South African Orthopaedic Journal

Diagnostic discordance between MRI and histology in suspected malignant transformation of osteochondromas: a retrospective review

Adrian Jansen van Rensburg — 2026-05-08

Background: Accurately identifying malignant transformation in osteochondromas remains a clinical challenge, particularly due to variability in cartilage cap thickness measurements on magnetic resonance imaging (MRI). This study evaluates the concordance between MRI findings as reported by radiologists and histological diagnosis of surgically resected osteochondromas.

Methods: A single-centre retrospective cohort study was conducted on patients diagnosed with an osteochondroma from January 2016 to June 2024. Patients were diagnosed with an osteochondroma based on plain film radiographs (X-rays). MRI scan results were reviewed, as reported by experienced radiologists from an academic radiology department. Histological reports from all surgically excised osteochondromas were reviewed and compared to preoperative MRI reports.

Results: Forty-two patients with radiologically confirmed osteochondroma were reviewed. Twenty-four patients underwent MRI investigation and subsequent surgical resection for potential malignant transformation. Radiology reports suggested potential malignant transformation in 11 patients (46%), but only one case (4%) had histologically confirmed malignant transformation. The discordance between MRI and histology was statistically significant (p = 0.002), indicating MRI overestimation.

Conclusion: MRI appears to overestimate malignant transformation in osteochondromas, with poor correlation to histology. We speculate that this discordance is due to inaccuracies in measuring the thickness of the cartilage cap during radiological (MRI) evaluation.

Level of evidence: 4

Susceptibility and molecular characterisation of Cutibacterium acnes from patients with bone and joint infection samples in South Africa

Justyna Wojno — 2026-05-08

Background: Cutibacterium acnes is a commensal on healthy human skin but can cause infections such as biofilm-associated prostheses/hardware infections. There is no published South African data on the susceptibility and phylogeny of C. acnes causing bone and joint infection. Empiric treatment, guided mainly by international data, shows high clindamycin resistance in C. acnes. Clindamycin would be a helpful oral treatment option due to its bioavailability and good bone penetration. The study aims to assess the susceptibility profiles of C. acnes isolates sent to the laboratory from prosthetic joint infection (PJI) patients in South Africa to guide antimicrobial therapy. The molecular characterisation seeks to assess the genetic similarity between the isolated strains and to determine which phylotypes predominate in bone and joint infections.

Methods: A retrospective analysis of antibiotic susceptibility profiles was performed for all intraoperative, periprosthetic samples from patients with PJI, fracture-related infection and post-rotator cuff repair sent routinely to Lancet Laboratories in Cape Town from January 2022 to May 2024. Only sample sets where C. acnes was isolated on two or more samples were analysed. One organism for each set of samples was used for the phylogenetic analysis. Single Locus Sequence Typing (SLST) was used to perform phylotyping on the viable C. acnes isolates.

Results: Thirty-one C. acnes isolates (one per set of samples) were identified. There was 100% (31/31) susceptibility to vancomycin, piperacillin-tazobactam, and penicillin; 81% (25/31) susceptibility to meropenem; and 87% (27/31) susceptibility to clindamycin. Of the 12 typed strains, all showed a high degree of genetic similarity.

Conclusion: These data show 100% susceptibility to the intravenous agents vancomycin, penicillin and piperacillin-tazobactam, and a high degree of susceptibility to clindamycin, which can be taken orally. This finding indicates that local susceptibility data is essential in guiding treatment strategies for South African populations. The local phylogeny indicates that strains share a common evolutionary history.

Level of evidence: 4

Percutaneous radiofrequency ablation as a treatment for chronic back pain: knowledge, attitude and practices of South African spine surgeons

Theresa N Mann — 2026-05-08

Background: Radiofrequency ablation (RFA) is a well-established treatment for spinal facet joint pain, especially in developed countries. However, several aspects of RFA lack high-quality evidence and the treatment remains contentious. In South Africa, little is known about the perception of RFA or how widely it is utilised. This study investigated the knowledge, attitude and practices of South African spine surgeons concerning the use of RFA to treat chronic axial back pain.

Methods: A survey was conducted at the 2023 South African Spine Society Congress. Spinal orthopaedic surgeons and neurosurgeons were eligible to participate. Responses were presented using descriptive statistics: overall and by subgroups who did and did not practise RFA. Factors associated with conducting RFA were investigated in univariate and multivariate analyses.

Results: Eighty-nine spine surgeons completed the survey, of which 43 (49%) conducted RFA. Full-time private practice had the strongest association with conducting RFA (adjusted risk ratio 2.52, 95% confidence interval [CI] 1.23–5.16). Overall, 62 of 87 (70%) respondents regarded RFA as a good treatment option in certain patients, including 19 of 45 (42%) of respondents who do not conduct the procedure. RFA training was heterogeneous, with course attendance the most common source of training (16 of 41, 39%). RFA practitioners conducted a median of 50 RFAs per year (interquartile range [IQR] 20–80 RFAs per year), although ten practitioners conducted ≥ 100 RFAs per year.

Conclusion: Among the spine surgeons surveyed, there was majority support for the use of RFA in certain patients, and approximately half of respondents conducted the procedure. Findings of potential concern included heterogeneity in RFA training and the observation that a few surgeons conducted particularly high volumes of RFA. Further research should explore whether RFA is used appropriately and effectively in the South African setting by investigating patient selection and technique.

Level of evidence: 3

A retrospective review of adolescent idiopathic scoliosis in a spinal unit in Cape Town, South Africa

Nomsa L Afrika — 2026-05-08

Background: The aim of this study was to retrospectively review adolescent idiopathic scoliosis (AIS) patients treated surgically at a tertiary institution in the Western Cape. Additional objectives were to determine whether clinical parameters prior to surgery are associated with specific peri- and postoperative outcomes, and to determine crude costs of AIS treatment in this spinal unit.

Methods: A retrospective observational study of clinical and radiological records was performed for 62 AIS patients treated between 1 January 2011 and 31 December 2019 at a tertiary academic hospital. Patient demographics and clinical characteristics were recorded, and appropriate correlation and associations were investigated, with post-hoc tests being performed where necessary, to investigate differences between multiple groups.

Results: The median age was 13.5 (interquartile range [IQR] 12–15) years and the cohort included predominantly females. It took a median of 405.5 (IQR 227–1 019) days before patients presented at the spinal clinic, after which they waited a median of 275 (IQR 207 379) days for surgery. The mean Cobb angle at presentation was 63.3° ± 18.5°, compared to 71.2° ± 18.3° prior to surgery, with 18% of participants progressing from a ‘non-severe curve’ (< 70°) to ‘severe’ (> 70°) while awaiting surgery. A weak positive correlation was observed between the curve magnitude prior to surgery and the total theatre time, with larger curves requiring more theatre time. As expected, a significant association between the curve magnitude and the number of vertebrae levels requiring fusion (p < 0.001) was observed. The cost of treatment for the total study cohort amounted to more than R9 million, with a crude estimate of R89 807 per patient.

Conclusion: AIS patients treated in this study demonstrated long waiting times for surgery with a significant use of financial and physical resources. Eighteen per cent of patients progressed from a nonsevere to a severe curve type due to prolonged waiting times. Early detection of AIS could potentially result in significant reduction of patients requiring surgery and as such, school and other screening programmes should be investigated as a potential tool to identify at-risk patients.

Level of evidence: 4

Infection prevention in shoulder arthroplasty: current practices among South African orthopaedic surgeons

R Kriel — 2026-05-08

Background: Periprosthetic joint infection (PJI) following shoulder arthroplasty is costly and difficult to treat. Effective perioperative infection prevention is thus of utmost importance. Recent years have seen advances in the scientific literature pertaining to infection prevention in shoulder arthroplasty, including an International Consensus Meeting (ICM). However, little is known about infection prevention practices in South Africa and to what extent they reflect the latest evidence. Therefore, the aim of this study was to investigate the current perioperative infection control practices for primary total shoulder arthroplasty among South African orthopaedic surgeons.

Methods: This cross-sectional study involved a survey conducted at the annual South African Shoulder and Elbow Surgeon Society Congress in 2023. The survey was developed based on the study aim and the existing literature. Surveys were distributed to delegates in paper-based form, and responses captured electronically for descriptive analysis.

Results: Fifty-two of 75 (69%) orthopaedic surgeon delegates completed the survey. Forty-one (79%) were in full-time private practice. Among preoperative measures surveyed, 30 of 47 (64%) respondents used chlorhexidine only as a preadmission skin preparation, 46 of 51 (90%) used cefazolin only as a preoperative antibiotic, and 28 of 51 (55%) used 0.5% chlorhexidine gluconate in 70% isopropyl alcohol as a pre-incision skin scrub. Among intraoperative measures, 51 of 52 (98%) used double gloving, 26 of 52 (50%) used iodine-impregnated adhesive drapes, 37 of 52 (71%) always used tranexamic acid (TXA), 42 of 52 (81%) always used antibiotic-impregnated cement, and 37 of 52 (71%) always redosed antibiotics for procedures > 2 hours. Postoperatively, 41 of 46 (89%) administered antibiotics for up to 24 hours.

Conclusion: There was a majority response for most of the items surveyed, indicating reasonable consensus in shoulder arthroplasty infection prevention practices. Most responses were generally in keeping with ICM recommendations, except routine use of TXA and antibiotic-impregnated cement. These measures were deemed by the ICM to have insufficient evidence. A minority of respondents indicated practices that show room for improvement in reducing periprosthetic joint infection risk.

Level of evidence: 3

Functional outcomes of patients with direct vs indirect fixation of tibial plateau fractures with posterior column involvement

Nasser R Falabella — 2026-05-08

Background: The study was undertaken to compare the effectiveness of direct fixation of the posterior column of the tibial plateau versus indirect fixation using medial or lateral approaches, using the Knee injury and Osteoarthritis Outcome Score (KOOS) questionnaire as the primary outcome measure.

Methods: A retrospective comparative study was conducted, with a minimum follow-up of two years on surgically treated patients, comparing direct fixation of the posterior column of the tibial plateau versus indirect fixation of the posterior column via a medial or lateral approach of the tibial plateau. These procedures were performed from January 2018 to January 2023 at the Orthopedic Hospital of the Red Cross in Mérida, Yucatán, Mexico.

Results: A total of 59 patients were obtained, of which 28 patients underwent direct posterior column fixation and 31 were operated with indirect posterior column fixation from classic medial or lateral approaches. Patients treated with direct posterior fixation showed significantly higher scores on the KOOS questionnaire in the symptoms (76.57 vs 70.0, p = 0.03), pain (83.21 vs 77.94, p = 0.02), and activities of daily living (87.54 vs 82.74, p = 0.03) subscales, as well as in the total scale score (75.14 vs 70.13, p = 0.04). No significant differences were found in the sports and quality of life subscales.

Conclusion: It was determined that patients undergoing direct posterior fixation presented significantly higher scores on the KOOS questionnaire, particularly in the symptoms, pain, and activities of daily living subscales. This suggests better long-term functional outcomes in patients undergoing direct fixation via a posterior approach.

Level of evidence: 3

Surgical management of the hallux valgus: a current concepts review

Duduzile Sigodi — 2026-05-08

Hallux valgus (HV) remains among the most prevalent forefoot deformities encountered in orthopaedic practice, characterised by complex multiplanar deformity involving lateral deviation, pronation and associated joint pathology. Its aetiology is multifactorial, encompassing extrinsic factors such as footwear and genetic predisposition, as well as intrinsic biomechanical alterations including ligamentous laxity and abnormal foot architecture. The pathogenesis involves deviations in the first metatarsophalangeal joint (MTPJ) biomechanics, destabilised by a dysfunctional windlass mechanism and contributing to cartilage degeneration, bony prominences and sesamoid subluxation.

Clinical assessment integrates detailed history, physical examination and radiographic evaluation of deformity parameters such as the HV and intermetatarsal angles. Conservative management includes orthoses, exercise therapy, footwear modification, and adjunct modalities, which alleviate symptoms and may delay surgical intervention.

Surgical correction remains the definitive treatment, with over 100 procedures described. Techniques are tailored based on deformity severity, including distal soft tissue procedures, various osteotomies (chevron, scarf, Mitchell, Lapidus) and arthrodesis, each with specific indications, advantages and complications. Recent advancements in minimally invasive surgery (MIS) have shown promising results, including superior deformity correction, reduced pain and quicker recovery, though long-term outcomes are comparable to traditional open techniques.

Comparative studies highlight benefits of MIS but emphasise the importance of surgeon experience and patient-specific factors. Overall, the evolution of surgical techniques offers a wide spectrum of options for halting deformity progression and restoring function, underscoring the importance of individualised treatment strategies guided by deformity severity, radiographic findings and patient preferences.

Level of evidence: 5

Casting out the truth: why ITT alone fails in trials that compare surgery to casting

Bryan Theunissen — 2026-05-08

Randomisation and intention-to-treat (ITT) analysis are pillars of trial methodology – and for many questions they are rightly so. But when the interventions under study are epistemologically dissimilar, ITT stops answering the clinical question clinicians and patients actually care about. In trials that compare a discrete, one-off surgical procedure to a prolonged therapeutic pathway of casting, the standard ITT framework produces a categorical mismatch: it analyses assignment rather than completed treatment. That mismatch is not a minor technicality – it is a fundamental design error.

Building resilience is not for the faint-hearted

Mari Thiart — 2026-05-08

We seem to be in a national crisis. Healthcare workers are faced with financial constraints, increased patient loads, and reduced staff. For many of us, the greatest struggle is the sense that we cannot help our patients in the way we know they deserve. When admissions are unrelenting, the emergency board is never-ending, and theatre time is insufficient, it is demoralising. I am not responsible for a trauma firm, but I still feel the heat.

CPD Questionnaire (V25N02)

Editorial Office — 2026-05-08

CPD Questionnaire