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Background: Due to increasing population and changing human habits the number of accidents and high energy trauma is rising. Management of open fracture tibia is a complex problem and is a challenge for both orthopaedic and plastic surgeons. The study was carried out to ascertain the efficacy and safety of interlocked intra-medullary nailing for open shaft tibial fractures in patients presenting at or after 24hr of injury., Methods: In this descriptive case series, over a period of 6 moths, 163 consecutive cases of open fracture of tibial shaft were reviewed in terms of clinical profile, time of presentation, and gender distribution., Results: In this study mean age was 30±0.02 years. Males comprised 85% of study population while 15% were females. Gustilo-I type fracture and Gustilo-II type fracture was diagnosed in 90% and 10% patients respectively. Thirty three percent patients had wound infection while fracture union was found in 15% cases. Moreover interlocked intramedullary nailing for open fracture shaft of tibia was safe in 80% patients while this procedure was effective in 85%., Conclusions: Un-reamed, interlocked intra-medullary nailing may be considered as a suitable option for treatment of open fractures of tibia.

Background: Many studies have demonstrated that honey has antibacterial activity in vitro, and a small number of clinical case studies have shown that application of honey to severely infected cutaneous wounds is capable of clearing infection from the wound and improving tissue healing. Research has also indicated that honey may possess anti-inflammatory activity and stimulate immune responses within a wound. The overall effect is to reduce infection and to enhance wound healing in burns, ulcers, and other cutaneous wounds. The objective of the study was to find out the results of topical wound dressings in diabetic wounds with natural honey., Methods: The study was conducted at department of Orthopaedics, Unit-1, Liaquat University of Medical and Health Sciences, Jamshoro from July 2006 to June 2007. Study design was experimental. The inclusion criteria were patients of either gender with any age group having diabetic foot Wagner type I, II, III and II. The exclusion criteria were patients not willing for studies and who needed urgent amputation due to deteriorating illness. Initially all wounds were washed thoroughly and necrotic tissues removed and dressings with honey were applied and continued up to healing of wounds., Results: Total number of patients was 12 (14 feet). There were 8 males (66.67%) and 4 females (33.33%), 2 cases (16.67%) were presented with bilateral diabetic feet. The age range was 35 to 65 years (46 +/- 9.07 years). Amputations of big toe in 3 patients (25%), second and third toe ray in 2 patients (16.67%) and of fourth and fifth toes at the level of metatarsophalengeal joints were done in 3 patients (25%). One patient (8.33%) had below knee amputation., Conclusion: In our study we observed excellent results in treating diabetic wounds with dressings soaked with natural honey. The disability of diabetic foot patients was minimized by decreasing the rate of leg or foot amputations and thus enhancing the quality and productivity of individual life.

Background: Talipes Equino-Varus (TEV) is one of the most common congenital anomaly. It is managed by various methods, i.e., conservative & surgery. Objective of this study was to determine the efficacy of modified Turco's postero-medical release in children's having congenital TEV., Methods: This descriptive observational study was conducted from June 2004 to June 2008 in the Orthopaedics Unit of Lady Reading Hospital (LRH) Peshawar. The inclusion criteria were children of age 6 months to 3 years of age having moderate and severe club foot. The exclusion criteria were clubfoot secondary to some other disorders such as cerebral palsy, arthrogryphosis multiplex congenita, myelodysplasia or congenital dislocation of the hip. The deformity was treated by modified Turco's one stage release. Follow-up was for one year. Results were graded according to modified McKay rating system., Results: A total 70 patients were included in this study with the age range of 6 months to 3 years with moderate to sever deformity. Thirty-eight, were male (54.2%) and 32 patients (45.72%) were female, twenty three patients (32.85%) had bilateral club foot while the rest of 47 patients (67.15%) had unilateral deformity. Positive family history of club foot was in 10 patients (14.2%). Results were concluded on 52 patients who completed one year follow-up. Excellent results were observed in 34 patients (65.38%), good in 9 patients (17.30%), fair in 2 patients (3.84%), and poor in 7 patients (13.46%)., Conclusion: Children up to three years age with congenital TEV can be successfully treated in almost all the cases by modified Turco's one stage postero-medial release.

Background: Femoral shaft fractures are common in adult population due to vulnerability to road traffic accident and firearm injuries. There are various treatment modalities to treat the femur shaft fracture, i.e., Plating & screws, Intramedullary nailing, External fixator and Interlocking nails. Comminuted fractures due to gun shot injuries are a challenging problem for orthopaedic surgeons. The objective of this study is to evaluate the role of interlocking nailing in the management of femoral fractures due to high velocity gunshot injuries., Methods: This descriptive study was conducted on 68 patients at Orthopaedic unit Postgraduate Medical Institute, Lady Reading Hospital Peshawar, from March 2002 to March 2004. The patients of each gender from age fifteen years onward having femoral shaft fracture due to high velocity gunshot injuries who had not previous surgical intervention were included in the study. The exclusion criteria were intertrochanteric, supracondylar femoral fractures and those who failed the follow-up. All the patients were treated with close or open interlocking nails. The outcome measures were graded excellent, good and poor according to radiological and clinical results. Follow-up was for eighteen months and in some cases up to thirty months., Results: Out of 68 patients 64 (94.12%) were male and 4 (5.88%) were female patients. The age range was from 15 to 65 years (average age of twenty nine years. The close interlocking nails were done in 64 patients (94.12%) and open interlocking nails were done in 4 patients (5.88%). The static interlocking nailing was performed in 58 patients (85.29%) while dynamic interlocking nailing was performed in 10 patients (14.71%). Knee flexion contracture in 5 cases (7.35%) and limb shortening of less than 2 Cm in 2 patients (2.94%). Non-union were in 4 cases (5.88%). Excellent results were in 42 patients (61.76%), good in 18 patients (26.47%) and poor in 8 patients (11.77%)., Conclusion: Interlocking nailing is one of the best options for the management of femoral shaft fractures due to high velocity gunshot injuries.

Background: Infection in orthopedic surgery is a disaster both for the patient and surgeon. Although its incidence has been reduced due to modern theatre facilities and aseptic measures but in developing countries its prevalence is still high. It is better to prevent infection rather than to treat it. The objective of this study is to know the frequency of infection in orthopedic implant surgery in a public hospital and to evaluate the risk factors, causative organism, complications and treatment., Methods: This prospective study was conducted in orthopedic unit-B Ayub Teaching Hospital, Abbottabad, from 1st April 2007 to 30th October 2007. Close fracture cases admitted for internal fixation devices were included. The exclusion criteria were soft tissue surgery, wounds and open fractures needing external fixation devices. The follow up was done for six months., Results: Infection developed in 6 patients (5.76%), out of which superficial and deep infections were 2 (1.92%) and 4 (3.84%) respectively. There were 2 infection cases in each stage of the infection i.e. early, delayed and late. The staphylococcus aureus was the commonest organism, i.e., 3 (50%) out of 6. The age of the patients was more than 60 years in 3 (2.88%) patients, 30 to 60 years in 2 (1.92%) patients and below 30 year in 1 (0.96%) patient. The smoking history was in 2 (1.92%) patients., Conclusion: Infection rate in our study was quite high and needs proper measures to control it because it had great financial burden on patient and on hospital resources and could lead to morbidity and mortality in patients. We could not find significant risk factors in our small sample size study although the infection was relatively more common in patients with advanced age, prolonged surgery time, smoking and skin abrasion at fracture site. Commonest organism was Staphylococcus aureus.

Background: Hepatitis B and C is a common global health problem and is spreading rapidly in developing countries due to lack of health education, poverty and illiteracy. Both of these infections can be transmitted through blood or body fluids, tattooing, through infected instruments, unsafe shave by barbers and sexual contact. Medical personnel are most exposed to these infections. There should be proper preventive measures to prevent its spread in the community., Methods: This is a descriptive study carried out from July 2003 to July 2004 on 1630 patients admitted in the department of Orthopaedics Ayub Teaching Hospital Abbottabad. Patients of either sex, of all ages undergoing surgery were included in the study. All patients underwent screening for Hepatitis-B and Hepatitis-C and confirmed by Elisa method in positive patients., Results: Out of 1630 patients 1205 (73.92%) were male and 425 (26.07%) were female. Hepatitis B and C was present in 84 (5.15%) patients. Out of 84 infected patients 51 (3.12%) were suffering from hepatitis C and 33 (2.02%) were suffering from hepatitis B. In 2 (0.12%) patients both hepatitis B and C infections were present. Out of 51 hepatitis C patients, 33 (64.71%) were male and 18 (35.29%) were female. Out of 33 hepatitis B patients, 28 (84.85%) were male and 5 (15.15%) were female patients. Among the predisposing factors previous history of surgery was positive in 18 (21.43%) patients, history of blood transfusion in 13 (15.47%) patients, dental procedure was in 7 (8.33%) patients, and abroad visit in 4 (4.76%) patients., Conclusion: The prevalence of hepatitis B and C in orthopaedic patients is quite high with the common risk factors: previous history of surgery or blood transfusion. Therefore, all patients which need surgery should be routinely screened for hepatitis B & C to prevent transmission to other patients, medical staff. There should be separate operation theatres facilities for these patients. There should be policy by the Government for protection of medical personnel who are exposed to these patients and there should be compensation for those who get infected with these infections during their service otherwise the medical personnel especially surgeons will hesitate doing surgeries on hepatitis B and C infected patients.

Background: Tibial bone defect lead to limb shortening and functional deficit and needs proper treatment. There are various treatment modalities for bone defect in long bone to restore length and function of the limb, i.e. bone grafting, vascularised bone graft, allograft and bone transport. Bone transport can be done through fixators (uniplaner or ring) and intramedullary nail system. This study was conducted on management of tibial non-union with Ilizarov external fixator., Method: This descriptive study was performed on 58 patients in Agency Headquarter Hospital, Bajawar and Lady Reading Hospital, Peshawar, from January 2000 to January 2006. Patients of either gender with age between 9 to 58 years, having nonunion (clean and infected nonunion) in tibia with defect of 2 to 7cm due to trauma or firearm injury were included in the study. These patients were followed up upto one year. Outcome measures were according to the classification of Association for the Study and Application of the Method of Ilizarov (ASAMI), which is based on radiological (defect filling) and clinical (functional) findings., Results: Out of 58 patients, 44 (75%) were male and 14 (25%) were female. Mean age was 30 years (9 to 58 years). 38 (65.52%) patients had infected non-union while 20 (34.48%) had clean non-union. Right tibia was involved in 32 patients (51.17%) and left was involved in 26 (44.83%) patients. The cause of initial trauma was road traffic accident in 27 patients (46.55%), firearm injury in 23 patients (39.65%) and a simple fall in 8 patients (13.79%). The length of average bone defect was 2.90 cm (200-7.00 cm). Radiological results were excellent in 33 (58.89%) patients, good in 12 (20.68%) patients, fair in 8 (13.79%) patients and poor in 5 (8.62%) patients. The clinical results were excellent in 33 patients (56.89%), good in 18 patients (31.05%), fair in 4 (6.89%) patients and poor in 3 patients (5.17%)., Conclusion: Ilizarov ring fixator is excellent treatment modality for tibial non-union with a defect, regarding bone union, deformity correction, infection eradication, limb length achievement and limb function but this needs prolonged learning curve for fresh orthopedic surgeons.

Background: Tennis elbow is a common disorder of upper extremity. It can be treated conservatively in majority of the patients but some resistant cases eventually need surgery., Material & Methods: This descriptive study was conducted at Department of Orthopaedics, Ayub Teaching Hospital, Abbottabad, from January 2002 to June 2006. Sixteen patients had surgical release of the extensor tendon origin along with excision of the lateral epicondyle ridge. These patients did not respond to conservative treatment i.e. rest, non- steroidal anti inflammatory drugs (NSAIDS), local steroid injections and physiotherapy. Patients were followed upto six months. Outcome was graded as excellent, good and poor according to pain relief and function of the hand., Results: Sixteen patients (17 elbows) were studied. Thirteen were female (81.25%) and three were male (18.75%). Fifteen patients (93.75%) had unilateral Tennis Elbow, while one had bilateral involvement (6.25%). In unilateral disease, right side was affected in eleven patients (68.75%) and left side in four (25%). Excellent outcome was noticed in eleven patients (68.75%) and good result in five patient (31.25%)., Conclusion: Open surgical technique of releasing extensor tendon origin along with excision of lateral condylar ridge of the humerus is new and simple procedure and yields excellent and good result in patients with resistant Tennis Elbow.

Background: Bone defect in long bones is a problem in orthopaedic which needs proper treatment to restore limb length and function of the limb. There are various treatment modalities available to fill the detect like bone grafting, vascularised bone graft, allograft and bone transport through fixators (Ring or Uniplanner). This study was done to determine the outcome of locally manufactured External Fixator (Naseer and Awais ) in the management of tibial bone defect due to trauma., Methods: This descriptive study was conducted on 20 patients in orthopedic department in Lady Reading Hospital Peshawar and Ayub Teaching Hospital Abbottabad, from Nov 1997 to Nov 2002. Patients from either gender aged between 20 to 50 years, having tibial bone defect of more than five centimeter due to trauma were included in the study. Follow up was done for two years. Outcome measures were adopted according to the classification of the Association for the Study and Application of the Method of llizarov (ASAMI) based on clinical (functional) and radiological findings (defect filling)., Results: Out of 20 patients 14 (70%) were males and 6 (30%) were female patients. Right tibia was involved in 12 patients (60%) and left tibia in 8 patients (40%). Bony defects due to firearm injury were in 14 patients (70%) and road traffic accidents were in 6 patients (30%). Radiological (bony) results were excellent in 12 patients (60%), good in 2 patients (10%), fair in 3 patients (15%) and poor in 3 patients (15%). Clinical (functional) results were excellent in 7 patients (35%), good in 8 patients (40%), fair in 4 patients (20%,) and poor in 1 patients (5%,). Post operative complications after distraction osteogenesis were pin tract infections in 8 patients (40%), Axial deviations in 6 patients (30%), foot equinus in 4 patients (20%) and refracture in 1 patient (5%)., Conclusion: Uniplanner locally manufactured (NASEER & AWAIS) External Fixator for distraction osteogenesis is cheap, easy to apply and gives excellent and comparable results in tibial bone defects.

Background: Osteomalacia is a common diagnosis in the Kohistani women presenting with aches and pains. This study was conducted to assess calcium and Phosphate levels in Kohistani women with osteomalacia., Methods: 50 diagnosed cases of Osteomalacia selected from amongst the women presenting with body aches were included in the study. History regarding age, marital status, parity, dietary habits, socioeconomic status etc was taken., Results: The median age was 23 years. 74% were married. Most of the women had 5 children (mode). Nine (18%) patients had hypocalcaemia, 10 (20%) had hypophosphatemia. Alkaline phosphatase was elevated in 13 patients (26%). Six (12%) patients were pregnant at the time. 74% of patients belonged to the poor class. 70% of the patients drank less than 1 cup of milk per day. Body aches (100%), waddling gait (14%), proximal myopathy (12%), bone tenderness (6%) and carpopedal spasm (8%)., Conclusions: We therefore conclude that in comparison with other parts of the world where individual risk factors cause osteomalacia. Kohistani population has a higher frequency of osteomalacia due to aggregation of three major factors namely lack of sunlight due to geographical location, excessive clothing blocking available sunlight and nutritional deficiency.