Orthopaedics

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A molecular study of the immunopathogenesis of TB spondylitis in HIV -infected and -uninfected patients.
(2008) Danaviah, Sivapragashini.; Cassol, Sharon.; Ndung'u, Peter Thumbi.
Abstract can be viewed in PDF document.
An integrated approach to adult chronic osteomyelitis.
(2014) Marais, Leonard Charles.; Aldous, Colleen Michelle.
No evidence-based guidelines exist on the treatment of chronic osteomyelitis of long bones in adults. Management is still largely based on expert opinion and consensus guidelines are not available. Choosing between a palliative and curative treatment strategy requires consideration of several factors. Principle amongst these is the host’s physiological status, which determines the patient’s ability to cope with the rigours of limb salvage surgery. This fact was recognized by Cierny and Mader, when they developed their popular staging system. The authors suggested palliative treatment in C-hosts, who will not be able to cope with the metabolic demands of an aggressive treatment plan. The problem however, is that the C-host was never accurately defined. Cierny and Mader predicted in their original paper that, as a result of the inadequate definition, the selection of surgical candidates would vary from institution to institution until there was standardization of this concept. The limitations of existing classification systems prompted the development of a novel approach to chronic osteomyelitis for use in South Africa. This involved the establishment of an objective definition of a C-host, as well the development of a novel classification system and an algorithmic guideline to treatment strategy selection. By integrating the physiological status of the host (based on pragmatic predefined criteria) with the selection of the appropriate curative, palliative or alternative treatment strategy we were able to achieve favourable short term outcomes in both low and high risk cases and in addition reduce the rate of amputation. Furthermore, we were able to report novel data on the outcome of palliative treatment, as well as the outcome of treatment of chronic osteomyelitis in HIV infected patients. While the preliminary results appear promising, long term follow-up will be required in order to determine the rate of recurrence of infection. The proposed approach was designed specifically with the South African clinical environment in mind and additional development of the algorithm may be required in order to render it useful in other clinical settings. The implementation of a refined host stratification, which incorporates objective criteria for C-host classification will, however, enable the comparison of results from studies employing different therapeutic interventions in the future. In addition, selection of patient-matched treatment options closes the gap in successful outcomes between healthy and compromised patients. The major benefit of the proposed approach is therefore the fact that the integrated approach places appropriate emphasis on the importance of host factor modification prior to surgical intervention.
The outcome of tibial non-union treatment using a revised definition, classification system and management strategy.
(2015) Ferreira, Nando.; Aldous, Colleen Michelle.
The management of tibial non-unions remains a challenge for orthopaedic surgeons. The treatment of tibial non-unions is historically based on small case series that frequently include a variety of non-union subtypes and infected cases. Fixation methods and treatment strategies also vary greatly between published series. This lack of uniformity in the available literature has rendered the establishment of evidence-based, reproducible protocols for the management of tibial non-unions difficult. Controversies regarding non-union definition and classification contribute to delays in treatment and exacerbate the morbidity that is commonly associated with non-union development. In this work we propose a new definition for non-union and introduced a novel concept of ‘potential non-union’ to emphasise the importance of early recognition and referral. The lack of reproducible, evidence-based treatment protocols, combined with the large volume of tibial non-union cases managed in KwaZulu-Natal, South Africa, lead to the development of a tibial non-union treatment algorithm. This algorithm was based on results from two retrospective audits of patients with tibial non-unions who were managed with circular external fixators over a four-year period. The algorithm classifies non-unions into four distinct groups, each with a specific treatment strategy. These reports also introduced the concept of mechano-biology to the management of tibial non-unions and were the first to use hexapod circular fixators for distraction of stiff hypertrophic tibial non-unions. Subsequently a prospective interventional study was undertaken aimed at evaluating the effectiveness of the proposed tibial non-union treatment algorithm.
The orthopaedic manifestations of osteogenesis imperfecta : a collective review.
(2016) Bhatta, Aabash Dev.; Rasool, Mahomed Noor.
Osteogenesis imperfecta (OI), or brittle bone disease, is a debilitating genetic disorder of connective tissue which is characterized by reduced skeletal mass and bone fragility. OI results from mutations in genes encoding for type I collagen. Since collagen is the major structural protein in bone, ligaments, tendons, skin, sclera and dentin, clinical manifestations of OI include fragile bones with skeletal deformity, blue sclerae, hearing loss, and opalescent teeth. The orthopedic manifestations of OI are diverse. Most OI patients present with long bone fractures, joint contractures, foot deformities and bowing of long bones. Successful treatment of this condition is potentially challenging and requires a multidisciplinary approach. Surgical intervention is cumbersome because of growing bone, poor bone quality and soft tissue contractures. Advances in the medical management of OI have shown promising increases in bone mineral density and decreases in fracture incidence.
Preoperative factors associated with extended postoperative length of stay in patients undergoing primary hip arthroplasty.
(2017) Dlamini, Nkanyiso Freedom.; Ryan, Paul Vincent.; Moodley, Yoshan.
Orthopaedic disorders of the hip are becoming more common in many countries around the world, including South Africa. Conservative medical treatment of severe hip disorders might sometimes be ineffective in reducing pain or restoring hip function in some patients. In these patients, surgical intervention, through primary hip arthroplasty, remains the only viable option for reducing pain and restoring hip function. The increasing demand for primary hip arthroplasty in South Africa poses a problem for many resource-limited orthopaedic units in the country. It is possible that many of these orthopaedic units will be forced to consider fast-track surgery and recovery protocols to cope with the increased demand for primary hip arthroplasty. These protocols aim to shorten postoperative LoS, reduce complications, and allow for more efficient financial expenditure and resource allocation per patient. An understanding of which characteristics are associated with extended postoperative length of stay (EPLoS) in primary hip arthroplasty patients would have important implications for fast-track postoperative protocols being implemented in South African settings. This was the impetus for the current study. This study was a retrospective chart review involving 185 South African primary hip arthroplasty patients. Univariate and multivariate data analysis were performed to identify crude and independent associations between various characteristics and EPLoS. There were three preoperative risk factors (gender, fixed flexion deformity, patient’s maximum walking distance) and one intraoperative risk factor (extended duration of surgery) which were independently associated with EPLoS following primary hip arthroplasty in South African patients.
Arthroscopic arthrolysis after total knee arthroplasty.
(2020) Desai, Yussuf Mohammed.; Ryan, Paul Vincent.
Arthrofibrosis is an uncommon reason for poor outcomes after Total Knee Arthroplasty (TKA). There is paucity of evidence for the management of this complication. The aim of this study was to assess the longitudinal changes in the range of motion pre- and post-TKA, pre- and post-arthroscopy and at final follow up in patients who had arthroscopic arthrolysis for arthrofibrosis after TKA. Patients were identified from a prospectively collected database who had an arthroscopic arthrolysis for decreased range of movement following TKA which was not present immediately post-TKA and not attributable to any other cause. Patients underwent a systematic arthrolysis, manipulation under anaesthesia (MUA) and intensive physical therapy thereafter. The main outcome measures were range of motion (ROM) recorded at different intervals and overall patient satisfaction. A total of 16 patients were included for analysis. Patients were followed-up for a mean of 20 months (range 1 - 48 months) after the arthroscopic arthrolysis and MUA. The median prearthroscopic ROM was 28° (IQR 18°- 40°) and following arthroscopy was found to be 90° (IQR 88°- 100°). These gains however decreased with time to a median of 65° (IQR 38°- 88°) at final follow up. The mean improvement in the range of motion from the pre-arthroscopy value to that v found at final follow-up was 32 (95% CI = 19.0 - 45.3, p < 0.001). Three quarters of patients were satisfied with the outcome of the procedure. One patient developed a complication in the form of an iatrogenic patella fracture. Where other causes for knee loss of movement and pain have been ruled out, and arthrofibrosis is likely to be the sole cause of knee stiffness, arthroscopic debridement may be of benefit to improve ROM even if performed more than one year after the arthroplasty.

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