation after total hip arthroplasty. curr rev 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2002(405):46-53. 11. howie dw, holubowycz ot, middleton r. large femoral heads decrease the incidence of dislocation after total hip arthroplasty: a randomized controlled trial. j bone joint surg am. 2012;94(12):1095-102. 12. jameson ss, lees d, james p, et al. lower rates of dislocation with increased femoral head size after primary total hip replacement: a five-year analysis of nhs patients in england. j bone joint surg br. 2011;93(7):876-80. 13. stroh da, issa k, johnson aj, et al. reduced dislocation rates and excellent functional outcomes with large-diameter femoral heads. j arthroplasty. 2013;28(8):1415-20. 14. romagnoli m, grassi a, costa gg, et al. the efficacy of dual-mobility cup in preventing dislocation after total hip arthroplasty: a systematic review and meta-analysis of comparative studies. int orthop. 2019;43(5):1071-82. 15. shituleni s, maqungo s. displaced intracapsular neck of femur fractures: dislocation rate after total hip arthroplasty. sa orthop j. 2018;17(1):30-34. 16. davies ps, graham sm, maqungo s, harrison wj. total joint replacement in sub-saharan africa: a systematic review. trop doct. 2019;49(2):120-28. 17. erasmus lj, fourie ff, van der merwe jf. low dislocation rates achieved when using dual mobility cup hip implants for femur neck fractures. sa orthop j. 2020;19(2):70-73. 18. esposito ci, gladnick bp, lee y-y, et al. cup position alone does not predict risk of dislocation after hip arthroplasty. j arthroplasty. 2015;30(1):109-13. https://orcid.org/0000-0002-5362-4197 https://orcid.org/0000-0001-6206-6687 page 17fourie pj et al. sa orthop j 2023;22(1) 19. kunutsor sk, barrett mc, beswick ad, et al. risk factors for dislocation after primary total hip replacement: a systematic review and meta-analysis of 125 studies involving approximately five million hip replacements. lancet rheumatol. 2019;1(2):e111-e21. 20. meek rm, allan db, mcphillips g, et al. epidemiology of dislocation after total hip arthroplasty. clin orthop relat res. 2006;447:9-18. 21. hermansen ll, viberg b, hansen l, overgaard s. ‘true’ cumulative incidence of and risk factors for hip dislocation within 2 years after primary total hip arthroplasty due to osteoarthritis: a nationwide population-based study from the danish hip arthroplasty register. j bone joint surg am. 2021;103(4):295-302. 22. yang s, halim ay, werner bc, et al. does osteonecrosis of the femoral head increase surgical and medical complication rates after total hip arthroplasty? a comprehensive analysis in the united states. hip int. 2015;25(3):237-44. 23. stafford gh, charman sc, borroff mj, et al. total hip replacement for the treatment of acute femoral neck fractures: results from the national joint registry of england and wales at 3-5 years after surgery. ann r coll surg engl. 2012;94(3):193-98. 24. wayne n, stoewe r. primary total hip arthroplasty: a comparison of the lateral hardinge approach to an anterior mini-invasive approach. orthop rev. 2009;1(2):e27. 25. perticarini l, rossi smp, benazzo f. unstable total hip replacement: why? clinical and radiological aspects. hip int. 2020;30(2_suppl):37-41. 26. kwon ms, kuskowski m, mulhall kj, et al. does surgical approach affect total hip arthroplasty dislocation rates? clin orthop relat res. 2006;447:34-38. 27. pellicci pm, bostrom m, poss r. posterior approach to total hip replacement using enhanced posterior soft tissue repair. clin orthop relat res. 1998(355):224-28. 28. bhandari m, matta j, dodgin d. anterior total hip arthroplasty collaborative investigators outcomes following the single incision anterior approach to total hip arthroplasty: a multicenter observational study. orthop clin north am. 2009;40(3):329-42. 29. tsukada s, wakui m. lower dislocation rate following total hip arthroplasty via direct anterior approach than via posterior approach: five-year-average follow-up results. open j orthop. 2015;9:157-62. 30. guyen o. constrained liners, dual mobility or large diameter heads to avoid dislocation in tha. efort open rev. 2016;1(5):197-204. 31. vajapey sp, fideler kl, lynch d, li m. use of dual mobility components in total hip arthroplasty: indications and outcomes. j clin orthop trauma. 2020;11(suppl 5):s760-5. 32. zijlstra wp, de hartog b, van steenbergen ln, et al. effect of femoral head size and surgical approach on risk of revision for dislocation after total hip arthroplasty. acta orthop. 2017;88(4):395-401. 33. ajrr. ajrr annual report: ajrr; 2020. available from: https://www.aaos.org/registries/ publications/ajrr-annual-report. 34. tsikandylakis g, mohaddes m, cnudde p, et al. head size in primary total hip arthroplasty. efort open rev. 2018;3(5):225-31. 35. lewinnek ge, lewis jl, tarr r, et al. dislocations after total hip-replacement arthroplasties. j bone joint surg am. 1978;60(2):217-20. 36. malik at, jain n, scharschmidt tj, et al. does surgeon volume affect outcomes following primary total hip arthroplasty? a systematic review. j arthroplasty. 2018;33(10):3329-42. 37. khatod m, cafri g, namba rs, et al. risk factors for total hip arthroplasty aseptic revision. j arthroplasty. 2014;29(7):1412-17. 38. kreder hj, deyo ra, koepsell t, et al. relationship between the volume of total hip replacements performed by providers and the rates of postoperative complications in the state of washington. j bone joint surg am. 1997;79(4):485-94. 39. kim h-y. statistical notes for clinical researchers: chi-squared test and fisher’s exact test. restor dent endod. 2017;42(2):152-55. _hlk104982683 south african orthopaedic journal editorial doi 10.17159/2309-8309/2022/v21n3a0burger e sa orthop j 2022;21(3) artificial intelligence and spine surgery outcomes: the beginning of a new era evalina burger* professor and chair robert d’ambrosia endowed chair, department of orthopedics, university of colorado anschutz medical campus, aurora, colorado, united states of america *corresponding author: evalina.burger@cuanschutz.edu in 1950, alan turing believed if a machine could carry on a conversation through a teleprinter, the machine could be described as ‘thinking’. in 1952, the hodgkin–huxley model of the brain as neurons forming an electrical network was published. at a conference sponsored by dartmouth college in 1956, these concepts were discussed and helped to spark the concept of artificial intelligence.1,2 according to the sas institute (statistical analysis system), ‘artificial intelligence (ai) makes it possible for machines to learn  from experience, adjust to new inputs and perform human-like tasks’. most ai examples that you hear about today – from chess-playing computers to self-driving cars – rely heavily on deep learning and natural language processing. using these technologies, computers can be trained to accomplish specific tasks by processing large  amounts of data and recognising patterns in the data.3 these systems will model human behaviour and thought, behave intelligently and rationally, and have applications that use techniques in machine learning, deep learning and other learning techniques. these machines can have semantic search engines (based  on  words)  and  mine  data  sets  to  find  new  relationships  and can even recognise images. the machines’ learning networks are based on pattern recognition. arguably, these computers are smarter at cognitive problem solving, such as we find  in only a  small percentage of people who are smart test takers. businesses are already using ai to predict customer behaviour, guard data and more efficiently analyse business opportunities. so how do we use this in spine surgery and how does it help our patients? the concept is not foreign in spine surgery. classifications  have been developed for many decades in order to group together cohorts of patients that have similar disease traits. this allowed for scientific advancement as we could at least all speak the same  language. ai propels this thought process forward by utilising millions of data points to recognise patterns that we can translate in predicting outcomes for surgery. if we can accurately predict the risk factor for failure of fusion, proximal junctional kyphosis and infection, we could save many a patient from harm. theoretically this can also help us to decide on the procedure needed to overcome failure. attempts at this synthetisation of mega data hold promise for us to educate our patients and make skilful unbiased decisions on the indications for and extent of surgery.4 with the embracement of technology, we can create personalised medicine. studying multiple genetic samples at the cu-anschutz school of medicine (som), we were able to determine which patients lack the enzyme to metabolise non-steroidal antiinflammatory drugs (nsaids) due to a genetic defect, hence the  unpredictability of post-surgical kidney failure with administration of nsaids. these patients’ charts were flagged.5 figure 1. sva per cent corrected sva: sagittal vertical axis; pt: pelvic tilt; pi-ll: pelvic incidence-lumbar lordosis sva no deterioration: 90% 39 cases with balanced sva at preop sva corrected: 61% 46 cases with unbalanced sva at preop pt no deterioration: 87% 38 cases with balanced pt at preop pt corrected: 55% 11 cases with unbalanced pt at preop pi-ll no deterioration: 80% 35 cases with balanced pi-ll at preop pi-ll corrected: 75% 40 cases with unbalanced pi-ll at preop legend:      unid data moal et al.6 page 122 burger e sa orthop j 2022;21(3) i vividly remember how i was told that ‘nothing kills confidence  like follow up’. when you start to incorporate data analytics into your practice and have a computer tell you outcome measures, it is sobering and really changes your thought process. not only does  it kill confidence but is unsettling and thought provoking. figure 1 depicts a graph that is readily available and updated in real time with every patient visit and follow-up x-ray. images are transferred to  the  hub  where  x-rays  are  analysed  and  up  to  28  sagittal  parameters recorded. looking at this data, the surgery corrected the pi-ll (pelvic incidence–lumbar lordosis) value in 70% of cases  (50% is standard in the literature) and showed that none of the  patients that were balanced before were worsened by the surgery.7 the platform also allows for accurate planning of cases. the ai platform stores the data of thousands of patients and, via pattern rcognition, creates a predicitve model. the value in this is knowing how patients will compensate post surgery. intuitively we know that patients will balance their spine over time. prediction of where they will end is not only critical for the long-term outcomes but can help us to not harm the patient with over or under correcting deformity. the example (figure 2) is that of an unbalanced congenital curve, and planning the rod and the sagittal balance gave us the template to execute the surgery (figure 3). these cases are complex and getting the sagittal balance correct in the face of a severe coronal deformity is always a challenge. figure 4 demonstrates an example of the predictive value that the model provides. we are able to see how the pelvis will relax and how much we should increase the thoracic kyphosis in order to balance the spine. this allows us to not only plan every osteomy but  also  order  a  patient-specific  rod  that  guides  the  surgical  correction. the rod is used as a template during surgery and the paradigm shifts to bringing the patient to the rod as opposed to placing the rod into the patient. collection of data on this scale will help to show value. if we cannot demonstrate value-based care, we will not be able to negotiate reimbursement for what we do. in tracking our patients for functional improvement (figure 5 and 6), the data demonstrate improvement of physical function and odi at one year.8 this outcomes data, although generic, can be enormously valuable when we combine patient-specific outcome scores with patient-specific  radiological outcomes, refining what we do to a science and not  only an art.8 many pitfalls will have to be negotiatied, including data integrity and protection of personal information. as data science evolves and platforms develop, this type of information will flow seamlessly  and be available to every surgeon to constantly test their skills and figure 2. 22 yom kyphoscoliosis and preop planning preop plan pelvic tilt, pt (°) 10 14 pelvic incidence, pi (°) 64 64 sacral slope, ss (°) 54 51 lumbar lordosis, ll (°) -71 -70 pi-ll (°) -6 -5 t1 pelvic angle, tpa (°) 20 11 sagittal vertical axis, sva (mm) 109 4 t4-t12 thoracic kyphosis, tk (°) 58 39 figure 3. 22 yom follow-up at 31 months 31m follow-up pelvic tilt, pt (°) 19 pelvic incidence, pi (°) 65 sacral slope, ss (°) 46 lumbar lordosis, ll (°) -70 pi-ll (°) -5 t1 pelvic angle, tpa (°) 20 sagittal vertical axis, sva (mm) 47 t4-t12 thoracic kyphosis, tk (°) 37 preop plan t4-t12 thoracic kyphosis, tk (°) 27 45 t1 slope (°) 29 20 roussouly classification, rc type 1 type 1 figure 4. predicted and improvement of t1 slope balance page 124 burger e sa orthop j 2022;21(3) push the boundaries to deliver the best care we can give to our patients. ai has found a home in medicine and surgery and will play a pivotal role in decision making in the future. the ethics of applying this knowledge in decision making has to be defined but  the science will be undeniable. references 1. reynoso, r. a complete history of artificial intelligence. 2021. available from: https://www. g2.com/articles/history-of-artificial-intelligence. accessed 5 june 2022. 2. foot k. a brief history of artificial intelligence. dataversity. 2022. available from: https://www. healthdatacompass.org/#h.p_gqkto03q80ri. accessed 5 june 2022. 3. knight m. what is artificial intelligence (ai)? 2021. available from: https://www.dataversity. net/?s=what+is+artificial+intelligence+%28ai%29%3f. accessed 5 june 2022. 4. ames cp, smith js, pellisé f, et al. artificial intelligence based hierarchical clustering of patient types and intervention categories in adult spinal deformity surgery: towards a new classification scheme that predicts quality and value. spine (phila pa 1976). 2019;44(13):915-26. https://doi.org/10.1097/brs.0000000000002974 5. colorado center for personalized medicine. infrastructure. c2022. the regents of the university of colorado. available from: https://medschool.cuanschutz.edu/ccpm/ infrastructure. accessed 5 june 2022. 6. moal b, schwab f, ames cp, et al.; international spine study group. radiographic outcomes of adult spinal deformity correction: a critical analysis of variability and failures across deformity patterns. spine deform. 2014;2(3):219-25. https://doi.org/10.1016/j. jspd.2014.01.003 7. available from: https://platform.medicrea.com/analytics/balance-analysis. accessed 5 june 2022. 8. cu cosmos (colorado orthopaedic surgery measurement of outcomes system) patient outcomes data. 46 44 42 40 38 36 34 32 30 baseline age < 65 years age ≥ 65 years ye ar s promis physical function 3 months postop 5 months postop 1 year postop age < 65 yr age ≥ 65 yr baseline 33.53 33.36 3 months postop 39.81 38.01 6 months postop 41.44 39.82 1 year postop 42.06 40.17 figure 5. promis physical function 55 50 45 40 35 30 25 20 baseline age < 65 years age ≥ 65 years ye ar s oswestry disability index 3 months postop 5 months postop 1 year postop age < 65 yr age ≥ 65 yr baseline 50.9 44.53 3 months postop 31.43 30.08 6 months postop 28.46 26.16 1 year postop 31.35 23.83 figure 6. oswestry disability index https://doi.org/10.1097/brs.0000000000002974 south african orthopaedic journal hand doi 10.17159/2309-8309/2022/v21n2a3keller mm et al. sa orthop j 2022;21(2) citation: keller mm, barnes ry, brandt c, hepworth lm. splints and immobilisation approaches used for second to fifth metacarpal fractures: a systematic review. sa orthop j. 2022;21(2):82-88. http://dx.doi.org/10.17159/23098309/2022/v21n2a3 editor: dr duncan mcguire, university of cape town, cape town, south africa received: june 2021 accepted: january 2021 published: may 2022 copyright: © 2022 keller mm. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: the authors declare that no commercial funding was received. the reviewer payments were funded by the early career academic development grant from the university of the witwatersrand. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background the second to fifth metacarpal fractures are immobilised with splints, plaster of paris (pop) or buddy strapping for a period of time. however, no recent evidence-based splinting and immobilisation programme exists for the management thereof, leaving a gap in the literature to inform clinical practice. this review aimed to review, appraise and collate the literature on splints and immobilisation approaches used for second to fifth metacarpal fractures after surgical and conservative management in adults aged 20 to 59 years. methods the review included experimental study designs, quasi-experimental studies, cohort studies and case-control studies from january 2008 to september 2018. two reviewers independently screened, selected, appraised and extracted data from the included studies. preferred reporting items for systematic reviews and meta-analysis (prisma) guided the reporting. joanna briggs institute (jbi) critical appraisal tools were used to assess the risk of bias for each included study. results database searches generated 1 005 articles with ten additional articles found on google scholar. ten articles were included: two randomised controlled trials (rcts), one quasi-rct, four prospective studies, one retrospective record review, one retrospective study and one comparative study with descriptive reporting of the results. conclusion high level 1b evidence suggests that no reduction, a soft wrap and buddy strapping for three weeks with early active finger and wrist mobilisation are effective for individuals who sustained boxer’s fractures with ≤ 70° angulation. to guide clinical practice, high-level research is needed to determine the immobilisation of second to fifth metacarpal fracture types. level of evidence: level 2 keywords: boxer’s fracture/s, immobilisation, metacarpal fractures, splints, orthosis splints and immobilisation approaches used for second to fifth metacarpal fractures: a systematic review monique m keller,¹* roline y barnes,¹ corlia brandt,² lauren m hepworth³ 1 department of physiotherapy, school of health and rehabilitation sciences, faculty of health sciences, university of the free state, bloemfontein, south africa 2 department of physiotherapy, school of therapeutic sciences, faculty of health sciences, university of the witwatersrand, johannesburg, south africa 3 occupational therapist, private practice, durban, south africa *corresponding author: monique.keller@wits.ac.za introduction metacarpal fractures account for 10% of bony injuries and are one of the most prevalent upper limb injuries among adults.1 among all hand fractures identified in the united states (us), metacarpal fractures have an incidence rate of 13.6 per 100 000 persons per year and a prevalence of 33%.2 fifth metacarpal neck fractures or boxer’s fractures account for 10% of all hand fractures that have left individuals with functional deficits, including weakened grip strength and decreased metacarpal joint range of motion (rom).3 the concern is the residual deficits that impact the young and working adult population as they seem to sustain metacarpal fractures more often.4 the potential functional implications of sustaining a second to fifth metacarpal fracture can impact the individual in all components of the international classification of functioning, disability and health (icf) framework, namely body functions and structures, activity and participation.5 the problem is that no best-evidence splinting and immobilisation programme exists to inform clinical practice. this can lead to disability, decreased hand function and poor healthrelated quality of life (hrqol). a period of immobilisation is widely deemed part of the management after sustaining second to fifth metacarpal fractures.6 surgical intervention includes open reduction internal fixation with compression and plates, screws, or https://orcid.org/0000-0002-1513-295x page 83keller mm et al. sa orthop j 2022;21(2) kirshner wires (k-wires) to improve stability, followed by a period of immobilisation.7-9 conservative management includes closed reduction if required, with external protection utilising a splint, u-shaped, non-circumferential plaster of paris (pop), strapping the injured metacarpal finger to the adjacent uninjured metacarpal finger (buddy strapping) or mobilisation. splints and immobilisation approaches for second to fifth metacarpal fracture management vary in the literature. fabrication of customised splints requires technical skill, in-depth knowledge of pathology and anatomy, bone-healing time frames, and surgery. occupational therapists and physiotherapists trained in the management of hand injuries are qualified to choose, design, apply, individualise and adjust splints according to their specific needs, and administer rehabilitation programmes. reviewing existing literature on splints and immobilisation approaches used for second to fifth metacarpal fractures would provide an appraisal of evidence on the various splints and immobilisation approaches currently used to provide guidance to clinicians in clinical practice. therefore, the research question guiding the scoping type systematic review was: what evidence is available for conservative and post-surgical splints and immobilisation approaches utilised (including, but not limited to, pop and/or splints) as part of initial management for adults older than 20 years and younger than 59 years of age, reporting on outcomes which included, but were not limited to, hand function, hrqol, disability, digital rom, grip strength and fine motor dexterity after sustaining single or multiple second to fifth metacarpal fractures? the review’s objective was to determine the immobilisation and splint approaches utilised for post-surgical and conservative management for 20to 59-year-old adults who sustained a single or multiple second to fifth metacarpal fracture. methods this research was registered with prospero (number crd 42019132620), and the review protocol adhered to prisma recommendations.10 databases accessible to the university of the free state and the electronic platforms searched were: academic search ultimate, medline with full text, cinahl with full text, cab abstracts, health source: consumer edition, africa-wide information, health source: nursing/academic edition, sportdiscus with full text and masterfile premier with additional searches on scopus and web of science. an information scientist, an expert librarian at the university of the free state was consulted and assisted with searching databases and searching for databases. the reference lists of included fulltext articles were screened for additional research/articles. an additional search for grey literature was performed on the internet with google and google scholar with the keywords: boxer’s fracture/s, immobilisation, metacarpal fractures, splints, orthotic devices, splinting with boolean operators. an example of the search strategy keywords for one database is presented in table i. an adapted cochrane document for randomised controlled trials (rct) and non-rcts (cochrane website) was piloted on three studies to ensure accuracy and consistency. two independent reviewers independently screened, selected, appraised and extracted data from three eligible studies. the pilot study was undertaken to assess the consistency of the review procedures. joanna briggs institute (jbi) critical appraisal tools were used to assess risk of bias for the pilot studies.12 no changes were made after the pilot study, a high inter-rater agreement was found, and one of the pilot studies was included in the final data extraction. eligibility intervention studies in english for the period january 2008 to september 2018 were included. eligible studies complied with the following inclusion criteria: adult participants between 20 and 59 years of age, reporting on conservative and post-surgical immobilisation and splints utilised (including, but not limited to, pop and/or splints, buddy strapping) for single or multiple second to fifth metacarpal fractures. studies with participants younger than 20 years were not included due to skeletal immaturity.11 nakashian et al. reported that very few individuals sustain metacarpal fractures after 59 years of age.2 thus, studies with participants older than 59 years were omitted. studies reporting on outcomes included, but were not limited to, hand function, hrqol, disability relating to the loss of hand function, digital rom, grip strength, return to work, and fine motor dexterity. exclusion criteria were studies investigating thumb metacarpal fractures, studies investigating second to fifth metacarpal fractures with an associated tendon injury, nerve injury or preexisting osteoarthritis or rheumatoid arthritis. studies reporting on concurrent fractures of the phalangeal, carpal, distal radius and ulna bones were also excluded. studies reporting on fractures with infections were also excluded. screening after the database searches, all identified articles were imported into endnote® (clarivate analytics, pa, usa), and duplicates removed. two reviewers independently screened the identified articles against their titles and abstracts. the remaining articles were independently assessed for eligibility according to the inclusion criteria in a standardised and unbiased manner. disagreement in selecting included articles was resolved between the reviewers. inter-rater reliability of 0.80 cronbach’s alpha among the two reviewers during the second phase indicated a substantial agreement and consensus during the eligibility phase. full-text articles were retrieved for all eligible articles. data was extracted from the included articles using the piloted data extraction template. data extraction the database searches generated 1 005 research articles, with ten additional articles identified through a google scholar search, table ii: database search results database number of records identified academic search ultimate 95 african-wide information 2 cab abstracts 34 cinahl 42 google scholar 10 health source: consumer edition 18 health source: nursing/academic edition 5 scopus 21 (which indexes embase) 409 masterfile premier 1 medline (with full text) 220 sportdiscus 8 web of science core collection 21 171 total 1 015 table i: search strategy keywords search search string #1 database: cinahl ((boxer* or metacarpal*) n2 fractur*) and (exercis* or program* or protocol* or ‘functional rehab*’ or rehab* or advis* or advic* or educat* or splint* or immobili* or physiotherap* or ‘physical therap*’ or ‘occupational therap*’ or outcome*) page 84 keller mm et al. sa orthop j 2022;21(2) resulting in 1 015 articles (table ll). from the total 1 015 research articles, 490 duplicates were removed, with 525 articles remaining for screening by the two reviewers. the reviewers excluded 515 articles due to languages other than english (69), paediatric articles (37), metacarpal fractures with associated tendon injuries (15), studies performed on animals (88), articles reporting on only surgical intervention for metacarpal fractures (295) and other sources with participants older than 59 years and first (thumb) metacarpal fractures (11) (figure l). assessment of the methodological quality the reviewers independently assigned a grade and assessed the risk of bias for each included study, with the jbi critical appraisal tools assessing the studies’ relevance, results and trustworthiness.12 depending on the study design, the aspects assessed were: use of true randomisation, concealment of allocation to treatment groups, clear description of the study setting, and included participant numbers, whether the exposure to the measurement was valid and reliable, identification of confounding variables, strategies to deal with confounding variables reported on, outcomes measured reliably and validly, appropriate statistical analysis, to name a few. to ensure methodological rigour, the reviewers assessed all the included eligible articles according to the grading of recommendations assessment, development and evaluation (grade) method.13 a high and moderate certainty level of evidence was accepted, and a low and very low certainty level was documented.11 ten articles were included in totality, showing a dearth of literature in the field. two articles had high-quality ratings, one moderate quality, and seven low-quality ratings, as shown in the summary of the findings table available online (supplemental table). highquality rating indicated confidence in estimating effects, and future research is unlikely to affect or change the confidence. a moderate quality rating indicated that further research is likely to impact confidence and may even change the estimate. a low quality indicated that future research has a very high likelihood of impacting the confidence in effect estimation.13 a narrative analysis of all ten included articles is provided with a summary of the findings in the supplemental table (https://saoj.org.za/index.php/ saoj/article/view/524/626). results according to the objective, the presentation of the narrative results below is to appraise and collate the literature on splint and immobilisation approaches for conservative and post-surgical immobilisation and splint approaches used in 20to 59-year-old patients who sustained a single and/or multiple second to fifth metacarpal fracture(s) according to the specified fracture levels. evidence on shaft metacarpal fractures a prospective study conducted in saudi arabia investigated the conservative management of spiral and long oblique shaft fractures of second to fifth metacarpal bones.14 participants presenting with minimally displaced, no significant angulation fractures with no rotation malalignment, were included in the study.14 a low grade quality of evidence rating was given. management included immobilisation using a wrist pop (20° to 30° wrist extension with fingers free) for two weeks, which was followed by mobilisation guided by a home programme. follow-up occurred at two weeks, six weeks, three months and six months postoperatively (n = 42). extension lag was noted in all participants (50%) at two and six weeks, but no extension lag was reported at six months. total active motion (tam) and grip strength were significantly increased by six months with a resulting mean tam of 260° and 90% grip strength compared to the contralateral hand.14 a prospective study conducted in the united kingdom included 30 individuals who sustained single or multiple, middle or border, closed spiral metacarpal fractures.15 all participants had fractures with malrotation.15 a low grade quality of evidence rating was given. management included both no splint and thus no id e n ti fi c a ti o n s c re e n in g e li g ib il it y in c lu d e d records identified through database searching (n = 1 005) records after duplicates removed (n = 525) records screened (n = 525) full-text articles assessed for eligibility (n = 10) studies included in qualitative synthesis (n = 10) studies included in quantitative synthesis (meta-analysis) (n = 0) records excluded (n = 515) full-text articles excluded, with reasons (n = 0) additional records identified through other sources (n = 10) figure 1. prisma 2009 flow diagram10 https://saoj.org.za/index.php/saoj/article/view/524/626 https://saoj.org.za/index.php/saoj/article/view/524/626 page 85keller mm et al. sa orthop j 2022;21(2) immobilisation. gradual early mobilisation was encouraged. the participants had to make a fist, up to 2 cm measured from finger to the palm, before they were discharged. twenty-five participants attended the follow-up session. at seven days after injury, malrotation was measured through visual observation, and no formal x-ray measurements were taken. malrotation was present in a third of the participants during the clinic follow-up session. the outcomes measured between six and 14 months after injury included: rom, grip strength, palpation of the fracture site to assess bone union, obtaining verbal feedback from participants on a scale of poor, fair and good, verbally assessing functional limitations, verbally assessing cosmetic satisfaction of the hand on a scale of good, fair and poor, and shortening of the fingers. fingers shortening ranged between 2 and 5 mm with a mean of 4 mm. the authors concluded that good hand function and no clinically significant sign of malrotation was present.15 the lack of formal x-ray measurements to ensure optimal bone healing and guide management is a concern. not using standardised outcome measures for hand function compromised the generalisability and quality of the findings. in nova scotia, a prospective research study was conducted on 61 patients with second to fifth non-scissoring spiral metacarpal fractures where they were managed conservatively.16 a low grade quality of evidence rating was given. exclusion criteria included metacarpal fractures requiring surgical intervention and thumb fractures. conservative management included immobilisation in a splint moulded to 20° of wrist extension, affected metacarpophalangeal joint (mcpj) with one adjacent unaffected mcpj in 30° flexion and the interphalangeal joints extended for one week. after one week, the splint was removed for showering, exercises, and at night for the patients deemed to be compliant and who no longer took pain medication or experienced pain. the splint was kept on during sleep periods and for more demanding activities during the day. during less busy daytime periods, the splint was removed, hands were moved when movements did not cause pain, but no other use of the hand was allowed. the splint was removed after three weeks. grip strength and rom as outcomes were measured at three, six and ≥ 22 weeks after the injury. at five months, the final follow-up, the mean grip strength for the uninjured hand was 36.18 kg and the injured hand 36.58 kg.16 from these three studies, the following splint can be used with confidence for individuals who sustained second to fifth metacarpal shaft fractures: • thermoplastic splint with the wrist in 20–30° with the fingers free. evidence on neck and shaft of fifth metacarpal fractures a turkish retrospective record review comparative study was conducted on 140 participants with a mean age of 30.56 years. a low grade quality of evidence rating was given. the inclusion criteria included sustaining an isolated, extra-articular, neck or shaft fifth metacarpal fracture with more than 30° of angulation. the participants were allocated to two groups.17 the management of group a included reduction and immobilisation of the fourth and fifth fingers in a short arm pop with the following joint positions: wrist 30° extension, mcpj 45° flexed, proximal interphalangeal joints (pipjs) and distal interphalangeal joints (dipjs) in 15° flexion for a mean of 29.15 days. group b’s management included reducing and immobilising the fourth and fifth fingers in a u-shaped gutter splint with the following joint positions: wrist 30° extension, mcpj 45° flexed, pipjs and dipjs in 15° flexion for a mean of 29.15 days.17 after removing the pop and splints, an x-ray was taken, and bone healing clinically assessed with pain present or absent on the fracture line. a month later, assessments were performed including: rom with a goniometer, clinical assessment of rotational deformity in the fifth finger and grip strength of the dominant and non-dominant hands with a jamar hand dynamometer. group a scored 90.38% grip strength compared to the unaffected side, and group b 90.58%. two participants from group a and group b had a 10° extension lag. in group a, two participants had hypoesthesia along the ulnar nerve’s dorsal cutaneous branch, which resolved in three weeks. one participant presented with a superficial wound between the third and fourth webspace due to pop pressure. no complications were experienced in group b. no significant statistical difference was found between groups for grip strength, range of motion (rom) and dorsal angulation. a clinical concern is that group a and group b, the wrist, pipj and dipj joints were included with possible reporting bias where complete rom reporting was omitted. in the pop group, the long period of immobilisation caused pressure points and neuropraxia. the participants preferred the u-shaped ulnar gutter splints for their comfort, which clinicians should consider. from these studies: • no best-evidence splinting and immobilisation approach can be deducted as unaffected joints are included in the immobilisation. evidence on neck, shaft and base of fifth metacarpal fractures a retrospective study was conducted in glasgow, on 162 individuals who sustained fifth metacarpal (neck, shaft, base) fractures.18 a low grade quality of evidence rating was given. exclusion criteria included dislocations, open injuries, intra-articular fractures, significant rotational deformities and polytrauma. the management had buddy strapping of the affected fifth finger to the neighbouring fourth finger for one week that allowed early active mobilisation, with information and no follow-up sessions. the information provided to the participants included an explanation of the fracture, guidance on how to commence early mobilisation and the natural history of the injury.18 assessments were performed at a mean follow-up period of 21.6 months via a postal questionnaire and a follow-up telephone call. outcomes assessed were: satisfaction with the injury outcome and the process on a four-point likert scale, hand function with the quickdash, and disability with the eq-5d. response from 59% of the contacted individuals indicated satisfactory outcomes. the results revealed a median eq-5d score of 0.87 (interquartile range [iqr] 0.74–1) out of a possible best score of 1 and a median quickdash score of 2.3 (iqr 0–6.8). normative quickdash data used to make comparisons were a mean of 10.9, median 4.5, a standard deviation of 15.3, iqr 0–14.3 and a range of 0–88.6. eighty-three participants (84.9%) were satisfied with the management process, and 79 participants (80.6%) were satisfied with the outcome of their injury. no significant difference was found when comparing eq-5d (p = 0.307) and quickdash (p = 0.820) scores of uninjured individuals.18 a lack of reporting on outcomes, such as pain information measured with the eq-vas, which is part of the eq-5d, tam of the fifth finger and grip strength, affects the generalisability of this study’s results to other populations. however, in a well-selected group of individuals who sustained fifth metacarpal neck, shaft and base fractures, the management pathway adds a valuable option for clinicians, especially in settings with limited resources. the benefits include decreased orthopaedic and hand therapy followup sessions, with positive financial and time implications for both government and patients. from the studies, the immobilisation that can be used with moderate confidence, for individuals who sustained single or multiple neck, shaft or base of fifth metacarpal fractures, is: • buddy strapping the fifth to the fourth finger. page 86 keller mm et al. sa orthop j 2022;21(2) evidence on neck of fifth (boxer’s) metacarpal fractures in switzerland, a randomised multicentre trial on 68 participants who sustained fifth metacarpal neck fracture with ≤ 70° of angulation and no rotational deformities was conducted.19 a high grade quality of evidence rating was given. the 68 participants were allocated to two intervention groups. management for one group included no reduction, a soft wrap around the palm, and a buddy strap around the fourth and fifth fingers for three weeks. immediate active wrist and finger mobilisation was encouraged with the soft wrap/buddy strap as conservative management. the other intervention included a reduction followed by a forearm wrist pop immobilisation extending to the pipj with mcpj in extension for four weeks.19 the quickdash questionnaire results at four months displayed a mean difference of −10.9 between the groups indicating no significant difference. for other outcomes: pain, mcpj rom, grip strength, and aesthetic appearance, no significant differences were found. however, a significant difference was measured with days off work. the soft wrap and buddy strapping group participants returned to their occupation on average 11 days sooner than the reduction and pop immobilisation group (p = 0.03).19 the evidence provides clinical guidance that using a soft wrap and buddy strapping is as effective as reduction and pop immobilisation with no complications for neck of fifth metacarpal (boxer’s) fractures with ≤ 70° of angulation and no rotational deformities. in turkey, a comparative study included 24 male participants working in professional environments and who sustained uncomplicated closed fifth metacarpal neck fractures.20 a low grade quality of evidence rating was given. the participants were allocated to either a conservative or a surgical group based on preference.20 the conservative management group’s intervention consisted of the jahss closed reduction manoeuvre and immobilisation in a u-shaped ulnar gutter splint. the u-shaped splints positioned the fourth and fifth mcpjs and the pipjs and dipjs in a slightly flexed position. follow-up appointments were conducted on the second and seventh days post-reduction, with the splint removed after four weeks. the surgical group underwent closed reduction with the jahss manoeuvre and insertion of two k-wires. u-shaped ulnar gutter splints were applied directly after wound dressing for the surgical group and were removed after seven days. the participants were allowed to perform self-care and other light everyday activities. outcomes included: satisfaction and hand function on days 30 and 45 follow-up, with the quickdash questionnaire, tam, angulation, shortening and rotation of the fractures at 30 days follow-up and return to work. all participants returned to work by 30 days postoperatively. no statistically significant difference between the conservative and surgical groups was seen in tam, final shortening and final angulation. however, statistically significant differences were seen when the surgical group returned to work earlier (p ˂ 0.001) and presented with improved hand function (p ˂ 0.05). the recommendation from the authors was that antegrade intramedullary k-wire fixation for fifth metacarpal fractures should be performed.20 randomisation, according to preference, is a limitation and a methodological flaw that affects the trustworthiness of the results. the prolonged period of immobilisation in the u-shaped ulnar gutter splints, which crosses the wrist for four weeks as conservative management compared to only seven days post-surgical immobilisation, may be the reason for a statistically significant difference in hand function and return to work. for clinical practice, it is advisable to have a shorter immobilisation period to avoid stiffness and facilitate earlier return to work. also imperative is not to include unaffected joints in the splints to improve the hand’s functionality. in a swiss study, 40 individuals sustained a closed neck of fifth metacarpal fracture with palmar displacement of 30° to 70°.21 a moderate grade quality of evidence rating was given. pseudorandomisation was used to allocate 20 participants to the surgical group and 20 participants to the conservative group. the surgical group was managed with a jahss manoeuvre reduction, k-wire insertion followed by a five-day immobilisation in a palmar two-finger splint, followed by a metacarpal hand-based brace (thermoplastic splint covering the dorsal and palmar aspects of the metacarpals of the fourth and fifth fingers) for five weeks where functional mobilisation was encouraged. k-wires were removed at three months. the conservative group received no reduction, with immobilisation for five days in a palmar two-finger splint, followed by functional mobilisation in the metacarpal hand-based brace for five weeks. no hand therapy was prescribed for either group. follow-up appointments were: two and six weeks, three, six, and 12 months. outcomes measured included: fifth finger mcpj rom, palmar angulation, mcpj shortening, grip strength, and patient satisfaction. the mean fifth mcpj rom for the operative group was 98° and 96° for the conservative group compared to the unaffected side. at one year, the surgical group’s mean grip strength was 51 kg, and 46 kg for the conservative group. none of the rom or grip strength was statistically significantly different between groups. the surgical group indicated higher satisfaction scores and satisfaction with hand appearance.21 the metacarpal hand-based thermoplastic splint used as immobilisation covered the metacarpal and the metacarpal head without covering the wrist or pipjs. strub et al. found similar results to van aaken et al., where conservative management for boxer’s fractures with ≤ 70° degrees of angulation had satisfactory patient satisfaction outcomes, mcpj rom and grip strength.19,21 a palmar two-finger splint, followed by a metacarpal hand-based brace, supports the fracture site while allowing hand function and rom while the fracture is healing. from the three studies, the following splints can be used with confidence for individuals who sustained neck of fifth metacarpal fractures: • soft wrap and buddy strapping the fifth to the fourth fingers for three weeks. • palmar two-finger splint for five days followed by applying a thermoplastic metacarpal hand-based splint including the fourth and fifth mcpjs for five weeks. in conclusion, in carefully selected individuals who sustained fifth neck of metacarpal fractures, buddy strapping and metacarpal hand-based splint immobilisation provide comfort, improved hand function, less stiffness and earlier return to work. evidence on second to fifth (not yet covered in other objectives) metacarpal fractures a german prospective cohort rct was conducted on 60 participants who sustained non-thumb metacarpal fractures.9 a high grade quality of evidence rating was given. the aim was to measure the effectiveness of a traditional physiotherapy (pt) programme compared to a home exercise (he) programme after surgical management with open reduction internal fixation procedures. the 60 individuals were divided into two groups. standardised controlled block randomisation was used to randomise participants into either a pt or he group. a dorsal splint, including wrist, placed the mcpj at 70° flexion (the interphalangeal joints were not included in the splint to move without restriction), was issued to both group participants for two weeks, after which the intervention and control group programmes commenced. the follow-up assessments at two weeks postoperatively demonstrated a severe loss of digital rom in both groups. the grip strength improved for the pt group from six weeks to 12 weeks page 87keller mm et al. sa orthop j 2022;21(2) from 68% to 91% (100% is 270°) and from 71% to 93% for the he group. at three months, the rom improved to 245° tam for the pt group and 256° tam for the he group out of a normal digit range of motion of 270°.9 a limitation of the study is that the management was not specific to the type of fracture sustained, and uninvolved joints were included during immobilisation. a further limitation was that a non-surgical management option was not included. in resource-restricted countries, surgical intervention with open reduction and internal fixation is not always feasible; thus, the results cannot be generalised to these countries, although they will greatly benefit from an he programme for individuals with second to fifth metacarpal fractures to save resources expended for follow-up sessions. in another article, an evidence-based pathway was compiled using a systematic review of all research before 2008.22 following the development, the evidence-based pathway was tested on a sample of 50 patients in london who received surgical or nonsurgical management for metacarpal fractures.22 thumb metacarpal and phalangeal fractures were excluded. the therapy treatment sessions included: splint fabrication, treatment administered and a leaflet describing fracture management. the pathway will now be presented according to the area where the fracture occurred, namely base, shaft, neck and head. the base of the metacarpal fracture treatment pathway of the index finger (if), middle finger (mf), ring finger (rf), and little finger (lf) was as follows: extraand intra-articular fractures treated conservatively or with k-wires were given a forearm wrist splint positioned with the wrist at 20° extension, for four weeks. at four weeks from the day of the injury, light function and wrist exercises were encouraged. the splint was discarded after six weeks. when the fracture was managed surgically with an orif, light function was commenced at two weeks, with the splint discarded at four weeks.22 the shaft of metacarpal fracture treatment pathway for the if, mf, rf and lf: forearm-based splints incorporating and positioning the wrist at 20° extension with the affected and one adjacent finger mcpjs positioned in 70° of flexion with a dorsal hood piece of the splint which was to be worn for three weeks. all other joints were left free and were able to move in the splint. after three weeks, the dorsal hood was removed, but the forearm-based splint was continued and only taken off for exercise periods. exercises at three weeks included wrist and mcpj active movement. the splint was worn only at night for two more weeks and discarded at six weeks. at four weeks, light function commenced. this time frame was applied to conservative or k-wire management of mjpj shaft fractures. the fracture was managed with an orif, light function was initiated at two weeks, and the splint was discarded at four weeks.22 neck and head metacarpal fracture treatment pathway for the if, mf, rf and lf: a splint (hand-based) that positioned the affected mcpj and an adjacent finger’s mcpj in flexion of 70° was worn for a period of two to four weeks. after this period, the splint was removed, and the finger’s buddy strapped for another two weeks. in conservative or k-wire management, light function was commenced at four weeks, splint intervention continued at night and for protection during activities, and discarded at six weeks. in the orif managed fractures, light function was commenced at two weeks, splint intervention continued at night and for protection during activities and discarded at four weeks. strengthening was started at six weeks.22 the evidence-based pathway was tested on 23 individuals.23 a low grade quality of evidence rating was given. telephonic interviews performed follow-up assessments at 10–24 weeks post injury with the following results: compliance with the splint intervention was 47%, no complications were present, no pain in 72% of patients, employed patients had all returned to work, 92% of patients had full hand function, satisfaction with service among patients was 8/10, and three therapy sessions on average were provided.23 the results’ generalisability was compromised by the small sample size and low compliance with the splint intervention. the lack of standardised outcomes used for hand rom, disability and grip strength, and telephonic interview assessments affect the trustworthiness of the results. however, the splints proposed in the evidence pathway remain highly valuable for clinical practice because of the careful consideration given to not immobilise unaffected joints. the authors made a recommendation to conduct further research to evaluate the evidence pathway.23 from these studies for individuals who sustained a variety of different types of single or multiple second to fifth metacarpal fractures: • thermoplastic customised splinting and immobilisation period with all the unaffected joints not included, with early active mobilisation of unaffected joints encouraged. discussion the purpose of this scoping-type systematic review was to determine the immobilisation and splint approaches utilised for post-surgical and conservative management for 20to 59-year-old adults who sustained a single or multiple second to fifth metacarpal fracture. a detailed description of the literature has been provided, indicating no single preferred splint and method of immobilisation for each type of second to fifth metacarpal fracture. shaft fractures of second to fourth metacarpals were managed with certain similarities, such as spiral fractures, receiving forearmbased wrist splints.15,16 active mobilisation was suggested for spiral fractures, but intraand extra-articular fractures were conservatively or surgically managed with forearm-based thermoplastic splints with a dorsal hood piece left for three weeks with the splint being removed from four weeks.14,23 wrist pop for two weeks was also suggested for spiral and long oblique fractures.14 a clinical recommendation is to use thermoplastic forearm wrist splints, which place the wrist at 20° extension, mcpj in 70° of flexion, not including the pipjs and dipjs. various articles suggest that care should be taken not to immobilise the unaffected joints, such as the wrist, for long periods, which will delay return to work and affect hand function.15,16,20 the authors in the sourced articles recorded various immobilisation methods for the neck (boxer’s) of the fifth metacarpal fractures. these included a short pop wrist splint, a u-shaped gutter splint including the wrist, a soft palmar wrap and buddy strapping for three weeks or a wrist pop up to pips for four weeks.16,19 also included was a u-shaped ulnar gutter splint for four weeks for conservative management and a u-shaped ulnar gutter splint seven days from k-wire insertion.20 another method was a k-wire palmar two-finger splint for five days followed by a metacarpal hand-based splint for five weeks and conservative no reduction and similar splints.21 the hand surgery group had higher satisfaction and hand appearance satisfaction (including head). finally, a hand-based thermoplastic splint for two to four weeks followed by buddy strapping for a further two weeks was used.23 in their multicentre rct, van aaken et al. preferred buddy strapping as management for boxer’s fractures with less than 70° palmar displacement.19 recent literature supports buddy strapping instead of pop immobilisation for uncomplicated neck of fifth metacarpal fractures, and for neck of fifth metacarpal fractures without rotation deformities and for volar angulation less than 70°, due to less time off work and no complications due to pop immobilisation.24,25 at eight weeks, participants who sustained neck of fifth metacarpal fractures managed with an elastic bandage around their metacarpals and wrist with early protected movement, displayed stronger grip strengths than the immobilisation in a u-shaped splint participants. 26 patients with closed, isolated neck of fifth metacarpal fractures without rotational deformity were managed either by functional metacarpal splints supporting only the metacarpals or page 88 keller mm et al. sa orthop j 2022;21(2) an ulnar gutter splint immobilising the wrist. at the six-month followup, both groups displayed similar grip strengths, reduction and hand function outcomes. in conclusion, patient comfort and splintwearing compliance seen in the functional metacarpal splint group should be considered in practice.27 for the metacarpal base, intraand extra-articular fractures, a forearm wrist splint for four weeks after k-wires and six weeks after conservative management was utilised.23 however, taking into account the post-surgical immobilisation for all types of second to fifth metacarpal fractures, a dorsal wrist splint for two weeks was sufficient as four weeks may be too long.9 in terms of positioning and type of material used, it was found that thermoplastic splinting material was preferred over pop due to the lower prevalence of pressure sores and hypoesthesia.17 the heterogeneity of the studies prevented the authors from conducting an effectiveness systematic review, and hence a scoping-type systematic review resulted. opendoar was not used in the grey literature search and is a limitation. conclusion we report on the evidence on splinting and immobilisation approaches used for second to fifth metacarpal fractures. the information provided should be used to guide decision making in clinical practice to ensure optimal hand function, decreased stiffness and early return to work. as the review only yielded ten relevant articles, a gap in the literature regarding evidence-based splinting and immobilisation programmes is seen, except for the initial immobilisation of boxer’s fractures, where adequate evidence was found. level 1b evidence for no reduction, a soft wrap and buddy strapping for three weeks with early active wrist and finger for management of boxer’s fractures was found to be effective. further research is, however, required for the other types of second to fifth metacarpal fracture immobilisation. it is recommended that future research focuses on the effects of splints and immobilisation approaches using adequately powered rcts and controlling for confounding variables, e.g., fracture type. standardised outcome measures for both conservative and postsurgical groups should be used. acknowledgements thanks to ms annamarie du plooy, an information scientist at the university of the free state, for assisting with searching the databases. thanks to prof. joanne potterton for her reading of the draft and her support. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to commencement of the study, ethical approval was obtained from the following ethical review board: the health sciences research ethics committee of the university of the free state, ethical clearance number ufs-hsd2019/0046/2602. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions mmk: conceptualised, drafted the protocol, submitted for ethical clearance, wrote the first draft and refined the article ryb: read, elaborated on and refined the article cb: read, elaborated and refined the article lmh: assisted as an independent reviewer, read, elaborated on and refined the article orcid keller mm https://orcid.org/0000-0002-1513-295x barnes ry https://orcid.org/0000-0002-3743-0077 brandt c 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strub b, schindele s, sonderegger j, et al. intramedullary splinting or conservative treatment for displaced fractures of the little finger metacarpal neck? a prospective study. j hand surg eur vol. 2010;35(9):725-29. https://doi.org/10.1177/1753193410377845. 22. toemen a, midgley r. hand therapy management of metacarpal fractures: an evidencebased patient pathway. hand therapy. 2010:15(4):87-93. https://doi.org/10.1258/ ht.2010.010018. 23. midgley r, toemen a. evaluation of an evidence-based patient pathway for non-surgical and surgically managed metacarpal fractures. hand therapy. 2011;16(1):19-25. https://doi. org/10.1258/ht.2010.010026. 24. pellatt r, fomin i, pienaar c, et al. is buddy taping as effective as plaster immobilization for adults with an uncomplicated neck of fifth metacarpal fracture? a randomized controlled trial. ann emerg med. 2019;74(1):88-97. https://doi.org/10.1016/j.annemergmed.2019.01.032. 25. martínez-catalán n, pajares s, llanos l, et al. a prospective randomized trial comparing the functional results of buddy taping versus closed reduction and cast immobilisation in patients with fifth metacarpal neck fractures. j hand surg am. 2020;45(12):1134-40. https:// doi.org/10.1016/j.jhsa.2020.05.013. 26. retrouvey h, jakubowski j, al-taha m, et al. prospective multicenter randomised controlled trial comparing early protected movement and splinting for fifth metacarpal neck fracture. plast surg. 2022;30(1):6-15. https://doi.org/10.1177/22925503211011952. 27. kaynak g, botanlioglu h, caliskan m, et al. comparison of functional metacarpal splint and ulnar gutter splint in the treatment of fifth metacarpal neck fractures: a prospective comparative study. bmc musculoskelet disord. 2019;20(1)169:1-10. https://doi.org/10.1186/ s12891-019-2556-6. https://orcid.org/0000-0002-1513-295x https://orcid.org/0000-0002-3743-0077 https://orcid.org/0000-0002-8445-1348 https://orcid.org/0000-0002-5747-7382 south african orthopaedic journal knee doi 10.17159/2309-8309/2022/v21n2a2beukes je et al. sa orthop j 2022;21(2) citation: beukes je, immelman rj, venter jh, janse van rensburg c, ngcelwane mv, de vos jn. comparing outcomes between enhanced recovery after surgery and traditional protocols in total knee arthroplasty: a retrospective cohort study. sa orthop j. 2022;21(2):76-81. http://dx.doi. org/10.17159/2309-8309/2022/ v21n2a2 editor: dr david north, paarl hospital, western cape, south africa received: july 2021 accepted: october 2021 published: may 2022 copyright: © 2022 beukes je. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background knee replacement surgery was traditionally associated with prolonged recovery and rehabilitation programmes in hospital. enhanced recovery after surgery (eras) protocols have been shown to be cost effective while not compromising patient safety or functional outcome. despite this proven efficacy, eras has not been widely adopted in south african orthopaedic practices. the aim of this study is to determine if it is possible to practise these guidelines in south africa so as to decrease the length of stay (los) without an increase in complication rate or compromise in functional outcome. methods included in the study were 119 patients undergoing elective total knee arthroplasty between 2013 and 2017. they were divided into two cohorts. the first group was treated with a traditional protocol and included 59 patients. the second group was treated with eras and included 60 patients, following implementation of the eras protocol in 2015. the functional outcome was assessed using the oxford knee score (oks). the 30-day readmission rate was used to assess safety of early discharge. los and patient demographics were also collected to compare the cohorts. results there was no clinically significant difference between the cohorts with regards to oks or readmission rate. two sample t-tests were used to compare these parameters. the mean oks for the traditional group was 59.1 (sd 2.4), and for the eras group, 58.7 (sd 5.0) (p = 0.73). the readmission rate was 8.5% in the traditional group and 10% in the eras group (p = 1.00). the los was significantly decreased in the eras group, with a mean of 2.3 days (sd 1.8) compared to 5.0 (sd 2.2) in the traditional group (p < 0.001). conclusion eras protocols used in the south african context in elective total knee arthroplasty significantly decrease the los without compromising patient safety or functional outcome. level of evidence: level 3 keywords: eras, total knee arthroplasty, length of stay comparing outcomes between enhanced recovery after surgery and traditional protocols in total knee arthroplasty: a retrospective cohort study janus e beukes,¹* reynard j immelman,² joachim h venter,³ charl janse van rensburg,⁴ mthunzi v ngcelwane,⁵ johannes n de vos² ¹ department of orthopaedics, tembisa provincial tertiary hospital, tembisa, university of pretoria, south africa ² private orthopaedic surgeon, life wilgers hospital, pretoria, south africa ³ specialist physician, life wilgers hospital, pretoria, south africa ⁴ statistician, medical research council, pretoria, south africa ⁵ department of orthopaedics, steve biko academic hospital, university of pretoria, pretoria, south africa *corresponding author: janus.eduard@gmail.com introduction osteoarthritis is the leading cause of disability around the globe.1 it is a major source of morbidity and an economic burden for the health system.2,3 for end-stage disease, not responsive to conservative treatment, joint replacement is the best option. it has proven to be a reliable option for return of function and effectively improves health-related quality of life scores.4 the primary total knee arthroplasty demand is estimated to grow by 673% from 2008 to 2030 in the united states.5 enhanced recovery after surgery (eras) protocols have been shown to be more cost effective and resource sensitive than traditional protocols. the future burden of disease worldwide emphasises the need for validating eras in countries such as south africa as well as contributing to research in this field. recent treatment protocols favour shorter hospital stays with accelerated recovery. with eras, emphasis is placed on pre-, intra and postoperative interventions specifically to decrease length of https://orcid.org/0000-0002-9103-776x page 77beukes je et al. sa orthop j 2022;21(2) stay (los), but we should be cognisant of the possible negative effects it can have on morbidity and mortality.6 the efficacy and safety of the eras protocol has been proven by studies done in developed world health systems. they speed up the recovery process, improve patient satisfaction and save medical resources without compromising patient safety or increasing the readmission rate.7,8 the short-term outcomes in joint arthroplasty are assessed in terms of function and complication rate. the oxford knee score (oks) and 30-day readmission rate is widely used internationally to quantify these parameters. both of them are accepted and validated for this purpose. common concerns and fears of the eras protocol is that these patients are discharged too soon, and thus, complications only present later that could have been prevented if picked up earlier and therefore now have a worse prognosis.9,10 the aim of this study is to determine if it is possible to practise eras in south africa so as to decrease the los without an increase in complication rate or a worse functional outcome. the primary objective is to measure the los, postoperative oks and 30-day readmission and compare the groups. materials and methods following approval from university of pretoria’s ethics committee, a retrospective cohort study was conducted in a private healthcare facility in gauteng. the patients enrolled for the study underwent elective total knee replacements during the period 2013–2017. in 2015 the senior author (jndv) changed his practice from the traditional protocol to the eras protocol. the patients were thus divided into two groups: traditional and eras. the statistician calculated that 40–60 patients would be required in each arm of the study to achieve statistical significance. the first 60 consecutive patients after implementation of the eras protocol on 1 march 2015, and the last 60 patients prior to the new protocol implementation, undergoing primary elective total knee replacement surgery, were included in the study. one patient had to be excluded from the traditional group as the data was insufficient. the following data was captured from the patients’ clinical records: patient demographics, comorbidity profile, anaesthetic type, 30-day readmission rate, oks and los. we also recorded major and minor complications according to the american college of surgeons’ national surgical quality improvement program (nsqip).11 all the patients were followed up for a period of 30 days postoperatively for readmissions. the patients residing in different provinces who failed to follow up at the practice were followed up telephonically to obtain their oks and enquire about admissions or complications requiring treatment in other units/hospitals. the readmission rate was determined by the number of patients, per cohort, that required readmission within 30 days postoperatively. the oks was done at least six months postoperatively and is routinely done for all patients in the practice. no preoperative oks was done. the treatment protocols followed in treating the two groups of patients were as follows: both groups had the same surgical procedure and technique performed, with the same prosthesis and manufacturer used. a cruciate-retaining, cemented, total knee prosthesis was used via a medial parapatellar approach. a tourniquet was used throughout the procedure and tranexamic acid was given intraoperatively for haemostasis. the traditional group was fasted for eight hours preoperatively. benzodiazepines were given preoperatively for sedation. a general anaesthetic was the preferred method of anaesthesia, with opioids table i: differences between traditional and eras pathways12 intervention traditional eras preoperative informed consent informed consent education session preoperative fasting npo for 8 hours preop clear fluids up to 2 hours preop preoperative medication benzodiazepine sedative stat medication • ketorolac ivi (intravenous infusion) • ondansetron ivi • paracetamol ivi • decadron ivi preadmission • pregabalin 2 days postoperative ward high care 1–2 days standard ward postoperative diet day 0 clear fluids day 1 full fluids day 2 full diet full diet from day 0 anaesthetic general preferred opioids benzodiazepine less emphasis on restoring fluid lost during fasting spinal no opioids no benzodiazepine preand intraoperative fluid status nb mobilisation day 0 – nil day 1 – bed programme, to chair day 2 – in room day 3 – out of room day 4 – stairs day 0 – out of room day 1 – stairs medication opioid containing, in hospital and upon discharge non-opioid containing* local infiltrative anaesthetic** (*opioid-containing analgesia given after discharge on prn basis **intraoperatively) other drain catheter surgical drain prn catheter prn *drain and catheter removed before mobilisation on day 0 page 78 beukes je et al. sa orthop j 2022;21(2) and benzodiazepines being used in theatre. all patients went to a high care facility postoperatively to be monitored for 1–2 days. a drain and catheter were used for all patients and only removed on day 1–2 postoperatively. only clear fluids were allowed on the day of surgery with a return to full ward diet by day 2 postoperative. the patients were not mobilised on the same day of surgery; mobilisation out of room was only done on day 3. opioid analgesia was used in hospital and given upon discharge. before a patient could be discharged, the c-reactive protein (crp) needed to show a downward trend, which was usually by day 4 to 5. more reliance on blood results postoperatively guided the discharge process. crp, renal function and haemoglobin was monitored daily. the eras protocol is a multidisciplinary approach. an education session was held preoperatively between the patient, surgeon, anaesthetist, nurse and physiotherapist. during this session the protocol was explained in detail to manage expectations. an information leaflet was also given to the patient. this protocol was compiled by the senior author based on international literature at the time. pregabalin was started two days prior to admission. the patient was allowed to take clear fluids up to two hours before surgery. medications given as a stat dose intravenously in theatre included: ketorolac, ondansetron, paracetamol and decadron. spinal anaesthesia was preferred with no opioids or benzodiazepines used in theatre. local infiltrative anaesthetic was used intraoperatively. preand intraoperative fluid status was a point of focus and was managed more attentively. postoperatively the patient was nursed in a standard ward with a full ward diet on the same day of surgery. a surgical drain and catheter were used only if deemed necessary by the surgeon and removed on the same day of surgery, before mobilisation out of the room on day 0 and on stairs on day 1. every team member reviewed the patient and made an assessment on readiness for discharge based on control of pain, ability to mobilise unaided and safely in the home environment and adequacy of wound and swelling. no medical reason to postpone discharge should be present. less reliance was made on blood results to guide the discharge process. fbc and renal function were still monitored but crp’s downward trend was not used to establish readiness for discharge. all patients were discharged home without utilisation of a stepdown facility. postoperative analgesia included a three month prescription of the following on an as necessary basis: celebrex 100 mg bd, ecotrin 81 mg bd, synaleve 1–2 6 hrly prn, lyrica 75 mg nocte, zopivane 1 nocte and topzole 40 mg mane. the differences between the two groups are summarised in table i. statistical methods the department of statistics at the medical research council analysed the results. descriptive statistics including mean, median, standard deviation (sd) and interquartile range was used to describe the continuous variables. frequencies and proportions were used to describe the categorical variables. the two-sample proportions test was used to compare readmission rates between the traditional and eras groups. the t-test was used to compare the los between the two groups. tests were evaluated at 5% level significance. stata 15 was used for all analysis. results there were 119 patients enrolled into the study – 59 in the traditional group, and 60 in the eras group, the latter being the first consecutive patients to be treated by this method in the practice. there were 57 males and 62 females. their ages ranged between 42 and 88 years with a mean of 65 in the eras group, and between 42 and 83 years with a mean of 66 in the traditional group. the bmi ranged between 18 and 47 with a mean of 31 in the eras group and 22 and 55 with a mean of 31 in the traditional group. there were five smokers in the eras group and six in the traditional group. the comorbidity profile was similar between the two groups, with no statistically significant difference present. we found that most patients had either one comorbidity (33 patients, 27%) or two comorbidities (32 patients, 27%). the patient demographics of each cohort are listed and compared in table ii. clinical outcomes no significant difference in oks was observed between the two groups. in the traditional group, the mean score was 59.1 (sd 2.4) and the eras group 58.7 (sd 5.0) (p = 0.73). the los was less in the eras group and was statistically significant (p < 0.001). in the traditional group, the mean los was 5.05 days (sd 2.2), compared to the eras group with 2.3 days (sd 1.8). table ii: patient demographics demographics traditional group eras group sex 28 (47%) male, 31 (53%) female 29 (48%) male, 31 (52%) female age (years) 66.0 (sd 9.1) 65.6 (sd 8.7) bmi 31.9 (sd 6.2) 31.7 (sd 6.7) smoking 10% 8% hypercholesterolaemia 61% 48% hypertension 34% 55% diabetes 15% 16% renal impairment 0% 5% copd 10% 7% ihd 10% 13% hepatic impairment 0% 0% table iii: comparison of results between traditional and eras groups parameter traditional group eras group p-value anaesthetic type 57 (96%) ga, 2 (3%) regional 49 (82%) regional, 11 (18%) ga p < 0.001 30-day readmissions 5 (8.47%) 6 (10%) p = 1.00 minor complications 3 (5.08%). 1 pain, 2 dvt 4 (6.67%). 1 pain, 2 dvt, 1 uti major complication 2 (3.39%). 1 ssi, 1 pe 2 (3.33%). 1 ssi, 1 haematoma oks mean 59.1 (sd 2.4) mean 58.7 (sd 5.0) p = 0.73 los mean 5.05 days (sd 2.2) mean 2.3 days (sd 1.8) p < 0.001 ga: general anaesthesia; dvt: deep vein thrombosis; ssi: surgical site infection; pe: pulmonary embolus; uti: urinary tract infection page 79beukes je et al. sa orthop j 2022;21(2) complications no significant difference in the 30-day readmission rate was observed between the two groups, with 8.5% (5) and 10% (6) in the traditional and eras groups respectively (p = 1.0). the reasons for readmission are indicated in figures 1 and 2 and classified as major or minor as indicated in table iii. a major complication is one that requires the patient to go back to theatre, for example, for surgical site infection (ssi) debridement, haematoma evacuation or the presence of a pulmonary embolus. a minor complication includes readmission for pain, deep venous thrombosis (dvt) or urinary tract infection (uti). table iii summarises the results between the traditional and eras groups. the type of anaesthesia given was a big change from the traditional to the eras protocol and forms one of the integral parts of change in enhanced recovery. in the traditional group, 57 (96%) had general anaesthesia and two (3%) regional anaesthesia. in the eras group, 49 (82%) had regional anaesthesia and 11 (18%) general anaesthesia. discussion research with a similar design to our proposed study was performed in seattle, washington, by auyong et al.8 they compared the evolution from traditional to eras protocols and found favourable los without an increase in readmission rates. this was also confirmed by a meta-analysis of zhu et al., where the length of hospital stays decreased from between four and 12 days to between one and three days without an increase in complications or readmissions.7 khan et al. even found decreased reoperation and readmission rates with lower transfusion rates in the eras group.14 gwynne-jones et al. had 528 patients in their eras group and 507 in the traditional (historical) cohort; they found that the enhanced recovery protocols are effective for an unselected public hospital population that had significant comorbidities, without relying on rehabilitation or stepdown facilities.15 the study by riemer et al. was also done in a private hospital setting in south africa. they included both total knee and hip replacement surgery in 46 patients, without a comparative control. they excluded patients with a body mass index (bmi) > 40; patients they expected might need high care or intensive care postoperatively; those with cognitive impairment; and patients with poor social circumstances or no support. the eras protocol followed was similar to ours. their study also concluded that eras is safe and that it is an effective way of managing arthroplasty patients without compromising rehabilitation.16 determining the magnitude of the effect of different principles within an eras protocol is difficult. to optimise the most positive outcome, more research is needed to standardise these enhanced recovery protocols.17 wainwright et al. investigated the individual components of the eras protocol and their efficacy perioperatively. they propose recommendations after compiling a consensus statement upon reviewing available literature. some of their best practice components, with high level evidence, include patient education and preoperative optimisation; avoiding spinal opioids and an opioidsparing multimodal analgesic approach; giving local infiltrative anaesthesia; administering tranexamic acid to decrease blood loss; and maintaining normothermia. all of these components correlate with the components in our eras protocol.18 further research is required to standardise an anaesthetic protocol in enhanced recovery protocols. in general, neuraxial techniques are favoured over general anaesthesia but the results from large epidemiological studies by memtsoudis et al. and randomised controlled trials by harsten et al. are contradictory as to whether neuraxial anaesthesia is favoured over general anaesthesia.19,20 the current recommendation by wainwright et al. is that both modern general anaesthesia and neuraxial techniques may be used while avoiding routine spinal opioids in the eras setting. further research is required to establish the detail of each technique.18 the study was done in a private healthcare facility which, in the south african context, usually means a well-resourced hospital and a patient population that lives in good social circumstances with access to personal transport and a home with all amenities. one cannot directly apply these results to all government facilities, dvt 2 ssi 1 pe 1 pain 1 figure 1. reasons for readmissions in the traditional group dvt: deep vein thrombosis; pe: pulmonary embolus; ssi: surgical site infection dvt 2 ssi 1 uti 1 haematoma 1 pain 1 figure 2. reasons for readmissions in the eras group dvt: deep vein thrombosis; pe: pulmonary embolus; ssi: surgical site infection; uti: urinary tract infection page 80 beukes je et al. sa orthop j 2022;21(2) some of which have limited resources and patients with poor social circumstances. it does, however, indicate that it is possible to obtain advantageous results with the eras protocol in south africa; this will have a significant and beneficial effect on the public sector if further investigated and implemented. shorter hospital stays, without routine high care admissions postoperatively, may translate to increased bed availability, decreased overall waiting times and possibly a decrease in hospital-acquired infections and complications of recumbency.16 implementing the eras protocol in the public sector is more challenging for various reasons. by gradually phasing in certain aspects of the protocol and doing regular audits, replacement surgery processes in public hospitals can be improved. this was also suggested and implemented by riemer et al.16 from the senior author’s experience with the eras protocol, we can advise that patient education is of utmost importance. having an arthroplasty team taking care of these patients and understanding and implementing the protocol is as important. this team includes a physician and anaesthetist for preoperative assessment and optimisation, a physiotherapist for aid in early mobilisation, and trained nursing staff to care for and monitor these patients in a standard ward. the following components can be phased in gradually to start implementing the eras protocol: • identify the patient that does not require high care admission postoperatively. by utilising a preoperative optimisation programme, which includes a risk assessment and prediction tool (rapt), one can identify the patient that requires preoperative assessment and optimisation by a physician.21,22 • ensure that the anaesthetist doing the preoperative assessment is the same doctor giving the anaesthesia. • allow clear fluids up to two hours prior to surgery. • avoid benzodiazepines perioperatively and opioids during surgery. • use adductor canal blocks and periarticular injection of local analgesia. • decisions as to whether it is necessary to use a surgical drain, urinary catheter and tourniquet are less important factors that can be phased in later. the current eras protocol being used in the practice is similar to the one used during the study period, with the addition of adductor canal blocks for some patients. this is a follow-up study of immelman et al., done in the same private healthcare facility, who compared the outcomes of the eras protocol and traditional protocol followed in elective total hip arthroplasty. los was also decreased in the eras group, with no statistically significant difference noted with regard to readmission rate or functional outcome.13 in the eras group, there were three (7.5%) readmissions for pain during early implementation of the protocol. more emphasis was placed on preoperative education, and discharge medication was adjusted. an amendment to the protocol was made to include oral opioids upon discharge on an ‘as necessary’ basis. after this adjustment, there were no more readmissions due to pain. comparing this to the eras protocol in knee arthroplasty, only one patient was readmitted for pain. the readmission rate for major complications in the hip study was 12.5% for the traditional group and 2.5% for the eras group. this rate was lower in the knee study, with 3.39% in the traditional group and 3.33% in the eras group. this is an interesting observation but does not correlate with international literature indicating that knee replacement surgery is generally associated with more complications than hip replacement surgery.23 when comparing the patient profile between the two studies, the female sex more commonly required knee replacement surgery, the patients were older and had a higher bmi. the mean los was shorter in the hip eras group, being 1.85 days compared to 2.3 days in the knee eras group. the retrospective nature of the study is the primary limitation. the fact that the two cohorts did not run concurrently is another limitation. this could possibly have had an effect due to changes in unknown factors such as theatre or nursing staff co-managing patients. the rest of the team members were unchanged during the study period for continuity of treatment. although the eras protocol is beneficial, we cannot quantify the effect of individual principles within the protocol and can only state that the outcomes are associated with the eras pathway. the oks obtained were not all done at the same time postoperatively but at least six months after surgery. therefore, those where the scores were obtained later might possibly have higher scores as they had more time to recover and rehabilitate. conclusion based on our findings, we can recommend an eras protocol for elective total knee arthroplasty in a healthcare facility with the necessary resources in south africa. our study corresponds to international literature that an eras protocol is safe, feasible and acceptable. by implementing the eras pathway in the management of elective total knee arthroplasty patients, the los can be significantly reduced without increasing the postoperative complication rate or impairing the functional outcome. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethical approval was obtained from the university of pretoria’s research ethics department, prior to data collection. each patient at the private practice also signed a consent form for de-identified information to be used for research purposes. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions jeb: data capture, first draft preparation, preparing manuscript rji: study conceptualisation, manuscript revision, design of study jhv: preoperative assessment and record of patient demographics cjvr: data analysis mvn: manuscript revision jndv: study conceptualisation, design of study, design of testing set-up, manuscript revision orcid beukes je https://orcid.org/0000-0002-9103-776x immelman rj https://orcid.org/0000-0001-5087-4425 janse van rensburg c https://orcid.org/0000-0002-6539-7833 ngcelwane mv https://orcid.org/0000-0001-7564-3308 de vos jn https://orcid.org/0000-0002-0926-4526 references 1. ernest 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https://doi.org/10.17159/2309-8309/2018/v17n1a1. 14. khan sk, malviya a, muller sd, et al. reduced short-term complications and mortality following enhanced recovery primary hip and knee arthroplasty: results from 6 000 consecutive procedures. acta orthop. 2014;85:26-31. https://doi.org/10.3109/17453674.20 13.874925. 15. gwynne-jones dp, martin g, crane c. enhanced recovery after surgery for hip and knee replacements. orthopaedic nursing. may/june 2017;36(3):203-10. https://doi.org/10.1097/ nor.0000000000000351. 16. riemer b, macintyre k, nortje m, et al. rapid mobilisation following total hip and knee arthroplasty. sa orthop j. 2017;16(2):58-62. 17. soffin e, yadeau j. enhanced recovery after surgery for primary hip and knee arthroplasty: a review of the evidence. br j anaesth. 2016;117(suppl 3):iii62-72. https://doi.org/10.1093/ bja/aew362. 18. wainwright tw, gill m, mcdonald da, et al. consensus statement for perioperative care in total hip replacement and total knee replacement surgery: enhanced recovery after surgery (eras) society recommendations. acta orthop. 2020;91(1):3-19. https://doi.org/10.1080/17 453674.2019.1683790. 19. memtsoudis sg, sun x, chiu yl, et al. perioperative comparative effectiveness of anesthetic technique in orthopedic patients. anesthesiology. 2013;118(5):1046-58. https:// doi.org/10.1097/aln.0b013e318286061d. 20. harsten a, kehlet h, ljung p, et al. total intravenous general anaesthesia vs. spinal anaesthesia for total hip arthroplasty. acta anaesthesiol scand. 2015b;59(4):542-43. https:// doi.org/10.1111/aas.12495. 21. sconza c, respizzi s, grappiolo g, monticone m. the risk assessment and prediction tool (rapt) after hip and knee replacement: a systematic review. joints. 2019;7:41-45. https:// doi.org/10.1055/s-0039-1693459. 22. bernstein dn, liu tc, winegar al, et al. evaluation of a preoperative optimization protocol for primary hip and knee arthroplasty patients. j arthroplasty. 2018;33:3642-48. https://doi. org/10.1016/j.arth.2018.08.018. 23. deng q, gu h, peng w, et al. impact of enhanced recovery after surgery on postoperative recovery after joint arthroplasty: results from a systematic review and meta-analysis. postgrad med j. 2018 dec;94(1118):678-93. https://doi.org/10.1136/ postgradmedj-2018-136166. _ref72784499 _ref72784514 _ref77012630 orthopaedics vol3 no4 sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 91 digital photography in orthopaedics: ethical considerations p o’farrell bvsc, mbbch n ferreira bsc, mbchb, fc orth(sa), mmed orth, phd department of orthopaedic surgery, grey’s hospital, nelson r. mandela school of medicine, university of kwazulu-natal corresponding author: dr peter o’farrell department of orthopaedic surgery grey’s hospital nelson r. mandela school of medicine university of kwazulu-natal 3201 pietermaritzburg south africa tel: +27 33 897 3000 email: peterthevet@gmail.com introduction advances in technology over the past ten years have resulted in the majority of mobile phones being equipped with high quality digital cameras. every person with a camera phone has the ability to capture and disseminate events happening around them. this, combined with the global popularity of social media, has led to people documenting most aspects of their lives in digital format. in the medical profession this ability has outstripped guidelines regarding the responsible and ethical use of clinical photographs. recently there have been incidences where patients’ photographs have been uploaded onto social media and into the lay press. arun et al. reported multiple cases where medical students have uploaded bedside clinical pictures onto social media.1 a medical doctor from rhode island, new york, wrote about one of her patient’s injuries on facebook and even though she did not reveal the patient’s name, a third party was able to identify the patient. the doctor was fired from the hospital, reprimanded by the state’s medical board and forced to pay a fine.2 another example is that of a runner (who happened to be a medical doctor) who tweeted a picture of himself assisting paramedics with an individual who had collapsed. part of the individual’s face was visible in this picture and was subsequently printed in a newspaper; this caused an outcry as the runner was deemed to be the patient’s doctor and bound by patient confidentiality.3 the taking of these pictures has become so simple that it can easily go unnoticed by patients and colleagues. this has led to the establishment of ‘no photo zones’ in certain hospitals,4 citing negative outcomes and adverse incidents in order to prevent violation of patient rights and possible litigation. despite these negative incidences, photos can be of excellent value as a clinical tool for communication, documentation and improved patient care. in specialities where skin conditions and wounds are managed, clinical photographs form an integral part of good clinical practice. pictures of open fractures, for example, are an invaluable tool for communication during orthopaedic handover and for consultation with plastic surgeons. as part of the boast 4 guidelines, the british orthopaedic association suggests that all open fractures should be abstract orthopaedic trauma surgery manages soft tissue damage with underlying bony injuries. as a part of the management, many surgeons use photographs to digitally capture the state of the soft tissues in order to plan further surgery. this area relies solely on individuals to regulate as to what is photographed and what happens to these images once they have served their purpose. this article reports a survey of orthopaedic surgeons in south africa, both in state and private practice, regarding their current views and habits when obtaining digital images of clinical cases. the results demonstrate that digital images form an integral part of orthopaedic practice and are used to aid handovers, referrals and communication with patients and colleagues. the problematic areas identified were those relating to the obtaining and documenting of consent and the secure storage of images. key words: photography, cellphone, multimedia, orthopaedic surgery, patient privacy http://dx.doi.org/10.17159/2309-8309/2016/v15n1a12 page 92 sa orthopaedic journal autumn 2016 | vol 15 • no 1 photographed to prevent unnecessary opening of wounds during consultations with the plastic surgeons.5 the use of clinical photography must be protected, but clinicians need to adhere to guidelines for its responsible and ethical use.6 the intersection between social media and medicine has begun to blur the line between moral conduct as it becomes easier to take and share images on personal devices, and professional responsibility to ensure patient privacy is protected. the aim of this study was to determine the extent of this grey area and suggest ways to clarify the boundaries while protecting a valuable resource. materials and methods to ascertain the current use of digital photographs in clinical practice, we conducted an online electronic survey among orthopaedic medical officers, registrars and consultants. a survey was generated on an online platform (surveymonkey) and a link to the survey was emailed to the south african orthopaedic association mailing list and the orthopaedic departments of the universities of cape town, stellenbosch, bloemfontein, gauteng (johannesburg and pretoria) and kwazulu-natal. the survey was conducted over a period of two months and covered three main areas: 1. scope of respondents’ practice and orthopaedic experience 2. the use of clinical photographs for patient care 3. the dissemination and storage of these images results a total of 150 medical practitioners completed the questionnaire. there were equal numbers of public and private surgeons and 30% were affiliated with an academic institution. geographically, 45% worked in kwazulu-natal, 28% in the western cape, 21% in gauteng, and the rest were spread over the remaining provinces. half of the respondents (52%) had worked in orthopaedics for more than ten years and 29% between five and ten years. two-thirds (67%) were consultants, 22% were registrars and the remainder (11%) were medical officers. almost all respondents (99%) admitted to taking photos of clinical cases; only one consultant and one registrar reported never using photos and both stated this was due to technical reasons. the most frequent use of images was as a communication tool for referrals and handovers (85%), followed by record-keeping (70%), use as a teaching aid (57%) and to monitor clinical progress (56%). close to half (47%) of respondents used the photos for research and in publications. almost two-thirds (61%) of clinicians had used clinical photos to aide communication with patients. a third (38%) of clinicians felt that clinical care would be negatively affected without the use of these images, while 27% felt that clinical photos made no difference to patient care. consent was where the responses varied the most. most surgeons (81%) had obtained written consent previously but did not do it routinely, 6% stated they always obtained written consent and 13% had never obtained written consent. of those who had obtained consent only 20% (28 respondents) had included permission to show these images to colleagues. the majority of respondents (74%) stored images on their mobile phones, 58% stored images on their laptops and 26% on usb flash drives. sixty-one per cent stated they had secured all the devices used for storing of images with a password or pin number while 24 respondents (16%) had no protection on any of their devices. two-thirds (71%) of respondents stated that no-one else had access to their images while 21% admitted that family, friends or repair technicians did have access to their images. three per cent admitted that non-medical people had accessed their clinical photos on a previous occasion. only 7% of respondents routinely deleted images after the clinical case was completed; the remainder stored the images for record-keeping (50%), teaching and presentations (47%). captured images were shared electronically via text or whatsapp© (58%) and email (80%). no respondents reported uploading clinical images to facebook, twitter, instagram or pinterest. most respondents (92%) did not think it would be appropriate to upload these images to a social network, even if anonymised. subset analysis revealed that registrars were more likely to password protect their images, take pictures without consent and use images during handover. forty-five per cent of registrars would delete images once the case is completed while 68% of consultants kept the images for teaching purposes. almost half of the registrars (48%) thought that treating time would be adversely effected if they did not have these images. consultants were evenly divided as to whether or not photographs make a difference to patient care; one-third (35%) thought it did make a difference, one-third did not (33%) and one-third were undecided. of those respondents who said that treatment and hospitalisation times would increase and clinical efficiency would decrease, almost half were in state practice (46%) with more than ten years’ experience (43%). discussion south africa has a heavy trauma burden with a high incidence of road traffic accidents and interpersonal violence.7,8 the care of trauma patients is often made more difficult due to a poor peripheral health service, often manned by relatively junior or inexperienced staff and frequent difficulty in transporting patients from the periphery to the regional referral centres. this can all contribute to patient morbidity. clinicians in peripheral centres need to be able to triage patients effectively, identifying the differences between those requiring urgent sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 93 transfer and those that can be managed successfully at the base hospitals. incorrect referrals can consume limited transfer resources and may delay the emergent transfer of appropriate patients. electronic images and photo sharing can improve patient care by ensuring appropriate referrals and conscientious use of a limited transfer resource and allowing immediate specialist review of injuries. these images also assist with communication across language barriers and lend themselves to efficient documentation for a case record and medico-legal purposes. once patients reach their referral centres they often require intradepartmental handover and interdepartmental referral during the course of their management. digital photography can assist with this communication and limit the need for wound exposure. a recent article by khanna et al. confirmed the effectiveness of ‘whatsapp’ as an intradepartmental communication tool to improve patient-related awareness, communication and handovers.9 this research found that clinical images are predominantly used as a handover tool for after-hours admissions. this was closely followed by interdepartmental referrals as is frequently required between orthopaedic surgery and plastic surgery. images used solely for these purposes should probably be deleted once they have served their purpose. the storage and dissemination of clinical images beyond their use for patient care is a major ethical concern and warrants specific attention. images that are not deleted are usually kept for teaching or research purposes. images saved for these purposes must be accompanied by duly documented informed consent that includes their use in research or publication in peer-reviewed journals.10 taking consent for clinical images was identified as the area that needs the most education and behaviour modification. as a profession this needs to be seen in the same context as ordering special investigations and minor procedures. the long-term storage of clinical images also needs special consideration. this was one area that our survey identified as being frequently neglected by medical practitioners. photographs saved on smartphones should be downloaded or moved onto a safer storage device as soon as possible such as password protected desktops and laptop computers and secure external hard drives. the use of usb flash drives to save images should be discouraged as these devices have the greatest potential to be misplaced and accessed by unintended individuals. digital photography can allow doctors to work more effectively and efficiently. it allows easy and instantaneous documentation for communication and record-keeping. to continue using this resource, doctors need to regulate themselves as a profession with regard to the use of digital photography in their daily clinical work. images should be stored in a secure manner to ensure that they are not accessible to the general public and these images should never be shared via insecure means or uploaded onto social media. consent needs to be obtained and documented appropriately in the patient’s notes or file. the greatest limitation of this study stems from its survey design. most respondents reported no major ethical breaches with their use of clinical photography. this could be due to the fact that surgeons who do not follow strict control with clinical images were more likely to decline to complete the survey. future research should focus on newer software that is becoming available. the figure1 application11 is designed to allow sharing of pictures between medical professionals to enable ‘brain storming’ of difficult cases. this software is a free photo sharing app for healthcare professionals and is available on ios and android. all images are reviewed by a medical officer and team of moderators. they verify that all identifying information has been properly removed from each image before it is uploaded. recommendations while the formulation of a set of guidelines is beyond the scope of this paper, it would be prudent for the medical profession to adhere to basic recommendations regarding the use of digital images in clinical practice. • consent: obtain and document consent for all clinical photos ensuring that all future uses of the photos have been defined in the consent form. • storage: store and protect images on passwordprotected devices. delete images when no longer needed. • dissemination: share images only when clinically relevant and use encrypted services where possible. refrain from uploading clinical images onto social media sites. conclusions digital photography is now at the fingertips of anyone with a modern mobile phone. although the use of pictures may aid in patient care, the inappropriate storage and unethical dissemination of these images should be guarded against. it is imperative that consent be obtained and documented for each case where pictures are taken. demonstrating this self-regulation to the relevant regulatory bodies would be beneficial in order to avoid directives that would prevent us from using these images as has been the trend internationally. conflict of interest statement ethical approval for conducting this research was obtained from the ukzn biomedical research ethics committee and all responses were anonymised. the content of this article is the original work of the authors. no benefit of any form has been received or will be received from a commercial party related directly or indirectly to the subject of this article. page 94 sa orthopaedic journal autumn 2016 | vol 15 • no 1 references 1. arun bt, sharmila v. photographing patients: an emerging unethical trend indian j med ethics. 2011;8(2). 2. er doc forgets patient info is private, gets fired for facebook overshare. http://abovethelaw.com/2011/04/ er-doc-forgets-patient-info-is-private-gets-fired-forfacebook-overshare/ (accessed november 2014). 3. the ethical dilemma of being a runner, doctor and journalist. http://www.kevinmd.com/blog/2014/05/ ethical-dilemma-runner-doctor-journalist.html (accessed november 2014). 4. http://med.stanford.edu/shs/update/archives/feb2011 /cellphone.htm (accessed november 2014). 5. cell phone photos are easy, maybe too easy, to take check rules before shooting patients http://www.bapras.org.uk / d o c s / d e f a u l t s o u rc e / d e f a u l t d o c u m e n t l i b r a r y / b a p r a s _ b o a l o w e r l i m b s t a n d a r d s r e a d o n l y. p d f (accessed november 2014). 6. mutalik s. digital clinical photography: practical tips. j cutan aesthet surg. 2010;3(1):48-51. 7. norman r, matzopoulos r, groenewald p, bradshaw d. the high burden of injuries in south africa. bulletin of the world health organization 2007;85(9):649-732 (pmcid: pmc2890139). 8. parkinson f, kent s, aldous c, oosthuizen g, clarke d. road traffic crashes in south africa: the burden of injury to a regional trauma centre. s afr med j. 2013;103(11):8502. doi:10.7196/samj.6914. 9. khanna v, sambandam s, gul a, mounasamy v. ’‘whatsapp’’ening in orthopedic care: a concise report from a 300-bedded tertiary care teaching center. eur j orthop surg traumatol. 10 jan 2015. 10. kunde l, mcmeniman e, parker m. ‘clinical photography in dermatology: ethical and medico-legal considerations in the age of digital and smartphone technology.’ australas j dermatol. 2013;54(3):192-97. 11. free, safe photo-sharing for health professionals. https://figure1.com (accessed 15 february 2015). this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj orthopaedics vol3 no4 sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 41 adult acquired flat foot deformity: the joint-preserving procedures in stage ii tibialis posterior tendon dysfunction np saragas mbbch(wits), fcs(sa)ortho, mmed(ortho surg)(wits) pnf ferrao mbchb(pret), fcs(sa)ortho netcare linksfield orthopaedic sports & rehabilitation centre (clinic), johannesburg and orthopaedic department, university of the witwatersrand, johannesburg, south africa corresponding author: dr np saragas tel: +27 11 485-1974/5 fax: +27 11 640-5313 email: saragas@global.co.za po box 1153 2037 highlands north johannesburg, south africa introduction the adult acquired flat foot (aaff) deformity is a chronic and progressive debilitating condition commonly associated with dysfunction of the posterior tibial tendon (ptt). the pathology is complex and consists not only of ptt insufficiency but also failure of the capsular and ligamentous structures of the foot, leading to a spectrum of deformity with varying degrees of hindfoot valgus, midfoot pronation and forefoot abduction. in later stages arthritic changes can develop in the hindfoot joints.1 ultimately this leads to a painful pes planus deformity and, with pathological changes in the deltoid ligament, associated ankle arthritis. initially there may not be a foot deformity at all, but aaff presents with medial foot pain and decreased function of the affected foot.2 unless the deformity is associated with a generalised medical condition such as rheumatoid arthritis, the diseased tendon is often overlooked and the diagnosis missed.3 kulowski initially described tibialis posterior tendinitis in 1936.4 it was not until 1983, however, that johnson discussed the condition in detail.3 anatomy and biomechanics the ptt originates from the posterolateral tibia, posteromedial fibula and interosseous membrane. it courses posterior to the medial malleolus and inserts into the abstract introduction: the adult acquired flat foot (aaff) deformity is a chronic debilitating condition commonly associated with dysfunction of the posterior tibial tendon (ptt). it is often missed unless it is associated with a generalised medical condition such as rheumatoid arthritis. surgical management is indicated when conservative treatment fails. the joint-preserving procedures have evolved over the years and are preferred for the flexible, non-arthritic deformity. materials and method: twenty-two patients were included in this prospective study. the mean age was 59.8 years with the majority being female. the average bmi was 28.7. the inclusion criterion was symptomatic aaff deformity due to stage ii ptt dysfunction. results: twenty patients were available for follow-up at one year. the mean aofas post-operative score of 89 was significantly improved from the pre-operative score of 42 (p value = <0.001). likewise most of the radiographic parameters also improved significantly. the complication rate was very low. conclusion: this prospective study shows that the joint-preserving procedures for aaff deformity due to stage ii ptt dysfunction are an effective and preferable option to arthrodesis. there is a low complication rate with high patient satisfaction. a certain amount of training and expertise though, is required. level 2 study. key words: adult acquired flat foot surgery http://dx.doi.org/10.17159/2309-8309/2016/v15n1a4 page 42 sa orthopaedic journal autumn 2016 | vol 15 • no 1 navicular tuberosity and the mid-point of the plantar aspect of the tarsus. blood supply to the tendon is poorest in the area behind the medial malleolus making it the most common site for rupture.5 the tibialis posterior tendon is the main supinator of the subtalar joint, an adductor of the midfoot and plantar flexor of the ankle. it is the primary dynamic stabiliser of the medial longitudinal arch and elevates it with its contraction. the midand hindfoot thus lock allowing the triceps surae to effectively push off the forefoot.6 the excursion of the ptt is only 1–2 cm and any ‘lengthening’ of this tendon has an adverse effect on its function.7 pathophysiology although acute/traumatic rupture of the ptt is an obvious cause of aaff deformity, the more usual cause is tendinosis (tendon degeneration) from repeated microtrauma. the weakness of this fibrotic ptt subsequently puts a repetitive load on the medial supporting structures, leading to eventual degeneration of the spring and deltoid ligaments. the consequent shortening of the gastrocnemius further aggravates the flattening of the medial longitudinal arch. with eversion of the subtalar joint forcing the heel into valgus and abduction at the talonavicular joint, the shortened gastrocnemius muscle1,8 further causes subluxation of the talonavicular joint as terminal dorsiflexion of the ankle is achieved by rotation around the talonavicular joint. the navicular thus moves superiorly, laterally and supinates further, rendering the medial column more unstable and collapses the arch.9 epidemiology this chronic debilitating condition typically occurs in obese middle-aged females,6,10-13 with up to 10% prevalence in this group14 and is known to increase with age,15,16 peaking at 55 years of age.8 other risk factors such as diabetes mellitus,15 hypertension,15 steroid injection around the tendon,17,18 and seronegative spondyloarthropathies6,19 have been implicated. mechanical factors must also be at play.20 abnormal forces arising from even mild flat-footedness may result in lifelong greater demands on the ptt.21-24 another possible mechanical cause is overpull of the opposing peroneus brevis muscle.25 classification johnson and strom first classified ptt dysfunction.26 myerson subsequently added to the classification when degenerative changes are present in the ankle joint or there is involvement of the deltoid ligament.6 johnson and strom’s original classification is based on the condition of the tendon, the position of the hindfoot and flexibility of the deformity.27 they identified three stages associated with dysfunction of the ptt, following a progressive course (table i). stage i is characterised by inflammatory changes of the ptt, but neither rupture of the tendon nor deformity. these patients present with tenderness and often oedema over the course of the ptt accompanied by pain and weakness with inversion of the foot,6,28 viz. single heel raise test. in stage ii disease patients present with an added flexible deformity, hindfoot valgus, collapse of the medial longitudinal arch and forefoot abduction, viz. ‘too many toes’ sign3 (figure 1). a fixed flat foot deformity is present in stage iii.26 myerson’s stage iv describes deltoid ligament insufficiency, valgus tilt of the talus and ankle arthritis.6 the ram (rearfoot [r] , ankle [a] , midfoot [m] ) classification further divides the aaff deformity into the individual components involved in the disease process (table ii).27 an even more ‘refined’ classification for stage ii disease has been adapted from bluman et al.8,29 (table iii). investigations plain erect ap, lateral and oblique radiographs of the foot and ankle are necessary to assess the degree of deformity and state of the ankle and hindfoot joints. mri, ct scan and ultrasonography are rarely required and only if the diagnosis is obscure. aaff deformity due to ptt dysfunction can be made clinically. table i: changes associated with various stages of tpt dysfunction26 stage 1 stage 2 stage 3 tpt condition peritendinitis and/or tendon degeneration elongation elongation hindfoot mobile, normal alignment mobile, valgus position fixed, valgus position pain medial: focal, mild to moderate medial: along tpt, moderate medial: possibly lateral, moderate single-heel-rise test mild weakness marked weakness marked weakness ‘too-many-toes’ sign with forefoot abduction normal positive positive pathology synovial proliferation, degeneration marked degeneration marked degeneration treatment conservative, 3 months: surgical, 3 months with synovectomy, tendon debridement, rest transfer fdl for tpt subtalar arthrodesis sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 43 management the aim of treatment is to relieve pain, improve function, restore alignment and arrest the progression of the disease. the management of ptt dysfunction is dictated by the stage of the disease. the johnson and strom classification discussed earlier is commonly used to guide management decision-making. stage i is the early inflammatory stage. this is ideally managed conservatively. the treatment consists of rest, support and rehabilitation. the patient must refrain from all impact and strenuous activities for at least six weeks. the ptt can be supported with either a custom supportive orthotic or specialised brace (airlift brace). in severe cases boot or cast immobilisation is required. rehabilitation is addressed with physiotherapy, consisting of anti-inflammatory modalities, strengthening and proprioception. figure 1. ‘too many toes’ sign table ii: the ram classification27 rearfoot ankle midfoot ia tenosynovitis of ptt neutral alignment neutral alignment ib ptt tendonitis without deformity mild valgus (<5ᵒ) mild flexible midfoot supination iia flexible planovalgus (<40% talar uncoverage, <30° meary angle, incongruency angle 20° to 45°) valgus with deltoid insufficiency (no arthritis) midfoot supination without radiographic instability iib flexible planovalgus (>40% talar uncoverage, >30° meary angle, incongruency angle >45°) valgus with deltoid insufficiency with tibiotalar arthritis midfoot supination with midfoot instability – no arthritis iiia fixed/arthritic planovalgus (<40% talar uncoverage, <30° meary angle, incongruency angle 20° to 45°) valgus secondary to bone loss in the lateral tibial plafond (deltoid normal) arthritic changes isolated to medial column (navicular-medial cuneiform or first tmt joints) iiib fixed/arthritic planovalgus (>40% talar uncoverage, >30° meary angle, incongruency angle >45°) – not correctable through triple arthrodesis valgus secondary to bone loss in the lateral tibial plafond and with deltoid insufficiency medial and middle column midfoot arthritic changes (usually with supination and/or abduction of the midfoot) table iii: ‘refined’ classification for stage ii disease8,29 stage subdivision pathology recommendation ii a flexible hindfoot valgus with flexible forefoot varus medial posting/brace + tendoachilles lengthening if forefoot varus corrects only in equinus fixed forefoot varus mdco (arthroereisis) + fdl transfer + cotton osteotomy if fixed forefoot varus b forefoot abduction (at transverse tarsal, first tmt joint or both talar head uncovering <40% mdco + fdl transfer talar head uncovering >40% fdl transfer + lateral column lengthening ± dco/arthroereisis (if residual heel valgus) c medial ray instability persistent forefoot varus after correction of heel talonavicular/naviculocuneiform/ first tmt joint level fusion of appropriate joint if arthritic/cotton osteotomy abbreviations: cotton osteotomy: opening wedge medial cuneiform osteotomy; fdl: flexor digitorum longus; tmt: tarsometatarsal page 44 sa orthopaedic journal autumn 2016 | vol 15 • no 1 cortisone injections play no role in the management of this disease. if symptoms are refractory to conservative management for three months, surgical intervention is indicated. if the tendon integrity is maintained a tenosynovectomy is performed. stage ii by definition is a flexible flat foot deformity with intrinsic tendon pathology. these patients are candidates for the so-called ‘joint sparing (preserving)’ procedures. this is the group of patients this study investigated. in the presence of a positive silfverskiöld test a gastrocnemius recession needs to be performed. stage iia is managed with a medial displacement calcaneal osteotomy, spring ligament plication and flexor digitorium longus (fdl) tendon transfer. in stage iib the above is done with the addition of a lateral column lengthening to address the severe forefoot abduction. there is a high risk of the spring ligament being completely ruptured requiring reconstruction (this type of procedure is beyond the scope of this article). stage iic is the patient with fixed compensatory forefoot supination. this is corrected with a dorsal opening wedge osteotomy of the medial cuneiform (cotton osteotomy). stage ii will be discussed in detail. when the flat foot deformity becomes rigid and/or hindfoot arthritis develops, it gets classified as stage iii. the only surgical option at this stage is a triple arthrodesis of the hindfoot joints with correction of the deformity. stage iv with ankle arthritis is best treated with a pantalar fusion. stage iv with deltoid insufficiency can be managed with a deltoid reconstruction. a couple of techniques have been described with limited results in the literature. therefore a fusion of the ankle is still commonly performed. failure of conservative treatment is the commonest indication to consider surgery. surgery is indicated in patients who have failed nonoperative management for three months or more.30 materials and method the purpose of this prospective study is to report on the effectiveness of treating stage ii ptt dysfunction by jointpreserving procedures. non-surgical, surgical management of the other stages and the merits of certain operative procedures is beyond the scope of this article. between march 2013 and july 2014, 22 patients (16 female and six male) met the inclusion criteria. the inclusion criteria were symptomatic aaff deformity due to stage ii ptt dysfunction not responding to at least three months’ conservative treatment. all patients had weight bearing ap, lateral and oblique radiographs of the involved foot and ankle. as the disease is characterised by medial longitudinal arch depression, talar depression and abduction of the forefoot, the appropriate radiographic parameters were measured as follows:31,32 talonavicular coverage angle (tnca); percentage talar head uncoverage(%tu); talo-first metatarsal angle (meary’s)(tfma); lateral talocalcaneal angle (ltca); calcaneal pitch angle (cpa) and medial cuneiform to floor distance (mcfd) (figure 2). figure 2. view radiographic measurement31.32 ap a = talonavicular coverage angle (angle >7° indicates lateral talar subluxation) δ = percentage talar head uncoverage lateral b = talo-first metatarsal angle (meary’s) c = calcaneal pitch angle (normal: 17°–32°) d = lateral talocalcaneal angle (normal: 25°–45°. >45° indicates hindfoot valgus e = medial cuneiform to floor distance (normal: 18.38 mm ± 3.66 mm) sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 45 ten patients had a pre-operative ultrasound, which showed varying degrees of ptt degeneration (moderate to complete rupture). all patients signed an informed consent form. surgical technique the patient is placed supine on the table with a bolster under the ipsilateral buttock as the calcaneal osteotomies are performed first. the procedure is performed under general anaesthesia with a regional block. a thigh tourniquet is used. medial displacement calcaneal osteotomy a 5 cm incision is made posterior to the peroneal tendons from the superior border of the calcaneal tuberosity distally to the inferior border of the tuberosity anterior to the inferior calcaneal spur (figure 3). the incision is parallel to the axis of the fibula and curves slightly anteriorly at its distal end. particular attention must be paid to the sural nerve branches, the peroneal tendons and the subtalar joint. it is prudent to use intra-operative fluoroscopy initially to identify the landmarks and the direction of the osteotomy. we have found that the larger the osteotomised calcaneal segment, the easier it is to displace it. once the osteotomy is complete (initially with a power saw and finished with fine osteotomes), two lamina spreaders are inserted in the osteotomy to prise it open and tear the medial periosteum (figure 4). the calcaneal tuberosity is shifted medially by approximately 8–10 mm. the osteotomy is fixed with either a 7.5 mm compression screw inserted from the posterior aspect of the tuberosity under image control or alternatively an edgelock™ plate (tornier sas, us, minneapolis, minnesota). the shelf of the anterior fragment created from the shift is ‘crushed’ with a punch so that the cortical continuity is maintained and no raw bony surface is left to cause adhesions of the soft tissue. lateral column lengthening if there is over 40% uncoverage of the talar head in the preoperative radiographs, a lateral column lengthening is performed. a second horizontal 4 cm incision is made, extending from the calcaneo-cuboid (c-c) joint, posteriorly across the neck. the c-c joint is identified with a hypodermic needle. the osteotomy is carried out approximately 15 mm from the c-c joint and extends between the anterior and middle facets of the calcaneus. the osteotomy is then distracted with either pin distractors or a lamina spreader, until the talus is adequately covered by the navicular as checked under image (figure 5). avoid overcorrection. once the desired distraction is achieved, the osteotomy is filled with a tricortical graft and staple or a maxlock extreme™ plate (tornier sas, us, minneapolis, minnesota) fixation (figure 6). we avoid c-c joint fusion. figure 3. skin incision for medial displacement calcaneal osteotomy figure 4. lamina spreader to prise osteotomy open figure 5. the lateral column lengthening figure 6. the lateral column lengthening with bone graft page 46 sa orthopaedic journal autumn 2016 | vol 15 • no 1 gastrocnemius recession the bolster is now removed from under the patient, allowing the leg to externally rotate. the gastrocnemius recession is indicated if the silfverskiöld test is positive pre-operatively. a small longitudinal incision is made posteromedially in the calf, approximately 15 cm from the achilles tendon insertion. the fascia of the gastrocnemius tendon is identified and dissected off the tendinous portion. the tendinous portion is horizontally transected starting from its lateral edge, extending medially under direct vision. be aware of the sural nerve laterally! flexor digitorum longus (fdl) tendon transfer an 8 cm curved incision is made over the ptt, extending from the medial malleolus to the naviculo-cuneiform joint (figure 7). the incision may extend more proximally, depending on the amount of ptt damage that will have to be debrided/resected. once the sheath of the ptt is opened, the tendon is inspected and debrided/repaired/excised (figure 8). peel off the ptt and roughen the insertion site on the navicular tuberosity by using a rongeur. the spring ligament is then inspected. it is identified as the tissue deep to the ptt attachment. it extends from the navicular tuberosity to the sustentaculum. the identification is easy when there is an obvious tear present (figure 9). more often it is attenuated. immediately behind and slightly posterior, at level of the medial malleolus, the sheath of the fdl is identified and opened (figure 10). the fdl is then delivered from its sheath and tugged with a tendon hook to make sure that the lesser toes move. a four-strand bioabsorable anchor, suturetak® #2 fiberwire® and two tigerwire sutures® (arthrex, naples, florida) is placed into the navicular tuberosity. the two strands of the anchor are used to repair/imbricate the spring ligament. this is secured first before the fdl (figure 11). the other two strands are used to secure the transferred fdl with the foot in full inversion and equinus (figure 12) (if there is no gastrocnemius recession), otherwise in neutral dorsiflexion under tension. if there is any good quality remainder of the ptt, this is attached to the fdl to further reinforce the transfer. do not leave any damaged ptt behind as it may be a pain generator. the distal portion of the transferred fdl need not be transected as it will ultimately stretch out and the lesser toe movement is not compromised. once all the repairs/transfers are secure, the ptt sheath is repaired with absorbable suture, as is the rest of the wound. the foot is maintained in full inversion and equinus/neutral dorsiflexion depending on whether a gastrocnemius recession was performed or not. a below-knee (b/k) non-weight bearing (nwb) cast is applied (figure 13). figure 8. damaged tibialis posterior tendon figure 9. torn spring ligament figure 10. the fdl tendon is identified figure 7. medial incision sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 47 spring ligament reconstruction is beyond the scope of this article. post-operative protocol the patient remains in the nwb cast for six weeks. radiographs are taken once the cast is removed. the patient is then placed in a ‘moon boot’ allowing progressive weight bearing to full weight bearing over a period of six weeks while receiving physiotherapy. the physiotherapy/biokinetics continues until full strength and proprioception is achieved. the patient is advised that the average time to maximum improvement is 9–12 months. active/passive eversion beyond neutral is avoided for at least three months. of note, the patient is covered with oral anticoagulants for six weeks until the cast is removed. there is a high risk of deep vein thrombosis (dvt) with this type of surgery together with immobilisation and nwb status.33 results twenty patients were available for follow-up. there were 15 females and five males, with an average age of 59.8 years (range 49 to 70 years). the patients were examined and radiographs taken at least one year post-operatively. all radiographic measurements (preand final post-operative radiographs) were reviewed by the senior author (nps) so as to eliminate inter-observer error. the aofas questionnaire was completed by both authors. statistical analysis the data were analysed using stata 13 statistical software (stata corporation, college station, tx usa). the following variables were included in the analysis: mcfd, tfma, cpa, tnca, ltca, %tu and aofas score. exploratory data analysis included histograms, box graphs, mean (standard deviation) and range of continuous variables. the paired sample t-test was used to determine if there was a statistically significant difference in mean values recorded preand post-surgery for each measure; statistical tests were two-sided at α = 0.05. the average pre-operative aofas score was 42 (range 17 to 65). the average post-operative score was 89 (range 50 to 100). the improvement was statistically significant (p value = <0.001). the average bmi was 28.7 (range 19 to 53). the demographics in terms of bmi, age and gender of our cohort of patients were in keeping with the reported literature. the radiographic improvement was as follows: the average pre-operative medial cuneiform to floor distance was 12.4 mm (range 0 to 20) and the average post-operative score was 16.3 mm (range 6 to 24), (p value = <0.001). the average pre-operative talo first metatarsal angle (meary’s) was −20.5° (range −35 to −2) and postoperatively was −12.3° (range −32 to 6), (p value = 0.003). the average pre-operative calcaneal pitch angle was 17.2° (range 10 to 26) and post-operatively was 18° (range 8 to 23), (p value = 0.288). the average pre-operative talo navicular coverage angle was 27° (range 6 to 39) and post-operatively was 18.4° (range 4 to 43), (p value = 0.002). figure 12. the foot in full inversion and equinus figure 13. immobilise the foot in equinus and inversion figure 11. transferring the fdl tendon and repairing the spring ligament page 48 sa orthopaedic journal autumn 2016 | vol 15 • no 1 the average lateral talo calcaneal angle was 50° (range 35 to 62) and post-operatively was 47° (range 38 to 59), (p value = 0.155). the average pre-operative percentage talar head uncoverage was 35.6% (range 15 to 50) and post-operatively was 26.2% (range 10 to 45), (p value = <0.001) (table iv). for mcfd, tfma, cpa, tnca, ltca and %tu the data included 16 matched results; for aofas score the data included 20 matched results. there was an increase in the mean values from pre-op to post-op for mcfd, tfma, cpa and aofas score; these results are statistically significant for mcfd, tfma and aofas score, for cpa the difference is slight and not statistically significant. figure 14: box graphs of preand post-op values table iv: results: preand post-operative measurements measurement pre-operative mean (sd) range post-operative mean (sd) range p-value ap aofas score 42,0 (13.3) 17; 65 89,5 (12.3) 50; 100 <0.001 talonavicular coverage angle 26.9 (7.9) 6; 39 18.4 (11.6) 4; 43 0.002 percentage talar head uncoverage 35.6 (7.7) 15; 50 26.2 (10.8) 10; 45 <0.001 lateral medial cuneiform to floor distance 12.4 (4.7) 0; 20 16.3 (4.0) 6; 24 <0.001 talo first metatarsal angle (meary’s) −20.5 (8.6) −35; −2 −12.3 (11.4) −32; 6 0.003 calcaneal pitch angle 17.2 (4.3) 10; 26 17.9 (4.5) 8; 23 0.288 lateral talo calcaneal angle 50.2 (6.7) 35; 62 47.2 (6.3) 38; 59 0.155 sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 49 there was a decrease in the mean values from pre-op to post-op for tnca, ltca and %tu; these results are statistically significant for tnca and %tu, for ltca the difference is slight and is not statistically significant. the data is further described in the box graphs, which compare median (iqr) of each set of matched values (figure 14). two patients had a lateral column lengthening (50% uncoverage of the talar head pre-operatively). no patients had a gastrocnemius recession. no patients had a cotton procedure. complications there were no wound complications. one patient had delayed union of the calcaneal tuberosity (radiologic union at three months). one patient took four months for the lateral column lengthening to unite (with fixatives failure – broken staple). thirty per cent of patients had transient numbness of the lateral heel. this became apparent only with direct questioning. there were no dvts. discussion multiple procedures have been described for the management of stage ii ptt dysfunction. initially, arthrodesis, either triple or double was the treatment of choice. joint-preserving procedures have evolved over recent years and a combination of soft tissue and bone procedures are now preferred34 yielding statistically significant improvement in the deformity, pain and function.34-41 we present a series of 20 patients with stage ii ptt dysfunction who underwent the joint-preserving procedures. these patients were followed up prospectively for one year. all patients were satisfied with respect to pain relief and functional outcome. only two patients considered reoperation for residual deformity. during the period of study no patient was converted to a fusion. this re-enforces the dictum ‘treat the patient and not the x-ray’. the individual procedures are technically demanding and should be carried out with good pre-operative planning and a solid foundation of the anatomy and aim of each individual procedure. it should not be undertaken by the occasional foot surgeon and a certain amount of training and expertise is required. since the above study, we are more prone towards gastrocnemius recessions and lateral column lengthening.35 conclusion in the surgical treatment of aaff deformity due to stage ii ptt, joint-preserving surgery which includes a combination of soft tissue and bone procedures, is preferred. most of these reconstructive procedures include a fdl tendon transfer and a calcaneal osteotomy with varying other components as required. our prospective study yielded a high patient satisfaction rate and minimal complications. we found that there is no correlation between general patient satisfaction and residual deformity. most of the radiographic parameters improved significantly so did the aofas score. although rehabilitation is lengthy, the procedure is functionally superior to arthrodesis of non-arthritic hindfoot joints. conflict of interest statement the content of this article is the original work of the authors. no benefits of any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. references 1. iossi m, johnson je, mccormick jj, klein se. short term radiographic analysis of operative correction of adult acquired flatfoot deformity. foot ankle int. 2013; 34(6):781-91. 2. mann ra. acquired flatfoot in adults. clin orthop rel res. 1983;181:46-51. 3. johnson ka. tibialis posterior tendon rupture. clin orthop rel res. 1983;177:140-47. 4. kulowski j. tendovaginitis (tenosynovitis): general discussion and report of one case involving the posterior tibial tendon. missouri state med assoc. 1936;33:135-37. 5. deland jt, de asla rj, sung ih, ernberg la, potter hg. posterior tibial tendon insufficiency: which ligaments are involved. foot ankle int. 2005;26(6):427-35. 6. myerson ms. adult acquired flatfoot deformity j bone joint surg. 1996;78a:780-92. 7. aronow ms. tendon transfer options in managing the adult flexible flatfoot. foot ankle clinics. 2012;17(2):205-26. 8. deland jt. adult acquired flatfoot deformity. j am acad orthop surg. 2008;16:399-406. 9. guha ar, perera am. calcaneal osteotomy in the treatment of adult acquired flatfoot deformity. foot ankle clinics. 2012;17(2):247-58. 10. kohls-gatzoulis j, woods b, angel jc, singh d. the prevalence of symptomatic posterior tibialis tendon dysfunction in women over the age of 40 in england. j foot ankle surg. 2009;15:75-81. 11. fuhrmann ra, trommer t, venbrocks ra. the acquired buckling flat foot. a foot deformity due to obesity? orthopaed. 2005;34:682-99. 12. mann ra, thompson fm. rupture of the posterior tibial tendon causing flat foot. surgical treatment. j bone joint surg am. 1985;67:556-61. 13. funk da, cass jr, johnson ka. acquired adult flat foot secondary to posterior tibial tendon pathology. j bone joint surg am. 1986;68:95-102. 14. kohls-gatzoulis ja, singh d. tibialis posterior dysfunction as a cause of flatfeet in elderly patients. foot. 2004;14:207209. page 50 sa orthopaedic journal autumn 2016 | vol 15 • no 1 15. holmes gbii, mann ra. possible epidemiological factors associated with rupture of the posterior tibial tendon. foot ankle. 1992;13:70-79. 16. pomeroy gc, pike rh, beals tc, manoli aii. current concepts review. acquired flatfoot in adults due to dysfunction of the posterior tibial tendon. j bone joint surg. 1999;81a:1173-82. 17. henceforth wd, 2nd, deyerle wm. the acquired unilateral flatfoot in the adult: some causative factors. foot ankle. 1982;2:304-308. 18. kohls-gatzoulis ja, angel jc, singh d, haddad f, livingstone j, berry g. tibialis posterior dysfunction: a common and treatable cause of adult acquired flatfoot. bmj. 2004;329(7478):1328-33. 19. myerson m, solomon g, shereff m. posterior tibial tendon dysfunction. its association with seronegative inflammatory disease. foot ankle. 1989;9:219-25. 20. mosier sm, pomeroy g, manoli aii. pathoanatomy and aetiology of posterior tibial tendon dysfunction. clin orthop rel res. 1999;365:12-22. 21. dyal cm, feder j, deland jt, thompson fm. pes planus in patients with posterior tibial tendon insufficiency: asymptomatic versus symptomatic foot. foot ankle int. 1997;18:85-88. 22. kohls-gatzoulis ja, singh d, angel jc. tibialis posterior insufficiency occurring in a patient without peroneii: a mechanical aetiology. foot ankle int. 2001;22:950-52. 23. mann ra, thompson fm. rupture of the posterior tibial tendon causing flatfoot. j bone joint surg 1985;67a:556-61. 24. yeap js, singh d, birch r. tibialis posterior tendon dysfunction: a primary or secondary problem? foot ankle int. 2001;22:51-55. 25. mizel ms, temple ht, scranton pe ii, gellman re, hecht pj, horton ga, et al. role of the peroneal tendons in the production of the deformed foot with posterior tibial tendon deficiency. foot ankle int. 1999;20:285-89. 26. johnson ka, strom de. tibialis posterior tendon dysfunction. clin orthop rel res. 1989;239:196-206. 27. raikin sm, winters bs, daniel jn. the ram classification. foot ankle clinics. 2012;17(2):169-81. 28. pomeroy gc, pike rh, beals tc, manoli aii. acquired flatfoot in adults due to dysfunction of the posterior tibial tendon. j bone joint surg am. 1999;81:1173-82. 29. bluman em, title ci, myerson ms. posterior tibial tendon rupture: a refined classification system. foot ankle clinics. 2007;12:233-49. 30. vulcano e, deland jt, ellis sj. approach and treatment of the adult acquired flatfoot deformity. curr rev musculoskelet med. 2013;6(4):294-303. 31. mehta sk, kellum rb, robertson gh, moore ar, wingerter sa, tarquino ta. radiographic correction of stage iii posterior tibial tendon dysfunction with a modified triple arthrodesis. foot ankle int. 2013;34(10):1355-63. 32. arangio ga, wasser t, rogman a. radiographic comparison of standing medial cuneiform arch height in adults with and without acquired flat foot deformity. foot ankle int. 2006;27(8):636-38. 33. saragas np, ferrao pnf, saragas e, jacobson bf. the impact of risk assessment on the implementation of venous thromboembolism prophylaxis in foot and ankle surgery. foot ankle surg. 2014;20:85-89. 34. hiller l, pinney sj. surgical treatment of acquired flatfoot deformity. what is the state of practice among academic foot and ankle surgeons in 2002? foot ankle int. 2003;24(9):701705. 35. silva mgan, tan shs, chong hc, su hcd, singh ir. results of operative correction of grade iib tibialis posterior tendon dysfunction. foot ankle int. 2015;36(2):165-71. 36. el-tayeby hm. the severe flexible flatfoot: a combined reconstructive procedure with re-routing of the tibialis anterior tendon. j foot ankle surg. 1999;38(1):41-49. 37. guyton gp. flexor digitorum longus transfer and medial displacement calcaneal osteotomy for posterior tibial tendon dysfunction: a middle term clinical follow-up. foot ankle int. 2001;22(8):627-32. 38. knupp mhb. the cobb procedure for treatment of acquired flatfoot deformity associated with stage ii insufficiency of the posterior tibial tendon. foot ankle int. 2007;28(4):416-21. 39. myerson ms. treatment of stage ii posterior tibial tendon deficiency with flexor digitorum longus tendon transfer and calcaneal osteotomy. foot ankle int. 2004;25(7):445-50. 40. parsons s. correction and prevention of deformity in type ii tibialis posterior dysfunction. clin orthop relat res. 2010;468(4):1025-32. 41. zaw h, calder jd. operative management options for symptomatic flexible adult acquired flatfoot deformity: a review. knee surg sports traumatol arthrosc. 2010;18:135-42. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj south african orthopaedic journal current concepts review doi 10.17159/2309-8309/2022/v21n3a6rocher agl et al. sa orthop j 2022;21(3) citation: rocher agl, o’connor m, koch o. wide awake local anaesthesia no tourniquet: a review of current concepts. sa orthop j. 2022;21(3):172-179. http://dx.doi. org/10.17159/2309-8309/2022/ v21n3a6 editor: dr ajmal ikram, stellenbosch university, cape town, south africa received: december 2021 accepted: may 2022 published: august 2022 copyright: © 2022 rocher agl. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background wide awake local anaesthesia no tourniquet (walant) is a local anaesthetic technique that employs lignocaine combined with adrenaline to maintain a pain-free and bloodless field during surgery on an awake patient, without the use of a tourniquet. methods this article is a narrative review of the literature on the use of this mode of anaesthesia in orthopaedic and hand surgery. results the review summarises the existing research pertaining to walant. it discusses the anaesthetic solution constituents, administration technique and applications of walant, highlighting the safety profile and benefits to patients and healthcare systems alike. conclusion the walant technique is safe, economical, and acceptable to patients. it should form part of the orthopaedic surgeon’s armamentarium. future research should investigate the benefits of intraoperative functional assessment of the awake patient. level of evidence: level 5 keywords: walant, wide-awake, narrative review, current concept review, awake surgery, orthopaedic wide awake local anaesthesia no tourniquet: a review of current concepts antoine gl rocher,¹* megan o’connor,¹ odette koch² ¹ discipline of orthopaedic surgery, university of kwazulu-natal, inkosi albert luthuli central hospital, durban, south africa ² 1 military hospital, department of orthopaedic surgery, university of pretoria; netcare pretoria east hospital suite m33, pretoria, south africa *corresponding author: rocher@ukzn.ac.za background the false belief that adding adrenaline to the anaesthetic solution, when providing local blocks to the fingers or hand, will cause digital necrosis has meant that many surgeons have missed the opportunity to use a safe and cost-effective means of anaesthetic. it has been established that patients accept this mode of anaesthetic, and it has demonstrated both outcome and postoperative painrelief benefits. the trepidation when using adrenaline with local anaesthetic originated before the 1950s when extremely acidic procaine was mixed with adrenaline, and when injected into digits, caused necrosis in some patients. procaine becomes more acidic over time, and medicine expiry dates were not regulated at that time. as early as the 1990s, surgeons sporadically started using lignocaine with adrenaline in hands and fingers. in the early 2000s, dr lalonde began popularising this method under the acronym walant (wide awake local anaesthetic no tourniquet).1 the premise of walant as he describes, is the injection of a tumescent local anaesthetic (large volume of low concentration solution injected subcutaneously until the tissues are firm and tense), mixed with adrenaline and sodium bicarbonate, at the site of surgery. these patients do not receive sedation, nor is a tourniquet required, as the temporary vasoconstriction of the adrenaline provides a bloodless field. local anaesthetic mixture because of its relatively low toxicity, lignocaine combined with adrenaline can safely be injected in volumes of up to 7 mg per kg. burk et al. published their experience during liposuction, where they used lignocaine volumes of up to 28 mg per kg and total adrenaline doses of up to 10 mg, with no side effects noted by either the patient or the administrator.2 lignocaine is rapidly unbound from sodium channels when the axonal membrane is hyperpolarised during rest, and is removed from the tissue by blood flow. the vasoconstrictive action of adrenaline, however, causes delayed clearance from the site of surgery, significantly prolonging the local analgesic action of lignocaine. lignocaine in the solution is typically diluted to 1% or less, contingent on the size of the surgical area. concentrations https://orcid.org/0000-0002-9710-5591 page 173rocher agl et al. sa orthop j 2022;21(3) as low as 0.25% lignocaine with adrenaline can provide adequate analgesia for 6–10 hours.2 in contrast to lignocaine, bupivacaine dissociates very slowly or incompletely from sodium channels, which prolongs its action, and potentially also prolongs its adverse effects.3 bupivacaine interferes with multiple cellular functions, which can result in cardiotoxicity, which is complex to treat and often fatal.3 patients can also experience protracted numbness after their pain sensation has returned when bupivacaine is used.4 in addition to prolonging the local effect of lignocaine, adrenaline serves to ensure a bloodless field, the safety of which has historically been questioned. lalonde described a 1:100 000 adrenaline solution, in which a 1 ml vial of 1:1 000 adrenaline is diluted with 99 ml of saline to produce 100 ml of the mixture (any volume mixture can be reproduced provided the ratios are maintained).1 confirmation of the safe use of adrenaline in hands and digits has been replicated in multiple studies and populations worldwide.5,6 in a prospective study, lalonde et al. reported on 3 110 consecutive cases in which they used adrenaline in the hand and digits; 1 340 of these cases had the solution injected in their fingers.5 they measured the number of times phentolamine was required as a rescue treatment for irreversible finger necrosis, but found that this was not necessary in a single case.5 tang et al. reported on the nantong and tianjin experience in china, where 12 000 cases were studied in which surgeons used adrenaline and local anaesthetic for hand surgery (involving extensive surgery in several cases such as advancement and vascularised pedicle flaps).7 they concluded that the mixture was safe, patient-friendly, economical, and found that there was no added risk of infection.7 moog et al. performed minor digital surgeries on 17 patients using a modified walant solution. articaine was used, which contains 1:200 000 adrenaline and articaine hydrochloride, and the solution was administered into the palmar base of the digits. they continuously measured tissue perfusion from just before injection up to 32 minutes after the injection. four of the patients had short episodes of critical tissue perfusion in the period 10 to 20 minutes after injection, but all patients had normal tissue perfusion measurements after 32 minutes.8 with the safety of adrenaline established, the benefit of adrenaline providing a bloodless surgical field, and eliminating the need for a tourniquet, can be appreciated.9 the difference in blood loss, comparing the use of walant and other forms of anaesthesia with a tourniquet, has been extensively investigated. farzam et al. performed a prospective trial assessing 86 patients who had hand surgery of 30 minutes or less. forty-three patients had a below elbow bier’s block, and 43 received walant. none of the walant group needed additional analgesia or sedation, but 20% of the bier’s block group required intravenous (iv) analgesia and sedation during the procedure due to tourniquet discomfort. furthermore, pain in the walant group was significantly less at one hour postoperatively.10 davison et al. compared 200 consecutive carpal tunnel releases (ctr), in which 100 received walant in one centre and had an open ctr, and 100 had endoscopic ctr performed at another centre, under sedation and local lignocaine with a tourniquet. while it seems both anaesthesia modalities were equally tolerated and safe, in both groups 93% of patients stated that they would choose the same method of anaesthesia for subsequent surgery and there were no anaesthetic complications in either group, the walant group had a mean of 2.6 hours shorter hospital stay and required fewer postoperative opioids on average.11 the final additive to the walant solution is sodium bicarbonate (nahco3). a 1% lignocaine, with 1:100 000 adrenaline, solution has a mean ph of 4.24 (standard deviation [sd] 0.42). by adding between 1.1 and 1.8 ml of 8.5% sodium bicarbonate to a 10 ml mixture (or 10% of any volume solution), the ph is increased to a value of between 7.38 and 7.62. this is termed buffering, when an additive to a solution stabilises the solution’s ph close to neutral. buffering the walant solution results in a higher ph, which lessens the pain of the injection, and accelerates the onset of action of the lignocaine.12-15 a premixed lignocaine solution with adrenaline becomes more acidic over time once opened, so it is recommended that the 8.5% sodium bicarbonate be added to the lignocaine on the day of use. anaesthetic administration in practice and special considerations for a typical walant slate in the authors’ practice, comprising three or four patients with a range of pathologies including tendon lacerations, dupuytren’s contracture, trigger finger or carpal tunnel syndrome, 200 ml of the solution is prepared. the authors choose to mix a large volume at the beginning of a slate to prevent mixing the solution in haste, where ratio and dosing discrepancies are most likely to occur, one of the few risks in conducting walant surgery. in a stepwise fashion, 122 ml of the contents of a 200 ml bag of saline is removed, 100 ml of 2% lignocaine (intravenous-use lignocaine) is then added to the contents, along with 2 ml (two ampoules) of 1:1 000 adrenaline and 20 ml of 8.5% sodium bicarbonate. sodium bicarbonate is added last to prevent precipitation of crystals, which occurs if sodium bicarbonate is mixed directly with the acidic lignocaine. this achieves the desired concentration ratio of 1% lignocaine, 1:100 000 adrenaline and 0.85% sodium bicarbonate solution, and can similarly be reproduced for any volume required. at this concentration, the average 70 kg male (using 7 mg per kg as the upper dose limit for lignocaine) can receive 49 ml of the mixture, and the total 200 ml of solution would be adequate for four patients requiring the maximum volume. figure 1 is a graphic depicting the volumes of constituents required to produce 10 ml of walant mixture using the same ratio, and figure 2 is a photo of the medications and consumables the authors use locally to 0.1 ml of 1:1 000 adrenaline 5 ml of 2% iv lignocaine 4 ml of normal saline 1 ml of 8.5% sodium bicarbonate 10 ml of buffered 1% lignocaine and 1:100 000 adrenaline figure 1. graphic depicting the ratio, concentrations and volume of constituents to produce 10 ml of walant solution page 174 rocher agl et al. sa orthop j 2022;21(3) reconstitute 20 ml of the mixture. the solution concentration can be altered; primarily this is performed when the surgical area is extensive, such that a larger volume of solution is required. in this instance, only the lignocaine volume is altered, and the adrenaline and bicarbonate volume ratios remain unchanged. table i lists common procedures for which the authors use the solution, and the corresponding approximate volumes and concentrations for each. the authors refer the reader to an instructional course lecture prepared by lalonde et al. for a more detailed description, beyond the scope of this article.16 significant bleeding during surgery has not been reported; however, it should be noted, according to a study by mckee et al., that after injecting adrenaline the surgical site takes on average 26 minutes (± 5 minutes) to reach the targeted maximum bloodless surgical field.17 while this is a considerable time to wait before conducting the surgery, the authors have learned to utilise this time to inject the following patient (so there is no delay in beginning the surgery for this patient), prepare patient paperwork and other necessary equipment, perform a surgical hand wash as well as clean and drape the patient for surgery. an additional concern when considering blood loss are those patients using chronic anticoagulation therapy. croutzet and guinand reported on 63 procedures performed under walant for patients on anticoagulation therapy (with international normalised ratios on occasion in the range 3–4) or antiaggregant therapy (clopidogrel).18 these patients underwent common hand procedures such as dupuytren’s excision, carpal tunnel release, trigger finger release and digital tumour excision. the authors reported that all the procedures were uncomplicated by bleeding, despite allowing all patients to continue their anticoagulation therapy.18 other considerations when conducting walant are patient factors that could result in negative outcomes. current literature supports the safety of walant for use in the hand and fingers, with fewer complications than bier’s block, sedation and local anaesthesia or general anaesthesia.19 there have, however, been isolated case reports of finger necrosis.20 one case occurred in a patient with raynaud’s disease, and other patient comorbidities included atherosclerosis, diabetes or a smoking history. in these rare instances, there was also no phentolamine rescue (alpha-blocking agent) available for reversal.20 phentolamine or alternatives are not currently available in south africa, so we caution surgeons to carefully evaluate patients for pre-existing peripheral vascular disease, circulatory conditions such as buerger’s or raynaud’s disease, and lignocaine allergy, prior to performing walant. in addition, part of the consent process should involve informing patients of the risk of digital necrosis. technique of injection there are two main goals when injecting local anaesthesia. the first is to infiltrate the subcutaneous tissue of the surgical site with a large volume of diluted local anaesthesia. the second is to do a b c d figure 2. medications and consumables used at the authors’ hospital to reconstitute the walant mixture. a) 50 ml of 8.5% sodium bicarbonate; b) one ampoule (1 ml) of adrenaline 1:1 000; c) 10 ml of normal saline; and d) two ampoules (each containing 5 ml) of 2% lignocaine for intravenous use page 175rocher agl et al. sa orthop j 2022;21(3) this as pain-free as possible, and several techniques have been advocated to achieve this. in a meta-analysis conducted in 2011, hogan et al. concluded that warming local anaesthesia before injection reduces the discomfort of the injection.21 the additional use of sodium bicarbonate as a buffer, discussed previously, has an even greater effect in reducing the discomfort of the injection.14 in a cleverly designed prospective study, yang et al. compared patients who underwent bilateral axillary surgery for axilla osmidrosis across three groups.22 group a received warm (40 °c) buffered lignocaine with adrenaline to one axilla, and cold (22 °c) buffered lignocaine with adrenaline to the opposite axilla. group b received a warm buffered solution to one axilla, and a warm unbuffered solution on the opposite side. group c received a warm buffered solution to one axilla and a cold unbuffered solution to the opposite axilla. the investigators assessed patients’ perception of pain in each group and found significant differences. patients had significantly less pain when injected with a warm, buffered lignocaine and adrenaline solution, as compared to the other combinations.22 in addition to solution preparation, the technique of injection has also been shown to reduce the pain experience.14 the initial injection should be at the most proximal part of the planned surgical incision, to ensure the distal nerve fibres located where subsequent injections will be administered are already anaesthetised. the clinician pinches the skin, drawing the skin onto the needle. the needle is kept perpendicular to the skin, and a subcutaneous tumescent bullous of local anaesthetic is slowly injected (figure 3). cognitive and sensory distraction can be performed by discussing unrelated topics with the patient and applying an ice pack proximal to the injection site. these distractions minimise the discomfort of the initial injection. the needle is then directed distally within the already numb region, and further local anaesthetic injected, advancing the anaesthetic bullous ahead of the needle tip. when blocks need to cover large areas, the injection can be performed through a single skin puncture, by replacing the short 27 g needle with a spinal or liposuction needle through the initial skin puncture. strazar et al. discuss these and other injection techniques to make walant administration as comfortable as possible for patients.13,14 utilising these methods, patients typically report pain scores of 4 or less on the visual analogue scale (vas) for walant anaesthesia administration.13 walant soft-tissue applications and benefits walant is most commonly used for minor soft tissue procedures on the hand. lee et al. found a significant difference in pain between two similar populations, who received either walant or conventional local anaesthetic with a tourniquet, for either a carpal tunnel, trigger finger or de quervain’s release.23 the walant group, injected according to the recommended methods outlined by strazar, had vas scores of 4 or less on average, during the administration of anaesthesia, as compared to a vas score of more than 6 on average for the conventional group.14,23 the walant group had much longer postoperative pain relief, with the most significant difference in vas scores occurring six hours postoperatively.23 furthermore, the walant group had lower vas scores and took less analgesia postoperatively for up to two days post-surgery.23 the applications and benefits of walant use in common soft tissue conditions of the hand have been studied extensively, in many geographical locations and by multiple authors. the consensus is table i: common hand and digital surgical procedures performed using walant by the authors, with associated walant solution volume requirement estimates and suggested concentrations procedure estimated volume required suggested concentration tendon procedures zone ii flexor tendon repair 10–15 ml (per ray) 1% solution tendon reconstructions or transfers in the palm 40–50 ml 1% solution trigger finger release 5–10 ml (per ray) 1% solution de quervain’s release 5–10 ml 1% solution radial nerve tendon transfer (3 transfers) 50–60ml 0.5% solution soft tissue excisions and amputation digital soft tissue biopsy 10–15 ml (per finger) 1% solution digital amputation 10–15 ml (per finger) 1% solution nerve decompressions primary carpal tunnel release 20 ml 1% solution cubital tunnel in-situ release 50 ml 1% solution digital contractures dupuytren’s contracture 10–15 ml (per ray) 1% solution bony procedures trapeziectomy 50 ml 1% solution figure 3. depiction of several techniques proven to reduce the pain of injection. grasping the skin around the target location provides a tactile distraction, and the introduction of a small gauge needle (between 25 g and 30 g is recommended) with the needle perpendicular to the skin, reduces the number of dermal nerve endings exposed to the pain stimulus.14 page 176 rocher agl et al. sa orthop j 2022;21(3) that walant is safe, effective and well-tolerated by patients.24 most commonly walant has been investigated for carpal and cubital tunnel release;25-28 de quervain’s tenosynovectomy;23 tenolysis;29,30 and trigger finger release.31-33 the advantage of walant in trigger finger release and tenolysis is the immediate assessment of the release – the awake patient is asked to actively move the affected finger or joint to determine if a pulley constriction or tethering still exists. similarly, immediate assessment of tendon repairs is especially beneficial. assessing the tensile strength of the repair and uninterrupted gliding of the tendon is possible during walant anaesthesia, where active finger range of motion can be performed by the awake patient. unresolved tendon repair gapping and pulley entrapment would otherwise result in poor outcomes, if not identified during surgery. there is also an opportunity for the surgeon to discuss the rehabilitation process with the patient, who can appreciate the functional result before postoperative pain and stiffness are experienced and while fully awake.34-36 the advantage of using walant during tendon transfer surgery has also been cited.34 retraining donor motor units after tendon transfers, before the advent of walant, was considered a lengthy rehabilitation process.37 bezuhly et al. and other investigators have found that the cognitive activation of the donor unit is immediate when appropriate synergistic muscles are used.34,37,38 in addition, under wide-awake conditions, the muscle tension, repair strength and excursion can immediately be assessed and altered if necessary, and the patients can witness the effect of the tendon transfer immediately.34,37,38 walant has also been utilised for extended soft tissue surgery applications such as local and distant flaps to cover hand and finger skin defects.7,39 xing and tang reported on 27 local soft tissue flap cases, for skin defect coverage, that were closely monitored by a trained nurse for five hours after surgery. one of the 27 patients was injected with phentolamine near the flap to reverse the effect of adrenaline.39 xu et al. reported 12 cases where abdominal or thoracic flaps were effectively performed for finger skin defects utilising only lignocaine and adrenaline at both the donor and recipient sites. a notable recommendation from this paper was to take precautions when injecting, being careful to avoid anaesthetic solution entering the vascular pedicle of the flap.40 wong et al. reported 12 cases of successful reimplantation of 12 digits using walant.41 four of the patients developed superficial skin necrosis but healed without further surgery, and the remainder healed without complication.41 the use of walant has recently been expanded to include small joint arthroscopy. the popularity of wrist, metacarpophalangeal and interphalangeal arthroscopy is increasing, and the use of walant for these procedures has been reported.42 in a 2019 article, liu et al. reported on their experience with walant for wrist arthroscopy. they did, however, caution that walant anaesthetic for arthroscopy should only be attempted by surgeons who are already proficient at wrist arthroscopy; that it is essential to select appropriate patients; and contingency plans should be in place for patients that do not tolerate the procedure. the benefits of having a fully awake patient, as proposed by the authors of this study, were that real-time kinematic assessments could be performed and that the findings could be demonstrated and discussed with the patient during the procedure.42 walant bony procedure applications and benefits common bony hand procedures, such as thumb carpometacarpal joint surgery, phalangeal fracture plating, and metalware removal from the fingers and wrist, have also been cited as appropriate indications for walant anaesthesia.33,43 bony procedures require additional deep administration of solution near the periosteum for effective anaesthesia. more recently, the use of walant has been investigated for use in the management of certain acute fractures by open reduction and internal fixation (orif).44 these include in the upper limb, olecranon, distal radius and clavicle fractures.45-47 walant use for distal radius fracture orif has been investigated extensively.48-51 abd hamid et al. compared distal radius orifs performed with the use of general anaesthesia (in 32 patients) and walant (33 patients) respectively, in a randomised controlled trial.52 they found no statistical difference in blood loss or functional outcome. the pain during surgery for the walant group was minimal. aggressive or gentle manipulation raised the average vas score to 1; during all other surgical periods the vas reported was zero.52 tahir et al.’s randomised controlled trial (rct) of 169 patents comprised three groups that compared walant, bier’s block or ga for distal radius orif. they concluded that distal radius fracture orif performed under walant was more cost effective, led to faster recovery (quicker return to light-duty work) and had fewer complications than either the ga or bier’s block groups (in which cases of tourniquet palsy, wound inflammation and local anaesthetic toxicity occurred).19 foot and ankle surgery the anaesthetic requirements for peripheral lower extremity surgery seem essentially the same as those of the wrist and hand. however, using walant for foot and ankle surgery has not yet been researched as extensively. bilgetekin et al. reported their experience with lateral and medial malleolus ankle fractures, toe phalangeal fractures, lisfranc injuries, achilles tendon ruptures, and various other bony and ligamentous injuries of the foot and ankle. they successfully treated these injuries under walant, without patients requiring additional anaesthesia.53 in an rct, borg figure 4. diagram indicating current applications of walant for fracture orif phalanges, metacarpals and carpals tarsals, metatarsals and phalanges clavicle fractures distal radius fractures medial and lateral malleoli olecranon figure 4. diagram indicating current applications of walant for fracture orif page 177rocher agl et al. sa orthop j 2022;21(3) et al. investigated 129 patients who underwent surgery for ankle fractures. of these patients, 62 received walant anaesthesia and 67 received spinal anaesthesia.54 they reported that the walant group patients were more comfortable during surgery and more satisfied (as measured by the short-form health questionnaire sf-12) one year post-surgery, despite similar surgical outcomes in both groups, although potential reasons for this were not elaborated on. surgery performed under walant was more cost-effective.54 figure 4 depicts the current applications of walant for fracture fixation of the upper and lower limb. efficiency and cost-saving economic and workflow considerations are institution-specific and not easily generalisable. to make universal claims in this regard is difficult, but cost-effectiveness and efficiency are recurring themes in many walant articles.31,55-57 the medications and equipment required to perform walant are inexpensive. furthermore, 7 mg per kg lignocaine dosing with adrenaline is safely administered without the need for routine preoperative blood testing, preoperative fasting, intraoperative iv access and intraoperative monitoring, which allows for more rapid patient turnover and cost-saving.2 postoperative recovery room monitoring is also not needed when using walant anaesthesia.1 due to the established safety of walant, minor surgical procedures have been performed in office side rooms and minor operating theatres, raising the concern for increased infection rates when surgery is performed in these less stringently controlled environments. in a prospective multicentre study of 1 500 cases, leblanc et al. reported that only six patients who had carpal tunnel release surgery performed in a minor procedure room developed superficial infections, of which four required antibiotics to resolve the infection.58 none of the 1 500 patients received prophylactic antibiotics, and none developed deep postoperative infections. furthermore, these cases were performed under field sterility, defined in the article as the surgeon applying a surgical mask, performing a surgical hand wash, and donning sterile gloves only (no gown, hair covering or shoe covering).58 the patient’s arm is prepped with chlorhexidine or povidone-iodine, and only the arm is draped. minimal draping, no gown usage, no iv-line requirements, no general anaesthetic medication, and the absence of need for monitoring disposables all result in a significant reduction in waste production, easier waste management and cost reductions.58 low and middle-income countries (lmics) as surgeons in the public sector in south africa, the authors regularly experience the frustration of scarce resources and unpredictable infrastructure, such as limited theatre access, limited availability of nursing and anaesthetic staff, and sporadic water and power shortages. resource constraints and disruption of infrastructure interrupt not only clinical service delivery but also training. having the hand surgery scarce skill, being reliant on an unstable infrastructure is unmerited. holoyda et al. described the establishment of an outpatient procedure room for walant hand surgery in their ghanaian hospital. they highlighted that despite the significant increase in surgical capacity afforded by the procedure room, the cost to the hospital and individual patients decreased.26 this is one of several articles from lmics that propose walant anaesthetic as a means to improve access to surgery in resourceconstrained settings.24,33,45,46,59 covid-19 and the positive patient experience not only did the simplicity of walant anaesthesia lessen the burden on overwhelmed health systems, but viral spread through airway manipulation was reduced (walant does not require intubation), hospital stays were shortened, and many elective hand surgery procedure cancellations avoided while patient surgical experience was maintained.60-62 with the healthcare system crippled by covid-19 and elective surgery ravaged by the lack of theatre time, the overwhelmingly positive patient experience with walant was the silver lining in those challenging times. walant was a game-changer worldwide during the peak of the pandemic. kurtzman et al.’s review article summarises the advantages of wide-awake surgery in optimising patient satisfaction, pertinent in the context of a pandemic where accessibility to theatre is reduced and resources constrained.44 patient-reported outcome measures such as the patients’ experience and satisfaction are increasingly necessary. in a multicentre study, davison et al. compared carpal tunnel surgeries performed with either walant or with a bier’s block and sedation. the wideawake group used fewer narcotics, spent less time in the facility and had less anxiety. all three of these findings emphasise the applicability of walant amidst a pandemic.11 minimal pain with the walant procedure and high patient satisfaction rates have also been demonstrated in a local study conducted by naude et al. patients’ mean vas score during the procedure in this study was 0.2 (sd ± 0.7), and 100% of the study population reported a preference for the walant procedure in comparison to hospital admission and surgery in the main operating theatres.63 similar positive patient experiences were reported in a study from a military medical centre in the us which reported that 73% of patients studied graded their pain scores as less painful than a dental procedure.64 so, while the covid-19 pandemic has been the catalyst for increased use of walant, these positive patient experiences should incite routine use of the technique in practice. research opportunities there has been ample research investigating the safety, benefits and applications of walant anaesthesia. in their article, festenschrier and amadio highlighted new investigative directions to pursue, particularly those where awake patients are required to perform active movement during surgery, a unique feature of walant.65 as an example, real-time kinematic imaging of the wrist and carpal bones is possible. in addition, they underscored that surgical outcomes can now be clearly separated from rehabilitation outcomes, proffering an interesting area for future study.65 conclusion there is consensus in the current literature in support of the use of walant for a wide range of surgical procedures. most notably its use is advantageous on account of its established safety profile, positive patient experience and postoperative benefits, and should form part of the orthopaedic surgeon’s armamentarium. additionally, pertinent to the local context, is the accord across investigations that utilisation of the technique profits resource-constrained healthcare systems by improving cost-saving, efficiency and expansion of surgical capacity. future investigation should be directed toward determining the benefits of intraoperative functional assessment. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. as this is a review article, no studies on humans or animals were conducted for this study. no ethics or institutional review board approval were required. declaration the authors declare authorship of this article and that they have 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hand surg rehabil. 2021;40(3):277-82. https://doi. org/10.1016/j.hansur.2021.02.001 49. ahmad aa, yi lm, ahmad ar. plating of distal radius fracture using the wide-awake anesthesia technique. j hand surg am. 2018;43(11):1045. https://doi.org/10.1016/j. jhsa.2018.03.033 50. huang yc, hsu cj, renn jh, et al. walant for distal radius fracture: open reduction with plating fixation via wide-awake local anesthesia with no tourniquet. j orthop surg res. 2018;13(1):195. https://doi.org/10.1186/s13018-018-0903-1 51. orbach h, rozen n, rubin g. open reduction and internal fixation of intra-articular distal radius fractures under wide-awake local anesthesia with no tourniquet. j int med res. 2018;46(10):4269-76. https://doi.org/10.1177/0300060518793036 52. abd hamid mh, abdullah s, ahmad aa, et al. a randomized controlled trial comparing wide-awake local anesthesia with no tourniquet (walant) to general anesthesia in plating of distal radius fractures with pain and anxiety level perception. cureus. 2021;13(1):e12876. https://doi.org/10.7759/cureus.12876 53. bilgetekin yg, kuzucu y, öztürk a, et al. the use of the wide-awake local anesthesia no tourniquet technique in foot and ankle injuries. foot ankle surg. 2021;27(5):535-38. https:// doi.org/10.1016/j.fas.2020.07.002 54. borg tm, tahir m, heidari n. the use of a wide-awake local anaesthesia no tourniquet (walant) technique in foot and ankle procedures a randomised control trial. br j surg. 2021;108(supple 2):znab134.456. https://doi.org/10.1093%2fbjs%2fznab134.456 55. leblanc mr, lalonde j, lalonde dh. a detailed cost and efficiency analysis of performing carpal tunnel surgery in the main operating room versus the ambulatory setting in canada. hand (n y). 2007;2(4):173-78. https://doi.org/10.1007/s11552-007-9043-5 56. alter th, warrender wj, liss fe, et al. a cost analysis of carpal tunnel release surgery performed wide awake versus under sedation. plast reconstr surg. 2018;142(6):1532-38. https://doi.org/10.1097/prs.0000000000004983 57. kamal rn, behal r. clinical care redesign to improve value in carpal tunnel syndrome: a before-and-after implementation study. j hand surg am. 2019;44(1):1-8. https://doi. org/10.1016/j.jhsa.2018.09.013 58. leblanc mr, lalonde dh, thoma a, et al. is main operating room sterility really necessary in carpal tunnel surgery? a multicenter prospective study of minor procedure room field sterility surgery. hand (n y). 2011;6(1):60-63. https://doi.org/10.1007/s11552-010-9301-9 59. ahmad ts, ahmad aa, abdullah s. hand surgery in malaysia. j hand microsurg. 2021;13(1):21-26. https://doi.org/10.1055/s-0040-1721942 60. hobday d, welman t, o’neill n, et al. a protocol for wide awake local anaesthetic no tourniquet (walant) hand surgery in the context of the coronavirus disease 2019 (covid19) pandemic. surgeon. 2020;18(6):e67-e71. https://doi.org/10.1016/j.surge.2020.06.015 61. turcotte jj, gelf jm, jones cm, et al. development of a low-resource operating room and a wide-awake orthopedic surgery program during the covid-19 pandemic. surg innov. 2021;28(2):183-88. https://doi.org/10.1177/15533506211003530 62. turcotte jj, petre bm, jones cm, et al. maintaining access to orthopaedic surgery during periods of operating room resource constraint: expanded use of wide-awake surgery during the covid-19 pandemic. j am acad orthop surg glob res rev. 2020;4(12):e20.00100. https://doi.org/10.5435/jaaosglobal-d-20-00100 63. naude jj, koch o, schmidt lw, et al. positive patient experience of wide awake local anaesthesia no tourniquet (walant) hand surgery in the government setting: a prospective descriptive study. sa orthop j. 2021;20(3):141-46. http://dx.doi. org/10.17159/2309-8309/2021/v20n3a1 64. rhee pc, fischer mm, rhee ls, et al. cost savings and patient experiences of a clinicbased, wide-awake hand surgery program at a military medical center: a critical analysis of the first 100 procedures. j hand surg am. 2017;42(3):e139-47. https://doi.org/10.1016/j. jhsa.2016.11.019 65. festen-schrier vjmm, amadio pc. wide awake surgery as an opportunity to enhance clinical research. hand clin. 2019;35(1):93-96. https://doi.org/10.1016/j.hcl.2018.08.003 https://doi.org/10.1016/j.hansur.2021.02.001 https://doi.org/10.1016/j.hansur.2021.02.001 https://doi.org/10.1016/j.jhsa.2018.03.033 https://doi.org/10.1016/j.jhsa.2018.03.033 https://doi.org/10.1186/s13018-018-0903-1 https://doi.org/10.1177/0300060518793036 https://doi.org/10.7759/cureus.1287 https://doi.org/10.1016/j.fas.2020.07.002 https://doi.org/10.1016/j.fas.2020.07.002 https://doi.org/10.1093%2fbjs%2fznab134.456 https://doi.org/10.1007/s11552-007-9043-5 https://doi.org/10.1097/prs.0000000000004983 https://doi.org/10.1016/j.jhsa.2018.09.013 https://doi.org/10.1016/j.jhsa.2018.09.013 https://doi.org/10.1007/s11552-010-9301-9 https://doi.org/10.1055/s-0040-1721942 https://doi.org/10.1016/j.surge.2020.06.015 https://doi.org/10.1177/15533506211003530 https://doi.org/10.5435/jaaosglobal-d-20-00100 http://dx.doi.org/10.17159/2309-8309/2021/v20n3a1 http://dx.doi.org/10.17159/2309-8309/2021/v20n3a1 https://doi.org/10.1016/j.jhsa.2016.11.019 https://doi.org/10.1016/j.jhsa.2016.11.019 https://doi.org/10.1016/j.hcl.2018.08.003 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 17 giant cell tumour of bone: a demographic study from a tumour unit in south africa dr a zanati mbchb, hdip orth(sa) dr n ferreira bsc, mbchb, hdip orth(sa), fc orth(sa), mmed(orth) dr lc marais mbchb, fcs orth(sa), mmed(ortho), cime, phd tumour sepsis and reconstruction unit, department of orthopaedic surgery, grey’s hospital, nelson r mandela school of medicine, university of kwazulu-natal corresponding author: dr nando ferreira tumour, sepsis and reconstruction unit department of orthopaedic surgery grey’s hospital nelson r mandela school of medicine university of kwazulu-natal 3201 pietermaritzburg, south africa tel: +27 33 897 3000 email: drferreiran@gmail.com abstract introduction: giant cell tumour of bone (gct) is a rare primary bone tumour. little is known about the epidemiology of this tumour in south africa as most demographic information is based on research from asia, europe and north america. this research aims to raise awareness and promote early recognition of these tumours. materials and methods: a retrospective analysis was conducted of all patients with biopsy-confirmed gcts that presented between january 2010 and december 2014. information pertaining to patient demographics, tumour location, treatment and outcome was recorded and analysed. results: twenty-two patients were included in the study. the mean age of patients was 32.4 years (range 12–63), and a slight male predominance (1.2:1) was observed. tumours were mainly located at the end of long bones (91%) with the distal femur and proximal tibia being most commonly affected (55%). two patients (9%) were diagnosed with primary malignant giant cell tumours. we observed a higher rate of lung metastases (18%) than previously reported. the median tumour volume was significantly higher in patients who developed lung metastases (467.4 cm3 vs 137.8 cm3; p=0.03). three of the patients with lung metastases were hiv-positive (odds ratio [or] = 10.5, 95% confidence interval [ci] = 0.84-130.66, p=0.076). all patients were treated surgically with extended curettage, local adjuvant therapy, polymethyl methacrylate (pmma) and internal fixation or en-bloc resection with prosthetic or osteochondral allograft replacement. conclusion: giant cell tumours of bone are uncommon. demographics from south africa emulate international statistics. no recurrence of gcts was observed in our cohort despite the relatively large tumours at time of presentation compared to international literature that report recurrence rates of approximately 2%. the incidence of metastases and primary malignant gct was higher than in previous reports. the association of these findings with hiv infection warrants further investigation. metastases appear to be associated with the size of the primary tumour. key words: giant cell tumour of bone, demography, benign tumour http://dx.doi.org/10.17159/2309-8309/2016/v15n4a2 saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 17 page 18 sa orthopaedic journal summer 2016 | vol 15 • no 4 introduction giant cell tumour of bone (gct) is a relatively uncommon primary bone tumour.1 it accounts for 5–6% of all primary bone tumours and approximately 20% of benign bone tumours. variations in incidence have been reported from around the word.2-4 significantly higher incidence rates have been observed in china and southern india, where these tumours constitute about 20% of all primary bone tumours.5 gcts are benign but locally aggressive mesenchymal neoplasms with unpredictable biological behavior.6 the majority of cases (80%) occur between the third and fifth decade of life and a slight female predominance with a male-to-female ratio of 1:1.5 has been reported.2,3 less than 3% of cases occur before the age of 14 years, and only 13% of cases occur in patients over the age of 50 years.5 these tumours are typically located at the ends of long bones (distal femur, proximal tibia, distal radius and proximal humerus) but have been reported in almost all other anatomical sites.6,7 patients usually present with swelling and activity-related pain that can progress to pain at rest. in rare occasions patients may remain relatively asymptomatic until they develop a pathological fracture.1,6 the diagnosis of gct is based on radiographic imaging in conjunction with confirmatory histology. standard radiographs exhibit lesions that are usually eccentrically located in the epiphysis, extending into the metaphysis, of long bones. these lesions appear purely lytic and are locally destructive. the centre of the lesion sometimes has a soap-bubble appearance due to ridging of the surrounding bone. there is typically no clear zone of transition, no marginal sclerosis and no periosteal reaction.1,5,6 magnetic resonance imaging (mri) findings include heterogenous high t2 signal with interspersed low signal areas or fluid–fluid levels in case of secondary aneurysmal bone cyst formation. mri provides useful information regarding involvement of the adjacent joint and the extent of the lesion within the bone and soft tissue.8 computerised tomography (ct) scans may add further information regarding the extent of the tumour but are not typically used. a bone scintigraphy scan is helpful if multi-centric tumours are suspected. histologically, gcts are characterised by numerous multinucleated osteoclast-like giant cells that are scattered in a background of homogenous mononuclear stromal cells.1 the mononucleated cells are composed of two distinct cellular components, a spindle-shaped major component and a minor component consisting of monocyte-derived macrophages. the spindle-like stromal cells are of the osteoblast lineage and form the main neoplastic component of these tumours. these cells play a central role in bone destruction through the production of receptor activator of nf-κb ligand (rankl) that binds to osteoclasts and induces osteolysis.9 secondary aneurysmal bone cyst formation may also be present.8 gct has the ability to metastasise although this does not necessarily herald malignant transformation. these benign metastases are usually to the lungs and have been reported to occur in 2% of cases.1,6 malignant change, on the other hand, is defined as sarcomatous change in the primary lesion.10 this malignant transformation is rare and only occurs in approximately 1% of cases.11-13 primary malignancy in gct refers to the synchronous coexistence of a sarcoma and benign gct within a lesion while secondary malignancy describes a sarcomatous growth in a previously treated, biopsy-confirmed, benign gct.14,15 the treatment of gcts has not changed much in the past 30 years. this is in part due to the relative rarity of the tumours and the lack of randomised clinical trials.4 surgery represents the mainstay of treatment. this usually involves extended curettage with a high-speed burr and chemical adjuvants in the form of either liquid nitrogen or phenol followed by filling of the tumour cavity with pmma bone cement.1,5 patients with unresectable tumours are treated with external beam radiation but transformations to malignant sarcoma have been reported.16 recently, new chemotherapeutic drugs like de nosumab (monoclonal antibody) have successfully been used in the management of gcts.17 this retrospective review aims to establish the first demographic data for gcts in south africa. materials and methods we retrospectively reviewed a cohort of consecutive patients, seen between january 2010 and december 2014, who were diagnosed with giant cell tumour of bone. all cases of biopsy-confirmed gct were included in the evaluation. patients charts were reviewed and data extracted pertaining to patient demographics, tumour location, treatment and outcome. institutional ethics committee approval was obtained prior to commencement of the study. management protocol all patients were admitted for local and systemic staging. local staging consisted of radiographs and an mri scan. systemic staging included work-up for medical comorbidities, laboratory investigations and a ct scan of the chest. tumour volume was calculated based on mri images using the formula for an ellipsoidal tumour mass, where volume = (π/6) × length × width × height. histology was obtained by formal incisional biopsy, according to standard biopsy principles, in all cases. diagnosis was subsequently confirmed by combined radiological and histological evaluation. definitive treatment involved either extended curettage or en-bloc resection. extended intralesional excision (incorporating the use of a high-speed burr to resect the adjacent bony margins) in conjunction with local adjuvant (80% phenol or liquid nitrogen), pmma and locked plating was performed in all cases without pathological fracture and/or intra-articular extension. in cases where concern existed about a break in the continuity of the saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 18 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 19 subchondral bone and cartilage, liquid nitrogen was preferred above phenol as local adjuvant therapy due to the risk of intra-articular spillage. cases involving pathological fracture with significant soft tissue extension, intra-articular extension or loss of structural integrity that was not considered reconstructable with pmma and locked plating were treated with en-bloc resection and modular endoprosthesis (gmrs, stryker) or osteoarticular allograft replacement. tumours with histological evidence of malignancy were treated by wide excision and modular endoprosthetic replacement. patients were followed up, clinically and radiologically, three monthly during the first two years postoperatively and then six monthly. statistical analysis statistical analysis was performed using stata 13.0 (statacorp. college station, texas). differences in continuous variables were compared with the use of the wilcoxon rank-sum test. categorical variables (metastases and malignancy) were cross-tabulated against hiv status and the association was analysed using the fisher exact probability test. all tests were two-sided and the level of significance was set at p ≤ 0.05. results twenty-four patients met the inclusion criteria. two patients were excluded. the first patient had polyostotic lesions with a histological diagnosis of a gct. this patient is however being further investigated for suspected hyperparathyroidism. the second patient had an initial histological diagnosis of gct of bone but confirmatory histology after definitive surgery showed a chondroblastoma with a minor aneurysmal bone cyst component. the final cohort consisted of 22 patients with a mean age of 32.4 years (range 12–63) (table i). the majority of patients (72.7%) were in the third and fourth decades of life. (figure 1) a slight male predominance with a male-to-female ratio of 1.2:1 (12 men and 10 women) was observed. seven (31.8%) patients were hiv positive with a mean cd4 count of 265.8 cell/cm3 (range 59–454). six hiv-positive patients were on highly active antiretroviral therapy. patients with cd4 counts below 350 cells/cm3 were started on antiretroviral therapy prior to surgery. the majority of giant cell tumours arose around the knee with nine out of 22 (40.9%) involving the proximal tibia and three (13.6%) involving the distal femur (figures 2 and 3). table i: patient details patient age (yr) gender hiv status anatomical location metastases histological diagnosis 1 36 male positive proximal tibia lung mets malignant gct 2 31 female negative proximal tibia none gct/secondary abc 3 22 male positive proximal tibia lung mets gct 4 28 male positive proximal tibia none gct 5 22 male negative proximal tibia none gct 6 25 female negative proximal tibia none gct 7 36 male positive proximal tibia lung mets gct 8 23 male negative proximal tibia none gct 9 35 female positive proximal tibia none atypical gct 10 29 female positive distal femur none gct 11 38 male negative distal femur none gct 12 46 male negative distal femur none gct 13 27 male positive proximal femur none gct 14 26 male negative proximal femur none gct 15 55 male negative proximal femur lung mets gct 16 34 female negative proximal femur none gct 17 12 male negative distal humerus none gct 18 30 female negative distal radius none gct 19 23 female negative distal radius none gct 20 63 female negative distal ulna none malignant gct 21 50 female negative pelvis (pubic ramus) none gct/secondary abc 22 16 female negative pelvis (iliac bone) none gct saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 19 page 20 sa orthopaedic journal summer 2016 | vol 15 • no 4 the remaining tumours arose from the proximal femur (n=2), proximal humerus (n=2), distal radius (n=2), pelvis (n=2), distal humerus (n=1) and distal ulna (n=1). average tumour volume was 201.7 cm3 ranging from 15.6 cm3 to 3 138 cm3. two patients (9.1%) were diagnosed with primary malignant gcts; the first involved the proximal tibia while the second was located in the distal ulna. four patients (18.2%) presented with lung metastases. three patients had histologically confirmed benign gcts while the remaining patient was diagnosed with a primary malignant gct of the proximal tibia. the median tumour volume for patients with lung metastases was 467.4 cm3 (range 160.4 cm3–3 138 cm3) compared to a median tumour volume of 137.8 cm3 (range 15.6 cm3–679.3 cm3) for patients without lung metastases (p=0.03). there was no significant difference in the size of the tumours according to hiv status (p=0.55). three of the patients with lung metastases were hiv-positive (odds ratio [or] = 10.5, 95% confidence interval [ci] = 0.84–130.66, p=0.076). we found no association between the presence of metastases and the age of the patient (p=0.4). all patients were treated surgically. ten patients underwent tumour resection and megaprosthesis reconstruction. four (40%) of these patients were hivpositive. megaprosthesis reconstruction was performed for seven tumours that were located around the knee, two proximal femurs and one proximal humerus. six patients were treated with extended curettage with liquid nitrogen followed by pmma bone cement and locking plate fixation. two patients with gcts involving the distal radius were treated by resection of distal radius followed by size matched allograft replacement and locking plate fixation. the tumour located in the ulna was treated by wide resection of the distal ulna without reconstruction. one tumour that was located in the superior pubic ramus was treated with bone graft following the extended curettage. two patients required amputation as the initial management in order to achieve pain control and limit impairment. both of these were massive tumours that were located in the proximal tibia and unresectable at time of presentation. average follow-up was 21 months and ranged from two to 54 months. one patient died during the follow-up period. this male patient was hiv-positive and presented with an unresectable tumour in the proximal tibia and lung metastases. no tumour recurrence was observed during the follow-up period. discussion the current study documents the demographic information, tumour location, treatment and outcome of 22 patients diagnosed, clinically and histologically, as gct of bone. figure 1. age distribution figure 2. anatomical locations figure 3: giant cell tumour of bone anatomical distribution saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 20 sa orthopaedic journal summer 2016 | vol 15 • no 4 page 21 we observed a slight male predominance (1.2:1), which is contradictory to international literature that reports a female predominance of 1:1.5.2,3,8 our results reflect international literature with 81% of cases being between the ages of 20 and 50 years.2,3 less than 5% of cases involved children younger than 14 years of age, and 9% of patients were older than 50 years.5 gcts are typically located at the ends of long bones.5-7 the distal femur and proximal tibia are involved in 50% to 65% of cases, with the distal radius being affected in about 10% of cases.4-6 the proximal femur and humerus are affected in less than 10% of cases respectively.18-22 gcts involving the pelvis and ulna are rare.23-25 our results mostly concurred with these reports, with 55% of tumours occurring around the knee, 9% in the distal radius and 9% in the proximal femur. we observed a slightly higher incidence of tumours involving the humerus (14%), ulna (4%) and pelvis (9%), than previously reported. fluid–fluid levels, con sistent with secondary formation of aneurysmal bone cysts (abc), have been reported in up to 14% of gct cases.5 we observed secondary abc formation in two tumours (9%). benign gcts have the ability to metastasise and this usually involves spread to the lungs. the overall risk for metastatic spread ranges from 1% to 9%, with the largest series reporting a rate of 2.6%.26,27 mortality from lung metastases in gcts range from 14% to 23%.26,28,29 we observed lung metastases in 15% of benign gcts. the median tumour volume was significantly higher in patients who developed lung metastases (467.4 cm3 vs 137.8 cm3; p=0.03). three of these patients (75%) were hivpositive, but this was found not to be statistically significant (p=0.07). the mortality rate of gct with lung metastases in our series was 25%. primary malignancy in gct accounts for less than 1% of cases in international reports.14 we observed two cases (9%) of primary malignancy. one occurred in the proximal tibia of a hiv-positive male and the other in the distal ulna of a hiv-negative female (p=0.54). the recurrence rate after extended curettage with highspeed burr and liquid nitrogen or phenol is reported to be as low as 2%.1,5 no recurrence was observed in this series with the use of extended curettage in combination with either cementing or bone grafting of the defect. this study has several shortcomings. the retrospective nature of the analysis and the small number of cases prevents drawing definitive conclusions. this report does however provide novel information about the demographics of gcts in the south african clinical setting and in hiv-positive patients. the increased rate of metastases is an interesting finding and the relationship with the size, duration or campanacci classification of the primary tumour needs further investigation. although there was a trend towards increased rate of metastases in hiv-positive patients, this did not reach statistical significance and larger series of cases will be required. conclusion this retrospective review presents the demographic results and treatment outcome of 22 patients with gct diagnosed and treated in a higher institution. we observed a slight male predominance and the majority of patients were in the third and fourth decades of life. the anatomical distribution of tumours was also consistent with previous reports. the incidence of metastases (15%) and primary malignant gct (9%) is higher than in other reports. the association between these findings and hiv infection warrants further investigation. the occurrence of lung metastases appears to be associated with the size of the primary tumour. compliance with ethics guidelines institutional ethics committee approval was obtained prior to commencement of the study. drs zanati, ferreira and marais declare that the content of this article is their original work. no benefits of any form have or will be received from any commercial party related directly or indirectly to the subject of this article. references 1. apley ag, solomon l. apley’s system of orthopaedics and fractures. 7th ed. butterworth-heimann. 1999;175-76. 2. gupta r, seethalakshmi v, jambhekar na, prabhudesai s, merchant n, puri a, et al. clinicopathologic profile of 470 giant cell tumours of bone from a cancer hospital in western india. ann diagn pathol 2008;12:239-48. 3. unni kk, inwards c. dahlin’s bone tumours: general aspects and data on 10,165 cases. 6th edition. philadelphia, pa: lippincott williams & wilkins 2010;225-42. 4. thomas dm, skubitz t. giant-cell tumour of bone. current opinion in oncology 2009;21:338-44. 5. chakarun cj, forrester dm, gottsegen cj, patel db, white ea, matcuk gr. giant cell tumor of bone: review, mimics, and new developments in treatment. radiographics 2013;33:197-211. 6. miller md. review of orthopaedics. 6th ed. philadelphia, pa: saunders. 2004;485-87. 7. hoch b, hermann g, klein mj, abdelwahab if, springfield d. giant cell tumour complicating paget disease of long bone. skeletal radiol 2007;36(10):973-78. 8. campbell’s operative orthopaedics, 11th ed. mosby, an imprint elsevier; 2007:883-85. 9. steensma mr, tyler wk, shaber ag, goldring sr, ross fp, williams bo, et al. targeting the giant cell tumour stromal cell: functional characterization and a novel therapeutic strategy. plos one. 2013 jul;8(7):e69101. 10. hunter rv, worcester j, francis kc, foote fw, stewart fw. benign and malignant giant cell tumors of bone. a clinicopathological analysis of the natural history of the disease. cancer 1962;15:653-90. 11. brien ew, mirra jm, kessler s, suen m, ho jk, et al. benign giant cell tumour of bone with osteosarcomatous transformation (‘dedifferentiated’ primary malignant gct): report of two cases. skeletal radiol.1997;26:246-55. saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/26 10:35 page 21 page 22 sa orthopaedic journal summer 2016 | vol 15 • no 4 12. gulhane sr, kate ms. sarcomatous transformation in a conventional giant cell tumour of femur. njirm 2011;2:124-26. 13. sakkers rj, van der heul ro, kroon hm, taminiau ah, hogendoorn pc. late malignant transformation of a benign giant-cell tumor of bone. a case report. j bone joint surg am.1997;79:259-62. 14. junior rz, de camargo op, ida cm, baptista am, ribeiro mb, bruno jm, et al. primary malignancy in giant cell tumour: a case report. sao paulo med j. 2009;127(5):310-13. 15. ferreira n, marais lc. primary malignant giant cell tumour of the proximal tibia: a case report. j cancer res ther. 2013;1(6):174-77. 16. mendenhall w, zlotecki r, scarborough m, gibbs c, mendenhall n. giant cell tumour of bone. am j clin oncol 2006;29(1):96-99. 17. thomas d, henshaw r, skubitz k, et al. deno sumab in patients with giant-cell tumour of bone: an open-label, phase 2 study. lancet oncol 2010;11(3):275-80. 18. dhatt s, tahasildar n, tripathy s, bk s, tamuk t. excision and endoprosthesis implantation for proximal femur giant cell tumor. webmedcentral orthopaedics 2010;1(11):wmc001236. 19. oda y, miura h, tsuneyoshi m, et al. giant cell tumor of bone: oncological and  functional results of long-term follow-up. jpn j clin oncol 1998;28:323-28. 20. o’donnell rj, springweld ds, motwani hk, et al. recurrence of giant-cell tumours of the long bones after curettage and packing with cement. j bone joint surg am 1994;76:18271-833. 21. sait sa, nithyanath m, cherian vm. giant cell tumour of the distal humerus treated with elbow arthroplasty: a case report. international journal of case reports and images 2012;3(4):37-40. 22. stiepan fe. giant cell tumour of the head of the humerus: a case report. j bone joint surg am 1954 oct;36(5):101419. 23. vanni d, pantalone a, andreoli e, caldora p, salini v. giant cell tumor of the distal ulna: a case report. journal of medical case reports 2012;6:143. 24. goldenberg rr, campbell cj, bonfiglio m. giant cell tumor of bone. an analysis of two hundred and eighteen cases. journal of bone and joint surgery 1970;52(4):619-64. 25. zheng k, wang z, wu s, ye z, xu s, xu m, et al. giant cell tumor of the pelvis: a systemic review. orthopaedic surgery 2015;7:102-107. 26. burke cs, gupta a, buecker p. distal ulna giant cell tumor resection with reconstruction distal ulna prosthesis and brachioradialis wrap soft tissue stabilization. hand (new york)2009 dec;4(4):410-14. 27. kay rm, echardt jj, seeger ll, mirra jm, hak dj. pulmonary metastasis of benign giant cell tumor of bone; six histologically confirmed including of one of spontaneous regression. clin orthop relat res 1994;302:219-30. 28. campanacci m, baldini n, boriani s, sudanese a. giant cell tumor of bone. j bone surg. 1987;69a:106-14. 29. tubbs ws, brown lr, beabout jw, rock mg, unni kk. benign giant cell tumor of bone with pulmonary metastases: clinical findings and radiologic appearance of metastases in 13 cases. ajr am j roentgenol. 1992;158:331-34. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj summer 2016.qxp_orthopaedics vol3 no4 2016/10/25 13:07 page 22 south african orthopaedic journal orthopaedic oncology and infections doi 10.17159/2309-8309/2021/v20n3a2 van der watt np et al. sa orthop j 2021;20(3) citation: van der watt np, koch o, le roux tlb, meijer jg, mcloughlin h. the prevalence of vascular injury utilising the lateral parapatellar approach for malignant distal femoral tumour resections: a case series. sa orthop j 2021;20(3):147-150. http://dx.doi.org/10.17159/23098309/2021/v20n3a2 editor: dr thomas hilton, university of cape town, cape town, south africa received: june 2020 accepted: december 2020 published: august 2021 copyright: © 2021 van der watt np. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background distal femoral tumour resections are mostly performed through a medial or anteromedial approach. the lateral parapatellar approach is an alternative method. this case series assessed vascular complications during the resection of malignant distal femoral tumours via the lateral parapatellar approach. methods a retrospective case series at a private practice in pretoria was performed. all patients who underwent malignant distal femoral tumour resections through a lateral parapatellar approach between 2001 and 2019 were included in the study. all cases were performed by a single surgeon. an analysis of the patients’ files was performed, to determine if there were any intraoperative or immediately postoperative vascular complications. results thirty-six patients were identified who underwent resection of their malignant distal femoral tumours via the lateral parapatellar approach. osteosarcoma was the most prevalent bone tumour (81%). all resection margins were clear on histology reports. the vascular complication rate was 3% (95% ci 0–8%). twelve patients demised over the 18-year period (33%). conclusion the findings suggest that a low risk of vascular complications can be expected when resecting malignant distal femoral tumours through a lateral parapatellar approach. this rate of vascular injury is comparable to other studies that also performed distal femoral tumour resections through other approaches. level of evidence: level 4 keywords: malignant distal femoral tumours, lateral parapatellar approach, vascular complications, tumour resection, endoprosthesis the prevalence of vascular injury utilising the lateral parapatellar approach for malignant distal femoral tumour resections: a case series nicolaas p van der watt,¹* odette koch,² theo lb le roux,² jannes g meijer,³ heather mcloughlin⁴ ¹ department of orthopaedics, university of pretoria, pretoria, south africa ² department of orthopaedics, 1 military hospital, university of pretoria, pretoria, south africa ³ department of orthopaedics, kalafong hospital, university of pretoria, pretoria, south africa ⁴ clinical psychologist, pretoria east hospital, pretoria, south africa *corresponding author: nvanderwatt@gmail.com introduction malignant bone tumours of the distal femur often abut and at times even encase surrounding neurovascular structures. due to the hypervascularity associated with these malignant bone tumours, vascular complications of dissection may include vessel laceration, venous or arterial intimal damage, arterial thrombosis with resultant limb ischaemia or venous thrombosis with possible thromboembolic events.1 surgery of malignant bone tumours has developed significantly over time but requires a high level of skill. it is a great responsibility for the tumour surgeon to provide a functional solution to the patient in the presence of such a devastating diagnosis. amputation of a limb would have been accepted as an appropriate outcome in the past; however, the aim is now to salvage the limb and ultimately improve the patient’s functionality, satisfaction and quality of life.2 myers et al. have shown that limb salvage is more cost-effective when compared to amputation in the long run.3 different surgical approaches to access the distal femur have been described. the most often used surgical approach and gold standard of accessing the distal femur for tumour resection is the anteromedial approach. this approach exposes the anterior aspect of the femur and gives access to the popliteal fossa. it identifies the neurovascular bundle in hunter’s canal and allows it to be mobilised and protected throughout the procedure. with this approach, additional soft tissue cover is seldom needed during distal femur resections; soft tissue cover is, however, frequently https://orcid.org/0000-0002-0706-2787 page 148 van der watt np et al. sa orthop j 2021;20(3) indicated during proximal tibia resections.4 the anteromedial approach is advised for experienced surgeons in the field of tumour and sepsis surgery. the lateral approach to the femur is the most used approach relating to benign bone lesions in the distal femur. it is considered to be surgically less demanding as there is no need for neurovascular dissection. the option of proximally extending the incision is readily available and holds benefits for future surgery.4 in the series described in this article, the lateral parapatellar approach was routinely used for the biopsy and resection of distal femoral tumours. there is theoretically an increased risk for vascular injury with these procedures, due to the proximity of the vascular structures and due to the neo-vascularisation associated with malignancy in bone. there is limited data in the literature regarding the incidence of vascular injuries when the lateral parapatellar approach to the distal femur for tumour resections is used.5-7 the available literature mostly reviews patient outcomes and endoprosthetic survival. the rarity of these procedures is confirmed by the long-term follow-up and extended time frames in which results were recorded.2,3,8,9 this study aimed to determine the prevalence of intraoperative and immediate postoperative vascular complications when resecting distal femoral tumours through a lateral parapatellar approach. it is based on the third author’s experience (tlbr) with 36 consecutive patients who had distal femoral tumour resections through a lateral parapatellar approach. materials and methods a retrospective case series at a private orthopaedic practice in pretoria was conducted. ethical approval was obtained prior to the commencement of data collection from patient records. all cases performed between january 2001 and july 2019 were scrutinised. patients included in the study were those that had a malignant primary or metastatic distal femoral tumour lesion that was resected (figure 1), and a prosthesis inserted through the lateral parapatellar approach (figure 2). an experienced tumour surgeon performed all cases. complete records of cases were mandatory with a minimum follow-up of six months. patients were excluded from the study if a distal femoral tumour resection was done via any approach other than the lateral parapatellar approach and if the extent of the tumour resulted in a non-salvageable resection. benign distal femoral tumours were excluded from the study. all tumour resections in this series were performed via a longitudinal lateral parapatellar approach to the femur. all resected tumours were sent for histological analysis. the patients were reviewed daily by the same surgeon until discharge from hospital. they were then followed-up at two weeks and six weeks postoperatively. treatment in the oncology unit continued as per protocol. surgical procedure the surgical procedure is routinely performed in the supine position. the foot is placed on a bolster, and the thigh is supported against a limb positioner. the patient’s mri is used to determine the level of the resection on the femur. the affected limb is draped with the charnley double-drape technique and prepared from the iliac crest to the foot. no tourniquet is used, and preoperative antibiotics are administered. the surgical incision is marked, including an ellipse around the previous biopsy area on the lateral aspect of the knee (figure 2). the knee is flexed, and this position allows for the soft tissue and vascular structures in the popliteal fossa to ‘fall with gravity’ away from the surgical area. a longitudinal incision is made in the midline from the tibial tubercle and extended as proximal as needed, utilising a lateral parapatellar approach and dislocating the patella medially. the femur is measured and marked at the level of the resection with a constant reference point on the tibia. this pre-resection measuring must be accurate as the aim is to restore the leg length when inserting the prosthesis. the incision can be extended proximally to the tip of the greater trochanter or the anterior superior iliac spine in cases where a figure 3. illustration showing an anteroposterior radiograph of a total femur endoprosthesis performed utilising the lateral parapatellar approach figure 1. illustration showing an osteosarcoma of the distal femur in a 13-year-old male, after a distal femoral tumour resection via a longitudinal lateral parapatellar approach figure 2. illustration showing the markings of the longitudinal lateral parapatellar approach, that can be extended as far proximally as the anterior superior iliac spine (note: ellipse excision of biopsy site) page 149van der watt np et al. sa orthop j 2021;20(3) total femur endoprosthesis is inserted (figure 3). an elliptical resection of the lateral biopsy site is performed with extension to the underlying tumour, including a 2 cm margin in all planes. this crucial part of the procedure emphasises the importance of placing the biopsy tract accurately in order to prevent tumour spillage. the skin, subcutaneous tissue and fascia lata are incised in line with its fibres. the perforators are ligated and managed. the vastus lateralis can be transposed anteriorly over the femur after all perforators are tied off. a margin of muscle can be left on the tumour for histological purposes, and the entire length of the femur can be exposed. the cruciate ligaments, collateral ligaments and posterior capsule are cut and the specimen is dissected from distal to proximal. particular attention is paid to the artery when the tumour is excised as it can be pulled towards the tumour. the vascular structures in hunter’s canal are not routinely identified on the medial aspect. the femur is resected at the predetermined level, and a sample of the proximal medullary canal is taken with clean instruments. a pathologist performs a frozen section on the specimen of the medullary canal to confirm tumour-free margins. the dorsalis pedis pulse is routinely checked at this stage of the surgery. after a glove change, the tibia is prepared using routine steps with clean instruments, while awaiting the pathology report. the procedure continues in a stepwise fashion after that. the wound is closed routinely in layers over a drain. all patients are observed in a high care facility postoperatively to optimise pain management and close monitoring of the limb. the same histopathologist who performed the frozen section is responsible for the formal pathology report of the excised tumour. statistical analysis continuous variables were described using mean and median with a range. categorical variables were described using frequency and proportions. the rate of complications was expressed as a proportion of all cases with a 95% confidence interval (ci). all analyses were conducted in excel 2013. results thirty-six patients over an 18-year period were included in the study. the study population consisted of 23 male and 13 female patients. the median age was 23.1 years (7–69 years) with interquartile range (iqr) of 14–38 years, mean=27.2 years, sd=17.7. the median time of follow-up was 19.4 months (6–94 months), iqr=10–41 months, mean=29.7 months, sd=25.7. nine patients were still being actively followed up at the time of this report. three patients had their follow-up elsewhere after they completed their six-months follow-up at the practice. histologically, the majority of tumours were osteosarcoma (29/36; 81%) (table i). all resection margins on the final histological reports were clear. no patients required additional soft tissue cover. over the 18 years, 12 patients died (33%). one vascular complication was recorded during the study period. an overall vascular complication rate of 3% (95% ci 0–8%) was thus reported. the vascular injury occurred in a 47-year-old male who presented with telangiectatic osteosarcoma. the vascular injury was recognised intraoperatively; the artery was injured on the medial border of the distal femur due to tumour displacement. an immediate arterial repair was performed by a general surgeon on call for the hospital. limb perfusion was, however, inadequate as measured by doppler flow studies. the patient was transferred to a specialist vascular surgeon, and a femoral-popliteal bypass procedure was performed within 12 hours of the injury. the limb was salvaged. the patient died six years later due to metastatic disease. discussion malignant primary bone tumours occur most commonly in the distal femoral area and in the proximal tibia.4 bone sarcomas account for 0.2% of all malignancies with an adjusted incidence rate of 0.9 per 100 000 per year for all bone and malignant joint tumours.10 primary bone tumours are a scarce entity. distal femoral tumours predominantly consist of osteosarcoma, chondrosarcoma and ewing’s sarcoma.11,12 neo-adjuvant chemotherapy, surgical resection with a wide margin and adjuvant chemotherapy is considered to be the mainstay of treatment of osteosarcoma and ewing’s sarcoma.13 reconstructive options have evolved significantly and differ for various age groups. these include osteoarticular allograft, allograft arthrodesis, prosthetic arthrodesis, rotationplasty and endoprosthetic replacement surgery.1 each tumour resection is individualised with regard to its location, histological type and extension into the soft tissues.3,4,9 in this series, 81% of the tumours resected were osteosarcoma, of which conventional osteosarcoma was the most prevalent. a recent local paper also reported that osteosarcoma accounted for 72.6% of all primary malignant bone tumours, of which the distal femur was the most common site (44.7%) with a slight male predominance. the average age in this study population was 27 years (range 7–69) and the mean age of diagnosis in the osteosarcoma group was 20.1 years (range 7–47). this is in keeping with findings in the literature, which shows a higher prevalence of osteosarcoma in the second decade of life.11 results in this series did not reflect a bimodal distribution. contrary to the literature, which shows a slight male predominance, this series had a slight female-to-male predominance ratio of 1.1:1.4,11,14 telangiectatic osteosarcoma represents 3–10% of all osteosarcoma.15 the age distribution for this subtype of osteosarcoma tends to be younger than conventional osteosarcoma.15,16 in this series, the patient who had the vascular injury had a telangiectatic osteosarcoma, which is rare at the age of 47 years. the series described in this article had a vascular complication rate of 3% (95% ci 0–8%). this complication rate is higher than the reported incidence rate found in a large study done by natarajan et al. in their series of 246 patients, they had one vascular complication which led to an amputation. their complication rate of 0.4% is lower than the current series and could be due to the large series they examined table i: description of tumour analysis and vascular complications tumours patients male/female tumour margin vascular injury mean age (years) osteosarcoma conventional telangiectatic parosteal 26 (72%) 2 (6%) 1 (3%) 12/14 2/0 0/1 complete complete complete 0 1 0 17 29 16 chondrosarcoma 5 (14%) 0/5 complete 0 59 metastatic disease renal clear cell ca b-cell lymphoma 1 (3%) 1 (3%) 1/0 1/0 complete complete 0 0 48 68 total 36 1 page 150 van der watt np et al. sa orthop j 2021;20(3) as well as the fact that they included benign and malignant bone tumours.8 a comparison of vascular complications pertaining to the lateral parapatellar approach could not be made due to the paucity in literature regarding this approach. accardo and colleagues investigated the outcomes of a quadriceps-sparing lateral approach to the distal femur for tumour resection and reported no vascular complications when the lateral approach was used. they stated that an added benefit to this approach was that the incision can be extended to the proximal femur to provide improved exposure if needed.17 all tumours were successfully resected with the approach used in this study and the complete resections were confirmed by the final histology report. there was no need for additional soft tissue cover or local flaps in this series. when the anteromedial approach was used, bickels et al. reported the need for 25 gastrocnemius flaps in a series of 110 patients, and capanna et al. reported the need for rotational or free flaps in three of their 14 patients utilising either an anteromedial or anterolateral approach.2,6 the main limitation of this study is its retrospective nature. all patients were operated by a single surgeon from a single institution and could therefore be subjected to bias. the small sample size of 36 patients being operated over an 18-year period is considered another limitation. there was no control group in this study. other outcome measures such as wound complications, patient outcome and functionality scores were not assessed. conclusion in this series, all distal femoral tumours were accessible and completely resected via the lateral parapatellar approach. the approach avoids dissection of the neurovascular bundle by staying lateral to the bundle, which reduces the risk of iatrogenic injury to vascular structures. this approach had a low vascular complication rate and proved to be safe and reliable. it should be in the orthopaedic surgeon’s armamentarium when resecting malignant bone tumours of the distal femur. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. ethical approval was obtained from the research ethics committee of the university of pretoria prior to the commencement of data collection (546/2019). all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions npw: study conceptualisation, data capture, data analysis and interpretation, first draft preparation, manuscript preparation and revision ok: study conceptualisation, data analysis and interpretation, manuscript review tlbr: study conceptualisation, manuscript review jgm: data capture, draft preparation, manuscript preparation and revision hm: data capture, data analysis orcid np van der watt https://orcid.org/0000-0002-0706-2787 o koch https://orcid.org/0000-0003-1871-9569 tlb le roux https://orcid.org/0000-00031871-9569 jg meijer https://orcid.org/0000-0001-7773-6081 h mcloughlin https://orcid.org/0000-0001-8330-6563 references 1. yang r-s. endoprosthesis-related complications after limb-salvage operation of malignant bone tumors around the knee. biomed eng. 2004;16(03):133-42. https://doi.org/10.4015/s1016237204000189. 2. bickels j, wittig jc, kollender y, et al. distal femur resection with endoprosthetic reconstruction: a long-term followup study. clin orthop relat res. 2002;(400):225-35. 3. myers gjc, abudu at, carter sr, tillman rm, grimer rj. endoprosthetic replacement of the distal femur for bone tumours. j bone joint surg br. 2007;89(4):521-26. 4. malawer mm, wittig jc, bickels j, wiesel sw. operative techniques in orthopaedic surgical oncology. 2nd ed. philadelphia: wolters kluwer; 2016. 5. biau d, faure f, katsahian s, et al. survival of total knee replacement with a megaprosthesis after bone tumor resection. j bone joint surg am. 2006;88(6):1285-93. 6. capanna r, scoccianti g, campanacci da, et al. surgical technique: extraarticular knee resection with prosthesis-proximal tibia-extensor apparatus allograft for tumors invading the knee. clin orthop relat res. 2011;469(10):2905-14. https://doi.org/10.1007/s11999-011-1882-2. 7. kawai a, muschler gf, lane jm, et al. prosthetic knee replacement after resection of a malignant tumor of the distal part of the femur. medium to long-term results. j bone joint surg am. 1998;80(5):636-47. 8. natarajan mv, sivaseelam a, ayyappan s, et al. distal femoral tumours treated by resection and custom mega-prosthetic replacement. int orthop. 2005;29(5):309-13. https://doi.org/10.1007/s00264-005-0677-z. 9. sevelda f, waldstein w, panotopoulos j, et al. survival, failure modes and function of combined distal femur and proximal tibia reconstruction following tumor resection. eur j surg oncol. 2017;43(2):416-22. https://doi. org/10.1016/j.ejso.2016.11.005. 10. dean b, whitwell d. (i) epidemiology of bone and soft-tissue sarcomas. orthop trauma. 2009;23:223-30. https://doi.org/10.1016/j.mporth.2009.05.006. 11. ferreira n, marais lc, pillay y. primary malignant bone tumours: epidemiological data from an orthopaedic oncology unit in south africa. s afr orthop j. 2016;15(4):12-16. https://doi.org/10.17159/2309-8309/2016/v15n4a1. 12. arora rs, alston rd, eden to, et al. the contrasting age-incidence patterns of bone tumours in teenagers and young adults: implications for aetiology. int j cancer. 2012;131(7):1678-85. https://doi.org/10.1002/ijc.27402. 13. rodriguez-merchan ec, liddle ad. joint preservation in the adult knee. cham, switzerland: springer; 2017. https://doi.org/10.1007/978-3-319-41808-7. 14. nie z, peng h. osteosarcoma in patients below 25 years of age: an observational study of incidence, metastasis, treatment and outcomes. oncol lett. 2018;16(5):6502-14. https://doi.org/10.3892/ol.2018.9453. 15. sangle na, layfield lj. telangiectatic osteosarcoma. arch pathol lab med. 2012;136(5):572-76. https://doi.org/10.5858/arpa.2011-0204-rs. 16. huvos ag, rosen g, bretsky ss, butler a. telangiectatic osteogenic sarcoma: a clinicopathologic study of 124 patients. cancer. 1982;49(8):1679-89. https:// doi.org/10.1002/1097-0142(19820415)49:8<1679::aid-cncr2820490824>3.0.c o;2-2. 17. foundation for orthopaedic research education [internet]. outcomes of the quadriceps-sparing lateral approach to the distal femur for tumor resection and endoprosthetic reconstruction. 2016. available from: https://foreonline.org/ ord-2016/. accessed 18 jun 2019. https://orcid.org/0000-0002-0706-2787 https://orcid.org/0000-0003-1871-9569 https://orcid.org/0000-00031871-9569 https://orcid.org/0000-0001-7773-6081 https://orcid.org/0000-0001-8330-6563 _hlk41419438 _hlk54185801 _hlk54183774 _hlk54184420 _hlk68842322 _hlk74043497 cover page 28 sa orthopaedic journal winter 2016 | vol 15 • no 2 early clinical outcomes of isolated low velocity gunshot radius fractures treated with closed reduction and locked intramedullary nailing s maqungo fc ortho, nj kauta mbchb, r dachs fc ortho, g mccollum fc ortho, m held fc ortho, s roche fcs(sa), ortho orthopaedic trauma service, department of orthopaedic surgery, groote schuur hospital, university of cape town correspondence: dr sithombo maqungo 4 granula place 7441 sunset beach tel: +27832341723 e-mail: sithombo@msn.com introduction diaphyseal forearm fractures in adults are treated with open reduction and plate osteosynthesis with consistently good and reproducible functional outcomes. however, this method requires more soft tissue dissection and periosteal stripping to achieve an anatomical reduction.1 the fracture comminution and soft tissue injury seen in low velocity gunshot injuries make the technique of open reduction and plate fixation less attractive for these fractures. closed reduction intramedullary nail fixation offers all the advantages of minimally invasive surgery with regard to preservation of biology at the fracture site.2 we hypothesised that with the new generation forearm nail designs allowing proximal metaphyseal fit and distal locking screws, closed reduction and locked intramedullary nail fixation of isolated gunshot radius fractures would produce good clinical and functional results. the aim of our study was to assess early clinical outcomes of closed reduction and locked intramedullary fixation of low velocity gunshot radius fractures. to our knowledge this is the first study in the english literature to report on isolated gunshot radius fractures in adults treated with an intramedullary nail. abstract background: the treatment goals in diaphyseal radius fractures are to regain and maintain length and rotational alignment and stability. open reduction and plating carries the inherent problems of soft tissue disruption and periosteal stripping. intramedullary nailing offers advantages of minimally invasive surgery and minimal soft tissue trauma. aims: to investigate the outcomes of locked intramedullary nailing for isolated gunshot diaphyseal radius fractures in adults. methods: a cross-sectional review of prospectively collected clinical and radiological data was performed. all adult patients with isolated gunshot radius fractures treated with closed reduction and locked intramedullary nailing between 2009 and 2013 were reviewed. twenty-two nails were inserted in 22 patients, all males with a mean age of 28.9 years (range 19–40). all surgeries were performed between 2 and 12 days after injury (average 4 days). follow-up was for an average of 11 weeks (range 8–24). results: all fractures united with the index procedure. mean time to union was 10 weeks (range 8–24). using the anderson classification, the clinical outcome was excellent in 14 patients (64%), satisfactory in six (27%) and unsatisfactory in two (9%). conclusion: closed reduction and intramedullary nail fixation of gunshot radius fractures shows promising results without significant complications. key words: gunshot radius fractures, closed reduction, intramedullary nail fixation http://dx.doi.org/10.17159/2309-8309/2016/v15n2a3 saoj winter 2016 press.qxp_orthopaedics vol3 no4 2016/07/05 10:50 page 28 sa orthopaedic journal winter 2016 | vol 15 • no 2 page 29 methods prospectively collected clinical and radiological data on all patients who presented with an isolated midshaft or proximal third low velocity gunshot fracture of the radius between 2009 and 2013 were reviewed. distal radial metaphyseal injuries were excluded from the study as these are not amenable to intramedullary nailing and are treated with a wrist-spanning external fixator in our unit. ethics clearance was obtained from our institution’s ethics committee and informed consent was obtained from all patients. all patients received anti-tetanus toxoid and intramuscular penicillin injections on presentation. the wounds were covered in a sterile dressing and immobilised in a cast splint while awaiting definitive surgery. low velocity gunshot wounds in the upper limb are not treated as open fractures in our unit so the surgery is not performed as an emergency. the surgery was performed by different surgeons at our orthopaedic trauma unit using a standardised technique on all patients. pre-operatively, all patients received intravenous cephazolin or clindamycin and this was continued for a further three doses post-operatively. we used the acumed (acumed, hillsboro, oregon) radius rod in all patients. all surgeries were performed under general anaesthesia and/or brachial plexus block. patients were positioned supine with the affected arm surgically prepped on a radiolucent arm table. for the entry point a 1 cm longitudinal incision is made just ulnar to lister ’s tubercle between the third and fourth extensor compartments. under fluoroscopy a starter awl is used to breach the cortex starting 5 mm proximal to the articular surface. the smallest reamer is then advanced in a retrograde manner up to the fracture site, closed reduction is performed and the reamer advanced into the proximal radius. reamers are sequentially inserted in appropriate increments to allow the insertion of a rod of desired length and diameter. the fluted radius rod comes anatomically pre-bent to recreate the radial bow and it is left and right specific. the titanium composition allows further patient-specific contouring. we screen the unaffected radius in the operating room to estimate each patient’s appropriate radial bow. the selected rod is advanced from distal to proximal and the proximal blade tip of the nail is anchored in the proximal metaphysis of the radius. fluoroscopy is used to confirm final placement and correct depth. rotation of the proximal fragment is checked under fluoroscopy using the position of the biceps tuberosity as described by evans.3 lastly distal locking is performed using the jig provided in a dorsal to volar direction (figure 1). no bone grafting was performed. in this surgical technique the fracture site is not opened. the devitalised edges of the bullet entry and exit wounds were debrided but not sutured and were allowed to heal by secondary intention. figure 1b. lateral radiograph: pre-operative showing a midshaft gunshot radius fracture figure 1a. ap radiograph: pre-operative showing a midshaft gunshot radius fracture with loss of radial bow figure 1c. ap and lateral radiographs: immediate postoperative with intramedullary nail in situ and radial bow recreated table i: anderson classification results criteria excellent fracture union loss of flexion/extension of <10º loss of pronation/supination of <25% satisfactory fracture union loss of flexion/extension of <20º loss of pronation/supination of <50% unsatisfactory fracture union loss of flexion/extension of >20º loss of pronation/supination of >50% failure fracture non-union unresolved chronic osteomyelitis saoj winter 2016 press.qxp_orthopaedics vol3 no4 2016/07/05 10:50 page 29 page 30 sa orthopaedic journal winter 2016 | vol 15 • no 2 no attempt was made to irrigate the fracture site or remove retained bullets or shrapnel unless these were palpable subcutaneously. the limbs were not immobilised post-operatively, and unlimited range of movement physiotherapy was commenced on the day following surgery. clinical and radiological follow-up was scheduled for weeks 2, 6, 10, 14, 18, 24 and 30 postoperatively. the range of forearm pronation and supination as well as wrist palmar flexion and dorsiflexion were recorded using a goniometer. the anderson forearm fractures outcome classification (table i) was used to determine the final outcome.4 we defined union clinically as lack of tenderness at the fracture site and radiographically as cross-trabeculation, the presence of bridging callus and obliteration of the fracture lines on three out of four cortices on two orthogonal radiographs. all radiographs were assessed by the corresponding author for union. results twenty-two radius rods were inserted in 22 patients. all were males with an average age of 29 years (range 19– 40). two patients had pre-operative nerve injuries, a median nerve and the other a posterior interosseous nerve injury. there were no neurovascular complications recorded post-operatively. all procedures were performed between 2 and 12 days of the injury (average 4 days). follow-up was for an average period of 11 weeks (range 8–24). all fractures united with the index procedure. the mean time to union was 10 weeks (range 8–24). fourteen patients (64%) had an excellent outcome with a supination/pronation range of 75% or more of the normal side. six (27%) had a satisfactory outcome with supination/pronation range within 50% of the normal side. two (9%) had an unsatisfactory outcome with more than 20% loss of pronation/supination. these were the two patients who presented with pre-operative nerve injuries. their nerve lesions did not recover and they were referred to our hand unit for definitive care. one patient required nail removal at union due to its proximity to the radiocapitellar joint. this was not due to implant migration or fracture collapse, but was present in the immediate post-operative radiographs as the nail had been placed subchondrally. when comparing the post-operative radiographs with radiographs at union we observed no fracture displacement or loss of rotational alignment. there was no clinical or radiographic evidence that the nail had penetrated the joint. orthogonal x-ray views were not helpful in terms of determining the exact location of the nail tip due to the concave nature of the proximal radial articular surface. instead of doing a ct scan to confirm the exact location of the nail, we opted to remove the nail at union. there were no superficial or deep infections recorded and there were no cases with radio-ulnar synostosis. discussion the severity of soft tissue and bony injury caused by a bullet depends on the available kinetic energy, which is a function of its mass and velocity.5 gunshot injuries are generally classified as low velocity (muzzle velocity of <350 m/s), intermediate velocity (350–500 m/s) and high velocity (>600 m/s).6 literature suggests that low velocity gunshot fractures can be regarded as closed fractures and each fracture treated on its own merit even though the bullet is not sterilised on discharge.7,8 one constant feature of low velocity gunshot fractures is comminution and propagation. this particular feature renders compression plating impossible, and bridge plating the only viable plating technique. bridge plating in the upper limb is typically performed by traditional open approaches. gunshot fractures with a long segment of comminution require the use of long plates. the extensive soft tissue dissection may interfere with the biology of fracture healing and predispose the injury to post-operative infection or delayed union. cadaveric and clinical studies have demonstrated that minimally invasive plate osteosynthesis can be safely performed for proximal humerus and humerus shaft fractures.9,10 such studies are lacking for forearm fractures. restoring and maintaining the radial bow, proximal and distal radio-ulnar relationships and a stable fixation to allow early range of movement are the primary goals in the surgical treatment of forearm fractures. earlier intramedullary implants such as rush rods and steinman pins were neither axially nor rotationally stable. this led to the development of locked nails; for maximal stability these were locked both proximally and distally. proximal locking (non-driving end) of these earlier implants posed a constant risk of injury to the posterior interosseous nerve and to avoid this they were locked via an open approach. the acumed radius rod allows for distal locking (driving end) only and the non-driving end of the nail has a blade tip that anchors in the proximal radius metaphysis ensuring axial and rotational stability. the available literature presents results of intramedullary fixation of both the radius and ulna without particular attention to the characteristics of the fractures treated nor their mechanism of injury.11-14 some of the studies have used both open and closed reduction in their patients. all of them, however, have shown very positive results with regard to union rates and functional recovery. gelbart et al. presented a union rate of 92% in their prospective case series of low velocity gunshot forearm fractures treated with intramedullary nailing.15 their study included both radius and ulna fractures which makes direct comparison to our study difficult. figure 2a. ap radiograph: pre-operative showing a proximal third radius fracture saoj winter 2016 press.qxp_orthopaedics vol3 no4 2016/07/05 10:50 page 30 sa orthopaedic journal winter 2016 | vol 15 • no 2 page 31 our study is unique in that we reviewed patients with isolated radius fractures due to gunshot wounds. saka et al. reported on 23 patients with isolated radius fractures treated with locked intramedullary nailing.16 their patients were treated with a closed or mini open reduction and locked nailing and they achieved a mean time to union of 12 weeks. there were no gunshot injuries in their series. our union rate of 100% and average time to union of 10 weeks compares very favourably with their results and other available studies that have used both plate fixation and intramedullary nailing. we did not consider the two patients with a poor outcome as surgical complications. both these patients had pre-operative nerve lesions that had not fully recovered at the time of union. intramedullary nailing offers the advantage of fixation of comminuted proximal third radius fractures where plate fixation would have been challenging and/or not technically possible (figure 2). a small sample size and the retrospective nature of this study represent its limitations. conclusion closed reduction and intramedullary nail fixation of gunshot radius fractures is a biologically and mechanically appealing fixation method for these complex diaphyseal fractures. these early clinical results are promising with respect to function and restoration of anatomy with no significant complications. randomised control trials comparing the long-term outcomes of plate fixation and intramedullary nailing are required. compliance with ethics guidelines ethics clearance was obtained from our institution’s ethics committee and informed consent was obtained from all patients. s maqungo, nj kauta, r dachs, g mccollum, m held and s roche declare that no benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. references 1. chapman m, gordon j, zissimos a. compression-plate fixation of acute fractures of the diaphysis of the radius and ulna. j bone joint surg am 1989;71(2):159-69. 2. lil na, makkar ds, aleem aa. results of closed intramedullary nailing using talwarkar square nails in adult forearm fractures. malays orthop j. 2012 nov;6(3):7-12. 3. evans em. fractures of the radius and ulna. j bone joint surg br 1951;33:548-61. 4. anderson ld, sisk d, tooms re, park wi 3rd. compressionplate fixation in acute diaphyseal fractures of the radius and ulna. j bone joint surg am 1975;57(3):287-97. 5. bartlett cs, helfet dl, hausman mr, strauss e. ballistics and gunshot wounds: effects on musculoskeletal tissues. j am acad orthop surg 2009;8(1):21-36. 6. dickey rl, barnes bc, kearns rj, tullos hs. efficacy of antibiotics in low-velocity gunshot fractures. j orthop trauma 1989;3(1):6-10. 7. geissler wb, teasedall rd, tomasin jd, hughes jl. management of low-velocity gunshot induced fratcures. j orthop trauma. 1990;4(1):39-41. 8. bowyer gw, rossiter nd. management of gunshot wounds to the limbs. j bone joint surg br. 1997 nov;79(6):1031-36. 9. apivatthakakul t, arpornchayanon o, bavornratanavech s. minimally invasive plate osteosynthesis (mipo) of the humeral shaft fracture. is it possible? a cadaveric study and preliminary report. injury. 2005 apr;36(4):530-38. 10. lau tw, leung f, chan cf, chow sp. minimally invasive plate osteosynthesis in the treatment of proximal humeral fracture. int orthop. 2007 oct;31(5):657-64. 11. gao h, luo cf, zhang cq, shi hp, fan cy, zen bf. internal fixation of diaphyseal fractures of the forearm by interlocking intramedullary nail: short-term results in eighteen patients. j orthop trauma. 2005 jul;19(6):384-91. 12. weckbach a, blattert tr, weisser ch. interlocking nailing of forearm fractures. arch orthop trauma surg. 2006 jul;126(5):309-15. 13. lee yh, lee sk, chung ms, baek gh, gong hs, kim kh. interlocking contoured intramedullary nail fixation for selected diaphyseal fractures of the forearm in adults. j bone joint surg am. 2008 sep;90(9):1891-98. 14. saka g, saglam n, kurtulmuş t, avcı cc, akpinar f, kovaci h, celik a. new interlocking intramedullary radius and ulna nails for treating forearm diaphyseal fractures in adults: a retrospective study. injury. 2014 jan;45 suppl 1:s16-23. 15. gelbart br, aden aa. evaluation of intramedullary nailing in low velocity gunshot wounds of the radius and ulna. sa orthop journal 2013;12(3):35-41. 16. saka g, saglam n, kurtulmus t, bakir u, avci cc, akpinar f, alsaran a. treatment of isolated diaphyseal fractures of the radius with an intramedullary nail in adults. eur j orthop surg traumatol. 2014 oct;24(7):1085-93. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj figure 2c. ap radiograph: 6 months postoperatively showing a united fracture figure 2b. ap radiograph: post-operative showing im nail in situ saoj winter 2016 press.qxp_orthopaedics vol3 no4 2016/07/05 10:50 page 31 orthopaedics vol3 no4 sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 51 the pathogenesis of tibial non-union n ferreira1 bsc, mbchb, fc orth(sa), mmed(orth), phd lc marais1 mbchb, fcs orth(sa), mmed(ortho), phd c aldous2 bsc, bsc(hons), msc, phd 1 tumour sepsis and reconstruction unit, department of orthopaedic surgery, grey’s hospital, nelson r. mandela school of medicine, university of kwazulu-natal 2 medical research scientist, school of clinical medicine, college of health sciences, university of kwazulu-natal corresponding author: dr nando ferreira department of orthopaedic surgery grey’s hospital 3201 pietermaritzburg kwazulu-natal south africa tel: +27 33 897 3000 email: nando.ferreira@kznhealth.gov.za introduction the human body has evolved the ability to spontaneously heal skeletal injuries through secondary bone healing and callus formation. this is evident from healed fractures observed in homo neaderthalensis and homo erectus fossils.1,2 this healing process is unique in nature as most tissues heal with scar tissue formation, while skeletal tissue repairs with bone that is histologically indistinguishable from the original bone. manipulating this natural healing process in order to ensure proper alignment, maintenance of limb length and faster return to function, has been the goal of physicians throughout the ages. the edwin smith papyrus from ancient egypt is the oldest existing medical text and describes in detail the splinting of extremity fractures to preserve function.3 non-union occurs when this natural healing process is hampered or disrupted and is one of the most dreaded complications of fracture management. non-union following tibial shaft fractures represents the most common long-bone non-unions that require treatment.4 quoted incidences range from 4% to 48% and an established non-union signals a significant impact on a patient’s function and quality of life.4-9 multiple factors have been implicated in the pathogenesis of long-bone non-unions.7,10,11 recognising these factors will help refine strategies aimed at prevention of non-union and may guide the management of established non-unions. in this review we explore the factors that influence normal bone healing and predispose to non-union development after a tibial shaft fracture. normal bone healing bone healing is a complex cascade of events that results in the repair of fractures without the formation of scar tissue and can be classified into two histological types, namely primary and secondary bone healing.12,13 primary bone healing (‘soudure autogene’) involves direct cortical remodelling through the formation of cutting cones that cross the fracture gap.13 this type of bone healing occurs when there is a combination of anatomical reduction, stable fixation and compression of the fracture site and is only seen with open reduction and rigid internal fixation. secondary bone healing represents the most common type of fracture healing and occurs when there is some motion at the fracture site, which induces callus formation. during this healing process both endochondral and intramembranous ossification occur in an ordered sequence divided into three phases.13 abstract bone healing is a unique and complex reparative process that results in fractures healing without scar tissue formation. multiple factors have been implicated in altering this process. this paper reviews the factors that influence the process of bone healing and predispose to non-union development. cognisance of these factors will assist orthopaedic surgeons in identifying fractures at risk of altered healing and guide the development of comprehensive management strategies for established non-unions. key words: tibia, non-union, pathogenesis, fracture, healing http://dx.doi.org/10.17159/2309-8309/2016/v15n1a5 page 52 sa orthopaedic journal autumn 2016 | vol 15 • no 1 the first phase starts with a haematoma that forms after the injury. this initiates an inflammatory response with the release of cytokines, including platelet derived growth factor (pdgf), tnf-α and interleukins from macrophages, neutrophils and platelets. these cytokines are responsible for the recruitment of fibroblasts and pluripotent mesenchymal cells that migrate to the fracture site. granulation tissue forms around the fracture ends, and osteoblasts and fibroblasts proliferate. this is followed by the reparative phase when primary callus is formed. the mechanical environment drives differentiation of either osteoblastic or chondroblastic cell lines. endochondral ossification mineralises a chondroid matrix while woven bone is generated through mineralisation of an osteoid matrix. the final stage involves remodelling the healed fracture site. this process is governed by wolff’s law in response to mechanical stresses on the bone. mechano-biology the mechanical environment plays a major role in fracture healing and can be described in terms of inter-fragmentary motion and strain.14,15 while a small amount of relative deformation (strain < 2%) induces callus formation, high strain (> 10%) will lead to bone resorption and eventual non-union.14 the amount of mobility allowed depends less on the displacement of the fragments alone than on the relation of the width of the fracture gap (l) and displacement (δl); δl/l.15 mechanical stimulation also has a direct effect on the physiology of fracture healing. ilizarov stated that functional load determines the structure, shape and volume of any limb. this is due to an increase in local blood flow during functional use that aids in tissue growth.5 mechanical stimulation also directly influences bone biology on a cellular level by stimulating the proliferation and differentiation of osteoblasts.5,16 mechanical force application patterns, as well as loading magnitude and frequency, also affect bone healing on a biochemical level.16 the rates of synthesis and degradation of extracellular matrix components are affected by force application patterns. loading magnitude affects cell size through increasing amounts of intermediate filaments and glycogen particles while changes in loading frequency can alter mrna synthesis of anabolic and catabolic genes.16 aggrecan gene expression is increased in response to mechanical stimulation and leads to an increased proteoglycan scaffold for type ii collagen.5 mechanical stimulation has further benefits in terms of union site remodelling according to wolff’s law. this phenomenon was originally ascribed to piezo-electrical charges that are generated in response to mechanical stresses. osteoblasts on the compressive side are stimulated by electronegative charges while osteoclasts are activated by electropositive charges on the tension side.17,18 this explanation is likely an oversimplification of a complex mechanism that regulates bone remodelling.19 current understanding of bone mechanosensation involves strain-generated potentials to explain how bone is able to respond to mechanical stresses. injury factors the tibia is the most commonly fractured long bone.4 its anatomical location exposes it to high energy trauma and its thin soft tissue envelope means that these injuries are frequently open fractures.20 this, along with a tenuous blood supply and complex fracture patterns that are frequently seen after high energy injuries predispose tibial fractures to complications that affect fracture healing.5,8,13,20 in an observational study of 200 patients, bhandari et al. identified open fractures and transverse fracture patterns as independent variables that predict re-operation following tibial shaft fractures.21 in this study, re-operation was defined as any surgical procedure aimed specifically at achieving bony union. in a more recent study, fong et al. identified open fractures, comminution, fracture with less than 25% cortical contact, oblique fracture pattern and segmental fractures to be associated with non-union development. after multivariable logistic regression analysis only cortical contact of less than 25% remained as a variable that was a strong predictor of non-union and re-operation.8 the thin soft tissue envelope of the tibia is frequently breached during high energy trauma leading to these injuries being the most common open fractures managed by orthopaedic surgeons.20 open fractures result in loss of the initial fracture haematoma, periosteal stripping and ischaemic bone and soft tissues.11 these factors contribute to an increased risk of non-union development in open fractures. gaebler et al. found that grade iii open fractures were five times more likely to develop delayed union compared to closed grade i and grade ii fractures.22 in a review of 104 patients, karladani et al. reported a relative risk of 8.2 (95% confidence interval) for developing non-union in open fractures.23 gaston et al. reviewed 100 patients with tibial shaft fractures. they also reported a higher risk of nonunion after open fractures with a relative risk of 3.4 (95% confidence interval).24 atrophic non-unions in particular appear to be related to the extent of the initial damage sustained.11,25 injuries that result in extensive soft tissue damage, severe fracture comminution and devitalisation of fracture fragments have an increased risk of atrophic non-union.5,25-27 gaston et al. found that comminuted fractures had a higher likelihood of altered healing. they reported that winquist and hansen type iii and iv tibial shaft fractures had 31% and 38% chance of non-union respectively compared to type i and ii fractures that had an 8% chance of non-union each.24 these high energy injuries appear to disrupt the vascularity of the fracture ends and affect the early stages of fracture healing.11,28,29 in a rabbit model for atrophic non-union, the vascularity of the fracture site during the early stages of fracture healing was implicated as the driving force for atrophic non-union development. sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 53 this study found that although the non-union site appeared well vascularised at eight and 16 weeks, no vessels were seen within the interfragmentary gap at one week following the injury.30 the specific injury characteristics and damage sustained at the time of injury cannot be modified by the surgeon. early identification of high-risk injury patterns should however prompt the treating surgeon to employ management algorithms that increase the chances of obtaining union. fracture management surgical intervention may inadvertently increase the chances of fracture non-union; the choice of fixation and the way in which it is executed can contribute to the overall risk of non-union. fractures fixed in distraction, unstable fixation and excessive soft tissue dissection all contribute to an increased risk of non-union development.13,25 for fractures to heal, the mechanical environment must be appropriate.31 obtaining the ideal inter-fragmentary strain is of vital importance. bhandari et al. identified fixation with a fracture gap as an independent risk factor for requiring additional surgery to achieve union.21 fracture gaps may potentially cause non-unions along two pathways. unstable fixation coupled with small fracture gaps result in a high strain environment that favours chondroid and fibrous differentiation over osteogenesis.25 exposing the initial soft callus to excessive motion may disrupt the reparative phase of fracture healing and may result in a hypertrophic non-union.27,32 on the other hand, fractures that are rigidly fixed in distraction may result in such low inter-fragmentary strain that no callus formation is stimulated. these situations often result in atrophic nonunions and fixation failure. the optimal mechanical environment is however not the only consideration when deciding on fixation method, as this should be offset against preserving the remaining biological potential to unite. open reduction and internal fixation might further disrupt a tenuous blood supply, especially in tibial fractures with concomitant soft tissue injury. excessive stripping of soft tissue and periosteum may exacerbate necrosis of bone ends and contribute to the loss of biological potential to heal, ultimately resulting in an atrophic non-union.25,29 following high energy tibial fractures it might therefore be prudent to follow management strategies that preserve the local biological environment. host factors not all patients have the same fracture-healing potential. some individuals have great ability to heal fracture gaps that might proceed to non-union in another person. the factors that contribute to impaired fracture healing include age, gender and certain concomitant systemic illnesses.7 age age has a major influence on the body’s ability to heal injuries. children have a thick periosteum and an osteogenic environment dedicated to skeletal growth. this results in large haematomas and rapid callus formation after paediatric injuries.33 as skeletally mature individuals advance in age a significant impact on skeletal repair is observed.34,35 as a result, the observed healing time of fractures in the paediatric population is about half that in adults. although there is no correlation between gender and non-union of fractures, healing problems are common among males since they have a higher incidence of high energy fractures.31 concomitant systemic disease • anaemia: low haemoglobin affects aerobic metabolic processes and alters the body’s ability to repair injuries following trauma. two animal studies investigated the effect of anaemia on fracture healing. rothman et al. reported that iron-deficient anaemic rats had poor mineralisation of fracture callus and a decreased rate of union.36,37 heppenstall et al. found that hypovolaemic, anaemic rabbits showed inhibition of fracture healing but after fluid resuscitation, normovolaemic anaemic rabbits had no adverse effects.38 varecka et al. conducted a retrospective review of 734 patients and concluded that patients with a haemoglobin level below 8 g/dl had an increased risk of non-union. this was particularly significant in tibial fractures. in their series, patients that were smokers combined with anaemia had a 100% risk of nonunion.39 • malnutrition: dietary and metabolic requirements increase during fracture healing.11,25,31 brinker et al. found that 85% of patients who developed unexplained nonunions had an underlying, undiagnosed metabolic or endocrine abnormality. the most common of which were vitamin d deficiencies.10 dodds et al. showed that vitamin b6-deficient rats had significant delays in callus maturation.40 osteoblast function has further been shown to be dependent on vitamin c.41 in order to optimise fracture healing, patients should undergo careful nutritional assessment and any identified deficiencies should be addressed. • diabetes: several clinical and experimental studies have shown that diabetes impairs bone healing.31,42 multiple animal studies using either rats with streprozotocininduced diabetes or bb wistar type i diabetic rats have investigated the effects of diabetes on fracture healing. these rats all show decreased callus stiffness and tensile strength in the early stages of fracture healing.43,44 diabetic rats were also found to have decreased cell proliferation, decreased collagen content and increased rates of cartilage resorption at the fracture site compared to controls.43,45-47 follak et al. showed that tight glycaemic control can produce normal fracture healing.48 a study by gandhi et al. further indicated that insulin might even play a direct role in healing at the fracture site.49 page 54 sa orthopaedic journal autumn 2016 | vol 15 • no 1 • hypothyroidism: urabe et al. investigated femur fracture healing in hypothyroid rats. they observed impaired healing as a result of deficient endochondral ossification. when these rats were treated with l-thyroxine, the healing process was returned to normal.50 the message from all these studies is clear: when confronted with a non-union, physicians should screen patients for these potential co-morbidities and all reversible or modifiable risk factors should be optimised during the healing process. smoking study data have conclusively revealed that smoking is associated with longer healing times, increased non-union rates and more wound complications after long-bone fractures.26,51-54 the impact of smoking appears to be particularly pronounced in open tibial fractures.55,56 several mechanisms have been proposed to explain how smoking impairs fracture healing and include alterations on a vascular, cellular and intracellular level. smoking causes vasoconstriction and local hypoxia that could predispose the patient to atrophic non-union development.11,57,58 nicotine in tobacco prevents cellular proliferation, alters macrophage and fibroblast maturation and is directly toxic to proliferating osteoblasts.11,31,59 nicotine further inhibits tnf-α expression, required for fracture healing, through the activation of the cholinergic antiinflammatory pathway.60 on an intracellular level, smoking inhibits alkaline phosphatase and collagen production.25 cobb et al. performed a case control study with patients undergoing ankle arthrodesis. they reported a relative risk of 3.74 for non-union in active smokers. when they analysed the patients without any other known risk factor for non-union development, the risk for non-union in smokers was 16 times that of non-smokers.61 bhandari et al. reported overall union rates of tibial shaft fractures to be higher in non-smokers (94%) when compared to smokers (84%).21 adams et al. showed that smokers had increased healing times after tibial fractures (32 weeks vs 28 weeks), required more bone graft procedures (26% vs 18%) and had a higher rate of non-unions, flap breakdown and infection.55 a recent meta-analysis by schenker et al. confirmed that the mean healing time for tibia fractures was longer for smokers (32 weeks) than for non-smokers (25 weeks) and that smokers with tibia fractures or open fractures had increased rates of non-union.62 cessation of smoking may not result in an immediate improvement. castillo et al. investigated patients who sustained open tibia fractures and found that current smokers were 37% and previous smokers 32% less likely to achieve union than non-smokers.63 it is clear from the available evidence that smoking negatively impacts healing of tibia fractures. it further appears that previous smoking negatively impacts outcome but to a lesser extent than current smoking. the question that remains to be answered is the time needed for the negative effects of smoking to dissipate after cessation of smoking. it is however prudent for physicians to encourage patients with acute fractures, and patients undergoing treatment for established non-unions, to stop smoking. nsaids non-steroidal anti-inflammatory drugs (nsaids) are frequently used to manage post-traumatic or postoperative pain. they inhibit cyclooxygenase (cox) enzyme activity and decrease prostaglandin production, which may have a detrimental effect during the inflammatory phase of fracture healing. conflicting evidence about their effect in clinical practice however remains.64,65 multiple clinical trials have failed to provide a definitive answer to the effect of nsaids on fracture healing.66 burd et al., giannoudis et al. and bhattacharyya et al. all reported significant risk for non-union of long bone fractures with the use of nsaids.67-69 davis et al. and adolphson et al., however, failed to show any correlation between the use of nsaids and abnormal fracture healing.70,71 it is notable however that both these studies were conducted on patients who sustained colles’ fractures that generally are unlikely to develop non-unions. studies investigating the effect of nsaids on spinal fusion also failed to provide conclusive answers, with some studies showing an inhibitory effect toward fusion while others contradict these findings.72-76 in vitro and animal studies has shown similar variations in outcome.64,65 the diversity in study design may have contributed to the lack of consensus, but even studies with identical study parameters sometimes report contradictory findings. conclusive evidence against the use of nsaids in acute fracture care cannot be drawn from the available evidence. the lack of evidence is, however, not proof of the absence of a detrimental effect and these drugs should be used with caution in patients with high-risk for abnormal fracture healing.64 other drugs • antibiotics: animal and in vitro evidence indicate that antibiotic therapy may have adverse effects on fracture healing.77-79 the quinolones, ciprofloxacin, levofloxacin and trovafloxacin have been shown to decrease cellular proliferation and dna synthesis which result in diminished healing during the early stages of fracture repair.77,78 the aminoglycosides gentamycin and tobramycin decrease proliferation of osteoblastic progenitors and are directly toxic to osteoblasts.80,81 experimental studies have shown that osteoblast proliferation might be inhibited by rifampicin at clinical doses.82 there is however little evidence on the effect of antibiotic therapy on fracture healing in humans.79 sa orthopaedic journal autumn 2016 | vol 15 • no 1 page 55 • anticoagulants: in vitro and in vivo evidence suggest that some anticoagulants may impair normal bone metabolism.83-85 several animal studies have demonstrated significant attenuation of fracture healing but no human trials are available for evaluation.5,31,83,85 a literature review by lindner et al. identified strong evidence that warfarin and heparin retard fracture healing, but low molecular weight heparins appear to have a less pronounced effect.86 • anticonvulsants: there is a growing body of evidence on the adverse effects of anticonvulsants in bone metabolism. phenytoin, phenobarbital, carbamazepine primidone and valproate have all been implicated in causing decreased bone mineral density and disorders of bone metabolism.87-91 the extent to which these drugs affect fracture healing in humans remains to be evaluated. • chemotherapy: chemotherapeutic agents significantly affect fracture healing. their cytotoxic and anti-proliferative properties impact neovascularisation and callus formation resulting in higher non-union rates.31,92 cyclophosphamide causes diminished calcium and phosphate deposition in callus.93 doxorubicin, cyclophosphamide, adriamycin and methotrexate results in decreased bone formation and these effects might last up to three weeks after administration.93 • corticosteroids: the effect of long-term corticosteroid use on bone metabolism and fracture healing is well documented.31,94,95 the long-term use of corticosteroids leads to osteoblast and osteocyte apoptosis and inhibition of osteoblastogenesis.5,13,92 waters et al. studied the effects of long-term steroid use on fracture healing in a rabbit model. they found an 85% rate of non-union in the corticosteroid group compared with 18% in the control group.94 in contrast, hogevold et al. investigated shortterm corticosteroids use on fracture healing in rats and found no statistically significant difference when compared to a control group.96 alcohol chronic alcohol consumption leads to osteopaenia, increased risk of fracture from falls and delays in fracture healing.97 many of these problems have been attributed to nutritional deficiencies and biochemical derangements frequently observed in chronic alcohol abuse. recent research has, however, illustrated that excessive alcohol use may have a direct impact on bone healing. it appears that excessive doses of ethanol in the early healing period inhibit new bone formation and that the newly formed bone lacks mineralisation, causing decreased stability and leading to increased incidence of delayed union.5,11,31,92 experimental evidence from ethanol exposed fracture healing in murine models indicates that ethanol impairs the biomechanical strength and decreases the volume of callus formation.98-100 chakkalakal et al. studied the effects of ethanol on a fracture model in rats. they found that rats that were fed ethanol as 35% of their total calorie intake had deficient bone repair that could not be attributed to nutritional deficiencies. they further found that removal of ethanol from the diet after the bone injury completely restored bone healing.99 a retrospective study by askew et al. was consistent with these animal findings. the investigators compared the healing time of fractures in 12 alcoholics and 18 nonalcoholics and found delayed healing time in alcoholics of more than twice that of non-alcoholics.101 these studies indicate that alcohol might have a direct negative effect on fracture healing. it appears, however, that these effects could be negated by the early cessation of alcohol intake following an injury. infection sepsis is often cited as a cause of non-union development.13 infection and non-union does not, however, have a simple cause-and-effect relationship. many factors that promote infection, like open wounds with extensive devascularisation, tissue necrosis and instability, are also implicated in non-union development.11,25 infection can however contribute to non-union development through bone death, creation of fracture gaps due to bone resorption, and instability because of implant loosening.25 human immunodeficiency virus hiv infection has recently been disputed as a risk factor for non-union development. initial studies showed an increased risk for non-union in certain hiv-positive subgroups. kamat and govender evaluated the effect of hiv infection on union rates of closed ankle fractures that were managed non-operatively. they concluded that there was no difference in union rates of hiv-negative and who clinical stage i, ii and iii hiv-positive patients, while patients with who clinical stage iv hiv infection had increased non-union rates. (12.45% vs 1.5% and 1.25%)102 chandanwale et al. compared healing rates in 80 haart naive hiv-positive patients with 80 hiv-negative controls. closed fractures had similar healing rates in the two groups when treated conservatively or operatively. open fractures in the hiv-positive group, on the other hand, showed a significantly increased risk of non-union. (50% vs 15%)103 aird et al. prospectively evaluated 133 patients (33 hiv-positive) with open fractures. they reported a non-union risk of 15% in hiv-positive patients compared to 4% in hiv-negative patients.104 more recent research has contradicted these earlier findings. gardner et al. prospectively evaluated union in 96 hiv-positive patients. they reported that 4% of these fractures failed to unite and concluded that hiv infection did not increase the risk of non-union in surgically managed fractures. this cohort, however, included only five open fractures.105 page 56 sa orthopaedic journal autumn 2016 | vol 15 • no 1 the exact mechanisms by which hiv infection affects fracture union remain unclear although multiple pathways have been suggested. molecular and biochemical hypotheses could explain a direct relationship between hiv and impaired fracture union. hiv infection is known to cause an altered cytokine environment that may impact bone healing. tnf-α is up regulated while igf-1 levels are reduced and an inverse correlation between igf-1 and il-6 is observed when compared to hiv-negative individuals.106 hiv may further affect fracture healing by its impact on general health through malnutrition, reduced body mass and opportunistic infections. considering the limited and controversial evidence regarding fracture healing in hiv-infected individuals, it might be well advised to take particular care to optimise bone healing in hiv-positive patients. a tailored fracture management strategy, improvement of nutritional status, avoidance of nsaids and cessation of smoking and alcohol consumption might assist in mitigating the potential negative effects of hiv infection on bone healing. genetics despite the lack of any apparent risk factors, some patients still proceed to non-union development.107 this has led to the hypothesis of a genetic predisposition to altered fracture healing.108 zeckey et al. identified a significant correlation between polymorphisms in the pdgf gene and non-union development after femoral and tibial shaft fractures.109 dimitriou et al. investigated the impact of genetic defects in the bmp signalling cascade on non-union development. the study identified two specific single nucleotide polymorphisms on the noggin and smad6 genes that were associated with an increased risk for atrophic nonunion development.110 fajardo et al. examined rna expression patterns of bmps, their receptors and inhibitors in hypertrophic non-union tissue. they found substantially elevated concentrations of bmp-4 and certain bmp inhibitors (drm/gremlin, follistatin and noggin) while levels of bmp-7 was lower than those seen in normal fracture healing.111 the extent to which these genetic components predispose to non-union formation, and their role and interaction with other risk factors, warrant further investigation. conclusion non-union development has a multifactorial pathogenesis that is not well understood. the weight that each variable 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16377462. 100. obermeyer ts, yonick d, lauing k, stock sr, nauer r, strotman p, shankar r, gamelli r, stover m, callaci jj. mesenchymal stem cells facilitate fracture repair in an alcohol-induced impaired healing model. j orthop trauma. 2012;26(12):712-8. pubmed pmid: 23010646. pubmed central pmcid: 3645443. 101. askew a, chakkalakal d, fang x, mcguire m. delayed fracture healing in alcohol abusers a preliminary retrospective study. open bone j. 2011;3:1-5. 102. kamat as, govender m. the effects of hiv/aids on fracture union. j bone joint surg [br] 2010;92-b(supp i):228. 103. chandanwale a, nawale s, bhosale s, jadhav s, anantraman c. fracture healing rate in hiv positive patients in india. xvi international aids conference. 2006. toronto, ontario. 104. aird j, noor s, rollinson p. is fracture healing affected by hiv in open fractures? j bone joint surg [br]. 2012;94-b(supp xix):16. 105. gardner ro, bates jh, ng’oma e, harrison wj. fracture union following internal fixation in the hiv population. injury. 2013;44(6):830-3. pubmed pmid: 23267724. 106. richardson j, hill am, johnston cj, mcgregor a, norrish ar, eastwood d, et al. fracture healing in hiv-positive populations. j bone joint surg [br]. 2008;90(8):988-94. pubmed pmid: 18669951. 107. gershuni dh. fracture nonunion. western j med. 1989;150(6):689-90. pubmed pmid: 2750154. pubmed central pmcid: 1026720. 108. dimitriou r, kanakaris n, soucacos pn, giannoudis pv. genetic predisposition to non-union: evidence today. injury. 2013;44 suppl 1:s50-3. pubmed pmid: 23351872. 109. zeckey c, hildebrand f, glaubitz lm, jurgens s, ludwig t, andruszkow h, hufner t, krettek c, stuhrmann m. are polymorphisms of molecules involved in bone healing correlated to aseptic femoral and tibial shaft non-unions? j orthop res. 2011;29(11):1724-31. pubmed pmid: 21538509. 110. dimitriou r, carr im, west rm, markham af, giannoudis pv. genetic predisposition to fracture non-union: a case control study of a preliminary single nucleotide polymorphisms analysis of the bmp pathway. bmc musculoskelet disord. 2011;12:44. pubmed pmid: 21310029. pubmed central pmcid: 3053586. 111. fajardo m, liu cj, egol k. levels of expression for bmp-7 and several bmp antagonists may play an integral role in a fracture nonunion: a pilot study. clin orthop relat res. 2009;467(12):3071-8. pubmed pmid: 19597895. pubmed central pmcid: 2772945. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. 404 not found 404 not found du plessis et al. sa orthop j 2020;19(2) doi 10.17159/2309-8309/2020/v19n2a1 south african orthopaedic journal http://journal.saoa.org.za arthroplasty citation: du plessis j, greeff r, singh v, fang n, frey ct. short-term results following two-stage revision for periprosthetic joint infection. sa orthop j 2020;19(2):64-69. http://dx.doi.org/10.17159/2309-8309/2020/v19n2a1 editor: dr thomas hilton, university of cape town, south africa received: august 2019 accepted: october 2019 published: may 2020 copyright: © 2020 du plessis j. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: none of the authors have any conflicts of interest to declare. abstract background: hip and knee arthroplasty procedures are successful surgical procedures, with total hip arthroplasty being named the operation of the 20th century. with there being an estimated rate globally of periprosthetic joint infection of 1% for hips and 2% for knees, this minimal infection rate represents a large global concern. the successful management of periprosthetic joint infection remains controversial with multiple proposed strategies. our aim is to present our short-term data for a two-stage revision protocol. methods: a single centre retrospective review of an existing database starting from january 2013 and including april 2019 was conducted looking at patients having undergone two-stage revision for periprosthetic joint infection. the unit utilised a standard approach to two-stage revisions. data was collected from the existing database to ascertain short-term success based on the delphibased international multidisciplinary consensus criteria. results: a total of 2 125 entries were reviewed from the database comprising 1 912 primary arthroplasty procedures. from all revision cases 19 patients were identified to have undergone a two-stage revision by our unit. of these patients we managed to collect sufficient data to gauge treatment success in 12 patients. of these 12 patients with a mean follow-up of 25.6 months, ten reported complete wound healing, pain improvement and no subsequent surgery. one patient demised from septic complications and one required subsequent arthrodesis which controlled the sepsis. conclusion: our results showed a high infection eradication rate following our two-staged revision protocol despite frequent delays between first and second stages as a result of resource constraints and limitations. level of evidence: level 4 keywords: revision, arthroplasty, two-stage, periprosthetic joint infection short-term results following two-stage revision for periprosthetic joint infection du plessis j1 , greeff r2 , singh v3 , fang n4 , frey ct5 1 mbchb(uct); registrar 2 mbchb(up), fcorth(sa); consultant 3 mbchb, fcorth(sa), mmed(orth)(wits); consultant 4 mbbch(wits); registrar 5 md, fcorth(sa); professor and head of arthroplasty department of orthopaedic surgery, chris hani baragwanath academic hospital, university of the witwatersrand, johannesburg, south africa corresponding author: dr jason du plessis, po box 2696, noordheuwel, krugersdorp, 1756; tel: 082 445 7247; email: jasondp_29@yahoo.com https://orcid.org/0000-0002-4617-9742 https://orcid.org/0000-0001-7691-5192 https://orcid.org/0000-0002-7876-2493 https://orcid.org/0000-0002-9020-1556 https://orcid.org/0000-0003-1692-9749 page 65du plessis et al. sa orthop j 2020;19(2) introduction hip and knee arthroplasty procedures are considered highly successful surgical procedures, with total hip arthroplasty being named the operation of the 20th century.1 globally, there is an increase in the number of these procedures due to an increasing elderly population; an increase in skilled surgeons; and the success rate of the operation.2 with an estimated rate globally of periprosthetic infection of 1% for hips and 2% for knees,3 even a minimal infection rate represents a large global concern medically2 and financially.4 the successful management of periprosthetic joint infection (pji) remains controversial, with multiple successful treatment options reported in the literature leading to uncertainty as to which is the best approach. the two-staged approach is still regarded as the gold standard5 for chronic infections defined as an infection after six to eight weeks from the index procedure.6,7 the two-staged approach has reported cure rates of over 90%,8,9 ranging from 76% to 100%. this figure depends on the definition of cure which has not been uniform throughout the literature,5 with some authors only looking at re-operation and others looking at loosening or combinations thereof.10 within the body of literature looking at the two-stage approach to pji, there is controversy regarding the specific aspects of each stage5 in terms of type of cement spacer, antibiotic dose within the spacer, time between stages and the relevance of further investigations such as an alpha-defensin test at the second stage. the purpose of this study was to assess the short-term success of our two-stage revision protocol in patients presenting with late chronic periprosthetic joint infection as defined by segawa et al.11 and further expanded on by tsukayama12 and summarised in table i following hip and knee arthroplasty at our institution. patients and methods institutional approval was obtained and a retrospective review conducted of patients managed for chronic deep pji using a twostage revision protocol. information was extracted from a patient database and included patients managed at our institution from january 2013 up to and including april 2019. the database, which was recorded on apple numbers (apple inc, cupertino, ca, usa), was analysed and all patients with radiographic evidence of having a cement spacer were included in the initial cohort. all patients with cement spacers were regarded to have been treated for a late chronic pji as defined by tsukayama,11,12 depicted in table i. thereafter patients who had been assessed following reimplantation and had documented outcomes were included. patients with no record of follow-up following reimplantation were excluded from the cohort. demographic data and details of respective surgical procedures were collected onto a spreadsheet using microsoft excel (microsoft, redmond, wa, usa). we documented the joint involved, the number of surgeries and the dates these were performed as well as the outcome of the most recent available assessment of the patient recorded. pji was routinely diagnosed based on the musculoskeletal infection society (msis) criteria for pji of 201113 prior to the initiation of a two-stage revision. after diagnosis patients were booked for and underwent a two-staged revision. the first stage consisted of a thorough joint debridement of all infected and necrotic tissue as well as removal of all implants. biopsies were sent from a minimum of five sites within the debrided joint, including from bone and synovium, for histological and microbiological analysis. cement spacers were made using casting moulds provided by zimmer biomet (zimmer biomet, warsaw in, usa). the cement spacers were made using 80 g palacos r+g (haraeus, hanau, germany) containing 1 g gentamycin with 3 g vancomycin and 3 g cefuroxime added. the cement was then allowed to harden in the moulds and implanted into the dead space as an articulating spacer. post-operatively patients were placed on six weeks of antibiotics, with intravenous vancomycin and oral rifampicin being the firstline empiric agents. after culture and sensitivity were obtained, antibiotics were tailored to the cultured organism and where possible oral agents were given (cloxacillin or linezolid with rifampicin) and the patients were discharged to continue their sixweek course as outpatients. following the six weeks of antibiotics, a minimum period of two weeks was allowed before repeat blood investigations were done, including white cell count, c-reactive protein, erythrocyte sedimentation rate and ferritin-iron ratio. if these were suppressed after the antibiotic-free period, the second stage was planned. the second stage consisted of removal of the cement spacers and a repeat debridement of the joint and bone ends. in cases where the eradication was clinically questionable, an alphadefensin test was planned to be done; if positive, a repeat first stage would be performed, and where negative, we would proceed with the second stage. multiple biopsies were again taken at the time of reimplantation, and reimplantation with revision implants was performed based on the bone defects encountered for each case, an example of which can be seen in figure 1. this was done despite evidence indicating that reimplantation cultures often did not correlate with poorer outcomes.5,14 following the second stage operation, patients were treated for another six weeks with antibiotics based on the original first stage culture results and tailored if needed based on the repeat culture results. the success of this systematic intervention was based on the delphi-based international multidisciplinary consensus criteria for the resolution on pji published in 2013.10 here, success was defined as: 1) no clinical failure (healed wound without fistula or draining sinus and pain-free joint, and no recurrence by the same organism; 2) no subsequent surgical intervention after reimplantation for infection; 3) no death caused by a condition linked to pji. results we reviewed a total of 2 125 entries for all arthroplasty procedures performed between january 2013 and april 2019, with 1 912 entries for primary arthroplasty procedures done. of the primary arthroplasty procedures done, total hip arthroplasty accounted for 1 041 entries and total knee arthroplasty accounted for 871 entries. from these entries, 19 patients were identified to have undergone two-stage revisions for chronic pji, with eight hips and 11 knees in that cohort. there were no patients documented to have required table i: classification of pji based on clinical presentation12 type 1 type 2 type 3 type 4 timing positive intra-operative culture early post-operative infection (a: superficial, b: deep) acute haematogenous infection late chronic infection definition >2 positive intra-operative cultures infection within 30 days of surgery haematogenous seeding in well-functioning prosthesis chronic infection present >30 days page 66 du plessis et al. sa orthop j 2020;19(2) a repeat first stage for questionable clearance and reimplantation. this correlates to an overall chronic infection rate of 0.99% (0.76% for hips and 1.26% for knees) as defined by tsukayama.12 with regard to these findings, it should be kept in mind that our institution is a referral centre and some revisions were done for primary joints done at other hospitals. similarly, we operate on patients from a large demographic area and some complications may not have returned to our institution but rather been managed elsewhere. of note there were also a total of 79 patients identified who were managed for acute post-operative periprosthetic joint infections (tsukayama type 2). of these, 51 were hips and 28 were knees. this correlated to an acute infection rate of 4.13% (4.9% for hips, 3.2% for knees). these patients were managed with debridement and implant retention (dair) with exchange of modular components, followed by six weeks of targeted antibiotics based on intraoperative culture specimens. there were no patients noted to have presented with acute haematogenous infection (tsukayama type 3). of the patients identified with acute infection, none progressed to two-stage revision following initial surgical management. from the identified 19 patients with tsukayama type 4 infection, 12 were found to have documented follow-up data which allowed them to be assessed according to the aforementioned delphi-based international multidisciplinary consensus definition of success (five hips, seven knees). the remaining patients had insufficient data on record or had not followed up again at our institution for assessment and were thus excluded from the study. the outcomes relating to treatment success were captured and tabulated (table ii). all patients undergoing revision were classified as type b hosts according to mcpherson et al.15,16 who modified the ciernymader classification for osteomyelitis (table iii) to include specific local and systemic factors (table iv). a d b e c f figure 1. case representing a two-stage hip revision. a: initial pre-operative radiograph showing right hip avascular necrosis; b: post primary total hip arthroplasty; c: proximal femur and acetabular lucency when presenting with draining sinus; d: first stage debridement with articulating cement spacer, with spacer removed at second stage (e); f: final implants following second stage reimplantation table ii: patient details and outcomes patient joint involved time between revision stages (months) time since reimplantation (months) wound healed pain subsequent surgeries 1 hip 24 36 yes, no sinus improved no 2 hip 5 4 yes, no sinus improved no 3 knee 5 6 yes, no sinus improved no 4 knee 4 6 yes, no sinus improved no 5 knee 29 29 yes, no sinus none no 6 hip 3 34 yes, no sinus none no 7 knee 10 17 yes, no sinus improved no 8 hip 6 24 yes, no sinus improved no 9 knee 6 28 yes, no sinus none no 10 hip rip rip rip rip rip 11 knee 5 20 yes, no sinus improved no 12 knee 7 78 yes, no sinus none knee fusion page 67du plessis et al. sa orthop j 2020;19(2) table iii: host classification by mcpherson16 description type a uncompromised, normal host type b compromised host with one or two local and/or systemic factors type c significant compromise with more than two compromising factors or one of the following • neutrophils <1 000 • cd4 count <100 • intravenous drug user • other chronic active infection • haematological malignancy table iv: local and systemic compromising factors as described by mcpherson16 systemic factors local factors age >80 years diabetes immunosuppressive medication systemic inflammatory disease (ra, sle) malignancy hepatic insufficiency (cirrhosis) chronic indwelling catheter renal failure requiring dialysis pulmonary insufficiency alcoholism chronic malnutrition current nicotine use systemic immune compromise active infection >3–4 months synovial cutaneous fistula soft tissue loss from prior trauma vascular insufficiency (arterial or venous) prior peri-articular fracture (crush) multiple previous incisions (skin bridge) prior local irradiation to wound area subcutaneous abscess >8 cm3 ra: rheumatoid arthritis; sle: systemic lupus erythematosus from the 12 patients with completed data there were four males and eight females, with a mean age at follow-up of 61.66 years (range 51–75, median 61). the mean follow-up time for the cohort was 25.6 months (range 4–78, median 24), with the mean time between the first and second stages being 9.45 months (range 3–29, median 6). one patient was found to have demised following the first stage of the revision process as a result of severe sepsis secondary to systemic pseudomonas aeruginosa. a second patient had recurrence of sepsis two years after the second stage, and subsequently underwent a knee fusion. all remaining patients (10/12, 83.3%) had complete wound healing with no erythema or recurrence of sinus tract formation. four patients reported no residual joint pain, with seven reporting some residual pain but an improvement compared to before the revisions. discussion the diagnosis and management of pji remains controversial with no definitive diagnostic tests17 or clear universally accepted management protocol or definition of treatment success. the diagnosis is based on a combination of clinical examination findings and laboratory results.17 the musculoskeletal infection society (msis) together with the infectious disease society of america (idsa) previously developed criteria aimed at standardising the definition and diagnosis of pji in 2011.13 these criteria were the recently revised into a scoring system17 to add weighting to different aspects of the criteria and possibly improve diagnostic accuracy. the management of pji is as contentious as the diagnosis, with multiple proposed treatment algorithms used in the literature. the literature becomes more confusing as there have been multiple definitions of treatment success or treatment failure, thus making the comparison of reported success rates difficult (table v).5 because of these diverse criteria for success, we used the delphibased international multidisciplinary consensus definition.10 twostage revision remains the gold standard for chronic pji,2 but success has also been reported for one-stage revision performed under strict conditions.18,19 within the realms of two-stage revision there remains controversy regarding the preferred protocol.5,20,21 our unit followed a similar protocol as described by sukeik et al.2 as far as possible, with some alteration to these steps based on the constraints of an overburdened public health system with long waiting lists and occasional drug availability constraints. this led to our patients having an extended spacer retention time averaging 9.45 months (range 3–29 months, median 6 months). fu et al.22 found the optimal timing of reimplantation to be between 12 and 16 weeks, but had a mean spacer retention time of 24 weeks in their success group22 whereas our time to reimplantation translates to approximately 110 weeks. despite these challenges our short-term results remain promising with 83.3% of reviewed patients showing good wound healing and improvement in pain and function without subsequent surgery. other authors have proposed some variation to the described two-stage approach. chung et al. recently described a protocol of two-stage debridement but with retention of implants.23 they table v: reported success rates following two-stage revision for pji (adapted from akgün et al.5) study (individually referenced in above article by akgün et al.) number of patients definition of failure rate of infection eradication (%) chen et al. 155 hips repeated operation long-term antibiotics 91.7 oussedik et al. 39 hips recurrent infection 96 tan et al. 186 knees 81 hips delphi-based definition 76 lange et al. 82 hips kamme et al. 85.4 triantafyllopoulos et al. 239 knees 261 hips wound healing problems elevated esr/crp long-term suppression 91.2 fink et al. 36 hips clinical signs of infection crp more than 10 mg/dl osteolysis 100 berend et al. 186 hips further surgery for infection 83 ibrahim et al. 125 hips recurrence of infection   leung et al. 50 hips recurrence of infection 79 page 68 du plessis et al. sa orthop j 2020;19(2) reported an overall success rate of 86.7% (93.8% in primary and 77.1% in revision arthroplasty) after an average follow-up of 41.8 months (12–171). in their protocol the modular components were removed, scrubbed and sterilised in the autoclave or antimicrobial soak then reinserted with antibiotic-impregnated cement beads. these beads were removed at repeat debridement five days later.23 other aspects of controversy affecting our methodology involve the relevance of a positive alpha-defensin test at the reimplantation stage. our protocol was to repeat the first stage procedure in the presence of a positive result. this practice is costly and time consuming for the unit and the patient. samuel et al.24 found that at one year a positive alpha-defensin at reimplantation correlated poorly with the presence of persistent infection and recommended against its routine use in patients with cement spacers.24 this finding is postulated to be a result of a possible inflammatory reaction to the cement spacer leading to higher false positive results.25 frozen section has been shown to correlate well with infection being present at time of reimplantation,22 but this was not part of our protocol as the service has been unavailable in the past, with staffing and resource constraints being cited as barriers to the service availability. complication rates for two-stage revisions are varied, with ibrahim et al.26 noting a high mortality rate (15%) in their study cohort, although there was no comparison group, whereas our cohort had a single sepsis-related mortality documented (8.3%). higher rates of subsequent dislocation have also been reported,27 with a 9% dislocation rate compared to the quoted 0.5%–5.3% dislocation rate in primary arthroplasty depending on the approach used.28 our cohort reported no such complications in the patients we were able to review. the possibility remains, however, that some unreviewed patients may have demised or dislocated since reimplantation but this was not ascertained. limitations of our study are the small numbers of patients undergoing revision reviewed and the short follow-up of the cohort relating to the recent nature of the digital database. the electronic database was also not completed for all patients, resulting in the exclusion of seven patients which, in a small cohort, could prove to be significant. conclusion a high short-term infection cure rate was achieved using a standardised two-stage revision protocol despite institution-related alterations regarding time to reimplantation. further follow-up is required to ascertain the mediumand long-term success of this management protocol, and the time to reimplantation should be shortened to be more in line with larger published studies. ethics statement prior to commencement of the study, ethical approval was obtained from the following ethical review board: hrec (wits) clearance certificate m170415 (obtained 29/05/2017, annual update 27/02/2019). the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions jdp contributed to the conception and design of the work; the acquisition, analysis, and interpretation of data for the work; drafting the work; final approval of the version to be submitted to the journal and ongoing input regarding corrections and editing. rg conceptualised the work and contributed to design and interpretation of the work. further contributions include critical revision and expression of intellectual content, as well as final approval of the version submitted to the journal. vs contributed to design of the work, analysis and interpretation of the data as well as revision and final approval. nf contributed to the collection of the data as well as approval of the final version. cf conceptualised the work and contributed to design and interpretation of the work. further contributions include critical revision and expression of intellectual content, as well as final approval of the version submitted to the journal. orcid du plessis j https://orcid.org/0000-0002-4617-9742 greeff r https://orcid.org/0000-0001-7691-5192 singh v https://orcid.org/0000-0002-7876-2493 fang n https://orcid.org/0000-0002-9020-1556 frey ct https://orcid.org/0000-0003-1692-9749 references 1. learmonth id, young c, rorabeck c. the operation of the century: total hip replacement. lancet. 2007;370(9597):1508-19. 2. sukeik m, haddad fs. periprosthetic joint infections after total hip replacement: an algorithmic approach. sicot-j. 2019;5. 3. kapadia bh, berg ra, daley ja, et al. periprosthetic joint infection. lancet. 2016;387(10016):386-94. 4. vanhegan i, malik a, jayakumar p, ul islam s, haddad f. a financial analysis of revision hip arthroplasty: the economic burden in relation to the national tariff. j bone joint surg br. 2012;94(5):619-23. 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c, holtom p, et al. periprosthetic total hip infection: outcomes using a staging system. clin orthop relat res (1976–2007). 2002;403:8-15. 17. parvizi j, tan tl, goswami k, et al. the 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. j arthroplasty. 2018;33(5):1309-14. e2. 18. zahar a, klaber i, gerken a-m, et al. ten-year results following one -stage septic hip exchange in the management of periprosthetic joint infection. j arthroplasty. 2019;34(6):1121-26. https://orcid.org/0000-0002-4617-9742 https://orcid.org/0000-0001-7691-5192 https://orcid.org/0000-0002-7876-2493 https://orcid.org/0000-0002-9020-1556 https://orcid.org/0000-0003-1692-9749 page 69du plessis et al. sa orthop j 2020;19(2) 19. zeller v, lhotellier l, marmor s, et al. one-stage exchange arthroplasty for chronic periprosthetic hip infection: results of a large prospective cohort study. jbjs. 2014;96(1):e1. 20. tan tl, gomez mm, manrique j, parvizi j, chen af. positive culture during reimplantation increases the risk of subsequent failure in two-stage exchange arthroplasty. jbjs. 2016;98(15):1313-19. 21. puhto a-p, puhto tm, niinimäki tt, leppilahti ji, syrjälä hp. two-stage revision for prosthetic joint infection: outcome and role of reimplantation microbiology in 107 cases. j arthroplasty. 2014;29(6):1101-104. 22. fu j, ni m, li h, et al. the proper timing of second-stage revision in treating periprosthetic knee infection: reliable indicators and risk factors. j orthop surg res. 2018;13(1):214. 23. chung as, niesen mc, graber t, et al. two-stage debridement with prosthesis retention for acute periprosthetic joint infections. j arthroplasty. 2019;34(6):1207-13. 24. samuel lt, sultan aa, kheir m, et al. positive alpha-defensin at reimplantation of a two-stage revision arthroplasty is not associated with infection at 1 year. clin orthop relat res. 2019;477(7):1615-21. 25. singh g, deutloff n, maertens n, et al. articulating polymethylmethacrylate (pmma) spacers may have an immunomodulating effect on synovial tissue. bone joint j. 2016;98(8):1062-68. 26. ibrahim m, raja s, khan m, haddad f. a multidisciplinary team approach to two-stage revision for the infected hip replacement: a minimum five-year follow-up study. bone joint j. 2014;96(10):1312-8. 27. mcalister ip perry ki, mara kc, et al. two-stage revision of total hip arthroplasty for infection is associated with a high rate of dislocation. jbjs. 2019;101(4):322-29. 28. moretti vm, post zd. surgical approaches for total hip arthroplasty. indian j orthop. 2017;51(4):368. _goback _hlk7255830 _hlk7255858 _hlk7256192 _hlk19537774 _enref_1 _enref_3 _hlk29467847 _hlk29467888 _enref_10 _enref_11 _enref_15 _hlk29468326 _hlk29468168 _enref_18 _hlk29468257 _hlk29468432 _enref_26 404 not found sa orthopaedic journal spring 2016 | vol 15 • no 3 page 63 the relationship of the size of the footprint of the fibular graft to the surface area of the vertebral endplate in the reconstruction of the anterior column of the spine dr rs rangongo bsc, mbchb(medunsa), mmed(orth)(up) department of orthopaedics, 1 military hospital, university of pretoria prof mv ngcelwane mbchb(natal), fcs(sa)orth, msc(orth)(london) head: department of orthopaedics, steve biko academic hospital, university of pretoria dr fe suleman mbchb, fcrad(d)sa, mmedrad(d)(ul) clinical head of unit: department of radiology, steve biko academic hospital, university of pretoria correspondence: prof mv ngcelwane department of orthopaedics steve biko academic hospital university of pretoria po box 667 0001 pretoria south africa email: mthunzi.ngcelwane@up.ac.za abstract introduction: the anterior column of the spine is often destroyed by trauma, infection or tumours. it is reconstructed by using an autograft, allograft or synthetic cages. the fibular autograft provides good strength, incorporates quickly and has less risk of disease transmission, which is a big advantage in communities with a high incidence of hiv. various authors cite that its major drawback is the size of its footprint because of the possibility of subsidence. we could not, however, find any literature that measures its size. aim: to measure the size of the footprint of the fibular graft in relation to the surface area of the vertebral endplate. the clinical relevance is that it may guide the surgeon in deciding how many struts of the fibular graft to use in reconstructing the anterior column, and also quantifies the statement that the fibular strut has a small footprint. material and method: ct angiograms are done frequently for peripheral vascular diseases. these angiograms show ct scan images of the lumbar and thoracic vertebrae, and fibulae of the same patient. we retrospectively examined 60 scans done during the years 2012 and 2013. from the ct scans, we measured the surface area of the endplates of the vertebral bodies of t6, 8, 12, l2, and the surface area of the cut surface of the proximal 10 cm, 20 cm and 30 cm of the fibular graft, all in square millimetres (mm2). we then compared the areas of the vertebral measurements to the area of the fibular graft measurements. results: the middle third of the fibular graft had the biggest axial surface area. the ratio of the fibular graft surface area to that of the thoracic vertebral endplate is 1:3–6. these ratios suggest that more than one fibular strut graft is required to reconstruct the anterior column in the thoracic spine. conclusion: the results show that the fibular graft is better suited for reconstruction in the upper thoracic spine. below that more than two struts are required. key words: vertebral body reconstruction, autograft, fibular graft http://dx.doi.org/10.17159/2309-8309/2016/v15n3a9 saoj spring 2016_bu.qxp_orthopaedics vol3 no4 2016/08/02 14:05 page 63 page 64 sa orthopaedic journal spring 2016 | vol 15 • no 3 introduction the anterior column of the spine is often destroyed by malignancy, infection, trauma and congenital abnormalities. the gold standard for the reconstruction of the anterior column is the use of autologous bone graft.1,2 over the years other materials such as allograft and metallic cages have become more popular. allograft is often preferred in the reconstruction of a destroyed anterior column of the spine. the bones often used are the humerus, femur, tibia or a fibula. the grafts are processed under strict conditions to minimise the risk of disease transmission and immuno-incompatibility.3 allografts are acquired through the bone bank and the quantity is therefore only limited if there are financial constraints or delivery problems. allografts are procured either from living donors or from human cadavers. their potential morbidity arises mainly from the possible transmission of pathogens, particularly viruses. however, processing of the grafts removes blood and bone marrow in which the viral agents reside.3 mechanical performance of the allograft is weakened by the negative effects of tissue processing, fatigue and post-operative fatigue.4 few guidelines exist regarding donor eligibility as to mechanical integrity of the structural allograft. the principal advantage of the allograft is the avoidance of graft harvest morbidity, and its availability in various shapes and sizes.4 current regulations address disease transmission and tissue contamination so that they are minimised.4 choosing between an allograft and autograft on the basis of economic cost is controversial because studies directly comparing these costs are lacking.2 the cost of allografts increases in direct proportion to their processing. the fibula is readily available and easy to access when harvesting it. it is strong and incorporates well with no risk of disease transmission when used as an autograft.5,6 the fibula is superior in axial strength. it provides up to 30 cm of bone which is easily accessible in the prone, supine and lateral positions. it has a low donor-site morbidity and can easily be harvested simultaneously during spine surgery. it is used extensively in the cervical spine for multiple level reconstruction. its use is less popular in the thoracic and lumbar spine, mainly because of the risk of subsidence or fracture of the graft. the size of the fibular footprint has however, to our knowledge, never been quantified. dvorak et al.7 mention that the footprint or configuration of the implant–bone interface has not been firmly established in thoracic and lumbar anterior column reconstruction. we undertook this study with the aim of quantifying the size of the footprint of the fibular graft in relation to the vertebral endplate. this information may be useful in helping the surgeon to decide whether it would be feasible to use a fibular graft in thoracic and lumbar spine. material the study was approved by the ethics committee of our university. it is a retrospective study of all the patients that had an angiogram of the lower limbs in our department of radiology for peripheral vascular diseases during the period january 2012 to december 2013. our attraction to these angiographic studies is that they show ct scans of the thoracic spine, lumbar spine and fibular graft, all from the same patient at the same time. we excluded from the study all patients who had had a leg amputation or who had pathology at the level of the relevant vertebral bodies. we reviewed the ct angiograms of the first 60 patients who met the requirements for the study. the number 60 was informed by the calculations from the bio-statistician to achieve a minimum power that gives significant statistical results. method a siemens somatom 64 slice ct scan was used to perform the angiograms. the patients were scanned in an axial mode, then coronal and sagittal reconstructions were done. a polygon region of interest was used to measure the circumference which was automatically converted to a surface area expressed in mm2. the measurements were done on the general electric health picture archiving and communication system (pacs). on the viewing status of the pacs system the coronal and axial views were cross-referenced to enable measurement of the circumference of t6, t8, t12 and l2 endplates. the cross reference between the two views enables one to identify the anatomical location precisely. the vertebrae t6 and t8 were chosen because tb of the spine is common in our setting and often affects the anterior elements of the thoracic spine.8 the t12 and l1 vertebra were chosen because the anterior columns in the thoracolumbar spine in our setting are often destroyed by trauma.7 the fibula was measured at 10, 20 and 30 cm from the tip of its head. a ratio was then established between the 20 cm cut surface area of the fibula and the vertebral endplates’ surface area. the results were used to establish a relationship between the size of the fibular graft footprint and the surface area of the vertebral body endplates. the 20 cm level was used to calculate the ratio because it represents the middle third of the fibula which is the part that is utilised as a graft. the statistical package stata 13 was used for the data analysis to determine a mathematical relationship between the size of the fibular graft and the surface area of the vertebral bodies. results the total number of 60 subjects consisted of 38 males (63%) and 22 females (37%). the ages ranged from 21 to 84 years, with a mean of 54.7 years. saoj spring 2016_bu.qxp_orthopaedics vol3 no4 2016/08/02 14:05 page 64 sa orthopaedic journal spring 2016 | vol 15 • no 3 page 65 the surface area of the endplates increased from 657.37 mm2 at t6 to 1 540.21 mm2 at l2. this is seen in both male and female patients, as shown in table i. this is a confirmation of the anatomical increase in size of the vertebrae from the thoracic to the lumbar vertebrae. the fibular surface area results show that the fibula has the greatest cross-sectional area in the middle segment, with a mean of 138.6 mm2 compared to 118.2 mm2 and 127.1 mm2 in the proximal and distal 20 cm respectively (table ii). the male patients show bigger surface areas at all three levels examined. table iii shows the ratio of the surface area of the endplate of the various thoracic lumbar and thoracic vertebrae to that of the fibula at 20 cm from the tip of the fibula. at t6, the p50 ratio is 4.6. this increases to 12.0 at l2. this means that at t6 we need 4.6 fibular struts to cover the surface area of the vertebral endplate, and 12 at l2. we however do not need to cover the whole endplate surface area with bone graft in reconstruction. figure 1 shows a comparison of the ratios between male and females. it shows no significant differences between the two genders in the ratios although the surface areas in males are bigger than those of the females. discussion bone grafting procedures are very common in orthopaedics. a retrospective study in belgium found the procedures to be 13.6% of all orthopaedic operations in a 3-year period.9 autograft bone graft is considered the gold standard in bone grafting and it is associated with higher rates of union as compared with allograft. there is currently a trend for surgeons to use allografts as substitutes for autografts due to their quantity, availability and decrease of theatre time.2,3 the increasing interest in bone allografts is due to the development of bone banks in many countries and the high safety measures that are maintained in allograft preparation. the choice of autograft vs allograft depends on surgeon experience, the number of levels being treated, the patient’s concern about potential donor site morbidity and other coexisting medical conditions. the fibular autograft is readily available and easy to access when harvesting. it is strong and incorporates well with no risk of disease transmission.5,6 it is used extensively in the cervical spine for multiple level reconstruction. its use is less popular in the thoracic and lumbar spine. the middle third of the fibula is typically harvested because of its tubular character and strength. it has the biggest surface area when compared to the proximal and distal parts, as shown in table ii. anatomically the fibular shaft provides muscle origin or attachment to muscles of the foot. it has four surfaces according to muscular attachment: extensor surface, peroneus surface, flexor surface and the tibialis posterior surface. this explains the strength and increase in size in the middle third segment, as confirmed by this study. table i: analysis of the surface area data of the vertebral endplates and the fibular graft at 20 cm from the tip of the fibular head, in mm2 gender n stats t6 t8 t12 l2 fib 20 cm female 22 mean 564.414 648.982 1 055.514 1 262.568 123.318 sd 110.553 158.864 212.732 387.065 31.331 male 38 mean 711.197 853.524 1 364.605 1 792.958 147.516 sd 160.639 210.853 254.717 374.301 36.864 total 60 mean 657.377 781.692 1 251.272 1 540.215 138.643 sd 160.066 217.332 281.705 431.939 36.604 table ii: analysis of the combined surface area data of the fibula at different heights gender n stats fibula 10 cm fibula 20 cm fibula 30 cm female 22 mean 112.818 123.318 125.068 sd 28.987 31.331 36.701 male 38 mean 121.432 147.516 128.337 sd 33.311 36.864 26.978 total 60 mean 118.273 138.643 127.138 sd 31.819 36.604 30.633 table iii: analysis of the combined computed ratio of surface areas in table i gender stats ratio t6/20 ratio t8/20 ratio t12/20 ratio l2/20 female n 22 22 22 22 mean 4.807971 5.503932 9.064269 10.81967 sd 1.323247 1.602212 2.955706 4.188323 min 2.881635 3.033557 5.217913 1.022543 max 7.529769 8.620899 17.45975 18.5079 p50 4.654064 5.125564 8.621651 11.56925 male n 38 38 38 38 mean 5.105856 6.084071 9.717685 11.97368 sd 1.7301 1.869948 2.689688 3.03704 min 2.567442 3.512565 5.47611 7.537051 max 9.783914 10.43128 16.66825 17.71636 p50 4.626639 5.928061 9.297252 12.07476 total n 60 60 60 60 mean 4.996632 5.871354 9.478099 11.55054 sd 1.587862 1.784947 2.783373 3.513201 min 2.567442 3.033557 5.217913 1.022543 max 9.783914 10.43128 17.45975 18.5079 p50 4.634661 5.584677 9.247819 12.07476 saoj spring 2016_bu.qxp_orthopaedics vol3 no4 2016/08/02 14:05 page 65 page 66 sa orthopaedic journal spring 2016 | vol 15 • no 3 the fibular length is 352.3 mm ± 15.1 mm.10 its main disadvantage is the small footprint which has been documented.7,11 dvorak et al.7 mention that the footprint or configuration of the implant–bone interface has not been firmly established in thoracic and lumbar anterior column reconstruction. iliac crest and fibular grafts maintain a relatively small area of contact with the endplate and thus may promote penetration through the endplate and subsidence into the vertebral body, resulting in the loss of sagittal alignment. winters et al.11 mention the use of multiple barrel strut grafts of free vascularised fibular graft to reconstruct the thoraco-lumbar anterior column. in the thoracic and lumbar spine, its use has been less popular because of the size of the footprint. in fact when it is used in the lumbar or thoracic spine, it has been used as two or three struts bundled together. this is because of the size of its footprint. to our knowledge this size has never been evaluated. table i in this study shows that the surface area of the endplate of the vertebra increases as one moves from upper thoracic spine to lumbar spine. this is found in both males and females. while one fibular strut is adequate for replacement of the vertebral body in the cervical spine, this study shows why multiple struts are used in the thoracic and lumbar spine. the relationship between the graft cross-sectional area and the area of the adjacent endplates has so far received no attention in the literature.12 using animals whose spines are comparable to humans, kubosch et al.12 demonstrated that a graft fractured if the graft cross-sectional area was smaller than 21% of the surface area of the endplates to be fused. the ideal footprint of the implant–bone interface has also not been firmly established. this is evidenced by the wide variability in design among the numerous prosthetic intervertebral devices currently available.7 the surface area of a commonly used commercial cage (synmesh, synthes®) for the thoracic vertebrae is 17 × 22 mm which is 374 mm2. this is found to be twice the surface area of a fibula at 20 cm from the tip as demonstrated in table ii (mean 138.64 mm2, sd 36.6). the vertebral endplate surface areas measured a mean of 657.3 mm2 at t6 and 781.6 mm2 at t8. we therefore extrapolated that two fibular struts can be used for support in the upper thoracic spine, up to t8 anterior column reconstruction. the surface areas at t12 and l2 are so big that it would be impractical to use a fibular graft with a small footprint as evidenced by the calculated ratio to the fibula at 20 cm, as shown in table iii. it would be technically difficult to use more than two strut grafts and stabilise them on the endplate. the possibility of graft displacement posteriorly and injury to the spinal cord will be increased. the shortcoming of this study is the limit in application with multilevel anterior column reconstruction. this study does not determine the height of the strut graft needed for a single vertebra and the intervertebral disc. we are therefore not able to determine how many levels of the vertebrae can be reconstructed at the upper thoracic spine. with the fibular graft harvesting and its associated morbidities, it will be impossible to harvest bilaterally to provide enough strut grafts to achieve multilevel reconstruction of the anterior column. the fibula has a dual biomechanical role of providing a site of origin for the muscles and of serving as a rigid body in load transfer.13-15 bilateral harvesting would therefore weaken muscles of the foot. the study does not aim to replace the present use of allograft as the preferred method of reconstruction. it aims to avail an option for the surgeon who cannot use an allograft for any reason. we used a novel way of determining the footprint of the fibular graft and measuring the vertebral endplate surface area which is non-invasive and reproducible. conclusion we have been able to evaluate the size of the footprint of the fibular graft and measure the surface area of the thoracic and lumbar vertebral endplate using a novel method, which is the use of a ct angiogram. data analysis shows that the fibular graft is big enough to be useful in the upper thoracic spine as two strut grafts. the lower thoracic spine and the lumbar spine require too many struts to be considered practical. acknowledgements mr n malebo, radiographer, for assisting with the measurement of the graft surface area. dr s olorungo, bio-statistician, for helping with the statistical analysis. figure 1. box plot of ratios of vertebral surface area to fibular surface area by gender r a ti o female male 20.0 20.0 5.0 10.0 15.0 ratio t6/f20 ratio t12/f20 ratio t8/f20 ratio l2/f20 saoj spring 2016_bu.qxp_orthopaedics vol3 no4 2016/08/02 14:05 page 66 sa orthopaedic journal spring 2016 | vol 15 • no 3 page 67 compliance with ethics guidelines rs rangongo, mv ngcelwane and fe suleman declare that they have no conflict of interest. this research was approved by the health sciences ethics committee of the university of pretoria, ref. no. 39/2015. references 1. brazenor ga. comparison of multisegment anterior cervical fixation using bone strut graft vs a titanium rod and buttress prosthesis. spine 2007;32(1):63-71. 2. malloy km, hilibrand as. autograft versus allograft in degenerative cervical disease. corr 2002;394:27-38. 3. albert a, leemruse t, druez v, delloye c, cornu o. are bone autografts still necessary in 2006? a three year retrospective study of bone grafting. acta orthop belg 2006;72:734-40. 4. kawaguchi s, hart ra. the need for structural allograft biomechanical guidelines. journal of the aaos february 2015;vol 23(2):119-25. 5. goldberg vm, stevenson s. natural history of autografts and allografts. clin orthop 1987;225:7-16 6. whitecloud ts, larocca h. fibular strut graft in reconstructive surgery of the cervical spine. spine 1976;1:33-43. 7. dvorak mf, kwon bk, fisher cg, eiserloh hl, boyd m, wing pc. effectiveness of titanium mesh cylindrical cages in anterior column reconstruction after thoracic and lumbar vertebral body resection. spine 2003;28(9):902-908. 8. govender s. the outcome of allografts and anterior instrumentation in spinal tuberculosis. corr may 2002;398:60-66. 9. govender s, parbhoo ah. support of the anterior column with allografts in tuberculosis of the spine. jbjs;81-b: 106-109. 10. nassr a, khan mh, ali mh, espiritu mt, hanks se, lee jy, et al. donor-site complications of autogenous nonvascularized fibula strut graft. the spine journal 2009;9:893-98. 11. winters hah, van engeland ae, jiya tu, van royen bj. the use of free vascularised bone grafts in spinal reconstruction. j of plastic, reconstructive & aesthetic surgery. 2010;63:516-23. 12. kubosch d, milz s, sprecher cm, sudkamp np et al. effect of graft size on graft fracture rate after anterior lumbar spinal fusion in a sheep model. injury, int. j. care injured 2010;41:768-71. 13. vail tp, urbaniak jr. donor site morbidity with use of vascularized autogenous fibular grafts. jbjs feb 1996; 78-a (2):204-11. 14. hughes ss, pringle t, phillips f, emery s. settling of fibula strut grafts following multilevel anterior cervical corpectomy, a radiographic evaluation. spine 2006;31:1911-15. 15. ackerman db, rose ps, moran sl, dekutoski mb, bishop at, shin ay. the results of vascularised free fibular grafts in complex spinal reconstruction. j spinal disord 2011;24(1):70-176. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj saoj spring 2016_bu.qxp_orthopaedics vol3 no4 2016/08/02 14:05 page 67 orthopaedics vol3 no4 sa orthopaedic journal winter 2016 | vol 15 • no 2 page 53 osteomyelitis in an infant with proximal focal femoral deficiency m mehtar mbbch orthopaedic registrar l hartford mbbch medical officer gb firth mbbch, fcs(sa)(orth), mmed(orth) orthopaedic consultant division of orthopaedic surgery, chris hani baragwanath hospital, university of the witwatersrand, johannesburg correspondence: dr gb firth dept. of orthopaedics wits medical school tel: (011) 717-2538 fax: (011) 717-2551 email: greg.firth@gmail.com introduction proximal focal femoral deficiency (pffd) is a rare congenital anomaly characterised by a developmental defect of the proximal part of the femur and hip joint.1,2 clinically the shortened bulky thigh segment is usually held in a flexed, externally rotated and abducted position.1,2 pffd occurs with an incidence of 1 in 52 000 live births.3,4 this case report highlights the unusual presentation of double pathology of pffd and associated osteomyelitis of the ipsilateral proximal femur with no preceding trauma or surgical intervention. this case shows how magnetic resonance imaging (mri) can be useful in localising subperiosteal infections of the proximal femur in the presence of abnormal pre-existing anatomy in very young patients. case report the mother of the patient, mrs zk, a 27-year-old, parity 2 gravidity 3, booked early at approximately 14 weeks of gestation, with normal booking bloods. she had a history of previous caesarian section for pregnancy-induced hypertension. she presented to chris hani baragwanath academic hospital for a foetal anomaly scan at 26 weeks of gestation and was reported to have placenta praevia major and shortening of all the long bones in the right upper and lower limbs. no other structural abnormalities were noted. three followup scans confirmed these findings. the mother of the patient was admitted from 33 weeks of gestation until delivery. two doses of betamethasone were administered prior to delivery. the patient was delivered via caesarean section at 36 weeks of gestation; uncomplicated delivery, baby born with good apgar scores of 9 at 1 minute and 10 at 5 minutes. abstract we present the case of a 6-week-old neonate with proximal focal femoral deficiency (pffd) complicated by osteomyelitis of the right femur with no preceding trauma or surgical intervention. key words: osteomyelitis, pffd, infant, mri, femur http://dx.doi.org/10.17159/2309-8309/2016/v15n2a9 page 54 sa orthopaedic journal winter 2016 | vol 15 • no 2 the birth weight was 2070 grams. he presented to the orthopaedic outpatient department with a limb length discrepancy and was assessed as having proximal focal femoral deficiency classified as group b according to the gillespie and torode classification and type a according to the aitken classification. the mother was counselled and follow-up was organised for three months’ time. he however returned to the paediatric ward at six weeks of age with an acute onset of new symptoms. the mother reported that the infant was not moving the right leg and cried with passive movement of the right leg with a few days duration. on examination, the neonate had low grade pyrexia and was irritable, particularly on passive movement of the right hip. he had a pseudo paralysis of the right hip and knee. an assessment of neonatal sepsis was made and the patient was admitted for further investigation and management under the care of the paediatric department. septic markers on admission were not obviously suggestive of infection with a white cell count of 10.01 and a c-reactive protein of 9.9. the paediatric orthopaedic team was called to see the patient after several days in hospital. ultrasound of the right hip was done a few days after admission, and showed a shortened right femur but no evidence of septic arthritis of the right hip or any collection of fluid in the proximal femur. an ap pelvis and femur xray was done after the ultrasound which showed a periosteal reaction around the proximal part of the right femur (figure 1). the patient was started on intravenous antibiotics (cloxacillin and cefotaxime). the patient had ongoing pyrexia in the days that followed. an mri scan was ordered and this showed a right femoral pseudarthrosis with a 9 mm collection posterior to the pseudarthrosis in the proximal part of the femur (figure 1). periosteal thickening of the right femur was noted with overlying muscular and subcutaneous oedema. the patient was taken to theatre 6 days after admission for incision and drainage of the right proximal femur collection. the delay in getting him to theatre occurred because the paediatricians were working him up and treating him as a pyrexia of unknown origin. the diagnosis was not initially clear until the mri had been done. a postero-lateral approach to the proximal femur was used as directed by mri findings. intra-operatively a small amount of pus was found under the periosteum at the level of the pseudarthrosis (figure 2). samples were taken for histology and microscopy, and the wound was washed out copiously with normal saline. histology showed the samples to be consistent with chronic osteomyelitis. staph. aureus was cultured from the specimen sensitive to cloxacillin. the baby responded to antibiotics and had an uneventful recovery. at one-year follow-up the baby had a painless hip with full range of motion and no signs of infection clinically or on laboratory investigations. the plain x-ray and repeat mri scan at one-year follow-up were negative for infection and showed a coxa vara with some development of the right femoral head (figure 3). discussion pffd is a rare spectrum of proximal femoral deficiencies characterised by failure of normal development of the proximal part of the femur and hip joint.1-3 the clinical spectrum of pffd is wide ranging from minimal shortening (femoral hypoplasia) in mild cases, to complete absence of the proximal femur and acetabulum in the most severe cases.1,3,4 fibular deficiency may be concomitantly present in approximately 50% of pffd cases.1,5 figure 1. initial x-ray and mri (stir) showing deficiency of the right proximal femur with a periosteal reaction. a sub-periosteal collection is noted with overlying muscular and subcutaneous oedema. figure 2. intra-op picture of right proximal femur demonstrating sub-periosteal femoral collection. the sciatic nerve is shown just posterior to the area of interest. sa orthopaedic journal winter 2016 | vol 15 • no 2 page 55 clinically patients typically present with a short and bulky thigh that is flexed, externally rotated and abducted.1-3,6 a clinical paradox exists in that the ‘hip joint’ in pffd is generally painless and relatively stable.7,8 westin and gunderson8 noted that ‘hip pain is seldom a complaint’ and that ‘in spite of the complete separation of the shaft from the proximal element, little or no telescoping occurs with weight bearing’. an associated pseudarthrosis of the proximal femur may occur too. pirani et al.7 postulated that the soft tissues assume a significant role in the stability and weight transfer across the hip in pffd based on the soft tissue anatomy they observed. the deficiency exists not only in the bony anatomy of the proximal femur, but also the muscle, capsule and soft tissues of the hip joint itself. plain x-rays should always be the first investigation used in the diagnosis of pffd but further investigation is useful in further delineating the extent of the condition. ultrasound is a valuable imaging modality; however, there are complex bony abnormalities at the junction of the epiphysis and metaphysis that are difficult to appreciate by ultrasound.3,9,10 mri should be considered the modality of choice when assessing pffd because of its ability to demonstrate the anatomy of the cartilaginous and bony proximal femur, which can facilitate appropriate treatment.3,4,11 osteo-articular infections in neonates are rare and usually present in an atypical way compared to older children.12 wilson et al.12 showed that infants can often have a worse outcome compared to older patients in their series possibly due to a delay in diagnosis. usually the child will present with pseudo paralysis as in the current case. the blood markers are usually less helpful than in the older child – as seen in this case. the most common organism cultured is s. aureus but often gram-negative organisms are cultured in the neonate.13-15 further imaging is usually required to confirm the diagnosis in this age group.13 it is also important to differentiate septic arthritis from extra-articular infection.16 mri could provide a precise diagnosis enabling debridement of the epicentre of infection and thus preventing a prolonged infectious process as well as avoiding unnecessary debridement of the joint and joint contamination.16 as we suspected an osteitis on the right side clinically, we started the relevant broad spectrum antibiotics (cloxacillin and cefotaxime). usually our protocol is to drain the collection as soon as possible – in a similar case we would have opened the hip and knee joint – if these were both negative the femur would have been drilled to decompress any intramedullary pus collection. the rationale in this case before surgical drainage was to accurately localise the collection, which required ultrasound, x-ray and mri, before the abscess could be appropriately identified and drained in such a small patient. there is a good chance that the small subperiosteal abscess, partly treated by the intravenous cloxacillin given by the paediatricians, would never have been localised without the mri, potentially causing a chronic osteomyelitis of the femur in this atypical case. the presence of the pffd in this case complicated things and so it was decided to investigate further with imaging studies. the x-ray did show a periosteal reaction of the proximal femur but was unable to isolate the exact site of the infection. a technetium bone scan could also have been done to localise the infection, but after discussion with the paediatricians, the mri was done instead. the ultrasound did not locate the collection which could only be seen on the mri. the mri was extremely useful in identifying the exact position of the collection for pre-operative planning. in this atypical case of pffd and femoral osteomyelitis, further investigation was directed by the change in the clinical findings of the child. ultrasound findings were equivocal but mri assisted in identifying the source of infection and enabled appropriate surgical intervention. figure 3. follow-up x-ray and mri (t1) at one-year follow-up showing presence of ossific nucleus of the right femoral head which is smaller compared to the left side. no evidence of infection. there is also dysplasia of the right acetabulum. no dissociation seen between the right femoral neck and shaft (aitken type a). page 56 sa orthopaedic journal winter 2016 | vol 15 • no 2 conclusion this atypical case highlights the importance and superiority of mri in assessing osteomyelitis in a neonate, in the setting of a second pathology – in this case pffd. the appropriate accurate surgical drainage was performed with the help of the mri which facilitated a favourable outcome. compliance with ethics guidelines m mehtar, l hartford and gb firth declare they have no conflict of interest. references 1. westberry de, davids jr. proximal focal femoral deficiency (pffd): management options and controversies. hip int 2009;19:s18-25. 2. koman la, meyer lc, warren fh. proximal femoral focal deficiency: natural history and treatment. clin orthop relat res 1982;162:135-43. 3. biko dm, davidson r, pena a, jaramillo d. proximal focal femoral deficiency: evaluation by mr imaging. pediatr radiol 2012;42:50-56. 4. dillon je, connolly sa, connolly lp. mr imaging of congenital/developmental and acquired disorders of the pediatric hip and pelvis. magn reson imaging clin n am 2005;13:783-97. 5. koman la, meyer lc, warren fh. proximal femoral focal deficiency: a 50 year experience. dev med child neurol 1982;24:344-55. 6. epps ch. current concepts review proximal femoral focal deficiency. j bone joint surg am 1983;65:867-70. 7. pirani s, beauchamp rd, li d, swatzky b. soft tissue anatomy of proximal femoral focal deficiency. j pediatr orthop 1991;11:563-70. 8. westin gw, gunderson fo. proximal focal femoral deficiency: a review of treatment experiences. in: aitken gt (eds). proximal focal femoral deficiency: a congenital anomaly. washington, d.c.: national academy of sciences; 1969: 100-10. 9. grisson le, harcke t. sonography in congenital deficiency of the femur. j pediatr orthop 1994;14:29-33. 10. kayser r, mahlfeld k, grasshoff h, merk hr. proximal focal femoral deficiency-a rare entity in the sonographic differential diagnosis of developmental dysplasia of the hip. ultraschall in med 2005;26:379-84. 11. maldjian c, patel ty, klein rm, smith rc. efficacy of mri in classifying proximal focal femoral deficiency. skeletal radiol 2007;36:215-20. 12. wilson nil, di paola m. acute septic arthritis in infancy and childhood. 10 years’ experience. j bone joint surg br 1986;68-b:584-87. 13. goergens ed, mcevoy a, watson m, barrett ir. acute osteomyelitis and septic arthritis in children. j paediatr child health 2005;41:59-62. 14. lavy cbd, thyoka m, pitani ad. clinical features and microbiology in 204 cases of septic arthritis in malawian children. j bone joint surg br 2005;87-b:1545-48. 15. robertson ajf, firth gb, truda c, ramdass da, groome m, madhi s. epidemiology of acute osteoarticular sepsis in a setting with a high prevalence of pediatric hiv infection. j pediatr orthop 2012;32:215-19. 16. mignemi me, menge tj, cole ha, mencio ga, martus je, lovejoy s, et al. epidemiology, diagnosis, and treatment of pericapsular pyomyositis of the hip in children. j pediatr orthop 2014;34:316-25. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj orthopaedics vol3 no4 page 32 sa orthopaedic journal winter 2016 | vol 15 • no 2 independent segmental bone transport of the radius and ulna: a case report ff birkholtz1,2 mbchb, mmed(orth), fcorth(sa) p greyling1 mbchb(pret), mmed(orth)(pret), fcs(orth)sa 1 department of orthopaedics, university of pretoria 2 walk-a-mile centre for advanced orthopaedics, centurion, pretoria correspondence: dr franz f birkholtz tel: 012 6442641 fax: 012 6442642 email: franz.birkholtz@walkamile.co.za address: po box 11328, centurion, 0046 introduction significant segmental bone loss in the forearm is a difficult clinical entity to treat. strategies described in literature include interposition grafting, double-barrel free fibula reconstruction, induced membrane techniques, and converting to a single bone forearm by establishing a crossunion. although the continuity of bone can be restored, the complex relationship of the radius and ulna may be disturbed, leading to a limitation of proand supination. reconstructing the radius and ulna independently with distraction osteogenesis bone transport has the theoretical advantage of maintaining the complex relationship between the radius and ulna in the forearm. in principle this should provide the ability to maintain a measure of proand supination after reconstruction. case report a 34-year-old woman was involved in a motor vehicle accident. she was a right-handed social worker at the time of injury and was systemically healthy. the injury was limited to the right upper limb, where she sustained severely comminuted fractures of the right radius and ulna. figure 1 shows the initial radiographic appearance. there was a large dorsal wound overlying the distal forearm region, measuring 5 × 8 cm. initially the patient presented to a regional hospital, where a primary debridement was performed and intravenous antibiotic therapy was instituted. an open reduction and internal fixation was performed with plates and screws. shortly afterwards she developed a fulminant infection in the fracture sites. she was splinted and referred to our unit for further management. a thorough debridement and removal of instrumentation was performed and the radius and ulna were fixed with a temporary modular bar-to-pin external fixator. three days later a wound inspection was carried out and approximately 5 cm of necrotic bone was removed from the radius and ulna. abstract significant bone loss in the forearm involving both the radius and ulna is a difficult problem to manage. the functional outcome may be limited due to loss of proand supination. we present a case where significant bone loss of both the radius and the ulna in an adult patient was successfully reconstructed using segmental bone transport. the radius and ulna were transported independently from each other to try and maintain function. a reasonable functional result was achieved. key words: bone transport, distraction osteogenesis, forearm bone loss, radius ulna transport, cement spacer http://dx.doi.org/10.17159/2309-8309/2016/v15n2a4 figure 1. radiograph depicting the patient’s initial diaphyseal radius and ulna fractures. note the extent of displacement, potentially indicating the severity of the injury. sa orthopaedic journal winter 2016 | vol 15 • no 2 page 33 an antibiotic cement spacer with gentamycin was created using off-the-shelf bone cement and inserted into the bone defect. broad-spectrum intravenous antibiotics were administered. figure 2 shows the antibiotic cement spacer in situ, as well as the stabilisation using the modular barto-pin external fixator. the patient was referred to the plastic and reconstructive surgeon who provided durable soft tissue cover with a radial forearm flap. six weeks later the temporary external fixator and polymethylmetacrylate cement spacer were removed. a paediatric monorail fixator (lrs, orthofix, verona, italy) was applied with six hydroxyapatite-coated half pins on each of the two forearm bones as depicted in figure 3. a predrilled osteotomy was done proximally for bone transport in both the radius and ulna. after a waiting period of 10 days, distraction progressed at a rate of 1 mm per day. throughout the distraction period, the patient was seen by the rehabilitation team and progressed with intensive hand therapy to maintain joint mobility and hand function. once distraction was complete and the bone defects obliterated by distraction osteogenesis, an open docking procedure was performed on both the radius and ulna. during this procedure, the bone ends at the docking site were freshened, interpositional fibrosis removed and the fragments compressed acutely using the external fixator. the docking site was augmented with cancellous autograft obtained from the right proximal tibia. figure 4 demonstrates the radiographic appearance after the docking procedure. approximately three months after docking, the lrs external fixators were removed and locking nails inserted into the radius and ulna. the ulna docking site was regrafted. final time in external fixator was 142 days which represents an external fixation index of just under 1 month per cm of bone lengthening. figure 2. radiograph depicting stabilisation of the radius and ulna with a modular pin-to-bar external fixator. also note the antibiotic bone cement spacer placed in the defect of the radius and ulna. figure 3. a clinical photograph showing the appearance of the two external fixators on the forearm. note also the presence of the radial forearm flap used to provide durable soft tissue cover. figure 4. radiograph depicting the forearm after distraction osteogenesis and subsequent open docking of the radius and ulna. figure 5. these clinical pictures were taken at final follow-up 4 years after the initial treatment and show a reasonable range of motion of the forearm. • saoj page 34 sa orthopaedic journal winter 2016 | vol 15 • no 2 two months later the fractures were radiologically and clinically united. the patient was followed up to 4 years after the index procedure and has returned to her prior occupation. she reported no chronic pain and has shown no evidence of infection. at final assessment she had an elbow arc of motion from 0 to 140 degrees of flexion. she was able to supinate to neutral and had pronation of up to 60 degrees (figure 5). discussion the special anatomical relationship between the radius and ulna require anatomical reduction to restore bone stability and function of forearm proand supination. the radius and ulna function as a unit together with the proximal and distal joints and is viewed as a bicondylar joint. for these reasons diaphyseal forearm fractures should be viewed as intraarticular lesions.1 most reconstruction techniques have been described for the lower limb. literature on treating forearm bone loss is limited to a small series of case studies. techniques that have been described to treat forearm bone loss include interposition grafting, double barrel free fibula reconstruction, induced membrane techniques, segmental bone transport and the creation of a single bone forearm by establishing a cross-union.2,3 these techniques do not replace the need for a thorough debridement and excision of necrotic and infected bone and tissue. infection is not healed by the simple compression of the fracture site alone.2-4 when dealing with forearm non-unions and bone loss, soft tissue adhesions and scar tissue need to be addressed.4 as was the case in this instance, meticulous attention to rehabilitation is needed to optimise the functional outcome. a cement spacer was used to manage the transport space. because it was preloaded with antibiotics, it provided an added benefit of local infection control. cement spacers have the added benefit of membrane induction, which leads to a bio-active pseudo-periosteum which can aid in bone reconstruction. durable soft tissue coverage is an important determinant in successful segmental bone transport.2 in this case it was provided by a radial forearm flap, which is a pliable, lowprofile fasciocutaneous flap. the monolateral frames used in this case provided the advantage of independently but concurrently reconstructing each of the two bones. the intention was to try and preserve the ellipse of the forearm and to preserve elbow range of motion in flexion, extension, pronation and supination. based on the range of motion at final assessment at 4 years’ follow-up, it seems that this philosophy was, in part, successful. an open docking procedure with an autologous bone graft at the docking site is in accordance with the data reported in the literature and important to prevent repeated fractures and nonunion.2,5 intra-medullary fixation provided stability maintaining the radius and ulna length, while still allowing the radius and ulna to function individually.3 in this instance it also provided internal stability to the tenuous regenerates and docking sites to facilitate rehabilitation and earlier external fixator removal. summary significant bone loss in the forearm involving both the radius and ulna is a difficult problem to manage. the functional outcome may be limited due to loss of pronation, supination and grip strength. this case report illustrates a novel surgical approach to independently transport the radius and ulna, and thus provide the best possible functional outcome in this devastating condition. compliance with ethics guidelines the content of the article is the sole work of the authors. ff birkholtz and p greyling declare that no benefits of any form have been or are to be received from a commercial party related directly or indirectly to the subject of the article. the procedures followed were in accordance with the ethical standards of the helsinki declaration (1964, amended most recently in 2008) of the world medical association. the patient’s written consent was obtained for inclusion of her data in this paper. references 1. jupiter jb, fernandez dl, levin sl, wysicki rw. reconstruction of posttraumatic disorders of the forearm. j bone joint surg am 2009;91:2730-39. 2. rigal s, merloz p, le nen d, mathevon h, masquelet ac, the french society of orthopaedic surgery and traumatology (sofcot). bone transport techniques in posttraumatic bone defects. orthopaedics and traumatology: surgery and research 2012;98:103-108. 3. gupta dk, kumar g. gap nonunion of forearm bones treated by modified nicoll’s technique. indian j orthop 2010;44(1):84-88. 4. liu t, liu z, ling l, zhang x. infected forearm nonunion treated by bone transport after debridement. bmc musculoskeletal disorders 2013;14:273. 5. chunshen w, zhaohua b, chenxi y, cheng c, huilin y, jun z. bone transport combined with locking plate and bone grafting for treatment of nonunion of the ulna: a case report. int j clin exp med 2013;6(10):996-1000. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. south african orthopaedic journal trauma and general orthopaedics doi 10.17159/2309-8309/2022/v21n2a1foster m et al. sa orthop j 2022;21(2) citation: foster m, du plessis j, jansen van vuuren m, jingo m, pietrzak jrt. the impact of the covid-19 lockdown restrictions on orthopaedic trauma admissions in a central academic hospital in johannesburg. sa orthop j. 2022;21(2):70-75. http://dx.doi. org/10.17159/2309-8309/2022/ v21n2a1 editor: prof. nando ferreira, stellenbosch university, cape town, south africa received: august 2021 accepted: november 2021 published: may 2022 copyright: © 2022 foster m. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background the novel coronavirus (sars-cov-2), commonly known as covid-19, has caused a global economic and healthcare crisis. many countries tried to curb the spread of the virus by implementing various lockdown restrictions to reduce transmission. the republic of south africa (rsa) implemented an alcohol ban as one of the lockdown restrictions. the objectives were to describe the effect of the lockdown alert levels and alcohol availability on orthopaedic trauma admissions, compared to the preceding two years. methods a retrospective review of clinical records was conducted. data included orthopaedic trauma admissions for the five-month period in a facility in johannesburg from 27 march to 31 august in the years 2018, 2019 and 2020. lockdown alert levels were categorised according to the department of health which included the ban, reintroduction and re-banning of alcohol consumption. data collected for 2018, 2019 and 2020 included demographics of sex and age, as well as fracture location, open or closed injuries, polytrauma patients and gunshot injuries. results overall, 672, 621 and 465 patients were admitted in 2018, 2019 and 2020, respectively. there was a decrease of 25% of orthopaedic trauma admissions during the five-month lockdown period in 2020 compared to 2019 (p-value = 0.020) and 30% from 2020 compared to 2018 (p-value = 0.010). in 2020, admissions increased by 112% (n = 82) from alert level 4, when alcohol was banned, to alert level 3 (3a), when alcohol was reintroduced. admissions decreased by 33% (n = 51) from alert level 3 (3a) to alert level 3 (3b), when alcohol was re-banned. motor vehicle accidents (mvas) were the commonest cause of admissions in alert level 3 (3a), accounting for 41% (n = 56). covid-19 tests were positive in 10% (n = 34) of the 346 tests performed on orthopaedic trauma admissions. conclusion our study showed the decrease in orthopaedic trauma admissions due to the covid-19 lockdown regulations. furthermore, our study demonstrated the impact of alcohol availability on orthopaedic trauma admissions in a central academic hospital in johannesburg. level of evidence: level 4 keywords: covid-19, orthopaedic trauma, alcohol the impact of the covid-19 lockdown restrictions on orthopaedic trauma admissions in a central academic hospital in johannesburg matthew foster,¹* jason du plessis,² marike jansen van vuuren,¹ maxwell jingo,¹ jurek rt pietrzak² ¹ division of orthopaedic surgery, university of the witwatersrand, johannesburg, south africa ² charlotte maxeke johannesburg academic hospital, division of orthopaedic surgery, university of the witwatersrand, johannesburg, south africa *corresponding author: matthew@drfoster.co.za introduction the novel coronavirus (sars-cov-2), commonly known as covid-19, was declared a pandemic in march 2020 by the world health organization (who) and has caused a global health crisis.1 the virus has spread rapidly worldwide spanning 223 countries to date with more than 172 million cases diagnosed and more than 3 711 672 deaths.1 at the time of writing, in the republic of south africa (sa), 1 675 013 cases have been diagnosed with 56 711 deaths recorded.2 on 15 march 2020, in response to the escalating number of infections, president cyril ramaphosa declared a national state of disaster in sa.3 the sa government made the decision to implement a nationwide lockdown in order to ‘flatten the curve’ and prepare an under-resourced healthcare system for the inevitable outbreak.2 the lockdown consisted of five alert levels, decreasing in stringency on restrictions of freedom of movement and accessibility to alcohol, with alert level 5 implemented on the 27 march 2020; at the time of writing, we are still under lockdown. a number of unique restrictions were enforced in sa that differed from the rest of the world. one such restriction was the prohibition of selling and distributing alcohol.3-5 trauma-related injuries claimed 4.9 million lives in 2016, of which 29% were as a result of road traffic accidents.6,7 the leading cause of death between the ages of 5 and https://orcid.org/0000-0001-7709-9529 page 71foster m et al. sa orthop j 2022;21(2) 45 years in lowto middle-income countries was injury, which is consistent with sa statistics, as trauma-related orthopaedic injuries currently remain the largest burden on orthopaedic departments across government hospitals.8 alcohol is a significant contributing factor to trauma-related injuries. the who predicts three million deaths worldwide are attributed to alcohol, representing 5.3% of all deaths and is a causal factor in over 200 conditions including injury.9 the devastating socioeconomic and healthcare sector impact caused by the burden of alcohol in sa is well documented, with 62 300 adults dying from alcohol-attributed deaths in 2015.10,11 the tangible financial cost of harmful alcohol use in sa is estimated at r37.9 billion or 1.6% of the gdp.12 worldwide, the impact of lockdown levels on orthopaedic trauma admissions has been widely documented (table i). waseem et al. reviewed over 665 studies noting a decrease in trauma admission rates ranging from 20.3% up to 84.6%.13 many studies from europe, asia, australasia and the united states of america have all shown varying degrees of a decrease in orthopaedic trauma admissions (table i).14-21 the aim of this study is to determine the impact of lockdown restrictions and subsequent alcohol prohibition imposed in response to the covid-19 pandemic on orthopaedic trauma admissions at a central academic hospital in johannesburg, compared to the preceding two years. methods our study was a retrospective review of patients admitted to a central academic hospital in johannesburg with a trauma orthopaedic injury for the five-month period from 27 march to 31 august in the years 2018, 2019 and 2020, respectively. all research data were collected with approval from both the hospital board and a local research ethics committee. our study defined acute orthopaedic trauma injuries as: fractures or dislocations of the upper and lower limbs, traumatic joint injuries, soft tissue injuries to the lower limbs, pelvis injuries and polytrauma patients. these were included in the study population. the legal age for alcohol consumption in south africa is 18 years; therefore, only patients above 18 years were included in this study. all patients with chronic orthopaedic injuries, musculoskeletal infection, hand fractures distal to the carpus, upper limb tendon injuries, spinal fractures as well as paediatric patients, were excluded as they were attended to by different specialist units. admission data were collected from a variety of sources including: trauma admission data sheets collected by the orthopaedic department daily, orthopaedic trauma admission books, clinical audits compiled by the orthopaedic departments six-monthly, as well as morbidity and mortality meeting statistics. all data were collected by the principal investigator (mf), and the results were collated using microsoft excel (microsoft, seattle, washington). table i: global decrease of orthopaedic trauma admissions14-21 author country of research report decrease in orthopaedic trauma admissions during lockdown policies hampton et al. uk 53.7% wong et al. hong kong 41.2% carkci et al. turkey 81.8% macdonald et al. scotland 26.6% luceri et al. italy 73.8% difazio et al. usa 44.9% christey et al. new zealand 43% jacob et al. australia 23‒34% data is expressed as percentages. table ii: summary of lockdown alert levels level 5 level 4 level 3 (3a) level 3 (3b) level 2 alcohol availability banned banned sales permitted with conditions banned sales permitted with conditions movement compulsory mask wearing no inter-provincial travel – only allowed to leave home to get essential goods or for healthcare compulsory mask wearing no inter-provincial travel except for returning home or exceptional conditions (e.g. funerals) walking/jogging allowed from 06:00–09:00 compulsory mask wearing no inter-provincial travel except for special circumstances: work travel, moving homes, funerals, obtaining medical therapy compulsory mask wearing no inter-provincial travel except for special circumstances: work travel, moving homes, funerals, obtaining medical therapy compulsory mask wearing inter-provincial travel allowed sectors permitted only essential services permitted all essential services, limited number of sectors with high economic value all economic activity permitted except where rate of transmission is high all economic activity permitted except where rate of transmission is high all economic activity permitted except where rate of transmission is high retail only essential goods permitted including food, medical supplies and hygiene products as per level 5, plus education supplies and stationery restaurants and takeaways only for delivery all retail permitted with strict health precautions and limitations of people all retail permitted with strict health precautions and limitations of people all retail permitted with strict health precautions and limitations of people gatherings all public gatherings prohibited all public gatherings prohibited all public gatherings prohibited six people indoor and 15 people outdoor permitted limited to 50 people curfew no persons allowed to leave home 20:00–05:00 except essential workers 22:00–04:00 21:00–04:00 22:00–04:00 public transport taxis and buses to transport essential workers, limited hours and capacity restrictions passenger rail, taxis and buses may operate subject to restrictions passenger rail, taxis and buses may operate subject to restrictions all allowed at 50% capacity no restrictions page 72 foster m et al. sa orthop j 2022;21(2) patients’ data were categorised into a variety of groups: demographics, fracture location and morphology, polytrauma, open or closed injuries and mechanism of injury. demographic data included the patients’ sex and age groups, which were divided into those patients younger than 30 years, 31–50 years, 51‒70 years and older than 70 years. fracture location was divided into upper limb, lower limb, pelvis and acetabulum, and polytrauma patients. upper limb injuries are defined from the clavicle down to carpal bones; lower limb injuries are defined as femoral head to phalanges of the foot; pelvis is defined as injuries to the ischium, ileum and pubis. hand injuries distal to the carpus and tendon injuries to the upper limb were excluded as they are managed by plastic surgery in our facility. upper limb and lower limb injuries were further categorised into the location of injury. pelvis injuries included injuries to the pelvic ring and acetabular fractures. polytrauma was categorised into more than two long bone fractures, a long bone with a pelvis injury and a long bone with other injury. open or closed injuries were defined as to whether the associated fracture had an associated breach of skin resulting in an open fracture or a traumatic joint injury. gunshot wounds (gsws) were recorded in 2018, 2019, 2020, but other mechanisms of injury (moi) were only recorded for 2020. these included a fall from standing height (ffsh), fall from height (ffh) (recorded as a fall greater than one step), motor vehicle/motor bike accident (mva/mba), pedestrian vehicle accidents (pva) and not otherwise specified. covid-19 results were recorded in 2020 and this is defined if the patient tested positive for covid-19 on a polymerase chain reaction (pcr) nasal swab. the time periods were categorised according to the months and lockdown alert levels in 2020, as published in the government gazette by the department of health, and corresponding time periods in 2018 and 2019.3-5 lockdown levels included alert level 5 which commenced on 27 march 2020 and lasted until 30 april 2020. restrictions included, but were not limited to, a complete ban of alcohol sales, a curfew, work from home except for essential workers with forced closure of all takeaway outlets and restaurants (table ii). alert level 4 commenced on 1 may 2020 until 31 may 2020 with a slight ease of restrictions, including allowing for takeaway outlets to operate but maintaining the alcohol prohibition. lockdown alert level 3 (3a) commenced on 1 june 2020 until 12 july during which time alcohol sales were permitted but subject to specific restrictions. revised alert level 3 (3b) was from 13 july to 17 august 2020, which did not allow alcohol sales or distribution (table ii). data analysis categorical variables were described using counts and percentages. two categorical variables were compared using chi-square test or fisher’s exact test when appropriate. logistic regression was used to determine associations between binary outcomes (e.g., hospitalisations in 2019 vs 2020 and hospitalisations in alert level 3 (3a) vs 3 (3b) and age, sex, moi and site. incidence rates were calculated as the number of events divided by the number of days in the given period. incidence rates were compared using an exact poisson test. results overall, 672 patients were admitted in 2018, 621 admitted in 2019 and 465 in 2020, during the five-month time period from 27 march to 31 august. there was a significant decrease of admissions by 25% between 2019 and 2020 (p-value = 0.020) and 30% between 2018 and 2020 (p-value = 0.010 ) (figure 1). in alert level 5 lockdown, 81 patients were admitted in 2020 compared to 116 in 2019 and 145 in 2018 for the same time periods. in alert level 4 lockdown, admissions decreased by 42% from 126 in 2019 to 73 patients in 2020 (p-value < 0.001). 200 180 160 140 120 100 80 60 40 20 0 2018 level 5 level 4 level 3a level 3b level 2 2019 2020 figure 1. orthopaedic trauma admissions during lockdown alert levels in 2020 and corresponding time periods in 2018 and 2019 160 140 120 100 80 60 40 20 0 level 5 level 5 level 5level 4 level 4 level 4level 3a level 3a level 3alevel 3b level 3b level 3b 2018 2019 2020 level 2 level 2 level 2 lower limb upper limb polytrauma open closedpelvis & acetabulum figure 2. site, open and closed injuries according to lockdown alert levels in 2018, 2019 and 2020 page 73foster m et al. sa orthop j 2022;21(2) table iii: total number of orthopaedic admissions in 2018, 2019 and 2020 2018 2019 2020 p-value 2020 vs 2018 p-value 2020 vs 2019 admissions 672 621 465 0.010 0.010 age (years) < 30 194 (29%) 165 (27%) 132 (28%) 0.020 0.021 30–50 330 (49%) 303 (49%) 243 (52%) 0.85 0.060 51–70 104 (16%) 107 (17%) 56 (12%) 0.002 0.291 > 70 44 (7%) 46 (7%) 34 (7%) 0.081 0.412 sex female 231 (34%) 220 (35%) 157 (34%) 0.022 0.112 male 441 (66%) 401 (65%) 308 (66%) 0.011 0.029 fracture location clavicle 18 (3%) 16 (2%) 12 (3%) 0.022 0.655 proximal humerus 10 (2%) 5 (1%) 11 (2%) 0.855 0.034 midshaft humerus 35 (5%) 27 (4%) 13 (3%) < 0.001 0.568 distal humerus 5 (1%) 2 (0.3%) 1 (0.2%) 0.65 > 0.999 proximal forearm 15 (2%) 15 (2%) 9 (2%) 0.079 0.596 radius/ulna shaft 19 (3%) 13 (2%) 9 (2%) < 0.001 0.852 distal radius/ulna 77 (12%) 58 (9%) 51 (11%) 0.03 0.072 carpus 1 (0.1%) 1 (0.1%) 1 (0.2%) > 0.999 0.309 other upper limb 20 (3%) 11 (2%) 6 (1%) < 0.001 0.770 per trochanteric 41 (6%) 46 (7%) 42 (92%) 0.665 0.113 femur shaft 54 (8%) 39 (6%) 19 (4%) < 0.001 0.229 distal femur 4 (1%) 4 (1%) 8 (2%) 0.004 0.046 patella 11 (2%) 17 (3%) 11 (2%) 0.043 0.637 proximal tibia 16 (2%) 19 (3%) 26 (6%) 0.201 0.021 tibia shaft 105 (16%) 81 (13%) 38 (8%) < 0.001 0.233 pilon and ankle 133 (20%) 145 (23%) 80 (17%) 0.087 0.465 foot 45 (7%) 19 (3%) 32 (7%) 0.022 0.002 other lower limb 17 (3%) 21 (3%) 14 (3%) 0.034 0.701 pelvis/acetabulum 17 (3%) 8 (1%) 20 (4%) 0.288 0.002 polytrauma two long bones 22 (3%) 45 (7%) 35 (8%) < 0.001 0.582 long bone + pelvis 6 (1%) 19 (3%) 9 (2%) 0.001 > 0.999 long bone + other 1 (0.1%) 4 (1%) 17 (4%) < 0.001 < 0.001 open injury open 98 (15%) 99 (16%) 83 (18%) 0.217 0.082 closed 574 (85%) 522 (84%) 382 (82%) 0.010 0.043 injury site lower limb 426 (63%) 394 (63%) 272 (59%) 0.001 0.067 upper limb 199 (30%) 146 (24%) 111 (24%) 0.002 0.086 pelvis/acetabulum 17 (3%) 8 (1%) 20 (4%) 0.045 < 0.001 polytrauma 30 (5%) 73 (12%) 62 (13%) < 0.001 0.077 data is expressed as counts with frequencies in parentheses. 60 50 40 30 20 10 0 level 5 level 4 level 3a level 3b level 2 mvagsw pva ffh ffsh figure 3. mechanism of injury during lockdown alert levels in 2020 180 160 140 120 100 80 60 40 20 0 level 5 alcohol prohibited level 4 alcohol prohibited level 3a alcohol allowed level 3b alcohol prohibited level 2 alcohol allowed figure 4. total admissions through different stages of lockdown page 74 foster m et al. sa orthop j 2022;21(2) demographics, fracture morphology and site of all admissions in 2018, 2019 and 2020 are illustrated in table iii. open fractures accounted for 16% and closed fractures accounted for 84% of the admissions in 2018, whereas in 2020, the proportion of open fractures increased to 18% (p-value = 0.157) and closed fractures decreased to 82%, respectively (p-value = 0.010) (figure 2). admissions increased by 112% (n = 82) in alert level 3 (3a) from alert level 4, followed by a decrease of admissions by 33% (n = 51) in alert level 3 (3b), from level 3 (3a) (p-value = 0.050). the incidence rate (ir) of admissions during alert level 3 (3a) vs 3 (3b) is 1.27 (95% ci: 0.99, 1.65). during alert level 3 (3a), patients < 30 years accounted for 34% of admissions compared to 20% in level 3 (3b). patients admitted in the 30‒50 years age group were 2.16 times more likely than patients < 30 years to be admitted in alert level 3 (3b) compared to alert level 3 (3a) (p-value = 0.020). from initiation of mandatory testing of all orthopaedic admissions from 19 may 2020, 346 covid-19 tests were performed on orthopaedic trauma admissions, of which 10% were positive (n = 34) (p-value = 0.001). of the 34 positive patients, 71% (n = 24) of patients were male (p-value = 0.001). no patients that were covid-19 positive sustained gsws and 3% (n = 1) of covid-19 positive patients sustained an open fracture (p-value < 0.001). during alert level 5, ffsh were the commonest moi accounting for 42% (n = 28) of admissions. mvas were the commonest cause of admissions in alert level 3 (3a), accounting for 41% (n = 56) whereas in alert level 3 (3b), mvas decreased to 12% (n = 12) (p-value = 0.001) (figure 3). in alert level 3 (3b), ffsh was again the moi which attributed to the most admissions at 39% (n = 38). gsws remained constant through all alert levels of lockdown ranging from 11% (n = 7) of admissions in alert level 5, up to 16% (n = 8) in alert level 2. discussion our study showed that there was a decrease of 31% and 25% in orthopaedic trauma admissions from the initiation of lockdown compared to the same time periods in 2018 and 2019, respectively. global reports have shown similar trends; however, many of these were conducted over a short time period, whereas this study has a longer time period to compare data. hampton et al. showed a decrease of 53.7% of orthopaedic trauma admissions in a united kingdom (uk) hospital from a two-week pre-lockdown time period to a two-week lockdown time period, and compared these rates to 2019.14 christey et al. noted a decrease of 43% of admissions in a new zealand facility and difazio et al. showed a 44.9% decrease in a usa facility, for a two-week period preand post-lockdown, but without the 2019 comparison.15,20 if we compare the combination of alert levels 4 and 5, referred to as the hard lockdown, to the same time period in 2019, the decrease in admissions was 36% which was more consistent with international data. sa has a higher burden of trauma relating to interpersonal violence compared to developed nations, where the majority of injuries in developed nations are caused by mvas or falls, and much less violence.22 a reasonable assumption can be made about the decrease in trauma admissions during lockdown. this was due to policies enforced by government such as: nonessential service employees working from home, a curfew, school closures and a ban on alcohol and cigarettes. this would result in fewer mvas/pvas and sporting injuries, and less interpersonal violence and crime. all of the above would be further decreased without the exaggerated harmful effects of intoxication, as alcohol has been proven in sa to have a severe negative impact on society.10 in sa, moustakis et al. looked at all surgical admissions in the north west in alert level 5, noting a 53% reduction in traumarelated conditions.23 navsaria et al. noted similar results with a decrease of 53% of all surgical trauma admissions during the hard lockdown in cape town.24 waters et al. specifically looked at the reduction of orthopaedic services from 01 january to 30 april 2020 at groote schuur hospital to compare pre-lockdown and lockdown admission rates, noting a decrease of orthopaedic admissions by 40% in april. our data was consistent with our colleagues in cape town, comparing a tertiary hospital in cape town to one in johannesburg; however, our study further looked at the availability and prohibition of alcohol, and the effects thereof.25 our study showed a significant increase in admissions of 112% from when alcohol was banned in alert level 4, to when it was available in alert level 3 (3a) (figure 4). the change in admissions between alert levels 4, 3 (3a) and 3 (3b) suggests the influence alcohol has on orthopaedic trauma. reuter et al. stated that 62 300 south africans die of alcohol-attributable causes annually and noted a sharp reduction in unnatural related deaths from pre-lockdown of 800‒1 000 per week to a rate of 400 per week during lockdown.26 furthermore, there was a 45% decrease in orthopaedic admissions from two weeks pre-lockdown to the first two weeks of lockdown from the hospital in george where reuter et al. conducted their research.26 the decrease in admissions due to mvas from 41% in alert level 3 (3a) to 13% in alert level 3 (3b) identified the significant impact alcohol availability had on mvas. the association between alcohol and mvas is consistent with global trends as papalimperi et al. identified 40.7% of all mvas over a seven-year period were alcohol related.27 shneider et al. looked at the burden of disease attributed to alcohol in sa, noting that interpersonal violence and road traffic accidents contributed significantly to disability adjusted life years, clearly illustrating the harmful effects of alcohol on south african society.28 when comparing 2018, 2019 and 2020, males have consistently accounted for almost two-thirds of admissions. our study showed no difference in this trend during lockdown, which is in keeping with global literature, as males are more prone to trauma-related injuries due to increased risk-taking behaviour and higher levels of interpersonal violence.9,29 when alcohol was allowed in alert level 3 (3a), the age group younger than 30 years accounted for 34% of admissions compared to 16% in alert level 4, when alcohol was banned. this illustrated the impact alcohol has on those younger than 30 years, which was consistent with caamaño-isorna et al.’s results, which showed the increase in alcohol-associated injuries in college students in spain.30 mandatory covid-19 testing of all admissions was not present during the early lockdown alert levels so the incidence of 10% was during our peak time period. pillai et al. concluded that the number of covid-19 positive patients increased with the easing of lockdown regulations to level 3 in gauteng, which is consistent with our data.31 in the covid-19 positive population, demographics, fracture pattern and mechanism of injury were similar to that of covid-19 negative patients. globally, the socioeconomic impact of orthopaedic trauma and alcohol is immense. in the usa, an estimated $53.1 billion is spent annually to treat musculoskeletal injuries, with over a million hospital discharges recorded for fractures.32 probst et al. identified the socioeconomic effect of alcohol on the south african population, noting that 60% of deaths due to alcohol occur in patients within the low socioeconomic status group.10 martin et al. calculated that the cost of treating an orthopaedic trauma patient secondary to a gsw in sa was $2 940 (r24 945 at the time), three hours of theatre time with an average stay of 9.75 days.33 the combination of financing healthcare costs, acute and chronic disability of patients, hospital stay and rehabilitation, as well as the time off work, places severe strain on our economy. alcohol is a major contributing factor, as demonstrated by this report, and the effects of which can be minimised. the who has led a global initiative to assist governments in decreasing alcohol-associated harm.34 page 75foster m et al. sa orthop j 2022;21(2) covid-19 and the effects of the lockdown policies have demonstrated significant associations between alcohol and orthopaedic trauma admissions. the data collected during this period can be utilised to guide government policies in limiting the harmful effects of alcohol on our society. data collection at our institution was not uniform and multiple sources were recorded to obtain data to get a global perspective. additional limitations included government lockdown bias as a curfew was imposed. this may contribute to diminished orthopaedic trauma admissions in conjunction with no alcohol availability. moultrie et al. concluded that the complete prohibition of alcohol had a significant reduction in unnatural deaths regardless of the length of the curfew.35 lastly, with the anticipated reintroduction of alcohol restrictions, people may have stockpiled alcohol, making it available to them during the time of repeat restrictions. conclusion covid-19 and the lockdown policies enforced by governments worldwide has had a significant effect on decreasing orthopaedic trauma admissions, with sa consistent with global trends. alcohol availability clearly has a major impact on orthopaedic trauma admissions which, through correct legislation, can be minimised. our study will hopefully allow government and policy makers to rethink the current legislature around alcohol availability and consider enforcing further regulations limiting alcohol access and the consequence thereof on our healthcare system. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. all research data were collected with approval from both the hospital board and university of the witwatersrand human research ethics committee (hrec) (clearance number: m200877). all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions mf: study conceptualisation, data capture, data analysis, manuscript preparation, revision and approval of final manuscript jdp: manuscript revision and approval of final manuscript mjvv: data collection and approval of final manuscript mj: manuscript revision and approval of final manuscript jrtp: study conceptualisation, manuscript revision and approval of final manuscript orcid foster m https://orcid.org/0000-0001-7709-9529 du plessis j 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age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the global burden of disease study 2013. lancet. 2015;385(9963):117-71. https://doi. org/10.1016/s0140-6736(14)61682-2. 23. moustakis j, piperidis aa, ogunrombi ab. the effect of covid-19 on essential surgical admissions in south africa: a retrospective observational analysis of admissions before and during lockdown at a tertiary healthcare complex. s afr med j. 2020;110(9):910-15. https:// doi.org/10.7196/samj.2020.v110i9.15025. 24. navsaria ph, nicol aj, parry cdh, et al. the effect of lockdown on intentional and nonintentional injury during the covid-19 pandemic in cape town, south africa: a preliminary report. s afr med j. 2020;13183. https://doi.org/10.7196/samj.2021v111i2.15318. 25. waters r, dey r, laubscher m, et al. drastic reduction of orthopaedic services at an urban tertiary hospital in south africa during covid-19: lessons for the future response to the pandemic. s afr med j. 2021;111(3):240-44. 26. reuter h, jenkins ls, de jong m, et al. prohibiting alcohol sales during the coronavirus disease 2019 pandemic has positive effects on health services in south africa. afr j prim health care fam med. 2020;12(1):1-4. https://doi.org/10.4102/phcfm.v12i1.2528. 27. papalimperi a, athanaselis s, mina a, et al. incidence of fatalities of road traffic accidents associated with alcohol consumption and the use of psychoactive drugs: a 7-year survey (2011–2017). exp ther med. 2019;18(3):2299-306. https://doi.org/10.3892/etm.2019.7787. 28. schneider m, bradshaw d, norman r, et al. estimating the burden of disease attributable to alcohol use in south africa in 2000. s afr med j. 2007;97(8):674-81. https://doi.org/10.7196/ samj.661. 29. gomez d, haas b, de mestral c, et al. gender-associated differences in access to trauma center care: a population-based analysis. surgery. 2012;152(2):179-85. https://doi. org/10.1016/j.surg.2012.04.006. 30. caamaño-isorna f, moure-rodríguez l, doallo s, et al. heavy episodic drinking and alcoholrelated injuries: an open cohort study among college students. accid anal prev. 2017;100:2329. https://doi.org/10.1016/j.aap.2016.12.012. 31. pillai j, motloba p, motaung ksc, et al. the effect of lockdown regulations on sars-cov-2 infectivity in gauteng province, south africa. s afr med j. 2020;110(11):1119-23. https://doi. org/10.7196/samj.2020.v110i11.14828. 32. bone and joint initiative usa. by the numbers. musculoskeletal conditions. diseases, disorders and injuries relating to bones, joints and muscles. available from: www. boneandjointburden.org. accessed 8 june 2021. 33. martin c, thiart g, mccollum g, et al. the burden of gunshot injuries on orthopaedic healthcare resources in south africa. s afr med j. 2017;107(7):626-30. https://doi. org/10.7196/samj.2017.v107i7.12257. 34. who. safera world free from preventable disease. available from: https://www.who.int/ initiatives/safer. 35. moultrie ta, dorrington re, laubscher r, et al. unnatural deaths, alcohol bans, and curfews: evidence from a quasi-natural experiment during covid-19. s afr med j. 2021;111(9):83437. https://doi.org/10.7196/samj.2021.v111i9.15813. https://orcid.org/0000-0001-7709-9529 https://orcid.org/0000-0002-4617-9742 https://orcid.org/0000-0003-2715-5742 http://orcid.org/0000-0001-5694-0016 ole_link1 south african orthopaedic journal spine doi 10.17159/2309-8309/2022/v21n3a3 cetinkaya m et al. sa orthop j 2022;21(3) citation: cetinkaya m, gezengana v, mann tn, du toit j, davis jh. halo-external fixator frame-assisted correction to treat severe kyphotic deformity in children younger than 4 years old. sa orthop j. 2022;21(3):154-159. http://dx.doi. org/10.17159/2309-8309/2022/ v21n3a3 editor: prof. robert n dunn, university of cape town, cape town, south africa received: june 2021 accepted: august 2021 published: august 2022 copyright: © 2022 cetinkaya m. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background severe kyphotic deformity in young children may have devastating outcomes when neglected. halo-pelvic traction has been shown to be very effective as part of the treatment for severe kyphosis, but little is known about application of this technique in very young individuals. the aim of this case series was to provide novel insights into the surgical technique associated with halo-external fixator frame (heff) treatment for severe spinal deformity in patients younger than 4 years old, along with the associated radiologic outcomes and complications. methods clinical and demographic characteristics including the duration in the heff, heff-associated change in kyphosis angle (ka) and final ka following definitive surgery were extracted from medical records. results five female patients with a mean age of 36 months (range 30–44) were included. three patients had thoracic spinal tuberculosis (mean ka 82°), one had lumbar spinal tuberculosis (ka 42°) and one had iatrogenic post-laminectomy cervical kyphosis (type 1 neurofibromatosis)(ka 112°). the heff was applied for a mean of six weeks and resulted in a mean thoracic deformity correction of 29° (38%), a lumbar correction of 23° (55%) and cervical correction of 47° (42%). definitive surgery resulted in a further mean overall deformity correction of 28, and patients had a satisfactory ka angle (23° lordosis to 31° kyphosis) at the last follow-up. heff-associated complications included pin-site infection, pneumonia and frame dislodgement. conclusion heff appears to be an effective method for correcting severe kyphotic spinal deformity in very young patients where other options are limited. it allows for independent mobilisation and can provide for spinal stabilisation while awaiting bony healing after definitive surgery. however, healthcare providers should be aware of the potential dangers of heff hardware, such as difficulty in establishing an airway due to the fixed position of the neck. level of evidence: level 4 keywords: external fixators, kyphosis, spine, child, tuberculosis halo-external fixator frame-assisted correction to treat severe kyphotic deformity in children younger than 4 years old mehmet cetinkaya,1,2 vuyo gezengana,1 theresa n mann,1,2 jacques du toit,1 johan h davis1,2* ¹ division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa ² institute of orthopaedics and rheumatology, mediclinic winelands orthopaedic hospital, stellenbosch, south africa *corresponding author: jdavis@ior.health introduction severe kyphotic deformities in very young patients may have devastating outcomes when neglected, including decreased thoracic volume and vital capacity, thoracic insufficiency syndrome and costo-pelvic impingement.1,2 the anteriorly folded trunk is usually accompanied by a posterior gibbus deformity, and longitudinal growth in the upper body is restricted. with extreme and progressive deformity, myelopathic changes of the spinal cord, and even paralysis, may occur.2,3 the treatment of choice for severe kyphotic deformity is surgical correction. however, these surgeries can be complex and high risk, especially in children. in the very young, the vertebrae are still largely cartilaginous, and even though instrumentation with spinal implants is possible, anchor strength is limited.4,5 furthermore, techniques that require long segment instrumentation and fusion are not suitable for young children as this age group still has high longitudinal growing potential. single-staged procedures for severe deformity may also have limited correction capacity in some cases and are associated with significantly increased perioperative complication rates due to the extensive surgical approach and risk to the spinal cord.3,6 given the problems associated with corrective surgery alone to treat severe kyphotic deformity, various traction techniques have been developed to promote an improvement in deformity prior to definitive surgical correction.7-11 a traction-induced decrease in deformity has been shown to reduce preoperative patient risk scores along with the complexity and duration of the subsequent surgery.8,12 furthermore, the gradual correction allows the spinal cord and its blood supply to adjust to the increased length and https://orcid.org/0000-0002-7131-4280 https://orcid.org/0000-0002-1909-7629 page 155cetinkaya m et al. sa orthop j 2022;21(3) shape of the spine, reducing the risk of neurological insult as in acute correction.13 severe deformity may be complicated by respiratory dysfunction, and traction has also shown substantial benefit for improving preoperative respiratory function in these cases.14,15 traction techniques described in the literature include halo-pelvic, halo-gravity, and halo traction, accompanied by anterior release procedures as indicated.7-12,14-17 halo-pelvic traction was first developed by o’brien et al. in 1958 and has been shown to be very effective as part of the treatment for severe kyphosis.7,8,14,16-18 for example, previous studies have reported significantly reduced blood loss and surgery time when comparing patients who received preoperative halo-pelvic traction to those who received surgical correction only.8,17 in one study, preoperative halo-pelvic traction also significantly improved deformity correction and patient height compared to surgery alone, whereas another study found reduced complications with preoperative halo-pelvic traction but a similar postoperative deformity correction.8,17 in recent decades, halo-gravity traction has gained prominence for the treatment of kyphotic deformity, with halo-pelvic traction less commonly reported.9,10,12,19 however, the latter technique remains an effective and affordable option and may even have advantages when it comes to very young children.8,16 while halo-gravity traction has the advantage of leaving the legs and pelvis unrestrained, it does nevertheless limit independent mobility by requiring a wheelchair or suspensive walking frame, effectively tethering the patient to their gravity suspension device. conversely, halo-pelvic traction allows for independent, bipedal mobility – an important consideration during the rapid growth and development of early life. this technique may also be more suited to the small body size and weight of very young children and, in addition, allows caretakers to carry and lift the patients for hygiene and other purposes without any alteration to the traction force or moment. to our knowledge, use of a halo-external fixator frame (heff), with adjustability in three dimensions, for the treatment of severe kyphotic deformities has not previously been described in young children in whom the spinal column is not fully developed. furthermore, to our knowledge, the use of six expandable struts with universal couplings joining the halo-ring to the pelvic ring construct, allowing for unique and controlled gradual correction of complex spinal deformities, has also not previously been reported. thus, the aim of this case series was to provide a novel description of the surgical technique, radiological outcomes and complications associated with heff use in children younger than 4 years old. materials and methods this case series followed the design of a retrospective cohort study and involved patients with severe spinal kyphotic deformity who underwent heff-assisted correction before definitive corrective surgery. the inclusion criteria were early-onset (< 4 years old) deformity and single kyphotic deformity with acute angulation that was corrected with heff as a last resort option. all procedures were performed by the same fellowship-trained senior orthopaedic spinal surgeon and took place at the same tertiary hospital between 2011 and 2017. the follow-up period presented spanned from the initial clinical examination to post-definitive surgical correction. data extracted from each patient’s medical records included demographic details, medical history and body weight as well as the length of time in the heff, and any associated complications. neurological status, kyphosis angle (ka) on radiographs before and after heff application and surgical procedure were also recorded. halo-external fixator-frame application the heff application was performed under general anaesthesia. after preoperative evaluation for any potential anaesthesiainduction contraindication, pin entry sites, ap and lateral scoliosis radiographs, and limited fine slice computerised tomography (ct) scans of the deformities were evaluated for preoperative planning. the patient was first positioned in the supine position on the operating table. the heff was mocked up prior to surgery to aid with selection of appropriate ring sizes. standard haloapplication technique for children was used, with eight skull pins inserted. the anterior pin location was 1.5 cm above the lateral thirds of the eyebrows (figure 1a). posterior pin entry points were located right across to anterior pins and just 1 or 2 cm distal to the prominent equator of the head, with additional pins interspersed to evenly spread holding forces (figure 1b). the pins were tightened in a cross-over fashion to 2 lbs/square inch (and subsequently re-tightened daily for three days). the pelvic ring was affixed with hydroxyapatite-coated schanz pins placed bilaterally under fluoroscopy imaging guidance. two pins were placed in the supraacetabular region directly over the palpable greater trochanter of the femur in a coronal plane. two pins were placed from anterior figure 1. a) anterior view of the halo-external fixator frame and pins; b) posterior view of the halo-external frame and pins (the hrec requested that the photographs be recreated using line drawings or other software to fully remove all potential ways of identifying the children as the authors were unable to obtain patient consent.) a b page 156 cetinkaya m et al. sa orthop j 2022;21(3) into the superior anterior iliac spines following the inter-table plane posteromedial, and a further two pins placed in the posterior iliac wings with an insertion point of posterior inferior iliac spine from posterior to anterior (figure 1b and figure 2). the pin tracts were drilled at low speed with a new sharp drill bit in order to avoid thermal necrosis and poor pin purchase. ha-coated pins were manually advanced until the threaded part was embedded in the bone with the smooth shank protruding from the soft tissue. the schanz pins were fixed to an ilizarov-type ring around the pelvis with at least 2 cm of distance between frame and skin (figure 1b). the external fixator frame ring and the halo rings were then connected with two anterior and two posterior expandable external fixation rods, or by six adjustable struts with universal couplings to the rings to allow angular correction, thus allowing gradual distraction or deformity correction by alternating lengthening of the struts in a pre-planned fashion (figure 3). frame positioning for thoracic, lumbar and cervical spine deformities is shown in figure 4. the pin sites were cleaned on a daily basis with sterile swabs and 2% chlorhexidine gluconate solution. no rod lengthening was done during the first postoperative week to allow for bone and hydroxyapatite-coated implant interface integration. after supposed ha-bone integration, sequential adjustments were made to the struts on a daily basis according to a predetermined plan to gradually correct the deformity specific to the individual case through distraction and/or segmental extension. weekly control radiographs were taken to monitor correction in figure 3. expandable rods and pelvic fixator rim (photograph recreated to protect patient identity.) figure 2. halo-external fixator frame pelvic pin placement: a) ap view; b) lateral view; c) superior view a b c figure 4. halo-external fixator frame positioning: a) thoracic deformity; b) lumbar deformity; c) cervical deformity a b c page 157cetinkaya m et al. sa orthop j 2022;21(3) deformity and careful daily clinical examinations (specifically neurological function) followed the daily adjustments. results patient characteristics and presentation there were five female patients who met the study criteria, with patient characteristics and diagnosis shown in table i. the mean age was 36 months (range 30–44), and the mean body weight was 13 kg (range 9–14). patients 1–3 presented with deformity of the thoracic region. each had a severe dorsal gibbus, and the mean initial ka was 82°. the spinous processes were typically splayed from distal adjacent ones. all patients appeared malnourished upon clinical examination. furthermore, each had a positive tb contact history and palpable cervical lymphadenopathy. a single patient (patient 2) was neurologically intact whereas patient 1 and patient 3 had neurological deficit with a frankel grade of b and d and ashworth spasticity score of 2 and 3, respectively. the latter two patients were described as having insidious onset of progressive lower limb weakness accompanied by faecal incontinence developed over the past six weeks. patient 2 had a previous t8–11 posterior onlay fusion (pof) when she was a 20-month-old. patient 4 presented with a lumbar kyphotic deformity. she had a cachectic appearance and was suffering from severe abdominal distension. she was initially investigated extensively for abdominal tb. however, mri demonstrated large psoas abscesses causing abdominal distension. she had palpable cervical lymphadenopathy and a lumbar region gibbus deformity corresponding to l2–4 levels and causing a loss in lumbar lordosis and increased pelvic retroversion. x-rays revealed a 42° lumbar kyphotic deformity. there was no clinically evident neurologic deficit (frankel e). patient 5 had involvement of the cervical spine and presented with a ka of 112° at c6–7 level and left arm weakness. she was able to walk with assistance but had a myelopathic gait disturbance and frankel grade of d. background medical history revealed cervical laminectomy for resection of epidural neurofibroma causing spinal cord compression and myelopathy when she was a 12-month-old. this resulted in a severe iatrogenic post-laminectomy, cervical kyphotic deformity. unlike the other patients, this patient had a halo attached to a ring mounted on the shoulders of a body jacket, through six adjustable struts with universal couplings to allow angular correction of the cervical kyphosis (figure 5). heff-assisted deformity correction time spent in the heff along with change in deformity and neurological status is shown in table ii. in patients 1–3, with thoracic involvement, the mean ka decreased from 82° to 53° (38%) after heff application, with a mean traction duration of 6.3 weeks. furthermore, patients 1 and 3, who had neurological deficit at baseline, showed one frankel grade of neurological improvement during heff correction. the definitive surgeries performed were t4–10 strut graft followed by t3–11 posterior instrumented fusion (pif), t6–11 anterior instrumentation and fusion, and t6–11 pif, respectively. the ka was further improved to a mean of 29° after the definitive surgery, with no neurological fallout. patient 4 spent five weeks in the heff, during which time her kyphotic deformity was decreased from 42° to 19° (55%). she then underwent l2–4 anterior debridement and strut graft table i: patient characteristics and diagnosis patient age (months) sex weight (kg) weight for age (% of expected) hiv status diagnosis 1 37 female 12 80% negative spinal tb 2 32 female 9 50% negative spinal tb 3 44 female 14 50% negative spinal tb 4 36 female 14 50% negative spinal tb 5 30 female 14 60% negative type 1 neurofibromatosis tb: tuberculosis figure 5. a) preoperative lateral x-ray of the cervical kyphotic deformity; b) lateral x-ray of the cervical deformity after implementation of the halo fixator frame a b table ii: time in the halo-external fixator frame, associated change in frankel grade and kyphosis angle and final kyphosis angle following definitive surgery patient vertebral level affected total time in heff (weeks) frankel grade kyphosis angle (°) initial after heff initial after heff (% reduction) after definitive surgery 1 t4–11 6 b c 60 29 (48) 26 2 t8–11 8 e e 90 59 (34) 30 3 t7–9 6 d e 96 70 (27) 31 4 l2–4 5 e e 42 19 (55) −23 5 c6–7 4 d d 112 65 (42) na heff: halo-external fixator frame; na: not available page 158 cetinkaya m et al. sa orthop j 2022;21(3) implementation followed by pof and remained in the heff for a further six weeks. her curve decreased to 23° lordosis after the surgery and, at the last follow-up, there was no neurological deficit. patient 5 spent four weeks in the heff, after which the cervical deformity was reduced from 112° to 57° (42%). she subsequently underwent an anterior three-level corpectomy and bone graft strut and was immobilised further in the heff while admitted to the paediatric icu. the patient regrettably demised shortly after this definitive corrective surgery as described under ‘complications’ below. complications during the time in heff traction, patient 1 had pin-site infection, and pin loosening three days before the intended removal of the frame. a hospital-acquired pneumonia developed and was effectively treated with antibiotics. patient 4 developed surgical site infection, which resolved with vacuum-assisted closure dressings and oral antibiotics, as well as a nosocomial sepsis with unknown source that resolved on intravenous antibiotics. patients 2 and 3 presented with dislodgement of the heff after a weekend pass-out in the care of their parents. in contrast, patient 5 did not experience complications during the heff traction. however, this patient developed respiratory arrest approximately 12 hours after a definitive surgical procedure, while still immobilised in the heff. after excluding obstructive airway compromise and all other surgery-related complications through post-mortem investigation, the death was attributed to a likely hypoventilation with progressive and gradual hypoxia secondary to opiate analgesia. the physician attending in icu was unable to intubate the patient for ventilation assistance due to the rigid halo frame fixating the head and not allowing for cervical extension. this incident highlighted the risk and difficulty of managing the airway in such a patient. the authors subsequently keep a bolt cutter and laryngeal mask airway in close proximity to these patients in the early postoperative period. discussion the current series constitutes one of the first descriptions of heffassisted deformity correction in children younger than 4 years of age. the series showed that 4–8 weeks in the frame resulted in a mean kyphotic deformity correction of 29° (38%) for the three patients with thoracic involvement and corrections of 23° (55%) and 47° (42%) for patients with lumbar and cervical involvement, respectively. definitive surgery resulted in a further mean overall deformity correction of 28° and patients had a satisfactory ka angle (23° lordosis to 31° kyphosis) at the last follow-up. the heff-associated deformity correction observed in the current series is broadly in keeping with previous reports of halogravity-associated correction in older children. for example, pourtaheri et al. reported a 33° (35%) mean reduction in thoracic kyphosis following a mean of 4.6 weeks halo-gravity traction among eight children 5–12 years of age.19 similarly, verhofste et al. reported a mean deformity correction of 38% in cervical kyphosis following 5.3 weeks of halo-gravity traction among 12 children with mean age of 11 years.20 iyer et al. summarised previous halo-gravity studies as showing 30–35% deformity correction.12 furthermore, in their own large study of 96 cases, the authors reported a mean deformity correction of 31% following halo-gravity traction among patients with a mean age of 17 years.12 in this instance, the mean period of traction period was 14 weeks, somewhat longer than that of pourtaheri et al., verhofste et al. and the current series. although patients in the current series developed complications such as infection or frame dislodgement, these could be resolved relatively easily and were generally similar to complications reported for other traction techniques. for example, complication rates of 53% and 34% have been reported for halo traction and halo-gravity traction, respectively, with the majority of complications consisting of pin-site infection.12,21 forms of halo traction can also carry a risk of neurological injury, including injury to the cranial nerves, although no such complications were observed in the current series.21 previously reported complications, such as limited range of motion in the cervical spine following prolonged immobilisation and avascular necrosis of the odontoid peg, were also not encountered in this series.22 this is possibly due to the shorter duration of traction and more flexible, yielding nature of the very young spine. in contrast to some of the aforementioned complications, the problem of airway access while fitted with a heff is clearly unique to this form of traction. while this constitutes a significant risk, such risk can be mitigated through having a bolt cutter and laryngeal mask readily available as a precaution. severe kyphosis is a relatively rare presentation and prospective studies to directly compare the effectiveness, required duration and complication rates of different traction techniques would be very challenging to execute. however, there is one notable retrospective study available.15 chen et al. compared outcomes following preoperative halo-gravity traction or halo-pelvic traction among 81 patients with severe, rigid kyphoscoliosis (cobb angle > 100º) and found largely in favour of the halo-pelvic technique.15 when compared to halo-gravity traction, halo-pelvic traction was associated with significantly shorter traction time, significantly better deformity correction, significantly better improvement in pulmonary function and fewer osteotomies.15 the authors noted that although halo-gravity traction is well tolerated, it has relatively poor strength and efficiency and may be subject to a ‘plateau effect’ within a relatively short period. thus, it was felt to be unsuitable for rigid deformities. in contrast, halo-pelvic traction provided powerful distraction forces but was associated with prolonged hospitalisation, cervical stiffness, early cervical degeneration and pin-site infections.15 with few other comparative studies available, clinical judgement may play a significant role in the choice of traction technique for a particular presentation. the major advantage of halo-gravity traction is that it leaves the lower body unrestricted, significantly reducing patient discomfort. nevertheless, this technique may provide relatively lower distraction strength and is thought to be unsuitable for rigid deformities.15 patients managed with halogravity traction may also require more assistive care, including weight adjustment when changing to a supine position. the main advantage of the heff is that it allows for independent, bipedal mobilisation rather than reliance on a wheelchair or walking frame. furthermore, independent mobilisation may somewhat reduce the level of assistive care required when compared to halogravity traction. from a technical perspective, the heff allows for gradual, controlled adjustment of traction in tiny increments every day and the nature of the apparatus allows for angular correction as well as length distraction. furthermore, it can provide for spinal stabilisation while awaiting bony healing after definitive surgery. a major disadvantage of the heff is that it is clearly very burdensome for patients to wear, although the modified, half-ring halo-pelvic apparatus described by wang and colleagues may partially relieve patient discomfort.14,16 this technique also typically involves prolonged hospitalisation and constant vigilance for pinsite infection. the main limitation of the current study was the small sample size. a larger sample size may have provided a better representation of average heff-assisted deformity correction and common complications in this population, increasing the generalisability of the findings. nevertheless, a large sample would have been difficult to achieve given that severe kyphosis in patients younger than 4 years is a rare presentation. for example, the current small sample was accumulated over seven years in a tertiary referral hospital. page 159cetinkaya m et al. sa orthop j 2022;21(3) 12. iyer s, boachie-adjei o, duah ho, et al. halo gravity traction can mitigate preoperative risk factors and early surgical complications in complex spine deformity. spine (phila pa 1976). 2019;44(9):629-36. https://doi.org/10.1097/brs.0000000000002906 13. kim n-h, kim h-j, moon s-h, lee h-m. 20-year-follow up of treatment using spine osteotomy and halo-pelvic traction for tuberculous kyphosis – a case report. asian spine j. 2009;3(1):27-31. https://doi.org/10.4184/asj.2009.3.1.27 14. qi l, xu b, li c, wang y. clinical efficacy of short-term pre-operative halo-pelvic traction in the treatment of severe spinal deformities complicated with respiratory dysfunction. bmc musculoskelet disord. 2020;21(1):665. https://doi.org/10.1186/s12891-020-03700-9 15. chen j, sui w-y, yang j-f, et al. the radiographic, pulmonary, and clinical outcomes of patients with severe rigid spinal deformities treated via halo-pelvic traction. bmc musculoskelet disord. 2021;22(1):106. https://doi.org/10.1186/s12891-021-03953-y 16. wang y, li c, liu l, qi l. halo-pelvic traction for extreme lumbar kyphosis: 3 rare cases with a completely folded lumbar spine. acta orthop. 2021;92(1):9-14. https://doi.org/10.1080/174 53674.2020.1824170 17. ouyang b, luo c, ma x, et al. [comparison of radiological changes after halo-pelvic traction with posterior spinal osteotomy versus simple posterior spinal osteotomy for severe rigid spinal deformity]. zhongguo xiu fu chong jian wai ke za zhi [chinese journal of reparative and reconstructive surgery]. 2020;34:900-906. 18. kalamchi a, yau ac, o’brien jp, hodgson ar. halo-pelvic distraction apparatus. an analysis of one hundred and fifty consecutive patients. j bone joint surg am. 1976;58(8):1119-25. 19. pourtaheri s, shah sa, ditro cp, et al. preoperative halo-gravity traction with and without thoracoscopic anterior release for skeletal dysplasia patients with severe kyphoscoliosis. j child orthop. 2016;10(2):135-42. https://doi.org/10.1007/s11832-016-0721-0 20. verhofste bp, glotzbecker mp, birch cm, et al. halo-gravity traction for the treatment of pediatric cervical spine disorders. j neurosurg pediatr. 2020;25:384-93. 21. limpaphayom n, skaggs dl, mccomb g, et al. complications of halo use in children. spine (phila pa 1976). 2009;34(8):779-84. https://doi.org/10.1097/brs.0b013e31819e2d90 22. dove j, hsu lc, yau ac. the cervical spine after halo-pelvic traction. an analysis of the complications of 83 patients. j bone joint surg br. 1980;62-b(2):158-61. https://doi. org/10.1302/0301-620x.62b2.7364826 conclusion preliminary evidence suggests that heff is a powerful and effective technique for correcting severe kyphotic spinal deformity in very young patients. a major advantage of this method is that it promotes independent mobilisation of patients. however, healthcare providers should be aware of the potential dangers of heff hardware, such as difficulty with intubation due to the fixed position of the neck. for this reason, it is advisable to have bolt cutters within easy access during heff implementation as a safety precaution in addition to a laryngeal mask airway at the bedside. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to submission of the case series, ethical approval was obtained from the following ethical review board: health research ethics committee of stellenbosch university (reference number c20/06/017). all procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the helsinki declaration of 1975, as revised in 2008. we applied for a waiver of informed consent, which was approved by the health research ethics committee. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions mc: data capture, first draft preparation, manuscript revision vg: data capture, first draft preparation, manuscript revision tm: manuscript revision jdt: data collection, manuscript revision jhd: study conceptualisation, data collection, manuscript revision orcid cetinkaya m https://orcid.org/0000-0002-7131-4280 gezengana v https://orcid.org/0000-0002-4846-0204 mann t https://orcid.org/0000-0002-9750-5106 du toit j https://orcid.org/0000-0002-0958-5450 davis jh https://orcid.org/0000-0002-1909-7629 references 1. tuli sm. severe kyphotic deformity in tuberculosis of the spine. int orthop. 1995;19(5):32731. https://doi.org/10.1007/bf00181121 2. jain ak, dhammi ik, jain s, mishra p. kyphosis in spinal tuberculosis – prevention and correction. indian j orthop. 2010;44(2):127-36. https://doi.org/10.4103/0019-5413.61893 3. jain ak, kumar j. tuberculosis of spine: neurological deficit. eur spine j. 2013;22 suppl 4:624-33. https://doi.org/10.1007/s00586-012-2335-7 4. sangondimath g, mallepally ar, yelamarthy pkk, chhabra hs. severe pott’s kyphosis in a 19-month-old child: case report and review of literature. world neurosurg. 2019;130:30-36. https://doi.org/10.1016/j.wneu.2019.06.097 5. horn a, watt j, dunn r. spinal fusion for paediatric lumbosacral spondylolisthesis. sa orthop j. 2018;17(4):39-43. https://doi.org/10.17159/2309-8309/2018/v17n4a5 6. kose kc, bozduman o, yenigul ae, igrek s. spinal osteotomies: indications, limits and pitfalls. efort open rev. 2017;2(3):73-82. https://doi.org/10.1302/2058-5241.2.160069 7. o’brien jp, yau ac, smith tk, hodgson ar. halo pelvic traction. a preliminary report on a method of external skeletal fixation for correcting deformities and maintaining fixation of the spine. j bone joint surg br. 1971;53:217-29. 8. muheremu a, ma y, ma y, et al. halo-pelvic traction for severe kyphotic deformity secondary to spinal tuberculosis. medicine (baltimore). 2017;96(28):e7491. https://doi.org/10.1097/ md.0000000000007491 9. koller h, zenner j, gajic v, et al. the impact of halo-gravity traction on curve rigidity and pulmonary function in the treatment of severe and rigid scoliosis and kyphoscoliosis: a clinical study and narrative review of the literature. eur spine j. 2012;21(3):514-29. https:// doi.org/10.1007/s00586-011-2046-5 10. iyer s, duah ho, wulff i, et al. the use of halo gravity traction in the treatment of severe early onset spinal deformity. spine (phila pa 1976). 2019;44(14):e841-45. https://doi. org/10.1097/brs.0000000000002997 11. bono cm. the halo fixator. j am acad orthop surg. 2007;15(12):728-37. https://doi. org/10.5435/00124635-200712000-00006 https://doi.org/10.1097/brs.0000000000002906 https://doi.org/10.4184/asj.2009.3.1.27 https://doi.org/10.1186/s12891-020-03700-9 https://doi.org/10.1186/s12891-021-03953-y https://doi.org/10.1080/17453674.2020.1824170 https://doi.org/10.1080/17453674.2020.1824170 https://doi.org/10.1007/s11832-016-0721-0 https://doi.org/10.1097/brs.0b013e31819e2d90 https://doi.org/10.1302/0301-620x.62b2.7364826 https://doi.org/10.1302/0301-620x.62b2.7364826 https://orcid.org/0000-0002-7131-4280 https://orcid.org/0000-0002-4846-0204 https://orcid.org/0000-0002-9750-5106 https://orcid.org/0000-0002-0958-5450 https://orcid.org/0000-0002-1909-7629 https://doi.org/10.1007/bf00181121 https://doi.org/10.4103/0019-5413.61893 https://doi.org/10.1007/s00586-012-2335-7 https://doi.org/10.1016/j.wneu.2019.06.097 https://doi.org/10.17159/2309-8309/2018/v17n4a5 https://doi.org/10.1302/2058-5241.2.160069 https://doi.org/10.1097/md.0000000000007491 https://doi.org/10.1097/md.0000000000007491 https://doi.org/10.1007/s00586-011-2046-5 https://doi.org/10.1007/s00586-011-2046-5 https://doi.org/10.1097/brs.0000000000002997 https://doi.org/10.1097/brs.0000000000002997 https://doi.org/10.5435/00124635-200712000-00006 https://doi.org/10.5435/00124635-200712000-00006 404 not found orthopaedics vol3 no4 page 32 sa orthopaedic journal winter 2017 | vol 16 • no 2 ligamentous integrity in spinal cord injury without radiographic abnormality (sciwora): a case series a horn mbchb(pret), fc orth(sa), mmed(uct)ortho consultant, orthopaedic surgery, groote schuur hospital, cape town mi workman bsc(physio)(wits), mbbch(wits) registrar, orthopaedic surgery, groote schuur hospital, cape town s dix-peek mbchb(uct), fc orth(sa), mmed(uct)ortho head of paediatric orthopaedic services, red cross children’s hospital and maitland cottage home for disabled children, cape town rn dunn mbchb(uct), fc orth(sa), mmed(uct)ortho consultant spine and orthopaedic surgeon, professor and head of department of orthopaedic surgery, university of cape town head: orthopaedic spinal services, groote schuur hospital and spinal deformity service, red cross children’s hospital, cape town. corresponding author: dr anria horn postnet suite 342 pvt bag x18 7701 rondebosch south africa tel: +27 (0)21 404 5108 fax: +27 (0)21 447 2709 email: anriahorn@gmail.com abstract purpose of study: prolonged bracing following injury in patients with spinal cord injury without radiographic abnormality (sciwora) remains controversial. some authors claim that there is occult instability and a risk of recurrent injury whereas others propose that the spinal column will deform elastically, but will return to its baseline stability by elastic recoil. we aim to assess the presence of ligamentous injury on mri and the incidence of recurrent instability following sciwora in order to determine the need for prolonged bracing. methods: a retrospective chart review was performed for a series of 12 patients with documented sciwora that presented to red cross children’s hospital over the past 8 years. details regarding mode of injury, age at presentation, neurological deficit at presentation, mri findings and long-term prognosis were documented. results: there were nine males and three females. the median age was 4.35 years. all patients were victims of high energy motor vehicle accidents. in two patients there was disruption of the ligamentum flavum at the level of the injury. there were no episodes of recurrent instability or neurological compromise in those patients that had recovered. none of our patients had rigid bracing following the diagnosis of sciwora. conclusion: infrequently observed disruption of isolated stabilising structures in sciwora did not lead to early or delayed instability in our patients. we did not find evidence to support the practice of prolonged rigid bracing to prevent recurrence following sciwora. level of evidence: prognostic case study, level iv key words: sciwora, paediatric spinal cord injury, mri findings in sciwora, bracing in sciwora, paediatric trauma http://dx.doi.org/10.17159/2309-8309/2017/v16n2a3 sa orthopaedic journal winter 2017 | vol 16 • no 2 page 33 introduction the clinical entity of spinal cord injury without radiographic evidence of spinal column disruption has been recognised since the 1920s.1 the term sciwora (spinal cord injury without radiographic abnormality) was popularised by pang and wilberger in 19822 and was defined as ‘objective signs of myelopathy as a result of trauma, whose plain films of the spine, tomography, and occasionally myelography carried out at the time of admission showed no evidence of skeletal injury or subluxation’. the concept of occult spinal instability following sciwora remains a contentious subject among authors. two conflicting theories exist. the ‘segmental spinal instability’ theory states that, following sciwora, the injured spinal column is prone to re-injury, even in the absence of any objective clinical or radiographic features of instability, including mri.2,3 the contradicting ‘differential stretch hypothesis’ is based on the fact that the inherently mobile paediatric spine will deform elastically under significant tension, exceeding the elastic deforming potential of the more fragile spinal cord, causing damage or rupture to the cord, but returning to baseline stability by elastic recoil.4 proponents of the ‘segmental spinal instability theory’ recommend immobilisation of the affected spinal segment in a rigid brace for 12 weeks following injury, regardless of the presence of radiographic signs of instability.2,3 those supporting the ‘differential stretch hypothesis’, on the other hand, recommend that protection in a soft collar for 2 weeks is sufficient and that bracing is unnecessary and does not prevent recurrence.4,5 rigid immobilisation of the spine, especially the cervical spine, is not without complications and is therefore best avoided if not indicated. the most common complication is pressure ulceration of the bony prominences of the head and neck. rigid collars also interfere with nursing, feeding, oral care, central venous catheterisation and patient positioning in the severely injured child.6 the purpose of this study is to determine whether there was any evidence of injury to the paraspinal soft tissues on mri in patients diagnosed with sciwora at our institution. we aim to provide objective evidence to support clinical practice, be it rigid immobilisation or not. the secondary aim was to gather data on demographics, clinical course, the incidence of recurrent injury, and other mri findings in order to improve our understanding of the epidemiology and natural history of this condition. materials and methods the picture archiving and communication system (pacs) of our institution’s radiology service was searched for patients with features of spinal cord injury (sci) on mri but no features of instability or injury on plain films or ct scan. the hospital records of these patients were obtained and data collected regarding demographic details, mode of injury, presenting complaint, x-ray and mri findings, in-hospital management, and neurological recovery. the presence of recurrent neurological complaints following resolution of the original injury was specifically sought for. the plain films and mri scans were reviewed by senior radiologists at our institution as well as by one of the authors (ah) for evidence of soft tissue injury or spinal instability. spinal instability was defined as an increase beyond the normal limit of the atlanto-dens interval (<3.5 mm) on plain films. soft tissue swelling was similarly defined as a retropaharangeal shadow exceeding 6 mm at the level of c3 and 14 mm at the level of c6. standard t1and t2-weighted mri sequences were performed on all patients. specific soft-tissue sequences were not routinely performed and are therefore not reported on in this review. table i: demographic details of patients with sciwora total number of patients 12 age (years) median (range) 4.35 (1.3–8.6) sex male:female 9:3 mechanism of injury mva passenger mva pedestrian 1 11 spinal level* upper cervical lower cervical thoracic 7 2 4 severity complete incomplete 5 7 *one patient had sciwora at cervical and thoracic level (figure 6a and b) figure 1. evidence of soft tissue swelling at the level of c0–c1 (encircled) in a patient thought to have sciwora, which was excluded from the study page 34 sa orthopaedic journal winter 2017 | vol 16 • no 2 due to the small cohort identified, meaningful statistical analysis was not feasible. we therefore report on descriptive statistics only. results the demographic details are summarised in table i. thirteen patients with a diagnosis of sciwora for the years 2006–2014 were identified. one patient was found to have soft tissue swelling on cervical spine x-rays (figure 1) and was excluded on the grounds that the injury was not technically a sciwora. of the remaining 12 patients, nine were male, all were aged 8 years or younger and all were victims of high energy motor vehicle accidents (mvas). all the patients in our series presented with significant neurological deficit. details of clinical and radiological findings at presentation and follow-up, as well as clinical course, are summarised in table ii. no evidence of spinal instability was identified on reviewing the available x-rays. mri was performed on all our patients. in two patients, focal disruption of the ligamentum flavum at the level of the injury (figures 2 and 3) was noted. there was no evidence of soft tissue swelling, ligamentous disruption or spinal instability in the other patients. the mri findings are summarised in table ii. all patients had hyperintense lesions on t2w series (figure 4), only five had hypointense lesions on t1w series (figure 5, red arrow). four patients had evidence of epidural bleeds on either t1w or t2w series. patients with changes on t1w series consistently had complete injuries and no neurological recovery, whereas those with t2w signal change only, demonstrated partial or full recovery at a median follow-up of 51 months (range 3–99 months). none of the patients had rigid spinal immobilisation following their injury. patients with c-spine lesions were treated in a soft collar for two weeks, those with thoracic table ii: clinical and radiological features patient spinal level neurological features at presentation associated injuries mri 1 t1–t3 noted to be withdrawing from pain. no specific documentation of neurological function skull fracture and cerebral oedema requiring intra-cranial pressure monitoring ↓ signal t1w, ↑ t2w, stir. disruption of ligamentum flavum at t1 2 c1–c2 power 1/5 left upper and lower limb none ↑ signal t2w. subepyndymal haemorrhage t1, t2 3 c3 normal sensation, power 1/5 right upper limb l1/l2 chance fracture and complete neurological injury ↑ signal t2w 4 c3 c7–t1 power 0/5 right upper and lower limb closed head injury ↑ t2w at c3 ↓ signal t1w and ↑ t2w at c7 5 t2–4 t8–9 no motor or sensory function, level t2 right clavicle and femur fracture, right pneumothorax ↓ signal t1w and ↑ t2w at t2–4 ↑ signal t2w at t8–9 6 t1–t3 power 3/5 right upper and lower limb none ↑ signal t2w 7 c7–t1 no sensation or motor function both lower limbs none ↑ signal t1w and ↓ t2w. epidural haemorrhage 8 c2 no sensory or motor function right arm or leg. intracerebral haemorrhage ↑ signal t2w and stir 9 c2 power 0/5 lower limbs, sensation not noted right pubic ramus fracture. closed head injury ↑ signal t2w at c2 and t12 10 (figures 6a and b) c2 t12 left upper limb monoparesis and l2 paraplegia, complete right femur fracture, right humerus fracture, right open tibia fracture ↑ signal t2w at both levels 11 c0–c1 power 3/5 left upper and lower limbs none ↑ signal t2w 12 c0–c3 power3/5 right upper and lower limbs none ↑ signal t2w ligamentum flavum disruption c0 sa orthopaedic journal winter 2017 | vol 16 • no 2 page 35 lesions were treated with bed rest until able to mobilise with the assistance of a physiotherapist. no recurrent injuries were reported in those patients who had recovered from the initial injury. one patient was documented to be ‘withdrawing from pain’ on admission, suggesting intact motor function, but was later found to be paraplegic (patient 1). the initial neurological examination in this patient was perfunctory to say the least, as there were significant distracting injuries for which the patient required prolonged icu admission and ventilation. the paralysis was only noted several days after admission. whether this represents neurological deterioration or a missed injury is uncertain. the use of corticosteroids in acute spinal cord injury is not routine at our institution and none of our patients received steroids as treatment for their spinal cord injury. figure 2. focal disruption of the ligamentum flavum at c0 (encircled). this patient recovered fully. timing of mri following presentation clinical course length of follow-up (months) neurological recovery deformity at final follow-up 12 days prolonged ventilation in icu, eventual tracheostomy, developed post-traumatic seizures during icu stay 99 t1 complete, no recovery thoracolumbar kyphoscoliosis 5 days rapid recovery to near normal 23 subjective weakness left upper and lower limb none 2 days has spinal fusion for chance fracture 12 c3 hemiparesis, recovered in 1 month. paraplegia 2° to l1/l2 chance fracture none 2 days prolonged ventilation in icu, required tracheostomy. post-traumatic seizures 73 paraplegic, no recovery with upper limb weakness thoracolumbar scoliosis 9 days uneventful 42 paraplegic, no recovery none 12 days uneventful 6 full recovery of hemiplegia at 3 months none 1 day uneventful 27 paraplegic, no recovery none 1 day ventilation in icu with bilateral pneumonia, extubated day 9 26 right hemiparesis but able to walk and jump none 5 days decreased level of consciousness, intubation and ventilation in icu, icp monitoring for cerebral oedema 23 residual weakness of dorsiflexion and knee extension on the left none 7 days femur and tibia surgically addressed, cast immobilisation for right humerus 7 left upper limb recovered fully in 1 month, lower libs power 3/5 after 3 months none 1 day uneventful 3 full recovery in 4 months none 3 days uneventful 14 full recovery at 6 months none page 36 sa orthopaedic journal winter 2017 | vol 16 • no 2 discussion demographics of sciwora although sciwora has been described in adults, it is much more common in children, and depending on the criteria used, accounts for 19–34% of paediatric spinal cord injury.7 several factors predispose the paediatric population to the development of sciwora and are generally agreed upon. the paraspinal soft tissues in a paediatric patient are more elastic and therefore more prone to significant distraction than in the adult spine. this includes joint capsules, paraspinal ligaments and intervertebral discs.2-5,7 bony stability is also reduced compared to the adult spine due to shallow, more horizontally oriented facet joints, absent uncinate processes and anterior wedging of the vertebral bodies.3 lastly, due to the relatively large head in the paediatric population, the cervical spine is subjected to greater bending forces during flexion and extension, placing it at greater risk for more severe injuries.3-5 as the paediatric spine assumes adult morphology around the age of 8 years,5 the incidence of sciwora decreases and children start exhibiting adult-type injuries such as fractures and dislocations. in our series, all the patients were younger than 8 years of age. most authors agree that children under the age of 8 have more severe injuries and worse prognosis,2,3,6-8 which is in keeping with our study findings. the mean age of patients with complete injuries in our study was 2 years, and for those who had incomplete injuries it was 6.1 years. in the infant and very young child, the fulcrum for maximum flexion is at the level of c2–3,3 predisposing this younger population to higher cervical injuries. this, by its very nature, explains the worse prognosis in this group of patients, as survival potential is extremely low with such a high injury. in the older age group, the fulcrum of maximal flexion is at the level of c5–6, the same as in adults. in our series, the more severe complete neurological injuries were seen in the younger patients, but interestingly, the average age for high cervical injuries was higher than for low cervical and thoracic injuries (5.8 years vs 2 years). occult instability and the need for immobilisation the question of occult instability following sciwora and the need for prolonged bracing remains contentious. several studies have been published citing series of patients who were seemingly normal following an injury to the spine and then subsequently, following relatively minor trauma, developed progressive neurology or a recurrence of the injury.3,7,9 the time from initial injury to ‘recurrent injury’ ranged from a few days to several months or even years. on closer examination of these cases, the majority occurred in patients older than 8 years of age, followed minor trauma such as sporting injuries, figure 3. focal disruption of the ligamentum flavum at c7–t1 (red arrow). t2w image showing marked hyperintensity indicative of cord oedema and haemorrhage figure 5. t1w image showing hypointense lesion at the level of c6. there is also evidence of an epidural haemorrhage (red arrow). figure 4. t2w image showing hyperintense lesion at the level of t12 (encircled) sa orthopaedic journal winter 2017 | vol 16 • no 2 page 37 and symptoms were mild and transient both on initial and subsequent presentation. in the very few patients in whom the recurrent injury led to severe, permanent neurological deficit, the possibility of an alternative diagnosis, such as acute transverse myelitis, was often considered but never excluded.3,6,7 an alternative explanation for the phenomenon of recurrent or delayed presentation, sciwora is the well understood progressive nature of spinal cord injuries. several inflammatory mediators such as arachidonic acid and glutamate cause progressive lipid peroxidation and cell membrane destruction in the injured spinal cord, gradually causing expansion of the zone of injury.10 in a recent comprehensive literature review by rozelle et al.,11 no compelling evidence could be found to suggest that any patient developed delayed instability when initial dynamic studies were normal. furthermore, even in the presence of paraspinal soft tissue injury on mri, no patient demonstrated early or delayed instability. the author’s recommendation, graded as level iii evidence, was 2 weeks’ immobilisation in a soft collar for patients with normal initial studies, including somatosensory evoked potentials, and 3 months’ rigid immobilisation for all other patients. in our study, patients were included based on an mri diagnosis of sciwora, which naturally excluded those with normal mri findings. only two of the 12 patients had evidence of paraspinal soft tissue injury on mri and no patient developed recurrent neurological symptoms or signs following resolution of the initial injury. flexion–extension films were not performed routinely to demonstrate occult instability, and until now has not been indicated. two patients (patients 1 and 4) in this study developed spinal deformity during the follow-up period. in both cases the deformity appeared to be as a result of paralysis and was below the level of the spinal cord injury. it is likely that more patients will demonstrate the development of deformity associated with paralysis with longer follow-up. our findings support the differential stretch theory as proposed by bosch et al.4 and gore et al.5 there is a wide spectrum of injury in spinal cord trauma, and certainly there are instances where instability is indeed a feature. however, in the absence of evidence of instability, either on plain films or ct, there appears to be no indication for immobilisation of the spine based on this series and other series reported in the literature.4 mri findings the description of the clinicoradiologic mismatch that is sciwora predates the age of mri and therefore does not include mri abnormalities. there has been much debate about the relevance of the term sciwora in an age where mri is readily available and often performed as initial investigation in patients with spinal injuries. several alternatives have been suggested, such as sciworet (sci without radiographic evidence of trauma), sciwoctet (sci without ct-evidence of trauma)12 or sciwona (sci without neuroimaging abnormality),13 which may be a more accurate and relevant description of this particular injury. three different types of injuries, as seen on mri, have been described in sciwora (table iii): complete transection of the cord; haemorrhage, either intraor extraspinal; and cord oedema.3,14 complete transection carries the worst prognosis, and neurological deficit will be complete and irreversible. table iii: mri changes associated with various types of sciwora short-tr (t1w) long-tr (t2w) transection hyperintense hyperintense haemorrhage hyperintense hyperintense oedema isointense very hyperintense figure 6a. patient 10, evidence of spinal cord oedema at the level of c2 (encircled) figure 6b. patient 10, evidence of spinal cord oedema at the level of t12 (encircled) page 38 sa orthopaedic journal winter 2017 | vol 16 • no 2 intraspinal haemorrhage also carries a poor prognosis and patients will not recover function beyond what they initially present with. small extraspinal haemorrhages and isolated cord oedema are associated with a better prognosis and patients usually demonstrate full or nearly full recovery.12 this prognostic value of early mri was confirmed in our study. t2-weighted images have the best prognostic value for closed spinal cord injuries and are excellent at demonstrating disc, capsular and muscle injuries.12 although the short tau inversion recovery (stir) method is preferred to detect subtle cord oedema in spine injured patients,14 not all of our patients had this sequence performed and we therefore did not report on it. in our patients, mri was often performed several days (median 7.5 days, range 1–12) following the initial injury. plain radiography and ct remain the primary investigations performed for acute spinal cord injury as mri is a relatively scarce and expensive resource. therefore, we believe the term sciwora does still have some clinical relevance in countries with limited resources. the authors also believe that sciwora, as originally defined, and as represented in our series, describes an injury pattern that does not compromise spinal stability but may have significant neurological consequences. the limitations of this study include the small cohort, the retrospective nature of the study and our chosen method of identifying candidates. systematic and detailed neurological examination was therefore either not performed or not properly documented, neither at presentation nor at most recent follow-up. our institution only treats patients of 12 years and younger, therefore excluding the older population from our database. we do however propose that our small population represents sciwora under the strictest definition, and therefore our results may well be extrapolated to the paediatric population at large. conclusion once sciwora has occurred, there is little that can be done to alter the natural history of the injury. it is however prudent to determine whether our treatment has any value and of course, to be able to predict the prognosis in order to inform and counsel our patients and their families adequately. based on our findings and a review of the current literature, we did not find convincing evidence to support the practice of prolonged, rigid immobilisation following sciwora. we also conclude that the neurological prognosis can be formulated on the basis of the mri features at presentation, as well as the severity of the initial injury. compliance with ethical guidelines no funding was received for the execution of this study. ethical approval was granted by our institutional human research ethics committee. all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. disclosure: the content of this article is the sole work of the authors. no benefits of any form have been or are to be received from a commercial party related directly or indirectly to the subject of this article. author identifying information: author ah has received no research funding and has no conflicts of interest to declare. authors mw, sdp rnd have no conflicts of interest to declare. references 1. crothers b. injury of the spinal cord in breech extraction as an important cause of foetal death and paraplegia in childhood. am j med sci 1923;94-110. 2. pang d, wilberger j. spinal cord injury without radiographic abnormality in children. j neurosurg 1982;57:114-29. 3. pang d. spinal cord injury without radiographic abnormality, 2 decades later. neurosurgery 2004;55(66):1325-43. 4. bosch pp, vogt mt, ward wt. pediatric spinal cord injury without radiographic abnormality (sciwora): the absence of occult instability and lack of indication for bracing. spine 2002;27(24):2788-2800. 5. gore pa, chang s, theodore n. cervical spine injuries in children: attention to radiographic differences and stability compared to those in an adult patient. semin pediatr neurol 2009;16:42-58. 6. scott te, coates pjb, davies sr, et al. clearing the spine in the unconscious patient: an update. journ int care soc 2002;13(3):227-31. 7. buldini b, amigoni a, faggin r, et al. spinal cord injury without radiographic abnormalities. eur j pediatr 2006;165:108-11. 8. kalra v, gulati s, mahesh k, et al. sciworaspinal cord injury without radiological abnormality. indian j pediatr 2006;73(9):829-31. 9. pollack if, pang d, sclabassi r. recurrent spinal cord injury without radiographic abnormalities in children. j neurosurg 1988;69:177-82. 10. bydon m, lin j, macki m, et al. the current role of steroids in acute spinal cord injury. world neurosurg. 2014. http://dx.doi.org/10.1016/j.wneu.2013.02.062 11. rozelle cj, aarabi b, dhall s, et al. spinal cord injury without radiographic abnormality (sciwora). neurosurgery 2013;72(2):227-33. 12. dreisen d, kim w, kim js, et al. will the real sciwora please stand up? exploring clinicoradiologic mismatch in closed spinal cord injuries. am j radiol 2015;205:863-60. 13. yucesoy k, yuksel kz. sciwora in the mri era. clin neurol neurosurg 2008;110:429-33. 14. szwedowski d, walecki j. spinal cord injury without radiographic abnormality (sciwora) – clinical and radiological aspects. pol j radiol 2014;79:461-64. this article is also available online on the saoa website (www.saoa.org.za) and the scielo website (www.scielo.org.za). follow the directions on the contents page of this journal to access it. • saoj south african orthopaedic journal hip doi 10.17159/2309-8309/2022/v21n4a2erasmus rd et al. sa orthop j 2022;21(4) citation: erasmus rd, fourie pj, janse van rensburg c, jacobs hw. an audit on the accuracy of freehand acetabular cup positioning in total hip arthroplasty with the direct lateral approach at a tertiary institution over seven years. sa orthop j. 2022;21(4):202-206. http://dx.doi. org/10.17159/2309-8309/2022/ v21n4a2 editor: dr chris snyckers, eugene marais hospital, pretoria, south africa received: august 2021 accepted: march 2022 published: november 2022 copyright: © 2022 erasmus rd. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background the direct lateral approach for total hip replacement has been traditionally reserved and described for neck of femur fractures. advantages of this approach include technically easy access to the acetabulum and femur and low incidence of hip dislocation. imperfect positioning of the acetabular component leads to increased risk for dislocations, accelerated wear, reduced range of motion and increased revision rate. freehand technique has been the gold standard for many decades, but newer technologies like computer navigation and robotic-assisted surgery have shown to improve the accuracy of cup placement. this study reports on the accuracy of freehand cup positioning via the direct lateral approach with mention of the dislocation rate. methods we retrospectively reviewed 253 patients who had total hip replacements done via the direct lateral approach. the patients’ files were evaluated for patient parameters, demographic details, aetiology of hip pathology, confirmation of approach used, comorbidities and history of previous relevant surgery. the postoperative radiographs were analysed for acetabular component position inclination and anteversion. dislocation rates were calculated as a secondary objective. results the radiographic analysis was performed using the liaw method based on trigonometry of the eclipse generated. this showed a mean cup inclination of 42.3° (95% ci: 41.3–43.3°) and anteversion of 12.7° (95% ci: 12.0–13.7°). a total of 57% of the acetabular cups were within the safe zones described by lewinnek. of them, 78% were in the 30–50° range for inclination and 73% in the 5–25° range for anteversion. there were ten dislocations within one year from the index procedure: a dislocation rate of 4.0% (95% ci: 2.8–8.5%). conclusion the freehand technique using the direct lateral approach for acetabular cup placement produces a poor overall accuracy of only 57%. although our study only commented on ten dislocations, the rate (4%) is significantly worse compared to the 0.43% reported in literature for the direct lateral approach. the radiographic results for inclination and anteversion are comparable to other freehand techniques, regardless of the approach used, but significantly worse than results achieved with navigation and robotics. level of evidence: level 4 keywords: lateral approach, total hip arthroplasty, cup positioning an audit on the accuracy of freehand acetabular cup positioning in total hip arthroplasty with the direct lateral approach at a tertiary institution over seven years raoul d erasmus,¹* pieter j fourie,¹ charl janse van rensburg,² hans w jacobs³ ¹ department of orthopaedic surgery, university of pretoria, pretoria, south africa ² biostatistics unit, south african medical research council, pretoria, south africa ³ department of orthopaedic surgery, steve biko academic hospital, university of pretoria, pretoria, south africa *corresponding author: erasmusrd@gmail.com introduction total hip arthroplasty (tha) is regarded as the most successful operation of the 20th century.1 a projected 572 000 thas are expected to be performed over the next 20 years.2 postoperative complications such as dislocation, polyethylene liner fracture, osteolysis, impingement, limb length discrepancy, reduced range of motion and increased wear are attributable to various patient and surgical factors.3 patient factors include body mass index, age, sex and primary diagnosis for the tha.3 surgical factors include surgeon experience, surgical approach, prosthetic design, acetabular component fixation method and orientation of the acetabular cup.3 although different factors affect the success of the procedure, the four basic principles defining success are still pain relief, stability, range of motion and survivorship.2 acetabular cup orientation is defined by acetabular inclination and acetabular anteversion angles.4 lewinnek et al. described a safe zone of acetabular cup placement: anteversion of 15° ± 10° and inclination of 40° ± 10°; cups outside this safe zone are associated with a higher dislocation https://orcid.org/0000-0001-6206-6687 page 203erasmus rd et al. sa orthop j 2022;21(4) rate.5 one of the most important surgical factors contributing to complications is accuracy of acetabular cup placement. the freehand technique is the most common method in performing this surgery. newer techniques include computerassisted navigation, robotic-assisted surgery and computer tomography-assisted navigation. alternative options to approach include anterior (smith-petersen), anterolateral (watson-jones) and direct lateral (hardinge). the posterior approach is associated with a higher dislocation rate compared with the other approaches, and the newer technologies are time-consuming and not always cost-effective, leaving much to be investigated with regard to the clinical results. dislocation is one of the most common complications seen after tha, having an incidence of 1–5%; 50% of dislocations occur within three months and 75% occur within the first year of the index procedure.3,6 dislocation after tha is the most common cause of revision surgery in the first two years.6 revision surgery, however, has had variable success.6 at our institution, steve biko academic hospital, we make use of the direct lateral approach to the hip as our primary approach in elective and emergency hip replacements. the aim of this study was to determine the accuracy of freehand acetabular cup placement using the direct lateral (hardinge) approach and to determine our dislocation rate and how cup placement relates to this dreaded complication. materials and methods a total of 388 primary total hip replacements were performed between 2009 and 2015 at our institution. twenty-five were excluded as the indication for surgery was unknown. a further 110 were excluded as it was not known whether dislocations occurred within a year of the hip replacement; either no follow-up radiographs were available on our patient archiving and communication system (pacs), inadequate radiographs taken postoperatively, or followup at the clinic was incomplete. we performed a retrospective chart and radiographic review of 253 primary total hip replacements. at our institution, we position our patients in the lateral decubitus position, keeping the pelvis stable with hip positioners. the hardinge approach and trial implants are used, aiming for 15° anteversion and 40° inclination; we also reference according to the transverse acetabular ligament as a collateral guide. the cup is then impacted and the femur addressed. the files of the study group were retrieved from our records department to obtain patient parameters, demographic details, aetiology of hip pathology, confirmation of the hardinge approach, associated comorbidities, and history of previous pelvic or hip surgery. the theatre register for the period between 2009 and 2015 was also retrieved, and information was gathered regarding the size of the acetabular component and the surgeons involved. immediate postoperative anteroposterior pelvic radiographs were used for analysis of component positioning on our pacs. these were true anteroposterior views of the pelvis, centred over the pubis. the inclination was measured using the ischial tuberosity line and a line connecting the most medial and lateral points of the cup. the anteversion was calculated using the liaw method: version = sinˉ¹ tan β, where β angle is the angle between the long axis of the component (ab in figure 1) and the line connecting the end of ab with the end-point of the ellipse (c in figure 1).7 angle β is used to calculate the anteversion. line dc is a perpendicular line at the midpoint of ab. all the hips were measured by the main author and co-author. interobserver reliability was calculated for anteversion and inclination. given a reliability of above 0.8, the averaged value across raters was used. the accuracy of three groups was determined: group 1 (the consultant was the main surgeon and the registrar assisted); group 2 (the registrar was the main surgeon and the consultant assisted); and group 3 (the registrar was the main surgeon and another registrar assisted). information regarding dislocations was gathered by reviewing the patients’ files and assessing radiographs of each patient on our pacs. all information was recorded in a data sheet in microsoft excel. to calculate our dislocation rate, the patient records and follow-up radiographs on pacs up until a year postoperatively were analysed. statistical analysis categorical variables were described using frequencies and proportions. the complication rate was estimated with a 95% confidence interval (ci). continuous variables were described using mean and standard deviation. scatterplots were constructed to visually assess points within the safe zones. the chi-square test was used to test associations between categorical variables. fisher’s exact test was used when expected frequencies were below 5, as in the case of the dislocation rate. the t-test was used to compare means between groups. interobserver reliability was evaluated using the intraclass correlation coefficient (icc), where above 0.8 is accepted as strong reliability. statistical significance was set at 5%. statistical analysis was conducted using statacorp. 2019, strata statistical software: release 16, college station, tx: stratacorp llc.7 results we reviewed 253 total hip replacements performed using the direct lateral approach. the mean (sd) patient age at time of surgery was 62.4 years (sd 12.7 years). there were 160 (63%) female patients and 93 (36%) male patients. one hundred and twenty-five were left hip replacements, while the remaining 128 were right hip replacements. the vast majority (120 hips; 47%) presented with neck of femur fractures, 77 (30%) with osteoarthritis, 51 (20%) with avascular necrosis and five (2%) with dysplasia (table i). the acetabular cups used during these procedures were uncemented in 220 cases (87%) and cemented in 33 cases (13%). cup sizes ranged from 36 mm to 64 mm, the most common being 50 mm. the acetabular liner was of polyethylene in all cases. the radiographic analysis was performed using the liaw method based on the trigonometry of the eclipse generated. an icc of 0.98 for both anteversion and inclination indicated strong reliability between raters. therefore, the values were averaged across figure 1. depiction of the method of liaw et al. b a c d β (13.4) figure 1. depiction of the method of liaw et al. page 204 erasmus rd et al. sa orthop j 2022;21(4) raters. the mean cup anteversion was 12.7° (95% ci: 12.0–13.7°) and mean cup inclination was 42.3° (95% ci: 41.3–43.3°). in figure 2, we present the cases according to anteversion and inclination in relation to the demarcated safe zone. more than half (144; 57%) of the acetabular cups were inserted within the safe zone described by lewinnek et al., with 73% in the 5–25° range for anteversion and 78% in the 30–50° range for inclination. the relationship between accuracy of cup positioning and dislocations can be seen in table ii. there were ten dislocations within a year of the index procedure, resulting in a dislocation rate of 4.0% (95% ci: 2.8–8.5%). there were 82 hips (32%) in group 1, 83 (33%) in group 2 and 88 (35%) in group 3. group 1 had a mean cup anteversion of 10.5° (95% ci: 8.5–12.4°) and a mean cup inclination of 43.4° (95% ci: 41.6–45.3°). group 2 had a mean cup anteversion of 14.5° (95% ci: 12.6–16.4°) and a mean cup inclination of 41.5° (95% ci: 39.8–43.3°). group 3 had a mean cup anteversion of 13.0° (95% ci: 11.4–14.6°) and a mean cup inclination of 42.0° (95% ci: 40.3–43.6°; table iii). discussion hassan et al. reviewed the radiographs of 50 patients treated using a lateral approach. they used a trigonometric measurement to calculate the accuracy of cup placement according to lewinnek et al.’s safe zones and reported an accuracy of 58% for anteversion and inclination together, of 68% for anteversion alone and of 84% for inclination alone, and no dislocations.8 hohmann et al. compared the accuracy of cup placement between imageless navigation and the freehand technique. all 30 patients in the freehand technique group were operated on via a lateral approach in a supine position. accuracy was determined using postoperative ct scans of all patients. according to the lewinnek et al. criteria, 20 of the 30 (66.7%) were in the safe zone for anteversion and 18 (60.0%) for inclination, while only six (20.0%) were in the safe zone for both. navigation, however, improved the accuracy for anteversion and inclination to 86.7%.9 in a groundbreaking study, callanan et al. compared the accuracy of freehand techniques using different approaches. applying lewinnek et al.’s criteria, they reported an accuracy of 57.3% (670 of 1 170 patients) for the posterolateral approach, an accuracy of 37.0% (207 of 560) for the anterolateral approach, and an accuracy of 32.0% (16 of 50) for the hardinge lateral approach.3 similar to the posterolateral group in the callanan et al. study, we achieved an accuracy of 57% and improved results compared with the hardinge lateral approach group for cups inserted in the lewinnek et al. safe zones for anteversion and inclination. although the literature has shown that inclination of less than 30° reduces range of motion, can cause impingement of the femoral neck on the cup and can lead to dislocation, none of the dislocations in our study occurred with regard to this inclination.10 ct scans remain the gold standard for true measurement of anteversion and inclination angles.11 radiographs can also be used to determine cup orientation; however, pelvic tilting and the difference between radiographic and anatomical landmarks can affect calculations. radiographs are accepted as a postoperative control after total hip replacement; they are much cheaper and do not expose the patient to high levels of radiation compared with ct scans.12 alzohiry et al. recommend the lewinnek et al. and liaw methods for determining the anteversion angle on anteroposterior pelvis or anteroposterior hip radiographs.13 figure 3 is an x-ray of a patient that sustained a right neck of femur fracture. in the liaw method, a line is drawn across the maximal diameter of the ellipse (ab) on the anteroposterior radiograph, and another point table i: patient demographics variable n % age (in years; mean) 62.4 sex male 93 37 female 160 63 aetiology neck of femur 120 47 osteoarthritis 77 30 avascular necrosis 51 20 dysplasia 5 2 side of pathology left 125 49 right 128 51 figure 2. scatterplot showing cases according to anteversion and inclination (in degrees) and indicating cases of dislocation a nt ev er si on (a vg ) inclination (avg) not dislocated dislocated 40 30 20 10 0 20 30 40 50 60 70 table ii: relationship between accuracy and dislocation range of acetabular anteversion range of acetabular inclination not dislocated dislocated total n (%) n (%) n (%) < 5°; > 25° < 30°; > 50° 14 (6) 1 (10) 15 (6) 5–25° < 30°; > 50° 39 (16) 2 (20) 41 (16) < 5°; > 25° 30–50° 49 (20) 4 (40) 53 (21) 5–25° 30–50° 141 (58) 3 (30) 144 (57) total 243 (100) 10 (100) 253 (100) table iii: mean cup anteversion and inclination by surgical group surgical group n (%) anteversion inclination anteversion and inclination mean (95% ci) n (%) in 5–25° mean (95% ci) n (%) in 30–50° n (%) in safe zone group 1 82 (32) 10.5° (8.5–12.4°) 50 (61) 43.4° (41.6–45.3°) 64 (78) 39 (48) group 2 83 (33) 14.5° (12.6–16.4°) 61 (73) 41.5° (39.8–43.3°) 63 (76) 45 (54) group 3 88 (35) 13.0° (11.4–14.6°) 74 (84) 42.0° (40.3–43.6°) 70 (80) 60 (68) page 205erasmus rd et al. sa orthop j 2022;21(4) (c) midway on the ellipse, which is the intersection of the ellipse, and a line perpendicular to and going through the midpoint of ab is determined.13 another line from the apex (b) to the point (c) is then drawn.13 the angle between lines bc and ab is then measured (α), and the anteversion is calculated according to sin-1 tan α (figure 4).13 inclination is measured by the angle between the ischial tuberosity line and a line connecting the medial and lateral borders of the cup (figure 5). alzohiry et al. found no statistical difference between ct measurements and the liaw method.13 park et al. showed that the liaw method is the most accurate method with reference to the anteversion obtained from the polyware software program.7 polyware is a better reference for radiographic anteversion, while ct better reflects anatomical anteversion.7 bayraktar et al. used a similar software program to assess acetabular cup orientation, and they found that the mean values for absolute differences between ct and radiographs were 7.2° for anteversion and 3.1° for inclination.11 newer technologies to improve cup positioning include computerassisted navigation, consisting of active, semi-active and passive navigation.14 active navigation employs robots to implant cups, and semi-active systems allow the surgeon to move the robotic arms but do not allow the arms to move beyond a milling boundary determined by preoperative three-dimensional imaging.14 passive navigation only guides the surgeon in implanting in the correct position and consists of three types of navigation: imageless navigation, ct-based navigation and fluoroscopic navigation.14 imageless navigation uses optical sensors as 3d-position sensors to track the target bones and surgical tools or implants and then gives feedback on anteversion and inclination of the acetabular cup, relative to the anterior pelvic plane.1 in their comparison of the freehand technique with computerassisted navigation, parratte and argenson found no differences between treatment groups with regard to the mean cup abduction and anteversion angles.15 however, the computer-assisted surgery system significantly reduced the percentage of outliers according to the criteria described by lewinnek et al. from 57% (17 of 30) in the freehand placement group to 20% (6 of 30) in the computerassisted group using an anterolateral approach, and there were no dislocations in either group.4, 15 dorr et al. compared imageless computer-assisted navigation and the freehand technique regarding the accuracy of cup placement in terms of anteversion and inclination, verifying component placement by ct.16 with imageless computer-assisted navigation, the variability was 4.1° for anteversion and 4.4° for inclination, whereas with the freehand technique, the variability was 12.3° for anteversion and 11.5° for inclination.16 we detected ten dislocations within the first year of the index procedure, resulting in a dislocation rate of 4%. we observed from our study that we did not have any dislocations if inclination was between 20–30°, regardless of the anteversion. on the other hand, we do not know how this affects wear of components, and prospective studies would be beneficial to provide more information. kwon et al. in their meta-analysis reported a dislocation rate of 0.43% (10 of 2 309) of thas performed via the direct lateral approach compared with a dislocation rate of 1.01% (21 of 2 084) of thas performed via the posterior approach.17 among the limitations of our study is that we used radiographs on our pacs to determine the anteversion and inclination, and radiographic measurements are subject to human error. these measurements were not calibrated against a ct scan. secondly, pelvic tilt or rotation may also have influenced the measurements. thirdly, the discretion of the surgeons was trusted in that all cups would be placed in anteversion, as cups that measured more than 5° theoretically could be retroverted, but this cannot reliably be confirmed unless ct scans are employed. we, however, argue figure 3. neck of femur fracture figure 4. anteversion d a b c α (10.0) figure 4. anteversion figure 5. inclination figure 5. inclination 35.6 144.4 page 206 erasmus rd et al. sa orthop j 2022;21(4) that this does not detract from the main findings of the study, as these associations do not affect the estimate of the dislocation rate, nor the overall accuracy of the surgical procedures. conclusion in our study, the freehand technique using a direct lateral approach for acetabular cup placement achieved an accuracy of only 57% regarding the safe zones of lewinnek et al. it is still a recognisable approach for neck of femur fractures, with 47% of our study population falling into this group. our study reported ten dislocations, a rate (4.00%) significantly worse than the 0.43% reported in the literature for the direct lateral approach. navigation and robotic surgery are developing fields within orthopaedics. improvements in accuracy of cup placement are evident. however, these newer technologies can be timeconsuming initially and expose patients to additional radiation and are not always cost-effective. prospective studies are needed to determine whether they are functionally significant and whether they reduce complications and secondary revision surgery. ethics statement the author/s declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. prior to the commencement of the study, ethical approval was obtained from the following ethical review board: faculty of health sciences research ethics committee, university of pretoria, reference no. 440/2019 declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions rde: primary author, study design, data collection, data analysis pjf: co-author, data collection cjvr: information technology and analysis hwj: conceptualisation, study design, manuscript revision and supervision orcid erasmus rd https://orcid.org/0000-0001-6206-6687 fourie pj https://orcid.org/0000-0002-5362-4197 janse van rensburg c https://orcid.org/0000-0002-6539-7833 jacobs hw https://orcid.org/0000-0002-4049-8283 references 1. snijders t, van gaalen sm, de gast a. precision and accuracy of imageless navigation versus freehand implantation of total hip arthroplasty: a systematic review and meta-analysis. int j med robot. 2017;13(4). 2. soderquist mc, scully r, unger as. acetabular placement accuracy with the direct anterior approach freehand technique. j arthroplasty. 2017;32(9):2748-54. 3. callanan mc, jarrett b, bragdon cr, et al. the john charnley award: risk factors for cup malpositioning: quality improvement through a joint registry at a tertiary hospital. clin orthop relat res. 2011;469(2):319-29. 4. moskal jt, capps sg. improving the accuracy of acetabular component orientation: avoiding malposition. j am acad orthop surg. 2010;18(5):286-96. 5. lewinnek ge, lewis jl, tarr r, et al. dislocations after total hip-replacement arthroplasties. j bone joint surg am. 1978;60(2):217-20. 6. abdel mp, von roth p, jennings mt, et al. what safe zone? the vast majority of dislocated thas are within the lewinnek safe zone for acetabular component position. clin orthop relat res. 2016;474(2):386-91. 7. park ys, shin wc, lee sm, et al. the best method for evaluating anteversion of the acetabular component after total hip arthroplasty on plain radiographs. j orthop surg res. 2018;13(1):66. 8. hassan dm, johnston gh, dust wn, et al. accuracy of intraoperative assessment of acetabular prosthesis placement. j arthroplasty. 1998;13(1):80-84. 9. hohmann e, bryant a, tetsworth k. a comparison between imageless navigated and manual freehand technique acetabular cup placement in total hip arthroplasty. j arthroplasty. 2011;26(7):1078-82. 10. deacon m, de beer j, ryan p. radiological analysis of component positioning in total hip arthroplasty using the anterior approach. sa orthop j. 2016;15(3):38-45. 11. bayraktar v, weber m, von kunow f, et al. accuracy of measuring acetabular cup position after total hip arthroplasty: comparison between a radiographic planning software and three-dimensional computed tomography. int orthop. 2017;41(4):731-38. 12. haenle m, heitner a, mittelmeier w, et al. assessment of cup position from plain radiographs: impact of pelvic tilting. surg radiol anat. 2007;29(1):29-35. 13. alzohiry ma, abdelnasser mk, moustafa m, et al. accuracy of plain antero-posterior radiographic-based methods for measurement of acetabular cup version. int orthop. 2018;42(12):2777-85. 14. bhaskar d, rajpura a, board t. current concepts in acetabular positioning in total hip arthroplasty. indian j orthop. 2017;51(4):386-96. 15. parratte s, argenson jn. validation and usefulness of a computer-assisted cup-positioning system in total hip arthroplasty. a prospective, randomized, controlled study. j bone joint surg am. 2007;89(3):494-99. 16. dorr ld, malik a, wan z, et al. precision and bias of imageless computer navigation and surgeon estimates for acetabular component position. clin orthop relat res. 2007;465:92-99. 17. kwon ms, kuskowski m, mulhall kj, et al. does surgical approach affect total hip arthroplasty dislocation rates? clin orthop relat res. 2006;447:34-38. https://orcid.org/0000-0001-6206-6687 https://orcid.org/0000-0002-5362-4197 https://orcid.org/0000-0002-6539-7833 https://orcid.org/0000-0002-4049-8283 south african orthopaedic journal current concepts review doi 10.17159/2309-8309/2022/v21n2a6kauta nj et al. sa orthop j 2022;21(2) citation: kauta nj, du plessis jp, de wet jj, vrettos b, roche sjl. current concepts on the assessment of a patient with a traumatic anterior shoulder dislocation. sa orthop j. 2022;21(2):100105. http://dx.doi.org/10.17159/2309-8309/2022/ v21n2a6 editor: dr cameron anley, stellenbosch university, cape town, south africa received: october 2021 accepted: february 2022 published: may 2022 copyright: © 2022 kauta nj. this is an openaccess article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract anterior shoulder dislocation is a common condition that most orthopaedic surgeons will have to deal with in their practice. nonoperative management of the initial traumatic anterior shoulder dislocation is likely to lead to a recurrent shoulder dislocation in more than 90% of cases in the younger active population. recurrent anterior shoulder dislocation can persist even after instability surgery in certain cases. a detailed, accurate assessment of the patient is of paramount importance for successful treatment. this review aims to provide insight into key concepts to consider in the assessment of an anterior shoulder dislocation. predisposing factors, clinical examination and the role of imaging in the assessment of an anterior shoulder dislocation will be reviewed. level of evidence: level 5 keywords: anterior shoulder dislocation, anterior shoulder instability, recurrent shoulder dislocation, anterior shoulder instability assessment current concepts on the assessment of a patient with a traumatic anterior shoulder dislocation ntambue j kauta,* jean p du plessis, johannes j de wet, basil vrettos, stephen jl roche adult reconstruction, shoulder and elbow unit, groote schuur hospital orthopaedic research unit, university of cape town, cape town, south africa *corresponding author: jimmy.kauta@uct.ac.za introduction anterior shoulder dislocation is the most common joint dislocation.1 following nonoperative management of the initial episode, the recurrence rate varies from 70% to more than 90% in the adolescent population group.1-3 recurrent instability has been reported in up to 30% of surgically treated adolescent traumatic anterior shoulder dislocation.4,5 two-thirds of patients with recurrent dislocation will develop instability arthropathy within 25 years of the initial dislocation episode.6 there is, therefore, a need to identify patients who are likely to recur and who may need surgical stabilisation. an understanding of factors that predispose to recurrent anterior instability, a thorough clinical examination to define the instability characteristics and an analysis of bone loss pattern through imaging are the steppingstones to an appropriate treatment algorithm. assessment of the unstable shoulder risk factors for recurrence after nonoperative management of the index traumatic anterior dislocation well-defined factors have been recognised as independent risk factors for recurrent anterior shoulder dislocation. these factors include: • young age at the initial dislocation3,7 • humeral or glenoid critical bone loss at initial dislocation8-11 • return to competitive contact sport activities12-15 • ligamentous laxity16-18 recurrent dislocation after initial nonoperative management is closely related to age younger than 20 years at the time of the first dislocation.3,19 roberts et al. prospectively observed a group of 133 adolescents who were treated nonoperatively for anterior shoulder dislocation and reported a 76% recurrence rate at two years.7 the presence and magnitude of humeral or glenoid bone loss is another consistent predisposing factor to recurrent shoulder dislocation. an off-track hill–sachs lesion has been noted to predispose to recurrent dislocation in 100% of the cases. this recurrence rate drops to 58% and 27% respectively when dealing with an on-track hill–sachs lesion or no lesion at all in young first-time dislocators.8,9 dickens et al. found that initial traumatic anterior shoulder dislocation could lead to minor glenoid bone loss (6.8% of the glenoid width), but this glenoid bone loss increased up to 22.8% in recurring dislocations.10 in the setting of glenoid bone loss, recurrence rates of 72% in the under 23-year-olds and 27% in the over 30-year-olds have been reported.11 burkhart and de beer reported that the inverted pearshaped glenoid due to anteroinferior bone loss was associated with recurrence of instability after arthroscopic bankart repair.20 https://orcid.org/0000-0002-7099 page 101kauta nj et al. sa orthop j 2022;21(2) for athletes who have been treated nonoperatively, it is accepted that return to play should be allowed after the injured shoulder has recovered more or less to equal strength and range of motion as the uninjured shoulder. this is often within two to three weeks of the dislocation.12 the rate of recurrence of anterior instability (dislocation and subluxation episodes) has been reported to vary between 30 and 90% when all professional sports are considered.12-14 return to competitive sport is therefore considered an independent risk factor for recurrent dislocation. this risk is not only seen in nonoperative treatment but also following surgery as reported by torrance et al., where they documented a 93% recurrence rate in rugby players younger than 16 years who had undergone an arthroscopic bankart repair. the recurrence occurred following another traumatic event after return to play. the type of sport and the level of participation play important roles in the recurrence rate.15 the role of generalised ligamentous laxity as an independent predisposing factor for unidirectional anterior shoulder dislocation has been investigated. some studies have suggested that generalised ligamentous laxity and increased external rotation of the shoulder to more than 85° predispose to acute and chronic shoulder injuries.16,17 akhtar and robinson found a 43% incidence of generalised ligamentous laxity in patients presenting with anterior shoulder dislocation suggesting that this condition could be a predisposing factor to both primary and recurrent anterior dislocation.18 balg and boileau21 have shown that patients with two or more of these risk factors were likely to fail an arthroscopic bankart repair as a stabilising surgical procedure. clinical evaluation the clinical examination of the unstable shoulder primarily aims to determine whether the shoulder instability is unidirectional (anterior, posterior or inferior), bidirectional (unstable in two directions) or multidirectional (unstable in more than two directions). an assessment of ligament laxity needs to be performed. associated soft tissues injuries (capsulolabral injuries, cuff tears) and neurovascular injuries must also be assessed. information obtained from the clinical evaluation is as important as the information obtained from imaging in the formulation of the treatment strategy for the unstable shoulder. directed clinical history clinical history should focus on the age at the index dislocation, the mechanism of injury and ease of relocation of the index dislocation. if the index relocation did not require sedation and was relatively easy, ligamentous laxity should be suspected. the number and frequency of recurrences as well as inciting events should be investigated. pre-existing medical conditions such as epilepsy should be assessed for and strictly controlled before instability surgery is undertaken. patients with more than two dislocations and limited bone loss on imaging should be assessed for a voluntary component to their instability since this may affect the management decision-making process. gerber and nyffeler classified voluntary dislocators into three groups: i) dislocators without apprehension; ii) symptomatic voluntary dislocators or subluxators; and iii) psychiatric patients.22 this classification should be considered when assessing voluntary dislocators due to the failure of surgical treatment in this group. general physical examination the examination of the unstable shoulder begins with a comparative inspection of both shoulders (appropriately exposed) for asymmetry in shoulder contour, muscle bulk, and the presence or absence of signs of acute injury such as bruising. inspection for scapula position is done in static and dynamic mode during range of motion to exclude subtle scapula dyskinesia. palpation of bony prominences is done to exclude occult or missed fractures, especially of the coracoid process. comparative range of motion assessment is done in the most relevant planes including forward elevation, external and internal rotation with the arm to the side and the shoulder in 90° of abduction. rotator cuff strength testing is done by isolating one muscle at a time according to standard clinical examination tests. neurovascular assessment concludes the general examination and focuses on axillary nerve, brachial plexus assessment and pulse status. instability-specific examination the specific shoulder instability evaluation starts with the assessment for generalised ligamentous hyperlaxity using the beighton criteria.23 specific shoulder hyperlaxity signs include a positive walch test (shoulder external rotation of more than 90°), indicative of laxity of the anterior shoulder capsuloligamentous tissues, and positive gagey’s hyperabduction sign (more than 105° of passive abduction), indicative of inferior ligamentous laxity of the shoulder.24,25 at this step, the patient is asked to try and dislocate or subluxate their shoulder. this would help identify the habitual or voluntary dislocator. provocative testing is conducted to determine the direction of instability and confirm whether the patient presents with unidirectional, bidirectional or multidirectional instability. the sulcus sign test assesses for the presence or absence of rotator interval laxity and inferior laxity. to elucidate the sulcus sign, the patient is first positioned upright with their arms resting at their side. the examiner then stabilises the shoulder and applies an inferiorly directed force on the elbow. excessive downward displacement of the humeral head that does not improve with external rotation denotes a deficiency of the rotator interval and inferior instability. the sulcus sign is graded by the amount of inferior translation: grade i is less than 1 cm translation, grade ii is 1–2 cm translation, and grade iii is greater than 2 cm translation.26 the higher the grade, the higher the degree of laxity of the rotator interval and inferior instability. the apprehension test aims to ascertain the presence of anterior instability. as originally described by rowe and colleagues, the test is performed either in standing or supine position, with the arm abducted 90°; the shoulder is externally rotated until the patient is apprehensive of a dislocation.27,28 rowe et al. stated that all their patients tested positive when examined in this fashion; however, the test could be positive in other conditions with pain and weakness in the shoulder.28 the apprehension test has a specificity of 95.7–100% and a sensitivity of 50–55.6%.29,30 it has many variations, but all of them essentially aim to provoke the humeral head to go over the anterior edge of the glenoid. the bony apprehension test is a variant of the traditional apprehension test and is used to detect bone loss, specifically, as a contributing cause of anterior glenohumeral instability.31 the test is performed with the shoulder positioned at 45° of abduction or less and at 45° of external rotation or less. a positive finding is a sensation of apprehension or symptoms of instability. the bony apprehension test has been shown to be more sensitive than preoperative plain radiographs for detecting bony lesions at time of surgery.31 the relocation test is performed for confirmation of the apprehension test. in frank jobe’s original description of this test, the patient is supine with the shoulder over the edge of the examination table.32 the apprehension test is performed as described above; once positive apprehension or guarding (feeling of subluxation and not pain) is expressed, the examiner places a page 102 kauta nj et al. sa orthop j 2022;21(2) posteriorly directed force over the anterior aspect of the shoulder. the test is positive when the apprehension feeling is relieved.32,33 while the patient’s shoulder is maintained in the apprehension test and a positive relocation test has been obtained, sudden removal of the examiner’s relocating hand will cause a sudden apprehension feeling. this manoeuvre was described as the surprise test by silliman and hawkins.34 this test is a concern as the patient may dislocate and we seldom perform it. the load and shift test evaluates the degree of shoulder laxity in the anterior to posterior plane.35 the test can be performed with the patient sitting with the arm at the side or with patient supine and the arm in 20° and 90° of abduction. the examiner grasps the patient wrist with one hand and with the other hand the examiner loads the humeral head into the glenoid fossa and pushes the humeral head forward. translation is graded from 0 to 3. grade 0 denotes no translation; grade 1 is translation to the glenoid rim; grade 2 is translation over the rim but humeral head reduces spontaneously; and grade 3 is translation over the rim but no spontaneous relocation.36 tzannes and paxinos reported that the load and shift was more positive with the arm abducted to 20 and 90° than with arm at 0° abduction with the patient sitting.37 other variants of this test include the anterior drawer and the anterior jerk tests.38,39 posterior instability testing must be done to exclude posterior instability before settling on the diagnosis of a unidirectional anterior instability. the jerk test, kim test and posterior drawer tests are all common practice in the assessment of posterior instability.38,40,41 this specific shoulder assessment is concluded by assessing for associated biceps and labral pathologies. the ‘3-pack’ examination, which includes the o’brien sign, throwing test and bicipital tunnel palpation, has an excellent sensitivity, negative predictive value, and inter-rater reliability for comprehensive evaluation of the biceps/labral complex pathology, making it an ideal screening tool for this purpose.42 imaging for anterior shoulder instability it is recognised that common soft tissue injuries such as anteroinferior capsulolabral injuries (bankart lesion) are an integral part of the pathology of anterior shoulder dislocation. the role of imaging is to detect uncommon soft tissue injuries such as humeral avulsion of the glenohumeral ligament (hagl), superior labral anteroposterior (slap) lesions as well as bony lesions. plain radiographs (x-rays) plain radiography has shown a suboptimal sensitivity and reliability in the detection of glenoid and humeral bone loss, making this imaging modality a poor screening tool for bone loss in shoulder instability.43 four standard views including a true anteroposterior view, axillary view, internally rotated and externally rotated views are initially obtained for the purpose of detecting bone loss. the diagnosis of a hill–sachs lesion on plain radiographs can be significantly increased if there is awareness that the internal rotation view may fail to show the injury, and if all four views are scrutinised.44 rozing et al. demonstrated the role of a stryker notch view in detecting hill–sachs lesion in their series of 27 cases.45 a loss of cortical line contour of anteroinferior glenoid on an anteroposterior view is suggestive of anteroinferior glenoid bone loss (figure 1). specialised views such as the west point and bernageau views have shown high correlation with computed tomography in detecting glenoid bone loss.46,47 although bone loss can be detected on plain radiographs it cannot, however, be precisely measured on plain radiographs.48,49 when precise measurement of bone loss is desired, a ct scan of the affected shoulder is warranted. computed tomography scan (ct scan) a three-dimensional (3d) ct scan is the gold standard for shoulder instability bone loss assessment. the humeral head subtraction technique and free body rotation of the entire scapula facilitate a precise en face sagittal oblique view of the glenoid surface. this allows accurate measurements of the magnitude of glenoid bone loss and allows for a distinction between a chronic attritional bone loss and an acute fracture. in addition, the humeral head can be rotated in different planes to visualise a hill–sachs lesion.50 figure 1. loss of cortical line at the anteroinferior edge of the glenoid indicative of glenoid bone loss (blue arrow) figure 2. 3d ct scan en face view and best fit perfect circle method for glenoid bone loss measurement; a) true glenoid width (23.5 mm), b) glenoid bone loss (4.9 mm) page 103kauta nj et al. sa orthop j 2022;21(2) indications for obtaining a ct scan with 3d reconstruction on patients with shoulder instability include a history of multiple dislocations, a prior failed stabilisation procedure, relative ease of dislocation through low energy mechanisms or activities of daily living, mid-range instability, or concern for glenoid bone loss on radiographs or mri.50 there are various methods described to assist in measuring or estimating glenoid bone loss. the first step in all methods is to establish an en face view of the glenoid on a 3d ct scan with humeral head subtraction (figure 2). the two most common methods include the surface area loss measurements and the width loss measurements. in surface area loss measurements, a best-fit circle surface area (bcsa) is superimposed onto the affected glenoid based either on the contralateral side or based on the intact posteroinferior borders of the affected glenoid (figure 2). in the bcsa methods, the surface area loss can be calculated using a software program or using a mathematical formula.51,52 in essence, the percentage of glenoid bone loss using surface area techniques is performed by measuring the area of the true circle not occupied by the glenoid surface and dividing this area by the area of the best-fit circle. the pico method is one example of the bcsa method commonly used. originally described by baudi et al., the pico method has demonstrated good interobserver (icc 0.90) and intraobserver (icc0.94, 0.96–1.0) reliability as well as a low coefficient of variation (2.2–2.5 %).51,53 according to the pico method, a perfect circle is first drawn on the inferior part of the healthy glenoid and then transferred to the injured glenoid. the surface of the missing glenoid part of the circle is measured; the size of the glenoid bone defect is expressed as a percentage of the entire circle. width loss measurement methods measure width loss from a circle approximated to the inferior glenoid (based on either contralateral or ipsilateral glenoid) and have been found to have good reliability and accuracy (figure 2).53,54 this is a simple calculation and advanced software calculations are not required. milano et al. have shown a strong correlation and agreement in detecting the presence, size and type of bone loss between referencing to the ct of the uninjured side and referencing from the posteroinferior margins of the injured glenoid.54 parada et al. have cautioned against the use of measurement referencing from the uninjured side since their cadaveric anthropometric study showed side-to-side glenoid widths, heights and surface area were statistically different in some cadavers.55 a systematic review by gottschalk et al. reported that several studies that had shown the limit of glenoid bone loss beyond which a bankart repair was likely to fail varied between 20 and 25% of the glenoid width.56 shin et al. disputed these values and showed that in their cohort, the critical glenoid bone loss value was 17.3%. glenoid bone defect of larger surfaces than 17.3% suffered failure of arthroscopic bankart repair.57 these glenoid bone loss critical values become irrelevant when an associated hill–sachs lesion is present.58 assessment of hill–sachs lesions the aim of hill–sachs lesion assessment is to determine whether it is an engaging lesion or not, depending on its width, length and depth. various methods have been described and each with a different critical size above which the lesion may be deemed engaging.59-61 in the assessment of bifocal lesions (coexisting glenoid and humeral bone loss), the two lesions need to be assessed individually and then correlated to each other to determine whether recurrent instability or dislocation can be expected after arthroscopic soft tissue stabilising procedures. di giacomo et al. in 2014 introduced the on-track off-track method using ct with 3d reconstructions where lesions were considered engaging, or off track if the hill– sachs interval exceeded the glenoid track.61 the glenoid track consists of the contact area between the humeral head and glenoid during shoulder abduction and external rotation and it represents approximately 83% of the glenoid width. the hill–sachs interval figure 3. on-track/off-track measurements a) r: line of medial margin of rotator cuff attachments; g2: line of medial margin of glenoid track of affected shoulder; g1: line of medial margin of glenoid track of intact shoulder; hsi: hill–sachs interval; bb: bone bridge; d: width of anterior glenoid bone defect; gtaf: width of glenoid track of affected shoulder; gtint: width of glenoid track of intact shoulder b) d: width of intact glenoid; d: width of glenoid bone defect (reproduced with permission from efort open rev. 2020;5:815-27. https://doi.org/10.1302/2058 5241.5.200049.) a b page 104 kauta nj et al. sa orthop j 2022;21(2) represents the width of the hill–sachs lesion in millimetres plus the width of the intact bone bridge in millimetres between the rotator cuff attachment and the lateral margin of the hill–sachs lesion. di giacomo et al.’s method consists of four evaluation steps: the first measures the diameter (d) of the inferior glenoid using the perfect circle method; the second measures the amount of glenoid anterior bone loss (d); the third calculates the width of the glenoid track (gt) = 0.83 × d−d; and the last measures the width of the hill–sachs interval (hsi), which is the width of the hill– sachs lesion plus the width of the bone bridge between the lesion and the rotator cuff insertion. if hsi > gt, the lesion is off track; if hsi < gt, it is on track (figure 3).61,62 magnetic resonance imaging (mri) the routine use of mri as a diagnostic tool in the diagnosis of anterior shoulder instability remains controversial. despite cost and availability, the use of mri in anterior shoulder dislocation is rising. leland et al. reported an increased trend in the diagnosis of bony bankart and/or hill–sachs on mri, documenting an incidence of 96% in patients undergoing mri in 2015–2018 compared to 52.9% in 1994–1999.63 the authors postulated that it may be associated with improved mri modalities, increased focus on identifying bony bankart and/or hill–sachs lesions, and increasing concern about glenoid bone loss.63 the main advantages of using an mri scan in the setting of shoulder instability are twofold. first, it helps to exclude other soft tissue injuries, such as slap lesions, hagl lesions, anterior labral periosteal sleeve avulsion (alpsa), glenoid articular cartilage defect (glad), rotator cuff tendon tears and more extensive cartilaginous injuries. secondly, it helps to confirm the diagnosis of dislocation. in patients who have had a dislocation which reduces spontaneously, there may be some uncertainty in the diagnosis. this can be confirmed on mri scan by the presence of bony oedema in the posterior aspect of the humeral head (in the region of a hill–sachs lesion). burke et al. demonstrated glenoid bone loss measurements performed on 3d mri reconstructions have close correlation with that of 3d ct, which is considered the gold standard.64 leland et al. noted that mri can estimate glenoid bone loss as accurately as ct scan.63 mr arthrography (mra) has little or no role in the acute setting and the use of mra has decreased over time due to the availability and quality of the modern 3t (3 tesla) mri.64 although not frequently used, it may still be an invaluable diagnostic tool in the young active patient with recurrent anterior shoulder instability with a subtle capsulolabral abnormality.64 conclusion this review outlines the role of a thorough clinical assessment and adequate imaging in identifying patients at higher risk of developing recurrent anterior shoulder instability and dislocation. patients younger than 20 years of age, those with ligament hyperlaxity and those with considerable bone loss are at higher risk of recurrence. while the debate is still ongoing with regard to the best method to measure glenoid and humeral bone loss, a 3d ct scan remains the gold standard imaging modality to assess bone loss. the on-track vs off-track concept is the most accepted method of assessing bone loss when there is bipolar bone loss. awareness and identification of these risk factors during the assessment of a patient with a traumatic anterior shoulder dislocation will inform the management decision-making process and hopefully prevent recurrent dislocations and subsequent arthropathy. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. as this is a review article, no studies on humans or animals were conducted for this study. no ethics or institutional review board approval were required. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions njk: first draft preparation, all revisions jpdp: manuscript revision jjdw: first draft preparation bv: manuscript revision sjlr: manuscript revision orcid kauta nj https://orcid.org/0000-0002-7099 du plessis jp https://orcid.org/0000-0001-6469-7765 de wet jj https://orcid.org/0000-0001-5464-749x vrettos b https://orcid.org/0000-0003-4226-0794 roche sjl https://orcid.org/0000-0002-5695-2751 references 1. dodson cc, cordasco fa. anterior glenohumeral joint dislocations. orthop clin north am. 2008;39(4):507-18. https://doi.org/10.1016/j.ocl.2008.06.001. 2. henry jh, genung ja. natural history of glenohumeral dislocation—revisited. am j sports med. 1982;10(3):135-37. https://doi.org/10.1177/036354658201000301. 3. bottoni cr, wilckens jh, deberardino tm, et al. a prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, first-time shoulder dislocations. am j sports med. 2002;30(4):576-80. https://doi.org/10.117 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changes in the diagnosis, injury severity and treatment for anterior shoulder instability over time in a us population. arthrosc sports med rehabil. 2020;2(6):e761-69. https://doi.org/10.1016/j.asmr.2020.06.012. 64. burke cj, rodrigues tc, gyftopoulos s. anterior instability: what to look for. magn reson imaging clin n am. 2020;28(2):195-209. https://doi.org/10.1016/j.mric.2019.12.004. _hlk101356016 _hlk101357328 _hlk101357837 south african orthopaedic journal letter to the editor doi 10.17159/2309-8309/2021/v20n3l1sa orthop j 2021;20(3) proposal for a south african sarcoma registry thomas hilton,1* henrik cf bauer2 ¹ groote schuur hospital and life vincent pallotti orthopaedic hospital, cape town; faculty of medicine and health sciences, university of cape town, cape town, south africa ² department of molecular medicine and surgery, karolinska institute, stockholm, sweden; faculty of medicine and health sciences, university of cape town, cape town, south africa *corresponding author: thomas@drthilton.com clinical registries have become a normality in virtually all fields of medicine. orthopaedics has in many ways led this development with early registries of knee and hip arthroplasties. the south african orthopaedic registry (saor) is an ambitious undertaking to register all orthopaedic procedures performed in south africa and will provide valuable data for quality assessment, teaching and allocation of resources.1 the first collection of data on sarcomas was based on bone pathologists recording histological features and some clinical data. these registries were not population based and had insufficient data on treatment and follow-up. the first sarcoma registry, as we now know them, was the southern sweden sarcoma registry which was founded by anders rydholm in 1970.2 this registry was expanded into the scandinavian sarcoma group (ssg) registry by rydholm and bauer in 1986 and now encompasses more than 10 000 patients.3 the type of data collected pertains to referral, diagnostics, tumour characteristics, treatment and follow-up. important variables include: • whether the patient had been operated on before referral to a sarcoma centre • type of biopsy they received • tumour size • tumour type and grade • amputation or limb-sparing surgery • surgical margins • neoadjuvant ± adjuvant chemotherapy or radiation therapy during follow-up, development of local recurrence or metastases are recorded. lastly, cause of death is recorded as tumour-related or not. sarcoma registries are the backbone of clinical research. for example, the ssg registry has been the basis for quality-of-care assessment and for in-depth studies of particular entities and treatment of sarcomas. creating standardised sarcoma care pathways may increase clinician awareness and improve referral to sarcoma centres.4 goals for specific events such as: time between referral and first visit, time to diagnosis, time to start of treatment, etc., are established. these time goals for the diagnosis and treatment of patients with a sarcoma can be used to assess quality and availability of care at individual institutions and nationally. sarcoma care in south africa is an underdeveloped entity characterised by late presentation of patients, frequent absenteeism, delays in treatment and difficulty in providing treatment due to resource constraints and cultural beliefs.5 however, the development of the south african oncology and limb salvage society, along with efforts in the major centres, is helping to improve access to sarcoma treatment for south africans. coupled with this are unique practices that include the initial visits to traditional healers together with the more well-known assumption that the musculoskeletal complaints are due to sprains and muscle tears, with physiotherapists and biokineticists being consulted first. sarcoma-related conditions are also less well known than those of carcinomas such as of the breast and prostate; therefore, soft tissue sarcomas are often considered benign until they are advanced, and the diagnosis reconsidered. treatment of sarcomas, as described above, is intensive and resource draining both for the service provider and patient. we currently do not have accurate data on the incidence and prevalence of sarcomas in south africa and a registry has been a long-term goal of many doctors here. data is powerful and would table i: proposed variables for sarcoma registry characteristics treatment follow-up referral date number of surgeries for primary tumour date of follow-up referral pattern date of surgery local recurrence diagnosis date surgery at sarcoma centre treatment of recurrence age at diagnosis local surgery or amputation metastases metastases at diagnosis surgical margin treatment of metastases preoperative biopsy type of reconstruction cause of death morphological diagnosis complications date of death malignancy grade adjuvant treatment tumour site date: start of chemotherapy tumour location date: start of radiotherapy pathological fracture radiotherapy dose and fraction size of primary tumour https://orcid.org/0000-0002-6178-5062 https://orcid.org/0000-0002-3557-0252 page 136 sa orthop j 2021;20(3) be useful to motivate for increased education and awareness surrounding sarcomas in south africa as well as allocation of resources for personnel and treatment. it would also be valuable in guiding research in this field to better understand a south african perspective on the disease and its outcomes. in order to address these issues, we propose the following plan: 1. set up a template for a sarcoma registry based upon variables from the ssg registry but adapt them to fit the local care system in south africa. a sarcoma registry has been approved by the uct faculty of health sciences human research ethics committee r005/2021 2. start entering patients treated in the cape town hospitals, both private and academic 3. explore the possibility of working with the south african cancer registry to locate sarcoma patients that have not been referred to a sarcoma centre 4. instigate cooperation with other sarcoma centres in south africa to launch a comprehensive south african sarcoma registry a prospective and population-based sarcoma registry could become an important instrument to monitor quality of care. reports from the registry would be used to make recommendations regarding referral, diagnostics and treatment. most data on sarcomas are based on studies from the united states, japan and western europe. a south african registry could be used as a basis for in-depth studies of different sarcoma types in a south african setting. maintaining long-term follow-up is always a challenging issue, especially in registries which are not managed or financed as a defined clinical study. in south africa, follow-up is probably more difficult to achieve because of communication issues between patients and hospitals, lack of electronic patient health records, and problems regarding compliance with follow-up schedules. however, follow-up is not paramount to achieve important information on quality of care. registering timelines to diagnosis and treatment are valuable measurement tools. furthermore, tumour and treatment characteristics such as referral patterns, evidence of metastases at diagnosis, surgical margins, rate of limb-sparing surgery, and the proportion of patients receiving adjuvant radiotherapy or chemotherapy, can be compared to data from other population-based registries. they can also be compared to treatment guidelines and followed longitudinally to ascertain whether sarcoma care improves or not. not least, just comparing the number of patients treated at dedicated sarcoma centres with the expected number based on sarcoma incidence, will tell how many sarcoma patients in south africa get adequate diagnostics and treatment. a sarcoma registry will increase knowledge and interest in sarcoma care in south africa, both at the general and specialist level, thereby improving the quality and accessibility of care. with local data from a south african registry, better decisions can be made around sarcoma treatment. it will also lead to more patients being referred to specialised sarcoma centres, which is paramount for a good oncologic outcome and to afford the least morbid treatment plan to ensure the best functional outcome available. once a south african registry is set up, a next step could be agreeing on a standardised care pathway for patients suspected of having a sarcoma. having common goals with respect to referral, time to diagnosis and treatment, and instruments to measure outcome, can be used both for educational purposes and to motivate sufficient resources to enhance quality care of sarcoma patients. references 1. bernstein b. message from the president: ‘the art of war’. sa orthop j. 2021;20(2):66. 2. alvegård t, bauer h, blomqvist c, rydholm a, smeland s. the scandinavian sarcoma group – background, organization and the ssg register – the first 25 years. acta orthopaedica scandinavica. supplementum. 2004;75(suppl 311):1-7. https://doi.org/10.1080/00016470410001708250. 3. trovik c, bauer hcf, styring e, laitinen m, lehtinen t. the scandinavian sarcoma group central register: 6,000 patients after 25 years of monitoring of referral and treatment of extremity and trunk wall soft-tissue sarcoma. acta orthopaedica. 2017;88(3):341-47. https://pubmed.ncbi.nlm.nih.gov/28266233. 4. andritsch e, beishon m, bielack s, et al. ecco essential requirements for quality cancer care: soft tissue sarcoma in adults and bone sarcoma. a critical review. crit rev oncol hematol. 2017;110:94-105. https://doi.org/10.1016/j. critrevonc.2016.12.002. 5. brown o, goliath v, van rooyen drm, aldous c, marais lc. cultural factors that influence the treatment of osteosarcoma in zulu patients: healthcare professionals’ perspectives and strategies. health sa. 2018 jun 28;23:1095. https://doi.org/10.4102/hsag.v23i0.1095. pmid: 31934385; pmcid: pmc6917416. mccaul j et al. sa orthop j 2020;19(2) doi 10.17159/2309-8309/2020/v19n2a5 south african orthopaedic journal http://journal.saoa.org.za spine abstract background: in paediatric trauma, measured increase in prevertebral soft tissue thickness on a lateral cervical spine (c-spine) x-ray is interpreted as swelling, raising suspicion of c-spine injury. defining swelling in absolute measurements is cumbersome – children’s sizes vary. published recommendations are largely lacking in evidence. there may be potentially more consistent tools, for example, to measure soft tissue thickness as a ratio of vertebral body width. the aim of this study was to determine whether consistent, measurable prevertebral soft tissue to vertebral body width ratios exist for use as simple diagnostic tools in the assessment of swelling and injury in paediatric c-spine trauma. patients and methods: c-spine trauma x-rays taken at a south african children’s hospital were randomly sampled. seventy-one unintubated x-rays from 85 controls were used to identify normal ratios. the authors measured vertebral bodies and soft tissue at each level, created all possible ratios, then chose the two least variable – one for the upper and one for the lower c-spine. twenty cases aided in determining diagnostic accuracy for c-spine injury. results: mean soft tissue at the second cervical vertebral level (c2) was 38% of the seventh vertebra (c7) (95% confidence interval [ci]: 34–41.9%, standard error [se]: 2.0%). mean c6 soft tissue was 65.6% of c7 vertebra (95% ci: 61.9–69.3%, se: 1.9%). in diagnosing c-spine injury, a receiver operating characteristic (roc) curve calculation gave an empirical optimal cut-point of 53.9% and 74.4% respectively. using practical cut-offs of 55% at c2 and 75% at c6 yielded specificities of 93.8% (95% ci: 84.8–98.3%) and 81.8% (95% ci: 70.4–90.2%), with negative predictive values of 90.9% (95% ci: 81.3–96.6%) and 91.5% (95% ci: 81.3–97.2%) respectively. conclusion: consistent and specific ratios exist in the upper and lower paediatric c-spine. both ratios have poor sensitivities and positive predictive values and so are poor screening tools; however, a positive result can raise suspicion of c-spine injury in high-risk individuals. this can help to motivate for further investigations such as computer tomography (ct) or magnetic resonance imaging (mri), which may not be easily accessible in under-resourced settings. however, further research is required to validate the diagnostic value of these ratios. level of evidence: level 4 keywords: prevertebral soft tissue, vertebral body width, cervical spine, paediatric, c-spine trauma, ratio correlation of soft tissue projection in injured necks (cspine) prevertebral soft tissue measurement in paediatric cervical spine trauma mccaul j¹ , horn a² , mccaul m³ , dix-peek s4 1 mbchb(uct), fcs(sa)orth(uct), mmed(uct); consultant, division of orthopaedic surgery, groote schuur hospital and red cross war memorial children’s hospital; university of cape town, south africa 2 mbchb(up), fcs(sa)orth(uct), mmed(uct); consultant, division of orthopaedic surgery, groote schuur hospital; university of cape town, south africa 3 msc(clin epi)(su); senior lecturer, division of epidemiology and biostatistics, department of global health, stellenbosch university, south africa 4 mbbch(wits), fcs(sa)orth, mmed(uct); consultant, red cross war memorial children’s hospital; university of cape town, south africa corresponding author: dr j mccaul, h49 old main building, groote schuur hospital, anzio rd, observatory, cape town, 7925; tel: +27 83 682 0060; email: jkmccaul@gmail.com https://orcid.org/0000-0003-1011-5912 https://orcid.org/0000-0002-4159-6520 https://orcid.org/0000-0002-2730-6478 https://orcid.org/0000-0002-3382-8790 page 85mccaul j et al. sa orthop j 2020;19(2) introduction paediatric cervical spine (c-spine) injury is rare but potentially devastating.1 although soft tissue swelling on x-ray has been referred to as an aid in identifying injury,1,2 published measurement methods and recommendations on what constitutes swelling vary, as does the diagnostic significance of said swelling.3-16 measurements in millimetres (mm) may not be applicable across wide age ranges and an alternative is measurement as a ratio of vertebral body width. some published normal values are based on primary evidence, but many statements regarding measurement norms are uncited, or citations do not correctly support the measurement.3-15 table i provides a summary of published normal values. the purpose was to determine whether measurement of prevertebral soft tissue as a ratio of vertebral body width on paediatric lateral c-spine trauma x-rays is consistent in uninjured, un-intubated patients and, as a secondary objective, is of diagnostic value in identifying c-spine injury. the hypothesis was that one such measurement would be identified for the upper and one for the lower c-spine; that these would have clinically acceptably narrow variability across age groups and sexes; and that measurements greater than these would correlate with c-spine injury. other secondary objectives were to describe the atlanto-dens interval (adi), basion-dens interval (bd) and effect of intubation on soft tissue thickness. materials and methods study design and setting a retrospective pragmatic quantitative cross-sectional study randomly sampled digital lateral c-spine x-rays taken in patients under 13 years of age at red cross war memorial children’s hospital in cape town, south africa, between december 2012 and february 2016. all x-rays were assigned consecutive numbers, then selected according to a computer-generated random number sequence. x-rays taken for non-traumatic reasons were excluded. additional x-rays of injured patients from pre-existing records and from the same period were added to the random sample to increase the number of injuries available for analysis to complete the secondary objectives. patient folders were reviewed. no followup was performed. dedicated erect or supine lateral c-spine views on conventional, mobile unit and whole-body low dose digital x-rays (lodox) of patients both with and without c-spine injury were included. patients assessed as being clinically clear according to the canadian c-spine,17 national emergency x-radiography utilization study group (nexus)18 or other pragmatic criteria and that were finally managed and discharged as having no c-spine injury were classified as controls. patients with normal c-spine x-ray, computerised tomography (ct) scan or magnetic resonance imaging (mri) report were also classified as controls. patients with bony, ligamentous, cervical cord or cervical nerve injury clinically or on imaging were classified as cases. there were 85 controls and 20 cases. measurements measurements were performed in mm up to one decimal point using the ruler tool of the phillips isite® enterprise radiology system. if an area could not be visualised, those specific measurements only (28 out of 1 365 possible measurements) were treated as missing data. soft tissue thickness was measured parallel to the adjacent vertebral body’s inferior endplate, from the most anterior–inferior aspect of that vertebral body to the most anterior edge of the tissue shadow. as the first cervical vertebra (c1) has no body, measurement started from the most anterior inferior aspect of c1’s anterior arch to the anterior edge of the soft tissue, along a line extended from the most inferior projections of c1 anterior and posterior arches. the soft tissue measurements were labelled c1–c7 according to the adjacent vertebra. in intubated cases, if the anterior edge of the soft tissue shadow was obscured by the tube, the measurement was taken up to the most posterior edge of the tube. vertebral body width was measured from the most posterior– inferior corner to the most anterior–inferior corner and labelled c2–c7. atlanto-dens interval (adi) was measured as drawn from the posterior inferior corner of the anterior arch of c1 to the adjacent anterior border of the odontoid, along the line between the most inferior projections of c1 anterior and posterior arches. basion-dens distance (bd) was measured from the anterior rim of the foramen magnum to the most prominent superior projection of the dens. see figure 1 for measurement examples. the age of the patient was extrapolated from the dates of birth and of the x-ray. sex was recorded for all patients and, where available, weight in kilograms up to one decimal point. mechanism of injury was extracted from the clinical information. digital radiology reports attached to x-ray, ct and mri images were examined and any comments on soft tissue and adequacy of images noted. it was recorded whether an injury was identified, excluded or unclear. this was correlated with clinical information regarding examination and management. blinding during measurement was not possible as clinical information was digitally linked to images; however, strict measurement protocols as above minimised risk of bias. a single author measured all images. statistical methods a sample size of 60 for the primary objective was calculated by hypothesising clinically acceptably accurate ratios and confidence citation: mccaul j, horn a, mccaul m, dix-peek s. correlation of soft tissue projection in injured necks (cspine): prevertebral soft tissue measurement in paediatric cervical spine trauma. sa orthop j 2020;19(2):84-91. http://dx.doi.org/10.17159/2309-8309/2020/v19n2a5 editor: dr johan davis, stellenbosch university, south africa received: september 2019 accepted: january 2019 published: may 2020 copyright: © 2020 mccaul j. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: all authors declare that they have no conflict of interest with respect to this article. page 86 mccaul j et al. sa orthop j 2020;19(2) table i: published normal values for prevertebral soft tissue in children (a lowercase measurement, e.g. c4, refers to the thickness of soft tissue adjacent to the numbered cervical vertebra – in this case, fourth. an uppercase measurement, e.g. c5, refers to the width of the numbered cervical vertebra – in this case, fifth) type of measurement recommendation source evidence base ratios in children (age in years) post-pharyngeal tissue (c4): 1.5 c5 (age 0–1) 0.5 c5 (age 1–3) 0.4 c5 (age 3–6) 0.3 c5 (age 6–14) post-ventricular soft tissue (c5): 2.0 c5 (age 0–1) 1.5 c5 (age 1–2) 1.2 c5 (age 2–14) hay3 (as re-drawn in keats and lusted4) measurements of 25 paediatric c-spine x-rays c2 = 0.3 c3 c6 = c6 hoffman and dix-peek5,6 no base of evidence found: statement of measurement unexplained and not cited by authors c1–4 = <0.5 adjacent vertebra c5–7 = adjacent vertebra di mascio and sivaraman7 no base of evidence found: statement of measurement unexplained and not cited by authors below cricoid cartilage ≤ 0.75 adjacent vertebra phelps8 no base of evidence found: statement of measurement unexplained and not cited by authors. possibly also applied to adults c3 ≤ 0.33–0.5 c3 c5 is ≤ 1.25 c5 or c6 baren et al.9 no base of evidence found: statement of measurement unexplained and not cited by authors retropharyngeal tissue ≤ adjacent vertebra retropharyngeal abscess only when retropharyngeal tissue = 2× adjacent vertebra yeoh et al.10 first measurement: incorrect citation (no such measurement mentioned in the references listed). second measurement: possibly based on measurements in cases of retropharyngeal abscess in nine paediatric (< 6 years old) c-spine x-rays. no actual measurements quoted or analysed in the original text retropharyngeal tissue = 0.5–0.66 adjacent vertebra egloff et al.11 incorrect citation (no such measurement mentioned in the references listed)* absolute measurements in children c2 upper limit = 7 mm c6 upper limit = 14 mm wholey et al.12 measurements of 120 normal paediatric (< 15 years old) c-spine x-rays c3 < 6 mm c6 < 14 mm warner and hedequist1 no base of evidence found: statement of measurement unexplained and not cited by authors c3 ≤ 5–7 mm c5 ≤ 14 mm baren et al.9 no base of evidence found: statement of measurement unexplained and not cited by authors mean retropharyngeal tissue = 6.2 mm (infant) mean retrotracheal tissue = 9.2 mm (preschool children) haug et al.13 measurements of 86 normal paediatric and adult c-spine x-rays (results stratified to age groups) soft tissue (rounded to nearest 0.1 mm) at c2, c5 and c6 for age groups (in years): age 0–1: c2 = 4.5–10.5 c5 = 9.2–12.6 c6 = 7.7–13 age 1–2: c2 = 4.1–12.2 c5 = 6.6–9.7 c6 = 4.7–9.6 age 2–3: c2 = 3.7–4.3 c5 = 7.9–13.2 c6 = 9.2–10.6 age 3–6: c2 = 3.7–6.6 c5 = 4.5–13.4 c6 = 3.8–10.2 age 6–14: c2 = 3.7–7.7 c5 = 7.8–16 c6 = 6.1–14.8 reyes et al.14 measurements of 50 normal paediatric (0–14 years old) c-spine x-rays mean c3 (similar at c2 and c4) = 3.7 mm 0.02 × age (years) + 0.01 × weight (pounds) sistrom et al.15 measurements of 227 randomly selected normal paediatric and adult (age 8–97 years) c-spine x-rays. formula based on stepwise regression model. also applicable to adults above cricoid cartilage ≤ 4 mm after the age of 2 or 3 years phelps8 no base of evidence found: statement of measurement unexplained and not cited by authors, possibly also applied to adults * one citation listed could not be accessed at time of publication page 87mccaul j et al. sa orthop j 2020;19(2) intervals: a 99% confidence interval (ci) of ±15% around a hypothesised mean of 90% and standard deviation (sd) of 45% was considered sufficient, based on anticipated estimated minimum and maximum values of 20% and 200%. random sampling was performed until 60 uninjured, un-intubated patients were identified. during this phase 13 intubated patients were also sampled as they were randomly interspersed. random sampling then continued until another two un-intubated (and one intubated) patients were added. due to counting error, 11 un-intubated patients were added. provisional data analysis was performed before and after the sample was enlarged. repeat data analysis failed to show a clinically significant difference in the consistency of measurements after the increase of the sample size, so it was concluded that further enlarging the sample was unlikely to change final results and so data collection was concluded. twenty injured patients were captured during random sampling as well as additions from preexisting records. data management and analysis was conducted in stata 14. simple descriptive statistics were used for demographic data. age was grouped into categories according to international conventions.19,20 the primary outcome was reported using means and 95% cis. the appropriate parametric and non-parametric tests were used and a p-value of <0.05 was considered statistically significant. ratios for every soft tissue thickness to every vertebral body width (42 ratios) were created in un-intubated controls. two ratios with the lowest standard error (one for upper and one for lower c-spine) were defined as the most consistent. in determining diagnostic accuracy of soft tissue swelling to predict presence of injury, these ratios of cases and controls (in un-intubated patients) were correlated to injury using point-biserial correlation. in addition, receiver operating characteristic (roc) analysis was used to compare these ratios to aid in identifying the optimal empirical diagnostic cut-point. a sensitivity analysis was conducted by excluding poor quality x-rays. missing data was excluded. results a total of 2 570 c-spine x-rays were digitally accessible, of which 893 were conventional or mobile c-spine x-rays and 1 731 were lodox, including dedicated lateral c-spine views. during random sampling, 48 x-rays taken for non-traumatic reasons were excluded. four patients with injury were identified by chance and added to the 16 known cases (figure 2). table ii provides a summary of demographic data. figure 1. measurements on x-ray solid arrows are measurement lines for: bd adi c1 soft tissue c2 soft tissue c6 soft tissue c7 vertebral body dashed lines are guides for measurement lines figure 2. sampling of x-rays 2 570 c-spine x-rays on digital system 137 x-rays randomly sampled 85 control (uninjured) x-rays 71 un-intubated controls 14 intubated controls 11 un-intubated cases 9 intubated cases 48 non-trauma x-rays excluded 4 case (injured) x-rays 16 database case (injured) x-rays page 88 mccaul j et al. sa orthop j 2020;19(2) the adi was measurable in 78 controls and the mean was 2.6 mm (sd 1.1). adi was measurable in all 20 cases and had a mean of 3.6 mm (sd 3.3). bd was measurable in 48 controls and had a mean of 9.4 mm (sd 2.8). bd was measurable in 13 cases with a mean of 11.3 mm (sd 5.8). main outcome results the soft tissue/vertebral body ratio for the upper c-spine with the lowest variance in un-intubated controls was c2/c7, with mean c2 soft tissue being 38% of c7 vertebra (95% ci: 34–41.9%, se: 2.0%, variance: 2.5%). for the lower c-spine the most consistent ratio was c6/c7 with mean c6 soft tissue being 65.6% of c7 vertebra (95% ci: 61.9–69.3%, se: 1.9%, variance: 2.3%). as sensitivity analysis, excluding x-rays reporting that the neck was flexed or the patient was crying, resulted in more precision and very slightly lower mean in c2/c7 (2% less) but no clinical or statistical difference. for these reasons, and as the study is pragmatic, it was decided to keep these x-rays in the overall analysis. in the study sample, those poor x-rays were not repeated before further clinical decisions were made. see table iii for a summary of these ratios in different patient groups. secondary outcome results: correlation and diagnostic accuracy soft tissue ratios at c2 and c6 in un-intubated controls were compared to un-intubated cases to determine correlation between soft tissue thickness and presence of injury. the point-biserial correlation coefficient for c2/c7 was 0.3060 (p-value: 0.0085) and for c6/c7 was 0.1059 (p-value: 0.3660) (figure 3). soft tissue thickness at these levels (as a ratio of c7 vertebra) in un-intubated controls was again compared to un-intubated cases to determine cut-off points with optimal sensitivity and specificity to diagnose c-spine injury. most importance was placed on specificity. roc curve calculation gave empirical optimal cut-points of 53.9% for c2/c7 and 74.4% for c6/c7. to create a clinically practical and easy-to-remember ‘cspine rule’ (correlation of soft tissue projection in injured necks), these values were rounded up to a cut-off of 55% at c2 and 75% at c6, which yields specificity of 92.3% (95% ci: 83–97.5%) and 81% (95% ci: 70.4–90.2%) respectively, with negative predictive values of 90.9% (95% ci: 81.3–96.6%) and 91% (95% ci: 81.3–97.2%). see table iv for a summary of the diagnostic test characteristics and figure 4 for the roc curve. table ii: sample demographics controls n (%) cases n (%) sex male 60 (70.6) 18 (90) female 25 (29.4) 2 (10) age 0–1 month 0 (0) 0 (0) 1 month–2 years 10 (11.8) 0 (0) 2–6 years 38 (44.7) 13 (65) 6–12 years 35 (41.2) 7 (35) 12–18 years 2 (2.3)* 0 (0) mechanism of injury pedestrian vehicle accident 56 (65.9) 10 (50) motor vehicle accident 7 (8.2) 8 (40) fall from height 12 (14.1) 1 (5) fall from same level 4 (4.7) 0 (0) blunt trauma 3 (3.5) 1 (5) crush 1 (1.2) 0 (0) bicycle to car 1 (1.2) 0 (0) unknown 1 (1.2) 0 (0) intubation status not intubated 71 (83.5) 11 (55) intubated 14 (16.5) 9 (45) type of injury upper cord oedema/contusion n/a 5 (25) cord transection at medulla oblongata n/a 1 (5) atlanto-occipital dissociation n/a 3 (15) upper spine ligamentous injury n/a 1 (5) c1/2 subluxation n/a 1 (5) dens fracture n/a 3 (15) c1 lamina/anterior arch fracture n/a 1 (5) c2 fracture n/a 1 (5) cord oedema/contusion c3–t2 n/a 1 (5) c3/4 unifacet dislocation n/a 1 (5) c6/7 dissociation (100% anterolisthesis) n/a 1 (5) c7/t1 fracture-dislocation n/a 1 (5) * both patients were under 13 years of age and were analysed together with the 6–12 years group during subgroup analysis. table iv: test characteristics of the cspine rule c2/c7 <55%: sensitivity 33.3% (95% ci 7.5–70.1%) specificity 93.8% (95% ci 84.8–98.3%) ppv* 42.9% (95% ci 9.9–81.6%) npv* 90.9% (95% ci 81.3–96.6%) c6/c7 <75%: sensitivity 44.4% (95% ci 13.7–78.8%) specificity 81.8% (95% ci 70.4–90.2%) ppv* 25% (95% ci 7.27–52.4%) npv* 91.5% (95% ci 81.3–97.2%) * ppv: positive predictive value; npv: negative predictive value table iii: c2/c7 and c6/c7 ratios in subgroups c2 soft tissue as % of c7 vertebra* c6 soft tissue as % of c7 vertebra* no c-spine injury (n=85) 42.7 (37.4–48) 62.2 (58.3–66.1) not intubated (n=71) 38 (34–41.9) 65.1 (61.5–68.8) intubated (n=14) 65.9 (44.5–87.3) 44.9 (34.6–55.2) c-spine injury (n=20) 65.2 (48.5–81.1) 59.3 (47–71.6) not intubated (n=11) 56.3 (33.5–79) 71 (54.6–87.3) intubated (n=9) 74.0 (50–98) 47.7 (32.2–63.2) * means and 95% cis page 89mccaul j et al. sa orthop j 2020;19(2) secondary outcome results: effect of intubation on soft tissue thickness soft tissue at each level was, for convenience, expressed as ratios of c7 vertebra and compared between un-intubated and intubated patients (table v). subgroup and confounder analysis subgroup analysis was performed for infants (1 month–2 years), young children (2-6 years) and older children (6–13 years). see table vi for a summary of c2/c7 and c6/c7 in un-intubated control patients in these age groups. weight was available for 36 patients. the correlation coefficient for weight compared to soft tissue thickness in un-intubated control patients was -0.2111 (p-value 0.3582) for c2/c7, and -0.3056 (p-value 0.1667) for c6/c7. discussion in our sample of un-intubated, uninjured patients, very consistent soft tissue to vertebral body ratios for both the upper and lower c-spine could be selected. both were normally distributed and cis were much narrower than anticipated as acceptable in the sample size calculation hypothesis. at c2, mean soft tissue was 38% of c7 vertebra (95% ci: 34–41.9%) and c6 was 65.6% of c7 vertebra (95% ci: 61.9–69.3%). the serendipitous fact that both ratios with least variability have c7 as denominator makes them extremely convenient. it also indirectly reinforces the need for adequate c-spine x-rays, i.e. where the c7 and first thoracic vertebra interface is visible. the upper c-spine ratio, c2/c7, was significantly larger in injured compared to uninjured patients regardless of intubation status. when considering only un-intubated patients, this increase was figure 3. c2/c7 and c6/c7 in un-intubated controls and cases figure 4. roc curves for c2/c7 and c6/c7 sc2vc7: soft tissue of c2 as a ratio of c7 body; sc6vc7: soft tissue of c6 as a ratio of c7 body table v: soft tissue thickness in intubated vs un-intubated control patients soft tissue thickness (as a percentage of c7 vertebra) un-intubated mean (sd) intubated mean (sd) p-value* c1 55.6 (38.1) 109.6 (82) 0.0213 c2 38 (15.8) 65.9 (38.9) 0.0098 c3 48 (28) 67.2 (29.7) 0.0239 c4 68.4 (24.8) 64.3 (23) 0.2926 c5 73.5 (18.4) 53.5 (19.8) 0.0005 c6 65.6 (15.1) 44.9 (18.7) 0.0006 c7 52 (22.2) 39.9 (17.5) 0.0445 * despite some ratios being normally distributed and others not, for the sake of consistency with other tables the mean is reported. however, p-values for the wilcoxon rank-sum test are reported for all variables in this table as it provided the more conservative measure of significance compared to the t-test. both tests also had the same result for significance or non-significance except c7, but as it followed the general trend it was assumed to be significant. table vi: c2/c7 and c6/c7 by age groups (un-intubated controls) c2 soft tissue as % of c7 vertebra* c6 soft tissue as % of c7 vertebra* infants (1 month–2 years) 46.3 (38.2–54.5) 57.6 (36.2–78.9) young children (2–6 years) 41 (32.6–49.4) 68.1 (62.1–74.2) older children (6–13 years) 34 (30.7–37.2) 64.1 (60.4–67.8) * means and 95% cis page 90 mccaul j et al. sa orthop j 2020;19(2) more marked, with a statistically significant correlation coefficient of 30.6% (moderate positive relationship). the lower c-spine ratio, c6/c7, was not significantly different between uninjured and injured patients, even when considering only un-intubated patients. the slight trend towards larger mean soft tissue in injured patients had a statistically non-significant correlation coefficient of 10.6% (weak positive relationship). the fact that upper c-spine swelling correlated more with injury than lower c-spine swelling is likely since most injuries in our sample were in the upper c-spine. this injury pattern is consistent with international literature.21 when testing sensitivity and specificity with the roc curve, the mean value of c2/c7 at 38% scored poorly with a sensitivity of 66.7% and specificity of 60.9%. even using the upper limit of the ci, 41.9%, resulted in improving specificity only to 76.6% at the cost of dropping sensitivity to 55.6%. the roc curve was used to calculate the optimal cut-point for specificity, as c-spine x-rays are not screening tests for the general population – they should be diagnostic tests for patients already screened and suspected of c-spine injury by history and examination. the calculated optimal cut-point of 53.9% provided specificity of 94% without worsening sensitivity further. rounding up to a more memorable 55% (or even 54%) unfortunately dropped sensitivity down to the next bracket (33.3%). however, cis for sensitivity are extremely wide due to low prevalence of injury, so the drop is statistically non-significant. the decision was made to suggest the ‘cspine’ rule that c2 soft tissue should be less than 55% of c7 vertebra. the method to develop the cspine rule suggesting that c6 soft tissue should be less than 75% of c7 vertebra followed similar patterns. debehnke and havel22 employed comparable methodology in adults and found similar patterns but did not accept any point on the roc curve as adequate. patel et al.16 also demonstrated similar high specificities and low sensitivities in testing adults using the ‘7 mm at c2 and 2 cm at c7’ rule. both ratios have extremely poor sensitivities, and are therefore poor screening tools, but can aid in ruling on injury in patients with high clinical suspicion of injury due to high specificity. the good negative and poor positive predictive values reflect low prevalence of injury. intubation in uninjured controls clinically and statistically significantly increased soft tissue thickness in the upper c-spine (c1–3). at c4 there was no difference. below c4 intubation significantly decreased soft tissue thickness. the lack of difference at c4 is possibly due to the inherent anatomic variability at the level of c4 (location of the glottis), or due to its fulcrum-like mid-position in the trend of upper c-spine tissue increasing and lower c-spine tissue decreasing after intubation. in injured patients, the effect of intubation at c2 and c6 followed the same trend, but without statistical significance. these findings in the upper c-spine are similar to di mascio and sivaraman’s7 findings in adults, but the trend of decreased soft tissue thickness below c4 is in contrast to their findings of no difference. univariate analysis determined whether weight or age confounded soft tissue thickness. weight was unavailable in about two-thirds of patients, possibly due to difficulties in placing polytraumatised patients on scales. in our sample, weight and soft tissue thickness had a weak negative correlation but without statistical significance. age had no effect on c6/c7, as evidenced by overlap of all three cis for available age groups. at c2, however, there seemed to be a trend towards decreasing soft tissue thickness as age increased. cis overlapped between infants and young children, and between young and older children, but were statistically different with no overlap between infants and older children. these, however, come very close to overlapping, with the upper limit in older children being 37.2% and the lower limit in infants being 38.2%. as these values are so close to the all-ages mean it was decided that difference between ages was not clinically significant. the finding of single useful ratios across age groups is in contrast with hay’s3 recommendations which differ between age groups. testing diagnostic accuracy and development of the optimal cut-point as a rule in diagnosing c-spine injury were secondary objectives, thus the sample size was not designed for that purpose. the study was powered to measure normal values for soft tissue thickness in uninjured, un-intubated patients. the study sample consisted of a much smaller group of cases than controls. this, however, is more closely representative of clinical practice where c-spine injury has relatively low prevalence, and as this is a crosssectional study, it was considered a minor limitation. in addition, the specificities have acceptably narrow cis to be of clinical use. there would need to be 95 cases in order to determine similarly narrow intervals for sensitivity, and there has anecdotally not been that many cases in the history of the hospital since their introduction of digital x-rays. the areas under the curve for the two diagnostic ratios are 0.67 (upper c-spine) and 0.58 (lower c-spine), which shows that prevertebral soft tissue swelling does not have good discriminative value for predicting soft tissue injury, especially in the lower c-spine. there were only four lower c-spine injuries and they were not specifically sub-analysed. no recommendation can therefore be made regarding the use of these findings in patients with lower c-spine injuries as such. comments and conclusions about diagnostic accuracy of the cspine rule and correlation of soft tissue thickness with presence or absence of injury in this study refer only to the possibility of injury somewhere in the c-spine rather than being directly related to an anatomical area. there is potential for further research in the diagnostic value of these ratios in different types of paediatric c-spine injuries, and validation of the ratios with further research that includes more cases of injury. this further research may help clarify if prevertebral soft tissue swelling should form part of the consideration in assessing for c-spine trauma in children. the findings are for children between the ages of 1 month and 13 years and may not be generalisable to neonates, adolescents or adults. conclusion this study demonstrates that there are consistent normal values when measuring prevertebral soft tissue thickness as a ratio of vertebral body width in un-injured, un-intubated paediatric patients: soft tissue at c2 and c7 should be 38% and 65.6% of c7 vertebral body, respectively. however, soft tissue measurement itself does not seem to be very sensitive in predicting injury. a more specific ‘cspine rule’ (soft tissue at c2 and c6 should be less than 55% and 75% of c7 vertebral body, respectively) can be followed. a positive result would raise suspicion of c-spine injury in high-risk individuals and can help to motivate for further investigations such as ct or mri, which may not be easily accessible in under-resourced settings. however, further research is required to validate the diagnostic value of these ratios. acknowledgements dr t mutengwa: research assistant: assistance in folder data collection prof. r dunn: assistance in identifying cases dr jp du plessis: assistance in identifying cases mr s cornelius: information technology assistance ms w smith: library assistance ethics statement prior to commencement of the study ethical approval was obtained from the following ethical review board: university of cape town health research ethics committee (reference number hrec: 118/2016). page 91mccaul j et al. sa orthop j 2020;19(2) no identifying information for any patient is included in this article. no human subjects were directly involved as it was a review of existing medical records. declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions jm contributed to the conception and design of the work; the acquisition, analysis and interpretation of the data for the work; drafting the work; and submitting the final version to be published. ah contributed to interpretation of the data, review of the manuscript, and study supervision. mm contributed to study design and data analysis. sdp contributed to the conception and design, the review of the manuscript, and study supervision. orcid mccaul j https://orcid.org/0000-0003-1011-5912 horn a https://orcid.org/0000-0002-4159-6520 mccaul m https://orcid.org/0000-0002-2730-6478 dix-peek s https://orcid.org/0000-0002-3382-8790 references 1. warner wc, hedequist dj. cervical spine injuries in children. in: beaty jh, kasser jr, eds. rockwood & wilkins’ fractures in children. 6th ed. lippincott williams & wilkins; 2006:775-814. 2. schöneberg c, schweiger b, hussmann b, et al. diagnosis of cervical spine injuries in children: a systematic review. eur j trauma emerg surg. 2013;39:653-65. doi:10.1007/ s00068-013-0295-1. 3. hay p. the neck. a roentgenological study of soft tissues. consideration of the normal and pathological. in: hoeber pb, ed. case jt: annals of roentgenology. a series of monographic atlases, vol 9. 2nd ed. new york, ny; 1930. 4. keats t, lusted l. atlas of roentgeongraphic measurement. 4th ed. year book medical publishers inc.; 1981. 5. hoffman eb, dix-peek s. cervical spine injuries in children. in: van as s, naidoo s, eds. baby steps into paediatric neuroradiology. oxford university press southern africa; 2004. 6. hoffman eb, dix-peek s. cervical spine injuries in children. in: van as s, naidoo s, eds. paediatric trauma and child abuse. oxford university press southern africa; 2006. 7. di mascio l, sivaraman a. cervical prevertebral soft tissue swelling in the traumatized patient: what is normality in the intubated patient? eur j trauma emerg surg. 2009;35(2):165-68. doi:10.1007/s00068-008-8003-2. 8. phelps pd. radiology of the pharynx and larynx. in: kerr ag, stel pm, eds. scott-brown’s otolaryngology vol 5. 5th ed.; 1987, pp 8-9. 9. baren jm, rothrock sg, brennan j, brown l. pediatric emergency medicine. saunders/elsevier; 2008. http://www.sciencedirect.com/ science/book/9781416000877. 10. yeoh lh, singh sd, rogers jh. retropharyngeal abscesses in a children’s hospital. j laryngol otol. 1985;99:555-66. doi:10.1017/ s0022215100097243. 11. egloff am, kadom n, vezina g, bulas d. pediatric cervical spine trauma imaging: a practical approach. pediatr radiol. 2009;39(5):447-56. doi:10.1007/s00247-008-1043-2. 12. wholey mh, bruwer aj, baker hl. the lateral roentgenogram of the neck. radiology. 1958;71(3):350-56. doi:10.1148/71.3.350. 13. haug rh, wible rt, lieberman j. measurement standards for the prevertebral region in the lateral soft-tissue radiograph of the neck. j oral maxillofac surg. 1991;49(11):1149-51. doi:10.1016/0278-2391(91)90405-b. 14. reyes mm, ricalde rr, tanalgo jb, baldoz cj. prevertebral soft tissue thickness among pediatric patients. philipp j otolaryngol head neck surg. 2011;26(2):5-9. http://apamedcentral.org/search. php?where=aview&id=10.0000%2fpjohns.2011.26.2.5&code=001 1pjohns&vmode=ar. accessed january 23, 2016. 15. sistrom cl, southall ep, peddada sd, shaffer ha. factors affecting the thickness of the cervical prevertebral soft tissues. skeletal radiol. 1993;22(3). doi:10.1007/bf00206147. 16. patel ms, grannum s, tariq a, et al. are soft tissue measurements on lateral cervical spine x-rays reliable in the assessment of traumatic injuries? eur j trauma emerg surg. 2013;39(6):613-18. doi:10.1007/s00068-013-0302-6. 17. stiell ig, wells ga, vandemheen kl, et al. the canadian c-spine rule for radiography in alert and stable trauma patients. jama. 2001;286(15):1841-48. http://www.ncbi.nlm.nih.gov/ pubmed/11597285. accessed september 13, 2017. doi:10.1001/ jama.286.15.1841. 18. hoffman jr, mower wr, wolfson ab, todd kh, zucker mi. validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. n engl j med. 2000;343(2):94-99. doi:10.1056/nejm200007133430203. 19. knoppert d, reed m, benavides s, et al. position paper: paediatric age categories to be used in differentiating between listing on a model essential medicines list for children. 2007. http://archives. who.int/eml/expcom/children/items/positionpaperagegroups.pdf. accessed august 2, 2017. 20. williams k, thomson d, seto i, et al. standard 6: age groups for pediatric trials. pediatrics. 2012;129(suppl 3). http://pediatrics. aappublications.org/content/129/supplement_3/s153. accessed august 2, 2017. doi:10.1542/peds.2012-0055l. 21. platzer p, jaindl m, thalhammer g, et al. cervical spine injuries in pediatric patients. j trauma inj infect crit care. 2007;62(2):38996. doi:10.1097/01.ta.0000221802.83549.46. 22. debehnke dj, havel cj, laib r. utility of prevertebral soft tissue measurements in identifying patients with cervical spine fractures. ann emerg med. 1994;24(6):1111124. doi:10.1016/ s0196-0644(94)70242-x. https://orcid.org/0000-0003-1011-5912 https://orcid.org/0000-0002-4159-6520 https://orcid.org/0000-0002-2730-6478 https://orcid.org/0000-0002-3382-8790 _hlk26195820 south african orthopaedic journal general orthopaedics doi 10.17159/2309-8309/2022/v21n3a1o’connor m et al. sa orthop j 2022;21(3) citation: o’connor m, ferreira n, smith m, webster p, venter rg, marais lc. high burnout among the south african orthopaedic community: a cross-sectional study. sa orthop j. 2022;21(3):132-142. http://dx.doi.org/10.17159/23098309/2022/v21n3a1 editor: prof. robert dunn, university of cape town, cape town, south africa received: september 2021 accepted: december 2021 published: august 2022 copyright: © 2022 o’connor m. this is an open-access article distributed under the terms of the creative commons attribution licence, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited. funding: no funding was received for this study. conflict of interest: the authors declare they have no conflicts of interest that are directly or indirectly related to the research. abstract background burnout is epidemic among physicians, with the orthopaedic speciality displaying one of the highest rates of burnout in international studies. the burnout rate of the south african orthopaedic community is unknown. this study aimed to determine the prevalence and causes of burnout, as well as the coping mechanisms and associations with burnout, in south african orthopaedic surgeons and trainees. methods we conducted a cross-sectional, secure, online survey of members of the south african orthopaedic association. the survey assessed demographic characteristics, workload, professional fulfilment and burnout (utilising the stanford professional fulfilment index), associated workplace distress conditions, causes of and coping strategies for burnout. a response was not compulsory for any question. statistical analysis was performed to assess for independent associations with burnout. results one hundred and fifty-six respondents, with a median age of 46.5 years (interquartile range [iqr] 37–58) participated. ninety per cent (139 of 155) of respondents were male. registrars accounted for 17% (27 of 155), while 83% (128 of 155) were qualified specialists. respondents were in orthopaedic practice for a median of 17 years (iqr 9–28). sixty per cent (76 of 127) practise in private, 17% (22 of 127) in public and 23% (29 of 127) in both sectors. the overall burnout rate was 72% (113 of 156). burnout was associated with being the parent of young children and having fewer hours of sleep on call. registrars were more likely to have burnout than consultants (or 5.68, 95% ci 1.3–25.2). gender, practice setting and subspeciality were not associated with burnout. self-reported causes of burnout that were found to be associated with actual burnout were: ‘hours at work’, ‘lack of free time’ and ‘work–life imbalance’. no selfreported coping mechanisms were found to be protective in this cohort, but the use of alcohol as a coping mechanism was associated with an increased likelihood of burnout (or 3.9, 95% ci 1.4–10.7). respondents felt that the concurrent experience of the covid pandemic at the time of running the survey reduced their experience of burnout. conclusion the burnout rate in the south african orthopaedic community is 72%. trainees were found to be particularly vulnerable. there appears to be a need to develop, assess and implement effective system-related initiatives aimed at reducing the burnout rate among orthopaedic surgeons and trainees in south africa. level of evidence: level 4 keywords: burnout, orthopaedic, south africa, professional fulfilment, stanford professional fulfilment index, moral injury, compassion fatigue, imposter phenomenon, second victim syndrome, approval addiction high burnout among the south african orthopaedic community: a cross-sectional study megan o’connor,¹* nando ferreira,² michelle smith,³ phillip webster,⁴ rudolph g venter,² leonard c marais¹ ¹ school of clinical medicine, department of orthopaedic surgery, university of kwazulu-natal, durban, south africa ² division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university, cape town, south africa ³ school of clinical medicine, department of surgery, university of kwazulu-natal, durban, south africa ⁴ independent practitioner, johannesburg, south africa *corresponding author: oconnorm1@ukzn.ac.za https://orcid.org/0000-0001-8864-4916 page 133o’connor m et al. sa orthop j 2022;21(3) introduction burnout is described in the international classification of disease (icd) 11th revision as an occupational phenomenon resulting from chronic workplace stress.1 the syndrome is described as having three components: emotional exhaustion (lack of enthusiasm for work), depersonalisation (cynicism) and lack of professional satisfaction (low sense of personal accomplishment).2-7 more than two decades of research have expounded the epidemic, which has notably affected the health professions disproportionately.8 burnout is particularly relevant in the health professions, due to the numerous downstream effects on the health system, on patients, and on the individual themselves. the estimated cost of burnout to the us health system is $4.6 billion annually.9 this is due to higher staff turnover, staff attrition, early retirement, reduced work effectiveness and professionalism, absenteeism and presenteeism (being at work when one should be off sick).4,5,7-11 physicians experiencing burnout have displayed higher rates of depression and suicidal ideation, broken relationships, increased alcohol and drug use, reduced work satisfaction, altered prescribing habits and test ordering, increased risk of medico-legal lawsuits and reduced cognitive ability.7-13 physical health can also be affected as burnout can result in higher rates of diabetes mellitus, cholesterol, pain, fatigue, cardiovascular disease and early death.7,11 within the branches of medicine, orthopaedic surgeons in the usa have one of the highest burnout rates.4 various international studies have demonstrated burnout rates of between 16% and 85%.3-5,7,14 this variability is similar to that seen among general surgeons, and can be accounted for by differing career stages, workload, work hours and number of calls.2,4,7 orthopaedic trainees are at higher risk, with reports suggesting work hours, electronic medical records (emr), lack of sleep and lack of supportive mentors as common predisposing factors.5,15 two studies identified female orthopaedic surgeons as being at greater risk of experiencing burnout.15,16 despite the paucity of data on physician burnout in lowand middle-income countries (lmics), much work has been done in south africa (rsa) to assess the prevalence of burnout among doctors.17 a national study found higher rates of burnout in medical doctors than comparative international figures.18 studies from various provinces reported rates between 52% and 100% in doctors of varying career levels and specialities, with none of these investigating orthopaedic surgeons exclusively.6,19-22 we aimed to determine the burnout rate in south african orthopaedic surgeons and trainees. in addition, we wanted to evaluate the perceived causes and coping mechanisms, screen for the presence of associated workplace distress conditions, determine the social impact of burnout and determine the independent risk factors for the development of burnout in this cohort. while not a primary aim, we also evaluated the impact of the covid pandemic on burnout. methods this cross-sectional study was performed by way of a ten-minute online survey. the survey was administered using checkbox® survey software (© checkbox survey, inc. 2002–2021). the questionnaire comprised six sections, namely, demographics, workload, the stanford professional fulfilment index (pfi), screening questions for associated workplace distress conditions, perceived causes of burnout and coping strategies for burnout. in considering the covid pandemic and its potential effect on burnout, each section concluded with a question to determine if the pandemic had affected the response. there was a single open-ended question. the remaining questions required numerical answers or selection of appropriate single or multiple options. the stanford pfi is a validated assessment tool comprising 16 questions scored on a 5-point likert scale of agreement; four questions aimed at establishing the presence of work exhaustion (we); and six for interpersonal disengagement (id). if the combined average score for these two variables was calculated at 1.33 or greater, it constituted burnout.10 the other six questions assessed professional fulfilment (pf). respondents were deemed professionally fulfilled if they scored an average of three points or greater for these six questions.10 five additional workplace distress conditions may be associated with burnout. ‘moral injury’ is defined as the distress caused in a person that arises from the challenge of simultaneously knowing what care patients require but being unable to provide it due to constraints that are beyond their control.23 ‘compassion fatigue’ is ‘the change in empathetic ability of the caregiver in reaction to the prolonged and overwhelming stress of caregiving’.24 ‘approval addicts’ are those whose self-esteem is attached to how other people perceive them.25 ‘imposter phenomenon’ is when a person has the psychological belief that they are a fraud, and fear being recognised as an imposter, despite objective evidence of success.26 the fifth condition, termed ‘second victim syndrome’, is used to characterise the feeling of responsibility that a healthcare worker experiences when a medical error occurs.27 for each of these conditions, a single or multiple questions were adapted from existing validated scores, or formulated from defining characteristics of the syndrome, for the purpose of screening for each of the conditions.25,27-30 all the members of the south african orthopaedic association (saoa) with listed email addresses were eligible to participate. invitations were emailed to members, with an attached link to the secure online survey. to proceed with the survey, respondents had to consent to participation, after reading an information page on the nature of the study. survey responses were completely anonymous, and respondents were limited to a single response. the survey was run for a total of six weeks over may and june 2021. two reminders were sent using the same platform at twoweekly intervals. no questions were compulsory to complete; however, the pfi section was completed by all respondents. the survey responses were exported to microsoft® excel for mac, version 16.50 (21061301), where descriptive statistics were summarised and the open-ended question encoded by the general theme of response. non-parametric continuous variables were summarised as medians with interquartile range (iqr), and categorical variables were expressed as percentages with counts. statistical analysis was performed with jamovi statistical software (version 1.6.23.0).31 univariate binomial logistic regression was employed to assess the associations of the risk factors with the presence of burnout. a multiple regression model was developed using reverse stepwise elimination to determine independently associated variables. significance was set at p < 0.05. results demographic details of the saoa members contacted, 960 had active email addresses. one hundred and fifty-six members completed the survey, constituting a response rate of 16%. the median age of respondents was 46.5 years (iqr 37–58). ninety per cent of respondents (139 of 155) were male, and 10% were female (16 of 155). qualified orthopaedic surgeons constituted 83% of the sample (128 of 155), and 17% (27 of 155) were registrars. sixty per cent of the specialists were private practitioners (76 of 127), 17% (22 of 127) practised exclusively in the public sector, and 23% reported working in both public and private (29 of 127). the median number of years in practice was 17 (iqr 9–28). page 134 o’connor m et al. sa orthop j 2022;21(3) specialists could record more than one response for speciality. ‘sport’, ‘hip’ and ‘knee’ results were grouped under arthroplasty. similarly, ‘reconstruction’ and ‘deformity correction’ were included under ‘tumour, sepsis and reconstruction’ (tsr), ‘upper limb’ responses were counted under both ‘shoulder and elbow’ as well as ‘hand’ groups. twelve per cent of respondents reported being generalists (14 of 115), 10% tsr (12 of 115), 6% paediatrics (7 of 115), 10% trauma (12 of 115), 7% spines (8 of 115), 10% foot and ankle (12 of 115), 19% shoulder and elbow (22 of 115), 11% hands (13 of 115) and 33% arthroplasty (38 of 115). table i summarises the demographic details of respondents. relationship factors of the entire group, 94% (143 of 153) reported being in a relationship. ninety-four per cent of the respondents reported that table i: descriptive statistics for respondent demographic characteristics counts (n) % of total median iqr age (years) 156 46.5 37–58 sex female 16 (155) 10% male 139 (155) 90% qualification specialist 128 (155) 83% registrar 27 (155) 17% years in practice 156 17 9–28 year of registrar time 27 3 2–4 1st 6 (27) 22% 2nd 4 (27) 15% 3rd 8 (27) 30% 4th 3 (27) 11% 5th 6 (27) 22% practice setting public 22 (127) 17% private 76 (127) 60% both 29 (127) 23% subspeciality general 14 (115) 12% tsr 12 (115) 10% paediatrics 7 (115) 6% trauma 12 (115) 10% spine 8 (115) 7% foot & ankle 12 (115) 10% shoulder & elbow 22 (115) 19% hands 13 (115) 11% arthroplasty 38 (115) 33% are you in a relationship? yes 143 (153) 94% no 10 (153) 7% how many children do you have? 156 2 1–3 how old is the youngest child? 122 11 4–23 how old is the oldest child? 113 16 9–29 how supportive is your partner? least supportive 2 (142) 1% minimally supportive 1 (142) 1% moderately supportive 6 (142) 4% largely supportive 34 (142) 24% maximally supportive 99 (142) 70% whose career is prioritised? mine 86 (140) 61% equally important 53 (140) 38% other 1 (140) 1% who is primarily responsible for childcare? me 3 (123) 2% my partner 41 (123) 33% both 66 (123) 54% other 13 (123) 11% continuous or ordinal variables expressed as medians with interquartile range (iqr). categorical variables expressed with counts and percentages of total. tsr: tumour, sepsis and reconstruction other lack of career progress potential lack of office space work–life balance performance anxiety lack of mentor staff shortages lack of free time discrimination government regulations lack of respect from patients lack of respect from colleagues and students lack of autonomy lack of compensation computerisation hours at work bureaucratic tasks figure 1. graphic representing respondents’ self-reported causes for burnout (counts, n = 153) 0 20 40 60 80 100 120 other religion or spiritual encounters prescription medication use cannabis smoke cigarettes shopping binge eat drink alcohol listen to music sleep talk to friends or family exercise isolate from others take leave hobbies psychology 0 20 40 60 80 100 120 figure 2. graphic representing respondents’ self-reported strategies for managing burnout (counts, n = 155) page 135o’connor m et al. sa orthop j 2022;21(3) their partner was largely or maximally supportive (133 of 142). sixty-one per cent of respondents reported that their career was prioritised (86 of 140). no one reported prioritising their partner’s career, and 38% reported equal career importance (53 of 140). there were three single parents in this cohort. respondents had a median of two children (iqr 1–3). two per cent of respondents (3 of 123) were the primary caregivers. in 33% of cases (41 of 123), the partner was the primary caregiver and 54% of the time, responsibility was shared (66 of 123). the option ‘other’ was reported by 11% of respondents. working hours thirty-five per cent of respondents reported working between 40 and 50 hours per week (54 of 156), 25% worked between 50 and 60 hours (39 of 156), and 31% 40 hours (46 of 156) or less. eleven per cent work more than 60 hours a week (17 of 156). most respondents reported that outpatient clinics, together with ward rounds or surgery, accounted for between 30% and 40% of the workload on average, followed by administration (20%), while teaching and research each contributed less than 10%. forty per cent of respondents reported between two and four weekday calls table ii: work distribution, work hours, call-related characteristics, sport and hobby participation of respondents work distribution count (n) % count (n) % count (n) % count (n) % count (n) % percentage of time allocated to: clinic & ward round surgery admin teaching research < 10% 8 (156) 5% 8 (156) 5% 49 (154) 32% 96 (133) 72% 112 (134) 84% 20% 18 (156) 12% 19 (156) 12% 65 (154) 42% 26 (133) 20% 14 (134) 10% 30% 36 (156) 23% 48 (156) 31% 21 (154) 14% 7 (133) 5% 7 (134) 5% 40% 45 (156) 29% 49 (156) 31% 7 (154) 4% 1 (134) 1% 50% 27 (156) 17% 19 (156) 12% 5 (154) 3% 3 (133) 2% 60% 16 (156) 10% 9 (156) 6% 5 (154) 3% 70% 4 (156) 3% 1 (156) 1% 1 (154) 1% 80% 2 (156) 1% 3 (156) 2% 1 (154) 1% 1 (133) 1% work hours and calls count (n) % average hours at work per week 0–20 7 (156) 5% 20–30 7 (156) 5 % 30–40 32 (156) 21% 40–50 54 (156) 35% 50–60 39 (156) 25% 60–70 14 (156) 9% 70–80 2 (156) 1% > 80 1 (156) 1% average hours working at home per week < 5 64 (156) 41% > 5 37 (156) 24% > 10 32 (156) 21% > 15 13 (156) 8% > 20 10 (156) 6% number of calls on weekdays 0–2 47 (155) 30% 2–4 62 (155) 40% 4–6 34 (155) 22% 6–8 6 (155) 4% > 8 6 (155) 4% number of calls on weekends 0–2 119 (155) 77% 2–4 36 (155) 23% leisure activities median iqr count how many hours per week do you do sport? 3 1–4 155 how many hours per week do you do hobbies? 5 3–10 156 average hours of sleep not on call 7 6–7 156 average hours of sleep on call 6 4–7 136 categorical variables were expressed as frequencies and percentages. continuous variables were expressed as medians with interquartile ranges iqr: interquartile range page 136 o’connor m et al. sa orthop j 2022;21(3) per month (62 of 155), and 77% (119 of 155) reported between zero and two weekend calls per month. a median of three times per week was reported for sports participation (iqr 1–4), and a median of five hours per week was spent on hobbies (iqr 3–10). time spent sleeping both on call and off call were similar, with medians of six hours (iqr 4–7) and seven hours (iqr 6–7) reported, respectively. table ii summarises these findings. results of stanford pfi table iii represents the results of the stanford pfi. eighty-four per cent (131 of 156) of respondents were found to be professionally fulfilled (pf), scoring a median of 3.9 (iqr 3.3–4.5) for these six questions. eighty-six per cent (134 of 156) scored 1.33 or more for the four questions assessing work exhaustion (we), and 76% (119 of 156) scored 1.33 or more for the six interpersonal disengagement (id) questions, with median scores of 2.8 (iqr 1.8–3.8) and 2.17 (iqr 1.3–3.0) respectively. burnout was present in 72% (113 of 156) of respondents (combined average we and id scores 1.33 or greater). causes of burnout regarding causes of burnout, ‘too many bureaucratic tasks’ (70%; 107 of 153), ‘lack of compensation’ (41%; 63 of 153) and ‘government regulations’ (40%; 61 of 153) were selected most frequently (figure 1). for female respondents, additional contributors to burnout were commonly ‘feeling of responsibility to others’ (63%; 10 of 16), ‘gender bias from colleagues’ (56%; 9 of 16), and ‘gender bias from patients’ (50%; 8 of 16). most people managed their burnout with exercise (68%; 105 of 155), hobbies (57%; 88 of 155) or taking leave (64%; 99 of 155) (figure 2). workplace distress conditions of the screening questions for workplace distress conditions captured in table iv, the most notable findings were that 84% of respondents (130 of 155) screened positive for moral injury, 71% (110 of 155) screened positive for at least one approval addiction question, and 93% (143 of 154) screened positive for at least one question about second victim syndrome. two-thirds of respondents (104 of 155) screened positive for compassion fatigue. effect of burnout on respondents burnout had a large or severe effect on 24% (37 of 155) of respondents, moderate effect on 37% (58 of 155), and a small or minimal effect on 39% (60 of 155) of respondents, respectively. burnout impacted relationships in 51% (79 of 154) of cases. thirtysix per cent (56 of 155) of respondents said they would take a table iii: stanford professional fulfilment index (pfi) questions and scores broken down into each of the three sub-categories and summarised overall burnout results average score category counts (n) % of total professional fulfilment* 3.82 i feel happy at work 3.54 i feel worthwhile at work 3.85 my work is satisfying to me 3.89 i feel in control when dealing with difficult problems at work 3.63 my work is meaningful to me 4.21 i’m contributing professionally in the ways i value the most 3.81 overall professional fulfilment no 25 (156) 16% yes 131 (156) 84% work exhaustion# 2.71 during the past two weeks i have felt: a sense of dread when i think about work i have to do 2.54 physically exhausted at work 2.76 lacking in enthusiasm at work 2.70 emotionally exhausted at work 2.85 overall work exhausted no 22 (156) 14% yes 134 (156) 86% interpersonal disengagement# 2.23 during the past two weeks my job has contributed to my feeling: less empathetic with my patients 2.1 less empathetic with my colleagues 2.22 less sensitive to others’ feelings/emotions 2.26 less interested in talking to my patients 2.15 less connected with my patients 2.24 overall interpersonally disengaged no 37 (156) 24% yes 119 (156) 76% burnout no burnout 43 (156) 28% burnout 113 (156) 72% categorical variables expressed with counts and percentages of total *professional fulfilment was scored on a scale of 0–4, where 0 is not true and 4 is entirely true #work exhaustion and interpersonal disengagement scored on a scale of 0–4, where 0 is not at all and 4 is very much page 137o’connor m et al. sa orthop j 2022;21(3) table iv: screening questions and results for each of the five associated workplace distress conditions count (n) % count (n) % moral injury no yes have you found yourself in a position where you felt patient care was compromised due to failure of the healthcare system of south africa? 25 (155) 16% 130 (155) 84% approval addiction no yes is your happiness dependent on what others think of you? 86 (154) 56% 68 (154) 44% do you struggle to say ‘no’? 45 (155) 29% 110 (155) 71% compassion satisfaction & fatigue no yes do you think you have ever felt fatigued by dealing with a patient who has experienced trauma? 51 (155) 33% 104 (155) 67% do you get satisfaction from being able to help patients? 156 (156) 100% imposter phenomenon no yes have you ever been surprised by your successful completion of a task or received promotion and felt it was most likely as a consequence of luck or ‘being in the right place at the right time’? 99 (152) 65% 53 (152) 35% do you find it hard to accept compliments or praise due to fear you will be ‘found out’ as a fraud or not as intelligent as you perceive people think you are? 109 (154) 71% 45 (154) 29% second victim syndrome no yes have you felt physically or psychologically distressed by a negative patient outcome for which you felt responsible? 11 (154) 7% 143 (154) 93% has the experience from the previous question negatively affected your desire to work, attend work, or changed your perception of your abilities? 69 (143) 48% 74 (143) 52% categorical variables expressed with counts and percentages of total. table v: univariate analysis of factors significantly associated with burnout burnout no burnout p-value or 95% ci power demographics and call-related characteristics qualification (n = 155) ref: specialist 0.022 0.022 0.04–0.78 81% specialist 88/128 (69%) 40/128 (31%) registrar 25/27 (93%) 2/27 (7%) dependants (median, iqr) how old is the oldest child? 13 (8–24) 28 (16–31) 0.002 0.95 0.91–0.98 90% how old is the youngest child? 8 (3–18) 23 (8–29) < 0.001 0.94 0.90–0.97 95% on-call hours of sleep 5 (2.14) 6.2 (1.49) 0.003 0.68 0.53–0.88 97% self-reported causes of burnout hours at work 37/40 (92%) 3/40 (8%) 0.005 6.00 1.74–20.76 94% lack of free time 47/51 (92%) 4/51 (8%) < 0 .001 6.41 2.14–19.23 99% work–life imbalance 46/52 (88%) 6/52 (12%) 0.005 3.89 1.51–10.02 89% associated workplace syndromes moral injury 101/130 (78%) 29/130 (22%) 0.003 3.77 1.55–9.16 81% compassion fatigue 113 (72%) 43/156 (28%) < 0.001 4.59 2.17–9.71 99% impact and coping mechanisms of burnout impact burnout on life (n = 155) ref: ‘no impact’ < 0.001 2.92 1.94–4.41 100% no impact 8/29 (28%) 21/29 (72%) little/minimal impact 21/31 (68%) 10/31 (32%) moderate impact 50/58 (86%) 8/58 (14%) large impact 26/29 (90%) 3/29 (10%) severe impact 7/8 (87.5%) 1/8 (12.5%) impact of burnout on relationships (n = 154) ref: ‘yes’ < 0.001 0.34 0.18–0.63 97% yes 69/79 (87%) 10/79 (13%) no 37/66 (56%) 29/66 (44%) prefer not to answer 6/9 (67%) 3/9 (33%) coping mechanisms alcohol 39/44 (89%) 5/44 (11%) 0.008 3.90 1.42–10.72 85% categorical variables were expressed as frequencies and percentages. continuous variables were expressed as medians and interquartile ratios. relationships between variables and the primary binary outcome, burnout, are expressed as odds ratios and 95% confidence intervals. significance level set at p < 0.05. reference categories listed alongside category label. or: odds ratio; ci: confidence interval; ref: reference page 138 o’connor m et al. sa orthop j 2022;21(3) salary reduction to improve their work–life balance. nine per cent (14 of 156) were on treatment for mood disorders and 10% (15 of 155) reported having experienced suicidal ideation. eighteen per cent (28 of 155) had sought professional help for burnout or depression. sixty-six per cent of respondents (101 of 154) reported their workplace did not have a mechanism to detect burnout, and 64% (99 of 156) reported their workplace did not have a programme to manage burnout. if burnout management programmes were available, most people had not attended them (80%; 16 of 20), and if programmes became available, 38% (58 of 153) reported it ‘unlikely’ that they would attend. thirty-nine per cent (61 of 156) of respondents provided suggestions for improving burnout. thirty per cent (18 of 61) suggested that system changes at the government and institutional level would reduce burnout most effectively. improving communication, support and social relationships among colleagues (20%; 12 of 61), improved staffing complement and staff efficacy (20%; 12 of 61), and reduced working hours (18%; 11 of 61) were other common suggestions. univariate analysis and multiple regression model table v provides a summary of the variables associated with burnout. of the demographic and call-related characteristics, ‘age of youngest child’ (p ≤ 0.001), ‘age of oldest child’ (p = 0.002) and on-call hours of sleep (p = 0.003), were inversely associated with burnout. that is to say; burnout was associated with respondents who had younger children and fewer hours of sleep on call. burnout was associated with being a registrar (p = 0.022), with no association to the current year of training (figure 3). there was no association between practice sector, gender, relationship status or workload. of the self-reported causes of burnout, i have not asked a colleague to prescribe medication for me using alcohol to cope with burnout burnout has not impacted my personal relationships burnout has had a moderate to severe impact on my life decreased burnout increased burnout odds ratio with 95% confidence interval 0.01 0.1 1.0 10.0 100.0 figure 5. the above table represents univariate logistic regression analyses for behavioural changes as well as social changes and their association with objectively categorised burnout. these relationships are presented as odds ratios and 95% confidence intervals. univariate analyses are only presented for variables with post hoc power exceeding 80%. work–life imbalance lack of free time decreased burnout increased burnout odds ratio with 95% confidence interval hours spent at work 0.0 0.1 1.0 10.0 100.0 figure 4. univariate logistic regression analyses for self-reported causative factors and their association with objectively measured burnout. these relationships are presented as odds ratios and 95% confidence intervals. univariate analyses are only presented for variables with post hoc power exceeding 80%. more sleep on call older age of youngest child older age of oldest child decreased burnout increased burnout odds ratio with 95% confidence interval specialist qualification 0.0 0.5 1.0 1.5 2.0 figure 3. univariate logistic regression analyses for demographic and call-related risk factors associated with objectively measured burnout. these relationships are presented as odds ratios and 95% confidence intervals. univariate analyses are only presented for variables with post hoc power exceeding 80%. page 139o’connor m et al. sa orthop j 2022;21(3) respondents that selected ‘hours at work’, ‘lack of free time’ and ‘work–life imbalance’ as causes of burnout, were more likely to have measured burnout (figure 4). no coping mechanisms were found to be associated with reduced burnout, but if respondents selected ‘alcohol’ as a coping mechanism, they had an increased risk of burnout (figure 5). screening positive for moral injury or one measure of compassion fatigue, placed respondents at increased risk of burnout. burnout was associated with the graded ‘impact of burnout’ measure (the greater the reported impact, the greater the risk of burnout), as well as to the reported impact on relationships. the multiple regression model that best explained the presence of burnout included the following factors: ‘lack of free time’, compassion fatigue, alcohol as a coping mechanism, ‘impact of burnout on life’, ‘impact of burnout on relationships’, age of children and on-call hours of sleep. compassion fatigue, and the impact of burnout on relationships were found to be independently associated with burnout. impact of covid on burnout we found several associations between covid and measured burnout (table vi). respondents who reported that covid had affected their sleep, had an increased risk of burnout, with the table vi: univariate analysis of covid effects on survey responses burnout no burnout p-value or 95% ci power covid effects on work–life characteristics has covid affected your sleep? (n = 146) ref: ‘no’ 0.005 3.96 1.53–10.25 94% yes 62/94 (66%) 32/94 (34%) no 46/52 (88%) 6/52 (12%) how severe has the impact of covid been on your sleep? (n = 52) ref: ‘minimal’ 0.004 5.66 1.73–18.54 94% minimal effect 1/4 (25%) 3/4 (75%) mild effect 6/7 (86%) 1/7 (14%) moderate effect 20/22 (91%) 2/22 (9%) severe effect 16/16 (100%) 0/16 (0%) maximal effect 3/3 (100%) 0/3 (0%) has the impact burnout has on your life been affected by covid? (n = 155) ref: ‘yes, increased’ < 0.001 0.30 0.19–0.48 100% yes, increased the impact on my life 72/77 (94%) 5/77 (6%) yes, decreased the impact on my life 6/11 (55%) 5/11 (45%) no, covid has had no effect my experience of burnout 35/67 (52%) 32/67 (48%) has covid altered your selection of causes burnout? (n = 156) ref: ‘yes, more options’ < 0.001 0.37 0.22–0.64 100% yes, i have selected more options 44/47 (94%) 3/47 (6%) yes, i have selected fewer options 12/17 (71%) 5/17 (29%) no 57/92 (62%) 35/92 (38%) the effect of covid on my mood disorder (n = 152) ref: ‘yes, covid has worsened’ 0.022 0.29 0.10–0.84 99% yes, covid has worsened my experience of mood disorder 22/22 (100%) 0/22 (0%) yes, covid has improved my experience of mood disorder 0/2 (0%) 2/2 (100%) no, covid has no effect on the experience of my mood disorder 87/128 (68%) 41/128 (32%) covid effects on stanford pfi has covid affected your pf score? (n = 155) ref: ‘yes, closer to 4’ 0.014 0.46 0.25–0.85 71% yes, more results closer to 4 (i.e. more professionally fulfilled) 11/17 (65%) 6/17 (35%) yes, more results closer to 0 (i.e. less professionally fulfilled) 51/53 (96%) 2/53 (4%) no change 51/85 (60%) 34/85 (40%) has covid affected your we score? (n = 155) ref: ‘yes, closer to 4’ < 0.001 0.27 0.16–0.46 100% yes, more results closer to 4 (i.e. more work exhaustion) 51/56 (91%) 5/56 (9%) yes, more results closer to 0 (i.e. less work exhaustion) 30/34 (88%) 4/34 (12%) no change 32/65 (49%) 33/65 (51%) has covid affected your id score? (n = 155) ref: ‘yes, closer to 4’ < 0.001 0.30 0.17–0.53 100% yes, more results closer to 4 (i.e. more interpersonally disengaged) 43/46 (93%) 3/46 (7%) yes, more results closer to 0 (i.e. less interpersonally disengaged) 27/33 (82%) 6/33 (18%) no change 43/76 (57%) 33/76 (43%) categorical variables were expressed as frequencies and percentages. continuous variables were expressed as medians with interquartile ranges. relationships between variables and the primary binary outcome, burnout, are expressed as odds ratios and 95% confidence intervals. significance level set at p < 0.05. reference categories listed alongside category label. or: odds ratio; ci: confidence interval; ref: reference; pf: professionally fulfilled; we: work exhaustion; id: interpersonally disengaged page 140 o’connor m et al. sa orthop j 2022;21(3) majority of respondents with burnout recording it had a moderate to maximal effect on their sleep. selection of ‘covid has increased the impact of burnout on my life’, ‘i have selected more burnout causes’ and ‘covid has worsened my experience of my mood disorder’ were all positively associated with increased risk of burnout. concerning the stanford pfi objective burnout measure and covid, in all three sub-categories, most respondents reported that covid had moved all their scores closer to zero, in essence decreasing their burnout score. this was associated with a reduced risk of burnout for most respondents (table vi). discussion we found a burnout rate of 72% in south african orthopaedic surgeons and trainees, which falls on the higher end of the spectrum compared to international studies (between 16% and 85%).5 numerous studies have identified several common associations with burnout and recognised groups within the health professions at higher risk of developing burnout.2,8,32 the majority of associations reported with burnout are health-system related or work environment issues such as: lack of autonomy, too many bureaucratic tasks, administrative responsibilities, high workload, remuneration, working hours and calls (correlated to sleep deprivation).2-4,8,10,11,14,15,33-36 the other causes pertain to work–life imbalance including: having dependants and inability to balance work and family responsibilities.2,5,7,11,32,36 specific groups shown to be at greater risk for developing burnout comprise: physicians of younger age, female gender and trainees.2,5,14 in our cohort, we found similar risk factors, such as having children of younger age and fewer on-call hours of sleep. although most respondents reported that burnout was caused by ‘lack of compensation’ and ‘bureaucratic tasks’, the factors that placed them at increased risk were rather, ‘hours at work’, ‘lack of free time’ and ‘work–life imbalance’. the significantly higher rate of burnout in registrars compared to specialists is consistent with findings from the usa and australia.37-40 this is a concern for training coordinators, as among many implications, burnout has notably been shown to contribute to poorer examination results.40 we found no association between gender and burnout in our study; however, the study was underpowered to detect a difference. physicians attending to cancer patients have been shown to have an increased risk of burnout, and in the orthopaedic context specifically, the highest rates of burnout were in arthroplasty surgeons in china (85%).10,41 neither arthroplasty nor orthopaedic oncology were found to be associated with burnout in our study. identifying as a paediatric subspecialist tended towards being protective against burnout but was underpowered to detect significance. this was an unanticipated finding. the paediatric orthopaedic association of north america (posna) reports burnout of 38% among their members, while 28% (two of seven) of orthopaediatric specialists in our cohort had burnout.16 once burnout has been established, international reports show that it contributes to: higher rates of depression and suicidal ideation, broken relationships, increased alcohol and drug use, and reduced work satisfaction.7,8,10-13 suicidal ideation rate (10%) in our cohort was similar to that of a usa medscape study (13%) in which orthopaedic surgeons had the second highest rate across the specialities represented.14 also from the medscape report was the finding that 47% of workplaces do not have programmes to manage burnout, compared to 63% in our cohort.14 in addition, the medscape respondents reported that even if workplace programmes to manage burnout did exist, 42% of them would be unlikely to attend it, similar to 38% reporting this in our cohort. the medscape respondents reported ‘fear of stigma in the workplace’, or felt the condition was not ‘severe’ enough to warrant attendance at such a programme as reasons for unlikely attendance. irrespective, participation in wellness programmes has only minimally improved burnout scores; likewise, resilience training studies reflect conflicting results.7,12,33 we feel that this is because the main causal agent is at the system or organisation level, rather than as a result of an individual’s behaviours. one of our respondents put it eloquently: ‘the likelihood that i would participate in any burnout program would depend on whether i perceive the program to be useful. viewing burnout as something that can be addressed at the individual level is pointless. it does not help to tell someone to exercise or meditate or something when they are being traumatised by an external system that doesn’t allow time for those things anyway.’ this emphasises our finding that no self-reported coping mechanisms were found to be protective against burnout. in addition, it echoes the current research direction, which has shifted focus toward changes that need to occur at a system or organisational level, such as administrative support, reduced working hours, supportive mentorship and advocacy for member support in medical societies, which hold promise.4,10,11,14 with the advent of covid-19, the south african health system has seen an increase in burnout due to increased demand for already strained resources.42 fear of contracting the virus, fear of infecting family members, and reduced staffing have also been contributory.43 younger doctors, female doctors and trainees remain at higher risk of burnout during the pandemic.44-46 interestingly, there are conflicting reports of burnout rates in healthcare workers that are in direct contact with covid-positive patients. some studies report reduced burnout rates or no difference in burnout rates.47,48 those who have lower burnout rates than their colleagues may be benefiting from ‘a return of a sense of autonomy’, or ‘the ability to display altruism’, or ‘the ability to relate to their patients’, argue hartzband and groopman.35 we explored the possible confounding nature of the covid pandemic on our findings. consistent with medscape’s national (us) physician burnout reports from successive years (2019– 2021), where orthopaedic surgeon burnout decreased after the onset of covid (from 38% in 2019 to 34% and 33% in 2020 and 2021 respectively), respondents in our study indicated that their selections on the measured burnout index were typically reduced since the advent of the pandemic. it bears mentioning that these responses are subject to recall bias. however, should this result be an accurate reflection of burnout during this time, we surmise that the majority representation of orthopaedic specialists, private sector practitioners, had a reduced workload due to elective surgery restrictions, and that could have contributed to this finding. in addition to this bias, there were other limitations. a priori sample size estimates for the regression model we utilised would have necessitated a 27% response rate; however, our response rate was 16%. although this was comparable to previous studies in orthopaedic cohorts (the majority of which quote rates around 20%, but range from 6–94%), it meant that our study was underpowered to detect significance for several variables.5 burnout studies regularly experience poor response rates. it is likely this reflects a lack of time to complete extensive questionnaires with minimal incentive, which we believe to be true in our context.5 in our questionnaire, we used the stanford pfi measure. while it is a validated burnout measurement scale, it limited comparison to only those studies that used this measure or those that reported an overall burnout score. we deemed this acceptable, however, as overall burnout was our outcome of interest. furthermore, the information sheet and consent form detailed that the survey aimed to evaluate the presence of burnout in orthopaedic surgeons. this could have introduced response bias and exhibited a priming effect on results. however, some of the questions explicitly asked about page 141o’connor m et al. sa orthop j 2022;21(3) ‘burnout’, and as such, the investigators felt this effect would have occurred despite blinding respondents. respondents were blinded to the fact that we screened for other associated workplace distress conditions, for which we found high rates in all five conditions. this uncovered a knowledge dearth that warrants further investigation. other gaps we did not explore in this study include whether burnout rates differ between provinces within south africa, or across rural and urban boundaries, findings which have been detected in previous burnout investigations both in south africa and abroad.6,19,22,49,50 conclusion burnout is prevalent in the south african orthopaedic community (72%). registrars are particularly vulnerable, and further investigation is necessary to identify risk factors particular to this group. modifiable system-based risk factors, and thus potential targets for initiatives to reduce the burnout rate, included: ‘hours at work’ and ‘lack of free time’. high rates of positive screening for associated workplace distress conditions warrants further investigation. additional information should you, after reading this article, recognise the symptoms of burnout in yourself and desire support, psychological assistance is available to you by contacting the healthcare workers care network helpline at 0800 21 21 21. alternatively, the south african orthopaedic association has initiated a mentorship programme, available to all members of the saoa. to get in touch, please email info@saoa.org.za. acknowledgements the south african orthopaedic association, for recognising the importance of the well-being of their members and supporting this initiative. ethics statement the authors declare that this submission is in accordance with the principles laid down by the responsible research publication position statements as developed at the 2nd world conference on research integrity in singapore, 2010. the study complied with the south african department of health ethics guidelines (2015), and the university of kwazulu-natal policy on research ethics. prior to commencement of this research, the appropriate ethical approval was obtained from the biomedical research ethics committee of ukzn (brec/00002150/2020). declaration the authors declare authorship of this article and that they have followed sound scientific research practice. this research is original and does not transgress plagiarism policies. author contributions mo: protocol revision, data capture, data analysis, first draft preparation, manuscript revision nf: protocol revision, initial design of data capture tool, draft manuscript review and revision ms: data analysis and critical review of manuscript draft and revisions for statistical method, preparation of statistical figures pw: saoa support of research initiative, review of data capture tool, draft manuscript and revision review rgv: protocol revision, draft manuscript and revision review lcm: conceptualisation, protocol development, review of data capture tool, data analysis, 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https://doi.org/10.2106/00004623-200407000-00032 https://doi.org/10.1177/230949901402200322 https://doi.org/10.5435/jaaos-d-19-00648 https://doi.org/10.5435/jaaos-d-19-00648 https://doi.org/10.2106/jbjs.18.00979 https://doi.org/10.2106/jbjs.18.00979 https://doi.org/10.1016/j.arth.2017.10.049 https://doi.org/10.1056/nejmp2011027 https://doi.org/10.1056/nejmp2011027 https://doi.org/10.1007/s00420-021-01695-x https://doi.org/10.1001/jamanetworkopen.2020.17271 https://doi.org/10.1371/journal.pone.0237301 https://doi.org/10.1371/journal.pone.0237301 https://doi.org/10.1016/j.jpainsymman.2020.04.008 https://doi.org/10.1016/j.jpainsymman.2020.04.008 https://doi.org/10.3205/000281 https://doi.org/10.1080/20786190.2016.1198088 https://doi.org/10.1111/ajr.12040 https://doi.org/10.1111/ajr.12040 _hlk105772567 _hlk105772834 saoa 2019 abstracts toc arthroplasty papers: 1 a high rate of early and late complications linked to pre-operative viral load and obesity exists in hivinfected patients undergoing tka 1 a prospective randomised trial comparing post-operative knee alignment following total knee replacement using patient specific knee instrumentation based on either ct or mri 2 an assessment of the accuracy of measurement of leg length discrepancy and inter-observer reliability, using a digital pacs x-ray system and templating software 2 complications associated with the direct anterior approach for total hip arthroplasty in a south african academic hospital 3 is there a change in patient weight and body mass index following elective primary total joint arthroplasty? 3 leg length correction in computer assisted primary total hip arthroplasty: a collective review of the literature 3 minimally invasive direct anterior approach total hip arthroplasty allows good functional outcomes and return to sports at mediumto long-term follow-up 4 popi-compliant smartphone-based data form inputting platform to manage an arthroplasty wait list in an academic hospital: a pilot project 4 prevalence of pathological fractures in patients undergoing arthroplasty for neck of femur fractures at a single tertiary academic hospital 5 prevalence of staphylococcus aureus colonisation in patients undergoing total joint arthroplasty at a south african academic hospital 5 primary total hip arthroplasty in the very young patient (<55 years) 5 proposal and validation of a novel, descriptive classification system for hip pathology in hiv-infected patients awaiting total hip arthroplasty 6 severe windswept deformity in patients undergoing total knee arthroplasty: what came first, the valgus or varus? 6 short-term outcomes of cementing a dual mobility cup into a high friction uncemented acetabular cup in revision hip arthroplasty surgery 6 the utility of alpha–defensin test in guiding second stage revision in patients with inflammatory arthritis 7 what they say vs what they do: assessing physical recovery after total knee arthroplasty comparing wearable motion sensors and self-reported proms foot and ankle papers: 7 mediumto long-term results of the hintegra total ankle arthroplasty: a south african perspective 8 reliability of the intra-operative radiographic visual assessment of the hallux interphalangeal angle after correction of hallux valgus deformity general papers: 8 a comparison of hip revision arthroplasty surgery in the private and public sectors 8 a comparison of knee revision arthroplasty surgery in the private and public sectors 9 bioactive glass as dead-space management following debridement of type 3 chronic osteomyelitis 9 completing an saoa endorsed hip and knee arthroplasty fellowship: review of the journey 9 description of a new open surgical technique for repair of chronic full thickness abductor muscle tears and evaluation of the mid-term results 10 direct anterior hip approach: a descriptive analysis of its implementation at a tertiary academic hospital 10 epidemiological data from a high-volume arthroplasty unit in south africa: a five-year retrospective review 10 evaluating knee arthroscopy skills in orthopaedic trainees 11 genicular nerve radiofrequency ablation in patients with end-stage knee osteoarthritis awaiting total knee replacement 11 hemiarthroplasty vs total hip arthroplasty in the management of neck of femur fractures: a comparison 12 local bone antibiotic delivery using porous alumina ceramic: clinical and pharmacological experience 12 orthopaedic syllabus for undergraduate medical students in southern africa: a consensus from local and international experts 12 performing hip arthroplasty on the ‘forbidden’ patients 13 rating of arthroplasty implants: what orthopaedic surgeons need to know 13 short to medium results of custom 3d-printed pelvic implants 13 south african perspective of collaborations for global surgery in africa gt du toit – registrar research papers: 14 antegrade flexible intramedullary nailing through the greater trochanter in paediatric femur shaft fractures 14 arthroscopic arthrolysis after total knee arthroplasty 15 biomechanical comparison of two different configurations of the truelok hex and taylor spatial frame external fixators 15 can anatomical contoured plates reduce scapula body, neck and glenoid fractures? 15 comparing outcomes between enhanced recovery after surgery and traditional protocol in total knee arthroplasty 16 open tibial shaft fractures: the effect of management delays on infection rates – a retrospective cohort 16 patient satisfaction following wide awake local anaesthetic no tourniquet hand surgery in a south african tertiary state hospital content 16 prevalence of a peri-operative troponin leak in patients undergoing hip arthroplasty for a neck of femur (nof) fracture in a south african population 17 relative metatarsal length change following the modified lapidus procedure 17 reliability of the radiographic measurement of the hallux interphalangeal angle 17 results of odontoid peg fracture treatment at a tertiary hospital 18 sarcopenia in patients presenting with fragility fractures of the hip at a tertiary facility in south africa 18 the burden of tibial diaphyseal fractures at an urban academic institution: time counts 19 the incidence of low energy hip fractures in the western region of the eastern cape province, south africa 19 the microbiology of chronic osteomyelitis in a developing world setting 19 the short-term outcomes of hip arthrodesis in paediatric patients with end-stage hip disease 20 tumour volume as a predictor of metastases in patients presenting with high-grade conventional osteosarcoma hand papers: 20 diagnostic accuracy of pre-operative clinical examination in zone v flexor injuries 21 the evaluation of the efficacy and complication rates of peripheral regional anaesthesia performed at our institution’s hand unit hip arthroscopy and preservation papers: 21 age, gender and a decline in functional outcome scores at three months may predict revision hip arthroscopy: a single surgeon series of 1 363 consecutive hip arthroscopies 21 an anatomical study of the prevalence and morphology of the corona mortis in a south african cadaver sample 22 post-operative rivaroxaban in patients at risk for deep vein thrombosis undergoing hip arthroscopy: a single surgeon series in a developing country 22 proximal femur geometry in the adult kenyan femur and its implication in orthopaedic surgery 23 there is a low rate of infections and subsequent 30and 60-day admission rates in primary hip arthroscopy, revision hip arthroscopy and cases converted to total hip arthroplasty knee papers: 23 not strong enough? insignificant movements generated during clinical examination of sagittal and rotational laxity in an acl-deficient cadaver knee 23 the management of acute knee dislocations: a global survey of orthopaedic surgeons’ strategies oncology paper: 24 the outcome of the lateral approach to distal femoral tumour resections – a retrospective clinical audit at a private practice in pretoria paediatrics papers: 24 a replacement for the kirschner wire: micro-ct and histological assessment of a bioabsorbable pin for paediatric fracture management 25 an overview of the patient population presenting with congenital talipes equinovarus (ctev) at a tertiary hospital in the western cape 25 appropriate age to transition paediatric patients to adult orthopaedics at an academic hospital 26 common causes of atraumatic swollen painful joints in south african children 26 effect of seasonal variation on the peak presentation of slipped capital femoral epiphysis: a comparison of children in johannesburg, south africa and london, united kingdom 26 epidemiology of paediatric and adolescent fractures admitted to a south african provincial hospital 27 femoral lengthening in children: complications and outcomes 27 outcomes of distal radius metaphyseal fractures in children 28 patient-based outcome after in situ percutaneous pinning for slipped upper femoral epiphysis (sufe) 28 perthes valgising osteotomy 28 primary total hip arthroplasty in paediatric patients (<20 years) 29 train surfing and train-related accidents, a growing scourge 29 tuberculosis of the extra-axial skeleton in children shoulder and elbow papers: 29 juggerknot soft anchors in arthroscopic shoulder stabilisation 30 retrospective audit of serum vitamin d levels in patients who underwent latarjet procedure for shoulder instability 30 the management of proximal humerus fractures by south african shoulder surgeons 31 the management of rotator cuff tears by south african shoulder surgeons 31 triceps off fascial sleeve (tofs) approach to the distal humerus spine papers: 31 influence of the newly introduced standard operating procedure on outcomes of acute cervical spine dislocated injuries at groote schuur hospital 32 lower lumbar burst (l3–l5) fractures: incidence and management 32 management strategies of lateral mass fractures of the cervical spine 32 pre-operative use of traction views in adolescent idiopathic scoliosis 33 the clinical outcome and surgical management of cervical spine tuberculosis 33 the efficacy of radical debridement and spinal instrumentation in adult patients with pott’s paraplegia trauma papers: 34 analysis of the complications of volar plate fixation for the treatment of distal radius fractures frykman type 3–6 34 neck of femur fractures at a tertiary academic hospital: a three-year descriptive analysis 34 open approaches for cruciate ligament reconstruction in knee dislocations 35 outcomes of primary fusion in high energy lisfranc injuries operated at groote schuur hospital: a retrospective study from 2013 to 2018 35 radial shortening following low velocity gunshot injuries treated with an intramedullary device 35 three months in tygerberg orthopaedic trauma – what is a registrar worth? 36 what is the preferred method of management of intertrochanteric femur fractures in south africa? a survey of orthopaedic surgeons posters: 36 a case of mesenteric ischaemia in revision hip arthroscopy 36 a case of tarso-carpal coalition in a 5-year-old 36 a case report of cephalomedullary nail implant failure 36 a rare sacral tumour 36 aneurysmal bone cyst of the sacrum 36 case report of a 6-year-old child presenting with deep vein thrombosis (dvt) as an orthopaedic complication 37 case report: single stage revision of total knee arthroplasty for metallosis 37 costing total hip arthroplasty in a south african state tertiary hospital 37 dislocation of a hip replacement due to intraoperative rim fracture of a lipped polyethylene liner. a case report and review of the literature 37 dissociation of a dual mobility head after a revision hip replacement. a case report and review of the literature 37 double immune compromise, hiv, diabetes and other factors affecting severity and bacteriology in hand infections 37 dysplasia hemimelica epiphysealis 37 femoral component fracture. a rare complication of total knee arthroplasty 37 follow-up of an anatomical cemented stem 37 isis ii double mobility cup, a geometry without overhang with a lower risk of iliopsoas tendinitis 37 multifocal septic arthritis complicated by osteomyelitis and pseudarthrosis of the humerus 37 neck of femur fractures managed at chris hani baragwanath academic hospital 37 non-contiguous tb spine 37 non-accidental injuries: avn of the hip following sexual assault 37 operative daily rate of recovery of thr and tkr and time to discharge decreases with post-directed physiotherapy in an academic hospital 37 os odontoideum in down syndrome 37 patient with bilateral madelung deformities as part of a leri-weill dyschondrosteosis 38 prevalence of hiv in orthopaedic trauma patients. most hiv infected patients present with high energy injuries 38 prevalence of orthopaedic injuries caused by known assailants at provincial tertiary hospital: prospective study 38 report on a rare case of congenital absent quadriceps and patella in a 7-year-old child 38 rosai-dorfman disease (rdd): a case presentation 38 screw and cement augmentation of tibial defects in primary total knee arthroplasty 38 short-term results following two-stage revision for periprosthetic joint infection 38 the effect of obesity on total hip and knee joint arthroplasty 38 the relevance of post-reduction computed tomography scans in adult patients with type i posterior hip dislocations and concentric reduction on plain radiographs 38 total hip replacement in an osteogenesis imperfecta patient. a case report and review of the literature 38 total knee replacement in an osteogenesis imperfecta patient. a case report and review of the literature 38 vertebral hydatidosis with paraplegia page 1 sa orthop j 2019;18(3) saoa 2019 absracts arthroplasty papers: a high rate of early and late complications linked to pre-operative viral load and obesity exists in hiv-infected patients undergoing tka paper: p43 category: arthroplasty presenting author: p ntombela co-authors: jrt pietrzak, j courcol, lz muller, k sikhauli, d van der jagt, l mokete background: the use of active antiretroviral therapy (haart) has changed the course and nature of patients infected by the human immunodeficiency virus (hiv). hiv-infected patients may be considered an independent risk factor for infection. a paucity still exists in the literature with regards the outcomes of tka in hivinfected patients. methods: the aim of this paper was to assess the outcomes of tka in hiv-infected patients in a sub-saharan academic hospital. we retrospectively reviewed the outcomes of 29 hiv-infected patients who underwent 36 tkas from january 2014-january 2018. results: there were 22 females and 7 males with an average age of 59.6 years. the average bmi was 33.8 and 34.5% (n=10) had ≥2 co-morbidities. there were 28 knees with osteoarthritis (oa) (24 tricompartmental oa) and 8 knees with inflammatory arthritis. the average pre-operative cd4+ was 674 and 19 patients had an undetectable viral load (vl) at the time of tka. the follow-up of all patients was 2 years and 4 months. the overall complication rate was 33.3% (n=12) which included 8 early complications (<6 weeks) and 4 late complications (>6 weeks). there were 2 dvts and cardiac complications. there were 4 surgical site infections (ssis) and 4 late deep infections. there were 4 dair (debridement, antibiotics, irrigation and retention of implants) procedures. three patients underwent 2 stage revision tka (1 failed dair, 2 chronic deep infections). septic sequelae were not related to pre-operative cd4+ count but to high pre-operative vl and obesity (bmi >40). haart was not initiated on 3 of 4 late deep infections. the culture profile was acinetobacter baumannii and proteus mirabilis in one patient that presented with deep infection. the remaining 3 patients cultured klebsiella pneumoniae, pseudomonasaeruginosa and methicillin-sensitive staphylococcus aureus. the 30-, 60and 90-day readmission rate was 13.9%, 2.8% and 2.8% respectively. there was an overall improvement in kss in 88.9% (n=32 tkas). the satisfaction rate was 75.8% (n=22 patients). conclusion: a significantly high rate of complications exist in hiv-infected patients undergoing tka. there is a high rate of both early and late infective complications linked to high pre-operative viral load but unrelated to cd4+ count. a prospective randomised trial comparing post-operative knee alignment following total knee replacement using patient specific knee instrumentation based on either ct or mri paper: p125 category: arthroplasty presenting author: l mokete co-authors: w ndou, lp selemela, n sikhauli, jrt pietrzak, d van der jagt background: accurate knee alignment following total knee replacement surgery confers a better long-term outcome than the mal-aligned knee replacement. patient specific instrumentation (psi) is a technique that has been developed with the aim of achieving accurate knee alignment while improving theatre efficiency. the technique involves manufacture of bone cutting jigs using rapid prototype technology based on pre-operative ct or mri of the lower limb. reports of both ct and mri based psi systems have revealed promising results when compared to conventional jigs with respect to limb alignment. however, there is a concern that ct tends to underestimate the dimensions of the knee, as cartilage mapping is imprecise with this imaging modality. page 2 sa orthop j 2019;18(3) aim: to compare the accuracy of ct based psi (ctpsi) or mri based psi (mripsi) as determined by limb alignment following knee replacement surgery. methods: seventy patients with advanced degenerative arthritis of the knee were randomised to receive a cemented posterior stabilised knee replacement (persona, zimmerbiomet) using ctpsi or mripsi. post-operative ct scans (perth protocol) were done within six weeks of surgery to determine leg alignment. results: forty-three females and ten males with a mean age of 66 years (range: 50-79 years) had a full data set. the groups were similar regarding age and gender distribution. there was no statistical difference (anova) in coronal and sagittal alignment between the groups (ctpsi versus mripsi, 2.3° ± 0.9 (-1° to 3°) vs 3.5° ± 0.8 (-2° to 1°), p=0.29) and (ctpsi versus mripsi, 0.1° ± 2.3 (-6° to 7°) vs 0.4° ± 2 (-3° to 7°), p=0.35) respectively. femoral rotation was more accurate with ctpsi (ctpsi versus mripsi, 0.1° ± 0.7 (1° to 4°) vs 0.4° ± 2 (1° to 8°), p=0.03). conclusion: ct based psi (ctpsi) is as accurate as mri based psi (mripsi) for coronal and sagittal alignment in knee replacement surgery. however, ctpsi is more accurate for femoral rotation. ctpsi is cheaper and is associated with less likelihood of failed pre-op scans. an assessment of the accuracy of measurement of leg length discrepancy and inter-observer reliability, using a digital pacs x-ray system and templating software paper: p121 category: arthroplasty presenting author: z moonda co-author: mb nortje background: leg length discrepancy (lld) is a major cause of morbidity and litigation following total hip replacement (thr) surgery. in order to achieve equal leg lengths during thr, pre-operative planning, including measuring lld, is carried out, to achieve adequate leg length correction (llc). this is often done using digital x-rays, however, the accuracy and reliability of these systems is sometimes questioned. aims: to assess the accuracy of measuring lld using a digital pacs x-ray system and templating software. inter-observer reliability of measuring preand post-operative lld of patients undergoing thr surgery was also assessed. methods: pre-operative x-rays of 50 patients undergoing thr were assessed by three different orthopaedic surgeons, to measure lld using a pacs system and templating software. post-operative x-rays were assessed to measure the llc achieved by thr. the measurements were done separately by each surgeon, and no discussions were had between them. the measurements of the surgeons were then compared and analysed. results: the average pre-operative lld measured was: surgeon a: 8.8 mm; surgeon b: 5.2 mm; surgeon c: 10.7 mm. the difference between observers was: a-b: 3.5 mm; a-c: 1.9 mm; b-c: 5.5 mm. the average inter-observer difference was 3.7 mm. the postoperative lld measurements were: surgeon a: 4.3 mm; surgeon b: 3.8 mm; surgeon c: 8.8 mm. the average difference between observers was 3.3 mm. conclusion: the average difference between observers in measuring both the preand post-operative x-rays was 3.5 mm, however this is not considered to be clinically significant. the difference in the measurements was considered to be due to variance between surgeons in choosing the most medial point on the lesser trochanter. good inter-observer reliability using this method was also demonstrated. we therefore conclude that the use of digital x-ray and templating systems is clinically acceptable, and is an important tool in correcting lld in thr. complications associated with the direct anterior approach for total hip arthroplasty in a south african academic hospital paper: p57 category: arthroplasty presenting author: w ndou co-authors: pn ntombela, jrt pietrzak, n sikhauli, d van der jagt, l mokete background: the total hip arthroplasty is one of the most successful procedures and has been dubbed the procedure of the century. with satisfaction rates between 80–90%, this has become one of the most commonly performed procedures in orthopaedic surgery with alleviating of pain and improved patients’ quality of life. the direct anterior approach carries a steep learning curve and high complications during the learning curve. the aims were to report on the complications of the direct anterior approach using a modified fracture table and to highlight and report on risk factors for complications using the direct anterior approach. methods: study design the study is a retrospective review. inclusion criteria all patients who underwent total hip replacement using the amis® approach on a modified fracture table using medacta® implants from january 2015 to february 2019. exclusion criteria revision total hip replacements and total hip replacements performed using the posterior or anterolateral approaches. measurement tools complications including: intraoperative periprosthetic fractures, nerve palsies, dislocation, wound infections and periprosthetic joint infections. demographic data was documented to identify potential risk factors to complications. results: a total of 224 anterior total hip replacements were performed by seven surgeons who all underwent training through the medacta® academy. 20/224 complications were recorded. seven femoral fractures (0.03%), six femoral nerve palsies (0.02), three acetabular fractures (0.01), two periprosthetic joint infections, one superficial surgical site infection and one dislocation. patient factors identified as risk factors included neck of femur fractures, avascular necrosis of the femoral head and inflammatory arthritides. larger acetabular cups and femoral stems were associated with acetabular and page 3 sa orthop j 2019;18(3) femoral fractures. a clustering of medical co-morbidities such as rheumatoid arthritis and hiv were found to be risk factors for wound and periprosthetic joint infections. conclusion: the direct anterior approach is a safe and reproducible approach for total hip arthroplasty, but has a steep learning curve. careful patient selection, pre-operative templating and meticulous surgery aids in limiting complications. patients with medical co-morbidities need to be optimised prior to planned surgery. is there a change in patient weight and body mass index following elective primary total joint arthroplasty? paper: p66 category: arthroplasty presenting author: bs khonye co-authors: jrt pietrzak, w ndou, k sikhauli, l mokete, dr van der jagt background: in total joint arthroplasty (tja), obesity is associated with poor perioperative and postoperative outcomes. however, reports of changes in weight after total knee (tka) and total hip (tha) arthroplasty are unreliable especially in a south african context. this study examined weight changes following tka and tha for osteoarthritis (oa) in an urban south african academic institution. methods: we assessed the change from pre-operative to post-operative weight and body mass index (bmi) in 101 patients that underwent elective tja at a minimum of 1-year follow-up. a retrospective chart review assessed the impact of co-morbidities, pre-operative activity levels, type of surgery and reason for surgery on potential weight change. results: there were 56 thas and 45 tkas, 15 males and 86 females in total who underwent surgery between january 2016 and december 2017. the mean follow-up time was 1.56 years (1.1 years to 2 years). the average pre-operative bmi for tja was 32 kg/m2 (19 kg/m2 to 49 kg/m2). the average bmi for tha and tka was 31.2 kg/m2 (19 kg/m2 to 49 kg/m2) and 38.63 kg/m2 (21 kg/m2 to 58 kg/m2) respectively. there were 64.3% (n=65) who gained weight post-operatively while 25.7% (n=26) lost weight and 10.8% (n=11) stayed the same weight. the average post-operative bmi for tha and tka was 33.12 kg/m2 (19 kg/m2 to 49 kg/m2) and 42.6 kg/m2 (21 kg/m2 to 58 kg/m2) respectively. there were 12 patients (11.88%) who became morbidly obese after total joint arthroplasty. patients who underwent tha were more likely to lose weight than those who underwent tka. females >70 years were most likely to gain weight. there were 75 patients (74.3%) who gained ≥2 bmi points. patients with ≥2 medical comorbidities were 2.3 times more likely to gain weight post-operatively. conclusion: the majority of patients gain weight 1 year after tja. careful consideration of morbidly obese patients undergoing tka is necessary as they are three times more likely to gain ≥2 bmi points post-operatively. better strategies than simple dietitian referral are necessary to ensure weight reduction. leg length correction in computer assisted primary total hip arthroplasty: a collective review of the literature paper: p132 category: arthroplasty presenting author: j rajpaul co-author: mn rasool aim: the aim of this study was to determine whether computer assisted surgery (cas) can provide a more accurate, reproducible technique to achieve equal leg lengths in total hip arthroplasty (tha) and to compare the clinical outcome with conventional on table judgement of leg lengths in unilateral total hip replacement. methods: a collective review of the literature was undertaken utilising applicable databases. research criteria were the following: (1) developing and developed country studies, (2) level ii, iii, iv and v studies, (3) human subjects only, (4) period of study from 1996 to 2017 english text only. the identified publications were assessed for their relevance and methodology and 20 articles were selected. results: the overall evaluation of the results demonstrates that cas provides a more accurate reproduction of limb length in tha compared to conventional freehand tha. short to medium-term studies have demonstrated no benefit in clinical outcome scores. there is a high degree of correlation between measurements provided by cas intra-operatively and radiographic measurements postoperatively. conclusion: cas provides a more accurate, reproducible technique to achieve limb length equality in tha compared to conventional freehand tha, however more intensive long-term studies are required to establish the effect on implant longevity and revision surgery rates in the two groups. minimally invasive direct anterior approach total hip arthroplasty allows good functional outcomes and return to sports at mediumto long-term follow-up paper: p123 category: arthroplasty presenting author: jrt pietrzak co-authors: k nortje, jn cakic background: total hip arthroplasty (tha) is a well-established, cost effective treatment option for patients with hip osteoarthritis (oa). the optimal surgical approach for tha, however, is debatable. minimally invasive direct anterior approach (daa) is an inter-nervous, intermuscular approach that is growing in popularity, but longterm outcomes remain controversial. the aim of this paper was to determine the long-term outcomes of minimally invasive daa by a single south african surgeon >5 years post-operatively. methods: we conducted a retrospective chart review of all tha performed from january 2007 to december 2013. demographic details, preoperative radiological features and implant details were recorded. an anonymous, on-line electronic questionnaire was sent to all patients. timeous reminders were sent 1 week apart for 3 weeks. patients were then contacted telephonically and asked to complete page 4 sa orthop j 2019;18(3) questionnaire. patient reported outcome measures (proms) recorded included the modified harris hip score (mhhs), forgotten joint score, the hip disability outcome score (hoos) and patient reported perception score. results: there were 259 patients who responded to the electronic questionnaire of 512 that were operated on during this period. the response rate was 50.58%. there were 185 females and 74 male patients, average age 57.34 ± 9.85 at a mean 7.64 year follow-up in this cohort. in this group there 145 oa (55.9%), 46 inflammatory oa (17.7%), 42 dysplastic hips (16.2%) and 26 avn hips (10%). the overall satisfaction rate was 91.9% with 3.1% being neutral about their outcome. there were 65.6% of patients that reported a completely natural feeling joint. rating the functionality of the joint: 40.9% indicated that they can do anything while 52.1% could do most things. the vas score showed that 90.3% of all patients experienced a pain score of ≤3, while 56.3% had a score of 0. the median fjs was 42.0. the average mhss was 80.5 with 87% having an excellent outcome. three in four participants (73.7%) reported that they were able to return to sports activities following surgery. conclusion: minimally invasive daa tha provides good long-term functional results and patient satisfaction rates. return to sports participation is achieved in the majority of cases. popi-compliant smartphone-based data form inputting platform to manage an arthroplasty wait list in an academic hospital: a pilot project paper: p137 category: arthroplasty presenting author: s swartbooi co-authors: jrt pietrzak, w ndou, n sikhauli, dr van der jagt, l mokete background: the burden of primary hip and knee replacement in the public sector in south africa continues to outstrip our ability to service patients in need of these procedures. this creates a queuing phenomenon and wait lists that require active management. set criteria for prioritisation on the wait list are helpful but rigid enforcement can be at odds with maximising efficiency of theatre slot utilisation. this fluid environment requires ease of access to information and manipulation of data. portable handheld communication devices including smartphones are convenient for inputting simple patient data. however, they do not lend themselves to handling spreadsheets as traditionally used for wait lists. currently we collect information at outpatient clinics for inputting into the wait list database on handwritten paper forms. the information is later typed into a desktop, which serves as the repository for our database. we are piloting a new integrative communication platform that is able to handle popi-compliant smartphone-based data and forms with storage on a desktop computer or the cloud to manage our wait list. aim: to compare the ease of use and retention of data of our established wait list and the new platform. methods: a retrospective study was done of the information collected for the arthroplasty wait list with both the current and the new method over a period of two months. fifteen random entries from the new platform and the established wait list were assessed for accuracy, quality and quantity of information. ease of use was assessed by way of a questionnaire. use of the state-trait anxiety inventory (stai) form revealed that anxiety over new technology decreased after the third patient’s data was captured. this new technology additionally allowed eight (53.33%) to be identified as high anaesthetic risk and simultaneously referred to a pre-assessment clinic. conclusion: use of a smartphone-based forms inputting platform resulted in consistently accurate collection of relevant data that enabled more efficient management of the database. the doctors reported that the platform was more user friendly, with minimal additional anxiety, than traditional handwritten paper forms resulting in more accurate retention of data. prevalence of pathological fractures in patients undergoing arthroplasty for neck of femur fractures at a single tertiary academic hospital paper: p119 category: arthroplasty presenting author: sa khan co-authors: jd jordaan, m burger, n ferreira background: femoral neck fractures continue to be a burden to the health system in developed and developing countries, with the annual incidence expected to increase. pathological fractures in the elderly population are most commonly caused by metastatic bone tumours and multiple myeloma. determining whether a fracture is pathological is generally based on clinical presentation and suspicious lesions on x-ray. femoral heads are sent for histology at the time of surgery to determine histological proof of malignancy. no studies in the literature use routine histology on all femoral heads to exclude occult pathological fractures. additionally, there is no south african data regarding prevalence of pathological femur neck fractures. at our institute, all femoral heads are sent for routine histology, hence definitively excluding pathological causes and giving a true prevalence of pathological fracture prevalence. the primary aim was to determine the prevalence of pathological neck of femur fractures at our institute between 2014 and 2016. a secondary aim was to determine whether sending all neck of femur specimens for histology would be justifiable in terms of the cost/benefit ratio. methods: all clinical data and histology results of patients who underwent hip arthroplasty after femoral neck fractures between 2015 and 2017, were evaluated. results: a total of 312 patients were evaluated of which 216 were female, 95 were male with a mean age of 73.4. 195 patients with complete data and histology were analysed. of those with histology results 0.3% (n=10) were pathological, which were all expected based on their clinical history and x-ray features. no occult pathological fractures were observed. the most common metastases were breast adenocarcinoma, followed by small cell lung carcinoma. conclusion: we report a 0.3% prevalence of pathological neck of femur fractures which is decreased compared to previous reports in the literature which reported 1.6% and 0.9%, respectively. no occult pathological fractures were identified. page 5 sa orthop j 2019;18(3) prevalence of staphylococcus aureus colonisation in patients undergoing total joint arthroplasty at a south african academic hospital paper: p55 category: arthroplasty presenting author: c hitge co-authors: j pietrzak, d dimitriou, r rajkoomar, l mokete background: staphylococcus aureus colonisation, whether methicillinsensitive staphylococcus aureus (mssa) or methicillin-resistant staphylococcus aureus (mrsa), is a risk factor for surgical site infections (ssi). ssis are a major source of morbidity and mortality. infections are nine times greater in s. aureus carriers than in noncarriers. the aim of this study was to determine the prevalence of mssaand mrsa-colonisation in patients awaiting total joint arthroplasty (tja) in a south african academic institution. methods: we prospectively assessed 119 consecutive patients awaiting tja. we tested three separate anatomical areas including the anterior nares, axilla and groin in all patients for both mssa and mrsa. patients with positive cultures were treated with intranasal mupirocin ointment and daily chlorhexidine showers for five days and re-tested. data was correlated with positive results and potential risk factors were evaluated. all patients were followed up for 30-, 60and 90-day readmissions and subsequently for a minimum of two years for any evidence of deep infection. results: there were 78 patients undergoing total knee arthroplasty (tka) and 41 patients undergoing total hip arthroplasty (tha). the incidence of s. aureus colonisation was 31.9%. there were no patients colonised with mrsa. nasal swabs, groin swabs and axilla swabs were positive in 81.6%, 39.5% and 28.9% respectively. patients older than 70 years and of indian extraction presented with lower prevalence rates. eradication was successful in 92.1% after 1 week’s treatment. failed treatment was as a consequence of poor compliance and all were decolonised after repeat treatment. the overall complication rate was 7.56% with 3 minor and 6 major complications. the 30-day readmission rate in the mssa-colonised group was 5.3%. there were no 60and 90-day readmissions. no cases were revised at two-year follow-up. conclusion: the rate of s. aureus colonisation was 31.9% and is equivalent to reported international rates. testing to identify s. aureus colonisation of the anterior nares is most significantly successful. intranasal mupirocin decolonisation is effective and results in a low rate of shortand mid-term infective complications. primary total hip arthroplasty in the very young patient (<55 years) paper: p110 category: arthroplasty presenting author: jd jordaan co-authors: j charilaou, m burger background: the successes of total hip arthroplasty (tha) have internationally resulted in more arthroplasty being performed in younger patients. the quadruple disease profile in developing countries such as south africa also contributes to a unique pathology profile that presents for tha. in particular, i) trauma, ii) the hiv pandemic and iii) alcohol abuse put the very young patient at risk for developing early hip arthritis which eventually results in the need for tha. the aim of this study was to provide an overview of population profile of young patients (<55 years) presenting at our institution for tha. methods: a retrospective review of all primary tha being performed in patients <55 years old in a single tertiary academic hospital in south africa, between may 2016 and april 2019, was conducted. demographical data as well as clinical data, including diagnosis, surgical approach and bearing surface, fixation technique and surgical seniority, was collected. results: a total of 186 tha were performed during the study period (7%, n=13 <25 years; 19%, n=35 <35 years; 22%, n=41 <45 years; 52%, n=97 <55 years), which included 58% (n=107) male and 42% (n=79) female participants. the primarily pathologies were avascular necrosis (31%, n=57) and post-traumatic osteoarthritis (30%, n=56) followed by primary osteoarthritis (19%, n=32), developmental dysplasia hip (8%, n=14) and inflammatory arthritis (7%, n=11). surgical approached included the posterior approach (63%, n=118), direct anterior (34%, n=64) and antero-lateral (2%, n=4) approaches. ceramic on crosslink polyethylene (51%, n=93) was the main bearing surface followed by ceramic on ceramic (24%, n=44). most femoral components (95%, n=175) and all acetabular components were uncemented. the primary surgeon in most cases was an arthroplasty consultant (50%, n=93), followed by an arthroplasty fellow (31%, n=57) and an arthroplasty registrar (19%, n=36). conclusion: we report a high volume of young patients, <55 years, requiring primary tha at a tertiary hospital in south africa. the main pathologies included avascular necrosis and trauma which highlights the quadruple disease burden of developing countries to contributes to an increased burden of very young patients presenting for tha. proposal and validation of a novel, descriptive classification system for hip pathology in hiv-infected patients awaiting total hip arthroplasty paper: p65 category: arthroplasty presenting author: t pillay co-authors: n sikhauli, w ndou, dr van der jagt, l mokete, jrt pietrzak background: improved life expectancy in patients with human immunodeficiency virus (hiv) results in an increased possibility of developing chronic degenerative and hiv-associated joint disease. no descriptive classification system exists to describe hip pathology in hiv positive patients awaiting total hip arthroplasty (tha). the aim of this paper was to evaluate the gross radiological hip pathology in patients awaiting tha. secondarily, the authors aimed to propose and validate a descriptive hip-specific radiological classification system for hiv-associated hip pathology. methods: we retrospectively reviewed pelvic radiographs of 75 consecutive hiv-infected patients and 119 hips with hip pathology necessitating tha consultation in a single at an arthroplasty unit between page 6 sa orthop j 2019;18(3) january 2015 and july 2018. each hip was classified as type 1 if avascular necrosis (avn) of the femoral head was evident; type 2 if the pathology was unrelated to hiv (osteodegenerative or inflammatory arthritic changes) and type 3 if a neck of femur (nof) fracture was present. type 1 hips were subclassified according to the acetabular reaction and subsequent position of the centre of rotation (cor) of the necrotic femoral head. subsequently, type 1a had normally contained femoral heads, type 1b had proximal erosion of the acetabulum, type 1c had proximo-lateral migration of the cor and type 1d had medial migration of the cor and acetabuli protrusio. interand intra-observer reliability was evaluated by 6 independent reviewers with at least 2 years orthopaedic surgery experience. results: seventy-nine hips (67%) were type 1. the majority, 33 patients (44.6%), were type 1a (well contained) while 12 (16.2%) showed proximal migration and superior acetabular erosion (type 1b) and 19 (25.7%) had acetabuli protrusion (type 1d). there were 33 (27.7%) who were type 2 with 21 with tonnis 2 oa and 6 with radiological inflammatory arthritis. there were 12 (10.1%) with nof fracture (type 3) of which 5 (41.7%) had coxa vara. there was both excellent interand intra-observer reliability (kappa-value 0.95) for the proposed classification. conclusion: we propose and validate a descriptive classification system for hivassociated hip pathology in patients awaiting tha. avn is present in the majority of cases. severe windswept deformity in patients undergoing total knee arthroplasty: what came first, the valgus or varus? paper: p89 category: arthroplasty presenting author: w ndou co-authors: l mokete, pn ntombela, n sikhauli, jrt pietrzak, d van der jagt background: total knee arthroplasty is a successful operation, which provides pain relief, improves knee function and restores quality of life. bilateral involvement of the knees with degenerative arthritis is common with either symmetrical varus or valgus deformity in both knees. the windswept deformity is a curious and uncommon presentation with unique challenges in restoring limb alignment. there is a paucity of information on the reasons behind this asymmetry. aim: to determine which deformity became symptomatic first in patients with a windswept deformity presenting for total knee arthroplasty. methods: data was collected prospectively over a period of 3 years (july 2016–december 2018). demographic data including age, sex, bmi as well as childhood history of skeletal dysplasias, inflammatory disease and metabolic bone disease were documented. patients were questioned during history taking as to which knee became symptomatic first. all data was captured using excel. results: a total of 10 patients (8 females, 2 males) were identified. none of the patients had a history of childhood dysplasias or metabolic bone disease. one patient had rheumatoid arthritis on disease modifying agents. the varus deformity averaged 23 degrees (range 10–30) and valgus deformity averaged 30 degrees (range 10–30). two patients with the severest valgus deformities required total knee arthroplasty using hinged prosthesis. six out of ten patients reported that the valgus knee became symptomatic first. conclusion: total knee arthroplasty in patients with severe deformities remains a challenge and the patient’s symptoms usually guide the side to be corrected first. our small case series showed that 60% of our patients were more symptomatic in the valgus knee. a larger case series is required to conclusively answer the study question. short-term outcomes of cementing a dual mobility cup into a high friction uncemented acetabular cup in revision hip arthroplasty surgery paper: p76 category: arthroplasty presenting author: d van der jagt co-authors: a sekeitto, ajl du toit, kr van der jagt, k sikhauli, jrt pietrzak, s mdou, l mokete background: revision hip replacement surgery has a high complication rate with acetabular bone loss and dislocations remaining a significant challenge. high friction metal acetabular shells and dual mobility bearings have offered attractive solutions but have only been used individually and not in combination. methods: we review 19 cases of hip arthroplasty where redapt high friction acetabular cups were implanted with best bone apposition, and with less regards for orientation. a polar dual-mobility cup was then cemented into the redapt cup, achieving optimal inclination and anteversion. the femoral component was implanted using established techniques. results: at review all 19 constructs remained well sited with no loosening. there was one dislocation which was reduced closed and did not re-dislocate. one patient, which had had a previous septic clearance had a recurrence of his sepsis and needed a repeat two stage septic clearance. 17 patients required no further intervention. conclusion: we conclude that the combination of dual mobility cups cemented into modern high friction acetabular cups where there is poor acetabular bone stock is a viable solution for this challenging problem. short-term results are very encouraging. the utility of alpha–defensin test in guiding second stage revision in patients with inflammatory arthritis paper: p90 category: arthroplasty presenting author: n sikhauli co-authors: l mokete, jrt pietrzak, w ndou, d van der jagt background: periprosthetic joint infection continues to be a major complication of total joint arthroplasty with devastating consequences and can lead to limb loss or loss of life. alpha-defensin test has a high accuracy in diagnosing periprosthetic joint infection however there are no studies that looks at the use of alpha-defensin test in guiding second stage revision/implantation in inflammatory arthritis patients. our hypothesis is that alpha-defensin test can be used as the ultimate test in proving the absence or presence of pji during 2nd stage implantation/revision. page 7 sa orthop j 2019;18(3) methods: retrospective review of 126 revision cases from 2015 to 2018 in a single academic centre. patients with inflammatory arthritis who underwent 1st stage revision with the use of cement spacer or use of lautenbach irrigation tubes and second stage revision where the alpha-defensin test was used were enrolled. results: total of 16 cases met the inclusion criteria, 13 knees and 3 hips. rheumatoid arthritis 11, systemic lupus erthromatosus 3, psoriatic arthritis 1 and gouty arthritis 1. we noted a disparity in infective markers (esr & crp) in all the cases. four cases underwent repeat first stage revision (exchange of spacers) due to high persistent of esr and crp. positive cultures were identified in five cases during first stage revision. the average wait from 1st stage to 2nd stage revision was 19 weeks (8–36). fifteen cases had a successful 2nd stage revision after negative alpha-defensin test with no readmission at 6 months, one case of gouty arthritis still has a cement spacer to date after undergoing two repeat 1st stage and a positive alpha-defensin test. conclusion: we conclude that the alpha-defensin test can be used safely and reliable as a confirmation for infection eradication in patients with inflammatory arthritis and polarising infective blood results at an average of 19 weeks following 1st stage revision. there is a need to establish the threshold duration at which the test can be safely and reliably used to guide the second stage revision. what they say vs what they do: assessing physical recovery after total knee arthroplasty comparing wearable motion sensors and self-reported proms paper: p63 category: arthroplasty presenting author: m van heukelum co-authors: s bolink, b grimm background: following primary total knee arthroplasty (tka), patients experience pain relief and report improved physical function and activity. however, there is paucity of evidence that patients are truly more active following tka. the primary aim of this study was to prospectively measure physical activity with a wearable motion sensor before and after tka and compare the data to patientreported levels of physical activity before and after tka, gathered using previously validated proms. a second aim was to investigate whether differences in physical activity after tka are related to levels of physical function. methods: twenty-two patients undergoing primary tka were measured preoperatively and 1–3 years postoperatively. patient-reported outcome measures (proms) included koos-ps (physical function) and squash (activity). physical activity was assessed during 4 consecutive days wearing an accelerometer-based activity monitor (am) at the thigh. data was analysed using algorithms in matlab. am-derived parameters included walking time (s), sitting time (s), standing time (s), sit-to-stand transfers, step count, walking bouts and walking cadence (steps/min). objective physical function was assessed by motion analysis of gait, sit-to-stand (sts) transfers and block step-up (bs) transfers using a single inertial measurement unit (imu) worn at the pelvis. imu-based motion analysis was only performed post-operatively. results: proms demonstrated significant improvement of perceived physical function (koos-ps=68±21 vs. 34±26; p<0.001) and physical activity (squash=2584±1945 vs. 3038±2228; p<0.001) following tka. am-based parameters of physical activity demonstrated no significant differences between preand postoperative quantitative outcomes. only walking cadence improved (81.41±10.86 (steps/ min) vs. 94.24±7.20 resp.; p<0.001). there was moderate correlation between self-reported levels of physical activity and objectively assessed levels of physical activity after tka (pearson’s r=0.36–0.43; p<0.05). outcomes of physical activity after tka were moderately correlated to imu-based outcome measures of gait, sts-transfers and bs-transfers (pearson’s r=0.31–0.48; p<0.05). conclusion: post tka, patient-reported and objective physical performance tests show improved function. however, the self-perceived higher activity level is not supported by objective measure. this may have implications for general health, rehabilitation and patient communication and expectations. foot and ankle papers: mediumto long-term results of the hintegra total ankle arthroplasty: a south african perspective paper: p23 category: foot and ankle presenting author: m khademi co-authors: np saragas, pnf ferrao background: total ankle arthroplasty (taa) is an accepted treatment option for ankle arthritis. this procedure is increasingly being performed of late, as the implant design has improved biomechanically with good outcomes. most reports on survivorship and complications are published by the designers. to our knowledge, this is the first study reporting on the shortto medium-term results of the hintegra mobile bearing taa to come out of africa. methods: all patients between 2007 and 2014 who had a hintegra taa were retrospectively reviewed. a total of 93 taa were performed using the hintegra prosthesis by a single surgeon. eight patients passed away prior to the review and 16 patients were untraceable. we included a total of 69 patients (69 ankles) in this study. all 69 patients were available for clinical and radiological examination as well as for completion of a visual analogue scale (vas) for pain, the american orthopaedic foot and ankle society (aofas) score and the self-evaluation foot and ankle score (sefas). results: mean follow-up was 60 months. mean vas score was 2, sefas was 47 and aofas was 87.28 at recent follow-up. eight patients had periprosthetic osteolysis of which five patients had revision surgery with bone grafting of the cysts. we detected polyethylene particles and calcification particles in specimens taken from osteolytic cysts page 8 sa orthop j 2019;18(3) by using various stain techniques. eight patients were converted to ankle arthrodesis. conclusion: the hintegra mobile-bearing total ankle arthroplasty had an 85.5% implant survival in the short to midterm. the ankle range of motion however did not improve from the preoperative range. this study demonstrated that taa is a valid option to maintain the hindfoot function. by using polarised microscopy, we have detected polyethylene particles in specimens taken from osteolytic cysts, which could be one of the causative factors. we also believe that the hydroxy apatite coating also plays a role in the pathogenesis of periprosthetic osteolysis of taa. reliability of the intra-operative radiographic visual assessment of the hallux interphalangeal angle after correction of hallux valgus deformity paper: p25 category: foot and ankle presenting author: m khademi co-authors: np saragas, pnf ferrao background: hallux valgus interphalangeus (hvi) contributes significantly in the total hallux valgus (hv) and should be corrected surgically in conjunction with the hv correction. akin osteotomy has been accepted as the standard osteotomy for correction of the hvi. the magnitude of the hvi dictates to the surgeon the size of the wedge to be resected when doing the akin osteotomy. visual estimate of the hvi angle intraoperatively is the most feasible and practical way to decide on the hvi correction. the purpose of this study was to evaluate the reliability and reproducibility of visual estimation of the hvi angle compared with direct measurement. methods: a total of 50 cases of hv were included in the study. two foot and ankle surgeons involved in the surgery estimated the hvi on the c-arm intraoperatively after correcting the hv by various types of osteotomies. the foot and ankle fellow measured the pre-akin hvi angle and once the akin osteotomy was completed on the x-ray. results: there was strong agreement between the two observers on the measurement (p<0.001) as well as between both observers and the exact measurement (p<0.001). conclusion: the interobserver reliability of radiographic visual assessment of the hvi is 78%. general papers: a comparison of hip revision arthroplasty surgery in the private and public sectors paper: p80 category: general presenting author: d van der jagt co-authors: a sekeitto, ajl du toit, kr van der jagt, k sikhauli, jrt pietrzak, s mdou, l mokete background: public and private sector patients are differentiated mainly on the basis of economic criteria. we initiated this study to determine if this influenced the revision profile in these patient groups. methods: we reviewed the clinical records of the last 50 revision hip arthroplasties performed in a large private practice and those performed in an arthroplasty dedicated academic unit in the public sector. we compared our findings to determine differences as well as similarities in these two groups of patients. the patient demographics were similar in the two groups of patients in respect of age, time to revision and sex. results: there was a similar rate of previous revisions in both groups of patients. the majority of patients revised in the public sector were for sepsis, periprosthetic fractures and occasional bearing wear sequelae with sepsis predominating. those in the private sector were revised for sepsis and prosthetic wear sequelae with nearly equal proportions. similar implants from the same cohort of suppliers were used in both groups of patients. sepsis is an equal problem in the public and private sector patients. conclusion: there was some shift in the revision load from the private to the public sector with some public sector patients having received their primary prosthesis in the private sector. conclusions from this study may be important when nhi is implemented. a comparison of knee revision arthroplasty surgery in the private and public sectors paper: p81 category: general presenting author: d van der jagt co-authors: a sekeitto, ajl du toit, kr van der jagt, k sikhauli, jrt pietrzak, s mdou, l mokete background: public and private sector patients are differentiated mainly on the basis of economic criteria. we initiated this study to determine if this influenced the revision profile in these patient groups. methods: we reviewed the clinical records of the last 50 revision knee arthroplasties performed in a large private practice and those performed in an arthroplasty dedicated academic unit in the public sector. we compared our findings to determine differences as well as similarities in these two groups of patients. the patient demographics were similar in the two groups of patients in respect of age, time to revision and sex. results: the majority of patients revised in the public sector were for sepsis and for periprosthetic fractures. those in the private sector were revised for instability, sepsis, prosthetic wear and for disease progression of degenerative changes in knees with unicompartment replacements. similar implants from the same cohort of suppliers were used in both groups of patients. no patients in either group had their primary prosthesis done in the other sector. conclusion: we conclude that patients in the private sector are less tolerant of instability issues, and this may be because they ‘pay’ for their procedure. instability issues in public patients are relatively unimportant because of the patient load. sepsis continues to be a revision burden in both groups of patients. there is no shift in the revision load from the private to the public sector. conclusions from this study may be important when nhi is implemented. page 9 sa orthop j 2019;18(3) bioactive glass as dead-space management following debridement of type 3 chronic osteomyelitis paper: p60 category: general presenting author: wt oosthuysen co-authors: n ferreira, r venter, y tanwar background: chronic osteomyelitis is a challenging condition to treat and although no exact treatment guidelines exist, the surgical management strategy includes wide resection of necrotic and infected bone followed by dead space management. this study evaluates the use of bioactive glass as a single stage procedure for dead space management following surgical debridement. methods: a consecutive series of 24 patients with cierny mader type 3 osteomyelitis, treated between march 2016 and june 2018, were identified and evaluated retrospectively. patients were managed with bioactive glass as dead space management following surgical debridement. results: of the patients who completed more than 12 months follow-up, all fourteen (100%) showed complete resolution of symptoms. of the remaining ten patients with less than 12 months follow-up, eight had complete resolution of symptoms resulting in a preliminary result of 22 out of 24 (91.65) having resolution of symptoms following debridement and dead space management with bioactive glass. one patient experienced a complication related to the use of bioactive glass. this manifested as prolonged serous wound drainage that resolved with local wound care. conclusion: the use of bioactive glass appears to be effective for dead space management following debridement of anatomical type 3 chronic osteomyelitis of the appendicular skeleton. completing an saoa endorsed hip and knee arthroplasty fellowship: review of the journey paper: p143 category: general presenting author: j charilaou co-authors: jd jordaan, m burger background: fellowships aim to equip an orthopaedic surgeon to excel in a subspecialty field. this encompasses surgical proficiency, patient management and decision making, exposure to a variety of pathologies and evaluation of implants, technology and innovation options. there is a strong academic component with research and teaching as cornerstones. this is all done in a supervised and structured environment in compliance with ethical and legal requirements. this report aims to highlight the processes and identify the outcomes achieved after completing a hip and knee arthroplasty fellowship of one year at a tertiary hospital in south africa. methods: descriptive analysis of clinical and academic outputs from july 2018–june 2019. this fellowship entailed public-private sector collaboration. it is primarily based at an academic hospital with weekly observerships to three private practice surgeons. results: surgical outcomes achieved during the first 9 months: involved in 295 arthroplasties with 92 primary procedures as the lead surgeon (hip=71, knee=21) as well as three revisions (hip=2, knee=1). a wide spectrum of complex hip and knee pathology was managed. assisted in 200 arthroplasties (state=109, private=91). research: presented at 2018 saoa congress. collaborating in multiple ongoing and long-term projects within the unit. mentorship: continuous interaction and mentorship on a variety of personal and professional aspects complemented the time spent within the system. teaching: involved in pre-graduate and registrar educational programmes and academic forums. being taught, but also acquiring the skill of also teaching others. learning: attendance of 12 local courses encompassing the whole spectrum of arthroplasty attendance of two international courses and visitations in switzerland and ireland. conclusion: the value of a well-structured and transparent fellowship programme is crucial to optimise time allocation and maximise skill development and maintain credibility. the public-private partnership and exposure further adds weight and broadens the scope of practice to achieve pre-set goals. local fellowships can compete with international peers and provide a crucial platform to continually improve the fraternity. description of a new open surgical technique for repair of chronic full thickness abductor muscle tears and evaluation of the mid-term results paper: p124 category: general presenting author: jrt pietrzak co-authors: k nortje, jn cakic background: tears of the abductor tendon complex, including the gluteus medius and gluteus minimus, are a distinct source of lateral hip pain and dysfunction. in general, these are recalcitrant to non-operative treatment measures. optimal surgical technique and management remains controversial. methods: we conducted a retrospective review of the mid-term outcomes of a single surgeon series of chronic full-thickness gluteus medius and gluteus minimus open surgical repair. all patients underwent mri scans to confirm the presence and size of complete tears. all patients failed a minimum of 3 months non-operative treatment. we describe this novel surgical repair technique which includes excision of bursa, diamond-shaped release of the ilio-tibial band (itb), microfracture of the greater trochanteric abductor footprint, quadrant-shaped suture anchor repair of gluteus minimus and speed bridge fixation and compression of gluteus medius over gluteus minimus. platelet-rich plasma augmentation is injected post repair before closure of itb. all patients were managed for 6 weeks in abductor-brace. previous greater trochanter prp and corticosteroid injections were noted. no patients had had previous ipsilateral total hip arthroplasty (tha). results: the study included 18 patients (14 females, 4 males) with a mean follow-up of 13.72 months (range 12.1–23.34 months). the average age of patients was 46.2 years (37–67 years) and page 10 sa orthop j 2019;18(3) 8 (44.4%) had lower back pathology. the overall patient satisfaction rate was 83.33% (n=15). vas pain scores improved from 7.92 (6.2–10) to 3.54 (2.3–7.2). the patient reported outcomes were measured according to the mhhs, hos-adl and ihot-33. the mean improvements from baseline to post-operative follow-up were 48.63 (range 32.80–82.70) – 78.57 (range 45.30–93.70) for mhhs, 63.93 (range 25.49–100.00) – 82.14 (range 48.53–100.00) for hos-adl and 38.85 (range 12.45–71.96) –78.23 (range 25.29– 93.80) for ihot-33. all four dissatisfied patients had received >1 prp and corticosteroid injection within 6 months of surgical repair. there were two (11%) patients who complicated with small wound dehiscence. conclusion: we present an open surgical technique for repair of chronic, recalcitrant full thickness abductor tears. at a minimum of 1-year follow-up this surgical approach yields both good functional results and satisfaction rates. direct anterior hip approach: a descriptive analysis of its implementation at a tertiary academic hospital paper: p142 category: general presenting author: j charilaou co-authors: jd jordaan, m burger background: the direct anterior approach (daa) to hip arthroplasty has gained popularity in south africa as a main and in some centres the preferred approach. however, few academic institutions teach and transfer this skill set to post graduate trainees. the steep learning curve of between 50 and 100 cases and the associated complications of this technique are well documented. the aim of this study was to analyse the introduction and routine use of the daa in a tertiary academic institution. methods: a retrospective review of all daa arthroplasties performed during a 16-month period (january 2018 to april 2019) was performed. primary surgeons were subdivided into consultant, fellow and registrar categories. results: a total of 220 patients were included. a female predominance of 62.4% was observed. eighty per cent (n=176) of surgical indications were due to neck of femur fractures. cemented stems were utilised in 19.6% (n=43) of cases. total hip arthroplasties were done in 63.2% (n=139) and hemiarthroplasties in 35.5% (n=78) of cases. lead surgeon roles per category: consultants 20.5% (n=45), fellows 40.9% (n=90) and registrars 38.6% (n=85). conclusion: the daa for hip arthroplasty can be implemented at a postgraduate level for trainees to sufficiently overcome the associated learning curve and limit complications. consultants have a longer learning curve despite being experienced and high-volume surgeons. fellows have a shorter learning curve due to the protected and supervised environment. registrars can become proficient in daa during a three-month arthroplasty rotation. epidemiological data from a high-volume arthroplasty unit in south africa: a five-year retrospective review paper: p84 category: general presenting author: v singh co-authors: c frey, rdv greeff background: limited data is available regarding the epidemiology of primary and revision hip and knee arthroplasty cases done in the state sector in south africa. as a result, we rely on international data to guide us. we suspect that international data may underestimate the spectrum of joint disease related to communicable diseases such as hiv and tuberculosis in south africa. furthermore, we suspect that our population group tends to present with more advanced joint disease, due to contrasting referral systems and healthseeking behaviour. by analysing the epidemiology of cases at our institution, we aim to better define the local diseases spectrum with regard to diagnosis and severity of disease. methods: a retrospective review of all patients operated in our arthroplasty unit between 1 january 2013 and 31 december 2018 were conducted. epidemiological data pertaining to patient demographics, diagnosis, stage of disease, asa grading and comorbidities were recorded and analysed. results: included in the review were 2 413 patients who were operated in our arthroplasty unit over the 5-year period. primary total knee arthroplasties accounted for 55.6% of cases while revision total knee arthroplasties accounted for 2.2% of cases. primary total hip arthroplasties accounted for 38.7% of cases while revision total hip arthroplasties accounted for 3.5% of cases. the majority of osteoarthritic knees presented with advanced degenerative disease (kellgren & lawrence grade 4), while most arthritic hips were graded as tonnis grade 3. conclusion: data from this review reflects that the majority of patients with degenerative disease present with advanced disease, while also having multiple comorbidities. this not only increases the difficulty of performing the joint replacement, but also carries a higher anaesthetic risk. we need to take cognisance of this fact when planning these patients for surgery. furthermore, more complex surgeries result in longer operating times and a higher cost per patient. evaluating knee arthroscopy skills in orthopaedic trainees paper: p68 category: general presenting author: k berry co-authors: j klopper, m held background: the emphasis on orthopaedic trauma in south africa might overshadow arthroscopic training. traditionally, the surgical competency of registrars has been assessed by an attending educator’s observations in the operating room, subjective endof-rotation evaluations, and case logs. we aimed to quantify the surgical competency of our registrars more specifically to their arthroscopy skills in a simulated setting. page 11 sa orthop j 2019;18(3) methods: a prospective observational cohort study was performed to assess the basic knee arthroscopic skills of orthopaedic trainees. participants were assessed using the modified basic arthroscopic knee skill scoring system (mbaksss) while performing a diagnostic arthroscopy on an artificial simulation knee on two separate assessments. they were assessed before and one month after a cadaver workshop. the mbaksss scores was documented along with the time needed for the task. results: twelve registrars (four in each of their second, third and fourth years of training) were assessed using the mbakass. participants with previous arthroscopy experience had higher mbakass (correlation coefficient 0.56). although there was a trend of more senior registrars having higher scores, this was not significant. there was no improvement of scores after a cadaver workshop. conclusion: registrars with more arthroscopy experience scored higher. a cadaver workshop had no impact on the skills of registrars over the period of the study. our registrar training might not lead to improved scores for senior registrars compared to their juniors. genicular nerve radiofrequency ablation in patients with end-stage knee osteoarthritis awaiting total knee replacement paper: p93 category: general presenting author: a minnis co-authors: s magobotha, a minnis background: chronic knee pain secondary to osteoarthritis (oa) is a common condition that is known to have a significant impact on both the quality of life and the degree of disability in any given population. many of these patients with kellgren-lawrence grade iv oa and severe intractable pain opt for a total knee replacement (tkr) for pain relief and restoration of function. the increased prevalence of knee osteoarthritis has resulted in increases in the number of patients and the length of time patients wait prior to receive a tkr. as a result of the larger waiting list, there is also increased and or prolonged use of nsaids and opioid medication along with which is an increased risk of associated adverse drug events. genicular nerve radiofrequency ablation (gnrfa) can be used in this patient population to reduce the pain levels, use of chronic medication and associated risk of adverse events. hypothesis: rfgna is an effective treatment alternative for reducing pain and improving function in patients waiting for tkr at a level 3 hospital. methods: a prospective study of series of consecutive patients awaiting total knee replacement from the arthroplasty clinic with radiological evidence of kellgren-lawrence grade iii/iv osteoarthritis, moderate to severe pain measured on the visual analogue scale (vas), and failed medical therapy will be eligible for gnrfa. any patient not meeting the inclusion criteria or patients with a seronegative/positive arthropathy, cognitive, psychiatric, bleeding disorder or those with previous gnrfa therapy are not eligible for participation. data collection will be conducted at various time periods preand postoperatively using a validated vas, western ontario and mcmaster university osteoarthritis index (womac) scores. appropriate statistical analysis of the differences will be undertaken. results: this cohort of patients have responded positively to gnrfa treatment and have reported significantly statistically lower pain scores using the vas. conclusion: genicular nerve radiofrequency ablation therapy is an effective treatment for patients with end-stage knee osteoarthritis awaiting tkr. rfgna can be used as definitive therapy in pain management in patients with end-stage knee osteoarthritis. hemiarthroplasty vs total hip arthroplasty in the management of neck of femur fractures: a comparison paper: p112 category: general presenting author: w mukiibi co-authors: j pietrzak, r netshamutsindo, w ndou, d van der jagt, k sikhauli, s van deventer, l mokete background: neck of femur (nof) fractures were once called ‘the unsolved fracture’ and optimal management remains controversial today. the outcomes of surgical treatment, hemiarthroplasty (ha) and total hip arthroplasty (tha), are still debatable and as the demand continues to grow, evaluation and quality improvement remains essential. in the absence of a standardised protocol we therefore sought to compare the outcomes of ha and tha for nof fractures in a single urban academic institution. methods: we conducted a retrospective chart review of all patients presenting with isolated intracapsular nof fractures to our institution from january 2016 to april 2019. the decision regarding ha or tha was based upon the sernbo score, age and pre-morbid level of activity. hospital efficiency including time to theatre, cancellations, reasons for cancellations, postoperative high care area stay and time to discharge were evaluated. peri-operative complications, short-term outcomes and mortality rates were determined for both ha and tha. results: there were 92 consecutive patients with nof fractures who underwent 48 tha and 44 ha between january 2016 and april 2019. the average sernbo score for tha was 18.9 (11–20) and ha was 14.1 (8–20). the time taken from admission to theatre was 6.4 days (1–22) and 7.6 days (2–31) for ha and tha respectively. the average number of times a tha and ha was cancelled was 1.4 (0–3) and 1.2 (0–2) times respectively. the most common reason was lack of post-operative high-care bed availability (15%). the peri-operative complication rate for tha was 6% and ha was 25% respectively. the 30-day mortality rate for tha and ha was 2.17% (n=1) and 2.32% (n=1) respectively. the preoperative mortality rate for ha was 18% (8). the 30-day readmission rate for tha and ha was 2.08% (n=1) and 6.98% (n=3). conclusion: a prolonged delay to surgery and significant cancellation rate of patients awaiting ha plays a role in the increased pre-operative mortality rate. mortality rate and readmission rate in tha was not linked to delayed surgical intervention. page 12 sa orthop j 2019;18(3) local bone antibiotic delivery using porous alumina ceramic: clinical and pharmacological experience paper: p15 category: general presenting author: e denes co-authors: f fiorenza, e toullec, f bertin, s el balkhi background: local concentration of antibiotic at the site of infection is a major parameter for its efficiency. however, bone diffusion is poor leading either to their non-use (ex: gentamicin) or the use of high concentration (ex: vancomycin). local administration could optimise their local concentration combined with lower side effects. we report the clinical experience and pharmacological results of an antibiotic-loaded porous alumina used to replace infected bone in four patients. methods: two patients had a destroyed sternum following mediastinitis; one presented a femoral chronic osteomyelitis due to mrsa and one had an infected ankle arthroplasty. the ceramic was loaded with gentamicin in three cases and vancomycin for the ankle infection. local dosages were performed thanks to redon’s drain. in parallel blood samples were done. loading was performed to protect the device while implanted in an infected area and was combined with conventional antibiotic therapy. results: in comparison to pharmacological parameters: cmax/mic>8 for gentamicin or auc/mic>400 for vancomycin, local concentrations were dramatically higher than the one needed (i.e. >50 folds) immediately after implantation and for at least 24 hours for the longer follow-up. vancomycin concentration was still high after h48. meanwhile, blood samples did not find the presence of gentamicin during the 48 hours following implantation. after more than one year of follow-up for all the patients, there is no relapse of infection or signs of device infection, whereas all samples perform during implantations grew with bacteria, meaning that loaded antibiotic played a major role avoiding device colonisation in combination with surgical debridement and cleaning. conclusion: this mode of administration allows an optimisation of the antibiotic delivery, maximising local concentrations while reducing systemic toxicity. in addition, ceramic mechanical characteristics allow bone replacement (strength >3 times the one of the cancellous bone and osseointegration) and thus enables one-stage surgery instead of two-stage like for the patient with chronic osteomyelitis thanks to a good primary stability. orthopaedic syllabus for undergraduate medical students in southern africa: a consensus from local and international experts paper: p45 category: general presenting author: m held co-authors: m laubscher, s graham, n kruger, p njisane, v njisane, r dunn background: most patients with orthopaedic pathology in south africa are treated by non-specialists. a curriculum to prepare undergraduate medical students for this should reflect the local pathology and offer feasible solutions. the aim of this study was to establish and prioritise an orthopaedic syllabus consisting of knowledge, clinical cases, and skills relevant to medical students in south africa. methods: a modified delphi consensus study was conducted, in the form of three interactive iterative rounds of communication and the prioritisation of items by experts from africa, europe and north america. for this, preferred priorities were selected but were limited to 50% of possible items. percentage agreement of more than 75% was defined as consensus on each of these items. results: most of the 43 experts who participated were orthopaedic surgeons from seven different countries in southern africa, but 30% were general practitioners from southern africa or international educational experts. experts prioritised cases like a multiple injured patient, a limping child and orthopaedic emergencies. the manipulation and immobilisation of dislocations and fractures were prioritised skills. the most important knowledge topics included orthopaedic infections, the treatment of common fractures and dislocations, red flags alerting to specialist referral, as well as backpain. surgical skills for the treatment of urgent care conditions were included by some experts who saw a specific need in their clinical practice but were ranked lower. conclusion: a wide geographic, academic, and expertise-specific footprint of experts informed this international syllabus through their various clinical and academic circumstances. knowledge, skills and cases in orthopaedic trauma and infections were prioritised with the highest percentage agreement. acute primary care for fractures and dislocations ranked high. furthermore, the diagnosis and treatment of conditions not requiring specialist referral were prioritised. this syllabus can inform national curricula, not just in southern africa, and assist in the allocation of student contact times. performing hip arthroplasty on the ‘forbidden’ patients paper: p138 category: general presenting author: jd jordaan co-authors: j charilaou, m burger background: traditional contraindications for total hip arthroplasty (tha) included: acute and chronic infection, neuropathic joint, severe paralysis or spasticity of lower limb muscles and uncompliant and or psychotic patients. significant heterogenicity exists between dislocation risk between traditional antero-lateral, posterior and direct anterior approaches to the hip joint. the reduction in dislocation rates after direct anterior hip surgery is well documented and this allowed us to offer tha in previous high-risk patients. the aim of this study was to describe the ‘forbidden’ patient population undergoing tha at a tertiary hospital in south africa. methods: a retrospective review of all primary direct anterior tha performed in traditionally high-risk patients that were performed from 2017 to 2018 in a single tertiary academic hospital in south africa was conducted. patients with proven lower limb spasticity, mental retardation and acute uncontrolled psychosis were included and basic demographic and clinical information was collected. page 13 sa orthop j 2019;18(3) results: six patients (eight tha) were included. bilateral staged tha was done for a quadriplegic cerebral palsy patient while bilateral single stage tha was performed in an acutely psychotic patient with old neck of femur fractures. single tha done for three severe mental retardation patients. finally, a single tha was performed for an acute uncontrolled psychotic patient. all operations were performed without any major intra-operative complications. time to discharge was at a mean of seven days post-surgery. one patient presented with a significant complication which resulted in excision arthroplasty. conclusion: successful tha could be performed via the direct anterior approach on patients that traditionally were excluded from hip replacement surgery. tha can potentially significantly improve the quality of life in these patients and future research should further investigate this vulnerable population. rating of arthroplasty implants: what orthopaedic surgeons need to know paper: p85 category: general presenting author: v singh background: orthopaedic surgeons today are faced with a wide range of hip and knee prostheses to choose from. as these various brands flood the market, one needs to be aware that they differ in terms of design as well as material used. even in cases where the design and alloy are a carbon copy of a proven implant, the track record of the individual implant is what ultimately dictates its rating. the food and drug administration in the usa approves implants for use in patients but does not make any statement regarding the track record of the implant. for this, we rely on implant rating systems. the most widely used of these is the odep (orthopaedic data evaluation panel) rating. methods: we looked at the details behind the odep rating, including how the system was developed and what the rating implies. we have compiled a simplified diagram of the rating as well as listed the current ratings of the most widely used hip and knee implants in south africa. results: we show that despite certain implants copying the design of well-known implants whose patent has expired, they require their own odep rating. the odep rating can only be escalated as the duration of use of the implant increases. newer implants should ideally maintain an a-grade within their year group. the most widely used hip and knee prostheses in south africa tend to have excellent ratings. conclusion: data from this investigation reflects that the odep rating of prostheses is increasing in importance as more and more implants are brought into the market. surgeons should be familiar with the rating system and take note of the rating before implanting the prosthesis into a patient. furthermore, companies marketing newer implants should strive to have their implant rated according to the odep system in order for us to have a common standard when choosing a prosthesis. short to medium results of custom 3d-printed pelvic implants paper: p28 category: general presenting author: a olivier co-author: g vicatos background: the use of custom designed pelvic implants has increasingly gained popularity in recent years. drawbacks of these implants include the time to design and manufacture. with major advances in additive manufacturing (am), custom implants can therefore be anatomically designed to assist in complex surgery of the bony pelvis in both orthopaedic oncology and orthopaedic reconstruction surgery. methods: this series includes three patients who had major pelvic bone loss after initially presenting with infection after previous total hip arthroplasty. the extent of the bone loss in the pelvis was severe and therefore impossible to be reconstructed by conventional ‘offthe-shelf’ implants. the patients’ pelvis was scanned producing a 3d virtual model of the entire pelvic girdle. to ensure symmetry, the unaffected opposite hemi-pelvis was mirrored, and the level and size of the acetabulum was ascertained. the implant was designed considering the remaining bony structures of the hemi-pelvis, to provide an anatomical, secured support for the reconstructed hip joint. reconstruction of the pelvis was performed together with a cemented (bipolar bearing) acetabular cup. in two of the three cases, a proximal femoral replacement was also necessary to compensate for bony defects. results: pre-operatively, two of the three patients had extremely poor function due to previous girdlestone procedures and were limited to using walking aids or confined to a wheelchair. post-reconstruction all patients were ambulant without walking aids, leg lengths were restored and had minimal pain. all three patients were infectionfree. conclusion: custom implants offer reconstruction solutions to surgeons dealing with complex and challenging cases with massive and complex bone loss of the pelvis. the modern technology combining mri and ct imaging with am, enables the rapid design and manufacturing of custom patient specific implants. average time for design and manufacturing is around two weeks. all patients in this study managed with this novel treatment option, proved to have a stable pelvic reconstruction with restoration of leg lengths, improvement of strength and independent ambulation at shortand mediumterm follow-up. south african perspective of collaborations for global surgery in africa paper: p49 category: general presenting author: s de villiers co-authors: k sewchurran, r dunn, g fieggen, b biccard, r duys, k chu, m held background: the academic field of global surgery has emerged from the drive to improve equitable access to high quality surgical care worldwide and while historically high income country (hic) institutions and individuals have determined the global surgery agenda, most page 14 sa orthop j 2019;18(3) beneficiaries live in low to middle income countries (lmics). recent voices however have demanded more equitable collaborative frameworks between hic and african partners. the aim of this research was to understand the south african perspective of global surgery by interviewing key stakeholders, including orthopaedic surgeons. methods: this was a qualitative study conducted through focus group interviews and informal discussion with key stakeholders in african global surgery. data in the form of propositions, observations and statements were collected in the interviews and analysed through codes, themes and dimensions. results: given the immense variation across our continent, we advocate for an africa-centred identity for african surgery. surgery in south africa must be intrinsically rooted within the country and continent to allow collaborations with international partners to be equitable and ultimately lead to transformation, empowerment, and local buy-in. major funding is often controlled by hic groups outside of africa, overshadowing local priorities. equitable collaborations which include a participatory and emancipatory strategy practice among african (and non-african) stakeholders will seek to define a local agenda to be evaluated locally and through national surgical, anaesthesia and obstetric plans. besides surgeons, anaesthetists and obstetricians, non-specialists are core stakeholders. a shortfall in the number of specialists means that most surgical care in south africa is provided by non-specialists at first and secondlevel hospitals. therefore, the south african global surgery agenda setting must include the entire non-specialist workforce providing surgical care. these frontline providers can contribute to global surgery efforts by identifying the barriers to improved surgical access. research must therefore aim to find solutions for adequate training, mentorship and retention leading to an effective and safe task-sharing surgical system. conclusion: south african surgery should be driven by a local agenda involving all relevant stakeholders to foster research and build clinical capacity within the continent. international collaboration has great impact when it aligns with this agenda. gt du toit – registrar research papers: antegrade flexible intramedullary nailing through the greater trochanter in paediatric femur shaft fractures paper: gt p44/p129 category: gt du toit – registrar research (paediatrics) presenting author: rc rosin co-authors: mn rasool, w sibanda, pd rollinson, d simmons aims: to determine whether an antegrade approach, through the tip of the greater trochanter, in femoral shaft fractures in children, is safe, achieves adequate union and results in significant proximal femoral growth complications. methods: the case records and radiographs of 23 paediatric patients aged 7 to 12 years with femur shaft fractures managed with stainless steel antegrade flexible nailing were reviewed retrospectively. preoperative radiographs were reviewed for fracture pattern, level and comminution. post-operative radiographs were reviewed to assess for union, alignment, osteonecrosis of the femoral head and epiphysiodesis of the greater trochanter. morphological changes of the proximal femur were assessed by comparing the neck shaft angle and articulo-trochanteric distance with the opposite hip. case records were reviewed for post-operative complications, patient reported complaints and leg length discrepancy. clinical outcomes were assessed with the criteria established by flynn. results: all patients achieved union, and none had evidence of osteonecrosis of the femoral head on follow-up. three patients had malalignment and two patients had radiographic evidence of greater trochanteric epiphysiodesis. two patients had morphological changes of the proximal femur, with one having an increased neck shaft angle and one an increased articulo-trochanteric distance. one patient had a leg length discrepancy of 2 cm. fifteen patients had excellent clinical outcomes, five had satisfactory outcomes and three had poor outcomes according the criteria established by flynn. conclusion: antegrade entry through the tip of the greater trochanter does not appear to compromise the blood supply to the femoral head or increase the risk of clinically significant morphological changes to the proximal femur. all patients achieved adequate union. furthermore, antegrade insertion avoided skin problems and prominent nail complications around the knee seen with retrograde insertion. arthroscopic arthrolysis after total knee arthroplasty paper: gt p52 category: gt du toit – registrar research (knee) presenting author: y desai background: arthrofibrosis after total knee arthroplasty (tkr) is an uncommon reason for poor outcomes. primarily, the patient will have decreased range of movement. there is paucity in good evidence for the management of this complication. the aim was to review the outcomes of the patients who had arthroscopic arthrolysis in our hospital for arthrofibrosis post tkr. methods: a total of 16 patients were found to have had arthroscopic arthrolysis post tkr for arthrofibrosis. three patients were found to have subsequent dual pathologies. patients underwent a systematic arthrolysis, manipulation under anaesthesia and physical therapy thereafter. range of movement (rom) was recorded at intervals and patient overall satisfaction was noted. results: there was a mean gain in rom from pre-arthroscopic arthrolysis to final follow up of 32.1° at 20.1 months. this had a 75% satisfaction with three of the four dissatisfied patients found to have other pathologies/complications in addition to arthrofibrosis. the mean time to arthroscopy from arthroplasty was 30 months (3–132). page 15 sa orthop j 2019;18(3) conclusion: where other causes for knee loss of movement and pain have been ruled out, and arthrofibrosis is likely to be the sole cause, arthroscopic debridement is a beneficial procedure to improve rom and patient satisfaction even if performed more than one year after the arthroplasty. biomechanical comparison of two different configurations of the truelok hex and taylor spatial frame external fixators paper: gt p29/p87 category: gt du toit – registrar research (trauma) presenting author: i steyn co-authors: c kat, f birkholtz, a barnard, e hohmann aim: determine the percentage strain at a simulated fracture between two different configurations of the truelok hex (tl-hex) and taylor spatial frame (tsf) external fixators. methods: two configurations each of tl-hex and tsf were constructed using a bone substitute with a 20 mm fracture gap. they included an allwire ring block construct and a half-pin and fine wire construct, tested under axial load in a schenck universal testing machine. constructs were loaded ten times at a rate of 5 mm/minute to a total load of 750 n. fracture displacement was measured at six fixed points 120 apart with a vernier calliper (accuracy 0.01 mm). strain at the fracture was calculated in the medial–lateral, anterior– posterior, and axial planes using a mathematical model based on the gough-stewart platform. results: at 750 n load the shear strain difference between the tl-hex and tsf all-wire ring block constructs in the medial-lateral plane was 2.6% ± 1.1% vs 2.7% ± 0.9% (mean ± sd). in the anterior-posterior plane the difference was 0.2% ± 1.6% vs 1.9% ± 0.8%. axial strain difference was 43.3% ± 1.3% vs 43.3% ± 0.6%. differences did not reach significance (p>0.9; p=0.5; p>0.9 respectively). at 750 n load of the half-pin and fine wire constructs, tl-hex allowed less strain in the anterior-posterior plane than the tsf 2.1% ± 2.3% vs 5.9% ± 4.3% reaching significance (p=0.014). tsf showed lower strain rates of 52.8% ± 3.5% vs 58.3% ± 1.2% in anterior-posterior plane which was significant (p<0.001). in comparison with the all-wire constructs, the half-pin and fine wire constructs had significantly increased strain in all planes (p≤0.05). conclusion: in this experimental design, half-pin and fine wire external fixators confer significantly less stability with resultant increased strain at the fracture site. there was significantly more strain at the fracture site in all planes with the half-pin and fine wire construct in both brands. there was no statistically significant difference between the tl-hex and tsf all-wire ring block construct. can anatomical contoured plates reduce scapula body, neck and glenoid fractures? paper: gt p43/p128 category: gt du toit – registrar research (shoulder and elbow) presenting author: jj de wet co-authors: s roche, b vrettos, jp du plessis, r dey background: the aim is to ascertain the anatomical congruence and fit of an available pre-contoured scapula plating system and evaluate their fracture fixation capability. the investigators hypothesised that 3d-printed models are a valuable pre-operative tool, but the current available pre-contoured anatomical plates fail to achieve adequate fixation and reproducible results. methods: the study is an observational basic science study. twenty-two scapulae with closed fractures who underwent shoulder ct scans following blunt trauma from 2012 to 2016 were included in the study. isolated acromion and coracoid fractures were excluded. the fracture patterns were evaluated and classified according to the anatomical location of the scapula and the glenoid. the investigators templated four plates: long lateral (ll), short lateral (sl), long medial (lm) and short medial (sm) plates. nine investigators classified the fractures and templated the plates on two separate sittings, one month apart. results: a plate score according to anatomical fit was calculated for each plate. only 54.8% of the ll, 5.1% of sl, 33.8% of lm and 28.8% sm reduced the fractures. the average fixability of the fractures was found to be 49.4%. conclusion: 77% of fractures were scapula body fractures and 36% glenoid fractures. the anatomical pre-contoured plates are designed to fit the thicker, more robust medial and lateral borders in order to get adequate screw fixation across the fracture site. higher incidents of body fractures and inadequate design of the plates reduced their ability to fix scapular (sub-acromion) fractures. furthermore, the short lateral plate was unable to reduce the glenoid fractures. in order to improve the average fixability, redesigning of the plates are recommended. the investigators remain of the opinion that 3d printing is a valuable pre-operative tool. comparing outcomes between enhanced recovery after surgery and traditional protocol in total knee arthroplasty paper: gt p11/p41 category: gt du toit – registrar research (arthroplasty) presenting author: je beukes co-authors: c janse van rensburg, jh venter, rj immelman, mv ngcelwane, jn de vos background: knee replacement surgery was traditionally associated with prolonged recovery and rehabilitation programmes in hospital. enhanced recovery after surgery protocols (eras) are cost effective and does not compromise patient safety. despite this proven efficacy, eras has not been widely adopted in south african orthopaedic practices. methods: 119 patients undergoing elective total knee arthroplasty was included in the study. they were divided into two cohorts. the first were treated with the traditional protocol and included 59 patients. the eras protocol was implemented in march 2015; following this 60 consecutive patients were included in the eras group. functional outcome was assessed using the oxford knee score (oks). the 30-day readmission rate was used to assess safety of early discharge. length of stay and patient demographics were also collected to match the cohorts. page 16 sa orthop j 2019;18(3) results: the length of stay was significantly decreased in the eras group; with a mean of 2.3 days and 5.0 in the traditional group (p<0.001). two sample t test was used to compare oks and 30 -day readmission rates. the mean oks for the traditional group was 59.1 and for the eras group 58.7. the readmission rate was 5 in the traditional group and 6 in the eras group. no clinical significant difference was present with regard to oks and readmission rate. conclusion: with the implementation of eras protocols in elective total knee arthroplasty, the length of stay can be significantly reduced without compromising patient safety or functional outcome. open tibial shaft fractures: the effect of management delays on infection rates – a retrospective cohort paper: gt p7/p27 category: gt du toit – registrar research (trauma) presenting author: tr basson co-authors: n ferreira, jj du toit, mc burger background: open tibial fractures, a multifaceted and challenging clinical scenario are still laden with controversies. the timing of the different treatment strategies plays an important role in the eventual outcome of these patients. first world guidelines have strict time standards that governs the treatment of these injuries. in the developing world, these time constraints cannot always be adhered to, causing uncertain secondary sequela, outcomes and complications. the aim of this study was to investigate the effects of time delays of basic surgical principles on the risk of infection in open tibia shaft fractures within a developing world setting. methods: records were reviewed for 82 open tibia fractures in 77 patients. the time interval from arrival to antibiotic administration (<3 hours vs >3 hours), first surgical debridement (<24 hours vs >24 hours), definitive skeletal fixation (<5 days vs >5 days) and soft tissue reconstruction (<7 days vs >7 days) was measured. results: no association between infection and antibiotic administration was observed when patients were treated within or after three hours (p=0.503) or if surgical debridement was done before or after 24 hrs (p=0.211). a significant association between a skeletal fixation time of less than 5 days and reduced risk of infection was observed (p=0.006). temporary fixation had a higher association with developing infection (p<0.001). soft tissue closure within 7 days had a significantly lower risk (p<0.001) of infection compared to those who had soft tissue closure after 7 days. conclusion: time delays in the treatment of open tibial fractures has detrimental effects on rates of infection. delaying definitive skeletal fixation and soft tissue reconstruction beyond the predefined times is associated with significant increased risk for developing infection. delaying of antibiotic administration and surgical debridement beyond the prescribed times had minimal effect on infection rates. patient satisfaction following wide awake local anaesthetic no tourniquet hand surgery in a south african tertiary state hospital paper: gt p24/p70 category: gt du toit – registrar research (hands) presenting author: m de buys co-authors: a aden, m tsama background: wide awake local anaesthetic no tourniquet (walant) hand surgery is a rapidly growing technique of performing hand surgery whereby a lignocaine/adrenaline/bicarbonate mixture is injected into the hand or fingers of the patient where the procedure is to be carried out. no tourniquets or sedatives are used providing numerous benefits for the patient, hospital and surgeon. methods: this is a retrospective study with prospective recall looking at the satisfaction of patients who underwent walant hand surgery at our institution in the first year of its inception. the questionnaire analysed basic demographics, compared walant to dental procedures, attempted to analyse the subjective and objective experience of the procedure, overall experience, expectations, pain felt at each stage of the procedure and finally surgical outcome. results: eighty procedures were included in the study which equated to 67 patients. some 86.6% would prefer walant for themselves in the future and 86.5% would ‘definitely’ or ‘probably’ recommend walant to friends or family. when compared to their previous dental procedures, 79.3% of patients said the pain was less or the same. some 70.1% of patients say the experience was better than expected and for 26.9% it was the same as expected. the pain assessment showed average pain scores of 3.89/10 during local anaesthetic injection, 1.25/10 during the procedure and 5.20/10 post-operatively, with post-operative pain starting an average of 9 hours following procedure completion. at time of follow-up, 85% of conditions were cured and there were no instances of digital ischaemia or infection noted. conclusion: the results of this study suggest that walant hand surgery is a safe, effective and satisfactory method of performing hand surgery in the south african context with the results being similar to international published data. the misconception regarding the use of lignocaine injections into the digits has once again been refuted as not a single case of ischaemia was seen. prevalence of a peri-operative troponin leak in patients undergoing hip arthroplasty for a neck of femur (nof) fracture in a south african population paper: gt p10/p31 category: gt du toit – registrar research (arthroplasty) presenting author: rd van zyl co-authors: mc burger, jd jordaan background: patients undergoing arthroplasty surgery are mostly of advanced age with various co-morbidities. the additional physiologic stress associated with a neck of femur (nof) fracture puts this population at higher risk for myocardial injury after non-cardiac surgery (mins). mins, diagnosed with the use of troponin testing, is underdiagnosed in arthroplasty patients and the south african population. previous research reported a 42% post-operative troponin leak prevalence among different types of hip and knee page 17 sa orthop j 2019;18(3) arthroplasty. of these, patients with nof fractures had the highest prevalence (67%). the aim of this study was to determine the prevalence of a peri-operative troponin leak in nof fracture patients undergoing hip arthroplasty to compare the prevalence at the time of admission and after surgery. methods: a prospective, longitudinal study of nof fracture patients undergoing hip arthroplasty at a tertiary academic hospital in south africa was conducted from april 2018 to july 2018. troponin levels were recorded pre-operative on admission and on day one and day three post-surgery using a highly sensitive cardiac troponin t assay (hs-ctnt). a level of >15 ng/l was considered abnormal and termed positive troponin leak while >100 ng/l is suspected in acute coronary syndrome (acs). results: thirty-nine patients (n=39) were included. twenty-three (n=23) patients (59%) recorded a positive peri-operative troponin leak of which twenty (n=20) patients (87%) had a positive leak on admission already. two (n=2) patients (5%) had a suspected acs. conclusion: patients with nof fractures are at risk for mins with a high one-year mortality rate, many of which die during hospitalisation or within one month after surgery. previous work from our unit reported a high post-operative troponin leak prevalence among nof patients while in the current study we report most patients (87%) had raised levels on admission already and potentially at greater risk for cardiac events prior to surgery. the additional stress associated with a fracture is an important risk factor in nof patients. troponin surveillance is an inexpensive and essential measure to diagnose patients at risk for mins. early detection before surgery allows for improved patient optimisation. we recommend routine perioperative testing for all nof fracture patients in south africa. relative metatarsal length change following the modified lapidus procedure paper: gt p4/p21 category: gt du toit – registrar research (foot and ankle) presenting author: w greeff co-authors: a strydom, pnf ferrao, np saragas background: the modified lapidus is a surgical treatment option for moderate to severe hallux valgus deformities, especially in the presence of the first tarsometatarsal joint arthritis or hypermobility. it has good long-term results, but reportedly can lead to transfer metatarsalgia due to shortening of the first metatarsal. methods: a retrospective analysis of the clinical records of all adult patients who underwent a modified lapidus procedure during a 3-year period. clinical notes were evaluated to look for non-union or any other complications related to the surgery. preand post-operative standard weight bearing radiographs were used to establish the relative metatarsal length (rml), intermetatarsal angle (ima), hallux valgus angle (hva) and distal metatarsal articular angle (dmaa). a total of 69 modified lapidus procedures were performed, with 32 included in the study. results: the mean rml was -0.77 mm and -4.86 mm preand postoperatively respectively. the average rml shortening due to the surgery was -4.09 (p<0.0001). the mean pre and post-operative ima was 15 and 5 degrees respectively (p<0.0001). the mean pre and post-operative hva was 33 and 9 degrees respectively (p<0.0001). no patients reported transfer metatarsalgia. conclusion: in this series there was a statistically significant degree of shortening (p<0.05) of the relative length of the first metatarsal. the low rate of transfer metatarsalgia following the modified lapidus procedure could be attributed to the sagittal plane correction and stability obtained by performing a first tmt fusion. reliability of the radiographic measurement of the hallux interphalangeal angle paper: gt p6/p24 category: gt du toit – registrar research (foot and ankle) presenting author: m khademi co-authors: np saragas, pnf ferrao, a strydom, z mayet background: the hallux valgus interphalangeus (hvi) deformity has a common association with hallux valgus and hallux rigidus. the hallux valgus interphalangeus angle is formed by the angle between the long axes of the proximal and distal phalanges. the normal value for this angular deformity in the coronal plane is less than 10 degrees. the aim of this study was to analyse the intraand inter-observer reliability of measuring the interphalangeal angle by orthopaedic surgeons. this study is going to be the first study to evaluate the reliability and reproducibility of measuring the hvi angle. methods: twenty-one x-ray prints of weight bearing feet constituted a set. sixteen qualified orthopaedic surgeons were asked to measure the hvi angle of all 21 x-ray images in the set. three randomised sets were sent to each evaluator at 4-weekly intervals. after all three sets were measured, data was retrieved and statistically analysed to determine the interand intra-observer variability and reliability in the measurement of the hvi angle. results: reproducibility of the hvi measurement was assessed using three categories which included the ability to measure the same angle three times and achieve: three degrees or less, five degrees or less and more than five degrees variation. the intra-observer reliability was found to be 5 degrees and less in 75.2% of participants and the inter-observer reliability was 61.2%. the researcher didn’t find significant correlation between the surgeons’ level of experience with respect to the reliability of measuring the hvi angle. conclusion: the interand intra-observer reliability of measuring the hvi angle is 61.2% and 75.2% respectively. the level of experience of the surgeon does not improve this reliability. results of odontoid peg fracture treatment at a tertiary hospital paper: gt p33/p100 category: gt du toit – registrar research (spine) presenting author: fm sukati co-author: mv ngcelwane background: the axis most frequently fractures at the odontoid peg waist. odontoid fractures account for up to 20% of all cervical spine fractures. historic treatment with traction and then immobilisation page 18 sa orthop j 2019;18(3) for 12 weeks has since evolved to include internal fixation of these fractures. we undertook the study to determine the prevalence of odontoid type ii fractures in relation to cervical spine fractures and clinical outcomes in patients treated in our hospital. methods: this is a retrospective review of patients admitted with axis fractures from january 2008 to december 2018. we excluded patients with pathological fractures. from the odontoid peg fractures patients’ demographics, neurological deficit, method of treatment, fracture union and clinical outcomes were recorded. results: of 231 fractures of the cervical spine, 42 involved the odontoid peg. of these, 36 were male and eight female. age range was 16–86 years. there was one type i, 24 type ii and 17 type iii fractures. the type i fracture was treated with a hard collar. cones callipers treatment was used in 17 of type ii fractures, seven of which were later converted into halo frame. three underwent primary surgical treatment. type iii fractures were treated with a collar in one patient, cones traction in 15, later converted to halo in two patients. one patient was treated surgically. six patients were treated surgically, two for non-union, four patients were treated primarily surgically after a few days of cones callipers immobilisation. all the patients went on to union, including the two that later required surgery for non-union. conclusion: odontoid peg fractures heal well with non-operative management. type ii fractures have a higher non-union rate on non-operative treatment. the introduction of a halo frame reduces hospital stay and may be the answer to the prolonged bed occupancy of these fractures. sarcopenia in patients presenting with fragility fractures of the hip at a tertiary facility in south africa paper: gt p28/p86 category: gt du toit – registrar research (trauma) presenting author: c laubscher co-authors: m burger, j charilou, mm conradie, r eagar, jd jordaan background: changes in body composition, including a decrease in muscle and bone mass, accompany ageing. sarcopenia is defined as the degenerative loss of skeletal muscle mass, quality, and strength associated with ageing. the aim of this study was to assess the prevalence of sarcopenia in patients that present with fragility fractures of the hip (ffh). methods: in this cross-sectional study, all patients presenting with an ffh were invited to participate. traumatic hip fractures, pathological hip fractures or patients with an acute concomitant disease were excluded. the european working group on sarcopenia in older people (ewgsop) criteria of a) low muscle mass together with b) evidence of impaired muscle function was used to diagnose sarcopenia. muscle mass was determined using a dual-energy x-ray absorptiometry (dexa) scan and hand grip strength, measured with a jamar hand dynamometer, was used to assess muscular function. routine blood sampling for calcium, inorganic phosphate, alp & 25-oh vitamin d was performed. results: over the 16 weeks study period, 65 of 100 patients that presented with an ffh were recruited. a total of 44 out of the 65 patients (68%) were sarcopenic. conclusion: this study reports a high prevalence of sarcopenia in our local ffh population. sarcopenia is associated with poor patient outcomes following surgical intervention and south african orthopaedic surgeons should therefore be cognisant of the presentation and associated risks of sarcopenia as our patient population ages. the burden of tibial diaphyseal fractures at an urban academic institution: time counts paper: gt p38/p114 category: gt du toit – registrar research (trauma) presenting author: as whitehead co-authors: j du plessis, jrt pietrzak, s van deventer, a robertson background: approximately 26 tibial diaphyseal fractures occur per 100 000 population per year worldwide. these fractures represent a significant burden on theatre resources. the aim of this study was to evaluate this burden in terms of time taken for intramedullary nailing of a tibia fracture by registrars and medical officers on a dedicated orthopaedic trauma list. methods: we conducted a retrospective chart review of all tibial diaphyseal fractures operated on at a single level one trauma centre in a major metropolitan area from april 2016 to april 2018. all cases underwent intramedullary fixation. the operating time was deducted from the total theatre time to determine the amount of time used for anaesthetic and set-up purposes. results: tibial fractures accounted for 18% of all orthopaedic admissions during this time period. there were 2 289 total orthopaedic trauma surgical procedures performed and intramedullary nailing of tibial fractures was the most common long bone trauma procedure done (n=238, 10.4%). a total of 169 tibial fractures in 165 patients were included (122 isolated, 43 polytrauma; 35 females, 130 males). there were 57% closed injuries (98) and 43% open fractures (71). the most common mechanism of injury was motor vehicle accidents (n=108, 65%), falls from height (n=17, 10%) and assaults (n=16, 9%). the mean operating time was 88 minutes (45–210). the mean theatre time 149 minutes (80–260). the anaesthetic and setup time represented 41% of theatre time (mean 61 minutes, 15–140 minutes). on average, the longest operating times were by medical officers (100 minutes, 60–160). operating times improved with each year of orthopaedic surgical training and peaked in the second year. registrars in the fourth year of training took an average of 10 minutes longer to complete the procedure than second year registrars (80). tibial nails done as isolated procedures were on average 17 minutes faster than those done as part of a polytrauma case (105, 60–135). conclusion: intramedullary tibial nailing is a significant burden on trauma services. non-operative tasks including set-up consume 41% of the time in the theatre. more judicious use of theatre time may expedite lists, save money and improve waiting lists. page 19 sa orthop j 2019;18(3) the incidence of low energy hip fractures in the western region of the eastern cape province, south africa paper: gt p5/p22 category: gt du toit – registrar research (trauma) presenting author: ml grundill co-author: d thomas background: the incidence of fragility hip fractures is increasing worldwide and the same can be expected in developing countries like south africa. south africa has traditionally been represented as having one of the lowest incidences of fragility hip fractures worldwide. recent work has shown a ten-fold increase in incidence as compared to previous data. this suggests that we may be underestimating our local fragility hip fracture burden. aim: determine the age, gender and race specific incidence rates of low energy fragility hip fractures within the western region of the eastern cape. this information will be compared to local and international data sets, with the aim of developing a more accurate understanding of fragility hip fractures in south africa. methods: a one-year retrospective record review of all fragility hip fracture cases was undertaken. data pertaining to age, gender, race and mechanism of injury were collected. age, gender and race specific incidences were calculated for the region. local data was compared to a number of regions across the world. results: a total of 305 hip fracture cases were reviewed. of these cases 253 were fragility hip fractures. some 70% of the cases occurred above the age of 65 years (214.77 per 100 000). 27% of the cases were between 45 and 64 years (27.85 per 100 000). 3% of the cases were younger than 45 years (0.82 per 100 000). the crude incidence in males and females is 14.58 per 100 000 and 23.41 per 100 000 respectively. overall crude incidence is 19.3 per 100 000. the highest incidence rate was found in the white population (46.64 per 100 000). conclusion: local incidences appear to be much higher than previously thought and mirror an upward trend as shown by another local subpopulation. despite this our crude incidences still appear to be on the lower end of the spectrum worldwide. our patients appear to be sustaining fractures at a younger age than western populations. of interest is that a subset of our young male population has one of the highest incidence rates worldwide. this work serves to contribute to a countrywide study, and highlights opportunities for further investigation. the microbiology of chronic osteomyelitis in a developing world setting paper: gt p3 category: gt du toit – registrar research (general) presenting author: pg mthethwa co-author: lc marais aims: the primary aim of this study was to identify the microorganisms that cause chronic osteomyelitis in a developing world clinical setting and to characterise the antibiotic sensitivity profile of these pathogens. furthermore, we aimed to determine whether the causative organisms vary in relation to physiological status of the host, the hiv status of the patient or cause. methods: we performed a retrospective review of consecutive adult patients treated curatively for chronic osteomyelitis of long bones, over a two-year period. patient charts were reviewed, and data extracted in respect of patient demographics, the cause of infection, physiological status of the host in accordance with the cierny and mader classification, hiv status, surgical treatment strategy and causative organism. results: a total of 108 organisms were identified in the 60 patients included in the study. multiple organism were cultures in 45% of patients, a single gram-positive organism in 22% and a single gramnegative organism in 26% of patients. in four cases (7%) no causative organism was cultured. the most prevalent organisms were enterobacteriaceae (34%), staphylococcus spp. (29%), pseudomonas aeruginosa (11%), and enterococcus spp. (9%). many isolates were found to be resistant to commonly used empirical anti-microbial agents. seventy per cent of enterobacteriaceae spp. were resistant to either cefuroxime and/or ampicillin-clavulanic acid. seventy-seven per cent of staphylococcus aureus isolates were susceptible to cloxacillin. more than 50% of pseudomonas aeruginosa strains were resistant to meropenem, imipenem, piperacillin-tazobactam or cefepime. there was a significant association between the aetiology of the infection and the microorganisms involved (p<0.01). the bacterial pathogen profile was, however, not associated with the physiological status of the host (p=0.22) or the hiv status of the patient. conclusion: while the majority of haematogenous chronic osteomyelitis still involved a solitary gram-positive organism, the incidence of gramnegative infections was found to be higher than previously reported. contiguous chronic osteomyelitis was mostly polymicrobial in nature and solitary infections involving a gram-negative organism was most common in the post-traumatic group. the bacterial pathogen did not vary in relation to the hiv status of the patient or the physiological status of the host. the short-term outcomes of hip arthrodesis in paediatric patients with end-stage hip disease paper: gt p50/p144 category: gt du toit – registrar research (paediatrics) presenting author: t mniki co-authors: lc marais, p maré background: management of end-stage hip disease has changed over time. total joint replacement has gained popularity due to retained mobility and stability. however, in the high demand paediatric and adolescent population, its use has been limited due to risk of repeated revisions. we believe that hip arthrodesis remains a good option to confer a stable painless hip with good functional outcome in this population group. methods: a single centre retrospective analysis was conducted, assessing paediatric patients with end-stage hip disease that underwent hip arthrodesis between 2010 and 2014. clinical records were reviewed to identify the underlying disease process, the obtained fusion position and fusion rate, functional outcome, complications and reoperation rate. page 20 sa orthop j 2019;18(3) results: fifteen patients (nine female) of the 22 patients on the database were eligible for inclusion. the average age at hip fusion was 11 years (6–18). the etiological spectrum included tb hip (nine cases), septic arthritis (three), neglected slipped femoral capital epiphysis (one), idiopathic chondrolysis (one) and chronic synovitis (one). uncomplicated functional fusion was achieved at a rate of 66% (10/15). all patients in whom fusion was achieved had relief of pain and returned to their normal activities. conclusion: we believe hip arthrodesis performed in the correct patient is a good procedure to preserve function and relieve pain. the procedure is technically demanding and careful follow-up to ensure optimal positioning tumour volume as a predictor of metastases in patients presenting with high-grade conventional osteosarcoma paper: gt p25/p73 category: gt du toit – registrar research (oncology) presenting author: sc phillias co-authors: lc marais, mv ngcelwane background: survival rates in osteosarcoma have been found to be in the region of 60% in patients with localised disease, 20–40% in metastatic disease, with current multimodality treatment protocols. tumour volume is one of the factors known to be poor a prognostic indicator. majority of patients present late with large tumours for treatment. aim: to investigate the association between tumour volume and the presence of skeletal or pulmonary metastases at time of presentation in patients with osteosarcoma. methods: a retrospective review was performed on the records of all patients with osteosarcoma referred to our tertiary level orthopaedic oncology unit, from 2010 to 2014. diagnosis of osteosarcoma was confirmed on histology. age at presentation, gender and anatomical site of the tumour were recorded. tumour size was measured on mri, pulmonary metastases on ct and skeletal metastases on technetium bone scan. strata statistical software was used to analyse the results. results: there were 61 patients. mean age was 21 years ([sd] 11.9 years) with an equal distribution between male and female (50.8 vs. 49.2%). evidence of metastasis at time of presentation (pulmonary n=44 (72%); skeletal n=16 (28%)). mean tumour volume at presentation was 1 114 cm3 (sd 1 285 cm3). there was no difference in the tumour volume at presentation between patients with and without pulmonary metastases at time of diagnosis (p=0.85). tumour volume, however, did appear to predict the presence of skeletal metastases (p=0.02). receiver operating characteristic (roc) analysis identified the optimal break point for tumour volume as a predictor of the presence of skeletal metastases as 1  383 cm3 (sensitivity 60%, specificity 87%). univariate analysis of tumour volume greater than 1  380 cm3 revealed an or of 13.6 (95% ci 2.5–72.5; p<0.01) for the presence skeletal metastases at time of presentation. multivariate analysis of a tumour volume greater than 1  380 cm3 yielded an or of 8.6 (95% ci 1.1–67.1; p=0.039) for presence of skeletal metastases. conclusion: there are greater chances of skeletal metastases in patients with tumour volumes greater than 1 380 cm3. hand papers: diagnostic accuracy of pre-operative clinical examination in zone v flexor injuries paper: p78 category: hands presenting author: ed osei co-author: mc sathekga background: zone v flexor region is densely packed with 12 tendons, three nerves and two major arteries. zone v flexor injuries can be very devastating to the patient and impair proper functioning of the hand. most often, the intra-operative findings differ significantly from the pre-operative clinical findings. this research was done to analyse the demographic data of patients who present with zone v flexor injuries and also assess the diagnostic accuracy of pre-operative clinical examination in predicting injuries to anatomical structures in zone v flexor injuries. methods: ethics clearance was obtained for the study. fifty-six patients who sustained zone v flexor injuries and fulfilled the inclusion criteria were enrolled in the study after they signed a consent form. demographic data of the patients were documented. patients were examined pre-operatively by orthopaedic doctors at the casualty and findings were documented. orthopaedic doctors in theatre documented their intra-operative findings. the frequency and proportions were reported for the demographic data. the pre-operative and intra-operative findings were analysed by crosstabulation to assess the accuracy of the pre-operative clinical examination. results: the male to female ratio was 4.1:1. more than half of the patients were employed. two-thirds of the injury occurred on the dominant hand of the patient. assault or homicide was the leading cause of zone v flexor injury. 39% of the patients were drunk when the injury occurred. more than two-thirds of the injury occurred on weekends. there were 25 cases of spaghetti wrist and 16 cases of ulna triad injuries. flexor digitorium superficialis injuries were missed more than flexor digitorium profundus injuries. 100% and 50% of superficial radial nerve and median nerve respectively were missed on clinical examinations. 75% and 48% of radial artery and ulnar artery injuries respectively were missed clinically. only five out of 42 partially torn anatomical structures were accurately diagnosed pre-operatively. page 21 sa orthop j 2019;18(3) conclusion: the study demonstrated a significant difference between preoperative finding and intra-operative findings of zone v flexor injuries. clinical examination skills, knowledge of functional anatomy of anatomical structures, lack of thorough examination, observer error and patient factors accounted for the high level of missed diagnosis. the evaluation of the efficacy and complication rates of peripheral regional anaesthesia performed at our institution’s hand unit paper: p135 category: hands presenting author: kb mogami co-author: mc sathekga background: regional anaesthesia is the administration of local anaesthetic agents and adjuvants to specific anatomic areas, resulting in a combination of motor and sensory blockade. as medical technology improves, more understanding and better techniques for both mechanism and administration of available local anaesthetic agents has led to an increase in the use of these techniques. the need for perioperative pain control in orthopaedic procedures is of vital importance. with improvement in techniques, the use of regional anaesthesia has been associated with better post-operative pain control, decreased narcotic use and thus narcotic-related side effects such as nausea and vomiting. in addition, brachial plexus blockade alleviates complications associated with administration of general anaesthesia such as hemodynamic instability, airway instrumentation, longer recovery times and slower discharge times post-operatively. aims: our study aims to evaluate the efficacy of peripheral regional anaesthesia: coracoid and axillary blocks, performed at our institution’s hand unit for upper extremity surgery as well as the associated complication rates. methods/results: this was a prospective study of all patients undergoing surgery in our unit under regional blockade. a total of 109 patients were reviewed for the study. there were 38 females and 71 males. the average age was 34, and the right hand was more commonly involved than the left. the majority of patients (80.7%) reported no pain during the operation, while 10.6% had mild pain, 7.7% severe pain and 2.9% had intolerable pain. complications were reported in only 1.8% of patients. the majority of patients said they would have a repeat procedure under regional blockade. furthermore, at 24-hour review, most patients reported satisfactory sleep with minimal discomfort, even though most required rescue medication. conclusion: based on our findings, we concluded that the majority of regional blocks performed in our unit are effective with low complication rates. there is great patient satisfaction likely due to longer analgesic effect of the blocks. hip arthroscopy and preservation papers: age, gender and a decline in functional outcome scores at three months may predict revision hip arthroscopy: a single surgeon series of 1 363 consecutive hip arthroscopies paper: p64 category: hip arthroscopy and preservation presenting author: jrt pietrzak co-authors: k nortje, jn cakic background: hip arthroscopy is a rapidly growing, evolving area within arthroscopic orthopaedic surgery. despite improvements in equipment and training, it remains a challenging procedure. the primary objective was to determine the success of joint preservation after hip arthroscopy and to determine whether patient characteristics or prom functional score trends could predict revision hip arthroscopy or total hip arthroplasty (tha). methods: we reviewed 1 363 hip arthroscopies performed from january 2010 to december 2016 by a single high-volume surgeon at a single institution. data was prospectively collected and retrospectively reviewed with a minimum two-year follow-up. hip arthroscopy failures were defined as tha or revision hip arthroscopy after index hip arthroscopy. results: there were 751 females and 612 males with an average age of 34.63 years (19–58 years). there were 199 cases (14.6%) of labrum repairs only, 286 (20.9%) cam and labrum repairs, 319 (23.4%) cam and pincer surgeries and 193 (14.1%) cam only surgeries. preoperative ihot-33 patient-reported outcomes scores (27.42 ± 6.2) improved significantly at the 6 week-, 3 monthand 6-month followup visits (p<0.05). the best improvements were seen in symptoms and functional improvements (ihot-sfl) (p<0.05). there were 223 failures, 131 patients (9.61%) underwent revision hip arthroscopy and 92 required tha (6.75%) at 18.45 months ± 7.34 months. the tha conversion rate was 8.4% for patients >50 years old and 3.72% for patients <50 years old. age (>50 years) and female sex were associated with increased risk of conversion to tha (p<0.05) while young (<25 years old) and female patients were most likely to undergo hip revision arthroscopy. surgery involving repair of the labrum only were more likely to result in revision arthroscopy surgery and tha (70.7% at 10.6 years). conclusion: joint preservation and no subsequent surgery at 10.6 years is 83.64%. this study showed that predictors of revision hip arthroscopy or tha included poor pre-morbid functional score, female gender, age >45 years, sudden functional score decrease at 3-months follow-up and cases in which only the labrum is surgically repaired. an anatomical study of the prevalence and morphology of the corona mortis in a south african cadaver sample paper: p109 category: hip arthroscopy and preservation presenting author: j naicker co-authors: n mogale, s matshidza page 22 sa orthop j 2019;18(3) background: orthopaedic surgeons are hurrying to perform the widespread anterior approach to the pelvis using the modified stoppa approach, a minimally invasive technique which may lead to iatrogenic haemorrhage and fatality in patients. such mortality is due to the accidental severing of the corona mortis (cm) vessels, the anastomosis between the obturator artery and the external iliac artery normally via an accessory obturator artery, which can also be consistent of the vessels venous counterparts. this study investigated the variations and incidence of the cm and the constituent vessels in a south african sample using 31 adult cadavers. methods: after careful dissection of the blood supply of the pelvis, the location of the cm in relation to bony landmarks encountered during anterior approaches to the pelvis was documented. these landmarks included the pubic tubercle, pubic symphysis and the anterior inferior iliac spine in order to map out ‘safe zones’ adjacent to these landmarks for surgeons to use when exposing the pelvis. any correlation between sex, side, age and body mass index (bmi) with the presence of the cm were recorded. the point of bifurcation of the abdominal aorta and the length of the common iliac vessels were documented. the position of these common iliac vessels along the quadrilateral plate of the pelvis, were also observed. results: the incidence of the cm was observed as 64.52%, with 61.29% being venous and 3. 23% being of arterial vessels. an incidence of 55% of cm occurred on the left with 45% occurring on the righthand side and a total of ten bilateral cm incidents were observed. venous cm resulted in an anastomosis between an accessory obturator veins which presented with a 75.81% incidence or a second accessory obturator vein with an incidence of 22.58%. arterial cm consisted of an anastomosis between the accessory obturator arteries which resulted in an incidence of 3.28%. conclusions: the results of this study will assist physicians in administering a more minimally invasive procedure where the risk of haemorrhage and mortality is greatly decreased by better understanding of the variations and precedence of the cm and its possible locations. post-operative rivaroxaban in patients at risk for deep vein thrombosis undergoing hip arthroscopy: a single surgeon series in a developing country paper: p67 category: hip arthroscopy and preservation presenting author: w verhoogt co-authors: j pietrzak, k nortje, j cakic background: globally, the demand for hip arthroscopy (ha) has increased 25fold in the united states. problematically, complication rates of ha have been underestimated in the literature. particularly, a recent systematic review finds that the risk of venous thromboembolic events (vte) is approximately 2%. this is likely also underestimated and therefore protocols to mediate vte may be more necessary than previously thought. a single high-volume surgeon specialising in ha in johannesburg south africa implemented a protocol between 2012 and 2018 to reduce the risk of vte. this protocol included the use of rivaroxaban in patients undergoing ha who were deemed to be at risk of vte. the aim of this paper was to retrospectively review this surgeon’s protocol and outcomes in order to determine the incidence of vte complications and to interrogate rivaroxaban’s use in vte prevention. methods: a retrospective chart review of 646 consecutive patients who underwent ha was conducted. all patients were treated according to a predetermined protocol in order to prevent vte post-operatively which classified patients as being high or low risk for vte. for high-risk patients (≥1 risk factor) this specifically included oral thromboprophylaxis for 2 weeks post-operatively. the incidence of vte and subsequent correlation with these risk factors were recorded and analysed in this study. results: there were 880 ha in 258 males and 388 females at an average age of 35.4 years. the overall complication rate was 4.3% (n=38) with 28% (n=6) of these being major complications and 72% (n=32) being minor complications. the total incidence of vte was 0.45% (3 dvt, 1 pe). within the highand low-risk groups for vte, the incidence of vte was 1.2% and 0.16% respectively. oral thromboprophylaxis was not associated with any post-operative bleeds, 30or 60-day readmissions. conclusion: this study demonstrated a lower rate of vte in both low risk and high-risk individuals than in the reported literature. it highlights the value of identifying patients with risk factors for vte, having a predetermined protocol for vte prophylaxis and initiating post-operative oral thromboprophylaxis in patients at risk. oral thromboprophylaxis for 2 weeks is safe and efficacious with a low side-effect profile. proximal femur geometry in the adult kenyan femur and its implication in orthopaedic surgery paper: p52 category: hip arthroscopy and preservation presenting authors: m n mouti, j kibet co-authors: c k lakati, b n ndeleva background: numerous orthopaedic procedures are carried out on the proximal femur. for optimal hip function, these procedures must restore the anatomy of the proximal femur to near normal. there are currently no local studies that have described in detail the normal anatomy of the proximal femur and its implications in operations on the proximal femur. the aim of this study was to determine the neckshaft angle, femoral neck anteversion angle, femoral neck width and femoral head diameter in adult femora, compare the results with other studied populations and examine the implications of the same in operations on the proximal femur. methods: femoral neck anteversion angle and the neck-shaft angle were determined from digital photographs of 70 cadaveric femora using an open-source image analysis software, imagej®. femoral neck width and femoral head diameter were determined by measurement using a digital vernier calliper. the dimensions of available implants were searched from local suppliers of the implants. results: mean femoral neck-shaft angle was found to be 129.21°, while the mean femoral neck anteversion angle was found to be 23.06°. mean neck-shaft angle was found to be 128.67° on the left while on page 23 sa orthop j 2019;18(3) the right side, it was 129.03°. mean femoral neck anteversion angle was found to be 23.97° on the left side, and 23.03° on the right side. mean femoral neck width was found to be 29.36 mm, with mean width of the left side being 28.67 mm and that of the right being 29.36 mm. mean femoral head diameter was 42.6 mm ,with mean diameter of the left side being 41.2 mm and that of the right side being 42.6 mm. the differences were not statistically significant. conclusion: the current study has shown that the femoral neck-shaft and anteversion angles in the kenyan femora vary from those of other populations. the available implants have angles which may not be suitable for a significant proportion of the local population. it would be prudent to avail a range of implants with different angles to improve the choices available to the surgeon when faced with a patient who requires an operation on the proximal femur. there is a low rate of infections and subsequent 30and 60-day admission rates in primary hip arthroscopy, revision hip arthroscopy and cases converted to total hip arthroplasty paper: p53 category: hip arthroscopy and preservation presenting author: w verhoogt co-authors: j pietrzak, k nortje, j cakic background: the incidence of hip arthroscopy (ha) has increased 25-fold worldwide. superficial infection complicates 0.3% cases and deep infections less than 0.1% of cases. however, complication rates may be underestimated in the literature. the aim of this paper was to determine the incidence of infective complications in primary ha, revision ha, and in cases converted to total hip arthroplasty (tha) after ha. methods: we conducted a retrospective chart review of all patients who underwent ha by a single high-volume surgeon in johannesburg from 2012 to 2018. the incidence of all complications, as well as the 30and 60-day readmission rates were noted. all revision ha and conversion tha had aspirate fluid sent for microscopy, culture, and sensitivity (mc&s) at surgical portal insertion and exposure capsulotomy respectively. the results of these investigations were subsequently reviewed. appropriate pre-operative antibiotics were given in all cases. results: there were 880 ha performed in 646 patients (258 males and 388 females) at an average age of 35.4 years. there was a total of 100 (11.3%) revision ha within the sample. there were 25 (2.8%) conversions to tha done following ha within the sample. the overall complication rate after index ha was 4.3% (n=38). primary ha, revision ha and conversion tha were complicated by superficial infections in 0,2% (n=2), 0.1% (n=1), and 0% respectively. there was no growth on mc&s from specimens taken at any revision ha or tha. there were no readmissions or complications in any conversion tha. no deep infections were reported in any case at a minimum 1-year follow-up. all three superficial infections were treated successfully with oral antibiotics. conclusion: primary ha has a low superficial infection rate. revision ha and conversion tha does not predispose to infective complications or increased 30or 60-day readmission rates provided prophylactic antibiotics are prescribed and appropriate precautions are followed. knee papers: not strong enough? insignificant movements generated during clinical examination of sagittal and rotational laxity in an acl-deficient cadaver knee paper: p47 category: knees presenting author: j le roux co-authors: cw bezuidenhout, j klopper, h hobbs, r von bormann, m held background: the decision to further investigate anterior cruciate ligament (acl) injuries is influenced by the initial clinical assessment of sagittal and rotational laxity. perceived laxity is often estimated in millimetres and degrees. we aimed to measure and compare this motion generated by clinicians in a cadaver model after acl and anterolateral ligament (all) were transected. methods: a group of orthopaedic surgeons and trainees examined a cadaver knee for sagittal and rotational instability at 30° and 90° with intact ligaments, after the acl was transected and after the acl and all were transected. rotational and sagittal movements during these examinations were recorded by pi galileo computer assisted surgery (cas) system (smith & nephew, memphis, tennessee) and compared. results: twenty-four participants with a wide range of clinical experience took part in this study. the median sagittal plane laxity captured by cas at 30° flexion was 7 mm (iqr 2) in the intact knee, 9 mm (iqr 1) after the acl was cut and 9 mm (iqr 3) after acl and all were cut. the median arc of rotational laxity measurements as captured by cas at 30° was 19° (iqr 7) in the intact knee, 24° (iqr 5) after the acl was cut and 22° (iqr 6) after the acl and all were cut. none of the differences in these movements was significant. conclusion: we could not generate enough force in a cadaver model, which could be measured objectively by cas as significant differences in sagittal or rotational motion when examining the intact knee, acl deficient (only), or combined acl and all deficient knee. we need to get stronger to accurately diagnose knees with acl injuries. the management of acute knee dislocations: a global survey of orthopaedic surgeons’ strategies paper: p106 category: knees presenting author: s venter co-authors: v khanduja, rpb von bormann, h hobbs, m held page 24 sa orthop j 2019;18(3) background: acute knee dislocations are uncommon injuries which can have devastating consequences. prompt diagnosis, followed by reduction of the dislocation, immobilisation of the knee and neurovascular monitoring form the basis of treatment in the acute setting. high volume centres in the developed world recommend early single stage arthroscopic ligament reconstruction with autoor allografts. yet, for resource constrained settings in low-income countries, there are no evidence-based guidelines which are adapted to local challenges. the objective is to assess the management approach of acute knee dislocations by orthopaedic surgeons in south africa and world-wide. the aim was to develop evidence-based guidelines for the treatment of acute knee dislocations in resourceconstrained settings. methods: this is a descriptive cross-sectional survey analysis using the website redcap. participants are orthopaedic surgeons registered with the south african orthopaedic association and/or sicot, both in independent and/or state practice. the survey will be sent out to approximately 1 000 orthopaedic surgeons, with an expected reply from 200 (an estimated response rate of 20% is expected). results: computed tomography angiography (cta) is selectively performed in patients with clinically abnormal vascular examinations. surgical management of multi-ligament knee injuries is favoured over conservative management in all socio-economic settings. the choice of autograft vs allograft varies among surgeons. collateral ligaments are most often acutely repaired, followed by staged cruciate ligament repair. most public and private centres have access to a dedicated physiotherapy unit. conclusion: although early, single stage arthroscopic ligament reconstruction is recommended for knee dislocations. the management varies, especially in resource-limited practices. ligament surgery is often delayed, staged and done via open cruciate surgery. dedicated post-operative rehabilitation plays a crucial role in functional outcome. oncology paper: the outcome of the lateral approach to distal femoral tumour resections – a retrospective clinical audit at a private practice in pretoria paper: p101 category: oncology presenting author: n van der watt co-author: o koch, t le roux background: in most european countries distal femoral tumour resections are traditionally performed through a medial or anteromedial approach. the medial approach identifies and protects the femoral artery in hunter’s canal and therefore limits intra-operative vascular complications. an alternative procedure that has been described in the literature involves the use of a lateral approach to the distal femur. currently, there is limited research available with regard to this approach and the safety thereof. this study aimed to assess the intra-operative and immediate post-operative vascular complications when using the lateral approach during the resection of distal femoral tumours. methods: we performed a retrospective clinical audit at a private practice in pretoria. we identified all distal femoral tumour resections followed by prosthetic replacements between 2006 and 2019. these surgeries were performed via the lateral approach by a single surgeon. we assessed the files of the patients to determine if there were any intra-operative or immediate post-operative vascular complications. results: we identified 35 patients who underwent resection of their distal femoral tumours via the lateral approach. two vascular complications were recorded during this period. both complications occurred intra-operatively and were immediately repaired. there were no subsequent post-operative complications secondary to these injuries. in our study group we found a low intra-operative risk of vascular injury when performing distal femur tumour resections using the lateral approach. conclusion: the findings of this retrospective study suggest that an overall positive outcome with a low risk of vascular complications can be expected when resecting distal femoral tumours through a lateral approach. paediatrics papers: a replacement for the kirschner wire: micro-ct and histological assessment of a bioabsorbable pin for paediatric fracture management paper: p19 category: paediatrics presenting author: sp mackenzie co-authors: rj wallace, ahrw simpson, aw murray, to white backgroud: kirschner wires are commonly used in paediatric fractures, however, the requirement for removal and the possibility of pin site infection provides opportunity for the development of new techniques that eliminate these drawbacks. the acumed biotrak helical nail is a bioabsorbable pin that could remain in situ to allow definitive closure of skin at the time of insertion minimising the risk of infection. however, their effect on the growth plate is not completely understood. page 25 sa orthop j 2019;18(3) methods: two helical nails were inserted across the distal femur physis in 12 immature sheep, and 1.6 mm kirschner wires in the contralateral limb acted as a control. the amount of femoral growth at six months was assessed. micro-ct was used to assess the helical nails and their effect on the growth plate in terms of percentage disruption, physeal thickness, and physeal bony infiltration. traditional histopathological techniques were used to assess for foreign body reactions. results: there was no difference in the length of the femora in each group. the nails disrupted 3.4% of the physeal volume. microct demonstrated that the helical nails lost their integrity due to intervening growth. two cases of physeal tethering adjacent to a helical nail were identified. physeal thickness and bony infiltration of the physis were not adversely affected. histopathology did not reveal any significant inflammatory or foreign body reaction adjacent to the nails. conclusion: the helical nail had a negligible effect on the growth plate and did not adversely affect femoral growth. there was clear microct evidence that the helical nail was overcome by the hydrostatic forces of growth. this suggests that the helical nail could provide initial fracture stability, before allowing subsequent unhindered growth. an overview of the patient population presenting with congenital talipes equinovarus (ctev) at a tertiary hospital in the western cape paper: p88 category: paediatrics presenting author: m thiart co-authors: c fenn, j du toit, mc burger background: clubfoot (or congenital talipes equinovarus) is as a common paediatric orthopaedic condition. globally, clubfoot is more prevalent in males and has a prevalence of 1/1 000 live births . treatment with the ponseti method occurs as soon as possible after birth in a developed world setting. the aim of this study was to provide an overview of the demographic profile and treatment regimen of the population treated for clubfoot at a high volume, tertiary level hospital in a developing world setting. methods: a retrospective cohort study, including all patients presenting with clubfoot between november 2013 and december 2018 was conducted. general demographic information as well as treatment information was collected. results: a total of 221 patients (62.8% male and 36.2% female) were included over the 62 months study period at a median age of presentation of 5.0 weeks (iqr 2.0–12.0 weeks). of these, 78.2% (n=173) of patients were diagnosed as having idiopathic clubfoot, 6.3% (n=14) with postural clubfoot and 12.2% (n=27) with syndromic clubfoot. the majority of patients (52.4%) had bilateral clubfoot with 20.4% having unilateral left and 26.7% unilateral right clubfoot. only 11.3% reported having a positive family history. patients had to travel a median distance of 20.9 km (iqr 10.2–23.0) to attend the clinic (range 2.1–325) and required a median of six casts (iqr 4.0–9.0), (range 1.0–35.0), before the next phase of treatment. a total of 47.5% (n=105) of 221 participants did not require a tenotomy, 39.4% required a tenotomy (n=87) and 13.1% (n=29) was not reported, before commencing maintenance treatment. a total of 20.3% (n=45/221) of patients had relapsed clubfoot, with 19% (n=42/221) undergoing repeat ponseti treatment and 9.1% (n=20/221) required a repeat tenotomy. conclusion: our demographic profile of mostly male patients suffering from bilateral and idiopathic clubfoot is in agreement with the global literature. however, we report a delayed age of presentation and a greater travel distance than would generally be expected. of interest is a reported family history of only 11.3% compared to the literature. future research should interrogate these findings further. appropriate age to transition paediatric patients to adult orthopaedics at an academic hospital paper: p72 category: paediatrics presenting author: m janse van vuuren co-authors: f ahmed, a robertson background: changing admission policies in our hospital motivated an inquiry into the demographics of adolescent orthopaedic admissions. the age cut off needs to ensure optimal management for the unique physiological, skeletal and psychosocial requirements of adolescent patients. we aimed to compare our policy to the national and international practices to deduce whether it is appropriate to reduce the age for transition to adult orthopaedics from 16 to 14 years at our institution. methods: a retrospective audit over 30 months (june 2016 to december 2018) of patients aged 14 years and older admitted to our paediatric orthopaedic ward was conducted to determine the spectrum of disease and treatment required for this age group. a survey of national and international paediatric orthopaedic admission practices was conducted and a literature review on appropriate age of transition for adolescent orthopaedic patients was performed. results: no national standardised admission age exists for paediatric orthopaedic patients in the public sector in south africa. admission cut-offs vary from 12–16 years with concessions made to admit older patients with congenital orthopaedic conditions as well as disabilities such as cerebral palsy. our audit revealed total paediatric orthopaedic admissions of 2 215 of which 158 fell between the 14 and 16 year age groups. the admission distribution profile for this age group indicated 77 (49%) trauma related admissions, with 45 (58%) of trauma related admissions requiring paediatric specific management. of the non-trauma admissions 36 (45%) were general paediatric orthopaedic admissions. the remaining non trauma admissions fell under subspecialties: spine 17, tumour and sepsis 19, and sports injuries 8. in total 117 (74%) of admissions required specific paediatric orthopaedic management. conclusion: decreasing the admission age to paediatric orthopaedic wards from 16 to 14 years of age, and treating adolescents as adult patients, may negatively affect the management of these patients who have not yet reached skeletal maturity. they constitute a very small group when compared to the overall admission numbers and thus pose little burden in the paediatric ward. an individualised approach may be required to admission protocols, rather than strict cut-offs purely based on age. page 26 sa orthop j 2019;18(3) common causes of atraumatic swollen painful joints in south african children paper: p46 category: paediatrics presenting author: s wever co-authors: m bruins, a upfill, s dix-peek, m held background: delayed or incorrect diagnosis of joint infections in children can lead to poor clinical outcome and lifelong impairment. thus, early recognition and accurate diagnosis is crucial to avoid these sequalae. the aim of this study was to evaluate the frequency of infections among children with swollen, painful joints in south africa. a secondary aim was to evaluate differences in laboratory parameters comparing pyogenic infections, tuberculosis (tb) infections and non-infectious conditions. methods: this was a retrospective review of consecutive patients, 12 years of age or younger, who presented with swollen, painful joints to a large urban south african children’s hospital from april 2013 to april 2015. a surgical database was used to search for patients and all children were included who underwent a biopsy to test for tb as part of the routine clinical workup. patients with injuries were excluded. these tests included histology, microbiology, culture, or xpert mtb rif. clinical notes, laboratory results, and histopathological findings of the patients were analysed. results: 104 children with a mean age of 5 years (59% male) were included. in 7 children, more than one joint was affected. most were diagnosed with a pyogenic infection (n=40; 38.5%), followed by tb (n=15, 14.4%), acute synovitis (n=15, 14.4%), or chronic synovitis (n=11, 10.6%). pyogenic infections were most commonly caused by staphylococcus aureus (n=23, 57.5%), followed by streptococcus pyogenes (n=4; 10%) and streptococcus pneumoniae (n=3; 7.5%). the knee was most commonly affected, followed by the hip and ankle. children with pyogenic infections presented more often with pyrexia (p<0.05), and had a higher white cell count (wcc) (mean 17 vs 10.9; p≤0.05) and erythrocyte sedimentation rate (esr) (mean of 176.8 vs 47.9; p≤0.05). there was a trend for a higher platelet count in patients with tb compared with pyogenic infections. (539.6 vs 433.23, p=0.074). conclusion: a high proportion of children with swollen, painful joints had infections and a large portion of these had tb. children with tb had a higher platelet count, whereas patients with pyogenic joint infections had a significantly higher temperature, esr and wcc. effect of seasonal variation on the peak presentation of slipped capital femoral epiphysis: a comparison of children in johannesburg, south africa and london, united kingdom paper: p26 category: paediatrics presenting author: m foster co-authors: g firth, c pieterse, y ramguthy, a izu, j bacarese-hamilton, m ramachandran background: the variation in peak presentation of slipped capital femoral epiphysis increases as the latitude increases over 40 degrees north of the equator. few studies have compared populations living on either side of the equator. the objective of this study was to compare two cohorts of children (one in south africa and the other in the united kingdom) and explore similarities and differences regarding demographic and epidemiological features, incidence and seasonal variation in peak presentation. methods: patients presenting with slipped capital femoral epiphysis at one of two hospitals in either south africa or the united kingdom between january 2011 and december 2017 were included in the study. a retrospective cohort was collected from hospital records and data was recorded using an excel spreadsheet. the following factors were recorded: duration of symptoms, chronicity, stability, seasonality, tri-radiate cartilage closure, severity and prophylactic pinning. statistical methods used included calculating incidence and confidence intervals, means and standard deviations for demographic and clinical data. results: a total of 137 patients were included in the study: 70 patients (80 hips) from south africa and 67 patients (73 hips) from the united kingdom. sixty per cent of children from south africa presented with a chronic slip compared to 53% in the united kingdom. there was higher delay to presentation in the united kingdom compared to south africa (90 days vs 60 days, p=0.0262). the uk population were more skeletally mature (32.8% had an open triradiate cartilage) compared with the south african population (64.9% had an open triradiate cartilage). in the south african population, the most common season of symptom onset and presentation was in summer. in the united kingdom, the most common season of symptom onset was summer, but the most common season of presentation was in autumn. conclusion: this study has compared two populations from either side of the equator and found significant differences including a more skeletally mature population in the united kingdom. both cohorts showed seasonal variation in peak incidence but there was more seasonal variation in peak incidence in the uk – in summer for onset of symptoms and autumn months for time of presentation. epidemiology of paediatric and adolescent fractures admitted to a south african provincial hospital paper: p30 category: paediatrics presenting author: s strydom co-authors: c hattingh, m ngcelwane, n ngcoya background: there are few studies available that examine the epidemiology of children and adolescents admitted with orthopaedic injuries in developing countries. south africa possesses several elements that make our population unique, which may influence fracture patterns and their management. these statistics can help to identify areas that can benefit from preventative measures. information regarding admission duration and type of management can also help hospital management to adequately plan and budget for these patients. methods: we did a cross sectional record review for the period from 1 january 2016 to 31 december 2017. convenience sampling was done, and demographic and clinical data collected from patient records. all patients younger than 18 years at the time of injury that page 27 sa orthop j 2019;18(3) were admitted with fractures of the appendicular skeleton, spine or pelvis were included. patients with incomplete clinical records and isolated tuft fractures were excluded. results: a total of 731 patients were admitted, with 526 (72%) remaining after incomplete records were excluded. from these records we found a higher percentage of males admitted (73%) compared to previous publications and the average age was 7.7 years (sd=4.5). a fall on level ground was the most common mechanism of injury (70.0%), followed second by pedestrian vehicle accidents (12.2%). the most frequently fractured regions that required admission were the forearm (36.4%), humerus (26.5%), femur (18.9%) and the tibia/fibula (12.5%). the average duration of admission was 8.6 days (sd=9.0). out of the 307 (58.3%) patients taken to theatre, hardware was used in 148 (28.1%). additional non-skeletal injuries were sustained by 15 patients and 13 patients sustained fractures to multiple regions. there was one death in a patient with gunshot trauma. conclusion: the need to provide safer environments for children has already been recognised in south africa. by providing a current descriptive picture of traumatic orthopaedic injuries and exploring current treatment practice patterns, we hope to guide policies that promote paediatric trauma prevention, improve treatment and reduce the associated morbidity and mortality. femoral lengthening in children: complications and outcomes paper: p61 category: paediatrics presenting author: a horn co-author: m sipilia background: we evaluated the outcomes following femoral lengthening by distraction osteogenesis in children. additionally, we determined the incidence and nature of complications, the management thereof and factors associated with the development of complications. methods: a retrospective review was performed of all patients who underwent femoral lengthening as an isolated procedure at our institution. data regarding presenting details and clinical course were collected and x-rays analysed. the healing index (hi) and the percentage lengthened were calculated. complications were defined as deep sepsis, joint contracture, fracture and neurological injury. results: fifteen patients underwent 16 femoral lengthenings from 2008–2018. nine patients had congenital short femur or proximal focal femoral deficiency, three patients had sequelae of meningococcaemia and four had various other pathologies. the median age at time of surgery was nine years (6–13). median follow-up was 1.6 years (0.5–6.6). the median hi was 32 days/cm (20–60). leg lengths were equalised to ≤2.5 cm in 11 patients, length achieved was as planned in all but three patients. eight patients sustained fractures on average six days (2–57) after frame removal, five were through the regenerate. four required surgery. thirteen patients developed joint contractures and six required additional procedures to address this. two deep infections required surgery. two patients developed neurological symptoms of which one recovered fully. higher percentage length gained (>20%) was associated with increased fracture and joint contracture rate. diaphyseal osteotomy, as opposed to metaphyseal, was associated with increased risk of fracture (71% vs 25%). a diagnosis of congenital short femur was associated with increased fracture rate. spanning the knee did not prevent joint stiffness in 4/5 patients but did prevent subluxation. conclusion: femoral lengthening using external fixation can be successful in achieving leg length equality, but complications are common and often require additional surgery. limiting lengthening to less than 20% of the original bone length and performing the osteotomy through the metaphysis decreases the risk of fracture and joint contracture. outcomes of distal radius metaphyseal fractures in children paper: p54 category: paediatrics presenting author: p ntombela co-authors: w mukiibi, m ramokgopa, y ramguthy background: distal radius fractures are one of the commonest fractures in children. fractures in the distal third of the forearm account for 75% to 84% of all forearm fractures. management of these fractures is met with many controversies. these range from manipulation under anaesthesia (mua) and casting alone versus the use of percutaneous pinning, the use of above-elbow cast versus a forearm cast. the aim of this study is to determine the outcomes of management in children treated for distal radius fractures. methods: this is retrospective review of patients who presented and were treated between january 2018 and december 2018 with a distal radius fracture in a south african hospital. short-term outcomes were reviewed. results: there were 20 girls and 76 boys with an average age of 9.1 years. fifty-eight per cent of the injuries involved the right side and 42% on the left. the majority (53%) of the fractures were as a result of falling on an outstretched hand (foosh) followed by soccer injuries (17%). thirty-nine per cent of patients were treated with an above-elbow cast, 40% in a below-elbow and 21% with k-wires plus forearm cast. of the k-wire group, two needed open reduction. there was a 100% union rate recorded, with fractures uniting at an average of 25.1 (14–46) days. the overall complication rate was 8.3%. two per cent (n=2) of patients needed re-operation, both requiring a re-manipulation and k-wire insertion one week after the initial manipulation. of note, both had been initially treated in a below-elbow cast. overall, 3% (n=3) required the cast to be bivalved because of swelling but none progressed to a compartment syndrome. no one from this lost reduction, two were initially in a forearm cast and one in an above-elbow cast. from the 21 patients treated with k-wires, 14% (n=3) developed low-grade pin tract sepsis. this resolved with a short course of antibiotics with no chronic complications. these made up 3% of the 8.3% complication rate. conclusion: the overall complication rate associated with distal radius metaphyseal fractures is relatively low. the use of k-wires is not a benign undertaking and should be reserved for specific cases that demand it. page 28 sa orthop j 2019;18(3) patient-based outcome after in situ percutaneous pinning for slipped upper femoral epiphysis (sufe) paper: p69 category: paediatrics presenting author: t phiri co-authors: a robertson, d simmons background: percutaneous in situ fixation with a single screw is regarded as safe and remains the gold standard of treatment of sufe. however, reliance is placed on subsequent remodelling of the femoral neck. healing in a non-anatomic position with insufficient remodelling predisposes the patient to femoro-acetabular impingement and degenerative arthritis the hip. consequently, some surgeons advocate surgical hip dislocation and reduction of a severe acute sufe. the aim of this study was to assess patient-based outcomes after in situ pinning. the hypothesis is that our patients remodel adequately and are pain-free and function well after at least two years’ remodelling after in situ pinning. methods: this was a study of a cohort of patients treated by in situ pinning of a sufe. patients were identified from the surgical registers from 2011–2016 and asked to return for follow up. they were all at least two years post-op. outcome measures were a modified harris hip score (hhs) and a visual analogue score (vas). results: seventy-six sufe patients were identified, but only 28 patients were available for follow-up. two were excluded as no pre-operative x-rays were available. of the twenty-six patients included, 16 were male and ten female, and ten had bilateral sufe. the mean age at surgery was 12.9 years. the average bmi was 28.5 kg/m2. the mean follow-up was 3.3 years (2–7 years). hips were classified radiologically into three groups; mild sufe (13), moderate sufe (12) and severe sufe (11). there was a significant deference (p=0.003) between the three groups in terms of functional outcome. mild and moderate slips had excellent outcome and severe slips had good results but with two complications (18%). the mean modified hhs for severe slips was 87.9 and mean vas pain score was 2.36. the overall complication rate for the three groups is 5.6%. conclusion: our results suggest that in our population in situ percutaneous pinning is safe with low complication rates. high patient satisfaction in terms of pain and function suggests that remodelling is effective, even for severe slips. perthes valgising osteotomy paper: p126 category: paediatrics presenting author: a naidoo co-author: mn rasool background: the main aim of operative treatment in perthes disease is containment of the femoral head and preventing further deformation. for advanced perthes, or a non-containable head, salvage procedures involving osteotomies of the pelvis or proximal femur have been described. within this non-containable group is a subset of patients who present with hinge abduction, and a large flattened head which is laterally subluxed. in this group of 18 patients we evaluate the use of a valgising osteotomy stabilised with an intermediate pin and plate, and the radiological and clinical outcomes. methods: eighteen patients with perthes disease were included in this study. they all presented with a painful short limb gait, a fixed flexion deformity of the hip and hinge abduction. they were treated between 2007 and 2017 by adductor tenotomy, a closing wedge valgising osteotomy, derotation to neutral was performed to correct any external rotation deformity, and extension to correct flexion deformity a pin and plate was applied. strict non weightbearing post op was enforced by a u-slab spica, or in an older child by a period of skin traction followed by non-weight bearing with crutches. results: there were 13 boys and five girls. hinge abduction was not present post osteotomy on the table. the leg length discrepancy improved by 1.5–2 cm in all patients, with a gradual improvement of hip range of movement. two patients also had a shelf osteotomy to improve containment of the head. radiographs show improved remodelling of the femoral head with an increase in the neck shaft angle. the pin and plate were removed at one year. conclusion: the valgising osteotomy is a useful salvage procedure to improve outcomes in perthes disease. primary total hip arthroplasty in paediatric patients (<20 years) paper: p113 category: paediatrics presenting author: jd jordaan co-authors: j charilaou, m burger background: the success of total hip arthroplasty (tha) in younger patients has expanded the age groups traditionally set out for hip replacement surgery. performing arthroplasty in the paediatric population group (<20 years) remains controversial, yet the primary aim of this procedure remains to relieve pain, restore function and allow physical and social development in this unique population. the main risk associated with tha in paediatric patients is projected longevity of modern generation hip arthroplasty materials, which has not been establish to date. the aim of this study was to provide an overview of paediatric patients requiring tha at a tertiary hospital within south africa. methods: a retrospective review of all primary tha in patients (<20 years), performed in single tertiary academic hospital in south africa between january 2015 and march 2019, was conducted. patient demographics, pathology and previous surgery, surgical approach, implants fixation and bearing surfaces, primary surgeon seniority and surgical complications were recorded. results: primary tha were performed in 11 patients (n=6 male and n=5 female) in the study period. mean age at surgery was 16 ± 1 year (range 14–19 years). four patients had no formal surgery prior to tha while seven patients had an average of four surgical events prior to tha. primary pathology included avascular necrosis (avn) (n=4), slipped femoral epiphysis surgery (n=4), idiopathic chondrolysis (n=3) and juvenile rheumatoid arthritis (n=1). painful hip ankyloses (n=7) and post-traumatic surgical failure (n=2) contributed to surgical difficulty. surgical approaches included posterior (n=9), direct anterior (n=1) and antero-lateral (n=1) approached. uncemented ceramic on ceramic implant were page 29 sa orthop j 2019;18(3) used in ten cases and uncemented ceramic on high cross-linked polyethylene in a single case. all surgery were performed by arthroplasty consultant. no follow-up surgery to the hip joint has been required to date for any patient, following the initial tha. conclusion: successful tha could be performed in 11 cases of paediatric patients at a tertiary hospital in south africa. the primary pathology in paediatric patients requiring tha in our population was avn followed by slipped femoral epiphysis and chondrolysis. no patient required follow-up surgery. train surfing and train-related accidents, a growing scourge paper: p71 category: paediatrics presenting author: b steyn co-authors: f ahmed, a robertson, d simmons background: in developing countries train travel is economical and popular for adults and children alike. train surfing is a high-risk phenomenon that has become a trend in various parts of south africa. lack of safety precautions on trains and stations also results in injury. we are presenting a case series of paediatric and adolescent patients presenting after train related trauma. we aimed to establish types of injuries and common trends in the mechanisms with the purpose of implementing preventive strategies. methods: a retrospective review of inpatient records of patients aged under 20 years presenting with train related injuries over 9 months (july 2018–march 2019). the family answered a detailed questionnaire relating to the circumstances resulting in trauma and also precise locations of the incidents. we established patient demographics, injury patterns, injury severity, outcomes of injuries and complications. results: six patients were identified. the patients ranged in age from 9 to 15 years (mean 13.2) at the time of injury. the mean length of stay was 26.4 days (range 2–42). of the six, five were male and one female. three were confirmed train surfers while three were trainrelated accidents. five of the six presented with very severe limb injuries. four required some form of amputation. three patients had an injury severity score (iss) of more than 32 and the average iss was 27. conclusion: train surfing has become popular among many youths in south africa. as an orthopaedic department we are seeing increasing numbers. the resultant injuries are severe and often result in disability. half of this series were injuries resulting from accidents related to train transport. these highlight a lack of safety precautions where children are using trains for transport. these cases indicate the need for preventive strategies that may include raising awareness around the danger that trains can pose, identifying train stations at which these injuries commonly occur for possible intervention and public education about train safety. we would also like to use mainstream media to highlight the danger of train surfing and poor compliance with train safety. tuberculosis of the extra-axial skeleton in children paper: p74 category: paediatrics presenting author: a horn co-author: s vajapey background: musculoskeletal tuberculosis (tb) is a disease entity that often mimics other orthopaedic conditions in its radiographic and clinical presentation, which can delay diagnosis and treatment. if left untreated, tb of the joints and bone can lead to severe disability. the purpose of this study is to examine the initial clinical and radiographic presentation of patients with musculoskeletal tb who were treated at our institution over the past ten years and determine the characteristic features that lead to the correct diagnosis. methods: this was a retrospective study consisting of 77 patients with extraaxial tb treated at our institution in cape town, south africa over the last ten years. we collected data on initial clinical presentation, laboratory values, radiographic findings, treatment, and outcomes. we performed quantitative and qualitative analysis to look for patterns in presentation that can help with diagnosis and factors affecting the clinical outcomes. results: the most common presenting complaint was pain or limping. our patients presented with thrombocytosis and anaemia but normal white blood cell count. esr and crp were raised with means of 42.1 mm/hr and 29.2 mg/l respectively. the hiv co-infection rate was 6.5%. among the diagnostic tests specific for tb, mantoux test had the highest sensitivity (70.1%), followed by tissue culture (51.9%), tissue pcr (50.6%) and sputum/gastric washings (14.2%). five patients had inh resistant tb, treatment was not altered for these patients. the most common joint involved was the hip followed by the knee. only three patients developed joint ankylosis. compliance to medical treatment was 97%. conclusion: musculoskeletal tb can be difficult to diagnose and treat. there are several patterns of laboratory values and radiographic findings that can be suggestive of tb as demonstrated in our study and may aid in diagnosing the disease timeously and correctly. no single test is 100% sensitive therefore a combination of clinical, radiological and laboratory investigations should be performed. biopsy is considered mandatory even in the face of clinical certainty, as single and multidrug resistance is becoming more common. medical treatment is typically all that is required; however, compliance is of utmost importance. shoulder and elbow papers: juggerknot soft anchors in arthroscopic shoulder stabilisation paper: p20 category: shoulder and elbow presenting author: m sarsam co-authors: dlj morris, a dekker, m espag, a tambe, d clark background: the juggerknot soft anchor system was launched in 2009 with novel all suture anchors. the juggerknot soft anchor 1.5 mm has been utilised in arthroscopic shoulder stabilisation in our unit since 2011. theorised benefits include reduced removal of bone and fewer hardware complications. however, despite promising page 30 sa orthop j 2019;18(3) biomechanical studies, little evidence is available for their success in vivo. consequently, we performed a service evaluation of implant outcomes in our unit. methods: retrospective cohort analysis of all patients in our unit that underwent arthroscopic shoulder stabilisation in which juggerknot soft anchors were utilised. exclusion criteria include revision procedure, engaging hill-sachs lesion and glenoid bone loss >20%. outcome measure was failure (dislocation and revision surgery). all patients were asked to complete a current oxford instability score (ois) via a postal questionnaire. results: sixty-seven patients underwent arthroscopic shoulder stabilisation utilising a juggerknot soft anchor met our inclusion criteria. mean age at time of surgery was 32.6 years (range 15–55 years). mean follow up is 34.5 months (minimum 13 months). no patient experienced a post-operative dislocation. however, one patient experienced subluxation episodes successfully treated with a latarjet procedure. two patients underwent revision stabilisation due to pain. consequently, failure rate was 4.5%. mean current ois result is 39 (n=49). conclusion: this series supports ongoing use of juggerknot soft anchors in arthroscopic shoulder stabilisation. the failure rate compares favourably with that previously reported in literature. patient reported outcome measure suggests favourable results in the majority of patients. retrospective audit of serum vitamin d levels in patients who underwent latarjet procedure for shoulder instability paper: p133 category: shoulder and elbow presenting author: pa rachuene co-authors: sjl roche, s de villiers, k berry, b vrettos, m mulder, jp du plessis background: vitamin d is important for bone development, growth and healing with well-studied physiological effects. hypovitaminosis d has been shown to interfere with bone healing and graft incorporation in laboratory experimental studies and clinical studies. shoulder instability is very common among young active adults with majority of the cases being post traumatic anterior shoulder instability. the method of stabilisation in many of these cases is the modifiedlatarjet procedure. we have previously documented complications in patient having this surgery, notably graft fracture and osteolysis/ resorption of the bone graft. in july 2017 we noted a patient’s coracoid graft at time of surgery appeared to be abnormally soft and on investigation the patient was found to be vitamin d deficient. we have therefore been offering patients vitamin d levels when the bone appeared soft at time of surgery since this index patient. methods: retrospective review of all patients who had a latarjet procedure from july 2017 until march 2019. patients who were deemed to have suspected soft bone at time of surgery and underwent a vitamin d level. these levels were documented. routine 6 week or 3 monthly post-operative x-rays were assessed for non-union or osteolysis. results: fifty-three patients underwent a latarjet procedure. three were females. the average age 27 years. eleven patients had vitamin d levels done. sixty-three per cent of those patients tested had abnormal vitamin d levels; two patients were deficient, and five were insufficient. there were no graft non-unions, and one graft fracture at 3 months. there was evidence of osteolysis in 35% of the grafts. conclusion: this study highlights a 63% vitamin d deficiency in young patients who undergo a coracoid graft and whom the surgeon perceives there is soft bone. this is a concern as it may lead to osteolysis and non-unions. unfortunately, the whole cohort was not tested and therefore we do not know their vitamin d status. this is the first study on vitamin d and instability patients and highlights the need for further studies including routine testing in this group of patients. the management of proximal humerus fractures by south african shoulder surgeons paper: p98 category: shoulder and elbow presenting author: c anley co-authors: jp du plessis, n ferreira, b vrettos, s roche background: proximal humerus fractures (phfs) account for 5–6% of all fractures, increasing to 10% in patients over the age of 65 years. the recent high profile profher trial (proximal fracture of the humerus evaluation by randomisation) has highlighted the role of conservative treatment in these patients. the results of this study have however not been universally accepted and the treatment of phfs remains debated at both congresses and within the literature. the purpose of this study is to establish what treatment options are currently preferred by south african orthopaedic shoulder surgeons for phfs. in addition, we would like to establish if the recently published profher trial has influenced this treatment. we hypothesise that there remain significant discrepancies in the treatment options employed. methods: this study was undertaken in person at the recent sases congress. the members were asked to complete a basic questionnaire to detail their background after which they were shown a powerpoint presentation containing the radiology of 6, randomly selected patients with phfs. each member completed a questionnaire classifying the fracture (neer classification) and indicating their preferred treatment option. results: a total of 36 members completed the questionnaire (70.5% of the active sases members). only 58% (21/36) of the members had heard of the profher trial and of these members only 38% (8/21) had read the trial. with regard to the six cases presented, there was poor interobserver agreement with regard to the classification of all six fractures and in four of the six fractures with regard to the treatment of the fractures. there was however excellent agreement on the remaining two fractures with regard to treatment. conclusion: the main findings of this study show that there is poor consensus among south african shoulder surgeons on the classification and management of patients with proximal humerus fractures. in addition, only 17% of the members acknowledged the profher trial had altered their management strategies in these patients. page 31 sa orthop j 2019;18(3) the management of rotator cuff tears by south african shoulder surgeons paper: p99 category: shoulder and elbow presenting author: c anley co-authors: a wang, g bain, s kirsten, s roche background: tears of the rotator cuff muscles become more common with increasing age and can range from small partial tears to large full thickness tears that are repairable but may progress to full thickness tears that are irreparable. in addition, these tears can either be traumatic or degenerative. the natural progression of tears remains largely unknown making the recommend treatment options more complex. despite being a common pathology, the preferred management of rotator cuff tears remains widely debated. specific entities commonly debated are if surgery is required, the timing of surgery if it is undertaken and what surgery should be performed (i.e. debridement versus repair.) at present there is no data available on the preferred treatment options among shoulder surgeons in south africa. the purpose of this study is to establish what treatment options are currently preferred by south african orthopaedic surgeons for rotator cuff tears. we hypothesise that surgical treatment is still the preferred treatment option. methods: this study was undertaken in person at the recent sases congress. the members were asked to complete a questionnaire containing six clinical scenarios of patients with rotator cuff pathology followed by a basic questionnaire to detail their backgrounds. finally, they were asked to rank 10 patient variables which may influence their decision to offer a rotator cuff repair from the most important to the least important contraindication. results: a total of 34 (67%) current sases members completed the questionnaire. the average number of years in practise is 16 years, with the average number of cuff repairs performed being 113/year. with regard to the six cases presented, there was poor interobserver agreement with regard to the management of all six scenarios. surgical intervention was more commonly suggested in the presented scenarios. finally, there was poor agreement with regard to the ranking of contraindications for rotator cuff repairs conclusion: the main findings of this study show that there is poor consensus among south african shoulder surgeons on the management of patients with rotator cuff tears. surgical intervention appears to be more commonly suggested than conservative treatment. triceps off fascial sleeve (tofs) approach to the distal humerus paper: p17 category: shoulder and elbow presenting author: w nkomo co-authors: m solomons, s roche, s maqungo aims: primarily, to prospectively describe the functional outcome of intraarticular distal humerus fractures that have already been addressed using this approach. secondary aims include an ultra-sonographic study to assess if the triceps is intact. methods: tools to measure functional outcomes: 1. disability of the arm, shoulder and hand (dash) questionnaire 2. active range of motion of the effected elbow 3. triceps strength, calculated with the aid of a measuring scale 4. sonographic assessment of the effected triceps tendon results: the patients were assessed twice, at a mean of 12 months and again at a mean of 18 months. the mean arc of motion was 104.7 degrees (100 degrees is what is acceptable). there was a decrease in mean triceps muscle strength compared with that of the normal side, at 45 degrees of elbow flexion the mean triceps strength was 65% of normal, at 90 degrees it was 82%, at 120 degrees triceps it was 89%. the mean dash score was 18.4 indicating mild residual impairment. the sonographic assessment showed the triceps tendon to be intact in all the participants. conclusion: an intra-articular distal humerus fracture is a devastating injury. the tofs approach is extensile enough to treat these injuries. our study has shown that these patients can recover to the level of a mild residual physical impairment and attain an acceptable arc of motion with an intact triceps tendon post operatively. the tofs approach is an option when addressing complex distal humerus fractures. spine papers: influence of the newly introduced standard operating procedure on outcomes of acute cervical spine dislocated injuries at groote schuur hospital paper: p75 category: spine presenting author: g ayik co-authors: t mukabata, c osborn, n kruger background: a retrospective analysis was performed on the impact that groote schuur hospital (gsh)’s standard operating procedure (sop) for cervical spine dislocations had on the timing of closed reduction. methods: the study was a retrospective review of patients who presented to gsh with cervical dislocation injuries and were managed with closed reduction. the patient records spanned from 2015 to 2018, data from the acute spinal cord injury database along with patients’ demographic information were gathered and compared. participants within the study time frame were diagnosed with a cervical facet dislocation based on clinical examination findings and radiological confirmation. patients who had reduction performed at other referring hospitals were excluded from the study. results: although it is now regarded as common practice within all western cape hospitals to perform closed reduction of cervical fracture page 32 sa orthop j 2019;18(3) dislocations as soon as possible after injury, in this study the time between injury and closed reduction before introducing sop was 13.13 hours on average, after introduction of sop, the time increased to an average of 14.28 hours. the main cause for delay was transfer time from site of injury to er. other reasons for delay include missed diagnosis, orthopaedic registrar unavailability, and reduction bed incomplete. conclusion: this study found that the time taken for orthopaedic management of cervical dislocations was decreased by an hour after introduction of sop, but the overall time to reduction did not decrease. this was due to delays in transfer to the er and referral to orthopaedics. we recommend that in our setting, reduction could be initiated within an hour of patient arrival, if emergency room doctors rapidly identified the problem and commenced cervical traction when the orthopaedic team was not immediately available. our impression was that there was poor adherence to new sop guidelines on time management by trauma team, and possibly transport delays prior to hospital admission. a further study to investigate the bottlenecks of the referral system is advisable. lower lumbar burst (l3–l5) fractures: incidence and management paper: p32 category: spine presenting author: sj mabusha background: biomechanical and anatomic characteristics of the lower lumbar spine differ from the thoracolumbar region and may account for the inherent stability of these injuries. the objective was to assess the incidence and outcome of management of lower lumbar burst fractures in an adult population. methods: twenty lower lumbar burst fractures were treated at our hospital, from january 2010 to december 2018, with an average follow up of 36 months for both the conservatively and surgically treated groups respectively. eight patients were treated surgically, and 12 patients were treated non-operatively. patients were evaluated for activities of daily living (adls), work status, lower back pain, visual analogue scale (vas), sexual and neurological symptoms. imaging modalities were reviewed for severity of initial injury, transverse process fractures and maintenance of initial correction. results: in general, neurologically intact patients in both groups returned to similar post-injury employment levels. persistent lower back pain was found to be more disabling in the surgically treated group, in which a fusion incorporating four or five lumbar segments was performed. there was no evidence of loss of initial reduction, and no patients experienced late neurological compromise in the surgical group. no patient presented with cauda equina syndrome. one patient reported sexual dysfunction in the form of poor erections. he was duly referred to the urologists. conclusion: conservative treatment of lower lumbar burst fracture is a viable option in the neurologically intact patients, but severe intractable pain, loss of lordosis and vertebral height may persist, leading to evolution of a kyphotic deformity. if surgery is chosen, a short rigid fixation with pedicular instrumentation may be of greater benefit. a long fusion with distraction instrumentation should be avoided in the lumbar spine, as long instrumented fusion can lead to persistent lower back pain. management strategies of lateral mass fractures of the cervical spine paper: p91 category: spine presenting author: ln bomela co-author: sn motsitsi background: cervical lateral mass injuries are rare and most literature about cervical lateral mass fractures is very limited and controversial. this study provides an essential tool in the study of our own population dynamics and confounding factors with regard to the management of lateral mass fractures. the objective was to review the management of the lateral mass fractures of the cervical spine. the study design was a retrospective review of prospectively maintained database. methods: a review was done of all the patients who sustained cervical spine lateral mass fractures over a 12-year period. the lateral mass fractures were classified according to kotani lateral mass classification. for the classification of different lateral mass fractures, a review of the medical records, pre-operative and postoperative x-rays, computed tomography and mri images (where indicated) were performed. results: there was a total of 46 patients. the male to female ratio was 2:1 and the average age was 36 years. the majority (89%) of the injuries were due to high velocity motor vehicle accidents, falls were 8.7% and assault were 2.2%. a third of the patients had varying neurological deficits. radiologically, the majority (37%) of the injuries were type c lateral mass fractures, followed by type a lateral mass fractures (30%). of the operated patients 76% were single level, 13% were two level and 4% were more than three level surgeries. conclusion: the lateral mass fracture represents a spectrum of cervical spine pathology. a third of patients with these injuries present with neurology and two thirds were treated with single level surgery. pre-operative use of traction views in adolescent idiopathic scoliosis paper: p118 category: spine presenting author: sm tlhabane co-authors: a rahman, iar elnour, sa khan background: the aim was to review the pre-operative use of traction x-rays views in the surgical management of adolescent idiopathic scoliosis, with the objective of documenting traction views under general anaesthesia as prediction method in surgical adolescent idiopathic scoliosis (ais) compared with bending views. the hypothesis question was: is pre-operative traction view under general anaesthesia adequate to predict posterior instrumented surgery correctability of the spine curves determined by lenke classification in ais? methods: a retrospective study was done at a single institution. inclusion criteria: all patients, both males and females between the ages of 2 and 20 years, with idiopathic scoliosis; angle more than 40 degrees, measured using cobb method. exclusion criteria: individuals with pathology other than idiopathic scoliosis. pre-operative bending page 33 sa orthop j 2019;18(3) views were obtained for all the patients and the cobb angle measured using cobb’s method. traction views were obtained once the patients were under general anaesthesia and similarly the cobb angles were measured using the cobb’s method. results: the study showed that traction views were able to predict final post-operative correction to as close as 80% compared to 60% predictability when using bending views. conclusion: traction views under general anaesthesia were found to be a good predictor of post-operative correction in the patients with ais. the clinical outcome and surgical management of cervical spine tuberculosis paper: p33 category: spine presenting author: sj mabusha background: normal cervical spine has certain physiological lordosis in standard sagittal position. if sagittal plane changes, the normal physiologic lordosis will be lost, and the cervical kyphosis will develop at different degrees. kyphosis in tuberculosis of the cervical spine tends to be severe and can lead to neurological fallout. methods: twenty-one patients with 23 lesions of cervical spine tuberculosis are reported. angular kyphotic deformity was present in eight patients and neurological complications were present in six patients. the goals of management of tuberculosis of the cervical spine are to eradicate the infection, to prevent or relieve neural compression, to prevent or correct cervical kyphosis and to achieve unrestricted mobilisation and normalisation of patient’s activities of daily living. the aim of the study was to evaluate the clinical and surgical management of the of cervical spinal tuberculosis. between january 2010 and 2018, we performed a retrospective chart review of clinical and radiological data from 100 consecutive spinal tuberculosis patients, including 21 patients who were diagnosed and treated for cervical spine tuberculosis. the patients were evaluated pre-operatively and post-operatively on the basis of haematologic, radiographic and neurological function. an anterior cervical corpectomy and fusion was performed via smith robison approach for all the patients. this case series involves 14 lumbar tuberculosis patients treated with the above given surgical procedure. the following parameters were evaluated: visual analogue scale (vas) score, erythrocyte sedimentation rate (esr) and c-reactive protein value, vertebral body loss, deformity angle, kyphotic angle, cervical lordotic angle and fusion status of affected segment. the mean time of follow-up was 38.2 months (30–46). results: significant improvement was found in all radiologic parameters, and significant decrease in vas and esr were noted after surgery. bony fusion was seen in all cases within a mean time of 4.3 months (range 3–7 months). no post-operative instrumental complication and recurrence were noted. conclusion: all the patients received standard therapy with rifampicin, isoniazid, ethambutol, and pyrazinamide for 18/12. the result of this study showed that anterior surgical approach is a viable option for the management of cervical tuberculosis. tb is a medical condition. the efficacy of radical debridement and spinal instrumentation in adult patients with pott’s paraplegia paper: p115 category: spine presenting author: mn mnisi co-author: ns motsisi background: to review the efficacy of radical debridement and spinal instrumentation in adult patients with pott’s paraplegia. the incidence of spinal tuberculosis has increased in developing countries. there is also an increase in hiv infection and antituberculosis drug resistance in these countries. antituberculosis chemotherapy is still the mainstay treatment of spinal tuberculosis. surgical intervention is indicated in patients with neurological deficit, failed chemotherapy, unstable spine and kyphotic deformity correction. methods: a retrospective study design, review of adult patients admitted in our spinal unit with pott’s paraplegia over a ten-year period. patients included were above the age of 18 years, patients that had surgical intervention combined with chemotherapy and those that only had chemotherapy. patients excluded did not conform to the inclusion criteria. a total of 84 patients files were reviewed. the female to male ratio was 1.05:1 and a mean age of 40 years. all the patients had antituberculosis chemotherapy for 8 weeks then reviewed. twenty-four (28.6%) of the patients had surgical intervention and were followed up for a minimum of 12 months. surgical intervention was anterior radical debridement and fusion plus instrumentation, posterior lateral debridement and fusion plus posterior instrumentation and anterior radical debridement with fusion. results: two-thirds of the patients improved on antituberculosis chemotherapy only. the remainder required surgical intervention. a total of the 24 patients had surgery, 15 of these had significant neurological improvement. from the 15 patients, eight patients improved from asia a to c, four patients from asia b to d and three patients from asia c to e. four of the patients then remained as asia a after 12 months of follow-up. conclusion: shows that two-thirds of the patients improve on antituberculosis chemotherapy in the short-term follow-up. antituberculosis chemotherapy is still mainstay treatment for tb spine. radical debridement and spinal instrumentation combined with antituberculosis chemotherapy is still indicated in patients with neurological deficit asia c and less, failed chemotherapy, progressive neurology, instability and kyphotic deformity. page 34 sa orthop j 2019;18(3) trauma papers: analysis of the complications of volar plate fixation for the treatment of distal radius fractures frykman type 3–6 paper: p146 category: trauma presenting author: s xaso co-authors: mm ramokgopa, sk magobotha background: the aim of the study was to analyse complications after open reduction and internal fixation using a volar plate in distal radius fractures. the hypothesis was that complications after open reduction and internal fixation using a volar plate for distal radius fractures occur less at our institution compared to incidences in the literature. methods: the study design was a retrospective study with prospective recall, with a sample of size of 63 patients. these were patients who were managed operatively between july 2015 and june 2017. inclusion criteria included: patients from 18 years of age and older, active male and female patients and patients with frykman type 3-6 distal radius fractures. exclusion criteria included patients with carpal bone involvement. data collection was done during orthopaedic trauma upper limb clinics by the principal investigator. data analysis was done with a biostatistician, and stata 14 and frequency tables were used. results: the results showed that some specific complications were more and some less than complication rates in literature. in terms of relationship between complications and surgical and patient factors, senior surgeons had less complications and better functional scores. patients with increased number of complications had poor functional scores. conclusion: the incidence of complications of distal radius fractures post open reduction and internal fixation is underestimated as shown by our study and the literature available. however, the complications have been shown to be much less for operations performed by senior colleagues. further research needs to be done as this study had limited number of patients. neck of femur fractures at a tertiary academic hospital: a three-year descriptive analysis paper: p141 presenting author: m manjra co-authors: j charilaou, jd jordaan, m burger, n mullajie background: with improved healthcare and an ageing population, developing countries face a significant increase in managing fragility hip fractures. this involves multifactorial considerations with monetary and social burdens increasing exponentially. many first world guidelines are formulated and despite our best attempts to adhere we are not making adequate advances in preventing and adequately managing this pandemic in developing countries. the aim of this study was to do an in-depth descriptive analysis of patients with neck of femur fractures (noff) at a tertiary south african hospital. methods: patient records of all patients who presented with a displaced noff who underwent hip arthroplasty between 2015 and 2017 were included in this study. general demographic and clinical information was collected and the in-hospital mortality rate was calculated. results: a total of 303 patients (mean age 73.8 ± sd 12.4) comprising 69% females and a left hip predominance (57%) were included. low energy mechanism falls from a standing height, implying severe osteoporosis, accounted for 90.8% (n=275) of fractures. an international comparable in-hospital mortality rate of 3% (n=9) occurred. only 5.3% (n=16) of patients complied to the one-year post-operative follow up visit. conclusion: the results of this study suggest comparable demographic and epidemiological profiles to international literature. unfortunately, noff are not well researched in the context of the south african health care system. future research should first interrogate the true burden of disease to make a concerted effort to formulate more appropriate local guidelines. open approaches for cruciate ligament reconstruction in knee dislocations paper: p48 presenting author: m held co-authors: b schenck, b wäscher, d richter, h hobbs, m laubscher, r von bormann background: open approaches for cruciate ligament surgery play a vital role in a referral setting with limited resources. it further avoids extravasation of arthroscopy fluid and the concomitant risk of compartment syndrome, and is mandatory in large traumatic arthrotomies. there are limited guidelines and reports for open surgery of knee dislocations. we aimed to evaluate patients who had undergone open cruciate surgery for multiple knee ligament injuries. methods: a prospective surgical database of a knee unit in a large urban tertiary care referral centre in south africa was interrogated between july 2016 and november 2018 and patients with a knee dislocation were selected who had undergone open cruciate ligament reconstruction or repair. a review of clinical notes and imaging was performed. demographic information, injury mechanism and type, associated injuries, operating time, complications, as well as patient reported outcomes and radiographic outcomes were described. results: twelve patients (two females, median age 35 years, iqr 21.5) were identified from a pool of 103 patients with multiple knee ligament injuries. all underwent open cruciate surgery. in three patients, extravasation into the posterior compartments during diagnostic arthroscopy triggered the open approach. in 9 patients a large traumatic arthrotomy enabled sufficient access to a medial (in seven patients) or lateral (in two patients) approach to address collateral ligament injuries. all injuries, except one were highenergy injuries caused by road traffic accidents. most patients had damage to three or more of the four main knee ligaments, and most had various associated injuries. the median operating time was page 35 sa orthop j 2019;18(3) 137.5 minutes (iqr 47.5). patients regained a median lysholm score of 80 (iqr 15) after a median of 12months (iqr 6). although 40% reported stiffness, all but one could flex beyond 90°. none required further ligament surgery. one patient had a surgical site infection and one patient had delayed wound healing. conclusion: open cruciate surgery is valuable in a select group of patients with knee dislocations and can achieve acceptable outcomes even in patients with severe injuries. stiffness, infection and wound healing is a concern. outcomes of primary fusion in high energy lisfranc injuries operated at groote schuur hospital: a retrospective study from 2013 to 2018 paper: p95 presenting author: v boskovic co-authors: ji wiegerinck, m laubscher, s maqungo, g mccollum background: high energy lisfranc injuries are relatively uncommon but can lead to severe disability and morbidity. primary fusion is a treatment option that can improve outcomes and reduce the re-operation rate. the purpose of this study was to evaluate our series of primary fusions for high energy lisfranc injuries, looking specifically at type of fusion, time to union, non-union rates, reoperation rates and quality of reduction. methods: folder numbers of patients who underwent surgery for lisfranc injuries were identified from the redcap surgical database and then retrieved from records. only cases of primary fusion in adults were included. we excluded low energy twists and athletic injuries, ipsilateral lower limb injuries and cases where reduction and fixation were done without fusion. radiographs were analysed from the i site enterprise pacs system (phillipstm). results: between 2013 and 2018, 14 cases of high energy lisfranc injuries were identified where primary fusion was done. 7 patients (50%) underwent fusion of first, second and third tarso-metatarsal (tmt) joint, first and second tmt joint were fused in only one case (7.1%), second and third tmt joint fused in four cases (28.6%). only two patients (14.3%) had removal of implants. plate and screws were the technique of choice used for fusion. there was 100% union rate and average time to union was 84 days. acceptable reduction was observed in ten cases (71.4%), four cases (28.6%) of malreduction were found among which one patient had pre-existing hallux valgus. average reduction parameters in the well reduced group were as follows: intermetatarsal angle of 8.04°, medial cuneiform first metatarsal angle of 16.9°, meary’s angle 6.1°, sagittal shift 0.26 mm and coronal shift 0.64 mm. conclusion: the majority of patient who underwent primary fusion of at least one tmt joint had good radiological outcome. no revision surgery was done. we concluded that our series of tarso-metatarsal fracture dislocation did well with primary fusion with a low re-operation rate for mid foot instability or arthritis. radial shortening following low velocity gunshot injuries treated with an intramedullary device paper: p104 presenting author: m abramson co-authors: m laubsher, s maqungo background: long bone fractures resulting from gunshot injuries contribute significantly to the burden of disease in orthopaedic fracture management in south africa. these injuries are often characterised by significant zones of comminution, precluding some of the traditional fixation methods. the intramedullary radial nail provides an additional option to treat these fractures. following its introduction in 2012 , we have performed a number of radial nails following low velocity, gunshot wound (gsw) fractures. routine radiological follow-up revealed shortening in a significant portion of cases. anecdotally it appears that certain areas of the radius are more at risk of shortening when treated with an intramedullary device. this retrospective radiological review aimed to substantiate the incidence of post-operative radial shortening and whether certain anatomical areas are more prone to this sequela. methods: we retrospectively reviewed all cases of radial nails performed for gsw fractures of the radius from 2012 to 2018. cases were divided according to the region involved. initial x-rays were compared to those immediately post-operatively and at fracture union and assessed for shortening using the ipsilateral ulnar as a guide. results: we performed 71 cases within the study period. 18 were excluded due to an ipsilateral ulnar fracture, and a further seven due to insufficient radiological follow up, leaving 46 cases for analysis. ten cases were performed for distal radial shaft fractures, 21 for middle third and 15 for proximal third. there was a total of ten cases assessed as being shortened at time of union. of these, four were seen in distal third fractures, five in middle third and one in proximal third. further analysis showed that seven cases were the result of surgical error in failing to restore fracture length, and three shortened after the index procedure before achieving union. conclusion: radial nails resulted in a significant proportion (22%) of postoperative shortening in our series. further scrutiny is needed to assess whether certain anatomical areas are at higher risk of shortening as it originally seems, or whether careful attention to detail intra-operatively and a sound understanding of the implants design can prevent this from occurring. three months in tygerberg orthopaedic trauma – what is a registrar worth? paper: p94 presenting author: h van zyl co-author: n ferreira background: tygerberg hospital is a tertiary hospital with a drainage area population of about 3.6 million people. the orthopaedic department manage about 6 000 trauma patients per year. the registrar training programme consist of three-month rotations through the different subspecialties of orthopaedics. there is a large discrepancy in the number of surgeons/training surgeons per population between public and private sectors. due to budget and theatre time constraints, the trauma waiting list often exceeds 50–60 patients needing urgent and emergent surgery. this is worsened by other surgical disciplines using orthopaedic theatre time for life threatening injuries due to lack of theatre availability. one of the page 36 sa orthop j 2019;18(3) proposed solutions to this problem is outsourcing of some of the cases to private medical facilities. methods: a retrospective review, of surgical records kept during the threemonth rotation (14 january 2019 to 14 april 2019) of all the surgeries in which the registrar was involved either as leading surgeon or assistant, was done. the surgeon fees were then calculated according to current medical aid rates at 100%. the implant cost was calculated at the average cost to state of the type of implant. no suture or dressing materials were included. results: during the three-month period 154 procedures were done ranging from total hip arthroplasty to septic hand debridements. eleven procedures were done per week. sixty cases were done after 19:00. surgeon fees amounted to r172  101.40 per month, three times that of the net salary of a registrar. implant costs amounted to over r1 250 000. these numbers become significant when taking into account that there are six registrars in the trauma rotation. conclusion: although a very small-scale study this shows the significant amount of trauma work done at a tertiary institution. with increasing budget constraints, pressure on theatre time and growing population, expansion of resources is needed but in a cost-effective way. it seems that increasing capacity in the state sector could be a cheaper option compared to private outsourcing although more indepth analysis needs to be done. what is the preferred method of management of intertrochanteric femur fractures in south africa? a survey of orthopaedic surgeons paper: p120 presenting author: r almeida co-authors: jrt pietrzak, s van deventer background: intertrochanteric femur fractures are a growing concern in society due to the incidence of these fractures in the elderly and our progressively ageing population. despite being a common pathology there is still no clear consensus on the management of these fractures. the aim of this study was to determine the level of agreement among orthopaedic surgeons from academic institutions working in south africa with regard to the treatment choices of intertrochanteric femur fractures. methods: an anonymous questionnaire was used to assess opinions of management of intertrochanteric femur fractures of orthopaedic surgeons who attended the 2018 south african orthopaedic association (saoa) registrar congress. the various orthopaedic surgeons represented eight south african academic institutions. the questionnaire evaluated the surgeon demographics, current training level, and operative considerations in the treatment of intertrochanteric fractures with regard to two case scenarios attached to a picture of an a-p pelvis x-ray showing an unstable type intertrochanteric femur fracture (ota 31–a2). scenario 1 involved an 80-year-old patient and scenario 2 involved a 50-yearold patient. results: forty-seven questionnaires were received back. with regard to scenario 1: 14.9% indicated that a dynamic hip screw (dhs) would be the treatment of choice and 85.1% indicated that a cephalomedullary nail (cmn) would be used, and fixed angle blade plate was not chosen as an option. out of the 40 respondents indicating the use of a cmn, 27.5% preferred a short cmn and 72.5% chose a long cmn. 12.8% respondents indicated they would consider total hip arthroplasty. with regard to scenario 2: 23.4% chose a dhs, 44.7% chose short cmn, 31.9% (n=15) chose long cmn and the option of total hip arthroplasty was not considered by any of the respondents. conclusion: the use of a cmn was preferred in both scenarios, with a long cmn preferred over a short cmn in scenario 1 and a short cmn preferred over a long cmn in scenario 2. this matches the global trend that despite the lack of evidence indicating the best fixation, cmns have become the preferred choice for managing intertrochanteric femur fractures, but nail length remains controversial. posters: a case of mesenteric ischaemia in revision hip arthroscopy poster: e116 category: arthroplasty owner: t pillay a case of tarso-carpal coalition in a 5-year-old poster: e103 category: general owner: d thompson a case report of cephalomedullary nail implant failure poster: e122 category: trauma owner: j wessels a rare sacral tumour poster: e145 category: spine owner: l gqamana aneurysmal bone cyst of the sacrum poster: e36 category: spine owner: s mabusha case report of a 6-year-old child presenting with deep vein thrombosis (dvt) as an orthopaedic complication poster: e96 category: paediatrics owner: s bhikha page 37 sa orthop j 2019;18(3) case report: single stage revision of total knee arthroplasty for metallosis poster: e14 category: arthroplasty owner: j du plessis costing total hip arthroplasty in a south african state tertiary hospital poster: e134 category: arthroplasty owner: ar sekeitto dislocation of a hip replacement due to intra-operative rim fracture of a lipped polyethylene liner. a case report and review of the literature poster: e82 category: arthroplasty owner: d van der jagt dissociation of a dual mobility head after a revision hip replacement. a case report and review of the literature poster: e83 category: arthroplasty owner: d van der jagt double immune compromise, hiv, diabetes and other factors affecting severity and bacteriology in hand infections poster: e59 category: hands owner: h verhoef dysplasia hemimelica epiphysealis poster: e127 category: paediatrics owner: a naidoo femoral component fracture. a rare complication of total knee arthroplasty poster: e38 category: arthroplasty owner: t greeff follow-up of an anatomical cemented stem poster: e39 category: arthroplasty owner: e denes isis ii double mobility cup, a geometry without overhang with a lower risk of iliopsoas tendinitis poster: e16 category: arthroplasty owner: e denes multifocal septic arthritis complicated by osteomyelitis and pseudarthrosis of the humerus poster: e37 category: paediatrics owner: p ntombela neck of femur fractures managed at chris hani baragwanath academic hospital poster: e139 category: arthroplasty owner: n mofokeng non-contiguous tb spine poster: e44 category: spine owner: n dlamini non-accidental injuries: avn of the hip following sexual assault poster: e40 category: paediatrics owner: p ntombela operative daily rate of recovery of thr and tkr and time to discharge decreases with post-directed physiotherapy in an academic hospital poster: e148 category: arthroplasty owner: n sikhauli os odontoideum in down syndrome poster: e34 category: spine owner: s mabusha patient with bilateral madelung deformities as part of a leri-weill dyschondrosteosis poster: e105 category: general owner: d thompson page 38 sa orthop j 2019;18(3) prevalence of hiv in orthopaedic trauma patients. most hiv infected patients present with high energy injuries poster: e29 category: trauma owner: v boskovic prevalence of orthopaedic injuries caused by known assailants at provincial tertiary hospital: prospective study poster: e117 category: general owner: k mogorosi report on a rare case of congenital absent quadriceps and patella in a 7-year-old child poster: e102 category: general owner: d thompson rosai-dorfman disease (rdd): a case presentation poster: e92 category: oncology owner: hc spangenberg screw and cement augmentation of tibial defects in primary total knee arthroplasty poster: e50 category: knees owner: c butcher short-term results following two-stage revision for periprosthetic joint infection poster: e51 category: arthroplasty owner: j du plessis the effect of obesity on total hip and knee joint arthroplasty poster: e97 category: arthroplasty owner: n fang the relevance of post-reduction computed tomography scans in adult patients with type i posterior hip dislocations and concentric reduction on plain radiographs poster: e42 category: trauma owner: a mthembu total hip replacement in an osteogenesis imperfecta patient. a case report and review of the literature poster: e79 category: arthroplasty owner: d van der jagt total knee replacement in an osteogenesis imperfecta patient. a case report and review of the literature poster: e77 category: arthroplasty owner: d van der jagt vertebral hydatidosis with paraplegia poster: e35 category: spine owner: s mabusha page 12 south african orthopaedic journal http://journal.saoa.org.za saoa president’s essay medal i’m a newly qualified orthopaedic surgeon. it was the hardest thing i have ever done. this essay is a reflection on the things i learnt doing it. i could say that i ‘burnt out’ during my surgical training. but that expression has been used to describe such a range of symptoms, from someone merely feeling depressed, to being the cause of a colleague’s suicide, that it has lost most of its meaning. in may 2019 the world health organization (who) clarified the term, and it has its own icd-11 code now: ‘qd85’. it’s not a disorder as such, but one of the ‘factors influencing health status or contact with health services’, specifically related to one’s work environment.1 and besides, i honestly don’t feel that the term accurately describes what happened to me. shortly before the cmsa intermediate examinations, i was not doing very well. after working in the orthopaedic trauma firms, being on call more than once a week, regularly working more than 90 hours per week, and burning the midnight oil on the days that i was at home, i moved over to the surgical icu for a few months. which i found to be a very stressful environment. my attention span was shrinking, my ability to concentrate was getting less by the day and it was making me more and more anxious. and depressed. besides, i hadn’t seen periosteum for weeks. i had started reading a book about a year before, called antifragile by nassim nicolas taleb2 who is something of a modern-day philosopher, mostly doing research on probability and randomness. as orthopaedic surgeons we are well aware of wolff’s law3,4 that describes how function dictates the structure of bone, and taleb had noticed that this principle – that some systems gain from disorder and stress – is found all around us, but no one has come up with a word for it. there is fragile, to describe something that doesn’t like changes in the environment (like a wineglass at an orthopaedic congress) and robust, that describes something that doesn’t care for changes in the environment (like a 30-year-old bristow elevator in the ‘major-ortho’ tray), but nothing that describes something that actually gets better in the face of repetitive stress, like bone. the actual opposite of fragile. thus, he came up with the word ‘antifragile’. i told myself that i was antifragile. just absorb the stress, and you’ll come out stronger on the other side. it had been my mantra all through my surgical training: operate as much as you can, study as much as you can, it’s temporary. but i was failing. why was i failing? the ‘impostor phenomenon’, or now more commonly known as ‘impostor syndrome’, is a term coined in 1978 by dr pauline clance.5 it describes a frame of mind in which one constantly doubts their accomplishments and competencies, despite ample evidence that they are qualified, and have a fear that they are eventually going to be caught out as a fraud. health professionals are especially affected. we have an ingrained ‘duty to care’. we are naturally hard working and perfectionistic personalities, and above all, we are working in an environment where high levels of responsibility and high levels of uncertainty collide. our patients and colleagues don’t need doctors who doubt themselves. and yet i do. i just hope no one finds out. and then something curious happened. i found myself in yet another situation where i was berating myself for not coping and not being good enough, when i had a thought: what if something is happening to me? i started asking for help. i even managed to convince a neurologist to do an mri of my brain. i found myself sitting in a psychiatrist’s office, feeling embarrassed, but then he helped me formulate a thought that had been brewing in the back of my mind: i have injured my brain at work. luckily, i happened on a psychiatrist who is also a researcher, and thinks like i do. there has been a lot of research about the effects of sleep deprivation and chronic stress on the brain. the first article i read about this was a 2001 study6,7 looking at chronically jet-lagged flight attendants over five years. it was a small sample, but it suggested that chronically raised cortisol levels and altered melatonin profiles made their temporal lobes and hippocampi atrophy, making them score worse on computerised cognition tests. more recently, in a 2018 paper8 the researchers describe using functional mri and wearable sleep-tracking devices to investigate how acute sleep deprivation alters the grey matter volume (gmv) in the brain, explaining the real effect of impaired cognition and memory impairments after periods of sleep deprivation. mercifully, they also showed how brains recover normal volume after periods of ‘sleep recovery’. my brain wasn’t shrunk forever. sitting at home one evening, scrolling through the mri slices of my own brain, i realised that it was an organ. an injured part of my body. i was like a training athlete that has torn a hamstring. honestly, for a moment i thought that i was the first to come up with the idea of viewing surgeons as athletes, but there has been much written about it. dr edward verrier is an american cardiothoracic surgeon who transcripted a lecture for the journal of american college of surgeons in 2017.9 it’s a recollection of his training days and how his love for sports has informed his decisions as a surgical programme director over the years. both athletes and surgeons are attracted to the field because they have talent. both realise quickly that it’s going to take more than talent to succeed. both have to rely on physical dexterity and improvisation, and both have to manage a team of people to have a good outcome. both need regular, deliberate exercise to reach and maintain peak performance: they are antifragile. but athletes have coaches. i have a friend that has been very involved in training, and doing research on, elite level cyclists. discussing this idea with him, he mentioned that most of a coach’s job, at that level of performance, is to make sure that training is effective, and that there is enough time for recovery between sessions to ensure that the performance antifragile orthopaedic surgeons: a reflection on the training experience rg venter mbchb(stell), mmed orth (stell), fc orth (sa) consultant orthopaedic surgeon, division of orthopaedic surgery, department of surgical sciences, faculty of medicine and health sciences, stellenbosch university corresponding author: dr rudolph g venter, division of orthhopaedic surgery, clinical building, 4th floor, tygerberg campus, cape town, 7505, south africa; tel: 021 938 9266; email: rgventer@sun.ac.za page 13south african orthopaedic journal http://journal.saoa.org.za peaks actually go up with time. they constantly have to hold the athletes back. explaining how difficult it can be to monitor athletes, he mentioned something called the ‘breakfast test’. imagine a cycling team on tour, staying at a hotel. now imagine the coach going down to the dining hall really early, before any of the cyclists have come down for their breakfast. then he observes them as they descend on breakfast, unaware that they are being watched. athlete a might always look hung-over at this time of the morning, but athlete b is usually bright and on top of things, but today they look equally groggy. it’s a complex process of interpreting trends and seeing warning signs that are specific to the individuals. as healthcare professionals we are expected to manage our own rest and recovery, and honestly, who better than doctors? but, somewhere along the line, i wasn’t being objective about myself and my performance anymore, i couldn’t see my performance dropping. that is something coaches do – they observe independently and objectively to see trends that the athletes do not. atul gawande is an endocrine surgeon, writer and researcher, and i can recommend reading any of his work. in 2011 he wrote an essay about reaching a plateau in his surgical career, and enlisting an old mentor, already retired, to come and coach him in the operating room.10 it’s a brilliant read, and explores his own hesitations and concerns about ‘being caught out’ when one of the cases doesn’t go as planned. maybe the antidote for impostor syndrome is letting the coach into the room. the way we train surgeons hasn’t changed in decades, as verrier discusses in his lecture mentioned above,9 but the environment in which we train them has changed; there is a much higher burden of disease, with limited staff and resources. and so have the trainees changed, now typically older, because the programmes are more competitive, and some have already started families. but most importantly, in my opinion, we are not monitoring them. when we plan a construct for fracture fixation we have to make sure that it will withstand the loads and create the optimal biomechanical environment for fracture healing. to make these decisions we need to understand the mechanical properties of the components we are working with. young’s modulus, or the modulus of elasticity, is a way to describe how different materials respond to load, specifically, the relationship between stress over strain: e = ε σ stress (σ) is equal to force applied to an amount of surface area but it does not describe how the material in question responds to the stress, just how much stress. strain (ε), on the other hand, describes how an object is deformed when stress is applied. ε = l δl here, the starting length of the object (l) increases as the object is stretched. more difference in length (δl) means more strain (ε). the implication here is that 10 cm of stretching will generate much more strain for an object that is 100 cm long, as opposed to one that is only 10 cm long to begin with. i’m sure you can see where i am going with this. first (and forgive me if i am taking the analogy too far), when we build systems with humans, we typically don’t consider how much stress and strain the individuals can tolerate, and we leave the monitoring up to the humans that make up the system. at worst, we blame them for the ‘construct’ failing. secondly, consider that an individual can tolerate varying amounts of stress, depending on how many ‘reserves’ (l) an individual has. with a new appreciation that even the most antifragile thing can fracture, i approached my situation as an occupational injury, treating acute symptoms and resting, followed by rehabilitation and reconditioning. and now, like an athlete with an old injury, i am more aware of myself in times of stress, and careful to actually rest when it’s time to recover. something unexpected that came from using this different terminology, was that others around me started talking too, as if the stigma had been lifted, and i became much more aware of how much strain the people around me were experiencing. i see myself as a near-miss in a way, and this is the part of the essay where i think of the friends and colleagues who didn’t make it through the programme and the one who didn’t make it at all.11 to go back to taleb’s book, he goes on to describe ways to measure the antifragility of abstract systems like economic markets. it is a bit too abstract to try and measure an individual’s ability to bounce back after stress, but i believe that it is something we can learn, and coach each other in. not just for registrar training, but for living as an orthopaedic surgeon, and surviving all the stresses life will throw at us, while maintaining high levels of expertise and competency. i was very happy to learn about the peer-reviewing processes that the saoa is instituting, and it is a sign that our profession is making healthy decisions about its future, making itself antifragile, and ready for the stress and strain to come. references 1. qd85 occupational burnout [internet]. [cited 2019 jun 27]. available from: https://icd.who.int/browse11/l-m/en#/http://id.who. int/icd/entity/129180281 2. taleb nn. antifragile: things that gain from disorder. random house us 2012. 3. wolff j. the law of bone remodelling. [internet]. 1st ed. springerverlag berlin heidelberg; 1986. available from: https://www. springer.com/gp/book/9783642710339 4. lee tc, taylor d. bone remodelling: should we cry wolff? ir j med sci 1999;168(2):102-105. 5. clance pr, imes sa. the imposter phenomenon in high achieving women: dynamics and therapeutic intervention. psychother theory, res pract [internet]. 1978;15(3):241-47. available from: http://doi.apa.org/getdoi.cfm?doi=10.1037/h0086006 6. cho k. chronic ‘jet lag’ produces temporal lobe atrophy and spatial cognitive deficits. nat neurosci. 2001;4(6):567-68. 7. van someren ej. article reviewed: chronic ‘jet lag’ produces temporal lobe atrophy and spatial cognitive deficits. sleep med. 2002;3(1):81-82. 8. dai x-j, jiang j, zhang z, nie x, liu b-x, pei l, et al. plasticity and susceptibility of brain morphometry alterations to insufficient sleep. front psychiatry. 2018;9(june). 9. verrier ed. the elite athlete, the master surgeon. j am coll surg [internet]. 2017;224(3):225-35. available from: http://dx.doi. org/10.1016/j.jamcollsurg.2016.11.004 10. gawande a. personal best [internet]. available from: https://www. newyorker.com/magazine/2011/10/03/personal-best 11. paarlpost. doctor’s body found on paarl mountain [internet]. available from: https://www.netwerk24.com/za/paarl-post/nuus/ doctors-body-found-on-paarl-mountain-20171220-2