The first purpose of this study was to survey patterns of unusual metastatic spread of soft tissue sarcoma in patients treated at the Musculoskeletal Tumour Unit in Pretoria, and the second to make recommendations regarding the treatment and follow-up of patients.

In 3671 cases of musculoskeletal tumours treated from 1986 to 2003, 346 cases of soft tissue sarcoma were reported. Unusual metastases were present in 11 male and four female patients, ranging in age from 15 to 76 years. The interval between diagnosis and first metastasis ranged from 1 to 56 months. Pulmonary metastases occurred in only six patients, all with metastases in unusual sites. In 10 patients the unusual metastases were diagnosed after the patients themselves had discovered them on self-examination. Meticulous clinical examination combined with radiographs, CT scan and ultrasonographic examinations led to the diagnosis of the other metastases.

This series highlights the importance of referring patients to tumour centres, where the multidisciplinary management approach facilitates the implementation of coordinated surveillance strategies and the early detection and treatment of distant metastases.

The purpose of this study is to compare functional results of hemipelvectomy and internal hemipelvectomy following resection of pelvic tumours. The emotional acceptance of such surgery is also examined.

From 1998 to 2003, 19 male and 13 female patients, aged from 6 to 76 years, underwent hemipelvectomy, and 12 male and seven female patients, aged from 13 to 65 years, underwent internal hemipelvectomy. In the series as a whole, follow-up ranged from 1 to 156 months. Five patients with external hemipelvectomy, six with internal hemipelvectomy and one who underwent internal hemipelvectomy followed by external hemipelvectomy were evaluated functionally, clinically and psychologically.

Patients expressed emotional concern about body image and mobility. Psychosocial adjustment was difficult for all patients, but some were able to overcome their difficulties more easily than others. Patients with internal hemipelvectomy rather than external hemipelvectomy had more difficulty adjusting emotionally.

The site of the tumour and morbidity rates, which remain high when limb-sparing surgery is performed for pelvic tumours, are important considerations when deciding upon the type of surgery. Patients and their families need extensive preoperative psychological preparation and postoperative psychotherapy is imperative.

From two orthopaedic theatres at Pretoria Academic Hospital 28 samples were randomly selected, including Hibiscrub soap dispensers and both fully-sealed and partially-used bottles of iodine/alcohol, Hibitane/alcohol and Hibitane/water. Samples were taken from the solutions and the bottlenecks and basic microbiological cultures were done. Only the Hibitane/water bottles yielded positive cultures, with Bacillus species cultured from three out of four.

We concluded from this small random study that with the exception of Hibitane/water mixtures it should be safe to use the same bottle of solution in different cases.

This was a prospective study to evaluate the changes in bacterial colonisation of the skin during hospital admission for elective surgery. It involved 48 patients who were admitted the day before surgery to Pretoria Academic and Pretoria East Hospitals. Within two hours of admission, cotton-tipped pus swabs were used to obtain samples from 56 skin sites in 48 patients. Postoperative specimens were obtained the day after surgery. The pre-operative cultures revealed a 73% Coagulase Negative Staphylococcus (CNS). Postoperative cultures revealed a 63% CNS. Preoperative methicillin resistance of the CNS was 6% and postoperative resistance to 49% (p < 0.01). The resistance of the organism to Cefazolin increased from 11% to 37%.

This study clearly indicates that multiple drug-resistant organisms colonise the skin of patients in the perioperative hospital stay. The postoperative rise in methicillin resistance of the CNS was alarming. Questions arising from this study include optimal admission time, length of postoperative stay, choice of perioperative antibiotic, use of occlusive dressings to prevent colonisation of wound site and routine screening for Methicillin-resistant CNS skin contaminants.

Human bone morphogenetic protein (hBMP) was prepared according to a modified method (Sampath et al). Implants were prepared with 500 μg of hBMP adsorbed onto a composite matrix (1 gm of insoluble collagenous bone matrix and 200 mg of lyophilised human gelatine).

The hBMP/collagen composite was used to treat 11 women and 23 men (mean age 36 years). All patients had failed to achieve union despite previous treatment by internal or external fixation, immobilisation in a cast, and/or allogenic or autogenic bone grafting. The mean age of the nonunions was 26 months (1 to 228).

At surgery a mean of 2 gm per patient of the composite was inserted at the site of the defect, which was stabilised by internal or external fixation. Supplementary allogenic cancellous bone particles and block configured spongy bone was used in 17 patients. At follow-up 1, 8, 16 and 23 weeks postoperatively, functional results were assessed according to weight-bearing. A score of 0 was given where there was no weight-bearing, a score of 1 for weight-bearing with the assistance of two crutches, 2 for light weight-bearing with one crutch, 3 for full weight-bearing with one crutch and 4 for full weight-bearing without crutches. At a mean follow-up of 17 weeks (8 to 32), the mean score was 3.25, higher than the mean preoperative score of 2.22 and mean one-week follow-up score of 0.5. Of the five patients who suffered recurrent infection, two failed to score above 2 at 17 weeks mean.

Present results indicate that hBMP composite implants may represent effective treatment of difficult nonunions.

We looked at long-term psychological effects of limb salvage surgery on young people treated for osteosarcoma and Ewing sarcomas with limb salvage surgery and high-dose neo-adjuvant chemotherapy.

After an extensive survey of the literature, we conducted semi-structured interviews with five young adult survivors. They reported various treatment-linked psychological symptoms, some of which persisted in varying degrees for up to 10 years after completion of treatment. Depending largely upon social and family support during and after treatment, the symptoms seem to become less invasive as time passes, but the survivors reported that some of them recur at transition periods in their lives and before annual follow-up visits. All view themselves as stronger people who have learnt much from their experience, and said that counselling and the provision of information at the treatment centres had helped in their adaptation.

The multi-disciplinary team approach in the treatment of adolescents and young adults with cancer is of paramount importance.

Since July 1996, we have treated 97 patients who developed sepsis following total knee arthroplasty and 53 who developed sepsis following total hip arthroplasty. We evaluated the rate of retention of prosthesis.

In 69 A-host patients, 80 B-host and 1 C-host, we identified 70 cases of Staphylococcus aureus, 76 of Staphylococcus epidermidis, 33 of Pseudomonas, 23 of Escherichia coli and 18 of Enterococcus. Five patients were diabetic.

Muscle flaps were used in 51 cases. Of the 131 patients available for follow-up, 94 healed with retention of prosthesis. Five patients had to undergo amputation. We are still treating 36 patients, some of whom have received a temporary prosthesis.

Most patients could be salvaged with a two-staged revision. Host status influenced outcome.

The purpose of the study was to determine the normal skin flora on 30 orthopaedic patients preoperatively and to ascertain whether it changed during the patient’s stay in hospital.

After ethical committee approval of the trial, on admission a swab sample was taken of the limb upon which surgery was to be performed. A postoperative swab was taken in the ward on the day of surgery.

Preoperatively Staphylococcus epidermidis was cultured in 24 cases, Staphylococcus aureus in three and Enterococcus faecalis in three. Postoperatively S. epidermidis was cultured in 25 cases and Enterococcus in four. All preoperative S. epidermidis cultures were sensitive to Cloxacillin, Kefzol, Augmentin, Oflaxin and Ciprobay. Ten cases of postoperative S. epidermidis were resistant to Cloxacillin and five to Augmentin.

Within 48 hours of admission, the bacterial flora with which patients were admitted changed to one that was more resistant to first-line antibiotics. We believe ‘simple’ antibiotics can be used prophylactically if the patient undergoes surgery the day of admission.

We evaluated the efficacy of two popular electrotherapy devices, the TENS and the Neurostim, for pain control in chronic low backache.

After obtaining ethical committee approval we designed a prospective randomised study. We withdrew pain medication from 24 patients, aged 40 to 85 years, attending the pain clinic because of chronic degenerative backache, and instituted a four-week course of treatment five days a week with either TENS or Neurostim. Both the patient and the physiotherapist were blinded. All patients signed an informed consent form and completed pain scale assessments before and after each treatment. A statistician evaluated the records.

The TENS apparatus functions with a voltage of 0.3 and an upper frequency of 15 000 Hz. The voltage pulse width is 50 to 250 ( biphasic. The Neurostim functions with a voltage of 8.2 and an upper frequency of 16 000 Hz. The voltage pulse width is 3 100 μ monophasic.

Slight skin pad irritation occurred in few patients. None of the patients reported worsening of pain during treatment. Twenty patients had significant relief of pain after treatment, lasting until the next treatment except for over weekends, when the pain increased again. There was no significant difference in the pain relief produced by the two devices.

Electrotherapy is an effective and virtually complication-free way of controlling chronic low backache.

The purpose of our study was to ascertain whether complete debridement and cancellous bone grafting prevents the progression of early (Ficat stages I to III) non-traumatic avascular necrosis of the femoral head.

Between 1995 and 2001 15 patients presented at the Pre-toria Academic Hospital with atraumatic avascular necrosis of the femoral head. The necrosis was staged according to the modified Ficat classification based on radiographs and on MRI and/or a bone scintigram: there were five Ficat stage-I, six stage-IIA, two stage-IIB and two stage-III hips. Postoperatively the diagnosis was confirmed histologically in all cases.

Using the Harris Hip Score (HHS), patients were clinically evaluated preoperatively and at each follow-up examination. The Ficat classification was also determined at each follow-up. A lateral approach with a trap door procedure was followed by debridement of the necrotic area and autogenous bone grafting. The mean follow-up period was 20 months, with the longest follow-up six years. There was no progression of disease in the five patients with Ficat stage-I hips, and there was a mean HHS improvement of 40 points. The six Ficat stage-IIA and two stage-IIB patients also had no progression of disease and exhibited 53 and 78 point respectively HHS improvements. Both Ficat stage-III patients progressed to total hip arthroplasties after a mean of 17 months.

We conclude that debridement and cancellous bone grafting is effective in treating patients with Ficat stage-I to IIB avascular necrosis.

The worldwide increase in the resistance of micro-organisms to antimicrobial drugs leads to an increase in morbidity, mortality and health care costs. It is important to identify the resistant organisms, to provide alternative antibiotic treatment protocols and to identify the high-risk infection areas.

We undertook a retrospective study of 693 musculoskeletal infections seen in the Musculoskeletal Tumour and Sepsis Unit of Pretoria Academic Hospital over five years, capturing data relating to the microscopy, culture and sensitivity to antimicrobial drugs of micro-organisms from tissue samples and pus swabs.

Most infections developed in patients aged 31 to 40 years. Sepsis most often occurred postoperatively. The next most common sepsis followed trauma. The femur was the most common site, followed by the tibia and the knee. In descending order, the most common organisms isolated were Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas sp., Escherichia coli, Enterobacter sp.

In the last two years there was an alarming increase in coagulase-negative staphylococci. All micro-organisms exhibited increased resistance to specific antimicrobial drugs over the five-year period.

The purpose of this study was to evaluate the safety of liquid collagen and cross-linked collagen in treating bone defects.

In a prospective trial, the use of liquid collagen and a stiffer, slightly more rigid cross-linked collagen allograft was evaluated. Bone cavities resulting from curettage of cysts or tumours were filled with either liquid or cross-linked collagen. The collagen was extracted from donor allograft and mixed with minute particles of crushed cortical bone. Patients were monitored clinically, radiologically and haematologically for complications, including infection, rejection or allergic reactions.

There were five patients with osteoid osteoma, five with chondrosarcoma, two with bone cysts, five with osteitis and three with chondroblastoma. One patient each had enchondroma, ossifying fibroma, osteosarcoma, aneurysmal bone cyst, fibrous dysplasia, thickening of the tibial cortex, avascular necrosis, Ewing’s sarcoma, a luxstacortical ganglion and a tumour of the pubic symphysis. Eleven patients received liquid collagen and 32 cross-linked collagen. The use of liquid collagen was abandoned because it was too fluid to keep in the cavity. The cross-linked collagen, though more solid, could be introduced even through small holes in a bone or spinal cages. No allergic reactions occurred and the bone graft behaved similarly to a combination of allograft/autogenous graft.

Cross-linked collagen is as effective as any other allogenic bone product in bone cavities. In this series there were no complications attributable to the graft.

Fifty-five adults who had sustained a tibial fracture, or a femoral fracture, or both, were subjected to a double-blind randomised study to determine the efficacy of methylprednisolone in treating the fat embolism syndrome. This drug maintained arterial oxygen levels, stabilised or reduced the serum level of free fatty acids, and decreased the risk of the fat embolism syndrome in a statistically significant proportion of patients. Gurd's criteria for the diagnosis of the fat embolism syndrome were found inadequate. Other more sensitive criteria for early diagnosis and effective management were determined. There were no deaths or serious morbidity in our series.