South African Orthopaedic Journal

The combined use of titanium elastic intramedullary nails and postoperative skin traction in unstable femoral diaphyseal fractures in children

Wed, 25 Mar 2026 00:00:00 +0000

Background: Paediatric diaphyseal femoral fractures account for less than 2% of all paediatric fractures. Studies suggest that children aged 5–11 years who weigh < 49 kg with femoral diaphyseal fractures may be the best candidates for titanium elastic nails. Elastic flexible nailing has gained wide use because it offers good results with minimal complications in stable femoral diaphyseal fractures. However, the effectiveness of titanium elastic nails for the management of unstable paediatric femoral fractures remains debatable. This study aimed to elicit the effectiveness of titanium elastic nails in unstable paediatric femoral diaphyseal fractures when combined with postoperative immobilisation with skin traction.

Methods: This retrospective review included paediatric patients aged 3–11 years with unstable femoral shaft fractures treated with titanium elastic nails who were admitted to the paediatric orthopaedic department at a tertiary academic hospital between January 2017 and December 2020, and had a minimum follow-up of six months. The unstable fractures were spiral, comminuted, or long oblique fracture patterns.

Results: A total of 67 patients were reviewed, with a mean age of 6 (4–7) years. Fracture union was noted at eight (8–9) weeks. Fifty patients (75%) had excellent overall outcomes according to the Flynn score.

Conclusion: Retrograde titanium elastic nailing may be indicated for the management of unstable paediatric femoral fractures when supplemented by postoperative immobilisation with skin traction in the initial two weeks.

Level of evidence: 4

The outcomes of the single-stage, three-incision surgical approach in the treatment of neglected cases of congenital vertical talus: a single centre’s experience

Wed, 25 Mar 2026 00:00:00 +0000

Background: Congenital vertical talus (CVT), also known as congenital convex pes valgus, is a rare orthopaedic deformity affecting approximately 1 in 10 000 live births. Neglected CVT (NCVT) cases pose a significant challenge in treatment due to the rigid and severe nature of the deformity, which often resists conservative management and requires extensive surgical intervention. Despite the importance of treating NCVT, the evaluation of their surgical outcomes in Zagazig University Hospital was limited, hence this was the aim of the current study.

Methods: This retrospective study was conducted on children with NCVT who presented to the university hospital during the period March 2019 to January 2023. The surgical technique included a single-stage correction performed through three incisions (medial, lateral and posterior) to provide comprehensive access for soft tissue release, tendon lengthening, and joint stabilisation. In two severe cases, naviculectomy was performed to achieve adequate reduction and medial–lateral arch balance. Preoperative assessment of cases included thorough clinical and radiological assessments. Data was collected, revised, coded and statistically analysed.

Results: The study included 24 feet from 16 children with NCVT, ten males and six females, with half the cases presenting as bilateral deformities. The patients’ mean age was 31.6 ± 3.8 months. Postoperatively, all feet showed satisfactory improvement with successful alignment and restoration of foot mechanics as evidenced by clinical appearance and function as well as radiological parameters. Surgical complications were minimal, with only four feet (17%) experiencing wound ischaemia due to pulling on the skin. No cases of infection or avascular necrosis were noted.

Conclusion: Single-stage surgical correction can be the best option in cases of NCVT that may miss long-term follow-up treatment with more stages. The outcomes highlight the efficacy of this surgical approach in achieving functional and plantigrade feet, even in complex and neglected cases of CVT. Further studies with larger numbers of patients and long-term follow-up are recommended to confirm the current findings and investigate long-term outcomes.

Level of evidence: 2

What is the current consensus among orthopaedic surgeons in South Africa regarding robotic-assisted surgery in total joint arthroplasty?

Wed, 25 Mar 2026 00:00:00 +0000

Background: Total joint arthroplasty (TJA), including total knee arthroplasty (TKA) and total hip arthroplasty (THA), are successful orthopaedic procedures, with survivorship reported at 98% at ten years and 95% at 20 years. The development of robotic-assisted total joint arthroplasty (RA-TJA) is one example of the continual evolution in technology in an attempt to improve these numbers. The use of RA-TJA is increasing, with little known about the potential factors which may impact the decision of surgeons to integrate robotic-assisted technology into their clinical practice. The aim of this study is to assess the usage and opinions of orthopaedic surgeons in South Africa regarding RA-TJA.

Methods: An anonymous online survey was distributed via email to all orthopaedic surgeons registered with the South African Orthopaedic Association (SAOA). Analysis was subsequently undertaken to establish factors which might influence opinions regarding RA-TJA.

Results: In total, there were 155 responses, with 37% (n = 57) of respondents being fellowship-trained in arthroplasty, either nationally, internationally or both. Seventy-one per cent (n = 110) of respondents were in private practice only, 6% (n = 9) in state practice only, and 23% (n = 36) in both. Forty-four per cent (n = 68) of surgeons are using RA-TJA, with 8% (n = 13) using both RA-THA and RA-TKA, 1% (n = 2) using RA-THA only, and 34% (n = 53) using RA-TKA only. The most common reason for using RA-TJA was higher precision in reproducibility of the procedure, at 91% (n = 62). The most common reason for hesitation in using RA-TJA is cost, at 69% (n = 60). Forty-seven per cent (n = 73) of surgeons believe it takes 11 to 20 cases to become competent using RA-TJA. The formation of an RA-TJA special interest group was agreed to by 71% (n = 110) of respondents.

Conclusion: The usage of RA-TJA in South Africa is higher than in other nations but it follows the same trend that there are more surgeons not using RA-TJA. Cost, lack of long-term data proving superiority, and the learning curve are the most common reported obstacles to RA-TJA, with improved precision a common reason for adopting RA-TJA. RA-TJA is a broad term, and further analysis of the type of systems currently in use and their possible perceived benefits will provide more information regarding the use of RA-TJA.

Level of evidence: 3

Outcomes of an all-suture anchor technique for the treatment of transverse olecranon fractures: a case series

Wonga Qwanyaza, Megan O'Connor, William Haynes, Johan Pretorius — Wed, 25 Mar 2026 00:00:00 +0000

Background: Mayo type IIa olecranon fractures are typically managed with plate osteosynthesis (PO) or tension band wire (TBW) fixation. Reoperation rates for the removal of prominent metalware are high following TBW. All-suture anchors (ASA) in a tension band configuration can potentially capitalise on tension band principles and reduce hardware irritation. This investigation aimed to review the outcomes of patients with Mayo IIa olecranon fractures managed with this technique.

Methods: This retrospective chart review describes the ASA surgical technique and assesses the outcomes of adult patients with Mayo IIa olecranon fractures managed with the technique between 1 August 2017 and 31 October 2021. Patient charts were used to capture basic demographic details, injury characteristics, timing of surgery and surgical outcomes. The outcomes of interest included the union rate, functional outcomes, complications and reoperation rates.

Results: Thirty patients met inclusion criteria; 60% were male, the majority of which (63%) were injured from a direct blow. Two injuries were compound. All but one fracture united, representing a union rate of 97%. The median postoperative total range of motion was 130°. The median Mayo Elbow Performance Score (MEPS) was 100 (excellent). Three cases complicated: two with superficial sepsis and exposed suture material, and one developed a fibrous non-union. No patients required reoperation.

Conclusion: The adult patients with transverse olecranon (Mayo type IIa) fractures managed with the described all-suture anchor technique in this investigation had a union rate of 97%, with excellent functional results as measured by the MEPS. No reoperations were required.

Level of evidence: 4

Poor prognostic features among soft tissue sarcoma patients: analysis based on the first sarcoma registry in South Africa

Dane Maimin, Robyn Waters, Nicholas Kruger, Henrik FC Bauer, Thomas Hilton — Wed, 25 Mar 2026 00:00:00 +0000

Background: Soft tissue sarcomas (STS) of the extremities are rare tumours with various prognostic factors. The epidemiology of STS is understudied in South Africa. Here we present the first data on extremity STS from the South African Sarcoma Registry.

Methods: The study comprised a retrospective review of extremity, pelvis and trunk wall STS patients collected from 2019 to 2023 in a prospective South African Sarcoma Registry. One hundred and three STS patients were referred to the orthopaedic oncology unit from 2019 to 2023 and, after exclusion of 14 patients with well-differentiated liposarcomas, data for 89 patients were analysed. To assess survival post-diagnosis, the South African Medical Research Council (SAMRC) National Population Death Registry (Burden of Disease Research Unit) was scrutinised using patient ID numbers. Only patients with ID numbers were utilised for two-year survival curve analysis. To assess factors associated with two-year survival rate, a univariate and multivariate Cox regression analysis was performed.

Results: The median age of the cohort was 49 years; the median tumour size was 11 cm; and metastasis was present at diagnosis in 17% of the cohort. Furthermore, less than half were referred before biopsy or surgery, and 10% were not operated due to metastatic disease at presentation. Overall two-year survival proportion for all patients was 0.70, and for those without metastasis at diagnosis it was 0.80. The two-year survival estimates for patients referred ‘untouched’ was 0.83, and for those referred with history of prior biopsy or surgery was 0.76. Tumour size was the only factor with a significant impact on two-year survival rates for patients without metastasis at diagnosis (p < 0.001).

Conclusion: In our registry, STS patients had more poor prognostic features compared to Scandinavian registry data. Patients tended to present younger, with larger tumours and more frequent metastasis at diagnosis. Generating clinical data through a prospective and consecutive accrual of patients into a registry is paramount for assessment of quality of care and for clinical research.

Level of evidence: 3

A retrospective cohort study investigating the epidemiology of bacterial hand infections at a tertiary hospital in the Western Cape of South Africa

Ridwaan Aboobaker, Hentas Van Zyl, Marilize C Burger — Wed, 25 Mar 2026 00:00:00 +0000

Background: Hand infections can cause serious morbidity and financial implications to patients and healthcare systems. This retrospective cohort study investigates the epidemiology of bacterial hand infections at a tertiary institution over a year, with a secondary objective of investigating factors that modify risk for complications.

Method: Patient demographics, clinical information, microbacterial spectrum, timeframes of patient’s pathway, and risk factors for complication development were investigated. Data related to antibiotic cover and any resistance to commonly used antibiotic therapy, specifically co-amoxiclav (Augmentin) and cloxacillin, was also captured. Relationships between risk factors and complications were investigated with a chi-squared or Fisher’s exact test at an alpha-level of 0.05.

Results: Overall, 529 patients (mean age of 33.0 ± 15.6 years; 73% male) were included. A delay of a median of 6.0 (IQR 3.0–9.0) days between onset of symptoms and admission occurred. Complications were experienced by 23% (n = 124) patients. These patients required soft tissue cover (55%, n = 69), relook-debridement alone (34%, n = 42), or an amputation (10%, n = 13). Methicillin-sensitive Staphylococcus aureus (MSSA) was most frequently cultured, at 79% (n = 281) of all cultured organisms. More of the cultured organisms were sensitive to co-amoxiclav (86%, n = 305) than they were to cloxacillin (78%, n = 278). Patients with necrotising fasciitis and co-amoxiclav resistance had a statistically significant increase in complications.

Conclusion: The findings of this study highlight a high burden of hand infections as well as a high rate of complications following treatment. Furthermore, co-amoxiclav was an appropriate choice of antibiotic cover in this population. Finally, patients with necrotising fasciitis and those with co-amoxiclav-resistant infections are more at risk of complications. These findings should be taken into consideration when treating patients with hand infections.

Level of evidence: 3

Embracing diversity and inclusion in orthopaedic surgery in South Africa: a path forward to become ‘stronger together’

Phakamani G Mthethwa — Wed, 25 Mar 2026 00:00:00 +0000

Undoubtedly, our Springbok rugby team, guided by their inspirational leaders Rassie Erasmus and Siya Kolisi, is our proud example of a winning South African team. Spearheading the Rugby World Cup final in 2023 to beat our traditional rivals, the All Blacks, and win the Webb Ellis Cup for the fourth time, was no child’s play. Seizing the lead by a one-point margin from extremely strong opposition in the dying seconds of the game wasn’t good for supporters’ heart health! President Ramaphosa, in a viral social media video, was heard saying in isiZulu, ‘inhliziyo yami chishe yama’ – loosely translated as ‘my heart almost stopped’. Turning the game around required team dedication, cohesion, confidence in the abilities of fellow players, and absolute commitment. The success after a hard-fought win was celebrated by people of diverse backgrounds, races, colours, shapes, sizes and skills. The necessity for diversity and inclusion within the South African Rugby Board (SARB) rankings has become increasingly evident. Historically, during the apartheid era, the SARB predominantly represented white individuals, neglecting the participation and representation of minority groups. At that time, rugby governing bodies aligned with specific racial groups, further exacerbating the divide. Today, the challenge of building a unified and competitive team, such as the Springboks, has been a significant task for the SARB. This journey toward inclusivity strengthens the team and reflects South African society’s rich diversity.

Value-based care: a South African perspective

Anton J Julyan — Wed, 25 Mar 2026 00:00:00 +0000

This communication is based on my experience with value-based care programmes for lower limb arthroplasty in South Africa’s private healthcare sector since 2018. It gives a glimpse into many hours of meetings with several stakeholders.

CPD Questionnaire (V25N01)

Editorial Office — Wed, 25 Mar 2026 00:00:00 +0000

CPD Questionnaire

Acknowledgement of reviewers

Editorial Office — Wed, 25 Mar 2026 00:00:00 +0000

The South African Orthopaedic Journal is able to publish good quality, peer-reviewed articles thanks to the valuable input provided by its tireless and generous reviewers. By applying their insights and knowledge gained in their areas of expertise, the reviewers ensure the scientific integrity and research quality of the articles. This they do without any reward, and we wish to thank them most sincerely for their contribution to the journal.