Background: The primary aim of this study was to explore the outcomes of Vancouver B periprosthetic hip fractures that were managed non-operatively with a particular focus on 1-year mortality. Understanding this mortality data will allow surgeons to better understand the risk associated with non-operative management. The secondary aim was to evaluate our case series and current literature with regards to identifying suitable patients for non-operative treatment.
Methods:Our electronic fracture database was interrogated for all Vancouver B periprosthetic fractures treated at our institution between April 2009 to April 2019; 18 patients were identified. All available data was then collected from radiographic, electronic and paper notes. A comprehensive literature search of PUBMED and EMBASE databases was then conducted with all relevant literature reviewed.
Results:1-year mortality of these patients was noted at 22.2%; highlighting the severity of these injuries. No patients required conversion to surgical management, sustained a dislocation or went into non-union. With regards to literature no case series focussing on non-operative management outcomes were reported.
Conclusion: To our knowledge this is the first published case series focussing solely on non-operatively managed Vancouver B periprosthetic hip fractures. This paper provides evidence from the first reported case series with which surgeons can counsel patients on the significant mortality risk associated with these fractures. Non-operative management of periprosthetic hip fractures is possible after careful analysis of the fracture configuration, implant and patient characteristics. Further research is required from a larger prospective case series in order to make additional evidence based recommendations.

Introduction: Fractures of the tibia are common and can incur in a multitude of sequelae. Careful soft tissue dissection and preservation are essential. Reamed tibial nailing offers good results with minimum soft tissue destruction near the fracture site, which improves fracture healing and decreases complication rate. The surgeon is faced with the choice of a transpatellar or parapatellar approach in intramedullary nailing, frequently concerning possible implication in future knee pain. The aim of this investigation was to evaluate possible causes for anterior knee pain after intramedullary tibial nailing. Methods: Thirty-three diaphyseal tibial fractures (AO 42) treated with reamed intramedullary nails, over a five-year period were reviewed. Including a total of 16 AO type-A, 8 AO type-B and 9 AO type-C. The presence or absence of residual anterior knee pain was inquired. Results: Nine patients (27%) reported anterior knee pain while resting and 11 patients (33%) only while kneeling or squatting. Parapatellar or transpatellar approach, age, sex, alcohol consumption, smoking habits, mechanism of trauma and fracture pattern showed no significant influence. Nail extraction was further performed in 15% of the total cases (5 patients), anterior knee pain resolved in all these patients. Conclusions: Choosing a parapatellar or a transpatellar approach has no influence in residual anterior knee pain. This choice should be made based on the surgeon's training and preference. We associated pain with nail protrusion; having in mind that of all the patients that reported residual pain hadn't yet undergone nail extraction. Further investigations with larger samples should be conducted.

Objective:
To estimate the no. of patients presenting with low back pain having low serum Vitamin-D levels and to determine the clinical efficacy of Vitamin-D supplementation on Visual Analog Pain scale (VAS) and Modified Oswestry Disability Questionnaire (MODQ) scores.

Methodology:
This prospective, cohort study was conducted for 02 years (10th February 2016 to 9th February 2018). All patients presenting with low back pain for more than 12 weeks duration and aged between 18 to 55 years were included. Serum Vitamin-D levels measured after an overnight fast. If levels between 30-100ng/dL – Normal, 20-30ng/dL – Insufficient and <20ng/dL – Deficient. Patients first with deficient Vitamin-D levels given Oral 50,000 IU Vitamin-D3 daily for 05 days, then once weekly for 08 weeks while with insufficient levels given Oral 50,000 IU Vitamin-D3 once weekly for 08 weeks. After that patient put into maintenance phase, i.e. Oral Vitamin-D3 – 50,000 IU once monthly for 06 months and stopped if level > 60 ng/dL. Vitamin-D levels measured and VAS and MODQ score done at 0,2,3 and 6 months.

Results:
590 patients included in study with mean age = 42.39 ± 10.84 years. Of the total,332 (56.27%) males, 258 (43.73%) females.After supplementation Vitamin-D levels improved from a baseline 13.32 ± 6.10 to 37.18 ± 11.72(p=<0.01).VAS scores declined from 81 (at baseline) to 36 (at 6months)(p=<0.01) and MODQ scores improved from 46 (at baseline) to 25 (at 6months)(p=<0.01).

Conclusion:
Improvement in pain & functional disability with Vitamin-D supplementation in patients presenting with low back pain.

Introduction:The most common complications after multi-level ACDF(Anterior Cervical Discectomy and Fusion) are adjacent level degeneration and pseudarthrosis.We aim to investigate the potential biomechanical factors contributing to these complications following 3-level ACDF using a validated finite-element model of the human cervical spine from C2-T1.Methods:The FEM model was programmed to simulate a 3-level ACDF with intervertebral spacers and anterior cervical plating and screw fixation from C4-7.The model was then constrained at the inferior nodes of the T1 vertebra, and physiological loadings were applied at the top vertebra.The pure moment load levels of 2 Nm were applied in flexion, extension and lateral bending.A follower axial force of 75 N to reproduce the head weight and muscle force was applied using standard procedures.The biomechanical characteristics were then analyzed and recorded.Results: The cranial adjacent level at C3-4 had significant increase in range of motion(+90.38%) compared to the caudal adjacent level at C7-T1(+70.18%), indicating that the cranial adjacent level has more compensatory increase in ROM after 3-level ACDF,potentially predisposing it to earlier adjacent level degeneration than the caudal adjacent level.In addition,within the C4-7 ACDF construct, the C6-7 level had the least robust fixation during fixation compared to C4-5 and C5-6, as reflected by the smallest reduction in ROM compared to intact spine(-71.30% vs -76.36% and -77.05%, respectively),potentially predisposing the C6-7 level to higher risk of pseudarthrosis.Conclusion:These findings can potentially help spine surgeons to predicate the areas with higher risks of post-operative complications and thus develop corresponding strategies to mitigate these risks and to optimize surgical outcome.

Introduction: Baseball is a relatively safe noncontact sport. However, when injuries do occur, little is known on a macro scale of hospitalized injuries, associated procedures, patient characteristics, and perioperative outcomes. Methods: The Kid’s Inpatient Database was queried for Baseball injuries from 1997-2012. Patient characteristics, hospitalization details, prevalent diagnoses, procedures, and perioperative outcomes were investigated. Results: 834 baseball sports injuries were isolated. The most prevalent primary diagnoses were unspecified closed ankle fractures (8.3%), closed fracture of fibula/tibial shafts (6.0%), closed bimalleolar fracture (4.7%), closed fracture of the orbital floor (blow-out)(3.1%), concussion (2.7%), closed malar/maxillary fracture (2.3%), and closed facial fractures (1.3%). The most prevalent primary procedures were open red-int fixation of tibia/fibula (18.3%), closed reduction without internal fixation of tibia/fibula (4.6%), closed reduction of fracture with internal fixation of tibia/fibula (3.4%), incision of mastoid/middle ear (1.7%), and open reduction of mandibular fracture (1.7%). 42 patients (5.0%) experienced a complication, the most common being anemia (19, 2.3%), followed by bowel complications (14, 01.7%) and neurological deficits (7, 0.9%). Conclusion: Baseball players were most likely to present with ankle fracture, bimalleolar fracture, tibial/fibular fractures, and facial fractures. Overall perioperative complication rate was 5%, consisting mostly of minor complications.

Though access to the cystic lesion of the talar body without damage to the articular surface is difficult, we have shown a case study of the same with better follow up. This case report is about a 23-year-old male who had a symptomatic huge cystic lesion in the left-sided talus bone. Radiograph and computed tomographic scan showed an expansile lytic lesion within the talar body. The magnetic resonance imaging revealed a well-defined lesion with fluid-fluid levels. The needle biopsy aspirate was hemorrhagic, and hence a diagnosis of aneurysmal bone cyst was made. As the lesion was beneath the talar dome with an intact neck and head, a medial approach with medial malleolar osteotomy was performed. The lesion was curated out, and the cavity was filled up with morselized bone graft. The limb was splinted for 6 weeks, and complete weight-bearing was started after 3 months. At one year follow up, the lesion had completely healed up, and the patient was pain-free with no recurrence.

Numerous orthopaedic trauma patients are seen at our hospital, with majority requiring internal fixation with orthopaedic implants. Most Filipinos are uninsured and pay for healthcare and implants from out of pocket. Studies have shown that being uninsured can increase their morbidity and mortality. A consignment policy was instituted that spares patients this cost. A study was performed to determine if there was a difference in outcomes in patients admitted prior to the institutionalization of the policy (Group A), and patients admitted afterwards (Group B). A total of 206 patients were included in the study, and we gathered data from department and hospital records regarding incidence of morbidity, mortality, and length of stay. In this study, we demonstrate no difference in morbidities and mortalities between the two groups. There is a slightly shorter preoperative stay, and a slightly longer postoperative stay, both statistically non-significant, for Group B patients.

The current global turmoil due to the coronavirus pandemic is having a severe effect with everyone being forced to adjust to the changing dynamics of social and interpersonal relationships. With most of the nations in a lockdown mode, an important aspect it to be considered is the impact of covid-19 on children mental and physical health. Though children are less commonly affected but one of the major consequences of lockdowns and school closures were that some children not able to engage in outdoor physical activities, which leads to vit D deficiency .Material and methods- we retrospectively collected data of 112 students of mean age 9.5 years ( male 54 female58) from june 2020 to march 21, presented with chief complaint of bilateral knee pain ,back pain , fibromyalgia and fracture distal end radius (in few cases ) for vit d levels, serum calcium , RFT , alkaline phosphatase and radiology. Results- 84 % of children found to be insufficient level of vit d (< 20 ng/ml). RFT were found to be normal in all cases. 76 % of all cases showed characteristic feature of rickets ( widened physis, metaphyseal cupping and pencil thin cortex. conclusion- Vit D plays a critical role in children's cognitive and physical development, and Surge in cases of rickets is a matter of concern during the pandemic. Good nutrition should be emphasized in children’s along with exposure to sunlight for minimum of 15 minutes at home.

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Aims: The purpose of this study is to report the clinical results and mid-term survivorship for total hip arthroplasty (THA) performed to treat displaced intracapsular hip fracture. Methods: Between January 2005 and December 2019, 414 patients underwent THA for acute displaced intracapsular hip fracture. The mean age of patients was 73.2±8.0. 89.6% received a cemented THA. Kaplan-Meier analysis was performed with implant survivorship and dislocation as separate end points. Complications and modified Harris Hip Score (HHS) at latest follow-up were also reported. Results: There was a total of nine revisions, six were performed for dislocation and three for infection. Kaplan–Meier implant survivorship was 99.0% at five years and 97.7% at ten years. Twenty (4.8%) patients suffered at least one dislocation and 11 suffered more than one, so following a first dislocation the chance of one or more further dislocations was 11/20 (55%). Kaplan–Meier analysis with dislocation as the end point showed risk of dislocation of 2.9, 4.4 and 5.2% at one, five and ten years respectively. Three (0.7%) patients suffered late periprosthetic fractures and 22 (5.3%) contralateral hip fracture. The mean modified HHS at latest follow-up was 86.3±18.9. Conclusion: In conclusion the present study shows excellent implant survivorship, good hip function and moderate risk of dislocation and contralateral hip fracture following THA for displaced intracapsular hip fracture. Our study shows that despite recent evidence questioning the benefits of THA for hip fracture in a selected group of patients results are favourable.

Covid-19, Telephone Consultations, Face to Face consultations
Introduction: With the advent of Covid-19 Pandemic, telephonic consultations were instituted as a measure of safety for both patients and healthcare professionals. These newly devised consultations were in line with the clinical guidelines of NHS England, NHS Improvement and British Orthopaedic Association. Using a retrospective analysis, we observed how effective these consults were at achieving an outcome for new orthopaedic patients. Methods: Data was collected retrospectively from electronic clinic templates over 3 months period(August-October 2020). All Telephone consultations for new orthopaedic during study time were included. Face to face, Follow up, Spine and Trauma patients were excluded. Results: 519 Telephone consultations were made for new patients referred from Primary care services. 67(13%) were from Shoulder and Elbow, 182(36%) from Hip and Knee,175(34%) from Hand and 95(18%) from Foot and Ankle Clinics. 52% patients were requested face to face clinics, 14% patients were sent for further investigations, 1% patients were referred to physio and only 15% patients were added to the list on these telephonic consults. 18% patients clinic outcome was categorized as other(Discharge, telephone follow up, referred to other organization or clinician). Limitations: Study doesn't account for variability in clinical complexity impacting need for face to face consults. There is variability of personal consultant preference. Conclusion: Telephone consultations often provide insufficient information to make a clinical decision. Patients added to lists are invariably invited for face to face consultations which remain the preferred choice to make a clinical decision.

introduction : thyroid cancers of follicular cell origin are most common. there is 50% reduction in survival rates in metastatic disease.bone metastases shows 10 year survival rate of 13–21%. compared to other malignancies with bone metastases, prognosis is still superior and hence warrants aggressive treatment. spine is commonest site of bone metastases followed by pelvis, skull, long bones. Case report :45 year old female came with complaints of pain and swelling in left thigh since 1 month and inability to walk since 2 days after trivial trauma at home, patient was a known case of follicular carcinoma of thyroid and thyroidectomy was done 3 months back patient was advised for radioactive iodine therapy by oncology dept. x ray suggested femur shaft fracture and radiolucent shadow at distal femur region. Surgery: patient was planned for closed reduction and internal fixation with retrograde femur nail spanning the metastatic region and fixing fracture . plating was avoided due to risk of dissemination while soft tissue dissection. while putting screws metastatic area was encountered and biopsy taken and area curated . patient was advised to walk without weight bearing for 2 months and start radioactive iodine therapy. On 5 months follow up patient is walking well without weight bearing and x ray shows complete bony union at fracture site. discussion and conclusion : for metastatic to bone palliation is most important to avoid complications of staying bedridden. chemo and radiotherapy are mainstay of management, orthopedic intervention done to ambulate patient. Which showed good results

Chronic osteomyelitis (COM) of Mixed bacterial infection in a long bone of a healthy individual is rare and its occurrence is usually seen in post-traumatic osteomyelitis and in patients who may have undergone surgery with implants. The occurrence of mixed infection in COM presents a treatment challenge as these organisms may have different antibiotics sensitivity pattern. To achieve good antibiotic treatment, correct identification of causative organisms with antibiotic sensitivity pattern is encouraged. In this report, we present the case of a 6-year-old boy with COM of the left tibia with 2 sinuses. At surgery, samples were taken separately from the sinuses and sent for culture and sensitivity which yielded Klebsiella Species and Proteus Vulgaris with different sensitivity pattern to antibiotics. This finding admonishes surgeons to take separate samples from different sinus sites with protruding sequestrum to ensure adequate effective treatment.

Objective: This study evaluates implant failure associated with surgical technique when using long gamma nails for proximal femoral fractures. Methodology: A retrospective audit of all patients who underwent treatment with long Gamma nails for proximal femoral fractures pre- intervention (1st January 2020- 30th June 2020, n=18) and post- intervention (1st July 2020 to 31st December 2020, n=18) were identified. Results: Pre-intervention, 28% of cases experienced implant failure due to surgical technique: lag screw cut out, lag screw back out and early implant fatigue (mean 78days from surgery) resulting in broken nail. Post- intervention, there were no implant failures or patient readmissions. Intervention: Saw bone workshop with the implant company for all surgeons within the department was carried out. Screw cut out and screw back out were due to the improper placement of the set screw. Once the set screw is engaged with the lag screw, the lag screw should not turn further with the T handle. If there is movement of the lag screw, this is an indication that the set screw requires further tightening to prevent lag screw cut out or back out. Notching at the nail-screw junction resulted in early implant fatigue failure. This was rectified by pre-drilling the lateral cortex of the femur prior to Kirchner wire placement for the lag screw, preventing eccentric placement of the Kirschner wire, eccentric reaming and notching at the proximal screw aperture. Conclusion: The workshop resulted in no further implant failures secondary to surgical technique improving overall patient morbidity and mortality.

Introduction: The aim of this study was to evaluate the long-term results of femoral varus osteotomy in unilateral Morbus Legg-Calve-Perthes-Disease (LCPD). Dynamic surface electromyography during gait was performed on 42 patients at a mean of 18 (10-27) years after surgery. Few studies have been done yet investigating the long term results of surgical therapy in LCPD. EMG-data has never been evaluated in these follow-ups. Methods: Electromyography was conducted using skin-surface electrodes attached to the muscles of interest while walking on a walkway. In 33 patients 6 muscles were detected (gluteus maximus, gluteus medius, rectus femoris, vastus medialis, vastus lateralis, biceps femoris). Each of these muscles was simultaneously recorded on affected and non-affected side in 7 sequences per patient. In 9 patients 2 additional muscles were evaluated (tibialis anterior, gastrocnemius, soleus). The absolute duration of activity of each muscle was calculated from the starting to final point of muscle activation and was evaluated statistically (paired t-test and ANOVA). Results: The comparison of both sides showed a significant prolonged activation time of the affected side for gluteus maximus, rectus femoris, vastus medialis, vastus lateralis. In the remaining muscles (gluteus medius, biceps femoris, tibialis anterior, gastrocnemius, soleus) no significant side difference in activation time was found. Conclusion: Even nearly 20 years after surgery there is still a difference in muscular activation patterns between affected and non-affected side. These changes could be muscle weakness or muscular coping mechanisms. These may be based on the biomechanical change due to femoral varus osteotomy in unilateral LCPD.

Introduction:Hereditary multiple exostoses (HME) is an autosomal dominant disorder affecting the skeletal system, which is characterized by multiple osteochondromas in bones leading to skeletal deformities, short stature, soft tissue, and neurovascular compressive symptoms. Case report:10 years old female presented with painless multiple swelling around the knee, wrist, and painful varus deformity in the lower third of the right leg. Radiographs revealed flattening and distortion of the right fibula by a large exostosis. CT scan showed multiple osseous outgrowths in the lower end of femur upper and distal tibia metaphysis and proximal and distal fibula metaphysis. The large exostosis of the right distal tibia was symptomatic and indenting the fibula which required excision along with the segment of the fibula of about 2.5 cm above the syndesmosis adjacent to the exostosis as the mass was adherent to the fibula. The histopathology revealed osteochondroma with no malignant transformation. The patient at one year of follow-up is pain-free and has a good range of motion of the ankle. Conclusion: Distal tibia osteochondromas are rare and can lead to deformity of the ankle if not managed early and properly. So early detection, proper planning, and management of periarticular distal tibia osteochondromas are essential to prevent the development of the deformity. Segmental fibulectomy is required to remove the adherent osteochondromas completely and to prevent the recurrence. It is essential to follow-up with the patient till skeletal maturity to identify the late progression of the ankle deformities.