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GUIDE TO THE

M MED TRAINING

PROGRAMME

DEPARTMENT OF

ORTHOPAEDIC SURGERY

UNIVERSITY OF

STELLENBOSCH / TYGERBERG HOSPITAL

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CONTENTS

1. BASIC SCIENCES 1.1 Anatomy 1.2 Physiology 1.3 Pathology 2. INTERMEDIATE 2.1 Surgical principles and I.C.U. 2.2 Orthopaedic Pathology 3. FINAL EXAMINATION 3.1 Orthopaedic Trauma 3.2 Reconstructive Orthopaedic Surgery 4. THESIS 5. FINAL EXAMINATION 6. PANEL OF EXAMINERS

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INTRODUCTION

To practice as an Orthopaedic Surgeon (Specialist) it is a requirement to have an

higher qualification in Orthopaedic Surgery such as the M Med (Orth) or the FC

(Orth).

In order to obtain the above a structured training programme is mandatory. With

this document I intended to give a sensible and realistic guide to core knowledge

and training fields which should be required by trainees by the end of their 5 year

training programme.

It is my hope that this document will be of value, not only to trainee Orthopaedic

Surgeons preparing for the M Med or the FC (Orth), but also to the training

programme directors and consultants undertaking the planning of the core

education programme.

By studying the different fields of Orthopaedic Surgery, the trainee must also be up

to date with the newest literature and journal publications in the wide field of

orthopaedic surgery.

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Overview The MMed Orthopaedic degree aims to equipt and qualify a doctor with theoretical and practical knowledge needed to practice as a general Orthopaedic Surgeon. The course is full-time and lasts 5 years. A candidate will be required to be working full-time as a Registrar in the Department of Orthopaedic Surgery in a requested Registrar post for the duration of the training period. If he/she registers with the University as a special student, the primary examination may be written prior to commencement of the training programme. For further detail regarding the scheduling and requisites of the examinations please consult the Registrar, Faculty of Health Sciences or the yearbook.

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1. BASIC SCIENCES 1.1 Anatomy A thorough knowledge of human anatomy is expected including the whole

muscular skeletal system, surgical anatomy as well as a basic anatomy of the neurological systems (A full curriculum planning will be provided by the Department Anatomy).

Convenor: Prof DF du Toit E-mail: mcdb@sun.ac.za Tel: 021-938 9397 1.2 Physiology This course is administrated by Prof JA Moolman, Dept of Physiology. Tel: 021-9392. E-mail: jamool@sun.ac.za 1.2.1 The following guidelines, from an Orthopaedic perspective, include: 1. The cell and its functions. Organization and function of all cells of the

musculoskeletal, haemopoetic and cardio respiratory systems. Genetic control of cell function and protein synthesis. Metabolism and hormonal regulation.

2. Growth process: Growth plate, how growth takes place and the control thereof.

Normal ages of ossification and growth plate closure. 3. Endocrine system: Hormones that affect cardio pulmonary and musculoskeletal

function and growth. 4. The nervous system. How nerves function and control skeletal and autonomic

functions. Membrane potentials and action potentials. Nerve conduction, myelinisation and development of the nervous system. Function of the bribn and spinal cord. Spinal reflexes, normal and suppressed. Formation and circulation of cerebro spinal fluid. Sensation – detection and transmission of tactile,, sensation, visceral sensation and pain. Control of upright posture.

5. Cardiovascular. The cardiovascular system and its response to trauma and

anaesthetic stresses. Physics of blood flow, local control of blood flow by the tissues. Short and long term regulation of arterial pressure.

6. Circulatory shock types physiology, recognition and treatment. 7. Joints: Types of normal histology, development, lubrication and nutrition 8. Bone: Bone structure, growth and remodeling and hormonal influence. Reasons for

the shape of bones and the curves of the spinal column. Relative strengths of

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musculoskeletal tissues and their elasticity, bone grafts, banking, tissue transplantation.

9. Skin: Functions of the skin including the effect of sunlight on the skin and on

hormones. 10. Respiratory: The respiratory system, blood gases and their transport to and from the

tissues. Principles of gas exchange, gas transport, regulation of respiration. 11. Reproductive system: Effect of sexual development on the growth process.

Musculoskeletal changes in childbirth. 12. The healing process: Repair of muscle, skin, bone, tendons and other

musculoskeletal tissues. 13. Blood cells, immunity and blood clotting. Blood groups, immunity and allergy,

haemostasis and blood coagulation, blood loss, fluid balance and blood transfusions. 14. The body fluids and kidneys. The functioning of the kidneys in regulating body

fluids, other functions of the kidneys. Regulation of acid base balance. 15. Metabolism and temperature regulation. Metabolism of carbohydrates, lipids and

proteins. Regulation of body temperature. Vitamin and mineral metabolism. Calcium and phosphate regulation. Normal nutrition requirements. Obesity and its effects on the musculoskeletal system.

16. Ageing of the skeletal system. Special features of neonatal physiology. Normal

ageing of bone, joints muscle and endocrine system. 17. Application / relevance of modern genetics to orthopaedic disease and treatment. 18. Tissues, growth function, injury and healing of tissues: 18.1 Bone 18.2 Cartilage (articular, meniscal) 18.3 Muscles and tendons 18.4 Synovium 18.5 Ligaments 18.6 Nerve 18.7 Intervertebral discs These are basic guidelines for physiology requirement for the M Med Part I

physiology - also the requirements from the Dept of Physiology.

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1.3 Pathology Basic pathology is required and will be outlined by the Department of Pathology. Convenor: Prof J Schneider E-mail: jws2@sun.ac.za Secretary: Ms Elke van Wyngaardt (efvw@sun.ac.za) Tel: 021-938 4041 2. INTERMEDIATE 2.1 Surgical pr inciples and I .C.U. A detailed requirement list will be obtained from the Department of Surgery Head of Department: Prof B Warren E-mail: blw@sun.ac.za Contact Dr C Fourie E-mail: cate@sun.ac.za Secretary: Mrs a Burger E-mail: abu@sun.ac.za Tel: 021-938 9271 See Annexure A as an example.

Annexure A

INTERMEDIATE TUTORIALS, TUESDAY 16:00 (A1 Seminar Room unless otherwise indicated on weekly programme) • Metabolic Response to Trauma

• Shock & Resuscitation

• Surgical Nutrition

• Fluid and Electrolyte Therapy; Acid/Base Metabolism

• Blood Transfusion + Component Therapy

• Disorders of Haemostasis

• Surgical Infection & Antibiotics I

• Surgical Infection & Antibiotics II

• HIV/AIDS and Surgery

• Surgical Asepsis

• Electrical & Physical Hazards in Theatre

• Wound Healing & Wound Care

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• Cardiac Arrhythmias and Cardiac Arrest

• Thoracic Trauma

• Mechanical Ventilation

• ARDS

• Fat Embolism

• Surgery & Diabetes

• Surgery & Corticosteroids

• SIRS, Sepsis & MODS I

• SIRS, Sepsis & MODS I

• Peritonitis & Intra-abdominal Sepsis

• Abdominal Compartment Syndrome

• GIT bleeding

• Cardiovascular Risk Evaluation

• DIC

• Soft Tissue Trauma/Crush Syndrome

• Vascular Trauma

• Compartment Syndrome & Reperfusion injury

DVT/Pulmonary Embolism

• Abdominal Trauma

• Urogenital Trauma

• The Acute Scrotum

• Oliguria/Anuria/Acute Renal Failure

• Intestinal Obstruction

• Gynaecological causes of Acute Abdomen

• Principles of Neonatal & Paediatric Surgical Care

• Head Injury

• Endocrine Crises

• Fractures & Dislocations

• Spinal Injuries

• The Hand

• Burns

• Skin grafting, Flaps and Free Flaps

• Principles of Transplantation: Surgery in the Immunosuppressed Patient

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2.2 Or thopaedic pathology Orthopaedic pathology will include: 2.2.1 Bone and joint disease A general understanding of the musculor skeletal diseases will be required. Each

disease can be considered under the headings of Etiology, Pathology, Clinical features, Investigations, Differential diagnosis, Management.

A knowledge of the multi-disciplinary assessment and surgical planning in the

patient with multiple joint diseases such as rumatoïd arthritis is also required. Diseases conditions include:

- Osteoarthritis - Osteoporosis - Metabolic bone disease - Rumatoïd arthritis and other arthropathes (inflammatory crystal etc.) - Hemophilia - Inherited muscular skeletal disorders - Neuromuscular disorders inherited and acquired - Osteonecrosis - Osteochondritis - Heterotopic ossification - Bone and soft tissue sarcomas - Metastases

ORTHOPAEDIC ONCOLOGY

- Knowledge of the presentation radiological features - Pathological features treatment and outcome for common benign and malignant

tumors are required - An understanding of the principles of management of patients with metastatic

bone disease in terms of investigation, prophylactic and definitive fixation of pathological fractures and oncological management

- Knowledge of the presenting features, management and outcome of soft tissue swellings including sarcomas

- Knowledge of all bone tumours which include differential diagnosis and basic histological features

INVESTIGATIONS The principles, applications and side effects of investigations must be known which

includes: - Blood tests - Musculoskeletal imaging: X-ray, contrast studies, CT, MRI, ultrasound and

radioisotope studies - Effects of radiation - Bone densitometry

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- Electrophysiological investigations OPERATIVE TOPICS Knowledge of the following will also be required:

- Tourniquets type and timing - Design of theatres - Anaesthesia – principles and practice of local and regional anaesthesia - Coagulation

INFECTION, THROMBO EMBOLISM AND PAIN The basic pathology, clinical features, investigations, treatment and prevention of

these problems must be known. Knowledge of the relevant recent literature is also expected which includes: - Infection of bone, joint, soft tissue, including tuberculosis, and their treatment

and prophylaxis - AIDS and surgery in high risk patients - Sterilisation of instruments - Skin preparation - Thrombo embolism and prophylaxis - Pain and pain relief - Complex regional pain syndromes such as reflex sympathetic dystrophy and

causalgia - Behavioural dysfunction and somatization

PROSTHETICS AND ORTHOTICS Candidates should be familiar with examples of common orthoses which includes:

- Principles of design - Prescription and fitting of standard prostheses - Principles of orthotic bracing for control of disease such as deformity,

instabilities etc. RESEARCH AND AUDIT Candidates should be able to illustrate answers with examples from experience in

recent literatures such as: - Design and conduct of clinical trials - Data analysis and statistics – principles and applications - Principles of epidemiology - Audit

MEDICAL ETHICS

- The duties of care - Informed consent - Medical negligence - Confidentiality - Professional conduct

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M MED PART I I A. TRAUMA 1. Anatomy - Applied to diagnosis and surgical treatment of common bone, joint and soft

tissue injuries - Knowledge of those anatomical structures particularly at risk from common

injuries or in surgical approaches - Physeal anatomy and its application to injury 2. Biomechanics - Application to open reduction and internal fixation of fractures and external

skeletal fixation - Applied to fracture formation and fracture treatment both operative and non-

operative - Biomechanics of implants and fracture fixation systems, including material

properties 3. Epidemiology and research methods - Research and audit methods including the design of clinical trials in the trauma

environment. 4. Pathology - Applied to fracture and soft tissue healing, including skin, muscle, tendon and

neurological structures - Classification systems for fractures and dislocations - Pathology of non-union of fractures - Response of the body and local musculoskeletal tissues to infection - Systemic response of body to major injury - Mechanisms underlying Acute Respiratory Distress Syndrome and similar life

threatening conditions - Science of fluid replacement therapy in the multiple injured. - Science and treatment of compartment syndrome - Response of infants, children and the elderly to injury 5. Clinical assessment - Initial clinical assessment of the patient with severe injury, including spinal

cord injury, soft tissue injury and head injury - Identification of life threatening / limb threatening injuries. Understanding

priorities of treatment - Assessment of all types of fracture and dislocation and their complications,

early and late 6. Investigations

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- Knowledge of the principles, application and side effects of commonly used investigations, including radiographs, CT and MRI scans, radio-isotope imaging, ultrasound scans and electrophysiological investigations.

7. Treatment - Knowledge of different treatment options for musculoskeletal injury, both non-

operative and operative. Ability to analyse the pros and cons for each method. - The ability to manage the overall care of the severely injured. - The ability to undertake the complete treatment of all types of common fracture

and dislocation including the bone and soft tissue treatment of open fractures and the treatment of pathological fractures.

- When common injuries are normally treated by a sub specialist (eg. spinal injury, arterial injury or intra cranial haemorrhage), there should be ability to manage the initial treatment of the patient and know the principles of the specialist treatment.

- Principles of reconstructive surgery for the injured, including treatment of non-union and mal-union of fractures, bone defects, chronic post-traumatic osteomyelitis and delayed treatment of nerve injury.

- The principles of amputation in the injured and the rehabilitation of such patients.

- Principles of soft tissue reconstruction. - Knowledge of literature concerning outcomes of various methods of fracture

management. RECONSTRUCTIVE ORTHOPAEDIC SURGERY 1. SURGERY OF THE SHOULDER AND ELBOW 1.1 Basic sciences - Detailed anatomy of the sternoclavicular, acromioclavicular, glenohumeral and

elbow joints to include the connecting bones, muscles and tendons acting across them, neurovascular supply, bursae and relationships to local structures.

- Surgical approaches: deltopectoral and posterior approaches to glenohumeral joint; transacromial approach to rotator cuff; approach to the acromioclavicular and sternoclavicular joints.

- Structure and function of the above joints; a clear understanding of the static and dynamic stabilisers of the glenohumeral and elbow joints.

- Biomechanics of the shoulder and elbow. - Knowledge of the various types of shoulder and elbow prostheses including the

factors influencing design, wear and loosening to the level of a general orthopaedic textbook.

1.2 Pathology - Sound knowledge of all commonly encountered benign and malignant

conditions affecting the shoulder girdle, elbow and surrounding soft tissues. - A thorough understanding of the pathology of:

- Impingement and rotator cuff disorders - Instability of the shoulder and elbow

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- Inflammatory and degenerative conditions affecting the articular cartilage and synovium

- Infection - Adhesive capsulitis of the shoulder - The pathology of the stiff elbow - Disorders such as ulnar neuritis and tennis elbow

1.3 Clinical assessment - History and examination of the painful, stiff or unstable shoulder or elbow - Knowledge of clinical tests used specifically to assess instability of the

shoulder and elbow, rotator cuff disorders, the stiff shoulder or elbow and the use of local anaesthetic in assessment. Examples are the apprehension tests for shoulder instability, impingement signs and tests, lift off test, Napoleon’s sign, elbow instability tests, ulnar nerve assessment.

- Knowledge of conditions causing referred symptoms to the shoulder and elbow (eg. cervical spine diseases, entrapment neuropathies and thoracic outlet disorders)

- Knowledge to the level of a small specialist textbook of common conditions affecting the shoulder including instability, impingement, rotator cuff tears, adhesive capsulitis, osteoarthritis, rheumatoid disease, avascular necrosis, biceps tendon disorders, fractures of the proximal humerus and clavicle, and disorders of the acromioclavicular and sternoclavicular joints and scapula.

- A similar level of knowledge of disorders affecting the elbow including instability, osteoarthritis, rheumatoid arthritis, causes of stiffness, soft tissue problems such as medial and lateral epicondylitis, neuropathies and fractures around the elbow.

1.4 Investigations - Knowledge of plain radiographs as used to access shoulder and elbow

disorders. This should include a knowledge of those special views (eg. Stryker notch, Neer outlet, cubital tunnel) required to assess adequately the conditions which commonly affect the shoulder and elbow. The ability to recognise correctly normal and abnormal plain radiographs.

- Knowledge of the value of ultrasound, arthrography, CT and MRI as used to assess the shoulder and elbow. An ability to identify straightforward abnormalities on CT and MRI (eg. full thickness rotator cuff tear on MRI, pathological anatomy of fractures around shoulder and elbow using CT).

- Knowledge of the use of arthroscopy of the shoulder and elbow including a knowledge of normal and abnormal findings.

1.5 Treatment - An ability to supervise the non-operative management of fractures, dislocations

and soft tissue injuries around the shoulder and elbow. - A complete knowledge of the management of straightforward fractures and

dislocations of the shoulder girdle and elbow. Knowledge of the treatment options for more complex fractures with an understanding that these might more appropriately be referred to someone with a special interest; examples of these might include four part fractures of the proximal humerus and complex

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intra-articular fractures of the distal humerus. An ability to recognise upper limb injuries involving the brachial plexus.

- A knowledge of injection techniques - Knowledge of both the non-operative and operative treatment of common

disorders such as recurrent anterior traumatic instability of the shoulder, rotator cuff impingement and small rotator cuff tears, adhesive capsulitis, acromioclavicular joint pain

- Knowledge of the management of soft tissue elbow disorders such as lateral and medial epicondylitis and ulnar neuropathy

- Knowledge of the indications, options and complications for prosthetic replacement of the shoulder and elbow.

- Knowledge of the indications and benefits of arthroscopy of the shoulder and elbow.

- Understanding the principles of management of tumours around the shoulder and elbow

2. HAND SURGERY 2.1 Basic Science – Anatomy of: - the wrist/MCP/PIP/DIP joints and CMC joint of the thumb - the flexor and extensor mechanism of the fingers including interaction between

extrinsic and intrinsic mechanism - the postur of the thumb in pinch, power and key grip - the nerve supply to the hand - the closed compartments of forearm and hand - principles of Z-plasty, skin graft and skin flaps 2.2 Pathology - An understanding of the special circumstances associated with swelling and

the effects of rising pressure in a closed compartment secondary to infection and injury

- An understanding of the special circumstances in which oedema causes fibrosis and permanent stiffness

- Tendon injury and healing - Nerve injury and healing - An appreciation of the imbalances and deformities associated with

inflammatory arthritis - A classification system for congenital hand disorders - Hand tumours (eg. ganglion / enchondroma) - Dupuytren’s Disease 2.3 Investigations - Interpretation of plain and stress X-rays of wrist. A Knowledge of other views - Awareness of role of MRI/Bone Scan/Arthrography/Arthroscopy - Place and interpretation of nerve conduction studies

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2.4 Clinical assessment - History and examination of hand and wrist in the assessment of tendons, distal

radioulnar and radiocarpal joints - Ability to elicit median, ulnar and radial nerve function and disorders - Recognition of patterns of presentation of common compressive neuropathies

and brachial neuralgia - Assessment of intrinsic and extrinsic motors in digits and recognition of

common deformities and deficiencies - Awareness of presentation of work-related hand disorders - Ability to examine and assess common rheumatoid hand deformities, eg:

inferior radioulnar subluxation and carpal translocation; MCP subluxation and ulna drift: digital Boutonniere and swan neck; thumb Boutonierre deformity and CMC disease

- Ability to recognise and assess focal hand swellings 2.5 Treatment - Knowledge of closed and operative options of treatment for fractures of distal

radius - Dislocations of carpus - Injuries of ulnar collateral ligament of thumb - Fractures of metacarpals and phalanges - Knowledge of surgical approach to digits with particular regard to the

restoration of function and prevention of stiffness - Knowledge of the principles of treatment for comon flexor and extensor tendon

injuries and of the common surgical approaches to the digital flexor and extensor compartments

- Ability to plan management for finger tip injuries and undertake closed management

- Knowledge of splinting techniques and rehabilitation principles - Ability to manage common hand infections - Familiarity with the surgical treatment of common compressive neuropathy - Familiarity with the surgical management of Dupuytren’s disease - Knowledge of a strategy of management for the rheumatoid hand - Awareness of the principles of tendon transfer and familiarity with simple

transfers, eg. indicis to EPL - Knowledge of the management of ganglia and other hand swellings - Knowledge of the management of stenosing tenovaginitis - Knowledge of levels for digital amputation 3. THE SPINE 3.1 Basic sciences 3.1.1 Anatomy - Development of the spine, spinal cord and nerve roots - Surgical anatomy of the cervical, dorsal and lumbosacral spine - Anterior and posterior surgical approaches to the spine at each level

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3.1.2 Biomechanics - Basic knowledge of the biomechanics of the cervical and lumbosacral spines - An understanding of the biomechanics of spinal instability as applied to trauma,

tumour, infection and spondylolysis/listhesis - Biomechanics of spinal deformity - A knowledge of the basic mechanics of spinal instrumentation 3.2 Pathology - Pathophysiology of the ageing spine and degenerative disc disease - Pathology of the acutely prolapsed cervical and lumbar disc - Acute and chronic infections of the spine - Tumours of the spine - Pathology of spinal deformity - Recognition of patterns of spinal injury and associated cord and nerve root

damage 3.3 Clinical assessment - A thorough knowledge of general and orthopaedic history-taking and

examination - A sound knowledge of clinical assessment of the spine for low back pain,

sciatica, spinal claudication, neck pain, radiating arm pain, spinal injury and incipient myelopathy

- Knowledge of the assessment of spinal deformity - Knowledge of the assessment of spinal tumour - An understanding of the assessment of thoracic pain - A basic knowledge of the assessment of a patient after failed spinal surgery 3.4 Investigation - A thorough knowledge of the basic investigations required in spinal surgery,

specifically: blood tests, plain radiographs, bone scintigraphy, discography, electrophysiological studies (including cord monitoring), CT scanning, MRI scanning and Myelography.

- A thorough knowledge of how each of these investigations contributes to the diagnosis and management of each of the major areas of spinal disease

3.5 Treatment 3.5.1 Non-operative - A knowledge of the non-surgical methods available for the treatment of low

back pain, sciatica, claudication, neck pain, spinal deformity, instability, tumour, infection and fracture to include:

- analgesics and NSAIDs, physiotherapeutic regimes, pain clinic techniques,

bracing, uses of radiotherapy and chemotherapy, non-operative management of spinal injuries

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3.5.2 Operative - A sound knowledge of the indications for and operative surgical management

of the acute prolapsed lumbar intervertebral disc, spinal stenosis, lumbar spinal instability due to spondylolysis/listhesis

- A knowledge of the indications for, and operative surgical management of the acutely prolapsed cervical disc, cervical stenosis, spinal injury and the surgery of spinal infection

- A basic knowledge of the surgery of spinal deformity and tumours of the spine 4. THE HIP 4.1 Basic Science 4.1.1 Anatomy - Basic knowledge of the regional anatomy of the hip including: - development of the hip joint - relationship of bony elements - blood supply of the femoral head - anatomical course of all major regional vessels and nerves - the capsule, labrum and related ligaments - an understanding of the action, anatomy and innervation of the regional

musculature - detailed knowledge of the applied anatomy of common surgical approaches

to the hip (medial, anterior, lateral and posterior) 4.1.2 Biomechanics - An understanding of the lever arms, muscle and body weight forces that

produce the joint reaction force in both normal and abnormal hips - An understanding of the application of these principles to the rationale of both

pelvic and femoral osteotomies, and replacement arthroplasty - Knowledge of the biocompatability and mechanical properties of materials in

common use in total hip arthroplasty 4.2 Pathology - Basic knowledge of the pathology of pyogenic and non-pyogenic arthritis,

slipped upper femoral epiphysis (SUFE), Perthes’ disease and hip dysplasia - Mechanism and pattern of common fractures and fracture dislocations around

the hip (intracapsular, extracapsular, acetabular and periacetabular, femoral head, etc.)

- Knowledge of the pathology of osteoarthritis, rheumatoid arthritis and the seronegative arthritides at the hip and of osteonecrosis of the femoral head

- Familiarity with current theories of the aetiopathogenesis of osteoarthritis - An understanding of the microbiological rationale for the prevention of sepsis

in total hip arthroplasty

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4.3 Investigation - A working knowledge of the interpretation of plain radiographs, dynamic

arthrography, CT, bone scintigraphy and MRI of the hip region - A working classification of proximal femoral and periacetabular fractures.

Also, mechanisms and classification of failure of joint replacement and of periprosthetic fractures

4.4 Clinical assessment - A sound knowledge of clinical assessment of the hip, lumbosacral spine and

knee. Particular reference should be paid to the gait, the Trendellenberg sign, limb length, loss of movement and deformity at the joint

- The trainee needs to be well-informed of current opinion regarding aeteology, pathogenesis, clinical presentation and appropriate investigation of:

- Proximal femoral fractures (intracapsular, extracapsular) and simple fracture dislocations of the hip

- Osteoarthritis and the inflammatory arthropathies - Perthes’ disease - Slipped upper femoral epiphysis - Septic arthritis - Osteonecrosis - Soft tissue conditions around the hip (snapping hip, gluteus medius

tendonitis, etc.) - A working knowledge of the clinical presentations and investigation of: - The sequelae of CDH and Hip dysplasia - The sequelae of SUFE - Juvenile chronic arthritis - Non pyogenic arthritis - The painful total hip replacement 4.5 Treatment 4.5.1 Non-operative - An understanding of the principles of traction, bracing and spica

immobilisation 4.5.2 Operative - A thorough knowledge of soft tissue surgery, osteotomy, arthrodesis and

arthroplasty (excision and replacement). A sound knowledge of anterior, anterolateral, lateral and posterior approaches to the hip and of the complications associated with each

- A sound knowledge of: internal fixation of proximal femoral fractures, hemiarthroplasty for intracapsular fractures, primary total hip replacement for OA and inflammatory arthropathies in the elderly, simple proximal femoral osteotomies. Familiarity with potential complications (i.e. thromboembolism, sepsis, dislocation, etc.) and be aware of current opinion on the prevention and management of these complications

- A knowledge of the indications for, and principles of, complex proximal femoral osteotomies, hip arthroscopy, reconstruction of the hip in young adults (JCA and hip dysplasia, etc.), complex hip revision surgery

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- An appreciation of complex acetabular and pelvic fractures, complex periacetabular osteotomies

5. THE KNEE 5.1 Basic sciences 5.1.1 Anatomy - Knowledge of regional anatomy of the knee, including: - embryology of the knee with particular reference to the patella - surface anatomy - neural and vascular structures and their relations with particular reference to

standard anterior and posterior surgical approaches - bones and joints - functional anatomy of ligaments and supporting muscles - innervation of the knee including controlling musculature - the extent and function of the synovium and bursae of the knee - the structure and function of the menisci, and articular cartilage 5.1.2 Biomechanics - The mechanics of the patello-femoral mechanism - The medial and lateral weight-bearing joints and their inter-relationship - The cruciate and collateral ligaments and other ligamentous and muscular

supports - Menisci and articular cartilage 5.2 Pathology - The mechanism of ligamentous, bony and combined trauma to the knee and

healing potential - A complete knowledge of arthritides, including degenerate wear, ageing

changes and traumatic damage - Pathology of inflammatory disease and infection affecting the knee - The response of synovium to debris - Benign and malignant conditions in the knee and surrounding structures

including recognised classification where appropriate 5.3 Investigations - Indications for and interpretations of: - radiographs – standard and specialised - blood investigation - aspiration - special investigations including CT, MRI and radioisotope scanning - arthroscopy - biomechanical testing 5.4 Clinical assessment - A sound knowledge and understanding of:

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- history and examination of the knee to include relevant surrounding structures

- the standard clinical signs of the knee and relevant adjacent structures and competent skill in describing these

- a critical understanding of rating and outcome measures in common use 5.5 Treatment - A sound working knowledge of conservative and surgical management,

including the indications for referral to a specialist of: - paediatric disorders including deformity, dislocations, epiphyseal disorders,

osteochondritis and discoid meniscus - adolescent disorders including patello femoral and meniscal dysfunction,

osteochondritis dissecans - young adult disorders including patello femoral and meniscal injuries,

instability and ligament deficiency, synovial disorders, benign and malignant tumours

- degenerative and inflammatory arthritis, including a balanced understanding of conservative and surgical options, including osteotomy, arthrodesis and arthroplasty

- traumatic disorders including skin and soft tissue injuries, fractures and dislocations of patella, tibia and femoral components, ligament ruptures and internal derangement of the knee. Conservative and surgical indications and detailed methods of treatment. Outcomes of conservative and operative management

- infections, particularly infections and inflammations of the bursae, intra-articular sepsis, prevention and management of sepsis in implant surgery

- A sound working knowledge of the range or arthroplasties for primary and

revision surgery for patello femoral, unicompartmental and total replacement of the knee with particular reference to secure bone anchorage, alignment, ligament stability and optimising range of movement; a good knowledge of post-operative complicatons, their prophylaxis and management

- A knowledge of the indicatons and techniques of revision surgery particularly for aseptic and septic loosening

- A good knowledge of arthroscopic techniques and access - A knowledge of simple arthroscopic surgery including meniscectomy,

trimming and shaving - An appreciation of complex arthroscopic procedures - An appreciation of medical and surgical techniques available to repair and

replace articular cartilage

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6. ANKLE AND FOOT SURGERY 6.1 Basic sciences 6.1.1 Anatomy - Bones and articulations - Ligamentous structures – ankle/hindfoot/midfoot - Plantar fascia and MTP anatomy - Surface markings of neural and vascular structures - Tendon anatomy - Muscle compartments of the foot 6.1.2 Biomechanics - Function of the lower limb and foot in gait - Ankle and subtalar joint - Plantar fascia mechanisms - Tendon function - Orthoses and footwear 6.2 Pathology 6.2.1 Ar thr itides - Degenerative joint disease - Rheumatoid foot disease 6.2.2 Neuropathy - Neuropathic joint and skin changes 6.2.3 Tumours - e.g. Osteoid osteoma and plantar fibroma 6.3 Investigations 6.3.1 Radiographs - Standard foot and ankle views 6.3.2 CT, MRI and scintigraphy - Knowledge of role of these ancillary investigations in certain specific

conditions e.g. infection, tumour, tibialis posterior rupture, osteonecrosis 6.3.3 EMG - Relevance in foot and ankle disorders 6.4 Clinical Assessment

- History and clinical examination of the foot and ankle in order to assess pain, joint function, deformity, nerve, muscle and tendon function

- Ability to recognise and assess the following diseases of the ankle and foot 6.4.1 Forefoot Disorders

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- Hallux valgus - Hallux rigidus - Lesser toe deformities - Metatarsalgia - Inflammatory arthritis 6.4.2 Ankle and Hindfoot Disorders - Hindfoot pain - Ankle instability - Heel pain - Degenerative disease of the ankle - Rheumatoid arthritis - Osteochondritis dissecans of talus 6.4.3 Complex Foot Deformity - Flatfoot deformity – mobile and rigid - Cavus deformity - Residual congenital foot deformity 6.4.4 Neurological Disorders - Charcot joint - Morton’s neuroma - Nerve entrapment - Neurological foot deformity 6.4.5 Diabetic Foot 6.4.6 Trauma - Evaluation of skin and soft-tissue injury - Compartment syndrome - Recognition of all fractures and dislocations 6.4.7 Tumours - Ability to recognise and assess local foot swellings 6.5 Treatment 6.5.1 Non-operative - Knowledge of rational basis for the use of footwear modifications, orthoses and

total contact casting 6.5.2 Operative - Detailed knowledge of closed and operative methods for management of

fractures and dislocations of ankle, hindfoot and forefoot, including knowledge of surgical approaches to ankle, os calcis, and subtalar joints

- Detailed knowledge of common reconstructive surgical procedures for foot deformity including hallux valgus, lesser toe deformity, acquired flat-foot, to include arthrodesis, osteotomy and soft-tissue reconstruction

- Knowledge of common amputations through foot and ankle

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- Knowledge of common reconstructive surgical procedures for degenerative and inflammatory disorders of ankle and foot including arthrodesis, excision arthroplasty

7. PAEDIATRIC ORTHOPAEDIC SURGERY 7.1 Basic sciences - Detailed knowledge of the growth of bones, physeal anatomy and its

application to fracture types and pathological processes and infection in particular

- Knowledge of the anatomy of bones and joints in the growing child and its application to growth and deformity

- Knowledge of the neurological processes involved in the production of deformity e.g. spina bifida, cerebral palsy and muscular dystrophy

7.2 Clinical assessment - Core knowledge should be at least that of the level of a general orthopaedic

textbook - The trainee must be able to clinically examine a child competently and to relate

effectively with the family - The trainee must be able to make proper management decisions in paediatric

and to refer appropriately for treatment 7.3 Investigations - Knowledge of the indications for plain X-ray, arthrogram, CT, MRI and the

ability to interpret the images - Knowledge of the indications for the use of ultrasound and nuclear imaging - Awareness of the limitations of certain investigations in paediatric practice 7.4 Treatment - A sound knowledge of normal variants e.g. knock knees, bow legs and flat feet - A detailed knowledge of the treatment for: - fractures (including non-accidental injury) and growth plate injuries and

recognise the sequelae - bone and joint infection - common childhood orthopaedic conditions, e.g. irritable hip, anterior knee

pain - A working knowledge of the treatment for: - slipped epiphysis - Perthes’ disease - developmental dysplasia of the hip - clubfeet - scoliosis - simple foot deformities ( e.g. hallux valgus, metatarsus varus) - simple congenital hand abnormalities (e.g. trigger thumb) - osteogenesis imperfecta - skeletal dysplasias - tarsal coalitions

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- torticollis - leg length discrepancy - A knowledge of: - screening services for congenital abnormalities - assessment of physical disability

4. THESIS A research project is a requirement for completion of the M Med degree and must

include a research project where there is: 4.1 A detailed review of literature 4.2 A Hypothesis 4.3 A method of conducting the investigation 4.4 Results 4.5 Discussion 4.6 Final evaluation how the hypothesis was proved / not proved This thesis will be evaluated by both an internal and external examiner and must

be finally past by the post-graduate committee at the Faculty of Health Sciences, Stellenbosch University.

5. A logbook of clinical experience and procedures must be kept. 6. FINAL EXAMINATION The final examination includes the following: 6.1 Two written papers of 3 questions each 6.2 Clinical examination which include: 6.2.1 A long case 6.2.2 Two sets of short cases 6.2.3 An X-ray examination 6.2.4 Plaster examination 6.3 An oral 7. PANEL OF EXAMINATION Prof / Head of Department External examiners Internal examiners

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8. RECOMMENDED BOOKS

* Campbells Operative Orthopaedics * Fractures – Rockwood & Green * Orthopaedic Journals * Shoulder Foot Hip Tumours Paediatrics

LIST OF BOOKS FOR MMED ORTHO PROGRAMME

STUDY GUIDES REFERENCES Principles of Orthopaedic Practice Roger Dee et al ISBN 0-07-016356-1

and Apley’s System of Orthopaedic and Fractures Louis Solomon et al ISBN 0-340-76372-8 ISBN 0-340-76373-6 (Student Edition) The Orthopaedic Physical Examination Bruce Reider et al ISBN 0-7216-7437-2 Differential Diagnosis of Tumors and Tumor-like Lesion of Bones and Joints Adam Greenspan et al ISBN 0-397-51710-6 The Hand Book Ulrich Mennen JL van Schaik Academic

Surgical Techniques : a) Campbell’s Operative Orthopaedics - Edited S Terry ISBN 0-8151-2087-7 b) Surgical Exposures in Orthopaedics: The Anatomic Approach - Stanley Hapenfeld and Piet de Boor → JB Lippencott Company Philadelphia