Background: Spinal fractures related to ankylosing spondylitis (AS) are often associated with serious complications. Therefore, knowledge of the incidence, best treatment, outcome, and prevention would assist in improving current guidelines. Objectives: This thesis aims at (1) analysing the complications and mortality of surgical treatment, (2) mapping the incidence and treatment modalities for these patients in Sweden, as well as (3) investigating the putative preventive effect of biological disease modifying anti-rheumatic drug (bDMARD) therapy on spinal fractures related to AS. Methods: Merged multiple national registries were used to identify predictors of mortality and spinal fractures in patients with AS. Beyond that a finite element model (FEM) was designed to simulating a cervicothoracic fracture related to AS. Results and Conclusions: During the last two decades an increase of the incidence of vertebral fractures in patients with AS was observed. With the introduction of bDMARD treatment of AS was revolutionised and quality of life and function improved.  It seems that the improved quality of life and function in these patients does not correlate with a reduced fracture risk. Still, for the first time a beneficial effect of bDMARD with regard to spinal fracture occurrence was provided. The risk of spinal fractures was not reduced, but the debut of a spinal fracture was delayed with bDMARD. Since for this study the observation interval was only a decade, a future follow-up should revisit the effect of bDMARD on spinal fractures related to AS. Furthermore, it was shown that posterior stabilisation is an effective method for restoring stability without the necessity of additional external fixation. Most likely the early rehabilitation reduced pulmonary complications, which in turn reduced early mortality of these fractures. The FEM could be used to identify the most appropriate implant configuration, since no well-established cadaver models exist. Clinical Trial Registration: ClinicalTrials.gov, Identifier NCT02840695.

Background: Hip fractures are among the most common causes of disability and hospitalisation in the elderly. Currently there are no studies available in South Africa that determine the factors that influence the early post-operative functional outcome in elderly patients with a hip fracture.Aim: To establish the factors influencing the early post-operative functional outcome in elderly patients with a hip fracture. Methodology: A prospective pre-test post-test observational study design was used. Consecutive sampling was used to recruit participants (n=72). Assessments were conducted pre-operatively, at discharge and six weeks post discharge at two public health care hospitals in Johannesburg, South Africa. Pre-operatively the pre-fracture functional mobility of the participants was determined using the New Mobility Score (NMS), the presence of pre-existing co-morbidities was assessed using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) and the cognitive function was assessed using the Six-Item Cognitive Impairment Test (6CIT). At discharge and at six weeks post discharge the participants post-operative functional level was assessed using the Elderly Mobility Scale (EMS) and the Lower Extremity Functional Scale (LEFS). A multiple regression analysis was used to determine associations. The study was set at p = 0.05 level of significance and 95% confidence interval (CI). Results: Participants were generally independent with pre-fracture mobility at baseline and presented with approximately three pre-existing co-morbidities. The presence of cognitive impairments in the participants decreased during the duration of the study, while the post-operative functional level in this population improved. Pre-fracture functional level was strongly related to and also the strongest predictor of post-operative functional outcome. The presence of co-morbidities and impaired cognitive function were also indirectly related. Conclusion: Pre-fracture functional mobility was found to be the strongest determinant of post-operative functional outcome, followed by cognitive function and the presence of pre-existing co-morbidities. By ensuring that these factors are optimal prior to sustaining a hip fracture, elderly patients are more likely to have better outcomes. For those patients who do sustain a hip fracture, intensive rehabilitation is especially necessary for the patient who presents with poor pre-fracture mobility, impaired cognition and pre-existing medical co-morbidities.

A research report submitted to the Faculty of Health Sciences at the University of the Witwatersrand in partial fulfillment of the requirements for the qualifications of MMed (Urology) 2017 / Background: Erectile dysfunction is one of the most important sequelae of pelvic fractures and may be transient or permanent. It can range from weak erections to severe sexual dysfunctions. Importantly, erectile dysfunction is more prevalent when the pelvic fracture is associated with urethral injury. Methods:  This was a retrospective study of patient records, with a prospective questionnaire arm for patients admitted to the hospitals with a pelvic fracture between 01/07/2011 to 30/04/2015.  The electronic databases of the Orthopedic Department at Helen Joseph Hospital and the Male Sexual Dysfunction Clinic at Charlotte Maxeke Johannesburg Academic Hospital were accessed for patients' contact details, by using the name and hospital number of each patient.  Each patient was contacted telephonically with an open speaker in a presence of a witness/translator. The information sheet was read to the patient before the telephonic consent was obtained.  After consent was obtained, patients were asked to verbally complete the International Index of Erectile Function score questionnaire. Results A total of 53 patients participated in the study, of which (43.4%) reported erectile dysfunction. The majority of patients indicated a recovery of erectile function between 2 8 | P a g e to 8 months after the injury. Most were found to still suffer from other forms of sexual impairment like orgasmic dysfunction and sexual satisfaction. However, sexual desire seemed to be preserved. Patients with sexual dysfunction were more likely to have had a urethral injury as well as a more severe fracture. Conclusions In our sample of 53 patients almost half reported sexual dysfunction after a pelvic fracture. Importantly, patients with urethral damage and a severe pelvic fracture should be followed up, as the risk of sexual dysfunction is high in these particular patients. / MT2017

A research report submitted to the Faculty of Health Sciences, the University of Witwatersrand in partial fulfilment of the requirements for the Degree of Master of Medicine in the branch of Orthopaedic Surgery. Johannesburg, 2017 / Study design: This is a prospective clinical audit of patient data. Objectives: to determine the clinical outcomes in patients who have undergone hemiarthroplasty surgery of the shoulder. Background: Hemiarthroplasty of the shoulder involves the replacement of the humeral head in patients with fractures of the proximal humerus deemed too severe to fix. It is done routinely at Helen Joseph Hospital. Methods: Our study cohort consisted of 32 patients who had undergone hemiarthroplasty surgery for proximal humerus fractures over a period of four years from 2009 to 2013. All patients were assessed for the following: • The amount of pain they are experiencing in the operated shoulder • Whether their pain post fracture resolved with the surgery • How their activities of daily living are affected • Any functional impairment they are experiencing in the operated shoulder The data that was obtained from the patients included age, gender, Disabilities of Arm, Shoulder and Hand (DASH) score1 and range of motion of both the operated shoulder and the unoperated shoulder. Data was first captured using Microsoft Excel and then Stata 13.0 was used to perform the analysis. Results: Of the 32 patients that participated in the study, there were 12 males and 20 females. The mean age of the patients was 70.5 years (range 51 – 84 years). The mean DASH score was 36.9 (range 18.3 – 53.3). The DASH scores were positively correlated with the ages of the patients. The active range of motion of the operated shoulder was compared to the opposite shoulder in each patient. The range of motion was assessed according to flexion, extension, abduction, internal rotation and external rotation. In each of the 5 movements, the degree of movement in the operated shoulder was less than in the opposite shoulder, which had not been previously operated on. These differences were statistically significant p <0.001. Conclusion: Hemiarthroplasty remains a viable option for the treatment of patients with proximal humerus fractures that are deemed too severe to repair. It provides good pain relief to patients, but the function of the operated shoulder is less than it was pre-injury. / MT2017

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Orthopaedic Surgery Johannesburg 31 January 2017 / Background Fractures of the radial head are classified according to the Mason System modified by Johnston. The fracture is managed according to its classification. Fractures of the Mason Type III and IV are complex and management is controversial. The early literature regarding the outcome of patients after arthroplasty of fracture dislocation of the elbow is limited by small patient numbers, short-term follow-up, and high complication rates. More recent literature has shown radial head replacement to have better functional outcomes in the short to medium term. Objectives To assess outcomes of radial head replacements in acute 3 and 4 radial head fractures by assessing elbow function, pain, elbow mobility post radial head arthroplasty and complications. Method A retrospective study design was used. Records were retrieved for all 40 patients who underwent a radial head replacement for a Mason III and IV fracture at Helen Joseph Hospital over a ten year period. Participants were traced and asked to complete a data sheet and undergo an examination by an interviewer. The data sheet included demographics, surgical and injury details, as well as details relating to function based on the Mayo Elbow Performance Score. Results Of a sample size n=16, 8 were male and 8 were female with an age range of 29 to 61 years and a mean age of 42.5 years. The length of follow up ranged from 2 to 8 years. When asked about daily functionality, 4 reported difficulty with one of the five tasks assessed on the Mayo Elbow Performance Score and 12 reported no difficulty with any of the tasks assessed. Moderate pain was reported by 8 with the other 8 patients reporting no pain.The flexion-extension arc ranged from 60º to 160º on examination with an average of 111º. An arc of greater than 100º was achieved in 11 out of 16 patients . A total of five patients had an arc of greater than 50º but less than 100. No patients had an arc less than 50º . Stability was assessed and scored. No study participants had any gross instability. Moderate instability was detected in 6 participants. Complications were noted in 2 of the 16 participants (One posterior interosseus nerve injury and one possible Essex-Lopresti injury). The final MEPS scores showed that 8 patients had good results and 8 patients had excellent functional outcomes with no fair or poor outcomes. Conclusions Good to excellent functional outcomes can be achieved with radial head replacement in Mason III and IV fractures with minimal complications however, longer term follow up with level one evidence is still needed. / MT2017

OBJECTIVE: To determine risk factors and examination findings that are predictive of orbital fractures in pediatric patients, in the hope of using the findings to develop a rule for when to obtain a Computerized Tomography Scan (CT). Additionally, we will examine the treatments underwent by patients with confirmed orbital fractures. METHODS: A retrospective cohort study was conducted on patients below the age of 22 who were seen in the Emergency Department (ED) at Boston Children's Hospital (BCH) between January 2009 and May 2013, and underwent Computerized Tomography Scan (CT) for evaluation of orbital fracture. 326 cases were selected for inclusion in analysis. Electronic medical records (EMR) of cases were reviewed and data was collected about mechanism of injury, symptoms, physical exam (PE) findings, diagnosis of orbital fracture, and treatment. Data collected was analyzed using SPSS Statistical Software v.21. Frequency of variables was determined, and chi-square analysis was performed comparing frequencies for patients with orbital fractures to patients without orbital fractures. RESULTS: Of the 326 cases undergoing CT, 133 (40.8%) had radiographic evidence of an orbital fracture. Nausea/vomiting, orbital tenderness, orbital swelling, orbital ecchymosis, and limitation of extraocular movement (EOM) were all identified as statistically significant clinical indicators of orbital fractures. 22 (16.5%) of patients with confirmed orbital fractures underwent surgery, with an average time to surgery of 4.5 days. CONCLUSION: We found that 16.5% of cases with orbital fractures, and only 6.7% of all cases, underwent surgery. We have identified 5 factors that can be used for the development of an evidence-based algorithm for determining when to obtain a CT to rule out an orbital fracture in a pediatric population. We believe that we can use this to improve the evaluation of orbital fractures ED, which in turn will improve the utilization of ED resources, and reduce the exposure of pediatric patients to the risks associated with CT.

INTRODUCTION: A recent area of interest has become adipose tissue of the bone marrow. Unlike fat found elsewhere in the body, it is able to respond to its microenvironment by expanding, contracting, and even releasing hormones of its own. The marrow adipose tissue (MAT) increases with age and even within anorexic patients. Changes in MAT may be directly linked to bone tissue, since both adipocytes and osteoblasts share a common progenitor cell population. This is supported by recent results showing that the constitutive deletion of the MRTF-A (Myocardin related transcription factor A) gene not only led to leaner mice leaner but also had a bone phenotype. The bones were shorter and had decreased bone mass; the female mice were more susceptible to osteopenia. It is unclear as to how this bone phenotype will respond to fracture repair, a coordinated process that is dependent upon differentiation toward the osteoblast lineage. Therefore, both male and female MRTF-A knockout (KO) and wild type (WT) mice were examined in a fracture study. METHODS: Male and female mice (KO and WT) aged 8-16 weeks were fractured using a closed, stabilized fracture model. Tissues were harvested as post-operative day 14, 21, and 37. Radiographic films and histological assessment were completed at each time point to visualize the progression of fracture repair. Gene expression studies using RT-qPCR were all done at time points 14 and 37. Results were compared between genotype and sex. RESULTS: Fracture calluses between WT and KO male and female mice appeared nearly identical via X-ray, suggesting that MRTF-A did not affect fracture repair. Only at the later time points did the histology show females had increased MAT regardless of genotype. Immunofluorescence with perilipin further confirmed this. Adipogenic, chondrogenic, and osteogenic markers also yielded differences in relative mRNA expression between the sexes. CONCLUSIONS: The MRTF-A KO mice did not show delayed or altered fracture repair compared to the WT mice. However, the data suggest difference in MAT deposition between male and female mice. Further work is necessary to fully understand this sex difference.

M.Dent., Faculty of Health Sciences, University of the Witwatersrand, 2008. / Objective: To determine the aetiology, biomechanics and demographics of patients with fractures of the midface. Materials and Methods: Patients with midface fractures (who consented to participate in the study) who presented to the Division of Maxillofacial and Oral Surgery over a 12 month period from December 2005 to December 2006 were included in the study. Data was recorded on age, race, gender, date and cause of injury, associated injuries and use of alcohol at the time of injury. The fractures were grouped into Le Fort, zygomatico‐maxillary, dentoalveolar and panfacial fractures. Results: The sample comprised 94 patients; 78 (82.98%) males and 16 (17.02%) females with an age range of 3 to 67 years. Blacks accounted for 77.66% of the total sample, followed by Whites (12.77%), Coloureds (6.38%) and Asians (3.19%). Blunt trauma due to interpersonal violence, motor vehicle accidents, gun shot wounds and falls contributed to 40.5%, 26.6%, 13.8% and 5.3% of the fractures respectively. Le Fort fractures were less commonly observed than zygomaticomaxillary complex midface fractures. Conclusion: A relationship exists between facial trauma, poverty and alcohol consumption. Blunt trauma due to interpersonal violence is the most common cause of midface injuries. Majority of injuries are sustained during weekends. Zygomaticomaxillary complex fractures are the most common midface fractures.

Thesis (M Dent(MFOS))--University of Limpopo, 2010. / Introduction-Craniofacial reconstruction following trauma is different for each individual as it highly depends on the nature and location of the patient’s injuries. The mandible is a unique bone, which has a complex role in both esthetics of the face and functional occlusion. Due to the prominent position of the lower jaw, mandibular fractures are the most common fracture of the facial skeleton Aim- The aim of this study is to assess the prevalence and distribution of combination fractures in the mandible among patients presenting at the University of Limpopo, Medunsa Campus, department of Maxillofacial and Oral surgery. The nature and site of injuries occurring in the mandible will be recorded, and correlated with the cause of injury. The data should establish a preoperative idea of fractures that can be expected in the mandible when associated with a particular type of injury, especially of the combination type. Materials and methods- The patient’s records and radiographs at the University of Limpopo Medunsa Campus, Department of Maxillofacial and Oral Surgery (MFOS) were accessed. Patients with mandibular fractures who presented to the department over a four-year period (ranging from January 2002 to December 2005) were included in this study. Results- There were 1755 patients treated for maxillofacial injuries during the period 2002 to 2005 (4 years). A total of 1222 (69.63%) patients sustained fractures to the mandible. However 505 (41.33%) patients sustained combination fractures of the mandible. This evidence statistically proves that there is a 41.33% chance of another fracture occurring in a patient who has been diagnosed with a single fracture to the mandible. Various etiological factors contributed to these mandibular fractures. Interestingly the major contributing factor was found to be assault. This study confirms the results that males are affected more than females. This study found the average male to female ratio to be 8.18:1. The age distribution ranged from 2 years to 86 years. The mean age was found to be 31.07 years with a standard deviation of 12.06 years. The highest frequency was recorded between 20 to 29 years (42.77%) followed by 30 to 39 vi years (24.36%). The sites of fractures varied with different combinations. The highest number of fractures was recorded in the left angle (159) followed by the right parasymphysis region (142). In the combination category however the left angle right parasymphysis combination (70) showed the highest incidence of combination fractures followed by left parasymphysis and right angle combination (47), right angle and left body combination (37) and left angle and right body (36) combination fractures. The incidence of sustaining a left angle and right parasymphysis combination fracture is 13.86%. A total of 92 (18.22%) condyles sustained fractures with various combinations. Fifty fractures occurred on the left side while 42 occurred on the right side. Conclusion- In conclusion this study has shown that there is a 41.33% chance of a combination fracture occurring in a fractured mandible. These results are statistically high given the fact that the mandible is a commonly injured bone. Therefore careful evaluation of diagnostic radiographs is necessary since some fractures are not diagnosed clinically. This can help improve treatment outcomes and reduce possible postoperative complications.

Thèse d'exercice : Médecine : Nancy 1 : 2009. / Titre provenant de l'écran-titre.