Doctoral Degrees (Orthopaedics)
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Item An integrated approach to adult chronic osteomyelitis.(2014) Marais, Leonard Charles.; Aldous, Colleen Michelle.No evidence-based guidelines exist on the treatment of chronic osteomyelitis of long bones in adults. Management is still largely based on expert opinion and consensus guidelines are not available. Choosing between a palliative and curative treatment strategy requires consideration of several factors. Principle amongst these is the host’s physiological status, which determines the patient’s ability to cope with the rigours of limb salvage surgery. This fact was recognized by Cierny and Mader, when they developed their popular staging system. The authors suggested palliative treatment in C-hosts, who will not be able to cope with the metabolic demands of an aggressive treatment plan. The problem however, is that the C-host was never accurately defined. Cierny and Mader predicted in their original paper that, as a result of the inadequate definition, the selection of surgical candidates would vary from institution to institution until there was standardization of this concept. The limitations of existing classification systems prompted the development of a novel approach to chronic osteomyelitis for use in South Africa. This involved the establishment of an objective definition of a C-host, as well the development of a novel classification system and an algorithmic guideline to treatment strategy selection. By integrating the physiological status of the host (based on pragmatic predefined criteria) with the selection of the appropriate curative, palliative or alternative treatment strategy we were able to achieve favourable short term outcomes in both low and high risk cases and in addition reduce the rate of amputation. Furthermore, we were able to report novel data on the outcome of palliative treatment, as well as the outcome of treatment of chronic osteomyelitis in HIV infected patients. While the preliminary results appear promising, long term follow-up will be required in order to determine the rate of recurrence of infection. The proposed approach was designed specifically with the South African clinical environment in mind and additional development of the algorithm may be required in order to render it useful in other clinical settings. The implementation of a refined host stratification, which incorporates objective criteria for C-host classification will, however, enable the comparison of results from studies employing different therapeutic interventions in the future. In addition, selection of patient-matched treatment options closes the gap in successful outcomes between healthy and compromised patients. The major benefit of the proposed approach is therefore the fact that the integrated approach places appropriate emphasis on the importance of host factor modification prior to surgical intervention.Item The outcome of tibial non-union treatment using a revised definition, classification system and management strategy.(2015) Ferreira, Nando.; Aldous, Colleen Michelle.The management of tibial non-unions remains a challenge for orthopaedic surgeons. The treatment of tibial non-unions is historically based on small case series that frequently include a variety of non-union subtypes and infected cases. Fixation methods and treatment strategies also vary greatly between published series. This lack of uniformity in the available literature has rendered the establishment of evidence-based, reproducible protocols for the management of tibial non-unions difficult. Controversies regarding non-union definition and classification contribute to delays in treatment and exacerbate the morbidity that is commonly associated with non-union development. In this work we propose a new definition for non-union and introduced a novel concept of ‘potential non-union’ to emphasise the importance of early recognition and referral. The lack of reproducible, evidence-based treatment protocols, combined with the large volume of tibial non-union cases managed in KwaZulu-Natal, South Africa, lead to the development of a tibial non-union treatment algorithm. This algorithm was based on results from two retrospective audits of patients with tibial non-unions who were managed with circular external fixators over a four-year period. The algorithm classifies non-unions into four distinct groups, each with a specific treatment strategy. These reports also introduced the concept of mechano-biology to the management of tibial non-unions and were the first to use hexapod circular fixators for distraction of stiff hypertrophic tibial non-unions. Subsequently a prospective interventional study was undertaken aimed at evaluating the effectiveness of the proposed tibial non-union treatment algorithm.Item A molecular study of the immunopathogenesis of TB spondylitis in HIV -infected and -uninfected patients.(2008) Danaviah, Sivapragashini.; Cassol, Sharon.; Ndung'u, Peter Thumbi.Abstract can be viewed in PDF document.