South African Orthopaedic Journal

Current concepts in thrower’s shoulder: a South African perspective

Mon, 01 Sep 2025 00:00:00 +0000

The overhead throw is a fundamental movement utilised in numerous sports for a variety of reasons such as pitching in baseball, fielding in cricket, and passing or shooting in water polo. In the throwing athlete, the delicate balance of an external rotation gain (ERG) with a reciprocal glenohumeral internal rotation deficit (GIRD) while maintaining a 180° rotational arc is known as the thrower’s paradox, described in baseball pitchers. This narrative review aimed to evaluate research findings and clinical experiences for two popular South African sports, namely cricket and water polo, to determine if these throwing athletes possess similar musculoskeletal and throwing characteristics classically described for baseball pitchers. Cricket and water polo players displayed distinctly different musculoskeletal characteristics to baseball pitchers. Cricketers did not present with the shoulder ERG frequently identified in throwing athletes, while water polo players did not demonstrate the decrease in internal rotation range commonly seen in throwers. A decreased external to internal rotation strength ratio (ER:IR) is a common risk factor in baseball pitchers. Cricketers and water polo players maintained a normal ER:IR ratio but presented with a decrease in both internal and external rotation strength. Finally, both cricketers and water polo players present with a downwardly rotated scapula at rest, which is contrary to previous findings in throwers. Water polo players had a significantly greater upward scapula rotation angle at 90°, which refutes subacromial internal impingement as a mechanism of injury in this group of overhead throwing athletes. Further differences are demonstrated in the throwing biomechanics of both sports, with cricketers using less shoulder external rotation and thoracolumbar range of motion while throwing compared to pitchers. Limited evidence found that water polo players use greater shoulder elevation than baseball pitchers or cricketers during shooting. While the literature documenting the types of shoulder pathology for cricketers and water polo players are scarce, there is clinical evidence that the different throwing athletes may present with a broad spectrum of shoulder injuries. In clinical practice, these insights can be used to enhance both the clinical assessment and management of overhead athletes.

Access to reverse shoulder arthroplasty in South Africa’s public healthcare system

Mon, 01 Sep 2025 00:00:00 +0000

Background: Access to healthcare services, particularly surgical interventions, remains a critical challenge in low- to middle-income countries (LMICs). Reverse shoulder arthroplasty (RSA) is the most frequently performed arthroplasty procedure of the shoulder and is recommended for the treatment of complex shoulder conditions in the elderly population. This study investigated the availability and accessibility of RSA within South Africa’s public healthcare system, focusing on equity in surgical care provision.

Methods: Using a multifaceted research approach, data were collected from 33 professionals across eight provinces, representing a significant proportion of the population.

Results: Results indicate significant disparities in access to RSA, with urban areas and tertiary hospitals having better resources and capacity. The majority of the tertiary level hospitals are easily accessible to urban compared to rural dwellers. Despite the growing need for RSA, particularly among older demographics, the study reveals a scarcity of skilled shoulder surgeons and inadequate infrastructure, especially in rural regions.

Conclusion: These findings underscore systemic barriers hindering equitable access to RSA and surgical care in South Africa. Recommendations include increasing resources for training, improving infrastructure, and enhancing referral systems to address these disparities and ensure universal access to essential surgical services.

Level of evidence: 4

Risk factors for complication requiring reintervention following reverse shoulder arthroplasty: a retrospective study 2011–2021

Jan du Plessis, Megan O'Connor, Odette Koch, Theo Le Roux — Mon, 01 Sep 2025 00:00:00 +0000

Background: Degenerative disease of the shoulder is successfully managed with arthroplasty. In the presence of a deficient rotator cuff, the non-anatomic reverse shoulder arthroplasty (RSA) is advantageous. High rates of complication following RSA have been reported in previous international investigations. We aimed to determine the local complication requiring reintervention rate, and identify any associated risk factors.

Methods: We conducted a retrospective electronic medical record review of all patients that underwent RSA between January 2011 and December 2021. Basic demographic details including type and number of comorbidities were captured, and follow-up notes reviewed for the documentation of complications. The data was summarised, the complication requiring reintervention rate calculated, and logistic regression performed to identify any factors associated with an increased risk of complication.

Results: A total of 93 patients met inclusion criteria, including six patients with bilateral pathology accounting for 99 cases, with a median follow-up of 1 121 days. The cohort comprised predominantly female patients (65%) with a median age of 72 years, and 55% required RSA for rotator cuff arthropathy. A total of 24% of cases complicated and required reintervention; 20% required additional surgery. Ten cases complicated with sepsis, 12 cases with instability, and one each with a haematoma and mechanical failure. Ninety-three per cent of patients had comorbid disease, and renal pathology was associated with a 5.9 times increased risk of complication.

Conclusion: In a ten-year review of patients undergoing RSA for degenerative disease, we report a 24% complication requiring reintervention rate. The most common complications included instability and sepsis. Patients with renal pathology were found to be at greater risk of complications requiring reintervention. Future prospective evaluation of RSA outcomes is needed to identify all factors contributary to complications.

Level of evidence: 4

Deep infection rate resulting in reoperation in minor hand surgery with wide-awake local anaesthesia no tourniquet (WALANT) under field sterility in an outpatient setting

Lee L Skosana, Odette Koch, Shade Olorunju, Lelanie Rademan, Theo Le Roux — Mon, 01 Sep 2025 00:00:00 +0000

Background: The study aims to determine the incidence of surgical site infection (SSI) leading to reoperation following minor hand procedures performed outside the main operating room using field sterility.

Methods: The investigators retrospectively reviewed clinical records of 504 cases in 440 patients who underwent wide-awake local anaesthesia no tourniquet (WALANT) minor hand surgery in a field sterility setting over a four-year period between March 2019 and June 2023. The data was collected at a tertiary institution which serves members of the South African Military Service via a wide catchment area. SSI was defined according to the Centers for Disease Control and Prevention (CDC) occurring within four weeks postoperatively. Cases included were elective WALANT minor hand procedures in patients above 18 years.

Results: The deep SSI rate within four weeks postoperatively resulting in reoperation was 1% (95% confidence interval [CI] 0.01–0.02); infection rate for carpal tunnel release (CTR) was 2%, (95% CI 0.74–5.20). The majority of procedures performed were carpal tunnel and trigger finger eleases, with a female predominance at 57% and the average age of patients being 57 years (SD ± 13 years).

Conclusion: The study’s infection rate is comparable to international infection rates for similar surgeries performed using field sterility in an outpatient setting. Minor hand procedures performed under field sterility using WALANT have a low SSI rate with acceptable morbidity. This implies that WALANT under field sterility is a safe clinical practice.

Level of evidence: 4

Outcomes of single-stage surgical treatment of diaphyseal non-union of the humerus

Dane Maimin, Sheldon Moss, Maritz Laubscher — Mon, 01 Sep 2025 00:00:00 +0000

Background: Non-union of diaphyseal humerus fractures occurs in up to 30% of non-surgically managedfractures and 10% of surgically treated fractures. Failed nonoperative treatment may present with muscle atrophy, pseudoarthrosis and shoulder and elbow stiffness; and surgically treated fractures may have compromised soft tissues, broken hardware and infection. There is no accepted gold standard of treatment for this complex problem.

Methods: A retrospective cross-sectional study was performed of data collected prospectively over an eight-year period, from February 2016 to January 2024. Our single-stage surgical technique is described.

Results: We included 32 single-stage non-union surgeries. The average age was 42 years, and 59% were male. Ten patients were smokers. Twelve were open fractures, including gunshot wounds. Seventy-two per cent of patients had already had some form of surgery to their arm, and four had confirmatory signs of infection prior to non-union surgery. Three patients required a debridement post non-union surgery due to new signs of infection. Two patients required late additional unplanned revision surgery due to ongoing non-union, but also ultimately united.

Conclusion: Single-stage revision surgery may be an effective form of treatment of diaphyseal humerus fracture non-unions. In our series, this was successfully used in the setting of active infection. The authors suggest performing a biopsy in all cases of humerus non-unions.

Level of evidence: 3

Development of an NSAID decision tool for perioperative pain management in adult orthopaedic patients: a modified Delphi study

Fri, 15 Aug 2025 00:00:00 +0000

Background: Orthopaedic surgery is rated among the most painful of surgeries, leaving patients at risk of experiencing moderate to severe postoperative pain. A multimodal analgesic approach helps reduce opioid requirements, with nonsteroidal anti-inflammatory drugs (NSAIDs) playing a key role in this strategy, provided they are not contraindicated. However, only limited guidance exists for safe perioperative NSAID use in orthopaedic patients with comorbidities. The objective of the study was to achieve consensus on safe, short course (≤ 1 week) administration of NSAIDs in adult orthopaedic patients with comorbidities, and to convert the results into a decision tool to aid clinicians in safe perioperative NSAID administration.

Methods: A Delphi panel of 18 experienced orthopaedic surgeons, physicians and anaesthetists participated in a three-round Delphi process. The panel assessed 42 patient characteristics using a nine-point Likert scale in the first two rounds. After the second round, consensus was defined as ≥ 75% either ‘disagreeing’ (Likert scale 1–3) or ‘agreeing’ (Likert scale 7–9) that NSAIDs ± proton pump inhibitors (PPIs) could or could not be administered safely. Characteristics without consensus by round 2 moved to round 3, where subspecialty experts conducted a rapid review of the literature. Consensus in this round required ≥ 75% support for expert recommendations.

Results: All panel members participated in the first and third rounds, with 16 in the second. After the second round, consensus was achieved for 24 of 42 patient characteristics. However, in preparation for the third round, three characteristics which had achieved consensus after round 2 were added to the pool of characteristics to be considered by subspeciality experts, resulting in 21 proceeding to the third round. In round 3, consensus for all remaining subspeciality expert recommendations was achieved and an NSAID decision tool with guidance in safe perioperative NSAIDs use ± PPIs was subsequently developed for the 42 patient characteristics.

Conclusion: This study establishes a consensus on short-term NSAID administration in adult orthopaedic patients with comorbidities, offering a decision tool to guide clinicians in safely incorporating NSAIDs into perioperative pain management strategies.

Level of evidence: 5

Rotator cuff repair: what works in 2025

Joe De Beer, Deepak N Bhatia — Mon, 01 Sep 2025 00:00:00 +0000

Rotator cuff repair is one of the most frequently performed shoulder surgeries worldwide. Rotator cuff surgery evolved from open to arthroscopic between 1995 and 2005. Significant advances in mechanisms of cuff healing and failure have changed our approach to arthroscopic cuff repairs, and newer basic science studies have added a biological perspective to existing surgical techniques. Massive and retracted tears, previously considered irreparable, are now salvageable, and joint preservation is once again gaining popularity. This editorial presents a summary of ‘trending’ techniques for management of cuff tears and outlines the preferred technique of the authors.

Simulate to elevate

Adrian Jansen van Rensburg — Mon, 01 Sep 2025 00:00:00 +0000

This letter calls for increased exposure to advanced techniques.

I have had the privilege of working closely with orthopaedic surgeons for most of my now-starting medical career. Observing and engaging with orthopaedic registrars as they progress through their rigorous training to become consultants has provided me with insights into the demands and challenges of this speciality. Orthopaedic surgery involves an array of skills, which include factual knowledge, motor skills, teamwork and management, attitudes and behaviours, adaptive strategies and how to interpret what is seen, heard and felt in preparation for and during surgery.¹ An essential part of an orthopaedic surgeon’s training is the exposure to these haptic experiences and learning to interpret and respond appropriately.¹ Haptic sensation plays a crucial role in the way an orthopaedic surgeon evaluates orthopaedic pathology and executes the surgical treatment of patients with musculoskeletal trauma.¹ Orthopaedic surgery is a physically and mentally demanding task; one of the challenges of orthopaedics is dealing with high mental demand due to stress based on the quantity and complexity of the work. The burning question: How can we decrease mental demand?

CPD Questionnaire (V24N03)

Editorial Office — Mon, 01 Sep 2025 00:00:00 +0000

CPD Questionnaire