Orthopedic procedures on foot and ankle have considerable risk for perioperative complications. We report our experience with 9 patients who undergone soft tissue reconstruction with reverse sural artery flap after developing skin and soft tissue defect in the ankle area. Age range was from 52 to 83 years. Regarding comorbidities, four patients were classified as ASA II and five patients as ASA III class. Two defects were following arthrodesis of the talocrural joint, six were following endoprosthesis implantation and one defect was posttraumatic after fracture of talus and consequent infected pseudarthrosis. Flaps varied in sizes from 4x3 cm to 8x10 cm. In 2 cases, the donor site was closed primarily, and in other cases, split-thickness skin graft was needed. In 4 cases, the taken sural flap was enough to cover the defect at the receiving site, and in 4 cases minor split-thickness skin graft was coapplied. Partial flap necrosis occurred in 1 case but needed no intervention and wound healed completely. In 8 cases the defect showed up in 1-3 months after primary orthopedic procedure. The posttraumatic case had a chronic osteitis and a prior skin defect. Follow-up until healed stage ranged from 3 to 15 months. Favorable results were present in 7 cases, 1 is still under follow-up and 1 resulted in amputation. None of the patients complained of any functional problem related to loss of sensation along the lateral border of the foot. Sural flap is a reliable method for providing soft tissue coverage in the ankle area.

Computer vision for analyzing immunohistochemical images usage can improve the quality of the research, increase the chances of early disease diagnosis and, as a result, patient treatment success. In the malignant transformation and biological behavior of existing tumors, the leading role is given to the proliferative activity of tumor cells. For the proliferation of malignant tumor cells determination, the analysis of the expression of the Ki-67 antigen, which is a marker of tumor proliferative activity, is used. This is the crucial characteristic of the tumor phenotype, which substantially determines the tumor growth rate, metastasis risk, treatment potential response and the outcome of the oncological disease.
The objectives of the research were the following:
• Neural network architecture for the model of AI selection;
• Dataset formation;
• Math model for analyzing images of immunohistochemical slides design;
• Solution for image capture from a microscope with online image analysis with automatic Ki-67 counting feature development.
Developed solution allows to analyze images of immunohistochemical slides, including AI methods, providing the tool for pathologists working in the field of oncological orthopedic diagnostics.
As it operations result, developed solution provides assessment of the proliferative activity of tumor cells.
Developed software has an intuitive interface, user documentation and can be used by doctors without additional training. It can be used as a cloud service without purchasing additional equipment, or as a standalone on premise solution which does not require Internet access. Proposed model of operations significantly simplifies it is practical usage.

Chronic infection of the spine can be a challenging condition to diagnose and treat. We present a case of a super-added aspergilloma of the spine, on pre-existing tubercular-spondylitis, in an immunocompetent patient, probably secondary to cottonoid foreign-body inoculation. Case – An 18-year-old immunocompetent male patient, presented with symptoms of lumbar canal stenosis, multiple discharging sinuses, and cold-abscess for 3 years. Multiple incision-drainage of the cold abscess with blind cottonoid packing along with inadequate treatment for tuberculosis was done over 2 years by a person of unknown qualification. At first presentation, radiology was suggestive of a soft-tissue mass in the L5-S1 spinal canal along with bony destruction and marrow edema, with elevated blood infection markers. Because of a history of insertion of foreign-body, and symptomatic claudication due to stenosis caused by soft-tissue mass, surgical decompression was done. Histopathological examination showed Aspergillus fungal-balls, which was managed post-operatively with voriconazole and empirical anti-tubercular therapy given the endemicity of the disease and typical progression of the disease as per history. The radiological characteristics of the osteomyelitis were also in concordance with a tubercular picture, with the localized soft tissue mass being attributed to super-imposed infection by Aspergillus, as is common in the lungs and sometimes, the brain. Conclusion – This is the first and unique case report showing Aspergilloma involving the vertebral column. Inadequate antibiotic regimen and blind introduction of foreign-body into sinus-tracts can lead to disastrous outcomes and fungal infections, which can closely mimic tuberculosis. Routine testing for fungus is advocated.

Introduction: The classic treatment of multiplanar deformity secondary to (SPTE): Slipped Proximal Tibial Epiphysis which previously thought to be Blount's is the same as treatment as any complex deformity after Blount’s disease by Hexapod and osteotomy and permanent physeal closure to avoid recurrence. However, here we prescribe a new simpler method for acute deformity correction of the complex deformity that can be more accurate than the current methods.

Method: Manual intraoperative acute correction of the deformity at it’s CORA in the physeal growth by manual separation between the metaphysis and the epiphysis then fixation by 2 crossing cannulated screws with augmentation by a ring fixator. A prospective case study performed on 6 patients ( 10 limbs ) with 5 years follow up with full correction and non recurrence.

Results
Acute correction of the varus, procurvatum & internal rotation was achieved intraoperatively and with fast union of the correction at the physeal growth plate level. Average follow up was 46 months for all cases. No complications encountered in either limb. There were no recurrence of the deformity and with excellent results and patients satisfaction.

Conclusion
“Dome Physioclasis” is a new novel surgical technique that allows acute tibial multi-plane deformity correction in patients with rare SPTE condition. Using Hexapod fixator after osteotomy is a major operation and may not be convenient to those patients. Our new technique may be an alternative simpler method of treatment for those patients. Future more familiarity in the technique may improve its understanding.
Level of evidence: IV.

Introduction: Calcar screws have long been in use as an important mechanical strut in proximal humerus locking plate fixation. However, calcar zone is vaguely described and surgeons often miss the appropriate positioning of this important screw. We hypothesise that a neck-gliding calcar screw in a proximal humerus fracture can yield excellent results. Methods: A multi-centre prospective case-control study was designed with 45 cases in the age group of 20-50 years (2022-23), who underwent fracture fixation with a neck gliding calcar screw in a proximal humerus locking plate construct. Neer’s two-part, three-part and four-part fractures were included in the study. Control group included 32 cases operated by different surgeons with the calcar screws outside the radiologically hypothesized neck-gliding zone. Radiological parameters measured by blinded analyzers on a true Antero-posterior shoulder X-rays included- neck shaft angle(NSA), screw calcar distance(SCD), varus collapse of head(VCH). Functional analysis was done at 6 months follow-up using the Oxford shoulder score. Radiological analysis was done at regular intervals until bony union. Results: Mean study age group was 38.7years with 80% male predominance. Mean VCH was 5.8° in case group while control recorded a mean VCH of 33.8°(p<0.01) . Mean SCD for neck gliding calcar screw group was 14.8mm while mean SCD was 29.2mm in control(p<0.05). Complete varus collapse of head was seen in three cases in control group while all cases in study group united. Conclusion: Calcar screws with SCD<15mm (neck-gliding calcar screws) showed low chances of post-operative varus head-collapse and hence recorded excellent outcome.

Introduction: At Ghurki Hospital Lahore a modified assembly of Halo traction named Halo pelvic ilizarov traction (HPT) is invented. It is in use that has its one end fixed to the skull and the other end is fixed to the pelvis via Schanz. This assembly spans the spine and thus can be used for stabilization as well as distraction of the spine. The aforementioned assembly has been used for reduction and then stabilization of cervical traumatic fractures that were not fit for orif. Methodology: This is a descriptive evidence base study on a cohort of 8 patients in which HPT was applied for cervical trauma with fracture of C1-C7 vertebrae that was unfit for orif with intact or partially reduced preoperative neurology. Results:In 8 patients HPT was applied with 7 males and 1 female with a mean age of 34.6 years. In which 2 patients had C1 fracture, 2 had C2, 1 had C3, 2 had C4 and one had C6 fracture. It was applied for a period of 3 months, 5 patients achieved bony union,1 patient achieved fibrous union, 1 patient didn’t achieved union, and 1 patient died due to some other comorbidities. Neurology was intact in all with 5 patients have good flexion of 80-85 °, extension of 65-70 °, lateral flexion of 25-30 ° and rotation of 80-85 °.1 patient had limited forward flexion of 60 ° and rotation of 50 °. Conclusion:Thus, it can be concluded that HPT is an effective alternative in treating cervical fractures.

Materials and methods. The materials were based on the observation of 11 patients (7 males and 4 females) with a diagnosis of aneurysmal bone cyst of the sacrum, who underwent minimally invasive surgical treatment between 2012 and 2023. All patients initially complained of pain in the sacral and/or complaints of deformation in the projection of the sacrum. The duration of complaints ranged from 2 to 12 months on average. 4 out of 11 patients had neurological symptoms. Severe flexion neurogenic contracture in the hip and knee joint was noted in 1 case along with neurological symptoms. Results. The results were monitored over a period of 1 to 10 years. The criteria for assessing the results were complaints, absence of relapse of the disease, signs of repair of the pathological focus according to CT data, restoration of the supporting ability of the sacrum. 2 patients with no complaints had a local relapse of the disease in the form of a residual cavity. All patients who received surgical treatment showed positive dynamics in the form of tumor repair according to CT data, regression of complaints and neurological symptoms. Conclusions. Minimally invasive method treatment requires long-term observation and a greater number of hospitalizations before achieving a positive result. However, this approach is less traumatic and carries fewer risks, while the volume of the resulting repair allows us to obtain support-able bone structures of the sacrum and significantly reduce tumor aggression, which has a beneficial effect on the volume of required open surgical treatment.

Background: Simultaneous fractures of the humerus and olecranon, radius or both are rare and are usually described as “floating elbow”. Another uncommonly documented injury is the humeral shaft fracture associated with glenohumeral dislocation.The authors describe a case where this two atypical pathologies occur in the same patient. Case Presentation: A 24-year-old male patient was admitted to the emergency room following a motorcycle accident. He exhibited a humeral shaft fracture, a right glenohumeral dislocation and an open Gustilo-Anderson (GA) type II olecranon fracture, In addition to the injuries to the right upper limb, he presented a comminuted segmental open fracture of the left femur type IIIB of GA. In an emergent context, the patient underwent osteotaxis of the femoral fracture, washing, debridement and closure of the olecranon wound and reduction of the glenohumeral dislocation. Subsequently, he underwent osteosynthesis of the diaphyseal fracture of the humerus with an endomedullary nail and osteosynthesis of the olecranon with an anatomical plate. Clinical Outcomes: The patient has good function of the right upper limb, with complete consolidation of the fractures and no evident shoulder instability noted. Discussion: The previous case is, to our knowledge, the first described in the literature of a floating elbow associated with ipsilateral glenohumeral dislocation. For both of these entities, treatment is usually surgical. The results described in the treatment of these complex injuries are modest (especially in floating elbows), However, in this case, a satisfactory outcome was obtained, both in terms of limb function and bone consolidation.

INTRODUCTION: Fragility fractures commonly occur among patients with osteoporosis, and they are considered an important public health issue. Low serum 25(OH)D levels are a risk factor for hip fracture.
OBJECTIVE: This study determined the serum concentration of 25(OH)D level in a 60 - 100-year-old Postmenopausal Woman with proximal femur fractures at the Philippine Orthopedic Center
METHODS: This is a cross-sectional analytical research study conducted at the Philippine Orthopedic Center from March 2022 to March 2023. This study determined the Serum concentration of 25(OH)D level in a 60 – 100-year-old Postmenopausal Women in a Philippine Orthopedic Center with proximal femur fracture.
RESULTS: Serum concentrations of Vitamin D 25(OH)D with an overall mean and standard deviation of 26.7±8.7 ng/mL, with a median of 25.1 ng/mL and an interquartile range (IQR) of 21-32.1 ng/mL. The frequency distribution of 25(OH)D levels in the entire sample showed that 69.6% of women had concentrations below 30 ng/ml, 26.4% of women 30-40 ng/ml and 4.0% of women above 40 ng/ml. These results suggest that as the serum concentration of Vitamin 25(OH)D decreases, the risk of hip fractures and OSTA scores increase.
CONCLUSION: Overall, the results suggest that a large proportion of postmenopausal women in this sample had insufficient levels of Vitamin D, which may have implications for bone health and other health outcomes.

Introduction
Hip fractures pose a threat to patients mortality, functionality and life quality.
Material and Methods
We analyzed patients over 65 years who were admitted to the orthopaedic clinic UCCS, with femoral neck (Colli femoris/CF) fractures and intertrochanteric (IT) fractures.
Results
Of 359 analysed patients, 190 had CF and 169 had IT fractures. IT patients had higher mortality (42%) than CF patients (14,7%), while it was highest in not operated patients (89,7%). Most patients were female (76,9%), mean surgery waiting time was 5 days in CF and 5,7 days in IT patients.
It can be concluded that these patients require increased intensive care and rehabilitation.

Background: The causal relationship between neurological abnormalities and idiopathic scoliosis remain controversial. This study aimed to investigate the potential association between suffering from viral encephalitis (VE) and an elevated risk of scoliosis development.

Method: 6634 VE patients and 26398 non-VE children at three hospitals were enrolled in the cross-sectional study. 1452 VE patients and 5608 non-VE children who underwent radiographs more than twice were recruited in the cohort study. The genetic instruments for scoliosis in mendelian randomization (MR) analysis were selected from FinnGen biobank with 297587 participants. The genetic association estimates for neuroimaging variables were obtained from the UK biobank.

Result: Viral encephalitis was associated with scoliosis in a multiple logistic regression analysis (OR = 2.561). Children with an abnormality in the cerebellum, brainstem, corpus callosum, and basal ganglia had a higher prevalence of scoliosis than other sites. In the cohort study, a history of VE was associated with a 3.604-fold increased risk of scoliosis development compared to children without VE (P<0.001). Multivariable Cox regression analysis within the VE group showed a 2.188-fold increased risk of scoliosis onset in children who had recovered from multiple brain lesions (P<0.001). Consistently, MR analysis indicated twelve imaging-derived phenotypes located in callosum, basal ganglia, brain stem, and cerebellum structures were causally associated with scoliosis.

Conclusion: Viral encephalitis and changes in specific brain areas increase the risk of new-onset scoliosis. This discovery supports the thesis that neurological changes have a causal association with scoliosis; if so, identifying modifiable mediators is required to inform prevention strategies.

introduction:
Neglected knee dislocation is a rare injury. We report a case of neglected posterior dislocation managed with open reduction and ligament reconstruction. Such cases are rarely reported in English literature
Case Report:
40 yr old male presented to our OPD with deformity and swelling of right knee. Knee ROM was 0-20 degree. Distal pulses were normal. Radiological investigation revealed posterior knee dislocation which was missed. MRI showed ACL injury, Chondral Defect in the medial femoral and tibial condyle with patellar tendon disruption. PCL and PLC was intact. Patient was posted for surgical management. Knee was opened through a medial para-patellar approach, adhesions were removed. Blunt tip of homan’s retractor was inserted on the under surface of inter-condylar notch and by levering the retractor on the tibia. After reduction, knee was stabilised with external fixator. Ruptured patellar tendon was stabilised with SS wiring. Patient was kept on Ex-Fix for 4 weeks. Knee mobilisation was started, once ROM was achieved to 0-100 deg. Arthroscopic reconstruction Of ACL with medial menisectomy was done. PCL was intact. Now patient at 3 year follow up, no residual instability with knee ROM of 0-90 deg
Conclusion
Acute knee dislocations are to be reduced immediately under anaesthesia. Our case is very rare in which dislocation was neglected with only patellar tendon disruption and ACL injury. PCL was intact. Management was open reduction of knee dislocation with patellar tendon stabilisation

AIM: To study the various types of structural failures of vascularised fibular graft for infected tibial bone loss. MATERIALS and METHODS: We retrospectively studied thirty seven cases of vascularized fibular graft done for infected gap non unions of the tibia. The age of the patients ranged from 21-72 yrs. All except one patient were males . The length of the vascularised fibular graft ranged from8-25 cm. RESULTS: There were 23 incidences of structural failures of the graft. We have identified these failures as of two types- Type I failure- stress fracture occurring in the graft shaft and Type II failure – within 1 -2 cm of the graft host junction or dissociation at the graft host junction. There were ten incidences of type I failure and thirteen incidences of type II failure. Type I failure was treated with initial above knee plaster of Paris cast for 6 weeks and were protected by a PTB cast or custom made brace for another six weeks and all of them united with hypertrophy of the graft. Type II failures were treated initially as type I and of the thirteen type II failures six of them united. The remaining seven needed the use of an Ilizarov ring fixator either in monofocal or bifocal mode to achieve union. CONCLUSION: It is important to identify which type of structural failure of the graft had occurred as type II failures have more than 50% incidence of non-union needing the use of an Ilizarov ring fixator

Background: Body Mass Index (BMI) is used for obesity estimation. Obesity is a known risk factor for the post-operative complications, its relevance to operative surgical field has not been well documented. We aimed to review a relationship between BMI and the depth of spinal surgical field. Methods: Retrospective review of the 356 single level lumbar discectomy patients was conducted. Surgical field depth (SFD) was defined as the distance from the skin to the posterior surface of the lamina while subcutaneous fat (SF) was defined as the distance from the skin to the posterior tip of the spinous process on the MRI scan. Patient age, gender and BMI were recorded. Results: 207 patients included, 99 females and 108 males. Mean BMI was 27.6 (28.3 for males and 26.7 for females). The mean SFD distance and mean SF distance were 64.4mm & 34.2mm respectively. 58 patients had normal BMI, 98 were overweight and 51 were obese. We found a positive correlation between BMI and SFD,SF. Weight significantly correlated with SFD & SF in females but not in males. When patients were categorized based on their BMI, there was a significant difference in the means of both SF and SFD. BMI, gender and age were independent predictors of SF & SFD in linear regression models .Conclusion: BMI has association with the depth of the surgical field and subcutaneous fat in the lumbar region. Although the values obtained are not absolute, they can help surgeons anticipate and discuss perioperative complications with the patients.