Inter-observer variation of the Schatzker and Khan classification of Tibial plateau fractures: Cohort study.

OBJECTIVE: To compare the inter-observer reliability of Shatzker classification and Khan Classification of Tibial plateau fractures. METHODS: This retrospective cohort study was conducted at The Indus Hospital, Karachi, Pakistan. Radiographs of 50 patients who presented with tibial plateau fractures from March 2015 to November 2016 were collected. Two observers classified these cases independently according to Shatzker and Khan Classification. Gwet's AC1 statistics applied to assess inter-observer reliability of both the classification systems. RESULTS: Moderate inter-observer agreement for Schatzker classification (p<0.001) and slight inter-observer agreement on Khan Classification (p=0.738) was observed. CONCLUSIONS: Khan Classification is more comprehensive in classifying tibial plateau fractures and can be used for clinical research purpose, while Shatzker classification with better inter-observer reliability is applicable for routine clinical practice.

Nottingham Hip Fracture Score as a predictor of 3 months postoperative mortality in patients undergoing surgical fixation of hip fractures: A prospective study.

OBJECTIVE: Nottingham Hip Fracture Score was utilized to evaluate its efficacy to identify high risk pateints interms of 3 months postoperative mortality.NHFS comprises of seven independent predictors that were incorporated into a risk score to identify patients who were high risk for post-operative mortality with hip fracture.. METHODS: NHFS was prospectively calculated for 88 patients who underwent surgeries for hip fracture from 25th December 2014 to 25th June 2015 at the Indus Hospital Karachi. Both neck of femur and Intertrochanteric fracture were included. NHFS of ≤4 was considered as low risk and a score of ≥5 as high risk for mortality. RESULTS: The 3 months post-operative mortality was 22%. Increase in number of mortality was observed in patients who belonged to the high risk (NHFS ≥5) group, with statistically significant relationship when compared with the low risk (NHFS ≤4) group (p=0.01). CONCLUSIONS: NHFS can be used to predict the risk of 3 months postoperative mortality in patients undergoing hip fracture surgery.

Frequency of Vertebral Fractures in Patients presenting with Hip Fractures.

OBJECTIVE: To determine the frequency of vertebral fractures in patients presenting with hip fractures. METHODS: This prospective study was conducted at The Indus Hospital, Karachi, from May 2018 to November 2018. All patients above 40 years presenting with hip fractures were enrolled and a dorsal lumbar lateral view radiograph was obtained to investigate for vertebral fractures. Data was entered and analyzed using SPSS. Post-stratification, Chi-square/Fisher exact test was applied as appropriate to assess the significant association. P value of ≤0.05 was considered significant. RESULTS: Three hundred thirty five patients were enrolled. Of these, 189 (56.4%) were females and 165 (49.3%) presented with neck of femur fractures. Out of 335 hip fractures patients, 77 (23%) were found to have concomitant vertebral fractures, with 73 (96.1%) having a compression fracture. T12 was the most common vertebra involved and 68.8% of patients were asymptomatic. Co-morbid conditions were statistically significantly associated with vertebral fractures. CONCLUSION: There is a high prevalence of asymptomatic vertebral fractures in our population, but low compared to studies from western countries. There is a need to evaluate these fractures separately for the prevention of morbidity and mortality.

Slipped capital femoral epiphysis after treatment of femoral neck fracture.

Slipped capital femoral epiphysis (SCFE) in children after treatment of femoral neck fracture is a very rare condition. This complication should be recognized promptly and treated urgently. The risk of development of this complication can be minimized by anatomical reduction of the fracture and stable internal fixation of the fracture. Five years old male child sustained right sided femur neck fracture and was treated with closed reduction and Hip spica cast application. The fracture healed with a varus deformity. After 7 months, he developed slip of femoral epiphysis with a coxa vara deformity of proximal femur, which was treated with in situ fixation with Cannulated screws. His subsequent course remained uneventful up to five months. Slipped capital femoral epiphysis (SCFE) after treatment of femoral neck fracture in children is a rare complication that should be recognized and treated promptly. The onset of SCFE may show inadequate reduction or fixation of the fracture. Anatomic reduction and stable internal fixation for femoral neck fracture in children provides best outcomes. Postoperative care and delayed weight bearing are also equally important to avoid complications.

The frequency of Deep Vein Thrombosis in patients with hip fractures.

OBJECTIVE: To find out the frequency of deep vein thrombosis in hip fracture patients. Methods: The prospective, cross-sectional study Was conducted at Indus Hospital, Karachi, from November 2016 to September 2017, and comprised patients with hip fractures who were scanned for the presence of deep vein thrombosis on both lower limbs preoperatively at the time of presentation and postoperatively on post-op day 3 and day 28. No thrombo-prophylaxis was provided to the patients. Risk factors for deep vein thrombosis were also assessed. Data was analysed using SPSS 21.. Results: Of the 109 patients, 50(46%) were male and 59(64%) were females. The overall mean age was 64.59 ± 9.82 years. Deep vein thrombosis was found in 4(3.66%) patients; 2(50%) preoperatively and 2(50%) in the early postoperative period. No deep vein thrombosis was found in any patient on postop day 28.. Conclusion: The frequency of deep vein thrombosis in Pakistani geriatric patients with hip fractures was found to be low compared to the western population.

The pulley suture: A reliable option for closure of selected soft tissue defects under tension- three years experience of a tertiary care hospital.

OBJECTIVE: To assess the outcome of closure of soft tissue defects through pulley suture in different clinical situations. METHODS: The descriptive chart review was conducted at The Indus Hospital, Karachi, and comprised data from May 2008 to November 2011. A detailed questionnaire was developed to address variables of interest. All patients with less than three months of follow-up or inadequate information were excluded. The data was collected through Health Management Information System. Data was entered and analysed by SPSS 16. RESULTS: There were 259 patients with 289 wounds in the study. The mean age was 29.2±11.9 years. At follow-up of two weeks, there was wound dehiscence in 2.07%, infection in 0.69% and partial flap necrosis in 1.03% patients. At 12 weeks, hypertrophic scar was reported in 2.07% and stretched scar in 0.3% patients. Acute pain was not reported in the first week of surgery. Type of wound was found to have significant association with complications (p value<0.005). Age and gender were not found have any significant association with complications (p value 0.372 and 0.238 respectively). None of the patients reported scar tenderness at 12-week follow-up. Cosmetic outcome was acceptable to all patients. CONCLUSIONS: Judicious use of pulley suture can lead to primary closure of selected soft tissue defects under moderate tension. The technique, however, needs to be utilised by surgeons experienced in soft tissue reconstruction.

A comparative review of three techniques of syndactyly release.

OBJECTIVE: To compare the outcome of three techniques of congenital syndactyly release; to identify factors leading to difference in outcome, and to identify the incidence of neurovascular abnormalities in various types of syndactyly. METHODS: The chart review was conducted at The Indus Hospital, Karachi, and comprised data of all patients who had undergone syndactyly release between August 2008 and December 2014. Three techniques of release were included as described in literature by Bauer, Skoog and Niranjan. The data was collected through Health Management Information System. A detailed questionnaire was designed to address variables of interest. RESULTS: The age of the 29 patients with 50 webs in the study ranged from 2.2 to 17.1 years. The male to female ratio was 21:8. The complications encountered were web creep, skin flap necrosis, flexion deformity and contracture of joint. Single neurovascular bundle was found in 04(8%)webs and 45(90%) required skin graft for resurfacing of the digits. CONCLUSIONS: Bauer technique was found to be to be superior for web formation and there was low incidence of web creep compared to Skoog technique. Inclusion of syndromic cases may lead to increased complication and dissatisfaction rate. Tight closure of flaps should be avoided and generous use of skin grafts is advocated for success.

Protection of heel flaps with Ilizarov fixator as an elevation frame: A case series and review of literature.

OBJECTIVE: To compare outcome of Ilizarov fixator for protection of heel and foot flaps with that of plaster of Paris boot technique. METHODS: The retrospective chart review was conducted at The Indus Hospital, Karachi, and comprised data of patients who underwent flap reconstruction of the heel from January 2011 to December 2014. All patients had a minimum follow-up of 3 months. The patients using Ilizarov fixator were placed in group A and those with modified plaster of Paris boot as the elevation device were placed in group B. A detailed questionnaire was developed to note down the relevant variables. RESULTS: Of the 31 patients, 21(70%) were in group A and 10(30%) in group B. The modified boot was considered heavy (70%) compared to none in the Ilizarov group. The mean time of removal was 5.9 wks in group A and 4.8 weeks in group B. The mean time for use of Foley\'s catheter was 16.8 hours in group A and 14.8 hours in group B. There was significant number of associated bony injuries (33%) in group A and none in group B. Both groups were satisfied with the outcome. CONCLUSIONS: While Ilizarov technique is recommended for patients with extensive wounds along the heel and foot, obese patients and those non-compliant to the positioning protocol, careful use of modified plaster of Paris boot technique in relatively simpler situations of heel reconstruction with flaps is also very rewarding.

Cost-effectiveness of the Ponseti method for treatment of clubfoot in Pakistan.

BACKGROUND: Clubfoot is disabling, with an incidence of 0.9/1,000 live births to 7/1,000 live births. It affects mobility, productivity, and quality of life. Patients are treated surgically or non-surgically using the Ponseti method. We estimated the cost per patient treated with both methods and the cost-effectiveness of these methods in Pakistan. METHODS: Parents of patients treated, either surgically or with the Ponseti method, at the Indus Hospital's free program for clubfoot were interviewed between February and May 2012. We measured the direct and indirect household expenditures for pre-diagnosis, incomplete treatment, and current treatment until the first brace for Ponseti method and the first corrective surgery for surgically treated patients. Hospital expenditure was measured by existing accounts. RESULTS: Average per-patient cost was $349 for the Ponseti method and $810 for patients treated surgically. Of these, the Indus hospital costs were $170 the for Ponseti method and $452 for surgically treated patients. The direct household expenditure was $154 and $314 for the Ponseti and surgical methods, respectively. The majority of the costs were incurred pre-diagnosis and after inadequate treatment, with the largest proportion spent on transportation, material, and fee for service. The Ponseti method is shown to be the dominant method of treatment, with an incremental cost-effectiveness ratio of $1,225. CONCLUSIONS: The Ponseti method is clearly the treatment of choice in resource-constrained settings like Pakistan. Household costs for clubfoot treatment are substantial, even in programs offering free diagnostics and treatments and may be a barrier to service utilization for the poorest patients.

A comparison between orthopedic surgeon and allied health worker in pirani score.

OBJECTIVE: To assess the strength of agreement for each of the Pirani assessment categories between an orthopaedic surgeon and allied health worker on scoring clubfeet. METHODS: The descriptive cross-sectional study was conducted at the Indus Hospital, Karachi, from November 2012 to June 2013, comprised children below 12 months of age with untreated unilateral or bilateral clubfoot deformity an allied health worker, who was a plaster technician, was given 1-week training in the Pirani Scoring method. The feet were scored by the surgeon and the paramedic independently. SPSS 21 was used for statistical analysis. RESULTS: The study had 57 patients, and 92 feet were assessed. The difference between the means of score of each parameter, including the hind foot score and total score, was less than 0.09. The means of total score were found to be identical. Total Hind Foot Score was 0.48 and Total Score was 0.354. The statistical inter-observer reliability for all components was rated as substantial to moderate agreement except Equinus Rigidityand Total Score, which showed fair agreement. CONCLUSIONS: Pirani scoring method for clubfoot assessment was found to be a reliable tool for use by plaster technicians for independent assessment of clubfoot. However, prior training and supervision in the early phase is necessary.

Perception about braces in parents of children with clubfoot.

OBJECTIVE: To access the acceptability of Steenbeek brace by children undergoing clubfoot correction and their parents to ensure long-term compliance. METHODS: The cross-sectional study was conducted at the Indus Hospital, Karachi from October 2013 to March 2014. A trained researcher interviewed the person primarily responsible for bracing the child using a pre-coded questionnaire. Modified Orthotics Prosthetics User Survey for satisfaction with either the Mitchell brace of the Steenbeek brace was used. It included 11 questions in the Parent Bracing Satisfaction Survey. SPSS 21 was used for statistical analysis. RESULTS: Interviews were completed with 110 primary caregivers among whom 90(81.8%) were mothers. Overall, 32(29.1%) children were using the Mitchell brace, 30(27.3%) the Steenbeek brace, 46(41.8%) had shifted from Mitchell to Steenbeek brace, and 2(1.8%) had shifted from Steenbeek to Mitchell brace. Median duration of current brace usage was 4 and 3.5 months for Steenbeek and Mitchell braces respectively. The mean age of the child was 1.4 ±0.7 years, and the mean of 4-point Likerts cale score of parent bracing satisfaction was 28.7±2.2 in children on the Mitchell brace versus 28.5±1.9 for those on Steenbeek brace (p=0.505). Overall, 82(74.5%) parents had favourable attitude towards braces in general, but there were no significant differences in the items except "brace is easy to put on" (p=0.040) and "durability between Mitchell and Steenbeek groups" (p=0.017). CONCLUSIONS: There were no differences in satisfaction levels between the two types of brace users.

Significance of strontium ranelate in healing of surgically fixed tibial diapyseal fractures treated with strontium ranelate vs placebo; a randomised double blind controlled trial.

OBJECTIVE: To determine the surgical outcome of patients with axial cervical spine fractures. METHODS: The randomised double-blinded placebo-controlled clinical study was conducted at the Indus Hospital, Karachi, from August 2011 to August 2013. Patients were randomised to receive placebo or strontium ranelate postoperatively after surgical fixation of tibial diaphyseal fractures. Assessment of fracture healing was done clinically and radiologically at 30, 60 and 90 days. SPSS 21 was used for statistical analysis. RESULTS: Initially, 76 patients were enrolled, but 63(82.9%) completed the study. Out of 63 patients, 32(50.8%) were randomly assigned to group A and 31(49.2%) to group B, which was administered the placebo. Overall enhancement of fracture healing efficacy of strontium ranelate group was 20(62.5%) versus 9(29%) of the placebo group. CONCLUSIONS: Strontium ranelate was effective in enhancing fracture healing based on clinical and radiological assessment. Hence, it can be considered an effective therapeutic agent for accelerating fracture healing.

Anthropomorphic mismatch between distal femurs and a standard total knee replacement system in Pakistani population.

AIMS: To compare the measurements of distal femurs of a Pakistani population and with the implants used. METHODS: The single-centre prospective cross-sectional study was conducted at the Indus Hospital, Karachi, from 01-06-2011 to 31-10-2011, and comprised total knee replacement patients. Surgeries were performed by the same team. Each measurement was taken after the resection of the trochlea (flush to the anterior femoral cortex), the distal cut and the anterior chamfer cuts. Measurements were taken intraoperatively with a sterile vernier calliper. SPSS 17was used to analyse the data. RESULTS: The mean age of the 33 patients in the study was 59.3±7years. There were 4(12.1%) males and 29(87.9%) females. A mismatch was found in per-operative measurements with the mean aspect ratio being 0.79±0.05and the standardised aspect ratio of the implants being 0.90 (SD±0.0). CONCLUSIONS: There are differences between anthropomorphometry of our skeleton and Caucasian designed implants. This could have implications in the long term.

Anthropometry of Proximal Tibia in Patients Undergoing Total Knee Replacement at a Tertiary Care Hospital.

Introduction Total knee arthroplasty is the standard of care treatment for advanced knee osteoarthritis. However, patients frequently continue to have pain and disability after surgery, with one of the most common reasons being a bone-implant mismatch. Notably, there is a significant difference reported in proximal tibia morphometry between Asian and Caucasian populations, and the currently available implants do not account for the anthropometric variations observed across ethnicities. We aimed to evaluate the proximal tibia anthropometry in a Pakistani population. Materials and methods A study was conducted at The Indus Hospital, Karachi Campus, from August 2019 to July 2020. All consecutive patients fulfilling the eligibility criteria and undergoing knee replacement surgery were included in the study. Baseline characteristics and anthropometry of proximal tibia were recorded on a pre-designed proforma. Statistical analysis was done using SPSS version 24. Results  A total of 30 patients were enrolled in this study, which included 17 females (56.7%) and 13 males (43.3%). The mean age was 61.6± 7.9 years and the BMI was 33±5.7 kg/m2. There was a significant difference found in the anteroposterior and mediolateral dimensions in both genders. A significant association was noted with body mass index (p-value 0.01) and occupation (p-value=0.02). Conclusion The results indicated that the anatomical profile of the proximal tibia in the Pakistani population is distinct, thus stressing the fact that it requires developing prostheses specifically tailored to this population's sizing requirements.

Survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association.

A survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association conducted in 2022 found considerable variation in care across the region. A Call to Action is proposed to improve acute care, rehabilitation and secondary fracture prevention across Asia Pacific. PURPOSE: Fragility fractures impose a substantial burden on older people and their families, healthcare systems and national economies. The current incidence of hip and other fragility fractures across the Asia Pacific region is enormous and set to escalate rapidly in the coming decades. This publication describes findings of a survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association (APOA) conducted in 2022. METHODS: The survey was developed as a collaboration between the Asia Pacific Osteoporosis and Fragility Fracture Society and the Asia Pacific Fragility Fracture Alliance, and included questions relating to aspects of care upon presentation, during surgery and mobilisation, secondary fracture prevention, and access to specific services. RESULTS: In total, 521 APOA members completed the survey and marked variation in delivery of care was evident. Notable findings included: Fifty-nine percent of respondents indicated that analgesia was routinely initiated in transit (by paramedics) or within 30 minutes of arrival in the Emergency Department. One-quarter of respondents stated that more than 80% of their patients underwent surgery within 48 hours of admission. One-third of respondents considered non-hip, non-vertebral fractures to merit assessment of future fracture risk. One-third of respondents reported the presence of an Orthogeriatric Service in their hospital, and less than a quarter reported the presence of a Fracture Liaison Service. CONCLUSION: A Call to Action for all National Orthopaedic Associations affiliated with APOA is proposed to improve the care of fragility fracture patients across the region.

Percutaneous Achilles tendon tenotomy in clubfoot patients with a 22 gauge needle in a low-resource setting.

Ponseti treatment has been well-established as the gold standard for the treatment of idiopathic clubfoot in high-income countries and middle- and low-income countries (LMICs). The tenotomy is usually performed in the clinic using a scalpel blade under local anesthesia. However, we believe that by adapting the technique from Minkowitz et al. to a low-resource setting, we can help address some of the known barriers to Ponseti care. Using a needle instead of a blade makes the procedure less cumbersome easier to learn and easier to understand for the provider, family and the patient. We were able show that the needle tenotomy technique can be implemented in a low-resource setting like Pakistan, and can be performed using only one assistant and materials that are locally and readily available for the same cost This paper and its attached educational videos can help spread the technique among providers in low-resource settings.

A single-center, single-blinded, randomized, parallel-group, non-inferiority trial to compare the efficacy of a 22-gauge needle versus a 15 blade to perform an Achilles tendon tenotomy in 244 clubfeet-study protocol.

BACKGROUND: Achilles tendon tenotomy is an integral part of the Ponseti method, aimed at correcting residual equinus and lack of dorsiflexion after correction of the adductus deformity in clubfoot. Percutaneous tenotomy using a number 15 scalpel blade is considered the gold standard, resulting in excellent results with minimal complications. The use of a large-bore needle to perform Achilles tendon tenotomies has been described in literature, but a large-scale randomized controlled trial is currently lacking. In this trial, we aim to show the non-inferiority of the needle tenotomy technique compared to the gold standard blade tenotomy technique. METHODS: We will randomize 244 feet into group A: needle tenotomy or group B: blade tenotomy. Randomization will be done using a block randomization with random block sizes and applying a 1:1 allocation to achieve an intervention and control group of the exact same size. Children will be evaluated at 3 weeks and 3 months post-tenotomy for primary and secondary clinical outcomes. The primary clinical outcome will be the range of dorsiflexion obtained the secondary clinical outcomes will be frequency of minor and major complications and Pirani score. The non-inferiority margin was set at 4°, and thus, the null hypothesis of inferiority of the needle technique will be rejected if the mean difference between both techniques is less than 4°. The statistical analysis will use a multi-level mixed effects linear regression model for the primary outcomes and a multi-level mixed effects logistic regression model for the secondary clinical outcomes. The physician performing the evaluations post-tenotomy will be the only one blinded to group allocation. TRIAL REGISTRATION: This trial was registered prospectively with ClinicalTrials.gov registration number: NCT04897100 on 21 May 2021.

Serum Vitamin D Levels in Patients With Distal Radius Fractures Presenting to a Tertiary Care Hospital.

Objective To compare the frequency of serum vitamin D levels in patients with and without distal radius fracture. Introduction Hypovitaminosis D is a common problem worldwide. Deficiency of vitamin D is not only associated with musculoskeletal problems, but also with chronic diseases like diabetes mellitus, cardiovascular disease and cancer. Vitamin D deficiency results in bone pain, aggravating osteoporosis and fragility fractures. Distal radius fractures are common upper limb fractures, mostly in the elderly population. Low serum levels of vitamin D have been reported to result in increased risk of distal radius fracture. Methodology This study was conducted at The Indus Hospital Karachi, from 1st March 2020 to 31st August 2020. Consecutive non-probability sampling was done. Patients aged between 20 to 80 years with and without distal radius fractures were enrolled and serum vitamin D levels were compared. Results A total of 130 patients were enrolled in this study, out of which 70 (53.8%) were males. The median (IQR) vitamin D, calcium, alkaline phosphate level, and albumin was 14.8 (9.5-23) ng/ml, 9.2 (8.9-9.5) ng/ml, 91 (77.3-111) U/L, and 4.2 (4-4.5) g/dl, respectively. No significant association between distal radius fracture and vitamin D levels was found in males, whereas a significantly higher proportion of females with no fracture had a mild-moderate deficiency in comparison to females with fracture. Conclusion No significant association was noted between patients with and without distal radius fracture and vitamin D levels, however, we recommend more studies on this topic so that more comprehensive results can be obtained.

Eight-year Review of a Clubfoot Treatment Program in Pakistan With Assessment of Outcomes Using the Ponseti Technique: A Retrospective Study of 988 Patients (1,458 Clubfeet) Aged 0 to 5 Years at Enrollment.

OBJECTIVE: To conduct an 8-year retrospective review of a clubfoot treatment program using the Ponseti technique with close monitoring of outcomes. METHODS: Between October 2011 and August 2019, 988 children with 1,458 idiopathic clubfeet were enrolled, ages ranging from new born up to 5 years. Ponseti treatment was used, and progress was monitored by comparing mean Pirani scores at enrollment (P1), initiation of bracing (P2), and end of treatment (P3) or most recent visit (P4) for children under treatment. RESULTS: A statistically significant reduction in Pirani scores was noted (P < 0.001) for all feet. For 320 feet completing treatment (213 children), the mean Pirani scores reduced from P1: 3.8 (±1.1) to P2: 1.1 (±0.6) and finally to P3: 0.6 (±0.3). Four hundred sixteen children are currently undergoing bracing. Higher education of the head of household and male sex of the child were markedly associated with improved outcomes in foot correction status. Correction was obtained with a mean of 5.8 casts per foot, the tenotomy rate was 68.2%, and the mean duration of bracing in children completing treatment was 3.6 years (±0.9). No surgical correction, other than tenotomy, was required. Relapse was noted in 12.1% of the total enrolled feet, and 32.0% children were lost to follow-up from the entire cohort of 988 children. CONCLUSION: Clubfoot treatment requires long-term follow-up. A dedicated clubfoot program is effective in maintaining continuity of care by encouraging adherence to treatment.

Alkaline phosphatase as a screening test for osteomalacia.

BACKGROUND: Vitamin D deficiency remains common in children and adults in Pakistan despite adequate sunlight exposure. Diagnosis in adults is usually delayed and is made following pathological fractures that result in significant morbidity. The objective of this study was to see whether Serum Alkaline Phosphatase levels could be used as a screening test for osteomalacia. METHODS: The Study was conducted at Fatima Hospital, Baqai Medical University, Gadap, Karachi, between July 2002 and June 2005. Serum calcium levels are commonly used to screen patients suspected of osteomalacia, and raised serum alkaline phosphatase (SALP) is considered a diagnostic finding. We used SALP to screen patients who presented with back or non-specific aches and pain of more than six months duration. RESULTS: Three hundred thirty-four (334) patients were screened of which 116 (35%) had raised SALP. Osteomalacia was diagnosed in 92 (79.3%) of these 116 either by plain radiographs, bone biopsy or isotope bone scan. Fifty-four (53.4%) of the 101 cases had a normal level of serum calcium. CONCLUSIONS: Osteomalacia is likely to be missed if only serum calcium is used to screen patients. Serum Alkaline Phosphate should be used as the preferred method for screening these patients.