Zone V flexor tendon injuries are devastating and may result in significant morbidity. There may be remarkable differences between preoperative clinical and the intraoperative findings of zone V flexor injuries. In this study, we assessed the demographics of patients presenting with zone V flexor injuries and the diagnostic accuracy of preoperative clinical examination. This was a prospective study of patients who presented with zone V flexor injuries at an emergency department of a tertiary academic hospital for a period of one year. The demographic data were analysed and the preoperative clinical examination findings were compared to the definitive intraoperative findings to assess the accuracy of the former. The one-sample test for proportion was used to assess if the difference between the two findings was statistically significant. Zone V flexor injuries occurred predominantly in males under 40 years of age. Assault was the leading cause of these injuries. Alcohol intake was a significant factor for the causes of these injuries. Almost one-third (33%) of lacerated anatomical structures were missed and 91% of partially lacerated anatomical structures were inaccurately diagnosed. The mean number of errors of the clinical examination was 3.55; only 9% of the clinical examination had no error and 42% had four or more errors. There was a significant difference between preoperative clinical examination and intraoperative findings and we recommend that all zone V flexor injuries extending beneath the subcutaneous tissue should be explored in theatre.

BACKGROUND: Burnout is epidemic among physicians, with the orthopaedic speciality displaying one of the highest rates of burnout in international studies. The burnout rate of the South African orthopaedic community is unknown. This study aimed to determine the prevalence and causes of burnout, as well as the coping mechanisms and associations with burnout, in South African orthopaedic surgeons and trainees METHODS: We conducted a cross-sectional, secure, online survey of members of the South African Orthopaedic Association. The survey assessed demographic characteristics, workload, professional fulfilment and burnout (utilising the Stanford Professional Fulfilment Index), associated workplace distress conditions, causes of and coping strategies for burnout. A response was not compulsory for any question. Statistical analysis was performed to assess for independent associations with burnout RESULTS: One hundred and fifty-six respondents, with a median age of 46.5 years (interquartile range [IQR] 37-58) participated. Ninety per cent (139 of 155) of respondents were male. Registrars accounted for 17% (27 of 155), while 83% (128 of 155) were qualified specialists. Respondents were in orthopaedic practice for a median of 17 years (IQR 9-28). Sixty per cent (76 of 127) practise in private, 17% (22 of 127) in public and 23% (29 of 127) in both sectors. The overall burnout rate was 72% (113 of 156). Burnout was associated with being the parent of young children and having fewer hours of sleep on call. Registrars were more likely to have burnout than consultants (OR 5.68, 95% CI 1.3-25.2). Gender, practice setting and subspeciality were not associated with burnout. Self-reported causes of burnout that were found to be associated with actual burnout were: 'hours at work', 'lack of free time' and 'work-life imbalance'. No self-reported coping mechanisms were found to be protective in this cohort, but the use of alcohol as a coping mechanism was associated with an increased likelihood of burnout (OR 3.9, 95% CI 1.4-10.7). Respondents felt that the concurrent experience of the COVID pandemic at the time of running the survey reduced their experience of burnout CONCLUSION: The burnout rate in the South African orthopaedic community is 72%. Trainees were found to be particularly vulnerable. There appears to be a need to develop, assess and implement effective system-related initiatives aimed at reducing the burnout rate among orthopaedic surgeons and trainees in South Africa Level of evidence: Level 4

BACKGROUND: Primary bone tumours, although rare, are an important rising cause of morbidity and mortality in Africa. Late presentation, delayed diagnosis and failure to obtain consent for surgical procedures are important causes of loss of limb and life especially in the West African subregion. Existing data on primary bone tumours in Nigeria have been based on studies performed at various regional levels. The aim of this study is to determine the epidemiological pattern of primary bone tumours in Nigeria in general, including demographics, predominant tumour types and predominant skeletal location by reviewing existing data METHODS: A search of the following databases: University of Edinburgh Library, PubMed, CINAHL and SCOPUS from 2000 till January 2021 following PRISMA guidelines was conducted to identify studies conducted in Nigeria with relevant epidemiological data on primary bone tumours in Nigeria RESULTS: The search yielded a total of 952 hits from which seven hospital-based retrospective studies met the inclusion criteria for review. The estimated incidence rate of primary bone tumours ranged from 0.08 to 0.31 per 100 000 population. All studies showed a male preponderance. The peak age group of individuals presenting with both benign and malignant primary bone tumours was 11-20 years. Overall, benign tumours were more common. Osteochondromas were the most common benign tumours, while the commonest malignant tumours identified were osteosarcomas. The most common location for both benign and malignant tumours were the tibia and fibula CONCLUSION: Nigeria shares some similar epidemiological characteristics of primary bone tumour with other countries; however, some peculiar differences have been identified in this study. Population-based studies are required to obtain more accurate epidemiological data about this disease Level of evidence: Level 2

BACKGROUND: Lower limb fractures occurring in and around the home environment and caused by collapsing access gates present frequently to our emergency unit. There is currently limited literature evaluating injuries resulting from access gate accidents. The aim of this study was to evaluate the patterns of lower limb fractures, management options offered and concomitant injuries in children as well as adolescents presenting with access gate-related lower limb traumas. METHODS: A retrospective cross-sectional review of 43 children with 46 lower limb fractures was conducted between 1 January 2017 and 31 December 2020. Hospital records and radiology archives of all children and adolescents under 12 years of age (24 males and 8 females) with lower limb fractures sustained following an access gate injury were reviewed and included for analysis. Data was analysed descriptively using SAS (SAS Institute Inc, Carey, NC, USA), Release 9.4. RESULTS: The prevalence of access gate-related injuries for all lower limb fractures in children and adolescents treated during the four-year period was 11%. The findings revealed that femur fractures are more common, accounting for 50.0% of the cases. The majority of cases were of patients younger than 6 years (71.9%), and predominantly affecting males (3:1). The fractures occurred in a home environment and were commonly related to non-motorised gates, in 93.8% of cases. The oblique fracture patterns comprised 40.6% of the fractures, and 68.8% of the fractures were located in the diaphysis. Open fractures constituted 50.0% of the tibia fractures. Mild head injuries associated with lower limb fractures were observed in 12.5% of the cases. CONCLUSION: The results demonstrated the prevalence of lower limb fractures above all injuries related to access gates. The majority of the injuries observed in this study occurred in manually operated gates, and commonly affected younger patients. In light of these findings, further studies are required into the reasons for these injuries and preventative measures Level of evidence: Level 4.

ABSTRACT BACKGROUND: With increasing pressure on our training hospitals, we undertook to ascertain whether our clinical orthopaedic surgery training platform is providing adequate surgical exposure, both in diversity and the level of trainee participation METHODS: The orthopaedic surgery database was interrogated for theatre procedures logged for the 12-month period 1 January to 31 December 2018. Each theatre case was assessed as to the level of trainee participation, whether it was performed during or after hours, and categorised as being elective or trauma in nature, as well as the orthopaedic subdiscipline RESULTS: A total of 3 147 orthopaedic surgical procedures were logged with an even split of elective (51.1%) and trauma (49.9%) cases. Adults predominated in the trauma group while the paediatric service contributed most to the elective cases, followed by arthroplasty and spine. Overall, 25.5% of procedures were performed by consultants and 74.5% by registrars. Registrars were more frequently the primary surgeon in trauma cases (90%) compared to elective procedures (59%) (p < 0.001). Of the elective cases, 37% were performed by registrars as supervised unscrubbed and 22% as supervised scrubbed operations. In total, 17.5% of cases were performed after hours, with 31.7% of trauma surgeries and only 2.9% of elective surgeries occurring after hours. Registrars were the primary surgeon in 98.7% of after-hours trauma cases and 58% of after-hours elective cases under unscrubbed supervision CONCLUSION: Our study presents the surgical experience and level of participation available to orthopaedic surgical trainees in a South African training hospital where their exposure was an equal number of elective and trauma cases. The vast majority of the cases were performed by the registrars in their supervised unscrubbed capacity although the more complex, elective cases were performed by consultants. Almost all after-hours trauma cases were performed by registrars. This suggests the platform allows for a high level of registrar surgical participation and training despite the challenges. Further review is required to assess achievement of trainee competency and whether in fact the current experience is adequate Level of evidence: Level 4 Keywords: orthopaedic registrar surgical experience, South African orthopaedic training exposure, orthopaedic case exposure

BackgroundThis study aimed to determine whether the addition of a lateral proximal tibial tension band plate, combined with proximal tibial dome realignment osteotomy, would decrease the recurrence rate in a group of children younger than 7 years with infantile Blount’s disease (IBD) and high recurrence risk, defined as a medial physeal slope ≥60°. MethodsWe reviewed the records of 14 children (22 limbs) under the age of 7 years with IBD and a medial physeal slope ≥60° that were treated with a combination of tibial osteotomy and tension band plates (group 2) to determine the recurrence rate and time to reoperation. These results were compared with a matched group of eight children (12 limbs) with IBD and a medial physeal slope≥60° that were treated previously with tibial osteotomy alone (group 1). ResultsThe two groups were matched in terms of age, sex, obesity, Langenskiold stage, tibio-femoral angle and medial physeal slope. The recurrence rate was 92% (11/12) in group 1 and 77% (17/22) in group 2 (odds ratio 0.31; 95% CI 0.03–3.01, p=0.312). The mean time to reoperation was 2.4 years in group 1 and 1.9 years in group 2 (p=0.319). There were two implant-related complications: one broken screw and one case of epiphyseal fixation failure in the tension band plate group, both in cases of recurrence. ConclusionThe addition of a lateral tension band plate to a proximal tibial realignment osteotomy may be an option to consider in children younger than 7 years with IBD and a high risk of recurrence. Further research is required to determine recurrence risk in IBD and to develop and evaluate surgical strategies to mitigate this risk with well-designed, multicentre controlled trials. Level of evidence: Level 4

ABSTRACT BACKGROUND: Multiple hereditary exostosis (MHE) is a rare autosomal dominant disorder predisposing to the development of multiple osteochondromas. Malignant transformation is an uncommon complication of osteochondromas and is especially rare in the paediatric population. Making a diagnosis of malignant transformation is recognised as a challenge globally METHODS: We obtained informed consent and ethics approval prior to reviewing the hospital file, radiology and pathology of our index patient, as well as conducting a directed literature search RESULTS: An 11-year-old male with MHE presented with new onset pain in the right leg with an associated inability to weight bear. Plain radiographs and magnetic resonance imaging (MRI) showed features consistent with malignant transformation. The child underwent a Malawer 1 resection of the proximal fibula with no complications. The pathology confirmed a grade 1 secondary peripheral chondrosarcoma (CS) arising in an osteochondroma The rate of malignant transformation in MHE is as high as 36.3% in select specialist tertiary centres. Ninety per cent of the resultant malignancies are chondrosarcomas. Malignant transformation before the age of 20 years is exceptional. Plain radiology is routinely used for monitoring of patients with MHE. Other modalities exist to assess for cartilage cap thickness, a much-debated criterion of malignant change. Pathology is essential for confirmation of malignant transformation as well as to exclude high grade lesions. Treatment is wide local excision (WLE) with limb-sparing surgery and long-term follow-up to detect for local recurrences. CONCLUSION: The malignant transformation of osteochondromas occurs more frequently in individuals with MHE and may even arise in the paediatric population. In the presence of suspicious clinical or radiological features, en-bloc surgical resection and histopathological correlation is mandatory to make the diagnosis. We encourage a multidisciplinary team approach with collaboration between the orthopaedic surgeon, radiologist and pathologist Level of evidence: Level 5 Keywords: multiple hereditary exostosis (MHE), chondrosarcoma, osteochondroma, malignant transformation

ABSTRACT BACKGROUND: Musculoskeletal tuberculosis (MSK TB) is a disease entity that often mimics other orthopaedic conditions in its radiographic and clinical presentation, which can delay diagnosis and treatment. The purpose of this study is to examine the clinical and radiographic presentation as well as the accuracy of various diagnostic tests, treatment, complications and outcome in paediatric patients diagnosed with MSK TB. We aim to provide insight into typical presenting features in order to expedite diagnosis in this perplexing disease. METHODS: We retrospectively reviewed 77 consecutive patients with extra-axial MSK TB treated at our institution over a ten-year period from 2008 to 2018. We collected data on initial clinical presentation, laboratory values, radiographic findings, diagnostic testing, treatment and outcomes. We performed quantitative and qualitative analysis to look for patterns in presentation that can help with diagnosis and factors affecting the clinical outcomes. RESULTS: The most common clinical presentation was pain of the affected limb. Constitutional symptoms were uncommon. Our patients presented with thrombocytosis and anaemia, but normal white cell counts. Inflammatory markers were mildly elevated. Of diagnostic tests employed, the Mantoux skin test yielded the most positive results (70%) followed by tissue PCR (53%). The hip was most frequently involved, followed by the knee and elbow. Most patients presented with normal appearing X-rays. We had a medical compliance rate of 94% with all patients followed up to completion of treatment having resolution of active disease. Thirty-nine per cent of our patients had residual joint stiffness or deformity following completion of treatment, ranging from ankylosis to mildly decreased joint range. CONCLUSION: Patients with MSK TB usually present with non-specific symptoms and signs, and a high index of suspicion should be maintained in endemic areas. Typical haematological findings are an elevated ESR and CRP accompanied by anaemia and thrombocytosis. Radiographs at presentation are non-specific in more than 50% of patients. A combination of diagnostic modalities should be employed as no single test is 100% sensitive or specific. Compliance with medical treatment reliably leads to resolution of the disease. Residual joint pathology is common and needs to be addressed secondarily. Level of evidence: Level 4 Keywords: musculoskeletal tuberculosis, paediatric tuberculosis, joints, anti-tuberculosis treatment, deformity, GeneXpert

With Yuval Noah Harari’s ‘I told you so’ still ringing in our ears and the battlefield still ablaze, one cannot help but wonder what the next microorganism assault on humankind is going to involve.1 While we are still fully engaged on our main front, another old enemy is gathering strength on our flanks. Bacterial resistance has been described as the single most important threat to public health in the 21st century.2 The United Nations interagency group on bacterial resistance estimates that drug-resistant disease could rise from a current figure of around 700 000 deaths per annum to around 10 million a year by 2050, if we don’t act.3 The six most common bacterial pathogens in orthopaedics are currently all on the CDC (Centers for Disease Control and Prevention) ‘Urgent’ or ‘Serious’ threat list.4 A meta-analysis estimated that 39% to 51% of surgical site infection in the USA was caused by bacteria that are resistant to the standard prophylactic antibiotics.5 Our primary tool against resistance is antibiotic stewardship programmes. But wil it solve the problem?