Research Articles (Orthopaedic Surgery)

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A morphometric study of posterior tibial slope differences by sex and ethnicity in a South African population
(Springer, 2025-01) Hohmann, Erik; Nel, Adri; Van Zyl, Reinette; Natalie, Natalie; Mogale, Nkhensani
PURPOSE : Posterior tibial slope (PTS) influences knee kinetics and kinematics. The purpose of this study was to investigate morphology and variation within a sample of the black and white male and female population. METHOD : 480 randomly selected lateral knee radiographs were included. The anterior tibial cortex angle (ATC), proximal anatomical tibial axis angle (PTAA) and the posterior tibial cortex angle (PTC) were measured using ImageJ 1.53e software. Between group differences (black male and females, white males and females) were analysed using one-way ANOVA. RESULTS : Significant differences between the three different angles (p = 0.0001, F = 50.68) but no between group differences for the individual angle measurements (ATC, PTAA, PTC) between ethnicity and sex. For ATC, the angles between groups ranged from 14.20 + 2.81 degrees (Females Black), 14.62 + 3.6 degrees (Male Black), 15.18 + 3.68 degrees (Male White) to 15.54 + 3.21 degrees (Females White). For PTAA, the angles between groups ranged from 10.37 + 2.59 degrees (Females Black), 10.61 + 3.27 degrees (Male Black), 10.68 + 3.27 degrees (Male White) to 10.83 + 3.27 degrees (Females White). For PTC, the angles between groups ranged from 6.07 + 3.13 degrees (Females White), 6.13 + 3.7 degrees (Male White), 6.35 + 2.67 degrees (Females Black) to 6.62 + 3.16 degrees (Male Black). CONCLUSION : This study could not establish differences in posterior tibial slope angles between males and females and ethnicity. Significant differences between ATC, PTAA and PTC angles were observed and PTC angles were smaller when compared to PTAA and ATC angles. The ATC angles ranged between 13.18 and 16.57 degrees, the PTAA angles ranged 9.38–11.87 degrees and the PTC angles ranged between 5.03 and 7.62 degrees for all groups.
The knee anterolateral ligament is present in 82% of North Americans and 65% of Europeans but only in 46% of Asian studies : a systematic review of frequency and anatomy
(Elsevier, 2025) Hohmann, Erik; Keough, Natalie; Molepo, Maketo; Arciero, Robert; Imhoff, Andreas
PURPOSE : To perform an updated systematic review on the prevalence and morphological characteristics of the anterolateral ligament (ALL) in human cadaveric specimens. METHODS : Medline, Embase, Scopus, and Google Scholar were searched for studies from 2012 to 2024 describing the morphology. Study quality was assessed using CASP checklist and QUACS scale. Heterogeneity was analysed with the I 2 statistic, funnel plot, and Q-test. Mean effect size and 95% prediction intervals were calculated. Prevalence and anatomical measurements (length, width, thickness) were analysed using mean and standard deviations. RESULTS : Thirty studies were included. CASP identified three low-quality studies. Twelve studies met the QUACS quality threshold. The prevalence of the ALL was 61.7% (82% North America, 64.9% Europe, 45.8% Asia). The femoral insertion showed variability near the lateral femoral epicondyle and lateral collateral ligament, while the tibial insertion was midway between Gerdy's tubercle and fibular head. Histological analysis revealed 60% of studies identified ligamentous tissue similar to the ACL. The mean ALL length was 39.7 mm, width 5.5 mm, and thickness 1.5 mm, with no significant morphological differences among populations. CONCLUSION : This systematic review reveals that the ALL is present in 61.7%, with prevalence rates of 82% in North American studies, 65% in European studies, and 46% in Asian studies. The femoral insertion exhibited substantial variability at/around the lateral femoral epicondyle and LCL, lacking consistency. The tibial insertion was more consistently described as being located about halfway between Gerdy’s tubercle and the fibular head. Histological analysis showed that 60% of the included studies identified the ALL as containing ligament-like or ligamentous tissue. The mean length of the ALL was 39.9 mm (range 31-59 mm), the mean width was 5.7 mm (range 2.2-9.0 mm), and the mean thickness was 1.5 mm (range 1.3-2.7 mm). No significant ethnic population differences were observed in the morphological measures.
Micro-fragmented adipose tissue has no advantage over platelet-rich plasma and Bone Marrow aspirate injections for symptomatic knee osteoarthritis : a systematic review and meta-analysis
(Sage, 2025) Hohmann, Erik; Keough, Natalie; Frank, Rachel M.; Rodeo, Scott A.
BACKGROUND : Micro-fragmented adipose tissue has been proposed for intra-articular treatment of knee osteoarthritis. There are little data comparing the outcomes of treatment between micro-fragmented adipose tissue and other biological treatments. PURPOSE : To perform a systematic review and meta-analysis comparing micro-fragmented aspirated fat injections to other ortho-biologics, hyaluronic acid, and corticosteroid injections for symptomatic knee osteoarthritis. STUDY DESIGN : Systematic review and meta-analysis; Level of evidence, 2. METHODS : A systematic review of the literature was performed to identify pertinent publications in the MEDLINE, Embase, Scopus, and Google Scholar databases, including all level 1 to 3 studies from 2000 to 2023. Validated knee scores (visual analog scale [VAS] for pain, Knee injury and Osteoarthritis Outcome Score [KOOS], Lysholm, International Knee Documentation Committee) were included as outcome measures. Risk of bias was assessed using Cochrane tools. The Grading of Recommendations Assessment, Development and Evaluation system was used to assess the quality of the body of evidence and the modified Coleman Methodology Score was used to assess study quality. Heterogeneity was assessed using χ2 and I2 statistics. RESULTS : Five studies were included in the analysis. One study had a high risk of bias; 4 studies had some risk of bias. The overall study quality was fair, and the certainty of evidence was low. The pooled estimate for VAS scores did not demonstrate significant differences at 3, 6, and 12 months. The pooled estimate for the KOOS Pain, Symptoms, Activities of Daily Living, Sport and Recreation, and Quality of Life subscales did not demonstrate significant differences at 3, 6, and 12 months. CONCLUSION : The results of this systematic review and meta-analysis demonstrated that there were no statistically significant differences for both the clinical outcomes and pain scores between micro-fragmented adipose tissue and other ortho-biologics for the treatment of knee osteoarthritis. However, modest study quality, some risk of bias, and low certainty of evidence reduce external validity, and these results must be viewed with some caution.
Breastfeeding following spinal cord injury : consumer guide for mothers
(American Spinal Injury Association, 2024) Krassioukov, Andrei; Elliott, Stacy; Hocaloski, Shea; Krassioukova-Enns, Olga; Hodge, Karen; Gillespie, Stephanie; Caves, Sherry; Thorson, Teri; Alford, Lindsay; Basso, Melanie; McCracken, Laura; Lee, Amanda; Anderson, Kim; Andretta, Elena; Chhabra, Harvinder Singh; Hultling, Claes; Rapidi, Christina-Anastasia; Sorensen, Fin-Biering; Zobina, Ineta; Theron, Francois; Kessler, Allison; Courtois, Frederique; Berri, Maryam
The World Health Organization (WHO) recommends that infants be breastfed exclusively for the first 6 months of age. However, there are few resources available on the effects a spinal cord injury (SCI) can have for breastfeeding mothers. It is difficult to find information to address the unique challenges women with SCI experience when planning or trying to breastfeed. Our international team, including women with SCI, health care providers, and SCI researchers, aims to address the information gap through the creation of this consumer guide. The purpose of this consumer guide is to share the most common issues women with SCI experience during breastfeeding and provide information, practical suggestions, recommendations, and key resources in lay language. General information about breastfeeding is available on the internet, in books, or from friends and health care providers. We do not intend to repeat nor replace general breastfeeding information or medical advice. Breastfeeding for mothers with SCI is complex and requires a team of health care providers with complementary expertise. Such a team may include family physician, obstetrician, physiatrist, neurologist, occupational and physical therapist, lactation consultant, midwife, and psychologist. We hope this consumer guide can serve as a quick reference guide for mothers with SCI planning of trying to breastfeed. This guide will also be helpful to health care providers as an educational tool.
Motherhood after spinal cord injury : breastfeeding, autonomic dysreflexia, and psychosocial health : clinical practice guidelines
(American Spinal Injury Association, 2024-05) Krassioukov, Andrei; Elliott, Stacy; Hocaloski, Shea; Krassioukova-Enns, Olga; Hodge, Karen; Gillespie, Stephanie; Caves, Sherry; Thorson, Teri; Alford, Lindsay; Basso, Melanie; McCracken, Laura; Lee, Amanda; Anderson, Kim; Andretta, Elena; Chhabra, Harvinder Singh; Hultling, Claes; Rapidi, Christina-Anastasia; Sorensen, Fin-Biering; Zobina, Ineta; Theron, Francois; Kessler, Allison; Courtois, Frederique; Berri, Maryam
The World Health Organization (WHO) recommends that children be breastfed exclusively for the first 6 months of age. This recommendation may prove challenging for women with spinal cord injury (SCI) who face unique challenges and barriers to breastfeeding due to the impact of SCI on mobility and physiology. Tailored provision of care from health care professionals (HCPs) is important in helping women navigate these potential barriers. Yet, HCPs often lack the confidence and SCI-specific knowledge to meet the needs of mothers with SCI. An international panel of clinicians, researchers, consultants, and women with lived experience was formed to create an accessible resource that can address this gap. A comprehensive survey on breastfeeding complications, challenges, resources, and quality of life of mothers with SCI was conducted, along with an environmental scan to evaluate existing postpartum guidelines and assess their relevance and usability as recommendations for breastfeeding after SCI. Building on this work, this article provides evidence-based recommendations for HCPs, including but not limited to general practitioners, obstetricians, pediatricians, physiatrists, lactation consultants, nurses, midwives, occupational therapists, and physiotherapists who work with prospective and current mothers with SCI.
Anterior and coracoid base tunnel location combined with single -or double clavicular tunnel techniques using double-button fixation for coracoclavicular ligament reconstruction both restore horizontal stability. A biomechanical cadaver study
(Elsevier, 2024-12) Molepo, Maketo; Keough, Natalie; Oberholster, Abraham Johannes (Abrie); Hohmann, Erik
BACKGROUND : The placement of clavicle tunnels in coracoclavicular ligament reconstruction is well established, but the optimal position of the coracoid tunnel remains unclear. This study aimed to investigate how the coracoid tunnel's position affects horizontal stability during coracoclavicular ligament reconstruction using a double-button technique. METHODS : Fifteen fresh frozen shoulder cadaver specimens were tested under various conditions: intact coracoclavicular ligaments, disrupted ligaments, and reconstructions with a single coracoid and clavicle tunnel or double clavicle tunnels. The coracoid tunnel was positioned at the coracoid base 1/9, and 1/5 anterior to the base. Specimens underwent displacement-controlled loading, with 2D motion analysis conducted on captured digital images using TEMA motion analysis. FINDINGS : Mean displacement for intact coracoclavicular ligaments was 1.61 ± 0.92 mm, and 3.69 ± 1.09 mm for disrupted ligaments. For reconstructed conditions, displacements were as follows: Single-Tunnel Base (1.87 ± 0.64 mm), Single-Tunnel 1/9 (2.54 ± 1.13 mm), Single-Tunnel 1/5 (2.62 ± 1.17 mm), Double-Tunnel Base (1.25 ± 0.73 mm), Double-Tunnel 1/9 (2.03 ± 1.22 mm), and Double-Tunnel 1/5 (1.88 ± 1.20 mm). Differences among intact, reconstructed, and disrupted states were statistically significant (p = 0.01–0.0001), with all reconstruction techniques restoring horizontal displacement near the intact state. INTERPRETATION : At point zero both single coracoid tunnel and single- and double-clavicle tunnel restored horizontal displacement to its intact state. Coracoid tunnel placement anterior to the base of the coracoid did not influence horizontal displacement but single coracoid at the coracoid base and single clavicle tunnel resulted in the most anatomic reconstruction. Single coracoid tunnel at the base and double-clavicle resulted in the most stable reconstruction.
Orthopaedic-related trauma in e-hailing motorcycle drivers at a single centre in South Africa
(Medpharm Publications, 2024-05) Govender, Sanishan T.; Connellan, Grant I.; Ngcoya, N.
BACKGROUND: Since the COVID-19 pandemic, there has been an increased usage of technologically based platforms throughout society. An example can be seen in the food and goods delivery industry, whereby e-hailing companies have shown a surge in both revenue and workforce. With this rise of e-hailing motorcycle drivers, a rise in road traffic accidents (RTAs) has also been noted. Our study set out to investigate the cumulative incidence of e-hailing motorcycle drivers sustaining orthopaedic-related trauma in comparison to the total number of orthopaedic trauma patients seen. The secondary aims included a treatment cost estimation as well as a qualification of the injuries sustained. METHODS: This was a prospective cross-sectional study conducted at a single centre, Tembisa Provincial Tertiary Hospital (TPTH), over a period of seven months. We included all e-hailing drivers using any form of motorcycle who experienced orthopaedic-related trauma while on duty. The cumulative incidence of the group was then determined. Lastly, a treatment cost estimation of the surgically managed group was generated and the injuries sustained were further qualified based on the type of injury, anatomical section injured, and management plan incurred. RESULTS: A total of 5 092 individuals experienced orthopaedic-related trauma, with 60 individuals being e-hailing motorcycle drivers who sustained injury while on duty. The cumulative incidence of the group was 118 per 10 000 patients over a seven-month period. A total estimated treatment cost of R2 781 941.70 was spent on the surgically managed group alone. Further analysis, in terms of injury qualification, revealed that 47 drivers experienced fractures or dislocations, with 34 of these injuries requiring surgical intervention. More extremity injuries were noted, with 28 injuries occurring to the upper limb and 34 injuries occurring to the lower limb. CONCLUSION: Our study determined the cumulative incidence of orthopaedic-related trauma in e-hailing motorcycle drivers at TPTH. The injuries they sustained were further qualified and suggestive to be more high velocity in nature, involving mostly the extremities. The treatment cost analysis was found to be an underestimation, and a more detailed cost analysis is suggested to quantify the true burden of this group on the Gauteng Department of Health.
The implementation of the South African Orthopaedic Registry (SAOR) : factors that improve usage
(Medpharm Publications, 2024-05) Bussio, Hannah T.; Swart, Xan; O’Connor, Megan; Khanyile, Sivesonke; Koch, Odette
BACKGROUND : Registries have been created to accrue comprehensive clinical data for evaluation, with purported benefits for clinical governance, public health and scientific investigation. As has been the experience internationally, orthopaedic surgeon contribution to data collection for the South African Orthopaedic Registry (SAOR) has been moderate. Due to this response, several awareness initiatives were implemented by the South African Orthopaedic Association (SAOA) to encourage surgeons to engage with SAOR. This study aimed to evaluate the efficacy of these initiatives. METHODS: This retrospective study evaluated SAOR’s operational data between 1 August 2019 and 30 June 2022. For each month, the number of new surgeons registering, new patients captured, and new registry pathways initiated were evaluated. These monthly increases were evaluated relative to the implementation of several awareness initiatives. Multiple linear regression was performed to determine if any initiative significantly increased recruitment rates. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) checklist was used for reporting. RESULTS: Thirty-five months of SAOR operational data were analysed. The cumulative number of surgeons enrolled to use the registry by June 2022 was 108, the number of patients captured 9 992, and the number of pathways initiated 9 585. Thirty-three awareness initiatives of four types took place in the period from January 2021 until June 2022. No interventions increased the recruitment of surgeons. Group promotional sessions and virtual group demonstrations significantly increased the number of patients captured on the registry. Group promotional sessions significantly increased the number of pathways initiated. CONCLUSION: The SAOR was established in 2019 by the SAOA with the intent to improve orthopaedic practice in South Africa. Several awareness initiatives have been implemented to engage surgeon contributions to the registry, none of which increased enrolment of new surgeons, but some of which increased the number of patients captured and pathways initiated. Ways to improve surgeon engagement with registries should be the focus of future research.
Return to sports following sports-related concussion in collision sports: an expert consensus statement using the modified Delphi technique
(Elsevier, 2024-02) Hohmann, Erik; Bloomfield, Paul; Dvorak, Jiri; Echemendia, Ruben; Frank, Rachel M.; Ganda, Janesh; Gordon, Leigh; Holtzhausen, Louis; Kourie, Alan; Mampane, Jerome; Makdissi, Michael; Patricios, Jon; Pieroth, Elizabeth; Putukian, Margot; Janse van Rensburg, Dina Christina; Viviers, Pierre; Williams, Vernon; De Wilde, Jean
PURPOSE : To perform a Delphi consensus for return to sports (RTS) following sports-related concussion (SRC). METHODS : Open-ended questions in rounds 1 and 2 were answered. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤80% for an item, if panel members were outside consensus or there were >30% neither agree/disagree responses, the results were carried forward into round 4. The level of agreement and consensus was defined as 90%. RESULTS : Individualized graduated RTS protocols should be used. A normal clinical, ocular and balance examination with no more headaches, and asymptomatic exertional test allows RTS. Earlier RTS can be considered if athletes are symptom free. The Sports Concussion Assessment Tool 5 and vestibular and ocular motor screening are recognized as useful tools to assist in decision-making. Ultimately RTS is a clinical decision. Baseline assessments should be performed at both collegiate and professional level and a combination of neurocognitive and clinical tests should be used. A specific number of recurrent concussions for season—or career-ending decisions could not be determined but will affect decision making for RTS. CONCLUSIONS : Consensus was achieved for 10 of the 25 RTS criteria: early RTS can be considered earlier than 48 to 72 hours if athletes are completely symptom-free with no headaches, a normal clinical, ocular and balance examination. A graduated RTS should be used but should be individualized. Only 2 of the 9 assessment tools were considered to be useful: Sports Concussion Assessment Tool 5 and vestibular and ocular motor screening. RTS is mainly a clinical decision. Only 31% of the baseline assessment items achieved consensus: baseline assessments should be performed at collegiate and professional levels using a combination of neurocognitive and clinical tests. The panel disagreed on the number of recurrent concussions that should be season- or career-ending. LEVEL OF EVIDENCE : Level V, expert Opinion.
On-field and pitch-side (sideline) assessment of sports concussion in collision sports : an expert consensus statement using the modiﬁed Delphi technique
(Elsevier, 2024-02) Hohmann, Erik; Bloomfield, Paul; Dvorak, Jiri; Echemendia, Ruben; Frank, Rachel M.; Ganda, Janes; Gordon, Leigh; Holtzhausen, Louis; Kourie, Alan; Mampane, Jerome; Makdissi, Michael; Patricios, Jon; Pieroth, Elizabeth; Putukian, Margot; Janse van Rensburg, Dina Christina; Viviers, Pierre; Williams, Vernon; De Wilde, Jean
PURPOSE : To perform a Delphi consensus for on-field and pitch-side assessment of sports-related concussion (SRC). METHODS : Open-ended questions in rounds 1 and 2 were answered. The results of the first 2 rounds were used to develop a Likert-style questionnaire for round 3. If agreement at round 3 was ≤80% for an item, if panel members were outside consensus, or there were >30% neither agree/disagree responses, the results were carried forward into round 4. The level of agreement and consensus was defined as 90%. RESULTS : Loss of consciousness (LOC) or suspected LOC, motor incoordination/ataxia, balance disturbance, confusion/disorientation, memory disturbance/amnesia, blurred vision/light sensitivity, irritability, slurred speech, slow reaction time, lying motionless, dizziness, headaches/pressure in the head, falling to the ground with no protective action, slow to get up after a hit, dazed look, and posturing/seizures were clinical signs of SRC and indicate removal from play. Video assessment is helpful but should not replace clinical judgment. LOC/unresponsiveness, signs of cervical spine injury, suspicion of other fractures (skull/maxillo-facial), seizures, Glasgow Coma Scale score <14 and abnormal neurologic examination findings are indications for hospitalization. Return to play should only be considered when no clinical signs of SRC are present. Every suspected concussion should be referred to an experienced physician. CONCLUSIONS : Consensus was achieved for 85% of the clinical signs indicating concussion. On-field and pitch-side assessment should include the observation of the mechanism, a clinical examination, and cervical spine assessment. Of the 19 signs and red flags requiring removal from play, consensus was reached for 74%. Normal clinical examination and HIA with no signs of concussion allow return to play. Video assessment should be mandatory for professional games but should not replace clinical decision-making. Sports Concussion Assessment Tool, Glasgow Coma Scale, vestibular/ocular motor screening, Head Injury Assessment Criteria 1, and Maddocks questions are useful tools. Guidelines are helpful for non-health professionals. LEVEL OF EVIDENCE : Level V, expert opinion
Cadaveric biomechanical laboratory research can be quantitatively scored for quality with the biomechanics objective basic science quality assessment tool: the BOBQAT score
(Elsevier, 2024) Hohmann, Erik; Paschos, Nikolaos; Keough, Natalie; Erbulut, Deniz; Oberholster, Abraham Johannes (Abrie); Glatt, Vaida; Molepo, Maketo; Tetsworth, Kevin
PURPOSE : To develop a quality appraisal tool for the assessment of cadaveric biomechanical laboratory and other basic science biomechanical studies. METHODS : For item identification and development, a systematic review of the literature was performed. The content validity index (CVI) was used either to include or exclude items. The content validity ratio (CVR) was used to determine content validity. Weighting was performed by each panel member; the final weight was either up- or downgraded to the closest of 5% or 10%. Face validity was scored on a Likert scale ranked from 1 to 7. Test-retest reliability was determined using the Fleiss kappa coefficient. Internal consistency was assessed with Cronbach’s alpha. Concurrent criterion validity was assessed against the Quality Appraisal for Cadaveric Studies scale. RESULTS : The final Biomechanics Objective Basic science Quality Assessment Tool (BOBQAT) score included 15 items and was shown to be valid, reliable, and consistent. Five items had a CVI of 1.0; 10 items had a CVI of 0.875. For weighting, 5 items received a weight of 10%, and 10 items a weight of 5%. CVR was 1.0 for 6 items and 0.75 for 9 items. For face validity, all items achieved a score above 5. For test-retest reliability, almost-perfect test-retest reliability was observed for 10 items, substantial agreement for 4 items, and moderate agreement for 1 item. For internal consistency, Cronbach’s alpha was calculated to be 0.71. For concurrent criterion validity, Pearson’s product-moment correlation was 0.56 (95% confidence interval [CI] = 0.38-0.70, P = .0001). CONCLUSIONS : Cadaveric biomechanical and laboratory research can be quantitatively scored for quality based on the inclusion of a clear and answerable purpose, demographics, specimen condition, appropriate bone density, reproducible technique, appropriate outcome measures, appropriate loading conditions, appropriate load magnitude, cyclic loading, sample size calculation, proper statistical analysis, results consistent with methods, limitations considered, conclusions based on results, and disclosure of funding and potential conflicts. CLINICAL RELEVANCE : Study quality assessments are important to evaluate internal and external validity and reliability and to identify methodological flaws and misleading conclusions. The BOBQAT score will help not only in the critical appraisal of cadaveric biomechanical studies but also in guiding the designs of such research endeavors.
Micro-fragmented adipose tissue demonstrates comparable clinical efficacy to other orthobiologic injections in treating symptomatic knee osteoarthritis: a systematic review of Level I to IV clinical studies
(Elsevier, 2025-02) Hohmann, Erik; Keough, Natalie; Frank, Rachel M.; Rodeo, Scott
PURPOSE : To perform a systematic review of clinical outcomes in patients who underwent treatment with micro-fragmented aspirated tissue for symptoms of knee osteoarthritis. METHODS : Medline, Embase, Scopus, and Google Scholar were screened for studies from 2000 to 2023. Risk of bias (ROB) was assessed using the Cochrane Collaboration’s tools and the Risk Of Bias In Non-randomised Studies-of Interventions tool. Study quality was assessed with the modified Coleman Methodology Score and Methodological Index for Non-Randomized Studies score. Heterogeneity was assessed using χ 2 and I 2 statistics. RESULTS : Twenty-one studies were included. One study had a high ROB, 1 had a critical ROB, 3 had serious ROB, and 16 had a moderate ROB. The mean Coleman score was 58, demonstrating fair study quality; the Methodological Index for Non-Randomized Studies score had a mean value of 13, indicating overall fair quality. Best evidence synthesis revealed moderate evidence. The visual analog scale score improved from 5.2 to 3.2 at 6 and 12 months. Knee injury and Osteoarthritis Outcome Score (KOOS) activities of daily living subscore improved from 58.8 to 70.2 at 6 months and 67.5 at 12 months. KOOS pain subscore improved from 54.3 to 70.2 at 6 months and 72.4 at 12 months. KOOS quality of life subscore improved from 33.1 to 43.6 at 6 months and 42.9 at 12 months. KOOS sports subscore improved from 23.7 to 43.6 at 6 months and 57.4 at 12 months. KOOS symptoms subscore improved from 55.3 to 70.1 at 6 months and 67.9 at 12 months. The Western Ontario and McMaster Universities Osteoarthritis Index score steadily increased from 61.8 at baseline to 78.4 at 12 months. CONCLUSIONS : Micro-fragmented aspirated tissue injection therapy for the treatment of symptomatic knee osteoarthritis is effective and improves pain and functional outcomes. Moderate study quality combined with a moderate risk of bias, moderate certainty of evidence, and moderate best synthesis evidence reduces external validity. Therefore, the results should be interpreted with a degree of caution. LEVEL OF EVIDENCE : Level IV, systematic review of Level I-IV studies.
A posteromedial portal allows access to the posteromedial knee, while a posterolateral portal risks common fibular nerve injury : a cadaveric analysis
(Elsevier, 2024-02) Greenwood, Kelsi; Mogale, Nkhensani; Van Zyl, Reinette; Keough, Natalie; Hohmann, Erik
PURPOSE: To investigate the safety and accessibility of direct posterior medial and lateral portals into the knee. METHODS: This study was a controlled laboratory study that comprised a sample of 95 formalin-embalmed cadaveric knees and 9 fresh frozen knees. Cannulas were inserted into the knees, 16 mm from the vertical plane between the medial epicondyle of the femur and the medial condyle of the tibia, and 8 (females) and 14 mm (males) from the vertical plane connecting the lateral femoral epicondyle and lateral tibial condyle. Landmarks were identified in full extension, and cannula insertion was completed with the formalin-embalmed knees in full extension and the fresh-frozen knees in 90 degrees of flexion. The posterior aspects of the knees were dissected from superficial to deep to assess potential damage caused by the cannula insertion. RESULTS: The incidence of neurovascular damage was 9.6% (n ¼ 10): 0.96% for the medial cannula and 8.7% for the lateral cannula. The medial cannula damaged 1 small saphenous vein (SSV). The lateral cannula damaged 1 SSV, 7 common fibular nerves (CFNs), and both the CFN and lateral cutaneous sural nerve in 1 specimen. All incidences of damage occurred in formalin-embalmed knees. The posterior horns of the menisci were accessible in all specimens. CONCLUSIONS: A direct posterior portal into the knee with reference to the medial bony landmarks of the knee proved safe in 99% of the cadaveric sample and allowed access to the posterior horn of the medial meniscus. A direct posterior portal with reference to the lateral bony landmarks demonstrated a higher risk of neurovascular damage in the embalmed sample but no damage in the fresh-frozen sample. Given the severe consequences of common fibular nerve injury, recommending this approach at this stage is not advisable. CLINICAL RELEVANCE: Direct posterior arthroscopy portals are understudied but may allow safe visualization of the posterior knee compartments and may also assist to manage repair of ramp lesions and posterior meniscus pathology.
Pre-operative planning for reverse shoulder arthroplasty in low-resource centres : a modified Delphi study in South Africa
(EDP Open, 2024-05) Rachuene, Pududu Archie; Dey, Roopam; Kauta, Ntambue Jimmy; Sivarasu, Sudesh; Du Plessis, Jean-Pierre; Roche, Stephen; Vrettos, Basil
BACKGROUND : Pre-operative planning for reverse shoulder arthroplasty (RSA) poses challenges, particularly when dealing with glenoid bone loss. This modified Delphi study aimed to assess expert consensus on RSA planning processes and rationale, specifically targeting low-resourced institutions. Our objective was to offer pre-operative decision-making algorithms tailored for surgeons practising in resource-constrained hospitals with limited access to computed tomography (CT) scans. METHODS : A working group generated statements on pre-operative imaging and glenoid of glenoid morphology and intra-operative decision-making. The study was conducted in three stages, with virtual consensus meetings in between. Stages 2 and 3 consisted only of closed questions/statements. The statements with over 70% were considered consensus achieved and those with less than 10% were considered disagreement consensus achieved. RESULTS : Twelve shoulder surgeons participated, with 67% having over five years of experience in shoulder arthroplasty. In the absence of glenoid bone loss, the sole use of plain radiographs for pre-operative planning reached consensus and is recommended by these groups, while 100% advise using CT scans when bone loss is present. Most surgeons (70%) recommend using patient-specific instrumentation (PSI) in cases of structural bone loss. Most of the statements on intra-operative decision-making related to component placement and enhancing stability failed to reach consensus. CONCLUSION : While consensus was achieved on most aspects of pre-operative imaging and planning, technical aspects of surgery lacked consensus. Planning for patients with structural glenoid bone loss necessitates CT scans and planning tools.
Intermittent catheterisation : individuals’ rights, accessibility, and environmental concerns
(Springer Nature, 2024-05) Krassioukov, Andrei; Wyndaele, Michel; Walter, Matthias; Keppenne, Veronique; Welk, Blayne; Vrijens, Desiree; Theron, Francois
Intermittent catheterisation (IC) is the mainstay for bladder management in individuals living with neurogenic lower urinary tract dysfunction (NLUTD), but many are not receiving the best evidence-based standard of IC care available. To garner opinion on individuals’ rights to access IC (including the best available care), representatives from disability organisations (Spinal Cord Injury [SCI] British Columbia, and SCI Ontario, QuadPara Association of South Africa [QASA], and Spina bifida en hydrocephalus [SBH] Nederland) and multidisciplinary experts from the global medical community came together for a ‘meeting of minds’; the aim was to discuss how to improve the lives of individuals living with NLUTD. This article summarises their combined opinion.
Clinical outcomes for grades III–V acromioclavicular dislocations favor double-button fixation compared to clavicle hook plate fixation : a systematic review and meta-analysis
(Springer, 2023-10) Hohmann, Erik; Tetsworth, Kevin
INTRODUCTION : The purpose of this study was to perform a systematic review and meta-analysis of both randomized controlled and observational studies comparing double-button suture fixation to hook plate fixation for types III–IV acromioclavicular joint dislocation. METHODS : Systematic review of Medline, Embase, Scopus, and Google Scholar, including all levels 1–3 studies from 2000 to 2022. Clinical outcome scores, range of motion, and complications were included. Risk of bias was assessed using the Cochrane Collaboration’s ROB2 tool and ROBINs-I tool. MINORS and modified Coleman Methodology Score (CMS) were used to assess within study quality. The GRADE system was used to assess the overall quality of the body of evidence. Heterogeneity was assessed using χ2 and I2 statistics. RESULTS : Fifteen studies were included. Three of the four included LOE II and eleven of the LOE III studies had a high risk of bias. Study quality was considered poor and fair for 67% by MINORS criteria and 93% for CMS criteria. The pooled estimate (SMD 0.662) for all clinical outcomes was statistically significant and in favor of button repair (p = 0.0001). The pooled estimate (SMD 0.662) for all VAS pain scores was statistically significant, again in favor of button repair (p = 0.001). CONCLUSIONS : The results of this meta-analysis demonstrated significantly better outcomes of button repair for acute ACJ dislocations when compared to clavicle hook plate. Button repair is also associated with a 2.2 times lower risk for complications. However, risk of bias is high, and study quality within and between studies was low. These results, therefore, must be viewed with caution.
Establishing the safety of the lateral femoral cutaneous nerve when using the bridging infix for anterior pelvic fixation
(MedPharm Publications, 2023-11) Van Schalkwyk, Jerolize; Keough, Natalie; Strydom, Sven; Snyckers, Christian H; Masenge, Andries; Mogale, Nkhensani
BACKGROUND Established subcutaneous internal fixation techniques have shown a better quality of life with reduced pain. However, complications still arise, with the most significant being injury of the lateral femoral cutaneous nerve (LFCN). A novel minimally invasive modified technique, the Bridging Infix, has been proposed; however, the safety of the LFCN during the procedure is currently unknown. The aim of the study, therefore, was to determine the relationship between the Bridging Infix and the LFCN. METHOD Fifty formalin-fixed cadaveric specimens and two fresh frozen cadaver specimens were utilised in the study. The Bridging Infix was inserted as per the technique guide. Superficial dissection of the surgical site was subsequently conducted. Bilateral measurements of the distance between the LFCN and the implant as well as palpable bony landmarks were taken to determine safe zones for implant placement. RESULTS Overall the LFCN was identified coursing deep to the inguinal ligament. The minimum distance from the LFCN to the most proximal cortical screw was 18.00 mm. The mean distance from the most proximal screw to the LFCN was 37.97 ± 12.20 mm. CONCLUSION The LFCN was not injured or impinged by the Bridging Infix in any of the cadaver specimens used in this study. Thus, the surgical procedure can be considered safe if layer by layer dissection is employed and the screws are directly inserted on the iliac crest, with no pressure being applied within three finger breadths medial to the anterior superior iliac spine.
Arthroscopic treatment and subacromial decompression of calcific tendinitis without removal of the calcific deposit results in rapid resolution of symptoms and excellent clinical outcomes in commercial airline pilots and cabin crew
(Springer, 2023-02) Hohmann, Erik; Tetsworth, Kevin
PURPOSE : The purpose of this study was to report the results of subacromial arthroscopic decompression (SAD) without removal of the calcific deposits in patients with calcifying tendinitis. METHODS : All patients between 2016 and 2019 were included if they were aged between 18 and 60 years and had an isolated calcific deposit. The Constant–Murley score (CMS), Disabilities of the Arm, Shoulder and Hand (Quick DASH) score, the Shoulder Pain and Disability Index (SPADI), the simple shoulder test (SST), and the single assessment numeric evaluation (SANE) were used for assessment. Time to return to work was recorded. RESULTS : 24 patients (13 pilots, 11 cabin crew) with a mean age of 47.1 ± 7.8 years were included. Quick Dash improved from 68.8 preoperative, to 8.4 at 3 months, and 0.1 at 24 months. CMS improved from 37.4 preoperative, to 83 at 3 months, and 94 at 24 months. SPADI improved from 73.8 preoperative, to 5.4 at 3 months, and 1 at 24 months. SST improved from 22.5 preoperative, to 94.2 at 3 months, and 100 at 24 months. SANE improved from 33.5 preoperative, to 78.7 at 3 months, and 95.6 at 24 months. MCID, SCB, and PASS reached values above 83% at 3 months and 100% at 6 months, with the exception of SANE which reached 29% at 3 months and plateaued to 96% at 6 months. The mean time to return to work was 7.1 ± 2.1 weeks. Pilots returned at a mean of 6.9 ± 1.8 weeks; cabin crew returned to work at a mean of 7.8 ± 2.5 weeks. CONCLUSIONS : The results of this study suggest excellent short- and mid-term clinical outcomes can be achieved in patients with calcific tendinitis undergoing arthroscopic debridement and subacromial decompression without removal of calcific deposits. In this patient population, early surgical intervention was a potentially viable alternative to nonoperative treatment, and allowed early return to work.
Corticosteroid injections for the treatment of lateral epicondylitis are superior to platelet-rich plasma at 1 month but platelet-rich plasma is more effective at 6 months : an updated systematic review and meta-analysis of level 1 and 2 studies
(Elsevier, 2023-09) Hohmann, Erik; Tetsworth, Kevin; Glatt, Vaida
BACKGROUND : The purpose of this study was to perform a systematic review and meta-analysis of studies comparing local injections of either platelet-rich plasma (PRP) or corticosteroid for the treatment of lateral elbow epicondylitis. METHODS : A systematic review of MEDLINE, Embase, Scopus, and Google Scholar was performed, and all level 1 and 2 randomized studies from 2000 to 2022 were included. Clinical symptoms, patient perceived outcomes, and pain were assessed by the DASH (disabilities of the arm, shoulder and hand questionnaire) and pain by the visual analog scale (VAS). Publication bias and risk of bias were assessed using the Cochrane Collaboration’s tools. The modified Coleman Methodology Score (CMS) and the GRADE system were used to assess the quality of the body of evidence. Heterogeneity was assessed using χ2 and I2 statistics. RESULTS : Thirteen studies were included in the analysis. Five studies had a high risk of bias, and the risk of bias across studies was assessed as unclear. There was no publication bias identified. Two of the four GRADE domains (inconsistency of results, imprecision of results) were downgraded to low quality, and the final GRADE assessment was downgraded to a low quality of evidence. The mean CMS score was 62.8, indicating fair quality. The pooled estimate for VAS at 1 month favored corticosteroids (P = .75) but favored PRP at three (P = .003) and six months (P = .0001). The pooled estimate for the DASH score favored corticosteroids at 1 month (P = .028) but favored PRP at three (P = .01) and six months (P = .107) CONCLUSION : The results of this meta-analysis suggest that PRP has no advantage over steroid injections within the first month of treatment, but that it is superior to steroids at both 3 and 6 months. These results also suggest that corticosteroids have a short-term beneficial effect during the early treatment period, although the quality of the available evidence is not very robust in support of this finding. However, these findings must all be viewed with caution as the high risk of bias and moderate to low quality of the included studies may not justify a recommendation of one treatment over another.
Surgical treatment is not superior to nonoperative treatment for displaced proximal humerus fractures : a systematic review and meta-analysis
(Elsevier, 2023-05) Hohmann, Erik; Keough, Natalie; Glatt, Vaida; Tetsworth, Kevin
BACKGROUND : The purpose of this study was to perform a systematic review and meta-analysis of both randomized controlled and observational studies comparing conservative to surgical treatment of displaced proximal humerus fractures. METHODS : We performed a systematic review of Medline, Embase, Scopus, and Google Scholar articles comparing surgical treatment to conservative treatment, including all level 1-3 studies from 2000 to 2022. Clinical outcome scores, range of motion, and complications were evaluated. Risk of bias was assessed using the Cochrane Collaboration's ROB2 tool and ROBINs-I tool. The GRADE system was used to assess the quality of the body of evidence, and heterogeneity was assessed using χ2 and I2 statistics. Twenty-two studies were incorporated into the analysis. Ten studies had a high risk of bias, and all included studies were of low quality. RESULTS : The pooled estimates failed to identify differences for clinical outcomes (P = .208), abduction (P = .275), forward flexion (P = .447), or external rotation (P = .696). Complication rates between groups were significantly lower (P = .00001) in the conservative group. CONCLUSIONS : This meta-analysis demonstrated that there were no statistically significant differences for either clinical outcomes or range of motion between surgically managed and conservatively treated displaced proximal humerus fractures. The overall complication rate was 3.3 times higher, following surgical treatment. The validity of this result is compromised by the high risk of bias and very low level of certainty of the included studies, and the conclusion must therefore be interpreted with caution.

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