Healthcare providers have been featured prominently throughout the global response to COVID-19. Images of first responders, nurses, and ICU doctors became the symbols of courage for the rest of us to follow. The roles and expectations of those on the front line are clear and their job is well defined. For others, like orthopaedic surgeons, finding our place in all of this has been more confusing. Trauma, infection, and cancer: these conditions do not stop because of a virus, but they account merely for a small subset of the whole of orthopaedic surgery. Orthopaedics by nature is a field designed to restore the health, temporarily lost, of the inherently well. Appropriately so, our patients were some of the first to have their procedures delayed, and our elective practices the least defendable to continue as the outbreak worsened.

Objective: To compare the subjective quality of various items used in short answer questions (SAQ) papers between Orthopaedics and other specialties used in internal examinations in MBBS course in a Medical College of Lahore. Methods: This retrospective descriptive study was conducted over a period extending from 25th October 2019 to 25th February 2020 at Avicenna Medical College Lahore. Previously used short answer questions (SAQ) papers (in internal assessments) of MBBS examination were collected from various departments of medical college. They were segregated in two groups as those from Orthopedic Surgery and those from Non Orthopedics subjects like general surgery, medicine and other subjects in the Miscellaneous group. SAQ in both the groups were assessed for the level of cognitive domain like C1(Recall),C2(Identify) and C3(Analyze) level and for clinically focused and relevant scenarios. The statements were evaluated whether scientifically correct and leading to an appropriatediagnosis without providing a lead into the question that would follow. All items were checked for mistakes in language or spelling and grammar. A comparison was made and P value calculated with Chi-square test. P value of < 0.05 was considered significant. Results: A total of 12 Orthopaedic SAQ papers comprising of 84 items and 14 miscellaneous papers comprising of 101 items were evaluated and compared. The number of C1 questions in Orthopaedic SAQ papers were 24(13%),C2 questions were 32(17.4%) and C3 was 28(15.2%).In the miscellaneous group C1 questions were 33(17.4%),C2 questions were 31(16.8%) and C3 questions were 37(20.1%). The number of SAQ scenarios were focused in 74(40%) SAQ in Orthopaedics versus 48(25.9%) in miscellaneous group(P value 0.013).The quality of statement was clear in 56(30.3%) SAQ in Orthopaedics while only 14(7.6%) of the miscellaneous papers had clear statement. Spelling mistakes were detected in 12(21.1%) SAQ of Orthopaedics and 22(38.8%) in miscellaneous group. Grammatical mistakes were noted in 10(17.5%) Orthopaedics SAQ and 5(8.8%) in miscellaneous group. Conclusion: The number of Orthopaedic SAQ with cognitive levels(C3,C4) were less than other specialty SAQ. However, the quality of scenarios were better focused and statement much clear in Orthopaedic SAQ than in miscellaneous group.

Objective: To determine theearlyclinical outcome of single level lumbar discectomy in patients with prolapsed intervertebral disc. Methods: This descriptive study was conducted from 3rdJanuary 2018 to 23rdJanuary 2020 in Orthopaedics and Spine Department Khyber Teaching Hospital Peshawar. All patients with prolapsed intervertebral disc in the lumbar spine and fulfilling the inclusion criteria were operated for single level lumbar discectomy. Post operative clinical outcome at one year was assessed with Oswestry Disability Index(ODI) and Modified Stauffer-Coventry criteria. The clinical outcome through Oswestry Disability Index (ODI) was interpreted as minimal, moderate, sever, crippled and bed bound disability while results of Modified Stauffer-Coventry criteria were graded as excellent, good, fair and poor clinical outcome. The clinical outcome score among stratified patient age, gender, occupation and education level was compared and Pvalue was calculated with Chi-square test(P< 0.05 was considered significant).Results: The total number of patients in our study were 50.The mean age was 42.6 ± 9.56 years(18-50 years). Male patients were 22(44%) and female 28(56%).Post operatively minimal disability was noted in 33(66%) patients, moderate in 9(18%) and severe in 8(16%) patients as assessed with ODI. Clinical outcome assessment with Modified Stauffer-Coventry criteria reported excellent outcome in 19(38%), good in 15(30%), fair in 12(24%) and poor in 4(8%) patients. Male patients with light physical work had better score than female patients and male patients with heavy manual work(P< 0.05). No major complication reported.Conclusion:Single level lumbar discectomy in patients with prolapsed intervertebral disc produced satisfactory outcome with minimal disability in majority of our patients.

Objective: To compare low versus high implant density in decreasing Cobb angle in Lenke Type 1 Adolescent Idiopathic Scoliosis(AIS) treated with segmental spinal instrumentation and pedicle screws. Methods: This retrospective Cohort study was conducted at Department of Orthopedic and Spine Surgery, Ghurki Trust Teaching Hospital/ Lahore Medical and Dental College, Lahore. The medical records of patients between 15th June 2015 to 15th June 2019 who underwent segmental spinal instrumentation for Lenke type 1 adolescent idiopathic scoliosis were reviewed. Low implant density was defined as patients with pedicle screw density per fused segment of 60 %( ?1.2) or less while high density patients had more than 60 % (> 1.2) screw density. Radiographs were evaluated preoperatively for Cobb angle of main thoracic curve, sagittal and lumbar modifier. Postoperative evaluation included postoperative Cobb angle, percent Cobb angle decease, implant density and implant cost. Independent sample t-test, paired Sample t-test and Chi-square test of association were applied to compare preoperative and postoperative variables between two groups. P<0.05 was set as significant. Results: The total number of patients in our study was 66. Female patients were 47(71.2%) and male 19(28.7%). In low implant density group there were 25 patients including 17(68%) female and 8(32%) male. Mean pre-operative and post-operative Cobb angle was 62.60±130 (450-900) and 13.80±8.070 (0-250) respectively. Mean percent Cobb angle decrease, implant density and implant cost was 78.56±12.07% (50-100%), 1.11±0.083 (0.9-1.20) per fused segment and rupees 85248±13414.57 respectively. High implant density group included total 41 patients with 30(73.2%) females and 11(26.8%) males. Mean preoperative and postoperative Cobb angle was 65.240±16.160 (450-1000) and 13.290±8.180 (0-250) respectively. Mean percent Cobb angle decrease, implant density and implant cost was 79.85±12.85%(44-100%), 1.499±0.09 (1.29-1.65) per fused segment and rupees 93658.53±10589.64 respectively. Comparison between the two groups showed no significant difference in percent Cobb angle decrease (P=0.868). However implant cost was significantly reduced in low implant density group (p=0.000) Conclusion: Correction of Cobb angle was not significantly influenced by metal density and henceforth low implant density can be used to obtain excellent correction in Lenke type 1 idiopathic Scoliosis(AIS) treated with segmental spinal instrumentation and pedicle screws.

Objective: To determine one year mortality rate in elderly patients who were operated for fracture proximal femur in District Headquarter Hospital Rawalpindi. Methods: This descriptive study was conducted in Orthopaedic Department District Headquarter Hospital Rawalpindi from 3rd January 2017 to 25th December 2019. All patients with proximal femur fracture (neck of femur, per trochanteric and sub trochanteric fractures) fulfilling the inclusion criteria and who were operated were included in our study. Post operatively all these patients were followed up at regular intervals up to one year to document mortality. Chi square test for independence was used to calculate P values of important variables and P value of <0.05 was considered statistically significant. Results: A total of 161 patients with mean age was 71.1± 10.0 years were included in our study. There were 90(55.9%) males and 71(44%) females. Majority(62.1%,n=100) of fractures were pertrochanteric followed by neck of femur(34.8%,n=56) and subtrochanteric fractures(3.1%,n=5).Dynamic Hip screw(DHS) was used to fix fractures in 105(65.2%),Austion Moore Prosthesis(AMP)in 31(19.3%),Total Hip Replacement(THR) in 17(10.6%) and Dynamic Condylar Screw(DCS) in 3(1.9%) patients. At one year the overall mortality rate was 20.5% (n=33). Patients of 80 years and above had significantly higher mortality (34.8%, n=15) rate than others (P= 0.006337).The mortality was also significantly greater in females (28.2%,n=20) than male patients (14.4%,n=13) with P value of 0.032201. Patients operated for neck of femur fractures had significantly higher mortality rate (30.4%, n=17) than those operated for pertrochanteric fractures (16%, n=16) with P value of 0 .02361. Conclusion: Elderly female patients age 80 years and above operated for neck of femur fractures exhibited a higher mortality rate at one year follow up than others.

Osteochondroma is the most common benign chondrogenic lesion of the skeleton. Arising mostly in the long bones of the appendicular skeleton but may involve flat bones as well. Calcaneum however, is an uncommon site. True incidence is still unknown as many are asymptomatic, growing during childhood through adolescent until skeletal maturity. These are managed conservatively in majority of cases. If persists or grows during adulthood with acute onset of pain should raise suspicion of malignant transformation to a chondrosarcoma which warrants its surgical excision. We present the clinical and radiological finding of a 15-year-old male with a solitary osteochondroma (35mm x 26mm) on the inferolateral aspect of right calcaneus, followed by surgical excision. Histopathology showed no malignancy and there was no recurrence at 1 year follow up.

A complex pelvic fracture is defined as a pelvic fracture that occurs together with an additional organ injury in the pelvic region, and includes urogenital, gastrointestinal, neurological and retroperitineal vessel injury. Besides these additional organ injuries, complex pelvic fractures are almost always unstable. The orthopedic surgeon managing complex unstable pelvic fractures must conceptually divide their management into the measures taken in the Emergency room setting, intermin measures, and definitive measures aimed to restore pelvic stability. Regarding Emergency room measures, circumferential sheeting, external pelvic fixation device, and the pelvic C-clamp, are all acceptable measures employed as part of patient resuscitation. The more historial pelvic sling, and frequently used external pelvic fixation device are both acceptable intermediate stabilization measures. Definitive management is reserved for unstable pelvic fractures where anatomical alignment cannot be achieved by external means. The complications of prolonged external pelvic fixation is however appreciated, and in centers experienced in the technique, internal plating fixation is preferred. We reported a series of two patients with complex unstable pelvic fractures, further complicated by acetabular fractures that were ultimately managed by internal fixation and a total hip replacement. Our case series followed these two patients from the emergency room setting until their definitive internal plate fixation and concluded by an evaluation of functional outcome assessed with Majeed score. The essential principles in the management of these patients are highlighted together with the frequent complications reported and our series is valuable to those orthopedic surgeons involved in the management of these challenging patients.

A complex pelvic fracture is defined as a pelvic fracture that occurs together with an additional organ injury in the pelvic region, and includes urogenital, gastrointestinal, neurological and retroperitineal vessel injury. Besides these additional organ injuries, complex pelvic fractures are almost always unstable. The orthopedic surgeon managing complex unstable pelvic fractures must conceptually divide their management into the measures taken in the Emergency room setting, intermin measures, and definitive measures aimed to restore pelvic stability. Regarding Emergency room measures, circumferential sheeting, external pelvic fixation device, and the pelvic C-clamp, are all acceptable measures employed as part of patient resuscitation. The more historial pelvic sling, and frequently used external pelvic fixation device are both acceptable intermediate stabilization measures. Definitive management is reserved for unstable pelvic fractures where anatomical alignment cannot be achieved by external means. The complications of prolonged external pelvic fixation is however appreciated, and in centers experienced in the technique, internal plating fixation is preferred. We reported a series of two patients with complex unstable pelvic fractures, further complicated by acetabular fractures that were ultimately managed by internal fixation and a total hip replacement. Our case series followed these two patients from the emergency room setting until their definitive internal plate fixation and concluded by an evaluation of functional outcome assessed with Majeed score. The essential principles in the management of these patients are highlighted together with the frequent complications reported and our series is valuable to those orthopedic surgeons involved in the management of these challenging patients.

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

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.

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 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.

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.

Objective:To determine the functional outcome of traumatic brachial plexus injuries managed in our institution with our own designated treatment protocol( Hand and Upper Limb Surgery-HULS). Methods:This descriptive study was conducted in Hand and Upper Limb Surgery center CMH Lahore Medical College from 12th October 2012 to 12th October 2020.Patients of either gender and all ages with traumatic brachial plexus injuries fulfilling the inclusion criteria were assessed and treated with our own designitated algorithm (HULS protocol). Post treatment functional results were gradded as excellent, good, fair and poor. Results:The total number of patients in our study were 336.Mean age was 32.72 ± 5.58 years.Male patients were 316(94%) and female 20(5.9%). Right sided brachial plexus injury was noted in 245(72.9%) patients and left in 91(27%).Mean follow up peroid was 18 months(range 12 to 23 months).Post treatment functional results were excellent in 16(4.7%) patients, good in 159(47.3%),fair in 121(36%) and poor in 40(11.9%) patients. Conclusion:Traumatic brachial plexus injuries managed as per HULS protocol resulted in excellent and good functional outcome in majorityof our patients.We found this protocol relevant, applicable and feasible with improved clinical decision making, patient care and outcomes in traumatic brachial plexus injuries.

Objective: To determine the outcome of local rotational fasciocutaneus flap in the treatment of exposed tibia bone. Methods: We conducted this descriptive study in Department of Orthopedic surgery Liaquat University of Medical and Health Sciences, Jamshoro in collaboration with department of plastic surgery Liaquat University of Medical and Health Sciences, Jamshoro from 3rd January 2017 to 3rd June 2020. Patients of either gender and age with open tibia fractures and skin loss meeting the inclusion criteria were enrolled in our study. All patients were operated for fracture stabilization and coverage of the skin defect with rotational fasciocutaneous flap. Flap survival was assessed and results were graded as good, fair and failure as per Ponten criteria. Results: In this study 23 patients were included. Majority (78.26%, n=18) were males while females were 5(21.73%). Mean age was 31.8±9(range 18 to 46 years). Right tibia was involved in 14(60.8%) and left in 9(39.1) patients. Skin loss involved middle third of tibia was in 12(52.1%) patients, proximal third in 5(21.7%), distal third in 3(13%) and skin loss extended from middle to distal third in 3(13%) patients. The length of the flap varied from 9cm to 19 cm while the width varied from 3.5 cm to 9.5 cm. Flap survival results were good in 20(86.9%) patients and fair in 3(13%) patients. No flap failure was noted. Conclusion: Tibia fracture with skin loss treated with local rotational fasciocutaneus flaps produced good and fair outcome results without any flap failure in our series. We therefore recommend local rotational fasciocutaneus flap a technique of choice for coverage of variable tibia skin loss with fractures.

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 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

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

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.

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

Healthcare providers have been featured prominently throughout the global response to COVID-19. Images of first responders, nurses, and ICU doctors became the symbols of courage for the rest of us to follow. The roles and expectations of those on the front line are clear and their job is well defined. For others, like orthopaedic surgeons, finding our place in all of this has been more confusing. Trauma, infection, and cancer: these conditions do not stop because of a virus, but they account merely for a small subset of the whole of orthopaedic surgery. Orthopaedics by nature is a field designed to restore the health, temporarily lost, of the inherently well. Appropriately so, our patients were some of the first to have their procedures delayed, and our elective practices the least defendable to continue as the outbreak worsened.

Objectives: To determine the frequency of union in open tibia fractures treated with unreamed interlocking intramedullary tibial nails. Methods: This descriptive study was conducted in Department of Orthopaedics and Spine Surgery Ghurki Trust Teaching Hospital Lahore from 15th February 2018 to 14th November 2019. All patients with open diaphyseal tibial fractures fulfilling the inclusion criteria were fixed with unreamed interlocking intramedullary nails. Patients were followed up at intervals for nine months and clinical and radiological union was noted at final follow up visit. Results: The total number of patients in our study were 214.The mean age of our study participant was 45.47 ± 9.65 years.Male patients were 133(62.15%) and female 88(37.85%).Majority(87.85%,n=188) patients revealed clinical and radiological union at nine months while 26(12.1%) patients had non union.No major complication noted. Conclusion: High union rate had been achieved in open tibial fractures treated with unreamed interlocking nails.Unreamed interlocking nails therefore, can be used to treat Gustilo Anderson type I and type II diaphyseal fractures of tibia with good results.

Objective: To compare the subjective quality of various items used in short answer questions (SAQ) papers between Orthopaedics and other specialties used in internal examinations in MBBS course in a Medical College of Lahore. Methods: This retrospective descriptive study was conducted over a period extending from 25th October 2019 to 25th February 2020 at Avicenna Medical College Lahore. Previously used short answer questions (SAQ) papers (in internal assessments) of MBBS examination were collected from various departments of medical college. They were segregated in two groups as those from Orthopedic Surgery and those from Non Orthopedics subjects like general surgery, medicine and other subjects in the Miscellaneous group. SAQ in both the groups were assessed for the level of cognitive domain like C1(Recall),C2(Identify) and C3(Analyze) level and for clinically focused and relevant scenarios. The statements were evaluated whether scientifically correct and leading to an appropriatediagnosis without providing a lead into the question that would follow. All items were checked for mistakes in language or spelling and grammar. A comparison was made and P value calculated with Chi-square test. P value of < 0.05 was considered significant. Results: A total of 12 Orthopaedic SAQ papers comprising of 84 items and 14 miscellaneous papers comprising of 101 items were evaluated and compared. The number of C1 questions in Orthopaedic SAQ papers were 24(13%),C2 questions were 32(17.4%) and C3 was 28(15.2%).In the miscellaneous group C1 questions were 33(17.4%),C2 questions were 31(16.8%) and C3 questions were 37(20.1%). The number of SAQ scenarios were focused in 74(40%) SAQ in Orthopaedics versus 48(25.9%) in miscellaneous group(P value 0.013).The quality of statement was clear in 56(30.3%) SAQ in Orthopaedics while only 14(7.6%) of the miscellaneous papers had clear statement. Spelling mistakes were detected in 12(21.1%) SAQ of Orthopaedics and 22(38.8%) in miscellaneous group. Grammatical mistakes were noted in 10(17.5%) Orthopaedics SAQ and 5(8.8%) in miscellaneous group. Conclusion: The number of Orthopaedic SAQ with cognitive levels(C3,C4) were less than other specialty SAQ. However, the quality of scenarios were better focused and statement much clear in Orthopaedic SAQ than in miscellaneous group.

discectomy in patients with prolapsed intervertebral disc. Methods: This descriptive study was conducted from 3rd January 2018 to 23rd January 2020 in Orthopaedics and Spine Department Khyber Teaching Hospital Peshawar. All patients with prolapsed intervertebral disc in the lumbar spine and fulfilling the inclusion criteria were operated for single level lumbar discectomy. Post operative clinical outcome at one year was assessed with Oswestry Disability Index(ODI) and Modified Stauffer-Coventry criteria. The clinical outcome through Oswestry Disability Index (ODI) was interpreted as minimal, moderate, sever, crippled and bed bound disability while results of Modified Stauffer-Coventry criteria were graded as excellent, good, fair and poor clinical outcome. The clinical outcome score among stratified patient age, gender, occupation and education level was compared and P value was calculated with Chi-square test(P < 0.05 was considered significant). Results: The total number of patients in our study were 50. The mean age was 42.6 ± 9.56 years(18-50 years). Male patients were 22(44%) and female 28(56%).Post operatively minimal disability was noted in 33(66%) patients, moderate in 9(18%) and severe in 8(16%) patients as assessed with ODI. Clinical outcome assessment with Modified Stauffer-Coventry criteria reported excellent outcome in 19(38%), good in 15(30%), fair in 12(24%) and poor in 4(8%) patients. Male patients with light physical work had better score than female patients and male patients with heavy manual work(P < 0.05). No major complication reported. Conclusion: Single level lumbar discectomy in patients with prolapsed intervertebral disc produced satisfactory outcome with minimal disability in majority of our patients.

Objective: To compare low versus high implant density in decreasing Cobb angle in Lenke Type 1 Adolescent Idiopathic Scoliosis(AIS) treated with segmental spinal instrumentation and pedicle screws. Methods: This retrospective Cohort study was conducted at Department of Orthopedic and Spine Surgery, Ghurki Trust Teaching Hospital/ Lahore Medical and Dental College, Lahore. The medical records of patients between 15th June 2015 to 15th June 2019 who underwent segmental spinal instrumentation for Lenke type 1 adolescent idiopathic scoliosis were reviewed. Low implant density was defined as patients with pedicle screw density per fused segment of 60 %( ?1.2) or less while high density patients had more than 60 % (> 1.2) screw density. Radiographs were evaluated preoperatively for Cobb angle of main thoracic curve, sagittal and lumbar modifier. Postoperative evaluation included postoperative Cobb angle, percent Cobb angle decease, implant density and implant cost. Independent sample t-test, paired Sample t-test and Chi-square test of association were applied to compare preoperative and postoperative variables between two groups. P<0.05 was set as significant. Results: The total number of patients in our study was 66. Female patients were 47(71.2%) and male 19(28.7%). In low implant density group there were 25 patients including 17(68%) female and 8(32%) male. Mean pre-operative and post-operative Cobb angle was 62.60±130 (450-900) and 13.80±8.070 (0-250) respectively. Mean percent Cobb angle decrease, implant density and implant cost was 78.56±12.07% (50-100%), 1.11±0.083 (0.9-1.20) per fused segment and rupees 85248±13414.57 respectively. High implant density group included total 41 patients with 30(73.2%) females and 11(26.8%) males. Mean preoperative and postoperative Cobb angle was 65.240±16.160 (450-1000) and 13.290±8.180 (0-250) respectively. Mean percent Cobb angle decrease, implant density and implant cost was 79.85±12.85%(44-100%), 1.499±0.09 (1.29-1.65) per fused segment and rupees 93658.53±10589.64 respectively. Comparison between the two groups showed no significant difference in percent Cobb angle decrease (P=0.868). However implant cost was significantly reduced in low implant density group (p=0.000) Conclusion: Correction of Cobb angle was not significantly influenced by metal density and henceforth low implant density can be used to obtain excellent correction in Lenke type 1 idiopathic Scoliosis(AIS) treated with segmental spinal instrumentation and pedicle screws.

Objective: To determine one year mortality rate in elderly patients who were operated for fracture proximal femur in District Headquarter Hospital Rawalpindi. Methods: This descriptive study was conducted in Orthopaedic Department District Headquarter Hospital Rawalpindi from 3rd January 2017 to 25th December 2019. All patients with proximal femur fracture (neck of femur, per trochanteric and sub trochanteric fractures) fulfilling the inclusion criteria and who were operated were included in our study. Post operatively all these patients were followed up at regular intervals up to one year to document mortality. Chi square test for independence was used to calculate P values of important variables and P value of <0.05 was considered statistically significant. Results: A total of 161 patients with mean age was 71.1± 10.0 years were included in our study. There were 90(55.9%) males and 71(44%) females. Majority(62.1%,n=100) of fractures were pertrochanteric followed by neck of femur(34.8%,n=56) and subtrochanteric fractures(3.1%,n=5).Dynamic Hip screw(DHS) was used to fix fractures in 105(65.2%),Austion Moore Prosthesis(AMP)in 31(19.3%),Total Hip Replacement(THR) in 17(10.6%) and Dynamic Condylar Screw(DCS) in 3(1.9%) patients. At one year the overall mortality rate was 20.5% (n=33). Patients of 80 years and above had significantly higher mortality (34.8%, n=15) rate than others (P= 0.006337).The mortality was also significantly greater in females (28.2%,n=20) than male patients (14.4%,n=13) with P value of 0.032201. Patients operated for neck of femur fractures had significantly higher mortality rate (30.4%, n=17) than those operated for pertrochanteric fractures (16%, n=16) with P value of 0 .02361. Conclusion: Elderly female patients age 80 years and above operated for neck of femur fractures exhibited a higher mortality rate at one year follow up than others.

Objective: To determine the frequency of different bacteria and their antibiotic sensitivity patterns in patients presenting with chronic Osteomyelitis. Methods: This descriptive study was conducted in Orthopedics and Trauma unit District Headquarter Hospital Daggar, Bunir, Khyber Pakhtunkhwa and Lady Reading Hospital Peshawar from 12th August 2016 to 3rd February 2019. Bone biopsy or sequestrum was taken from all patients of long bones of chronic osteomyelitis fulfilling the inclusion criteria and sent to laboratory for culture and sensitivity. Results: The total number of patients enrolled in our study were 193. Majority (78.76%, n=152) of patients yielded positive growth on culture while no growth was documented in 41(21.24%) patients. Staphylococcus aureus was the most common bacteria(64.36%, n=97) followed by Pseudomonas Aeruginosa (17.10%,n=26), E. Coli (11.84%,n=18) and Proteus Mirabilis(7.24%,n=11).Maximum antibiotic sensitivity(> 90%) was noted for Vancomycin and Fusidic Acid while maximum resistance(35.05%,n=34) was noted for Penicillin. Conclusion: Staphylococcus Aureus was the most common bacteria isolated. Majority of isolated bacteria were sensitive to Vancomycin and Fusidic acid.

Objectives: To assess the knowledge and awareness of Osteoporosis in female population of Hyderabad Pakistan. Methods: This cross-sectional study was conducted from 10th April 2019 to 10th June 2019 in Muhammad Medical College and Hospital Mirpurkhas, Pakistan. All female post-menopausal women of Hyderabad district fulfilling the inclusion criteria and attending Orthopaedic Outpatient Department (OPD) were included in our study. The knowledge and awareness of Osteoporosis was assessed through a questionnaire based on Osteoporosis Health Belief Scale (OHBS) and explained in local language. The bone mineral density (BMD) and body mass index (BMI) of all the participants were also determined. Important study variables like BMI was compared with BMD and Chi square test was used to calculate P value (P value <0.05 was considered significant) Pearson’s correlation and Spearman’s ? analysis was done for important variables of OHBS questionnaire. Results: This study included 200 women. The mean age was 54± 4 years. There were 36(18%) women with Osteoporosis, 110(55%) with Osteopenia and 54(27%) were normal. The mean BMI were 28.2± 3.11 among normal women, 26.2±3.37 among Osteopenic women and 25.2±3.65 among Osteoporotic women. Only few (39.5%, n=79) women agreed that they were susceptible to Osteoporosis, 71(35.5%) disagreed and 50(25%) were neutral. About 81(40.5%) women were serious about Osteoporosis, 65(32.5%) neutral and 54(27%) disagreed that Osteoporosis was a serious health problem. The benefits of physical exercises were acknowledged by 50(25%) women while 84(42%) ladies disagreed. The importance of enough dietary calcium and supplements were recognized by 79(39.5%) women while 68(34%) ladies disagreed. About 98(49%) women agreed that health motivation was essential to prevent Osteoporosis, 66(33%) disagreed and 36(18%) were neutral. Conclusion: Although many women agreed that health motivation was essential to prevent and treat Osteoporosis, their level of knowledge and awareness of Osteoporosis was low.

Osteochondroma is the most common benign chondrogenic lesion of the skeleton. Arising mostly in the long bones of the appendicular skeleton but may involve flat bones as well. Calcaneum however, is an uncommon site. True incidence is still unknown as many are asymptomatic, growing during childhood through adolescent until skeletal maturity. These are managed conservatively in majority of cases. If persists or grows during adulthood with acute onset of pain should raise suspicion of malignant transformation to a chondrosarcoma which warrants its surgical excision. We present the clinical and radiological finding of a 15-year-old male with a solitary osteochondroma (35mm x 26mm) on the inferolateral aspect of right calcaneus, followed by surgical excision. Histopathology showed no malignancy and there was no recurrence at 1 year follow up.

Cerebral Palsy (CP) is caused by a non-progressive lesion to an immature brain and results in different types of neurological problems including spasticity, motor weakness, poor coordination, dystonia and ataxia. Spasticity is the commonest type of problem seen in CP. The primary neurological damage in CP results in abnormal tones, selective control, coordination and motor imbalance. The mainstay of treatment in the first 6-7 years of age is tone management and physical therapy. The primary neurological problem is static but the muscles and bones are under the influence of abnormal muscle tone and muscle imbalance during growth, secondary problem (musculoskeletal) such as torsional deformities of long bones and contractures of muscle and joint develops with time. Contractures, joint stiffness and subluxation becomes more obvious and compromise walking after the age of 7-8 years. Orthopaedic intervention to correct these secondary skeletal deformities starts to play a more important role after this age.

A complex pelvic fracture is defined as a pelvic fracture that occurs together with an additional organ injury in the pelvic region, and includes urogenital, gastrointestinal, neurological and retroperitineal vessel injury. Besides these additional organ injuries, complex pelvic fractures are almost always unstable. The orthopedic surgeon managing complex unstable pelvic fractures must conceptually divide their management into the measures taken in the Emergency room setting, intermin measures, and definitive measures aimed to restore pelvic stability. Regarding Emergency room measures, circumferential sheeting, external pelvic fixation device, and the pelvic C-clamp, are all acceptable measures employed as part of patient resuscitation. The more historial pelvic sling, and frequently used external pelvic fixation device are both acceptable intermediate stabilization measures. Definitive management is reserved for unstable pelvic fractures where anatomical alignment cannot be achieved by external means. The complications of prolonged external pelvic fixation is however appreciated, and in centers experienced in the technique, internal plating fixation is preferred. We reported a series of two patients with complex unstable pelvic fractures, further complicated by acetabular fractures that were ultimately managed by internal fixation and a total hip replacement. Our case series followed these two patients from the emergency room setting until their definitive internal plate fixation and concluded by an evaluation of functional outcome assessed with Majeed score. The essential principles in the management of these patients are highlighted together with the frequent complications reported and our series is valuable to those orthopedic surgeons involved in the management of these challenging patients.

Objective: To determine the outcome of posterior interosseous artery (PIA) flap in terms of coverage of the defects and survival of the flap in patients with complex defects over the dorsum of hand and distal forearm. Methods: This descriptive study was conducted in Hand and Upper Limb Surgery (HULS) CMH Lahore Medical College, Lahore, Pakistan from 15th July 2017 to 15th August 2019.All patients with complex defects of the dorsum of the hand and distal forearm were treated with posterior interosseous artery (PIA) flap. Post operatively the grafts were observed for coverage of the defects and graft survival. Results: The total number of patients were 24 with 19(79.1%) males and 05(20.8%) females. The mean age was 37±7SD(range 21 to 56 years). Right hand was involved in 17(70.8%) patients and left in 7(29.1%) patients. Complete coverage of the defects were achieved in all cases. Successful graft survival and uptake was seen in 20(83.3%) flaps. Partial loss was seen in 03 (12.5%) flaps which required debridement and subsequent Split Thickness Skin Grafting. Complete graft loss was seen in 01 (4.1%) flap Conclusion: Posterior interosseous artery flap (PIA) had higher survival rates and larger area of the dorsum of the hand and distal forearm were entirely covered with this graft. We recommend posterior interosseous artery flap as first line surgical technique to treat complex tissue defects of the dorsum of the hand and distal forearm.

Objective: To determine the frequency of osteoporosis and osteopenia among the general population of District Khuzdar, Baluchistan Pakistan. Methods: This was a cross-sectional study and the data was collected on “World Osteoporosis Day” 20th October 2019 during an awareness session arranged by Shaheed Baz Muhammad Kakar Foundation at Baluchistan University of Information Technology, Engineering and Management Sciences Khuzdar Campus. The bone mineral density of all participants fulfilling the inclusion criteria was determined with DMS PEGASUS SMART Bone Densitometer. The T-scores were measured based on the readings of each individual and further characterized as Normal (+1 to -1 Standard Deviations), Osteopenia (-1 to -2.5 Standard Deviations), and Osteoporosis (<-2.5 SD). Results: The total participants screened were 246 including 169(68.7%) males and 77(31.3%) females. The mean age was 37±7. Most(49.2%, n=121) participants were in the age range of 15 to 25 years. Majority (75.6%,n=186) of the participants had normal bone mineral density. Osteopenia was detected in 47(19.1%) and Osteoporosis in 13(5.3%) participants. Conclusion: Majority of our study participants had normal bone mineral density. However, osteopenia and osteoporosis was detected in good proportion of our study sample. Proper treatment can prevent insufficiency fractures in this osteoporotic fraction of our population.

Objective: To determine the frequency and severity of cervical spine injuries in motorcycle riders with and without helmet use. Methods: This descriptive study was conducted in Accident and Emergency Department, Khyber Teaching Hospital Peshawar from 23rd January 2019 to 23rd December 2019. All patients fulfilling the inclusion criteria were enrolled in the study. The Abbreviated Injury Scale(AIS) was used for documenting the frequency and severity of cervical spine injuries in helmeted and unhelmeted motorcycle riders. The neurological status was evaluated with American Spinal Injury Association(ASIA) impairment scale. Results: A total of 559 motorcycle riders were included in our study. Helmet users were 123(22%) and non-users were 436(77.9%). The mean age of helmeted group was 39±6SD and unhelmeted group was 28±11SD. The frequency of cervical spine injury was noted in 8(6.5%) patients wearing helmets and in 87(19.9%) patients not wearing helmets.( P value <0.05)The cervical spine injuries in helmeted were AIS1 in 6(75%) patients and AIS2 in 2(25%) patients. The types of cervical spine injuries in unhelmeted were AIS2 in 10(11.4),AIS3 in 70(80.4%) and AIS4 in 7( 8%) patients. No neurological impairment was noted in helmeted group while unhelmeted group had ASIA C in 7(8%) and ASIA D in 10(11.4%) patients on arrival to hospital. Conclusion: The frequency and severity of cervical spine injuries in unhelmeted motorcycle riders were more than helmeted riders. Motorcyclists wearing helmets were not prone to increased risk of cervical spine injuries during collisions, rather wearing helmet had some protective advantage. Key Words: Abbreviated Injury Scale, ASIA Impairment Scale , Cervical spine, Helmet, Motorcycle.

Objective: To determine the clinical and radiological outcome of AO Type C fracture distal radius treated with 2.4mm Titanium volar locking plates. Methods: This descriptive study was conducted in Department of Hand and Upper limb Surgery(HULS) Combined Military Hospital(CMH) Lahore Pakistan from 23rd January 2016 to 4th January 2019.All adults patients of either gender with distal radius fractures(Type C) fulfilling the inclusion criteria were treated with 2.4mm volar locking plates. Post operative flexion and extension of the wrist was measured with goniometer and grip strength with a weighing scale. Radiological outcome was determined by comparing pre operative and post operative radial height, radial inclination and volar tilt. P value was calculated for net improvement of radiological outcome and < 0.05 was considered significant. Results: The total number of patients in our study were 52.Mean age of the patients were 40.26 ± 12.7 years(range 18 to 69 years).Male patients were 39(75%) and female 13(25%).Right radius was fractured in 28(53.8%) patients and left in 24(46.1%).AO type C2 fracture was noted in 24(46.1%),C1 in 19(36.5%) and C3 in 9(17.3%) patients. Post operative mean wrist flexion was 78°±7 (range 62° to 80°) and extension 68°±4 (range 60° to 75°)at last follow up. The grip strength was excellent in 22(42.3%), good in 18(34.6%) and average in 12(23%).The mean value of pre operative Radial Height(RH) was improved from5.35±3.32 to 11.42±0.800, Radial Inclination(RI) from 13.83±3.71 to 21.09±0.793 degrees, and Volar Tilt(VT) from 5.43±11.9 to11.22±0.951 degrees. The net improvement in RH, RI and VT was 6.11 ± 2.77, 7.26 ± 2.89 and 15.65 ± 14.26 (P > 0.05).No major complication was documented in our study. Conclusion: Titanium volar locking plates produced excellent functional and radiological outcome in patients with intra articular fractures of the distal radius. We therefore, recommend 2.4mm Titanium volar locking plate as implant of choice to treat Type C fractures.

Objective: To determine the functional outcome of arthroscopic shoulder stabilization of anterior shoulder instability using all-suture anchors. Methods: This descriptive study was conducted in Department of Orthopedics, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences (PGIMS) Rohtak, India from 9th June 2017 to 31st October 2019.All patients of shoulder instability fulfilling the inclusion criteria were treated with arthroscopic capsule labral repair using all-suture anchors. Post-operatively patients were followed up every two weeks for two months and then monthly for six months and final visit at 15th months follow up. The functional outcome was assessed with Rowe Scoring scale and UCLA(The University of California Los Angeles) scale. Based upon the Rowe score the outcome was rated as excellent(score 100 to 90),Good(89 to 75),Fair(74-51) and poor((50 or less).The UCLA score was rated as excellent/Good( > 27) and Fair/Poor score( < 27 score).Chi-square test was applied and P value was calculated for comparing pre and post op Rowe Score and UCLE score and value of < 0.05 was considered significant. Results: The total number of patients enrolled in our study were 25. The average age of our patients was 23.6 years±5.50 (range 18 to 39 years).Male patients were 23(92%) and female 2(8%).The Rowe score improved from mean preoperative value of 41.8±11.72 to 94.4 ±1.66 post operatively(P< 0.05).The UCLA score improved from mean value of 24.56 ± 1.98 preoperatively to 34.68 ± 1.11 postoperatively(P < 0.05).As per Rowe score all the subjects had excellent outcome while 23(92%) patients had excellent outcome and 2(8%) good outcome as per UCLA score. None of the patients had recurrent dislocation or instability postoperatively. Conclusion: Arthroscopic shoulder stabilization using all-suture anchors produced excellent functional outcome without any recurrent instability. It is a nearly scarless, minimally invasive procedure providing robust stability and mobility in selected patients and help patients to return to preinjury level in short span of time.

Objective: To determine the clinical and radiological outcome of the inter trochanteric femur fractures in elderly patients fixed with Dynamic Hip Screw( DHS) without image intensifier. Methods: This retrospective cohort study was conducted in Department of Orthopaedics Bolan Medical Complex hospital Quetta from 25th November 2017 to 23rd November 2019.The medical records of inter trochanteric fractures fulfilling the inclusion criteria who were operated for DHS without image intensifier were analyzed retrospectively. The screw placement technique, post operative position of lag screw in radiographs, union and complications were noted in each case. Results: The records of 23 patients with mean age 75 ±7 years(range 58 to 90 years) were analyzed. Male patients were 15(65.2%) and female 8(34.7%). The position of lag screw was central position in 14(60.8%) patients and posterior inferior in 4(17.3%) patients while in 5(21.7%) patients the screw was in anterio superior position. Fracture union was noted in 22(95.6%) patients and implant failure in 1(4.3%) patient. Conclusion: DHS under image intensifier should be the gold standard treatment of intertrochanteric fractures. However, acceptable radiographic position of DHS lag screw in femoral head and neck and ultimate union can be achieved in selected inter trochanteric fractures fixed without image intensifier. However experience of the operating surgeon and accurate preoperative templating and per operative lag screw placement techniques are mandatory.

Objective: To determine the radiological and functional outcome of Ilizarov ring fixator in the management of infected nonunion of long bones of the lower limb. Methods: This descriptive study was conducted in Mercy Teaching Hospital Peshawar from 3rd January 2011 to 23rd June 2019. All patients of infected non-union of tibia and femur meeting the inclusion criteria were treated with Ilizarov ring fixator. Post-surgery outcomes were analyzed in terms of bone and functional results as per “Association for the Study and Application of Methods of Ilizarov (ASAMI) Scoring System”. Results: A total of 40 cases including 37(92.5%) males and 3(7.5%) females with the mean age 33.325± 9.4 years (range 3 to 60 years) were included in our study. In 30(75%) cases tibia and in 10(25%) cases femur was involved. Bone defect after radical debridement was 2-centimeter(cm) or less in 25(62.5%) cases and they were treated with monofocal compression distraction technique using Ilizarov ring fixator. In 15(37.5%) cases bone loss after radical debridement was more than 2cm with mean defect 7.06 cm (ranging from 4cm to 12 cm) and they were treated with bone segment transport. Post-operative outcome as assessed with ASAMI scoring system showed excellent radiological result in 35 (87.5%) patients and good in 5 (12.5%) cases. Excellent functional results were noted 30 (75%) cases, good in 9 (22.5%) and fair in 1 (2.5%) case No poor radiological or functional results were reported. Conclusion: The Ilizarov ring fixator produced excellent and good radiological and functional results in majority of our patients with infected nonunion of long bones of the lower limb. We therefore recommend that Ilizarov should be the first treatment modality to treat infected non unions of tibia and femur.

Objective: To determine the mid-term functional and radiographic outcome of primary total knee replacement with all-polyethylene tibial components. Methods: This descriptive study was conducted in Orthopaedic Department of Ghurki trust Teaching Hospital Lahore from 25th June 2014 to 29th June 2019.All patients fulfilling the inclusion criteria who were operated with all-polyethylene tibial component were included in our study. Post-operative functional outcome was assessed at three years with Knee Society Score and graded as excellent, good, fair and poor for Knee score and Function. Radiological outcome was assessed by measuring tibial angle, tibial-femoral angle and femoral flexion angle on anterio posterior and lateral radiographs. Results: During this study 65 knees of 34 patients were replaced by using all-polyethylene tibial component implant. Male patients were 15(44.1%) and females 19 (55.8%). Mean age of our patients were 60.4±6.12 years (range 50-80 years). Bilateral total knee replacement (TKR) was done in 31(91.1%) patients while 3(8.8%) had unilateral knee Arthroplasty. At three years follow up the knee score was excellent in 3(8.8%), good in 15(44.1%), fair in 12(35.2%) and poor in 4(11.7%) patients. The function score was good in 11(32.3%) fair in 14(41.1%) and poor in 9(26.4%). Anterio posterior radiograph revealed mean tibial angle 89±1.72°(range 84-92°), tibia-femoral angle 5.0±0.53°(range 4-6°) and femoral flexion angle 96±1.88°( range 94° to 102°).Lateral radiograph showed mean tibial angle 89.9±1.24°(range 85 to 92°) and mean femoral flexion angle 10.83±1.49°(range 10-16°). Conclusion: Total knee replacement with all- polyethylene tibial components had excellent and good functional and radiological mid-term outcome in majority of our patients

Pisiform dislocation is very rare. Only few cases have been reported and all were post- traumatic. Due to its rarity, there is no optimum treatment. Literature suggest close reduction and open reduction or excision of pisiform with good results. We present a case of dislocated pisiform identified post traumatically in a 10-year-old female with ipsilateral greenstick radius and ulna fracture. She presented in emergency room(ER) after a simple fall over the outstretched hand. X-rays and CT scan confirmed the dislocated pisiform bone. The pisiform bone was surgically excised. The patient was given a below elbow back slab for 4 weeks. At 3 months, follow up she was completely pain free with full range of motion of wrist and no functional deficit. We suggest that excision of Pisiform bone after dislocation can be performed without the risk of any future consequences. Removal of bone