Introduction: To determine the mid-term outcomes of conventional cementless Total Hip Arthroplasty (THA) in patients with avascular necrosis (AVN) of the femoral head and compare to patients with primary hip osteoarthritis (OA). Method: A total of 330 consecutive primary THA procedures (AVN and OA) performed between 2010-2013 by a single surgeon and in a single center using the direct anterior approach (DAA) were included. Assessments including SF-26, WOMAC, and Harris Hip Scores (HHS) were retrieved from patients before the surgery and at the latest follow-up. Clinical and functional outcomes were compared between the AVN and OA groups. Results: A total of 294 consecutive THA (AVN=107, OA=187) with 104.4 ± 6.2 months follow-up were analyzed, which AVN patients were significantly younger (32.0 vs. 59.6 y/o). Corticosteroid 34 (31.8%), idiopathic AVN 31 (29.0%), and use of unapproved weight gain supplements (UWGS) 23 (21.5%) were the main reasons for AVN. Despite that preoperative scores were comparable (P>0.05), the HHS, SF-36, and WOMAC scores are significantly higher in the AVN group after THA surgery (P<0.05). Moreover, flexion and abduction ROM were significantly higher in the AVN group (P<0.05). Regarding each complication, no significant difference was observed between groups. In the whole sample, there were 5 (1.7%) revisions due to loosening of acetabular components, all in OA the group (P>0.05). Conclusion: Conventional cementless THA with highly cross-linked polyethylene provides satisfactory mid-term results in patients with AVN with a low rate of postoperative complications. Compared to primary OA patients, this group reaches superior postoperative scores.

Purpose: The purpose of this retrospective study is to compare the clinical and radiologic outcomes between tension band wiring and our novel suture anchor technique in patellar inferior pole fracture.
Methods: This retrospective study included patients who underwent tension band wiring or suture anchor fixation for patella inferior pole fracture and who had a minimum postoperative clinical follow-up of two years from 2015 to 2019. A total of 63 patients were divided into two groups according to the surgical procedure: the tension band wiring (TBW) group (n=35) and the suture anchor fixation (SA) group (n=28). Clinical outcomes comprised visual analogue scale (VAS) score, range of motion (ROM) of the knee, Lysholm score, Kujala patellofemoral score, and patient satisfaction score were used. Radiologic outcomes comprised time to radiological union, nonunion, loss of reduction, and Insall-Salvati (IS) ratio.
Results: Significant improvements in clinical outcomes were observed in both groups and there was no significant difference between the two groups. Bone union was achieved in all patients and there was no significant difference in time to radiological union and IS ratio between the two groups. All patients in the TWB group underwent removal of the implant. Among them, 12 patients (34.3%) request the removal of the implant due to skin irritation. However, no patient underwent removal of implant or skin irritation in the SA group.
Conclusion: Our novel suture anchor technique could provide comparable fixation strength and good clinical outcome with less complication in patellar inferior pole fracture.

Introduction: Despite the standardization of two-stage knee revision protocols, a high percentage of failures still occurs. Identifying predictors of failure is necessary to determine appropriate management and counsel for patients with a periprosthetic knee infection. This study aimed to identify risk factors predicting the failure, to describe implant survival, and to report the mid-term clinical outcomes of patients undergoing two-stage revision for periprosthetic knee infection. Methods: Data of patients who underwent two-stage knee revision from 2012 to 2016 were analyzed, and 108 patients were included. The mean follow-up was 52.9 ± 15.6 months. Logistic regression was conducted to identify predictors of treatment failure. Kaplan-Meier curves were generated to assess implant survival. Preoperative outcomes were compared to those registered at the final follow-up. Results: Difficult-to-treat infections (OR = 4.2, 95% CI 1.2-14.5, p = 0.025), the number of previous surgeries (OR = 1.8, 95% CI 1.2-2.6, p = 0.005), and the level of tibial bone defect (OR = 2.3, 95% CI 1.1-4.7, p = 0.027) significantly predicted the failure of two-stage knee revision. Survivorship of implants was significantly lower for patients presenting these risk factors (p < 0.05). Mean Knee Society Score and Oxford Knee Score improved from 49.0 ± 12.0 to 80.2 ± 13.6. and from 22.2 ± 4.9 to 36.1 ± 6.0 points, respectively. Conclusion: Difficult-to-treat pathogens, number of previous surgeries, and the level of tibial bone defect were independent risk factors of two-stage knee revision failure. Overall, the two-stage protocol provided a good survival rate and functional outcome.

Objective: Intramedullary nail has been considered the “gold standard” for femur diaphysis fracture fixation. (1) However, even at this era, plate and screw for femur shaft fixation is still common in many centers. We studied plating and intramedullary nailing (IMN) femur in a tertiary center, Hospital Sultan Ismail, Johor Bahru in 2018. Method: Retrospective study based on operation database of Jan to Dec 2018, 68 fixations done for isolated femur diaphysis fracture. 14 cases lost to follow up. Femur diaphysis is defined as the segment between 5 cm distal to lesser trochanter and 6 cm above knee joint line. Results: Among 54 patients, 41 patients were male (mean age: 24 yo). 4 cases were open fracture, all Gustilo type 1. 28 patients were treated with IMN (3 retrograde femoral nail, 25 antegrade interlocking nail). All remaining 26 patients treated with broad dynamic compression plate and bone screws. Discussion: Plating group averagely takes 3 weeks shorter to get union. There is shorter waiting time for operation, shorter operation time, too. Theoretically, IMN has been proven superior biomechanically, but not reflected in our setting. This could probably be explained by long waiting time of averagely 3 weeks which lead to longer operation time. Many IMN cases required open reduction which compromised fracture healing. Long waiting time is caused by volume of case load, lack of facility eg availability of traction table, image intensifier, OT hours. Conclusion: Plating still has a major role in femur diaphysis fracture fixation, especially in the developing country.

Introduction: We aim to analyze the role of patient-related factors on the yield of progenitor cells in the bone marrow aspiration concentrate (BMAC). Materials & Methods: We performed a retrospective analysis of patients who underwent autologous iliac crest-based BMAC therapy between Jan 2021–and June 2021. Patient-related factors such as age, sex, and comorbidities and procedure variables such as aspirate volume were analyzed. The yield of the bone marrow aspiration concentrate was assessed with MNC count and CFU assay from the aspirates. Results: 63 patients with a mean age of 51.33±17.98 years were included in the study. There were 31 males and 32 females in the study population with a mean volume of 67.16±17.312 ml being aspirated from the iliac crest for the preparation of BMAC. The final aspirate had a mean MNC count of 20.16±15.73x10^6 cells which yielded a mean of 11±12 CFUs. We noted significant negative correlation between age and MNC count (r=-0.671, p<0.001) and CFUs (r=-0.688, p<0.001). We did not find the sex to have any significant role in MNC (p=0.082) count or CFUs formed (p=0.348). The presence of comorbidity significantly reduced the MNC count (p=0.003) and CFUs formed (p=0.005). The aspiration volume significantly negatively correlated with MNC count (r=-0.731, p<0.001) and CFUs (r=-0.618, p<0.001). Conclusion: The MNC count and CFUs formed from the BMAC depend on the patient-specific subjective variables such as age, and comorbid conditions present in them. Sex and volume of aspiration do not alter the MNC count or the CFUs formed from BMAC.

Aim/background: Pain and physical limitations are often a part of the lives of children with lower limb deformities. The ideal way to assess the impact of these deformities on a child’s quality of life, is by using a Patient Reported Outcome Measure (PROM). Such a disease-specific PROM is currently under development, called LIMB-Q Kids. The aim of this study was to perform a Danish translation and cultural adapt (TCA) of LIMB-Q Kids.
Material and Method: To undertake a TCA of LIMB-Q Kids, the guidelines from World Health Organization and the Professional Society for Health Economics and Outcomes Research were applied. This process can be divided into: Two independent forward translations, a reconciliation meeting, a backward translation, assessment of the backward translation, an expert meeting, cognitive interviews and proof reading. As it is an advanced translation, results from this translation process will influence the development of the original LIMB-Q Kids.
Results: The different steps of the TCA process contributed to the Danish version of LIMB-Q Kids. The reconciliation meeting resulted in a Danish version, with no major discrepancies between the two forward translations. The revision of the backward translation compared with the original version resulted in 12 corrections and the expert meeting resulted in 26 changes.
Discussion/Conclusion: The rigorous advanced translation process has led to a linguistically validated and cultural adapted Danish version of LIMB-Q Kids. Next step is international field-testing and using this data to look at the psychometric properties of LIMB-Q Kids.

Background: Acetabular Inclination and version are dependent on each other and influential. Effective lower limb version (ELLV) is the appropriate dynamic version of the femoral stem in relation to the long axis of tibia. The coaxial stitch technique used to correct and avoid any sort of Limb length discrepancy (LLD). Achieving appropriate combined version (CV) with no LLD is the key factor while performing 3D balancing of Total Hip Arthroplasty (THA).
Methods: prospective study including 30 patients using Mobile application along with coaxial stitch technique between February and April 2022. The primary results analyzed clinically and radiologically parameters, clinical outcome (Harris Hip Score). Secondary results included complications like LLD, infection, dislocation.

Results: The original socket was placed with appropriate inclination angle as of the trial component checked using mobile application. The post operative socket version using ischiolateral view method conformed the same finding. The average socket inclination angle was planned between 31* to 35* and version of 10* to 15*. The combined version was to be placed between 30*to 45* using mobile app. HHS improved with significant statistical significance (P< 0.001). There was significant improvement in terms of VAS preoprative and postoperative with no limb length discrepancy.
Conclusion: This study underlines the fact that even young surgeons with less experience can improve their cup placement in terms of inclination and version. 3D balancing of the hip with no LLD using angle inclinometer mobile application is an easy and cost effective method in developing nations.

Surgical treatment of the chronic stage (Eichenholtz stage3) of the Charcot neuroarthropathy of ankle is extremely challenging, especially for those with disappearing talus (Dounis type III). In the present study, we present a new surgical technique to treat this difficult condition. The surgery involved a small anterolateral incision centered lateral malleolus, distal fibular osteotomy to mobilize the distal fibular as vascularized bone graft for reconstruction of the talus bone defect. The same incision was used for tibia-talus and sub-talus joint preparation by removing of cartilage till bleeding bone. A small medial incision over talus-navicular was also made for joint preparation and fixation. A pre-assembled Styker LRF circular external fixator was then applied across the ankle joint. Gross deformity was corrected by traction via unlocked telescopic struts. The fine tone correction was achieved by push/pull technique using additional pin or turning locked struts. Once deformity correction was satisfied. a guide pin was then inserted through calcaneus, talus and the distal tibia to hold the position. The TTC nail was then inserted as usual. The circular external fixator was removed after medullary canal preparation. Additional screw may be added to secure the fixation of the distal fibular to the distal tibia or talus. Our technique combines the advantage of ring fixator deformity correction without extensive dissection and adequate compression plus secure fixation of TTC nail for ankle and hind foot fusion for Charcot ankle. It is safe and effective with minimal bony work and soft tissue release, which leads to less complications.

Introduction :- ACDF has been considered as gold standard for symptomatic cervical disc degeneration, cervical myelopathy, cervical vertebra fracture and prolapsed intervertebral disc. It is effective at achieving immediate stability, restoring the normal lordotic curve, and increasing fusion rates. It is safer as compared to posterior approach in cervical region. ACDF is usually done, by placing the distractor pins in central position, following which another hole is made for plate insertion in para central position. This study shows the surgical and functional outcomes of using a new novel technique, by placing the distractor pin in Para-Central position while doing ACDF surgery. Paracentral pin placement has not been described in literature previously. Materials and Methods :- Studied 25 consecutive Anterior Cervical Discectomy and Fusion (ACDF) cases. Pathologies like cervical radiculopathy and cervical myelopathy needing anterior approach were included. Cases of traumatic spine and infective spine were excluded. Patients were evaluated in parameters like- operative time, blood loss during surgery, postoperative dysphagia and Oswestry Disability Index score. Results :- 25 cases were operated with this technique. Blood loss and surgical time was less as compared to the cases done with central pin placement. Oswestry Disability Index(ODI) showed comparable improvement in patients done by para-central pin placement. Conclusion :- The use of Paracentral Pin insertion in ACDF surgeries is found to be an effective technique in terms of reduction of medial retraction thus reducing post-operative dysphagia . The functional outcomes operated by this technique is comparable to the one by standard technique.

Introduction: Gorham-Stout disease (GSD) is a rare, idiopathic disease of unknown etiology characterized by massive osteolysis with replacement of lymphatic vessels of one or multiple bones. To date, there is no established treatment or diagnosis strategy for GSD and prognosis is frequently poor, leading to functional impairment, neurological problems and visceral involvement. Aims of this study were to propose a diagnostic algorithm to simplify diagnosis based on clinical and radiological findings and a treatment strategy to prevent further lysis. Methods: We analyzed all 352 reported cases of GSD in literature from 1955 up to date focusing on epidemiology, complications, treatment strategies and outcome. Of the 352 patients analyzed 80 (23%) were children under the age of 10. Treatments include anti-resorptive agents, radiotherapy, angiogenesis inhibitors, mild chemotherapy, beta blockers and many others, often associated to reconstructive surgery. Results: We found 136 cases of major visceral complications, more than half of which in children. Most frequent complications were chilothorax, cerebro-spinal fluid leakage and skin malformations. In childhood and adolescence, all 20 patients with fatal outcome had developed chilothorax. We realized a diagnostic algorithm based on clinical findings, first and second line radiological exams and our multi-targeted therapy to prevent further osteolysis and to stop lymphangiogenesis. Conclusions: GSD is a rare disease and diagnosis is usually challenging and late. Surgery plays a key-role but must be accompanied by adequate medical therapy. Outcome has improved over time but is still poor and burdened with severe sequelae in many cases.

Background: Traumatic distal tibia fractures often occur in younger, high demand patients, though the literature surrounding management remains contentious. This study sought to quantitatively determine differences in kneeling ability and self-reported knee functional deficits in patients managed with either intramedullary nailing (IMN) or open reduction internal fixation (ORIF) with compression plating following uncomplicated distal tibia fracture. Methods: Retrospective sampling of public hospital data with outpatient prospective functional testing were completed. The primary outcome was the Kneeling Test (KT). Secondary outcomes were The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Forgotten Joint Score (FJS) for the knee joint. Results: There were 28 patients recruited (18 IMN and 10 ORIF, mean age 44 years). Mean overall follow-up was 13.3 months (range 8-25, SD 3.6). The IMN affected limb had significantly worse overall kneeling function than their non-affected limb (mean KT: 70.4 vs 94.9 respectively, p<0.005). While no significant differences (p>0.05) in kneeling function existed for the ORIF group when comparing affected and non-affected limbs, the IMN group were worse compared to the ORIF group (mean KT 70.4 vs 92.5 respectively, p<0.005). Secondary outcomes showed worse overall WOMAC and FJS in the IMN compared to ORIF groups (mean WOMAC 19.3 vs 6.9 respectively, p=0.040; mean FJS 38.3 vs 75.9 respectively, p=0.005). Conclusion: In younger, active patients, locked compression plating should be considered to preserve their kneeling ability and diminish chronic anterior knee pain. For those undergoing intramedullary nailing, information should be provided on the reduction in kneeling tolerance.

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.

We report a case of ulnar nerve entrapment in a national bowling athlete. He presented with 4 months history of right medial elbow pain radiating to ring and little finger, associated with numbness of the aforesaid fingers. Symptoms occur especially at the end of his bowl in full elbow flexion and eventually with repetitive bowl, pain became constant and affecting his game. Prior to referring to our hand and microsurgery unit, he underwent aggressive physiotherapy by sports medicine team to which his symptoms did not improve. On examination there is no weakness or numbness due to his ulnar nerve compression. However Tinel's sign was positive and tenderness present over the cubital tunnel. He has upcoming major tournament soon hence opted for surgery. We decided to perform the surgery under wide awake local anaesthesia no tourniquet (WALANT) so that we could immediately assess his symptoms intra-operatively and avoid having ulnar nerve subluxation by enabling active range of motion of the elbow. Symptoms resolved immediately post operative and he was able to imitate his bowling motion and eventually restore his throwing and swing function. Cubital tunnel syndrome has not been reported in bowling athlete previously, however early diagnosis and treatment could enable them to return to play accordingly without morbidities. Surgery under WALANT enables the surgeon to identify the exact site of compression and targeted release can minimise the incidence of ulnar nerve subluxation post surgery.

Introduction: The bone defects that arise often have a severe negative long-term impact on patients’ lives and present complex treatment challenges. Thus, the management of non-union is a challenging problem and it becomes a terrible situation if accompanied by gap non-union or contaminated milieu. An experimental bony wound used to assess repair should be large enough to preclude spontaneous healing. An experimental bony wound of this nature may be termed a critical size defect (CSD). The use of culture-expanded osteoprogenitor cells grown on porous bioceramic scaffolds can result in substantial improvement in our ability to repair large defects in long bones. Materials & Methods: Twelve adult rabbits were selected for the study. Two cm. piece of bone isolated from mid-one-third of the left ulna. Osteoblasts were isolated and grown in alpha modified eagle medium (MEM). Cells were seeded onto a gelatine-hydroxyapatite scaffold and allowed to grow for 21 days. Cultured autologous osteoblast over 3D scaffold was inserted to the same defect while right ulna served as control. Follow-up was done at 4, 8, and 12 weeks by gross, X-ray, and histological examination. Results: The reunion was found in 05 rabbits, synostosis in 02 rabbits, and persistence of fracture gap in 01 rabbit, while no bonding between bone and scaffold in 02 rabbits. Two rabbits died in 1st postoperative week. Conclusions: The study demonstrates new bone formation can be elicited in critical‐sized defects in the long bone of Rabbit by implantation of autologous osteoblast impregnated in a 3D scaffold.