Search

Safety of simultaneous bilateral TKA (simBTKA) and staged BTKA (staBTKA) have been compared in previous systematic reviews but functional outcome remains neglected aspect of the debate. We performed a systematic review of contemporary literature to compare the functional outcome of simBTKA and staBTKA. We searched PubMed/MEDLINE, EMBASE and Cochrane Central Database to identify all articles published between 2000 and July 2020 that evaluated the outcome of patients undergoing BTKA either in simultaneous or staged manner. Ten articles were identified which met the inclusion criteria. Functional outcome was reported in terms of Knee Society score (KSS), range of motion (ROM), Oxford Knee Score (OKS) and Western Ontario and McMaster University score (WOMAC) in seven, five, four and two studies respectively. KSS gained on average 66.6 points (47.5-95.3) for simBTKA and 65.1 points (44.4-97.2) for staBTKA without significant difference between two groups. There was no difference in post-operative ROM (maximum post-operative flexion being 124.4 and 125.1 for simBTKA and staBTKA groups respectively). Mean improvement in OKS ranged from 20 to 32.6 for simBTKA and 21.6 to 33.1 for staBTKA. There was moderate evidence to suggest that both simultaneous BTKA and staged BTKA produce equivalent improvement in functional scores.

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.

Objectives: There is currently no clear consensus on the benefits of performing simultaneous bilateral total knee arthroplasty (SBTKA) for patients with bilateral knee osteoarthritis. The purpose of this study was to analyze whether SBTKA provides equivalent reduction in pain and functional outcome as comparable with unilateral surger­ies (UTKA). Study Design: Cross sectional study. Setting: Ghurki Trust Teaching Hospital, Lahore, Pakistan. Period: January 2013 and July 2016. Material & Methods. 637 TKAs in 386 consecutive patients, who underwent total knee arthroplasty for bilateral knee osteoarthritis between Patients were split into 2 groups: those who underwent unilateral TKA (n=135) and those who underwent si­multaneous bilateral TKA (n=251). Knee range of motion, Knee Society Scores (KSS) and knee function scores were obtained pre­operatively and 2 or more years postop­eratively. Results: Mean±SD flexion was 111.6°± 8.6° for patients in the bilater­al group and 110.8°± 9.02° for patients in the unilateral group (p=0.34). Mean±SD KSS was 86.4 ± 9.3 in the bilateral group and 85.34 ± 10.5 in the unilateral group (p=0.236). Mean±SD function score was 83.4± 5.4 in the bilateral group and 80.90 ± 7.2 in the unilat­eral group (p

Aims It has been generally accepted that open fractures require early skeletal stabilization and soft-tissue reconstruction. Traditionally, a standard gauze dressing was applied to open wounds. There has been a recent shift in this paradigm towards negative pressure wound therapy (NPWT). The aim of this study was to compare the clinical outcomes in patients with open tibial fractures receiving standard dressing versus NPWT. Methods This multicentre randomized controlled trial was approved by the ethical review board of a public sector tertiary care institute. Wounds were graded using Gustilo-Anderson (GA) classification, and patients with GA-II to III-C were included in the study. To be eligible, the patient had to present within 72 hours of the injury. The primary outcome of the study was patient-reported Disability Rating Index (DRI) at 12 months. Secondary outcomes included quality of life assessment using 12-Item Short-Form Health Survey questionnaire (SF-12), wound infection rates at six weeks and nonunion rates at 12 months. Logistic regression analysis and independent-samples t-test were applied for secondary outcomes. Analyses of primary and secondary outcomes were performed using SPSS v. 22.0.1 and p-values of < 0.05 were considered significant. Results A total of 486 patients were randomized between January 2016 and December 2018. Overall 206 (49.04%) patients underwent NPWT, while 214 (50.95%) patients were allocated to the standard dressing group. There was no statistically significant difference in DRI at 12 months between NPWT and standard dressing groups (mean difference 0.5; 95% confidence interval (CI) -0.08 to 1.1; p = 0.581). Regarding SF-12 scores at 12 months follow-up, there was no significant difference at any point from injury until 12 months (mean difference 1.4; 95% CI 0.7 to 1.9; p = 0.781). The 30-day deep infection rate was slightly higher in the standard gauze dressing group. The non-union odds were also comparable (odds ratio (OR) 0.90, 95% CI 0.56 to 1.45; p = 0.685). Conclusion Our study concludes that NPWT therapy does not confer benefit over standard dressing technique for open fractures. The DRI, SF-12 scores, wound infection, and nonunion rates were analogous in both study groups. We suggest surgeons continue to use cheaper and more readily available standard dressings. Cite this article: Bone Joint J 2020;102-B(7):912–917.

Introduction: There are two techniques for reconstruction of anterior cruciate ligament (ACL), open technique and arthroscopic assisted technique. Arthroscopic assisted technique has many advantages over open procedure but it needs more expertise and cost comparatively.The objective of this study is to identify the clinical outcomes on basis of lyshlomknee score (LKS) system and find out patients satisfaction after performing both procedures in two groups separately. Material and Methods: Retrospective analysis of 600 patients undergoing open ACL reconstruction and arthroscopic reconstruction from 2005 to 2018 was done, at the Department of Orthopaedics, Ghurki Hospital, Lahore. We included all those patients who were 18 to 45 years of age and had at least 1 year follow up.

Objective: Rehabilitation is considered vital aspect of treatment strategy post total hip replacement and results in improvement in functional activities as well as reduction in pain. Telerehabilitation is emerging as alternative to traditional face to face rehabilitation in home care. To explore the current evidence on effectiveness of telerehabilitation as compared to face to face rehabilitation for patients after total hip replacement. Methodology: A systematic review was conducted. Data bases were searched including Cochrane, Medline, Embase and PEDro from 2000 to latest. A thorough search was performed to retrieve articles missed through databases as well as unpublished grey literature. Methodological quality assessment was performed using Cochrane risk of bias tool and included studies were critically appraised using PEDro scale. Results: 13 articles finally met the inclusion criteria and were included in the review based on eligibility. However data was not extractable from 1 study due to which 12 studies were finally reviewed. There were 4 Randomized trials, 3 randomized controlled protocols, 3 randomized pilot studies and 1 prospective cohort study. The summary of critical appraisal of included studies through Physiotherapy Evidence Database scale was done which showed that majority of studies had high quality and few studies fall under the category of fair. Conclusion: Telerehabilitation group reported similar improvement in terms of activities of daily living and quality of life as compared to traditional rehabilitation. This systematic review has established that home based telerehabilitation mode of health care services delivery is an acceptable practical alternative among patients who underwent Continuous...

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.

Study Design: Retrospective cohort study. Objective: We aimed to evaluate the improvement in neurological deficit following early versus late decompression and stabilization of thoracolumbar junctional fractures. Methods: This is a retrospective evaluation of all patients with a traumatic spinal cord injury (SCI) from T11 to L2 treated at a teaching hospital between 2010 and 2017. Grouped analysis was performed comparing the cohort of patients who received early surgery within 24 hours (group 1) with those operated within 24 to 72 hours (group 2) and more than 72 hours after SCI (group 3). The primary outcome was the change in ASIA (American Spinal Injury Association) motor score at 12-month follow-up. Results: There were 317 patients (225 males and 92 females with mean age of 31.55 ± 12.43 years). A total of 144, 77, and 96 patients belonged to groups 1, 2, and 3 respectively. Improvement of at least 1 grade on ASIA classification was observed in 80, 45, and 33 patients in groups 1, 2, and 3 respectively ( P = .001). Overall, 32, 12, and 10 patients improved ≥2 grades on ASIA classification in groups 1, 2, and 3, respectively ( P = .069). On logistic regression analysis, early surgery and severity of initial injury (complete [ASIA A] vs incomplete SCI [ASIA B-D]) were found to significantly influence the potential for neurologic improvement ( P = .004 and P < .0001, respectively). Conclusion: We believe that the earlier the decompression, the better. The 72-hour cutoff represents the most promising time window during which surgical decompression has the potential to confer a neuroprotective effect in the setting of incomplete SCI (ASIA B-D) in the distal region of the spinal cord (conus medullaris).

Among orthopedics trauma, the Olecranon fractures are one of the most commonly seen in the emergency room. The cause of such injuries are either fall or road traffic accident. The coronoid process stabilizes the humerus against the distal ulna. There is loss of extensor mechanism at the elbow joint whenever there is fracture of Olecranon. So, its management is always operative. Objectives: The main objective of this study was to determine the functional outcome of patients with olecranon fractures treated with tension band wiring and K-wires. Study Design: Descriptive case Series. Setting: Department of Orthopedics and Spine centre, Ghurki Trust teaching Hospital, Lahore. Period: 25th March 2016 to 30th September 2016. Materials and Methods: 85 patients were selected using Non Probability/ Consecutive sampling technique. Informed consent was taken and demographic information was noted. Surgery was performed by single team of orthopedics surgeons. Patient was followed after 06 weeks. Post-operatively for the assessment of functional outcome in terms of very good to good, fair and poor according to Murphy’s system. All the collected data was entered and analyzed on SPSS version 20. Results: In our study the mean age of the patients was 36.62±14.09 years, the male to female ratio of the patients was 0.7:1. The mean value of total Murphy’s score of the patients was 5.98±2.03. In this study the good functional outcome was observed in 35(41.18%) patients, fair outcome was observed in 46(54.12%) patients. Conclusion: The tension band wiring with K-wires shows good and satisfactory functional outcome for the management of olecranon fractures.

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.

With increasing urban populations, high vehicle miles have made the concept of a compact city imperative. A compact city is characterized by high-density development and mixed land use with no urban sprawl. City managers are trying hard to make their cities compact and livable. The potential conformance to a compact city development requires scaling before any significant intervention. Several studies have been conducted on the different aspects of the compact city in the developed world, but there is limited understanding in the South Asian context. This study aimed to fill this research gap and proposes a theoretical matrix to gauge the potential compactness of Lahore, Pakistan. It comprises some key attributes, such as landscape ecology, measurement of density, density distribution, transportation network, accessibility, dispersion index, and mixed-use land consumption, which were analyzed in this research. The data were analyzed using Geographical Information System (GIS) and ERDAS IMAGINE software to make a scaling matrix. The research findings show that Lahore is a semi-compact city, with high potential to become a true compact city. The paper recommends that the urban extent should not be extended until targeted colonization is achieved, and the spatial growth of the city should be managed by encouraging infilled development, high-density living, and public transport provision. This research will help policymakers, urban planners, and transport planners devising policies for compact city development.

Aim: To assess the functional outcome after metacarpal fracture fixation with mini fragment plates. Study design: Prospective cohort study Place and duration of study: Department of Orthopaedic Surgery, GTTH, Lahore from 01-01-2015 to 31-07-2020. Methodology: Sixteen patients who were operated with mini fragment plates for metacarpal fractures. Functional outcome was evaluated with help of American Society for Surgery of the Hand (ASSH) Total Active Flexion (TAF) score and the disabilities of the arm, shoulder. Results: Union was achieved in all patients. The functional outcome was excellent in 13 and good in 2 and poor in 1. Three cases of infection (all superficial) were noted, which settled with dressings and antibiotics. Conclusion: Mini fragment plates for metacarpals fractures are a good option, providing early mobilization and excellent functional outcome. Keywords: Functional outcome, Metacarpal fracture, Mini fragment plat, Open reduction internal fixation (ORIF)

Study Design: Cross-sectional comparative.Purpose: To characterize the scores of disc degeneration, inflammation, and nerve density in herniated disc samples and associate findings with the presence of vertebral endplate (VEP) changes on magnetic resonance imaging (MRI).Overview of Literature: Considering the role of disc composition in spontaneous regression and persistence of pain during conservative management, it is important to identify the influencing factors. VEP changes are highly associated with disc degeneration, but their correlation with herniated disc composition has not yet been reported.Methods: Fifty-one discs were obtained from patients undergoing surgery for herniated disc. Their ages ranged from 19-65 years, and 31/51 were male. Pre-surgical T1 and T2 weighted lumbar-spine MRIs were analyzed to observe Pfirrmann grade, VEP defects, herniation type, Modic changes, and high-intensity zones (HIZ) at the affected level. Five-micron thick sections were stained with hematoxylin and eosin, Alcian blue periodic acid–Schiff stain; examined for histological degeneration scores (HDS; 0–15), inflammation (0 [absence]–3 [severe]), and presence of cartilaginous endplate (CEP). Three-micron thick sections were stained with protein-gene-product 9.5 and expression was counted/mm2. Data was analyzed, and pppp=0.01). Histological sections with CEP showed increased HDS (ppr=0.27, p=0.02).Conclusions: VEP changes can modulate degeneration and inflammation of herniated discs. Presence of these changes is highly predictive of the occurrence of CEP in herniated discs, which leads to slow resorption and persistent clinical symptoms.

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

City administration has given prime importance to public transport services in Lahore. But still desired level of convenience and efficiency has not been achieved because of the absence of any integrated public transport system. Metrobus, LTC operated buses and Qingqi Rickshaws are all operating through their independent schedules with least consideration to that of others. Travellers using more than one modes of transport for their complete trip do not find whole system well harmonized. There is a need to find whether integration of currently independently operating transport systems can bring any improvements in services. This research work significantly points out short comings in city’s existing transport system; quantifies the impact of related factors through chi-square, co-relation and other statistical analyses; and provides some policy guidelines for pragmatic improvements in the system.

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.]

Background: Retrograde nailing for fracture of distal shaft of femur is commonprocedure but data about post-operative functional outcome in terms of knee range of motion,union and pain at 6 weeks, 6 months and 1 year follow-up is lacking. Objectives: The mainaim of this study was to determine post-operative functional outcome after performing nailingin a retrograde fashion for distal disphyseal femoral fracture in terms of knee range of motion,pain and union at 6 weeks, 6 months and at least 1 year follow-up. Study Design: Descriptivecase series. Setting: Orthopedics and Spine Centre, Ghurki Trust Hospital Lahore, Pakistan.Period: 1st July 2015 to Dec. 2016. Materials and Methodology: 140 patients of either sex andage with fractures of distal disphyseal femoral fracture and were operated using retrogradenailing were included in the study. All the data were analyzed using SPSS 17.0 version.Results: 140 patients were included with mean age of 31.81± 7.117 ranged from 16 to 75years of age.97 patients (69.3%) were male and remaining 43 patients (30.7%) were female.Pain was significantly decrease in all patients on Visual analogue scale. Mean union were 32.3± 5.3 weeks, Knee range of motion after last follow up were more than 1200 in 126 patients.Conclusion: Retrograde Nailing for distal diaphyseal fractures is an excellent option with goodfunctional outcome. It should always be considered while managing such fractures.

Knee Osteoarthritis (OA) is considered as one of the leading cause of disability around the world1. Total knee Arthroplasty is known to be the best treatment option available for reduction in pain and symptoms in case of failure of conservative management2. Recently enhanced recovery pathways have been followed after knee replacement surgery which includes a combination of early mobility, education of patient and care giver, nutritional and fluid support. These enhanced pathways lead to shorter hospital stay3. Due to the shortened hospital stay, the aspect of self-management by patient becomes fundamental. Post-operative self-management of patients following knee replacement is a crucial factor for successful recovery. Self-management as defined by World Health Organization is the ability of patients, care givers and community to effectively manage with the disease, either with the support of health service provider or independently. In knee replacement, self-management includes pain management, physical therapy exercises, daily self-activities and precautionary measures4.

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.

The treatment of choice for osteoarthritic knee is Total knee arthroplasty (TKA)and the most important problem in it is the blood loss. Objectives: To compare the postoperativemean blood loss with Tranexamic acid versus control after Total Knee Arthroplasty.Study Design: Randomized controlled trial. Setting: Ghurki Trust Teaching Hospital Lahore.Period: 01 year. Methodology: 100 patients were included and divided in 2 groups, selectedby non-probability purposive sampling, fulfilling inclusion and exclusion criteria. Group T(Tranexamic) received 15mg/kg IV Tranexamic acid 10 minutes before inflating tourniquet andthe same dose intravenously 3 hours post-operatively. Group C (control) received placebo(normal saline) intravenously. Blood loss collected in a container was measured with syringe/jarafter 24 hours of surgery. Results: In group C there were 23(46%) males and 27(54%) femaleswith male to female ratio 1:1.7 with mean age of 64yrs ± 6.3 yrs. In group T there were 28(56%)males and 22 (44%) females with male to female ratio 1.2:1 with mean age of 65yrs ± 7.4 yrs.After 24 hours Mean blood loss in Group C were 694 ±151 ml with 74 % patient in range of600-900ml while Mean blood loss in Group T were 388 ml ±105 ml with 76 % patient in rangeof 300-600ml. Mean decrease in blood loss with the use of tranexamic acid { mean blood lossin T group – mean blood loss in T group } were 306 ml which were statistically significant(p

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.

As the interest about electric vehicles has increased due to factors such as the raising fuel price and pollution, the number of torque control strategies are being researched to improve the drivability of EVs. Modern vehicles need a high degree of refinement to meet customer demand. Drivability of vehicle can be improved through recent research in automotive electronic control. Rapid boost of torque by an electric motor creates undesired torsional oscillations, leading to problems which regard to comfort drivability, wheel slip and increased fatigue of driveline components. In this research paper, we have designed torque management strategies using PID for traction and cruise control applications, to damp out driveline oscillations, and to improve drivability of EVs considering backlash as disturbance. A model-based design approach has been adopted in this research since it can be used effectively for designing, developing and prototyping of controllers. Accordingly, the scope of this research falls under 3 categories: modeling, control design and control evaluation.

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.

Background: Tibia is the most commonly fractured bone because of itsstructure and position. Tibial fractures are increasing with time to time and hence the morbidityand mortality are increasing despite proper public health efforts. There is a lack of nationalepidemiological data on the characteristics of patients with tibial shaft fractures. Therefore,epidemiological assessment is crucial for fracture. The purpose of this study was to provide upto-date information about patients baseline demographics, distribution of fracture classification,trauma mechanism and to formulate the preventive measures. Study Design: Retrospectivestudy. Setting: Emergency or OPD at Orthopaedics and Spine Centre, Ghurki Trust TeachingHospital, Lahore. Period: 1st January 2011 to 31st December 2015. Material and methods:Any type of diaphyseal tibial fracture. The data were taken from hospital database and includeclinical, epidemiological and radiological records. The results were analyzed using SPSS 20.Results: A total of 2120 patients were included in the study. 1980(93.4%) were male and 140(6.6%) were females. Male to females ratio were 14.14:1 with mean age of 33.28 ± 21.02.Between 0-20 years, 519(24.5%) of patients were admitted, 1021(48.2%) of patients werebetween 21-40 years, 467(22.0%) were between 41-60 years and only 113(5.33%) were above60 years. Type A2 in 444(20.9%) were the most common pattern of fracture found. The traumaswere most common in months of May, June and July and Motorbike accidents were the maincause. The mid shaft of tibia is the most commonly fractured i-e 1038 (49.0%) followed bydistal part i-e 611(28.8%) and the least is the proximal i-e 471(22.22%). Conclusion: Thisstudy shows AO-type 4A2 was the most common fracture type, representing 20.9% of all tibialshaft fractures. The individuals between 21-40 years were mostly affected and the motorbikeaccidents were found the main cause for such traumas.

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.

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.].

Several factors influence air pollution, but effect of land uses is pivotal and has direct consequences on growth and development of a city. In order to assess consequent effects of land uses on air pollution, it is important to transform a set of variables into significant components by using principal component analysis. These components help to develop an effective model between air pollution and land uses by application of regression analysis. Lahore, titled as “Paris of the East,” has some featured commonalities with Paris and was jointly selected for research to adopt common policies and measures to combat air pollution. A two-step cluster analysis has been applied to testify resemblance of Paris to towns of Lahore as a cluster. This paper is trying to develop a calibrated model which helps to estimate about air pollution at a significant level with only one independent variable. Furthermore, it helps to control air pollution through sensitization of land uses in Lahore.

Objective: To assess the efficacy and safety of aceclofenac in the treatment ofosteoarthritis. Study design: Randomized double blind Phase IV trial. Place and Duration ofstudy: This study was conducted in the department of Orthopaedics & Spine Surgery, GhurkiTrust Teaching Hospital, Lahore. The duration was eight weeks. Methodology: A total of 90subjects, fulfilling the inclusion criteria and willing to give free informed consent were enrolled inthis trial. All these subjects were randomized into two treatment groups (A & B). Subjects eitherreceived Aceclofenac 100 mg twice daily or Diclofenac 75 mg twice daily for 08 weeks. During thescreening visit, information on their demographic characteristics, medical history and previousand current medications were collected. A thorough physical examination and necessarylaboratory investigations were carried out before drug administration and after the completion oftreatment (end of week 8). Clinical examination was done at baseline visit, randomization and 2, 4and 8 weeks. Gastrointestinal (GI) safety was assessed using adverse drug reaction (ADR)reports. WOMAC questionnaire was used to see improvement in activities of daily living and painwas assessed using visual analogue scale (VAS). All data was collected in the case report form(CRF). Statistical evaluation was performed at the end of the trial and results were analyzed usingSPSS. Results: 70 subjects completed the study while 20 were lost in follow-up. There were 28males and 34 females in the study with mean age of 56 years. There was a significant decrease inWOMAC and VAS scores in both groups. In group A (Diclofenac group) VAS decreased from7.107 to 2.538 (p= 0.000) and WOMAC decreased from 32.75 to 7.38 (p=0.000). In group B(Aceclofenac group), VAS decreased from 7.912 to 6.0 (p=0.001) while WOMAC decreased from37.29 to 21.50 (p=0.000) showing the efficacy of both drugs. There was also significant decreasein the disease severity in both groups at the end of treatment. But the safety profile of (Diclofenac)group A was not significant (p=0.767) as compared to (Aceclofenac) group B (p=0.022).Conclusions: Aceclofenac is efficacious and safe drug for the treatment of osteoarthritis in adultsas compared to Diclofenac.

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.

IntroductionLow Back pain and lumbar radicular pain due to Lumbar spine stenosis is one of the most common complaint in the Spine outpatient department or hospital admissions. Epidural steroid inje...

IntroductionTuberculosis is a common problem specially in under developed countries. Tuberculosis of the vertebral column constitutes nearly 50% of all lesions of osteoarticular tuberculosis. The c...

IntroductionThe aim of surgical treatment for adolescent idiopathic scoliosis (AIS) is correction of the three dimensional deformity, achievement of stability and preservation of as many distal mot...

Introduction Tuberculosis is the leading cause of death in third world countries, from a single infectious disease. It paralyses the society when it affects the spine because of its resultant neurological deficit in the form of quadriplegia, paraplegia, loss of bladder and bowel control, bed sores, and continuous financial burden on family and whole society. Early spinal decompression and stabilization with standalone cage have dramatic results in terms of improvement in neurology, relief of pain, and correction of deformity. The objective of the study is to determine outcome of anterior decompression and stabilization with locally made standalone cage and bone graft in caries spine in terms of improvement of neurology, relief of pain, and improvement of kyphotic angle. Patients and Methods It is a prospective case series study including 850 cases who were treated at GTTH from 2003 to 2010. After preoperative assessment of pain, neurology, and measurement of angle of deformity, all patients were treated with anterior decompression and then stabilization was achieved with bone graft and standalone locally made cage. After surgery, patients were followed at 6 weeks, 3 months, 6 months, and 1 year to assess neurology, relief of pain, and kyphotic angle. Results Neurology improved in 92% of patients, pain relieved in 95% of cases, and there was mean correction of 18 degrees in kyphotic angle at the end of 1-year follow-up. Conclusion Early diagnosis and early intervention give excellent results. After anterior decompression, stabilization with cage and bone graft results in significant improvement of neurology, relief of pain, and correction of kyphotic deformity. There is no need for added instrumentation.