Introduction: The purpose of this study was to investigate whether there exist differences in the changes in ankle symptoms and ankle and hindfoot alignments, according to the severity of ankle osteoarthritis(OA) when the alignment of lower extremity is changed in a patient who undergoing Medial opening-wedge high tibial osteotomy(MOWHTO). Methods: The 130 patients who followed up for at least 4 years were reviewed. Patients were classified into 2 groups according to the severity of ankle OA (Group 1: Kellgren-Lawrence (K-L) grade 0–1 and group 2: K-L grade 2 or more). The radiographic parameters were included to evaluate the ankle and hindfoot alignment: tibial plafond inclination(TPI), talar tilt(TT), varus-valgus angle(VVA). The visual analogue scale(VAS) was evaluated for ankle pain. The clinical outcome of the knee was evaluated using the WOMAC score. Results: In group 2, the amount of changes in TPI, TT, VVA were significantly smaller than in group 1 (all p<0.05). Ankle pain VAS was more severe in group 2 pre- and postoperatively (all p<0.05). In both groups, knee WOMAC scores improved and there was no differences pre- and postoperatively (all p>0.05). The small VVA change (odds ratio:0.764) and preoperative severe OA grade of ankle joint (odds ratio:5.708) predicted increased ankle pain VAS following MOWHTO. Conclusion: Although the clinical outcome of knee joint was improved regardless of whether or not there is ankle OA, ankle pain was worsened in patients with ankle OA following MOWHTO. The inadequate compensatory change in hindfoot alignment affected increased ankle pain in these patients.

Introduction:
Based on several studies, certain measurements have been implemented that guide acute treatment strategy of polytrauma patients. The aim of this study was to investigate the predictive quality of measurements taken within 2h and 72h after admission of polytrauma patients using big data analysis.

Methods:
A retrospective cohort study of trauma patients treated at one level 1 trauma center was performed. lnclusion criteria were: polytrauma (ISS ≥16), primary admission and complete data set. Exclusion criteria were: end of life treatment based on DNR form. Complications included pneumonia, sepsis, multiple organ failure and mortality. The prediction model was calculated based on multiple regression analysis. Variables included in prediction model were calculated based on optimal predictive quality of data.

Results:
3586 patients were included. Mean age 45.5±20 years, mean ISS 28.2±15.1, incidence pneumonia 19.0%, sepsis 14.9%, death from hemorrhagic shock 4.1 %, death from multiple organ failure 1.9%, overall mortality rate 26.8%. The highest predictive value for complications within 2h include abbreviated injury scale (AIS), new injury severity score (NISS) and SIRS score. The highest predictive quality for complications within 72h include late lactate values, hematocrit, leukocytes, and CRP. Sensitivity and specificity of late prediction models using a 25% cutoff were 73.61% and 76.24%, respectively.

Conclusion:
The predictive quality of parameters strongly depends on the time point of measurement. The dynamics of pathophysiologic responses should be considered, especially during decision making of secondary definitive surgical interventions and treatment strategies.

Clubfoot is a congenital deformity of unknown etiology. Ponseti method is gold treatment choice which is challenging in resistant and neglected cases. Gradual correction with Ilizarov is another treatment option. Previous literature has reported its outcome mostly with limited soft tissue dissection with side effect of damaging and dislocation of mid foot joints because of over distraction. The current study reports small series of neglected clubfeet managed with Ilizarov using mid foot osteotomy approach. 10 patients (mean age±SD:20±3.8, 8M/2F) with 14 feet having neglected clubfeet deformities were treated with Ilizarov from January 2017 to October 2021. Ilizarov assembly was applied and mid foot osteotomy was done at the apex of deformity. Average frame time was 2.5 months with distraction rate of 2 mm per day. After removal of frame walking cast was given for 8 weeks followed by an ankle-foot orthosis for 20 hours/day for 6 months. Correction was assessed clinically according to Reinker and Carpenter scale with minimum follow-up of 6 months to up to 24 months. Plantigrade foot was achieved in all feet. Results were excellent in 3 feet; good in 6; fair in 4 & poor in 1. 10/ 14 had superficial pin tract infection. One patient that still had residual cavus after correction, mid foot closing wedge osteotomy was done after removal of assembly. Recurrence of the deformity was observed in left foot of one patient during follow-up. Ilizarov with mid foot osteotomy allows to achieve very good results with minimum risk of relapse and complications

Purpose: Carpal tunnel syndrome (CTS) is a common peripheral nerve entrapment disorder.
The American Academy of Orthopedic Surgeons developed an appropriate use criteria (AUC) for the management of CTS. This study aimed to assess the appropriateness of our practice and the usability of the AUC through comparing the actual management provided at our institution with AUC recommendation.

Methods: A retrospective review of the electronic medical records was performed between Jan. 2016 and Dec. 2019. The collected data were input into the AUC application to determine the rate of the appropriateness of the treatments. Afterwards, the agreement between the actual treatment provided and the AUC recommendation was assessed. The primary outcome was the appropriateness rate. Descriptive statistics such as the mean, range and percentage were used for analysis.
Results: There were 127 patients with a mean age of 50 years. Most of the included patients were females(78%). Obesity was the most frequent risk factor (64.5%) and bilateral wrist involvement was the most common presentation (58%). The overall appropriateness rate and agreement with the AUC recommendations among all interventions was (84%). A sub-analysis of carpal tunnel surgical release across different surgical specialities showed appropriateness rates of 88%, 89%, 54% in orthopaedics , neurosurgery and plastic surgery teams, respectively (P 0.000613).
Conclusion: This study demonstrated that most of the treatments provided at our institution were appropriate and in agreement with the AUC recommendations. Additionally, the AUC for carpal tunnel syndrome is a valuable and practical tool that can be applied in clinical settings.

Introduction
Studies have reported favorable outcomes using the paratricipital approach for fixation of distal humeral intra-articular fractures. However, literature evaluating the clinical results of the approach remains limited. The objective of this study is to compare clinical outcomes after open reduction and internal fixation of type 13C2 distal humeral fractures with outcomes after repair of type 13C1 fractures using the same approach and type of plate.
Methods
We retrospectively analyzed data from 29 of these patients (19 with type 13C1 fractures and 10 with 13C2 fractures) who met the inclusion criteria. All subjects were followed for a minimum of 2 years postoperatively. Clinical and radiologic results were analyzed to determine differences in outcomes between the two types of fractures.
Results
The patients’ mean age was 51 years, and the mean duration of follow-up was 29 months. Mean ROM was 129.5±21.5° in type 13C1 group and 123.0±20.6° in 13C2 group(p=0.20). Mean q-DASH score was 12.6±11.7 in 13C1 group and 16.2±19.8 in 13C2 group(p=1.00). Mean MEPS was 92.9±8.5 in 13C1 group and 85.0±14.1 in 13C2 group(p=0.09). Carrying angle did not differ significantly between the 13C1 and 13C2 groups. No patient in either group exhibited nonunion, or post-traumatic arthritis.
Conclusion
Although the paratricipital approach has the disadvantage of limited visualization of articular surfaces, there were no differences in surgical outcomes between type 13C1 and type 13C2 distal humeral fractures using this approach. Thus, surgeons may consider using the paratricipital approach for open reduction and internal fixation of 13C2 distal humeral fractures.

Background: Distal forearm fractures are the most common paediatric fractures. The aim of our study was to investigate the effectiveness of below elbow cast (BEC) treatment for displaced distal forearm fractures in children compared with above elbow cast (AEC) through meta-analysis of randomized controlled trials.Methods: We searched several databases from 2000 to October 2021 for randomized controlled trials that evaluated BEC versus AEC treatment of displaced distal forearm fractures in children. We based the main meta-analysis comparison on the relative risk (RR) of loss of fracture reduction between children undergoing BEC versus AEC treatment. We also investigated other outcome measures including re-manipulation and cast-related complications. Results: Nine studies were eligible with a total of 1049 children. The relative risk of loss of fracture reduction between BEC and AEC groups was in favour of BEC but not statistically significant (RR=0.74,95% CI:0.49,1.13). Re-manipulation (RR=0.66,95% CI:0.36,1.22) and cast-related complications (RR=0.59,95% CI:0.16,2.22) did not reach statistical significance. Loss of fracture reduction was reported in 21.5% of children treated with BEC and 28.9% in AEC. Re-manipulation was attempted in 48.1% versus 53.8% of children who lost fracture reduction in the BEC and AEC groups respectively. Conclusions: Although BEC treatment was favoured in terms of loss of fracture reduction and re-manipulation, this did not reach statistical significance and was not associated with an increased risk of cast-related complications. The cumulative evidence at present does not support AEC treatment and BEC treatment should be the mainstay for displaced distal forearm fractures in children.

Introduction: Phaeohyphomycosis is a rare form of sporadic infection caused by dematiaceous fungi commonly detected in the tropics and sub-tropics. Infections follow invasive trauma in immunocompromised patients and vary from subcutaneous infections to fungal septicaemia. Case presentation: A 60 year old lady presented with pain and swelling of right ring finger since four months. Physical examination showed a firm, tender, subcutaneous swelling of size 2 x 3 cm, not fixed to underlying structures. X-ray revealed osteopenia of 4th metacarpal, thickening, sclerosis and periosteal reaction of proximal phalanx with arthritic changes. Her magnetic resonance imaging showed fluid collection around flexor digitorum superficialis and flexor digitorum profundus suggestive of tenosynovitis and osteomyelitis of 4th metacarpal. She underwent incision and drainage, wound debridement and curettage. Copious necrotic debris was let out. Bacterial cultures were negative. Biopsy showed many granulomas with fungal hyphae in fibrocollagenous tissue with minimal inflammatory tissue and areas of caseous necrosis. Culture for acid fast bacilli and staining was negative. Fungal culture on saboraud’s dextrose agar grew Phaeoacremonium parasiticum. She was treated with oral Itraconazole following which she regained good hand function, was pain free, however, had a few degrees of fixed flexion deformity for which she was not keen on surgical correction. Conclusion: Phaeoacremonium parasiticum is a recently discovered species of phaeoid fungi. It causes subcutaneous infection of extremities in susceptible hosts but osteoarticular involvement is very rare. Surgical excision with oral Itraconazole is the standard treatment protocol for these infections.

Purpose: This scoping review seeks to characterize our current understanding of the prevalence of both pediatric and adult lower limb deformities from congenital, traumatic, infectious and nutritional etiologies in low-income countries. It also aims to calculate what this burden represents in terms of impact on quality of life in low-income nations as quantified through calculations of Disability-Adjusted-Life-Years (DALYs). Methods: A scoping review is currently underway. PubMed, Embase, and Web of Science were all searched via relevant search terms and MeSH subject headings capturing the epidemiology of congenital, traumatic, infectious, and nutritionally-acquired musculoskeletal deformities in low-income countries as approached through the lens of socioeconomic impact analyses. A total of 3,291 articles are currently undergoing title/abstract screening after duplicate search results were removed. The articles that meet set inclusion criteria during this first phase of review will progress to full text screening. The data extracted from the articles selected for inclusion during the full-text review will be categorized by country and etiology of lower limb deformity. Prevalence data from the literature will be used to extrapolate and estimate the burden of lower-extremity deformities in terms of DALYs. Results: Results will include qualitative data reviewing existing studies of the epidemiology of lower-extremity deformities in low-income countries. Results will also involve quantitative calculations of how such deformities impact quality of life and the socioeconomic burdens on low-income countries in terms of DALYs.

Introduction:Osteochondromas are most common benign bone tumours. They probably are developmental malformations rather than true neoplasms and are thought to originate within the periosteum as small cartilaginous nodules.The lesions consist of a bony mass produced by progressive endochondral ossification of a growing cartilaginous cap. Osteochondromas usually are found on the metaphysis of a long bone near the physis like distal femur, proximal tibia, and proximal humerus.However intra-articular osteochondromas also occur.surgical treatment for femur neck osteochondroma is difficult due to the high risk of avascular necrosis (AVN) following excision .These lesions in femur are in close proximity to important neurovascular bundle and can cause symptoms related to their compression . Also the symptoms related to labral tear and hip impingement are common.Recurrence is rare and probably is caused by failure to remove the entire cartilaginous cap.
Case report:A 25 year old female presented with complaints of pain in the right hip and difficulty in walking and running since 1 year. On radiological examination Right femur neck osteochondroma was diagnosed ,it was located along the posteroinferior margin of the femur neck. CT scan and MRI was done for diagnosis.Patient operated in lateral decubitus position using posterolateral approach to hip without dislocation of the femur, gluteus maximum was split and external rotators identified. Tumour was just beneath the rotators of hip. Which was then traced to origin and excised with osteotome.Conclusion : osteochondroma at femur neck can be safely removed without surgical hip dislocation.It’s necessary to remove it completely to avoid recurrence .

A 44 year old male presented with a painful swelling over the lateral aspect of his left knee associated with paraesthesia and weakness of ankle dorsiflexion and great toe extension over a duration of 2 years. The swelling had increased in size gradually over the preceding year, with pain exacerbated on exertion and deep flexion. On examination there was a positive Tinnel's sign over the common peroneal nerve and associated reduced sensation over the superficial peroneal nerve distribution and an MRC grade 3 over the Tibialis Anterior and EHL.
An MRI of the knee demonstrated a large (3x4cm) lobulated extra-neural ganglion cyst arising from the proximal tibio-fibular articulation, engulfing and compressing the common peroneal nerve. Nerve conduction studies showed evidence of severe axonal proximal neuropathy of the left common peroneal nerve, with normal neurography of the left tibial nerve.
The patient underwent a radical resection of the lesion neurolysis of the common peroneal nerve.

Histology confirmed a fibrous walled cystic structure with mucoid degeneration, consistent with a ganglion cyst.

The patient had an uneventful recovery and at one month follow-up the patient reported an improved sensation at the lateral aspect of the left leg and the 1st digital web space, and Motor function MRC 4+/5 for both ankle dorsiflexion and great toe extension.
 
Our case highlights the rare complication of common peroneal nerve palsy associated with ganglion cysts arising from around the knee joint.

Introduction:Our aim was to analyse the functional outcome of various methods of management of combined bone and soft tissue loss in femur and tibia in open injuries.Methods:We included 119 patients with 122 open fractures of femur and tibia. It was a retrospective and prospective observational study. All the patient who received in the emergency room were evaluated and debrided by the orthoplastic team as soon as possible.Once debrided, bone,skin,and musculotendinous units were evaluated using GHOISS. On follow up we looked at fracture union, functional outcome and complications.We correlated the factors affecting the outcome variables such as the total number of admissions, length of hospital stay, the total number of procedures,and union time. Functionally assessed using LEFS and ASAMI.Results: The mean GHOIS bone score of our study was 3.11, skin score was 4.04, musculotendinous score was 1.97 and the mean total GHOISS was 10.78. The mean union time was 51.6 weeks, mean time to soft tissue coverage was 6.21 days. The average LEFS score is 61.39. Only 6 fractures went on to nonunion (4.9%). Superficial SSI was noted in 49 patients requiring antibiotics and 28 patients developed deep infection which required either a debridement or implant removal . Of flap complications, there were 9 partial failures (7.37%) and 3 (2.45%) were total failures.Conclusion:Total GHOISS correlates with hospital stay, number of surgeries, number of admissions, and union time. There is a significant correlation between the BMI of the patient and the infection rate. GHOISS has prognostic value in addition to decision making.