Fragility fractures are an emerging healthcare problem in Sub-Saharan Africa and hip fractures (HFs) are associated with high levels of morbidity, prolonged hospital stays, increased healthcare resources utilization, and mortality. The worldwide average healthcare cost in the first-year post HF was US$43,669 per patient in a 2017 systematic review, however there are no studies quantifying fracture-associated costs within SSA. We estimated direct healthcare costs of HF management in the South African public healthcare system.

We conducted a prospective ingredients-based costing study in 200 consecutive consenting HF patients to estimate costs per patient across five regional public sector hospitals in KwaZulu-Natal (KZN). Resource use including staff time, consumables, laboratory investigations, radiographs, operating theatre time, surgical implants, medicines, and inpatient days were collected from presentation to discharge. Counts of resources used were multiplied by relevant unit costs, estimated from KZN Department of Health hospital fees manual 2019/20, in local currency (South African Rand, ZAR). Generalised linear models were used to estimate total covariate adjusted costs and cost predictors.

The mean unadjusted cost for HF management was ZAR114,179 (95% CI; ZAR105,468–125,335). The major cost driver was orthopaedics/surgical ward costs ZAR 106.68, contributing to 85% of total cost. The covariate adjusted cost for HF management was ZAR114,696 (95% CI; ZAR111,745–117,931). After covariate adjustment, total costs were higher in patients operated under general anaesthesia compared to surgery under spinal anaesthesia and no surgery.

Direct healthcare costs following a HF are substantial: 58% of the gross domestic per capita (US$12,096 in 2020), and six-times greater than per capita spending on health (US$1,187 in 2019) in SA. As the population ages, this significant economic burden to the health system will increase. Further research is required to evaluate direct non-medical, and the indirect costs incurred post HF.

Aim:

To review the use of traction x-rays under anaesthesia in Late Onset Scoliosis to correlate traction x-ray flexibility and postoperative correction using posterior nonsegmental all pedicle screw constructs.

Aim:

To audit pertrochanteric fractures treated with a cephalomedullary device in a public health institution.

Introduction and aim:

With up to 70% of adults with tuberculosis in Sub-Saharan Africa infected with human immunodeficiency virus (HIV), severe spinal tuberculosis presents a different set of clinical and surgical challenges. To overcome the disadvantages of various traditional techniques, particularly in patients who are HIV-positive with opportunistic pulmonary pathology, and to obviate the need to violate the diaphragm in the lower thoracic and upper lumbar spine, a posterior vertebral column resection through a single posterior approach was proposed. The aim of this study is to report on the early results of the single-stage posterior only vertebral column resection.

Introduction

Surgical complications are common and most of them are preventable. Up to 70 % of surgical errors originate outside theatre and recent studies have shown that pre-op checklists can reduce such problems. We hypothesized that in our institution outcomes could be improved by introducing a safety checklist.

Purpose

Adipose derived stem cells have been shown to enhance both wound and bone healing. The stem cells are harvested, purified, cultured and the viability assessed in order to provide adequate cellular yield. The isolation process requires trained laboratory staff, intensive procedures utilizing multiple purification solutions and expensive equipment for culturing and interpretation of viability of the isolated stem cells.

The aim of the study was to investigate the effect of simple lipo-aspirate on wound and bone healing.

In the last few decades pedicle screw placement has brought in a genuine scientific revolution in the surgical care of spinal disorders. The technique has dramatically improved the outcomes of spinal reconstruction requiring spinal fusion. Short segment surgical treatments based on the use of pedicle screws for the treatment of neoplastic, developmental, congenital, traumatic and degenerative conditions have been proved to be practical, safe and effective.

The reported incidence of nerve root damage after the use of pedicle screws ranges from 2% to 32%. The utilization of computerized image-guided technology in lumbosacral spinal fusion surgery offers increased accuracy of pedicle screw placement. We decided to review our x-rays of pedicle screw placement, and to assess the percentage misplacement of pedicle screws inserted without computer assistance. This is a retrospective study and our results are compared with those in the literature.

80 Post operative radiographs of patients operated on for trauma and degenerative conditions of the thoracolumbar spine were studied. Initially these were looked at independently by 2 orthopaedic spinal surgeons and a radiologist, and subsequently all x-rays were reviewed together to see where consensus could be reached where there was any disagreement.

The percentage of misplaced screws inserted under fluoroscopy was obtained, and compared to the percentage of misplaced screws inserted under image guidance reported in the literature. Our study shows that there is no significant difference between the 2 techniques.

The lumbar spine consists of a mobile segment of 5 vertebrae, which are located between the relatively immobile segments of the thoracic and sacral segments. The bodies are wider and have shorter and heavier pedicles, and the transverse processes project somewhat more laterally and ventrally than other spinal segments. The laminae are shorter vertically than are the bodies and are bridged by strong ligaments. The spinous processes are broader and stronger than are those in the thoracic and cervical spine.

Internal fixation as an adjunct to spinal fusion has become increasingly popular in recent years. Stainless steel or titanium plates or rods are longitudinally anchored to the spine by hooks or pedicle screws. Powerful forces can be applied to the spine through these implants to correct deformity. Implants provide immediate rigid spinal immobilization, which allows for early patient mobilization, and provides a more optimal environment for bone graft incorporation. Numerous clinical and experimental studies demonstrate higher fusion rates in patients with rigid internal fixation than in controls without instrumentation. Although various implants are available, pedicle fixation systems are the most commonly used implant type in the lumbosacral spine. The large size of the lumbar pedicles minimizes the number of instrumented motion segments required to achieve adequate stabilization.

Many authors have reported loss of postoperative deformity correction after transpedicular screw fixation, ranging from 2.5 degrees to 7.1 degrees. The general preference is to stabilize the fractured vertebra by fusing one level above and one level below. With this technique, the rate of loss of correction is high. At our institution, we routinely stabilize the unstable thoracolumbar fractures by fusing one level above and one level below. In addition, we put screws into the pedicle(s) of fractured vertebrae. The reason for this is the following:

To correct the deformed body of the fractured vertebra for better load sharing.

Plain radiographs were analysed post operatively and compared for reduction of the fracture fragments and correction of kyphotic deformity to pre-operative films. 74 Patients were admitted with thoracolumbar spine fractures to our hospital. 48 Patients were surgically treated, and 34 patients were available for follow up. We found that inserting the pedicle screws into the fractured vertebra provided good stabilization for very unstable fractures. No loss of correction was seen in the follow up x-rays. We conclude that including the fractured vertebra into the fracture fixation device not only provides better fracture reduction, but also gives improved rotatory stability.

This is an evaluation of outcomes in 12 patients with tuberculosis of the lower lumbar spine (L3 and below) treated by the author between 1998 and 2003.

Clinical presentation, demographics, comorbidity, treatment and response to treatment over 12 months were assessed. All patients presented with backache. Two had abscesses, one in the groin and one at the Petit triangle. Three patients had Frankel-D neurological fallout. In most, L3/4 was involved. Two patients had L5/ S1 involvement, with associated spondylolisthesis. Two were HIV-positive and one was diabetic.

All patients were treated with antituberculous medication and initial bed rest until they were free of pain. The only surgical treatment was needle biopsy and abscess drainage. The acute back pain with which patients presented was better by the 4th week. The neurological symptoms resolved in all three patients. At final follow-up, there was good bony fusion although all had loss of lumbar lordosis. None of the patients who were working became unemployed.

In keeping with results in the literature, good outcomes were achieved with conservative treatment. With the advent of good pedicle instrumentation and vertebral body cages, there is a temptation to manage these patients with radical surgery. However, there is no justification for such an approach, especially if one considers that so far no relationship between kyphosis and backache has been shown.

The limitation of this study is the small number of patients.

Introduction and Aims: The management of cervical spine dislocation is a challenge and can be a topic of big debate. Delay diagnosis of these injuries presents a bigger challenge. The aim of this study is to review patients who presented and were managed after four weeks from the time of injury.

Method: A retrospective study of 15 patients with unifacet and bifacet dislocation referred to the author four weeks after the injury between 1990 and 2003 were reviewed. Their clinical records and x-rays on admission and up to final discharge from follow-up were studied. Some patients were interviewed by telephone and a recent x-ray was requested. The following factors were assessed: age, mechanism of injury, delay period from the time of injury when referred, clinical picture at presentation, treatment given and clinical picture at final discharge or interview.

Results: The age range at presentation was 24 to 56 years. The delay period to presentation and management by the author was six weeks to three years. At presentation all had neck pain, three had upper limb paraesthesia, six had radiculopathy, four had Frankel D myelopathy and two were neurologically intact. Eleven patients had involvement of C5/6, three had C4/5 and one had C6/7 involvement. Seven patients had been treated by the primary medical team with traction, five with a soft collar for a few weeks, two had no treatment and one was a re-injury. Skeletal traction was applied to all patients on admission. Only three patients were successfully reduced with the prolonged traction; they were further managed by anterior discectomy, fusion and anterior cervical spine plating. The remaining patients were treated by corpectomy of the caudal vertebrae, strut graft and anterior cervical spine plating. None of the patients had posterior surgery. Fusion was achieved in all the patients. Cervical lordosis was restored in 10 of the 12 patients who underwent corpectomy, strut graft and plating. Motor power improved in all but two patients, who had radiculopathy. None of the patients had deterioration of neurology or neck pain at final follow-up.

Conclusion: Anterior corpectomy of the caudal vertebrae, strut graft and cervical spine plating obtained good cervical lordosis and neurological improvement in patients with late presentation of cervical spine dislocation, which did not reduce with initial skeletal traction. This approach is less challenging than those advocated by previous authors exposed to managing these injuries.

Tuberculosis of the spine is very common and it is important to do confirmatory testing.

This retrospective study involved 40 patients in whom tuberculosis of the spine was diagnosed after clinical examination and investigations. All underwent decompression of the spine for neurological fallout. Intra-operatively, histological tissue, MCS and polymerase chain reaction (PCR) were assessed. PCR was positive in only 50% of the patients, but was complementary to histology and MCS.

The success of lumbar spine fusion depends on good patient selection and bone grafting technique. Instrumentation of the fusion, now popular, improves fusion rates, eliminates the need for postoperative braces and allows early mobilisation. However, the stress shielding caused by rigid internal fixation is thought to lead to osteopoenia and degeneration of adjacent segments. Theatre times, intra-operative complications and costs are increased when pedicle screw fixation is added.

This is a report of a pilot study of eight patients who had one-level fusion and unilateral instrumentation between 1998 and 2000. Theatre time, fusion rate and functional outcomes were evaluated. The minimum follow-up time was eight months. Fusion was achieved in all patients and there was no metal failure. One patient continued to have back and leg pain in spite of a solid fusion.

Although this is a small study undertaken over a short period, the results suggest that unilateral pedicle screw fixation can be safely undertaken.

Sciwora lesions are common in children but rare in adults. In adults, they are often associated with spondylosis, and minor trauma may result in paralysis of varying degrees.

In our unit we conducted a retrospective analysis of adult patients with spinal cord injuries. Only two had Sciwora lesions. One lesion was in the thoracic spine and the other in the lumbar spine. The thoracic lesion led to complete paraplegia, with intrinsic cord damage. It was treated conservatively and the patient did not recover. The lumbar lesion was incomplete, with traumatic disc prolapse that recovered after discectomy.

Management of Sciwora lesions of the thoracic and lumbar spine depends on MRI findings.

Fractures of the thoracolumbar spine are now so common that most orthopaedic surgeons are likely to have to handle one. It is important that we have common terms of reference when we assess, manage and discuss outcomes of these injuries.

The authors plan to assess the intra-observer and inter-observer interpretation of six plain radiographs of thoraco-lumbar fractures. Volunteer orthopaedic surgeons attending the SAOA Congress will be asked to classify the six radiographs twice, on different days, and the radiographic labelling will be changed. Participants will be given the Margel and Dennis classifications for reference. Participants’ names will not be required, only their year of qualification and exposure to spinal surgery.

The results will be analysed statistically and communicated to the orthopaedic community in due course.