South African Orthopaedic Journal

Narrative review of the valgus knee in primary total joint arthroplasty

Richard P Almeida — 2024-03-18

The valgus knee is less common than the neutral or varus aligned knees in primary total knee arthroplasty (TKA). TKA is technically more challenging in the valgus knee because of the relative difficulty of restoring the joint line, correcting limb alignment, ensuring stability and correcting patellofemoral tracking. Consequently, TKA outcomes are poorer in the valgus knee. The valgus deformity may be intra- or extra-articular or a combination of both, with bony and soft tissue changes resulting in alteration of the rotational profile of the lower limb. Bony changes in the femur include hypoplasia of the distal femur lateral condyle and erosion of the posterior aspect of the lateral condyle. Bony changes in the tibia include remodelling of the lateral tibia plateau and metaphyseal bone. Soft tissue structures on the lateral aspect of the knee may be contracted or tightened with attenuation of the medial stabilising structures. These features contribute to a change in the rotational profile of the knee resulting in external rotation of the tibia and lateral subluxation of the patella with maltracking. Clinical examination should be thorough in both standing and supine positions and must the include the foot and ankle as hindfoot alignment affects the mechanical axis of the weight-bearing lower limb. Neurovascular assessment of the limb should document peroneal nerve integrity as this nerve is at risk of damage at the time of deformity correction. Radiological assessment should, ideally, include long limb weight-bearing views in multiple planes. Computer tomography scanning may be appropriate in cases of severe bony deformities or poorly appreciated anatomical landmarks on standard radiographs. This review delves into the various classification systems for valgus knees and finally, focuses on surgical approaches, appropriate implant choices and technological advancements in the management of the valgus knee. A clear understanding of the pathoanotomy of the valgus knee together with a thorough clinical assessment and appropriate use of technology should help improve outcomes of TKA in the valgus knee.

Level of evidence: Level 5

A radiological assessment of tibia shaft fractures stabilised with intramedullary nails by trainee surgeons

Alexis S Whitehead — 2024-03-18

Background: This retrospective cohort study analysed patient files and radiographs of 158 patients who underwent tibial nail surgery between April 2016 and March 2018 at a level one trauma centre in South Africa. The aim was to evaluate the radiological adequacy of reduction of tibial fractures treated by intramedullary nailing at our institution, and to identify factors associated with poor reduction and the causes of early loss of reduction.

Methods: Demographic and injury data were collected, and radiographs were digitally measured at two time points. The data were analysed to determine the success rate of adequate reductions and identify any factors associated with unacceptable reductions.

Results: Out of 163 tibial fractures, the majority showed adequate reductions that were maintained until follow-up. Motorised vehicle accidents were the most common cause of fracture (64%), and the majority of fractures were closed injuries (60%). A malalignment rate of 32% was found overall, with the bulk of these being minor deviations of a few degrees. Fractures in the proximal third were most likely to be malaligned. However, fractures in the distal third were most likely to displace after surgery. Surgeon level of experience and time of day the surgery occurred were associated with rates of malalignment.

Conclusion: This study demonstrates a high rate of acceptable reduction that is in keeping with international standards. These procedures were commonly performed by trainee orthopaedic surgeons, and the results demonstrate that trainee orthopaedic surgeons can perform tibial nail surgery to an acceptable standard. Factors correlated with poor reductions were proximal third fractures requiring three proximal screws, and complex cases done during daytime hours.

Level of evidence: Level 3

3D printing in osteosarcoma of the scapula: a unique case

Dheeraj Makkar — 2024-03-18

Background: Osteosarcoma is a malignant tumour that typically originates in long bones. We present a case of a subject afflicted by osteosarcoma in the left shoulder, an extremely uncommon location.

Case report: The subject, a 14-year-old adolescent, presented with a manifestation of osteosarcoma in an atypical location, namely the left shoulder. Radiographic analysis, including scapula plain radiograph, identified a radiodense lesion. Subsequent computed tomography disclosed compromised cortical integrity without medullary tissue involvement. Histological verification confirmed osteosarcoma. The absence of a commercially available suitably sized endoprosthesis for this unique anatomical location prompted the innovative use of a 3D-printed version based on the dimensions of the unaffected right shoulder. Post scapulectomy, a hernia mesh was employed for glenoid capsule reconstruction, ensuring subluxation prevention and yielding excellent postoperative outcomes.

Discussion: This case underscores the complexities and innovations in osteosarcoma treatment when occurring in unconventional anatomical sites, exemplified by its manifestation in the scapula. The integration of 3D-printing technology emerges as a promising avenue for tailoring solutions in orthopaedic oncology, particularly addressing the constraints posed by the absence of commercially available devices for rare anatomical locations.

Conclusion: Managing scapular osteosarcoma necessitates innovative approaches. The incorporation of 3D-printing technology and the unconventional use of hernia mesh exemplify a viable strategy for achieving successful outcomes in challenging cases, emphasising the importance of adapting techniques to unique clinical scenarios.

Level of evidence: Level 4

Improving quality of care in total knee arthroplasty using risk prediction: a narrative review of predictive models and factors associated with their implementation in clinical practice

Daniel J Gould — 2024-03-18

With the growing capacity of modern healthcare systems, predictive analytics techniques are becoming increasingly powerful and more accessible. Careful consideration must be given to the whole process of prognostic model development and implementation to improve patient care in orthopaedics. Using the example of risk prediction models for total knee arthroplasty outcomes, the literature was reviewed to identify evidence and examples of factors associated with successfully taking predictive models from the computer and implementing them in the clinical environment where they can influence patient outcomes. There were 164 articles included after screening 439 abstracts, 37 of which reported models which had been implemented in the clinical environment. Six of these 37 articles reported some form of clinical impact evaluation, and five of the six evaluated the Risk Assessment and Prediction Tool (RAPT) for arthroplasty. These models demonstrated some positive impacts on clinical outcomes, such as decreased length of stay. However, the findings of this review demonstrate that only a small proportion of developed risk prediction models have been successfully implemented in the clinical environment where they can achieve this positive clinical impact.

Level of evidence: Level 5

Measurement of functional acetabular column sizes using a 3D CT model, for guiding percutaneous screw fixation of acetabular fractures using fluoroscopy

Sven Strydom — 2024-03-18

Background: Percutaneous acetabular screw fixation remains a technically challenging procedure, despite good outcomes being reported with appropriate patient selection. In the developing world, where intraoperative computer tomography (CT) guidance (O-arm) and dedicated screws are not readily available, this procedure becomes even more challenging, as surgeons often place screws under fluoroscopic guidance only. Additionally, incorrect screw sizing can lead to cortical breaching with catastrophic vascular damage and other serious consequences. This study aimed to demonstrate how surgeons working with intraoperative fluoroscopy can use preoperative three-dimensional (3D) reconstructed CT scans to plan and safely insert screws into these ‘functional fluoroscopic corridors’, and to compare column sizes for screw selection in the South African population to existing literature.

Methods: A retrospective study using data obtained from CT scans of adult patients was performed. Threedimensional reconstructions of the pelvis were used to create a novel technique of simulating the ‘functional’ bone corridors used during fluoroscopic surgery in order to take the measurements of the anterior and posterior acetabular columns in 301 patients (163 male and 138 female). Exclusion criteria were: any previous trauma and fractures of the pelvis, congenital abnormalities and tumours involving the bony pelvis. We also demonstrate the use of this technique in a clinical case.

Results: Our study confirmed that column sizes in the South African population are in keeping with previous publications. We demonstrate how this novel preoperative 3D-CT planning technique can be used to identify intraoperative surgical corridors using fluoroscopy.

Conclusion: Although column sizes in the South African population are shown to be in keeping with international literature, our study demonstrates a novel technique for using 3D CT reconstructions preoperatively, in the same orientation used intraoperatively with fluoroscopy, to help guide screw size choice and placement. This technique shows promise for reducing cortical breaches in settings where intraoperative O-arms are not available, as appropriately sized screws can be preselected on an individualised basis.

Level of evidence: Level 3

Thirty-day unplanned reoperation following spinal surgery: how does the South African private sector measure up?

Marcus van Heukelum — 2024-03-18

Background: Thirty-day readmission rate and 30-day reoperation rate are recognised indicators of perioperative quality of care. While these indicators have been reported in numerous studies from developed countries, little is known about readmission and reoperation following spinal surgery in South Africa. The main aim of this study was to describe the overall rate of 30-day reoperation and 30-day readmission following spine surgery in a large open medical scheme. Secondary aims were to describe the reasons for 30-day reoperation and 30-day reoperation by spine region and for certain procedures.

Methods: This retrospective cohort study was based on an anonymised dataset of spine surgeries funded by the largest open medical scheme in South Africa between 2008 and 2017. The dataset was processed to identify descriptors of each surgery, including the year of operation, patient demographics, spinal pathology, spine region and certain procedures. The primary outcome was reoperation within 30 days, which was identified based on the time to the second operation, diagnostic codes and procedure codes.

Results: A total of 49 395 spine surgeries were included in the study, of which at least 38 218 (77%) were for degenerative pathology. Overall, 3 204 (6.5%) surgeries were associated with 30-day readmission for any cause and 415 (0.8%) patients underwent a second unplanned spine surgery within 30 days of the initial spine procedure. The most common reasons for the 415 reoperations were neural compression (n = 160, 39%) and infection (n = 79, 19%).

Conclusion: Spine surgery in the South African private sector is associated with low rates of 30-day readmission and reoperation, suggesting good quality of perioperative care. Furthermore, the findings compare favourably with those from developed countries. Future studies should investigate long-term reoperation following spinal surgery to provide more comprehensive insight into the quality of spinal surgery care in the South African private healthcare setting.

Level of evidence: Level 3

Intimate partner violence: an orthopaedic agenda

Christian Cotchobos — 2024-03-18

In 2019, South Africa made global headlines as thousands marched to parliament following the murder and rape of a 19-yearold university student. The population was taking a stand against gender-based violence (GBV). Femicide in South Africa is five times higher than the global average,¹ with intimate partner violence (IPV) being the primary contributor.² One in three women globally have experienced IPV in their lifetime, with the brunt borne by low-to-middle-income countries (LMICs).^2,3 Despite this, the IPV challenge remains largely neglected in the LMIC setting, with a lack of meaningful interventions. Action needs to be taken.

Clinician-driven strategies to sustain health justice in the public health sector

Ntambue Kauta — 2024-03-18

One objective of the South African National Health Act No. 61 of 2003 is the provision of best possible healthcare services to all within the limits of available resources.¹

Cost consciousness and prevention of wasteful expenditure is required to sustain the provision of a high standard and affordable medical care to all. When available resources are threatened and diminishing, as is the case in our nation in these recent months and likely to persist for the foreseeable future, elective surgeries are at imminent risk of being postponed indefinitely. The tendency to delay or postpone elective surgery emanates from the natural need to prioritise patients with acute life-threatening conditions or traumatic injuries which compete with elective pathologies for resources. Postponement of elective surgeries prolongs patient suffering and poor quality of life, and does not support the mandate of health justice.

Universal healthcare coverage: we might not need to throw the baby out with the bathwater

Leonard C Marais — 2024-03-18

I believe there is not a healthcare worker (HCW) in South Africa, either in the public or private sector, who will oppose the idea of universal healthcare coverage (UHC) for all the people of South Africa. The big question though, which will certainly be a lot more controversial among HCWs, is: What is the optimal healthcare model to achieve this objective in South Africa? Currently, policymakers are aiming to achieve this goal through the establishment of a South African National Health Insurance (NHI). The South African National Department of Health’s (NDoH) medium-term strategic framework for 2019–2024, as well as the NDP’s (National Development Plan) Implementation Plan for 2019–2024, identified achieving UHC by implementing the NHI policy as a strategic goal. The NHI Bill was introduced in Parliament in August 2019 and was passed by the National Assembly in June 2023. At the time of writing, the bill was with the President of South Africa after being passed by the National Council of Provinces’ Select Committee on Health and Social Services for consideration. The NDoH strategic plan document stated that 2026 was being targeted for the implementation of NHI. In the words of the acting director general at the time, ‘The National Health Insurance (NHI) policy of government aims to dismantle the system and introduce several structural reforms’.

CPD Questionnaire (V23N01)

Editorial Office — 2024-03-18

CPD Questionnaire