COVID-19 was first reported in Wuhan, China on 17th November 2019 and since then it has affected 2,76,15,676 people worldwide, with 8,98,426 deaths.1 WHO declared COVID-19 as a public health emergency on 30th Jan 2020 and a global pandemic.2 Pakistan reported its first corona virus infected case on 26th Feb. 2020.3Since then the number of affected people in Pakistan increased exponentially reaching a figure of 2,98,509 confirmed cases on 5th September 2020.4

Background Volkmann’s ischemic contracture (VIC) is a disabling condition of the extremities and is quite common condition. When this condition sets in, the prognosis is almost always guarded, despite vigorous physical therapy and a variety of reconstructive surgeries. This study was done to assess the outcome of Max Page muscle sliding operation in VIC (moderate degree) of the forearm. Materials and methods. A single-center retrospective review of Volkmann’s ischemic contracture patients operated between 2010 and 2018 was carried out at National Orthopedic Hospital Bahawalpur. Thirty three patients were selected meeting the inclusion criteria. The functional outcome (measured as the sensibility score and range of motion) was analyzed pre- and postoperatively. At the end of the study the results were rated as either good, fair or poor. Outcomes. Tight external bandages secondary to radius and ulna fracture was the main cause in majority of patients. Mean time to operation was 10.81 ±2.46 months whereas mean follow up was 13.09 ±7.60 months. By applying t-test, it was found that the improvement in sensibility score and range of motion was statistically significant (P <0.05). Twenty five patients had good functional results and eight had fair results. Postoperatively all the variables had significant improvements. Conclusion. The Max Page muscle sliding operation had good functional outcomes in moderate degree of Volkmann’s ischemic contractures. It is easy and simple procedure. Proper muscle release, neurolysis and good postoperative physiotherapy are important for good functional results.

Aim: To determine the functional and structural outcomes of rotator cuff tears after arthroscopic single row repair with biodegradable suture anchors. Methods: This descriptive study was conducted in Hand & Upper Limb Surgery centre, CMH-Lahore Medical College, Lahore from 3rd January 2016 to 20th August 2019.All patients with rutator cuff tears fulfilling the inclusion criteria were operated arthroscopically with a single row(SR) technique using biodegradable suture anchors. Post operative functional outcomes were assessed at six months follow up with University of California Los Ageles score(UCLA), American Shoulder and Elbow Surgeon score(ASES) and pain assessment with Visual Analogue Scale(VAS).Post operative structural integrity of the rotator cuff was evaluated with ultrasonoghrapic examination. Pearson’s correlation test and Fisher’s exact test were applied to find the significant association between functional outcomes and different demographic variables. P value < 0.05 was considered significant. Results: A total of 40 patients including 36(90%) male and 4(10%) female were included in our study. Mean age at the time of operation was 46.45±13.79 years (range 24-70 years). Right side was involved in 28 (70%) cases and left in 12(30%) patients. Traumatic and degenerative tears were noted in 28(70%) and 12(30%) patients respectively. Mean follow up peroid was 18.1± 6.17 (range 9-31) months. Functional outcomes at final follow up according to UCLA improved from 23.35±7.47 pre operatively to 33.51±1.1 post operatively while ASES score improved from 43.6±4 preoperatively to 70.45±19.87 post operatively.Pre-operative average shoulder pain on VAS was 5.9±0.69 (range 4-8). At last follow up average shoulder pain was 1.95±0.82 range (1-3) with average improvement of 3.95±1.5. Structural integrity on post operative ultrasonoghrapic examination revealed intact rotator cuff in 36 (80%) cases while 8 (20%) cases had re-tear. Conclusion: Arthroscopic single row rotator cuff repair produced excellent functional and structural outcomes and significant pain reduction in majority of our patients. We therefore, recommend this intervention as a suitable treatment option for small to medium size rotator cuff tears.

Objective: To determine the efficacy of reverse fascio-cutaneous sural artery flap in the treatment of heel pad injuries due motorbike spoke-wheel trauma. Methods: This descriptive study was conducted in Department of Orthopedic Surgery and Department of Plastic Surgery Liaquat University of Medical and Health Sciences, Jamshoro, Sindh from 15th October 2017 to 15th December 2019. All adults patients of either gender and age with motorbike spoke-wheel injuries and heel pad defects fulfilling the inclusion criteria were graded and treated as per Zhu and Li classification with reverse sural artery flap and followed up for flap survival and ankle range of motion. Results: A total of 15 patients with motorbike spoke-wheel injuries and heel pad defects were included in our study. Male patients were 12(80%) and female were 3 (20%). Mean age of our patients was 24.4±5.1 years(range 18 to 36 years). Right foot was involved in 13 (86.6%) cases whereas 2 (13.3%) patients had left foot injury. Mean duration from injury to flap coverage was 16 ±4 days(range 5 to 20 days).In majority(86.6%,n=13) of our patients reverse sural artery flap survived while in 2(13.3%) patients partial necrosis was noted. Normal ankle range of motion was regained in 14(93.3%) patients while 1(6.6%) had restricted dorsiflexion. Conclusion: Reverse sural artery flap proved to be a reliable surgical technique for coverage of heel pad wound defects due to motorbike spoke-wheel injuries. We therefore, recommend this flap as a technique of choice to treat heel pad defects due to motorbike spoke-wheel injuries.

Background Volkmann’s ischemic contracture (VIC) is a disabling condition of the extremities and is quite common condition. When this condition sets in, the prognosis is almost always guarded, despite vigorous physical therapy and a variety of reconstructive surgeries. This study was done to assess the outcome of Max Page muscle sliding operation in VIC (moderate degree) of the forearm. Materials and methods. A single-center retrospective review of Volkmann’s ischemic contracture patients operated between 2010 and 2018 was carried out at National Orthopedic Hospital Bahawalpur. Thirty three patients were selected meeting the inclusion criteria. The functional outcome (measured as the sensibility score and range of motion) was analyzed pre- and postoperatively. At the end of the study the results were rated as either good, fair or poor. Outcomes. Tight external bandages secondary to radius and ulna fracture was the main cause in majority of patients. Mean time to operation was 10.81 ±2.46 months whereas mean follow up was 13.09 ±7.60 months. By applying t-test, it was found that the improvement in sensibility score and range of motion was statistically significant (P <0.05). Twenty five patients had good functional results and eight had fair results. Postoperatively all the variables had significant improvements. Conclusion. The Max Page muscle sliding operation had good functional outcomes in moderate degree of Volkmann’s ischemic contractures. It is easy and simple procedure. Proper muscle release, neurolysis and good postoperative physiotherapy are important for good functional results.

Objective: To compare the results of closed interlocking nail shaft of femur versus open interlocking nail in terms of union, non-union and infection rate. Methods: We conducted this retrospective Cohort study in Department of Orthopedics Jinnah Medical College Hospital Karachi and Dow University Hospital- Ojha Campus Karachi. The medical record of all patients meeting the inclusion criteria and operated for interlocking nails(closed/open) shaft of femur in the time period extending from 23rd February 2018 to 3rd March 2019 were included in our study. The demographic details, radiographs, operative notes and follow up records of both groups were noted. The post-operative results of union, non-union and infection at final evaluation at one year were compared in both groups. Chi square test was applied and P value calculated. P value < 0.05 was considered significant. Results: The medical record of 116 patients with mean age 31.1±8 were examined. Closed interlocking nail (group A) was done in 62 patients with mean age 31.1±7.9 years(range 20 to 55 years) while fracture site was opened(group B) in 54 patients with mean age 31.2±8.2years(range 19 to 57 years. The average time of radiological union was 20.5 ±3 weeks in closed versus 26.3±6 weeks in open nailing( P value <0.05).The rate of union in group A was 95.1%(n=59) and 77.7%(n=42) in group B.(P <0.05) Delayed union was documented in 6(9.6%) patients in group A and 14(25.9%) in group B(P<0.05).Non-union was noted in 03(4.8%) patients in group A and 12(22.2%) patients in group B. Superficial infection was noted in 4(6.4%) in group A and 13(24%) patients in group B.(P <0.05) Conclusion: Closed interlocking nail for fracture shaft of femur resulted in earlier union, better union rates and less infection rate than open interlocking nail. Every effort must be made to avoid opening fracture side in interlocking nail femur.

Objective: To determine the effectiveness and safety of “Lobenhoffer approach” for treating large posteromedial tibial fractures of the proximal tibia. Methods: The descriptive study was carried out from 23rd January 2017 to 25th December 2019 at Qaisrani Medical Center (QMC) Multan. All patients of proximal tibia fractures having a large posteromedial plateau fragment alone or in combination with bicondylar fractures (Hohl and Moore type I /Schatzker type IV) fulfilling the inclusion criteria were operated with Lobenhoffer approach. Fracture reduction was confirmed by per-op visualization with image intensifier and post operatively with radiographs. The radiological reduction was anatomical if fracture was accurately reduced without any step and non anatomical if step was noted(? 2mm).The patients were followed up for one year and radiological evaluation, functional assessment and any potential complication was documented. Comparison of important outcome variables were made and P value was calculated with the help of Chi square test (P value < 0.05 was considered significant) Results: A total of 15 patients were included in our study. The mean age was 36.73± 10.9 years (range 18 to 56 years). Posteromedial and bicondylar fracture was present in 12(80%) patients while 3(20%) patients had isolated posteromedial fracture. Immediate post operative radiographs revealed anatomical reduction in 12(80%) and non anatomical reduction in 03(20%) patients (P >0.05). No per operative or immediate post operative complication was noted. Union was achieved in all patients. Majority(73.3%,n=11) patients achieved full range of knee motion, only 1(6.6% ) patient had extension lag of 10 degrees( P < 0.05 ). Grade II osteoarthritis was noted in 2(13.3%) patients(P >0.05). Conclusion: Accurate anatomical reduction and excellent functional outcome can be achieved by fixing posteromedial tibial fractures through Lobenhoffer approach in lateral decubitus position. It is a safe approach and has no major per operative or post operative complications. We recommend this approach for all proximal tibial fractures with posteromedial fragment.

Objective: To determine the functional outcome of open reduction and internal fixation (ORIF) of intra-articular distal humerus fractures treated with Bryan Morrey approach. Methods: This descriptive was conducted in Department of Orthopaedics Abbasi Shaheed Hospital Karachi from 1st January 2018 to 31st December 2019. All patients with intra-articular distal humerus fractures fulfilling the inclusion criteria were included. Open reduction and internal fixation was carried out in all patients using Bryan-Morrey approach. Functional outcome was assessed with Mayo Elbow Performance Index(MEPI) at the end of one year and graded as excellent (MEPI score 90 to 100 points),good(75-89),fair(60-74) and poor(<60).Stratification of data based upon age, gender, type of fracture and time since fixation was done and post stratification comparison of functional outcome was done.Chi square test was applied and P value calculated( P value < 0.05 was considered significant) Results: We operated 35 patients of intra-articular distal humerus fracture with Bryan Moorey approach. Male patients were 23(65.8%) and female 12(34.3%). Mean age was 43.8±13.31(range 20 to 65) years. Right humerus was fractured in 21(60%), left in 10(28.6%) and bilateral in 4(11.4%). AO 31C1 fractures were noted in 10(28.6%) patients,31C2 in 15(42.9%) and 31C3 in 10(28.6%) patients. Excellent functional outcome was observed in 13 (37.1%) patients, good in 14 (40%), fair in 6 (17.1%) and poor in 2 (5.7%) patients. No statistically significant difference was found in functional outcome of male and female patients, different types of fractures and age below 40 years versus above 40 years(P value >0.05).However fractures fixed within 4 days of sustaining fractures showed better functional outcome than those fixed late(P value <0.05).No major complication reported. Conclusion: Excellent and good functional outcomes were achieved in majority of our patients of intra-articular distal humerus fractures fixed with Bryan-Morrey approach. We therefore recommend Bryan-Morrey approach as a technique of first choice for all intra-articular distal humerus fractures.

Introduction The pre-operative use of MRI to identify occult intraspinal anomalies before surgical correction of paediatric spinal deformity contributes widely accepted best practice recommendations. However due to economic and resource constraints these recommendations are not universally implemented in many health-care settings. Study was conducted to document the frequency and types of encephalomyelonic Axis Anomalies found in a consecutive cohort of paediatric and young adult patients undergoing spinal deformity surgery with the aim of consolidating the case for pre-operative MRI imaging of all surgical patients. Methods Departmental prospective database used to identify consecutive paediatric and young adult patients undergoing scoliosis correction between January 2015 and December 2018 at a tertiary spine referral center in Pakistan. Data collected on clinical and MRI findings. Clinical data included age, sex, scoliosis type (idiopathic, congenital, neuromuscular & syndromic) and presence of abnormal neurological findings. MRI data included presence and type of neural axis abnormalities (NAA). Results 87 patients were included having the diagnosis of idiopathic and congenital scoliosis, and from these patients, 33.3% (n =29) were male, and the majority were female patients as 66.7% (n=58) diagnosed with a different type of scoliosis (Idiopathic or congenital) with an average age of 13.7±3.87 ranged from (4-27) years. Idiopathic and congenital scoliosis were found as 56 ( 64.4% ) and 31 (35.6 % ) respectively. Considering divergent anomlies , Diastomyelia was documented in 4 (04.59 %) .likewise ,Tethered Cord in 2 ( 2.29 % ) patients , 10 ( 11.49 % ) of patients had Syringomyelia and Chiari Malformations was noticed in 2 ( 2.29 % ) patients. Lipoma and diplomyelia was not screened in single patient. However, 2 (2.29% ) was having dural fault, conus 9 ( 10.34 % ) and 1 (1.15% ) foramen magnum compression. When rare anomalies were viewed ,Hydromyelia was detected in 3 (3.44 % ), tonsillar ectopia in 2 (2.29% ) and OS Odontoideum in 1(1.14% ).Moreover,only 5 (5.74% ) of patients having neurology involved while other were having intact neurology. Conclusion ;Patients with scoliosis having discrete anamolies that can be missed on clinical examination and X-rays. Pre operative Magnetic Resonance Imaging has vital role to identify these peculiar abnormalities in these patients before considering any surgical intervention.

Pakistan reported its first confirmed case of the novel coronavirus on 26th February, 2020.1 After the initial outbreak, the virus began to engulf the entire nation. Up till 25th of August, 2020

Objective: To determine the frequency of intra operative anatomical variations in patients undergoing surgical release for de Quervain’s disease. Methods: We conducted this descriptive study in Department of Orthopaedics and spine surgery Khyber Girls Medical College/Hayatabad Medical Complex Peshawar from 21st January 2017 to 24th December 2019.All patients of de Quervain’s disease fulfilling the inclusion criteria were surgically released under local anaesthesia. The frequency of intra operative anatomical variations of Abductor Pollicis Longus(APL) and Extensor Pollicis Brevis(EPB) were noted and classified according to the Hiranuma classification. Results: We enrolled 80 patients (86 wrists) in our study. The mean age was 41years(range 25 to 75 years).Female patients were 71(88.7%) and male patients were only 9(11.2%).Majority(88.7%,n=71) of patients had right sided de Quervain’s disease while left sided was involved in 3(3.7%) patients and 6(7.5%) patients had bilateral de Quervain’s disease. Hiranuma Type II was the predominant anatomical variation noted in 53(61.6%) wrists followed by type I(26.7%,n=23).Majority(91.8%,n=79) of wrists had 1 APL tendon followed by 2 APL tendons in 4(4.6%) and 3 tendons in 3(3.4%) wrists. The number of EPB was 1 in 82(95.3%) wrists,2 in 1(1.1%) and absent EPB in 03(3.4%) wrists. Conclusion: Majority of our patients had APL and EPB in separate compartments with complete septation and had single APL and EPB tendon in each compartment. On the contrary the traditional or classical presentation of APL and EPB lying side by side in a single compartment was noted in less number of patients.

Fibrous dysplasia is a rare developmental abnormality of bone formation. The clinical presentation varies from asymptomatic disease to gross deformity and disability. Proximal femur bowing and coxa vara(Shepherd’s Crook deformity) is frequently noted in polyostotic fibrous dysplasia. For treating Shepherd’s Crook deformity but We treated our patient in a single stage surgery with valgus osteotomy, fibular strut grafting and proximal femur locking plate. At one year follow up she had excellent functional outcome. Our case report highlighted three important principles of managing fibrous dysplasia with pathological fracture neck of femur. Firstly, fixation of the fracture and accelerating bone healing with a fibular strut graft. Secondly, simultaneous restoration of the mechanical axis by correcting the deformity with valgus osteotomy. Thirdly, total hip replacement will be technically easy without needing further corrective surgery if the patient subsequently develops osteoarthritis or avascular necrosis of the femur head in future.

Objective: To determine the frequency of musculoskeletal pain among hospital cleaning workers in tertiary care hospitals of Lahore. Methods: This cross-sectional study was conducted in University of Lahore Teaching Hospital and Services Hospital Lahore from 3rd Septemberer 2019 to 22nd February 2020. Hospital cleaning workers of either gender and all ages fulfilling the inclusion criteria were interviewed face to fac for musculoskeletal pain complaints.The data were collected using Nordic Questionnaire and analyzed through descriptive and analytical statistics.Frequency of musculoskeletal pain in workers with normal body mass index(BMI) and those with increased BMI was compared and P value was calculated with Chi-square test(P value <0.05 was considered significant). Results:We interviewed 130 hospital cleaning workers. There were 73 (56.2%) females and 57 (43.8%) males. The mean age was 38±11.7 years.Majority(80.8%,n=105) of the hospital cleaning workers had musculoskeletal pain while only 25(19.2%) had no pain. The pain was moderate in intensity 59 (45.3%) and sever in 46 (35.4%) workers. Low backach was reported in 31 (23.8%) workers,knee pain in 15(11.5%) and neck and shoulder pain in 14(10.7%) workers. Majority(53.8%,n=70) of cleaning workers did not missed their duty during the previous week inspite of musculoskeletal pain.The frequency of musculoskeletal pain was more in overweight and obese workers than normal weight workers.(P value 0.001) Conclusion:The frequency of musculoskeletal pain among hospital cleaning workers was very high.Overweight and obese workers were more prone to had musculoskeletal pain.

Objective: To determine the safety of pedicle screw fixation of the spine by free hand technique in terms of screw malposition and screw related post-operative complications. Methods: This descriptive study was conducted in Orthopedic department Lady Reading Hospital Peshawar Pakistan from 23rd April 2017 to 23rd March 2020.Patients of either gender and age operated with pedicle screw fixation of the spine by free hand technique using universal entry point were included. Post-operative radiographs of the spine were utilized for screw position. Patients with malposition radiographic screws and those with screw related post-operative complications were screened with CT scan of the spine. CT based position of the pedicle screw was classified as per Zhang classification as type 0 (good), type 1 (Acceptable), type 2 (Unacceptable) and type 3 (Grievous). Revision surgery was performed for symptomatic pedicle screws and type 2 and type 3 malposition screws. Results: The total number of patients enrolled in our study were 96. Mean age was 34.20±9 years (range 10 to 70 years). Male patients were 45(46.9%) and female 51(53.1%). Total number of screws were 717 with maximum number of screws (n=425, 59.27%) in lumbar spine followed by thoracic spine (n=250, 34.87%) and sacral spine (n=42, 5.86%). Radiologically 684(95.40%) screws were within the pedicles and patients were without any symptoms while 33(4.6%) screws were malposition. CT scan classified 29(4.0%) malposition screws as type 1 but the patients were asymptomatic. Only 3(0.4%) screws in two patients were symptomatic type 2 and revision was done. No screw related vascular or visceral complication was reported. Conclusion: Free hand technique of pedicle screw fixation using universal entry point is a safe and reliable method in the absence of advance navigation system. Thorough knowledge of the spine, anatomy of the vertebrae and surgeon’s experience are however mandatory for safe placement of pedicle screw with free hand technique.

Intramedullary nailing of long bone fractures have been associated with fat embolism and thermal necrosis due to reaming.1,2 An attempt to reduce the incidence of these complications Reamer-Irrigation-Aspiration(RIA) system was developed (Synthes, Paoli, PA, USA).This innovative system provides simultaneous continuous irrigation and suction while reaming long bones. The marrow contents, bone fragments and irrigation fluid is passed through a filter first and then into a suction bag. The second generation RIA system was launched in 2019 (Fig. I). It has new design for easy handling, small reamer head size of 10 mm (first generation RIA system has 12 mm reamer head size) and has larger holes for improved irrigation and suction. The design and characteristics of this reamer are different from standard reamer and detailed guidelines of RIA technique and usage has already been established.3 The purpose of this editorial is to update the Orthopaedic community of Pakistan about the expanded indications, safety and efficacy of RIA system. The indications of RIA have been expanded recently. It has been used for treating post operative osteomyelitis,4 non unions of long bone 5-9 and for obtaining mesenchymal stem cells.10 Zalavras4 treated 8 tibial osteomyelitis and 3 femur osteomyelitis with debridement of the medullary canals utilizing RIA system and reported no infection at six months follow up.

Objective: The determine the functional outcome of custom-built fixed hinged prosthesis for tumors around the knee. Methods: This descriptive study was conducted in Department of Orthopedics & Spine Surgery Ghurki Trust Teaching Hospital Lahore from 3rd January 2015 to 3rd January 2021.All adults patients of either gender and age with tumours of distal femur,proximal tibia or both fulfilling the inclusion criteria were operated for custom-built fixed hinged prosthesis.Post operative functional outcome was determined using Musculoskeletal Tumor Society(MSTS) system and results were graded as excellent(75-100%), moderate (70-74%), Good (60-69%), Fair(50-59%) and Poor (<50%) outcome.Functional outcome was compared for type of tumor,gender and site of tumour and P value calculated with simple Pearson Chi-Square test.P value<0.05 was considered significant. Results: A total of 34 patients were included in our study.The mean age was 30.65±14.23 years.Male patients were 23(67.6%) and female 11(32.4%). Osteosarcoma was present in 25(73.5%) patients,Giant cell tumour in 5(14.7%) and Ewing Sarcoma in 4(11.8%). Tumor involvement of the distal femur was present in 25(73.5%), proximal tibia in 7(20.6%) and both femur and tibia in 2(5.9%) patients. The mean Musculoskeletal Tumor Society(MSTS) score at 2.5 years was 73%(range 34% to 95%).Excellent functional outcome was noted in 22(64.7%), moderate in 2(5.9%),good in 7(20.6%), fair in 1(2.9%) and poor in 1(2.5%). No significant difference was noted when functional outcome was compared for gender,type of tumour,stage of tumor,location of tumor, side of tumor and type of stem fixation (P>0.05).

Objective: To determine the effectiveness and safety of Prakash method of shoulder reduction in patients of anterior shoulder dislocation presenting to the emergency department. Methods: This cross-sectional study was conducted in the emergency department of Al Qassimi Hospital Sharjah, United Arab Emirates, from 3rd July 2018 to 3rd July 2020. All patients with anterior shoulder dislocation meeting the inclusion criteria were managed using Prakash technique. Outcome was determined in terms of successful reduction and documentation of any technique related complications. Results: A total of 100 patients with mean age 32.5?±?8.3 years were included in this study. Males were 72(72%) and female 28(28%).Majority(96%,n=96) of the shoulders were successfully reduced with Prakash method. No complication related to the technique was noted. Conclusion: Prakash method of shoulder reduction had a high success rate and without any complication. We recommend this procedure as a technique of choice to reduce anterior shoulder dislocations presenting to the emergency department.

Objective: To determine the severity and pattern of bony injuries among the victims of motor bike motorbike accidents presented to the Accident and Emergency Department of Dr. Ruth K.M Pfau Civil Hospital Karachi. Methods: This descriptive study was conducted in Dr. Ruth K.M Pfau Civil Hospital Karachi from 12th January 2019 to 12th January 2020. All adult patients of motorbike accidents with extremity fractures fulfilling the inclusion criteria were included in this study. In the included subjects the locations of fracture or dislocation and whether closed or open were noted. Results: The total number of patients were 380 with mean age of 28.67 ± 12.07 years. Lower extremity fractures were noted in 273(71.8%) patients and upper extremity in 107(28.1%) patients. Tibia fibula was the commonest lower limb fracture documented in 157(41.3%) patients while radius was the commonly fractured upper limb bone in 46(12.1%) patients. Majority (75.2%, n=286) of the fractures were closed while open fractures were seen in 94(24.7%) patients. Conclusion: Victims of motorbike accidents sustained variable bony injuries. Majority of these fractures were closed. Tibia fibula was the commonest bone fractured.

Objective: To determine the frequency of Achilles tenotomy in patients with Congenital Talipes Equinovarus (CTEV) treated with Ponseti serial castings. Methods: This descriptive study was conducted in department of Orthopedic Surgery Khyber Teaching Hospital Peshawar from 12th September 2019 to 12th December 2020. All children of CTEV who were treated with Ponseti serial castings and fulfilled our inclusion criteria were enrolled in this study. Achilles tenotomy was performed at the end of casting in those children who had corrected cavus, varus with head of talus covered and with Pirani Equinus score of 1 or 0.5. The frequency of tenotomy was noted. Important variables of children with tenotomy were stratified and post stratification Chi-square test was applied to calculate P value. P value< 0.05 was considered significant. Results: We treated 86 feet in 69 children with Ponsti serial castings. Majority (75.36%,n=52) of children had unilateral club foot deformity while 17(24.63%) had bilateral deformity. Male children were 41(59.42%) while 28(40.57%). The mean age at the time of Achilles tenotomy was 10.3+0.28 weeks. The initial Pirani score was 3+0.74 and final Pirani score was 1+0.74. Correction was achieved in 5+0.84 castings. Achilles tenotomy was done in 57 (66.27%) feet to correct the equinus deformity before application of final cast. Conclusion: The frequency of Achilles tenotomy after Ponesti serial casting was high as more than half our children had persistent equinus deformity.

Objective: To determine the outcome of Spinal Accessary nerve to Suprascapular nerve and motor branch of Radial nerve transfer to the Axillary nerve for restoration of shoulder abduction and external rotation in patients with C5-C6 brachial plexus injury. Methods: We conducted this descriptive study in National Orthopedics Hospital Bahawalpur. The study period extended from 12th June 2015 to 12th December 2020.All patients with C5-C6 injury fulfilling the inclusion criteria were operated with Spinal Accessary nerve to Suprascapular nerve and motor branch of Radial nerve transfer to the Axillary nerve. Post operative functional assessment was done by measuring shoulder abduction, external rotation and strength of abduction. Results: The total number of patients in this study were 14. Male patients were 13(92.85% ) and female 1(7.14%).The mean age was 29.2±7 years. Right shoulder was affected in 9(64.28%) patients and left in 5(35.7%). The mean follow up period was 24.2±3.3 months. The shoulder abduction improved from pre operative 0 o to 97.8o±4o while external rotation from 0 o to 30 o± 5o postoperatively. The abduction muscle strength as per Medical Research Council (MRC) scale was M4 in 9(64.28%) and M3 in 3(21.42%) patients. Conclusion: Satisfactory shoulder abduction with adequate muscle strength and external rotation was achieved in majority of our patients of C5-C6 brachial plexus injury treated with dual nerve transfer,This transfer utilized Spinal Accessary nerve to Suprascapular nerve and motor branch of Radial nerve to the Axillary nerve.

Objective: To compare the functional outcome of paediatric supracondylar fractures of the humerus treated with closed reduction and percutaneous(CRP) K wire fixation versus open reduction(OR) and K wire fixation. Methods: The design of our study was retrospective Cohort and was conducted in Department of Orthopaedics Civil Hospital Karachi. The medical record of all the children who were operated in the time period of 8th March 2019 to 07th September 2020 for type III distal humerus fractures were reviewed. All the children fulfilling the inclusion criteria were called for follow up. Patients were divided into group A(CRP crossed K wire fixation) and group B(OR crossed K wire fixation through posterior midline incision with triceps sparing approach). Functional outcome in both groups was evaluated with Flynn’s criteria and graded as Excellent, Good, Fair(satisfactory) and Poor(unsatisfactory).The results of both group A and B were compared and statistical significance documented by calculating P value with Chi-Square test(P <0.05 significant). Results: The total number of children were 60 and divided equally into Group A(n=30) and Group B(n=30).The mean age of group A was 6±1.1 years and group B 6.9 ± 3.83 years. Male children were 21(70%) in Group A and 18(60%) in group B while female children were 9(30%) and 12(40%) in Group A and Group B respectively.in Group A children results were excellent in 21(70%) and good in 9(30% ) children. In group B excellent results were noted in 9(30% ),good in 08(26.6%), fair in 6(20%) and poor in 7(23.3% )children. The difference among the excellent, fair and poor outcome of the two groups was found significant( P Value < 0.05) Conclusion: CRP K wire fixation of supracondylar fractures of the humerus was better than OR K wire fixation because it yielded excellent and good outcome in most patients

Objective: To determine the functional outcome of arthroscopic anterior cruciate ligament reconstruction (ACLR) using hamstring tendon as autograft and endobutton followed by supervised physiotherapy. Methods: This descriptive study was conducted in AO hospital Karachi from 2nd April 2017 to 2nd December 2020. All patients with Anterior Cruciate Ligament (ACL) tear meeting the inclusion criteria were operated arthroscopically for anterior cruciate ligament reconstruction (ACLR) using hamstring tendon as autograft and endobutton followed by 6 weeks supervised physiotherapy. The functional outcome was assessed with knee range of motion, Tegner-Lysholm score and International Knee Documentation Committee (IKDC) at 3rd, 6th and 12th months follow up and compared with pre-operative values. P value was calculated with Chi-square test for statistical significance. P value < 0.05 was considered significant. Results: The total number of patients in our study were 79. The mean age was 25±3 years (range 18 to 40 years).Full range of knee motion (118±60) was achieved in 75(95%) patients. The mean pre-operative IKDC score of 38.95±5 improved to 67.92±2 at 6th months and to 90.73±7 at 12th months follow up. The mean pre-operative Tegner-Lysholm score of 51(poor) improved to 87(good) at 6th months and 97(excellent) at 12th months. The Lachman’s test and pivot shift test was negative in all patients postoperatively and 56(70.8%) patients could performed single legged hopping test without any difficulty at 6th months post operatively. Conclusion: Anterior Cruciate Ligament Reconstruction (ACLR) using hamstring tendon autograft with endobutton fixation and supervised rehabilitation yielded excellent functional outcomes in majority of our patients. We therefore recommend this protocol as treatment of choice for all patients with ACL tear.

Objective: To compare the radiological and functional outcome of stable intertrochanteric femur fractures treated with Dynamic Hip Screw(DHS) and Proximal Femoral Nail(PFN). Methods: This randomized controlled trial was conducted in Department of Orthopaedics Pakistan Railway General Hospital Rawalpindi from 20th March 2018 and 19th March 2020. All patients with stable intertrochanteric fractures fulfilling the inclusion criteria were randomly allocated to group A(DHS) and B(PFN). Patients were reviewed radiologically for healing and functional assessment was done with Harris Hip Score(HHS) and graded as poor(score <70),fair( 70 to 80),good( 80 to 90) and excellent(90 to 100). Comparison of outcomes in both groups were done at 3rd,6th and 12th month and P value was calculated with independent sample t test and Chi-square test. P<0.05 was considered significant. Results: The total number of patients were 60.They were equally and randomly divided into group A and B with 30 patients in each. The mean age of group A was 59.20±5.94 years and group B was 58.80±6.67 years. Male patients were 19( 63.33% ) in group A and 17( 56.66%) in group B. Female patients were 11(36.66%) in group A and 13(43.33% ) in group B. The mean radiological union time in group A was 13.4±3 weeks while in group B 13.5±5 weeks(P>0.05). The Harris Hip Score(HHS) at 3 months follow up was 53.50±3.91(poor) and 34.93±3.98(poor) in group A and B respectively.(P< 0.05) At 6 months group A had HHS 89.37±4.03(good) and B 81.87±4.10.( P< 0.05)At one year HHS was 93.73±1.99(excellent) and 92.57±2.30(excellent) in group A and B.( P>0.05). Conclusion: For stable intertrochanteric fractures both DHS and PFN yielded similar outcome in terms of radiological union. The short term functional outcome of both DHS and PFN at 3rd and 6th was poor and good but DHS had statistically better score than PFN.At one year follow up both DHS and PFN had similar excellent functional outcome but without any statistically significant difference in the score.

Objective: To determine the outcome of Spinal Accessary nerve to Suprascapular nerve and motor branch of Radial nerve transfer to the Axillary nerve for restoration of shoulder abduction and external rotation in patients with C5-C6 brachial plexus injury. Methods: We conducted this descriptive study in National Orthopedics Hospital Bahawalpur. The study period extended from 12th June 2015 to 12th December 2020.All patients with C5-C6 injury fulfilling the inclusion criteria were operated with Spinal Accessary nerve to Suprascapular nerve and motor branch of Radial nerve transfer to the Axillary nerve. Post operative functional assessment was done by measuring shoulder abduction, external rotation and strength of abduction. Results: The total number of patients in this study were 14. Male patients were 13(92.85% ) and female 1(7.14%).The mean age was 29.2±7 years. Right shoulder was affected in 9(64.28%) patients and left in 5(35.7%). The mean follow up period was 24.2±3.3 months. The shoulder abduction improved from pre operative 0 o to 97.8o±4o while external rotation from 0 o to 30 o± 5o postoperatively. The abduction muscle strength as per Medical Research Council (MRC) scale was M4 in 9(64.28%) and M3 in 3(21.42%) patients. Conclusion: Satisfactory shoulder abduction with adequate muscle strength and external rotation was achieved in majority of our patients of C5-C6 brachial plexus injury treated with dual nerve transfer,This transfer utilized Spinal Accessary nerve to Suprascapular nerve and motor branch of Radial nerve to the Axillary nerve. REFERENCES

Objective: To compare the clinical and radiological outcomes of freehand patellar resection technique versus cutting guide technique in primary total knee arthroplasty. Methods: This randomized controlled trial was conducted in the Institute of Orthopaedics and Surgery Karachi from 1st February 2019 to 1st July 2020. All patients with primary total knee arthroplasty (TKA) fulfilling the inclusion criteria were divided randomly into patellar resection with freehand technique(group A) and cutting guide technique(group B).The post operative clinical and radiological parameters were compared in both groups and P value was calculated with Chi-square test for statistical significance. P value< 0.05 was considered significant. Results: The total number of patients in our study were 114 divided equally into group A and group B with 57 patients each. In group A male patients were 24(42, 1%) and female 33(57.8%). In group B male patients were 21(36.8%) and female 36(63.1%).The mean age of group A patients was 57.00 ± 5.60 and group B 57.65 ± 5.55 years. Post operatively slightly lesser frequency of patients had positive patellar glide test, patellar grind test, patellar edge tenderness and anterior knee pain in group A than in group B(P>0.05). No statistically significant difference in the mean values of lateral patellar tilt(LPT), lateral patellar displacement(LPD), Insall-Salvati (IS) index and hip knee ankle(HKA) angle and their outliers in both the groups were noted.(P>0.05). Conclusion: Identical clinical and radiological results were achieved by both free hand patellar resection technique and cutting guide technique. Freehand patellar resection technique however had slightly lower but not significant positive patellofemoral tests and anterior knee pain than cutting guide technique.

Objective: To determine the functional results of distal tibia metaphyseal fractures treated with modified (shortened) interlocking nail and K wire fixation of the fibula. Methods: This descriptive study was conducted in Trimax Hospital Karachi from 20th June 2017 to 20th June 2020. All adults patients with distal tibia (5cm) and fibula (?10cm) meeting the inclusion criteria were operated with modified (distal one centimeter of the standard nail was cut) interlocking nail in the tibia and K wire in the fibula. Functional results were assessed at 6th month with the American Orthopaedic Foot & Ankle Society (AOFAS) questionnaire score and graded as excellent, good, fair and poor. Comparison of AOFAS scores in both gender, sides and fracture types was done and P value was calculated for statistical significance. P < 0.05 was considered significant. Results: The total number of patients in our study were 60. The mean age of our patients was 33±11.5 years. Male patients were 51(85%) and female 9(15%).Right tibia fibula was fractured in 49(81.6%) and left in 11(18.3%). The average union time was 15±4 weeks (range 13 to 18 weeks) As per AOFAS questionnaire score 36(60%) patients had excellent outcome,13 (21.6%) good and 11(18.3%) had fair outcome. No significant difference was found in AOFAS scores with regard to gender, sides and type of fractures (P>0.05). Conclusion: Majority of the patients treated with modified (shortened) interlocking nail tibia and K wire fixation fibula achieved excellent and good functional outcome. We therefore recommend this treatment protocol for all patients with distal tibia and fibula fractures.

Objective: To determine the outcome of percutaneous endoscopic interlaminar lumbar discectomy for prolapsed intervertebral disc in terms of pain reduction and functional disability. Methods: This descriptive study was conducted in Department of Orthopaedics & Spine Surgery Hayat Abad medical complex Peshawar from 3rd October 2018 to 3rd December 2020.All patients with lumbar disc prolapse fulfilling the inclusion criteria were operated with percutaneous full endoscopic interlaminar lumbar discectomy. Post operative back pain and leg pain was assessed with Visual Analogue Scale(VAS) and functional disability with Oswestry Disability Index (ODI) questionnaire at 2nd week,3rd month and 6th months. Preoperative VAS and ODI was compared with post operative VAS and ODI and P value was calculated with independent-sample t test for statistical significance. P value <0.05 was considered significant. Results: A total of 50 patients including 31 (62%) males and 19 (38%) females with a mean age of 37.10±7.95 years were included in this study. The VAS for back pain and leg pain improved from pre operative 4.68±2.01 and 7.44±1.47 to 0.90±1.61 and 0.74±1.30 respectively at 6th months follow up(P <0.05). The mean ODI score improved from pre operative 34.4±7 36±4 to 5.3±2 post operative at 6th month( P < 0.05). Conclusion: Percutaneous endoscopic lumbar discectomy for prolapsed intervertebral disc is an effective alternative to open discectomy as it resulted in significant pain reduction and minimum functional disability in our patients.

Objective: To determine the pattern of motorbike spoke wheel injuries in terms of severity and location in children presenting to the Accident and Emergency Department of our hospital. Methods: We conducted this descriptive study in Accident and Emergency Department Liaquat University Hospital Hyderabad from 23rd January 2018 to 23rd January 2021.All children with motorbike spoke wheel injuries fulfilling the inclusion criteria were enrolled in this study. The location and severity of injury was noted and classified as per Tscherne and Oestern classification from grade 0 to grade III. Results: The total number of children in our study were 150.The mean age was 8.4±7.1 years. Male children were 111(74%) and female 39(26%).Right foot was injured in 103(68.66%) and left in 47(31.33%).Grade II injury was documented in 56(37.33%), grade I in 44(29.33%), grade III in 27(18%) and grade 0 in 23(15.33%) children. Heel pad was the commonest area injured in 82(54.66%) children. Tendon ruptures were seen in 14(9.33%) children. Fractures were noted in 12(8%) children. Neurovascular injury was noted in 1(0.66%) child. Conclusion: Motorbike spoke wheel injury had variable pattern of tissue damage and fractures. Most of the children had major soft tissue loss. Heel pad was the commonest injured area. Calcaneus and phalanges fractures were the commonest.

Musculoskeletal injuries constitute a large proportion of global burden of trauma. Lack of proper treatment of musculoskeletal trauma results in disability and morbidity.1 In developing countries patients with musculoskeletal trauma usually do not present to hospital on time due to lack of transportation, poverty and ignorance. Furthermore many government hospitals do not have adequate infrastructure and trained staff resulting in delayed diagnosis or suboptimal treatment of these injuries. 2 Due to high influx of patients and constrained resources in state-owned hospitals of our country patients had to wait for their turn for surgery which cause frustration and anger amongst these patients and most of them leave hospital without definitive treatment and unfortunately do not get effective alternative treatment outside. Poverty and superstitious believes are a contributing factor for consulting bonesetters and improper treatment.3 Neglected musculoskeletal injuries are thus untreated injuries due to one or other reasons. In developed countries neglected musculoskeletal injuries are less frequent except missed injuries of the hip and spine reported in some polytrauma patients. Whereas in India 29% patients with fractures and dislocation in a teaching hospital had 50% neglected musculoskeletal injuries.4

Objectives: To compare the radiological and functional outcomes of lateral, medial and posterior approaches for open reduction and k wire fixation in children with type III supracondylar fractures of the humerus. Methods: We conducted this retrospective Cohort study in Orthopedic department Dr. Ruth K M Pfau Civil Hospital Karachi. All children with type III supracondylar fracture of the humerus fulfilling the inclusion criteria operated in time period extending from 3rd January 2018 to 3rd December 2020 and with minimum one year follow up were included. The clinical records were reviewed for surgical approaches and children with lateral approach(LA),medial approach(MA) and posterior approach(PA) were asked for follow up visit. Radiological outcome was assessed by measuring Shaft Condylar Angle(SCA) and Baumann angle. Flynn’s criteria was used for functional outcome in all children and results were categorized into Excellent, Good, Fair(satisfactory) and Poor(unsatisfactory). Results of lateral, medial and posterior approach were compared and P value was calculated with Chi-Square test and Kruskal-Wallis test (P value <0.05 significant). Results: The total number of children in our study were 90. Each LA, MA and PA had 30 children each. Mean age of children in LA was 8.54 ± 4.5 years, MA 7.21 ± 3.5 years and PA 8.1 ± 6.1 years. Mean Shaft Condylar Angle was 42.2±7.1o, 42.5±3.2o and 41.3±2.7o in LA,MA and PA respectively(P> 0.05). Mean Bauman angle was 19.4±4.0o in LA, 20.3±6.3o in MA and 21.6±3.1o in PA (P> 0.05). Excellent outcome was noted in 22(73.33%),17(56.66%) and 15(50%) in LA,MA and PA respectively. ( P> 0.05)Good outcome was noted in 8(26.66%) children in LA, 13(43.33%) in MA and 15(50%) in PA.(P >0.05) Conclusion: Lateral approach for supracondylar fracture yielded better radiological and functional outcome than medial and posterior approach in our patients. The difference was however not statistically significant.

Objective: To determine the functional outcome of massive rotator cuff tear treated with tensor fascia lata autograft. Methods: This descriptive study was conducted in Hand and Upper limb surgery Center CMH Lahore Medical College Lahore from 23rd December 2016 to 23rd December 2020.All adults patients of either gender and age with massive rotator cuff teat fulfilling the inclusion criteria were operated with tensor fascia lata autograft. Post operative functional outcome was assessed with Shoulder Pain and Disability Index(SPADI). Pre operative and post operative SPADI score was compared and P value was calculated with paired-t test. P value < 0.05 was considered significant. Results: The total number of patients in our study were 10. Mean age was 46.21±8.21 years. Male patients were 8(80%) and female 2(20%).Right shoulder was involved in 7( 70%) patients and left in 3(30%). A significant improvement in SPADI score at 2 years follow up was noted(from 94.34±7% to 19.2±3% with P 0.001).Repeat MRI at 12th week revealed complete cuff healing in 9(90%) patients and partial healing in 1(10%) patient. No retear was noted. Conclusion: Massive rotator cuff tears treated with tensor fascia lata autograft produced complete healing and excellent functional results without any retear. Fascia lata autograft should be the technique of choice for massive irreparable rotator cuff tear.

Musculoskeletal injuries constitute a large proportion of global burden of trauma. Lack of proper treatment of musculoskeletal trauma results in disability and morbidity.1 In developing countries patients with musculoskeletal trauma usually do not present to hospital on time due to lack of transportation, poverty and ignorance. Furthermore many government hospitals do not have adequate infrastructure and trained staff resulting in delayed diagnosis or suboptimal treatment of these injuries. 2 Due to high influx of patients and constrained resources in state-owned hospitals of our country patients had to wait for their turn for surgery which cause frustration and anger amongst these patients and most of them leave hospital without definitive treatment and unfortunately do not get effective alternative treatment outside. Poverty and superstitious believes are a contributing factor for consulting bonesetters and improper treatment.3 Neglected musculoskeletal injuries are thus untreated injuries due to one or other reasons. In developed countries neglected musculoskeletal injuries are less frequent except missed injuries of the hip and spine reported in some polytrauma patients. Whereas in India 29% patients with fractures and dislocation in a teaching hospital had 50% neglected musculoskeletal injuries.4

Objective: To determine the functional and radiological outcome two ring hybrid Ilizarov fixator in the management of proximal tibial fractures in adults. Methods: This descriptive study was conducted in department of Orthopaedic surgery Nishtar Medical University Multan from 5th May 2018 to 24th June 2020. All adults patients with proximal tibial fractures meeting the inclusion criteria were treated with two ring hybrid Ilizarov fixator. Post operative functional outcome was assessed with knee range of motion and Rasmussen functional knee score and graded as excellent, good, fair and poor. Radiological outcome was assessed with fracture healing on radiographs. Comparative analysis of results were done after stratification of age, gender, type of fracture and time since fracture and P value calculated with Chi square test and student-t test. P value < 0.05 was considered significant. Results: The total number of patients in our study was 50.The mean age was 40.7 ± 10.16.Male patients were 45(90%) and female 5(10%). Shatzker type VI fractures were present in 30(60%) patients, Shatzker type V fractures in 11(22%), extra articular metaphyseal fractures in 5 (10%) and proximal one third shaft fractures in 4(8%) patients. All the fractures achieved union with mean union time 17.58±3.43 weeks. Functional outcome as per Rasmussen functional knee score was excellent outcome with more than 90° knee flexion in 32(64%) patients, good outcome and up to 90°flexion in 15(30%) and fair outcome with 45°flexion at the knee in 3(6%) patients. Younger patients were able to tolerate early weight bearing than elderly (P=0.006) Patients with open fractures had lower Rasmussen score (P=0.043), decrease knee flexion (P=0.043), and increased pin tract infection (P=0.031). Conclusion: Proximal tibial fractures treated with two-ring hybrid Ilizarov fixator is an effective technique as excellent functional and radiological outcome was achieved in majority of our patients.

Objective: To determine the diagnostic accuracy of MRI in detecting ACL tears in patients presenting with knee injury taking arthroscopy as gold standard. Methods: This Cross sectional study was conducted in department of Orthopedic Surgery Khyber Teaching Hospital Peshawar from 2nd February 2019 to 28th August 2020. All patients with clinical ACL tear fulfilling the inclusion criteria had MRI of the knee joint followed by arthroscopy. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of MRI was calculated with reference to arthroscopy as gold standard. Results: The total number of patients in our study was 106 with mean age 32±9 years. Male patients were 77 (72.64%) and female 29 (27.35%) were female. Left knee was involved in 67 (63.20%) patients and right in 39 (36.79%).ACL tear was noted in 43 (40.56%) patients on MRI while 86 (81.13%) patients had ACL tear diagnosed on arthroscopy. Sensitivity of MRI was 66.67%, specificity 75.90%, PPV 81.13%, NPV 59.43% and diagnostic accuracy 70.28%. Conclusion: MRI is a useful diagnostic modality but we found low diagnostic accuracy of MRI for ACL tear considering arthroscopy as gold standard. Diagnostic arthroscopy is therefore recommended for confirming ACL tear in doubtful cases.

Objective: To determine the outcome of modified stoppa approach for fixation of acetabular fractures in terms of operative time, complications, radiological and clinical outcome criteria of Matta. Method: This was a descriptive study conducted from 12th September 2018 to 12th January 2021 in Orthopedic Unit of Ghurki Trust Teaching Hospital Lahore. All patients with acetabular fractures meeting the inclusion criteria were operated via modified Stoppa approach. Outcome was assessed in terms of mean operative time, complications rate and Matta’s radiological and clinical criteria at 16th week. Results: The total number of patients in this study were 52. The mean age was 31.1±12.4 years. Male patients were 36(69.2%) males and female 16(30.8%). The fractures were associated type in 34(65.3%) and elementary in 18(34.6%) patients. The mean follow-up time was 4.8 months (range 6 to 11months). The mean operative time was 176.32±88.29 min. According to Matta’s radiological criteria post operative anatomical reduction was achieved in 39(75%) cases, imperfect in 8(15.3%) cases and poor in 5(9.6%) cases. The clinical results were excellent in 13(25%) cases, good in 31(59.6%) cases and poor in 8(15.3%) cases. Superficial surgical site infection (SSI) was noted in 2(4.3%) patients and resolved with antibiotics. Conclusion: Modified Stoppa approach is an effective and safe alternative to Ilioinguinal approach for acetabular fractures yielding satisfactory radiological and clinical outcome with minimal complications.

Objective: To determine the frequency of complications of Transforaminal Lumbar Interbody Fusion (TLIF) in tertiary care hospital. Methods: This retrospective Cohort study was conducted in Department of Orthopedics and spine surgery Hayat Abad medical complex Peshawar. All patients who underwent Transforaminal Lumbar Interbody Fusion (TLIF) for various indications fulfilling the inclusion criteria and operated in time period extending from 2nd January 2012 and 3rd Jan 2020 were included in this study. A thorough evaluation of the patients records were done and frequency of post operative complications were noted. Results: Based upon our inclusion criteria the medical records of 208 patients were examined. Male patients were 50(24%) and female 158 (76%).The mean age was 45±7(range 20 to 74 years).The overall complication rate was 33.6%(n=70).Dural tear was documented in 9(4.3%) patients, 16(7.6%) had postoperative ileus, wound infection in 14(6.7%), radiculopathy in 12(5.7%),motor weakness in 1(0.4% ), 6 (2.8%) had pseudoarthrosis and 12(5.7%) patients had implants related complications. The re surgery rate was 6.2%(n=13) Conclusion: Transforaminal Lumbar Interbody Fusion (TLIF) is a reliable surgical procedure to achieve fusion in a variety of clinical conditions. The complication rate is variable. Careful patient selection, preoperative planning and meticulous intra-operative execution can avoid these complications.

Objective: To determine the functional outcome of Subscapularis release and Latissimus dorsi transfer to Infraspinatus in children with obstetric brachial plexus palsy. Methods: This retrospective Cohort study was conducted in National Orthopaedic and General Hospital Bahawalpur and Orthopaedic unit Lady Reading Hospital Peshawar.The records of all children of obstetric brachial plexus palsy fulfilling the inclusion criteria and operated with Subscapularis release and Latissimus dorsi transfer to Infraspinatus in time period extending from 25th January 2016 to 25th December 2020 were reviewed.Functional outcome was assessed by comparing pre-operative and post operative shoulder abduction and external rotation and P value was calculated with Chi-square test( P value <0.05 was considered significant). Results: We operated 19 children of obstetric brachial plexus palsy with Subscapularis release and Latissimus dorsi transfer to Infraspinatus.Male children were 13(68.42%) and female 6(31.5%).The mean follow-up was 9.78±2.48 months. Right side was involved in 11(57.89%) patients and left in 8(42.1%).Preoperatively mean external rotation was -12.63?±7.5 and abduction 65?±14.24 All patients showed significant improvement in shoulder range of motion with postoperative mean external rotation 50.78?±9.46 and abduction 117.63?±13.37( P value <0.05). Conclusion: Subscapularis release and Latissimus dorsi transfer to Infraspinatus is a good surgical technique with excellent functional outcome. We recommend this technique in children with obstetric brachial plexus palsy without spontaneous recovery.

Objective: To compare the efficacy of Diclofenac sodium and Pregablin in reducing post operative pain in patients with surgeries around the knee. Methods: This randomized controlled trial was conducted in Department of Orthopedics Surgery and Traumatology Mayo Hospital Lahore from 23rd December 2017 to 23rd December 2020. All adults patients of either gender and age with surgeries around the knee fulfilling the inclusion criteria were randomly divided into two equal groups as group A (Diclofenac sodium 50 mg BD) and group B (Pregablin 75 mg BD). The drugs were administered orally for two days after surgery. Post operative pain intensity was determined with visual analogue score (VAS). Comparison of VAS in both group was done and P value calculated with paired-t test. P value < 0.05 was considered significant. Results: The total number of patients were 80 and equally divided into group A and group B. In group A 26 (65%) were male and 14 (35%) were females. In group B 25 (62.5%) were male and 15 (37.5%) females. The mean age of group A patients was 30.5±7.33 and group B 31.15±9.97 years. The mean VAS in group A was 4.08±0.95 and in group B was 4.012±0.96 (P value 0.5) on first post-operative day. On second post-operative day group A had mean VAS 4.012±0.96 and group B 1.55±0.59.(P value 0.001) Conclusion: Post-operative oral Pregablin is more effective than Diclofenac sodium in reducing postoperative pain in patients with surgeries around the knee.

Objective: To determine the functional outcome of open Latarjet procedure for recurrent anterior shoulder dislocation. Methods: This descriptive study was conducted in Department of Orthopaedics, Lahore General Hospital Lahore from 21st January 2019 to 29th December 2020. All adults patients of recurrent anterior shoulder dislocation fulfilling the inclusion criteria were operated with open Latarjet procedure. Functional outcome was assessed with Constant-Murley shoulder score at 6th months and rated as very good outcome (86-100 score), good outcome (71-85 score), fair outcome (56-70 score) and poor outcome (< 56 score). Comparative analysis of important outcome variables was done with paired-t test and P value < 0.05 was considered significant. Results: The total number of patients were 35. There were 34 (97.14%) male and 1(2.85%) female. The mean age of our patients was 48.4±9.0 years. Right side was involved in 26(74.28%) and left in 9(25.71%). At 6th month postoperatively very good outcome was noted in 23(65.71%), good in 8(22.85%), fair in 2(5.71%) and poor outcome in 2(5.71%) patients. Significant pain reduction and improved range of shoulder motion was documented at 6th month. (P value < 0.05). Conclusion: Open Latarjet technique is a reliable and safe option for recurrent anterior shoulder dislocation as very good functional outcome was achieved in majority of our patients.

Objective: To compare McKenzie back program and conventional physiotherapy in reducing pain and functional disability in patients with backache due to lumbar disc prolapse. Methods: This randomized controlled trial was conducted in Orthopedic Department Pir Abdul Qadir Jeelani Institute of Medical Sciences, Gambat Khairpur Sindh. The duration of this study extended from 2nd March 2019 to 2nd February 2021. All patients with backache due to lumbar disc prolapse fulfilling the inclusion criteria were randomly divided into two equal groups: Group A (McKenzie back program) and group B (Conventional physiotherapy). Pre-intervention pain assessment was done with Visual Analogue Scale (VAS), spine mobility with Fingertip-to-Floor distance (FTF) measured in centimeter and disability with Oswestry Disability Index (ODI) questionnaire in both groups and compared with post-intervention values at 4th, 6th and 8th week. P value was calculated with Chi-square test. P value< 0.05 was considered significant. Results: The total number of patients analyzed were 120.Both group A and B had 60 patients each. The mean age of group A patients was 46.4±5.3 years and group B 45.8±6.4 years. Male patients were 36 (60%) and female 24 (40%) in group A. In group B male patients were 33 (55%) and female 27 (45%). Statistically significant improvement was noted in FTF in group A at 2nd and 4th week (P < 0.05) post-intervention. At 8th week post-intervention VAS, FTF and ODI significantly improved in group A (P< 0.05) than in group B. Conclusion: McKenzie back program is more effective in reducing pain, increasing lumbar spine mobility and decreasing disability than conventional physiotherapy and stretching exercises in patients with backache due to lumbar disc prolapse.

Training of post graduates is a fast changing field all over the world. Microteaching has been a time tested technique since long but its use has decreased over time especially in medical field. It is a group activity for teachers to learn how to teach. They plan and teach one by one a small lesson. It is watched by his group members and critiqued later. A special emphasis is upon evaluation whether teaching session has met its planned objectives or not. Use of teaching aids and other techniques are evaluated and discussed as a group. A recent interest in the technique has found many applications in learning how to teach. Post graduate trainees have been seen to benefit a lot from such learning activities. There is enough evidence pointing to the need for revisiting the concept and finding newer possibilities for its use. This article is a brief description of concept, techniques, advantages and uses of microteaching.

The incidence of club foot is 4 to 6 per 1000 births and majority of the babies with club foot are born in the developing countries.1Multiple factors are responsible for this deformity. The vascularity and the accessory muscles of the feet also have an important role to play.2,3 We also know that there is an abundance of collagen in the ligaments which are stretchable but the collagen in Tendoachillis is not stretchable therefore, Tenotomy has to be done.4 Out of many classifications of club foot, Pirani classification and the Dimeglio classification are accepted all over the world today.5 The radiography in club foot has many pitfalls6,7 whereas, the ultrasonography shows significant correlation as the non ossified Talar bones can also seen.8 The computerized pedobarography although popular in some centers also does not correlate with the clinical outcome.9 Even today the treatment of this deformity although looks simple is still challenging as it has high rate of recurrence in some countries.

Osteosarcoma is the most common malignant bone tumor of Paediatric and adolescent age. Historically radical treatments were opted but with advances in diagnosis and neoadjuvant chemotherapy limb salvage has now become possible in most of the cases. In this case report we presented an 8 year old girl who was diagnosed with osteosarcoma of the distal femur. She was treated successfully with neoadjvant chemotherapy followed by limb salvage surgery using partial resection of medial femoral cortex with lateral cortex remains in continuity and poraline silicon bone substitute for filling the defect. She is disease free after 3.5 year and walking pain free on her limb.