Objective: To determine the short term functional and radiological results of open reduction of Developmental Dysplasia of Hip (DDH) through anterolateral approach. Methods: This was a descriptive study conducted in Paediatric unit of Orthopaedic department, Khyber teaching hospital, Peshawar from January 2018 to December 2018.Children with DDH fulfilling the inclusion criteria were treated with open reduction via anterolateral approach. Post-operative clinical outcome was assessed with Mckay’s criteria while radiographic outcome was assessed by measuring Acetabular index, neck shaft angle and restoration of Shenton line and concentric reduction. Results: Total patients were 35(age more than 18 months).Male were 9(25.7%) while female were 26(74.3%). Mean age was 3.1 ± 1.71 years. Family history of DDH was positive in 06 cases (17.1%). According to Mckay’s criteria 20(57.1%) patients had excellent functional outcome, 8(22.8%) had good, 2(5.7%) fair and 5(14.2%) patients had poor results. Mean Pre-operative Acetabular index (AI) was improved from 35.70 ± 5.830 to post-operative 22.50 ± 5.60. Concentric reduction were found in 34(97.1%) patients and subluxation in one (2.8%) patient. About 6(17.1%) patients had femoral head avascular necrosis (AVN). Mean follow up period was 18 months. Conclusion: Anterolateral approach of hip for open reduction is an excellent approach as it gives better functional and radiological outcome in neglected Developmental Dysplasia of Hip (DDH).

Objective: To find out whether increasing the volume of intra articular steroid injection for the treatment of Subacromial Impingement Syndrome(SIS) causes more pain relief and mobility than conventional small dose injection. Methods: We conducted this randomized study in Orthopedic Department of CMH Lahore Medical College from December 2018 to February 2019. All patients of subacromial impingement syndrome(SIS) with shoulder pain fulfilling the inclusion criteria were enrolled in this randomized controlled trial. After randomly dividing the patients into two groups, group A patients were administered about 10 ml of 1% Xylocane plus 40 miligram of methylprednisolone in subacromial region wile group B patients were injected 10ml of 1% xylocaine plus 40miligram of methylprednisolone plus 20 ml of normal saline. Pre injection pain in the affected shoulder was assessed in resting state and during activity with the help of Visual Analogue Scale(VAS).Pre injection shoulder motion was documented with the help of a goniometer. Post injection shoulder pain and motion was recorded immediately after the intervention in both groups and subsequently at one month and three months follow up visits. Results: A total of 100 patients with mean age of 61 years+/- 10.32 SD were equally divided in group A and group B.Post injection pain on VAS decrease by 6 to 8 points in both groups at three months follow up. Range of motion after treatment in Group A was more markedly improved by the end of 3 months than group A, with some patients experiencing almost full range of motion. But no statistically significant difference between the outcome of the two groups was found(P value > 0.05). Conclusion: The increased volume of intra articular steroid injection for the treatment of Subacromial Impingement Syndrome(SIS) has no significant effect in reducing shoulder pain and range of motion than conventional small volume injection.

“I feel mentally and physically exhausted”, “I wish I could get rid of my patients”, “I don’t feel empathy toward my patients any more”, “whats the use of all this hard work that I am doing”. Has any of these thoughts occurred to you? If yes, you might be suffering from “Physician’s Burnout syndrome”. According to Christina Maslach, who developed the tool for measuring burnout “The Maslach Burnout Inventory (MBI), Burnout is “an erosion of the soul caused by a deterioration of one’s values, dignity, spirit and will”. A physician’s job is considered to be very stressful. However, there is a difference between “Stress” and “Burnout”. We all feel exhausted, tired and toasted after long operating hours or forty-eight hours on call. But we recharge when we go home, have good sleep, spent quality time with the family and next morning we are ready to start over with full energies. Burnout begins when we fail to recharge ourselves during the off times. That’s when we start hating ourselves and our job when we go for it the next morning. There is a growing epidemic of physician’s burnout throughout the world. Different studies have shown that one out of three physicians’ in United States suffer from this problem. If we look around, we will find many colleagues around us suffering from this problem. Physician’s burnout is directly linked to a number of undesirable consequences. These include lower patient satisfaction, increased chances of medical error, reduced work output, increased chances of substance abuse, and in worst scenario, physician’s suicide. In short, physician’s burnout is bad for physician himself, his family, patients and his institution.

Objectives: To determine the functional and radiological outcome of arthrodesis of the ankle using the ilizarov method. Methods: This descriptive study was conducted in Bolan Medical Complex Hospital Quetta and National institute of Rehabilitation Medicine Islamabad, from January 2015 to December 2018.Twenty patients fulfilling the inclusion criteria under went arthrodesis of the ankle using ilizarov method. At follow up visit patients were assessed clinically for pain and walking and radiologically for union. Results: A total of 20 patients with mean age 41.0 years ± 13.61 were included in our study. In 18(90%) a stable pain free ankle arthrodesis was achieved successfully after a mean ilizarov external fixator time of 147 days (range 105-195 days). There were minimal complications despite early weight bearing. No further surgery was required except in 02(10%) cases in which primary arthrodesis was not achieved. Conclusion: Ilizarov external fixator used for ankle arthrodesis give excellent stability, allowing early weight bearing without pain and results in higher rates of union with minimal post operative complications.

Objective: To assess the functional and radiological outcome of segmental transport by Ilizarov fixation in case of bone loss in tibia. Methods: This descriptive study was conducted at King Abdullah Teaching Hospital, Mansehra from 1st January 2016 to 31st February 2019 and comprised 20 patients. Patients fulfilling the inclusion criteria were fixed with were Ilizarove fixator and followed for bone union and functional outcome. Results: A total of 20 patients with mean age 36.80+8.49 years (range 26-52 years) were included in our study. Male patients were16 (80%) while 4 (20%) were females. The mean tibial gap was 6.05+4.14 cm (range 1.5-13.5 cm) and mean period of Ilizarov treatment was 7.30+1.94 months (range 5-10 months) while mean follow-up was 30.80+7.19 months (range 20-38 months). Post op results were excellent in 6 (30.0%) patients, good in 8 (40%) patients and fair in 6 (30%) patients. Conclusion: Cases of tibial bone loss treated with Ilizarov produce excellent to good functional and radiological results in majority of patients.

Objective: To determine the functional outcome of dynamic condylar screw in the treatment of unstable proximal femoral fractures in adult patients. Methods: This descriptive study was conducted in Department of Orthopedics, Bolan teaching hospital Quetta from January 2017 to December 2018.All adults patients of proximal femoral fractures meeting the inclusion criteria were fixed with dynamic condylar screw(DCS).Post operatively functional outcome was assessed Harris Hip Score. Results: We operated 147 patients with mean age of patients 54.26 ± 5.14 years. The male to females ratio was 1.94:1. Post operative functional outcome was excellent in 69(46.4%) patients, good in 58(39.45%), fair in 12(8.16%) and poor in 8(5.44%) patients. Post operatively Harris Hip score was excellent(>90) in 69(46.94%) patients, Good score ( 80-89 ) in 58 (39.45%) patients ,Fair score(70-79) in 12(8.16%) patients and poor score(<70) in 8(5.44%) patients.Non union was reported in only 3(2.04%) patients. Conclusion: Unstable proximal femoral fractures fixed with Dynamic Condylar Screw(DCS) results in excellent and good functional outcome in majority of patients. We therefore recommend DCS as a suitable alternative to intramedullary implants to treat subtrochanteric fractures.

Objective: To determine the causes of delay in treating clubfoot in our set up. Methods: This descriptive study was conducted from October 2015 and December 2018 in Hayatabad Medical Complex and Mercy Teaching Hospital Peshawar. Parents of all the patients of club feet meeting the inclusion criteria were interviewed in person about the possible causes of delay in treatment. Data stored in proforma. Results: In our study parents of 46 patients with clubfeet were interviewed. Male patients were 27(58.7%) while female 19(41.3%). Age ranges from 01 to 05 years with mean age of 1.7 ± 2.12 years. Majority (82.6%,n=38) of the parents actually consulted a qualified doctor and started treatment for the deformity earlier, but were either inadequate or incorrect. About 27(58.7%) patients could not afford the treatment after being diagnosed and counseled for further treatment. Some (17.4%,n=8) children were truly neglected as 05(10.8%) of them were taken to bonesetters, while 03(6.5%) parents initially noticed the deformity but considered it untreatable. Conclusion: Inadequate or incorrect treatment and inability to afford proper treatment are the main causes of neglected clubfeet in our set up.

A fistula of the tenosynovium of tibialis anterior tendon and the skin in front of lower leg with discharge as a sequela of injury has not been previously reported in literature. We described two patients of cutaneous tenosynovial fistula of tibialis anterior tendon between 1994 and 2008. Both the patients were male with a mean age of 49 years. The cause of fistula was tight plater cast in one patient while the other had skin puncture by wooden stick of bushes in the jungle. Both patients presented with spontaneous drainage of clear viscous synovial fluid. Conservative treatment by immobilization and prophylactic antibiotics and surgical treatment by primary closure proved unsuccessful. In both patient’s excision of necrotic tissue and coverage with a flap resolved the drainage and healing of wound. No complication of flap noted. No recurrence was reported.

Objective: To introduce a simple clinical criteria for assessment of residual or relapsed idiopathic club foot and to improve its outcome by appropriate surgical management. Methods: This descriptive study was conducted in the Department of Pediatric Orthopedic surgery The Children’s Hospital, Lahore, from June 2014 to June 2018.All patients meeting the inclusion criteria were clinically assessed for dorsolateral hump, midfoot crease, hind foot crease and equinus and were divided into three groups according to the severity and number of these deformities present. Surgery was done according to the pre- decided plan for each group on all club feet. Patients were followed up at 3 months, 6 months and at 1 year after surgery and outcome were evaluated according to the functional rating system for club foot surgery. Results: We had a total of 35 children with mean age of 21 months (range 6 to 36 months). Male were 24(68.5%) and female were 11(31.4%). Bilateral clubfeet were present in 15(42.8%) and unilateral residual idiopathic club foot in 20(57.1%) making it 50 club feet. A total of 8 (16%) patients had flexible dorsolateral hump only so required posteromedial release procedure while 23 (46%) patients had flexible dorsolateral hump with half midfoot crease with or without hind foot equinus so required posteromedial and abductor planter release. In 19 (38%) feet rigid dorsolateral hump with or without other deformities were present and they underwent posteromedial, lateral and abductor planter release. Outcome was excellent in 26 (52%), good in 19 (38%), fair in 4 (8%) and poor in 1 (2%) of patients. Conclusion: The choice of surgical procedure according to the properly assessed residual or relapsed deformity by our proposed clinical criteria makes the surgical management precise and gives excellent and good results in residual or relapsed idiopathic club foot.