Introduction: Patients with osteoporotic fractures require long-term medical treatments to maintain skeletal integrity, reduce the risk of further bone loss and fracture recurrence. Some treatments have been stopped or delayed as a result of COVID-19 pandemic, thus efforts in reducing the osteoporotic care gap were significantly impacted. The objectives of this study are to determine the impact of COVID-19 pandemic on the management of fragility fractures in Hospital Canselor Tuanku Muhriz, Kuala Lumpur. Methods: This is a prospective study from January 2020 to 31 December 2021, Fracture Liaison Service (FLS) coordinators identified patients with fragility fractures presented to the hospital. Demographics data, surgical data and medication prescriptions were recorded. Results: A total of 385 patients (79% Female and 21% Male) were identified with mean age of 77.1 years old. Majority were Chinese ethnics (61%), followed by Malay (30%) and Indian (8%). Most common fractures were hip fracture (65%) followed by spine (13%), wrist & humerus (13 %) and others (9%). 43% patients were treated surgically and 57% on conservative management. 65% patients were treated with anti-osteoporotic medications and 87% patients were prescribed with calcium and vitamin D supplements. Conclusion: During the pandemic periods, even clinic cancellation rates were high, treatment for osteoporosis can be maintained at an acceptable level with the help of our FLS coordinators.

Introduction: Traditional bonesetting is widespread in low-and-middle income countries and provides musculoskeletal care in areas where there are limited orthopedic surgeons. There are, however, concerns about bonsetters’ training, regulation, and complications. This study assesses where bonesetters are practicing, and the orthopedic perspective on the general practices, benefits, and concerns about traditional bonesetters globally. Methods: A RedCap survey was distributed via email to the SIGN Fracture Care and ACTUAR databases. Data were analyzed using Stata. Results: Of 1,542 emails contacted , 339 (22%) completed the survey. Eighty-one percent had completed training in orthopedic surgery and were from Sub-Saharan Africa (48%) or Latin America & the Caribbean (25%). Of 52 countries represented, 42 (77%) reported having traditional bonesetters practicing in their country. Forty-eight percent reported that without practicing bonesetters, there would not be enough providers of musculoskeletal care. Although 61% of providers had patients referred to them by bonesetters, 97% of providers had never referred patients to bonesetters. The most commonly treated bonesetter complications were malalignment, nonunion and infection. Surgeons reported that patients sought bonesetter care due to lower cost, cultural beliefs and family influence. Fifty-six percent agreed that increased partnership between orthopedic surgeons and bonesetters would improve fracture care in their country. Conclusion: Traditional bonesetters practice globally with varying acceptance from the orthopedic community. Most of the orthopedic community is open to increased partnerships with bonesetters. Future studies should assess traditional bonesetters’ willingness to participate in partnership and what such a partnership should entail to optimize access and quality of care.

Introduction: Measuring the disease activity level and modulating the treatment of Rheumatoid arthritis on its basis has generated research curiosity off late. Micro RNAs specifically Mir-24 has been postulated to correlate with RA activity. Objectives: To determine plasma MiR-24 expression in patients with RA as compared to healthy volunteers and correlate its expression in RA patients with their disease activity score (DAS-28). Materials and Methods: A cross-sectional case control study with two groups (RA patients and healthy controls) was conducted in a tertiary care centre. 60 diagnosed cases of RA and 15 healthy volunteers were included post ethical clearances and consent. They were assessed clinically and DAS28 scores were calculated, subsequently blood samples were obtained and MiR 24 expression levels was tested by real-time PCR. Results: The mean DAS 28 scores in the patient group was 4.92 (+/- 1.38) and in the control group was 2.29 (+/- 0.44) which was significantly different (mean difference= 2.63 ,95% CI= 2.22- 3.04, p value <0.0001). MiR24 expression ( mean ∆CT values) in the patient group was 7.02(+/- 8.94) while in the control group was 1.63 (+/-2.44) and was significantly different (p value < 0.0001). The MiR24 expression correlated significantly with the clinical score (DAS 28) values in Pearson correlation test (p =0.003). Conclusion and Implications: MiR 24 is a potential candidate for biomarker in RA and its role in assessing disease activity and specially its correlation with clinical scores can help in portraying clinical activity in face of treatment administered.

Introduction: Vitamin D deficiency is very common in most part of the world including India which leads to defective bone mineralization and generalized or localized vague bone pain in different parts of the skeleton and/or proximal muscle weakness .This study was undertaken to find the prevalence of Vit D deficiency in outpatients with musculoskeletal pains.
Material and method: 145 out patients who presented with musculoskeletal pain were included in this study. Their 25(OH) Vit D was measured. Three months after vitamin D therapy had begun; measurements of all the parameters were repeated, along with clinical assessment of pain using VAS score.
Result: The presence of vitamin D <20ng /ml was 128/145(88.3%) with mean serum level of 12.05ng/ml and severe deficiency <10 ng/ml was 42/145(29%). The lowest mean 25(OH)Vit D, 11.86 ng/ml was seen in the age group 20-29 yrs. The pre and post therapy VAS difference was also highly significant (Paired t test,t=48.374 ,P=.000 or p<0.001) along with pre and post therapy Vit D level was also statistically significant (paired t test,p,0.0001), however there was no significant correlation between VAS and Vit D level(p>0.05 or p=.773,r = -0.024) and between Vit. D level with sex or age P>0.05(t test).
Conclusion: Assessment of serum 25(OH)D level in India should not be limited to patients with proven osteomalacia only but for nonspecific musculoskeletal pains also. Symptomatic improvement in pain found after Vit D supplementation proves it’s deficiency as a major cause of musculoskeletal pain syndromes.

Purpose: Evaluate the impact of the social isolation due to COVID-19 pandemic on incidence, epidemiological profile, and treatment of orthopaedic trauma in a reference trauma center.
Methods: Retrospective observational study, which analysed the medical records of patients who received medical care at the Emergency Department of the Hospital Universitário Evangélico Mackenzie between March 20th and May 20th, 2019 and in the same period in 2020. The data collected included the epidemiological profile of the patients, trauma mechanism, affected limbs, mode of arrival, type of treatment performed, time of hospital admission and discharge status.
Results: total of 733 medical records from 2019 and 664 from 2020 were analysed, representing a 9.4% reduction in the number of admissions. Falls were the main cause of trauma (43.9%) and the upper limbs were the most affected site (30.4%). In 2020, there was a decrease of 42,4% in the number of patients who arrived by ambulance, a reduction of 82.8% in the number of pedestrians being run over, fewer lower limb, knee and spine injuries, plus a 32.2% shorter hospital stay compared to 2019. On the other hand, the number of walk-in patients increased by 59%. Increased crush injuries (700%) and fall from another level (25.9%).
Conclusion: COVID-19 pandemic and social isolation brought changes to the care of orthopaedic trauma, such as reduction in the total number of patients, in the number of people run over, and shorter hospital stay. At the same time, the number of falls and accidents increased.

Background: Osteoporotic fractures of the hip are associated with high morbidity, mortality, and secondary fracture. Objective was to investigate how frequently do orthopaedic surgeons who treat primary fragility fractures of the hip undertake appropriate investigations (Blood parameters, DEXA) and treatment for the underlying cause of fragility fracture which is osteoporosis. Methods: All observational studies that mentioned hip fracture as an index fracture with any of the secondary fractures. Databases used were PubMed, Google Scholar, Cochrane Library and PRISMA guidelines was used. Analysis carried out with MedCalc. Five studies were excluded for duplication from 9937 studies. From those 191 articles were screened excluding 9746. 25 articles matched eligibility criteria but 11 excluded for different study design. Fourteen articles were then assessed. Results: The highest value of pooled proportion of 95% CI showed 34.8% of the patients the orthopaedic surgeons do not know what happened to these patients. 8.76% to as high as 36.5% of patients are not investigated nor are they treated for the cause of osteoporosis Only 5% and 2% patients are investigated with DEXA scan or with blood workup respectively. Patients of those are treated somehow, either empirically or investigated and treated are 3.7%, 10.4% respectively. Conclusion: We recommend surgeon education to increase awareness on how to investigate and treat osteoporosis after fragility fracture. Collaboration between orthopedic units, metabolic services, nuclear medicine units with a help of a coordinator can prove helpful.

Among 388 extra-articular femoral fracture pseudarthroses among adult patients treated with high-energy focused shock waves (ESWT) from 2002 -2019, bony healing occurred in 51% of cases. Proximal fractures healed better than diaphyseal and distal fractures.
The definition of pseudarthrosis resp. delayed or non-union was based on the E.S.T.R.O.T. definition.
Radiological findings, assessments by external traumatologists or symptom-free full weight-bearing capacity after implant removal were used as criteria for bony healing.
Lithotripters with focused shock waves and an energy flux density up to a maximum of 1.25 mJ/mm² were used e.g. STORZ Modulith SLK, or SIEMENS Modularis Variostar.
The outcome was not significantly influenced by concomitant polytrauma, serious risk factors, or the number of shock waves. Only a higher patient age and a longer course of pre-treatments had a negative effect on the healing rate.
Our results do not meet the ambitious expectations of the international scientific literature. In Germany, however, ESWT has become accepted as a therapeutic alternative to surgical revision. Its advantages are the outpatient character and a lack of need for anaesthesia, hardly any side effects and largely absence of complications.

Techniques for resecting distal femur and proximal tibia in mechanical and anatomical alignment techniques are standardized. Kinematic alignment is based on individual resection planes. Whether significant variation exists, to warrant departure from standardized resection planes, has not been shown thus far in a large cohort of knees and with a wide range of Osteoarthritic (OA) knees. The aim of this study was to determine whether CPAK classification can be reliably applied on Osteoarthritic knees in the Indian population using EOS imaging. 250 full-leg weight-bearing radiographs were analyzed using CPAK classification. CPAK comprises nine phenotypes based on the arithmetic HKA (hip-knee-ankle angle) that estimates constitutional limb alignment and joint line obliquity (JLO). Results: The most common category was Type I (46%) followed by Type IV (24%). CPAK Types VII, VIII, and IX were rare. Type I knees showed values medial intra-articular bone loss. Type IV knees showed values close to reported normal knees. 31% OA knees showed Extrarticular deformity in terms of either in femur or Tibia. CPAK classification was reliable in predicting OA phenotype (Cronbach alpha 0.8) with Intraclass coefficient (ICC) >0.9.Discussion: There is considerable variation in the OA phenotype in the coronal morphology of the femur and tibia. CPAK Type I was most common in the Indian population as compared to Type IV reported in the literature which could be attributed to late presentation along with severe deformity and severe tibial bowing. EOS imaging helped in 3D imaging as compared to standard 2D radiographs.

Introduction: Aim was to develop a mobile based software application to identify the
prevalence of co morbid risk factors among patients undergoing joint arthroplasty and
their impact on postponement of scheduled surgery and preoperatively optimizing them
using it as a tool.
Material and method:
Study was designed as a prospective study in Sri Jayawardenepura General Hospital from
1st October to 30th November 2020. A mobile based software was developed and it was
used in the patient assessment during pre-operative visits and in hospital stay in terms of
above co morbid risk factors and surgery postponement.
Results: Out of the 68 patients 54(79%) were females. Age ranged from 36 to 83 with a
mean of 62.4. Total knee arthroplasty (TKA) was the commonest procedure with 37 cases
(54%). 48 patients (70%) were diagnosed hypertensives and 47 patients (68%) diagnosed
diabetes mellitus. Pre-operatively 5 patients (7%) were found to have MRSA colonisation
and 15 patients (22%) had positive urine cultures. Pre op haemoglobin level was found
to be less than 10g/dl in 3 patients (4%). 13 patients (19%) were found to have FBS levels
above cut-offs in pre-operative visit. Main reasons for postponement (16 cases) were
uncontrolled blood pressure (25%) and repeated positive MRSA swab cultures (25%).
Discussion and Conclusions:
Pre-operative diagnosis, identification and management of common comorbidities at
clinic level was made easy by the developed mobile based software and it was useful to
minimize postponements of scheduled surgery to prevent wastage of theatre hours.

In our scenario we often encounter neglected Achilles tendon ruptures which are debilitating. There have been variety of technique to reconstruct ruptured Achilles tendon but following this procedure complications especially wound breakdown are not infrequent which might need plastic surgical procedures. We present here long term (>8 years) results of mini-invasive reconstruction of Achilles tendon rupture. Between June 2012 and December 2000, total 31 patients, 23 men and 8 women aged 48 to 62 (mean, 56) years underwent reconstruction of neglected ruptured Achilles tendon with either paroneus brevis (n=15 or flexor hallucis longus tendon(n=16). The mean interval from rupture to surgery was14 (range, 12–32) weeks. Pre- and post-operative American Orthopaedic Foot and Ankle Society (AOFAS) hind foot scores were compared. Wound healing, push-off, and patient satisfaction were also evaluated. Preoperative mean AOFAS scores were 66 (range, 60–78) and were improved to 90 (range, 80–94) postoperatively. All patients (28 patients, 3 patients lost to follow up) were able to stand on tiptoe and regained the spring in their step. Twenty-two patients had excellent and 6 had fair results. Three patients developed wound healing complications but only several dressing that all need to overcome problem. Twenty-three patients had satisfactory push-off and 5 had weak push-off but endured no restriction in the activities of daily living. There was no major complication or sural nerve injury or no rerupture till date. Mini invasive reconstruction is safe ,effective and satisfactory method for reconstruction of neglected Achilles tendon rupture .

Introduction: Twenty percent of patients report dissatisfaction following TKR, 45% of this group complain of Anterior Knee Pain (AKP). There is interest in studying the ‘Third Space’ or patellofemoral joint. Currently there is no method of characterising the patellofemoral loading occurring dynamically in the native knee or during knee replacement. We describe a novel apparatus to dynamically measure patella loading in the native and replaced knee, and the effect of varying patella resection.
Method: A sensory apparatus was attached to the patella undersurface recording pressures through flexion in the patellofemoral joint in the native cadaveric knee at superior, inferior, medial and lateral positions. The femur was then replaced as for a TKR and the measurements repeated. The effect of different levels and angles of patella resection were noted. Reliability and reproducibility was shown in an in vitro test rig and verified in three cadaveric studies.
Results: A clear, reproducible pattern of patellofemoral loading occurs in the native cadaveric knee. Following femoral replacement this was significantly changed in both pattern and magnitude (p<0.01). Changing the level and angle of patella resection altered patellofemoral loading (p< 0.05). In some cases, this replicated natural patellofemoral loading.
Summary: a characteristic pattern of patellofemoral loading is shown in the native knee which is significantly altered following TKR, implicating abnormal loading in AKP. Altering patella resection depth and angles allows loading in TKR to approach that of the native knee, offering the possibility of reducing AKP by more accurate balancing of the patellofemoral forces.