Ischemic necrosisis a common complication of orthopedic random skin flaps surgery. The goal of this study was to investigate the changes of ischemic extra-long flaps with L-Borneol and its possible mechanism. We raised dorsal McFarlane flaps in 54 Sprague-Dawley rats. We designed three groups of rats: high- L-Borneol group (HLB, 200 mg/kg/d), low- L-Borneol group (LLB, 50 mg/kg/d), and control group. The flap survival rate was calculated, seven days after flap construction. Blood perfusion was detected by laser Doppler flow imaging, and angiogenesis wasdetected by Lead oxide/gelatin angiography. Oxidative stress levels of flaps were determined by detecting superoxide dismutase (SOD) and malondialdehyde (MDA). The histopathological status of flap was evaluated by hematoxylin and eosin (H&E) staining. Immunohistochemistry was used to determine the expression of hypoxia Inducible Factor 1α (HIF-1α), vascular endothelial growth factor (VEGF), Toll-like receptor 4 (TLR4), tumor necrosis factor-α (TNF-α), interleukin (IL)-6, IL-1β,The flap survival rates and SOD activity in the experimental groups were significantly higher, while MDA activity was lower. Experimental groups showed significantly improved microcirculatory blood flow to the flap and increased angiogenesis. Immunohistochemistry revealed that paeoniflorin was associated with significantly increased VEGF and HIF-1α expression, and decreased level of TNF-α,IL-6, IL-1β.L-Borneol effectively enhanced the survival of rat random skin flaps by reducing inflammatory response, inhibiting ischemia reperfusion injury and promoting angiogenesis. And its effect may be mediated by regulating HIF-1α/VEGF pathway.

INTRODUCTION Elective operating has been severely affected by tgecovid Pandemic across the UK, with extending waiting lists across the country. Lock down has reduced the level of patients' activity OBJECTIVES Comparison of productivity, andpatient outcomes in Arthroplasty pre and post covid Pandemic METHODS #Retrospective study over 2 X 6 months periods.
GROUP 1, Pre Pandemic 01/10/2019 to 31/03/2020 (191 joints) GROUP 2, Post Pandemic 01/10/2021 to 31/03/2022 (67 joints) #Null hypothesis: Patients would be: older, frailer, wait longer, longer hospital postoperative stay, higher rate of complications # Mann-whitey U test for statistical significance. RESULTS*Average age was found to be 71 in group 1, and 69 in group 2 (P value- 0.14686 ; statistically not significant). Average ASA was found 2 in group 1, and 2.4 in Group 2 (P value - 0.00082 ; Statically significant). Average wait to have surgery was found to be 19 weeks in Group 1, and 44.8 weeks in Group 2 (P value - 0.00001; statistically significant). Average postoperative hospital stay was found to be 4 days in both groups. Complications rate was found to be 14.13% in Group 1, and 23.88% in Group 2 ( P Value- 0.11702; statistically not significant. Average drop in haemoglobin was found to be 10.3 in Group 1, and 20 in Group 2 (P value 0.2327 ; statistically insignificant) CONCLUSION: Despite longer waiting time, and objectively de-condtioned patients post Pandemic, tge length of postoperative hospital stay, and the rate of complications were found statistically insignificant in both groups.

Introduction:The iliolumbar ligament(ILL) may be an important cause of acute and chronic low back pain (LBP). Methods: From January 2022 till December 2022, all patients with clinically suspected iliolumbar syndrome(ILS) were included in this study. Patients underwent an ultrasonography (US) to confirm the diagnosis. The thickness of the inflamed ligament should be higher than 1mm. The ultrasound was always performed bilaterally to compare both sides. Patients were injected under US-guidance with 2cc (11,6 mg betamethasone) and 8cc (2% lidocaine). The patient's assessment of LBP was recorded before and 6 weeks after the injection with a visual analogue scale (VAS) for pain. Results: 54 consecutive patients with clinically suspected ILS were evaluated by US. Mean age 38.8 years (30–57 years) and 41 were women. US showed, in all patients, an inflammation of ILL. In five patients, the ILL was inflamed at both sides. The mean thickness of the ligament was 2.66 mm (1.5–5mm). All 56 patients underwent injection in ILL and 51 patients (91%) showed reduction in mean VAS from 8 ± 0.7 (at presentation) to 0.6 ± 1.02 after 6 weeks follow up (P < 0.0001). ILL thickness was significantly decreased (P < 0.001) from diagnosis (2.66 ± 0.22 mm) to 6 weeks after US-guided infiltration (0.81 ± 0.42 mm). Conclusion: Ultrasonography allows the diagnosis of ILS in patients with LBP. US is a useful tool to guide corticoids infiltrations in ILL as an effective therapy for this pathology. Prospective randomized studies are needed to confirm our findings.

Abstract:Introduction: Proximal humerus fractures are a common injury that can result in significant disability and morbidity. The Minimally Invasive Reduction and Osteosynthesis System (MIROS) technique is a minimally invasive surgical approach that has been used for the treatment of these fractures. The purpose of this study is to evaluate the outcomes of the MIROS technique for proximal humerus fractures.Objectives: The primary objective of this study is to evaluate the effectiveness of the MIROS technique for the treatment of proximal humerus fractures. The secondary objective is to assess the complication rates associated with this technique.Methods: A retrospective chart review was performed for patients who underwent the MIROS technique for proximal humerus fractures . Data was collected on patient demographics, fracture characteristics, surgical details, and postoperative outcomes. Statistical analysis was performed to evaluate the effectiveness and safety of the MIROS technique.Results: A total of 12 patients were included in the study. The MIROS technique resulted in a successful reduction of the fracture in all patients. The mean time to union was 12 weeks, and the mean Constant score at 12 months was 80. There were no major complications associated with the MIROS technique.Conclusion: The MIROS technique is an effective and safe treatment option for proximal humerus fractures. It results in successful fracture reduction and good functional outcomes without major complications. This technique may be a valuable addition to the armamentarium of orthopedic surgeons treating proximal humerus fractures.
Keywords: proximal humerus, minimal invasive, k wire, MIROS

Virtual Fracture Clinics “VFC” are introduced to filter out referrals to fracture clinics. Pathpoint ® Electronic referral software system was launched in 2022 across four “North Eastern Hospitals groups (Our Lady of Lourdes-Drogheda, “OLOL”, Our Lady’s Hospital-Navan “OLH”, Louth County Hospital-Dundalk “LCH” & Cavan/Monaghan Hospitals “CGH”) aiming curtailing inappropriate referrals and reduce unnecessary workload. All trauma referrals are made to OLOL-Drogheda where on-call trauma-orthopaedics teams are based. Guidelines were set for “VFC” referrals: Acute fractures suitable for fracture clinic review and physiotherapy, No Elective Orthopaedics cases to be posted on Pathpoint ®, Orthopaedic on call consultation for all open fractures, open or close tendon injuries and back pains. AIM: VFC via Pathpoint ® functioning as per guidelines, review referrals not meeting criteria, highlight and reduce inappropriate referrals from each hospital, and indentify areas where staff education required. Method: Prospective three months study (July through September), reviewing 2500 referrals with x-rays and their reports. Inappropriate referrals were highlighted and feedbacks sent electronically to respective Emergency Medicine “ER” consultants. Results: 361(14%) Inappropriate referrals identified, with following breakdown: OLOL-Drogheda: 154, OLH-Navan: 17, LCH-Dundalk: 53, “CGH”-Cavan/Monaghan: 137. Reasons: Chronic cases: Dupuytren’s, Tennis Elbows, Carpal Tunnels, Soft Tissues Injuries, Back-Pains, Sciatica. Recommendations: Staff education on inclusion criteria, Inappropriate referrals flagged for ER consultants to review and educate their junior doctors, Colour code inappropriate referrals until reviewed by ER consultants, All open injuries/tendon ruptures and spine fractures to be consulted with on-call orthopaedics, If unsure consult orthopaedics on-call and re-audit in six months after implementing changes.

Introduction: Plantar fasciitis is a debilitating clinical condition and is one of the most common causes of
heel pain. The risk factors include frequent and prolonged running, obesity, a sedentary lifestyle, work-
related weight bearing, and inappropriate footwear. Ultrasonography being a non-invasive, cost-effective,
and easily available modality is a useful adjunct in the diagnosis.
Methods: A prospective observational study was conducted among 30 patients with unilateral plantar
fasciitis. The diagnosis was based on history and examination. Heel pad thickness and plantar fascia
thickness were recorded using ultrasonography.
Results: The ultrasonography results showed increased plantar fascia and heel pad thickness in the affected
limb with plantar fasciitis than the normal one (p<0.001). The BMI was positively correlated with the heel
pad thickness (p<0.05). The receiver operating characteristic (ROC) curve showed 90% sensitivity and 60%
specificity for heel pad thickness (p<0.001).
Conclusions: Ultrasonography is a sensitive and specific tool to identify patients with plantar fasciitis.

Objective To introduce the fixation of supercutaneous locking plate for the treatment of open metacarpal fractures, and to discuss the advantages and disadvantages of the locking plate external fixator, summarize the indications of the fixrator. Methods From March 2015 to December 2016, 16 cases of open metacarpal fractures were treated with supercutaneous locking plate after emergency debridement. The outcome was evaluated after functional rehabilitation postoperativly. Results The mean operation time was 46.8（35 to 108）minutes. All cases were followed up for an average of 9.8 (7 to 25) months. All fractures healed without breakage or looseing of the supercutaneous locking plate. The average fracture healing time was 6.2 weeks. Nail tract infection occurred in 3 cases (18.8%). According to the TAM evaluation criteria, excellent results were achieved in 5 and 11 cases, good results in 8 and 4 cases, fair results in 2 and 1 cases and poor results in 1and 0 case, and the overall satisfactory rate was 81.3% and 93.8% at the fourth weeks and twenty-fourth weeks postoperatively. Conclusions For open metacarpal fractures with severe pollution or soft tissue injury, the supercutaneous locking plate fixation can achieve better clinical results.

Background: Tibial defect more than 4 cm is a common clinical entity, particularly among population with sever acute trauma, infection sequalae, congenital pseudoarthrosis tibia and following tumor resection. Segmental bone transport by using Ilizarov external fixator become the treatment of choice. Aim of the work: The aim of this study was to evaluate the results of using Ilizarov fixator in treatment of tibial defect, its advantages and complications. Patients and Methods: Our prospective study was conducted involving 44 cases with tibial defects (from 4 to 15 cm) of different causes. All patents treated by segmental bone transport by using Ilizarov external fixator. All patients were operated at Zagazig University Hospitals. Results: 44 patients were followed up from March 2019 to December 2022. Infection was eradicated in all cases and union was achieved in all cases with no cases limb amputation. The infection was eradicated in all the infected cases without the need for prolonged antibiotics and without reactivation throughout the period of follow up. The union was achieved in all the cases.Conclusion: Distraction histogenesis is a good solution for the segmental tibial defects. The Ilizarov technique is complicated and requires a great deal of expertise to perform successfully. Ilizarov in bone defect reconstruction was less expensive, and easier to perform. Bone graft at the docking site may be needed to enhance the union and shortens the time in fixation.Keywords: bone transport, bone lengthening, ilizarov, distraction osteogenesis

Introduction: The coronavirus disease 2019 (COVID-19) pandemic was an unprecedented global phenomenon that greatly affected healthcare systems worldwide. Like many countries, Singapore’s healthcare system was placed under stress during this pandemic. The aim of this study was to determine if the COVID-19 pandemic influenced the duration from admission to surgery for patients admitted via the emergency department for thoracolumbar compression or burst fractures. Methods: All patients admitted via the emergency department with thoracolumbar vertebrae burst or compression fractures and underwent single stage instrumentation from August 2015 to August 2022 at our institution were included in this study. Polytrauma patients were excluded from this study. The COVID-19 period was defined as the months from February 2020 to August 2022. The variables of interest included age, gender, date of admission, date of surgery and time from admission to surgery. All significance tests were two-tailed, with p < 0.05 representing statistical significance. Data analysis was performed with Stata13. Results: There was no difference in monthly average emergency admissions for thoracolumbar burst or compression fractures when comparing the COVID-19 and pre COVID-19 periods. The median time from admission to surgery was not affected by the pandemic. However, there was a significant increase in the proportion of weekend surgeries being performed during the COVID-19 period. This is indicative of our centre’s capabilities to cater to emergency spinal surgeries despite the challenges posed by the pandemic. Our approach to the management of patients with spinal conditions during the pandemic was described in an earlier study.

Purpose: We aimed to document published cases of femoral head avascular necrosis (FHAVN) post-COVID-19, to report the COVID-19 disease characteristics and management , and to evaluate how the FHAVN were diagnosed and treated.
Methods: A systematic literature review was performed per the PRISMA guidelines through a comprehensive literature search on January 2023 through four databases (Embase, PubMed, Cochrane Library, and Scopus), including studies reporting on FHAVN post-COVID-19. Results: Fourteen articles were included, ten (71.4%) were case reports, and four (28.6%) case series reported on 104 patients having a mean age of 42.2±11.7 (14:74) years, in which 182 hip joints were affected. In 13 reports, corticosteroids were used during the COVID-19 management plan for a mean of 24.8±11 (7:42) days, with a mean prednisolone equivalent dose of 1238.5±492.8 (100:3520) mg. A mean of 142.1±107.6 (7:459) days passed between. Most hips (147, 80.8%) were treated non-surgically, of which 143 (78.6%) hips received medical treatment, while 35 (19.2%) hips were surgically managed, 16 (8.8%) core decompression, 13 (7.1%) primary THA, five (2.7%) staged THA and three (1.6%) had first stage THA (debridement and application of antibiotic-loaded cement spacer). The outcomes were acceptable as regards hip function and pain relief. Conclusion: Femoral head avascular necrosis post-COVID-19 infection is a real concern, mostly attributed to corticosteroid usage, besides other factors. Early suspicion and detection are mandatory, as conservative management lines are effective during early stages with acceptable outcomes. However, surgical intervention was required for progressive collapse or patients presented in the late stage.

Introduction: Scoliosis is complex and challenging for the anesthesiologist and the orthopedician secondary to mortality and morbidity. ERAS (Enhanced recovery after surgery ) is a step forward in alleviating the challenges ahead . We hypothesized that these patients would benefit
immensely from ERAS which aims at minimizing the surgical stress response. . Materials and Methods: Retrospective analysis of 150 patients who underwent scoliosis surgery were recruited from a single centre . The patient groups were divided into a ‘pre-ERAS’ category between July 2016 to December 2018 and a ‘post-ERAS’ category between January 2019 to March 2022. The outcome measures included length of hospital stay (LOS), postoperative complications, Intensive Care Unit (ICU) stay, post-operative mechanical ventilation and patient-reported outcome measures (visual analogue scale [VAS] and Oswestry Disability Index [ODI] score).
Results and discussion:A total of 150 patients were included—with 71 patients in the pre-ERAS group and 79 patients in the post-ERAS group. There was no significant difference in the two groups with respect to age, sex distribution, body mass index, comorbidities, distribution of diagnosis,
type of surgical approach, average number of levels fused, or estimated blood loss. Postoperative Complications, days to ambulation,ODI Scores in Pre ERAS (45% ) vs Post ERAS (31%) showed significant complication reduction.ICU admission, postoperative mechanical ventilation, and readmission rate were lower in the post ERAS group, but not significantly. Conclusion: ERAS protocol implementation is feasible in scoliosis surgeries and results in a reduction in
complication rates and better recovery.

ABSTRACT
Background. Patellofemoral osteoarthritis (PF OA) is a leading cause of significant pain and disability of knee joint. Stair climbing dysfunction is commonly reported in this cohort. Objectives. To compare the temporal muscle activation between females with PF OA and healthy controls during stair ascent and to decide whether there is a link between altered core activity and Patellofemoral osteoarthritis. Methods. An observational comparative study was conducted on 31 females with PF OA and 11 healthy ones. The electromyographic onset times of vasti, gluteus medius (GM), multifidus and transversus abdominus (TrA) muscles were measured during the initiation of stair ascending task. Results. A non-significant difference was detected between females with PF OA and controls regarding the onset times of all tested muscles except for the multifidus muscle which showed a significantly delayed activation in the PF OA group. Conclusion. Females with patellofemoral osteoarthritis showed a significantly delayed multifidus activation during ascending stairs which indicated the neuromotor dysfunction of core muscles compared to healthy controls. Core stability may be of clinical significance in the management of patients with patellofemoral osteoarthritis. Prospective longitudinal studies are recommended for prioritizing the dysfunction.