Musculoskeletal (MSK) injuries are one of the leading causes of disability worldwide. Despite improvements in trauma-related morbidity and mortality in high-income countries over recent years, outcomes following MSK injuries in low and middle-income countries, such as South Africa (SA), have not. Despite governmental recognition that this is required, funding and research into this significant health burden are limited within SA. This study aims to identify research priorities within MSK trauma care using a consensus-based approach amongst MSK health care practitioners within SA. Members from the Orthopaedic Research Collaborative (ORCA), based in SA, collaborated using a two round modified Delphi technique to form a consensus on research priorities within orthopaedic trauma care. Members involved in the process were orthopaedic healthcare practitioners within SA. Participants from the ORCA network, working within SA, scored research priorities across two Delphi rounds from low to high priority. We have published the overall top 10 research priorities for this Delphi process. Questions were focused on two broad groups - clinical effectiveness in trauma care and general trauma public health care. Both groups were represented by the top two priorities, with the highest ranked question regarding the overall impact of trauma in SA and the second regarding the clinical treatment of open fractures. This study has defined research priorities within orthopaedic trauma in South Africa. Our vision is that by establishing consensus on these research priorities, policy and research funding will be directed into these areas. This should ultimately improve musculoskeletal trauma care across South Africa and its significant health and socioeconomic impacts

The optimal management of rotationally-unstable ankle fractures involving the posterior malleolus remains controversial. Standard practice involves trans-syndesmotic fixation (TSF), however, recent attention has been paid to the indirect reduction of the syndesmosis by repairing small posterior malleolar fracture avulsion fragments, if present, using open reduction internal fixation. Posterior malleolus fixation (PMF) may obviate the need for TSF. Given the limited evidence and diversity in surgical treatment options for rotationally-unstable ankle fractures with ankle syndesmosis and posterior malleolar involvement, we sought to assess the research landscape and identify knowledge gaps to address with future clinical trials. We performed a scoping review to investigate rotational ankle fractures with posterior malleolar involvement, utilizing the framework originally described by Arksey and O'Malley. We searched the English language literature using the Ovid Medline and Embase databases. All study types investigating rotationally-unstable ankle fractures with posterior malleolus involvement were categorized into defined themes and descriptive statistics were used to summarize methods and results of each study. A total of 279 articles published from 1988 to 2018 were reviewed, and 70 articles were included in the final analysis. The literature consists of studies examining the surgical treatment strategies for PMF (n=21 studies, 30%), prognosis of rotational ankle fractures with posterior malleolar involvement (n=16 studies, 23%), biomechanics and fracture pattern of these injuries (n=13 studies, 19%), surgical approach and pertinent anatomy for fixation of posterior malleolus fractures (n=12 studies, 17%), and lastly surgical treatment of syndesmotic injuries with PMF compared to TSF (n=4 studies, 6%). Uncontrolled case series of single treatment made up the majority of all clinical studies (n=44 studies, 63%), whereas controlled study designs were the next most common (n=16 studies, 23%). Majority of research in this field has been conducted in the past eight years (n=52 studies, 74%). Despite increasing concern and debate among the global orthopaedic community regarding rotationally-unstable ankle fractures with syndesmosis and posterior malleolar involvement, and an increasing trend towards PMF, optimal treatment remains unclear when comparing TSF to PMF. Current research priorities are to (1) define the specific injury pattern for which PMF adequately stabilizes the syndesmosis, and (2) conduct a randomized clinical trial comparing PMF to TSF with the assistance of the orthopaedic community at large with well-defined clinical outcomes

Aims

Chronic osteomyelitis (COM) of the lower limb in adults can be surgically managed by either limb reconstruction or amputation. This scoping review aims to map the outcomes used in studies surgically managing COM in order to aid future development of a core outcome set.

Introduction. Core decompression is used in precollapse lesions to forestall disease progression in avascular necrosis (AVN) of femoral head (FH). The author reports a new technique using reverse bone graft technique to effectuate core decompression. Aim. To prevent precollapse in Ficat Type 1&2 and revascularization using synthetic bone graft material. Methods. A 18 year female police trainee with Magnetic Resonance Imaging (MRI) confirming AVN Stage 2 Ficat, clinically painful hip not evident in x-rays consented to undergo this new technique. Reverse bone graft technique with a Coring reamer – Patent 5423823. A minimally invasive technique with lateral 2 cm incision introducing 8.5 mm core reamer to remove a core of bone up to the subchondral bone. The subchondral cyst decompressed and curetted under video recorded Image Intensifier (II). Demarcated avascular bone segment excised and bone graft reversed and inserted with cortical bone acting as a support to prevent collapse and the distal segment augmented using 5 grams of osteoconductive granular synthetic bone graft material based on calcium phosphate hydroxyapatite (HA 2500–5000 μm). Avascular segment histopathologically confirmed AVN. The metaphyseal entry was extrapoliated at the lateral cortex using the combined necrotic angle described by Kerboul in the anteroposterior and lateral views under II. Protected weight bearing for 2 months to prevent stress riser. Biomaterials. HA granules named as GranuMas™ developed under Intensified Research in Priority Areas (IRPA) Research Project (No. 03-01-03-0000-PR0026/05) and invented by the Advance Materials Research Centre (AMREC) and manufactured by GranuLab –Patent P1 20040748 fulfilling the criteria for American Society for Testing and Materials (ASTM) F1185-88(1993) Standards which is ‘Standard Specification for Composition of Ceramic Hydroxyapatite for Surgical Implants’. Derived from Malaysian limestone, ranging from 200–5000 μm gamma sterilized. Results. After 6 months, there was no collapse of subchondral bone and the FH showed revascularization along bone grafted site with viable graft and increased radiotracer activity using 99-Tc MDP Bone Planar Scintigraphy. Clinical analysis follow up at 2 years was descriptive rather than statistical with a x-ray evident incorporated graft and with pain free full range of movement. Discussion. Reduction in intraosseous pressure is achieved by using large bore 8.5 mm coupled with HA granules promoting revascularization. The core tract entering through the metaphyseal region reduces risk of subtrochanteric fracture a potential complication of vascularized fibular grafts and with less morbidity with other treatment methods for osteonecrosis of the femoral head. The concept can be extended in introducing stem cell and biologic material to treat AVN. Conclusion. This technique is minimally invasive and effective in young patients with early stage of FH AVN and has shown revascularization along the bone grafted site