To determine the bony outcomes of patients treated at our Institution after sustaining femur fracture and arterial injury, due to gunshot, in the ipsilateral limb, studied over a four-year period.

The database at the Department of Vascular Surgery at our Institution was searched for cases that had sustained both arterial injury and femur fracture of the ipsilateral leg. Their case notes and X-rays were reviewed for the following:

Time line from injury to discharge

During the period from 2002 to the end of 2005 there were 12 patients who qualified to be included in the audit group. Three of the 12 (25%) had to undergo a primary amputation upon arrival. The other nine cases underwent surgery. One of these received an intra-medullary device, another skeletal traction and the rest external fixation following the vascular surgery. Five of the 7 external fixation devices were converted to an intramedullary device in due course. All nine cases went on to union. There were no reported cases of iatrogenic vascular repair disruption. Of the 12, only three cases reported any infection. One case developed severe osteomyelitis of the femur.

Primary vascular repair with temporary external fixation that was later converted into an intramedullary device (within 14 days) provided satisfactory results.

This retrospective study examines the outcomes of 17 semi-constraint elbow replacement procedures done over 7 years.

There were 14 primary and three revision procedures. The mean age of patients was 61 years. The indication for surgery was RA in 11 patients, trauma in six and tuberculosis in one. All but two patients, who died of unrelated causes, were available for follow-up. In 13 patients the mean follow-up time was 4 years, and in the other two there was an 8-month follow-up. The results were assessed according to the Mayo Elbow Performance (MEP) score.

There were seven excellent MEP scores, seven good and one fair. Mean flexion was 132°, extension −23°, with the range of motion 107°. Except in two patients, pronation and supination were full. Radiographs showed two patients had radiolucent lines of more than 2 mm, which covered less than 50% of the interface. To date no revisions have been necessary.

Medium-term results of semi-constraint elbow replacements are gratifying.

Introduction and Aims: There is a clinical impression that rheumatoid involvement of the hand and wrist in black patients differs from white patients. The aim of this study was to look at the hand and wrist involvement in black patients and to compare it with the available series in white patients.

Method: The wrist and hand x-rays of 75 black patients with proven rheumatoid arthritis were used. The x-rays were classified according to the Larsen criteria. We also classified the wrist involvement according to the Stanley and Simmen classifications. We also looked at the extent of wrist involvement and the stability of the wrist.

Results: The Larsen score for the fingers was counted out of 100 – where each MP-joint and each PIP-joint, including the IP-joint of the thumb, counts five (5 x 20). The Larsen score for the left hand was 9,65 and for the right hand 10,32. The Larsen score for the wrist was counted out of five. It was 2,48 for the left wrist and 2,73 for the right wrist. According to the Stanley classification on the right side, 18 fell into the conservative group, 16 into the reconstructive group, 28 into the salvage group and 13 into the irretrievable group. In the Simmen classification on the right side, 23 were classified as normal, 14 as ankylosed, nine as osteo-arthritic and 29 as disintegrated. On the left side, 22 were classified as normal, 12 as ankylosed, 12 as osteo-arthritic and 29 as disintegrated.

Conclusion: Our conclusion is that rheumatoid arthritis involvement was more or less the same as reported in other series, but finger joint involvement was considerably less. This finding must influence surgical decision-making and also the results of drug trials, whenever black patients are involved.

Introduction and Aims: To establish how effective conservative treatment is for rotator cuff impingement. To look at the clinical presentation and the factors that influences the outcome.

Method: A retrospective study of 189 patients, who attended the Upper Limb Clinic, was done. The response to physiotherapy and cortisone injections was noted. We also looked at the shape of the acromion and tried to correlate it with effectiveness of conservative treatment.

Results: All patients had either a positive Neer or Hawkins sign. What is more significant is that in 123 patients internal rotation was markedly restricted to the 10^th dorsal vertebrae or less. One hundred and nineteen patients received a sub-acromial cortisone injection. It was repeated in 52 patients, and 25 patients received a third injection. Forty-four patients needed surgery. Therefore, conservative treatment was effective in 83% of cases. Of the group who was operated on, only nine patients had a large spur and only 12 patients had a Bigliani Type-III acromion. It does not seem as if the spur is the main cause for impingement.

Conclusion: Conservative treatment is very effective in the treatment of rotator cuff impingement. However, we believe that the right exercise program is of essence. Stretching the posterior capsule of the shoulder joint and increasing the internal rotation, which are the two most important initial exercises, should be concentrated on. Thereafter the depressor muscles, like sub-scapularis and infra-spinatus must be strengthened.

The purpose of the study was to determine the prevalence of rotator cuff tears at long-term follow-up after arthroscopic subacromial decompression.

Between 1991 and 1994, arthroscopic subacromial decompression was done on 42 shoulders for impingement syndrome. None exhibited signs of a rotator cuff tear. The patients were re-evaluated at a mean postoperative follow-up time of 10 years. At follow-up, the mean age of the patients was 54 years (33 to 69). The evaluation consisted of a clinical examination (including the Constant shoulder score) and an ultrasonographic examination. Only seven patients were found to have developed rotator cuff tears and only one needed a repair procedure. Their mean Constant score was 95. The mean Constant score of 34 patients was 97. One patient refused follow-up owing to a subjective poor result. There were no complications.

We conclude that this is an effective intervention for impingement syndrome, protecting the rotator cuff.

Our study aimed to determine the presence of rotator cuff tears in asymptomatic shoulders of patients with symptomatic tears in the contralateral shoulder.

We asked 50 patients between the ages 40 and 83 years to complete a questionnaire. A single radiologist carried out ultrasonographic evaluation of both shoulders. Impingement signs were graded according to Neer’s classification and tears were graded according to Wiener and Seitz’s classification.

In 53% of asymptomatic shoulders there were tears that did not greatly differ from those on the symptomatic side. The only difference between asymptomatic and symptomatic tears was subacromial bursitis and biceps tendinopathy.

The high incidence of asymptomatic rotator cuff tears suggests that initial treatment of rotator cuff tears should be conservative and based on clinical judgment rather than on imaging modalities.

Introduction and Aims: A prospective analysis of the sonographic findings of asymptomatic shoulders in black patients over 40 years of age, to determine the prevalence of rotator cuff lesions in this group.

Method: Physical examination and bilateral sonograms were performed on 106 black patients, who visited the Trauma Clinic. Patients with shoulder trauma were excluded. Scans were made of sub-scapularis, supra-spinatus and infra-spinatus insertions. The size of the tears were measured in millimetres and divided in partially and full thickness tears.

Results: There were 66 male and 50 female patients. Mean age 52.8 years. Thirty-three patients had a history of previous trauma, but were asymptomatic at the time of the examination. The pain score for the whole group was 1.3 on an analogue scale of five, which means that pain is present now and then, but no medication is necessary. Forty-two cuff lesions were present in 34 patients. The biggest lesion (3.5 cm) was in a 73-year old patient. In 17 shoulders, the tear was more than one cm and in 13 shoulders it was a partial tear. There was almost no weakness of sub-scapularis, supra-spinatus and infra-spinatus.

Conclusion: Asymptomatic rotator cuff tears were as common in the black population as in the Caucasian population. The symptoms present are mild and the patients experienced it as normal. Weakness as such may not be a problem in patients with a rotator cuff tear. Weakness may become a problem if the tear increases in size. Pain may become a problem when the shoulder becomes unstable.

The identification of certain character traits in orthopaedic surgeons (OS), as compared with their general surgery counterparts, has potential implications in terms of the selection of registrars in orthopaedics.

A self-developed questionnaire about schooling, sports, hobbies, etc., was distributed to some 400 OS, 120 general surgeons, and 60 physicians across South Africa. There was a 29.2% response rate (117 replies) from OS, and 14 surgeons and 20 physicians replied.

The findings were inconclusive but nonetheless interesting. Profiles of the ‘average’ OS showed similarities with regard to race, gender, sports participation at school, and job satisfaction, especially when compared to the control group. There were notable individual differences in terms of age, marital status, number of children and use of free time. Most OS had attended urban public high schools. Golf was by far the most popular sport. More OS than members of the control group took part in sport, but they did not reach higher levels than their counterparts did.

The profile of the average OS does not seem to differ significantly from the control group, and more in-depth research seems necessary.

To determine whether HIV seropositivity is a significant risk factor for infection following open fractures of long bones, we undertook a prospective cohort-type analytical study.

We obtained Ethics Committee approval and invited suitable patients (adults with open fractures of long bones) presenting to our institution to participate in the study. Written informed consent was obtained and the patient registered. Baseline blood tests were done (Hb, HIV, Albumin, CD4 count), after which treatment proceeded in the standard manner. At set intervals, patient records were accessed and information captured in a database. Patients were followed up until bony union had occurred.

To date, 50 patients have been recruited to the study. Of these, 19 were followed up until bony union. All but one of these patients was male and the mean age was 34.5 years. Fractures included three femora, two humeri, two radii and 15 tibiae. There were five Gustilo-Anderson grade-I, seven grade-II, six grade-IIIa and three grade-IIIb open fractures. Three of the 19 patients tested positive for HIV (15.8%). Infection occurred in five patients (26.3%), none of whom was HIV-positive. The strongest predictor for infection was the time delay to wound inspection, with mean delays of 56.9 hours and 100.2 hours respectively in patients who did and did not develop infection.

Although our study is small, it suggests that asymptomatic HIV seropositivity is not a significant risk factor for infection following open fractures of long bones. Delayed wound inspection puts patients at increased risk.

This study was undertaken to identify certain high-risk patient groups admitted following trauma, in an attempt to improve their management.

We retrospective reviewed 207 patients admitted to the ICU with orthopaedic injuries between 1997 and 2003, excluding from the study spinal patients, paediatric orthopaedic patients, and patients having elective surgery. The mean age of the patients was 36.7 years.

The mean duration of stay in the ICU was 8.4 days. In 32% of patients, the only injuries were orthopaedic, with 51% of this group having multiple fractures. Of the patients with associated injuries, 34% had chest injuries. Acute respiratory distress syndrome (ARDS) developed in 46 patients (22%), of whom 33 (71%) had more than one long bone fracture. The incidence of ARDS in patients with no associated injuries was 11%. The overall mortality rate was 13.5% (28 patients), and the mortality rate of patients with only orthopaedic injuries was 5% (10 patients). Death occurred on the day of admission in 28.5% and 70% of the deaths occurred after 8 days in the ICU. Overall, there was a 10% mortality rate in patients admitted to the ICU for more than a day.

We advise close observation of all orthopaedic patients with associated chest injuries and recommend appropriate fracture management within 8 days of admission.

With the aim of identifying appropriate treatment and diagnosis, this paper discusses 12 of 107 elbow dislocations and 56 elbow fracture dislocations seen over four years.

One patient presented with arterial injury, two with olecranon fractures and dislocation, and three with radial head, olecranon and coronoid fractures. One patient had an intra-articular fracture, two had collateral ligamentous injuries and two had radial head fractures and dislocations.

Depending on treatment, the results can be very poor or excellent. An awareness of the pitfalls in dislocations and fracture dislocations of the elbow is necessary to prevent poor outcomes.

All patients who had received an Austin Moore hemi-arthroplasty between 6 February 1998 and 14 July 2002 were included in the study. Of the 101 patients, 34 were lost to follow-up, 34 had passed away and one did not give consent for the study. The Physical Performance of Activities of Daily Living (PODL) was evaluated, using a modified version of the functional status index by Jette. The level of social functioning was determined by a questionnaire developed by House . Muscular function was evaluated by a timed ‘carpet run’ of 20 m and measuring the time it took to rise twice from an armless chair. The data were compared to an age-matched control group of 44 volunteers.

The 45% complication rate in the study group included four dislocations (12%), two femoral fractures (6%) and three deep infections (9%). The social functioning questionnaire showed an average or above average score in most of the patients, 22 of whom (69%) were satisfied with the results. On the PODL score 19 patients (60%) were above average in dependency. Ten (31%) reported no functional pain and four (10%) reported severe pain. Muscular function tests showed a statistically significant difference between the operated group and the control group, with the mean ‘carpet run’ three times longer.

Even though the study showed good results as far as dependency and social functioning was concerned, there was a high complication rate and a low objective functional outcome. We concluded it was an effective procedure for patients who did not have high functional expectations, and that physiological status should play a greater role than chronological age in therapeutic decision-making.

Our retrospective study of 189 patients aimed to establish the efficacy of conservative treatment for rotator cuff impingement and also to assess the clinical presentation and the factors that influence the outcome.

We noted patients’ response to physiotherapy and cortisone injections. We looked at the shape of the acromion and tried to correlate it with effectiveness of conservative treatment.

All patients had either a positive Neer or Hawkins sign. In 123 patients internal rotation was markedly restricted. Subacromial cortisone injections were administered to 119 patients. The injection was repeated once in 52 patients and twice in 25. Surgery was necessary in 44 patients. In other words, conservative treatment was effective in 83%.

Only 12 of the patients who underwent surgery had a Bigliani type-III acromion and only nine had a large spur.

An appropriate exercise programme is critical if conservative treatment is to be effective. It should focus first on stretching the posterior capsule of the shoulder joint and increasing internal rotation, and subsequently on strengthening the subscapularis and infraspinatus muscles. We believe it is the imbalance of muscle power rather than the acromial spur that is the major cause of impingement.

In this prospective analysis of the sonographic findings of asymptomatic shoulders to determine the prevalence of rotator cuff lesions in black patients over the age of 40 years, we examined 106 black patients.

Patients with shoulder trauma were excluded. Bilateral sonography was done on the subscapularis, supra-spinatus and infraspinatus insertions of 66 men and 50 women (mean age 52.8 years). The tears were measured and classed as partial or full thickness tears. In 33 patients, there was a history of previous trauma, but they were asymptomatic at the time of the examination. The pain score for the whole group was 1.3 on an analogue scale of 5, which means that pain is present intermittently but no medication is necessary. In 34 patients there were 42 cuff lesions. The largest (3.5 cm) was in a 73-year-old. In 17 shoulders the tear measured more than 1 cm, and in 13 shoulders the tear was partial. There was almost no weakness of subscapularis, supra-spinatus and infraspinatus muscles.

We concluded that asymptomatic rotator cuff tears are as common in the black population as in the Caucasian population.

We evaluated the effectiveness of arthroscopic repair in patients with shoulder instability owing to a bony fragment as part of the Bankart lesion, using spiked Suretacs, sutures and anchors.

Over a two-year period, we followed up 23 of 25 consecutive cases, all with a bony fragment as part of the Bankart lesion. The mean age of patients, all of whom were male, was 21 years (17 to 35). Almost all injuries were sustained playing sports. Patients were clinically evaluated at six weeks and 20 weeks postoperatively and interviewed telephonically.

Full arthroscopic examination was performed in a lateral decubitus position. The affected capsular structures and labrum, with its attached bony fragment, were fully mobilised. The bony fragment was always attached to the capsular structures, with labral ring intact. We used a spiked Suretac anchor to reattach the bony fragment to its original anatomical position, and Mitek anchors and no. 1 Ticron sutures for individual reattachment of the capsule and ligaments. Postoperatively patients were immobilised in a shoulder sling for six weeks. Early restricted active and passive movements were advised. Patients routinely received postoperative physical and biokinetic rehabilitation. The mean follow up period was 16 months (5 to 29). There was no redislocation or subjective instability.

This technique yields excellent results, but because it is technically difficult should be used only by experienced shoulder arthroscopists with thorough knowledge of pathological shoulder anatomy.

Because there is little in the literature about specific presentation and examination methods for acromioclavicular (AC) joint pathology, we aimed to define and identify the most reliable tests.

We identified and examined 30 patients with probable AC joint pathology. We then excluded eight patients who experienced no pain relief after local Lignocaine infiltration, and examined 22 patients, two of whom had bilateral shoulder problems.

There were 15 complaints of AC joint pain, 13 of anterior pain, five of posterior pain and five of lateral pain. Pain radiated anteriorly in 14 patients, posteriorly in two, laterally in three and to the cervical region in three. Pain increased with weight-bearing in 18 shoulders, on elevation in five, on activities of daily living in six, at night or on being lain on in 11, and on reaching across the body in three. Clinical examination revealed swelling in seven shoulders and AC joint prominence in seven. There was local tenderness in 21 shoulders and there were crepitations in four. The forced cross-body test produced pain in 22 shoulders. In 22 shoulders, elevation was less than 60°. Jobe’s test was positive in 20, the Speed’s test in 19, O’Brien’s test in 15, the compression test in 15, the distraction test in 13. A painful arc was present to 160° in 13 shoulders. There was neck tenderness in 13 patients. Associated conditions included two cases of shoulder arthritis, six of impingement, two rotator cuff tears, two cases of biceps tendinitis and two of cervical pathology. Radiological changes were evident in 19 AC joints, 13 shoulder joints and 11 cervical spines. On ultrasonography, pathology was resent in 10 of 15 cases.

The most common symptoms were pain with weight-bearing, elevation and lying on shoulder. Anterior and posterior pain was the most common. The most common clinical findings were local tenderness, pain on elevation and the forced cross-body test, positive Jobe’s and Speed’s tests. Because no test is 100% accurate, the whole clinical presentation must be taken into account. Local infiltration of the AC joint is extremely helpful.