We live in an amazing world at amazing times as we are in the evolutionary stages of Orthobiologics. Now we are increasingly looking for biological solutions of biological problems and the best news is that it has gone from science fiction to a very real entity. Similarly access to investigations for previously impossible tasks have become a reality. Imagine a scenario when one is playing sports and hurts his shoulder and we would like to investigate him after a thorough clinical assessment. We would like to order a Magnetic Resonance Imaging (MRI) to exclude soft tissue injuries and we run into a well as the patient is claustrophobic, has a pacemaker or is overweight or has metal inside his body.1,2 Although clinical examination and MRI play a key role in diagnosis, sometimes interpretation can be unclear or even wrong.3,4 Nothing is more accurate than direct visualization, particularly when we have to determine if the patient need surgery.5,6With forward thinking and innovation technology there is now a real solution Office -Based Needle Arthroscopy.7 It is a small Gadget that will make a Big Difference to the clinical practice.8 (Fig IA, IB, IC, ID) Clinic or of?ce based arthroscopy is by no means a new idea but it has previously failed to become widely used. This is probably due the dif?culties in transferring the type of required equipments (which closely mirrored that used in operating theatres) to the clinic environment

Objective: To determine the radiological outcome of Scaphoid nonunion treated with modified Matti-Russe technique. Methods: This descriptive study was conducted in Department of Orthopedics Khyber teaching hospital Peshawar from 23rd June 2017 to 23rd June 2020. All patients with Scaphoid nonunion fulfilling the inclusion criteria were treated with modified Matti-Russe technique. Regular follow up was done and radiological union was confirmed with X ray wrist AP and lateral View. Results: The total number of patients enrolled in our study were 16. Male patients were 14(87.5%) and female were 2(12.5%). Mean age was 32.5±5.87 years. Right sided scaphoid non union was present in 10(62.5%) patients and left in 6(37.5%) patients. Mean time since fracture at presentation was 17 ±4.49 weeks(range 12 to 18.3 weeks).Post operatively all patients achieved radiological union. The average union time was 15±2.5 weeks (range 13.4 to 16 weeks). No major complication noted. Conclusion: Modified Matti-Russe technique is a reliable option for the treatment of Scaphoid nonunion as it showed high percentage of healing in our series. We therefore recommend this technique as treatment of choice to treat Scaphoid non union.

Objective: To determine the short term radiological outcomes of Lenke type 5C adolescent idiopathic scoliosis in terms of Cobb angle correction and coronal balance after selective posterior segmental spinal instrumentation with pedicle screws. Methods: This retrospective cohort study was conducted in Department of Orthopedic and Spine Surgery Ghurki Trust Teaching Hospital/ Lahore Medical and Dental College Lahore. The medical records of patients from 17th April 2015 to 29th October 2019 who underwent selective spinal fusion with pedicle screws for Lenke type 5C adolescent idiopathic scoliosis were reviewed. Pre-operative radiographs were evaluated for Cobb angle of lumbar or thoracolumbar curve as well as sagittal and lumbar modifier on anteroposterior and lateral standing films. The curve correction, implant density, number of segment fused and coronal balance was assessed on post operative radiographs. The pre and post operative comparison of important study variables were done and P value was calculated with the help of Chi-square test. P value < 0.05 was considered statistically significant. Results: The total number of patients were 34. Majority (94.1%,n=32) were females while only 2(5.9%) were males. The mean age at the time of operation was 14.35±2.19 years (range 8 to 19 years). Mean pre-operative and post-operative Cobb angles were 61.790±13.120 (range 400 to 850) and 10.550±8.710 (range 00 to 300) respectively (P value 0.00). The mean percentage of curve correction and percentage of fulcrum flexibility was 83.35±13.07 % (range 55% to 100%) and 59.56%±15.07 (range 28.57% to 84.60%) respectively (P value 0.469). Mean implant density and fusion mass was 66.03±7.94% (range 53 to 79%) and 10.32±2.8 (range 7 to 15%) segments respectively. The coronal balance was achieved in all patients. No major complication was noted. Conclusion: Near normal Cobb angle correction and coronal balance was achieved in all patients of Lenke type 5C adolescent idiopathic scoliosis treated with posterior segmental spinal instrumentation utilizing pedicle screws.

Objective: To determine the efficacy of hematoma block in reducing distal radius fractures in terms of radiological correction and frequency of re manipulation. Methods: We conducted this descriptive study in Department of the Orthopedic Surgery Bolan Medical Complex Hospital(BMC) Quetta from 3rd January 2018 to 3rd June 2020.All patients with distal radius fractures fulfilling the inclusion criteria were manipulated and casted under hematoma block in emergency department. Fracture reduction was confirmed by measuring important radiological parameters on immediate post reduction radiographs and at weekly interval for six weeks. Radiographic reduction was graded as excellent, good, fair and poor as per modified Sarmiento criteria. Patients with unacceptable radiographic correction were re-manipulated. P value was calculated by using Chi-square test for determining significance between important proportions.(P value< 0.05 was considered significant). Results: The total number of patients in our study were 120. The mean age was 60.9±8 years(range 51 to 89 years).Female patients were 91(75.8) and male 29(24.1%).Majority(65.8%,n=79) of our patients had right sided fracture while left side fracture was noted in 41(34.1%) patients. Immediate post reduction radiographs revealed excellent outcome in 109(90.8%) patients and good in11(9.1%) patients and no re-manipulation or revision was needed. The percentage of re-manipulation rate was 1.6%(n=2) at one week as radiographic reduction was not acceptable (P value < 0.05). At final follow up at 6th week excellent and good radiographic reduction was noted in 106(88.3%) and 14(11.6%) patients respectively and no re-manipulation was documented (P value < 0.05).No complication was noted. Conclusion: Distal radius fractures in elderly patients treated with closed reduction and casting under hematoma block in emergency department achieved excellent radiographic reduction in majority of our patients. A very low re-manipulation rate was noted.

Objective: To determine the efficacy of hematoma block in reducing distal radius fractures in terms of radiological correction and frequency of re manipulation. Methods: We conducted this descriptive study in Department of the Orthopedic Surgery Bolan Medical Complex Hospital(BMC) Quetta from 3rd January 2018 to 3rd June 2020.All patients with distal radius fractures fulfilling the inclusion criteria were manipulated and casted under hematoma block in emergency department. Fracture reduction was confirmed by measuring important radiological parameters on immediate post reduction radiographs and at weekly interval for six weeks. Radiographic reduction was graded as excellent, good, fair and poor as per modified Sarmiento criteria. Patients with unacceptable radiographic correction were re-manipulated. P value was calculated by using Chi-square test for determining significance between important proportions.(P value< 0.05 was considered significant). Results: The total number of patients in our study were 120. The mean age was 60.9±8 years(range 51 to 89 years).Female patients were 91(75.8) and male 29(24.1%).Majority(65.8%,n=79) of our patients had right sided fracture while left side fracture was noted in 41(34.1%) patients. Immediate post reduction radiographs revealed excellent outcome in 109(90.8%) patients and good in11(9.1%) patients and no re-manipulation or revision was needed. The percentage of re-manipulation rate was 1.6%(n=2) at one week as radiographic reduction was not acceptable (P value < 0.05). At final follow up at 6th week excellent and good radiographic reduction was noted in 106(88.3%) and 14(11.6%) patients respectively and no re-manipulation was documented (P value < 0.05).No complication was noted. Conclusion: Distal radius fractures in elderly patients treated with closed reduction and casting under hematoma block in emergency department achieved excellent radiographic reduction in majority of our patients. A very low re-manipulation rate was noted.

Objective: To determine the accuracy and validity of Bhatti Functional Scoring System (BFSS) for the evaluation of post-surgical reduction of Developmental Dysplastic Hips versus clinical evaluation systems designed by Ferguson and Howarth and McKay’s clinical Criteria. Methods: This cross-sectional study included patients with Developmental Dysplastic Hips operated for open reduction during 1st June 2016 to 30th June 2017 with minimum follow up duration of one year. The study was conducted in Department of Orthopaedic Surgery Paediatric Orthopaedic section at Jinnah Postgraduate Medical Centre (JPMC) Karachi and Neurospinal Cancer Care Institute (NMI Hospital), Karachi Pakistan. The functional outcome was evaluated by Ferguson and Howarth rating system, McKay’s Criteria and Bhatti functional scoring system. The parameters compared were time consumed, patient’s compliance, difficulties incurred, functional limitations on clinical evaluation and its compatibility with the eastern lifestyle. Post stratification 2/2 table was used to calculate the Kappa statistics and accuracy. Results: The total number of patients in our study were 48. Male children were 9 (18.8%) and female 39 (88.3%). The mean age was 3 ± 1.45 years(range 2 to 7 years).Excellent outcome was noted in in 87.5%(n=42) patients and good in 6.2%(n=3) patients as per Ferguson Howarth and McKay’s criteria while 89.5%(n=43) patients had excellent outcome and 4.1%(n=2) good as per Bhatti scoring system. The compliance for Bhatti Scoring System was excellent to good in 48 (100%) patients and for Ferguson Howarth and McKay’s criteria 39 (81.25%) patients had excellent to good compliance. The mean time consumed for calculating the Ferguson and Howarth range of motion index was 6.31 ± 0.92 minutes while for of Bhatti scoring system it was 2.0 ± 0.26 minutes(P value <0.05). Bhatti Scoring system was found to be accurate in all patients with validity and cumulative percentage as Kappa 1.00. Conclusion: The Bhatti Functional Scoring System (BFSS) was less time consuming, patient’s friendly and exhibited a more satisfactory compliance. The results were comparable with the Ferguson Howarth rating and McKay’s criteria and validated its accuracy.

Objective: To determine the frequency of micro organisms in open fractures of the extremities and their sensitivity pattern to the commonly used antibiotics. Methods: This descriptive study was conducted in the Department of Orthopaedic Surgery Nishtar Medical University Hospital Multan. The duration of our study extended from 29th June 2019 to 5th July 2020. Patients of either gender and age 18 to 60 years with open fractures meeting the inclusion criteria were enrolled in our study. Wound swabs were taken with Levine technique before surgical debridement and sent to laboratory for Gram staining and culture and sensitivity of the microbial agents. Post stratification comparison of important variables were done and P value was calculated with the help of Chi-square test. ( P<0.05 was considered statistically significant) Results: The total number of patients in our study were 195.Male patients were 161(82.6%) and female 34(17.4%). The mean age was 38.86±8.05 years. The most common fractured bone was tibia (20.5%, n=40) followed by humerus (19%, n=37%) and metacarpals/phalanges (16.9%, n=33). Gustilo Anderson type IIIA was the predominant type of fracture present in 71(36.4%) patients followed by type II (27.2%, n=53).Majority (62.6%, n=122) of the patients were presented to the hospital in time period extending from 6-12 hours of sustaining the injury. The culture report was positive in 187(95.8%) patients while no growth was noted in 8(4.1%) patients. Staphylococcus Aureus was reported in 112(57.4%) patients, Streptococcus in 34(17.4%) and E. Coli in 22(11.3%). Gram positive cultures were most sensitive to first generation Cephalosporin (60.5%, n=118) while Gram negative cultures to Quinolones (69.4%, n=25). Conclusion: Majority of open fractures of the extremities had positive culture of bacteria. Gram positive organisms were the most common isolated pathogens. First generation Cephalosporin was the most sensitive group of drugs against gram positive bacteria.

ntroduction: CoVID-19 (Coronavirus disease) pandemic has involved the whole globe and exposed the limitation of health care system of different countries. Although , different countries have introduced various modalities to protect both general population and health care provider to counter this world health crises but still lacked immensely leading to higher probability of contracting disease .We followed standard protocols and sharing our experience of 2688 cases. Physiological stress compromise immunity of patient result in increasing complications .We also determined rate of mortality and infection in covid and non- covid patients. Methods: Clinical data of 2688 patients was assessed retrospectively who underwent orthopaedics surgeries during the period of COVID-19 wave in Pakistan at Ghurki Trust Teaching Hospital in Lahore, between march 19 to June 30, 2020.Hospital protocol for Covid screening was followed including questionnaire soughting respiratory symtoms,travel history, contact history and investigations like CBC, CRP and chest radiography. HRCT and nasopharyngeal PCR swabs are only performed in highly suspicious patients. Results: Out of 92 highly suspicious patients ,71 came out to Covid-19 positive. Group A patients were significantly younger compared to group B (32.1±18.9 vs. 40.6±26.9, p value 0.008). There was male preponderance in both groups. Lower limb trauma constituted more than half of workload. Majority of patients were given spinal anaesthesia. Operative time was significantly higher in group B (p value <0.0001). Post-operatively, proportion of patients requiring admission to ICU was significantly higher for patients who were COVID positive (p-value 0.002). In 30 day post-operative period 3 (4.2%) COVID positive and 59 (2.3%) COVID negative patients died (p-value 0.22). Conclusion: In this retrospective surgical audit , mortality and complications were equivocal when Covid positive patients were matched with non Covid patients. Therefore ,it is suggested we should continue treating patients .However, protocols and necessary preventive measures should be followed.

Knee Osteoarthritis affects millions of people around the world. Although joint replacement for end stage osteoarthritis improves the quality of life of many it is expensive and some people may not be satisfied with this procedure. However, concerns regarding conservative treatment of patients with early- to end-stage osteoarthritis is mounting. The usual conservative treatment options available for early- to moderate-stage osteoarthritis are anti-inflammatory drugs, steroids and hyaluronic acid injections, Ozone and prolotherapy. Evidence suggests that all such treatment have their own merit and demerits and none is safe in the long term. Due to potential side effects of the available treatment options, it is believed that regenerative medicine (stem cells and platelet rich plasma) can be a good alternative with better long-term outcome and minimal side effects for all stages of osteoarthritis. Regenerative medicine is the new treatment on the horizon that promises to enhances the healing process of damaged tissues and organs with or without the need of surgery and has better efficacy and safety profile.

Objective: To determine the functional outcome of intertrochanteric fractures in elderly patients treated with Dynamic Hip Screw(DHS). Methods: This descriptive study was conducted in Orthopaedic Unit Pakistan Railway General Hospital Rawalpindi from 16th February 2016 and 16th February 2021.All elderly patients with stable intertrochanteric fractures(Evans type IA and Type IB) fulfilling the inclusion criteria were treated with DHS and functional outcome was evaluated at 6 months with Harris Hip Score(HHS) and results were graded as excellent(HHS score 90 to 100),good(HHS score 80 to 90), fair(HHS 70 to 80) and poor(HHS score <70). Results: We operated 280 patients of intertrochanteric fractures with DHS. The mean age was 65.49±7 years. Male patients were 170(60.71%) and female 110(39.28%). Excellent outcome was documented in 151(53.92%), good in 90(32.14%),fair in 22(7.85%) and poor in 17(6.07%) with HHS score of 93.3±5,88.7±7, 77.3±4 and 33.1±9 respectively. Conclusion: Elderly patients with stable intertrochanteric fractures treated with Dynamic Hip Screw(DHS) yielded excellent and good functional outcome in majority of our patients. We recommend DHS an implant of choice to treat stable intertrochanteric fractures in elderly patients.

Objective: To determine the post operative hospital stay and in-hospital complications of total hip replacement (THR) in Lady Reading Hospital Peshawar. Methods: This Descriptive study was conducted in Department of Orthopedic and Trauma, Medical Teaching Institute Lady Reading Hospital Peshawar from 21st February 2020 to 21st October 2021. All patients with Osteoarthritis hip fulfilling the inclusion criteria and operated with cemented total hip arthroplasty were included in this study. Risk Assessment and Prediction Tool (RAPT) Score was calculated pre-operatively for every patient and hospital stay was arranged accordingly and documented any in hospital complications. Patients with RAPT score of less than 6 were labelled as high risk,6 to 9 score medium risk and more than 9 score were labelled as low risk for in-hospital rehabilitation. Results: In this study 39 patients were included. Male patients were 26(66.7%) and female were 13(33.3%). The mean age was 63.05± 4.359 years. Left sided hip was operated in 17 (43.6%) patients and right side in 22(56.4%) patients. Pre-operative Risk Assessment and Prediction Tool (RAPT) Score was less than 6 in 3(7.7%) patients, 6 to 9 in 16(41.0%) and more than 9 in 20(51.3%) patients. The mean post operative hospital stay was 4.28±1.65 days(range 2 to 7 days).The mean post operative hospital stay of three days was noted in 11(28.2%) patients, five days in 8(20.5%) and six days in 7(17.9%). There were 2(5.12%) cases of superficial surgical site infection. Conclusion: The mean post operative hospital stay was short and in-hospital complications were minimum in our series. Preoperative assessment with Risk Assessment and Prediction Tool (RAPT) Score predicted hospital stay accurately in majority of our patients,

Objectives: To determine the indications and complications of implant removal from extremities in adult Orthopaedic patients in Abbasi Shaheed Hospital Karachi. Methods: This retrospective Cohort study was conducted in Orthopedics department Abbasi Shaheed Hospital Karachi. The medical records of all adults patients fulfilling the inclusion criteria who were operated for implant removal were reviewed. The review period extended from 21st January 2019 to 9th January 2021. The indications of implant removal, per operative and post operative complications of implant removal were noted in each case. Results: We reviewed the record of 64 patients. The mean age was 33±13.3 years. Male patients were 47(73.4%) and females were 17(26.5%). The most common indication of implant removal was infection(23%,n=23.4%) and pain(20.3%,n=13).The most common implant removal was locking compression plates in 19 (29.6%) patients followed by 3.5mm dynamic compression plates in 13(20.3%) and interlocking nail in 12(18.7%) patients. Tibia was the most commonly involved(28.1%,n=18) bone. Per operative complications were difficulty to access the implant in 8(12.5 %) cases, screw breakage in 5(7.8%) patients and implant breakage in 3(4.6%) patients. Post operatively 16(25%) patients were complaining of limb pain while 12(18.7%) patients had persistent local infection. Conclusion: The most common indication of implant removal was infection in our series. Difficulty to access the implant and screw breakage were the most common per operative complications while pain and persistent local infection were the most common post operative complications.

The Pakistan Orthopedic Association(POA) and Aga Khan University Hospital has the honor and pleasure to host the 34th international Orthopaedic conference 2021 which is to be held on 11th to 14th November 2021 in Pearl continental hotel Karachi Pakistan. The theme of the conference is “Aging gracefully”. We invite you not only to actively participate in an extraordinary scientific meeting but to meet friends and connect with other Orthopedic surgeons as well. It is our aim to allow as many Orthopedic surgeons as possible to report their scientific and clinical experience. At the same time we want to bring together all the various disciplines of Orthopedic surgery from all parts of the country. All main topics of Orthopedic surgery will be included into the scientific program.

More than one hundred thousand children are born each year with congenital clubfoot, or talipes equinovarus, mostly in low and middle-income countries (LMIC) where there are often deficiencies in access to health services. The overall burden of disease can be appreciated by adding these incident cases to the hundreds of thousands of cases that have not received treatment or have residual deformities following previous treatment. There are also numerous cases associated with syndromes and neuromuscular diseases, and also patients who have had a relapse after previous treatment including extensive surgical releases. While the disability due to a neglected or untreated clubfoot has not been quantified to our knowledge, consequences may include pain and/or reduced endurance during ambulation, calluses or skin breakdown from altered loading and shear stresses, and the inability to accommodate standard footwear. Perhaps the greatest disability may be rooted in the social stigma, children may be subject to verbal abuse, females may suffer more than males, and in some cultures a young lady may be unable to have an arranged marriage if she has an untreated clubfoot. Addressing the global burden of clubfoot is a multifaceted challenge. On one hand we need trained orthopaedic surgeons who are comfortable with a variety of procedures to provide technical solutions for individual patients. At the population level we need a public health approach in which systems for delivering the Ponseti method are developed and integrated within the health system, focusing on screening for early diagnosis, prompt referral for treatment, and adequate follow-up to address relapses and/or other concerns. It is clear that “one size does not fit all” when either caring for individual patients or organizing services to different regions of a country, contextually relevant solutions must be sought.

Objective: To determine the functional and radiological outcomes of Ilizarov fixator in managing open fractures shaft of femur. Methods: This descriptive study was conducted in Orthopaedic department Aga khan University hospital Karachi from 23rd January 20015 to 25th December 2020.All adults patients of both gender and age with open fracture femur fulfilling the inclusion criteria were operated with Ilizarov fixator. Functional and radiological outcomes were determined by using the Association for the Study and Application of Methods of Ilizarov (ASAMI) scoring system. The bone results and functional results were graded as excellent, good, fair and poor as per ASAMI scoring system. Results: We operated 32 patients of open fractures femur with Ilizarov fixator. The mean age was 41±7 years. Male patients were 31(96.87%) and female 1(3.12%). Right sided femur shaft fracture was present in 17(53.12% ) and left sided in 15(46.87%). The aetiology of fractures was road traffic in 24( 75%) and gunshot in 8( 25%) patients. Gustilo Anderson type IIIA fractures were present in 22(68.75%) and type IIIB in 10(31.25%) patients. Post operative bone results using ASAMI score were excellent in 16(50%), good in 15(46.87%) and fair in 1(3.12% ) patient. Function result using ASAMI score were excellent in 18(56.25%),good in 13(40.62%) and fair in 1(3.12%) patient. The average cost of treatment was 350,000 rupees. Conclusion: Illizarov fixator is a cost effective option for managing acute open femur fractures. Excellent and good functional and radiological results were achieved in majority of our patients.

Objective: To determine the outcome corticosteroid injection in reducing the intensity of pain in patients with plantar fasciitis. Methods: This was a descriptive study conducted in Department of Orthopaedics, Jinnah Post Graduate Medical Centre (JPMC), Karachi, Pakistan from 1st January 2018 to 1st January 2020.All patients with plantar fasciitis meeting the inclusion criteria were injected single injection of Triamcinolone in the heel and followed in the OPD at two weeks, four weeks and twelve weeks interval. Outcome was assessed in terms of pain reduction as measured with Visual analog scale (VAS). Results: The total number of patients were 50. The mean age was 41.83 ± 14.07 years. Male patients were 27(54%) while female patients were 23(46%). The mean pre injection VAS improved from 5.41±3.1 to 1.3±7 post injection (P=0.03). Conclusion: Plantar fasciitis treated with single injection of corticosteroid injection resulted in significant pain reduction.

Objective: To compare the functional outcome of double Peroneus Longus with Quadrupled Hamstring in primary isolated Anterior Cruciate Ligament Reconstruction(ACL) Methods: This randomized trial was conducted in Orthopaedic department Allied Hospital Faisalabad from 23rd March 2015 to 23rd March 2020.All adults patients with ACL tear fulfilling the inclusion criteria were randomly and equally divided into group A( double Peroneus Longus ) and group B( Quadrupled Hamstring) and operated arthroscopically.Post operative functional outcome was assessed with Tegner-Lysholm score and International Knee Documentation Committee (IKDC) and American Orthopaedic Foot and Ankle Society Score(AOFAS) at 12th months follow up and compared with pre operative values. P value was calculated with paired t test for statistical significance. P value < 0.05 was considered significant. Results: A total of 62 patients were enrolled in this study but 56 completed the study. Both group A and B had 28 patients each. Male patients were 26( 92.85%) in group A and 27( 96.42%) in group B. Female patients were 2(7.14% ) in group A and 1( 3.57%) in group B. The mean age of group A was 39.4±6 years and group B 39.6±2 years. Right ACL was ruptured in 17(60.71% ) in group A and 19(67.85% ) in group B. The mean Tegner-Lysholm score improved from preoperative 69.1 + 2.9 to post operative 92.2 + 2.5 at 12 months in group A while in group B it improved from 70.5 + 1.5 to 91.4 + 1.7(P >0.05).The mean IKDC score improved from 40.7±3 to 91.4±1 in group A while group B had pre operative IKDC score of 42.5±5 and improved to 92.7±3(P >0.05) at 12 months. The mean pre-operative AOFAS score of group A was 100 and post-operative score was 98.4 ± 2.1(P >0.05). Conclusion: Both double Peroneus Longus autograft and Quadrupled Hamstring was effective in treating ACL reconstruction. No statistically significant difference however was noted in the functional outcome of double Peroneus Longus autograft when compared with Quadrupled Hamstring for primary Anterior Cruciate Ligament Reconstruction(ACL) at 12 months follow up

Objective: To determine the aetiology of total knee arthroplasty (TKA) failure and assess the functional outcome of patients who underwent revision total knee arthroplasty. Methods: It was a descriptive study conducted in Orthopaedic department Aga khan university hospital Karachi from 3rd Jan 2010 to 25th December 2020. All patients with primary total knee replacement who underwent revision total knee arthroplasty were included in this study. The indications for revision arthroplasty were documented. Functional outcome of revision total knee arthroplasty was assessed at 6 months with Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire. The preoperative and post operative WOMAC score were compared with Student-t test an P value calculated. P value <0.05 was considered significant Results: The total number of patients included in this study were 29 with 33 knees. The mean age was 60.60 ±6.78 years. Majority(86.20%,n=25) of our patients were female while males were only 4(13.7%).Unilateral revision arthroplasty was done in 25(86.20%) patients and bilateral in 4(13.79%). The aetiology of revision arthroplasty was Infection in 15(45.45%) knees, aseptic loosening in 14(42.42%) and periprosthetic fractures in 4 knees (12.12%). The pre revision WOMAC pain score was 18.4±3, stiffness score 8.1±7 and function score was 72.5±4.Revision arthroplasty yielded significant improvement in WOMAC score at 6 months with WOMAC pain score of 2.2±1,stiffness 3.4±6 and function 10.4±4(P<0.05). Conclusion: Infection was the most common cause of revision arthroplasty in our series. Revision arthroplasty yielded acceptable functional outcome in majority of our patients.

Objective: To determine the surgical outcomes of fungating sarcomas. Methods: This descriptive study was conducted in Orthopaedics and Spine Unit Hayatabad Medical Complex Peshawar and Rehman Medical Institute Hayatabad Peshawar from 2nd January 2016 to 2nd December 2020.Patients of both gender and all ages with fungating sarcoma of bony or soft tissue origin meeting the inclusion criteria were included in this study and operated. Analysis of patient’s characteristics, tumour type, surgery, complications, recurrence and mortality was noted in each case. Results: We operated 16 patients of fungating sarcomas. The mean age was 30.5±17 years. All patients were male. Soft tissue sarcoma was present in 8(50%) and bony in 8(50%). Upper limb sarcoma was noted in 9(56.25%),lower limb in 6(37.5%) and neck in 1(6.25%) patient. Resection of soft tissue sarcomas followed by reconstruction was performed in 4( 8.69%) patients. Forequarter amputation was performed in 6(37.5%) cases, 3(18.75%) patients underwent hip disarticulation and 3(18.75%) patients had transfemoral amputations. Local complication was noted in 4(25%) patients with 3(18.75%) had wound dehiscence and 1(6.25%) had local recurrence at three months. Post surgery the mean survival time was 8 months and at 2 years follow up only 4(25%) patients were alive. Conclusion: Poor post operative prognosis and high mortality was noted for fungating sarcoma in our series. We however advise surgery for fungating sarcomas to alleviate symptoms and misery of these patients and improve their quality of life.

Objective: To determine the effectiveness of intra-articular injections of Platelet Rich Plasma (PRP) in early Osteoarthritis knee in terms of pain reduction and improvements in functional outcome. Methods: This descriptive study was conducted in Department of Orthopedics Surgery Punjab Rangers Teaching Hospital Lahore/ Rahbar Medical and Dental College Lahore from 23rd March 2018 to 23rd March 2021.All patients with early osteoarthritis knee fulfilling the inclusion criteria were administered two intra-articular pure PRP injections. Follow up assessment was done at 6 weeks, 3 months, 6 months and one year for pain reduction measured on Visual Analog Scale (VAS) and functional improvement assessed with Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire. The pre and post injection WOMAC and VAS values were compared P value calculated with Student-t test. P value <0.05 was considered significant. Results: Two intra-articular injections of PRP were administered to 84 knees in 61 patients. Female patients were 35(57.37%) and male 26(42.62%). The mean age was 61.5±2.3 years. Majority (60.71%,n=51) of knees had grade II Osteoarthritis while 33(39.28%) knees had grade I Osteoarthritis. In each follow up visit a significant improvement (P <0.05) in pain reduction(VAS) and functional outcome(WOMAC) was observed which persisted till last follow up visit at one year follow up. No complication was reported. Conclusion: Two intra-articular PRP injections in early Osteoarthris knee yielded significant reduction in pain and improvement in functional outcome.

Objective: To determine the functional outcome of closed humeral shaft fractures treated with functional brace. Methods: This descriptive study was conducted in Orthopedic Department District Headquarter hospital Teaching Hospital Kohat Development Authority(KDA) Kohat and Khyber Teaching Hospital Peshawar from 23rd February 2018 to 23rd February 2020.All patients with humeral shaft fractures meeting the inclusion criteria were treated with functional brace. Functional assessment was done at 6 months follow up according to Stewart and Hundley criteria and graded as good, fair and poor. Results: The total number of patients in this study were 22. The mean age was 36.23±9.05 years. Males patients were 14 (63.64%) and females were 8 (36.36%). According to Stewart and Hundley criteria, functional outcome in our patients was good in 17(77.27%) patients, fair in 3(13.64%) and poor in 2(9.09%)patients. We achieved union in 20 (90.91%) patients. However, non-union was seen in 2 (9.09%) patients. Conclusion: Closed humeral shaft fractures treated with functional brace had satisfactory union rates and good functional outcome in majority of our patients.

Total hip and knee replacement is one of the most common procedure in the world. Infection of the hip and knee replacement could be devastating. The infection rate after primary arthroplasty is 1% to 2% and after revision arthroplasty is 2.5% to 3.2%. The infection of ipsilateral hip and knee is a rare condition. We are presenting a case of 48 years old female who presented to us with this condition. She had Klebsiella Pneumonia infection of the ipsilateral hip and knee. She undergone removal of the total hip and total knee implants followed by multiple debridement and irrigation of the femur and tibia. Later on revision total hip arthroplasty was done with custom design prosthesis and knee arthrodesis at the ipsilateral knee. Patient did very well and manage to walk out of the hospital. We managed to salvage the limb with good outcome.

Objective: To determine the functional outcome of limited fasciectomy for the treatment of Dupuytren’s contracture. Methods: This descriptive study was conducted in District Head Quarter Hospital Timergara Khyber Pakhtunkhwa and Khyber Teaching Hospital Peshawar from 21st March 2018 to 21st March 2021. All patients of Dupuytren’s contracture fulfilling the inclusion criteria were treated with limited fasciectomy (LF). Post operative functional outcome was assessed with Khan and Iqbal criteria and graded as excellent, good, fair and poor. Results: In this study 12 patients (20 hands) were included. All patients were male. The mean age was 61.5± 7 years. The mean duration of follow up was 14.4±3(range 12 to 16 months). Excellent outcome was reported in 14(70%) hands, good in 5(25%) and fair in 1(5%) hand. No intra operative or post operative complications were noted. We reported recurrence in one hand. Conclusion: Excellent functional outcome was achieved with limited fasciectomy in patients with Dupuytren’s contracture in our series. We recommend limited fasciectomy as the technique of choice to treat Dupuytren’s contracture.

Objective: To compare the percentage of slip difference using the standing and supine lateral radiographs in symptomatic degenerative lumbar Spondylolisthesis. Methods: This descriptive study was conducted in department of Spine surgery unit Hayat Abad Medical Complex Peshawar from 2nd January 2019 to 2nd December 2020.All adults patients of both gender with low backache due to degenerative Spondylolesthesis meeting the inclusion criteria were enrolled in this study. All patients underwent standing and supine lateral radiographs. Slip of Spondylolesthesis was calculated according to Dupuis technique. Percentage of slip on standing radiographs were compared with supine and p value calculated using student t test. P value <0.05 was considered significant. Results: The total number of patients were 30. The mean age was 44.60±6.62 years. Male patients were 5 (16.7%) and female 25 (83.3%). Spondylolesthesis was noted at L4-L5 level in 17 (56.66%) patients while 13 (43.33%) patients had L5-S1 level involved. The mean slip percentage on standing x ray was 34.60± 20.03 and on supine 11.97±8.65 showing a significant slip reduction on supine radiographs.(p=0.01) Conclusion: Supine lateral radiographs showed significant slip reduction in degenerative Spondylolesthesis. We therefore recommend routine use of supine lateral radiographs for the assessment of degenerative Spondylolesthesis.

Lymphoma is a malignant disease primarily originating from the lymphoid cells. Lymphoma can be classified as Hodgkin (HL) and Non Hodgkin lymphoma (NHL). Most lymphoma in bones are non-Hodgkin lymphomas and 80% are Diffuse Large B cell subtype (DLBCL). All children with primary lymphoma of bone (PLB) that were diagnosed and treated at Agha Khan University Hospital from 25th October 2000 to 25th October 2020 were included in this case series. Three cases of Paediatric PLB were documented. All of them were DLBCL. Chemotherapy was started. None of them required surgery. One of them expired and the rest of the two are in remission. The disease is rare so we had very few patients. Our case series suggests that PLB in children can be managed successfully with a multidisciplinary approach and focusing on chemotherapy and radiotherapy.

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

Dear Editor, 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

The most common tumours of the clavicle are Myeloma and Ewing’s sarcomas while chondrosarcomas being a relative rarity at this location. However, a clavicular chondrosarcoma is considered favourable compared to the traditional more challenging locations like pelvis, femur and humerus. The subcutaneous location of the clavicle facilitates early detection. A further favourable consideration is that a complete claviculectomy without incurring significant morbidity can be performed. We reported an adult male patient who presented to our unit with a massive clavicular chondrosarcoma with radiological spread to the retro-pectoral lymph nodes. A total claviculectomy was performed with en bloc removal in the first stage followed by local lymph node clearance and adjuvant chemotherapy and radiotherapy. At one year follow up no recurrence was noted and the patient had good functions of the shoulder. We recommend total claviculectomy as the procedure of choice for clavicular chondrosarcomas.

The Global pandemic of COVID-19 has affected the health care system worldwide. Hospitals in Pakistan are getting overcrowded with COVID-19 patients and healthcare workers are getting infected with virus in increased numbers leading to shortage of hospital workforce. Orthopedic practice needs to be adjusted accordingly to maintain safety of health care workers and conserve hospital resources while maintaining continuity of care to patients with musculoskeletal problems. This article discusses the challenges to Orthopaedic practice in Pakistan in this pandemic and their solutions that may also apply to other specialties.

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.

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.

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.

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. Keywords: Max Page release, Volkmann’s ischemic contracture, Tight external bandage

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.

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.