Monthly Archives: July 2013

Letter to Editor

 


Vol 1 | Issue 1 | July - Sep 2013 | page 42 | Shah KC, Shah PK


Dear Sir,

Every postgraduate doctor aspires to let the world know about his three years of hardwork- his Thesis. But many are unable to publish it because of lack of guidance, opportunity, complicated rules regarding manuscripts and a low acceptance rate. This venture by Indian Orthopaedic Research Group (IORG), overcoming all this, is a dream come true for all young researchers. Our heartiest congratulations to you on initiating the Journal of Medical Thesis.

With new rules and regulations from the universities and Medical Council of India, both stressing on research and publication, JMT provides an apt platform for publication of their first research document. Instead of an elaborate manuscript demanded by other journals, JMT needs submission only of an extended abstract. Also, JMT being a valuable repository of thesis, it will be a useful guide to all postgraduate students in the process of writing their dissertation and also improve its quality by avoiding plagiarism.

In this era of evidence based medicine and multidisciplinary approach towards patient care, JMT provides a one stop destination for all sub-specialities of medicine to come together to share, discuss and research together for the best patient outcome. In future multidisciplinary studies can be undertaken with the help of such varied and eminent faculty.

Overall JMT is an innovative answer to the need of the hour. We wish a very bright future for the journal.

Dr Kunal Shah,
Department of Orthopedics,
Sancheti Institute for Orthopaedics and Rehabilitation
Pune. India

Dr Prachi Shah,
Department of Anesthesia,
Government Medical College,
Surat. Gujarat, India


How to Cite this Article: Shah KC, Shah PK. Letter to Editor. Journal Medical Thesis 2013  July-Sep; 1(1):42

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kunal and prachi

 

 

 

 


 

Transtibial vs Anatomical tunneling techniques for arthroscopic ACL Reconstruction in non-athletic population


Vol 1 | Issue 1 | July - Sep 2013 | page 35-36 | Electricwala A, Latkar C, Patil S, Jog V, Mahajan A, Deshpande S


Author: Ali Electricwala1, Chintamani Latkar1, Sanjay Patil1, Vilas Jog1, Amit Mahajan1, Shantanu Deshpande1

Department of Orthopaedics, BharatiVidyapeeth University, Pune, India

Institute at which research was conducted: Bharati Vidyapeeth University, Pune, India.
University Affiliation of Thesis: BharatiVidyapeeth University, Pune, India.
Year of Acceptance: 2013

Address of Correspondence
Dr Ali Electricwala.
Department of Orthopaedics, BharatiVidyapeeth University, Pune, India
E mail: ali.electricwala@gmail.com


 Abstract

Background: Transtibial tunneling technique has been the gold standard for arthroscopic ACL reconstruction for many years,. Despite this high level of success, a growing body of literature has questioned whether this technique sufficiently re-creates the anatomy and function of the native ACL.This created a vogue amongst the arthoscopists for anatomical ACL reconstruction using the anteromedial portal. The purpose of this study was to compare the stability and functional outcome using both the techniques.
Materials and methods: 50 patients (39males and 11 females),all non-athletes with ACL deficient knees underwent ACL reconstruction, 25 by transtibial and 25 by anatomical technique. on the basis on stability using Lachman's and Slocum's tests and functional outcome using Lysholm knee score at 3,6 and 12 months.
Result: There was no significant difference in the Functional outcome (Lysholm Knee score), anteroposterior stability (Lachman's test) and rotational stability (Slocum's test){p values > 0.05}.
Conclusion: Both groups have equally good stability in both the anteroposterior and rotational plane.
Keywords: Transtibial tunnel, anatomical tunnel, non athelete, ACL injury

                                                        THESIS SUMMARY                                                             

Introduction:

Anterior Cruciate ligament (ACL) injuries of the knee are verycommantoday due increasing incidence of road traffic accidents and sports injuries. ACL autograft can be prepare dusing Bone-Tendon-Bone (BTB) or Hamstring graft harvest. For ACL reconstuction,tibial tunnel is prepared using a standard jig.The femoral tunnel can be prepared either through the tibial tunnel(Transtibial) or through the anteromedial portal(Anatomical).Transtibial tunneling technique has been the gold standard for arthroscopic ACL reconstruction for many years. Despite this high level of success, a growing body of literature has questioned whether this technique sufficiently re-creates the anatomy and function of the native ACL. The advantage of anteromedial portal are femoral and tibial tunnels are drilled independently of each other,allows preservation of any remaining intact ACL fibers, allowing isolated reconstruction of the anteromedial or posteriolateral bundle ,revision can be done using a new anatomical femoral tunnel and femoral end can be positioned at ideal 10 or 2 o clock positions ensuring better rotational stability .The advantages of transtibial technique are straight guide wire tunnel ,technically easy, Longer and less oblique tunnel giving better AP stability and endobutton is resting on good cortical bone .The disadvantages of anteromedial portal are shorter tunnel hence less AP stability ,risk of peroneal nerve injury ,femoral tunnel must be drilled with the knee in hyperflexion (130 to 140 degrees) ,visualization in the notch is obscured when the knee is placed in hyperflexion, due to poor circulation of the arthroscopic inflow fluid and debris from drilling the femoral tunnel and dragging of the fat pad into the femoral notch ,technically more demanding ,endobutton is resting on the cortex of cancellous bone and working with the knee in hyperflexion causes a loss of the normal anatomical relationships in the notch, leading to spatial disorientation. Advantages of the transtibial tunnel technique are that it is familiar to most surgeons, it is simple and quick and it does not require the knee to be flexed beyond 90° of flexion when the femoral tunnel is drilled. The major disadvantage of the transtibial tunnel technique is that it is not possible to independently drill the ACL femoral tunnel. Anatomical and clinical studies have demonstrated that the transtibial tunnel technique tends to place the tibial tunnel too posterior and the femoral tunnel too high and deep in the intercondylar notch.The purpose of our study was to compare the stability and functional outcome achieved with each technique in non-athletic population.

Materials and methods:

50 patients (39males and 11 females),all non-athletes with ACL deficient knees underwent ACL reconstruction, 25 by transtibial and 25 by anatomicaltechnique.This was a randomized control trial. All patients were operated by a single surgeon. Patients from both the groups were evaluated on the basis on stability using Lachman's and Slocum's tests and functional outcome using Lysholm knee score at 3,6 and 12 months.The duration of study was 3 years. All surgeries were performed under spinal anesthesia under tourniquet control.Quadrupled hamstring graft (Semitendinosus and Gracilis) was used.Thetibial tunnel was prepared using a standard tibial angle guide. The femoral tunnel was drilled either through the tibial tunnel(Transtibial technique) or the anteromedial portal(anatomical technique).The tibial side of the graft was fixed using an interference screw and the femoral tunnel with either interference screw or endobutton.The graft was cycled 15 to 20 times before closure of portals. All patients underwent a same physiotherapy protocol.

Results:
Demographic data was comparable in both groups. The the mode of injury and injury to surgery interval was similar in both groups.the length of femoral tunnel was similar in both groups.there was no statistical difference in range of motion at 3 ,6 and 12 month.There was no significant difference in the Functional outcome (Lysholm Knee score), anteroposterior stability (Lachman's test) and rotational stability (Slocum's test){p values > 0.05}.

Conclusion:
From our study we conclude that-
1) Both groups have equally good stability in both the anteroposterior and rotational plane.
2) Both groups have a good functional outcome in non-athletic group of individuals.

Key Words:
transtibial tunnel, anatomical tunnel, non athlete, ACL injury

Bibliography:

1. Aglietti P, Buzzi R, Menchetti PM, Giron F. Arthroscopically assisted semitendinosus and gracilis tendon graft in reconstruction for acute anterior cruciate ligament injuries in athletes. Am J Sports Med 1996; 24: 726-31.
2. Arnold MP, Kooloos J, van Kampen A (2001) Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study. Knee Surg Sports TraumatolArthrosc 9:194–199
3. Bedi A, Altchek DW; The "footprint" anterior cruciate ligament technique: an anatomic approach to anterior cruciate ligament reconstruction.Arthroscopy. 2009 Oct;25(10):1128-38.
4. Gonzalo Samitier, Pedro Álvarez; Anteromedial portal versus transtibial drilling techniques in ACL reconstruction: a blinded cross-sectional study at two- to five-year follow-up; INTERNATIONAL ORTHOPAEDICS; Volume 34, Number 5 (2010), 747-754.
5. Behrendt S, Richter J. Anterior cruciate ligament reconstruction: drilling a femoral posterolateral tunnel cannot be accomplished using an over-the-top step-off drill guide. Knee Surg Sports TraumatolArthrosc. 2010; 18(9):1252-1256.
6. Brophy RH, Pearle AD. Single-bundle anterior cruciate ligament reconstruction: a comparison of conventional, central, and horizontal single-bundle virtual graft positions. Am J Sports Med. 2009; 37(7):1317-1323.
7. Jepsen CF, Lundberg-Jensen AK, Faunoe P; Does the position of the femoral tunnel affect the laxity or clinical outcome of the anterior cruciate ligament reconstructed knee? A clinical, prospective, randomized, double-blind study. Arthroscopy. 2007 Dec;23(12):1326-33.
8. Pearle AD, Shannon FJ, Granchi C, Wickiewicz TL, Warren RF; Comparison of 3-dimensional obliquity and anisometric characteristics of anterior cruciate ligament graft positions using surgical navigation; Am JSports Med. 2008 Aug;36(8):1534-41.
9. Omer A.Ilahi, N. JanetVentura, Amad A.Qadeer; Femoral Tunnel Length: Accessory Anteromedial Portal Drilling Versus Transtibial Drilling; Arthroscopy. 2012 Apr; 28(4):486-91.
10. Arnold MP, Kooloos J, van Kampen A (2001) Single-incision technique misses the anatomical femoral anterior cruciate ligament insertion: a cadaver study. Knee Surg Sports Traumatol Arthrosc 9:194–199.
11. Pearle AD, Shannon FJ, Granchi C, Wickiewicz TL, Warren RF; Comparison of 3-dimensional obliquity and anisometric characteristics of anterior cruciate ligament graft positions using surgical navigation; Am JSports Med. 2008 Aug;36(8):1534-41.
12. Behrendt S, Richter J. Anterior cruciate ligament reconstruction : drilling a femoral posterolateral tunnel cannot be accomplished using an over-the-top step-off drill guide. Knee Surg Sports TraumatolArthrosc. 2010; 18(9):1252-1256.


How to Cite this Article: Electricwala A, Latkar C, Patil S, Jog V, Mahajan A, Deshpande S. Transtibial vs Anatomical tunneling techniques for arthroscopic ACL Reconstruction in non-athletic population. Journal Medical Thesis 2013  July-Sep; 1(1):35-36

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Art 13 JMT July Sep 2013

Art 13 JMT July Sep 2013 2nd half

Management of Diaphyseal Fractures of Long Bones in Children with Intramedullary Flexible Nail Nailing


Vol 1 | Issue 1 | July - Sep 2013 | page 37-41 | Sachdeva G, Kamble S


Author: Gaurav Sachdeva1, Suhas Kamble1

Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Maharashtra, India.
Institute at which research was conducted: Padmashree Dr. D. Y. Patil Medical College, Pune, India.
University Affiliation of Thesis: D. Y. Patil University.
Year of Acceptance: 2012

Address of Correspondence
Dr. Gaurav Sachdeva
Department of Orthopaedics, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune, Maharashtra, India.
E mail: g_s2001in@yahoo.com


 Abstract

Background: Ideally, fixation of paediatric diaphyseal fractures should produce an “internal splint” that shares loads, maintains reduction until hard callus formation, and does not endanger the growth areas or blood supply. Results from several studies have shown that FIN / TENS fixation meets these requirements because it allows rapid mobilization, potentially no risk for osteonecrosis, low risk for physeal injury, and reduced risk for refracture. ESIN meets the requirements of this ideal device.
Materials and methods: 31 cases of Diaphyseal fractures in 30 Patients were included. Final outcome was graded excellent, satisfactory or poor based on criteria described by Flynn et al.
Result: The results according to Flynn et al were Excellent in 26 patients (86.67%) , Satisfactory in 3 patients (10%),and Poor in 1 patient (3.33%).
Conclusion: Enders nailing is a simple and useful technique for stabilization of Diaphyseal fractures in longbones in children as it permits adequate rotational stabilization.

Keywords: Diaphyseal fractures, titanium elastic nail, intramedullary nail, children

                                                        THESIS SUMMARY                                                             

Introduction:

Recently there has been a growing trend towards surgical treatment of Diaphyseal fractures in children .To some extent this reflects a more interventionist attitude
among Orthopaedic Surgeons but is also due to technical development, notably that of ESIN(Barry & Paterson, 2004).The treatment for children between the ages of 6 and 10 years is the most controversial. Many such patients may be treated successfully with immediate closed reduction & casts. However, external fixation and flexible intramedullary rod fixation are being used more frequently, particularly in patients with multiple trauma.However, in older children and adolescents operative treatment should be considered to avoid complications such as delayed union, malunion, rotational deformity, refracture, knee stiffness, limb length discrepancy and psychosocial problems.Operative treatment results in shorter hospitalization and early mobilization, which has psychological, social, educational and economic advantages over conservative treatment. A variety of therapeutic alternatives mentioned above such as external fixator, compression plating, rigid Intramedullary nailing and elastic stable intramedullary nailing are being used for Diaphyseal fractures in children.
With the use of external fixator, there is a high incidence of pin tract infection, refracture after removal of external fixator. Also the external fixator is more uncomfortable and cumbersome for the child (Linhart & Roposch, 1999)Submuscular Compression plating needs two major operations - one for insertion and another one for the removal of the plate (Gonzalez et. al.1995).Rigid intramedullary nails have their own pros and cons. They not only increases risk of AVN of femoral head in children and adolescents (Thometz and Lamdan, 1995), but also there is a high incidence of abnormalities at the proximal end of the femur including coxa valga, arrest of growth of greater trochanter, thinning of the neck of the femur because of damage to trochantero-cervical region.
Ideally, fixation of paediatric diaphyseal fractures should produce an “internal splint” that shares loads, maintains reduction until hard callus formation, and does not endanger the growthareas or blood supply. Results from several studies have shown that FIN / TENS fixation meets these requirements because it allows rapid mobilization, potentially no risk for osteonecrosis, low risk for physeal injury, and reduced risk for refracture. ESIN meets the requirements of this ideal device (Flynn et al. 2001).
Upper age limit for ESIN in Pediatric Diaphyseal fracture is until the time of closure of the proximal growth plate after which conventional rigid locked intramedullary nailing can be used safely. Sanders J.O et al (2001) The choice of treatment may be influenced by the age of the child, the level and pattern of the fracture and to a great extent, by regional, institutional or surgeons preferences.

Materials and methods:

This is a Prospective Study based on patients admitted with Diaphyseal Fractures in Long Bones in the age group of 6 years - 16 years The study was done on 31 cases of Diaphyseal fractures in 30 Patients.all Recent Diaphyseal fracture of Transverse, short oblique, minimally comminuted type were included. Postoperative data collected was no. of nails, postoperative immobilization, period of hospital stay, period of radiological union , return to normal work, any complication , time to nail removal. Radiographs were evaluated for alignment, nail size, nail shape (C or S), callus formation, nail position, and measurement of fracture location . Final outcome was graded excellent, satisfactory or poor based on criteria described by Flynn et al.

Results:
The results according to Flynn et al were Excellent in 26 patients (86.67%) , Satisfactory in 3 patients (10%),and Poor in 1 patient (3.33%). Only 3 patients (10.03%) had complication in the form of skin erosion (superficial infection). 23 patients (76.67%) had radiological callus within 8 weeks of operation, while 7 patients (23.33%) had there
radiological callus by 12 weeks .24 patients (80%) had a hospital stay of upto 10days , while only 6 patients (20%) had a stay of more than 10 days. The geometry of fracture was Transverse (54.80%), Oblique (22.60%) and unicortical communition (12.90%).

Conclusion:
The following conclusion could be drawn from the present study:
1) Enders nailing is a simple and useful technique for stabilization of Diaphyseal fractures in long bones in children as it permits adequate rotational stabilization.
2)It is suitable for short oblique or transverse fractures and fractures with unicortical comminution. Unstable fractures with long obliquity or significant comminution are not suitable for
stabilization with Enders nailing on account of its relatively poor longitudinal stability.
3)Early callus formation and better healing time following use of Enders nail indicates advantages of undreamed nails over plating osteosynthesis and external fixator in fracture healing, specially
in fresh fractures.
4)Minimum of two Enders nails with use of both medial & lateral portals is desirable to provide adequate rotational stability and to counteract the angular stresses produced in humerus, femur and tibia. One nail is sufficient in radius & ulna.
5)Significant incidence of distal migration of the nail and knee pain at a later stage is one the limiting factor of Enders Nail in Diaphyseal fracture in long bones in children which can be prevented by use of a locking 4mm screw / K-wire through the eye of enders nail. However disappearance of symptoms with nail removal does neutralize these problems to some extent, though, one has to wait till sound bony union before the nails can be removed.

Elastic stable intramedullary nailing is an excellent method of managing most, but not all, pediatric diaphyseal fractures that need operative stabilization. It is by no means the only technique nor is there evidence yet that it is superior to other methods. Its advantages make it a valuable choice to consider in managing these fractures. Ultimately, the choice should reflect best evidence and also incorporate patient
preferences.

Key Words:
Diaphyseal fractures, titanium elastic nail, intramedullary nail, children

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62. Garg S, Matthew BD, Perry LS, Scott JL, Gordon JE. Surgical treatment of traumatic pediatric humeral diaphyseal fractures with titanium elastic nails. J Child Orthop 2009 April; 3(2): 121–127.
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64. Weiss JM, Choi P, Ghatan C, Skaggs DL, Kay RM. Complications with flexible nailing of femur fractures more than double with child obesity and weight >50 kg. J Child Orthop 2009 Feb; 3(1): 53-8.
65. Saseendar S, Menon J, Patro D. Treatment of femoral fractures in children: is titanium elastic nailing an improvement over hip spica casting?. J Child Orthop 2010; 4(3):245–251.
66. Fernandez FF, Eberhardt O, Wirth T. Elastic stable intramedullary nailing as alternative therapy for the management of paediatric humeral shaft fractures Z Orthop Unfall. 2010 Jan;148(1):49-53.
67. Nishikant K, Laljee C. Titanium Elastic Nails for Pediatric Femur Fractures: Clinical and Radiological Study. Surgical Science 2010; 1: 15-19.
68. Iqbal M, Manzoor S, Cheema GM, Ahmed E. Comparative Study of Fracture Shaft of Femur in Children Treated with Titanium Elastic Nail and Early External Fixator. Annals 2010 Apr – Jun; 16(2): 82-86.
69. Sink EL, Francis F, John P, Katherine F, Jane Gralla. Decreased Complications of Pediatric Femur Fractures With a Change in Management. J Pediatric Orthop 2010 October/November; 30 (7): 633–637. 82
70. Navdeep S, Kanav P, Suhail V, Harish D. Closed reduction and internal fixation of fractures of the shaft of the femur by the Titanium Elastic Nailing System in children. The Internet Journal of Orthopedic Surgery. 2010; 17(1).
71. Kanthimathi B, Kumar AK. Flexible Intramedullary Nailing for Paediatric Shaft of Femur Fractures – Does the Number of Nails Alter the Outcome? . Malaysian Orthopaedic Journal 2011;5(2): 28-33.
72. Hosalkar HS, Nirav KP, Robert HC, Glaser DA, Morr MA, Herman MJ. Intramedullary Nailing of Pediatric Femoral Shaft Fracture; J Am Acad Orthop Surg August 2011; 19:472-481.
73. Brinker MR, Cook SD, Dunlap JN, Christakis P, Elliot MN. Early Changes in Nutrient Artery Blood Flow Following Tibial Nailing With and Without Reaming: A Preliminary Study. Journal of Orthopaedics Trauma 1999 Feb; 13(2): 129-133.
74. Muller, AllogwerM, Willeneger H – Manual of Internal Fixation, Berlin , Spinger,1977
75. lynn JM, Skaggs DL, Sponseller PD, Ganley TJ, Kay RM, Kellie KK. The operative management ofpediatric fractures of the lower extremity. J Bone Joint Surg Am. 2002; 84: 2288–300.


How to Cite this Article: Sachdeva G, Kamble S. Management of Diaphyseal Fractures of Long Bones in Children with Intramedullary Flexible Nail Nailing.  Journal Medical Thesis 2013  July-Sep; 1(1):37-41

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Art 14 JMT July Sep 2013

 

 

A Comparative Study Of Chlorhexidine-Alcohol Versus Povidone-Iodine For Surgical Site Antisepsis In Clean & Clean Contaminated Cases


Vol 1 | Issue 1 | July - Sep 2013 | page 33-34 | Patil RA, Gaikwad VV, Kulkarni RM


Author: Ranjeet A. Patil1, V. V. Gaikwad1, R. M. Kulkarni1

Department Of General Surgery, D. Y. Patil Medical College, D. Y. Patil University, Kolhapur.

Institute at which research was conducted: D. Y. Patil Medical College, D. Y. Patil University, Kolhapur, India.
University Affiliation of Thesis: D. Y. Patil University.
Year of Acceptance: 2012

Address of Correspondence
Dr. Ranjeet Patil
Department of General Surgery, D. Y. Patil Medical College, D. Y. Patil University, Kolhapur, India.
E mail: ranjeet04@yahoo.com


 Abstract

Background: Surgical Site Infections are the third most commonly reported nosocomial infections all over the world. Despite the advances made in preoperative asepsis, patients subjected to operations naturally have to face the risk of complications due to infections. Patient's skin is a major source of pathogens that cause Surgical Site Infection
Materials and methods: Our study compares the efficacy of Chlorhexidene-Gluconate (2.5%) & Isopropyl Alcohol (63%) to Povidone-Iodine (5%) in preventing surgical site infections in 508 clean and clean contaminated cases. Patients were preoperatively evaluated which included Medical & Surgical history, Physical Examination, Routine hematologic and blood chemical laboratory tests. This study is conducted as a single blinded Randomised control trial.
Results: Our results showed that Surgical Site Infections are significantly less in Chlorhexidene-Alcohol group of patients than in Povidone-Iodine group(9.96% vs 15.95 p<0.05).
Conclusion: Chlorhexidene - Alcohol is more efficacious than Povidone-Iodine in preventing Surgical Site Infections in Clean & Clean Contaminated Cases.

Keywords: Chlorhexidine-Alcohol, Povidone-iodine, Surgical Site infection

                                                        THESIS SUMMARY                                                             

Introduction:

Surgical Site Infections are the third most commonly reported nosocomial infections all over the world [1]. Despite the advances made in preoperative asepsis, patients subjected to operations naturally have to face the risk of complications due to infections. Patient's skin is a major source of pathogens that cause Surgical Site Infection .Povidone-Iodine (5%) is been used for preoperative skin preparation in surgeries since 1955 and is preferred universally. But even then a surgical site infection is a major complication it fails to control completely.Chlorhexidene has been widely used as oral antiseptic solution in mouth washes. Chlorhexidene-Alcohol with its increased efficacy has been recently made available all over as an antiseptic and disinfectant[2]. This study compares the efficacy of Chlorhexidene-Gluconate (2.5%) & IsopropylAlcohol (63%) to Povidone-Iodine (5%) in preventing surgical site infections in clean and clean contaminated cases.

Materials and methods:

This is a single blind prospective randomized controlled study conducted on 508 patients. Patients undergoing proposed clean & clean-contaminated surgery with no focus of infection on the body were admitted The study included patients above 18 years of age, undergoing clean & clean-contaminated surgery in department of general surgery and orthopaedics.The study excluded patients with proposed Contaminated and Dirty wounds or patients with history of allergy to Chlorhexidene, Alcohol or Iodophorers or evidence of infection at or adjacent to operative site or perceived inability to follow the patients' course for 30 days after surgery or for 1 year in case of implants and patients who did not give consent.

Results:
A total of 740 subjects were randomly assigned to a study group, 352 to the Chlorhexidine–alcohol group and 388 to the Povidone–iodine group (Fig. 1). Of the 740 subjects who qualified for the analysis, 251 received Chlorhexidine–alcohol and 257 received Povidone–iodine.232 subjects were excluded from the per protocol analysis: 57 underwent Class III (Contaminated) and Class IV (Dirty) rather than Clean and Clean-contaminated surgery. 175 subjects (76 in the Chlorhexidine–alcohol group and 99 in the Povidone–iodine group) did not complete follow-up protocol. Therefore, 508 subjects (251 in the Chlorhexidine–alcohol group and 257 in the Povidone–iodine group) were included in the per-protocol analyses. The subjects in the two study groups were similar with respect to demographic characteristics, coexisting illnesses, risk factorsfor infection, preoperative antimicrobial prophylaxis and duration and types of surgery.

Conclusion:
The infection rates observed in Chlorhexidine-alcohol and Povidone-iodine in present study were 9.96% and 15.95% respectively. This difference in infection rates is statistically significant. This proves the hypothesis that Chlorhexidine is superior to Povidone iodine. The superiority of Chlorhexidine alcohol can be attributed to its various properties such as Chlorhexidine leaves a protective film whereas Povidone-iodine leaves no film once rinsed off the skin leading to longer residual action Presence of blood or serum protein does not alter Chlorhexidine-alcohol's bactericidal activity. Chlorhexidine-alcohol has rapid lethal action against both transient and resident flora, especially on anaerobic bacteria.Therefore it can be safely concluded that Chlorhexidine-alcohol can be used for preoperative skin preparation as an alternative to Povidone-iodine in clean and clean-contaminated surgeries. Since the superiority of Chlorhexidine-alcohol was proved in decreasing incision site colonization and postoperative wound infection, it would be prudent to use this regimen in contaminated and emergency surgeries as well.

Key Words:
Chlorhexidine-Alcohol, Povidone-iodine, Surgical Site infection.

Bibliography:

1. N P Patel. “Antimicrobial Agents for Surgical Infections.” Surgical Clinics of North America April2009; 89: 365-90.
2.C F Brunicardi,“Surgical Infections.” Schwartz's Principles of Surgery, McGraw Hill Company, 9th International edition, 2010p. 132-88.
3.R O Darouiche “Chlorhexidine–Alcohol versus Povidone–Iodine for Surgical-Site Antisepsis” New England Journal of Medicine; 36; 2010:218-26.
4. NChaiyakunapruk. “Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis”. Ann Intern Med; 136, 2002:792-801.
5.L J Hayek. “A placebo-controlled trial of the effect of two preoperative baths or showers with Chlorhexidine detergent on postoperative wound infection rates.” J HospInfect.Sep; 10(2); 1987:165-7
6. P J Culligan. “A randomized trial that compared povidone iodine and chlorhexidine as antiseptics for vaginal hysterectomy.” American Journal of Obstetrics and Gynecology, Feb; 192(2); 2005: 422-25.
7. VPaocharoen. “Comparison of surgical wound infection after preoperative skin preparation with 4% chlorhexidine [correction of chlohexidine] and povidone iodine: a prospective randomized trial”. J Med Assoc Thai; 92(7); 2009:898–902.
8. OMimoz. “Chlorhexidine-Based Antiseptic Solution vs Alcohol-Based Povidone-Iodine for Central Venous Catheter Care”. Evid Based Nurs, 13:2010: 36-37.


How to Cite this Article: Patil RA, Gaikwad VV, Kulkarni RM. A Comparative Study of Chlorhexidine-Alcohol Versus Povidone-Iodine For Surgical Site Antisepsis In Clean & Clean Contaminated Cases.  Journal Medical Thesis 2013  July-Sep; 1(1):33-34

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Art 12 JMT July Sep 2013

Functional Evaluation of Proximal Humerus Fracture Managed by Locking Plate


Vol 1 | Issue 1 | July - Sep 2013 | page 29-32 | Gangurde YS, Mahajan NP, Sonawane DV


Author: Yogesh Savliram Gangurde1, Neetin Pralhad Mahajan1, Dhiraj Vithal Sonawane1

1Grant Medical College And Sir J.J.Group Of Hospitals Mumbai, India
Institute at which research was conducted: Grant Medical College And Sir J.J.Group Of Hospitals Mumbai, India
University Affiliation of Thesis: Maharashtra University of Health Sciences
Year of Acceptance: 2012

Address of Correspondence
Dr. Yogesh Savliram Gangurde
Dept. Of Orthopaedics , Sir J.J. Group Of Hospital, 2nd Floor Main Building. Mumbai, Maharashtra, India.
E mail:dryogeshg18@gmail.com


 Abstract

Background: Our study is planned to evaluate functional evaluation of proximal humeral fractures treated with open reduction and internal fixation with locking plates in view of range of movement, possible returns of basic functions around shoulder girdle, radiological outcome and resultant remaining disability in the course of healing and after completion of healing.
Materials and methods: Over two and half years 35 patients with proximal humerus fractures were managed With locking plate .34 of them completed mean follow up 11months and evaluated using SPADI score.
Result: Average SPADI score for different fracture type according to Neers classification were suggestive of there is no statistically significant difference between these fracture types managed with locking plate. We found approximately equal Mean SPADI score in all 2 part, 3 part and 4 part fractures. Overall functional outcome found to be moderate to good in 92% of our patient but 8% patient had poor outcome due to associated complications postoperatively.
Conclusion: Proximal humeral locking plate is an exciting new method of osteosynthesis for complex proximal humerus fractures allowing early mobilization, good functional outcome and is a superior treatment option to hemiarthoplasty.

Keywords: Proximal humerus locking plate, SPADI score.

                                                        THESIS SUMMARY                                                             

Introduction:

Fractures of the proximal humerus are representing no more than 3% of all upper extremity fractures and approximately 4% to 5% of all fractures.1
Three fourths of the fractures occur in older individuals with an occurrence three times more often in women than in men .
Severely displaced and comminuted fractures warrant surgical management for optimum shoulder function.
Traditional surgical treatment methods include percutaneous or minimally invasive techniques such as pinning, osteosynthesis using cancellous screws , open reduction and internal fixation with proximal humeral plates, and the use of intramedullary nails, hemiarthroplasty .
Various complications associated with above methods are implant failure, loss of reduction, non-union or malunion of the fracture, impingement syndrome, and osteonecrosis of the humeral head.
The key to this technology is fixed angle relationship between the screws and plate.
Even biomechanical analysis studies have showed the superiority of such locking fixation .
Therefore our study is planned to evaluate functional evaluation of proximal humeral fractures treated with open reduction and internal fixation with locking plates in view of range of movement, possible returns of basic functions around shoulder girdle , radiological outcome and resultant remaining disability in the course of healing and after completion of healing.

Materials and methods:

Over two and half years 35 patients with proximal humerus fractures were managed All patients with age between 20 and 60 years and Closed two part post traumatic fracture with major Humeral diaphyseal displacement or three or four part fracture with tuberosity displacement enough to cause significant subacromial impingement were included.they were treated with with locking plate . Patients were evaluated on OPD basis at 6 weeks, 12 weeks,6 months and 1 year follow up visit standard AP and axillary radiographs were obtained and All radiographs were evaluated for fracture healing ,implant related problems- screw perforation, screw loosening or backing out, plate pullout or breakage,anatomical alignment- major varus or valgus and evidence of postoperative osteonecrosis. Functional outcome was assessed using Shoulder Pain And Disability Index (SPADI) score at each follow up done at 6 week, 3 month. 6 month and 1 year
34 of them completed mean followup 11months and evaluated using SPADI score. The statistical analysis was done using SPSS 17th Edition.

Results:
All fractures united with average time taken for union was approximately 3 months.
Average SPADI score for different fracture type according to Neers classification were suggestive of there is no statistically significant difference between these fracture types managed with locking plate.
On comparison with respect to age distribution patients in 6 th decade shows comparatively low functional outcome as compare to lower age group.
In four patients we have found complications which are screw penetration, impingement, implant failure and infection. We found approximately equal Mean SPADI score in all 2 part, 3 part, 4 part fractures .But Mean SPADI score in 6 th decade is on higher side as compare to 3rd, 4th,5th decade.
overall functional outcome found to be moderate to good in 92% of our patient but 8% patient had poor outcome due to associated complications postoperatively.

Conclusion:
We believe that a reproducible standard surgical technique is necessary for improved patient outcome..Proximal humeral locking plate is an exciting new method of osteosynthesis for complex proximal humerus fractures allowing early mobilization, good functional outcome and is a superior treatment option to hemiarthoplasty.

Key Words:
Proximal humerus locking plate, SPADI score.

Bibliography:

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2. Ralph Hertel Lindenhofspital, Berne, Fractures of the proximal humerus in osteoporotic bone Osteoporos Int. 2005 Mar;16 Suppl 2:S65-72. Epub 2004 Oct 30.
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4. Nho SJ, Brophy RH, Barker JU, Cornell CN, MacGillivray JD. Innovations in the management of displaced proximal humerus fractures. J Am Acad Orthop Surg. 2007 ;15(1):12-26.
5. Wijgman AJ, Roolker W, Patt TW, Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus J Bone Joint Surg Am 2002 01;84(11):1919-1925.
6. Gerber C, Werner CM, Vienne P Internal fixation of complex fractures of the proximal humerus. J Bone Joint Surg Br. 2004 Aug ,848-55. Department of Orthopaedics, University of Zürich, Balgrist, Switzerland.
7. Esser RD. Open reduction and internal fixation of three- and four-part fractures of the proximal humerus. Clin Orthop Relat Res. 1994 Feb;(299):244-51.
8. Paavolainen P, Björkenheim JM, Slätis P, Paukku P. Operative treatment of severe proximal humeral fractures. Acta Orthop Scand. 1983 Jun;54(3):374-9.
9. Aggarwal S, Bali K, Dhillon MS, Kumar V, Mootha AK Displaced proximal humeral fractures: an Indian experience with locking plates J Orthop Surg Res. 2010 5:60.
10. Südkamp N, Bayer J, Hepp P, et al Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am 2009 01;91(6):1320-1328.
11. Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Szyszkowitz R A new locking plate for unstable fractures of the proximal humerus. Clin Orthop Relat Res. 2005 Jan;(430):176-81.
12. Koukakis A, Apostolou CD, Taneja T, Korres DS, Amini A. Fixation of proximal humerus fractures using the PHILOS plate: early experience. Clin Orthop Relat Res. 2006 Jan;442:115-20.
13. Kettler M, Biberthaler P, Braunstein V, Zeiler C, Kroetz M, Mutschler W. Treatment of proximal humeral fractures with the PHILOS angular stable plate. Presentation of 225 cases of dislocated fractures . Unfallchirurg. 2006 Dec;109(12):1032-40.
14. Bigorre N, Talha A, Cronier P, Hubert L, Toulemonde JL, Massin P. A prospective study of a new locking plate for proximal humeral fracture. Injury. 2009 Feb;40(2):192-6. Epub 2008 Dec 13.
15. G.G.KONRAD, A.MEHLHORN, J.KÜHLE,P.C.STROHM, N. P SÜDKAMP Klinikum der Alber Proximal Humerus Fractures - Current Treatment Options t-Ludwigs-Universität Freiburg,Germany 2006 ACTA CHIRURGIAE ORTHOPAEDICAE ET TRAUMATOLOGIAE ČECHOSL., 75, 2008, p. 413 - 421.
16. Antuña SA, Sperling JW, Cofield RH Shoulder hemiarthroplasty for acute fractures of the proximal humerus: a minimum five-year follow-up. J Shoulder Elbow Surg. 2008 Mar-Apr;17(2):202-9. Epub 2008 Jan 11.
17. Dietrich M, Meier C, Lattmann T, Zingg U, Grüninger P, Platz A. Complex fracture of the proximal humerus in the elderly. Locking plate osteosynthesis vs hemiarthroplasty Chirurg. 2008 Mar;79(3):231-40.
18. Solberg BD, Moon CN, Franco DP, Paiement GD Surgical treatment of three and four-part proximal humeral fractures. J Bone Joint Surg Am. 2009;91(7):1689-1697
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21. Michael Leonard, Leibo Mokotedi, Uthman Alao, Aaron Glynn, Mark Dolan, and Pat Fleming . The use of locking plates in proximal humeral fractures: Comparison of outcome by patient age and fracture pattern INT J SHOULDER SURG. 2009 OCT-DEC; 3(4): 85–89.
22. Chu SP, Kelsey JL, Keegan TH, et al.: Risk Factors For Proximal Humerus Fracture. Am J Epidemiol 2004, 15(160):360-367.
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26. Meier RA, Messmer P, Regazzoni P, Rothfischer W, Gross T. Unexpected high complication rate following internal fixation of unstable proximal humerus fractures with an angled blade plate. J Orthop Trauma. 2006 Apr;20(4):253-60.
27. Paul C. Siffri, Richard D. Peindl, Edward R. Coley, James Norton, Patrick M. Connor and James F. Kellam Biomechanical Analysis of Blade Plate Versus Locking Plate Fixation for a Proximal Humerus Fracture: Comparison Using Cadaveric and Synthetic Humeri J Orthop Trauma 2006;20:547–554.
28. Dr.k kodandapani. Proximal humerus fracture Management — Presentation Transcript 2012 ;page 2.
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31. Kim SH, Lee YH, Chung SW, Shin SH, Jang WY, Gong HS, Baek GH Outcomes for four-part proximal humerus fractures treated with a locking compression plate and an autologous iliac bone impaction graft. Injury 2012 Oct;43(10):1724-31.
32. Michael J. Gardner, MD, Yoram Weil, MD, Joseph U. Barker, MD, Bryan T. Kelly, MD, David L. Helfet, G. Lorich, The Importance of Medial Support in Locked Plating of Proximal Humerus Fractures J Orthop Trauma 2007;21:185–191.
33. Plecko M, Kraus A. Internal fixation of proximal humerus fractures using the locking proximal humerus plate .Oper. Orthop. Traumatol 2005;17:25-50.
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37. Norouzi M, Naderi MN, Komasi MH, Sharifzadeh SR, Shahrezaei M, Eajazi A. Clinical results of using the proximal humeral internal locking system plate for internal fixation of displaced proximal humeral fractures. Am J Orthop (Belle Mead NJ). 2012 May;41(5):E64-8.
38. Ruchholtz S, Hauk C, Lewan U, Franz D, Kühne C, Zettl R. Minimally invasive polyaxial locking plate fixation of proximal humeral fractures: a prospective study. J Trauma. 2011 Dec;71(6):1737-44.
39. Crispin C. Ong, MD, Young W. Kwon, MD, PhD, Michael Walsh, PhD, Roy Davidovitch, MD, Joseph D. Zuckerman, MD, and Kenneth A. Egol, MD Outcomes of Open Reduction and Internal Fixation of Proximal Humerus Fractures Managed With Locking Plates . Am J Orthop. 2012;41(9):407-412.
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41. Juan Agudelo, MD, Matthias Schu¨rmann, MD, Philip Stahel, MD, Peter Helwig, MD,§ Steven J. Morgan, MD,Wolfgang Zechel, MD, Christian Bahrs, MD,§ Anand Parekh, Bruce Ziran, MD, Allison Williams, ND, PhD, and Wade Smith, MD* Analysis of Efficacy and Failure in Proximal Humerus Fractures Treated With Locking Plates. J Orthop Trauma 2007;21:676–681.
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43. Eric J. Strauss Current status of locking plate .The good, bad,ugly . Journal of ortho. trauma,2008,22,479,486.
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46. Duralde XA, Leddy LR. The results of ORIF of displaced unstable proximal humeral fractures using a locking plate. J Shoulder Elbow. Surg 2010;19:480-8.
47. Clavert P, Adam P, Bevort A, Bonnomet F, Kempf JF Pitfalls and complications with locking plate for proximal humerus fracture. Ricchetti ET, Warrender WJ, Abboud JA .Use of locking plates in the reatment of proximal humerus fractures. J Shoulder Elbow Surg. 2010 Mar;19(2 Suppl):66-75.
48. Olerud P, Ahrengart L, Söderqvist A, Saving J, Tidermark J.Quality Of Life And Functional Outcome After A 2-Part Proximal Humeral Fracture: A Prospective Cohort Study On 50 Patients Treated With A Locking Plate. J Shoulder Elbow Surg. 2010 Sep;19(6):814-22.
49. Parmaksizoğlu AS, Sökücü S, Ozkaya U, Kabukçuoğlu Y, Gül M Locking plate fixation of three- and four-part proximal humeral fractures. Acta Orthop Traumatol Turc. 2010;44(2):97-104.
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How to Cite this Article: Gangurde YS, Mahajan NP, Sonawane DV. Functional Evaluation of Proximal Humerus Fracture Managed by Locking Plate.  Journal Medical Thesis 2013  July-Sep; 1(1):29-32

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Prevalence and Analysis of Risk Factors of Osteoporosis in Persons of Above 40 Years Age Group in Amritsar – A Study of 500 Cases


Vol 1 | Issue 1 | July - Sep 2013 | page 23-28 | Singh T,  Singh S,  Sharma R,  Kapila R


Author: Tarandeep Singh [1], Sohan Singh [1], Rakesh Sharma [1], Rajesh Kapila [1]

Dept of Orthopaedics, Govt. Medical College, Amritsar, Punjab, India.

Institute at which research was conducted:Govt. Medical College, Amritsar, Punjab, India.
University Affiliation of Thesis: Baba Farid University of Health Sciences, Faridkot
Year of Acceptance: 2011

Address of Correspondence
Dr. Tarandeep Singh
Dept of Orthopaedics, Govt. Medical College, Amritsar, Punjab, India.
E mail:drtarandeep81@gmail.com


 Abstract

Background: In India 61million people have suffered from osteoporosis; 200% rise in last decade and 50% rise expected in next 10 years. It is a syndrome with many causes and a number of clinical forms. In this study we intend to study prevalence of osteoporosis in the different population groups greater than 40 years age and identify risk factors associated with osteoporosis in them.
Materials and Methods: Five hundred persons of either sex of more than 40 years age group were analyzed with the help of Achilles express (calcaneal ultrasonometer) based upon their -T score.they were screened for various modifiable and non modifiable risk fact.
Results: It is more common in postmenopausal females. Thin, frail and short people are more prone to osteoporosis. Sedentary life style coupled with increased intake of alcohol and tobacco is important modifiable factors.
Conclusion: Osteoporosis is a silent killer. Prevention is better than cure as prevention requires simple steps such as good dietary habits, active life style, good control of systemic disorders, and reduced intake of coffee, tobacco and alcohol. Proper control of systemic disorder such as diabetes and hypertension helps to control osteoporosis

Keywords: Osteoporosis, risk factors, elderly, amritsar.

                                                        THESIS SUMMARY                                                             

Introduction:

Osteoporosis is now recognized as “Silent epidemic disorder”. In India 61million people (1 in 3women and 1 in 8 men) have suffered from osteoporosis; 200% rice in last decade and 50% rise expected in next 10 years. An estimated 75 million people in Europe, USA and Japan. In the USA it affects >25 million people, predispose to >1.3 million fractures annually, of which predominantly post menopausal women. During the course of various bone diseases, common skeletal response is bone loss and it is not surprising that what we call osteoporosis is, in fact a syndrome with many causes and a number of clinical forms. Osteoporosis may be localized or generalized.
The two major determinants of risk in the development of osteoporosis are peak bone mass and rate of bone loss. These two determinants are influenced by a number of genetic and environmental factors. Roughly 70% of cases of osteoporosis are probably as a result of genetic predisposition, including the role of genetics in dictating how an individual will respond to exogenous stressors. The remaining 30% of cases probably triggered by environmental factors. In this study we intend to study prevalence of osteoporosis in the different population groups greater than 40 years age and identify risk factors associated with osteoporosis in them.

Materials and methods:

Five hundred persons of either sex of more than 40 years age group were analyzed with the help of Achilles express (calcaneal ultrasonometer) based upon their -T score. Detailed history of each person as referred to their Age, Sex and Marital status whether married or unmarried was recorded. Persons were analyzed based upon their residential area whether belong to rural or urban population. Educational level of the person was depicted as illiterate or literate. Those persons who cannot read or write were included under illiterate. Literate persons include those who can read and write. Literate persons further analyzed as under matric, matric, plus two, graduate, postgraduate or more based upon their education level. Religion of the person was also recorded as different religions such as Hindu, Sikh, Christian, Mohammedan, Persian, Jain, Buddhist, Yahudi had different dietary habits. Working of the person was recorded as the type of work they were performing to know if the nature of their work was sedentary, medium or heavy work. Persons were also analyzed based upon their economic status which includes family monthly income. Body weight and height of all the persons were also recorded because it also affects the bone mass. Amount of alcohol intake, No. of cigarette per week they were taking also recorded. Blood sugar level of the person all the persons was taken to know whether they belong to Diabetic or Non-diabetic community. Similarly to study the effect of blood pressure level on bone mineral density persons were depicted as Hypertensive or Non-hypertensive groups after recording their blood pressure, normal blood pressure was taken as 130/90 mmHg. To put light on hormonal effect on bone mineral density, reproductive status of the person especially in case of females was included such as no. of pregnancies, duration of lactation, last pregnancy, abortions if any, Pre/Postmenopausal, contraceptive used or not. Whether differ drugs affect bone mineral density, history of drug intake (corticosteroid, anticonvulsants, heparin, anticancer drugs, gluthemide, thyroid hormone, LHRH, GNRH agonists, cyclosporine, methotrexate, lithium ) included as one of the assessment criteria. To ascertain the affect of dietary habits such as vegetarian-those who eat only plant sources without diary product, lacto-vegetarian-who eat diary product also, ovo- vegetarian- those who eat eggs but no meat and non-vegetarian-those who take meat also and amount of tea/coffee intake on bone mineral density history of specific type of dietary pattern was recorded. Further family history of hip/spine fracture in >40 years age, history of previous surgery/hospital admission, history of previous fracture, history of prolonged immobilization, history of malignancy (multiple myeloma, metastatic bone disease, lymphoma), history of gastrointestinal intolerance, history of radiation therapy, history of connective tissue disease, history of chronic obstructive pulmonary disease, any spinal deformity, any other relevant factor was asked and observations were made accordingly.

Results:
Prevalence was more among females (17.27%) as compared to males (14.86%). Because of majority of females belonged to postmenopausal age group. Postmenopausal females have more prevalence (26.85%) as compared to premenopausal (11.76%) because of estrogen deficiency. Prevalence of osteoporosis was more among urban population (17.67%) as compared to rural (14.0%) because of modern life style adopted by urban population. Prevalence was more among persons practicing sedentary work (22.43%) as compared to medium (12.50%) or heavy work/exercise (3.80%). Increased mechanical stress leads to more stimulation of osteoblasts and hence more bone mineral density. Osteoporosis was more prevalent among Muslim (100.0%) as compared to Hindu (17.77%) and Sikh (14.28%) because wearing of burke in Muslims, vegetarian dietary habits among Hindus and religiously banning of smoking among Sikhs. Persons belonging to higher socioeconomic strata (monthly family income more than 10,000 Rs) have less prevalence of osteoporosis (13.44%) as compared middle (monthly family income between 5000-10,000Rs) (16.23%) and lower socioeconomic group (monthly family income less than 5000Rs) (18.36%). This was due to poor nutritional health and low education status in persons belonged to low socioeconomic strata. Prevalence was more in males as well as females of less than 60 kg weight (18.24%, 18.75%)as compared with weight more than 60 kg(16.15%,13.79%). Higher body weight causes increased mechanical stimulation of osteoblasts and hence increase in bone mineral density. Females and males with height less than 160 cm have more prevalence (17.82%, 17.04%) as compared with height more than 160 cm (15.78%, 13.43%) because of their good nutritional habits. Alcoholics have more prevalence (23.75%) as compared to non-alcoholics (14.76%). Alcohol causes direct toxicity of osteoblasts, altering liver profile leading to deranged metabolism of calcium and vitamin-D hence decrease in bone mineral density. Smokers have more prevalence (22.48%) as compared with non-smokers (14.0%) because smoking causes premature menopause in females and nicotine is directly toxic to osteoblast differentiating sialoproteins. Diabetic females as well as males have more prevalence (23.53%, 25.0%) as compared to non-diabetics (15.42%, 13.15%) because of various neural and vascular pathologies occurring in diabetes. Hypertensive persons have more prevalence (20.27%) as compared to non-hypertensive persons (15.49%) because of high urinary excretion of calcium in hypertensive persons. Females as well as males with non-vegetarian dietary habits have less prevalence (14.81%, 11.88%) as compared to lacto-vegetarian dietary habits (18.34%, 17.95%).Females as well as males taking coffee (27.45%, 15.62%) have more prevalence as compared to tea taking (14.98%, 14.73%). Caffeine causes increased urinary excretion of calcium not compensated in 24 hr dietary intake.

Conclusion:
Osteoporosis is a common geriatric problem which can lead to devastating complications if not rectified early. It is more common in postmenopausal females probably due to estrogen deficiency. Thin, frail and short people are more prone to osteoporosis. Besides this bone health is severely eroded by various modifiable factors. Sedentary life style coupled with increased intake of alcohol and tobacco are important modifiable factors. Diet rich in calcium and proteins, reduced intake of caffeine (coffee) and proper control of systemic disorder such as diabetes and hypertension helps to control osteoporosis. Osteoporosis is a silent killer and prevention is better than cure as prevention requires simple steps such as good dietary habits, active life style, good control of systemic disorders, reduced intake of coffee, tobacco and alcohol. So we should organize mass awareness programs both at hospital level and by involving various channels of mass communications such as news paper, radio, television and cinema to highlight these facts. This thing can go a long way in the prevention of osteoporosis and many serious complications like fractures (hip and spine) especially in geriatric patients.

Key Words:
osteoporosis, risk factors, elderly, Amritsar.

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How to Cite this Article: Singh T,  Singh S,  Sharma R,  Kapila R. Prevalence and Analysis of Risk Factors of Osteoporosis in Persons of Above 40 Years Age Group in Amritsar - A Study of 500 Cases.  Journal Medical Thesis 2013  July-Sep; 1(1):23-28

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Art 10 JMT July Sep 2013

Functional Outcome of Total Knee Replacement in Patients with Rheumatoid Arthritis – A Prospective Study

 


Vol 1 | Issue 1 | July - Sep 2013 | page 20-22 | Reddy AK, Rao AS, Reddy AVG


Author:K R Anil Kumar Reddy1, A S Rao2, AV Gurava Reddy1

Sunshine Hospital, Hyderabad, Andhra Pradesh, India.
2Krishna Institute Of Medical Sciences, Secunderabad Andhra Pradesh, India

Institute at which research was conducted: Krishna Institute of Medical Sciences, Secunderabad, India.
University Affiliation of Thesis: National Board of Examination, India
Year of Acceptance: 2011

Address of Correspondence
Dr. Anil Kumar Reddy
Sunshine Hospital, Hyderabad, Andhra Pradesh, India.
E mail:docanil21@gmail.com


 Abstract

Background: Total knee replacement in rheumatoid arthritis requires special precautions to be taken because of valgus deformity, more blood loss, osteoporotic bone and systemic nature of disease in our study we intend to study functional outcome of total knee replacement in patients with rheumatoid arthritis.
Materials and methods: 34 patients undergoing TKR having rheumatoid arthritis as diagnosis were enrolled. knee society scores done at pre operative period and postoperatively at 3 months, 6 month and 1 year.
Results: We found out that 27 of the 34 patients had excellent functional score , 2 patients had good functional score and 2 patients had fair functional score according to Knee society scoring system at the end of 1 year.
Conclusion: More than 80 percent of patients in our study had excellent functional scores at the end of 1year. Total knee replacement is good surgical option for rheumatoid arthritis of knee.

Keywords: Rheumatoid knee, total knee replacement, functional outcome.

                                                        THESIS SUMMARY                                                             

Introduction:

The functional outcome for total knee replacement in knee arthritis has been declared excellent, most of the studies done have been for primary osteoarthritis. The available literature for total knee arthroplasties in patients with rheumatoid arthritis is very limited and almost nil specifically for Indian population. Rheumatoid arthritis is a disease which has few features inherent to it that are separate from primary degenerative osteoarthritis.characteristics commonly seen in rheumatoid arthritis are valgus deformity,juxtaarticular osteoporosis, systemic involvement of musculature,upper extremity involvement which affects rehabilitation,reduced immunity leading to wound healing problems,severe anemia which causes general malaise,younger age at presentation and ipsilateral hip involvement.We believe these characteristics may influence the surgery during total knee arthroplasty and the functional outcome of the surgery. Hence we carried out this study to assess the functional outcome of total knee replacement in patients with rheumatoid arthritis.

Materials and methods:

The subjects in the study were patients with rheumatoid arthritis who underwent total knee replacement. The diagnosis of rheumatoid arthritis was made based on criterion given by American association of rheumatologists. All the patients in the study were positive for rheumatoid factor. Our study consisted of 34 patients.28 patients were females and 6 patients were males. The age range of the patients was 40-75 and mean age was 57.6 years. Our patients were from both urban as well as rural background. Baseline scores were measured preoperatively.The patients were followed up regularly for a period of 1 year with knee society scores done at pre operative period, 3 months post operative period, 6 months post operative period and 1 year. As a routine we do cruciate retaining type of total knee arthroplasty at our hospital. However when the patients have valgus deformity of more than 20degrees or fixed flexion deformity of more than 40 degrees we prefer to do cruciate sacrificing type of total knee arthroplasty. In our study of 34 patients we had 5 patients who underwent cruciate sacrifing type of total knee arthroplasty either because of severe deformity, ligamentous instability or difficulty in soft tisse balancing.

Results:
Patients with total knee replacement has excellent outcome in patients with rheumatoid arthritis. More than 80 percent of patiens in our study had excellent functional scores at the end of 1year.Age of the patient at the time of presentation doesn't have direct linear correlation to functional outcome. The patients in the younger age group had better functional scores than the older age group, however the mean improvement in functional scores was similar in all age groups.Weight of patient also did not show direct linear correlation to functional outcome. Patients in different weight groups showed similar mean improvement in functional scores. However, the morbidly obese patients took longer time to achieve better functional scores when compared to the others. The associated comorbid conditions such as Diabetes mellitus .Hypertension and Coronary artery disease did not influence the functional outcome of the surgery per se. The data in our study group showed significant difference in functional outcome after total knee arthroplasties between the 2 groups. The group where PCL was retained had superior clinical and functional scores compared to the group where PCL was sacrificed. However the difference was more significant in functional scores than clinical scores. Patelloplasty was done in all the patients who underwent toal knee arthroplasty in our study.

Conclusion:
In our study we observed and analysed the data of 34 patients with rheumatoid arthritis who underwent total knee arthroplasty without patellar resurfacing. All the patients were evaluated according to knee society scoring system. 3 patients were lost for follow Up in our study at the end of 1 year. we found out that 27 of the 34 patients had excellent functional score , 2 patients had good functional score and 2 patients had fair functional score according to Knee society scoring system at the end of 1 year.Total knee arthroplasty in patients with rheumatoid arthritis is a “good surgical option” with about 80 percent of people having “excellent” functional outcome according knee society scoring system.

Key Words:
Rheumatoid knee, total knee replacement, functional outcome.

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9.Sun Z, Sun Y, Cao J, Wang L, Tian M, Zhang Y, Liu J, Wang P. Cause analysis and clinical management of postoperative wound complications after total knee arthroplasty Chinese journal of reparative and reconstructive surgery 2009 Jun;23(6):644-7.
10.Patella V, Speciale D, Patella S, Moretti B, Pesce V, Spinarelli A. Wound necrosis after total knee arthroplasty.Orthopedics. 2008 Aug;31(8):807.
11.Yurube T, Takahi K, Owaki H, Fuji T, Kurosaka M, Doita M. Late infection of total knee arthroplasty inflamed by anti-TNFalpha, Infliximab therapy in rheumatoid arthritis.Rheumatol Int. 2010 Jan;30(3):405-8.
12.Debarge R, Nicolle MC, Pinaroli A, Ait Si Selmi T, Neyret P. Surgical site infection after total knee arthroplasty: a monocenter analysis of 923 first-intention implantations. Rev Chir Orthop Reparatrice Appar Mot. 2007 Oct;93(6):582-7.
13.Simmons TD, Stern SH.Department of Orthopaedic Surgery, Diagnosis and management of the infected total knee arthroplasty. Am J Knee Surg. 1996 Spring;9(2):99-106.
14.Laiho K, Mäenpää H, Kautiainen H, Kauppi M, Kaarela K,Lehto M, Belt E.Rise in serum C reactive protein after hip and knee arthroplasties in patients with rheumatoid arthritis. Ann Rheum Dis. 2001 Mar;60(3):275-7.
15.Gualtieri G, Bettelli G, Ferruzzi A, Calderoni P, Gualtieri I,Knee prosthesis in rheumatoid patients. Chir Organi Mov. 1997 Jul-Sep;82(3):269-74.
16.Holt G, Miller N, Kelly MP, Leach WJ. Retention of the patella in total knee arthroplasty for rheumatoid arthritis.Joint Bone Spine. 2006 Oct;73(5):523-6. Epub 2006 Apr 19.
17.Ogon M, Hartig F, Bach C, Nogler M, Steingruber I,Biedermann R. Patella resurfacing: no benefit for the long-term outcome of total knee arthroplasty. A 10- to 16.3-year follow-up. Arch Orthop Trauma Surg. 2002 May;122(4):229-34. Epub 2002 Jan 8.
18.Hasegawa M, Ohashi T. Long-term clinical results and radiographic changes in the nonresurfaced patella after total knee arthroplasty: 78 knees followed for mean 12 years. Acta Orthop Scand. 2002 Oct;73(5):539-45.
19.Bhan S, Malhotra R, Eachempati KK. Total knee arthroplasty without patellar resurfacing in patients with rheumatoid arthritis. Clin Orthop Relat Res. 2006 Sep;450:157-63.
20.Goldring SR,Wojno WC,Schiller AL,Scott RD: In patients with rheumatoid arthritis the tissue reaction associated with loosened total knee replacements exhibits features of a rheumatoid synovium .J Ortho Rheum 1988;1:9-21.
21.Steinberg J, Sledge CB, Noble J,Stirrat CR: A tissue-culture Model for cartilage breakdown in rheumatoid arthritis: quantitative aspects of proteoglycan release.Biochem J 1979;180:403-412.
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How to Cite this Article: Reddy AK, Rao AS, Reddy AVG. Functional Outcome of Total Knee Replacement in Patients with Rheumatoid Arthritis – A Prospective Study.  Journal Medical Thesis 2013  July-Sep; 1(1):20-22

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Anil & AV

 


 

An Interventional Randomized Study to Evaluate a new Supraglottic Airway Device (I-gel) in Comparison with the Classical LMA


Vol 1 | Issue 1 | July - Sep 2013 | page 17-19 | Chandura RA, Kantharia BN, Shah PK


Author: Rachana A Chandura1, Bansari Naresh Kantharia1, Prachi Kunal Shah1

 1Govt. Medical college. Surat, Gujarat, India.

Institute at which research was conducted: Govt. Medical College, Surat, Gujarat, India.
University Affiliation of Thesis: Veer Narmad South Gujarat University, Surat, India.
Year of Acceptance: 2012

Address of Correspondence
Dr. Prachi Kunal Shah
301, Kasturi Park, New Maneklal Estate, S.N. Mehta Marg, Ghatkopar (west), Mumbai-400086, Maharashtra, India.
E mail: rachana.chandura@gmail.com


 Abstract

Background: This prospective, randomized controlled clinical trial was done to compare the newer supraglottic airway device(SGD) I-gel with the LMA-classic.
Materials and methods: Sixty adult patients of 18-60 years age group were enrolled. The patients were randomly divided in to two groups, in group 1, I-gel and in group 2, LMA-C was inserted. Both group evaluated regarding the hemodynamic stability, ease of insertion, number of attempts and airway manipulations required during insertion, time required for insertion of the SGD and adverse events occurring intra-operatively and post-operatively.
Result: I-gel is better than LMA in all parameters measured with fewer complications.
Conclusion: I-Gel can be used as a better alternative to the LMA-C.

Keywords: Randomized controlled trial, I-Gel, LMA-Classic, supraglottic airways

                                                        THESIS SUMMARY                                                             

Introduction:

Supraglottic devices are useful advent in the airway management, filling a niche between the facemask and tracheal tube in terms of both the anatomical position and the degree of invasiveness. It is easy to insert them blindly in to the hypopharynx to form a seal around the larynx and has an important role in the management of difficult intubation and failed intubation. Laryngoscopy and muscle relaxation are not necessary for the insertion of supraglottic device. As it avoids invasion of vocal cords, incidence of injury inside the oral cavity and the occurrence of sore throat also decreases. These devices are better tolerated than the tracheal tube at 'lighter' levels of anaesthesia and have minimal cardiovascular response. They can be inserted in awake as well as anaesthetized patients with or without using muscle relaxant. The I-Gel is a new, single use, non-inflatable supraglottic airway for use in anaesthesia during spontaneous or intermittent positive pressure ventilation. The shape, softness and contours accurately mirror the perilaryngeal framework itself and create the perfect fit. As it has no inflatable cuff, it has several potential advantages including easier insertion,minimal risk of tissue compression,stability after insertion and an integrated gastric channel is provided for gastric suction for passage of nasogastric tube to empty the stomach. The objective of our study was to compare two supraglottic devices, classic LMA and I-Gel for ease of insertion, position within the airway, ease during mechanical ventilation, hemodynamic parameters before, during and after insertion and postoperative complications in anaesthetised patients undergoing elective surgical procedures.

Materials and methods:
Sixty patients of either sex in the age group of 18-60 years were selected randomly. Patients were divided into two groups comprising of thirty patients each and comparison was made between LMA-C Classic and I-Gel supraglottic device. In group 1, I-gel and in group 2, LMA-C was inserted. The hemodynamic stability, ease of insertion, number of attempts & time required for insertion and airway manipulation required for insertion were noted. After insertion, pulse rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, SpO2 & EtCO2 were noted at different time intervals. Anesthesia was maintained with 66% N2O with O2 and Isoflurane 0.5 -1% and muscle relaxation was provided with vecuronium. Insertion of nasogastric tube was done through the gastric channel of the I-gel using appropriate size of nasogastric tube.
Adequacy of oxygenation was determined as SpO2 >95% and adequacy of ventilation was defined as EtCO2 between 30-40 mmHg. At the end of surgery, neuromuscular blockade was reversed with Neostigmine 50 mcg/kg and Glycopyrrolate 8 mcg/kg IV. After suctioning from the hypopharynx and once the consciousness was regained, patients were asked to open their mouth and device was removed after the protective reflexes had returned.
The devices were examined for the presence of blood on it and any adverse events occurring post-operatively were noted.The statistical analysis was done using EPI INFO software using the "two tailed students' 't' test for unequal variance." the difference was considered to be statistically significant when p<0.05 and highly significant when p<0.01.

Results:
The demographic data of both the groups was comparable. In both the groups pulse rate, systolic blood pressure, diastolic blood pressure and mean arterial pressure remained below the baseline values and remained lower in the I-Gel group compared to the LMA-C group throughout the observation period.
A significantly higher pulse rate was noted in LMA-C group at 3 min following insertion as compared to the I-Gel group (p<0.05). The difference in mean systolic blood pressure was significant at 1 & 3. min after insertion (p<0.05) and in mean diastolic pressure, it was significant at 5 min after insertion (p<0.05), where it was higher for the LMA-C group. The MAP was comparable in both the groups throughout the observation period (p>0.05).
There was no statistically significant difference in SpO2, EtCO2and they remained within normal limits (p>0.05), chest compliance and ease of IPPV were adequate in both the groups.
The insertion of the I-Gel required less attempts and less airway manipulation as compared to LMA-C.Insertion of I-gel was possible in single attempt in all 30 patients whereas,in the LMA-C group it was possible in 27 patients while 2 patients required 2 attempts and 1 patient required 3 attempts for insertion. Manoeuvres for airway manipulation like jaw lift, adjusting head and neck position and twisting, rotating or reinsertion of the device were not needed in 20 patients of I-Gel group and one manoeuvre was needed in remaining 10 patients. In the LMA-C group, 6 patients did not require any airway manipulation, 17 patients needed one, 2 patients needed two and 1 patient needed three manoeuvres. I-Gel was easy to insert in 100% patients as compared to 73.33% patients in LMA-C.I-Gel required less time for insertion (8.26±2.88 sec) as compared to the LMA-C (25.13±31.71 sec).
One patient of the I-Gel group developed bradycardia (pulse< 60/min) intra operatively. I-Gel insertion was associated with less post-operative complications like sore throat (3.33%) as compared to the LMA-C (20%). I-Gel did not show staining of device with blood and tongue, lip or dental trauma whereas; it was seen in 13.33% and 10% of the patients of the LMA-C group respectively. None of the patients in the I-Gel group experienced cough, hoarseness of voice and vomiting whereas, it was seen in 6.66%, 3.33% and 6.66% of the patients of the LMA-C group respectively.

Conclusion:
Thus it can be concluded from the study that the I-Gel is easy to insert with less airway manipulations, requiring less time and attempts for insertion, maintaining better hemodynamic stability following insertion and causing less post-operative complications compared to the LMA-C.
The I-Gel can be used as a better alternative to the LMA-C.

Key Words:
randomized controlled trial, I-Gel, LMA-Classic, supraglottic airways

Bibliography:

1.Al Ali Muneer Is the I-Gel airway device as safe and effective as the standard LMA UZ Leuven Belgium, 2009.
2.Ali Sarfarazsiddiqui, Ummesumayyah, SafiaZafarSiddiqui et al Comparison of performance & safety of I-Gel with LMA-C for general anaesthesia with controlled ventilation Anaesthesia pain and intensive care; 2010; 14(1):17-20.
3.Amr M. Helmy, Hossam M. Atef, Ezzat M. El-Taher Comparative study between I-Gel, a new supraglottic airway device, and classical laryngeal mask airway in anaesthetized spontaneously ventilated patients Saudi journal of anaesthesia vol 4, issue 3, September- December 2010.
4.Ansar Ali, Naseem Ali Sheikh and Liaqat Ali et al Comparison of I-Gel supraglottic with laryngeal mask airway Professional Med J Dec 2010; 17(4): 643-647.
5.AshishKannaujia and Uma srivastava et al A preliminary study of I-Gel: a new supraglottic airway device Indian Journal of Anaesthesia 2009; 53 (1):52-56.
6.Atkinson, Rashman and Davis Lee's Synopsis of Anaesthesia, 11th edition.
7.Ayedi M., Zouari J., Smaoui M. The performance of the I-Gel in comparison with the LMA classic 2010; airway management; page 233.
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9.Benumof Jonathan l Laryngeal mask airway, indication and contraindication Anaesthesiology, 1993; 77; 843- 846.
10.Bimla Sharma and RaminderSehgal et al PLMA vs. I-Gel: a comparative evaluation of respiratory mechanics in laparoscopic cholecystectomy Anaesthesia Clinical Pharmacology, 2010; 26(4): 451-457.
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14.Ishwar Singh, Monika Gupta and MansiTondon: Comparison of clinical performance of I-Gel with LMA Proseal in elective surgeries Indian Journal of Anaesthesia 2009; 53 (3): 302-305.
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Use of LMA as an alternative to the tracheal tube during
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18.Lorenz G. and Theiler et al Crossover comparison of the laryngeal mask supreme and the I-Gel in simulated difficult airway scenario in anaesthetized patients
Anaesthesiology, V 111, No 1, July 2009: 55-62.
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21.Parul Jindal, AslamRizvi and JP Sharma Is I-Gel a new revolution among supraglottic airway devices M.E.J. Anaesth 20(1), 2009.
22.Theiler and Lorenz G. et al Performance of the pediatric sized I-Gel compared with the Ambu AuraOnce laryngeal mask in anaesthetized and ventilated children Anaesthesiology, V 115: no 1, July 2011: 102-110.
23.Understanding anaesthesia equipment Jerry M. Dorsch and Susan E. Dorsch; 5 th edition: page 462-466.
24.V. Uppal, S. Gangaiah, G. Fletcher, and J. Kinsella Randomized crossover comparison between I-Gel and the LMA Unique in anaesthetized, paralyzed adults British Journal of Anaesthesia 103(6): 882-5 (2009).
25.William Donaldson and Alexander Abraham et al I-Gel vs. AuraOnce laryngeal mask for general anaesthesia with controlled ventilation in paralyzed patients Biomed Pap Med FacUnivPalacky Olomouc Czech Repub. 2011 Jun; 155(2): 155-164.
26.Wylie & Churchill- Davidson's A Practice of Anaesthesiology 1995, 6 th edition.
27.Zouche I., Ayedi M., Smaoui J., Abidi S. Comparison of two supraglottic devices: I-Gel and LMA-classic in Pediatric anaesthesia 2010; airway management; page 233.


How to Cite this Article:Chandura RA, Kantharia BN, Shah PK.  An Interventional Randomized Study to Evaluate a new Supraglottic Airway Device (I-gel) in Comparison with the Classical LMA.  Journal Medical Thesis 2013  July-Sep; 1(1):17-19

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The Evaluation of Intrathecal Morphine for Post Operative Analgesia in Vaginal Hysterectomy


Vol 1 | Issue 1 | July - Sep 2013 | page 14-16 | Trivedi DA, Patel H, Shah PK


Author: Darshan Ashvin Trivedi1, Harsha Patel1, Prachi Kunal Shah1

1Govt. Medical College, Surat, Gujarat, India.

Institute at which research was conducted: Govt. Medical College, Surat, Gujarat, India.
University Affiliation of Thesis: Veer Narmad South Gujarat University, Surat..
Year of Acceptance: 2013

Address of Correspondence
Dr. Darshan A Trivedi Dept of Anaesthsiology, Govt. Medical college and New Civil Hospital, Majura Gate, Surat. 395001, Gujarat, India.
E mail: trivedida@gmail.com


 Abstract

Background: A prospective randomized study was undertaken to evaluate the efficacy of intrathecal morphine along with bupivacaine for post-operative analgesia in patients undergoing vaginal hysterectomy.
Materials and methods: The study was conducted on 80 female patients in the age group of 18 to 60 years, belonging to ASA grade I to III scheduled for vaginal hysterectomy. Patients were randomly divided in to two equal groups,one receiving morphine(group M) and other normal saline(group B). Baseline pulse rate, blood pressure, respiratory rate, Visual analogue scale and sedation score were recorded & monitored at regular intervals.
Result: Respiratory rate & Oxygen saturation remained normal in both groups. Fall in pulse rate was more in group M Blood pressure was lower in group M as compared to group B. Higher sedation score in group M, sensory and motor blockade achieved was faster in group M with improved VAS score and less serious side effects.
Conclusion: We thus conclude that intrathecal administration of 0.1mg preservative free morphine along with 0.5% bupivacaine (17.5mg) significantly prolongs the duration of post-operative analgesia up to 14 hours. It also reduces post-operative analgesic requirement in first 24 hours.

Keywords: Intrathecal morphine, spinal anesthesia, vaginal hysterectomy.

                                                        THESIS SUMMARY                                                             

Introduction:

Intrathecal morphine has been one method of providing postoperative pain relief for more than two decades. Morphine, which is more hydrophilic than other opioids, has a longer residence time in the CSF and therefore may reach rostral sites over a longer period than other opioids. The basis of this is related to the location of opioids receptors in the substantia gelatinosa of the spinal cord. Opioid receptor activation inhibits the presynaptic release and postsynaptic response to excitatory neurotransmitters from nociceptive neurons. Transmission of pain impulses are interrupted at the spinal cord level. Consequently, there is a potential of achieving adequate and long-lasting analgesia with an intrathecal injection of morphine. However, the downside of this hydrophilic character is an increased risk of adverse effects, especially delayed respiratory depression. By providing good analgesia for an extended period, intrathecal morphine considerably reduces the systemic opioids requirement. The side effects associated with intrathecal morphine are pruritus, sedation, nausea, vomiting and delayed respiratory depression which warrants close monitoring of the patients for the first 24hours. Some of the side effects can be reversed with naloxone.This study was undertaken to evaluate the efficacy of intrathecal morphine added to bupivacaine spinal anaesthesia in patients undergoing vaginal hysterectomy with regard to onset and duration of anaesthesia, haemodynamic effects, postoperative analgesia, sedation, and occurrence of any side effects.

Materials and methods:

A prospective randomized study The study was conducted on 80 female patients in the age group of 18 to 60 years, belonging to ASA grade I to III scheduled for vaginal hysterectomy Patients were randomly divided in to two equal groups.

They received intrathecal drugs as follows.
In pre anaesthesia room, pulse rate, blood pressure and respiratory rate were noted & patients were preloaded with 1litre of crystalloids and premedicated with inj glycopyrrolate 0.004 mg/kg and inj odansatron 4 mg intravenously.

In operation theatre, lumbar puncture was performed under strict aseptic and antiseptic precaution in the lateral decubitus position at the level of L3-4 or L2-3 inter space using 23G or 25G number spinal needle. After ensuring free flow of CSF, study drug was injected. The time of intrathecal injection was noted and immediately after it patients were turned to supine. Baseline pulse rate, blood pressure, respiratory rate and sedation score(ramsay scale) were recorded & monitored every 5 minutes up to 30 minutes, at 45 minutes, 60 minute, 90 minute, 120 minute, 150 minute, 3h, 4h, 5h, 6h, 9h, 12h and at 24 hour. Visual analogue scale for pain was recorded at 1h, 2h, 3h, 4h, 5h, 6h, 9h, 12h and at 24hrs. Sensory blockade was assessed after injection of the drug to complete ablation of pinprick test. Motor blockade was assessed by bromage scale. Post-operatively rescue analgesia was supplemented with inj. diclofenac sodium 1.5 mg/kg intramuscularly when VAS score > 3. Patients were observed for side effects like hypotension, bradycardia, respiratory depression, nausea, vomiting, urinary retention and itching.

Results:
The age and weight of the patients and duration of surgery were comparable in both the groups (p > 0.05).A fall in pulse rate was more in group M as compared to group B but it was statistically significant (p < 0.05) only during 120 minutes to 5 hours after intrathecal injection of the drug. The lowest values of pulse were seen between 90-120 minutes in group M and B.Blood pressure was lower in group M as compared to group B during whole study period but did not reach statistical significance (p > 0.05). The lowest values of blood pressure were seen between 90-120 minutes in group M and B.Respiratory rate & Oxygen saturation remained normal in both groups at all time intervals during surgery and for 24hrs postoperatively. (p > 0.05).Higher sedation score in group M as compared to group B from 25 minutes after intrathecal injection of the drug up to 6 hours (p < 0.001). During this period, the patients were easily aroused but asleep when not disturbed. In the rest of period, the sedation score was comparable with group B (p > 0.05). The mean time of sensory blockade from intrathecal injection to onset of sensory analgesia at L1 level was 1.169 ± 0.731 minutes in group M and 1.806 ± 0.952 minutes in group B (p < 0.05). In both groups highest sensory level achieved was T4 – T8. The mean time to achieve highest sensory level was 5.950 ± 2.490 minutes in group M and 6.400 ± 3.078 minutes in group B (p > 0.05).The mean time of motor blockage from intrathecal injection to onset of grade 3 motor block was 5.0 ± 1.536 minutes in group M and 5.400 ± 1.905 minutes in group B (p > 0.05). The mean duration of motor block was 207.750 ± 23.176 minutes in group M and 214 ± 25.201 minutes in Group B (p > 0.05).VAS score was higher in group B as compared to group M at all time intervals except at 12th hours (p < 0.001), as by that time all patients in group B had already received rescue analgesia. In group M, 8 patients (20%) did not require analgesic on the day of surgery. The average duration of analgesia was 13.825 ± 4.206 hours in group M and 4.762 ± 0.679 hours in group B (p < 0.001).Total number of rescue analgesic doses required were significantly less in group M (1.225 ± 0.480 injections) as compared to group B (2.65 ± 0.580 injections) (p < 0.001).Intra-operatively, bradycardia occurred in 17.5% of patients in group M and 2.5% of patients in Group B, it was treated with inj atropine sulphate 0.6 mg intravenously. No patient developed hypotension which required treatment. 37.5% patients in group M and 15% patients in group B developed nausea and vomiting (p < 0.05). 37.5% patients in group M developed pruritus while no patients in group B developed pruritus (p < 0.001). No patients in any group developed respiratory depression.

Conclusion:
We thus conclude that intrathecal administration of 0.1mg preservative free morphine along with 0.5% bupivacaine (17.5mg) significantly prolongs the duration of post-operative analgesia up to 14 hours. It also reduces post-operative analgesic requirement in first 24 hours. It leaves the patient calm, comfortable, minimally sedated though easily arousable during intraoperative and immediate post operative period without any serious adverse effects except vomiting and pruritus which is easily treatable.

Key Words:
Intrathecal morphine, spinal anesthesia, vaginal hysterectomy.

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How to Cite this Article: Trivedi DA, Patel H, Shah PK. The Evaluation of Intrathecal Morphine for Post-Operative Analgesia. Journal Medical Thesis 2013  July-Sep; 1(1):14-16

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Guest Editorial : Dr Hrutvij Bhatt


Vol 1 | Issue 1 | July - Sep 2013 | page 7 |  H Bhatt


Author: Dr Hrutvij Bhatt

Consultant spine surgeon
The Spine Clinic, Shalby Hospital
Ahmedabad, Gujrat, India.
Email: hrutvij.bhatt@gmail.com


Medical thesis is the one of the most important and the very first step of all medical students' life towards basic research. During our training all students are assigned one specific subject or problem and prepare a thesis on that subject. Preparing thesis which is sometime considered a formality or a herculean task by medical students and often wonder why it's a compulsory part of our curriculum.
Basically thesis writing is the first step and an important exercise to train us about research. Every year more than six to seven thousand medical thesis are been written in our Country, However very few (less than 10%) see the light of publication. A lot of them do not get published in mainstream journals, as authors feel it is not good enough or there are lacunae or there are issues with the designing of the study. However all thesis do involve collection of data which has potential to answer a question. If we consider these numbers then we can imagine how much important data do not get the light of publication.

Even if the thesis has a small learning point or a small practical or statistical point to make, we feel it is worth publishing. Journal of Medical thesis is an attempt to fill up these lacunae and provide a platform for publication of the more and more medical thesis in form of publications.
Journal of Medical thesis is unique Journal dedicated to publishing medical thesis all across the globe. It is an initiative of International Organisation of Research Groups through the Indian Orthopaedic Research group.
JMT will not only provide an opportunity to students to publish the medical thesis and get credit to themselves and their teachers, but will also help to reduce the plagiarism. In addition to being a Journal, JMT is also envisioned to be a platform where thesis can be discussed and help regarding Thesis can be provided. Through JMT we will be trying to improve the standard of thesis and research in our country.
JMT will also like to thank the Editorial board members who believed in our idea and supported us when we were putting our first steps.
And as I conclude with each and every drop of water makes a mighty ocean likewise each thesis work getting published can add to important data which can be very helpful for various meta analysis and systemic reviews.


How to Cite this Article: H Bhatt.  JMT Guest Editorial : Dr Hrutvij Bhatt. Journal Medical Thesis 2013  July-Sep; 1(1):7

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Art 4 Guest Editorial JMT July Sep 2013


 

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