Background
Management of mid-shaft clavicle fractures is a great controversy and there is growing interest for open reduction and internal fixation (ORIF), even in the absence of absolute indications; claiming it yields better results.
Aim to compare union rates, functional results, complication rates and patient satisfaction after management of clavicle fractures either operative or non-operative.
Patients and Methods
Between January 2021 and June 2021; an RCT on 30 patients with mid-shaft clavicle fractures was conducted. Fifteen were managed non-operatively and the other 15 patients received ORIF. All patients were followed up for a mean of one year. We included all patients with a mid-shaft clavicle fracture after skeletal maturity. Patients with absolute indications for ORIF, pathological fractures, associated fractures were all excluded from the study. All patients were assessed for complete union using X-rays, clinically for range of motion (ROM) and using functional scores, namely Constant-Murley, DASH and VAS pain scores.

Results
There was a statistically significant difference between both groups regarding union rates and return to work; favoring the ORIF group, (P value 0.005). No statistically significant difference was found regarding the functional scores; quick DASH, Constant and VAS pain scores. Regarding complications, no significant difference was seen between both groups, although minor differences existed.
Conclusion
ORIF offers better union rates and early return of function as compared to non-operative treatment. Although it is associated with skin and wound complications and hardware irritation, this is not significant to make it an inferior treatment option compared to non-operative treatment

The aim of the study was to perform second look evaluation with in-office needle arthroscopy (Nanoscope) in a group of patients who underwent ACL repair and to correlato with MRI findings.
The hypothesis was that healing of a repaired ACL could be reliably assessed with MRI and Nanoscope.

Methods: 15 patients underwent a second look in-office needle arthroscopy. Healing of the repaired ACL was evaluated considering the macroscopical appearance of the femoral insertion and was classified in 4 grades. The second look appearance of the ACL was compared with magnetic resonance imaging (MRI) signal intensity to evaluate graft maturity according to Howell scale in 4 grades. The side-to-side laxity assessed with KT-1000 were recorded.

Results: 15 patients were included in the study. There were 11 males and 4 females. The mean age was 33.1 years The mean follow-up time was 7.2 months (range 6-10 months). The mean side to side laxity was 2.3 ± 3.4 mm. The healing was graded as A for 10 patients, B for 4 patients and D for one. Howell grade I, indicative of better graft maturity, was assessed in 10 patients, 2 patients had grade II, 2 patients grade III, and one grade IV. There was a correlation between Grade of Healing and Howell Grade (Spearman correlation=.847, P<.001).

Conclusions: The use of an in-office needle arthroscopy can allow an easy and direct visualization of the repaired ACL and it can also allow a biomechanical evaluation of the ligament with probe.

It is not uncommon for a severe traumatic brachial plexus injury to involve all 5 roots, resulting in a flail upper limb. The transfer of the contralateral C-7 (cC-7) is commonly used in an attempt to restore basic hand function, but results are notoriously unreliable and inconsistent. Wang's technique involves a cC-7 transfer via a prespinal route, extensive mobilization of the ipsilateral lower trunk by sacrificing branches, adducting the arm, and (if necessary) shortening the humerus to accomplish direct coaptation.
The authors report their observations in 22 patients. Direct cC-7 repair via the prespinal route was performed in 12 patients. Shortening of the humerus was necessary in 9 of 12 patients. In 10 patients, a direct repair was not feasible and nerve grafting was performed. The median follow-up was 26 months for the direct coaptation group and 28.5 months for the nerve graft group.
In the direct repair group, 10 of the 12 patients regained Medical Research Council Grade 3 wrist and finger flexion, while the remaining 2 patients had Grade 2 function. Flexion appeared 12–14 months postoperative. In contrast, nerve graft group resulted in Grade 3 strength in only 2 of 10 patients, while 7 had Grade 2 strength, and 1 experienced failure.
In this small series, the authors demonstrated a distinct advantage associated with the avoidance of grafts when trans- ferring the cC-7. The authors conclude that efforts to achieve direct approximation of the donor C-7 and the recipient lower trunk are necessary and justified.

Introduction: The study objective includes analyzing the predictors for ICU (intensive care unit ) admission of patients
operated on for pediatric spine deformity. Secondly, to investigate the risk factors associated with
ICU stay for posterior spinal fusion using univariate and multivariate analysis.
Methods: A single institutional, retrospective data of 81 patients were included who underwent posterior spinal
fusion only. We analyzed
preoperative factors (demographic parameters, etiology, preoperative PFT, and Cobb’s angle) and
intraoperative factors (number of spinal segments fused, osteotomy, blood loss, and temperature`)
influencing the ventilation and intensive care admission. Univariate and multivariate analyses were
performed to identify various influencing parameters.
Results: The cohort's mean age was 14.8+/-2.5 years with males (32, 40 %) and females (49, 60%). The
deformity etiology included congenital (48%), idiopathic (36%), syndromic (10%), and neuromuscular (6%) . The mean Cobbs angle was 63.7 +/-15.1 degree with mean fused
segments -9.3+/-3.1 vertebra. 31 patients of the cohort required ICU stay with a mean average of 2+/-0.8
days. Univariate analysis demonstrated preoperative factors - Cobbs angle >60, FEV1 <60, FVC <60 and
intraoperative factors – hypotension, hypothermia, blood loss were statistically significant parameters
influencing ICU admission. Multivariate analysis revealed preoperative factor –degree of the curve (Cobb’s
angle, 0.023) and intraoperative parameters (hypotension (0.021), hypothermia (0.013), and duration
(0.067)) were independent risk factors.
Conclusion: Modifiable parameters - hypothermia, intraoperative hypotension, and operative
duration in deformity correction surgeries can directly reduce the incidence of ICU stay and further lead
to better resource utilization especially during this pandemic scenario.

Introduction: The study purpose was to assess efficacy and safety of a novel minimally invasive technique to reconstruction Achilles tendon. Methods: Our series was comprised of 14 patients (M:F=11:3), with a mean age of 45.6 years. Each patient had chronic Achilles tendon rupture. The mean interval from rupture to surgery was 5.5 months (2-10). The mean follow-up was 30.1 months (12-78). All patients were operated with a central turndown flap augmented with free semitendinosus tendon graft and percutaneous sutures in a minimally invasive approach assisted by endoscopy. The patients underwent retrospective assessment by clinical examination, the American Orthopaedic Foot & Ankle Society (AOFAS) ankle and hindfoot score, and the Achilles Tendon Total Rupture Score (ATRS). Paired t-tests were used to assess the preoperative and postoperative AOFAS scores, ATRS scores, and ankle range of motion. Results: The mean length defect was 5.1cm (3 to 8cm), while the mean length of the turndown flap was 10.1cm (8 to 13cm). The mean AOFAS score improved from 64.5 points preoperatively to 96.9 points at the last follow-up. The mean ATRS score improved from 49.4 preoperatively to 91.4 points at the last follow-up. None of the patients developed a wound complication. No patient had a re-rupture or sural nerve damage. Conclusion: All patients in our study had a favourable outcome with no complications. We believe that with this triple-repair technique, one can achieve a strong and robust repair such as in open surgery while at the same time reducing the incidence of complications.

Background: Periprosthetic joint infection (PJI) is a devastating complication of joint arthroplasties with a high rate of culture-negative cases. This meta-analysis aimed to assess the role of synovial next generation sequencing (NGS) in diagnosing PJIs and compare its performance with that of cultures. Methods: This systematic review and meta-analysis was conducted according to PRISMA guidelines. PubMed, Web of Science, Cochrane, and Google Scholar were searched from inception until 8 Jan 2022 for literature investigating the role of NGS in comparison to culture in the diagnosis of PJI. Diagnostic parameters such as sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, accuracy, and area under the curve (AUC) were calculated for the included studies to evaluate the performance of NGS in comparison to culture in PJI diagnosis. Results: The total number of the included patients was 341 from 7 articles. The pooled sensitivity, specificity and diagnostic odds ratio of NGS were 94% (95%CI: 91%-97%), 89% (95%CI: 82%-95%) and 138.5 (95%CI: 49.12-390.52), respectively. NGS has positive and negative likelihood ratios of 7.88 (95%CI: 3.99-15.56) and 0.07 (95%CI: 0.04-0.13), respectively. The SROC curve showed that the accuracy (AUC) was 91.9% and that the positive and negative predictive values were 8.624 (95%CI: 4.951-19.480) and 0.067 (95%CI: 0.027-0.115), respectively. Conclusion: NGS has a potential role in diagnosing hip and knee PJIs due to its high sensitivity, specificity and accuracy. However, the sensitivity and specificity reported by the studies varied according to the time of synovial sampling (preoperative, postoperative or mixed).

Acute irreducible Volar Distal Radioulnar Joint Dislocation Treated With Open Reduction Through Dual approaches: A Case Report.

Abstract
Introduction:
Acute irreducible dislocation of the distal radioulnar joint (DRUJ) is a rare pathology. Few cases were reported in the literature. Most cases were managed with closed reduction, but few patients required open reduction.
Case presentation:
This paper reported a rare case of acute DRUJ volar dislocation that failed closed reduction in the emergency department. Open reduction was tried using a dorsal approach which failed to achieve joint reduction. A second volar approach to release volar joint capsule only resulted in joint reduction.
Discussion and Conclusion
Acute irreducible volar dislocation of DRUJ is a rare injury with only sporadic case reports are mentioned in the literature. When the injury was diagnosed early, most cases were treated with closed reduction, and only few reported acute cases failed the closed reduction and mandated open procedures. Hence, sufficient clinical sense and appropriate radiographic technique are necessary to diagnose this rare injury pattern accurately.

INTRODUCTION: Congenital radioulnar synostosis causes a lot of parental distress in cultures were eating with hands is common. We treated, synostosis which are fixed in pronation of more than 10 degrees. METHODS: Proximal ulna osteotomy and distal end radius osteotomy was performed. The forearm was rotated to get 60 degree true supination of forearm. We documented the technical difficulties faced in achieving correction. 58 forearm surgeries were studied for – duration of surgery, ease of correction, stability after osteotomy, need for fixation, cast complications, time for union, and finally parent reported outcome. RESULTS : 16 children with bilateral forearm deformity and 26 children with unilateral deformity underwent this procedure. Children of age 2.2 to 18 years participated in our study. Duration of tourniquet use was 30 to 48 min in children < 7years while 48 min to 90 mins in children >7 years. Children >10 years required shortening to achieve correction. Stability after the osteotomy and need for fixation was related to distance between the radius and ulna osteotomy, with age <7 years and gap >18 cm being stable in above elbow cast only. Time to union was prolonged in 12 children <7 years and 4 cases of age >12 years who needed plate fixation for osteotomy. CONCLUSIONS: This study reflects our learning curve withthis method of correcting the deformity. While this is a good procedure, certain points like age of correction, size of synostosis, degree of correction, stability after correction should be kept in mind while performing the surgery.

Introduction: We performed this systematic overview on the overlapping meta-analyses that analyzed autologous platelet-rich plasma (PRP) as an adjuvant in the repair of rotator cuff tears and identify the studies which provide the current best evidence on this subject and generate recommendations for the same. Materials and methods: We conducted independent and duplicate electronic database searches in PubMed, Web of Science, Scopus, Embase, Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects on September 8, 2021, to identify meta-analyses that analyzed the efficacy of PRP as an adjuvant in the repair of rotator cuff tears. Methodological quality assessment was made using Oxford Levels of Evidence, AMSTAR scoring, and AMSTAR 2 grades and used the Jadad decision algorithm to generate recommendations. Results: 20 meta-analyses fulfilling the eligibility criteria were included. The AMSTAR scores of the included studies varied from 6-10 (mean:7.9). All the included studies had critically low reliability in their summary of results due to their methodological flaws according to AMSTAR 2 grades. The initial size of the tear and type of repair performed do not seem to affect the benefit of PRPs. Among the different preparations used, leucocyte poor (LP)-PRP possibly offers the greatest benefit as a biological augment in these situations. Conclusion: Based on this systematic overview, we give a Level II recommendation that intra-operative use of PRPs at the bone-tendon interface can augment the healing rate, reduce re-tears, enhance the functional outcomes and mitigate pain in patients undergoing arthroscopic rotator cuff repair.

Introduction: The existing Paediatric hip clinical evaluation systems most used, include the parameter of presence of pain, limp, stability in the supine position, Trendelenburg sign, deformity, ROM, functional limitations, and endurance. The evaluation of functional limitations in these systems have been designed with needs of western lifestyle in mind. The current study introduces a novel BFHS system that include functional parameters of eastern lifestyle sitting habits of Squat (Crouch Sitting), Palthi (Cross leg sitting) & Tashahhud (Kneeling). Methods: The study includes 48 Patients with 60 of Developmental Dysplastic Hips operated for open reduction, with minimum one year followup. The Parameters compared included functional limitations as exhibited on the sitting postures of Squat, Palthi & Tashahhud & its compatibility with the eastern lifestyle. The additional parameters included, time consumed, patient’s compliance, pain, limp, endurance & limitation of movement and Trendelenburg sign. Results: Patient’s compliance with BFHS was 100%, compared to 81% in McKay’s & Ferguson systems. Time consumption was 50% less, compared to other. The evaluation score of Pain, Limp, Endurance & Trendelenburg was nearly similar with both methods. BFHS was found superior scoring system to evaluate functional limitations having better compliance, less time consuming, reliability and accuracy better than MacKay & Ferguson with kapa value 100.0. Conclusion: The BFHS provides real time information for functional limitations that was having significant compatibility with Eastern (Asian) Lifestyle compared to other clinical evaluation scales. BFHS is a best tool for bias free, long-term comprehensive, remote evaluation of Post-surgical Paediatric hips.

Introduction: APC provides an excellent surgical option to the traditional techniques in EOS; designed to remodulate the most-wedged vertebra besides providing other benefits. The current study builds on earlier clinical studies on the APC technique, aiming to quantify and understand the vertebral remodulation using a FE approach.
Methods: 5 patient-specific models were developed to match AP and lateral radiograph data. These pre-op models were then used to simulate the surgical process. Next, the effect of gravity forces and spinal growth were simulated. Parameters such as Cobb, AVT, vertebral wedging etc. were recorded for these models. To ensure clinical relevance, the model inputs and process were confirmed with a surgeon.
Results: The correction in the ratio of convex to concave-side vertebral height for the 3 vertebrae in the tethered area averaged at 2.25% compared to 0.5% in the control vertebrae. Data also showed excellent correction post-surgery; reduction of the primary curve was 45% (27 degrees), kyphosis reduced by 27% (7.1 degrees) and the AVT reduced by 46% (2.3 cm) on average. Additionally, at the 6-month follow-up, the same parameters indicated a maintenance of correction for all patient models.
Conclusion: The results quantify the correction of the vertebral wedging, with the correctional effect being transferred beyond the most-wedged vertebrae. This coupled with indications of maintained correction over the spinal growth augurs well for long-term outcomes for APC. While this study is limited in terms of follow-up time, it indicates the potential of this technique and paves the way for additional research.

Introduction: Superior capsular reconstruction (SCR) using fascia lata autograft is a promising procedure for patients with irreparable rotator cuff tear. signal intensity (SI) of the graft tissue on magnetic resonance imaging (MRI) may reflect the degree of graft healing. SNQ is a reliable parameter for the assessment of graft maturation and its clinical relevance to patient outcomes in rotator cuff repair. Methods: Fifteen patients who underwent SCR using fascia lata autograft from March 2013 to December 2017 were analyzed, retrospectively. MRI was taken at postoperative 3 and 12 months. SNQ was measured at three different parts; humerus insertion site (SNQh), mid-substance (SNQm), and glenoid insertion site (SNQg). For clinical outcomes, the American Shoulder and Elbow Surgeons (ASES) score, Constant score, Single Assessment Numeric Evaluation (SANE) score, Visual Analog Scale (VAS) for pain and active shoulder range of motion (Forward Elevation, External Rotation) were evaluated preoperatively, postoperative 3 and 12 months. The correlation between SNQ and clinical outcomes was analyzed. Results: SNQh, SNQm and SNQg at postoperative 12 months decreased, compared to those of postoperative 3 months. Of them, SNQh showed significant difference between 2 time points (P < 0.01). SNQh at postoperative 12 months showed significant negative correlation with the ASES score, Constant score, and SANE score. Conclusion: Signal intensity (SNQh) of the fascia lata autograft on postoperative MRI decreased at postoperative 12 months compared to the postoperative 3 months after SCR, and there were negative correlations with functional outcomes after surgery.

Joint dislocations as a result of trauma are fairly common injuries and are considered as orthopedic emergencies.Overall shoulder joint dislocation is most common. Dislocations usually involves single joint. But simultaneous ipsilateral fracture -dislocation of the hip and knee joint due to high energy trauma is a rare type of injury . there is inadequate amount of data published in literature on this topic. We report a case of a 27-year-old male patient who presented to us in casualty with ipsilateral hip and knee fracture-dislocation on the right side after being involved in a high energy trauma. After necessary stabilization and clinical and radiological confirmation of intact distal pulses, we tried closed manual reduction of hip and knee at emergency. After failed attempt of closed reduction patient was shifted to Emergency theatre . Again, closed reduction under spinal anesthesia and fluoroscope guidance was tried. After failed second attempt of hip dislocation and knee. Knee spanning external fixator was given for right knee and Urgently by Kocher-Langenbeck approach, right side head of femur approached and obstructing head of femur is reduced (Pipkin type 1) and hip joint is immobilized and traction is given with per-cutaneous Steinman pin. At one-year follow-up patient had no pain in the hip or knee during daily routine activities except minimal restriction of range of motion at hip and knee. Regular Radiographical evaluation revealed no evidence of avascular necrosis or arthritis of the femoral head.