Navigating adversity: the orthopaedic surgeon and complications
Orthopaedic surgery is an innovative and demanding speciality covering a broad anatomy and complex pathologies treated with a wide range of procedures. Orthopaedic surgeons typically have heavy workloads and work long hours. The registrar training programme in Orthopaedic Surgery is arduous. Specialist orthopaedic practice, in both the private and public sectors, is associated with specific and increasing demands and difficulties. On the one hand, we have an enduring professional obligation to advocate for surgery that improves quality of life and outcome. On the other, we practise in an era of relentless increase in our understanding of surgical pathology and surgical techniques; and treat patients in an environment of heightened and increasing patient expectations.
Complications of surgically managed pelvic and acetabular fractures
Pelvic and acetabular fractures commonly occur following high energy trauma and have been reported to account for approximately 0.3–25% of all fractures encountered in the emergency department, especially in the polytraumatised patient. They frequently occur in conjunction with injuries that affect multiple systems and are associated with a mortality rate of up to 31%. Patient selection for operative management can be challenging; however, in cases with instability, operative intervention has been shown to improve functional outcomes but has inherent risks.
Analysis of orthopaedic injuries in CT pan scans of polytrauma patients at a quaternary academic hospital
Traumatic injuries account for ten per cent of the global burden of disease. The proportion of traumatic injuries is greater in low-to-middle-income societies, with 90% of all global cases of trauma-related mortality occurring in these countries. South Africa represents one of these countries, being a middle-income country, with the reported rate of trauma-related mortality being six times higher than the global rate. In South Africa, we frequently see patients who have sustained major trauma, suffering from multiple injuries. These patients are often described as polytrauma patients, which is defined as a combination of two or more severe injuries occurring in two or more anatomical areas; rarely, two or more severe injuries in one region where one injury is life-threatening.
The Bridging Infix: a modified, minimally invasive subcutaneous anterior pelvic fixation technique
Early treatment with appropriate surgery for complex or unstable pelvic fractures is essential. Transiliac/sacral screw fixation is an effective treatment for most posterior injuries. At the same time, stabilisation with external fixation, open reduction and internal fixation with submuscular plating (ORIF), retrograde pubic rami screw fixation, or newer subcutaneous techniques are possible for anterior instability. External fixation, being a minimally invasive technique, serves to preserve the fracture site’s biology and allows for easy removal. Despite its convenience for the surgeon, it is often unsightly and cumbersome for the patient and has an associated complication rate as high as 62%. The most significant benefits of ORIF include allowing for anatomic reduction and no need for removal of any implants at a later stage. It also remains biomechanically the most rigid construct at the symphysis pubis. Despite these advantages, ORIF is associated with a high surgical morbidity rate. Retrograde pubic rami screw fixation has grown in popularity because it provides a minimally invasive internal fixation option. These screws are, however, not suitable for all fracture types and have a reported loss of reduction in 15% of cases, with advanced age and female sex being major predictors of failure. These drawbacks have led to the development of newer subcutaneous fixation techniques.
Orthopaedic surgical antibiotic prophylaxis administration compliance with prescribing guidelines in a private hospital in North West province, South Africa
Surgical antibiotic prophylaxis (SAP) entails the prevention of surgical site infections (SSIs) through the administration of effective antibiotics prior to possible contaminant exposure during surgery. The primary purpose and benefit of SAP is to prevent SSIs and, subsequently, the impact thereof on the patient and healthcare system. SSIs are surgical site microbial infections that can develop within 30 days of an operation or within one year following an orthopaedic procedure with the insertion of an implant. An estimated 60% of SSIs are preventable with the correct use of SAP, consequently decreasing the patient’s length of stay (LOS) in hospital. The appropriate use of SAP is founded on evidence based research describing the correct SAP indication, antibiotic choice, route of administration, antibiotic dosing and re-dosing, administration time and duration.
Acute haematogenous osteomyelitis in the paediatric population: a current concepts review
Acute haematogenous osteomyelitis (AHOM) is a bacterial infection localised in bone that usually occurs after an episode of bacteraemia. Acute haematogenous osteomyelitis is commonly encountered by doctors in low- and middle-income countries (LMICs) and, if not recognised early and managed appropriately, can harbour significant early and late complications, including death. Premature growth arrest, limb deformity and leg length discrepancy lead to severe disability, especially in this young population.2-6 Predictors of poor outcome include concomitant septic arthritis, as damage to the joints in these young patients leads to severe degenerative arthritis. Although perhaps not very high, a mortality rate of 1.06% is significant, especially for a treatable condition.
Cutaneous adenoid cystic carcinoma: clinical conundrum of a lower limb mass
Adenoid cystic carcinoma (ACC) is a rare epithelial tumour of the salivary glands. It arises even more rarely in the aerodigestive tract, lacrimal glands and adnexal skin glands. Acral metastasis is a rare presentation of carcinoma of unknown origin with incidence ranging from 0.007% to 0.3%. Head and neck malignancies with acral metastasis are extremely rare.