A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the degree of Master of Medicine in the branch of Orthopaedic surgery / Introduction: The medical record is critical for the documentation of the patient’s current and possible future health status, as well as for communication between the healthcare professional and other service providers, statutory and regulatory bodies. Statutory and /or regulatory bodies and medical councils around the world emphasises the importance of accurate, adequate and comprehensive medical records. The operative notes are the official documentation of a surgical operation or procedure and serves as a key form of surgical communication between healthcare professionals and other healthcare service providers. Surgical operative notes also serve other important functions related to medical cost billing, quality assurance, medical education, research purposes and medico-legal issues. There is no consensus among surgical disciples on the required standard operative notes or acceptable operative notes documentation. The royal college of surgeons of England (RCSE) has published guidelines on the operative notes documentation that are widely accepted in the United Kingdom and supported by the British Orthopaedic Association. Aim: The aim of the study was to assess the completeness of the clinical records for the Orthopaedic surgery operative notes to:  Evaluate the completeness of operative notes with respect to the RCSE 2008 guidelines  Determine the essential information that was omitted from operative notes Methodology: The study was a retrospective, descriptive single centre study conducted at Chris Hani Baragwanath Academic Hospital between 01 August 2013 and 30 November 2013. Clinical records were evaluated specifically for the orthopaedic surgery operative notes details and compared to the guidelines based on the RCSE 2008. The data were collected from 25 % of all orthopaedic surgical procedures performed in the year 2013. Results: A total of 400 clinical records were available for the review of orthopaedic surgery operative notes. All operative notes were hand-written and no separate operative notes proforma or template was used for operative notes documentation; all operative notes were written in the daily ward round progress sheet. No aide-memoire was available or used to assist the surgeon and or assistant with writing of the operative notes. The study revealed poor documentation of essential information in the operative notes with only 0.25 % meeting all the parameters as per RCSE guidelines. Up to 93.3 % of the operative notes were written by the medical officers and registrars, whereas 4.3 % of the operative notes were written by the consultants. In addition, 56.8 % were missing 5 – 9 parameters, and of the additional parameters included in the study 50.6 % were missing 5 – 9 parameters and 48.5 % missing 10 or more parameters. Poor documentation was found with regards to details of prophylactic antibiotics missing in 90.8 % of all operative notes, tourniquet usage missing in 58.4 %, operative findings not mentioned in 55.8 %, identification of prosthetic material or implants missing in 77.0 % and use of blood and or blood products missing in 95.5 %. Discussion: The study represents 25 % of all orthopaedic surgery operations performed in the year 2013. The findings of the study are consistent with the previous published studies reporting poor operative notes documentation without the use of aide-memoire, proformas, computerised or paper based templates and procedure specific proforma following acceptable guidelines. Conclusions: The findings of this study confirm poor documentation and significant deficiency of essential parameters in the operative notes that is required for the patient safety and highlight lack of consensus on the essential parameters required for a complete operative notes details. Future research using the orthopaedic operative notes template and/or proformas is recommended to assess completeness of the operative notes documentation. / MT2017

Purpose: This study evaluates the accuracy and reliability of clinical examination for knee laxity in degrees and millimetres when compared to movement measured by computer-assisted navigation. Methods: A cadaver lower limb was connected to a computer assisted knee surgery system (CAS) and calibrated through a mini medial parapatellar arthrotomy. Examiners estimated millimetres of sagittal and degrees of rotational laxity of the knee at 30º and 90º of knee flexion. This examination was done in the ligamentous intact knee and again after sequential release of the anterior cruciate ligament (ACL) and anterolateral ligament (ALL). The clinical assessments were compared with measurements produced by CAS. Intraclass correlation coefficient (ICC), correlation coefficient (CC) and Bland Altman plots were used to compare and summarize the data. Results: At least 21 participants assessed the knee after each sequence of ligament sectioning. The reliability of clinical examination when correlated with the CAS measurements was poor for all examination groups. The ICC was poor for sagittal laxity at 30º (R=0.02; p=0.04), rotational laxity at 30º and 90º (R=0.17; p=0.04) (R=0.3; p=0.04) respectively and sagittal laxity at 90º(R=0.47; p=0.04). The correlation coefficients were very weak for sagittal laxity at 30º (R=0.09; p=0.46), weak for rotational laxity at 30º (R=0.24; p=0.06) and 90º (R=0.3; p=0.01) and moderately weak for sagittal laxity at 90º(R=0.4; p=0.001). Clinical examination was only accurate in the detection of sagittal laxity greater than 11.6mm at 30°, and greater than 9.4mm at 90°. Clinical examination for rotational laxity was only accurate for rotational instability greater than 27.7° at 30°flexion, and 28.9° rotation at 90°. Conclusions: There was poor reliability and weak correlation between clinician estimated sagittal and rotational laxity and measurements produced by CAS. This study showed that participants could not accurately estimate laxity in degrees and millimetres and supports the need for accurate objective knee laxity measurements.

Includes bibliographical references. / First introduced by Kuntshner, femoral nailing has become the 'Gold Standard' of treatment for femur fractures. The efficacy and benefit of early osteosynthesis by this technique is well established. Some of the acute complications of intramedullary manipulation and nailing are fat embolism syndrome, pulmonary dysfunction and Adult Respiratory Distress Syndrome (ARDS). One of the causes of fat embolism is a raised intramedullary pressure. Investigators have shown the direct correlation of intramedullary pressure with fat intravesation and embolism in both animal and human studies. Fat embolism syndrome is unpredictable and the true incidence is unknown. Mortality from fat embolism syndrome ranges from 10-35%. The incidence is increased with associated pulmonary trauma and in the multiply injured patient. The aim of our study was to investigate the intramedullary pressure rise during reamed prograde femoral nailing and determine whether fracture level and complexity affect the peak pressures. The relevance is that certain fracture types or levels that result in the highest pressures can be identified before the operation. Measures could be taken to reduce the intramedullary pressure during the procedure, particularly in those patients at greatest risk of pulmonary complications from fat embolism. We hypothesised that more proximal, simple fractures generate higher pressures during nailing because there is a long 'closed tube' distal to the fracture. Pressure proximal to the fracture does not reach the same high levels because the intra-medullary content is able to decompress through the fracture as the reamer moves distally. With proximal fractures there is a greater volume of medullary content distal to the fracture which can enter the venous system and embolize. Fracture comminution and complexity should lead to lower intramedullary pressures because there is a greater length of the femur through which the intramedullary content can decompress. The study sought to answer the question of whether fracture level makes a difference with respect to the intramedullary pressure rise during reamed prograde nailing. The results of this study have not been submitted for publication at the time of submission of these results for the thesis.

Includes abstract. Includes bibliographical references.

Purpose: The Oxford Shoulder Score (OSS) is a robust and universally utilised shoulder score that has been translated for use in Western and Asian countries. This study aimed to translate, cross-culturally adapt and psychometrically validate the Afrikaans version of the OSS for use in Africa. Methods: Translation and cross-cultural adaptation was performed in accordance with guidelines in the literature. 108 consecutive patients with either degenerative or inflammatory pain of the shoulder were prospectively enrolled. Patients were evaluated by completing the Afrikaans OSS, Constant-Murley, quickDASH, and the Subjective Shoulder Value (SSV) scores. Comprehensibility and acceptance, as well as any floor or ceiling effects, were calculated. Reliability was assessed through reproducibility. Internal consistency was assessed using Cronbach’s alpha. Validity was determined using a Pearson Correlation Co-efficient between the Afrikaans OSS and the other validated shoulder scores. Results: Comprehensibility and acceptance were excellent, and no floor or ceiling effects were observed. Reproducibility (r = 0.99) and internal consistency (Cronbach’s alpha = 0.93) were both excellent. Correlation of the Afrikaans OSS with the Constant-Murley and quickDASH was excellent (r = 0.84; r = 0.81 respectively), and very good with the SSV and VAS pain score (r = 0.73; r = 0.66). Conclusion: The Afrikaans OSS proved understandable, acceptable, reliable and valid. It is an appropriate instrument for use in Afrikaans speaking patients with shoulder pain from degenerative or inflammatory origin.

Includes bibliographical references / The aim of our study was to review our conservative management of neurovascular complications in displaced extension-type supracond ylar fractures of the humerus in children. We critically analysed the outcomes. Our results shall aim to clarify the management of this contentious issue.

Includes bibliographical references. / The purpose of this study will be to review the outcome of a subtotal capsulectomy of the hip for idiopathic chondrolysis. Idiopathic chondrolysis of the hip is a very rare condition. It is characterized by cartilage necrosis of the hip joint not associated with trauma, SUFE, infections or other demonstrable causes. It was first described in 1971 by Jones from the Princess Alice Orthopaedic Hospital in Cape Town. It occurs mainly in adolescent girls. The outcome in South Africa has been reported as a progressive downhill course resulting in a painful, stiff hip. The aetiology of the disease remains unknown. Theories suggested are mechanical (decreased movement with loss of synovial nutrition; increased joint pressure) and an auto-immune response in genetically predisposed individuals. The differential diagnosis includes atrophic-type tuberculosis of the hip. Suggested treatment ranges from NSAIDs and range of motion exercises alone to early aggressive surgical treatment. Our experience with continuous passive motion (CPM) and NSAID treatment have been disappointing.

Aims This study aims to compare the leg length correction (LLC) measured intra-operatively using the Vertical Measurement SystemTM (VMS) in total hip arthroplasty (THA), with the LLC measured on a 6-week post-operative Xray. We also wanted to quantify any residual leg length discrepancy (LLD) using this method. Patients and Methods A prospective cohort study was conducted, in which patients undergoing primary THA were enrolled at two centres in Cape Town, over a period of 19 weeks. THA's were performed by four surgeons. Pre-operative leg length discrepancy measurements were obtained in 92 patients. The VMS was used to predict intra-operative leg length correction (LLC), and this measurement was compared to the post-operative leg length correction measured on the 6-week follow-up X-ray. These measurements were statistically compared using Mann-Whitney U Test. Results The difference between the intra-operative VMS calculation and the 6-week radiological measurement was not significant (p>0.05), with the difference in their mean values being 0.07 ± 3.26mm. In the cohort, 81.52% of the patients (n=75) were within 5mm of the target LLC, and 95.65% of patients (n=88) were within 10mm of the target LLC. The mean absolute residual LLD at 6 weeks was 3.22 ± 3.13mm. Conclusion The intra operative LLC measurement obtained using the VMS accurately predicts the 6-week post op radiographic LLC measurement.

Study Rationale: Purely ligamentous lesser arc, Mayfield grade 3 and 4, perilunate dislocations (PLD's) are uncommon. Current recommendations are for open reduction and repair of the interosseous ligaments to prevent the development of scapholunate dissociation and degeneration to a scapholunate advance collapse (SLAC) wrist. This study proposes a less invasive treatment method which includes closed reduction and pinning alone without repair of the scapholunate interosseous ligament. We propose that the majority of patients will obtain good function and pain scores and the few that develop instability may still have a reconstruction performed through a naïve surgical field. Methods: Dislocations were reduced anatomically and held with buried k-wires which were removed at 6 weeks with no specific rehabilitation protocol observed. Subjective assessment included MAYO wrist scoring system, wrist range of movement, instability and grip strength testing. Radiological measurements included scapholunate distance, scapholunate angle, radiolunate angle and osteoarthritis. Results: 10 male patients, median age of 35, were followed-up for a median of 22 months. 7 patients underwent a closed reduction and anatomical pinning while 3 underwent open reduction due to unachievable reduction by closed means. All of these patients presented at a median of 14 days after the injury occurred. None of the patients had their scapholunate ligaments repaired or reconstructed. MAYO scores included, 3 excellent scores, 2 good scores and 5 fair scores. Instability was found clinically in 1 asymptomatic patient who had a positive Watson shift test. Radiological scores include a median scapholunate distance of 2mm, a scapholunate angle of 70° and a radiolunate angle of 15°. Osteoarthritis was found in 2 patients, all of whom were asymptomatic. Discussion: Current recommendations in the literature are that PLD's should be reduced via an open surgical technique with repair of the SLIL and percutaneous pinning. However the results of this treatment strategy are not optimal and do not confer uniformly good results. We propose a closed anatomical reduction and percutaneous pinning of the PLD. Our study shows that the majority of patients will demonstrate good function and pain scores when managed this way. A smaller number of these injured wrists will go on to develop instability. However the advantage of our method over the current recommendations is that when this happens the reconstruction of the SLIL will be made easier through a naïve surgical field. Conclusion: We recommend the closed reduction and anatomical pinning of a purely ligamentous lesser arc injury. This treatment strategy yields good results at medium term follow-up and preserves the option for the reconstruction of the scapholunate interosseous ligament should instability develop.

Introduction: Ankle sprains remain the single most frequent injury in modern sports with increasing evidence that it is not as innocuous as previously thought. Conservative treatment options include various forms of immobilization such as casts, moonboots and stirrup braces, followed by a rehabilitation period involving different modalities. Despite clinical evidence there seems to be a divergence between research and practice with an increase in acute surgical repair especially with regards to professional athletes. Design: Descriptive cross-sectional survey analysis Aim of the study: To assess the approach on management of acute ankle sprains by orthopaedic surgeons in South Africa. Methods: A two part study. Firstly, a questionnaire was emailed to participating orthopaedic surgeons, consisting of eight treatment options for a grade 3 lateral ankle sprain in a non-professional athlete. Secondly, a literature review to establish the current best practice concerning ankle sprain management. Results: The total number of respones where 129 out of 719 that were sent out. Surgical repair was offered in 24 (19%). Conservative treatment including either cast or moonboot for a period of 6 weeks was chosen by 49 (38%) and 2 to 4 weeks by 55 (43%) as their preferred treatment. Only 39 (30%) of responding SAOA members chose a short period of immobilization followed by functional rehabilitation in accordance with the current best evidence available, based on the literature review done. Conclusion: Despite good clinical evidence there seem to be a lack of consensus in the management of grade 3 lateral ankle sprains.