Background: To determine the pass rate of the final exit examination of the College of Orthopaedic Surgeons of South Africa [FC Orth(SA)] and to assess the correlation between the written component with the clinical and oral component. Methods: Results of candidates who participated in the FC Orth(SA) final examination during a 12-year period from March 2005 through to November 2016 were assessed retrospectively. Pass rates and component averages were analysed using descriptive and inferential statistics. Spearman's rho test was used to determine the correlation between the components. Results: A total of 399 candidates made 541 attempts at the written component of the examination; 71.5% of attempts were successful and 387 candidates were invited to the clinical and oral component, of which 341 (88%) candidates were certified. The second-attempt pass rate for those candidates who wrote the written component again was 42%. The average annual increase in the number of certified candidates was 8.5%. The overall certifying rate increased by 1.5% for this period. Invited candidates who scored less than 54% for the written component were at significant risk of failing the clinical and oral component. The written component showed weak correlation with the clinical and oral component (r=O.48). Conclusion: While the written component was found to be an effective gatekeeper, as evidenced by a high eventual certifying rate, the results of this component of the FCOrth(SA) final examination did not correlate strongly with the performance in the clinical and oral component. This finding confirms the value of the written component as part of a comprehensive assessment for the quality of orthopaedic surgeons.

Thesis (MMed (Surgical Sciences. Orthopaedic Surgery))--University of Stellenbosch, 2010. / Objective: This research paper reports on the radiographic outcome of unstable thoracolumbar injuries with short segment posterior instrumentation as standalone treatment; in order to review rate of instrumentation failure and identify possible contributing factors. Background: Short segment posterior instrumentation is the treatment method of choice for unstable thoracolumbar injuries in the Acute Spinal Cord Injury Unit (Groote Schuur Hospital). It is considered adequate treatment in fracture cases with an intact posterior longitudinal ligament, and Gaines score below 7 (Parker JW 2000); as well as fracture dislocations, and seatbelt-type injuries (without loss of bone column - bearing integrity). The available body of literature often states instrumentation failure rates of up to 50% (Alanay A 2001, Tezeren G 2005). The same high level of catastrophic hardware failure is not evident in the unit researched. Methods: Sixty-five consecutive patients undergoing the aforementioned surgery were studied. Patients were divided into two main cohorts, namely the “Fracture group” (n=40) consisting of unstable burst fractures and unstable compression fractures; and the “Dislocation group” (n=25) consisting of fracture dislocations and seatbelt-type injuries. The groups reflect similar goals in surgical treatment for the grouped injuries, with reduction in loss of sagittal profile and maintenance thereof being the main aim in the fracture group, appropriately treated with Schantz pin constructs; and maintenance in position only, the goal in the dislocation group, managed with pedicle screw constructs. Data was reviewed in terms of complications, correction of deformity, and subsequent loss of correction with associated instrumentation failure. Secondly, factors influencing the aforementioned were sought, and stratified in terms of relevance. Results: Average follow up was 278 days for the fracture group and 177 days for the dislocation group (all patients included were deemed to have achieved radiological fusion – if fusion technique was employed). There was an average correction in kyphotic deformity of 10.25 degrees. Subsequent loss in sagittal profile averaged 2 degrees (injured level) and 5 degrees (thoracolumbar region) in the combined fracture and dislocation group. The only factor showing a superior trend in loss of reduction achieved was the absence of bone graft (when non-fusion technique was employed). Instrumentation complications occurred in two cases (bent connection rods in a Schantz pin construct with exaggerated loss in regional sagittal profile, and bent Schantz pins). These complications represent a 3.07% hardware failure in total. None of the failures were considered catastrophic. Conclusion: Short segment posterior instrumentation is a safe and effective option in the treatment of unstable thoracolumbar fractures as a standalone measure.

Thesis (MMed (Surgical Sciences. Orthopaedic Surgery))--University of Stellenbosch, 2010. / No abstract available

The discipline of orthopaedic surgery is a fast growing surgical specialty directed at the diagnosis and management of disorders of the musculoskeletal system e.g. acute trauma, fractured or dislocated joints, elective reconstructive surgery as well as related research. The standard of care in orthopaedic surgery treatment reflects the status of its evolution and what is currently available in terms of the knowledge, surgical expertise, orthopaedic implant materials, and equipment. It is the duty of the orthopaedic surgeon to live up to the promise as best he or she can to heal when it is possible to heal and to provide the level of care expected that transcends simple surgical expertise and bio-technological intervention. The informed consent process is an often neglected but vital component of the standard of care which has to satisfy prescribed ethical and legal requirements. This research is focused on how to heighten the awareness of, and to encourage engagement within the orthopaedic surgery fraternity with the informed consent process. If the informed consent is given more recognition within this group, it will benefit the potentially vulnerable orthopaedic patient, protect the orthopaedic surgeon against litigation, and importantly, contribute to the ethical imperatives bound in a doctor-patient relationship. For this research, a vast search of the available local and international literature has been perused and my finding is that the application of Ethics and recognition of the informed consent concept within the medical community in general is gathering momentum and it must be both supported and internalized by those in orthopaedic surgical practice.

Purpose: To highlight the histopathological characteristics of the skin in congenital clubfoot and correlate the clinical findings in clubfoot with the changes in the dermal layers. Materials and methods: One hundred skin specimens, from 77 infants (6 to 12 months), were studied between 2004 and 2008. Using the Pirani scoring system, the clinical severity was recorded. The mobility of the skin and the correctability of the medial ray were assessed clinically. A skin specimen (1cm x 1mm) was taken from the medial side of the foot at surgery following failed plaster treatment. The layers were studied under light microscopy. The thickness of the dermis and the histopathological features of clubfoot skin were compared with 10 normal skin specimens. Results: The dermis of clubfoot skin showed significant fibrosis with thick bundles of collagen fibres (P = .001) on Haematoxylin and Eosin staining (H&E). The dermal thickness ranged between 1.0mm and 5.2mm in clubfoot skin, compared with controls (0.64-1.28mm). Fibrosis extended into the subcutis in a septolobular fashion in 95% of the cases. Significant atrophy of eccrine glands was seen in 98% (P = .001). Hair follicles were absent in 78%. The elastic fibres of clubfoot skin, stained with Elastic van Gieson staining (EVG), showed hypertrophy in varying degrees in all skin specimens. They were fragmented, with loss of their parallel arrangement. There was no significant inflammatory reaction in the dermis. The Pirani score was significantly increased (mean 7.8). Discussion: Fibrosis and thickening of the dermis were the most significant histopathological features of the clubfoot skin. The elastic fibres were also abnormal. There was atrophy of the skin appendages due to the fibrosis. There was a strong correlation between the Pirani score and the severity of the deformity(P 0.016). The cases with poor outcome had a higher score than those with a satisfactory outcome.Lack of a significant inflammatory reaction suggests that neither the serial manipulations of the foot, nor the repeated plaster cast changes, were responsible for the dermal fibrosis, which is probably present from birth and contributes to the deformity. / Thesis (Ph.D.)-University of KwaZulu-Natal, Durban, 2012.

PURPOSE: The goal of this thesis research project is to evaluate and compare post-operative complications among patients, who underwent short and long segment Anterior Cervical Discectomy/Corpectomy and Fusion (ACDF/ACCF). METHODS: Retrospective cohort study design allowed for evaluation of series of variables (age, sex, diagnosis, general post-operative outcome, and complications) while comparing them between the short and long segment groups. RESULTS: Patients within both cohorts tended to experience similar complications, except pseudarthrosis and adjacent segment disease, which both were more prevalent in the long segment group. Diagnosis or short versus long segment length did not have an effect on the general post-operative outcome. One-level ACDF patients were younger than multilevel ACDF surgery patients. Dysphagia was more likely to occur in older patients, with the risk of dysphagia incidence increased by 7% with each year of patient’s age. CONCLUSIONS: Study indicated that longer segment ACDF/ACCF does not carry higher risk of complications incidence than short segment treatment. Further studies are advised to increase generalizability of these results.

Bones have a large capacity for repair and regeneration after an injury. 5-10% of the nearly 8 million fractures that occur every year in the United States do not heal properly. Bone repair and regeneration is a complex process that utilizes molecular and cellular interactions to return to its original structure. Phosphate is essential for healthy bone growth and when phosphate deficient it has been shown to impair the process of fracture healing. It is unknown if replenishing phosphate to the diet will help return the injured bone to its original properties. Some of the differences in fracture repair may be due to genetic variability that contributes to morphology of bone and fracture healing. This study was carried out to assess how genetic variability affects the process of fracture healing. To determine how genetic differences interact with phosphate deficiency fractures were generated in three different inbred mouse strain (A/J (AJ), C57BL/6J (B6), C3H/HeJ (C3)) that had previously been shown to have different endochondral bone formation. Animals were placed on a phosphate restricted diet two days prior to fracture, and was maintained for 15 days, which covered the normal duration of endochondral bone development. To determine if replenishing phosphate in the diet could recover the normal healing, phosphate was returned to the diet after 15 days. There was also control groups that were on a regular diet for the entire time of the study, which was used for comparison. Micro-computed tomography (micro-CT), biomechanical torsion testing, and contrast enhanced micro-computed tomography (CECT) were methods used to asses the properties of the callus over the course of fracture healing. Micro-CT and mechanical test results showed that there were significant differences within AJ, B6, and C3 strains of mice at the various post-operative day (POD) time points. Results from micro-CT data showed that as the POD time point increased there was an increase in the amount of mineralized tissue and a decrease in fracture callus. These results were confirmed by with the increase in strength measurements from mechanical testing conclusions. Further, the fracture callus is less rigid at the early time points and as the fracture callus becomes mineralized there is an increase in the rigidity measures. Other measures of mechanical properties showed that there were significant differences in the B6 and C3 strains of mice among the various POD time points and control and phosphate restricted diets. Assessing cartilage content via CECT showed that there were significant differences in the control and phosphate restricted diets at POD 14, however many of these differences were recovered at the later time points. Visualization of the fracture callus using CECT confirmed that there was diminishing cartilage present in the fracture callus. These results provide insight into the fracture healing process and much information about the return of stability and strength to the fractured bone. Taken together, the outcomes of this study indicate that the bones heal and mechanical strength is recovered once the phosphate has been added back into the diet.

Distributive justice is a bioethical principle concerned with the fair distribution of resources and benefits in society. In the context of orthopaedic surgery management, distributive justice is an important consideration in ensuring that all patients have equal access to the resources and care in the treatment of their injuries. The literature well documents demographic and socioeconomic factors in the allocation of elective orthopaedic surgeries, but unfortunately a similar analysis is lacking when it comes to orthopaedic trauma surgeries. This study examines fundamental philosophical perspectives that underly healthcare delivery specifically pertaining to orthopaedic trauma. In doing so, the influence of race, socioeconomic status, insurance status and other factors on access to care and allocation of resources are described. Findings for various orthopaedic trauma surgery cases suggest decreased allotment to those of black race, lower socioeconomic, educational, and non-insurance status. Although the reason is multifactorial and complex, I suggest a shift in focus to the equity and fair distribution of surgical resources by considering the role of population health, understanding multidisciplinary interactions, improving research methodology, and community partnership. / Urban Bioethics

Background: Cubitus varus is a cosmetically unacceptable complication of supracondylar fractures of the elbow in children. We have performed the lateral closing wedge (French) osteotomy to correct the varus for 27 years. More complex osteotomies have been described to correct the associated hyperextension and internal rotation deformities and to prevent a prominent lateral condyle. Methods: We retrospectively reviewed 90 consecutive patients (1986-2012). The mean age of the patients at surgery was 8.2 years (3 to14 years). The varus angle (mean 21.4°, range 8°- 40°) was assessed pre-operatively with the humero-elbow-wrist (HEW) angle. The postoperative carrying angle (mean 10.4) and the pre- and postoperative range of movement were assessed clinically. The lateral condylar prominence index (LCPI) was retrospectively measured at union. Results: Seventy five (93.3%) of the patients had a good or excellent result. Six (6.7%) had a poor result (residual varus, loss of >20°of pre-operative range of flexion or extension or a complication necessitating repeat surgery). There were no neuro-vascular complications. The mean LCPI was +0.14. Conclusions: The results of the French osteotomy are comparable to the more technically demanding dome, step-cut translation and multi-planar osteotomies, with a lower complication rate. The literature reports adequate remodelling of the hyperextension deformity ( ≤ 10 years) patient. Level of evidence: Level IV: Case series

Bakgrund: Ren intermittent katetrisering (RIK) är en åtgärd som utförs dagligen på ett flertal patienter inom sjukvården, där sjukvårdspersonal tränger innanför patientens integritetssfär. Patienter har olika personliga gränser för när den personliga integriteten hotas och deras upplevelse vid RIK postoperativt, är sparsamt belyst i tidigare forskning.  Syfte: Att beskriva patienters upplevelse av ren intermittent kateterisering postoperativt. Metod: Datainsamlingen genomfördes med semistrukturerade intervjuer där tretton patienter som kateteriserats postoperativt deltog. Data analyserades med kvalitativ innehållsanalys. Resultat: Resultatet visade att patienterna upplevde vårdpersonalen som kompetenta och de förlitade sig på att vårdpersonalen visste vad som var bäst för patienterna som också kände sig omhändertagna. Det upplevdes vara viktigt att bevara den personliga integriteten och de påtalade vikten av tillräckligt insynsskydd vid kateteriseringen vilket inte alltid varit tillfyllest. Patienterna uttryckte också rädsla dels för smärta i samband med kateteriseringen och dels för att de trodde att det var något fel eftersom de inte kunde urinera. Några beskrev det som en lättnad att få hjälp att tömma blåsan, medan andra kände sig utlämnade och upplevde det som att de inte hade något val. Majoriteten av patienterna hade inte fått/kom inte ihåg att de fått adekvat information om att kateterisering kunde komma att behövas postoperativt och de påtalade vikten av att detta gavs innan operationen. Slutsats: Vårdpersonalens bemötande av patienter som behöver genomgå RIK är av största vikt för patientens upplevelse av vårdsituationen. Vikten av att information ges, som är adekvat och lättförståelig, poängteras. Det är en fördel om patienten görs delaktig i sin vård och att hänsyn även tas till speciella önskemål, som t.ex. kön på den som utför kateteriseringen. / Background: Clean intermittent catheterization is an action that is performed daily on several patients in health care, where health care staff penetrates inside the patients privacy sphere. Patients’ have different personal limits when privacy is threatened and research with focus on the patients experience of clean intermittent catheterization postoperatively is limited. Aim: To describe patients’ experience of clean intermittent catheterization postoperatively. Method: Data collection was conducted by using semi-structured interviews with thirteen patients that had been catheterized postoperatively. Data were analysed using qualitative content analysis. Result: The result showed that patients’ experienced health care staff as competent and they relied on that the medical staff knew what was best for the patients who also felt cared for. It felt to be important to preserve privacy and they stressed the importance of sufficient transparency protection during catheterization which had not always been satisfactory. The patients’ expressed fear partly for pain associated with catheterization and partly because they thought there was something wrong since they were unable to urinate. Some described it as a relief to get help emptying the bladder, while others felt vulnerable and felt that they had no choice. The majority of patients’ had not got or could not remember if they had received adequate information that catheterization could be needed postoperatively and they emphasized importance of that this information was given before surgery. Conclusion: Health care staff treatment of patient’s requiring clean intermittent catheterisation is crucial for the patient's experience of the care situation. The importance that the information given is adequate and understandable was emphasized. It is an advantage if the patient is involved in care and that consideration to special requests, such as that the gender of the person performing catheterisation is considered.