Kimberley Provincial Hospital provides the sole public sector orthopaedic surgical service to the entire Northern Cape Province of South Africa (SA). Ankle fractures form part of the trauma burden and pose a challenge owing to high numbers and limited resources. The incidence of ankle fracture is reported to be 169.7/100 000/year. [1] Currently there are no statistics on the incidence in the Northern Cape. An alternative surgical method of treatment was explored in the form of a prospective cohort series, to increase turnaround time of patients needing surgery and thus improve service delivery. Data collection while conducting this prospective trial highlighted loss to follow-up in ankle fracture patients, which prompted this report. Numerous studies have highlighted the challenges in terms of loss to follow-up when conducting trials in musculoskeletal injuries. [2-5] The main factors contributing to this loss to follow-up are reported to be socioeconomic, and include level of education, poverty, male gender, smoking and alcohol abuse. [6] Young individuals as well as the very elderly are prone to be lost to follow-up. Potential reasons for this vary, but are hypothesised to include an increased frequency of substance abuse in younger populations and lack of mobility in older populations. [2,7] In addition, smokers are reported to have an 80% higher risk of loss to follow-up compared with non-smokers. The reason for this is not clear, but it has been postulated that individuals with substance use may lack motivation to change their behaviour for health-related purposes. [2] Several other studies also report smokers to be at risk of not attending for follow-up as expected. [4,5,8] This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Aim This study compared functional outcomes between anatomical shaped fibular plates and intramedullary nail fixation of adult patients who sustained unstable ankle fractures. Methods A prospective randomized control trial was conducted between November 2013 and December 2016 on patients that presented with an unstable ankle fractures. They were randomized into a plate-and-screw group and a fibula nail group. At each post-operative visit the wounds were reviewed, and specific outcome measures were recorded, which included (i) the patient reported outcome measure (PROM) Olerud and Molander functional score, (ii) the Grimby score, (iii) swelling around the malleoli, (iv) plantar flexion, (v) dorsiflexion, (vi) inversion, and (vi) eversion. Results Significant differences were observed in scar size (p < 0.001) and screening time (p < 0.001) whilst no differences were observed in functional and PROM measures. Although not statistically significant, of clinical value is one deep infection that occurred in the plate group, whilst no infections occurred in the nail group. Conclusion Both fixation methods yielded very similar functional results with differences only in scar size, screening time and swelling. Although none of these warrant a change in surgical decision-making processes, taken together, these factors potentially influence the decisions made in terms of surgical modalities used.

The urgency of closed reduction of acute low-velocity cervical facet dislocations has recently been highlighted by the Constitutional Court of South Africa (SA), following a permanent spinal cord injury that a young rugby player sustained during a club-level match. The court found that if emergency care of the complainant had resulted in rapid closed reduction of his cervical spine injury, he might not have suffered permanent neurological damage. [1] The findings of the court were based on research by Newton et al., [2] who specifically looked at the timing of reduction of low-velocity cervical facet dislocation sustained by rugby players. In their cohort, reduction of facet dislocation within 4 hours after injury was associated with improved neurological outcomes. By performing an early closed reduction of the cervical spine, pressure is relieved from the spinal cord, preventing secondary ischaemic trauma and thus improving the possibility of neurological recovery. [3-5] It is important to note that this cohort of patients sustained low-velocity injuries. These may include sports-related injuries, falls from a standing height and blunt object assault. The severity of spinal cord trauma, or the viscous response of spinal cord tissue, is a product of the severity of compression, duration of compression and rate at which compression is applied, [6] which can also be referred to as the velocity of trauma. When compression is applied at a lower velocity, the spinal cord is more likely to show recovery and can withstand higher loads of compression than when subjected to the same compressive load applied at a higher velocity. Animal studies demonstrated this threshold to be 3 m/s, which equates to a fall from a standing height. [7] The current dispensation in SA demands that injuries of this nature be treated in specialised orthopaedic or neurosurgical units, or by qualified surgeons, with limited, if any, attempts at a closed reduction prior to arrival at a dedicated unit or service. The question of feasibility of mandatory closed reduction of cervical facet dislocations within 4 hours is therefore raised. This study reviews the time delays, delaying factors and success rate of closed reductions of cervical facet dislocations in an orthopaedic department at a tertiary-level training hospital over a period of 8 years. Methods A retrospective review of case notes and imaging screens of patients >18 years of age with cervical facet-joint dislocations presenting to a tertiary-level academic hospital in Western Cape Province of SA was performed. The university-affiliated hospital has a capacity of 1 899 beds and provides advanced trauma and This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.