The burden of road traffic accident-related trauma to orthopaedic healthcare and resource utilisation at a South African tertiary hospital : a cost analysis study

BACKGROUND : Road traffic accidents (RTAs), the second commonest cause of trauma in South Africa (SA), are on the rise. It is therefore important to study and understand the burden of RTA-related injuries on our orthopaedic healthcare and healthcare in general, in order to devise new prevention strategies to minimise the number of RTAs. METHODS : A retrospective analysis of data from orthopaedic trauma intake records was done for patients admitted with RTA-related injuries to the orthopaedic department at a South African tertiary hospital between February 2019 and January 2020. Hospital records and the PAC (picture archiving and communication) system were analysed for radiological studies done. The Uniform Patient Fee Schedule (UPFS) was analysed for individual costing of all variables being studied. RESULTS : There were 642 patients seen and managed with RTA-related injuries included in this study. Seventy-one per cent of them were males, with an average age of 35 years. The majority (76.2%) were motor vehicle occupants, whereas 17% were pedestrians. Seventeen per cent of them had polytrauma. Four hundred and sixty-two (76%) patients required some form of surgical intervention and spent an average of 171 minutes in theatre per procedure. Ten per cent of these patients required ICU/HCU admission for an average of 13 days. The total length of hospital stay was an average of 21.8 days. The majority of patients (67%) had some form of orthopaedic implant inserted, with an average of 1.3 implants per patient. The average cost per patient was R92 737.39. The major cost drivers were hospital stay, ICU/HCU stay, implant cost, radiological studies and theatre utilisation, respectively. CONCLUSION : Management of RTA-related trauma puts a significant burden on orthopaedic healthcare management and resource utilisation. While we may not be able to directly influence other contributing factors to high costs, reducing the use of temporary external fixators may help reduce the cost of managing RTA victims. These findings provide scientific data which will help support the implementation of preventative measures aimed at minimising the numbers of RTAs we see on our roads, thereby minimising the burden this puts on our healthcare system.http://journal.saoa.org.zadm2022Orthopaedic Surger

Multiple tendon ruptures in ochronosis : case report and review of prophylactic therapy

Ochronosis is dark pigmentation of connective tissue in patients with alkaptonuria. The dark pigmentation is caused by accumulation of homogentisic acid (HGA) and its metabolites in the connective tissues, due to deficiency of an enzyme that degrades HGA in the tyrosine degradation pathway. The deposition of HGA in connective tissue causes weakness of the tendon and subsequent rupture, especially the large tendons in the body. Rupture of isolated tendons has been reported in many case reports in the literature. We report on a patient with multiple sequential tendon ruptures, and review the literature to see if there is a way of preventing subsequent tendon ruptures after an initial rupture in this condition.http://www.charpublications.co.za/C_JournalsORTH.aspam201

Epidemiology of paediatric and adolescent fractures admitted to a South African provincial hospital

BACKGROUND : There are limited studies available that examine the epidemiology of children and adolescents admitted with orthopaedic injuries in developing countries. Several unique factors in South Africa, such as a large socio-economic divide and a public health sector with limited resources, are suggested to influence injury patterns and fracture management. The data emanating from this study may play a role in identifying potential preventative measures. The aims of the study were to determine the age, sex, duration of admission, aetiology and management regimen of paediatric and adolescent patients admitted with fractures in a South African provincial hospital. PATIENTS AND METHODS : We did a cross-sectional review of medical records for the period 1 January 2016 to 31 December 2017 at a South African provincial hospital. Convenience sampling was done, and demographic and clinical data was collected from patient records. All patients younger than 18 years at the time of injury who were admitted with fractures of the limbs, pelvis or spine were included. Patients with incomplete clinical records were excluded. RESULTS : A total of 731 patients were admitted during this period. After excluding patients with incomplete records, 526 (72%) were included in the study. From these records we found a higher percentage of males admitted (73%) and the average age was 7.72 years. The average duration of admission was 8.59 days. A fall on ground level was the most common mechanism of injury (70.0%), followed by pedestrian vehicle accidents (12.2%). The most frequently fractured regions were the forearm (36.4%), humerus (26.5%) and femur (18.9%). Multiple fractures were sustained by 2.4% and additional non-skeletal injuries were sustained by 2.9%. There was one fatality: a patient who presented with gunshot trauma. CONCLUSION : Despite fall-related injuries being the most common cause for admission, pedestrian vehicle accident prevention can have the greatest effect on admissions. They require significantly longer hospitalisation and present more frequently with additional injuries. By implementing safety strategies and improving road infrastructure, we can theoretically decrease the number of serious paediatric admissions. LEVEL OF EVIDENCE : Level 4.http://journal.saoa.org.zaam2021Orthopaedic Surger

The relationship of the size of the footprint of the fibular graft to the surface area of the vertebral endplate in the reconstruction of the anterior column of the spine

INTRODUCTION : The anterior column of the spine is often destroyed by trauma, infection or tumours. It is reconstructed by using an autograft, allograft or synthetic cages. The fibular autograft provides good strength, incorporates quickly and has less risk of disease transmission, which is a big advantage in communities with a high incidence of HIV. Various authors cite that its major drawback is the size of its footprint because of the possibility of subsidence. We could not, however, find any literature that measures its size. AIM : To measure the size of the footprint of the fibular graft in relation to the surface area of the vertebral endplate. The clinical relevance is that it may guide the surgeon in deciding how many struts of the fibular graft to use in reconstructing the anterior column, and also quantifies the statement that the fibular strut has a small footprint. MATERIAL AND METHOD : CT angiograms are done frequently for peripheral vascular diseases. These angiograms show CT scan images of the lumbar and thoracic vertebrae, and fibulae of the same patient. We retrospectively examined 60 scans done during the years 2012 and 2013. From the CT scans, we measured the surface area of the endplates of the vertebral bodies of T6, 8, 12, L2, and the surface area of the cut surface of the proximal 10 cm, 20 cm and 30 cm of the fibular graft, all in square millimetres (mm2). We then compared the areas of the vertebral measurements to the area of the fibular graft measurements. RESULTS : The middle third of the fibular graft had the biggest axial surface area. The ratio of the fibular graft surface area to that of the thoracic vertebral endplate is 1:3–6. These ratios suggest that more than one fibular strut graft is required to reconstruct the anterior column in the thoracic spine. CONCLUSION : The results show that the fibular graft is better suited for reconstruction in the upper thoracic spine. Below that more than two struts are required.http://www.scielo.org.za/scielo.php?script=sci_serial&pid=1681-150X&lng=pt&nrm=isoam2017Orthopaedic SurgeryRadiolog

The posterior horn of the medial and lateral meniscus both reduce the effective posterior tibial slope : a radiographic MRI study

PURPOSE : The purpose of this study was to quantify the posterior horn meniscal slope and determine its contribution to the reduction in posterior tibial slope. METHODS : Patients aged between 16 and 60 years and had intact menisci with no evidence of previous injury or surgery were included. Patients with radiological evidence of osteoarthritis Grade II–IV, any acute or chronic meniscus injuries, fractures, and ligamentous injuries were excluded. The posterior bony slope (PTS) and the meniscus slope (MS) of the posterior horns were measured at 25, 50, and 75% from the medial and lateral borders of the tibial plateau. RESULTS : 325 MR images (mean age 37.1 ± 10.9 years) were included. There were 194 males and 131 females, with 162 left and 163 right knees. The PTS in the medial compartment ranged from (−) 2.8° to 3.7° and from (−) 1.3° to 1.9° in the lateral compartment (p = 0.0001). The MS in the medial compartment ranged from 27.4° to 28.2°, and from 27.8° to 28.7° in the lateral compartment (p > 0.05). The differences between the medial and lateral knee compartment were statistically significant. At the 25% interval the p level was 0.037, at 50% p = 0.00001, and at 75% p = 0.0001. There were no significant between gender differences. CONCLUSIONS : The results of this study demonstrated a significant reduction in posterior tibial bone slope by the posterior horns of both the medial and lateral meniscus, from a mean of (−) 1° to 2° to a more horizontal anterior slope. The posterior bone slope was larger in the medial compartment by 1°, resulting in a smaller slope reduction in the lateral compartment.https://link.springer.com/journal/276hj2022AnatomyOrthopaedic Surger

New horizons in the diagnosis of tuberculosis of the spine : the role of whole genome sequencing

STUDY DESIGN : Prospective study. PURPOSE : To evaluate the utility of whole genome sequencing (WGS) in drug resistance testing, lineage of the organisms, and organism-related factors responsible for bacilli settling in the spine. OVERVIEW OF LITERATURE : The workstream for the diagnosis of tuberculosis (TB) involves isolation and culture of the organism and drug resistance testing using phenotypic methods. Xpert MTB/RIF Ultra is a genetic-based method that detects for Mycobacterium tuberculosis DNA in the rpoB gene. Meanwhile, WGS is a newer genetic-based method that assesses the whole genome of the bacterium. Very few studies have reported the use of WGS for extrapulmonary TB. Herein, we used WGS to diagnose spinal TB. METHODS : Tissues from 61 patients undergoing surgery for spinal TB underwent histologic examination, Xpert MTB/RIF Ultra, and culture and sensitivity testing. DNA from the cultured bacteria was sent for WGS. The test bacterial genome was compared to a reference strain of pulmonary TB. RESULTS : Acid-fast bacilli were observed in 9/58 specimens. Meanwhile, histology confirmed TB in all the patients. Bacilli were cultured in 28 patients (48.3%), and the average time to culture was 18.7 days. Xpert MTB/RIF Ultra was positive in 47 patients (85%). WGS was performed in 23 specimens. Overall, 45% of the strains belonged to lineage 2 (East Asian). There was one case of multidrug-resistant TB and two cases of non-tuberculous mycobacteria on WGS. We could not confirm any genomic difference between pulmonary and spinal TB strains. CONCLUSIONS : Xpert MTB/RIF Ultra of tissues or pus is the investigation of choice when diagnosing spinal TB. Meanwhile, WGS can diagnose multidrug-resistant TB and non-tuberculous mycobacteria more accurately. No mutations were identified in spinal and pulmonary TB bacteria.https://asianspinejournal.orgOrthopaedic Surger

Comparing outcomes between enhanced recovery after surgery and traditional protocols in total knee arthroplasty : a retrospective cohort study

BACKGROUND : Knee replacement surgery was traditionally associated with prolonged recovery and rehabilitation programmes in hospital. Enhanced recovery after surgery (ERAS) protocols have been shown to be cost effective while not compromising patient safety or functional outcome. Despite this proven efficacy, ERAS has not been widely adopted in South African orthopaedic practices. The aim of this study is to determine if it is possible to practise these guidelines in South Africa so as to decrease the length of stay (LOS) without an increase in complication rate or compromise in functional outcome. METHODS : Included in the study were 119 patients undergoing elective total knee arthroplasty between 2013 and 2017. They were divided into two cohorts. The first group was treated with a traditional protocol and included 59 patients. The second group was treated with ERAS and included 60 patients, following implementation of the ERAS protocol in 2015. The functional outcome was assessed using the Oxford Knee Score (OKS). The 30-day readmission rate was used to assess safety of early discharge. LOS and patient demographics were also collected to compare the cohorts. RESULTS : There was no clinically significant difference between the cohorts with regards to OKS or readmission rate. Two sample t-tests were used to compare these parameters. The mean OKS for the traditional group was 59.1 (SD 2.4), and for the ERAS group, 58.7 (SD 5.0) (p = 0.73). The readmission rate was 8.5% in the traditional group and 10% in the ERAS group (p = 1.00). The LOS was significantly decreased in the ERAS group, with a mean of 2.3 days (SD 1.8) compared to 5.0 (SD 2.2) in the traditional group (p < 0.001). CONCLUSION : ERAS protocols used in the South African context in elective total knee arthroplasty significantly decrease the LOS without compromising patient safety or functional outcome.http://journal.saoa.org.zadm2022Orthopaedic Surger

Tumour volume as a predictor of metastases in patients presenting with high-grade conventional osteosarcoma of the extremities

BACKGROUND: The aim of this study was to compare the initial tumour volume in patients with and without pulmonary and/or skeletal metastases at time of presentation. The secondary aim was to compare the value of tumour volume in the prediction of metastases at time of presentation with known predictive factors, namely serum alkaline phosphatase (ALP) and lactate dehydrogenase (LDH). MATERIALS AND METHODS: A retrospective cross-sectional analysis was performed comparing the primary tumour volume in patients with and without metastases. All patients with histologically confirmed high-grade conventional osteosarcoma over a five-year period were included. RESULTS: The study comprised 61 patients. The mean age was 21 years (SD: 11.9, range 5–56) with an equal distribution of males and females (51% vs 49%). There was no correlation between tumour volume and age at presentation (p=0.31). There was no evidence of metastases in only 20% (n=12) of patients. Skeletal metastases were present in 28% (n=16) of the patients and pulmonary metastases were present in 44 cases (72%). There was no significant difference in the tumour volume at presentation between patients with and without pulmonary metastases (p=0.11). However, tumour volume did appear to predict the presence of skeletal metastases (p=0.02). A tumour volume of 1 383 cm³ had a negative predictive value (NPV) of 92% and positive predictive value (PPV) of 55% for the presence of skeletal metastases (area under curve [AUC]=0.76; sensitivity 66%; specificity 87%). A tumour volume of 480 cm³ had a 100% NPV for the presence of skeletal metastases (AUC=0.74). A tumour volume ≥1 380 cm³ had an odds ratio (OR) of 13.6 (p<0.01; 95% CI 2.6–72.5) as an independent variable in relation to skeletal metastases. Multivariate analysis (with ALP and LDH) of tumour volume ≥1 380 cm³ yielded an OR of 8.6 (p=0.04; 95% CI 1.1–67) for presence of skeletal metastases. CONCLUSION: In this series of conventional high-grade osteosarcoma of the extremities, we found a very high rate of metastases at time of diagnosis. While there was no association with pulmonary metastases, increased tumour volume was associated with an increased risk for the presence of skeletal metastases. More studies in the developing world clinical setting are required to investigate this further; the high rate of metastases seen at time of diagnosis also requires further investigation.http://journal.saoa.org.zapm2021Orthopaedic Surger

Non-operative treatment of odontoid peg fractures

OBJECTIVE: The aim of this study was to review the results of non-operative treatment of odontoid fractures in Steve Biko Academic Hospital, Pretoria. METHODS: Records for all patients treated for odontoid fractures from 2008 to 2018 were reviewed. 28 patients met the study criteria. Demographic data, mechanism of injury, associated injuries, neurology, imaging studies and treatment were reviewed. RESULTS: There were 23 males and 5 females. The average age at presentation was 39.5 years. 25 patients were injured in road traffic accidents. Associated injuries were present in 21 patients, mostly involving the spine and head. 18 fractures were classified as Type II and 15 as Type III. Fracture comminution (5), angulation (6) and translation (10) were noted. Primarily treatment modalities were cones callipers, Philadelphia collar or halo vest. Fracture union was assessed radiologically at 3, 6 and 9 months. Type II and III fractures had high union rates at 6 and 9 months. Significantly displaced fractures had a statistically lower union rate (p = 0.0285) at 6 months. CONCLUSION: Minimally displaced odontoid Type II and III fractures can be effectively treated non-operatively in young adults. Extent of fracture displacement is the single important factor in non-union rate.www.scirp.org/journal/oalibjpm2021Orthopaedic Surger

Open tibial fractures : risk factors for infection in conversion of external fixator to intramedullary nail at a tertiary academic hospital

AIM : To determine the rate of infection in open tibial fractures treated by conversion of an external fixation into an intramedullary nail, and to identify the factors contributing to the infections. METHODS : The study included a total of 52 patients. Multiple variables were assessed as risk factors that could lead to infection in open tibial fractures treated primarily with an external fixator and later converted into an intramedullary nail. The factors looked at were: age, average time taken from injury to debridement, average time taken from admission to debridement, antibiotics administration, facility that admitted the patient before intramedullary nail, average time for conversion of external fixator into intramedullary nail insertion, type of soft tissue management, initial Gustilo and Anderson classification and retrospective re-classification of fractures, existence of superficial sepsis or pin-tract infection, radiologic evidence of infection, the Injury Severity Score and the type of external fixator used. A p value < 0.05 was used as the threshold for level of significance. RESULTS : The average follow-up was 37 weeks (median 24 weeks). We had a 40% infection rate CI [27%, 55%]. Factors that were found to be the most statistically significant (p≤0.05) were amount of soft tissue injury and fracture comminution; this is after the fractures were retrospectively re-classified. All other factors looked at were not statistically significant as risk factors for infection (p>0.05). CONCLUSION : The study suggests that correct classification of open tibial fractures, with recognition of soft tissue injury and bone comminution, is important in reducing infection rates and in ensuring proper initial management of these fractures. Treatment should be based on the classification done in theatre during the initial debridement, rather than on presentation in the trauma unit.http://journal.saoa.org.zaam2019Orthopaedic Surger