Background:
Minimally invasive techniques for forefoot surgery are increasingly used nowadays with short operative time and smaller incisions allowing early rehabilitation. Consequently, the purpose of this study was to evaluate a novel technique for 3-dimensional correction of hallux valgus deformity using small incisions.

Materials and methods:
A single-center, prospective study was conducted from February 2016 to February 2019. The study included a total of 36 feet in 34 patients with hallux valgus deformity treated with soft tissue release combined with osteotomy of the first metatarsal base with correction of angular, rotational deformities of the hallux and fixation by transverse pinning to the second metatarsal. Patients were assessed radiographically for union and measurements as well as clinically using the “The American Orthopedic Foot and Ankle Society (AOFAS)” for functional assessment.

Results:
Union was achieved in all cases. Hallux valgus angle improved from a mean of 40±5.9 degrees to a mean of 9.1±2.3 degrees (P<0.001). Intermetatarsal angle improved from a mean of 17.5±2.1 degrees to a mean of 6.1±1.5 degrees (P<0.001). At the final follow-up period (2 y), the mean hallux valgus angle was 10.9±2.8 degrees (P<0.001) and the mean intermetatarsal angle was 7±1.7 degrees (P<0.001).

Conclusion:
This technique yielded good radiographic and functional outcomes and can be a viable option in management of mild, moderate, and severe cases of hallux valgus deformity.

Level of Evidence:
Level IV, Therapeutic study.

Introduction:Intramedullary nailing (IM) for proximal humerus fractures is an attractive treatment option. However previous IM had high rate of complications, so new designs were developed. The objective was to report outcomes and complications of a third-generation straight nail design. Methods:Retrospective study comprising 18 patients with proximal humeral fracture treated with IM, between 2017 and 2020. Minimum follow-up of 6 months. Results included radiographic measures and functional outcomes: Constant score (CS) and disabilities of the arm shoulder and hand (DASH) scores. Malunion defined as neck-shaft angle (NSA) less than 120°. Statistical analysis was performed with SPSS 25.0. Results:Three patients were excluded due to loss of follow-up (deaths) and two early reverted to reverse arthroplasty (osteosynthesis failures). Mean follow-up of 28 months (6-45), mean age 75 years-old (53-92). One case (8%) resulted in nonunion. The last mean NSA was 111,7° (80-142,3), with a rate of 46,2% malunions. Proximal migration of the nail present in 40% of cases, with associated mechanical conflict. Mean CS and DASH scores were 69,2 (31,6-100) and 45,2 (0,8-80), respectively. A lateral entry point was related with a lower NSA (p=0,012). Patients with migration of the nail had a worse DASH score (p=0,009). Conclusions:There was difficulty in performing the entry point correctly centered, which had conditioned poor radiographic results. However, the functional results are comparable to those in the literature. The inadequate security of the screws and the poor bone quality, can justify the high rates of material migration and the mechanical conflict problems, reducing the functional results.

Introduction
Since the outbreak of Covid19, we have seen enormous changes in our clinical practice and healthcare management to cope-up with this unprecedented demand on acute healthcare setup. The objective of this study is to assess the effect of these changes on acute spinal referrals and hospital attendances during the primary and secondary waves of the pandemic.

Method
All acute spinal referrals and hospital attendances to the emergency department (ED) in a busy district general hospital were analysed. The data were evaluated for three periods: Pre-Covid, Early Covid and Late Covid. The spinal referrals were assessed for duration and nature of symptoms, MRI findings and the interventions performed and finally changes in referral pattern.

Result
The acute spinal referrals and the hospital attendances decreased by 18% during the primary wave compared to the pre-Covid-19 period; however, during the second wave, the referrals increased by 46% compared to the primary wave. Even when compared to the pre-Covid-19 period there was a 34% increase in acute referrals.
10% had intervention in the form of surgery and 6% had injection during the pandemic.
8% returned to the ED requiring further assessment and repeat scan.

Discussion
This study has shown that there was a significant reduction in acute spinal referrals during the primary outbreak of Covid-19. However, the continuation of the pandemic into its second wave has paradoxically resulted in a tremendous increase in acute referrals to the ED. Community-based screening and support led by the spinal physiotherapist are recommended to support the pathway.

Aim: During COVID-19 pandemic, there has been worldwide cancellation of elective surgeries to protect patients from nosocomial viral transmission and peri-operative complications. With unfolding situation, there is definite need for exit strategy to reinstate elective services. Therefore, more literature evidence supporting exit plan to elective surgical services is imperative to adopt a safe working principle. This study aims to provide evidence for safe elective surgical practice during pandemic. Methodology: This single centre, prospective, observational study included adult patients who were admitted and underwent elective surgical procedures in the trust’s COVID-Free environment at Birmingham Treatment Centre between 19th May and 14th July’2020. Data collected on demographic parameters, peri-operative variables, surgical specialities, COVID-19 RT-PCR testing results, post-operative complications and mortality. The study also highlighted the protocols it followed for the elective services during pandemic. Results: 303 patients were included with mean age of 49.9 years (SD 16.5) comprising of 59% (178) female and 41% (125) male. They were classified according to American Society of Anaesthesiologist Grade, different surgical specialities and types of anaesthesia used. 96% patients were discharged on the same day. 100% compliance to pre-operative COVID-19 testing was maintained. There was no 30-day mortality or major respiratory complications. Conclusion: Careful patient selection, simultaneous involvement of the pre-assessment and anaesthetic team, strict adherence to peri-operative protocols and delivering vigilant post-operative care for COVID-19 infection can help providing safe elective surgical services if the community transmission under reasonable control. However, it is particularly important to maintain COVID-free safe environment for such procedures.

Background: There is substantial controversy as to what approach to take when considering joint injections or aspiration in patients taking warfarin. Some authors have recommended stopping warfarin and reversing its effects prior to conducting the procedure to avoid an increased risk of bleeding complications (such as bruising or hemarthrosis). In contrast, others have suggested that stopping oral anticoagulants prior to joint injection or aspiration can increase the risk of disturbing the anticoagulation control and increase the risk of life-threatening thromboembolic events. Purpose: To assess the rate of bleeding complications in patients on warfarin that have a knee or shoulder injection/aspiration whilst continuing their regular warfarin anticoagulation.Methods: A literature search of 3 online databases was conducted by 2 reviewers using the Cochrane methodology for systematic reviews. Eligibility criteria were any study that reported bleeding complication rates in adult patients on warfarin that had a knee or shoulder injection/aspiration whilst continuing their regular warfarin anticoagulation. Studies reporting on less than 5 patients and studies reporting on injections/aspiration using radiological guidance were also excluded. Meta-analysis was conducted using a random-effects model. Results: The search of databases resulted in a total of 847 articles. After screening, a total of 6 articles were deemed suitable to be included in the analysis. These described a total of 835 injections/aspiration procedures. Only 5 joints had bleeding complications. Conclusions: The results of this meta-analysis show that it is relatively safe to perform knee and shoulder injections whilst continuing warfarin anticoagulation

Introduction
Hip fractures form a significant proportion of admissions during the national lockdown periods in 2020 and 2021.
Since 2007 NHFD has reported a improvement in 30-day mortality after hip fracture and this trend continues with just 6.1% dying in 2018, against 6.9% in 2017. Various regional studies in the UK reported the prevalence of COVID-19 during the 1st National lockdown, from 19.4% (82/422) in London to 8.5% (27/317) in Scotland, and 30-day mortality rates of 30.5% (25/82) and 33.3% (9/27).

Aim, Methods
To compare the admission and 30 day mortality rate of NOFs and Periprosthetic femur fractures during 1st and 2nd covid waves. Data collected retrospectively of the patients admitted during 01/03/2020- 24/05/2020 (1st wave) and 04/02/2021- 07/03/2021 (2nd wave)

Results
Admissions
95 NOFs, 9 PPs admitted in 2020
77 NOFs, 5 PPs admitted in 2021

30-day mortality
18 NOF deaths (17.3%) in 2020 (No PP deaths in 2020)
3 NOF deaths (3.9%) in 2021 and 1 PP death 2021

Covid status and related deaths
2020, 17 were covid positive, of which 7 died (2 PPs)
2021, 2 were covid positive of which 0 died (0 PPs)

Time to surgery
2020 – All NOF patients operated <36 hours
2021 – 1 NOF patient operated at 48 hours due medical optimisation

In 2020, 38.8% deaths among covid infected NOFs+PPs
In 2021, no deaths among covid infected NOFs+PPs

Conclusion
We have reported significant improvement in the standard of care of NOFs in terms of covid testing and mortality rate since 2020

The aim of our study was to present the long term clinical and radiological results of severe hallux valgus treated with triple osteotomy of the first ray. Patients with severe hallux valgus treated with basal medial opening wedge, distal Chevron and Akin osteotomy at our hospital from 2008 to 2012 were included in the study. Radiological outcomes such as pre-and post-operative Hallux Valgus Angle (HVA), Intermetatarsal Angle (IMA) and Distal Metatarsal Articular Angle (DMAA) were collected retrospectively, as were data on complications and reoperation rate. Patients were called to complete Foot and Ankle Outcome Scores (FAOS).
19 patients underwent 20 triple osteotomies of the first ray. The mean radiographic and clinical follow up was 1.22 years. The mean pre-op HVA, IMA and DMAA were 43.3, 20 and 37.85 respectively. The mean first post-op HVA, IMA and DMAA was 8.2, 11.65 and 12.8, a 63% improvement in radiological parameters. The median number of post-operative follow-up radiographs was 3 with a mean HVA, IMA and DMAA of 15, 12.2, 15.95 at final radiographic assessment. 3 patients suffered from complications, with one superficial wound infection treated successfully with oral antibiotics, one deep wound infection treated with washout and metalwork removal and one prominent metalwork requiring removal. Patient satisfaction was high with a mean FAOS of 92.55 taken at 10 years follow up.
Triple first ray osteotomy is a successful mode of treatment for severe hallux valgus, with high levels of patient satisfaction and excellent improvement in radiological parameters measured over long-term follow-up.

Background: Minimally invasive reconstruction techniques are used for anatomical ligaments construction of the lateral ankle ligament complex, but the two key elements for the identification of the anatomic locations of the bone tunnel and the appropriate graft tension during the surgery are not clearly reported.
Methods: The patients with chronic ankle instability who received arthroscopic anatomic lateral ligament complex reconstruction were retrospectively analyzed. The anatomical locations of the bone tunnel were performed under arthroscopy combined with fluoroscopy for accurate location of the bone tunnel entrance. The graft tension and routing were controlled under arthroscopic visualization. The clinical outcomes were assessed using the Karlsson-Peterson score, Sefton articular stability scale, and Visual Analogue Scale (VAS). The complications were recorded at each follow-up.
Results: A total of 18 patients were enrolled in the final analysis. The mean final follow-up was 33.33 ± 3.69 (range, 24 to 36) months. No patient had the recurrence of ankle instability after the surgery. According to Sefton articular stability scale, 94.5% of the patients had excellent/good function. The mean value of the anterior drawer tests and the talar tilt angle examination were decreased. The mean of the Karlsson-Peterson score and the Visual Analogue Scale (VAS) score were both improved significantly.
Conclusions: The anatomic reconstruction of the ankle lateral ligament complex to treat chronic ankle instability using the arthroscopic combined with the fluoroscopic technique improved the clinical functions, patient’s satisfaction and reduced pain.

Limb deformity leads to pathological load across joints and facilitates the progression of osteoarthritis, being its correction essential to prevent functional disability. Distal femur is the most common location of pathologic genu valgum but it can arise from tibia too - the specific procedure in each case with its own unique problem is not universally agreed upon. This study reports to a 16-year-old boy forwarded for consultation due to bilateral painful genu valgum with impaired gait. Image exams showed a bilateral 12º deformity with the CORA located in the tibia. It was performed bilateral assembly of hexapodal device and double osteotomy of tibia and fibula at CORA and suprasyndesmotic level respectively. Patient was allowed to full weight bearing and free joints mobilization. Proper limb realignment with improved functional scores were achieved after 2 months of close monitoring. Gradual correction of bilateral genu valgum deformity using the Ilizarov distraction osteogenesis technique proved to be a reliable option - it reduces the complications associated with acute correction as peroneal palsy and provides better correction specially in multiplanar deformities. Besides, it’s possible to bypass the difficult intraoperative mechanical axis assessment, can be considered the effect of weight bearing on its measurements and has the potential to allow fine-tuning of the correction without any further surgical intervention. However, pin tract infections and patient’s discomfort of having to cope with a bulky fixator represent some disadvantages of this method. Individual education and discussion are keys to the success in complex deformities.

Leiomyomas are benign epithelial tumours with a female preponderance usually in the uterus, gastro-intestinal tract & skin.They are well capsulated tumours with no mitotic activity and little pleomorphism.Primary leiomyoma in the upper cervical spine region is rare and occurrence of these lesions in young immunocompetent males is extremely rare.15 year old male had swelling over the nape of neck since 4 years with slight difficulty in neck movements since a few months. Asymptomatic 4 years back be developed a painless swelling at the nape of neck on the right side initially the size of a pea which gradually increased size. A 10x8cm firm,non-tender & non pulsatile swelling at the nape of neck on the right extending from the occipital nuchal line and crossing the midline upto the posterior border of sternomastoid. Skin over the swelling wasn’t adherent and the swelling did not reduce on neck movements. Neck movements were terminally restricted with restriction on rotation towards the right. Routine Xrays and MRI were suggestive of a soft tissue mass in the inter-muscular plane on posterior aspect more on the right side with a cystic component and causing thinning of the C2 lamina with no intra spinal extension. Biopsy was done.Findings were suggestive of a spindle cell benign tumour. Posterior en bloc excision was planned and the lesion blog with the entire capsule was excised and sent for histopathology which revealed the lesion was a leiomyoma. The patient has shown no clinical or radiological evidence of recurrence at 4 year followup.

Introduction: Disc degeneration is a common condition associated with low back pain. Aetiology of disc degeneration is multifactorial and debatable. Low grade infection has been suggested as a cause for disc degeneration . This study aims at finding causal relationship between herpes simplex virus(HSV) and degenerative disc disease, which will help in addressing the problems of disc degeneration more correctly. Material and method:this study includes total 10 patients, with lumber disc disease, of both sex(6 male and 4 female) with mean age of 41.6years(age group 28 to 60 year). Intervertebral disc from these patients were obtained by discectomy and stored in liquid nitrogen foe transfer to molecular biology lab. DNA from the acquired disc material was extracted and with the help of polymerase chain reaction(PCR) and genotyping it was identified. Result: DNA of herpes simplex virus1 was identified in disc sample of 9 out of 10 patients with degenerative lumbar disc disease. All the 9 patients showed IgG antibodies and none of them showed IgM antibodies towards HSV on serology which ruled out any acute herpes virus infection .Discussion: Finding out aetiology of degenerative disc disease will help controlling the outcome. Presence of HSV DNA shows that it can be a causative organism or it increases susceptibility of disc for degeneration by mechanical cause. Key words: Disc degeneration, Herpes simplex virus.

Giant cell tumor also known as osteoclastoma, is a benign but locally aggressive tumor of epiphyseo-metaphyseal region of the long bone. While most cases are benign, 1%-9% can metastasize to lungs. It rarely involves the small bones of hand, foot and ankle, with 1%-2% incidence. There have only been a few case reports of GCT talus in the past. We report a case of 16-year old boy having pain and swelling in left ankle for 6 months. Conventional radiograph and CT scan show eccentric osteolytic lesion on medial aspect of the talar body extending up to the neck region. MRI T2 image show hyperintense signal with T1 intermediate signal involving talus likely benign tumor with no soft tissue extension and no articular involvement. The patient also underwent core needle biopsy from lesion under mobile fluoroscopic system guidance, the report of which was inconclusive. Finally surgical excision and curettage of lesion and adjuvant treatment by high speed burr, phenol, diluted hydrogen peroxide and sterile water were done. The talus is then packed with autologous iliac bone graft. After which slab support was given for six week Following which pain and swelling were relieved. . Histopathological examination of excised tissue shows spindle and round to oval shaped mononuclear cells with highly vascular stroma and numerous osteoclastic giant cells in uniform distribution, confirming the diagnosis of GCT. At six month of follow up there was no evidence of talus collapse or recurrence of GCT.