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Purpose: Reduction and stable fixation of the quadrilateral plate are challenging primarily due to its location in the true pelvis, limited bone stock, juxta-articular nature, and its comminution. The current study aimed to investigate the quality of reduction and functional outcomes after open reduction and internal fixation (ORIF) with infrapectineal buttress plating of the quadrilateral surface via an anterior intrapelvic approach. Materials and Methods: We conducted a retrospective review of twenty-one patients with acetabular fractures involving quadrilateral plate operated at Ghurki Trust Teaching Hospital between January 2017 and December 2018. Radiological assessment of the quality of reduction was conducted using criteria described by Matta. Functional outcomes were evaluated using a modified Postel Merle d’Aubigne score. Results: The current study included 15 males and 6 females with a mean age of 40.67±12.17 years (range, 22- 62 years). The most common fracture pattern was anterior column and posterior hemi-transverse in eight patients followed by true bicolumn and T-type fractures in seven and four patients respectively. Both transverse fractures were transtectal. The quality of reduction according to Matta criteria was anatomical in 14 patients, imperfect in five and poor in two. Functional outcomes were excellent in 47.6% cases, good in 42.9%, and fair in 9.5% cases. Both patients with fair outcomes had non-anatomical reduction, and one required total hip arthroplasty at a later time. Conclusion: Quadrilateral plate reconstruction with an infrapectineal buttress plate applied though an anterior intrapelvic approach provides high rates of anatomical reduction and yields good functional outcomes.

BACKGROUND Orthopedic infections are difficult to manage. Methicillin-resistant Staphylococcus aureus (MRSA) is one of the most dangerous and harmful bacteria and is difficult to eradicate because of its changing strains as well as sensitivity to different antibiotics. The main aim of this study was to determine the prevalence of pathogens, especially MRSA, associated with orthopedic wounds and their sensitivity to different antibiotics. METHODS A prospective study was conducted from September 2015 to August 2016. Pus samples of 1,350 patients who presented at the out-patient department or admitted with a wound infection after an orthopedic intervention were taken with the help of culture swab and were sent for culture and sensitivity according to hospital protocol. Data analyses were made using the SPSS software, version 17 (IBM). RESULTS Adults aged between 15 and 30 years were most affected, with 444 (32.9%) cases. Of the patients, 268 (19.9%) had negative cultures. Among the patients with positive cultures, the gram-positive cocci and gram-negative rods were 497 (36.8%) and 377 (27.9%), respectively. The most common pathogen was MRSA (240; 17.8%), followed by Escherichia coli and methicillin-sensitive S. aureus. CONCLUSIONS Multiple pathogens are involved in patients having an orthopedic surgical intervention. The high occurrence of MRSA and E. coli has an increasing economic burden on patients because of these pathogens high resistance to antibiotics. Thus, proper preventive measures should be done to decrease the occurrence of such infections as well as their associated morbidity.

Background: Halo-traction device has been seen with favorable outcome in managing the patients with severe kyphotic deformities preoperatively, however, associated complications are inevitable. Slight modifications can improve the outcome and clinical efficacy. Case Description: A 14-year-old boy was presented with severe kyphotic deformity of 141° from T1 to T10 thoracic vertebrae with diffuse paraspinal calcification in thoracic spine and complete loss of power of both lower limbs. A modified halo-pelvic distraction device was applied before the definitive surgery. The device comprised halo and pelvic assembly, the halo ring was connected to the head with 06 pins, while pelvic assembly had Ilizarov half pins connected to the arches. The assembly construct had four threaded rods, two of them were placed anterolateral and the other two were posterolateral. Distraction at the rate of 3 mm/day was started from 1st postoperative day for 35 days. The neurology improved in both lower limbs and kyphotic angle reduced to 56° from 141°. Surgery at this stage was done and a standalone solid titanium cage was placed from T1 to T10 vertebral body after debridement. No peri- or post-operative complications were observed. Conclusion: The application of halo-pelvic distraction before corrective surgeries can not only reduce the severity of the kyphotic deformity making the definitive surgery easy but neurology can also be improved. The high-risk complications associated with acute correction of deformities can be minimized using our modified halo-pelvic distraction device.

Introduction The use of a tourniquet during total knee arthroplasty (TKA) is still a topic of debate, given the conflicting results in the literature with respect to complications, pain, functional outcome, and blood loss. However, due to a lack of convincing data on early patient-reported outcomes (PROMS), this study aims to compare pain and functional outcomes in total knee arthroplasty patients with and without a tourniquet. Methods A randomized controlled trial was set up at a tertiary care hospital that spanned from 1st February 2015 to 31st July 2018. We included all primary total knee arthroplasties performed for patients aged between 50 and 80 years. Oxford Knee Score (OKS), Numerical Pain Rating Score (NPRS), Visual Analogue Scale (VAS) for satisfaction, active range of knee motion, and Short Form-12 Survey (SF-12) scores were collected pre-surgery and then at six-weeks and six-months interval with a p-value of 0.05 considered to be significant. Results Two hundred and forty patients participated in the study; 117 patients were randomized to surgery with the tourniquet inflated and 123 to surgery with the tourniquet deflated. There were 43.4% males, and 56.6% females in the tourniquet inflated group with an average age of 62.29±9.63 years while in tourniquet deflated group, there were 46.7% males and 53.3% females with a mean age of 65.41±9.042 years (p-value for age is 0.404; the p-value for gender is 0.086). Despite the increase in intraoperative blood loss in both the groups, there was no significant increase in blood transfusions as both groups recorded the need for postoperative blood transfusion - 12 patients in the tourniquet group and 19 in the non-tourniquet group, but this difference was statistically insignificant (p=0.231). The perioperative blood loss was significantly lower (p

Purpose: The purpose of this report is to describe the Global Spine Care Initiative (GSCI) contributors, disclosures, and methods for reporting transparency on the development of the recommendations. Methods: World Spine Care convened the GSCI to develop an evidence-based, practical, and sustainable healthcare model for spinal care. The initiative aims to improve the management, prevention, and public health for spine-related disorders worldwide; thus, global representation was essential. A series of meetings established the initiative’s mission and goals. Electronic surveys collected contributorship and demographic information, and experiences with spinal conditions to better understand perceptions and potential biases that were contributing to the model of care. Results: Sixty-eight clinicians and scientists participated in the deliberations and are authors of one or more of the GSCI articles. Of these experts, 57 reported providing spine care in 34 countries, (i.e., low-, middle-, and high-income countries, as well as underserved communities in high-income countries.) The majority reported personally experiencing or having a close family member with one or more spinal concerns including: spine-related trauma or injury, spinal problems that required emergency or surgical intervention, spinal pain referred from non-spine sources, spinal deformity, spinal pathology or disease, neurological problems, and/or mild, moderate, or severe back or neck pain. There were no substantial reported conflicts of interest. Conclusion: The GSCI participants have broad professional experience and wide international distribution with no discipline dominating the deliberations. The GSCI believes this set of papers has the potential to inform and improve spine care globally. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.]

Objectives: To determine the outcome of pelvic support osteotomy with Ilizarovmethod in patients undergoing Girdle stone procedure in terms of pain relief and limb lengthdiscrepancy. Study Design: Descriptive case series. Setting: Department of Orthopaedicand Spine Surgery, Ghurki Trust Teaching Hospital/Lahore Medical & Dental College, Lahore.Duration of Study: Six months (19-11-09 to 18-05-10) for sample collection and follow upfor next one year after the procedure. Materials and Methods: Forty five patients having hipjoint problems were included. The radiographs would include plain radiographs of the pelvisin neutral and single limb standing position and the femur of involved side to assess the pelvicobliquity. Surgery was performed in the supine position under spinal anesthesia. A proximalfemoral osteotomy was performed at the level of ischial tuberosity. The other distal femoralosteotomy was performed to lengthen and adjust the mechanical axis. Both these osteotomieswere then stabilized with Ilizarov external fixator. The standard rate of distraction is 1 mm/dayfor lengthening. Results: There were 30 male patients and 15 were female patients with maleto female ratio was 2:1. The mean ± SD between the ages was 23.69±7.80 years. Among allpatients, 43 patients had pain relief and 41 patients of limb length discrepancy. Conclusion:By using the Ilizarov technique, we could prevent the valgus effects created by the valgusextension osteotomy while achieving lengthening of the femur through the distal osteotomy inthe femur. It is an excellent technique for those patients who are not fit for total hip replacement.

Vascularized or non-vascularized fibula transport is a novel procedure for limb salvage but has been associated with high failure rates and complications. Ipsilateral medial fibular transport (IMFT) using Ilizarov apparatus is a modification of the procedure to prevent complications and increase success rate. This article presents the largest series of limb salvage for massive tibial bone loss in children due to pan-osteomyelitis by IMFT with Ilizarov apparatus.A case series of 12 patients with a mean age of 12 (6-18) years is described. At the first stage of surgery, the excision of all dead bone was performed, and Ilizarov without traction apparatus was applied. In second stage, ipsilateral fibula is gradually transferred to tibial defect with the help of ilizarov olive wires. In the third stage, the freshening of docking sites of fibula to tibia was performed. The minimum follow up was of two years.Hypertrophy of the transported fibula accompanied by full weight bearing and satisfactory joint motion occurred in all patients. Removal of sequestrated bone resulted in control of infection in 27.17 ± 7.76 days. Fibular transport took 16.58 ± 4.14 days. The length of tibial bone loss replaced by fibula was 9.50 ± 2.23 cm. The mean days required for union after freshening of the docking site was 76.58 ± 6.20 days.Ilizarov frame for pan tibial osteomyelitis with bone excision and medial fibular transport works well for limb salvage in children.نقل الشظية بالأوعية الدموية أو من غير الأوعية الدموية هو إجراء جديد من إجراءات إنقاذ الأطراف، ولكنه ارتبط بمعدلات فشل ومضاعفات عالية. نقل الجزءالإنسي من الشظية بنفس الجهة باستخدام جهاز إليزاروف هو تعديل الإجراء الجراحي لمنع المضاعفات وزيادة فرص النجاح. وتعرض هذه المقالة أكبر سلسلة من إنقاذ الأطراف لفقدان جزء كبير من العظم الظنبوبي لدى الأطفال بسبب إلتهاب العظم والنقي الكامل، بواسطة نقل الجزء الإنسي من الشظية بنفس الجهة بجهاز إليزاروف.نَصف في هذه المقالة سلسلة من الحالات ل ١٢ مريضا بمتوسط عمر ١٢ عاما (٦-١٨). في المرحلة الأولى من الجراحة، تم استئصال جميع العظم الميت، وتم تثبيت جهاز إليزاروف من غير شد. وفي المرحلة الثانية، عادة بعد شهر من إعادة التشكيل تتم بواسطة النقل التدريجي للجزء الإنسي للشظية في نفس الجهة باستخدام جهاز إليزاروف للشد بواسطة أسلاك الزيتون، بعد عمل القص العظمي للجزءالقاصي والداني للشظية. في المرحلة الثالثة، تم تنضير مواقع استقبال الظنبوب للشظية. وكان الحد الأدنى للمتابعة عامين.يصحب تحمل كامل الوزن تضخم في حجم الشظية المنقولة، وحركة مرضية للمفصل تحدث عند جميع المرضى. وإزالة العظام المحجوزة تؤدي إلى التحكم في الإلتهاب في ١٧.٢٧ ±٧.٧٦ يوما. يأخذ نقل الشظية ٥٨.١٦ ± ١٤.٤ يوما. وكان طول الجزء المفقود من عظمة الظنبوب والمستبدل بالشظية ٩.٥ ± ٢.٢٣ سم. بينما كان متوسط الأيام اللازمة لإتحاد العظام بعد تنضير موقع الاستقبال ٧٦.٥٨ ± ٦.٢ يوما.يعمل إطار اليزاروف للإلتهاب الكامل للعظم والنقي الظنبوبي بواسطة استئصال العظم ونقل الجزء الإنسي من الشظية بشكل جيد لإنقاذ الأطراف عند الأطفال.

Objectives: To evaluate the functional outcome of unstable thoracolumbarfractures fixed with pedicular screws and rods. Study Design: Descriptive case series. Setting:Department of Orthopedics and Spine surgery Ghurki Trust Teaching Hospital Lahore. Period:February 2013 to October 2015. Material & Methods: Patients of either gender or all ageswith thoracolumbar fractures fulfilling the inclusion criteria were fixed with pedicular screwsand rods under general anesthesia. Post operatively patients were reviewed monthly for oneyear and results were analyzed according to modified McNab criteria as excellent, good, fairand poor at final follow up. Results: A total of 281 patients including 193(68.68%) males and88(31.32%) females with mean age 28.32 years (range 18 to 60 years) were included in ourstudy. Majority (91 patients) had fractures of L1 followed by L2 (73 patients) fracture and D12(67 patients) fracture. Pre operatively 95(33.81%) were neurologically graded as Frankle gradeD,73 (25.98%) grade C while 49(17.44%) were graded as Frankle grade E.Post operatively finalfollow up at one year yielded excellent clinical outcome in majority (91.46%,n=257) while goodand fair outcomes were reported in 6.41%(18 patients), and 2.14%(6 patients) respectivelyaccording to modified McNab criteria. No post op neurological detoriation, mortality or othermajor complication was reported in the study. Conclusion: Pedicular screw and rod fixationfor unstable thoracolumbar fractures gave excellent functional results in majority of patient as itreduces complications of recumbency and helps in early mobilization. We recommend it as afirst line treatment for such fractures.

Introduction Optimal implant density for posterior spinal fusion in adolescent idiopathic scoliosis (AIS) remains controversial. We aimed to examine radiographic outcomes of AIS cases treated with limited density pedicle screw constructs. Methods This is a retrospective analysis of 96 patients (89 females and 7 males with mean age of 13.8 ± 4.4 years) with AIS who underwent posterior spinal instrumentation at Ghurki Trust Teaching Hospital between 2014 and 2016. Construct characteristics and radiographic measurements were compared preoperatively and at 2 year follow-up using paired t-test. Pearson's correlation coefficient between curve characteristics and metal density was calculated. Results Preoperative coronal Cobb angle was 68.5 ± 6.9°. Flexibility of the curve was 47.5 ± 10.3% based on push-prone films. The mean number of vertebrae in the fusion was 10.7 ± 1.6. The implant density was 62%. The mean postoperative Cobb angle was 18.6 ± 4.2°, giving a mean correction of 72.5 ± 6.8%. Metal density was not correlated with preoperative coronal or sagittal radiographic variables; MT Cobb angle (r = 0.02, p = 0.847), MT curve flexibility (r = 0.129, p = 0.210), preoperative thoracic kyphosis (r = -0.119, p = 0.247) or lumbosacral lordosis (r = −0.048, p = 0.645). There was a significant correlation between the flexibility of the curve as assessed by push-prone radiographs with the percentage correction achieved (r = 0.368, p, Highlights • Metal density does not influence either amount of main thoracic curve correction or post-operative Cobb angle. • We conclude that posterior fusion constructs with implant densities of approximately 60% can safely be used in moderate, flexible (45–80°, average 47% flexibility) idiopathic curves to attain and maintain correction in adolescent idiopathic scoliosis. • There is a significant correlation between the flexibility of the curve as assessed by push-prone radiographs with the percentage correction achieved as well as absolute correction in degrees. • We found that preoperative coronal or sagittal radiographic variables like main thoracic Cobb angle, curve flexibility, preoperative thoracic kyphosis or lumbosacral lordosis did not influence surgeon's decision for implant density. • Longer fusions were required for larger and less flexible curves.

A 9-year-old girl presented with malunited Salter-Harris type I fracture of distal femur treated by bone-setter (unreliable-practitioner). Assessment revealed 3 cm limb-length-discrepancy and affected leg was unable to bear weight, knee was stiff with no active-range of motion; radiographs showed displaced sagittally malunited femoral condyle with 163° posterior distal femoral angle (PDFA). Correction planned with circular-ring-external Ilizarov fixator using distraction-osteogenesis through supracondylar osteotomy and gradual anterior opening. Partial weight bearing allowed from first postoperative day on walker. Eight weeks follow-up showed restored anatomical position of femoral condyle and PDFA. During anterior-distraction and angulation correction, tibia subluxated posteriorly, for that assembly extended to tibia which gradually translated tibia anteriorly and reduced knee. Twenty weeks after removal of assembly patient was advised knee-ankle-foot-orthosis. At 40 weeks of frame removal, patient was walking without support and pain. Managing such rare injuries with distraction-osteogenesis technique allows gradual correction and monitoring, till desirable degree of correction is achieved.

Objectives: To determine the clinical and radiological outcome of Tibio-talocalcanealarthrodesis with Retrograde intramedullary SIGN Nail in patients with tibiotalar andsubtalar joint pathologies. Study Design: Descriptive case. Period: September 2012 to May2015. Setting: OPD or Emergency at Orthopaedics Unit of Ghurki Trust Teaching HospitalLahore. Materials and methods: 40 patients study. Detailed history, clinical examination andinvestigations were done after proper consent. Pre operative diagnosis was made on anteroposterior and lateral views of plan x rays. Retrograde Intramedullary fixation was done underimage control. All post operative patients were followed regularly on opd basis and outcomeof intramedullary fixation was determined on 6th post-operative month. Results: There were40 patients who underwent arthrodesis and fixation. There were 82.5% male and 22.5%female with mean age of 41.5 years. 95% of the patients having pain improvement whileonly 2.5% of the patients didn’t get benefit from it. Infection and non union were seen inonly 1 patient. Conclusion: retrograde sign nail is a good option for ankle and subtalar jointarthrodesis. Early weight bearing and healing in shorter period of time are its main advantages.

Objectives: To evaluate the functional and radiological outcome of metaphysealcore decompression of distal radius for treating Keinbock’s disease. Study Design: Descriptivecase series. Place and Duration: Orthopaedic A Unit Lady Reading Hospital Peshawar andGhurki Trust Teaching Hospital, Lahore and District Headquater Hospital Temargarah LowerDir from January 2014 to June 2016. Material and Methods: Patients of all ages and bothgender with pain and restricted wrist motion and radiologically diagnosed Lichtman’s stageI, II and III (A) were included in the study. Metaphyseal core decompression of distal radiuswas performed in the included subjects and patients were followed fortnightly for two monthsand then monthly for at least one year. At each visit pain was assessed with Visual AnalogueScale (VAS), wrist flexion and extension measured with goniometer and Stahl index with x raywrist. Results: A total of eleven patients including 9(81.8%) males and 2(18.1%) females with\mean age 31.2 years (range 24 to 42 years) were included in the study. Lichtman’s stage Ipatients were 2(18.1%), stage II were 6(54.5%) while stage III (A) patients were 3(27.2%).Postoperatively complete pain relief was achieved (VAS 0) for all stage I and II and most stage III (A)patients (90.9%, n=10) while mild pain (VAS 1) was reported in one (9%) patient of stage III (A)disease at final visit. Normal wrist flexion and extension was achieved in all stage I and II andmost of stage III (A) patients (90.9%). Only one (9 %) patient of stage III (A) could not achieveadequate wrist mobility at last follow up. Pre and post op Stahl index remained the same for allstages. No complication was reported. Conclusion: Metaphyseal core decompression of distalradius results in excellent functional outcome in majority patients and should be the treatmentof choice for early Keinbock’s disease (stage I’II and III (A).

Purpose: The purpose of this study was to investigate differences in component alignment between first and second knees in simultaneous bilateral total knee arthroplasty (SBTKA) and unilateral TKA (UTKA). Materials and Methods: 274 SBTKAs and 198 UTKAs were included in study. Patients were divided into three groups as SBTKA on the right knee (group A), SBTKA on the left knee (group B) and UTKA (group C). Femoral and tibial component alignment was checked in both coronal plane (alpha [α] and beta [β] angles) and sagittal plane (gamma [γ] and delta [δ] angles) radiographs. Results: There were no statistically significant differences among groups in the preoperative anatomical varus angle and Kellgren-Lawrence gonarthrosis classification grade (p=0.139 and p=0.329, respectively). In the coronal plane, the alignment of femoral component (α angle) and tibial component (β angle) was similar in all three groups (α angle, 95.01 vs. 95.14 vs. 94.9, p=0.945; β angle, 90.03 vs. 89.67 vs. 89.98, p=0.483). The sagittal plane alignment of femoral component (γ angle) and tibial component (δ angle) did not show significant differences (γ angle, 7.04 vs. 6.98 vs. 7.00, p=0.132; δ angle, 86.56 vs. 87.41 vs. 86.73, p=0.610). Conclusions: The angular alignment of components was similar between SBTKA and UTKA.

Introduction: Treatment of developmental dysplasia of hip (DDH) diagnosed after 10 years of age is extremely difficult because of the soft tissue and bone deformities. In this study, we evaluated short-term results of a single-stage procedure performed with surgical hip dislocation, femoral shortening and capsular arthroplasty. Patients and Methods: A retrospective review of charts of five patients with DDH, older than 10 years, who underwent capsular arthroplasty at Ghurki Trust Teaching Hospital between 2013 and 2015 was performed. Post-operative functional evaluation was performed using modified McKay’s scoring system and radiographic assessment using Severin’s scoring method at a minimum of 2-year follow-up. Results: We present results of five patients (six hips) with a mean age of 18.16 years. All patients had limping gait and International Hip dysplasia Institute classification (IHDI) class 4 hip dislocation. Harris hip score showed a significant improvement (53.13 vs 84.16; p = 0.0001). Femoral shortening of 2–2.5 cm was done. Additional shelf procedure was required in one patient. This patient persistently has post-operative hip subluxation. All patients had good to excellent outcomes according to McKay classification. Post-operative Severin classification was 1A in all patients. No case of avascular necrosis of the femoral head was noted during the follow-up. Conclusion: Capsular arthroplasty with subtrochanteric shortening is a useful procedure for neglected cases of DDH in patients older than 10 years.

Purpose: Spinal disorders, including back and neck pain, are major causes of disability, economic hardship, and morbidity, especially in underserved communities and low- and middle-income countries. Currently, there is no model of care to address this issue. This paper provides an overview of the papers from the Global Spine Care Initiative (GSCI), which was convened to develop an evidence-based, practical, and sustainable, spinal healthcare model for communities around the world with various levels of resources. Methods: Leading spine clinicians and scientists around the world were invited to participate. The interprofessional, international team consisted of 68 members from 24 countries, representing most disciplines that study or care for patients with spinal symptoms, including family physicians, spine surgeons, rheumatologists, chiropractors, physical therapists, epidemiologists, research methodologists, and other stakeholders. Results: Literature reviews on the burden of spinal disorders and six categories of evidence-based interventions for spinal disorders (assessment, public health, psychosocial, noninvasive, invasive, and the management of osteoporosis) were completed. In addition, participants developed a stratification system for surgical intervention, a classification system for spinal disorders, an evidence-based care pathway, and lists of resources and recommendations to implement the GSCI model of care. Conclusion: The GSCI proposes an evidence-based model that is consistent with recent calls for action to reduce the global burden of spinal disorders. The model requires testing to determine feasibility. If it proves to be implementable, this model holds great promise to reduce the tremendous global burden of spinal disorders. Graphical abstract: These slides can be retrieved under Electronic Supplementary Material.[Figure not available: see fulltext.].

Purpose This study was performed to assess the clinical and radiological outcomes following one-stage hip reconstruction, consisting of open reduction femoral shortening and pelvic osteotomy, for neglected developmental dislocation of the hip (DDH). Materials and methods This is a retrospective analysis of 77 hips in 65 patients (46 females and 19 males; 12 had bilateral dislocations), operated at a Ghurki Trust Teaching Hospital in Pakistan between 2013 and 2015. The average age at surgery was 11.02±3.43 years. According to the Tonnis classification, there were 10, 14, 22, and 31 patients in grades 1, 2, 3, and 4, respectively. The pelvic procedure utilized in this study was triple osteotomy (47 hips) followed by double and Salter osteotomy (18 and 12 hips, respectively). Postoperative evaluations were conducted using the modified MacKay's scoring system (functional outcomes) and Severin's scoring method (radiological assessment). Results Postoperatively, there were 38 (49.4%), 19 (24.7%), 14 (18.2%), and 6 (7.8%) hips in Severin grade I, II, III and IV, respectively. According to the modified McKay criteria, there were 22 hips (28.6%) in excellent condition, 44 (57.1%) in good condition, 9 (11.7%) in fair condition and 2 (2.6%) in poor condition. Both patients with poor outcomes had an unstable, painful hip with evidence of avascular necrosis of the femoral head. Conclusion Based on the results presented here, we recommend the single stage procedure of open reduction, femoral shortening and pelvic osteotomy for treatment of DDH in older children with good to excellent functional and radiological outcomes.