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 Orthopaedic Surgery Johannesburg, 2017 / Background: The anterolateral approach to the spine for the surgical management of the Tuberculosis of the spine has been described. The surgical technique has evolved since the gold standard published by Hodgson et al. in 1956. The use of a Titanium Mesh Cage and the anterior instrumentation to construct the anterior column after adequate debridement defined the evolution. The aim of the study is to review the results of the patients that underwent this procedure between January 2012 and December 2015. Methods: The study was a retrospective study where 60 patients treated with this technique from 2012 – 2015 were reviewed. Sixty-one percent (61%) of the tested patients were HIV positive and 70.4% of the patients were female in the age group of 31-45 years. The surgical procedure was standardised for all the patients irrespective of their HIV status. The clinical and radiological outcomes measured consisted of the patients’ disability using the Oswestry Disability Index (ODI), the Frankel Neurological grading to measure neurological deficits and the Cobb angle to measure Kyphosis. The diagnosis of Tuberculosis of the Spine was confirmed in all the patients. Results: At a mean follow up period of 21.25 months, the ODI improved from a mean of 95.42% ± 6.57% before surgery to a mean of 8.00% ± 12.15% at the last follow up. There were 58 patients who were unable to walk independently before the surgery (Frankel A or B) but at the last follow up, 52 of the patients had achieved independent ambulation (Frankel D or E). The mean kyphosis was 33.90 ± 12.44 degrees before surgery, and in the immediate post-operative period, the mean kyphosis was 23.69 ± 10.31 degrees, and a mean of 26.27 ± 10.91 degrees was measured at the last follow up. There was a 30.12% correction achieved in the immediate post-operative period and an overall correction of 22.51% at the last follow up reflecting a loss of 7.61% in the kyphosis correction in the period between the immediate post-operative period and the last follow up. Complications were documented in six patients including two deaths unrelated to the procedure. Discussion: The ODI score showed an improvement as the mean value decreased by 87.42%. This is statistically and clinically significant (p=0.001). According to the work of Solberg et al. (2013) in degenerative spine, the threshold for a success is a mean change of 20% in the ODI scoring after lumbar disc surgery. Using this value as a proxy, an improvement of 87.42% is an excellent outcome. Before surgery, fifty-eight patients (96.7%) were non-ambulatory using the Frankel Neurological score. At the last follow up, 53 patients (91.4%) achieved a Frankel score of D or E and independent ambulation. This outcome compares favourably with ones published in the literature. The overall post-operative kyphosis correction achieved was 26.27 degrees (which translated to 22.51% correction) at the last follow up. This reflects a kyphosis correction loss of 7.61% that was not associated with any neurological deterioration and is therefore of no clinical significance. There were six cases of complications including two deaths unrelated to the procedure but the general debilitation of military Tuberculosis and Nosocomial infection. Conclusion: The anterior column reconstruction using the Titanium Mesh Cage and Anterior Instrumentation is safe and effective for the surgical management of the Tuberculosis of the Spine. There were good clinical outcomes as measured by the ODI score and the Frankel Neurological Grading system, and even though there was a loss of Kyphosis correction at the last follow up, this was not associated with a negative neurological outcome. Despite its limitation as a retrospective study, this study demonstrates that the procedure is safe and effective when used as an adjunct to the medical treatment of the Tuberculosis of the Spine. / MT2017

Impaired wound healing in SCI patients contributes to the progression in severity of PIs. Best practice guidelines suggest that surgical flap reconstruction is an option for chronic stage 4 PIs that have failed to heal with more conservative measures, but little is known about the epidemiology of surgically reconstructed PIs in SCI patients. Rates of surgical wound complications are high, and cost of management is extensive. Accordingly, this study aims to establish a systematic approach for identifying SCI patients with surgically reconstructed PIs, to facilitate study of predictors of sustained wound closure, quantify costs of surgical reconstruction, and evaluate efficiency of treatment and recovery options. To address gaps in the literature, this study’s objectives were: (1) estimate surgical reconstruction hospital costs for stage 4 PIs in SCI patients and characterize the relationship of demographic, socioeconomic and lifestyle factors to cost at discharge, (2) explore a standardized method of identifying these cases in large databases, (3) identify and validate risk factors for complications at discharge from wound care follow-up, and (4) identify long-term cost and health care utilization of persons with SCI who have undergone surgical flap closure. It proved difficult to identify our own cohort of patients using administrative codes applied, making population-based study using administrative data less than ideal. Factors associated with open incision at three-to-six weeks post-index surgery included number of nursing visits in the previous year, and revision surgery within the six-week follow-up period. The cost of persons with SCI and PI was high one year prior to surgery (look-back) and almost double in the first year look-back. However, significant cost and health care utilization was demonstrated in Year 2 and 3 post-index surgery. Further prospective studies exploring models of health care delivery and addressing some of modifiable risk factors may improve cost-effectiveness and outcomes. / Thesis / Doctor of Philosophy (PhD) / Pressure ulcers, also known as pressure injuries (PI) or bedsores, are a common secondary complication in persons with spinal cord injury (SCI). While surgical closure is an option offered to patients, little is known about the long-term outcomes, including cost and use of health care services following the surgery. Risk factors for complications following surgery are known from a physical/co-morbidity/technique perspective, but environmental and behavioural factors have not been included these studies, and the use of health care administrative databases to accurately identify these patients for research has not been studied. A historical cohort study was conducted at one tertiary care centre in Toronto, Canada to identify known cases of SCI and PI reconstruction. Hospital codes were recorded in an algorithm used to evaluate the accuracy in identifying the known cases in the database. Health care usage and costs were also recorded, and risk factors for complications were also evaluated.

Osteoid osteomas are common, painful, osteoblast tumors that frequently present in adolescents and young adults. Surgical management is indicated for cases with associated symptoms, such as headaches, dizziness, diplopia, proptosis, sinusitis, and facial deformity. The authors report a case of a 15-year-old male with an enlarging frontal sinus osteoma. Virtual surgical planning was utilized to design a KLS Martin Resorbable plate for the graft site, as well as a cutting guide for the graft procedure. A split-calvarial bone graft was used to reconstruct the central bony defect in the anterior table of the frontal sinus. Virtual surgical planning sessions were initiated with KLS Martin biomedical engineers to design a graft. Design cutting guides were created for frontal craniotomy, and an interlocking cutting guide was created for the split calvarial bone graft. The graft was harvested from the non-dominant right parietal hemisphere to best match the curvature of the frontal bone. Post-operatively, the patient has not had any complications to date. This procedure proves to be a valuable consideration for the surgical treatment of pediatric osteomas.