ABSTRACT Objective: To determine the effectiveness of facet joint steroid injection in combination with lignocaine in chronic low back ache by measuring the reduction of pain intensity. Methods: This Descriptive study was conducted at the Department of Orthopedic and Trauma Khyber Teaching Hospital Peshawar from 1/02/2018 to 31/07/2018.All patients with chronic low back ach(for three months or more) meeting the inclusion criteria were included. Pre pain was assessed using visual analog scale (VAS). Under image intensifier each facet joint was be infiltrated with a mixture containing 10 mg of steroid and 2 ml of 1% lidocaine. Follow ups were done at six weeks time and improvement was measured using the same grading system(VAS) to confirm the effectiveness of the procedure. Treatment was considered effective if the patient score below 4 on VAS after treatment with facet joint steroid injection. Results: In our study 145 patients with chronic low back ache were analyzed. The mean age was 56 years with SD ± 22.91. The percentage of male patients were 52% while 46% were female. Mean duration of low back ache was 8 month with SD ± 3.37. Facet joint steroid injection was efficacious in 67% patients and was ineffective in 33% patients. Conclusion: Facet joint steroid injection in combination with lignocaine is effective in reducing chronic backache and discomfort to the patients.

Introduction: Midflexion instability in primary total knee replacement (TKR) is an evolving concept. Successful treatment of instability requires an understanding of the different types of instability. Methods: A literature review was performed to identify information pertinent to midflexion instability in primary total knee replacement, utilising some guidelines. Results: Three factors, i.e., elevated joint line, multiradii femoral component and medial collateral ligament (MCL) laxity, were identified to influence midflexion instability. Literature suggested mediolateral instability at 30–60° of flexion as diagnostic of midflexion instability. Literature search also revealed paucity in clinical studies analysing midflexion instability. Most of the evidence was obtained from cadaveric studies for elevated joint line and MCL laxity. Clinical studies on multiradii femoral component were limited by their small study size and early followup period. Conclusion: Elevated joint line, multiradii femoral component and MCL laxity have been suggested to cause midflexion laxity in primary TKR. Due to limitations in available evidence, this review was unable to raise the strength of overall evidence. Future well-designed clinical studies are essential to make definitive conclusions. This review serves as a baseline for future researchers and creates awareness for routine assessment of midflexion instability in primary total knee replacement.

Objective: To determine the functional outcome of Austin Moore Prosthesis(AMP) Versus Bipolar hemiarthroplasty prosthesis in fracture neck of femur Methods: This Prospective randomized controlled trial was conducted at the Department of Orthopedics, Ward-17, Jinnah postgraduate Medical Centre, Karachi, from January 2016 to December 2016. The patients included 60 years or older, having displaced intra capsular neck of femur fractures. Patients with co-morbids, arthritis and pathological fractures were excluded. Patients were randomly divided equally in 2 groups, each group operated upon using standard techniques for Austin Moore and Bipolar hemiarthroplasties respectively. Functional outcome was measured as very good, good, fair and poor using Harris Hip Score at monthly interval and at 6th months follow up visit. Results: The total numbers patients were 148(74 in each group). Final functional outcome showed that, in Bipolar prosthesis 72 (97.3%) patients had satisfactory status while 2 (2.7%) patients had unsatisfactory status. In Austin Moore group 64 (86.5%) patients had satisfactory status while 10 (13.5%) had unsatisfactory status Conclusion: Bipolar prosthesis had better functional outcome than Austin Moore hemiarthroplasty. We recommend this as a treatment of first choice in elderly patients with fracture neck of femur.

Objective: To compare Bipolar and unipolar hemiarthoplasty (HA) treatment for neck of femur fracture in elderly population. Methods: This is a descriptive randomized study, conducted from January 2014 to May 2015. All the patients were sixty years and above with Garden type III and IV Neck of femur fracture. The patients were randomly placed in two groups. Group A were treated with bipolar and B with unipolar Austin Moor (AM) hemiarthoplasty (HA). Non-weight bearing mobilization on 1st postoperative day. Weight bearing with crutches on 3-5th postoperative day. Early outcome was assessed at 3 months follow-up, using Harris hip score. Results: Thirty patients were divided into two groups, i.e., 15 in each. Patients in group A have returned to daily living activities earlier then patients in group B. Group A has 87% (n=13) excellent, 13% good with no fair and poor results while group B has 53% excellent, 33% good and 13% fair results. Conclusion: Bipolar hemiarthoplasty is an effective treatment for neck of femur fractures in elderly population.

Objective: To analyze the results of schtzkar type VI tibial fractures treated with ilizarov external fixator. Methods: This study was conducted at Mardan Medical Complex from January 2015 to December 2017.All patients with Schatzker Type VI tibial plateau fractures meeting the inclusion criteria were treated with Ilizarov fixator. Outcome was assessed with radiology for fracture reduction and union and functionally with Knee Society Score(KSS). Results: Total 26 patients with tibial schatzkar type VI fractures were included in the study. Fifteen patients were open and 11 were closed fractures .Ilizarov external fixator was applied under image intensifier. All patients incurred Schatzker Type VI tibial plateau fractures caused by motor vehicle accident (12 patients), motorcycle accident (6 patients), pedestrian and automobile (8 patients). Five patients had Gustilo Grade IIIA open fractures, 10 had Gustillo type II open factures. Post operatively all the fractures healed. Assessment with knee society score showed fair result in 46.1 %( 12) patients, good in 30.7%(8),excellent in 15.3%( 4) and poor in 7.6%( 2) patients. Conclusion: Ilizarov external fixator is better treatment option for the schtzkar type VI fractures as adequate reduction, wound care and early mobilization not only reduces knee stiffness but leads to early fracture union.

Objective: To determine the functional outcome of Austin Moore Prosthesis(AMP) Versus Bipolar hemiarthroplasty prosthesis in fracture neck of femur Methods: This Prospective randomized controlled trial was conducted at the Department of Orthopedics, Ward-17, Jinnah postgraduate Medical Centre, Karachi, from January 2016 to December 2016. The patients included 60 years or older, having displaced intra capsular neck of femur fractures. Patients with co-morbids, arthritis and pathological fractures were excluded. Patients were randomly divided equally in 2 groups, each group operated upon using standard techniques for Austin Moore and Bipolar hemiarthroplasties respectively. Functional outcome was measured as very good, good, fair and poor using Harris Hip Score at monthly interval and at 6th months follow up visit. Results: The total numbers patients were 148(74 in each group). Final functional outcome showed that, in Bipolar prosthesis 72 (97.3%) patients had satisfactory status while 2 (2.7%) patients had unsatisfactory status. In Austin Moore group 64 (86.5%) patients had satisfactory status while 10 (13.5%) had unsatisfactory status Conclusion: Bipolar prosthesis had better functional outcome than Austin Moore hemiarthroplasty. We recommend this as a treatment of first choice in elderly patients with fracture neck of femur.

Objective: To demonstrate the rate of union after closed elastic intramedullary nail fixation of paediatric femoral shaft fractures. Methods: The design of our study was descriptive and was conducted from 15-04-2016 to 15-10-2016 at Sheikh Zayed Medical College/Hospital, Rahim Yar Khan. All patients fulfilling inclusion criteria who underwent femur elastic intramedullary nail insertion in retrograde fashion for the treatment of Paediatric femur fractures were enrolled in the study. Patients were in regularly followed un-till radiological union. Results: A total of 55 patients including 33 males and 22 females with mean age 6.5±1.65 years and mean weight 19.11±4.46 kg were included. Fracture union was seen in 47 (85.45%) patients. There was almost equal union in both male and females with p value of 0.88. Better union was seen in age group of 5 to 8 years with union in 26 out of 29 patients as compared to age group of 9-12 years(p=0.35) Union was better seen in patients with weight less than 20 kg and duration of fracture 5 days or less with p values of 0.06 and 0.45. Thirty (90.91%) out of 33 patients had union in simple fractures as compared to comminuted in 17 out of 22 with p values of 0.16 as displayed. Conclusion: Elastic intramedullary nailing results in early union of femur shaft fractures in children with simple fractures who presented early and with body weight of less than 20 kilogram.

Objective: The objective of this study was to determine the functional outcome of arthroscopic stabilization of anterior shoulder instability using anchor sutures. Methods: It was a prospective study done at Hand and Upper Limb Surgery (HULS) Center CMH Lahore Medical College, from January 2017 till July 2018. We included 60 patients who underwent arthroscopic stabilization with the help of anchor sutures. Pre-operative assessment included detailed history, physical examination, joint hyper laxity, plain radiographs, MR-arthrogram and in some cases CT scan of the shoulder joint. Post operatively; functional outcome was evaluated by complete examination of both shoulders mobility, Rowe score, Oxford shoulder instability score and Constant score. Comparison was made with the normal one. Data was analyzed with SPSS ver. 21. Results: Total patients were 60 (57 male and 3 female) and mean age at the time of operation 41.35±13.86 (range17-78) years. Right side was involved in 66.7% and dominant side in 70% patients. All patients were followed for minimum one year and mean follow up was 18.25 ±3.5 (range 11-22 months).At final visit in the follow up the mean Rowe score was 92.48 ±6.5 and 88.3% (53), 8.3% (5), 3.3% (2) belong to excellent, good and fair group respectively. Mean Oxford shoulder instability score was 43.03±5.99 and 83.4% (50), 13.3% (8) and 3.3% (10) belong to excellent, good and fair group respectively. Mean Contant score was 91.7±11.6 and 80% (48), 10% (6) 6.7% (4) and 3.3% (2) belong to excellent, good, fair and poor group respectively. Conclusion: Arthroscopic shoulder stabilization is an expedient procedure with excellent functional results for recurrent shoulder dislocation. We strongly recommend it for anterior shoulder instability.

Objective: The objective of this study was to determine the functional outcome of arthroscopic stabilization of anterior shoulder instability using anchor sutures. Methods: It was a prospective study done at Hand and Upper Limb Surgery (HULS) Center CMH Lahore Medical College, from January 2017 till July 2018. We included 60 patients who underwent arthroscopic stabilization with the help of anchor sutures. Pre-operative assessment included detailed history, physical examination, joint hyper laxity, plain radiographs, MR-arthrogram and in some cases CT scan of the shoulder joint. Post operatively; functional outcome was evaluated by complete examination of both shoulders mobility, Rowe score, Oxford shoulder instability score and Constant score. Comparison was made with the normal one. Data was analyzed with SPSS ver. 21. Results: Total patients were 60 (57 male and 3 female) and mean age at the time of operation 41.35±13.86 (range17-78) years. Right side was involved in 66.7% and dominant side in 70% patients. All patients were followed for minimum one year and mean follow up was 18.25 ±3.5 (range 11-22 months).At final visit in the follow up the mean Rowe score was 92.48 ±6.5 and 88.3% (53), 8.3% (5), 3.3% (2) belong to excellent, good and fair group respectively. Mean Oxford shoulder instability score was 43.03±5.99 and 83.4% (50), 13.3% (8) and 3.3% (10) belong to excellent, good and fair group respectively. Mean Contant score was 91.7±11.6 and 80% (48), 10% (6) 6.7% (4) and 3.3% (2) belong to excellent, good, fair and poor group respectively. Conclusion: Arthroscopic shoulder stabilization is an expedient procedure with excellent functional results for recurrent shoulder dislocation. We strongly recommend it for anterior shoulder instability.

Objective: To determine the radiological, functional and anatomical outcome in patients with osteoarthritic knee undergoing high tibial osteotomy. Methods: This descriptive study was conducted in the Orthopedic Departments of District Head Quarter Hospital Faisalabad affiliated with Punjab Medical University Faisalabad from Jan 2016 to March 2018.A total of 40 patients of both genders, between 40-65 years of age having advanced degenerative disease of knee limited to medial compartment of joint. Medial open wedge osteotomy was done and outcome was evaluated after 5 years of surgery in terms of radiological knee mechanics, functional outcome scores and arthroscopic evidence of cartilage regeneration in the medial compartment. A signed written consent was taken from every patient. Results: There was a female predominance(1:4 male female ratio) .The mean age of the patients was 53.2±6.9 years. The values of the radiographic parameters signi?cantly changed from pre-operative condition after high tibial osteotomy; MTFA (-8.1±1.2o vs. 2.5±1.2o; p-value<0.0001), TPI (5.3±1.1o vs. 3.4±1.1o; p-value<0.0001), G-KJLO (0.3±0.1o vs. 4.6±1.5o; p-value<0.0001) and G-AJLO (8.3±3.2o vs. 2.3±1.7o; p-value<0.0001). There was significant improvement in patient’s functional status; KOOS-ADL score (45.5±7.8 vs. 73.7±8.6; p-value<0.0001), IKDC score (42.4±6.9 vs. 68.5±12.7; p-value<0.0001), IKS score (149.4±11.9 vs. 179.4±10.2; p-value<0.0001), KSS (54.2±5.6 vs. 69.7±12.7; p-value<0.0001) and HSS (50.8±3.3 vs. 64.8±10.7; p-value<0.0001). 42.5% patients showed excellent regeneration of femoral and 30.0% patients showed excellent regeneration of tibial cartilage in the medial compartment. Conclusion: By significantly alternating the knee biomechanics, high tibial osteotomy was found to unload the medial compartment leading to regeneration of the articular cartilage and dramatic improvement in the symptoms and quality of life of these patients. It is therefore recommended in the management of patients with arthritic changes limited to medial compartment only

ABSTRACT Hereditary multiple osteochondromatosis (HMO) is a rare familial bony disease largely diagnosed in early childhood. It is characterized by multiple bony outgrowths at the juxtaepiphyseal regions of long bones, or the surfaces of flat bones. Mutations in EXT 1 and EXT 2 genes are understood to be responsible for the pathogenesis of HMO. To highlight the importance of genetic counseling for affected individuals, we describe the case of a 21 years old female, who presented for the first time with clinically apparent multiple osteochondromas at various sites. The largest one found was at the back of the left knee. This particular osteochondroma caused discomfort and a degree of functional impairment, and was consequently surgically excised. Unusual to this case is that her two younger siblings, a brother and sister, were also discovered on examination to have multiple asymptomatic osteochondromas. All three children have osteochondromas around both knee joints in common. Genetic counseling is a vital platform for educating patients on the disease itself and its pattern of inheritance, so to reduce the risk of transmission of the defective trait to future generations.

Objective: To know about the role of dynamization in fracture healing of femoral shaft fracture fixed with interlocking intramedullary nail. Methods: This prospective comparative study was conducted between January 2015 to July 2016 orthopedics department of PIMS hospital. Inclusion and exclusion criterion were determined. Patients were stratified randomly into non dynamized (Group A) and dynamized (Group B) groups. At six weeks dynamization was performed. Results: 60 patients (30 in each group) were included in the study. The mean age was 34.16±10.03 years. In group A, 21(70%) patients were male and 9(30%) were female. In group B, 23 (76.7%) patients were male and 7 (23.3%) were female. Fracture union rate was compared between the two groups. Conclusion: Although Dynamization reduces the time of union of fracture, it has no effect on rate of fracture healing,

Objective: To assess early functional outcome of total hip arthroplasty for displaced femoral neck fractures. Methods: This clinical trial study conducted in Jinnah Hospital Lahore Orthopaedic unit 2 from August 2015 to October 2017. Eighty-five patients with displaced femoral neck fractures were managed by cemented primary total hip arthroplasty. We included otherwise physically and mentally healthy patients who were community ambulators of the age group ranging from 55 to 80 years with an average age of 62.37 years. All the patients with infection, nonunion, pre-existing rheumatoid arthritis and pathological fractures were excluded from the study. A modified Hardinge approach was used in all patients and cemented total hip prosthesis was used. Every patient received pre-operative, intra operative and post-operative antibiotic regime. Low molecular weight heparin was administered prophylactically. All the patients underwent specific rehabilitation protocol and mobilized on the first post-operative day. Functional outcome in all patients was evaluated in terms of harris hip score (HHS) after six weeks, 3 months and 6 months Paired t test was used to assess difference between means HSS at 3 weeks and 6 months for statistical significance with p < .05. Results: 57.6% (49) males and 42.4% (36) females with a mean age of 62.37 + 28.42 years ranging from 55 to 80 years were studied. A total of 45.9% (39) patients were operated on right and 54.1% (46) operated of left hips. The mean Harris hip score at six weeks was 78.117 + 5.757, at three months was 83.5294 + 5.785, and at six months was 88.600. + 4.746 (P< .000). Conclusion: Total hip replacement has a good functional outcome in displaced femoral neck fractures in otherwise healthy and lucid patients. On basis of better functional scores in our results we can infer that cemented total hip replacement offers early return to function so this procedure is suggested in elderly active patients with femoral neck fracture.

Objective: To assess the Radiological & Functional outcome of open reduction and internal fixation with crossed K Wires in Gartland III displaced Fractures Supracondylar humerus in children using medial approach. Method: It was a prospective study conducted on 95 patients with displaced supracondylar fractures of the humerus Gartland III in children. All patients were managed with open reduction and internal fixation using crossed K Wires via medial approach. The most common mechanism of trauma was fall while playing; fall from height and road traffic accident. The mean follow-up time was six months and results were assessed according to Flynn’s criteria. Results: Total 95 patients with closed supracondylar fractures of the humerus Gartland III were included in this study. Male to female ratio was 56:39 (59 %:41 %). 50 (52.6 %) patients got trauma to their right elbow while left elbow was involved in 45 (47.4 %) of cases. The mean age of the patients was 7.5+2.08 years. 60 (63.15%) patients gained excellent results according to Flynn’s criteria while 17 (17.90%) patients had good and 13 (13.69%) patients achieved satisfactory results. Only 5 (5.26%) patients had poor results. The main cause of poor results was late presentation and initial quack management. No case of neurovascular injury and cubitus varus deformity was reported. All patients were happy with their scar appearance. Conclusion: Management of displaced supracondylar fractures of the humerus in children with Open reduction and internal fixation using medial incision is simple, safe and straightforward, providing more anatomical reduction and functional outcome with good scar cosmoses.

Objective: To evaluate the advantages of combined motor and sensory evoked potential monitoring during scoliosis surgery. Methods: We performed and analyzed the records of 107 (83 Female (77.5%) and 24 male (22.4%) Scoliosis surgery patients with Transcranial electric motor evoked potential and somatosensory evoked potential performed at spine surgery center, Ghurki Trust Teaching Hospital Lahore. Mean age was 14.7 years. Patients who showed significant up to (45%) in baseline signals loss unilateral or bilateral limbs during surgical intervention in scoliosis surgery under total intravenous anesthesia is included. Results: Motor Evoked Potentials and Somato-Sensory Evoked Potenials of 107 patients in intraoperative neurophysiological monitoring were performed jointly. 21 (19.6%) patients have mark or significant changes in baseline signals on transcranial motor evoked potentials. Seventeen 17 (15.8%) Patients have complete return of baseline signals after surgical intervention by surgeon, whereas 04 (3.73%) patients have return of motor signals after 14 hours of surgery. Transcranial electric motor evoked potentials monitoring was 100% specific and 100% sensitive, however Somatosensory evoked potential was 100% specific and 84% sensitive. Conclusions: MEPs and SSEPs, in combination gives accurate and correct information of any surgical insult and neurology in real time during Scoliosis surgery.

bjective: To know the earliest age limit when surgical intervention can be avoided in Congenital Dislocated Knee. Methods: This Prospective study was carried at Jinnah Postgraduate Medical Centre Karachi, Pakistan from January 2013 to December 2016.The patients with Idiopathic, Type II & III Congenital Knee Dislocations (CDK), in newborn to three months were managed by serial manipulation and Casting with and without per Cutaneous Quadriceps Tenotomy (PCQT). Results: At 26 months median follow-up, out of 32 knees of 23 patients, 29(90.62%) behaved Excellent and 2(6.25%) behaved good. Average 4 casts required, to achieve >1200 flexion, stable knees with negative Drawers test in 96.87% Knees. The required number of casts increased from 3 to 5 as age increased from one day to one month & above, moreover 7 knees of 3 patients, who got treatment initiated after 3 weeks of birth also required PQCT. Conclusion: The CDK is easy to reduce without significant manipulation time, when treatment is started within 24 hours of birth. With increasing age from hours to four weeks, the manipulation takes more time to reduce and required more number of cast to maintain reduction. After three weeks of age, CDK often require an addition procedure of PCQT.

bjective: To determine the different pattern of injuries and their frequency in motor bike accidents Methods: This Case series study was conducted at Department of Orthopedics, Jinnah Post Graduate Medical Centre(JPMC), Karachi, from January 2017 to December 2017. Patients aged 5-65 years, any gender and every kind of injury were included in the study. Pathological fractures and concealed injuries were excluded. Patients were admitted through Accident & Emergency Department of JPMC and informed consent was taken. Injuries were divided in different regions. Examination and required investigations were done. Injuries were recorded in proforma. Statistical analysis was done using SPSS version 18. Results: Two thousand patients were included. Mean age was 29.6 years. 1588 (79.4%) were males and 412 (20.6%) females. Male to female ratio was 3.85:1.A total of 684 (34.2%) patients were between age 16-30 years and 512 (25.6%) between 31-40. Lower limb injuries were 1136 (56.8%) while upper limb injuries were 544 (27.2%). Abrasions were 1874 (93.7%), lacerations 1362 (68.1%) and bruises 1040 (52%). Fractures in lower limb were 450 (22.5%) and upper limb 272 (13.6%) Conclusion: Younger males were more prone to motorbike injuries. Lower limb abrasions and fractures were the most common injuries.

Objective: To evaluate the treatment outcome in AO type C, distal femoral fractures using longer lever arm anatomical plates with minimally invasive plate osteosynthesis (MIPO) technique. Methods: This prospective cases series was done using probability sampling technique at two centers including Orthopedics and Spine Institute, Doctors Hospital, Medical Center, Lahore and Department of Orthopedics Surgery and Traumatology, Post-graduate Medical Institute, Lahore General Hospital, Lahore from January 2016 to August 2017. AO type C close distal femoral fractures fulfilling the inclusion criteria were included in the study. We fixed all fractures with longer lever arm anatomical plates with minimally invasive plate osteosynthesis (MIPO) technique. On each follow up patients were assessed using American Knee Society Score(AKSS) for functional outcome and x rays for union. SPSS version 20.00 was used to analyze the data and p-value <0.05 was taken as significant. Results: Out of the total 35 cases there were 21 (60%) males and 14 (40%) females. The mean age of the patients was 39.7429±12.577. There was primary union in 31 (88.6%) cases and non-union in two (5.8%) cases, delayed union in two (5.8%) patients. Amongst 35 cases, 32 (91.4%) didn’t required bone graft and only 03 (8.6%) had primary bone grafting due to severe comminution. Post-operatively American knee society score was excellent in 24 (68.4%), good in 6 (16.1%), fair in 04 (11.4%) and poor in only 01 (2.9%) patient. Conclusion: Longer lever arm plates with MIPO has good to excellent results regarding union, knee range of motion and minimal infection.

Objective: To evaluate the treatment outcome in AO type C, distal femoral fractures using longer lever arm anatomical plates with minimally invasive plate osteosynthesis (MIPO) technique. Methods: This prospective cases series was done using probability sampling technique at two centers including Orthopedics and Spine Institute, Doctors Hospital, Medical Center, Lahore and Department of Orthopedics Surgery and Traumatology, Post-graduate Medical Institute, Lahore General Hospital, Lahore from January 2016 to August 2017. AO type C close distal femoral fractures fulfilling the inclusion criteria were included in the study. We fixed all fractures with longer lever arm anatomical plates with minimally invasive plate osteosynthesis (MIPO) technique. On each follow up patients were assessed using American Knee Society Score(AKSS) for functional outcome and x rays for union. SPSS version 20.00 was used to analyze the data and p-value <0.05 was taken as significant. Results: Out of the total 35 cases there were 21 (60%) males and 14 (40%) females. The mean age of the patients was 39.7429±12.577. There was primary union in 31 (88.6%) cases and non-union in two (5.8%) cases, delayed union in two (5.8%) patients. Amongst 35 cases, 32 (91.4%) didn’t required bone graft and only 03 (8.6%) had primary bone grafting due to severe comminution. Post-operatively American knee society score was excellent in 24 (68.4%), good in 6 (16.1%), fair in 04 (11.4%) and poor in only 01 (2.9%) patient. Conclusion: Longer lever arm plates with MIPO has good to excellent results regarding union, knee range of motion and minimal infection.

Objective: To determine functional and fusion outcomes of postero-lateral decompression in spinal tuberculosis. Methods: This multi-centric study was done from January 2014 to December 2017. We included 52 patients with spinal tuberculosis spondylitis between 15 to 60 years of age of both genders diagnosed on history, routine investigation and magnetic resonance imaging (MRI). All patients were operated via posterior approach under C-arm. We stabilized the involved vertebrae with pedicle screws involving one motion segments above and below. Tuberculosis abscess was drained and decompression of the spinal cord was done. All patient’s fusion and functional outcome was assessed using Oswesrty Disability Index. We followed patient post-operative 2 weeks, 6 weeks, 12 weeks, 6 months and 1 year. Results: Amongst the total 52 patients, there were 36 (69.2%) male and 16 (32.8%) female. Mean age of the patients was 24.615±12.281 with maximum patients between 16 to 30 years of age. There were 19 (36.4%) cases of lumbar spine, 16 (30.7%) dorsal spine and 17 (32.9%) dorso-lumbar spine. Mean surgical time from start of time till closure was 101.8654±16.88. There was improvement in Oswestry disability index post-operatively, and out of total 51 patients 43 (84.31%) had no disability and only 06 (11.76%) had moderate disability and 02 (3.9%) has sever disability. Conclusion: Posterolateral decompression in patients with spinal tuberculosis has good functional and fusion outcome.

Objective: To evaluate the knee society and functional score in pre-and post-operative patients of Total Knee Replacement. Method: A cross sectional, observational study comprising of 40 patients evaluated at 1 year follow up done by single surgeon in same setup from July 2015 to June 2016. Data taken from Pakistan national joint registry (PNJR). Knee society score evaluated pre-operative and post-operative at 1 year follow up. Result: In our study total of 40 patients were analyzed which comprises of 30% (n= 12) male and 70% (n= 28) female patient with age range of 40 to 70 years with mean age of 55.45 9.25 years. Out of 40, 90 % patients (n=36) had osteoarthritis and 10 % (n= 4) had rheumatoid arthritis. The average pre-operative knee society score is 51.07±13.3 and functional pre-operative score is 42.87 16.4 while post op knee society score is 91.75 3.44 and functional score post op is 87.32 6.33. Conclusion: Total Knee Replacement is the best modality for arthritis of knee as the scores in terms of knee society and functional score has improved.

Objective: To determine the functional outcome of posterior triceps muscle sparing versus muscle splitting approach in supracondylar humerus fracture in children. Methods: This prospective randomized controlled study was conducted from September 2014 to March 2016. Thirty-eight patients from pediatric age group (5 to 14 years) and either gender side with the delayed presenting (4.97± 1.69 days) supracondylar humerus fracture [SHF], Gartland type III. Patients were randomly divided into group A (triceps muscle sparing approach) and group B (triceps muscle splitting) each having 19 patients, for Open Reduction and Internal Fixation [ORIF]. Functional outcome was determined in outpatient department on follow up using Gruber and Healy scoring system. Results: Out of 38 patients, 24 (63.1%) were male and 14 (36.8%) were females. The mean age of the patients in our study was 9.13± 4.97 years and the mean delay in presentation was 4.97± 1.69 days. These patients were randomly divided into group A and group B, each having 19 patients. Group A patients underwent triceps muscle sparing technique while group B had triceps muscle splitting technique. The success of either procedure was assessed by functional outcome using Gurber and Healy score on progressive follow ups in outpatient department. The fractures in group A united radiologically in a mean duration of 7.52 ± 1.46 weeks, while in group B the mean duration of union was 8.12 ± 1.34 weeks. We found that the muscle sparing approach had excellent functional outcome in 18 (94.73%) patients as compared to 09 (47.36%) patients in muscle splitting (group B) which was significant, p value < 0.05. Conclusion: Supracondylar humerus fractures requiring open reduction and fixation in children with triceps muscle sparing technique had better functional outcome than triceps muscle splitting approach.

Objective: To determine the outcome of locally delivered antibiotics via bone cements in infective non-union, chronic osteomyelitis and joint infections Methods: The study was conducted between January 2016 to June 2017. Patient with chronic osteomyelitis and infective non-union of long bones were chosen. Debribement / sequestrectomy and antibiotics beads placement was done in chronic osteomyelitis. In selected cases antibiotic, coated nail was put and in arthroplasties, antibiotic was added to spacer as prophylaxis to infection. The infected bone was scraped out leaving an opening in the bone. The antibiotic beads were then packed into the opening and the wound was closed for 4-5 weeks when they were removed. Bone was fixed in case of instability, when there were no signs of infections per operatively. Results: Twenty-seven (90%) out of 30 patients showed no signs of recurrence of osteomyelitis at the mean of 15 months follow up. Infection subsided in 2 out of remaining 3 patients, with re- debridement and beads and 1 patient did not show any sign of improvement even after second procedure. No significant complication was noted during the study. Conclusion: Antibiotics loaded Beads in the treatment of chronic osteomyelitis are safe and effective. Its advantages include lower cost, low systemic effects of the drug, shorter hospital stay and high concentrations of antibiotics at the site of infection.

Objective: To determine the radiological and functional outcome of different types of distal femoral fractures fixed with locking plates. Methods: This descriptive case series study was conducted at Department of Orthopaedic & Traumatology, Lady Reading Hospital Peshawar from February 2015 to June 2018. Patients of either gender or age with different types of distal femoral fractures fulfilling the inclusion criteria and fixed with distal femoral locking plates were enrolled into the study. Post-operative follow up visits were carried out at 4th week, 6th week and then monthly for 06 months and then every 3rd month till 02 years. Radiological and functional evaluation was done with modified Mize outcome criteria and graded as excellent, good, fair and failure. Results: A total of 107 patients with mean age 44.57 ±SD12.03 years were operated with distal femoral locking plate. Only 6(5.6%) patients were lost to follow up and thus excluded from the study. Male patients were 68(67.3%) while female was 33(32.6%). Intra articular multifragmentary (33-C3) was the predominant fracture present in 29(28.7%) patients. Majority (n=85,8.1%) of the patients had excellent outcome as assessed with modified Mize outcome criteria while good outcome was achieved in 16(15.8%) patients. No non-union or implant failure was reported. Conclusion: Distal femoral locking plates produced an excellent radiological and functional results in majority of the patients with different types of the distal femoral fractures. We recommend locking plate as an implant of first choice to fix all types of the distal femoral fractures.

Objective: To evaluate the management of long bones infected nonunion. Methods: This retrospective study was conducted between July 2014 and July 2017. Inclusion criteria was to include all cases of infected nonunion of long bones with no evidence of union within six to eight months, irrespective of loss of bone. All patients were thoroughly investigated and evaluated clinically, labs and X-rays. All patients were assessed by the Association for the Study and Application of Methods of Ilizarov(ASAMI) criteria for radiological and functional outcomes. Results: In this study, Twenty cases of infected nonunion (tibia 14, and femur 6) were used. There were 14 males and 6 female subjects, for whom the average age was 35±6.21 SD (range 18-52). 15 patients had open fracture while 5 patients were post internal fixation. Infection was eradicated and the union was achieved in all cases. The average time to union was a mean of 10±1.1SD months, ranging from 8 to 12 months). The follow up was a mean of 18 months (range 16-20 months). In case of tibia and femur as per the ASAMI score, radiological results were excellent in 14/20 (70%) and good in 4/20 (20 %), 2/20 (10%) showed fair results and no patient had poor result. Functional outcomes were excellent in 13/20 (65%) subjects, 5/17 (25%) were rated as good, and 2/20 (10%) as fair. Union was achieved in all three cases of humerus. Conclusion: Infected non-unions pose challenge to both patient and surgeon. Ilizarov fixator gave good and excellent results in complex non-union of long bones by eradicating infection, filling the defect with bone transport and correcting the deformity.

Objective: To reveal the association of cervical rib with chest wall anomalies. Methods: Observational study conducted at the private radiology clinics Rawalpindi & Islamabad from January 2015 to December 2017, which included Patients coming for X-RAY chest. The patients were selected through convenience sampling. Radiographs were discussed with a consultant radiologist to diagnose the cervical rib and associated anomalies of sternum and rib cage. The age groups were from one to thirty-five years. Results: The study comprises one hundred and fifty patients. Fifty-eight ere female and ninety-two were male patients. The ages of patients were between 10-35 years. The cervical rib was detected in 8.69% male patients and 5.17% female patients. Bifid ribs, Diaphyseal aclasis, fused ribs and Rachitic rosary was found in 1.008% of the cases. No sternal anomaly was detected. Conclusion: Association of Rib anomalies with cervical rib is more common as compared to sternal and vertebral anomalies.

femur treated by PFNA. Methods: A prospective analytic cross-sectional study was conducted at Orthopaedic Surgery department, Dow Medical College & Dr. Ruth Pfau Civil Hospital Karachi during the period from January 2017 to May 2018. Thirty-three patients with Subtrochanteric femur fracture according to Russell and Taylor Classification Type IA & B were operated with Proximal femoral nail antirotation (PFNA). Patients were assessed clinically for functional outcome based on Harris hip score and radiologically for union. Typical post-surgical morbidity (i.e., Infection, delayed union, nonunion, mal-union and fixation failure) were noted. Multiple fractures in polytrauma patients, pathological fractures, open fractures, poor ambulatory patients previous to the fracture and related neurovascular injuries were excluded from the study. Results: A total of 33 patients (21 males, 12 females; mean age 49.5 years) were treated with PFNA. Based on Russell and Taylor classification: 18 had Type IA and 15 had Type IB fractures. The mean follow-up duration was 11 months (range, 9 to 16 months). All fractures were united in an average time of 18.4 weeks). Superficial stitch infection was seen in 5 cases. We had no instance of deep infection. Distal locking screw was broken in two patients. Implant failure and / or Nonunion were not observed whereas delayed union was noted in 5 patients. The functional outcome results were (as per Harris hip scoring system) excellent and good in 27(81.8%) and fair to poor in 6 (18%) cases. Conclusions: The post-operative clinical and radiological outcome suggest that PFNA is an exceptional device for treatment of fracture subtrochantric femur. Although technically demanding, it avoids extensive soft tissue dissection and iatrogenic bony devascularization thus decrease the incidence fracture nonunion and implant failure and at the same time provide much more axial stability due to its intramedullary placement thus it allows the patients to move relatively early following surgery.

femur treated by PFNA. Methods: A prospective analytic cross-sectional study was conducted at Orthopaedic Surgery department, Dow Medical College & Dr. Ruth Pfau Civil Hospital Karachi during the period from January 2017 to May 2018. Thirty-three patients with Subtrochanteric femur fracture according to Russell and Taylor Classification Type IA & B were operated with Proximal femoral nail antirotation (PFNA). Patients were assessed clinically for functional outcome based on Harris hip score and radiologically for union. Typical post-surgical morbidity (i.e., Infection, delayed union, nonunion, mal-union and fixation failure) were noted. Multiple fractures in polytrauma patients, pathological fractures, open fractures, poor ambulatory patients previous to the fracture and related neurovascular injuries were excluded from the study. Results: A total of 33 patients (21 males, 12 females; mean age 49.5 years) were treated with PFNA. Based on Russell and Taylor classification: 18 had Type IA and 15 had Type IB fractures. The mean follow-up duration was 11 months (range, 9 to 16 months). All fractures were united in an average time of 18.4 weeks). Superficial stitch infection was seen in 5 cases. We had no instance of deep infection. Distal locking screw was broken in two patients. Implant failure and / or Nonunion were not observed whereas delayed union was noted in 5 patients. The functional outcome results were (as per Harris hip scoring system) excellent and good in 27(81.8%) and fair to poor in 6 (18%) cases. Conclusions: The post-operative clinical and radiological outcome suggest that PFNA is an exceptional device for treatment of fracture subtrochantric femur. Although technically demanding, it avoids extensive soft tissue dissection and iatrogenic bony devascularization thus decrease the incidence fracture nonunion and implant failure and at the same time provide much more axial stability due to its intramedullary placement thus it allows the patients to move relatively early following surgery.