SA Orthopaedic Journal

No Issue Number

• <b>Limited pedicle screw constructs in adolescent idiopathic scoliosis surgery and clinical correlation</b>
  STUDY DESIGN: Retrospective study of 31 patients treated for adolescent idiopathic scoliosis utilising posterior double rod constructs with a limited number of strategically placed screws. OBJECTIVE: Review of the radiological and clinical outcomes of strategic screw placement in posterior double rod constructs with respect to implant density. SUMMARY OF BACKGROUND DATA: The trend in scoliosis surgery dictates the use of pedicle screw constructs with anchors at every level. Favourable correction and clinical outcomes have been reported using this technique. The cost burden of such an implant construct is high; with the additional risk of pedicle breach and neurological compromise multiplied by the number of screws. The sustainability of this practice is questionable. METHODS: Thirty-one patients, treated surgically for adolescent idiopathic scoliosis, with a minimum two-year follow-up, were included. Posterior double-rod constructs were used in all cases. Cobb angles were measured pre-operatively, post-operatively and at two-year follow-up. Patient satisfaction and clinical outcome were evaluated through the SRS22 questionnaire. RESULTS: Lenke classification yielded 16 type I, seven type II, four type III, two type IV and two type VI curves. The average Cobb angle pre-surgery was 68.5° (±17.6°), with a flexibility of 38%. This was corrected to an average of 24°±11.9°. The correction was maintained at two-year follow-up. In terms of thoracic sagittal profile, 25 patients measured 'normal' (10°-40°) post-operatively, compared to 17 pre-operatively. This correction was achieved with a 52.2% metal density over an average of nine instrumented segments. Average SRS22 patient satisfaction score was at 89%. CONCLUSION: Strategic screw placement, in adolescent idiopathic scoliosis surgery, yields adequate correction and curve maintenance. High levels of patient satisfaction were achieved at a dramatically reduced cost, with a diminished risk for pedicle violation.
  
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• <b>Hyperextension at the cervicodorsal junction in osteogenesis imperfecta - a case report</b>
  Hyperextension at the cervico-dorsal (CD) junction is rare in osteogenesis imperfecta (OI) with no cases being reported in the literature. We report a three-year-old child with OI (Sillence type III²) who presented with: hyperextension at CD junction; low bone mass; thoracolumbar kyphosis; bilateral anterolateral bowing of femora; and failure to thrive.
  
• <b>Anterior surgical correction of thoracolumbar and lumbar scoliosis: efficacy and morbidity</b>
  STUDY DESIGN: A retrospective review of adolescent patients undergoing instrumented anterior spinal fusion (ASF) by a single surgeon for thoracolumbar or lumbar (TL/L) scoliosis. OBJECTIVE: The aim of this study is to investigate the efficacy and associated morbidity of anterior instrumented corrective fusion for thoracolumbar and lumbar scoliosis. MATERIALS AND METHODS: The medical records and radiographs of 36 consecutively managed patients who underwent anterior spine surgery for thoracolumbar or lumbar curves by a single surgeon between 2001 and 2011 were retrospectively reviewed. The cohort consisted of 26 female and 10 male patients with idiopathic scoliosis as the commonest aetiology. Data collated and analysed included patient demographics, surgical factors, post-operative management and complications. In addition, radiographic analysis was performed on pre-operative and follow-up X-rays, and Scoliosis Research Society (SRS 22) scores were collated. RESULTS: Thoracolumbar/lumbar curves were corrected from 68.4°±18.8° (34°-120°) to 25.9°±16.6° (7°-66°) (average of 62.1% correction). The thoracic compensatory curve spontaneously corrected from 32.8°±14.0° (12°-53°) to 18.4°±14.2° (4°-44(0)) (average of 43.9% correction). Sagittal imbalance of greater than 4 cm was found in 40% of patients pre-operatively and in 16% post-operatively (85% negative sagittal imbalance, 15% positive sagittal imbalance). Rotation according to the Nash-Moe method corrected by 1.2 of a grade (2.37±0.69-1.17±0.58). Average operative time was 194 minutes and estimated blood loss was 460 ml. The diaphragm was taken down in 34 of the 36 patients but no patients required post-op ventilation. The average high care stay was 1.2 days. Average follow-up was 16.9 months. Good maintenance of correction was shown at most recent follow-up, with the mean thoracolumbar/lumbar curve measuring 27.9°±16.7°, and the mean compensatory thoracic curve measuring 20.9°±16.3°. There were no significant neurological or respiratory complications, and no cases had radiological signs of pseudoarthrosis. Scoliosis Research Society scores were obtained in 75% of the idiopathic scoliosis group (18/24), and improved from 75.91 pre-operatively to 84.72 post-operatively. A total of 93.8% were satisfied/very satisfied with their treatment, and 87.5% would probably/definitely have the same treatment again. CONCLUSION: Anterior corrective fusion for thoracolumbar and lumbar scoliosis is effective in both deformity correction and the maintenance thereof. Spontaneous correction of the thoracic curve can be expected and thus limit the fusion to the lumbar curve. Despite the concerns of taking down the diaphragm, there is minimal morbidity. LEVEL OF EVIDENCE: Level IV.
  
• <b> <i>SA Orthopaedic Journal</i> </b> <b> Summer 2012 volume 11 number 4</b>
  STUDY DESIGN: A retrospective review of adolescent patients undergoing instrumented anterior spinal fusion (ASF) by a single surgeon for thoracolumbar or lumbar (TL/L) scoliosis. OBJECTIVE: The aim of this study is to investigate the efficacy and associated morbidity of anterior instrumented corrective fusion for thoracolumbar and lumbar scoliosis. MATERIALS AND METHODS: The medical records and radiographs of 36 consecutively managed patients who underwent anterior spine surgery for thoracolumbar or lumbar curves by a single surgeon between 2001 and 2011 were retrospectively reviewed. The cohort consisted of 26 female and 10 male patients with idiopathic scoliosis as the commonest aetiology. Data collated and analysed included patient demographics, surgical factors, post-operative management and complications. In addition, radiographic analysis was performed on pre-operative and follow-up X-rays, and Scoliosis Research Society (SRS 22) scores were collated. RESULTS: Thoracolumbar/lumbar curves were corrected from 68.4°±18.8° (34°-120°) to 25.9°±16.6° (7°-66°) (average of 62.1% correction). The thoracic compensatory curve spontaneously corrected from 32.8°±14.0° (12°-53°) to 18.4°±14.2° (4°-44(0)) (average of 43.9% correction). Sagittal imbalance of greater than 4 cm was found in 40% of patients pre-operatively and in 16% post-operatively (85% negative sagittal imbalance, 15% positive sagittal imbalance). Rotation according to the Nash-Moe method corrected by 1.2 of a grade (2.37±0.69-1.17±0.58). Average operative time was 194 minutes and estimated blood loss was 460 ml. The diaphragm was taken down in 34 of the 36 patients but no patients required post-op ventilation. The average high care stay was 1.2 days. Average follow-up was 16.9 months. Good maintenance of correction was shown at most recent follow-up, with the mean thoracolumbar/lumbar curve measuring 27.9°±16.7°, and the mean compensatory thoracic curve measuring 20.9°±16.3°. There were no significant neurological or respiratory complications, and no cases had radiological signs of pseudoarthrosis. Scoliosis Research Society scores were obtained in 75% of the idiopathic scoliosis group (18/24), and improved from 75.91 pre-operatively to 84.72 post-operatively. A total of 93.8% were satisfied/very satisfied with their treatment, and 87.5% would probably/definitely have the same treatment again. CONCLUSION: Anterior corrective fusion for thoracolumbar and lumbar scoliosis is effective in both deformity correction and the maintenance thereof. Spontaneous correction of the thoracic curve can be expected and thus limit the fusion to the lumbar curve. Despite the concerns of taking down the diaphragm, there is minimal morbidity. LEVEL OF EVIDENCE: Level IV.
  
• <b>Leiomyoma of the calf muscle in a child with calcification and ossification - a case report</b>
  Leiomyomas (smooth muscle tumours) arising in skeletal muscle are extremely rare in children, especially in the extremities. A 3-year-old girl presented with a slow-growing mass in the left calf which had been present since the age of 6 months. Plain radiographs revealed a well-circumscribed mass, fusiform in shape, not attached to bone. There was widespread calcification of the tumour. MRI confirmed extensive calcification and ossification in the soleus and medial head of the gastrocnemius displacing the neurovascular bundle anteriorly. A diagnosis of a sarcoma was suggested. The mass was well defined at surgical exploration, encapsulated and easily dissected from the soleus, gastrocnemius muscles and blood vessels. The tumour was gritty on cutting with a saw and histology confirmed a leiomyoma of the soleus muscle. Immunohistochemical markers for smooth muscle actin and desmin were positive. The recovery was uneventful at five-month follow-up.
  
• <b>The paediatric 'floating arm' or segmental humerus fracture - a case report</b>
  Segmental upper limb fractures in children are extremely uncommon with the commonest injury described being the 'floating elbow'. In this report a case is described of a 'floating arm' - flexion-type Gartland grade III supracondylar fracture of the humerus and simultaneous ipsilateral Salter Harris type II proximal humerus fracture. The management, outcome and available literature on this rare combination of injuries are discussed.
  
• <b>Tuberculosis of the hip joint region in children</b>
  AIM: To describe the clinical and radiological manifestations of tuberculosis of the hip joint and the resemblance to common osteoarticular lesions in children. METHODS: Thirty-six children (1 to 12 years) were reviewed retrospectively between 1990 and 2011. Clinical, laboratory and radiological features were assessed. The hips were classified and the outcome was graded as described by Shanmugasundaram. RESULTS: Common clinical features were a limp, flexion, adduction and internal rotation contractures. Common radiological features were osteopaenia and cystic lesions in the neck and acetabulum. Permeative lesions, focal erosions, pathological fractures and sequestra were less common. Seven children had extra-articular lesions. Of the 29 with osteoarticular involvement, six had purely synovial involvement. Osteoarticular lesions mimicked benign bone and joint conditions. Follow-up was 1 to 6 years, 36% were graded as good, 36% fair and 28% had poor outcome with ankylosis. Other complications included avascular necrosis, coxa vara, coxa magna, growth arrest and flexion-adduction contractures. CONCLUSION: Tuberculosis of the hip can mimic various benign conditions. Biopsy from a bony lesion is important. The initial radiological appearance predicts the outcome, especially in the 'normal' type of hip.
  
• <b>Controversies around modern bearing surfaces in total joint replacement surgery</b>
  Patients in need of total hip or knee arthroplasty are continuously getting younger which produce the need for bearing surfaces that can withstand both the high functional demand as well as the longevity of the patient. New developments are continuously flooding the market and the promotion of these products is directed towards patients themselves who, most of the time, will not have the necessary insight to choose the best possible product. Due to recent introduction into the market, these products all lack long-term independent clinical follow-up, but all have promising results in manufacturer-funded, short-term clinical trials and laboratory simulator trials. This leaves the surgeon with the dilemma of using new untested technology with potentially devastating results or keeping to the tried and trusted. Technological advances in bearing surfaces include modifications of known materials and the introduction of totally new materials, all in an attempt to find the perfect bearing coupling. This paper summarises the most important new developments in bearing surfaces and bearing couples in arthroplasty and puts emphasis on the dangers of using untested technology.
  
• <b>The gamma crosslinking of polyethylene prostheses - some technical perspectives</b>
  The two major radiation crosslinking techniques developed for ultra-high molecular weight polyethylene (UHMWPE) prostheses and the ensuing clinical implications thereof are discussed, indicating the effects of the different techniques on clinical outcomes.
  
• <b>Multiple tendon ruptures in ochronosis: case report and review of prophylactic therapy</b>
  Ochronosis is dark pigmentation of connective tissue in patients with alkaptonuria. The dark pigmentation is caused by accumulation of homogentisic acid (HGA) and its metabolites in the connective tissues, due to deficiency of an enzyme that degrades HGA in the tyrosine degradation pathway. The deposition of HGA in connective tissue causes weakness of the tendon and subsequent rupture, especially the large tendons in the body. Rupture of isolated tendons has been reported in many case reports in the literature. We report on a patient with multiple sequential tendon ruptures, and review the literature to see if there is a way of preventing subsequent tendon ruptures after an initial rupture in this condition.
  
• <b>Management of femoral neck fractures</b>
  Femoral neck fractures are the second most common non-vertebral fragility fracture, and their management is complicated by multiple controversies. This article aims to review the recent literature in an attempt to elucidate current concepts critical to the management of intra-capsular femoral neck fractures. The optimal timing of surgery remains controversial. A recent meta-analysis was able to show that a delay of longer than 24-72 hours resulted in a statistically significant increase in mortality. Internal fixation of undisplaced fractures remains undisputed. In terms of displaced fractures, two well-designed studies have shown significantly higher re-operation rates in patients treated with closed reduction and internal fixation. While there appears to be renewed interest in the use of bi-polar hemiarthroplasty, conflicting evidence has been published with regard to total hip replacement for hip fractures in the elderly, and it may only be indicated in selected subgroups of relatively healthy patients. The peri-operative use of tranexamic acid has recently been shown to result in a reduction in transfusion requirements. Arguably the most important recent development in the management of hip fractures is the decrease in mortality provided by intravenous bisphosphonate therapy. Apart from a reduction in subsequent fractures the therapy also appears to reduce mortality due to cardiovascular and pulmonary causes. Recent investigations into thrombopro-phylaxis have highlighted the fact there is very little data to show that potent anti-coagulation decreases the risk of fatal pulmonary emboli.
  
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• <b>Retention of medical records</b>
  Femoral neck fractures are the second most common non-vertebral fragility fracture, and their management is complicated by multiple controversies. This article aims to review the recent literature in an attempt to elucidate current concepts critical to the management of intra-capsular femoral neck fractures. The optimal timing of surgery remains controversial. A recent meta-analysis was able to show that a delay of longer than 24-72 hours resulted in a statistically significant increase in mortality. Internal fixation of undisplaced fractures remains undisputed. In terms of displaced fractures, two well-designed studies have shown significantly higher re-operation rates in patients treated with closed reduction and internal fixation. While there appears to be renewed interest in the use of bi-polar hemiarthroplasty, conflicting evidence has been published with regard to total hip replacement for hip fractures in the elderly, and it may only be indicated in selected subgroups of relatively healthy patients. The peri-operative use of tranexamic acid has recently been shown to result in a reduction in transfusion requirements. Arguably the most important recent development in the management of hip fractures is the decrease in mortality provided by intravenous bisphosphonate therapy. Apart from a reduction in subsequent fractures the therapy also appears to reduce mortality due to cardiovascular and pulmonary causes. Recent investigations into thrombopro-phylaxis have highlighted the fact there is very little data to show that potent anti-coagulation decreases the risk of fatal pulmonary emboli.
  
• <b>Guidelines for writers and reviewers for submissions to the <i>SA Orthopaedic Journal (SAOJ)</i> </b>
  Femoral neck fractures are the second most common non-vertebral fragility fracture, and their management is complicated by multiple controversies. This article aims to review the recent literature in an attempt to elucidate current concepts critical to the management of intra-capsular femoral neck fractures. The optimal timing of surgery remains controversial. A recent meta-analysis was able to show that a delay of longer than 24-72 hours resulted in a statistically significant increase in mortality. Internal fixation of undisplaced fractures remains undisputed. In terms of displaced fractures, two well-designed studies have shown significantly higher re-operation rates in patients treated with closed reduction and internal fixation. While there appears to be renewed interest in the use of bi-polar hemiarthroplasty, conflicting evidence has been published with regard to total hip replacement for hip fractures in the elderly, and it may only be indicated in selected subgroups of relatively healthy patients. The peri-operative use of tranexamic acid has recently been shown to result in a reduction in transfusion requirements. Arguably the most important recent development in the management of hip fractures is the decrease in mortality provided by intravenous bisphosphonate therapy. Apart from a reduction in subsequent fractures the therapy also appears to reduce mortality due to cardiovascular and pulmonary causes. Recent investigations into thrombopro-phylaxis have highlighted the fact there is very little data to show that potent anti-coagulation decreases the risk of fatal pulmonary emboli.
  
• <b>Simplifying venous thromboembolism management</b>: <b>a new and safer era</b>
  BACKGROUND: Anterior stab wounds to the spine are extremely rare. Depending on the weapon, trajectory and anatomical level, patients are likely to present with associated damage to large vessels, the lungs, heart, and the gastrointestinal, as well as genitourinary system. METHODS: In this case report, we describe the management of a 21-year-old male patient who presented with an injury to the cauda equina after an abdominal stab with a glass bottle. The patient escaped a thorough secondary survey and neurological examination due to massive intra-abdominal injuries, which required initial damage control surgery. Weak left-sided dorsiflexion of the ankle with paraesthesia in the left L4 and L5 nerve root distribution was initially overlooked. RESULTS: During a follow-up appointment, one month after discharge, chronic pain and cauda equina symptoms were noted. Further imaging revealed a large glass fragment, which had been driven, transabdominally, through the L4/L5 disc into the spinal canal. The fragment was removed through a posterior approach, which alleviated the chronic pain, although the neurological deficit remained unchanged. CONCLUSION: Neurological damage through anterior stab wounds to the spine has not yet been described. The best approach to these patients is a staged management initially directed at treating life-threatening injuries in the form of damage control surgery. Once stable, a thorough neurological reassessment must follow to rule out spinal cord injuries
  
• <b>Ethical musing about the allocation of scarce resources, renal transplants and commercialisation</b>
  BACKGROUND: Anterior stab wounds to the spine are extremely rare. Depending on the weapon, trajectory and anatomical level, patients are likely to present with associated damage to large vessels, the lungs, heart, and the gastrointestinal, as well as genitourinary system. METHODS: In this case report, we describe the management of a 21-year-old male patient who presented with an injury to the cauda equina after an abdominal stab with a glass bottle. The patient escaped a thorough secondary survey and neurological examination due to massive intra-abdominal injuries, which required initial damage control surgery. Weak left-sided dorsiflexion of the ankle with paraesthesia in the left L4 and L5 nerve root distribution was initially overlooked. RESULTS: During a follow-up appointment, one month after discharge, chronic pain and cauda equina symptoms were noted. Further imaging revealed a large glass fragment, which had been driven, transabdominally, through the L4/L5 disc into the spinal canal. The fragment was removed through a posterior approach, which alleviated the chronic pain, although the neurological deficit remained unchanged. CONCLUSION: Neurological damage through anterior stab wounds to the spine has not yet been described. The best approach to these patients is a staged management initially directed at treating life-threatening injuries in the form of damage control surgery. Once stable, a thorough neurological reassessment must follow to rule out spinal cord injuries
  
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• <b>An unusual case of a transabdominal, transdiscal stab wound to the spine</b>
  BACKGROUND: Anterior stab wounds to the spine are extremely rare. Depending on the weapon, trajectory and anatomical level, patients are likely to present with associated damage to large vessels, the lungs, heart, and the gastrointestinal, as well as genitourinary system. METHODS: In this case report, we describe the management of a 21-year-old male patient who presented with an injury to the cauda equina after an abdominal stab with a glass bottle. The patient escaped a thorough secondary survey and neurological examination due to massive intra-abdominal injuries, which required initial damage control surgery. Weak left-sided dorsiflexion of the ankle with paraesthesia in the left L4 and L5 nerve root distribution was initially overlooked. RESULTS: During a follow-up appointment, one month after discharge, chronic pain and cauda equina symptoms were noted. Further imaging revealed a large glass fragment, which had been driven, transabdominally, through the L4/L5 disc into the spinal canal. The fragment was removed through a posterior approach, which alleviated the chronic pain, although the neurological deficit remained unchanged. CONCLUSION: Neurological damage through anterior stab wounds to the spine has not yet been described. The best approach to these patients is a staged management initially directed at treating life-threatening injuries in the form of damage control surgery. Once stable, a thorough neurological reassessment must follow to rule out spinal cord injuries
  
• <b>Pelvic fractures in children</b>: <b>experience at a Johannesburg academic hospital</b>
  BACKGROUND: Pelvic fractures in the paediatric population are rare. The skeletally immature pelvis is flexible and therefore a pelvic fracture suggests significant force with a high association of concomitant injuries. Despite these being potentially devastating injuries there are no clear outlines with respect to the investigation, classification and management of these fractures. MATERIALS AND METHODS: We retrospectively reviewed 20 children with pelvic fractures. We utilised the Injury Severity Score (ISS) and Revised Trauma Score (RTS) to assess the physiological instability of the patient. The Torode and Zieg classification was used to describe pelvic fractures. At follow-up the functional independence for self-care, mobility and cognition was assessed. RESULTS: Pelvic fractures represented only 0.03% of paediatric orthopaedic admissions. Concomitant injuries were present in 55% of patients. Four of the 20 pelvic fractures were unstable (type 4), of which three required ICU admission and external pelvic fixation for haemodynamic instability. At a mean follow-up of 4 months all patients were functionally independent. CONCLUSIONS: Although rare, pelvic fractures in children have a high rate (55%) of concomitant injuries. The ISS and RTS scoring systems are useful to predict the severity of the injury. Conservative management and external pelvic fixation (in haemodynamically unstable type 4 fractures) resulted in favourable outcomes
  
• <b>Clinical assessment of the flexor digitorum superficialis muscle to the fifth finger -accuracy of common tests</b>
  INTRODUCTION: There are several tests described to determine the presence of the flexor digitorum superficialis (FDS) muscle in the fifth digit, though it is unclear which of them is most accurate. We conducted a study to determine the accuracy of three common tests. METHODS: A prospective study was conducted comparing three common clinical tests among patients and students in a large teaching hospital in East Africa to determine their accuracy in ascertaining the presence of the FDS in the fifth digit. RESULTS The modified test was the most accurate in detecting the FDS, followed by the new test. The most inaccurate test was the standard test. DISCUSSION The modified test was the most accurate test and is recommended in clinical studies trying to demonstrate the FDS function to the fifth digit.
  
• <b>Outcomes of the treatment of gunshot fractures of lower extremities with interlocking nails</b>
  Gunshot injuries are gradually on the increase in civilian populations in developing countries due to the increase in violence in our society. The treatment of fractures from such injuries is changing with the use of locked intramedullary nailing becoming an acceptable and effective method of fixation. The Surgical Implant Generation Network (SIGN) interlocking nail is gaining universal acceptance in developing countries due to its ease of use without the need for an image intensifier. The purpose of this study is to evaluate the outcome of the use of SIGN interlocking nailing in gunshot fractures of the lower limbs. This is a prospective study of all patients in three tertiary centres in developing countries who had gunshot fractures of the lower limbs fixed with SIGN nails from 1 June 2007 to 31 May 2009 and followed up for a period of two years. There were 28 patients with 31 fractures with an average age of 32.5 years ± 12.6 SD. All the patients were males except for one female. Fractures occurred in the femur in 20 (71.4%) and tibia in 11 (29.6%). The SIGN nail was used to fix all fractures, and union was achieved in all the patients. The most common complication was wound infection in five patients (15.2%). The intramedullary locked nail provided an effective method of fixation for gunshot fractures of the lower extremity with minimum complications.
  
• <b>Bell's cruciate paralysis</b>: <b>a rare neurological diagnosis</b>
  Bell's cruciate paralysis is a rare incomplete spinal cord syndrome characterised by brachial diplegia. It is caused by an insult to the cervicomedullary junction of the spinal cord. We report three cases of cruciate paralysis following traumatic injury to the cervical spine. In all three cases the clinical diagnosis of cruciate paralysis was confirmed with magnetic resonance imaging (MRI). The prognosis varies according to the underlying cause, but is generally good. The clinical diagnosis of cruciate paralysis helps localise the injury to the cervicomedullary junction.
  
• <b>Circular external fixator application for midshaft tibial fractures</b>: <b>Surgical technique</b>
  The use of fine wire circular external fixation has recently undergone a resurgence in popularity among orthopaedic trauma and reconstructive surgeons. Their modularity, biomechanical characteristics and minimally invasive application make these fixators indispensable for complex trauma and post-traumatic limb reconstruction. The application of these fixators is technically demanding and a steep learning curve exists. This article aims to provide a simplified, stepwise approach to the application of a circular external fixator to the tibia.
  
• <b>A randomised controlled trial of steroid injection in the management of plantar fasciitis</b>
  ABSTRACT BACKGROUND: The management of plantar fasciitis varies among clinicians because no single treatment has strong scientific evidence to support its use to improve outcome. Steroid injections are more commonly used in our practice with varied and unpredictable response. This study set out to compare the effects of steroid injections with conservative regimen (analgesics, stretch exercises and insoles) versus conservative management alone for the treatment of plantar fasciitis. METHODS: A double blind randomised controlled trial. Eighty-eight patients with plantar fasciitis were randomised to two treatment arms, 47 to the steroid injection arm and 41 to the control arm. Both arms received standard conservative management. Visual analogue scale (VAS) and Foot Function Index (FFI) scores of the patients were recorded at study entry, at one month and at two months. RESULTS: The mean age of the overall study cohort was 42.9 years (SD 9.1). Forty-eight per cent were male. There was a significant reduction in mean pain scores, after one month and after two months in both the steroid and the control arms (p<0.005). The mean FFI at study entry was 50.5 (SD 18.2). At one month and two months follow-up, the mean FFI scores were 43.4 (SD 16.2) and 41.4 (SD 15.3), respectively (P<0.001). There was no statistically significant difference in pain scores between patients who received steroid injections 7.36 (SD 1.6) and those in the control arm 7.22 (SD 1.7) at one month (P = 0.73) (CI-0.64 to 0.9). There was also no statistically significant difference in pain scores between the two groups of patients: steroid injections 6.77 (SD 1.8) and the controls 6.54 (SD 1.7) at two months (P = 0.59) (CI-0.61 to 1.06). FFI scores at one month were 43.25 (SD 17.63) for the steroid group and 43.79 (SD 14.73) for the control group (P = 0.88) (CI-7.78 to 6.6). At two months, the scores were 42.26 (SD 17.19) for the steroid arm and 40.48 (SD 13.30) for the control arm (P = 0.615) (CI-5.21 to 8.75). CONCLUSIONS: Patients with plantar fasciitis improve significantly with conservative management. At one and two months, compared to a control group of conservative management alone, injection of steroids does not make a difference in improving pain and functionality.
  
• <b>Massive bone loss around the knee - the orthopaedic oncological perspective</b>
  Massive bone loss, as a consequence of tumour resection, has been dealt with historically by a variety of techniques. This article describes the techniques commonly used in the management of intercalary, intra-articular and extra-articular resections with uncontained bone defects.
  
• <b>In defence of South African Orthopaedic Training</b>
  
• <b>Posterior vertebral column resection for severe spinal deformities</b>
  STUDY DESIGN: A retrospective review of patient records and imaging. OBJECTIVES: The purpose of this study is to review the indications, surgical challenges and outcomes of patients undergoing posterior vertebral column resection (PVCR). SUMMARY OF BACKGROUND DATA: PVCR is indicated in the management of severe rigid spine deformities. It is a complex surgical procedure and is only performed in a few spine centres due to the technical expertise required and associated risk. METHODS: Twelve patients with severe spinal deformities who underwent PVCR were retrospectively reviewed after a follow-up of 2 years. Surgery was performed with the aid of motor-evoked spinal cord monitoring and cell saver when available. The average surgical duration was 307 minutes (100-490 ± 126.3). The average blood loss was 1350 ml (4OO-3OOO ± 897.9). The indication for PVCR was gross deformity and myelopathy which was due to congenital spinal deformities and old tuberculosis (TB). Clinical records and the radiographic parameters were reviewed. RESULTS: Kyphosis of an average of 73° was corrected to 29° and coronal Cobb was corrected from an average of 48° to 22°. Ten patients improved neurologically to ASIA D and E. One patient deteriorated immediately post-operatively, required revision with no initial improvement but reached ASIA E by 6 months post-op. Four patients had associated syringomyelia. All were re-scanned at 1 year. The three with small syrinxes demonstrated no progression on MRI and a large syrinx resolved completely. In addition to the neurological deterioration, complications included one right lower-lobe pneumonia. CONCLUSION: PVCR is an effective option to correct complex rigid kyphoscoliosis. In addition it allows excellent circumferential decompression of the cord and neurological recovery. When the congenital scoliosis is associated with syringomyelia with no other cause evident, it may allow resolution of the syrinx.
  
• <b>Is everything presented in medical journals or presentations true'</b>