South African Orthopaedic Journal

A new approach in the treatment of hip osteoarthritis: ultrasound-guided 3-in-1 injection

Burak T Dede — 2025-11-24

Osteoarthritis (OA) of the hip is a very common chronic condition characterised by progressive erosion of the articular hyaline cartilage, inflammation of the synovial membrane, and degeneration of the joint capsule and musculotendinous structures, resulting in structural damage to the entire joint. The treatment approach for hip OA is multifaceted, focusing on pain reduction and improvement in function. There are many treatment modalities, and non-surgical treatment options remain popular, especially in the younger population. Among non-surgical treatments, intra-articular injections, treatments for trigger points in myofascial pain syndrome, and nerve blocks are frequently used.^1-3

Rethinking arthroscopy: orthopaedic surgeons’ responsibility in combating climate change through sustainable practices

Pududu Archie Rachuene — 2025-11-24

In recent months, South Africa has experienced a series of extreme weather events that underscore the growing impact of climate change on our planet. The rare and destructive tornado that struck KwaZulu-Natal in May and June of 2024, the unusual snowfall in Gauteng in 2023, and the devastating floods in KwaZulu-Natal and the Eastern Cape provinces serve as stark reminders of the changing climate. A startling truth has been revealed by recent studies: the healthcare sector is the third-largest emitter of greenhouse gases, responsible for an alarming 4 to 5% of these emissions globally.¹ Reports indicate that the healthcare sector would rank as the fifth-largest emitter of greenhouse gases if it were a country, highlighting the urgent need for immediate attention to this sobering reality.²The operating theatre is the most prominent example of this impact within the healthcare ecosystem, as the convergence of technological advancements and surgical practices has introduced an era of unprecedented consumption. In an effort to serve as an appeal to my colleagues, I have composed this editorial.

Functional and patient-reported outcomes of terrible triad elbow fracture-dislocations

Jacobus P Strydom — 2025-11-24

Background: The elbow ranks second only to the shoulder as the most commonly dislocated large joint in the human body. Terrible triad elbow injuries, or simply terrible triad (TT), involve an elbow dislocation coupled with a radial head and coronoid fracture. This study aimed to assess functional and patient-reported outcomes for surgically managed TT patients.

Methods: An ambidirectional observational study included all adults who underwent surgical treatment for TT over a six-year period. Demographic data, elbow range of motion (ROM), and QuickDASH scores were collected. Elbow ROM data was used in a preferential order of a participation goniometer measurement followed by a photographic measurement and, lastly, recorded values within the patient’s file.

Results: Of the 49 eligible patients (mean age 37.5 ± 12.3 years), 39 patients followed up postoperatively at a median of 18.0 (2.0–34.3) months. Thirty-six of the 39 patients followed up postoperatively and had relevant data pertaining to elbow ROM. Of these, 17 were successfully recruited to participate. The mean flexion and extension endpoints were 118.7° ± 19.4° and 39.9° ± 19.3° respectively, while mean flexion-extension arc (FEA) was 77.4° ± 28.5° (n = 36). Pronation and supination had mean endpoints of 58.4° ± 26.4° (n = 32) and 54.9° ± 32.5° (n = 30) respectively, with mean prosupination arc (PSA) at 111.2° ± 52.3° (n = 30). Median (interquartile range) QuickDASH score among participants was 31.8 (9.1–47.7), with seven participants scoring < 25 (9.1 [8.0–10.2]) and eight participants between 25 and 50 (40.9 [35.2–48.3]). Functional flexionextension ROM, accepted as 130° flexion and 30° extension with a FEA of 100°, was not met, but prosupination functional ROM (50° prosupination and 100° PSA) was retained.

Conclusion: Discrepancies that exist between the measured ROM and the subjective patient outcomes suggest that further investigation is needed to understand the clinical impact on patient experience and functionality.

Level of evidence: 3

The neurological outcomes of patients with cervical spinal cord injury treated by closed reduction and surgical stabilisation: a retrospective longitudinal study

Silas B Mabitsela — 2025-11-24

Background: Cervical spinal cord injury (CSI) from cervical spine dislocation as a result of motor vehicle accidents (MVAs) and low-velocity trauma are common in South Africa. Taking into consideration the pathophysiology of traumatic CSI and the possible neurological benefits of early cervical spinal cord decompression, it remains imperative that patients with CSI post-cervical spine dislocation be managed urgently by early closed reduction, which can be conducted safely. The study aimed to evaluate the neurological outcomes of patients who sustained cervical spine fracture-dislocations or dislocations with CSI who were treated with closed reduction.

Methods: This is a retrospective study of 62 patients who sustained subaxial cervical spine fractures/dislocations with CSI and were managed by closed reduction and surgical stabilisation. We documented the demographics of the patients and the radiologic level of injury. The American Spinal Injury Association (ASIA) scoring system was used to assess neurology at presentation, post-closed reduction, post-surgical stabilisation, and during the follow-up period (one, three, six and 12 months post-operation). Time intervals between injury and closed reduction, and timing between injury and surgical stabilisation, were noted.

Results: Seventy-nine per cent of patients who underwent satisfactory closed reduction experienced neurological improvement by the end of follow-up. Thirty-nine per cent improved within the first 24 hours post-injury. Only 2% of those reduced after 24 hours showed neurological recovery. A statistically significant difference in neurological outcomes was observed (p < 0.001) between patients who underwent closed reduction within 24 hours of injury and those who had reduction after 24 hours of injury, emphasising the urgency of early treatment for optimal recovery in CSIs.

Conclusion: Patients who underwent closed reduction within 24 hours of injury demonstrated significantly better neurological outcomes compared to those treated later, with a statistically significant difference in recovery rates. These results emphasise the critical need for prompt dislocation reduction to optimise neurological recovery in managing CSIs.

Level of evidence: 3

Blood management strategies in posterior corrective surgery for idiopathic scoliosis

Mohammad HS Aftab — 2025-11-24

Background: Corrective surgery for adolescent idiopathic scoliosis (AIS) is associated with large volumes of blood loss and a need for blood transfusion. Our study aim was to measure blood loss and blood products used intraoperatively in corrective surgery, and to identify modifiable factors that may influence blood loss.

Methods: The study was a retrospective review of patients who underwent posterior corrective surgery for AIS between 2015 and 2020 at a single centre. A total of 43 patients were identified, of which 36 met the inclusion criteria. Sociodemographic data, intraoperative blood loss parameters, transfusion requirements, and use of tranexamic acid (TXA), intraoperative cell salvage (ICS) and ultrasonic bone scalpel (UBS) were documented. Data were analysed to identify factors affecting intraoperative blood loss and blood transfusion.

Results: The 36 patients (30 female, 6 male) had a median age of 16 (interquartile range: 13–17) years. The mean duration of surgery was 355 (± 75.4) minutes, and the average number of segments fused was 10.3 (± 1.9). The mean estimated blood loss (EBL) was 722.2 (± 328.3) ml, with the mean percentage blood loss being 23 (± 11.6)%. A total of 11 patients (31%) received a blood transfusion; in these patients every 139.6 ml of blood lost resulted in one unit of blood being transfused (p = 0.005). Statistically significant differences in mean EBL were found with the use of TXA (p = 0.018) and UBS (p = 0.01). Use of ICS did not result in statistically significant differences in mean EBL. A direct correlation was also found with EBL and the duration of surgery (p = 0.025), and the number of segments fused (p = 0.005).

Conclusion: Multifactorial blood management strategies should be implemented to decrease blood loss and reduce the need for blood transfusion in corrective scoliosis surgery. These include the use of TXA, UBS and ICS. Additionally, attempts should be made to decrease the duration of surgery.

Level of evidence: 3

HIV and multiple myeloma: do patients present at a younger age? A perspective from a South African orthopaedic oncology unit

Oatile Phakathi — 2025-11-24

Background: Multiple myeloma (MM) is the third most common haematological malignancy and the most common malignancy affecting the skeletal systems of the elderly. Skeletal-related events (SREs) such as hypercalcaemia, bone pain, spinal cord compression, and pathological fracture are common sequelae of multiple myeloma bone disease (MMBD) and are the reasons patients might consult an orthopaedic surgeon. It has been established that infection with the human immunodeficiency virus (HIV) increases one’s risk of developing haematological malignancies. However, there is scant literature on how HIV infection affects MMBD, particularly from a South African perspective. We hypothesised that MMBD presents at a younger age and with more advanced disease in HIV-positive individuals.

Methods: A retrospective single-centre descriptive study was undertaken of patients with newly diagnosed MM presenting with SREs to an orthopaedic oncology unit between 1 January 2016 and 31 December 2020. Patient demographic data (e.g., age, race and sex), biochemical and histopathological results, and whole-body X-rays (WBXR) were collected for each participant.

Results: Twenty-seven patients were included. The median age at presentation was 56 years (interquartile range [IQR]: 49‒47). Regarding HIV infection, 19% (n = 5) were HIV-positive, 45% (n = 12) were HIV-negative, and 37% (n = 10) had an unknown status due to absent screening. The age at presentation in HIV-positive patients was 44 years (IQR: 41–51); in HIV-negative patients, it was 58 years (IQR: 48–66). The difference in age at presentation between HIV-positive and HIV-negative patients was statistically significant, with a Kruskal-Wallis p-value of 0.041. Among HIV-positive patients, 60% (n = 3) presented with International Staging System (ISS) stage III disease, while 50% (n = 10) of HIV-negative patients presented with ISS stage II disease, with the Fisher’s exact p-value = 0.836 indicating an insignificant difference. The presenting complaint was mainly a pathological fracture in 67% (n = 20), predominantly affecting the femur in 50% (n = 10).

Conclusion: The majority of MM patients present to the orthopaedic surgeon with pathological fractures and commonly have more advanced disease. In our setting, when treating a young HIV-infected individual with a pathological fracture, one should always consider MM as a likely diagnosis.

Level of evidence: 4

Contemporary indications for neoadjuvant chemotherapy for conventional osteosarcoma: results from a survey of South African surgeons and onco

Phakamani G Mthethwa — 2025-11-24

Background: This study describes the contemporary approach to using neoadjuvant chemotherapy (NACT) in high-grade conventional osteosarcoma (COS) of the extremities in South African clinical practice. Secondarily, we determine if any factors were associated with routinely using NACT.

Methods: A cross-sectional questionnaire-based online survey was performed involving orthopaedic oncology surgeons and medical oncologists working in South Africa on the indications and use of NACT in COS. For statistical analysis, we employed Stata Version 18 and GraphPad Prism analysis to generate descriptive statistics and encode open-ended responses. We used chi-square or Fisher’s exact association tests to summarise variables with medians and percentages. Univariate and multivariate logistic regression assessed associations with NACT use in COS, with significance at p < 0.05. The reliability of the survey scale was Cronbach’s alpha coefficient (0.6409).

Results: NACT was routinely prescribed by 69% of all respondents. Orthopaedic surgeons were less likely to recommend the use of NACT than oncologists (odds ratio [OR] 0.16; 95% confidence interval [CI] 0.02 to 0.95; p = 0.044). Notably, orthopaedic surgeons were also more likely to treat a high volume of COS cases per annum (OR 0.02; CI 0.002 to 0.25; p < 0.001). Regarding NACT administration without limb salvage, orthopaedic surgeons were less likely to prescribe NACT prior to amputation surgery than oncologists (OR 0.11; CI 0.02 to 0.73; p = 0.041). A public practice clinical setting was associated with worse outcomes regarding disease progression (DP) on NACT (OR +infinity; CI 1.364 to +infinity; p < 0.043) and NACT response rate < 50% (OR 18.33; CI 2.51 to 102.5; p = 0.005).

Conclusion: In South African clinical practice, we observed disparities in the approach to treating highgrade conventional osteosarcomas of the extremities among clinicians regarding the use of neoadjuvant chemotherapy. This further elucidates the need for more data pertaining to COS in South Africa to enable the development of pragmatic treatment guidelines tailored to our context to improve outcomes.

Level of evidence: 5

Surgical management of carpometacarpal joint arthritis of the thumb: a current concepts review

John Myburgh — 2025-11-24

The thumb carpometacarpal (CMC) joint is the hand joint second most affected by arthritis. It is significantly more prevalent in females, articularly post-menopausal women. Clinical assessment of the thumb CMC arthritis is enhanced by the arthritic quintet examination, which includes the following five elements: inspection for thenar atrophy, palpation for joint line tenderness, assessment of range of motion, grind test for crepitus and pain, and evaluation of grip and pinch strength. This structured approach improves diagnostic accuracy and ensures standardised evaluation. The diagnosis of CMC joint arthritis is based on a combination of history and clinical examination, supported by radiography. The Eaton and Littler classification and its modified versions remain widely adopted in staging thumb CMC arthritis. The surgical indications depend not solely on the radiological findings but on the clinical symptoms, such as functional deficits and pain. The primary indication for surgery is intolerable pain with minimal response to non-surgical management. Surgery aims to diminish pain and improve function without any complications. High-quality research is lacking, and a recent Cochrane review update failed to show that any operative procedure demonstrated superiority over another in terms of pain, function, patient global assessment, range of movement, or strength. Trapezium-sparing surgical strategies aim to preserve native anatomy while alleviating pain and restoring stability. Denervation of the CMC joint improves pain and function, but there is a lack of information in the literature on reliable longterm results. CMC joint arthroscopic-assisted techniques show improvement in pain, a smaller effect on grip strength, and no effect on pinch strength. A Wilson closing wedge osteotomy of the thumb metacarpal shows pain relief, patient satisfaction, and an increase in both grip and pinch strength. CMC joint arthrodesis indicated in younger patients who perform manual labour has a high non-union rate. Spacers have a high complication rate. The new generation arthroplasty implants have a ten-year survival rate in excess of 90%. Trapeziectomy, with or without tendon interposition, remains one of the most commonly performed operations. Variations include simple trapeziectomy, trapeziectomy with ligament reconstruction, and trapeziectomy with a suspension device (TightRope). Trapeziectomy alone had fewer complications than the other procedures.

CPD Questionnaire (V24N04)

Editorial Office — 2025-11-24

CPD Questionnaire (V24N04)