Positive patient experience of wide awake local anaesthesia no tourniquet (WALANT) hand surgery in the government setting: a prospective descriptive study

ABSTRACT BACKGROUND: The purpose of this study was to establish a subjective patient experience with wide awake local anaesthesia no tourniquet (WALANT) procedures performed in the institution from May 2019 to March 2020. WALANT surgery was initiated to improve standard operating procedure and to decrease theatre burden METHODS: This prospective, descriptive study included 100 patients with a mean age of 59 years who required either a carpal tunnel or trigger finger release. The patients' pain experience was documented on the visual analogue scale (VAS) for the local anaesthetic injection and the surgical procedure. Overall experience was assessed on the patient's preference to have the procedure performed by the WALANT method or the conventional method RESULTS: One hundred patients were included, of which 67 had medical comorbidities. The mean VAS score was 1.5 (SD±1.6) with pain on injection. The mean VAS pain score during the surgical procedure was 0.2 (SD±0.7). One hundred per cent of patients (100/100) felt they would do the WALANT outpatient procedure again instead of admission to hospital and surgery in the theatre. Two complications occurred related to wound care problems, and were successfully managed. None of the patients required reoperations for incomplete release of the carpal tunnel or trigger finger surgery CONCLUSION: The results of this study suggest that minor hand surgery using the WALANT protocol can be performed effectively and with high patient satisfaction rates in the orthopaedic outpatient clinic, and is a useful tool in the skillset of a hand surgeon Level of evidence: Level 4 Keywords: WALANT, hand surgery, trigger finger, carpal tunnel release

Treatment outcomes of civilian gunshot tibia fractures at a major trauma centre

ABSTRACT BACKGROUND: The aim of this retrospective longitudinal study was to describe the overall burden and outcomes of surgically managed gunshot tibia fractures at a major trauma centre. Secondary objectives were to identify possible risk factors for complications including non-union and infection and to highlight any differences in outcomes between treatment modalities METHODS: All consecutive patients who sustained gunshot injuries to the tibia between January 2014 and December 2017 including children and multiple gunshots injuries were considered for inclusion. Information related to patient demographics, injury characteristics, treatment information and treatment outcomes with respect to rate of fracture union and occurrence of infection were obtained from patient records. All patients with insufficient medical records were excluded RESULTS: The records of 197 patients who sustained gunshot tibia fractures were reviewed. The mean follow-up was 4.1 months (interquartile range [IQR] 2.5-6.8). The majority of cases were young males (89%) with a mean age of 29.2±10.2 years. Extra-articular diaphyseal fractures were observed in the majority of cases (91%). Definitive treatment included formal debridement in theatre and plaster cast immobilisation (44%), intramedullary nail fixation (27%), circular external fixation (22%) and plate fixation (7%). The study revealed an overall fracture-related infection (FRI) rate of 11% and bone union rate of 91%. Circular external fixation showed the lowest fracture union rate (86%) and highest FRI rate (21%) of the modalities included in this study. No associations between independent risk factors and presence of complications were identified CONCLUSION: The study reports encouraging outcomes for tibia fractures caused by civilian gunshot injuries. Various definitive surgical stabilisation techniques showed high proportions of union and low burden of FRI Level of evidence: Level 4 Keywords: tibia, gunshot, fracture, outcome

Tuberculosis of the extra-axial skeleton in paediatric patients

ABSTRACT BACKGROUND: Musculoskeletal tuberculosis (MSK TB) is a disease entity that often mimics other orthopaedic conditions in its radiographic and clinical presentation, which can delay diagnosis and treatment. The purpose of this study is to examine the clinical and radiographic presentation as well as the accuracy of various diagnostic tests, treatment, complications and outcome in paediatric patients diagnosed with MSK TB. We aim to provide insight into typical presenting features in order to expedite diagnosis in this perplexing disease. METHODS: We retrospectively reviewed 77 consecutive patients with extra-axial MSK TB treated at our institution over a ten-year period from 2008 to 2018. We collected data on initial clinical presentation, laboratory values, radiographic findings, diagnostic testing, treatment and outcomes. We performed quantitative and qualitative analysis to look for patterns in presentation that can help with diagnosis and factors affecting the clinical outcomes. RESULTS: The most common clinical presentation was pain of the affected limb. Constitutional symptoms were uncommon. Our patients presented with thrombocytosis and anaemia, but normal white cell counts. Inflammatory markers were mildly elevated. Of diagnostic tests employed, the Mantoux skin test yielded the most positive results (70%) followed by tissue PCR (53%). The hip was most frequently involved, followed by the knee and elbow. Most patients presented with normal appearing X-rays. We had a medical compliance rate of 94% with all patients followed up to completion of treatment having resolution of active disease. Thirty-nine per cent of our patients had residual joint stiffness or deformity following completion of treatment, ranging from ankylosis to mildly decreased joint range. CONCLUSION: Patients with MSK TB usually present with non-specific symptoms and signs, and a high index of suspicion should be maintained in endemic areas. Typical haematological findings are an elevated ESR and CRP accompanied by anaemia and thrombocytosis. Radiographs at presentation are non-specific in more than 50% of patients. A combination of diagnostic modalities should be employed as no single test is 100% sensitive or specific. Compliance with medical treatment reliably leads to resolution of the disease. Residual joint pathology is common and needs to be addressed secondarily. Level of evidence: Level 4 Keywords: musculoskeletal tuberculosis, paediatric tuberculosis, joints, anti-tuberculosis treatment, deformity, GeneXpert

Patella dislocations and patellofemoral instability: a current concepts review

ABSTRACT Lateral patellar dislocation affects young, active patients with an incidence rate of 5.8 per 100 000. The management of first episode dislocations is non-surgical in the majority of cases, unless associated pathology dictates surgical intervention. Approximately 40% of cases that are treated non-surgically will develop recurrent patellofemoral instability. Evidence supports surgical intervention in these cases; however, the best approach is debatable. Most research and consensus statements agree that medial patellofemoral ligament reconstruction (MPFLR) should be performed in most cases. Additional procedures can be used 'a la carte' according to certain conditions or pathology. A tibial tubercle osteotomy (TTO) is usually indicated in patients with maltracking and/or patella alta, but the direction and degree of correction must be carefully considered. Trochleoplasty is technically demanding and should be reserved for a select few patients with severe trochlear dysplasia. It should be performed by an experienced knee surgeon due to the high risk of inadvertent complications. Level of evidence: Level 5 Keywords: patellofemoral instability, patellar dislocation

Correlation of the squat-and-smile test against other patient-reported outcome scores in knee pathology

ABSTRACT BACKGROUND: The use of patient-reported outcome measures (PROMs) for knee pathology may be affected by socioeconomic factors, language barriers and time constraints in busy outpatient clinics. The squat-and-smile test (SST) is an example of such a test that has previously been validated for femur fractures. The aim of this study was to validate the SST against other PROMs in patients with knee pathology METHODS: Patients presenting to a subspecialist knee clinic in a large hospital in sub-Saharan Africa were approached to participate. They were asked to squat and the depth of the squat as well as the need to support themselves were classified into four categories. To describe their pain, participants also selected one of three smiley faces (unhappy, neutral, smiling). These test scores were correlated to the patient's Knee injury and Osteoarthritis Outcome Score (KOOS), Tegner Lysholm score and EQ-5D scores RESULTS: Seventy patients (median age 53.4 years) were included. The squat depth correlated moderately with the KOOS score (r=0.56) and poorly with the EQ-5D and Lysholm scores (r=0.46; r=0.43). The need for squat support had poor correlations with the KOOS, EQ-5D and Lysholm scores (r=0.29; r=0.31; r=0.31), as did the smiley face component (r=0.40; r=0.32; r=0.30 CONCLUSION: For patients with knee pathology, the squat depth correlates moderately with other PROMs. It could therefore be used in settings for which conventional PROMs have limited application. Support needed to squat, and a visual analogue scale of smiley faces, had poor correlation when compared to other knee PROMs and should not be used for the assessment of knee pathology Level of evidence: Level 4 Keywords: squat and smile, KOOS, PROM, smiley faces, outcome score

Intra-operative extracorporeal radiation therapy for skeletally immature patients with malignant bone tumours

ABSTRACT BACKGROUND: Management of malignant bone tumours has changed dramatically in recent years. Neoadjuvant chemotherapy, irradiation and conservative surgery have improved local control as well as functional outcome. Depending on the histology of the lesion, other modalities like chemotherapeutic agents or radiation can be selected in place of surgical intervention. Operative intervention is the main modality with wide marginal excision and fixation of bone graft from different sources or mega prosthesis to maintain congruity of the bone anatomy. Reconstruction, optimum fit and stability at the affected site are the major areas of concern with this modality. Radiation given outside the body to kill the tumour cells in the bone is called extracorporeal radiotherapy (ECRT). After resection of the bone, it is cleaned of all the surrounding soft tissue and marrow contents and placed in a container. It is then subjected to 50 Gy of radiation which kills all the tumour cells. METHODS: The study was conducted from June 2014 to May 2020, and included 15 patients (out of 18) diagnosed with either Ewing's sarcoma or osteosarcoma. They were followed up for an average of 4.44 years, up to May 2020. All 15 cases were analysed for bony union at the osteotomy sites. Cases reported with poorly differentiated sarcomas (total three) were subjected to immunohistochemistry and managed with other modalities of treatment. RESULTS: The average time for union of irradiated bone was 8.1 months (range 5-10; the metaphyseal end united faster than the diaphyseal end). At the final follow-up, the functional status was determined using the Musculoskeletal Tumour Society (MSTS) scoring system. Ninety-three per cent of patients had involvement of the lower limb (14 out of 15). All patients (except one who developed recurrence) did not have symptoms of the disease and no one had died at last follow-up. CONCLUSION: Biological limb salvage procedures are considered a successful treatment and a welcome alternative for patients who either cannot afford or be treated with an endoprosthesis. Early diagnosis and referral to specialised unit is of vital importance. This procedure can be used for selected patients with malignant bone tumours. Cost factors, and social and cultural considerations also play a role Level of evidence: Level 4. Keywords: ECRT, extracorporeal radiation therapy, malignant bone tumours, bone sarcoma, osteosarcoma, Ewing's sarcoma

Polio-like deformity: a diagnostic dilemma

ABSTRACT BACKGROUND: Significant advances have been made in the global effort to eradicate polio. Vaccine-associated poliovirus, or other enteroviruses, may still affect the anterior horn cell and cause acute flaccid paralysis. Following the acute disease, residual paralysis results in lower motor neuron weakness, altered growth and deformity. Our study aims to describe the clinical manifestations of a group of children that mimic that of classic paralytic poliomyelitis METHODS: We identified six children from our paediatric orthopaedic database that presented with polio-like deformities. Their clinical and imaging records were reviewed and described, together with the clinical manifestations of paralytic poliomyelitis RESULTS: Limb hypoplasia, pathological gait patterns and foot deformities were consistent features. The median leg length discrepancy was 2.5 cm (range 2-4 cm). The gait patterns observed included a Trendelenburg gait in 33% (n=2), a short limb gait in 50% (n=3), and one case with a combination of Trendelenburg, short limb and steppage gait. Tensor fascia lata contracture was present in 50% (n=3) of our patients. Foot deformities ranged from calcaneo-cavo-valgus to equino-cavo-varus deformities CONCLUSION: Despite significant advances made in the global fight to eradicate polio, we still see children with clinical manifestations reminiscent of the disease. Orthopaedic surgeons should remain familiar with the assessment and diagnosis of the sequelae of paralytic poliomyelitis Level of evidence: Level 5 Keywords: poliomyelitis, vaccine-associated paralytic poliomyelitis, polio-like deformity, acute flaccid paralysis

The management of chronic osteomyelitis in adults: outcomes of an integrated approach

ABSTRACT BACKGROUND: This study presents the outcomes of the management of chronic osteomyelitis of the appendicular skeleton according to an integrated approach at a dedicated bone infection unit in South Africa. METHODS: A retrospective record review identified 80 patients who were treated between January 2016 and December 2018. RESULTS: Sixty patients (75%) presented with fracture-related infections, 17 patients (21%) developed chronic osteomyelitis following haematogenous spread and three (4%) from contiguous wounds. According to the Cierny and Mader classification, 21 patients presented with anatomical type I, 14 with type II, 24 with type III and 21 with type IV chronic osteomyelitis. Positive microbial cultures were obtained in 63 (79%) cases. Follow-up for the cohort ranged from 1 to 29 months, with a mean follow-up of 10.4 months. The overall complication rate for the cohort was 6% and included sterile drainage from the surgical site after management with bioactive glass (S53P4), refracture after hardware removal, and development of non-union. Five patients experienced recurrence after the initial procedure to eradicate infection, resulting in an overall resolution rate of 94%. CONCLUSION: Using single-stage surgeries and tailored dead space management strategies according to a comprehensive integrated approach developed in South Africa, results comparable to international literature can be achieved. Level of evidence: Level 4. Keywords: chronic osteomyelitis, dead space management, bioactive glass, Lautenbach technique