Osteoarthritis and muscle tendon pathologies are among the most common causes of pain and disability in humans and have a great impact on quality of life.1 These conditions are often corelated with aging, but early onset of disability might be a consequence of traumatic events. Tissues affected by these pathologies have limited self-healing potential thus creating a difficult challenge for orthopaedic surgeons. In the past we have treated these ailments with NSAID and corticosteroids to mask symptoms, inhibit the inflammatory process and healing but caused rupture of tendons, muscle and skin and fat atrophy. 2 International Orthopaedics in 2010 published a study that steroids therapy is worst than no treatment at all at 6 months.3 Orthobiologics are substances that Orthopaedic surgeons use to help injuries heal more quickly. They are used to improve the healing of broken bones and injured muscles, tendons, and ligaments. These products are made from substances that are naturally found in our body. When they are used in higher concentrations, Orthobiologics substances help speed up the healing process. Some key benefits associated with Orthobiologics conservative therapies include minimizing the impact of degenerative disease, all procedures are completed in the office as an outpatient and recovery is more rapid than surgery.4 Orthobiologics therapies are a specific type of regenerative medical treatment. The best news is that it has gone from science fiction to a very real and very accessible form of treatment for a variety of orthopaedic injuries and joint degeneration. We were finding mechanical solutions like joint replacement and arthroscopy in not so long past. Over the years we have realised this is biology and now we are increasingly looking for biological solutions for biological problems. This all started initially as mechanical biologics with visco-suplemntation as first biologics, with limited success for a limited time with results lasting weeks at best.5, 6 Blood stream biologics were next introduced with microfracture as the forefront followed by Glucosamine and lately collagen peptides which are a dietary supplement of small peptides that is highly soluble and highly absorbable and considered as functional foods.7, 8 PRP (Platelet rich plasma) emerged as the second generation of Orthobiologics, and the first Orthobiologics of the autologous form. 9, 10 In recent years, Bone Marrow Concentrate (BMC) has emerged as the third generation of Orthobiologics therapy and also lately stromal vascular fraction from a variety of origins including fat cells. Stromal vascular fraction with PRP is also showing encouraging results especially in Knee arthritis.11 The evidence is out there. We have now numerous randomised control studies for arthritis of knee with over a thousand patients in the review.11-14 The result suggests PRP is better than visco- supplementation, steroids, Ozone and placebo.12 PRP reduces pain improves function and improve quality of life for at least 1 year with no side effects.14 Some studies have shown detrimental effect of PRP on cartilage but when leucocyte rich PRP was excluded the results is amazing.15 There is now established outcome in multiple pathologies. Multiple injections seem to do better than a single shot.16 Lately a combination of PRP and Plant origin collagen has been successful in cuff tears, Patella tendon Achilles tendon and muscle tears that can be treated non surgically, the combination is called tendo-acp which has collagen that act as a scaffold and PRP initiates healing and repair.17The new kid on the block is monocyte therapy. There was already a role identified in management of Stroke patients Alzheimer’s disease and burns but now being extended to orthopaedics. The monocytes are cell sorted with selective charged membrane filtration, from one’s own blood and are showing exceptional results in tendon injuries, focal cartilage defect and bone consolidation delays. 18-20

The word Plagiarism has a Latin origin, “plagiarius,” meaning “kidnapper” or “abductor” and “plaga” meaning “hunting net” 1,2 The term is very old and has many definitions. The Committee on Publication Ethics (COPE) define plagiarism as “the unreferenced use of others published and unpublished ideas.”3 The authors, however must be cautious that using published photos, videos, images, art work, graphs and tables without written permission is also plagiarism.2 Plagiarism is the most common among ethics issues in research and although there are many forms of plagiarism like collusion plagiarism, self-plagiarism, technical plagiarism, patchwork plagiarism, and blatant plagiarism none is acceptable ethically and legally.4 The exact prevalence of plagiarism is not known.1 However some studies have reported a rejection rate of 9.8% to 16% research papers due to plagiarism and a higher incidence of plagiarism has been reported in some countries like Japan, Korea, Italy, France, China, Iran, Turkey and India.5,6

Objective: To determine the outcome of Ponseti treatment for clubfoot(Congenital Talipes Equino Varus) deformity in neonates. Methods: It was a descriptive study conducted in District Head Quarter Hospital Timergara Khyber Pakhtunkhwa from 25th July 2017 to 25th August 2018. All children below one year of age with Congenital Talipes Equino Varus(CTEV) deformity meeting the inclusion criteria were included in our study. The pretreatment severity of clubfoot deformity was scored through Pirani Scoring system. All the children were then subjected to manipulation and weekly serial casting by Ponseti technique and the final outcome was assessed by improvements in the Pirani score and graded as excellent, good and poor. Results: In our study the total clubfeet were 48 in 32 neonates. Mean age was 4.3 months(range 2.5 to 11 months) Male children were 22(68.7%) and female 10(31.2%).Bilateral clubfeet were present in 20(62.5% ) children while unilateral in 8(25%).The pre-treatment mean Pirani score was 5.5 while post treatment mean score was less than 0.5.Excellent and good outcome was achieved 46( 95.8%)and 2( 4.1%) feet respectively. Conclusion: Ponseti treatment for Congenital Talipes Equino Varus deformity in neonates produced excellent outcome in majority of patients. The Ponseti technique of serial casting should be the treatment of choice to treat congenital clubfoot deformity.

Objective: To determine the functional and radiological outcome of posterior interosseous bone flap in reconstruction of intercalated defects of the hand and distal forearm. Methods: This descriptive study was conducted in Millat Orthopedic and Trauma Surgery Hospital Sargodha from 23rd March 2015 to 23rd June 2019.All patients of segmental bone loss in the hand and distal forearm fulfilling the inclusion criteria were treated with posterior interosseous bone island pedicle flaps for filling of defects. Donor site wounds were directly closed. The patients were assessed clinically for viability of the flap and hand functions and radiologically for transferred bone union. Results: The total number of patients were 6 with mean age 33.3 years(range 19 to 48 years).All patients were male. Right side was involved in 4(66.6% ) and left in 2(33.3% ).The aetiology was gunshot injury in 3(50% ), saw cut in 2(33.3% ) and infection in 1( 16.6% ) patient. First metacarpal bone defect was present in 2 (33.3% ) patients, second and third metacarpal in 1(16.6%),third metacarpal in 1(16.6% ) proximal phalanx of the thumb in 1 (16.6% ) and distal radius in 1 (16.6% ) patient. Posterior interosseous osteocutaneous flap were used in 4(66.6% ) and osseous flap in 2(33.3% ).The mean length of bone transported was 4.3 cm(range 2.5 to 5.5 cm). All flaps survived completely without any untoward sequelae. No donor site morbidity regarding fracture and cosmesis was reported. The transported bone in all cases were incorporated successfully without any resorption. All the patients were able to use their hands for daily activities without any major functional impairment. Conclusion: The intercalated defects of the hand and distal forearm treated with posterior interosseous bone flap resulted in acceptable functional and radiological outcome. In an injured hand with composite bone defects of metacarpals or proximal phalanges if there is no biological spare part available then the use of posterior interosseous bone island flaps should be the preferred choice for reconstruction.

Objective: To compare the outcome of Fibrin glue with micro suture technique for the treatment of Brachial plexus and peripheral nerve injuries. Methods: This randomized control trial was conducted at Military Hand Surgery Centre in Lahore Pakistan from July 2015 to December 2017. We managed 70 cases with brachial plexus and peripheral nerve injuries fulfilling the inclusion criteria in two groups. One repaired with fibrin glue(group A) and other with microsuture(group B) with follow up of one and half year. Outcomes were measured as convenience of the surgeon, duration of surgery and efficacy in the form of motor recovery. Post stratification Chi square test and independent sample t tests were applied to important variables taking P value of ? 0.05 as significant. Results: A total of 70 patients were equally divided in two groups A and B (35 each).The mean age of group A patients were 34.37 ±8.23 and group B was 33.89 ±9.13.Brachial plexus injuries(BPI) were noted in 18( 25.7% ) patients in group A and 15(21.4% ) patients in group B. Peripheral nerve injuries(PNI) were noted in 17( 24.2%) patients in group A and 20( 28.5%) patients in group B. The surgery was found convenient in Group A with Fibrin Glue repair where it was seen in 32 (91.42%) vs. 20 (57.14%) with p value of 0.02. Duration of repair was significantly high in Group B, with 6.34 ± 0.87 vs. 31.43 ± 8.31 minutes with p values of 0.0001 respectively. The efficacy was seen in 26 (74.28%) vs. 24 (68.57%) with p value 0.68. Conclusion: Fibrin glue repair is a good alternative to micro suture technique in terms of convenience to surgeon and decrease duration for surgery. However, the efficacy was similar with no significant difference in grade of motor recovery in both groups.

Objective: To determine the frequency of femoral ante version in patients presenting with Developmental Dysplasia of Hip (DDH). Methods: This Cross-sectional was conducted in Ghurki Trust Teaching Hospital, Lahore from April 2019 to September 2019.All children of DDH fulfilling the inclusion criteria were subjected to Craig test for the evaluation of femoral anteversion. An angle more than 15° (normal 8-15°) was termed as femoral anteversion (internal torsion). Results: In our study total 57 children with mean age 5 years± 3.26 were included. Male children were 33 (58%) and female 24 (42%). The frequency of femoral anteversion was detected in 30(52%) children with DDH. Conclusion: Femoral anteversion was found in most of children suffering from developmental dysplasia of hip. All children with DDH must be screened for femoral anteversion and the operating surgeon must plain to correct this deformity precisely while operating on patients with DDH.

Objective: To determine the functional and radiological outcome of Ilizarov ring fixator for nonunion of femur and tibia in pediatrics and adolescent. Methods: This descriptive study was conducted in Bolan Medical Complex Hospital Quetta, from 3rd February 2016 to 24th February 2019.All paediatrics and adolescent patients with non union femur and tibia meeting the inclusion criteria were operated for Ilizarov ring fixator. Post operative functional and radiological outcome was assessed through AASAMI(Association For The Study And Application Of Methods Of Ilizarov) scoring system at final follow up and graded as Excellent, Good, Fair and Poor. Results: We included 30 patients with mean age 12.7+ 2.16years(range 8 to 15 years).Male children were 25(83.33%) and female 5 (16.67%).Among the participants infected non-union of femur was present in 11 (36.7%), infected non union tibia in 8 (26.7 %), non union femur 9 (30.0 %) and non union tibia in 2 (6.7%).A total of 8 patients (26.7%) had no previous surgeries, 9 (30.0%) patients had only one surgery and 13 (43.3%) had two previous surgeries. Excellent results were achieved in 8(40%) good in 6(20%) and fair in 6(20%) patients with femur Ilizarov. Tibial Ilizarov produced excellent results in 8(80% ) and good results in 2(20% ) patients. Conclusion: Non union femur and tibia in children and adolescent treated with Ilizarov produced excellent and good results in majority of patients. We therefore recommend Ilizarov ring fixator as a first line treatment modality to treat non union of femur and tibia in children.

Objective: To determine the functional and radiological outcome of fracture distal femur treated with retrograde interlocking nail. Methods: This was a descriptive study conducted at Department of Orthopaedics surgery Jinnah Post Graduate Medical Centre(JPMC) from 15th February 2016 to 10th January 2019.All patients fulfilling the inclusion criteria were treated with retrograde nailing. Post operative functional outcome was evaluated with Schatzker and Lambert criteria as graded as excellent, good and poor. Radiologically union was assessed with x rays. Results: There were 97 patients with mean age of 35.20±10.66(range 20 to 50 years) of age. Male patients were 74(76.2%) and female 23(23.7%). Majority(70.1%,n=68) of fractures were due to motor vehicle accidents. Right side fracture was present in 60(61.9%) patients and left in 37(38.1%). Excellent outcome was noted in 72(74.2%) patients and good in 25(25.7%).No non union was documented. Conclusion: Excellent and good functional and radiological outcome was achieved in distal femur patients treated with retrograde interlocking nailing. We recommend retrograde interlocking nail as an implant of first choice for selected distal femur fractures.

Objective: To compare the results of hydraulic distention (HD) and manipulation under anesthesia (MUA) intervention in patients with frozen shoulder (FS). Methods: The study was conducted in department of orthopedics, Shakeih Zaid bin Ayan Hospital Combined Military Hospital, Rawalakot, Azad Jammu Kashmir(AJK). The duration of study was one year extending from 1st March 2018 to 28th February 2019. The design of study was randomized. The sampling technique was non probability convenience sampling. The sample size was 158 patients with 79 patients in each group randomly allocated to group A (HD) and group B (MUA). The pre and post procedure Shoulder Pain and Disability Index( SPADI) score was used to determine the outcome in both groups. Results: A total of 158 patients participated in the study, out of which 81 (51.27%) were females and 77 (48.73%) were males. They were randomly allocated to group A (HD) and group B (MUA). The mean age of the subjects in group A was 46.6 ± 8.3 years, while 46 ± 9 in group B. In group A the mean pre management score was 82.20 ±4.7 and the mean post management score was 20.6± 3.4. Out of 79 patients in group B the mean management score was 84.2 ±6.0 before surgical intervention in patients who underwent MUA, while SPADI score improved to 30.6±2.5 after intervention. The chi square test showed the p-value of 0.39 which was not significant statistically. Conclusion: The comparison of hydraulic distention and manipulation under anaesthesia depicted that both the procedures had equal efficacy in treating frozen shoulder.

Objective: To determine the functional and radiological outcome of supracondylar fractures humerus in children treated with Dorgan’s lateral cross pinning technique. Methods: This descriptive study was carried out at Orthopaedic division Lady Reading Hospital Peshawar and Rahman medical and surgical center Buner Khyber Pakhtunkhwa Pakistan from 2nd June 2017 to 20th June 2019. All children with supracondylar fracture humerus meeting the inclusion criteria were fixed with Dorgan’s lateral k wires stabilization technique. Post operative outcome was assessed with X rays for union/malunion and functionally with Flynn’s criteria and graded as excellent, good, fair and poor. Results: A total of 30 children with mean age 4.90 ± 2.48 years were included in our study. Boys were 20(66.7%) and girls 10(33.3%). There were 11 (36.7%) Gartland type II and 19 (63.3%) Gartland type III fractures.Post operatively radiological union was achieved in all patients. Excellent results were achieved in 22(73.3%), good in 5(16.6%) and fair in 3(10%) patients. No ulnar nerve or radial nerve injury was noted. Conclusion: Excellent and good functional and radiological results were achieved with Dorgan’s lateral cross pinning technique. We recommend this technique as first line treatment option to stabilize supracondylar humerus fractures in children.

Objective: To compare the functional and radiological results of locking plate versus shortened interlocking nail for treating extra-articular distal tibia fractures. Methods: This randomized trial was conducted in Department of Orthopaedics, Lahore General Hospital from 25th June 2017 to 25th July 2019.All patients of distal tibia fractures fulfilling the inclusion criteria were randomly and equally divided into group A(shortened interlocking nail) and group B(anatomically contoured distal tibial locking plate). Post operatively functional outcome was determined by assessing ankle and knee range of motion. Radiological union was assessed through callus formation on X ray AP and Lateral view. The time of radiological union and range of motion in both groups were compared and chi square test was applied to note any statistical significance with P value of < 0.05 was considered significant. Results: Total 24 patients were equally divided into two groups A and B with 12 patients in each group. The mean age of group A was 22.5 years(range 20 to 34.5 years) while group B had mean age 31 years(range 22 to 35 years).In group A all the patients were male. Group B had 1(8.3%) female patient. Majority(91.6%,n=11) of patients in group A regained normal range of motion of ankle and knee at final follow up. In group B the normal ankle range of motion was noted in 8(66.6%) patients. Non union was documented in 1(8.3%) patient in group A and 3(25%) patients in group B. The functional and radiological outcome was significantly better in interlocking nail group than locking plate group(P value of < 0.05). Conclusion: Extra articular distal tibia fractures treated with shortened intramedullary nail produced better functional and radiological results than locking plate. Shortened intramedullary nail should be the treatment of first choice to treat these fractures.

Objective: To determine a point score system for predicting the likelihood of blood transfusion after Shoulder and elbow arthroplasty. Methods: The current study represents a retrospective analysis of all shoulder and elbow arthroplasties performed at the Manor Teaching Hospital United Kingdom by the senior surgeon/Author from Jan 2010 to Dec 2014. A database of 183 patients that underwent elective surgery at a teaching hospital was used for analysis to determine potential variables that was predictive of blood transfusion. The predictor variables evaluated included type of arthroplasty (shoulder vs. elbow, primary vs. revision, trauma vs. arthritis.) and age, sex, and medical co morbidity. The outcome variable was allogeneic blood transfusion. Results: The record of 124 patients were reviewed. Females were 91(73.3%) and males 33(26.6%). The average age was 72 years (Range 39-91 years). There were 57(45%) primary arthroplasty surgeries involving the shoulder, 5 (4%) were shoulder revision surgery, 5 (4%) Delta shoulders for rotator cuff problems and one(0.7%) excision arthroplasty. Shoulder arthroplasty due to trauma was done in 30(24.1%) cases. There were 15 (12%) primary elbow replacements,11(8.7%) revision elbows and 4(3.2%) patients had elbow arthroplasty for trauma. One(0.8%) patient had Polaris hemi Arthroplasty for metastasis in shoulder and one(0.8%) patient had total elbow replacement for metastasis. Pre-operative Haemoglobin ranged from 9.4G/dl to 17.9G/dl (average 12.7) and post-operative Haemoglobin 6.8G/dl to 14.3G/dl (average 10.6). Blood transfusion (100 units) was done in 53(42%) patients. The average number of transfusion per patient was 1.88 (Range 1 – 4 units) with 28(65.1%) transfusions in arthroplasties for trauma,12(75%) transfusions in revision arthroplasties and 13(10%) patients with other procedures. The two most important variables which were highly significant were revision and trauma (p <0.001),while age was not very significant at all. Conclusion: It is possible to predict patients undergoing upper limb arthroplasty that will need postoperative blood transfusion Shoulder and elbow arthroplasty in trauma and revision cases are strong predictor of blood transfusion.

Objective: To compare the treatment outcome of combination of corticosteroid injection with physiotherapy and physiotherapy alone in patients with adhesive capsulitis in term of shoulder pain and disability index (SPADI) score. Methods: This was a randomized controlled trail conducted using probability simple random sampling technique at the Department of Orthopedic Surgery, Fatima Jinnah Medical University, Sir Ganga Ram Hospital, and King Edward Medical University, Mayo Hospital Lahore from February 2106 to September 2018. All patients of frozen shoulder fulfilling the inclusion criteria were randomly divided into two groups as A & B by lottery method. Pre treatment shoulder pain and disability index (SPADI) was calculated. Group-A was given intra-articular corticosteroid and physiotherapy while group-B received only physiotherapy. Post intervention SPADI score of both groups were calculated 6-week after the treatment on follow-up in the out-patient department. Independent sample t-test was used to compare the SPADI score between two groups and p-value <0.05 was taken significant. Results: Out of the total 80 patients in both groups(40 in each group), the mean age of the patients in group-A was 45.18±7.29year while in group-B it was 43±7.43year. The mean duration of the symptoms in group-A was 3.29±1.62month while in group-B it was 3.25±1.69year. In group A, SPADI score at baseline was 71.68±7.67 while in group B it was 71.88±6.74 (p-value=0.902). After 6-week SPADI score in group A was 36.7±5.28 while it 39.78±5.89 in group B. It was found statistically significant in both group (p value 0.016). For age and gender stratification with SPADI score at baseline and 6-week we found statistically significant difference. Conclusion: Combination therapy of corticosteroid injection with physiotherapy was effective treatment in patients with adhesive capsulitis in pain relieve and reduction in disability index.

Objective: To determine the frequency, aetiology and age distribution of different fractures in patients presenting to a tertiary care center in Peshawar. Methods: This was a descriptive cross-sectional study, conducted at Rehman Medical Institute, Peshawar, Khyber Pakhtunkhwa in the months of March 2018 to September 2018. A total of 1829 records related to fractures were obtained from the hospital archives. All fractures from all causes were taken into consideration, with in-patient records from 2004 to 2014 period. Data obtained was entered into MS Excel 2013 and were analyzed through formulating pivot tables. Percentages of the site-based fractures with three sets of age brackets were determined. Results: The total fractures were 1829 in 72.9% (n=1334) males and 27.1% (n=495) female patients. Individuals in the age group 15 to 64 years were in majority (67.3%, n=1230). The most common site of fracture was femur (38%,n=695) and least common scapula( 0.3 % ,n=5). The most frequent (37.5%) cause of fracture was road traffic accident (RTA) and majority cases (29) were reported in 2013. Conclusion: A general trend of lower limb fractures followed by upper limb and spine can be depicted from the data at hand. The most commonly occurring fracture was that of the femur with majority of the patients involved being in the 15 to 64 years age group. These fractures occurred mainly due to road traffic accidents.

Objective: To determine the accuracy of Lachman test in diagnosing tears of Anterior Cruciate Ligament (ACL) taking Magnetic Resonance Imaging (MRI) as gold standard. Methodology: Our study was cross sectional in design and all patients with knee pain and instability after trauma were enrolled. Lachman test was performed followed by MRI of the same knee. Sensitivity of Lachman test, its specificity, positive predictive value and negative predictive value were determined while taking Magnetic Resonance Imaging(MRI) as the gold standard for comparison. Results: There were 110 (86.61%) males and 17 (13.38%) females. True positive patients of ACL tear based upon Lachman test were 36(28.34%) while true negative were 87 (68.50%). False positive patients of ACL tears were 1 (0.78%) and false negative 3 (2.36%). The Lachman test was found to be 92.30% sensitive and 98.86% specific for detecting ACL tears. The positive predictive value of Lachman test was 97.29% and negative predictive value 96.66%. We found that Lachman test had a diagnostic accuracy of 96.85%. Conclusion: Lachman test was found to be more specific and had high negative predictive value in detecting ACL tear. It can be used as a diagnostic tool for determining tears of anterior cruciate ligament in place of MRI in uncomplicated cases.

Objective: To determine the radiological and functional outcome of “vascularized bone graft spare parts” fashioned from severely damaged but viable parts of the hand and used for reconstruction of hand defects. Methods: This descriptive study was conducted from 3rd January 2014 to 25th January 2018 in Millat Orthopaedic and Trauma Surgery Hospital Sargodha. All patients with traumatic hand defects fulfilling the inclusion criteria were reconstructed with vascularized bone graft spare parts technique. Patients were followed regularly for viability of graft, bone union and functions of the hand. Results: A total of 6 patients with mean age 33.3 years (range 19 to 45 years) were included in our study. The aetiology of hand trauma was saw cut in 2(33.3%), crush injury in 2(33.3%), firearm in 1(16.6%) and sepsis in 1(16.6%) patient. Segmental defects in the first metacarpal were present in 3(50%) patients, first and third metacarpal in 2(33.3%) and third metacarpal in 1(16.6%) patient. Vascularized bone graft spare part pedicle of index phalangeal osteocutaneous was used in 6 patients, 2nd metacarpal osseous in 1(16.6%) and ring phalangeal osteocutaneous in 1 (16.6%). The average length of harvested bone graft used was 4.13cm (Range 3 to 5.5cm). All the flaps survived and bones united. Acceptable hand functions were restored in 4(66.6%) and mangled hand in 2(33.3%) patients. All patients resumed their work status and functional results were satisfactory. Conclusion: Severely damaged and complex hand injuries treated with vascularized bone graft spare parts technique had good radiological and functional outcome. We, therefore recommend that vascularized bone graft pedicle spare parts of a severely injured hand should be innovated as a possible source for one stage reconstruction of the hand.

Objectives: To determine the functional and radiological outcome of arthrodesis of the knee using the Ilizarov method. Methods: This descriptive study was conducted in Bolan Medical Complex Hospital Quetta and National Institute of Rehabilitation Medicine Islamabad from January 2016 to January 2019.All patients meeting the inclusion criteria were operated with Ilizarov for knee arthrodesis. Clinical evaluation was conducted at follow up with assessment of post-operative pain and patient’s ability to ambulate. Progressive bone fusion and limb alignment were evaluated on serial radiographs. The criterion for a complete arthrodesis was bone bridging on at least two views. Results: The total number of patients in our study were 11 with mean age 35.2 ± 13.6(range 23 to 70) years. All the patients were male. The indications for arthrodesis were post-polio fixed flexion contracture of the knee in 3(27.3%) patients, failed knee arthrodesis with other methods in 2(18.2%),sever knee trauma in 2(18.2%),sever knee pain in 1(9.1%),tuberculosis of knee in 1(9.1%), septic arthritis in 1(9.1%) and Charcot arthropathy in 1 (9.1%) patient. Patients were allowed to had partial weight bearing day after surgery. Full weight bearing was allowed a mean of 145 days (range105-195 days). The average follow up from frame removal was 21 months (range, 12-24months). In all 11(100%) a stable arthrodesis clinically and radiologically was achieved after a mean Ilizarov external fixator time of 147days (range120-195 days). Minimal complications were noted despite early weight bearing and no further surgeries were required. Conclusion: Knee arthrodesis with Ilizarov resulted in stable arthrodesis and pain free mobility. The technique offers several advantages compared with other arthrodesis methods because of fixation versatility, stability and early weight bearing. It had a high union rate and minimal post-operative complications.

Objective: To determine the efficacy of 1% Silver Sulphadiazine and Chlorhexidine dressing combined versus 5% Chlorhexidine dressing alone in preventing pin tract infection in external fixators. Methods: This was a comparative study done in the Orthopedic Department Hayatabad Medical Complex(HMC) from March 2015 to March 2018 on 198 patients with external fixator in tibia. This study compares the frequency of pin tract infection(PTI) in patients treated with 1 % Silver Sulphadiazine and 5% Chlorhexidine combine (group A) and 5% Chlorhexidine alone(group B).Patients were labelled to have pin tract infection if signs of infection(redness, tenderness, discharge) were noted at pin sites. Result: The total number of patients in our study were 198 and equally divided into group A and group B. Treatment in group A was effective in 90 (90.9%) patients while group B was effective in 71(71.7%). The difference was statistically significant (p value 0.001). Conclusion: Combined 1% Silver Sulphadiazine and 5% Chlorhexidine was effective in preventing pin tract infection in majority of patients with external fixators than 5% Chlorhexidine dressing alone.

It is a matter of honour for me to write this editorial for Journal of Pakistan Orthopaedic Association (JPOA). In my short carrier of more than two decades in Pakistan, I have seen Orthopaedic grow from trauma service and few individual shining stars to rapid growth of orthopaedic subspecialty. This trend is spreading to all major cities of Pakistan. The opportunities for young orthopaedic surgeons have never been so widespread. Orthopaedics is passion and is not for the faint at heart. So, I believe and so was my motto when I took onto orthopaedic surgery as a career. I have come a long way down the road and as immediate past president of Pakistan Orthopaedic Association (POA), it is a matter of immense pleasure for me to have represented the orthopaedic fraternity of this country at the highest possible level. I have represented Pakistan internationally at various orthopaedic congresses at USA, Australia, UK, Turkey, Singapore, China and Malaysia.

Talus dislocation with a fracture of the body of talus is a relatively rare clinical entity. Medial subtalar dislocation accompanying this type of fracture was reported only once in Germany in 1968. For the past 50 years, there have been no other cases in the literature. In this article, we report the results of surgical treatment and 2-year follow-up of a patient who presented to the emergency department with such an injury. Radiographs of the ankle revealed a subtalar medial dislocation; however, a talus fracture was not detected. An Xray in the lateral projection of the right ankle obtained after closed reduction under sedative anesthesia showed a fracture of the talar body with displacement. Under spinal anesthesia with anteromedial and anterolateral exposure to the ankle joint, fracture was openly reduced and fixed two cannulated screws(4.5 mm)n the day of presentation to support subtalar joint stability, and one 2-mm Kirshner wire was placed toward the calcaneus to the talus. At 2-year follow-up excellent functional outcome of ankle joint was noted without any avascular necrosis of talus or tibiotalar and subtalar arthrosis.

Objective: To compare the mean (days) required for correction of deformity by using classical versus accelerated Ponseti techniques in patients with congenital idiopathic clubfoot. Methods: It was a Randomized controlled trial conducted in General Orthopaedic Ward Ghurki Trust Teaching Hospital affiliated with Lahore Medical & Dental College, Lahore. The Study was carried out over a period of six months from 25-07-2017 to 24-1-2019.The total number of patients were 80 (40 patients in each group) in this study. Group-A was treated with Standard Ponseti (SP) method and group-B was treated with accelerated Ponseti. Results: Patients mean age was 1.6.±0.79 and 1.58±0.79 months in Group A and Group B, respectively. In Group A, 24 patients (60%) and in Group B 18 patients (45%) were males while 16 patients (40%) in Group A and 22 patients (55%) in Group B were females. Comparison of mean time (days) required for correction of deformity were 36.88±5.11 days and 20.73±3.40 in Group A and Group B respectively with p value <0.05. Conclusion: The Accelerated form of Ponseti technique is a very effective way for managing patients with congenital club foot.It reduces the duration of total casting without any effect on outcome as compared to classical method of ponseti.

Objective: To determine the radiological and functional outcome of open reduction and internal stabilization of lateral condyle humerus fracture in children. Methods: This study was conducted in Orthopedic unit, Mardan medical complex, Mardan with a total number of 38 patients. The study duration was from from15 March 2017 to 14 March 2019.All the children had mean age of 6.68 (range; 2-14) years including 25 male and 13 female patients. Among them, 25 patients had Milch Type II while rest had Milch Type I fracture. All the patients were operated and stabilized with k-wire added by the back slab. Plaster removed after 6 weeks and k-wires within 4-6 week. All patients were followed on 2nd, 4th, 6th and at 12th week. At last, follow up the childrens were assessed for the union, carrying angle and elbow range of motion through Hardacre criteria. Results: All fractures united in a mean time of 4.73 weeks with a range of 4-7weeks. Outcomes were excellent in 78.98% patients, good in 18.42 % and poor in 2.63%. No major complication reported in any case. Conclusion: Open reduction and internal stablization with k-wire is an excellent method of fixing lateral condyle fractures in children with excellent radiological and functional results.

Objective: The objective of our study was to assess the functional results of Ilizarov fixator for treating proximal tibial fractures. Methods: The design of our study was descriptive and we conducted this study in the department of Orthopedics Surgery Unit-I, PGMI/ AMC, Lahore General Hospital, Lahore from 14-5-2018 to 14-11-2018. In this study, 75 patients fulfilling inclusion criteria were selected. After informed consent demographic information like name, age, gender and address of each patient was noted. The surgery is performed under C-arm fluoroscopy. All the patients were followed clinically for 24 weeks. In each visit pain was assessed with Visual Analogue Sacale (VAS) and range of knee motion measured with a goniometer. Results: A total of 75 patients with mean age 39.25±10.84 years were included in our study. Majority (81.3%,n=61) were males. Mean value of body mass index was 25.04±4.04. Majority(40%,n=30) of the cases belonged to Schatzker type III. Mild pain according to VAS was noted in the 43(57/3%). Knee range of motion was 106±6.82 degree post operatively. Conclusion: The Ilizarov external fixator is an excellent method of treating Proximal tibial fractures. It results in good knee range of motion post operatively and with low pain.

Objective: To objective of the study is to find out the prevalence of vitamin D deficiency in patients with non-specific musculoskeletal pain presenting to outpatients department at a tertiary care hospital of Khyber Pakhtunkhwa. Methods: The design of our study was cross section and was conducted on 253 patients with age above 15 years presenting to Orthopedic Out Patients Department (OPD) of a tertiary care hospital from from 21st June 2018 to 20th June 2019.These patients presented with non-specific musculoskeletal pain like generalized body aches, bone pain, weakness and fatigue with no other complaints such as fever, visceral pain and any other trauma history. Their routine test like complete blood count(CBC), Renal Function Tests(RFT),Erythrocyte Sedimentation Rate (ESR) and random blood sugar (RBS) were normal. They were screened for Vitamin D level. Results: out of 253 patients 37.94 %( n= 96) were male and 62.05% (n= 157) were female .Vitamin D deficiency was below normal in 75.49% (n= 191) patients comprising of 58.1% (n= 111) patients had deficiency and 41.8% (n= 80) had insufficiency while 24.5% ( n= 62) showed sufficient level. In comparison to other age groups Vitamin D level was deficient and insufficient in 15 to 35 age group. Conclusion: A high prevalence of vitamin D deficiency is present in our population. The Orthopaedic surgeon must keep his suspicion high for of vitamin D deficiency in patients of non specific musculoskeletal pain.

Objective: To evaluate functional outcome of the anterior interosseous nerve transfer to the motor branch of the ulnar nerve for cases of high ulnar nerve injuries Methods: This descriptive study was conducted in Hand and Upper Limb Surgery (HULS) CMH Lahore Medical College Pakistan from 21st July 2016 to 21st August 2018. A total of 13 patients (10 males, 03 females), mean age 32years(range 18 to 42) with injury to the ulnar nerve(high) were treated with anterior interosseous nerve(AIN) transfer to the motor branch of ulnar nerve. Functional outcome was evaluated clinically preoperatively, immediately postoperatively and 03 to 06 month follow up to evaluate motor functional grading system. Results: In high ulnar nerve injury in whom anterior interosseous nerve was transferred all cases showed good outcomes (M3 to M4 by motor functional grading system) with mean initial recovery period of 3.5 months Conclusion: Treatment of high ulnar nerve injury with transfer of the anterior interosseous nerve to the motor branch of the ulnar nerve results in early near normal intrinsic recovery and restoration of hand functions.

Objective: To determine the survival of sural artery flap reconstruction of complex soft tissue defects around the knee and use of ilizarov for fixation of proximal tibial fracture. Methods: This descriptive study was conducted in Orthopedic Department of Sheikh Zayed Medical College/Hospital, Rahim Yar Khan in the period extending from 23rd February 2014 to 23rd June 2019. All the patients fulfilling the inclusion criteria were operated for proximally based sural artery flap to cover the defect and fracture stabilized with Ilizarov fixator. Follow up was for a period of minimum of 06 months for flap survival and up to 1 year for fracture union and knee range of motion. Results: There were total 17 cases including 14(82.3%) male and 3(17.6%) female with mean age 35±9 years. Road traffic accidents were responsible for majority(64.7%,n=11) of cases while 6(35.2%) had gunshot injuries. The flap sizes ranged from 6x6cm up to 12x cm with pedicel length ranges from 4x10cm.Majority(88.2%,n=15) of flap survived. Proximal tibial fractures united in all patients. Full knee range of motion was documented in all the patients at final follow up. Conclusion: Proximally based sural artery fasciocutaneous flap with Ilizarov fixator is a reliable method for reconstruction of complex soft tissue defects around the knee. It has good outcome and only few complications.

Objective: To determine the frequency of text neck syndrome in medical undergraduate students using smart phone, tablets or laptop. Methods: It was a cross-sectional survey using non-probability convenient sampling technique at Combined Military Hospital(CMH) Lahore medical college and Institute of dentistry, Lahore from January 2019 to February 2019 in a period of one month. Our sample size was 500 undergraduate students from first year till final year MBBS and BDS. The inclusion criteria of the study were all medical undergraduates who were using smart phone, tablet and laptop for past six-month or more. We filled all questionnaire at the spot. The exclusion criteria of the study were all questionnaire which were filled with the help of colleague, going through internet, and left incomplete. Data was obtained using pre-tested self-administered questionnaire. Results: Out of total 500 medical students, 292 (58.4%) were female and 208 (41.6%) were male. The mean age of our study subjects were 23 ±2 years. The frequency of text neck syndrome was documented in 218 (43.6%) students. There was no disability (0-4 scores) in 292(58.4%) students, mild disability(5-14 score) in 150(30%) students and moderate disability (15-24 scores) in 58 (11.6%) with p-value <0.004. Conclusion: Text neck syndrome was common in medical students using smart phones. Females students were more prone to have text neck syndrome than male students.

Objective: The objective of our study is to determine the frequency of non union in ipsilateral femur and tibia fractures treatment. Methods: This descriptive study included 30 patients having ipsilateral femur and tibia fractures in District Headquarter Hospital(DHQ)Teaching hospital Dera Ismail Khan( DI khan) from January 2016 to December 2018.Adult patients of either gender having ipsi lateral femur and tibia fractures fulfilling the inclusion criteria and treated surgically were included in this study. Postoperatively all the patients were seen at 2 weeks, and then every month till union is achieved. Results: In our study male were 27(90%) and female 3(10%).The mean age of our patients were 43±4SD. Femur interlocking nailing was done in 23(76.6%) cases and platting in 7(23.3%) cases, while tibia platting was done in 25(83.3%) cases and interlocking in only 5(16.6%) patients. A total of 11(36.6%) patients had non union. In 7(23.3%) patients femur alone went to non union while in 4(13.3%) patients femur non union was accompanied with tibia. Femur fractures treated with plating had a non union percentage of 20%(6 patients) while 5(16.6%) patients with interlocking nail reported non union.Among patients of tibial non union, 2(6.6%) had interlocking nail and 2(6.6%) had plating. All femur plates were replaced with interlocking nails and exchange nailing was done in all six interlocking femur nonunion cases. In all four tibial nonunion only bone grafting was added at nonunion site after refreshing the area. Conclusion: The frequency of non union in ipsilateral femur and tibia treatment is higher in femur than in tibia. Patients treated with femur platting had more chances of non union than with interlocking nail.

We present a rare case report of bilateral radial nerve palsy in a man with tibia fracture who used axillary crutches for mobility. Upon diagnosis axillary crutches were discontinued, fracture stabilized with nail and elbow supports given immediately, followed by physical and occupational therapy. 12 weeks after his first presentation, radial nerve function was fully recovered bilaterally. Radial nerve function loss due to improper use of crutches requires prompt diagnosis and treatment to have early and full recovery. Demonstration of proper use of crutches and proper fitting can prevent its complications. Patients should be well informed in unequivocal terms not to put weight on axillary bars directly. We report a case of an uncommon entity of both sides wrist drops in a patient of tibia fracture who was using axillary crutches for mobility.