Vol 2 | Issue 1 | Jan - Apr 2014 | page 35-38 | Suranigi SM, Shetty N, Shah HM

Author: Shishir Murugharaj Suranigi[1], Naresh Shetty[2], Harshad Mohan Shah[2]

[1]Pondicherry Institute of Medical Sciences,Pondicherry-605014, India.
[2] M.S.Ramaiah Medical College and Hospitals, Bangalore-560054.

Institute at which research was conducted: M.S.Ramaiah Medical College and Hospitals, Bangalore-560054
University Affiliation of Thesis: Rajiv Gandhi University of Health Sciences, Bangalore (R.G.U.H.S), Karnataka, India.
Year of Acceptance: 2010

Address of Correspondence
Dr.Shishir.S.M,
Assistant Professor,
Department of Orthopaedics,
Pondicherry Institute of Medical Sciences,
Pondicherry-605014, India
Email: shishir100@gmail.com

 Abstract

Background: Subtrochanteric fractures are one of the common fractures encountered in today's orthopaedic practice. Choice of implant still remains with the surgeon. The advantages and disadvantages of the Gamma nail have been well established in several studies done in the past, usually by comparing the results with the Dynamic hip screw (DHS). This study deals with the comparison of Proximal femoral nailing (PFN) versus Dynamic hip screw (DHS) in treatment of subtrochanteric fractures.
Methods: This study was conducted in M. S. Ramaiah Hospitals from October 2007 to August 2009. During this period 50 cases of adult patients with subtrochanteric fractures of femur were selected according to the inclusion criteria and classified according to Seinsheimer's classification.
Results: We found that PFN was superior to DHS in many ways such as reduced intra-operative blood loss, lesser operative time, reduced radiation exposure, less amount of limb shortening, reduced hospital stay, lesser infection rates and early mobilization.
Conclusion: Nailing has the advantage of providing rotational as well as axial stability in cases of subtrochantric fractures allowing a faster postoperative restoration of walking ability, when compared with the dynamic hip screw.
Key Words: Subtrochanteric fractures; Proximal Femoral Nailing ; Dynamic Hip screw, Reverse oblique subtrochanteric fractures.

Introduction

Subtrochanteric fractures are one of the common fractures encountered in today's orthopaedic practice. The incidence of subtrochanteric femoral fractures has increased significantly during recent decades, and this tendency will probably continue in the near future owing to the considerable increase in the life expectancy leading to an increasing geriatric population. Many treatment options are available. The goal of the treatment of these fractures is stable fixation, which allows early mobilisation of the patient. The advantages and disadvantages of the original design of the Gamma nail have been well established in several studies done in the past, usually by comparing the results with the dynamic hip screw (DHS). In this context there is inadequate data available about an alternative, the proximal femoral nail (PFN), and its merits in the management of subtrochanteric fractures. The present study was done to compare the advantages and disadvantages of proximal femoral nail over dynamic hip screw among patients with subtrochanteric fracture.

Aims and Objectives

The main aim of this dissertation was to:
I)Study the different types of subtrochanteric fractures.
ii)Study the principles and management of subtrochanteric fractures with proximal femoral nailing and DHS.
iii)To critically analyze both the groups for
1.Intra-operative blood loss, duration of surgery and intra-operative radiation exposure.
2.Duration from the day of surgery to mobilization.
3.Infection rates.
4.Duration of stay at hospital.
5.Implant failure rates.
6.Union rates.
7.Return to normal function.
8.Residual disability or deformity.
iv)Assessment of results based on subjective parameters, objective parameters and radiological findings.
In this study, an attempt has been made to review the literature and compare our results with other studies.

Methods

This was a prospective randomized study conducted in M. S. Ramaiah Hospitals from October 2007 to August 2009. During this period 50 cases of adult patients with subtrochanteric fractures of femur were selected according to the inclusion criteria. Alternate patients who fulfilled the inclusion and exclusion criteria underwent PFN and DHS respectively.

INCLUSION CRITERIA
a)Age: >18 yrs
b)Sex: Both sexes
c)All types of subtrochanteric fractures treated with
proximal femoral nail or Dynamic hip screw.
d)No specific duration of illness.

EXCLUSION CRITERIA

a) Previous surgery of the proximal femur.
b) Pathologic fractures other than osteoporosis.
c)Ongoing chemotherapy or irradiation treatment due to malignancy.
d)Polytrauma.
e)Individuals who were unable to give consent.

Results

The fractures were classified according to Seinsheimer's classification. Type IIIA constituted maximum number of cases (n=20) with 12 in PFN group and 8 in DHS group; followed by Type IV (n=08) with 2 in PFN group and 6 in DHS group. Rest of 22 patients belonged to Type IIA(n=02), Type IIB(n=05), Type IIC(n=05), Type IIIB(n=05) and Type V(n=05). There were no Type I pattern of fractures in our study. Out of the 50 patients, 26 of them underwent fixation with Proximal Femoral nailing and rest 24 of them were treated with DHS irrespective of their fracture pattern. Out of the 50 patients, 48 patients were available for follow-up. In our series maximum age was 96 years and minimum of 18 years(mean age=62.36 years). Maximum patients were belonging to the 60-80 years age group(n=19). Males were 37 and females 13. Right side was affected in 24 cases and left in 26 cases. The most common mode of injury in our series were trivial fall (n=35), Road Traffic Accidents (RTA) accounting for 13 cases and followed by fall from height in 2 cases. All patients were treated on elective basis. Surgery was performed on average of 3 days with a range of 1-11 days. The average time taken for DHS procedure was 124.58 minutes as compared to PFN which was 102.3 minutes.The average duration of radiation exposure was 56.35 seconds for nailing as compared to 96.25 seconds for DHS procedure. The average amount of blood loss was 208.7 ml for PFN procedure and 483.33 ml for DHS procedure. In PFN Series, Postero-Medial cortical defect was seen in 4 cases for which iliac cancellous bone grafting was done whereas bone grafting was required in 10 cases of DHS Series.
The intra-operative complications encountered during proximal femoral nailing are as follows:
1.Jamming of the nail in the proximal fragment while insertion was noted in one case, requiring progressive reaming of the proximal fragment and the use of a lesser diameter nail.
2.In ten cases we had to do 'free hand technique' for distal screw locking due to mismatch of the Jig and nail,
3.In one case, fixation of the fracture occurred in varus angulation.
4.In one case, iatrogenic fracture of the lateral cortex of the proximal fragment was noted, which was minimally displaced. No intervention was done for that fracture. Weight bearing was delayed post-operatively.
5.In six of our cases we had to perform open reduction, due to wide displacement of the fragments .
6.In one case, with delay in surgery of 11 days was noted as the patient was not fit to be taken up for surgery. We had difficulty in reduction of the fracture in this patient, so the fracture site had to be opened up for reduction. These were commonly seen in Type IV , V fractures and in obese individuals. No intra-operative complications were encountered during DHS procedure. In our DHS series, we had a case of wound infection at the operative site which required intravenous antibiotics for a period of 3 weeks. Wound healed without the need for any further intervention. No post-operative complications were seen in PFN series. The average time taken for mobilization from the time of surgery for PFN series was 1.5 days and for DHS series was 2.12 days. The average duration of hospital stay following surgery was 7.9 days ranging from 5-14 days in the PFN series and 12.04 days ranging from 5-20 days in the DHS series. There was no mortality in this study. The average duration of follow up was 15 months ranging from 5 – 26 months, of which 2 patients were lost to follow up, one in DHS series and other in PFN series. Both the patients were lost during the 2nd month of follow up. In PFN series, out of the 26 cases, 10 cases showed union at 12 weeks, 7 cases showed union at 14 weeks duration, 4 cases showed union at 18 weeks duration. 4 cases of delayed union were seen. 2 cases of delayed union required dynamization which were followed up till bony union, which took 7 months and 8 months respectively. Two other cases required bone grafting at the fracture site, which united at 6 months and 7 months respectively. One case of breakage of implant in situ at 5 months was noticed. Patient had broken the implant after a fall at home. It was treated with implant removal and re-nailing with PFN and bone grafting. Fracture united after 18 weeks of re-nailing. In DHS series, out of the 24 cases, 8 cases showed union at 12 weeks duration, 6 cases showed union at 14 weeks duration, 3 cases showed union at 18 weeks duration. 3 cases of delayed union were seen, for which bone grafting at the fracture site was done at 8weeks, 10weeks and 12 weeks. Fracture subsequently united after 10 weeks, 10 weeks and 14 weeks respectively from the time of bone grafting. Three cases of breakage of implant in situ were noticed at 12 weeks, 20 weeks and 25 weeks. Two of which were treated by implant removal and repeat DHS application with bone grafting. They united after 14 weeks and 16 weeks respectively. Other case was treated by implant removal and nailing with gamma nail and bone grafting, which united after 20 weeks from the second surgery. Bony union was achieved in 24 out of the 26 cases (92.3%) in PFN series as compared to 20 out 24 cases (83.33%) in DHS series. 69.33% of the cases had good results in PFN series as compared to 70.8% in DHS series.

Conclusion

In our series we found that PFN was superior to DHS in many ways such as reduced intra-operative blood loss, lesser operative time, reduced radiation exposure, less amount of shortening, reduced hospital stay, lesser infection rates and early mobilization.
We have concluded that all reverse oblique fractures are to be managed by PFN only as the chances of failure of fixation are very high with extra-medullary devices.

Clinical Message

Nailing has the advantage of providing rotational as well as axial stability in cases of sub-trochanteric fractures allowing a faster postoperative restoration of walking ability, when compared with the DHS. The nails are load-sharing implants, whereas extra-medullary devices are load-bearing. Proximal femoral nailing creates a shorter lever arm, which translates to a lower bending moment and a decreased rate of mechanical failure⁵².

Key Words

Subtrochanteric fractures; Proximal Femoral Nail; Dynamic Hip screw; reverse oblique subtrochanteric fractures

Bibliography

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10.David A, Von Der heyde D, Pommer A. Therapeutic possibilities in trochanteric fractures” orthopaedics 2000;29(4);294-30
11.Harper MC, Walsh T: Ender nailing for peritrochanteric fractures of the femur: an analysis of indications, factors related to mechanical failure, and postoperative results, J Bone Joint Surg 67A:79, 1985
12.Kinast C, Bolhofner BR, Mast JW, Ganz R: Subtrochanteric fractures of the femur: results of treatment with the 95-degree condylar blade-plate, Clin Orthop 238:122, 1989.
13.Robert j Medoff “A New Device for the fixation of unstable pertrochanteric fractures of the hip”JBJS, 1991, 73(A), 1192-1199.
14.Halder SC: The gamma nail for peritrochanteric fractures, J Bone Joint Surg 74B:340, 1992.
15.K S Leung, W S SO, W Y Shen, P W Hui” gamma nails and dynamic hip screws for peritrochanteric fractures” JBJS (Br) 1992; 74(B):345-51.
16.Shepherd F. Rosenblum, Joseph Zuckerman” A Biomechanical evaluation of the gamma nail” JBJS (Br) 1992; 74(B):352-7.
17.Philip J. Radford, Maurice needoff, john k Webb” a prospective randomized comparison of the dynamic hip screw and the gamma locking nail” JBJS, 1993; 75(B) 789-793.
18.Martyn J. Parker” a new mobility score for predicting mortality after hip fracture” JBJS, 1993; 75(B); 797-799.
19.“Treatment of subtrochanteric fractures with AO dynamic condylar screw”.J Injury 1993 Feb, 24(2); 90-2.
20.“Subtrochanteric fractures of the femur treated with Zickel nail”Arch-ortho.Belg, 1994 ;( 60); 129-33.
21.Taglang G, Favrel E, “77 patients ,mean age 75 years, one year follow up”. Paper presented to advanced course in Intramedullary locking nailing, Courchel, France.1991.
22.Vanderschof P. et al. 1995. “A review of 161 subtrochanteric fractures- risk factors influencing outcome: age, fracture level and fracture pattern”. Unfallchirug, 98(5):265-71.
23.Simmermacher RK, Bosch AM, Van der Werken C: “The AO/ASIF proximal femoral nail (PFN): A new device for the treatment of unstable proximal femoral fractures”. Injury 30:327–332, 1999.
24.Hardy DCR, Descamps PY, Krallis P, et al: Use of an intramedullary hip screw compared with a compression hip screw with a plate for intertrochanteric femoral fractures, J BoneJoint Surg 80A:618, 1998.
25.L J Domingo” trochanteric fractures treated with a proximal femoral nail” international orthopaedics (SICOT) 2001, 25:298-301.
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27.Ramakrishnan M, Prasad SS, Parkinson RW, Kaye JC: “Management of subtrochanteric femoral fractures and metastases using long proximal femoral nail”. Injury 35:184–190, 2004.
28.Ely L Steinberg, Nehemia Blumberg, Shmuel Dekel “The fixion proximal femur nailing system: biomechanical properties of the nail and a cadaveric study” Journal of biomechanics38 (2005)63-68.
29.Daniel F A Menezes, Axel Gamulin, and Bruno Noesberger. “Is the Proximal femoral nail a suitable implant for treatment of all trochanteric Fractures? ” clin ortho and rel research 2005 439, 221-227.
30.Pajarinen J, “ pertrochanteric femoral fractures treated with a dynamic hip screw or a proximal femoral nail. A randomized study comparing post operative rehabilitation” JBJS (Br) 2005, 87(1); 76-81.
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Vol 2| Issue 1 | Jan - Apr 2014 | page 7-10 | Deshmukh G, Rocha S, Shyam A, Sancheti P

Author: Gajanan Deshmukh[1], Steve Rocha[1], Ashok Shyam[1], Parag Sancheti[1]

[1]Sancheti Institute, Pune, India
Institute at which research was conducted: Sancheti Institute, Pune, India.
University Affiliation of Thesis: MUHS Nashik University,
Year of Acceptance: 2014.

Address of Correspondence
Dr Gajanan Deshmukh
Department of Orthopaedics, Sancheti institute, Pune, India
Email: gajanan9690@ gmail.com

 Abstract

Background: Fractures of the metacarpal and phalanges are common and constitute 10% of all fractures. “Too often these fractures are treated as minor injuries and major disabilities occur” underlying the wrong practice of considering these fractures as trivial and worthy of being treated by the junior most resident.
Methods: 50 patients of metacarpal fracture (43males and 7 females),all were treated using k wires ,ao screws and plates and evaluated with DASH ,VAS AND ROM at 3 months ,6 months and 1 year.
Results: All patients at end of 1 year showed improvement in functional score irerespective of implant used .
Conclusion: All patients treated surgically of metacarpal fracture showed good functional outcome at the end of 1 year .
Key Words: Metacarpal fracture,k wire, ao screws.

Introduction

Fractures of the metacarpal and phalanges are common and constitute 10% of all fractures. “Too often these fractures are treated as minor injuries and major disabilities occur” underlying the wrong practice of considering these fractures as trivial and worthy of being treated by the junior most resident1,2,3.

Epidemiology
Thirty to forty percentages of all fractures in the hand occur in the metacarpal. Border metacarpals (1st and 5th) are more commonly involved, the base being more commonly involved in the former and neck in the latter. Diaphyseal fractures are common in non border metacarpals. Life time incidence of metacarpal fractures is 2.5%. No where in the body, the form and function are so closely related to each other than in hand. So any skeletal injury in the hand is likely to alter the function4,5.

Surgical anatomy
Metacarpal bones are concave, short tubular bones with in built longitudinal arch and a collective transverse arch. The metacarpal bases form the CMC joints with the carpal bones, the first being the most mobile, the 2nd and 3rd being most rigid and the 4th and 5th being relatively mobile. The saw tooth articular arrangement of the 2nd and 3rd CMC joints along with reinforcement of the capsule by FCR anteriorly and ECRL, ECRB posteriorly make the joints extremely rigid and immobile and any disruption of these joints indicate a high energy injury. The attachment of APL and ECU on the base of the 1st and 5th makes these joints more prone for unstable fracture dislocations.The cam-shaped head of the metacarpal bones makes the collateral ligaments relaxed in extension and stretched in flexion making it safer to immobilise the MP joints in Flexion (ideally 70-90°) than in extension. This flexed position of the MP joint is also the most stable position of the MP joint in power pinch and grip..The volar plate of the MP joints is a cartilaginous structure which is thicker at the phalangeal attachment and thinner at the metacarpal attachment. The lateral extension of the volar plate constitutes the deep transverse metacarpal ligament which provides the additional volar stability of the MP joint.6. Metacarpal bones are subcutaneous bones dorsally with a gentle volar concavity. Fracture of the shaft or the neck of the metacarpal caused either due to direct or axial loading injury will mostly result in dorsal apex angulation due to the deforming forces of interossei and other volarly placed muscles. For this reason when these fractures are treated conservatively, the MP joint needs to be immobilised in flexion to relax the lumbricals and the interossei.

General considerations
“Hand fractures can be complicated by deformity from no treatment, stiffness from overtreatment, and both deformity and stiffness from poor treatment”- A fracture is considered functionally stable when during clinical examination it is possible to actively move the fractured digit by 50% of range of motion painlessly. The fracture is considered radiologically stable when the radiographs of the fractured fragment in two planes show minimum angulation and displacement. A fracture is considered unstable if it can not be reduced or maintained in an anatomic or near anatomic position without implant fixation when the hand is placed in the safe or functional position. The four factors that determine stability are 1) external force, 2) muscle imbalance 3) fracture configuration or personality 4) integrity of soft tissue including periosteal sleeve.

Aims and Objectives

1.To study the various mechanism and pattern of metacarpal fractures and their surgical management

2. To study the functional outcome of metacarpal fractures treated surgically.

Methods

This was a prospective and retrospective study of the patients admitted and treated in our hospital during the period between Jan2012 to December 2013. In this study we studied patients with metacarpal fractures treated surgically. All patients with metacarpal fractuures were screened using inclusion and exclusion criteria and those willing to participate in the study were included. This protocol was approved by Institutional rieview board.
INCLUSION CRITERIA
1. All patients with metacarpal fractures

EXCLUSION CRITERIA
1. Pathological fracture
2. Crush injury to hand

METHODOLOGY
All patients with metacarpal fractures were screened using inclusion and exclusion criteria and those willing to participate in the study were included. Those who meet up with the criteria were studied them during the peri-operative & post operative period. Post operative follow up to asses union radiologically will be done at 6 weeks, 3 months, 6 months, 1 year. During each follow up repeat X-rays and assessment of complications if any was documented. Improvement in range of motion at metacarpophalengeal joint was evaluated at each follow up visits.
During their each visit, we measure the following parameters-
1. Hand Xrays
2. DASH Score.
3. Range of Motion
4. VAS (Visual Analog Score) for pain.

Results

50 patients were treated using different implants such as k wires and screws and plated and followed at end of 1 year there was significant improvement in functional outcome at end of 1 year irrespective of implant used.

Conclusion

Most metacarpal fractures can be treated conservatively.
Patient with multiple fractures, open fratactures ,intraarticular requie operative reduction and stabilization to obtain the optimal position for bone healing and to allow early movement.

Clinical Message

Operative intervention is treatment of choice for early recovery and mobilization of metacarpal fracture.

Bibliography

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16. Kozin Sh, thodar JJ Lieberman G operative treatment of metacarpal and phalangeal shaft fractures. J Am orthop surg 2000 Apr8(2)111-21.
17. Meals RA Meuli HC Carpenter's nails, phonograbh needles,pianowires and safety pins; the history of operative fixation of metacarpal and phalangeal freactures.JHand surg[Am]1985Jan10(1)144-50.
18. Dumont C Funchs MBurchhardt H applet D Bohr S SturmerKM Clinical results of absorbable plates for displaced metacarpal fractures.J hand Surg {Am] 2007 Apr32(4)491-6.
19. Edmunds JO traumatic dislocations and instability of the trapeziometacarpal joint of the thumb Hand Clin2006Aug22(3)365-92.
20. Kawamura K,chung KC ,fixations choices for closed simple unstable oblique phalangeal and metacarpal fractures Hand clin 2006 Aug 22.
21. Roth JJ Aurbech DM Fixation of hand fractures with bicortical screws J Hand Surg [AM]2005 Jan 30.
22. Fusetti C Meyer H Borisch N ,Stem R Santa DD Papaloizos M Complications of plate fixations in metacarpal fractures J trauma 2002.
23. Penning D Gausephol T ,Mader K Wuleck A the use of minimally invasive fixation in fractures of the hand the minifixator concept injury 2000.
24. Capo JT Hastings H 2nd Metacarpal and phalangeal fractures in atheletes Clin sport med 1998.
25. Watanabe K Nishikimj J Muro T Ireducible fracture of neck of 5th metacarpal J Hand Surg 1996 Aug 21.
26. Foster RJ Stabilization of ulnar carpometacarpal dislocation or fracture dislocatios. Clin Orthop Relat Res.1996Jun.
27. SchuindF Donkerwolcks M,Burny F External minifixation for treatment of closed fractures of metacarpal bones. J Orthop Trauma 1991.
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Vol 2 | Issue 1 | Jan - Apr 2014 | page 24-30 | Dube AS, Goel S, Rastogi A, Vashisht A, Swarop A

Author: Abhay Shankar Dube[1], Siddharth Goel[1], Anurag Rastogi[1], Arun Vashisht[1], Arunim Swarop[1]

[1] Subharti Medical College
Institute at which research was conducted: Subharti Medical College.
University Affiliation of Thesis: Swami Vivekanand Subharti University, Meerut, U.P
Year of Acceptance: 2012.

Address of Correspondence
Dr. Siddharth Goel
Dept. of Orthopaedics, Subharti Medical College,
Bye – Pass Road, Meerut, 250002.
Email: drsiddharthgoel@gmail.com

 Abstract

Background: Pertrochanteric fractures are the most commonly operated fracture type globally but have the highest fatality rate post-operatively. The conservative management of these fractures is associated with almost double the rate of fatality. The dynamic hip screw (DHS) plate system continues to be the preferred implant as “collapse to stability” remains a distinct advantage. This study was to analyze the implications of “surgeon unrelated” morbidities like age, gender, fracture type, degree of comminution, osteopenia and “surgeon related” morbidities like fracture reduction, screw placement and tip apex distance (TAD).
Methods: 96 fractures in mean 68.43 years subject age were selected, the fractures classified. The uninjured hip used to grade pre-existing osteopenia by Singh's index and compare neck shaft angle restored after surgery. All fractures operated by a standard lateral proximal femoral approach and fixed with 135° DHS. Post- operative skiagrams done to assess union and complications like varus mal-union or unacceptable fracture collapse and implant related complications like loosening, cut-out, intra-articular migration, impingement or breakage.
Results: 55.21% presented with medial, posterior or lateral wall comminution. 75.86% had grade 3 and 4 osteopenia and 18 patients had grade 1, 2 or 5 osteopenia. Valgus (68) and anatomical (14) reduction was the commonest choice of acceptance by operating surgeon in both stable and unstable fractures and this type of reduction showed least varus collapse or screw cut out risk as compared to varus (3) and medialized (11) reduction.
Conclusion: The 'surgery unrelated' morbidity factors did not affect the risk of varus collapse or screw cut out. The overall varus collapse, malunion or cut out risk correlated significantly with 'surgery related' factors related to screw placement and quality of reduction accepted. The central-central screw placement was found ideal for minimum 'cut out risk'.
Key Words: morbidity factors, pertrochanteric fractures, DHS, TAD.

Introduction

The term extra-capsular fracture neck femur is now better defined as pertrochanteric fracture which extends from extacapsular basal neck to lesser trochanter before the anatomical differentiation of the medullary canal.
The evolution of surgical expertise and implant design makes surgery the choice in the management of these fractures. The conservative management of these fractures is associated with almost double the rate of fatality as compared to the operative group. Even in those who survive the risk of mortality by conservative treatment, the inevitability of complications like uncontrolled shortening and varus collapse leave behind considerable morbidity.
Even with the advantage of other modified sliding hip screw systems and cephalo-medullary nail, the use of dynamic hip screw (DHS) is preferred worldwide as “collapse to stability” remains a distinct advantage. The goal of surgery is strong and stable fixation to maintain reduction during union. Varus collapse and associated implant cut out in head region and intraarticular penetration remain the major unacceptable outcome especially in fractures rendered unstable due to posteromedial or lateral wall comminution, subtrochanteric extension, reverse oblique type, and intracapsular extension of fracture line.

Aims and Objectives

This study was conducted to analyze whether the personality of a pertrochanteric fracture treated with DHS in all types of these fractures is related to the patient, the fracture or the surgery by studying:

1. The surgery unrelated factors like fracture instability, degree of comminution, osteopenia, femoral neck shaft angle, irrespective of age and gender, which should concern the surgeon as possible factors influencing clinical and radiological outcome and to correlate their contribution in possibly increasing the morbidity.
2.The surgery related factors like implant placement, compromised reduction, inability to take care of comminution and provision of lateral buttressing.

Methods

Out of 1350 internal fixations by DHS done, between 2007 to 2012 for pertrochanteric fractures, 111 patients above the age of 50 years (mean age 68.43 years; range 50-100 years) were randomly selected for this study; 15 were excluded from the study (14 had died a natural death following post operative recovery; 1 had early post-operative infection). Remaining 96 fractures were operated by a standard lateral proximal femoral approach by 5 senior surgeons after optimizing existing medical illness in the patient and were studied over a period of two years. The exclusion criteria were:
1.Patients with significant medical or neuro-psychiatric co-morbidity.
2.Contralateral hip disease or deformity.
3.Any significant postoperative complication, e.g. infection, wound dehiscence, intra-operative nerve damage.
4.Intertrochanteric fractures managed with an implant other than DHS.
5.Patients who expired or were lost in followup.
The preoperative underlying morbid factors related to age, gender, smoking habit, alcohol excess, drug intake, fracture type, displacement and its plane, degree of comminution and osteopenia were observed to study the fracture personality. The pre-operative anteroposterior (AP) skiagram of pelvis with both hips and lateral (Lat) skiagrams of the fractured hip were studied to assess if the fracture was unstable, by authors individually to minimize inter-observational variance. Boyd and Griffin, Evans, Kyle's and Gustilo and AO/OTA classification systems were all used to identify instability related to posteromedial and lateral wall comminution and reverse obliquity. The image of uninjured hip was used to grade pre-existing osteopenia by Singh's index and comparison of neck shaft angle restored after surgery. The post-operative skiagrams in AP/Lat projection were studied to observe:
1.Type of reduction preferred by the surgeon – whether anatomical, medialized or valgus.
2.Screw placement in the quadrant of the head as accepted by the surgeon and seen in the AP/Lat post operative skiagram. The central placement of screw i.e. that placed in the axis of femoral neck in both AP/Lat skiagram was taken as the reference in assessing the quadrant of screw placement in the femur head.
3.TAD index achieved was measured as a sum of the distance between the tip of implant and head of femur in AP/Lat views. The change in magnification of the images was accounted for by the method standardized by Baumgartner et al.
4.Any post-operative change in neck shaft angle from that measured on the contralateral side for comparing the restored angle after surgery.
5.The ability of the implant to support any existing comminution of the lateral wall and to stabilize any major comminution in the medial wall especially a large displaced lesser trochanter fragments.
Post operative follow up and evaluation
Whether the fracture remained stably reduced and the implant did not migrate during union were evaluated by assessing post operative skiagrams for:
Occurrence of any union related complications like varus mal-union or unacceptable fracture collapse.
Implant related complications like loosening, cut-out, intra-articular migration, impingement or breakage.
Correlations of the observed outcome with the surgery related or unrelated morbidity factors were done using statistical tools like Chi-square test, Z test for proportion and ANOVA single factor test to establish their role.

Results

By the different classification system, 53 fractures were labelled ‘unstable’ and 43 fractures were ‘stable’ and out of 86 fractures in the 50-80 years age group, 48 were unstable and 38 were stable and 67 (77.01%) patients were in Singh’s index osteopaenia grade 3 and grade 4. Only 8 (8.33%) fractures had lateral wall comminution. Medial and posterior wall comminution of various magnitudes, although their degree of comminution could not be quantified, was seen in 53 fractures (55.21%). The neck shaft angle ranged from 1180 to 1400 (average 129.010), that in females ranged 1180 to 1400 (average 129.230) and in males from 1200 to 1400 (average 128.830). The surgeons “accepted” 68 fractures in valgus reduction, 14 fractures in anatomical reduction, 11 fractures with medialization and 3 fractures in varus reduction. In the 8 (8.33%) fractures which had lateral wall comminution, no mechanical or biological reconstruction of the lateral wall was done. Medialization was done in these patients for stability. No bone grafting was done for biological augmentation of comminution. Augmentation with a derotation screw or wire done as the need be. A correlation of the TAD with screw tip position in the quadrant of femoral head was observed. Among the 79 patients who had ideal (<25mm) TAD, the best accepted position was central-central (47) followed by inferior-posterior (19) followed by superior-anterior (8), central-posterior (5) in this order. Only two cases had unacceptable TAD (>30mm).
Follow up
The neck shaft angle achieved after reduction and its shift from the target contra-lateral neck shaft angle was evaluated along with the difference of TAD achieved from the ideal (<25 mm) in early follow up before union (average 6.84 weeks) and after clinical union (average 11.7 weeks). The shift from ideal TAD at union in the fractures with no change in neck shaft angle in the anatomical reduction group clearly indicated a controlled collapse. In the valgus reduction group, 61% fractures showed some loss in their valgus reduction but only 17.6% showed further shift in TAD at union, none with a cut out. In the varus reduction group, whether or not medialized, all fractures progressed to further varus with progressive shift of TAD with consequential ‘cut out risk’ in 20% fractures. In fractures with medialized reduction with valgus neck-shaft angle there was initial loss of valgus and shift in TAD but none further at union. In the group of 79 fractures with TAD < 25mm, 74 (93.7%) showed satisfactory union without varus collapse, 4 (5.06%) fractures showed union with varus collapse all with initial medialization, and 1 patient showed non-union with screw migration after initial medialization. In the group of 15 fractures with ‘acceptable’ TAD of 26-30mm, 11(73.3%) satisfactory union with 2 fracture showing some varus collapse was observed and 4 had non-union with screw migration. In the 2 patients with ‘unacceptable’ TAD more than 30mm, both with initial medialization, non-union with screw migration was seen.
The non-union observed in 7 (7.29%) fractures strongly correlated to two factors:
a) medialized reduction and
b) TAD >25mm (85.7%).

Conclusion

Despite variations in the normal neck shaft angle, a 135⁰ DHS is a preferred solution for stabilization of peritrochanteric fractures. A larger angle would risk the placement of screw tip in superior quadrant and a narrower angle would interfere with control of collapse by getting jammed. Good stable reduction in both anteroposterior and lateral view, valgus positioning, if required in maintaining good screw position even in osteoporotic situations, the target of central screw placement, non-acceptance of varus or medialization, central or inferior screw positioning in the anteroposterior view,  use of contra-lateral un-fractured hip image as a template for post-operative reconstruction and the judicious use of adjuvant, derotation cancellous screw are some of the important strategies the surgeon must use to achieve a good TAD and successful union without the risk of varus collapse and cut out. For the fractures with reverse obliquity, the use of DHS remains debatable. The limitations of this study are that the study of factors related to pre-existing osteoporosis in affecting the results is not feasible in this short-term study of associated morbidity, and the role of smoking, alcohol intake, associated medical co-morbidities in affecting outcome also needs a different study module.

Clinical Message

The risk of varus collapse or screw cut out relate to 'surgery related' factors concerned with reduction and screw placement. 'Surgery unrelated' morbidity factors like age, gender, fracture type, degree of comminution and osteopenia do not affect the outcome. The central-central screw placement is ideal for minimum cut out risk.

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90. Dawson-Hughes B, Harris SS, Krall EA, et al. Effect of calcium and Vitamin D and supplementation on bone density in both men and women 65 years age or older. N England J Med 1997; 337:670-6.
91. Kalyani RR, Stein B, Valiyil R, Manno R, Maynard JW, Crews DC.: Vitamin D treatment for the prevention of falls in older adults: systemic review and meta-analysis. J American Geriatics Society 2010; 58 (7):1299-1310.
92. Rizzoli R, Boonen S, Brandi ML, Burlet N, Delmas V, Reginster JY.: The role of calcium and vitamin D in the management of osteoporosis. J Bone & Joint Surgery 2008; 42:246-249.
93. Hartholt KA, Oudshoorn C, Zielinski SM, Burgers PTPW, Panneman MJM, Beeck EdF, Patka P, Cammen TJM van der.: The Epidemic of Hip Fractures: Are We on the Right Track?. PLoS ONE 2011 July; 6 (7).
94. Russell TA.: Intertrochanteric fractures. In Rockwood & Green's: fractures in adult – Ed Bucholz RW, Court-Brown CM, Heckmen JD, Tornetta III P, LWW.7th ed. 2010; 2 (48):1597-1640.
95. Cummings SR, Navitt MC.: A Hypothesis: the causes of hip fractures. J Gerontol 1989; 44 (4):107-111.
96. Hopkinson-Woolley JA, Parker MJ.: Fracture of the Hip: does the type of fall really affect the site of fractures?. Injury 1998; 29 (8):585-587.
97. Vochteloo AJH' Burg BLSBVD, Mertens BJA' Niggebrugge AHP' Vries MRD, Tuinebreijer WE, Bloem RM, Nelissen RGHH, Pilot P.: Outcome in hip fractures patients related to anemia at admission and allogeneic blood transfusion: an analysis of 1262 surgically treated patients. BMC Musculoskeletal Disorders 2011; 12:262.
98. Gupta RK, Sangwan K, Kambo PJ, Punia SS, Walecha N.: Unstable trochanteric fractures: the role of lateral wall reconstruction. International Orthopaedics (SICOT) 2010; 34:125–129.
99. Koval KJ, Oh CK, Egol KA.: Does a traction-internal rotation radiograph help to better evaluate fractures of the proximal femur?. Bull NYU Hosp Jt Dis 2008; 66 (2):102-106.
100. Jensen JS.: Classification of trochanteric fractures. Acta Ortho Scand 1980 Oct; 51 (5):803-810.
101. Fung W, Jhonson A, Buhren V et al.: Classifying intertrochanteric fractures of proximal femur: does experience matter?. Med Princ Pract 2007; 16 (3): 198-202.
102. Bijlani RL.: Medical Research: all you wanted to know but did not know whom to ask. Jaypee Brothers Medical Publishers 2008.
103. Pervez H, Parker MJ, Vowler S.: Prediction of fixation failure after sliding hip screw fixation. Injury 2004; 35:994-998.
104. Wu CC, Shih CH, Lee MY.: Biomechanical analysis of location of lag screw of a dynamic hip screw in treatment of unstable intertrochanteric fractures. J Trauma 1996; 41:699-702.
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Vol 2 | Issue 1 | Jan - Apr 2014 | page 31-34 | Kotwal U, Raina TR, Sidhu M, Dogra M

Author: Urvershi Kotwal[1], Tilak Raj Raina[2], Meena Sidhu[3] , Mitu Dogra[1]

[1]MD Immunohematology & Blood Transfusion Medicine,GMC Jammu
[2] MD Pathology, GMC Jammu
[3] MD Pathology, MAMC New Delhi
Institute at which research was conducted: GMC Jammu
University Affiliation of Thesis: Jammu University
Year of Acceptance: 2012.

Address of Correspondence
Dr Urvershi Kotwal
c/o Blood bank,Dr Ram ManoharLohia Hospital
New building gate 6,Baba kahragsinghmarg
New delhi 110001.
Email: urvashikotwal@gmail.com

 Abstract

Background: Out of twenty nine Blood group systems discovered so far, ABO & Rh system is the most important with respect to Blood Transfusion, Hematopoietic Stem Cell Transplantation & Solid Organ Transplantation.
Methods: It was a Cross-sectional, hospital based study involving blood donors over a period of one year. Blood donors were divided into five major ethnic groups and ABO & Rh D blood grouping was done by conventional tube technique.
Results: Among the total 13,281Blood Donors97.51% donors were male &2.49% were females. 89.09% donors were below 40 years of age with mean age of the 29.87 years. Maximum Donors were Dogras (78.20%) followed by Non Gujjar Muslims (9.28%), Sikhs (5.92%), Gujjars (4.31%)& Kashmiri Pandits (2.30%). The most prevalent ABO phenotype among donors was B (34.85%) followed by O (30.64%), A (24.77%) &AB (9.73%). Out of the total 3291 A blood group, there were 30 cases of A2thus comprising of 0.91%.Among the study group 94.52% were positive for Rh D antigen &5.48% were Rh D negative. Prevalence of Weak D was 0.0075% and among the Rh (D) antigen Negative Blood Donors (728) it was 0.14%. The prevalence of Rh D negative blood donors was highest among Non-Gujjar muslim donors 10.06%, followed by Kashmiri pundits 9%, Gujjars8.22%, Sikhs 6.62%& Dogras 4.60%. In Dogra (34.80%), sikhs(38.80%) and non gujjar muslims(34.98%) donors B blood group was commonest. In Kashmiri Pandits(32.45) and Gujjars(34.09%) the O phenotype was common.To conclude our region is having a blood group distribution trend B>O>A>AB, which does not follow the Asiatic trend of O > B > A > AB with marked differences of distribution among the ethnic groups especially with reference to Rh D antigen.

Introduction

Karl Landsteiner in 1901 discovered the ABO Blood Group System and by 1902, he described that there are four blood groups existing in human being & in this way Landsteiner truly opened the doors of blood banking.Out of the twenty nine Blood Group Systems discovered so far, ABO & Rh systems are the most important with respect to Blood Transfusion, Hematopoietic Stem Cell Transplantation and Solid Organ Transplantation.(Hod E.A.; 2009)1. Inspite of advancements in blood grouping & crossmatching techniques transfusion of wrong ABO & Rh is one of the leading cause of deaths reported to FDA (Harmening D.M.; 2008)2. The basis of pretransfusion testing is to detect ABO incompatibility between donor & the recipient. ABO Forward & Reverse grouping tests are required to be performed on all the donors & recipients as there is always a reciprocal relationship between the Forward & Reverse type, thus one serves as a check on the other. ABO subgroups are phenotypes that differ in the amount of A & B antigens carried on red cell membrane & also in body secretions. In general A subgroups are more common than B subgroups(Cooling Laura; 2008)3. In addition to A2 several other weaker A subgroups are described (A3,AxA,Ametc.) the extremely weaker A(B) subgroups  are infrequently encountered & are usually recognised by apparent discrepancies between red cell (forward) & serum (reverse) grouping results. The frequency of these blood groups in the white population is O-45%; A-40%; B-11%; AB-4%; O & A are most common & AB is rare among Westerns. However, frequencies of ABO groups differs in a few selected populations & ethnic groups like blood group B is found twice as frequently in Blacks & Asians as in whites & sub group A2 is rarely found in Asians. The Rh System is next only to the ABO system in importance in Transfusion Medicine. Rh system was discovered by Levine & Stetson in 1939 who detected an irregular antibody in the serum of a mother whose foetus had Haemolytic Disease of Foetus &Newborn. (Makroo RN.;2009)4. Rh Antigens especially D are highly immunogenic &Clinical importance of Rh Blood Group System lies in the fact that the Haemolytic Disease of Foetus & Newborn may occur in Rh Negative pregnant women having a Rh Positive foetus & Rh antibodies may develop in any Rh Negative individual if transfused Rh Positive bloodleading to Haemolytic Transfusion Reaction's(Makroo RN.;2010)5. Even exposure of 0.1 ml of Rh (D) antigen Positive cells can elicit an antibody response in Rh Negative persons.Rh antigens are present only on red blood cells.Once initiated Rh antibody production is irreversible & circulating antibodies last for years.Weaker variants of D are defined as the weakened expression of normal D antigen i.e. fewer than normal D antigens present per red cell. Previously known as Du. Thisis an inherited characteristic. In Blood Donors Weak D is taken as D positive & in recipients Weak D is taken Rh Negative. Mothers with Du positive foetus require Rh immunoprophylaxis. (Mayne K.; 1990)6. Jammu also known as Duggar Desh, is one of the three administrative divisions within the state of Jammu and Kashmir. Population of Jammu division consists of 65% Hindus, 30% Muslims & remainder are Sikhs. Hindus are subdivided into different ethnic groups like Dogras, Kashmiri Pandits, Sikhs, Brahmins, Rajputs, Thakkars, jats etc. Muslims are subdivided mainly into Gujjars and Non-Gujjars. Aim of the study was to determine the prevalence of ABO & Rh D blood groups among blood donors (voluntary & replacement) of Jammu region and their distribution in various ethnic groups of Jammu Province. Also to report the cases of Weak D & Bombay Phenotype in Jammu Province if any.

Methods

It was a Cross-sectional, prospective hospital based study involving blood donors carried out in the Post-Graduate Department Transfusion Medicine, Government Medial College, Jammu from November 2010 to October 2011.Blood Donors were selected & rejected as per per the Donor Questionnaire framed under DGHS/NACO guidelines & SOP available in the Department. Blood Donors belonging to five major ethnic groups namely Dogras, Gujjars, Kashmiri pandits Non-Gujjar Muslims and Sikhsdonated blood at our centre after undergoing pre-blood donation check up & being declared medically fit. Approximately, 3 ml of blood sample was taken in the EDTA vial which was then used for blood phenotyping & blood screening. ABO & Rh D blood grouping was done by conventional tube technique. The Rh D negative donors were further typed for the Weak D antigen. Bombay phenotyping of all the Blood group O donors was done.

Results

During the one year study period, a total of 13,281 Blood units were subjected to ABO & Rh (D) Blood Grouping. Among the study group, 12,950 donors (97.51%) were male & 331 (2.49%) were females.There were 11,832 (89.08%) Blood Donors in the age group of 18-40 years and 1,449 (10.91%) Blood Donors in the age group of 41-60 years. Mean age of study group came out to be 29.87 years. Our study population consisted of Blood Donors belonging to five main Ethnic Groups namely Dogras, Kashmiri Pandits,Sikhs, Gujjars & Non-Gujjar Muslims  as shown in figure 1Among all the Blood Donors included in the study, the ABO Phenotypic distribution irrespective of Rh (D)antigenic expression is shown in fig 2. Among the total A Positive Blood Donors 30 cases of Blood group A2 were found having a prevalence of 0.91% (ConfidenceInterval -2.48-4.30) among the total 3,291 A Positive Blood Donors &0.23%(ConfidenceInterval -1.47-1.93) among total 13,281 Blood Donors taken in the present study. On  RhD antigen phenotyping, 12,553 donors (94.52%) were Rh DAntigen Positive & 728 donors (5.48%) were Rh DAntigen Negative. Weak D (Du) testing was done using Indirect Antiglobulin test and only one Blood Donor was Weak D positive. So, the prevalence of Weak D (Du) among the total Blood Donor population in the present study came out to be 0.0075%(Confidence Interval -1.69-1.71)& among the Rh (D) antigen Negative Blood Donors it was 0.14% (Confidence Interval -7.19-7.47). The distribution of ABO & Rh (D) Blood Group in study group is shown in Fig 3.

Discussion

Blood groups are genetically determined and the incidence of ABO and Rh genes and their phenotypes vary widely across races and geographical boundaries despite the fact that the antigens involved are stable throughout life. The resultant polymorphism remains important in population genetic studies, estimating the availability of compatible blood, evaluating the probability of haemolytic disease in the new born, resolving disputes in paternity/maternity and for forensic purposes. The present study has therefore provided useful information on the status of ABO and Rh (D) blood group distribution in Jammu region. In present study there were 97.51%male donors &2.49%female. It may be because of the prevalent customs, lack of exposure,  awareness and opportunity among them. Another reason is deferral of females for being anaemic which is in accordance to the overall prevailing prevalence of anaemia among the females all over India as more than 50% females in the reproductive age group in India are anaemic.(REF). Range of the age distribution among the Blood Donorstaken in the present study was 18-60 years. 89.09% donors were below 40 years of age with mean age of the 29.87 years. The most prevalent ABO phenotype among our population came out to be B (34.85%) followed by O (30.64%),A (24.77%) & AB (9.73%). Thus, it is concluded that the parts of North India & its adjoining areas of Pakistan show the predominance of Blood Group B as supported by various studies. Khan MS et al.(2004)7Khalid  M and Qureshi M A (2006)8Tiwari A et al.( 2010)9Maheshwari P.(2010)10table 3. Studies from the South India generally show a variable pattern of Blood group predominance showing O to bethe most commonest blood group like Das P K et al.(2001)11PeriyavanS. et al.(2010)12Nag I et al.(2009)13. Frequency of Rh DNegative is in accordance with many studies across the country like Nanu A. et al.(1997)14 Calcutti R A et al.(2003)15Alam M.(2005)16 Nag I et al.(2009)11,PeriyavanS et al.(2010)12. There are a few studies which show a higher prevalence of Rh (D)Negative phenotype like Sharma S et al.(2011)17Khan MS et al.(2004)7. As per the ethnic distribution, prevalence of the Rh D Negative Blood Donors was highest among Non-Gujjar Muslim donors (10.06%), followed by Kashmiri Pandits (9%), Gujjars (8.22%), Sikhs (6.62%) & Dogras (4.60%). There are no studies regarding the distribution of ABO and D antigens in various ethnic groups. The prevalence of Weak D positivity among the total Blood Donor population (13281) in the present study came out to be 0.0075%(Confidence Interval -1.69-1.71)& among the Rh (D) antigen Negative Blood Donors (728) it was 0.14% (Confidence Interval -7.19-7.47). Frequency of weak D is low in present study in accordance with study by makroo et al5. In DograsB phenotype,Kashmiri Panditsethnicity the O , Sikh Blood Donors B phenotype, Gujjar ethnicity O,Non-Gujjar muslimsB phenotype are the commonest.Non-Gujjars muslims have shown a relatively higher percentage of Rh (D) Negative (10.06%) phenotype as compared to Rh (D) Negative prevalence among the various studies done across the country as well as the prevalence of Rh (D) Negative (5.48%) as seen among Blood Donors in our study. This high prevalence of the Rh (D) Negative phenotype among a particular ethnic group may be because of the consanguinity which is a very common practice seen among the Non-Gujjar Muslimsas it is their custom. The terrain of our state is hilly & there a few areas which still are inaccessible and there the population is isolated and people living there have a less exposure to the people living in the other parts of the state and the rest of the country. Other factor responsible may be that it is believed that the ancestors of the people living here have migrated from Pakistan and other adjoining countries where similar pattern of distribution has been found.(REF). Present study  is having a blood group distribution trend as B>O>A>AB. This trend doesn't follow the trend as seen in rest of Asiathat is O > B > A > AB.The knowledge of the distribution of ABO and Rh (D) blood groups is essential for the effective management of a Blood Bank's inventory, whether it isin a smaller Local Transfusion centre or a Regional or National Blood Transfusion Service.Blood Transfusion Service (BTS) is an integral part of modern health care system without which efficient medical care is impossible. The main aim of a Blood Transfusion Service is to provide effective blood and blood products, which should be as safe as possible, and adequate to meet patient's need. It is therefore hoped that the data generated in this study would assist in the planning and establishment of a more efficient functioning Blood TransfusionService that would meet the ever-increasing demand for safe blood and blood products. Jammu as a region has got some special constraints & peculiarities like a very low density of population, difficult and hilly terrain, poor connectivity by roads, lack of infrastructure and limited presence of private sector/NGO's. This study has provided a very valuable information regarding the distribution of Blood Groups in Jammu region as generation of a simple database of blood groups provides data about the availability of human blood in case of regional calamities to which our area is more prone. Inspite of the valuable information provided by this study, it is suggested to extend this study to the district & sub-district levels to have an assessment of the needs & provision of the better health care facilities even to the grass root level, especially in view of the special constraints of the region & the needs of the people. Thus, the data generated by this study will be useful for the health planners, while making efforts in delivering the better health care facilities like establishing the FRU's so that all the people living in the region have the access to and have the maximum benefit of these health care facilities.

Conclusion:

The present study has given us a very valuable information because the knowledge of Red Cell ABO & Rh (D) Antigen phenotype frequencies in a given population in terms of their ethnic distribution, is helpful in creating a Blood Donor data base which not only provides data about the availability of human blood in case of regional calamities, but is also helpful for preparation of indigenous cell panels, and also providing the compatible blood to the patients. Some ethnic groups like Kashmiri Pandits & Non-Gujjar Muslims have a very high prevalence of Rh (D) Negative phenotype suggesting that Haemolytic Disease of Foetus & Newborn may be a particular concern in these subgroups. Thus, it would make the data generated by the study, to be useful for health planners, while making efforts to face the future health challenges in the region.

Bibliography

1. Hod E.A., Spitalnik P.F, & Spitalnik S.L Carbohydrate Blood Groups, Rossi's Principles Of Transfusion Medicine Fourth Edition 2009 page no 89-108.
2. Harmening D.M.; Firestone D. The ABO Blood Group System, Modern Blood Banking & Transfusion Practices Fifth Edition2008 page no 108-132
3. Cooling Laura ;ABO,H,Lewis Blood Groups & Structurally Related Antigens, Technical manual AABB sixteenth edition 2008'p.no 361-385
4. Makroo RN. 2nd ed. New Delhi: 2009. Compendium of transfusion medicines
5. Makroo R N, Raina V, Chowdhry M, Bhatia A, Gupta R, and Rosamma NL Weak D prevalence among Indian blood donors Asian J Transfus Sci. 2010 July; 4(2): 137–139
6. Mayne K, Bowell P, Woodward T, Sibley C, Lomas C, Tippett P. Rh immunization by the partial D antigen of category DVa. Br J Haematol. 1990;76:537–9
7. Khan MS, Subhan F, Tahir F, Kazi BM, Dil AS, Sultan S, Deepa F, Khan F and Sheikh MA Prevalence of blood groups and Rh factor in Bannu region (NWFP) Pakistan Pakistan J. Med. Res.Vol. 43 No.1, 2004
8. Khalid M and Qureshi M A Frequencies of blood group antigens and corresponding alleles in the population of Mirpur, Azad Jammu & Kashmir, Pakistan J. Anim. Pl. Sci. 16(3-4): 2006
9. Tiwari A, Pandey P, Joseph N P, Frequency of ABO blood group system in northern India Abstract of 37 th Annual Conference of Indian Society of Blood Transfusion and Immunohematology (ISBTI). Asian J Transfus Sci 2011;5:63-109
10. Maheshwari P Distribution of ABO and Rh blood group- A population based study from north India Abstract of 37 th Annual Conference of Indian Society of Blood Transfusion and Immunohematology (ISBTI). Asian J Transfus Sci 2011;5:63-109
11. Das PK, Nair SC, Harris VK, Rose D, Mammen JJ, Bose YN, Sudarsanam A. Distribution of ABO and Rh-D blood groups among blood donors in a tertiary care centre in South India. Trop Doct. 2001 Jan;31(1):47-8.
12. Periyavan S, Sangeetha SK, Marimuthu P, Manjunath BK, Seema DM. Distribution of ABO and Rhesus-D blood groups in and around Bangalore. Asian J Transfus Sci [serial online] 2010 [cited 2010 Sep 21];4:41
13. Nag I, Das S S et al ABO and rhesus blood groups in potential blood donors at Urgapur steel city of the district of Burdwan, West Bengal Abstract of 37 th Annual Conference of Indian Society of Blood Transfusion and Immunohematology (ISBTI). Asian J Transfus Sci 2011;5:63-109
14. Nanu A, Thapliyal RMBlood group gene frequency in a selected north Indian population. Indian J Med Res. 1997 Sep;106:242-6.
15. Calcutti RA, Lone MK, Ahmed S, Shah BA, Jan N Blood Groups in the Kashmir Valley ,JK SCIENCEVol. 5 No, 3, July-Septembcr 2003
16. Alam M ABO and Rhesus blood groups in potential blood donors at Skardu(northern areas)Pak J Pathol Jul - Sep 2005;16(3):94-7.
17. Sharma S et al Prevalence of phenotypes and genes of ABO and Rhesus (Rh) bloodgroups in and around Amritsar district, Punjab – A four year study ( June 2007- June 2011) Abstract of 38 th Annual Conference of Indian Society of Blood Transfusion and Immunohematology (ISBTI). Asian J Transfus Sci 2012;6:63-109.

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Vol 2 | Issue 1 | Jan-April 2014 | page 1-2 | Shyam AK

Author: Dr. Ashok K Shyam

MS Orthopaedics
Editor - Journal of Medical Thesis
Email: drashokshyam@yahoo.co.uk

Ideas and Hypothesis are the starting point of all research. To trace them back, they evolve from a general pool of curiosity in the mind of the researcher. They begin as a disturbance in status quo and an intention to improve the present. Over a period this intention becomes very specific mostly related to the field of specialisation and takes form of a question which demands an answer with force of logic. This primordial question is then put into a vitriol mixture of rational thought process, current literature, lateral thinking and personal experience. Through this process the primordial question is transformed into a full blown Idea or ‘Hypothesis’. This is the seed through which the strong tree of ‘Research’ stems from and this is in no way a less demanding process than the complete research. In fact many research projects, when completed, may not appear satisfactory, primarily due to defects in the hypothesis which were overlooked and are now magnified at the end of the study. The health of the Hypothesis actually defines the health of the completed projects and ultimately their conclusions and their effect on patient care and advancement of medical knowledge and research. As convention only the complete research projects are subjected to peer review and are published in Literature with very few exceptions [1]. I strongly believe these ‘Hypothesis’ or ‘Idea’ should also undergo a peer review process and be published before the actual research project is started. This will help in refining the idea and also assessing the quality of the idea. If the ideas do not primarily meet the requirements of scientific inquiry they may be rejected and unnecessary experimentation can be avoided. Of course this will be and should be through a stringent scientific peer review process and should have rapid publication time. Journal of Medical Thesis will be offering this platform to publish hypothesis and ideas related to all medical specialities. As mentioned above this will help in making good ideas better and also may filter out not so good ideas and avoid unnecessary use of resources. From this issue we are now accepting hypothesis, ideas, opinions and synopsis for publication in Journal of Medical Thesis. Guidelines for all of these are now included in the authors section, but the basic outline will consist on detailing what is the current knowledge, how is the new idea different form the existing context and how will it change the viewpoint with clinical benefits in mind. Lastly it should also outline how the experiment should be designed to prove the hypothesis.

Although the idea of publishing hypothesis stems from an intention to improve the question so that we get better answers, it can also be viewed as an intellectual property tool. Intellectual property may be defined as legally recognised exclusive rights conferred to an individual over creations of his mind. Although an idea or a hypothesis is essentially an intellectual property by definition, it is almost impossible to register them before they are develop into a practically testable product or process that can be patented. Specifically in medical field it is very difficult and at times impractical to develop such a product or a process due to various reasons of which time availability for experimentation and resources available for research are main. Many a times this leads to authors shying away from publishing their idea and hypothesis. This may lead to a lot of delay in implementation of a potentially beneficial idea or possibly complete loss of the idea. If the hypothesis is published in JMT, it will not only be as good as a patented intellectual property but will also make the idea available in public domain and open to development by other researchers. Again any further refinement of the idea or hypothesis will always require the future researcher to quote and cite the original hypothesis paper in JMT. Thus such publication will act as a perpetual intellectual copyright of the idea and impart true credit to the originator of the idea. This has more relevance specifically to medical filed where many ideas or hypothesis are part of clinical skills, surgical expertise or patient oriented outcomes and may not be in any ways be ethically copyrighted except through publications in peer reviewed journals like JMT. Also after publication the idea will be read by many and may stimulate new ideas in minds of readers thus initiating a chain reaction ultimately leading to better and integrated ideas and concepts.

The last part will focus on the concept of Defensive Publications. These are effectively means of defending ones Intellectual property rights by putting the idea or hypothesis primarily in public domain thus preventing anyone else to present patent consideration. Although these are most of the time used in pure sciences and technology and engineering fields and such publications can be more effectively used in medical field. For example, a surgeon or a physician over a period of time develops an improvement of existing technique of treatment of a particular disease, however he fails to publish it (probably due to reasons as stated above and other reasons why clinicians fail to publish). However what he does is that he presents it in conferences and shares with his colleagues. Any colleague from the audience can then potentially perform a study based on the similar technique and publish the results. The publication will be in name of the other physician rather than the original author who had developed the idea. Although it may also happen that two physician totally disconnected can have similar ideas at same times but again one who publishes the idea first gets the first credit and others have to be content with merely citing the original paper. Such incidences are not very rare and time and again I have heard from senior colleagues who have read a recent article and state that they have been using the similar surgical technique for years (but of course have failed to publish). Thus publishing the idea, hypothesis gives the researcher their rightful place as the originator of the thought process and helps defend against idea high jacking.

Publication of hypothesis, ideas, and opinions will lead to improvement of the original idea, safeguarding of the intellectual property and protects the rights of the original thinker along with widespread spread of the idea thus accelerating the process from idea to practical process of clinical importance. JMT will provide all support to such authors and will have rapid peer review and publication policy for such hypothesis and ideas. Again through widespread use of open access online publication with creative common rights permissions we intend to make the publication reach the widest and relevant readers. However this will imply more rigorous peer review and more responsibility on the editorial team to allow only scientific and rational hypothesis and ideas to be published. We believe this will definitely add to the literature. With this I take this opportunity to invite scientific hypothesis, synopsis, ideas and opinions for publication in Journal of Medical Thesis.

Dr Ashok Shyam

Editor – JMT

References:

1. Shyam AK. Editorial: Journal of Medical Thesis: Creation of A Unique Paradigm - Principles and Vision. Journal Medical Thesis 2013 July-Sep; 1(1):1-3

2.Shyam A K. Editorial: Journal of Medical Thesis: Research Education and Journal of Medical Thesis. Journal Medical Thesis 2014 May-Aug; 2(2):1-2.

3. Shyam AK. Editorial: Journal of Medical Thesis: Hypothesis, Intellectual Property and Journal of Medical Thesis: Concept of Defensive Publication. Journal Medical Thesis 2014 Jan-Apr ; 2(1):1-2

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Vol 2 | Issue 1 | Jan - Apr 2014 | page 19-23 | Gupta S,  Hegde J

Author: Saurabh Gupta[¹], Jayasheel Hegde[¹]

[¹]Basappa Memorial Hospital
Institute at which research was conducted: Basappa Memorial Hospital.
University Affiliation of Thesis: National Board Of Examinations ,
New Delhi .
Year of Acceptance: 2013.

Address of Correspondence
Dr. Saurabh Gupta
C/o Gupta Nursing Home , Hanumangarh Road , Distt: Sirsa , Po: Ellenabad , Haryana
Email: drguptaforyou@yahoo.co.in

 Abstract

Background: The conventional method of treatment of paediatric femur fracture by traction, splinting & cast application have reduced over the decade & given way to minimally invasive internal fixation.
Methods: Overall result achived were Excellent in 18 patients. Satisfactory in 2 patients. No patient showed Poor results. All fractures healed with an average time of union of 6- 10 weeks. Soft tissue irritation around the knee was the most common problem encountered. Shortening and restriction of flexion were hardly observed. There was no delayed union , or non union , or refracture. Removal of nail of 2 mm and proximal migration was technical problem encountered in few cases.
Conclusion: We strongly belive that with proper intra operative technique . Appropriate instrumentation , and after care, TENS may prove the most ideal implant for pediatric femoral fracture.

Introduction

Pediatric diaphyseal fractures account for 1.4% to 1.7% of all fractures in the pediatric population. Orthopaedic Surgeons from a long time have choosen that paediatric femoral diaphyseal fractures to be treated by conservative method such as Hip Spica due to good remodelling of bone in this age group  , but  with time  and experience it has been found that all paediatric diaphyseal fractures are not united  properly and angulation , malrotation &  Shortening , have been observed. Beyond doubt children below 6 year of age are well treated by Spica cast , & children above 16 yeras are generally well treated by Interlocking nail , but the biggest Debatable age agoup is 6- 14 yeras of age , and for this age group many different modality of treatments are available such as eg: Traction followed by casting , Plate fixation , External fixation and Flexible Intramedulary nails with no clear cut guidlines to a preferred treatment. In recent times the trend have been shifted to a more aggressive and Operative approach and to avoid complication that might come with conservative treatment  as Shortening , Malrotation , and Angulation . Operative Fixation allowes rapid recovery, early mobilization and reintegration of patient. It avoides prolonged hospital stays ,and relief from difficulties  to family and care takers. It also has psychological , social , educational and economic advantage over conservative treatment.In recent times Ideal fixation device that have surfaced is flexible Intramedullary Nail , Notably Titanium Elastic Nail , which is a Load sharing Internal Splint ,and  which maintains length and reduction . It also prevent Physis damage . Titanium elasticity promotes callus formation by limiting stress shielding. Titanium also has excellent biocompatibility. The biomechanical principle of TENS is based on the symmetrical bracing action of two elastic nail inserted in to the metaphysis ,each of which bears against the inner bone at three points.

Methods

After  obtaining Approval from Institutional board and Informed consent prospective study of patients presenting with diaphyseal fracture of femur in age group of 5- 12 Years was done. Study was conducted on 20 Patients with diaphyseal fracture of femur with 12 boys and 8 girls in the study. Patients were treated with 2 titanium elastic nails. Follow up of patients was done both clinically and radiologically for one year . Fresh Closed displaced / undisplaced  and fresh type 1 and type 2 open femoral diaphyseal fractures were Included in study. Segmetal and Pathological fractures were also included. About 13 patietnts had right side fracture and 7 had left side fracture. Majority of patients had transverse fracture followed by Oblique and spiral fracture. Following Variable analysed were also evaluated such as duration of hospital stay , duration of union , return to activities in days , duration of implant removal , any LLD or  malalignment. Final outcome was evaluated based on Flynn Criteria.

Results

Results were evaluated based on Flynn et al  criteria , 90% of patients had excellent result and 10%  had satisfactory results. Majority of  patients return to activity by 9-11th week. In majority 40 % of patients, the implant were removed by 5th Month.  90% of patient had LLD of  less then 1cm. Majority,70% of patients had no complications, Only 20% had Irritation at entry site , 5% had Infection and proximal nail migration. There were no delayed union , non-union or refracture . Majority 90 % of the patients were discharged before 10 th post op day. Radiologically callus formation was seen by 8th week in 50 % patients.whereas 40 % patients had callus formation by 5-6th week.

Conclusion

We Strongly belive that Titaninum elastic nailing is by far the safest , and the most ideal modality of treatment for pediatric  femoral diaphyseal fractures. It  has considerably decreased the hospitalisation time, resulting in early return to home by the patient, thus cutting the cost of the treatment and also has psycological benefits. It is a simple technique and minimum invasive method for  stabilisizing pediatric femoral shaft fractures .The incidence of knee Stifness , malrotation , Angulation and delayed union which devlope with Conservative treatment such as Spica cast application is significantly reduced. Incidence of pin site infection which develop with External fixation is also reduced. TENS allows a biological environment that enhances both  the rate of fracture healing and quantity of callus formation. Most of the complication associated with it are infact features of inexact technique and can be eliminated by strictly adhering to the basic principles and technical aspects. However we belive that with appropriate instrumentation and proper  post operative rehabilitation TENS may prove to be the most ideal implant for pediatric femoral diaphyseal fractures.

Key Words

Pediatric ; Femur ; Titanium Elastic Nail.

Bibliography

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Vol 2 | Issue 1 | Jan - Apr 2014 | page 16-18 | Jain SR, Shah HM, Shetty N, Patel M, Tekkati RK, Khanna A

Author: Sachin R Jain[1], Harshad M Shah[2], Naresh Shetty[2], Maulik Patel[3], Rajesh Kumar Tekkati[4], Angshuman Khanna[5]

[1]Sancheti Institute for Orthopaedics and Rehabilitation, Pune
[2]M.S.Ramaiah Medical College, Bangalore
[3]Birrd hospital, Tirupati.
[4]K S hedge medical academy, Mangalore.
[5]Gauhati Medical College and Hospital
Bhangagarh, Guwahati

Institute at which research was conducted: M.S.Ramaiah Medical College, Bangalore. India
University Affiliation of thesis: Rajiv Gandhi University Of Health Sciences
Year of Acceptance: 2012

Address of Correspondence

Dr.Sachin Ramesh Jain
Room no 37, Thube park, Sancheti guest house, near sancheti hospital, Shivaji nagar, Pune - 411005.
Email: dr.sachin_jain@yahoo.com

 Abstract

Introduction: Non union of tibia associated with infection have always been a challenge to Orthopaedic surgeons. Conventional methods do address the multiple complex problems. Ilizarov method has been a boon for such cases.
Aims and Objectives: Assess the efficacy and safety of ilizarov fixator method of treatment in infected non-union tibia and various complications associated with ilizarov external fixation.
Methods: 21 patients, 20 males and only one female, minimum 20 years & maximum age 75 years, average age 36.8 years with infected non union of tibia treated by Ilizarov methods and principles have been analysed. 2 fractures were in proximal 1/3rd, 6 in the mid 1/3rd, 3 in the junction between mid and distal 1/3rd, 7 in distal 1/3rd and 3 were segmental / comminuted. They were all treated with debridement, excision of the non union & fibular partial excision was done as required. Acute docking in 6 patients & acute shortening was done in others. Corticotomy was done at same time or if infection was severe, it was performed after two weeks.
Results: The most common complication was pin tract infection which healed by antibiotic usage & pin tract dressings. Knee & ankle stiffness was seen in several patients due to the seriousness of the cases. According to Dror Paley's bony criteria, results were excellent in 3, good in 12, fair in 4 and poor in 2 cases.
Conclusion: Ilizarov technique gives satisfactory results in infected non union of tibia. Considering the complexity of the condition it is the choice of treatment. It addresses to the problems of non union, infection, correction of deformity and lengthening of the limb.
Key Words: Fracture Shaft Tibia, Infected non-union, Ilizarov external fixation, limb length discrepancy, distraction osteogenesis.

Introduction

Infected non-union of tibia per se is a challenge to treat. Secondary skeletal defects due to infected non-union may require bone grafts1, extensive debridement and local soft tissue rotational flaps 2,3, packing of the defects with Papineau-type open cancellous bone grafting4 , tibiofibular synostosis5,6 , and free microvascular soft tissue and bone transplants7-9. Subcutaneous bone causes susceptibility to compartment syndrome, non-responsive infection, non-union, fibrosis, sinuses, deformities, shortening and various other sets of problems which are associated with it. There is flaring of the infection and various antibiotics not acting frustrate the patient as well as the surgeon. Patient getting depressed and the huge burden of cost of different modalities make life miserable. Ilizarov method addresses all the above problems simultaneously. The stability of the fixation allows weight bearing ambulation and joint mobilisation. Progressive bone histogenesis following corticotomy and bone transport helps in filling bone gaps eradicating infection and promoting fracture union. Infection control is achieved by radical debridement of the infected tissues including bone and followed by bone transport to reconstruct the residual bone defects.

Methods

23 patients with established infected non-union of the tibia were evaluated prospectively for the study. Clinical history including co-morbidities, social habits including smoking and alcohol consumption, previous treatment offered for the fracture, complications, duration of non-union. All patients had preoperative full-length radiographs of the affected leg for assessment of the level and type of fracture non-union, plane of deformity, bone quality and presence of sequestrum. All patients were counselled about the procedure to be performed, and the expected outcome of treatment. All patients were optimized preoperatively for the proposed operation. Culture swabs from draining sinuses and open wounds were carried out in all patients and appropriate antibiotic therapy was initiated. This was repeated whenever necessary throughout the duration of treatment. The site of non-union was in the distal, middle and proximal thirds in 14, 6 and 3 patients respectively. The initial diagnosis was closed fracture in 3 Gustilo type 1 open fractures in 2, Type 2 in 5 and type 3 in 13 patients. Type of fixation before Ilizarov surgery was Intra-medullary nail in 9 and Plate and screw fixation in 3 and, 11 had external fixation followed by plaster immobilization as definitive treatment. The co morbidities were Diabetes in 2 patients. Limb shortening ranged from 1-8 cm (2.75cm avg) Pus culture in all patients obtained pre operatively, revealed a mixed a bacterial growth. The Ilizarov frame was constructed pre-operatively in all patients and modified intraoperatively. All patients had debridement combined with ring fixator application as a single stage procedure. 8 patients had bifocal osteosynthesis (compression of the fracture site with bone transport following corticotomy) and 15 patients underwent monofocal osteosynthesis. Bone marrow infiltration was done in 67% of our cases but no bone grafting was needed. 8 patients had proximal tibial corticotomies. Postoperatively all patients had radiographs of tibia and fibula for assessment of the corticotomy and position of the wires. Corticotomy site distraction was initiated between 5-7 days at the rate of 1 mm per day and compression and distraction technique. Follow up x-rays were done at 3 weeks for assessment of the regenerate and at 4 weeks interval thereafter until fracture union. and distraction rate was reduced to 0.5mm/day until satisfactory appearance on x-rays. Patients were mobilised partial weight bearing, within comfort by a trained physiotherapist. Patients were discharged upon satisfactory compliance and followed up in the fracture clinics at monthly intervals for assessment of fracture union, regenerate progress and ensuring compliance with physiotherapy. Fixator was retained further for the duration equal to the period of bone transport after bone docking. Bone union was confirmed by conventional radiographs and the fixator was removed under anesthesia. The operated limb was protected in a functional cast brace for at-least twice the duration of bone transport. The period of follow up after fracture union ranged from 6 months. The outcomes were assessed using the Association for the Study and Application of Methodology of Ilizarov [ASAMI] criteria.

Results

The study group consisted of 23 patients in the age group of 16 - 75 years [Average: 38.87].There were 21 male and 2 female patients. 1 patient expired with fixator in situ so couldn't be evaluated for results. All patients had limb oedema, equinus deformity of the ankle, and sub-talar and knee joint stiffness. Fracture union was achieved in 22 patients without the need for bone grafting. The problems and complications in the cohort of patients studied are as per Table 1. Bony and functional results [Tables 2 and 3] were evaluated as laid down by the ASAMI Criteria. Of 22 patients in the study, Average bone gap was 2.75 cm (1-8cm). Average length of the regenerate was 2.56 cm(0.5 to 6cm). Average duration of fixator period was 8.6 months (1.5-14months). According to ASAMI bony criteria, results were excellent in 13(59%), good in 6(27%), fair in 2(9%), and poor in 1(4.6%) cases and functional results were excellent in 15(68%), good in 2 (9%), fair in 2(9%) and poor in 3(13%).

Discussion

Reconstruction of segmental bone defects remains a difficult problem. Bone transport is one of the most innovative contributions of Ilizarov to orthopaedic surgery10- 17 With the different methods of segmental bone transport, long osseous tissue can be reconstructed without the need for bone grafting. The newly formed bone rapidly ossifies and becomes corticalized .
A fracture non-union is a significant problem to the patient and the surgeon. In many instances the patient has undergone one or more surgical procedures, has lost considerable time from his job or her life style, and has been forced to alter his or her life style. Furthermore, the psychological and physical trauma to the patient when faced with the prospect of another surgery is often underestimated. The problems facing the surgeon are no less formidable. In many instances consolidation of the non-union must be achieved with correction of axial and rotational malalignment18. The mixed organism growth from bacterial cultures of nosocomial origin required repeated hospitalisations and expensive antibiotics for infection control. Despite being advised about proper pin site care, very few patients strictly adhered to the instructions. We have followed the criteria laid down by ASAMI. Treatment time with Ilizarov is lengthy with a considerable risk of complications. Bone grafting at the docking site is recommended in order to shorten the duration of treatment and to prevent re-fracture and non-union. No patient required bone grafting in our cohort of patients. Patients tolerate docking well up to 5 cm of shortening and the bony and functional results were uniformly poor beyond 5 cm. However, it may help shorten the duration of treatment and thus ensuring compliance. No patient in our study had neurovascular deficits. In our study, all patients had varying degrees of knee, ankle and sub-talar joint stiffness. Though knee stiffness was largely overcome with physiotherapy, foot and ankle stiffness persisted and worsened despite bony union.

Conclusion

Ilizarov technique gives satisfactory results in infected non union of tibia. Considering the complexity of the condition it is the choice of treatment. It addresses to the problems of non-union, infection, correction of deformity and lengthening of the limb.

Bibliography

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9. Nusbickel FR, Dell PC, McAndrew MP, Moore MM. Vascularized autografts for reconstruction of skeletal defects following lower extremity trauma. A review. Clin Orthop Relat Res 1989;243:65-70.
10. llizarov GA. Basic principles of transosseous compression and distraction osteosynthesis[in Russian]. Ortop Travmatol Protez 1971;32:7-15.
11. lIizarov GA. The tension-stress effect on the genesis and growth of tissues. Part I. Theinfluence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res
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12. llizarov GA. The tension-stress effect on the genesis and growth of tissues: Part II. The influence of the rate and frequency of distraction. Clin Orthop Relat Res 1989;239:263-85.
13. llizarov GA. Fractures and non-unions. In: Coombs R, Green S, Sarmiento A, editors. External fixation and functional bracing. Frederick: Aspen; 1989.
14. lIizarov GA. Transosseous osteosynthesis. Heidelberg: Springer-Verlag; 1991.
15.Ilizarov GA, Kaplunov AG, et al. Treatment of psuedoarthroses and ununited fractures, complicated by purulent infection, by the method of compression-distraction osteosynthesis [in Russian]. Ortop Travmatol Protez 1972;33:10-4.
16. Ilizarov GA , Ledleaev VI. Replacement of defects of long tubular bones by means of one of their fragments [in Russian]. Vestn Khir Im I I Grek 1969;102;77-84.
17. Ilizarov GA, Ledleaev VI, et al Operative and bloodless methods of repairing defects of the long tubular bones in osteomyelitis. Vestn Khir Im I I Grek1973;110:55-9.
18. Kempf I, Grosse A, Rigaut P. The treatment of noninfected pseudoarthrosis of the femur and tibia with locked intramedullary nailing. Clin Orthop 1986, 212: 142-545.

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Vol 2 | Issue 1 | Jan - Apr 2014 | page 11-15 | Harshavardhana NS,  Desai MM

Author: Nanjundappa S Harshavardhana[^1], Mohan M Desai[^2]

^[1]Inverclyde Royal Hospital, Greenock; Scotland
^[2]Seth G S Medical College & K.E.M Hospital, Mumbai – India

Institute at which research was conducted: Seth G S Medical College & K.E.M Hospital, Mumbai – India

University Affiliation of Thesis: Mumbai University

Year of Acceptance: 2004

Address of Correspondence

Dr. NS Harshavardhana MS(Orth)
2A Albert Road, Gourock – PA19 1NH, Scotland; United Kingdom
Email:nharsha@outlook.com

 Abstract

Background: Post-surgical orthopaedic infections utilise limited resources, affects quality of life and could be fatal.
Our objectives were to:
1.Report early infection rate(IR) for orthopaedic surgeries
2.Study the complex interplay of variables and effect of co-morbidites on IR
3.Report mortality rate and measures to reduce it
Methods: All consecutive surgeries assisted/performed by a resident over 25 consecutive months against stringent inclusion/exclusion criteria formed the study cohort. Prospective data pertaining to patient demographics, nature of surgery and environmental factors were collected adhereing to a structured proforma. Thus collected data was analysed by SPSSv.11 and uni/multivariate analysis with logistic regression was performed.
Results: 22/745 developed infection (superficial[8];deep[14]). There were two deaths. The overall IR was 2.95%. The relative risk(RR) of dying following infection was 12.63 (p<0.005). The average follow-up was 14 months (range: 3-25 months). One patient had persistent infection and amputation was contemplated to optimize function. The most common organism was MRSA. There was no difference in IR between those who had 3 vs. 14 days of antibiotics.
Conclusion: This study resulted in major restructuring of trauma services and streamlining of admissions for elective cases. Infection register was set-up to monitor all infections. A standardised post-op antibiotics prescription policy was implemented.
Key Words: Surgical site infections (SSI), Infection rate (IR),Prophylactic antibiotics ,Relative risk (RR),Case fatality rate (CFR).

Introduction

Postoperative infection could be devastating as they consume enormous amount of limited resources and manpower. They are also associated with functional disability, poorer quality of life and may be potentially fatal. A myriad of agent, host and environmental factors act in a complex fashion predisposing some individuals to acquire surgical site infections (SSI). As rightly quoted “An ounce of prevention is better than a pound of cure”, it's better to be meticulous and diligent in preoperative work-up and intraoperative techniques coupled with appropriate prophylactic antibiotics and excellent postoperative care to keep the infection rate (IR) to minimum. Certain co-morbidities like rheumatoid arthritis (RA), diabetes mellitus (DM), tuberculosis (TB), human immunodeficiency virus (HIV) and remote site infections (RSI) all enhance the risk of developing SSI. Despite best efforts, infections may be inevitable in some cases (e.g. Multidrug resistant tuberculosis [MDR-TB] and patients on anti-cancer medications). Advances in theatre sterility and use of high energy particulate air (HEPA) filters have significantly reduced the IR in contemporary era. The recommended IR in elective orthopedic total joint replacement surgeries as accepted standard of care recommended by the American academy of orthopedic surgeons (AAOS) is <1%.

Aims and Objectives

- To establish early infection rate (IR) at our institute
- To study the influence of various predisposing factors on incidence of infection
- To evaluate the complex interplay of such predisposing factors and calculate relative risk(RR) with 95% confidence intervals for each variable
- To formulate good clinical practice (GCP) guidelines to aid existing ones in reducing IR.

Materials and Methods

715 consecutive patients who underwent 749 orthopedic procedures on 745 anesthetic episodes which a resident (NSH) was involved in over 25 months as a part of his residency rotation formed the study cohort. The data pertaining to patient demographics (age at surgery / sex / socio-economic status), nature of surgery (simple vs. polytrauma / closed vs. compound fractures / arthroscopic and percutaneous vs. open surgeries / elective vs. emergency operations / use of tourniquet), associated medical comorbidities (DM / RA / TB / HIV), preoperative blood investigation results (serum hemoglobin, total proteins and white blood cell counts), duration of surgery & preoperative inpatient stay in hospital, venue of surgery (i.e. laminar vs. non-laminar air flow theatres), rank of lead operating surgeon, use of prophylactic antibiotics (drugs used and duration of administration), amount of perioperative blood transfusion and venue of surgery was comprehensively collected as per a structured proforma (fig 1). The first 70 procedures in 69 patients was collected retrospectively and the remaining 679 procedures in 646 patients was collected prospectively. In total, 17 parameters that potentially influences one in developing a SSI were assessed and evaluated in detail. The minimum follow-up in all patients was at least one month. All infected patients were followed up at least until cure / control of infection or mortality whichever was latter. No patient in infected group was lost for follow-up.Permission from departmental head and faculty members was taken prior to collection of data as IRB and ethics committee permission was not mandatory to undertake this project.Consent for participation in this study was taken from all patients. The stringent inclusion and exclusion criteria was strictly adhered to throughout the course of study. The criteria for labelling patients as infected or otherwise (i.e. not infected) were as per center for disease control (CDC) guidelines for SSI. An 'Infection register' with detailed records of all patients who had SSI was maintained and updated diligently at regular intervals that provided invaluable insight into understanding and preventive measures to be employed in reducing infections.

Results

22 of 715 patients developed SSI and this included 16 males and 6 females. Eight of them were superficial and 14 were deep infections. The overall infection rate (IR) was 2.94% and the deep infection rate was 1.87%. The most common organism isolated on culture and sensitivity was methicillin resistant staphylococcus aureus (MRSA) which was seen in nine out of 14 deep infection cases. None of the eight superficial infections grew any organism. There were two deaths out of 22 patients and the case fatality rate (CFR) was 9.1%. The relative risk of dying on contacting orthopedic SSI was 12.6 and was statistically significant (p<0.005). One patient had persistent infection and above knee amputation was contemplated to optimize function.The use of laminar air flow theatres was associated with reduced infection rate though this did not statistical significance. The study also interestingly shattered the myth that administration of antibiotics (Abs) up to suture removal (14 days) did not confer any additional benefit by reducing IR in comparison to those who received prophylactic Abs for only 3 days. The relative risk (RR) for each of the 17 individual parameter with 95% confidence intervals and infection rate were tabulated. The single most important factor that was statistically significant on multivariate analysis and logistic regression (SPSS v10, Chicago, IL; USA) was 'amount of blood transfusion'. Finally the power analysis (i.e. 1 – β) was low (i.e. <80%) for fiveparameters (small sample size).
The independent risk factors that were statistically significant on univariate analysis were:
- Duration of surgery
- Preoperative stay in hospital as in-patient
- Amount of perioperative blood transfusion (in units; 1 unit = 350mls of whole blood).

Conclusion

This was the first study at our institute that challenged the conventional notion of administering prophylactic Abs until suture removal (i.e. 14 days). The study brought a sea change in orthopedic trauma service delivery by streamlining the orthopedic trauma theatre traffic and up gradation into a laminar air flow OT to curb infection rate (IR). The general surgical trauma cases were segregated from orthopedic ones to further reduce risk of contamination with gut / gram negative organisms. Other changes implemented as part of department's efforts to further reduce IR were:
- Streamlining of all elective orthopedic admissions where in majority of patients were admitted either the night before or on the day of surgery to optimize bed utilization, reduce pre-op inpatient stay and prevent colonization by nosocomial / drug resistant organisms.
-Establishment of department's Infection register along the lines of Arthroplasty register with prospective collection of data about all patients with SSI following orthopedic surgeries
-Collaboration between microbiology and orthopedic departments to formulate guidelines regarding use of prophylactic Abs
-Commitment to follow-up and treat all infected patients until they were completely cured / eradicated of infection.
-Objectively measure risk ratio (RR) of parameters that predispose an individual to SSI and utilize this research info to counsel patients appropriately when consenting for surgeries
-Introduction of preoperative MRSA swabbing from nose, throat and groin in patient scheduled for total joint replacements as this was the most common organism causing deep infections
-Get insight into complex interplay of risk factors that predisposed an individual to infection and innovative strategies to break this chain and attempts towards improving quality of care to our patients / taxpayers.

Clinical Message

Surgical site infections (SSI) are due to a complex interplay of agent, host and environmental factors and SSI following orthopedic surgeries can be fatal.
- Administration of prophylactic antibiotics beyond 3 days did not reduce infection rate in this series of 715 patients and may potentially promote emergence of drug resistant organisms.
- The most common organism causing deep infection following orthopedic surgeries was MRSA (methicillin resistant staphylococcus aureus).
- The relative risk (RR) of death following orthopedic SSI in this study was 12.60 and case fatality rate (CFR) was 9%.
- Maintenance of infection register and regular collaboration with microbiologists in optimizing the choice of prophylactic Abs is of paramount importance in reducing IR.
- Individualized antibiotic prophylaxis driven by patients' unique characteristics maybe standard of care in coming years / near future.

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Vol 2 | Issue 1 | Jan - Apr 2014 | page 14-16 | Kothari SA,  Kothari AR, Ichaporia NR, Divate UP

Author: Simpal Ajay Kothari[1], Ajay Ramesh Kothari[2] , N R Ichaporia[1], Uma P Divate[1]

^[1]Jehangir Hospital & Research Centre , Pune
^[2]Sancheti Institute For Orthopedic & Rehabilitation, Pune.
Institute at which research was conducted: Sancheti Institute For Orthopedic & Rehabilitation, Pune.
University Affiliation of Thesis: DNB, Delhi.
Year of Acceptance: 2008

Address of Correspondence

Dr Ajay Ramesh Kothari, Dnb Orthopedic, Consulting Spine Surgeon .
Sancheti Institute For Orthopedic & Rehabilitation, Pune
16 ,shivajinagar, Pune-411005,india
Email: drajaykothari@gmail.com

 Abstract

Background: Long-term antiepileptic drug (AED) therapy is a postulated risk factor for bone loss and fractures. To study this we have compared cases (patients on phenytoin) with age & sex matched controls.
Objectives: A1) To determine the effect of phenytoin (> 1 year therapy) on bone mineral density in 20-50 year old epileptic patients. 2) To compare them with age & sex matched healthy controls.
Methods: We prospectively examined femoral neck & spine bone mineral density (BMD) by dual-energy x-ray absorptiometry in 50 patients, aged between 20 and 50 years old (mean age, 37 years), who were attending an outpatient epilepsy clinic or were admitted to our hospital . Low BMD values were analyzed for known risk factors for bone loss. Dual-energy x-ray absorptiometry scans (LUNAR DPX PRO) were repeated in all patients, 12 months later, to assess the rate of change in BMD over time. This was also compared with age & sex matched controls (case control study).
Result: Statistical analysis revealed that patients receiving phenytoin was an important risk factor associated with low femoral neck & spine T- score as matched with normal control group (p value <0.05). Analysis of femoral neck & spine T-score revealed that more than 50% of patient group had either osteopenia/osteoporosis as compared to control group. Females were more affected than male. T-score was low in the younger age group. But there was no significant correlation between BMD & various parameters like- 1) serum calcium level, 2) serum phenytoin level and 3) BMD after 1 year of phenytoin therapy.
Conclusion: Long-term phenytoin therapy causes significant bone loss at the hip & spine. Dual-energy x-ray absorptiometry scanning is useful in identifying patients who are particularly susceptible to rapid bone loss while taking phenytoin.

Introduction

Osteoporosis has been better defined by the Consensus Development Conference as “a disease characterized by low bone mass and micro-architectural deterioration of bone tissue, leading to enhanced bone fragility and consequent increase in fracture risk”.Patients with epilepsy have a higher incidence of skeletal fractures due to multiple reasons. Postmenopausal women and elderly men are particularly vulnerable to osteoporosis. A major convulsive seizure can often lead to falls and may result in fractures. Antiepileptic therapy may have seemingly contradictory effects on bone health. It can effectively reduce the incidence of major seizures and prevent the seizure related falls and fractures. Long-term antiepileptic therapy may lead to a reduction in bone mineral density, with consequent increase in bone fragility. This can increase the risk for fractures with attendant high morbidity and mortality. Dual energy X-ray absorptiometry (DEXA) is currently the gold standard for assessing bone mineral density. Multiple pathophysiologic mechanisms have been proposed for the reduction in bone mineral density associated with antiepileptic therapy. Most of the available data are from the patients treated with conventional antiepileptic drugs (AED).

Materials and methods

We prospectively examined femoral neck & spine bone mineral density (BMD) by dual-energy x-ray absorptiometry in 50 patients, aged between 20 and 50 years old (mean age, 37 years), who were attending an outpatient epilepsy clinic or were admitted to our hospital . Low BMD values were analyzed for known risk factors for bone loss. Dual-energy x-ray absorptiometry scans (LUNAR DPX PRO) were repeated in all patients, 12 months later, to assess the rate of change in BMD over time. This was also compared with age & sex matched controls.

Results

Statistical analysis revealed that patients receiving phenytoin was an important risk factor associated with low femoral neck & spine T- score as matched with normal control group (p value <0.05). Analysis of femoral neck & spine T-score revealed that more than 50% of patient group had either osteopenia/osteoporosis as compared to control group. Females were more affected than male. T-score was low in the younger age group. But there was no significant correlation between BMD & various parameters like- 1) serum calcium level, 2) serum phenytoin level and 3) BMD after 1 year of phenytoin therapy. What should we recommend to our epilepsy patients taking phenytoin regarding their bone health? It is becoming clear that this issue is confined not only to women with epilepsy or women in the general population but is also important for men. We have shown for the first time that Indian patients (male & female) who have seizures sustain significant bone loss at the femoral neck as well as spine while receiving AED therapy. The finding that >50% had a T-score lower than -1 at these site indicates that a substantial number are at an increased risk for hip or vertebral fractures. Thus, it is possible that the younger male skeleton with enhanced bone turnover from AED therapy may require a substantially higher calcium intake to adequately suppress bone resorption and optimize bone mineralization. Individual other drugs should also be examined for their association or otherwise with low BMD. A range of pharmacological options is available for patients with reduced BMD including HRT, biphosphonates, vitamin D; calcium etc. patients with osteoporosis identified in this study have been commenced on treatment.

Discussion

Statistical analysis revealed that patients receiving phenytoin was an important risk factor associated with low femoral neck & spine T- score as matched with normal control group (p value <0.05). Analysis of femoral neck & spine T-score revealed that more than 50% of patient group had either osteopenia/osteoporosis as compared to control group. Females were more affected than male. T-score was low in the younger age group. But there was no significant correlation between BMD & various parameters like- 1) serum calcium level, 2) serum phenytoin level and 3) BMD after 1 year of phenytoin therapy. What should we recommend to our epilepsy patients taking phenytoin regarding their bone health? It is becoming clear that this issue is confined not only to women with epilepsy or women in the general population but is also important for men.We have shown for the first time that Indian patients (male & female) who have seizures sustain significant bone loss at the femoral neck as well as spine while receiving AED therapy. The finding that >50% had a T-score lower than -1 at these site indicates that a substantial number are at an increased risk for hip or vertebral fractures.Thus, it is possible that the younger male skeleton with enhanced bone turnover from AED therapy may require a substantially higher calcium intake to adequately suppress bone resorption and optimize bone mineralization. Individual other drugs should also be examined for their association or otherwise with low BMD.
A range of pharmacological options is available for patients with reduced BMD including HRT, biphosphonates, vitamin D; calcium etc. patients with osteoporosis identified in this study have been commenced on treatment.

Conclusion

Long-term phenytoin therapy causes significant bone loss at hip and spine as compared to age and sex matched normal control.
- In our study, those patients who were on phenytoin therapy for more than 15 years, all of them revealed significant reduction in T-score (<-1).
- BMD in females were more affected than male.
- There was no significant correlation between BMD & various parameters like- 1) serum calcium level, 2) serum phenytoin level and 3) BMD after 1 year of phenytoin therapy.
- Not only postmenopausal women but also adults with epilepsy should be encouraged to attend for bone density screening. As in our study young patients were more affected.
- Dual-energy x-ray absorptiometry scanning is useful in identifying patients who are particularly susceptible to rapid bone loss while taking phenytoin.
- These patients should be supplemented with bone calcium antiresorptive therapy to prevent osreopenia or osteoporosis.

Key Words

Intrathecal morphine, spinal anesthesia, vaginal hysterectomy.

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JOURNAL OF MEDICAL THESIS

ISSN     2347 -  5595 

VOLUME 2  |  ISSUE 1 | Jan– Apr 2014

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Editorial

Hypothesis, Intellectual Property and Journal of Medical Thesis: Concept of Defensive Publication

Dr Ashok K Shyam  

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Articles

Effect of phenytoin (antiepileptic) on bone mineral density

Simpal Ajay Kothari , Ajay Ramesh Kothari, N R Ichaporia , Uma P Divate

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Surgical and Functional Outcome of Metacarpal fracture

Gajanan Deshmukh, Steve Rocha, Ashok Shyam, Parag Sancheti

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Audit of Early Post-Surgical Orthopaedic Infections in a Tertiary Center

Nanjundappa S Harshavardhana, Mohan M Desai

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Study of efficacy of ilizarov external fixation in infected non union tibial fractures

Sachin R Jain, Harshad M Shah, Naresh Shetty, Maulik Patel, Rajesh Kumar Tekkati, Angshuman Khanna

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Prospective Study of Management of Diaphyseal Fractures of Femur in Paediatric Age Group by Titanium Elastic Nailing System

Saurabh Gupta, Jayasheel Hegde

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Implications of Surgery or Fracture Related Morbidity Factors in the Outcome of Pertrochanteric Fractures Managed by Dynamic Hip Screw

Abhay Shankar Dube, Siddharth Goel, Anurag Rastogi, Arun Vashisht, Arunim Swarop

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Distribution of ABO & Rh (D) Blood Groups Among Blood Donors of Jammu Region with Respect to Various Ethnic Groups

Urvershi Kotwal, Tilak Raj Raina, Meena Sidhu , Mitu Dogra

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Study Comparing the Advantages of Proximal Femoral Nail Over Dynamic Hip Screw Among Patients with Subtrochantric Fractures

Shishir Murugharaj Suranigi, Naresh Shetty, Harshad Mohan Shah

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