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Aim: To explore the core competencies needed on part of the medical and dental teachers to carry out effective digital teaching for their students., Methods: It was a qualitative study which employed phenomenological approach. The data were collected from 12 teachers who were purposively selected for semi-structured interviews. They were all expert digital teachers. The data were transcribed verbatim, coded and analyzed thematically. Textural and structural description of the themes helped to develop a new competency framework., Results: The data yielded 47 selective codes with 15 sub-themes and five themes. The emergent themes included general digital competencies, specific digital teaching competencies, mastery of the subject matter, mastery of pedagogical strategies and proficiency in using innovative digital technologies for teaching. The themes 1, 2 and 5 relate to digital competencies only whereas the themes 3 and 4 are generic competencies which apply to both digital and non-digital teaching. These generic competencies form the basis of all kinds of teaching, hence equally important for digital teaching., Conclusion: Medical teachers should possess diverse digital competencies. The competency framework that emerged in the current research encompasses the essential attributes that should be included in any future training program aiming at the digital capacity building of the teachers. This will keep them primed for effective digital teaching. Given its crucial importance, the digital teaching competency should be considered as a cross-cutting competency that applies to almost all of the famous eight roles of medical teacher.

Background: In order to create a solid evidence base for the development of improved management methods, this study was performed to describe the epidemiology and outcome of nontraumatic lower limb amputations (LLAs)., Methods: This descriptive case series was conducted over a period of 4 years. It included all patients of both sexes and all ages who underwent LLAs for nontraumatic indications., Results: There were a total of 217 patients with 136 (62.67%) men and 81(37.32%) women. The age range was 7 to 71 years, with a mean of 54.25 ± 11.49 years. The most common indication for amputation (41.47%) was diabetic foot gangrene. The most common level of amputation (48.29%) was below knee amputation., Conclusion: Patients with diabetic foot gangrene, malignant tumors, and chronic neuropathic ulcers with osteomyelitis constituted the bulk of the amputees. Diabetes mellitus, obesity, and hypertension were the commonest comorbidities identified among them. Public awareness and education would ensure prompt and early health seeking at the appropriate time and help to prevent the need for major amputations in many instances. The amputees' improved reintegration into society and ability to become contributing members of society would be ensured by the provision of vigorous rehabilitation., Competing Interests: The authors declare that they have no competing interests., (© 2023 Iran University of Medical Sciences.)

Background: This descriptive case series documented the clinical presentation of tumours around the knee in our population and explored the outcome of lower limb salvage with oncological resections and megaprosthetic reconstructions. The variables analysed included return of knee function, disease free survival and any complications observed over a follow up period of 5-years., Methods: The study spanned over a period of 13-years. It included adult patients of all genders who presented with tumours around the knee and underwent tumour resections followed by megaprosthetic reconstructions at our institute., Results: Out of 73 patients, there were 43 (58.90%) males and 30 (41.09%) females. Their ages ranged between 16-53 years with a mean of 32.97±10.68 years. The tumours included giant cell tumours (n=41), osteosarcomas (n=24), Spindle cell sarcoma (n=5), chondrosarcoma (n=2) and Ewing's sarcoma (n=1). The average postoperative musculoskeletal tumour society (MSTS) score was 84.65%. Various complications encountered included superficial infections/ delayed wound healing among 9 (12.32%) patients, local recurrence in 6 (8.21%), deep infections among 5 (6.84%) and transient palsy of peroneal nerve in 3 (4.10%) cases. There was aseptic loosening and traumatic disruption of extensor mechanism one each (1.36%). There were 7 (9.58%) mortalities in our series., Conclusions: Giant cell tumours and osteosarcomas were the most frequent tumours observed around the knee. The tumours affected relatively younger population. Safe oncological resections of the tumours followed by megaprosthetic reconstructions provided reasonable outcome in the majority of patients.

Background: This randomized clinical trial was carried out to document the clinical presentation of isolated high radial nerve palsy (high RNP) and compare the outcome of triple tendon transfers., Methods: The study included patients of all genders and ages who presented with isolated high RNP. Half of them were randomly assigned to the flexor carpi radialis set (FCR-set) of tendon transfers (group A) and a half to the flexor carpi ulnaris (FCU-set) of tendon transfers (group B)., Results: Out of 44 patients, 38 were males, and 6 were females. The age ranged from 7 years to 55 years. 26(59.09%) patients had primary RNP in association with fractures of the humerus. The postoperative mean disability of arm, shoulder, and hand score (Quick DASH-11 score) for the patients in the FCR-set of transfers was 34.54%% versus 41.81% for the FCU-set of transfers. 11 patients (25%) developed radial deviation deformity., Conclusion: RNP was predominantly found among males of the young age group, and the majority of the cases resulted from preventable causes. The triple tendon transfers among patients of the two groups robustly restored the lost extension of the wrist and digits in a matching way. The patients also subjectively reported remarkable improvement in terms of the favorable Quick-DASH-11 scores. Radial deviation deformity occurred among half of the patients who underwent the FCU set of tendon transfers.

Background: To document the clinical presentation of carpal tunnel syndrome (CTS) and evaluate the outcome of mini-incision open carpal tunnel release in terms of surgical complications, relief/persistence of symptoms at 4 months, and recurrence at 1 year. Methods: This prospective case series included patients of all genders and ages who presented with CTS. They underwent release of transverse carpal ligament (TCL) under local anesthesia and tourniquet control on day care basis. Mini-incision of 2 cm to 2.5 cm was employed. The data were subjected to statistical analysis using SPSS version 21 (SPSS Inc). The percentages of key categorical variables were compared by employing the chi square test, and a P value of less than.05 was regarded as statistically significant. Results: There were 67 patients with 77 CTS affected wrists. A Significant majority of the patients (n = 54; 80.59%) were females, whereas 13 (19.40%) patients were males. The age range was 26 to 69 years, with a mean age of 41.01 ± 11.70 years. The CTS was found to be moderate among 34 (44.15%) and severe among 43 (55.84%) patients. The majority of patients had no operative complications. At 4 months follow-up, the majority of patients (n = 74; 96.10%) reported symptomatic relief, whereas 3 (3.89%) patients continued to have persistent severe symptoms. All the cases with persistent symptoms had diabetes mellitus of more than 5 years duration. There was no case of recurrence at one year follow-up. Conclusion: CTS predominantly affected women aged 30 to 45 years. The open carpal tunnel release with mini-incision yielded good results in terms of relieving symptoms among the majority of patients and was associated with no critical complications or recurrence at 1 year., Competing Interests: Conflicts of Interest: None declared, (© 2021 Iran University of Medical Sciences.)

Background: To document the clinical presentation of glomus tumors of the hand and evaluate the outcome of complete surgical excision in terms of relief of symptoms, any postoperative nail deformities and tumor recurrence over a period of one year., Methods: This descriptive case series spanned over a period of twelve years. All patients of either gender and all ages who had histologically confirmed glomus tumors of the hands were included. All of them underwent surgical excision under local anesthesia., Results: Out of 17 patients, majority (n=12; 70.58%) were females. The mean age was 41.17±13.7 years. The dominant hand was involved in 11 (64.70%) patients. There were 14 patients (82.35%) with subungual tumors whereas 3(17.64%) had volar pulp glomus tumors. The mean diagnostic delay was 18.88±9.3 months. The tumor size ranged from 2 mm to 1.1cm with a mean of 4.05±4.3mm. All the patients (n=17,100%) experienced complete symptomatic relief within 2-4 weeks after surgical excision. There were no postoperative nail deformities. There was no recurrence over a period of one year., Conclusion: Glomus tumors of the hands were more frequently found among women in their fourth and fifth decades. Dominant hand, index finger and distal phalanx represented the commonest affected anatomic locales. Majority of the tumors were subungual. Majority of the patients suffered over 12 months in distressful pain before being diagnosed. Complete surgical excision under local anesthesia provided rapid relief of the symptoms. Creation of awareness about the tumor among doctors as well as public would help to ensure early presentation to plastic surgeon, prompt diagnosis and hence avoidance of the prolonged periods of agonizing misery.

Background: This randomized clinical trial was undertaken to document the clinical presentation of de Quervain's disease and evaluate the outcome of management with triamcinolone acetonide (TAC) injection versus surgical decompression., Methods: Half of the patients were assigned to the corticosteroid injection group (group A) and half to the surgery group (group B). In group A, 40 mg of TAC was injected into the affected first extensor compartment. In group B, surgical decompression of first extensor compartment was performed., Results: There were 56 patients with 38 (67.85 %) females and 18(32.14%) males. The age range was 23-66 years. In group A, one injection was employed among 7(25%) patients whereas two injections among 21(75%) patients. Local complications with injections were observed among 7 patients. Symptomatic relief with injection at 6-weeks was observed among 25% patients whereas recurrence at one year was observed among 9(32.14%) patients. In group B, no critical complications were encountered following surgery; all the patients had symptomatic relief at 6-weeks and there was no case with recurrence at one year., Conclusion: Surgical decompression provided superior results in terms of providing symptomatic relief at 6-weeks among all patients, absence of complications and no recurrence. The corticosteroid injections (CSI) were associated with the need for repeat injections among 75% cases and a recurrence rate of 32.14% at one year, rendering it to be comparatively a poorer choice.

Background: Burn in developing countries still has high burden of inadequately managed severe burns. This study compared supraclavicular artery flap and skin graft in managing neck post-burn contractures., Methods: In National Institute of Rehabilitation Medicine and Pakistan Institute of Medical Sciences, Islamabad, Pakistan, 30 patients with neck post-burn contractures were enrolled. Half of patients randomly underwent supraclavicular artery flap and half received skin graft. The outcome measures including initial improvement in neck extension, patient's satisfaction with color-texture-match and recurrent contracture formation rate were assessed., Results: Among patients, 80% were female and 20% were male. Preoperatively, each group had post-burn contractures of grade II among 26.66% of patients, grade III among 60% and grade III among 13.3%. Postoperatively after three months in the two groups, 86.66% improved to grade I and 13.3% improved to grade II. Patient's satisfaction with color-texture was 84.66% in supraclavicular artery flap group, whereas it was 42.66% for skin graft group. Complications were hypertrophic scar at donor site (13%) and flap tip necrosis (6.66%) in supraclavicular artery flap group. In skin graft group, partial skin graft loss was noticed among 33% of patients and delayed healing of donor site among 20%. The recurrent contracture formation rate at one year was 73.33% in skin graft group, whereas there was no case of recurrent contracture in supraclavicular artery flap group., Conclusion: Supraclavicular artery flap was superior to skin graft in managing post-burn neck contractures. It provided better color-texture match and was associated with no recurrence of contracture formation.

Objectives: To document the presentation of infected non-unions of femur in pediatric and adolescent population and evaluate the outcome of segmental bone transport with the Ilizarov method., Methods: This prospective case series study was carried out over a period of five years, from January 01, 2015 to December 31, 2019. The study included all children and adolescent patients who presented with femoral infected non unions. The study excluded patients above the age of 16 years and those who had pathological fractures secondary to bone pathologies such as cysts, tumors or metabolic bone diseases., Results: Out of 31 patients, 27(87.09%) were males and 4(12.90%) were females. The mean age was 13.48±1.98 years. The underlying mechanisms that lead to the causation of fractures included road traffic accidents (n=23;74.19%), fall from height (n=7;22.58%) and firearm injuries (n=1;3.22%). The bone gaps ranged from 3-5 cm with a mean of 4.00± 0.856 cm. Bone union was achieved among 28(90.32%) patients. Infection was eradicated among 27(87.09%) patients whereas the remaining patients continued to suffer persistent infection. The most common complications included pin tract inflammation/ infection among (n=31;100%) patients and stiffness of knee joint among (n=19;61.29%) patients., Conclusion: Majority of the patients were males, aged 9-16 years. Road traffic accidents were the commonest cause of the fractures. The Ilizarov method of segmental bone transport was effective in treating the majority of infected non-unions., Competing Interests: Conflicts of Interest: None., (Copyright: © Pakistan Journal of Medical Sciences.)

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19., Competing Interests: NoteConflict of Interest The views expressed in this article are those of the authors and do not represent the official policy of the any country. None declared., (Society of Indian Hand & Microsurgeons. This article is published by Thieme.)

Competing Interests: Conflict of Interest None declared.

Background: Cutaneous melanomas (CMs) account for only a small proportion of skin cancers, however these are responsible for most skin cancer deaths. There has been a consistently increasing trend in their incidence across the globe., Methods: This prospective case series study spanned over a period of three years. All patients with histologically confirmed CMs were included., Results: There were 31 patients including 28 males and 3 females with the mean age of 58.25±11.33 years. The histological subtypes included 13 cases (41.93%) of nodular melanoma (NM), 11 patients (35.5%) of acral lentiginous melanoma (ALM), 3 cases (9.67%) of superficial spreading melanoma (SSM) and lentigo maligna melanoma (LMM) and one case (3.22%) of desmoplastic melanoma. Two patients (6.45%) presented with stage II, whereas 21 patients had (67.74%) stage III melanoma. There were 8 patients (25.80%) with stage IV. Time interval between onset of the lesion and first presentation to hospital ranged from 6 to 17 weeks with a mean of 12.45±3.2 weeks. The overall median survival for patients with stage III and IV was 8.75 months. The overall survival for stage II at one year was 100%., Conclusion: CMs more frequently affected males aged ≥58 years. Feet, face, trunk, hands and scalp were the affected anatomical body parts in decreasing order of frequency. NM and ALM were the more common histological subtypes. Majority of patients presented late and advanced stages of melanoma. Awareness about the sinister course of the disease will ensure early presentation with better treatment outcome.

Melanoma constitutes one of the most sinister and troublesome malignancies encountered by humanity. Generally, the diagnosis of advanced melanoma connotes a grave prognosis, prompting a sense of looming threat of death, however, the early-stage detected disease responds well to robust treatment resulting in reasonable survivorship. Scalp melanomas are even more troublesome, because they typically exhibit more aggressive biologic behavior and are often diagnosed at a late stage. This review tries to comprehensively highlight the various diagnostic, therapeutic, and outcome aspects of scalp melanomas. The literature research includes peer-reviewed articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) till May 2020 and reference lists of respective articles. Only articles published in English language were included., (© 2020 Wiley Periodicals LLC.)

Background: Established Volkmann's ischemic contractures (VICs) represent the eventuality of neglected acute compartment syndrome (ACS) of the forearm. This study assessed the clinical and demographic presentation of VICs., Methods: This study was conducted at Department of Plastic Surgery, National Institute of Rehabilitation Medicine, Islamabad, Pakistan over a period of three years and included all patients of either gender who presented with VICs and analyzed various corrective procedures instituted as surgical remedies., Results: Among 37 included patients, 83.78% were male and 16.21% were female (mean age: 16.51±9.1 years). The underlying causes of the initial traumatic insults were tight bandages employed by traditional bone setters for treating forearm fractures (83.78%), high voltage electric burns involving hands/forearms (13.51%) and supracondylar fracture with vascular compromise (2.70%). Majority of patients belonged to Holden type 2 (97.29%) and Tsuge type 2 VICs (48.68%). The most common sufferers of VICs were young, illiterate males coming from rural regions. Treatment for forearm fractures by traditional bonesetters constituted the most common underlying cause. Most of the patients were managed with combination of procedures including tendon transfers, excision of the fibrosed muscles, tenolysis and neurolysis of median and ulnar nerves. Tendon transfers were the commonest corrective procedures instituted., Conclusion: This study highlighted the gravity of this largely preventable but neglected catastrophe and there is a need to institute robust preventive measures to address the issue. Emphasis should be on creation of public awareness and robust education of health care providers to ensure correct primary management of upper limb trauma.

Background: Gastrocnemius muscle flap has been in vogue for approximately five decades. The current study was carried out to document the indications and outcome of proximally based medial gastrocnemius muscle flap in our patients., Methods: This case series was conducted in Department of Plastic Surgery and Orthopedics, National Institute of Rehabilitation Medicine (NIRM), Islamabad, Pakistan during 3 years. It included all patients who were managed with proximally based medial gastrocnemius muscle flap for various indications., Results: There were 31 patients with 24 (77.41%) males and 7 (22.58%) females. The age ranged between 16- and 53 years (mean: 27.47±10.33 years). The indications for gastrocnemius muscle flap included traumatic defects with exposed tibia/ knee joint (n=20; 64.51%), prophylactic coverage of megaprosthesis employed for knee joint reconstruction (n=9; 29%), excisional defect of cutaneous squamous cell carcinoma with exposed tibia (n=1; 3.22%), and salvage of infected total knee arthroplasty (n=1; 3.22%). The hospital stay was 7-16 days (mean: 12.41±2.87 days). The flap survival in our series was 100%. There was partial skin graft in two patients (n=2; 6.45%)., Conclusion: Gastrocnemius muscle flap was a quick, easy and reliable coverage tool for small to moderate sized defects around the knee, the proximal third of the tibia as well as coverage of prosthesesis employed for knee arthroplasty. Inclusion of 2-4 cm tendon enhances the flap dimension without causing any additional morbidity.

Background: Complex soft-tissue defects of the distal third of the leg, proximal third of foot and similar wounds around the ankle represent formidable foes for plastic surgeons. This study compared the outcome of 2-staged interpolated flap design versus single stage islanded flap design of reverse flow superficial sural artery flap., Methods: Thirty-four patients were enrolled, while half randomly underwent interpolated flap design (group A) and for half, islanded flap design (group B). The outcome measures were frequency of epidermolysis, flap-tip necrosis, partial flap loss, total flap loss and number of secondary procedures required for addressing these complications., Results: Among patients, 79.41% were male and 20.58% were females. The age range was 12-51 years (mean: 28.82±10.76 years). The wound locations were hind foot (50%), ankles (17.64%), heel (14.70%), distal third of leg (11.76%) and dorsum of proximal third of foot (5.88%). In group B, epidermolysis was noted in 35.29% of flaps, and flap tip necrosis and partial flap necrosis in 17.64%. In group A, 5.88% were tip necrosis with no other problems. In group B, 76.47% of secondary procedures were done to address various flap related complications, whereas in group A, 5.88% additional procedures were required to address the flap tip necrosis., Conclusion: The reverse flow superficial sural artery flap constituted a practical solution to address complex defects of the distal leg, ankle, heel and proximal foot. The 2-staged interpolated flap design considerably enhanced the flap reliability and reduced the frequency of venous congestion and resultant flap necrosis of variable proportions., Competing Interests: The authors declare no conflict of interest.

Objective: To evaluate the management outcome of complex non-union of femoral fractures with Ilizarov method in terms of bone union, functional results and any complications., Methods: This case series study was carried out at the Departments of Orthopedic Surgery, National Institute of Rehabilitation Medicine (NIRM), Islamabad and Civil hospital, Quetta over a period of three and half years, January 1, 2015 to June 30,2018., Results: There were 50 patients in the study. There were 48(96%) males and 2(4%) females. The ages ranged between 17-54 years with a mean of 33.58±8.9 years. As per ASAMI criteria, the bone results were excellent in 17(34%), good in 30(60%), fair in 1(2%) and poor in 2(4%) patients. The functional results were excellent in 15(30%), good in 24(48%), fair in 8(16%) and poor in 3(6%). The bone union rate was 98% whereas infection eradication rate was 94%. The most frequent complications were pin tract infection affecting 80% patients, knee stiffness 60% patients and K-wires loosening 20% patients., Conclusion: The Ilizarov method provides an effective solution to address the complex non-union of femur fractures. It helps to ensure fracture healing, eradicates infection and provides good functional outcome. The attended complications are mild to moderate and manageable with conservative means., Competing Interests: Conflicts of Interest: None declared.

Objective: To document the presentation of tibial infected non-union and analyze the management outcome with Ilizarov technique in terms of bone results, functional outcome, bone transport time, external fixation time, external fixation index and any complications., Methods: This case series was conducted at the Departments of Orthopedic Surgery, National Institute of Rehabilitation Medicine (NIRM), Islamabad and Civil hospital, Quetta over a period of 3-years., Results: There were 56 patients with 53(94.64%) males and 3(5.35%) females. The age range was 16-50 years with a mean of 32.58±9.98years. According to ASAMI criteria, bone results were excellent in 37(66%), good in 10(17.85%), fair in 6(10.71%) and poor in 3(5.35%). The functional results were excellent in 37(66%), good in 9(16%), fair in 7(12.5%) and poor in 3(5.35%). The bone union rate was 98.21%., Conclusion: Ilizarov method beautifully addresses the formidable issue of infected non union of tibia with good outcome in terms of bone healing and infection eradication. The treatment period is relatively lengthy and hence patience on part of patient as well as the surgical team is imperative for achieving favourable outcomes., Competing Interests: Conflicts of Interest: None declared.

Objective: To document the clinical presentation of neglected DDH and evaluate the outcome of triple procedure., Methods: It was a descriptive case series study, conducted at the Department of Orthopedic Surgery, National Institute of Rehabilitation Medicine (NIRM), Islamabad over a period of 8-years. It included children aged >1 and <9 years who underwent the triple procedure of open reduction, femoral shortening and Salter's osteotomy. Clinical evaluation was performed using McKay's criteria. Tonnis classification and Severin's scoring system were employed for the radiological evaluation., Results: There were 193 children with 213 DDH affected hips. The mean age was 3.31±1.6 years. The preoperative severity of the femoral head dislocation per Tonnis classification was Grade-I in 7.98%(n=17), Grade-II in 48.35%(n=103) and Grade-III in 43.66%(n=93) hips. The postoperative MacKay criteria was 'Good' to 'Excellent' in 193(90.61%) hips. The postoperative Severin's class was I in 113(53%) hips, II in 48(22.53%) hips, III in 43(20.18%) and IV in 9(4.22%) hips. The preoperative acetabular index ranged from 39° to 51° with a mean of 43.91±3.69°. The mean postoperative AI was 18.42±2.99°. The postoperative centre edge angle ranged from 21° to 26° with a mean 23.18 ±1.35°., Conclusions: The single stage triple procedure offers the surgical remedy of choice with favourable results for managing neglected and late diagnosed DDH among children aged 1-8 years., Competing Interests: Conflicts of Interest: None declared.

To describe the epidemiologic profile of children sustaining electrical burn injuries and assess the outcome in terms of need for amputations, hospitalization, and the associated in-hospital mortality. This case series study was performed over a 5-year period (January 2008 to December 2012) at the Department of Plastic surgery and Burn Care Centre, Pakistan Institute of Medical Sciences (PIMS), Islamabad. All children of either gender up to 15 years of age were included. They were admitted for indoor management with standard burn care protocols. The demographic profile of the child, injury characteristics, and outcome were recorded and the data analyzed statistically. Of 85 children who presented with electrical burn injuries during the study period, 89.41% (n = 76) were males and 10.58% (n = 9) were females. The age ranged from 1 to 15 years with a mean age of 10.47 ± 4.09 years. High-voltage burns were the commonest type (n = 61; 71.76%). There were 35 major limb amputations. The mean hospital stay was 6.78 ± 5.01 days (range 1-25 days). The mortality rate was 2.35%. Male children aged 10 to 15 years are the most frequent victims of electric burn injuries, and high-voltage injuries constitute the commonest form of these injuries. There is associated considerable morbidity due to inevitable major amputations of the limbs among otherwise healthy children. There is dire need for primary prevention.

Backgrond: Burn wound infections carry considerable mortality and morbidity amongst burn injury victims who have been successfully rescued through the initial resuscitation. This study assessed the prevalent microrganisms causing burn wound infections among hospitalized patients; their susceptibility pattern to commonly used antibiotics; and the frequency of infections with respect to the duration of the burn wounds., Methods: This study was carried out at Burn Care Centre, Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan over a period of two years (i.e. from June 2010 to May 2012). The study included all wound-culture-positive patients of either gender and all ages, who had sustained deep burns and underwent definitive management with wound excisions and skin auto-grafting. Patients with negative cultures of the wounds were excluded. Tissue specimens for culture and sensitivity were collected from burn wounds using standard collection techniques and analyzed at microbiological laboratory., Results: Out of a total of 95 positive microbial growths, 36 were Pseudomonas aeruginosa (35.29%) as the most frequent isolate found, followed by 21 Klebsiella pneumoniae (20.58%), 19 Staphylococcus aureaus (18.62%), 10 Proteus (9.80%), 7 E. coli (6.86%), 7 Acinetobacter (6.86%), and 4 Candida (3.92%). A variable antibiotic susceptibility pattern was observed among the grown microbes. Positive cultures were significantly more frequent among patients with over two weeks duration of burn wounds., Conclusion: P. aeruginosa, K. pneumoniae and S. aureus constituted the most common bacterial microbes of burn wounds in our in-patients cases. Positive cultures were more frequent among patients with over two weeks duration of burn wounds. Early excision and skin grafting of deep burns and adherence to infection control measures can help to effectively reduce the burden of these infections.

Background: The Surgical Informed Consent (SIC) is a comprehensive process that establishes an information-based agreement between the patient and his doctor to undertake a clearly outlined medical or surgical intervention. It is neither a casual formality nor a casually signed piece of paper. The present study was designed to audit the current knowledge and attitudes of doctors towards SIC at a tertiary care teaching hospital in Pakistan., Methods: This cross-sectional qualitative investigation was conducted under the auspices of the Department of Medical Education (DME), Pakistan Institute of Medical Sciences (PIMS), Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), Islamabad over three months period. A 19-item questionnaire was employed for data collection. The participants were selected at random from the list of the surgeons maintained in the hospital and approached face-to-face with the help of a team of junior doctors detailed for questionnaire distribution among them. The target was to cover over 50% of these doctors by convenience sampling., Results: Out of 231 respondents, there were 32 seniors while 199 junior doctors, constituting a ratio of 1:6.22. The respondents variably responded to the questions regarding various attributes of the process of SIC. Overall, the junior doctors performed poorer compared to the seniors., Conclusion: The knowledge and attitudes of our doctors particularly the junior ones, towards the SIC are less than ideal. This results in their failure to avail this golden opportunity of doctor-patient communication to guide their patients through a solidly informative and legally valid SIC. They are often unaware of the essential preconditions of the SIC; provide incomplete information to their patients; and quite often do not ensure direct involvement of their patients in the process. Additionally they lack an understanding of using interactive computer-based programs as well as the concept of nocebo effect of informed consent.

Marjolin's ulcer (MU) represents malignant degeneration that typically ensues over a period of time in the post-burned lesions and scars or any other chronic wound. This review highlights various facets of the presentation and management of MUs that originate from post-burned lesions. The incidence of MUs in such lesions is reported to be 0.77%-2%. This malignancy characteristically develops in the areas of full thickness skin burns that had been allowed for weeks to months to heal spontaneously by secondary intention, or burn wounds which never healed completely over years and the unstable post-burned scars. In the majority of cases, the MU is a squamous cell carcinoma (SCC). The MUs contribute to an overall 2% of all SCCs and 0.03% of all basal cell carcinomas of the skin. Clinically MUs present in two major morphologic forms. The commoner form is the flat, indurated, ulcerative variety while the less common form is the exophytic papillary variety. Lower limbs represent the most frequently affected body parts. Surgical resection of the primary tumor with 2-4 cm horizontal clearance margin, nodal clearance and radiotherapy constitute the cornerstones of effective oncologic management. Despite best efforts, the overall mortality is reported to be 21%.

A qualitative investigation was undertaken to determine and analyse the pattern of existing practices regarding informed consent for surgery at PIMS, Islamabad. Adult postoperative patients who had undergone surgical interventions were randomly selected face-to-face with the help of a team of junior doctors. A questionnaire was employed for data collection and the responses of the patients to the questions regarding various attributes of the consent process were analysed. Overall inadequacy existed in the prevailing practices. There is a need to revisit the consent related practices and make the process more informed and adequate. Instead of taking it as a casual formality, our doctors should regard it as an equally important exercise equivalent to other components of care such as the surgery itself.

Background: Self-inflicted burn injuries carry considerable mortality and morbidity among otherwise fit young individuals. This study assessed the epidemiologic pattern and outcome of these injuries in a burn care facility in Pakistan., Methods: The study was carried out at Pakistan Institute of Medical Sciences (PIMS) Burn Care Centre in Islamabad over a period of 2 years. It included all adult patients of either gender, aged over 14 years who presented as cases of burn suicides and attempted burn suicides during the study period. Convenience sampling technique was employed. The sociodemographic profile of the patients, motives underlying the act of self-immolation, any underlying psychiatric illness, alcohol abuse, total body surface area (TBSA) burnt, depth of burn injury, associated inhalation injury, duration of hospital stay, and mortality were all recorded., Results: Seventy five patients (80.64%) were female while 18 patients (19.35%) were male. The overall mean age was 26.89±6.1 years (range=15-52 years). The affected TBSA ranged from 15%-100% with an overall mean of 69.30±25.42%. The hospital stay ranged from 1-37 days with a mean of 7.16±6.60 days. Marital conflicts constituted the most frequent motive underlying the suicidal attempts (n=57; 61.29%) followed by failed love affairs (n=9; 9.67%). There was an overall mortality of 84.95%. The most common sufferers of self inflicted burn injuries were young, married, illiterate housewives who were resident of rural area. Getting marriage was the most common triggering cause for such injuries., Conclusion: There is need to institute appropriate preventive measures to address the issue in a national perspective.

Background: Doctor-patient communication has far reaching influences on the overall well-being of the patients. Words are powerful tools in the doctor's armamentarium, having both healing as well as harming effects. Doctors need to be conscious about the choice of their words. This study aimed to determine the frequency and pattern of Nocebo Phenomenon (NP) un-intentionally induced by the communication of surgeons and anesthetists through the course of various interventional procedures such as surgery, anesthesia, and crucial communication encounters with their patients., Methods: The study was carried out by the Department of Medical Education (DME), Pakistan Institute of Medical Sciences (PIMS), Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), Islamabad over six months period. All residents and faculty members serving at our institute in various surgical and anesthesia departments constituted the study population. A questionnaire was employed as the data collection tool., Results: Significant proportions of the doctor-patient communications under scrutiny entailed NP. It was more frequently observed in association with female gender of the involved professionals, residency status versus faculty position, and shorter professional experience (i.e. <5 years). Although the participants endorsed the fact that the choice of their words influenced the well-being of their patients, none of them were actually aware of the concept of NP., Conclusion: NP existed in the clinical practice of the surgeons and anesthetists during their communication with patients. It was more frequently found among females, residents and professionals with less than five years of working experience. There is need to create awareness among these professionals about the subtle negative messages conveyed by such communication and alert them that the nocebo effects have negative repercussions on the clinical outcomes of their patients. The professionals should be formally educated to avoid nocebo words and phrases.

Background: This study was undertaken to determine the efficacy and safety of subcutaneous lateral internal sphincterotomy (SLIS) for chronic anal fissure by assessing the relief of defecatory pain, duration of wound healing and associated complications such as bleeding, infection, and anal incontinence., Methods: This descriptive case series was carried out at the Department of Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad from September 1, 2008 to February 28, 2009., Results: Out of fifty patients 31 were males and 19 were females. The mean age was 30.04 ± 8.49 years. Defecatory pain and bleeding per rectum were the commonest symptoms, found among all patients. Symptomatic relief of pain following surgery was observed among all patients at 4th week while all fissures healed at 8th week. At 4th weeks follow-up visit none of the patients had flatus incontinence while at 8th weeks all patients had good faecal continence. Majority (76%) of the patients were managed as Day case or Extended day case surgeries. There was no in-hospital mortality in this case series., Conclusion: SLIS is a valuable surgical procedure for patients with chronic anal fissure. It is effective and safe, offers quick relief of defecatory pain, and promotes early fissure healing without being attended by any major complications. The initial transient incontinence of flatus and faeces improves spontaneously over few weeks period. Majority of the patients are manageable on day case or extended day case surgery basis.

Background: Penetrating and impalement injuries of the hand and fingers are one of the commonest presentations at the hospital's emergency rooms. This study assessed the characteristics of patients who suffered foreign body injuries to the hands and documented the pattern of diagnosis and management at a specialist plastic surgical facility., Methods: The study was conducted at the Department of Plastic and Reconstructive Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad over a period of six years (i.e. from September 1, 2007 to July 31, 2013). All adult patients (37 subjects) of either gender who were managed for hand foreign bodies during the study period were included by convenience sampling technique. The demographic profile of the patients, cause of injury, type of foreign body, occupation of the patient, diagnostic yield of plain x-rays, type of procedure undertaken for retrieval of foreign body, and complications were all recorded on a form. A follow-up of three months was done., Results: Eighteen (48.64%) were males while 51.35% (n=19) were female. The mean age was 26.78±9.94 years. The commonest sufferers were housewives 29.72% (n=11). Majority of patients (n=16; 43.24%) presented on day 3 (i.e. >48-72 hours), among the injury causing mechanisms, the commonest were accidents with sewing machines 45.94% (n=17) and sewing machine needles 45.94% (n=17) were the commonest foreign bodies observed. The plain x-ray hands reveled the diagnosis in all patients except those with wooden foreign bodies (n=3; 8.10%). All patients had successful surgical exploration and retrieval of the foreign bodies under local anesthesia and tourniquet control. In two cases, image intensifier was employed to locate the foreign bodies per-operatively. Wound infection was found in 0.8% (n=4) patients, all of whom were managed successfully with oral antibiotics. None of patients had hospitalization. All patients were fine at 3 months follow up., Conclusions: Surgical exploration and careful retrieval under local anesthesia and tourniquet control suffice as the definitive treatment. Rarely intra-operative image intensifier is needed to locate foreign bodies per-operatively.

An analytical study was conducted to find out the diagnostic accuracy of leukocytosis in predicting acute appendicitis in patients undergoing emergency appendicectomy. The degree of inflammation of the resected specimens was grossly assessed and graded into acute inflammation, acute inflammation with complications (such as gangrene, perforation, abscess) and un-inflamed appendix. The operative findings were correlated with leukocyte counts using 2 x 2 table. Out of 233 appendicectomies, with exclusion of the negative appendicectomies (17.59%, n = 41), there were 67.38% patients (n = 157) with elevated leukocyte count. The overall sensitivity, specificity, positive predictive value and negative predictive value of elevated leukocyte counts for inflamed appendix were 91.81%, 43.55%, 81.77% and 65.85% respectively.

Objective: To document clinical status and disabilities among live treated leprosy patients., Methods: The observational, descriptive study was carried out at the Leprosy Field Clinic, Diamer, Gilgit-Baltistan, Pakistan, over a period of six months from April 1, 2009 to September 30, 2009. All leprosy patients of either gender and all ages presenting at the centre were included. Diagnosis was made through detailed history, physical examination and leprosy-specific investigations including skin, nasal and ulcer smears for Bacterial Index of M. leprae. The sociodemographic profile of the patients, type of leprosy, previous treatment received, persisting disabilities were all recorded on a proforma. SPSS 10 was used for statistical analysis., Results: Of the total 186 cases in the study, 141 (75.80%) were males and 45 (24.20%) were females. The age range was 14-91 years with a mean of 53 +/- 13.20 years. Borderline Tuberculoid leprosy was the most frequently found subtype of leprosy (n = 81; 43.54%), while Midborderline leprosy was the least common variety (n = 17; 9.13%). The cases had received multi drug therapy for a least 12-18 months previously., Conclusion: Leprosy was prevalent in the study area. A significant number of treated leprosy patients continue to have disabling sequelae of the disease.

Objective: To assess the clinical presentation and outcome of surgical management of benign thyroid disorders in a tertiary care set up in Pakistan., Methods: The clinical audit was carried out at the Department of Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad, from September 2002 to December 2010. The data were recorded on a pre-designed proforma, which comprehensively encompassed the relevant variables and outcome measures. SPSS 10 was used for statistical analysis., Results: Out of 527 patients, there were 474 (89.94%) females and 53 (10.05%) males. The overall age ranged 21-56 years, with a mean of 41.99 +/- 9.07 years. Symptoms due to local pressure effects of the goiter were the commonest presenting features found in 473 (89.75%) patients. The mean duration of thyroid disorder was 11.85 +/- 3.41 years. Hypothroidism was the commonest biochemical abnormality found in 117 (22.20%) patients, while hyperthyroidism was found in 63 (11.95%) patients. Multinodular goitre was the most frequent disorder found in 439 (83.30%) patients. Subtotal thyroidectomy constituted the commonest surgical procedure performed in 398 (75.52%) patients. Temporary hypocalcaemia was the most common post-operative complication observed in 93 (17.64%) patients. The mean hospital stay was 4.76 +/- 2.14 days. There was no in-hospital mortality., Conclusion: Benign thyroid disorders are prevalent in our population and commonly affect the younger females. Majority of the patients have a family history of thyroid disorders. Most of the patients present with several years history of the disease. Subtotal thyroidectomy is the most frequently offered surgical procedure, which is safe.

Objective: To assess the clinical presentation and outcome of surgical management of various parotid gland disorders requiring parotidectomy., Study Design: Case series., Place and Duration of Study: Department of General Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad, from January 2003 to December 2010., Methodology: Patients presenting in surgical OPD with parotid gland disorders requiring parotidectomy were included. Data were obtained through the Hospital Management Information System (HMIS) and patient charts. The sociodemographic profile of the patient, presenting features among patients, benign versus malignant nature of the disease, FNAC reports, type of surgical procedure instituted, complications encountered and histology reports of the surgical specimens were all recorded on a proforma. The data were subjected to statistical analysis with SPSS version 15., Results: Out of 126 patients, 62 (49%) were males and 64 (51%) females with mean age of 41 ± 12.6 years. All had presented with a lump usually painless. One hundred and fourteen (90.47%) patients had benign pathology while 9.52% (n = 12) had malignanciy. Superficial parotidectomy was carried out in 79.36% (n = 100) patients, total parotidectomy in 19% (n = 24) and extended total parotidectomy was performed in 2 cases (with mucoepidermoid carcinoma). The most common post-operative complication was greater auricular nerve paresis (n = 19; 15%) followed by facial nerve transient paresis (n = 10; 8%). There was no in-hospital mortality., Conclusion: Parotid gland lumps commonly affect relatively young individuals of either gender. Most of the patients have benign pathology. Superficial parotidectomy is the most commonly offered surgical procedure. Parotid surgeries are safely performed in general surgery units with low morbidity and no mortality.

A 26 years old manual labourer from Azad Jammu Kashmir presented with four days history of an extensive exfoliation of skin involving the entire body. Histology of the lesion showed epidermal necrolysis. The patient was a recently diagnosed case of epilepsy and had been started on therapy with sodium valproate three weeks ago. Following admission in our center, intensive care and wound care were instituted according to standard protocols. Despite all therapeutic measures the patient kept on deteriorating and developed multi-organ failure with pneumonia. He died on 7th day of hospitalization.

Objective: To document and analyse the presentation and outcome of surgical management of liver trauma., Methods: The study was a retrospective review of records of all surgeries carried out at the Department of General Surgery, Pakistan Institute of Medical Sciences (PIMS), Islamabad, from January 2003 to December 2010. The study included all adult patients of either gender who presented with liver trauma and underwent operative management. Convenience sampling technique was employed. The study excluded patients who were managed conservatively. The data were collected through a proforma and analysed through SPSS 10., Results: Out of 113 cases of liver trauma, 91 (80.5%) were males and 22 (19.4%) were females. The mean age was 34.8 +/- 9.7 years. Road traffic accidents were the leading cause (n = 75; 66.3%) of injuries. There were 37 (32.7%) patients with grade I injury; 41 (36.2%) with grade II injury; 29 (25.6%) with grade III injury; and 7 (6.1%) patients with grade IV injury. Besides, 62 (54.8%) patients had associated extra-hepatic injuries. Majority of the patients presented with haemodynamic compromise (n = 97; 85.8%). Perihepatic packing was the commonest operative procedure instituted (n = 43;38%). The in-hospital mortality was 9.7% (n = 11)., Conclusion: Liver trauma constitutes an important cause of emergency hospitalisation, morbidity and in-hospital mortality in our population. It predominantly affects the younger males and road traffic accidents are the leading cause. Majority of the patients are successfully managed with perihepatic packing.

This study aims to document the epidemiologic pattern and outcome of burn injuries in the country's first national burn centre. This case series study was conducted over a 2-year period at Burns Care Centre (BCC), Pakistan Institute of Medical Sciences (PIMS), Islamabad. The study included all burn injury patients who primarily presented to and were managed at the centre. Those patients who presented more than 24 h after injury or those who were initially managed at some other hospital were excluded from the study. Initial assessment and diagnosis was made by thorough history, physical examination and necessary investigations. Patients with major burns, high voltage electric burns and those needing any surgical interventions were admitted for indoor management. Patients with minor burns were discharged home after necessary emergency management, home medication and follow-up advice. The sociodemographic profile of the patients, site of sustaining burn injury, type and extent (total body surface area (TBSA), skin thickness involved and associated inhalational injury) of burn and outcome in terms of survival or mortality, etc., were all recorded on a proforma. The data were subjected to statistical analysis. Out of a total of 13,295 patients, there were 7503 (56.43%) males and 5792 (43.56%) females. The mean age for adults was 33.63±10.76 years and for children it was 6.71±3.47 years. The household environment constituted the commonest site of burns (68%). Among all age groups and both genders, scalds were the commonest burns (42.48%), followed by flame burns (39%) and electrical burns (9.96%). The affected mean TBSA was 10.64±11.45% overall, while for the hospitalised subset of patients the mean TBSA was 38.04±15.18%. Most of the burns were partial thickness (67%). Inhalation injury was found among 149 (1.12%) patients. Most of the burns were non-intentional and only 96 (0.72%) were intentional. A total of 1405 patients (10.58%) were admitted while the remainder 11890 patients (89.43%) were managed on an outdoor basis. The mean hospital stay was 12.16±6.07 days (range 2-73 days). There were 197 deaths among the hospitalised patients constituting a 14% mortality rate for the hospitalised subset of patients, while there was an overall mortality rate of 1.48% for the entire study population., (Copyright © 2012 Elsevier Ltd and ISBI. All rights reserved.)

Objective: To determine the residents' rating of the quality of their residency training by measuring their level of satisfaction with the various educational attributes of their training., Study Design: Cross-sectional survey., Place and Duration of Study: Department of Medical Education (DME), Pakistan Institute of Medical Sciences (PIMS), Islamabad, from September to November 2008., Methodology: Residents who had been pursuing residency training for over a period of one year were included. A comprehensive questionnaire consisting of 14 questions was employed which covered fundamental attributes of the quality of postgraduate training. A five point response scale was used to rate responses to questions. Results for each of the measures of all the included residents were added up, and then an average was calculated and scaled to a score out of 100 to form the Index Score. In this way the residents' level of agreement or disagreement with the questioned statement was measured from 'Strongly disagree' (0%) to 'Strongly agree' (100%)., Results: Out of a total of 150 residents contacted, 109 answered the questionnaire. The response rate was thus 73%. Residents variably rated the various educational attributes of their residency training. Relatively favourably rated areas included regular conduct of case/ topic discussions (75.96%), consultant's supervision during interventional procedures (70.27%) and regularly holding journal clubs (69.54%). The less favourably rated areas included constructive feedback by supervisor (54.49%), consultant as role model (54.49%) and faculty as the source of learning (50.82%). Overall, the Index Score was 60.55%., Conclusion: Significant room exists for improvement in the quality of residency training as indicated by the less than desirable ratings of the various educational attributes of the residency programme. Faculty members who constitute the cornerstone of educational process are pivotal to effect the desired improvements.