Monthly Archives: August 2014

Charcots Arthropathy in Diabetics : An Experience in Treatment with Ilizarov External Fixator Technique


Vol 2 | Issue 2 | May - Aug 2014 | page 21-28 | Sheikh F, Sheikh I, Shah S, Menon A


Author: Fahad Sheikh[1], Irfan Sheikh[1], Suhas Shah[1], Aditya Menon[1]

[1]DNB Ortho K B Bhabha Municipal General Hospital, Mumbai
Institute at which research was conducted: DNB Ortho K B Bhabha Municipal General Hospital, Mumbai
University Affiliation of Thesis: National  Board of  Examinations
Year of Acceptance:  2012

Address of Correspondence
Dr. Irfan Sheikh
Plot No 8,Paradise Colony, Amravati,Maharashtra, India.
Email: drirfan02@gmail.com


Abstract

Background:A case of diabetic foot with charcots joints is an unfavourable situation of soft tissues due to associated neuropathy and vascular compromise.Fusion of the neuropathic ankle joint is extremely difficult and associated with many complications. The use of the Ilizarov fixator in ankle fusion for patients with neuropathic arthropathy is not clear. We aimed to evaluate the results of the Ilizarov method for ankle arthrodesis in diabetic patients with charcots arthropathy.
Methods: From 2009 to 2011, 25 surgeries were performed with the Ilizarov apparatus in diabetic foot with charcots joints(eichenholtz stage II & III). The mean age of the patients was 51 years (range, 35-67 years), all patients were diabetic. Deformity and instability of the ankle resulting in a nonplantigrade foot was the operative indication.
Results: Solid fusion was obtained in all patients except one, at an average of 16.1 weeks (range, 12-20 weeks). At final follow-up, excellent results were obtained in eighteen patients, good in four, fair intwo , and poor in one. No major complication occurred.
Conclusion: The Ilizarov fixator presents a successful , alternative and effective means for management of diabetic foot with charcots arthropathy where complications of neural and vascular compromise preexist, especially when the usage of internal fixation methods have limitations. In our series all patients were plantigrade with foot ulcers healed.
Keywords: Charcot joint,single step management,ilizarov,diabetic joint,Successful
management .

                                                        THESIS SUMMARY                                                             

Introduction

Diabetic charcots joints is a potentially limb threatening disorder developing in a patient with long standing diabetes mellitus and associated sensory neuropathy. Both vascular and neuropathic complications make it adreaded disorder to treat.
Since the wieghtbearing articular area of the tibia is involved, the aim of treatment is directed towards achieving bony stability, soft tissue preservation and early mobilisation. Hence, limited internal fixation along with external fixation has become the favourite treatment of choice.
In charcot’s joints with non-healing wound and infection, we advocate the fusion primarily at the ankle and subtalar joint.
We undertook a prospective study of ilizarov treatment of patients with charcot’s arthropathy and analysed the longterm clinical and radiological outcome, improvement in vascularity with achievement of a weightbearing plantigrade foot and associated complications.

Aims and Objectives

1. To study diabetic foot with charcots arthropathy using maryland foot score system.
2. To review the literature
3. To study biomechanics and surgical technique of ilizarov external ring fixator.
To evaluate the clinical and functional outcomes of ilizarov external ring fixator in management of diabetic foot in our patients and compare them with those in the literature.

Methods

(A)SOURCE OF DATA :
K.B.Bhabha Municipal General Hospital, Mumbai. A tertiary health care center located in prime sub-urban area of metropolitan city of Mumbai. This serves as first contact for the patients residing in and near by places.
(B) STUDY POPULATION :
1. All adult male / female patients attending out-patient department (o.p.d.) between the age of 25 years and above.
2. All adult male / female patients between age 25 years and above admitted in in-patient ward.
3. Population includes both urban/ rural/slum dwellers.
(C) SAMPLE SIZE:
25 cases of diabetics foot with charcots arthropathy.
(D) DATA COLLECTION PROTOCOL :
1. Mode of collection – direct interview
2. Parameters for data collection
a) Registration number
b) Name of patient
c) Age of patient
d) Sex – male / female
e) Address of residence
f) Occupation of patient
g) Diabetic status (controlled)
h) Duration of illness
i) Radiographs of ankle (frontal and lateral views) and foot (frontal and oblique)
j) Staging of disease by eichenholtz staging
k) Foot score – maryland foot score system –pre operative and post operative
(E) INCLUSION CRITERIA :
All adult patients with eichenholtz stage II ( coalesence stage) and III (reconstructive stage) at presentation.
(F) EXCLUSION CRITERIA :
• All adult patients with eichenholtz stage I ( developmental /resorptive stage)
• All those patients who found the apparatus aesthetically unacceptable.
(G) INVESIGATIONS :
Pre-operatively all necessary routine investigations pertaining to anesthesia fitness were done and specific investigations of all associated medical illness were carried out.
The routine investigations done were –
• Haemogram (hb,tlc,dlc)
• Bleeding time \ clotting time.
• Serum creatinine
• Serum bilirubin (direct and indirect)
• Blood sugar level – fasting & post prandial
• HIV \ HBsAg.
• Radiograph of the chest
• Radiographs of ankle (frontal and lateral views) and foot (frontal and oblique)
(H) PREOPERATIVE PLANNING :
The following necessary implants and instruments were checked • Wires 1.5 mm , 1.8 mm , olive wires , cancellous & cortical wires
• Rings (160mm,180mm,200mm) – half rings , 5/8th rings
• Other ilizarov appliances – rancho cubes, male & female posts, wire fixation bolts, nuts & bolts, washers, connecting rods
• Wire tensioner / Dynamometer
• Hand drill set / power drill set.
• Image intensifier machine (‘c’ arm machine).
• Tourniquet set.
• All necessary operation theatre equipments including bone grafting set.
An intravenous line was secured and patient shifted to the operating room
(I) SURGICAL TECHNIQUE :
• Anaesthesia – spinal anesthesia is given and pre-operative antibiotic 3rd generation cephalosporin
• 4 to 6 external rings of different sizes-160 half,180 half, 5/8th rings, foot frame
• Ankle joint arthrodesis with the help of ilizarov ring fixator with bone grafting
• Procedure involved for ankle fusion
o Ankle joint was exposed by anterior approach
• Incision is made on the anterior aspect of the leg 7.5 to 10 cm proximal to the ankle and extend it distally to about 5 cm distal to the joint.
• Divide the deep fascia in line with the skin incision.
• Isolate, ligate, and divide the anterolateral malleolar and lateral tarsal arteries, and carefully expose the neurovascular bundle and retract it medially.
• Incise the periosteum, capsule, and synovium in line with the skin incision, and expose the full width of the ankle joint anteriorly by subcapsular and subperiosteal dissection.
o Preparation of talus and tibia for fusion by scraping their articular surfaces and exposing raw bone
o When the talus is completely destroyed then the calcaneus articular surface is freshened
o The talus and the tibia are then docked and stabilized by k –wires
o Bone grafing is performed from the iliac crests and inserted in the area of arthrodesis.
• Skin closure is performed,if possible in layers
• Erection of ilizarov ring fixator frame is performed using two full rings in the distal tibia and a foot frame, consisting of a ½ ring for the forefoot placed in a coronal plane and a 5/8th ring for the hindfoot.
• The wires used in the upper ring of tibia is posteromedial to anterolateral and another wire passed posterolateral anterior to fibula to anteromedial. The wires of the lower ring are inserted in the same way but the lateral wire is passed through the fibula and parallel to the ankle joint.both rings should be parallel to each other. The wire in the forefoot is passed through the 1st & 5th metatarsal heads and tensioned on the ½ ring to prevent footdrop. Two wires are passed through the calcaneum and tensioned
• Compression is performed at the arthrodesis site by 2mm
• Debridement of ulcers is performed
• Wound and pin tract dressings are given

(J) POST OPERATIVE CARE :
• Limb elevation
• Distal neuro-vascular status monitoring
• Intravenous antibiotics for 48 hours
• Wound dressing after 48 hrs
• Daily/alternate day dressing-of the debrided ulcers ,as the situation may be
• Pin tract care (taught to patient and performed twice daily from 48 hours post operatively))
• Ring compression/distraction as the situation may be
• Full weight bearing is started as early as possible ( within 2 to 5 days)
(K) FOLLOW UP :
Patients will be followed up regularly after discharge from hospital at opd using parameters of maryland foot scoring system .
(L) DATA ANALYSIS:
Analysis of the study was done by direct observation by means of proportions, Kruskal Wallis test was done to assess the significance of change .
(M) TYPE OF STUDY :
Non randomized prospective clinical trial.

Results

Radiological improvement of charcots arthropathy in diabetic foots was achieved in 24 patients , at an average of 15 weeks, with improvement of ulcers and ability to bear weight on a plantigrade foot. One patient developed non-union.
22 patients required ankle (tibio-talar) artrodesis and 3 required tibio-calcaneal fusion. Ulcer on the foot healed in 24 patients of which five required another sitting of debridement. 1 patient had ulcer remaining on the foot after three debridements , which was then kept on regular dressings. Full weight bearing was achieved in all patients by the end of 18 weeks. 11 patients had 1 to 3 cm limb length deformity and showed short limb gait were treated by shoe raise, rest did not complain of limb length deformity.

Discussion

Diabetic foot is associated with multiple problems like
- Ischemia
- Neuropathy
- Infection
o To perform surgeries using internal fixation and modalities other than ilizarov ring fixator causes further damage to an already compromised limb
o Principles of Ilizarov and Ilizarov technique of external ring fixator increases the survival chances of foot and avoids amputation
o In our series all patients can be salvaged from amputation and 96 % achieved healing of ulcers completely
o Up untill recently the diabetic foot has defeated every health care system in the world
o Advances in our understanding have led to improvements in care
o Ulcers are now healed and amputations can be prevented with help of Ilizarov fixator
The ilizarov external fixator presents a successful alternative for the management of diabetic foots with charcots joints where complications of neural and vascular compromise preexist.

Clinical Message

From the conducted study, we are convinced that ilizarov ring fixator for the management of diabetic foot with charcots arthropathy is a successful alternative for the management of diabetic foots with charcots joints where complications of neural and vascular compromise preexist.
We recommend the following guidelines to achieve excellent results –
a. There should be a selection of patients , eichenholtz stage II & III for the following procedure, since in stage I the acute setting does not allow immediate weight bearing, making the whole surgery not worthwhile.
b. The procedure should be performed by an experienced orthopaedician, after a thorough study of the ilizarov ring fixator application and planning of the technique.
c. We recommend the use of two full rings in the distal tibia and a foot frame consisting of a ½ ring for the forefoot placed in a coronal plane and a 5/8th ring for the hindfoot.
d. Acute docking of the talus with the tibia should be done, reduction can be held with k wires. Cancellous bone grafting done and the frame is constructed.
e. The wires used in the upper ring of tibia is posteromedial to anterolateral and another wire passed posterolateral anterior to fibula to anteromedial. The wires of the lower ring are inserted in the same way but the lateral wire is passed through the fibula and parallel to the ankle joint.both rings should be parallel to each other. The wire in the forefoot is passed through the 1st & 5th metatarsal heads and tensioned on the ½ ring to prevent footdrop. Two wires are passed through the calcaneum and tensioned.
f. Further study on the subject to be conducted with large sample size along with comparison with other standard methods of treatment of such injuries.

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121. Papa J, Myerson M, Girard P (1993) Salvage with arthrodesis,in intractible diabetic neuropathic arthropathy of thefoot and ankle. J Bone Joint Surg Br 75:1056–1066S.M. Rajbhandari et al.: Charcot neuroarthropathy in diabetes mellitus 1095.
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How to Cite this Article: Sheikh F, Sheikh I, Shah S, Menon A. Charcots Arthropathy in Diabetics :An Experience in Treatment with Ilizarov External Fixator Technique. Journal Medical Thesis 2014 May-Aug ; 2(2):21-28

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A comparative evaluation of anticonvulsant activity of Magnesium Sulfate with Phenytoin and Valproate in experimentally induced seizures in albino rats


Vol 2 | Issue 2 | May - Aug 2014 | page 1-5 | Khobragade A, Patel S, Deokate M, Bhagat S, Patil N


Author: Akash Khobragade[1], Sadiq Patel[1], Milin Deokate[1], Sagar Bhagat[1], Narendra Patil[1]

[1]Grant Govt. Medical College & Sir J. J. Group of Hospitals, Mumbai Institute at which research was conducted: Grant Govt. Medical College & Sir J. J. Group of Hospitals, Mumbai University Affiliation of Thesis: University of Mumbai Year of Acceptance: 2008 Address of Correspondence Dr. Akash Khobragade Department of Pharmacology, Grant Govt. Medical College & Sir J.J. Group of hospitals, Mumbai. Email: akash.khobragade@gmail.com


 Abstract

Background:Epilepsy is a global heath problem. Many studies have suggested that N-methyl-D-aspartate (NMDA) receptors may play a role in the development and expression of seizures. Therefore the present study was designed to explore the potential of magnesium sulfate (MgSO4), which is a NMDA receptor antagonist, as an anticonvulsant drug. Methods: A randomized, prospective, active placebo controlled study was conducted on eighteen Swiss albino rats. In this study MgSO4 was compared with phenytoin in maximal electroshock seizure (MES) model, with valproate in pentylenetetrazole (PTZ) induced convulsions model and with both in aminophylline induced convulsions model Results: The results in MES model, showed that MgSO4 when compared with phenytoin was significantly effective (p<0.0001). The combination of MgSO4 and Phenytoin was more effective than either of the drugs used singly. In the PTZ model, valproate was able to control the parameters observed. MgSO4 was not able to control any of the parameters when compared with valproate. In the aminophylline model MgSO4, valproate and phenytoin were not able to control any of the parameters. Conclusion: MgSO4 appears to be effective in MES model but not in the PTZ and aminophylline models. Keywords: Epilepsy, NMDA receptor antagonists, MgSO4, MES model

                                                        THESIS SUMMARY                                                             

Introduction

Epilepsy is a group of disorders characterized by chronic, recurrent, paroxysmal changes in neurologic function caused by abnormalities in the electrical activity of brain. Using the definition of epilepsy as two or more unprovoked seizures, the incidence of epilepsy is approximately 0.3 to 0.5% in different populations throughout the world, and the prevalence of epilepsy has been estimated at 5 to 10 persons per 1000. The ideal antiseizure drug would suppress all seizures without causing any unwanted effects. Unfortunately the drugs used currently have low therapeutic index, they not only fail to control seizure activity in some patients, but frequently cause unwanted effects that range in severity from minimal impairment of cental nervous system to death, from aplastic anemia or hepatic failure. As a general rule, complete control of seizures can be achieved in up to 50% of patients, while another 25% can be improved significantly. Thus a need for a new antiepileptic drug with minimal side effects & equal efficacy to existing drugs is perpetual. Many studies have suggested that N-methyl-D-aspartate (NMDA) receptors may play a role in the development and expression of seizures. There is considerable evidence from in vivo and in vitro studies that NMDA antagonists can suppress epileptiform activity. Early investigations found that these antagonists had anticonvulsant action in several chemical models of epilepsy and maximal electroshock seizures. NMDA and non NMDA mediated potentials may contribute to burst triggering and duration. NMDA receptor antagonists can slow the frequency of spontaneous bursts and can shorten the duration of each burst. Antagonists of the NMDA receptors decrease calcium influx through this receptor operated calcium channel. Magnesium sulfate (MgSO4), an effective drug in eclamptic seizures, is an inorganic calcium antagonist and blocks receptor operated calcium channels as well. Therefore the present study was designed to explore the potential of magnesium sulfate as an anticonvulsant drug.

Aims and Objectives

1.To study the anticonvulsant efficacy of MgSO4 in comparison with phenytoin in maximal electroshock induced seizure (MES) in albino rats. 2.To study the anticonvulsant efficacy of MgSO4 in comparison with valproate in pentylenetetrazole (PTZ) induced seizure in albino rats. To study the anticonvulsant efficacy of MgSO4 in comparison with phenytoin and valproate in aminophylline induced seizure in albino rats.

Methods

A randomized, prospective, active placebo controlled study was conducted on 18 Swiss albino rats in the Department of Pharmacology, Grant Medical College & Sir J.J. Group of hospitals, Mumbai, after approval from the institutional animal ethics committee. Study was done in 3 parts. Initially in Group 1 study, MgSO4 was tested and compared with phenytoin by the Maximal Electroshock seizure (MES) method. A combination of MgSO4 and phenytoin was also tested with the individual drugs. After that in Group 2 study, MgSO4 was tested and compared with valproate by the Pentylenetetrazole (PTZ) induced convulsions method. A combination of MgSO4 and valproate was also tested with the individual drugs. Finally in Group 3 study, MgSO4 was tested and compared with phenytoin and valproate by the Aminophylline induced convulsions method. There were 6 rats in each sub-group of Group 1 & these rats were given a washout period of 10 days & were randomly reassigned for the Group 2 study, again a washout period of 10 days & they were randomly reassigned for the Group 3 study. 1. Group 1 (MES seizure model): On the previous day of testing the pre-determined strength and duration of current was given to each of the animals by ear clip electrodes. This was standardized 150 mA, 100 V for 0.2 sec. The ears were cleaned with spirit to remove any oil film due to sebaceous gland secretions in the skin of the ear and then with saline for electric contact. Only those rats which showed tonic clonic convulsion were selected. Next day rats received the test and standard drugs as per the study groups 30 mins before being subjected to an electric shock. The parameters studied were: a.Duration of tonic extensor phase (in sec.) b.Duration of entire convulsion (in sec.) c.Duration of post-ictal phase (in sec.) i.e. time to resumption of normal activity following post-ictal stunning. 2. Group 2 (PTZ induced convulsion model): On the previous day of testing Pentylenetetrazole was injected intraperitonially at a dose of 50 mg/kg. Only those rats which showed clonic convulsions in the next 15 minutes were selected. Next day rats received the test and standard drugs as per the study groups 30 min before being subjected to PTZ treatment and the animals were observed for 30 mins. The parameters studied were: a.Time of onset of first clonic convulsion (in sec.) b.Duration of the clonic convulsion (in sec.) c.Duration of post-ictal phase (in sec.) i.e. time to resumption of normal activity following post-ictal stunning. 3. Group 3 (Aminophylline induced convulsion model): On the previous day of testing Aminophylline was injected intraperitonially at a dose of 280 mg/kg. Only those rats which showed clonic convulsions in the next 15 minutes were selected. Next day rats received the test and standard drugs as per the study groups 30 min before being subjected to Aminophylline treatment and the animals were observed for 60 mins. The parameters studied were: a.Time of onset of tonic clonic convulsion (in min.) b.Duration of convulsion (in sec.) c.Duration of postictal phase (in sec.) i.e. time to resumption of normal activity following post-ictal stunning. All quantitative data is presented as mean & standard error of mean (SEM). Data of MES and PTZ induced seizure is analyzed by using student's unpaired 't' test. Data of aminophylline induced seizure is analyzed by one-way ANOVA. For all tests, a 'p' value of < 0.05 is considered as significant.

Results

Maximal electroshock seizure (MES) model: a.Comparison of MgSO4 with Phenytoin : MgSO4 (270mg/kg), compared with phenytoin (20mg/kg), significantly reduced the duration of tonic extensor phase (p<0.0001), duration of convulsion (p<0.0001) as well as duration of postictal phase (p<0.0001). b.Comparison of MgSO4 with Combination of MgSO4 and Phenytoin: The combination of MgSO4 (135mg/kg) and phenytoin (10mg/kg) was more significant than MgSO4 (270mg/kg) alone in reducing the duration of tonic extensor phase (p<0.0001), duration of convulsion (p<0.0001) as well as duration of postictal phase (p<0.0001). c.Comparison of Phenytoin with combination of MgSO4 and Phenytoin: The combination of MgSO4 (135mg/kg) and phenytoin (10mg/kg) was more significant than Phenytoin (20mg/kg) alone in reducing the duration of tonic extensor phase (p<0.0001), duration of convulsion (p<0.0001) as well as duration of postictal phase (p<0.0001). Pentylenetetrazole induced convulsion (PTZ) model: a.Comparison of MgSO4 with valproate: Valproate (200mg/kg) compared with MgSO4 (270mg/kg), significantly increased the time of onset of clonic convulsion (p<0.0001), and significantly reduced the duration of clonic convulsion (p<0.0001) as well as duration of postictal phase (p<0.0001). b.Comparison of MgSO4 with combination of MgSO4 and Valproate: The combination of MgSO4 (135mg/kg) and Valproate (100mg/kg) compared with MgSO4 (270mg/kg) alone significantly increased the time of onset of clonic convulsion (p<0.0001), and significantly reduced the duration of convulsion (p<0.0001) as well as duration of postictal phase (p<0.0001). c.Comparison of Valproate with combination of MgSO4 and Valproate: Valproate (200mg/kg) compared with combination of MgSO4 (135mg/kg) and Valproate (100mg/kg), significantly increased the time of onset of clonic convulsion (p<0.0001), and significantly reduced the duration of clonic convulsion (p<0.0001) as well as duration of postictal phase (p<0.0001). Aminophylline induced convulsion model: MgSO4 (270mg/kg), valproate (200mg/kg) and phenytoin (20mg/kg) were not able to control any of the parameters.

Conclusion

MgSO4 appears to be effective in maximal electroshock seizure (MES) model but not in the pentylenetetrazole induced convulsion (PTZ) model and Aminophylline induced convulsion model.

Clinical Message

MgSO4 is an established drug for the treatment of eclampsia wherein the drug helps to control the convulsions. There is hope that MgSO4 could be effective in patients who are refractory to presently available standard antiepileptic medication. MgSO4 could be of value for acute treatment of status epilepticus, perhaps in conjunction with conventional agents.

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How to Cite this Article:Khobragade A,  Patel S, Deokate M, Bhagat S, Patil N  : A comparative evaluation of anticonvulsant activity of  Magnesium Sulfate with Phenytoin and Valproate in  experimentally induced seizures in albino rats. Journal Medical Thesis 2014 May-Aug; 2(2):1-5

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Comparison between effect of equal intensity training with Suryanamaskar or Physical Education activity or combination of both on Physical fitness in Adolescent Urban School children – A Randomized Control Trial : A Hypothesis


Vol 2 | Issue 2 | May - Aug 2014 | page 16-20 | Shimpi A, Shetye J, Mehta A


Author: Apurv Shimpi[1], Jaimala Shetye[1], Amita Mehta[1]

[1] Seth GS Medical College and KEM Hospital, Mumbai
Institute at which research was conducted: Secondary Schools in an urban city of Maharashtra
University Affiliation of Thesis: Research Hypothesis (Synopsis) submitted for PhD Registration to Maharashtra University of Health Sciences (MUHS), Nashik
Year of Acceptance: 2014

Address of Correspondence
Dr. Apurv Shimpi
Physiotherapy School and Centre, Seth Gordhandas Sunderdas Medical College and KEM Hospital, Parel, Mumbai
Email: apurvshimpi@sha.edu.in


 Abstract

Background: Adolescent Age is the age of maximum physical & mental development. Fitness and Physical activity plays a major role in the growth and development of a child in this age. Physical education (PE) has been considered as a very important step in the growth and development of children. The Global recommendations proposes a minimum of 60 minutes of moderate to vigorous physical activity for children aged 5 – 17 years of age daily. But studies evaluating physical education, comment that the present PE system does not achieve the standards required for maintenance of optimal physical fitness in children and may not be adequate to meet these levels of Physical Activity. Thus a specific programmed physical activity by adding Suryanamaskar training (SN) to the present PE activity is necessary. The study objective is to study the effectiveness of Suryanamaskar Training, Physical Education exercises and combination of both on health and performance related Physical fitness parameters in Adolescent Urban School children of age13-15 years by a Prospective Randomized Single blind Control Trial on 1500 children (500 per group) subjected to Physical Education activity training (I), Suryanamaskar training (II) and combination training of both (III) for 3 days a week for 8 weeks.
Hypothesis: A combination of Suryanamaskar training with general physical education exercises would offer higher benefits in improving physical fitness in School children as compared to only Suryanamaskar training or the physical education activities.
Clinical Importance: Adding a combination of Suryanamaskar to the structured Physical Education components would help enhance the physical fitness of the children thereby helping to make the future generation more healthy and fit and help improving their immunity and reducing/ preventing the risks of non-communicable & communicable diseases
Future Research: Additional benefits of SN training can be studies on all the systems and even on mental and social fitness of the children.

                                                        THESIS SUMMARY                                                             

Introduction

Adolescent Age is the age of maximum physical & mental development. Fitness and Physical activity plays a major role in the growth and development of a child in this age. The population based approach of Childhood obesity prevention of World Health Organization (WHO) estimates more than 170 million children of less than 18 years in the upper-middle income (developing) countries to be obese. It proposes that, this rapid change in the number and pattern of obesity will have a serious public health challenge in the 21st century [1]. The Global recommendations for Physical activity and health of WHO proposes a minimum of 60 minutes of moderate to vigorous physical activity for children aged 5 – 17 years of age daily. They propose an aerobic nature of activity for minimum of 3 days per week for maintenance of optimal fitness. This may be achieved by physical activities including play, games, sports, planned exercise or Physical education activity [2]. Physical education (PE) has been considered by authors as a very important step in the growth and development of children [3-6, 8-11]. But, studies evaluating physical education, comment that the present PE system does not achieve the standards required for maintenance of optimal physical fitness in children [4-6, 9, 11]. Developed countries have recommended modifications their PE programs to increase the physical activities to moderate – vigorous levels, especially in girls and all the secondary school children [5]. But in developing countries, like India, a steady decline in the level of moderate – to – vigorous Physical activity patterns amongst urban school children has been found, especially in girls [6, 10]. This has resulted in reduction in physical fitness levels amongst urban school children, mainly in girls [6, 7]. Physical training in Indian Schools is restricted to a 30-60 minutes PE activity period once or twice a week wherein students may perform a series of structured physical activities. Further, reduction in the level of moderate to vigorous Physical activities in secondary school children have been attributed primarily to lack of time due to increase in the duration of classes, tuitions, homework, TV/ video viewing, sedentary activities and reduction in sleep time [6]. The activities in the PE class include more of open chain, systematic aerobic activities/ movements. But the intensity of these activities in terms of Exercise Heart rate/ Rate of Perceived exertion has not been measured. Thus, to obtain the moderate to severe level of physical activity, as recommended by WHO, it becomes necessary to evaluate the level of intensity of the present PE programs. As per Center for Disease control (CDC), only around 17 – 39% of children are involved in organized physical activity for at least 60 minutes per day. Recommendations are to increase the intensity of Physical activity in children from 60 minutes per week to 200 minutes per week [12]. CDC expresses the need to increase the levels of Physical Education activities, as well as have a more structured program for enhancement of fitness in school children [8]. Physical Education has been proved to have a significant contribution in the physical activities levels of children. But this can be only achieved if the structure of this PE is planned and delivered considering the moderate – to – vigorous levels of physical activities required by children [9]. Also, focus of Physical activities should not be only on Health related fitness parameters, but also on performance related parameters [10]. But, conventional PE programs may not be adequate to meet these levels of Physical Activity. Thus a specific programmed physical activity is necessary [6, 9-11].

Hypothesis

Suryanamaskar (SN), which is a traditional Indian exercise and health regime, has been well studied for its effectiveness in adults [13] for improvisation of strength, endurance and body composition [14-15]. This exercise involves attainment of a series of yogic postures in succession, coordinating with breathing, and has been found to be effective in improving cardio respiratory functions [16, 18] but with lesser stress on it compared to exercises of similar intensities [17]. SN is slow, sustained, repetitive activity utilizing both the aerobic and the anaerobic systems. It includes closed chain activities, even of the upper limbs, which is optimal for osteogenesis[13]. Effectiveness of SN training has also been observed in children in regards to their ability to help improve the musculoskeletal and cardiorespiratory functioning and thus is a safe process to be introduced in adolescent children [19]. Thus, it becomes necessary to introduce and evaluate a structured program like Suryanamaskar in the PE program in schools and also to increase the intensity of physical activity to obtain a change in the level of physical fitness of children hereafter. Thus, it is hypothesized that Suryanamaskar training combined with general physical education exercises offers higher benefits in improving physical fitness in School children as compared to only physical education exercises or only Suryanamaskar training. The present research aims to study the effectiveness of equal exercise intensity training of Suryanamaskar, Physical Education exercises and combination of both on health and performance related Physical fitness parameters in Adolescent Urban School children of age13-15 years. A Prospective Randomized Single blind Control Trial will be performed post ethical approval in schools from an urban region in the state of Maharashtra. The sampling will be done by computer generated block random allocation of 1500 (500 per group) children from schools consenting for participation. This is based on the 2011 census report propagating around 3,21,646 children in the specific urban city between the age group 13 to 15 years. Children who are non-school goers, participating in Professional sports, having Physical deformities or complications inhibiting participation in studyor from Special Schools shall be excluded from the study. The concerned schools and participants, on their assent and parents' consent, will be randomly divided in one of the three groups, also based on the interest of the school management & concerned physical education teachers of the school and on their willingness to introduce Suryanamaskar as part of their physical education component. The pre study physical fitness parameters will be assessed as per guidelines laid by FITNESSGRAM®[20]. 1) Aerobic Capacity will be calculated by the maximal oxygen uptake (VO2 max) by the PACER test using the beep test CD of FITNESSGRAM. 2) Body Composition Analysis shall be done to calculate the percentage body fat by the Skin fold caliper method at the triceps, abdominal & calf regions 3) Flexibility shall be assessed by the Back saver sit & reach test using a standard Sit & reach Box. 4) Strength & Endurance shall be assessed by the 90 degree pushup test & curl up test using a metronome for a set up pace & cadence. 5) Agility will be assessed by the Agility Drill 6) Balance and Coordination will be assessed by the Star Excursion Balance test (SEBT) 7) Power will be assessed by the Vertical Jump Test 8) Speed will be calculated by the number of Laps covered in Shuttle run test of VO2 Max 9) Reaction time shall be measured by the Reaction time analyzer All the students shall perform exercises for a minimum of 3 times in a week for 8 weeks. Group I: 12 step Suryanamaskar at a moderate pace, 3 days in a week (alternate days) for 8 weeks. The number of SN shall be as per that achieved in Phase I of the study by a cross-over pilot study wherein the PRE of the present PE activity shall be equated with the number of SN's performed by the students. The following steps shall be used in SN training [22]: 1. Pranamasan, 2. Hastauttanasan, 3.Hastapadasan, 4.Ashwasanchalanasan5.Parvatasan, 6.Chaturnamaskar, 7.Bhujangasan, 8.Parvatasan, 9.Ashwasanchalanasan, 10.Hastapadasan, 11.Hastauttanasan, 12.Pranamasan Group II: Students in this group shall perform structured Physical Education exercises (PE) which are routinely followed in the schools. These involve dynamic open chain upper limb & lower limb movements, 3 days in a week (alternate days) for 8 weeks. Group III: Combination of Suryanamaskar training and Structured Physical Education activities shall be given to this group. Week 1 shall consist of 2 days of SN (e.g. Monday and Friday) and 1 day of PE (e.g. Wednesday) [SN-PE-SN]. Week 2 shall consist of 2 days of PE (e.g. Monday and Friday) and 1 day of SN (e.g. Wednesday) [PE-SN-PE]. This will be repeated for 8 weeks. Thus all the students will be exposed to minimum of 135 minutes of Physical activity per week for 8 weeks post which the above outcome measures will be assessed and compared using SPSS. Intra Group analysis will be by the paired t test for assessment of Aerobic Capacity, Flexibility, Body Composition, Agility, Balance and Coordination, Power, Speed and Reaction time while Strength & Endurance shall be assessed by Wilcoxon Test.Inter group analysis shall be by Oneway ANOVA for all the parameters except Strength & Endurance which will be assessed by Repeated ANOVA. Alpha shall be set at > 0.05 and level of confidence at 95%.

Discussion

Physical Education and activities regarding Physical education have been studied by researchers globally and all of them have generally narrowed down to the component that the time devoted to PE is extremely less in children as compared to the minimum criteria being laid down by global bodies like WHO, CDC etc. [1-6, 8-12]. Even in India, the same problem exists wherein the level of participation of the children in PE activities in very less in children, more due to the increased level of academic competitions and the rat race that all the children are subjected to[6,10]. This has predisposed children to reduced levels of physical fitness making them susceptible to problems in the early stages of their life[6,7]. Various authors have laid down the importance of a structured PE program for health enhancement in children and also stated that PE programs can be modified to obtain a better result in the fitness of children [5,9,11]. But in country like India, questions have been raised not only on the acceptance of the policy makers to be actively involved in induction of such programs, but also on the financial constraints that will be encountered while trying to induce PE in form of sports at the school levels. We all talk of making our future generation healthy & fit and produce world class athletes, but no efforts are made to ensure that some structured form of fitness programs should be introduced within the curriculum for school children [6]. Suryanamaskar has been researched to be an effective and useful tool for health and fitness enhancement [13-19]. It has also proved in efficacy and ability to be introduced in children for their fitness enhancement [19]. Thus introduction of Suryanamaskar will definitely help in health enhancement in children and can be used as an alternative tool for PE program. Also the time requirement for performance of SN has been found to be lesser compared to other fitness techniques like treadmill or circuit training to achieve the same level of exercise training intensity as measured with their Rate of Perceived Exertion(RPE)[15]. SN uses the component of breathing coordination with exhalation during trunk flexion (rechak) and inspiration during trunk extension (purak) and a hold (kumbhak) during the stage of chaturnamaskar. This coordinated breathing helps in improving the respiratory system as well [15-19]. Thus, SN may surely be a viable solution for exercise prescription in PE, especially in adolescent urban school children from 13-15 years age who are in their 8th to 10th standard and are extremely tied up with their busy schedules of schools, classes, tuitions, study charts etc. to involve them in moderate-to-severe level of physical activities[6]. Although SN is described experts as a complete exercise, it does possess certain drawbacks. SN limbers the spine in alternate flexion and extension movements. But no documented literatures show the presence of trunk rotations in SN. Also the effects and benefits documented are very much dependent on the factor of speed of performance of the namaskar[19]. Also the effect of SN on body composition is controversial as different studies have found different results on body composition with SN [14,15]. Thus combining SN with the Structured PE activity would offer more benefits than SN alone as this would work on both the aerobic and anaerobic systems of the body in terms of enhancement of strength, endurance, flexibility and aerobic capacity. SN by itself is an extremely coordinated and repetitive activity. It involves a series of aasans (postures) which also can work on development on balance on the child. Combined with the structured PE activity, it can also help in enhancement of the performance related factors of fitness, viz. power, balance, coordination, agility, and speed of the child. A study on yoga on women has demonstrated the beneficial effects of yoga on the cognitive functions of the subjects [23]. SN, as a component of yoga, may also help in improvement of the higher functions, and thereby reaction time, in children as well. Thus, the study hypothesis states that a combination of Suryanamaskar training with general physical education exercises would offer higher benefits in improving physical fitness in School children as compared to only Suryanamaskar training or the physical education activities.

Clinical Importance

Adding a combination of Suryanamaskar to the structured Physical Education components would help enhance the physical fitness of the children thereby helping to make the future generation more healthy and fit and help improving their immunity and reducing/ preventing the risks of non-communicable & communicable diseases.

Future Direction

Additional benefits of SN training can be studies on all the systems and even on mental and social fitness of the children.

Bibliography

1) World Health Organization [Internet]. Population – based approaches to Childhood Obesity Prevention ; 2012 - [cited 2014 Mar 23]. Available from: http: //www.who.int/ dietphysicalactivity/ childhood/WHO_new_childhoodobesity_PREVENTION_27nov_HR_PRINT_OK.pdf (ISBN 978 92 4 150478 2, WHO Document Production Services, Geneva, Switzerland).
2) World Health Organization [Internet]. Global recommendations on physical activity for health; 2010 – [cited 2014 Mar 23]. Available from: http://www.who.int/dietphysicalactivity/global-PA-recs-2010.pdf (ISBN 978 92 4 159 997 9, WHO Document Production Services, Geneva, Switzerland).
3) Penney Dawn, Pope Clive, Hunter Lisa, Phillips Sharon, Dewar Paula - The University of Waikato [Internet]. Physical Education and Sport in Primary Schools ; 2013 - [cited 2014 Mar 23]. Available from: http://www.sportnz.org.nz/Documents/Research/awarded-grants/Physical%20Education%20in%20Sport%20Final_2013-02-22.pdf.
4)Koutedakis Y, Bouziotas C. National physical education curriculum: motor and cardiovascular health related fitness in Greek adolescents. Br J Sports Med. 2003 Aug;37(4):311-4.
5) Jago R, McMurray RG, Bassin S, Pyle L, Bruecker S, Jakicic JM, Moe E, Murray T, Volpe SL. Modifying middle school physical education: piloting strategies to increase physical activity. PediatrExerc Sci. 2009 May;21(2):171-85.
6) Swaminathan S, Selvam S, Thomas T, Kurpad AV, Vaz M. Longitudinal trends in physical activity patterns in selected urban south Indian school children. Indian J Med Res. 2011 Aug;134:174-80.
7) RevadkarMayur, Shimpi Apurv. Health related physical fitness of adolescent children in an urban city (Pune-Maharashtra) [Dissertation]
8) Centers for Disease Control and Prevention [Internet]. The Association between School – based Physical activity, including Physical Education and Academic Performance. Atlanta, GA: U.S. Department of Health and Human Services; 2010 - [cited 2014 Mar 23].Available from: http:// www.cdc.gov/ healthyyouth/health_and_academics/pdf/pa-pe_paper.pdf .
9) Fairclough S, Stratton G. 'Physical education makes you fit and healthy'. Physical education's contribution to young people's physical activity levels. Health Educ Res. 2005 Feb;20(1):14-23. Epub 2004 Jul 14. PubMed PMID: 15253994.
10) Ningappa A, Somaraya. Sports & Physical Education in Indian society –An Overview.Global Research Analysis. 2012 Nov;1(5):110-111 [cited 2014 Mar 23]. Available from: http:// theglobaljournals.com/ gra/file.php?val=MjYx .
11) Farias ES, Paula F, Carvalho WR, Gonçalves EM, Baldin AD, Guerra-Júnior G. Influence of programmed physical activity on body composition among adolescent students. J Pediatr (Rio J). 2009 Jan-Feb;85(1):28-34.
12) Löfgren B, Daly RM, Nilsson JÅ, Dencker M, Karlsson MK. An increase in school-based physical education increases muscle strength in children. Med Sci Sports Exerc. 2013 May;45(5):997-1003.
13) Omkar SN, Mour M, Das D. A mathematical model of effects on specific joints during practice of the Sun Salutation--a sequence of yoga postures.J BodywMovTher. 2011 Apr;15(2):201-8.
14) Bhutkar MV, Bhutkar PM, Taware GB, Surdi AD. How effective is sun salutation in improving muscle strength, general body endurance and body composition? Asian J Sports Med. 2011 Dec;2(4):259-66.
15) Jakhotia Komal, Shimpi Apurv. Suryanamaskar – An equivalent approach towards management of physical fitness in obese females – A randomized controlled trial. [Dissertation]
16) Sinha B, Ray US, Pathak A, Selvamurthy W. Energy cost and cardiorespiratory changes during the practice of Surya Namaskar. Indian J PhysiolPharmacol. 2004 Apr;48(2):184-90.
17) Sinha B, Sinha TD, Pathak A, Tomer OS. Comparison of cardiorespiratory responses between Surya Namaskar and bicycle exercise at similar energy expenditure level.Indian J PhysiolPharmacol. 2013 Apr-Jun;57(2):169-76. PubMed PMID: 24617167.
18) Mody BS. Acute effects of Surya Namaskar on the cardiovascular & metabolic system.J BodywMovTher. 2011 Jul;15(3):343-7.
19) FITNESSGRAM [Internet]. Fitness testing items and Fitness zones; c 2014 - [cited 2014 Mar 23]. Available from: http://www.fitnessgram.net/program-overview.
20) The Cooper Institute [Internet]. Aerobic Capacity Lookup Charts; c 2014 - [cited 2014 Mar 23]. Available from: http://www.cooperinstitute.org/lookup-tables.
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22) Chattha R, Nagarathna R, Padmalatha V, Nagendra HR. Effect of yoga on cognitive functions in climacteric syndrome: a randomised control study. BJOG.2008 Jul;115(8):991-1000.


How to Cite this Article: Shimpi A, Shetye J, Mehta A. Comparison between effect of equal intensity training with Suryanamaskar or Physical Education activity or combination of both on Physical fitness in Adolescent Urban School children – A Randomized Control Trial: A Hypothesis. Journal Medical Thesis 2014 May-Aug ; 2(2):16-20

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Apurv Shimpi


 

Role of Physiotherapy in India – A Cross-sectional Survey to Study the Awareness and Perspective among Referring Doctors


Vol 2 | Issue 2 | May - Aug 2014 | page 11-15 | Shimpi A, Writer H, Shyam A, Dabadghav R.


Author: Apurv Shimpi[1],  Hutoxi Writer[2],  Ashok Shyam[1],  Rachana Dabadghav[1]

[1] Sancheti Institute for Orthopedics and Rehabilitation, Pune.
[2] BYL Nair Charitable Hospital and TN Medical College, Mumbai.
Institute at which research was conducted: BYL Nair Charitable Hospital and TN Medical College, Mumbai.
University Affiliation of Thesis: Mumbai University.
Year of Acceptance: 2009.

Address of Correspondence
Dr. Apurv Shimpi
Sancheti Institute College of Physiotherapy, 12, Thube Park, Shivaji Nagar, Pune - 411005.
Email: apurvshimpi@sha.edu.in


 Abstract

Purpose of Study: Physiotherapy plays a major role in rehabilitating a patient. The role of a Physiotherapist is to deal with application of physiotherapy skills & knowledge to the assessment, design, delivery & evaluation of physiotherapeutic treatments in the management of the various conditions of acute or chronic sickness, disability or handicap. The history of physiotherapy, in India, was laid back in 1952 following an epidemic of poliomyelitis. Slowly and steadily physiotherapy did establish a firm base in India with lot of new developments, but still by large, physiotherapy remains a secondary referral profession not only in our country, but in other countries too. Further development of physiotherapy would be dependent on the awareness of referring physicians. It has been seen in the literature that there is a lack of awareness among the general practitioners and physician students. Hence this study was conducted to look at the Physicians (Doctors) Perspective as to how much importance is given to Physiotherapy, their perception of the role of a Physiotherapist & their need to interact with the Physiotherapist for effective treatment outcome of the patient.

                                                        THESIS SUMMARY                                                             

Introduction

The year 2014 marks the completion of 62 years of Physiotherapy in India. Physiotherapy may be defined as, `A Health care profession concerned with human function & movement & maximizing its potential. It uses physical approaches to promote, maintain & restore physical, psychological & social wellbeing, taking account of variations in health status [1]. The role of a Physiotherapist is to deal with application of physiotherapy skills & knowledge to the assessment, design, delivery & evaluation of physiotherapeutic treatments in the management of the various conditions of acute or chronic sickness, disability or handicap [2]. Physiotherapy took a firm base around World War I when surgery gave rise to the new branch of orthopedics with improved treatment techniques & followed by rehabilitation of the injured soldiers [3]. The foundation of Physiotherapy was laid in India in 1952 following a major epidemic of poliomyelitis in Mumbai & soon in 1953 the first school & centre for Physiotherapy was established in Mumbai as a joint collaborative project of Government of India, State Government, & the then Bombay Municipal Corporation (BMC) with technical support by World Health Organization (WHO) [4]. Slowly but steadily Physiotherapy formed a firm base with the formation of its own association, The Indian Association of Physiotherapists (IAP), in 1962. Although a number of achievements have been noted in this duration, but the awareness among the other medical professionals about the science & field of physiotherapy still remains a question.  Survey by Sheppard et al aimed at knowing the awareness of the field of physiotherapy in general public in Australia [5]. They felt this to be an important tool in understanding the scope of physiotherapy and the extent to which it meets the demands. It is still seen that physiotherapy, by large, remains a secondary referral profession not only in our country, but in other countries too [4]. Thus the further development of it will depend on the awareness among the referring fraternity. The reference depends on the referring professional, his interest, understanding & interaction with the physiotherapist and his ideas and concepts about physiotherapy. This may also be a reason for variation in referral rates [6]. A lack in awareness among the general practitioners and physician students has been reported in literature [7, 8]. A better awareness will also lead to better patient management and resource utilization [9]. Studies have shown that physiotherapy services can be more efficiently utilized by early referral to physiotherapist [6, 10]. To the best of our knowledge a survey among the referring fraternity for physiotherapy is not reported in literature. In this study, we tried to look at the Physicians (Doctors) Perspective as to how much importance is given to Physiotherapy, their perception of the role of a Physiotherapist & their need to interact with the Physiotherapist for effective treatment outcome of the patient. Prime issues were raised consisting of the awareness & interaction with the Physiotherapists, types of references with inclusion / exclusion of patient's diagnosis, a professional autonomy regarding choice of Physiotherapy treatment & duration of treatment & autonomy regarding patient practice i.e. a first contact practice with the patients.

Methods

The `E' Ward of BMC [Brinhanmumbai Municipal Corporation] was identified as the study area. The doctors to be included in the study were: General Practitioners - minimum MBBS degree with internship completed & into active clinical practice, Specialty Practitioners (Consultants) - Having MD, MS or higher degree & attached to a consultancy clinic or nursing home; Hospital Residents/Registrars - Post Graduation students (any year) belonging to any clinical field/ specialty within a post- graduation (MD/MS) teaching institution; Hospital Teachers - Post Graduate Doctors (MD, MS or higher) involved in teaching clinical medical subjects & appointed as Lecturers, Associate Professors, Professors, Heads of Unit, Heads of Department. These doctors were classified according to their specialties e.g. General Practitioners, Orthopedics, Medicine etc. A sample size calculation was done using a doctor population ratio of 200 per 100000 populations with power of 90% and p value of 0.05%. With assumption of 20% contingencies like non responder, incomplete form filling etc we calculated a sample of 254 doctors. The Post – Graduation Academic Committee & the Ethics Committee of this Institution also approved this sample size. These 250 doctors were selected randomly with an equal number of selections from each group & also near equal selection into each specialty. Doctors were selected depending on their availability & interest to participate in the study and a written informed consent was taken from them. In keeping with the above-mentioned objectives, a Questionnaire was prepared to be administered among the doctors. Care was taken to keep the Questionnaire Self Informed & Self Administered to prevent any misinterpretation & also as far as possible the questions were closed ended for easier grouping & to prevent any statistical errors. This questionnaire was piloted within fifteen doctors (subjects) selected unevenly from the different groups at random. Post-pilot study, a few changes were brought forward & were made & questionnaire finalized [Appendix A]. It was administered to all the doctors at their place of work, at their convenient timings & a blank white envelope was provided along with it to seal the questionnaire to maintain secrecy & preserve confidentiality. The subjects were left to their options to tick/ circle the required answers or cancel the non-required options & no instructions were provided for this. Q 10 was left open ended for the subjects to write what they feel. The Questionnaires were sealed & coded. All suggestions were welcomed either on the questionnaire or on personal meeting (during collection of sealed envelopes) & doubts, queries; debates by the doctors were answered to best of our abilities. The analyst opened the sealed envelopes and all valid & acceptable data was entered and a master chart was formed to be analyzed group wise, specialty wise & question wise on a computer (on Microsoft Excel and SSPS). The result of Two hundred & Twenty doctors was found favorable for the study. The data was analyzed, according to the pre requisites with test of significance applied to the formed tables. (Pearson's Chi- Square Test).

Results

All the included doctors responded to the questionnaire and all had idea regarding scope of physiotherapy and 95.9% (188 out of 196) did refer their patients. There was a significant awareness of Physiotherapy and its various functions (150 out of 196) with a high number of written informed references (172 out of 196). Most of the doctors did include a medical diagnosis in the reference. Significant number of doctors not only allowed physiotherapists to decide choice of treatment (110 out of 196) but also interacted with the physiotherapists (123 out of 196). Most of them did interact regarding the home management of the patient and were willing to extend the duration of therapy if necessary. The Physiotherapists were given the autonomy of patients' treatment but 56% (110 out of 196) doctors objected to the Physiotherapist having a first contact practice.

Discussion

Such surveys help in recognizing the importance of a faculty not only by the faculty members but by the fellow medical fraternity too. According to this survey there exists reasonably high awareness of physiotherapy practices in major faculty groups however many variations exist among the referring patterns and involvement in patient treatment. According to us this is a first of its kind survey in this country. Although specialties like PSM, ophthalmology and psychiatry had a very less sample size still some interesting observations were made. With the participation of physiotherapists in community care programs along with the PSM department, referrals from hospital PSM department too were significantly high (87.5%) showing awareness of physiotherapy in the area of prevention, rehabilitation & care. The only fields referring lesser patients were ophthalmology & psychiatry. Ophthalmology is one field in which physiotherapy does lack any major application & hence there were no references. Among psychiatrists, the awareness of occupational therapy was found to be far more than that of physiotherapy. This was probably due to the involvement of the occupational therapists in the field of psychotherapy. Although physiotherapist do deal with pain & pain relating to psychosomatic origin and with problems related with depression which has a major application in psychiatry [11]. However references were very few from the psychiatrists (33.3%) and the awareness of physiotherapy application was poor. Although oncology gave 100% reference for physiotherapy, the sample size was extremely small. This was because community practitioners in oncology were less in the chosen area and in the institutes, not many oncologists could be contacted. Further discussion will focus on the main groups that were studied in detail namely medicine, Orthopedics, general practitioners and others. All the doctors included in the study claimed awareness of the role of physiotherapy in patient care & only 23.5% of these doctors felt that they were not aware of all the various functions carried out by the physiotherapist . Similarly, it can be seen  that a significant number of doctors (69.9%) knew the name of the physiotherapist working with them. We also found that a significant number of doctors from all the groups (95.5%) made references for physiotherapy . This clearly indicates high level of awareness among the various faculties although a good number of general practitioners (36%) felt that they lacked knowledge about various functions of physiotherapy. Most of the doctors (87.8%) provided a medical diagnosis while making a reference. In a retrospective study by Wong & Galley, a decrease in the number of doctors providing diagnosis in the references was seen in 1989 as compared to 1982 [12]. This might mean greater autonomy expected from the physiotherapists. In our series the doctors explained that they wanted to target the attention of the physiotherapists towards a particular problem of the patient and that the autonomy to the Physiotherapists was not questioned by them. The remaining doctors (12.2%) did not provide with a medical diagnosis as they expected the physiotherapists to diagnose and decide the patient's treatment. The percentage of these doctors was almost similar in all faculties with slightly higher percentage among the general practitioners. Among all the specialties, a significant number of the doctors (74.5%) gave a written reference. They did this in order to make the patients treatment program legal and said that a written documentation was important. Also within institutions, it was a rule to give the patients references in writing. But only 10% doctors commented that no follow up or feedback (written or oral) was provided to them by the physiotherapists & were of an opinion that bilateral communication was important to seek out this problem. This written method of reference was significantly less popular among the general practitioners (56%), (p= 0.002) as they preferred to refer verbally or on telephone. The other less popular methods of references were by verbal communication (40.3%) & references over the telephone (34.7%). But these methods helped in improving the communication between both the fields & increasing the awareness of physiotherapy further as an exchange of information & ideas occurs & thus queries are resolved faster. Also a greater interaction occurs, which increases the respect of both the fields to each other. In the study done by Sheppard, she concludes that an increase in communication between the doctors & physiotherapists indirectly creates an increased awareness within the public [5]. Wong & Galley had mentioned about an increased need of autonomy, which was expected from the physiotherapists regarding not only the patient's diagnosis but also choice of physiotherapy treatment [12]. In our study we observed that a significant number of doctors (55.6%) left the treatment decisions to the physiotherapists (especially doctors from medicine, other groups & general practice). However 26.5% of the doctors felt it important to direct the physiotherapists a significant number of whom were from orthopedics (47.4%) & cardiology. They thought it was necessary in order to inform the physiotherapists about what they expected in the patients treatment and not to question the competency of the physiotherapists. One study reported significant variability among the orthopedic surgeons and physiotherapist regarding need for physiotherapy in a trauma case. This may be one of the factors why there exists a need to guide the therapist and high lights need for better communication. [13] Only 14.3% doctors insisted on a dialogue or discussion between them and the physiotherapists rather than directing or giving complete autonomy, as they were the primary treating faculty and had more knowledge about details of the medical conditions of the patients. The given options of choice of communication were consult/ approach/ interact and showed varying level of interaction among the physiotherapist and the faculties. Consult with the physiotherapist showed a higher degree of respect given to the therapist as masters of their science and indicated that the field of physiotherapy as an accepted and much needed branch in health care management. Approach to the physiotherapist also shows an active initiation taken by the physician but slightly masks the position given to the physiotherapist in consult category no such mark of authority can be seen in interact although a great deal of interaction occurs with exchange of ideas & views. It shows an equal need towards each other by both the fields. Our study reports that a significant number of the doctors (63.3%) from orthopedics, medicine & other group claimed to interact with the physiotherapists rather than approaching or consulting them showing that they respected the profession equally & needed to communicate with the physiotherapists. While a significantly small number (10.2%) approached & (19.4%) consulted their physiotherapists and felt that they could look up to the physiotherapists as masters in their own field. Among the 7.1% doctors that did not interact at all 22% were General practitioners who showed a less awareness regarding all functions carried by the physiotherapist (maximum references being for physiotherapy in orthopedics) & did not voice their need for feedback from the physiotherapists. This point is also reported by other studies [6, 14]. The knowledge and importance of a field also depends on the number of times a person seeks help from that field. Thus the frequency of interaction is important as with more interaction, a better communication occurs. Orthopedics (31.6%) & Medicine (28.6%) showed an increased frequency of references given daily or at least once a week where as frequency of interaction was significantly less among the General Practitioners (less than once a week i.e. 'sometimes'.) All the doctors were asked if they knew the difference between Occupational Therapy & Physiotherapy. This was done because a large number of references for physiotherapy had common reference for occupational therapy or at times references of occupational therapy sent to physiotherapy & vice versa. Although there is overlap between these, however there exists sufficient diversity to label them as different [15]. In the questionnaire, none of the doctors were asked to specify the differences but were only asked if they knew the differences. A significant number of the doctors (81.1%) claimed to be aware of the differences. (But almost 12% were unable to explain when just asked out of curiosity. But this was beyond the scope of this study.) All the doctors were also asked if they would extend the patients Physiotherapy treatment sessions if the therapist so desires. Although a significant number of doctors of all the specialties & general practice (69.9%) did agree, an early discharge was sought due to financial restraints. This shows that the doctors respected the physiotherapists in being responsible for the functional independence of the patients and also felt that the functional independence should be the criteria for the patient's discharge. However, community hospitals, being acute care setup with less number of beds and the huge load of patients, this was always not possible. This emphasizes the need of a ward or an indoor area, which could be specific for rehabilitation and restoration of functions of the patients and can be a transient home for the patients before discharge. This also shows the trust & acceptance of the physiotherapist's decision regarding the duration of the patients stay. Home management program was discussed with the therapist by 53.6% of the doctors. Of these doctors, a statistically significant number of orthopedic surgeons (84.2%) took interest in the patient's discussions with the therapist showing an extreme awareness & a good interaction. The rest of the doctors claimed to respect the therapist's decision as a professional & thus let them decide the patient's home management program. Surprisingly,  we see that only 44.4% of the doctors felt that a physiotherapist could have a first contact practice with the patients. It was a decision challenging the very norms of the autonomy & decision making capacity of the physiotherapist. The reasons for disagreement varied from questioning the knowledge of the physiotherapist for a first contact with the patients to the existence of their own practice if the physiotherapists directly take over the patients thus hampering the referral practice with its associated customs. In the study carried out by Ferguson & Griffin in 1999, this very issue of a first contact practice was raised [15]. The Department of Health in Britain and in Australia has already accepted the Physiotherapists capability to handle the patients directly. The one major factor that holds a barrier to such a practice, especially in third world countries like India is the low level of literacy and thus lack of awareness of the availability of special Medical & allied health services among the patients. This awareness is poor even in the educated or the literate class. Also the availability of Physiotherapists is not uniform where only a few areas may be targeted depending on its Geography & Economy & the rest neglected. Also Ferguson & Griffin stated that many of the physiotherapists restrict their freedom to treat patients without reference from a doctor for a variety of reasons [15]. According to the solution offered by Sheppard, marketing & advertising can be done in a fair manner to increase the awareness of our profession among the doctors & among the public [5]. Ritchey et al stated that expanding physical therapy role will not lead to a turf battle and that physician education is of utmost importance if autonomy has to be gained by the physiotherapist [10]. Self referral is a feasible and acceptable option [17] but lack of awareness among the public will not help because patients will not approach the physiotherapist directly until and unless he knows for sure what the physiotherapist can offer or do for him. Thus it is very important to maintain an excellent rapport with all the doctors, as an awareness of physiotherapy within them will create an improved awareness within the general people. Nevertheless a traditional doctor therapist relation and a team approach is most desirable [18]. Even all the doctors in the study found it important to maintain a good rapport between the physicians & the physiotherapists to obtain a better patient treatment outcome. Important factors like faculties years of practice, expectation from the physiotherapist, institutional or private practice into account [5] which is one of the main limitations of our study. Also this being a self informed community based survey the results and interpretation are limited by information provided by the responders. In view of specific context, limited sample size and restricted geographical area, we are unable to comment on generalization of our results. However we do believe that important conclusions have been reached in our study.

Conclusion

We found that there is a significant awareness about Physiotherapy & the various functions of Physiotherapy including a high number of informed references sent for Physiotherapy, preferably given in writing. Also a significant number of doctors let the physiotherapists decide the choice of treatment for the patients taking care to interact with the physiotherapists. The physicians did agree with physiotherapist's choice of management & decision for their patient care but more than half of the physicians objected to the physiotherapists having a first contact with the patients.

Bibliography

1] Chartered Society of Physiotherapy. Curriculum framework for qualifying programmes in physiotherapy. London CSP; 2002.
2]Eckersley P., Grimley A.M.D. Trent Regional Health Authority Physiotherapy. The Physiotherapist in Pediatrics, Roles & Responsibilities 1989: 9-15.
3] Greathouse DG, Sweeney JK, Hartwick AM. Textbook of Military Medicine, Volume 1. Washington, DC:1989: 19-30.
4]Dastoor D. Looking back at 50 years of Physiotherapy. Physiotherapy Publication of School & Centre of Physiotherapy, Seth GSMC & KEMH. 2003: 9- 10.
5] Sheppard L. Public perception of physiotherapy: implications for marketing'. Aust J Physiother 1994; 40: 265- 271.
6] Hendriks HJM, Wagner C, Brandsma JW, Oostendorp RAB, Dekker J. Experiences with physiotherapists' consultation. Results of a feasibility study. Physiother Theory Pract 1996; 12: 211-220.
7]Kersons J.J. and Groenewegen P.P. Referrals to physiotherapy: the relation between the number of referrals, the indication for referral and the inclination to refer. Soc Sci Med 1990: 30; 797–804.
8]Stanton PE, Fox FK, Francois KM, Hoover DH, Spilecki GM. Assessment of resident physicians' knowledge of physical therapy. Phys Ther 1985: 65; 27-30.
9]Clemence ML, Seamark DA. GP referral for physiotherapy to musculoskeletal conditions--a qualitative study. Fam Pract. 2003: 20; 578-82. 10]Ritchey FJ, Pinkston D, Goldbaum JE, Heerten ME Perceptual correlates of physician referral to physical therapist: Implications for role expansion. Soc Sci Med 1989: 28; 69-80.
11]Houge NH. Physiotherapy in certain aspects of psychosomatic medicine. Psychother Psychosom. 1979: 32; 302-5.
12]Wong WP, Galley PM, Sheehan MC. Changes in medical referrals to an outpatient physiotherapy department. Aust J Physiother 1994: 40; 9- 14. 13] Archer KR, Mackenzie EJ, Castillo RC, Bosse MJ. LEAP Study Group.Orthopedic surgeons and physical therapists differ in assessment of need for physical therapy after traumatic lower-extremity injury. Phys Ther. 2009: 89; 1337-49.
14]Lamb M. Referral: General practitioners perceptions and contract needs within an outcome audit of a hospital out- patient Physiotherapy department. Physiother. 1995: 81; 222- 228.
15]Shearer B, Burnham J, Wall JC, Turnbull GI. Physical and occupational therapy: what's common and what's not? Int J Rehabil Res. 1995: 18; 168-74.
16]Ferguson A., Griffin E., Mulcahy C. Patient self referral to Physiotherapy in general practice – A model for the new NHS?' Physiotherapy 1999: 85; 13-20.
17]Holdsworth LK, Webster VS. Direct access to physiotherapy in primary care: now and into the future. Physiotherapy 2004: 90; 64-72. 18]Twomey L and Cole L. The changing face of Australian physiotherapy. Physiother Theory Pract 1985: 1; 77-85.
19]Archer KR, MacKenzie EJ, Bosse MJ, Pollak AN, Riley LH 3rd. Factors associated with surgeon referral for physical therapy in patients with traumatic lower-extremity injury: results of a national survey of orthopedic trauma surgeons. Phys Ther. 2009: 89; 893-905.


How to Cite this Article: Shimpi A, Writer H, Shyam A, Dabadghav R . Role of Physiotherapy in India – Role of Physiotherapy in India – A Cross-sectional Survey to Study the Awareness and Perspective among Referring Doctorss. Journal Medical Thesis 2014  May-Aug ; 2(2):11-15

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Apurv Shimpi 1


 

Evaluation of cephalomedullary implant fixation in unstable trochanteric fractures


Vol 2 | Issue 2 | May - Aug 2014 | page 6-10 | Bajpai J, Nautiyal VK, Maheshwari R.


Author: Jeetendra Bajpai[1], V. K Nautiyal[1], Rajesh Maheshwari[1]

[1]Himalayan institute of medical sciences

Institute at which research was conducted: Himalayan institute of medical sciences
University Affiliation of Thesis: Himalayan Institute of Medical Sciences, HIHT University, Jolly Grant, Dehradun, Uttarakhand, India
Year of Acceptance: 2011

Address of Correspondence
Dr. Jeetendra Bajpai
Himalayan institute of medical sciences, M.S orthopaedics, Department of Orthopaedics, jolly grant, dehradun, Uttarakhand, India
Email: dr.jbajpaii@gmail.com


Abstract

Introduction: Hip fractures continue to be a major cause of mortality and disability among the elderly.
Methods: The study includes 32 patients with closed unstable intertrochanteric fracture classified as AO 31A2 &31A3, over a period of 30 months between may 2008 to november 2011.
INCLUSION CRITERIA-All mature skeleton above 50 years of age .Closed Unstable Trochanteric Fracture Classified as AO 31 A2 & A3.
EXCLUSION CRITERIA-Immature skeleton,Pathological fracture of any cause other than osteoporosis, ,Inability to walk independently prior to injury.
Results: The average duration between injury and surgery was 5.06 days(range 1-9days). The average duration of surgery was 51.33 minutes(range 31-90 minutes). The average blood loss during surgery was124.33 ml(range 50-199ml), 2 patient had shortening >1cm but less than 2cm, 1 patients had superficial wound infection, 2 patients had varus ranging from 1-4 degree, 2 patients had varus ≥ 5 degree maximum of 15 degree, 8 patients had valgus ranging from 1-4 degree.
Conclusion: It is a implant of choice for osteoporotic and unstable trochanteric fractures, and imparts greater biomechanical stability with lesser post-oerative complications.
Keywords: hip, unstable, intertrochanteric fracture, cephalomedullary implant.

                                                        THESIS SUMMARY                                                             

Introduction

Population of senior citizens is increasing as longevity increases day by day (1). Hip fracture is the second most common cause of hospitalization for elderly patients (2). Ninety percent of intertrochanteric fracture in elderly patients result from a simple (3).
By 2040 the incidence is estimated to be doubled, and the figure may be much more in India (3).
Operative management has become the treatment of choice for the trochanteric fractures as it permits early mobilization and minimizes the complication of prolonged bed rest. Over the past fifty years, a wide variety of implants and fixation strategies have been utilized for the surgical stabilization of trochanteric fractures (4).
In surgical practice, it is important to know whether a fracture is stable or unstable. The introduction of sliding compression hip screw and side plate device till 1990 were considered the standard treatment for trochanteric fractures of femur for nearly 40 years and produced excellent results in stable fractures (4). The absence of medial support of lesser trochanter in the fracture area and dorsal-medial comminution in unstable fractures lead to implant failure, particularly cut out and subsequent loss of reduction (5).
The cephalomedullary nails have some advantages over the dynamic side hip plate and the sliding screw. It combines intramedullary shaft stabilization with sliding features of a hip screw. Such a device may offer a decreased bending strain because the shaft fixation is moved medially in the intramedullary canal, and thus decreases the lever arm of fixation. Moreover, its mass act as internal block against neck translation and prevent medial displacement of the shaft. Such a nail may offer biological advantage of combining a closed technique with limited periosteal disruption (6).

Review of Literature

Ashhurst in 1913 was the first to distinguish between fractures of the neck of femur (intracapsular) and those outside of the joint capsule (extracapsular) through the trochanteric level (7).
Schipper et al in 2005 conducted study to investigate the handling of the modified PFN (mPFN), the stability and strength of the construct, the incidence and type of implant-related complications, and whether the angulating hip pin concept functioned in clinical practice. They found reduced incidence of the knife effect (Z-effect), and no cut- out or inward migration with adequate fracture reduction and implant positioning (8).
Pajarinen et al in 2005 in their study concluded that PFN in the treatment of trochanteric fractures have positive effect on speed of restoration of walking and well restored anatomy when compared with DHS (9).
Bonnaire et al (10) and Gardner et al in 2005 concluded in there study that treatment of unstable trochanteric fracture with cephalomedullary implant offers beneficial features such as closed insertion, a shorter lever arm and controlled telescoping of the head and neck fragment (11).
George et al in 2006 concluded in their case report that there was forward gliding movement and penetration of the pelvis with previous history of cut out of lag screw with DHS in intertrochanteric fracture, and he recommended use of locking screw after DHS fixation to prevent forward migration and which allows controlled backward impaction of the fracture (12).
Babulkar in 2006 concluded in their study that stable fractures can easily dealt with DHS but unstable trochanteric fractures needs to be fixed with cephalomedullary implant to prevent rotational instability (13).
Reska et al in 2006 concluded in their study that the introduction of short reconstruction nail into practice has caused an evident quality shift in the therapy for fractures of proximal femur, especially in unstable trochanteric fractures. The mini-invasive surgical approach with minimal trauma to soft tissue and decreases the risk of infection; more over the advantages of primary haematoma are retained. This solution brings less post-operative pain to the patient and enables early rehabilitation. (14).
Morihara in 2007 concluded in their study, that operating time and blood loss are both less in patients undergoing PFN as opposed to gamma nail procedures, because reaming is not necessary and PFN may provide better impaction for unstable fractures. The presence of an additional anti-rotation screw, and free sliding mechanism of lag screw may increase rotational stability of cervico-cephalic fragment and decrease overload on femoral head (15).
Koval in 2007 concluded in their prospective study, that the sliding hip screw showed dissatisfactory results with its use, particularly in unstable fracture patterns. Use of cephalomedullary implant limits the amount of lag screw sliding and resultant limb deformity, particularly shortening (16).
Kasimatis et al in 2007 concluded in their study that cephalomedullary implant are useful in treatment of proximal intertrochanteric fracture and have low implant failure rate. When reduction is inadequate with no posteromedial support it is important that protected weight bearing should continue until callus consolidation (17).
Russell et al in 2008 concluded in their study that with use of cephalomedullary implant with minimal incision in proximal femoral fractures significantly decreases the occurrence of malalignment in proximal femoral fractures (18).
Paraschou et al in 2009 concluded in their study that cephalomedullary and cephalocondylic nails in the treatment of trochanteric fracture is technically demanding and is very effective in achieving high rate of union and low incidence of complication (19).
Anjum and Hussain (20) and Porecha et al in 2009 concluded in their study that PFN provides stable fixation with biomechanical advantage of shorter lever arm, which is more stable under loading. The antirotation screw prevents the rotational element of the proximal fracture fragment, fluting the nail tip decreases the stress at the distal end. Patients operated with cephalomedullary implant have shorter operative time, less blood loss, shorter hospital stay and lower rate of infection when compared to sliding hip screw-plate extramedullary device (21).

Aims and Objectives

To evaluate the effectiveness of cephalomedullary implant fixation in management of unstable trochanteric fractures of femur.

Methods

The prospective study was conducted in our institute over a period of 30 months in patients having unstable trochanteric fractures of femur with minimum follow-up of 1 year and maximum follow-up of 2 1/2 year.
Patients were included in the study after obtaining informed written consent.
INCLUSION CRITERIA: All mature skeleton. Closed Unstable Trochanteric Fracture Classified as AO 31 A2 & A3 (22).
EXCLUSION CRITERIA: Immature skeleton, Pathological fracture of any cause other than osteoporosis,Open fractures.,Inability to walk independently prior to injury event, Neurological and psychiatric disorders that would preclude assessment (eg, Parkinson disease, Multiple sclerosis, severe depression).
METHODS
TECHNIQUE: After general anesthesia, patient Supine on fracture table. Closed reduction of fracture on fracture table and confirmed the reduction by image intensifier. Lateral skin incision and entry point on tip of greater trochanter identified and made with awl. Introduction of guide wire into proximal fragment & distal fragment. Reaming of canal in ante-grade direction. Introduction of nail of appropriate diameter and Length. Proximal screws placement and distal locking with help of jig. Closer done in layers. Blood loss was calculated .
Postoperatively patient was assessed for any postoperative complications. Partial weight bearing crutch walking after 48 hours / drain removal. Physiotherapy was started from next day. Suture removal on 12th day.
FOLLOW-UP
Patient was followed up at 6th weeks, 12th weeks, 18th weeks and 24th week, 1year, 2 year and 2 ½ year. They were assessed clinically and radiologically. After union of fracture the functional outcome was assessed after 1 year as per 'Harris Hip Score' (23).
The data thus collected was subjected to standard statistical analysis

Results

In our study, we included 32 patients with unstable intertrochanteric fractures out of which 2 patients died due to some other ailment within 2 months of surgery, so we included only 30 patients with minimum follow up of 1 year and maximum follow up of 2 1/2 years.
In our study minimum age of the patient was 28 years, and maximum age was 85 years. Maximum numbers of patient were between 60 years to 89 years. The average age was 66.7 years (ranging from 20 years to 99 years). There were 20 males and 10 females.
Total number of patients were 30, out of which 27 patients were 31-A2 and 3 patients were under 31-A3 as per AO classification . In our study, the average duration between injury and surgery was 5.06 days, ranging from 1day to 9 days.
In our study minimum duration of surgery was 35 minutes and maximum of 90 minutes. The average duration of surgery was 51.33 minutes (ranging from 31 minutes to 90 minutes). Minimum blood loss during surgery was between 80 ml and maximum blood loss of 190 ml. Average blood loss during surgery was 124.33 ml (ranging from 50 ml to199 ml). Out of thirty patients 2 patients had varus ranging from 1-4 degree, 2 patients had varus ≥ 5 degree maximum of 15 degree, 8 patients had valgus ranging from 1-4 degree, 18 patients had no change in their neck shaft angle, this is in comparison to normal side.
Functional assessment was done after complete radiological union, out of 30 patients 18 patients had good grade, 10 patients had fair grade and 2 patients had excellent outcome. In post-operative period 1 patient had superficial infection and 2 patient had limb shortening of > 1 cm maximum of 1.8 cm. when compared with normal limb.

Discussion

Intertrochanteric fractures is one of the most common fractures of the hip especially in the elderly with porotic bone, usually due to low energy trauma like simple falls. The incidence of intertrochanteric fracture is rising because of increasing number of senior citizen with osteoporosis (3). The primary goal in the treatment in elderly patients with an intertrochanteric hip fracture is to return the patients to his prefracture activity level as soon as possible (24). Surgery is the treatment of choice for early mobilization and prompt return to pre-fracture functional level, as well as for reducing mortality and morbidity (6). Treatment of unstable trochanteric fracture with cephalomedullary implant or with extramedullary implant has been the topic of discussion for years together. The present study was conducted to evaluate the role of cephalomedullary implant in unstable trochanteric fractures. A total number of 32 patients who presented with unstable intertrochanteric fractures were included in this study, out of which 2 patients died due to age related problems after 2 months of surgery who were excluded from the study, and only 30 patients were included in the study. In the present study, the age of the patient ranged from 28 years to 89 years with mean age of 66.6 years. Majority of the patients, 80% were in the age group of 60 years to 89 years. Kuderna et al (25) in their study had 72% of the patients over 60 years of age with average age of 68 years ranging from 21 years to 94 years. This is comparable to our study. Bonnaire et al (10) implicated in their study that in this age group proximal femoral fractures are on increase with morbid outcome, and intertrochanteric fractures account for approximately half of the hip fractures.
In our study of 30 patients, 20(66.6%) were male and the rest of 10(33.33%) were female. Gadegone and Salphale et al (26) in their study of 100 patients, 62(62%) were male and 38(38%) were female, which is comparable to our study. This may be on account of the fact that males are more involved in out door activity and more liable to sustain fractures.
In our study, the fracture type according to AO classification 27(90%) patients had 31-A2 type of fracture and rest 3(10%) patients had 31-A3 type of fracture. Morihara (15) in their study of all unstable intertrochanteric fracture they had 88.2% of patients who had 31-A2 type of fracture and rest 11.7% patients were having 31-A3 type of fracture. Cleveland et al (27) concluded in their study that unstable trochanteric fractures are common in patients over 60 years age and more common in severely osteoporotic bone as compared to femoral neck fractures. In the present study, the average duration between injury and surgery was 5.06 days, ranging from 1 day to 9 days. Tyllianakis et al (28) who in their study had average duration of 3 days between injury and surgery, ranging from 1day to 7 days. This delay between injury and surgery is because of, as our hospital which is tertiary center of hill region, most of the patients were coming from far distance in hills, due to which patient came to hospital after 2-3 days of injury.
In the present study, the average duration of surgery was 51.33 minutes, ranging from 30 minutes to 90 minutes. Gadegone and Salphale (26) had similar finding in their study with 50 minutes the average duration of surgery (ranging from 45 - 65 minutes), which is comparable to our study. In first 4 cases the duration for surgery was more than 60 minutes because of being new technique, it needs expertise, after being familiar with the instrumentation and technique rest 26 cases were operated between 31minutes to 60 minutes. Agarwal et al (29) in their study had 75 minutes the average duration of surgery when treating unstable trochanteric fractures with extramedullary implant, which was much higher when compared with intramedullary implant. Thus it shows that cephallomedullary implant have advantage over extramedullary implant as it reduces morbidity related to prolonged anaesthesia. In the present study, the average blood loss during surgery was 124.33 ml (ranging from 50 ml to 199 ml). Hardy et al (30) in their study showed, that when operating with cephalomedullary implant in unstable trochanteric fracture the average blood loss was 144 ml (ranging from 24 – 144 ml) which is comparable to our study. However, where extramedullary implant was used, average blood loss of 198 ml (ranging from 115 – 280 ml). Thus with use of extramedullary implant blood loss is more when compared with cephallomedullary implant. In the present study, the association of varus ranging from 1-4 degree was found in 2 (6.66%) patients, varus ranging from 5 degree or > 5 degree was found in 2(6.6%) patients, maximum of 15 degree. Russel et al (64) in their study concluded that acceptable reduction is less than 5 degree of angulation in any plane, they had similar finding with malreduction more than 5 degree in 10% cases and acceptable reduction in 90% cases which is comparable to our study. The varus malreduction may be due to severe communition, wrong trajectory of the entry portal and adducted position of the limb during final insertion of proximal part of nail, particularly in obese patients. Kim et al (31) in their study had 27.7% angular malreduction when extramedullary implant was used in unstable trochanteric fracture, thus we can conclude that cephalomedullary implant have less angular malreduction when used in unstable trochanteric fractures. In the present study, post operatively patients were followed up for minimum of 24 weeks and were assessed radiologically for the union, out of 30 patients 22(73.33%) patients showed union at the end of 18 weeks and 8(26.66%) patients showed union by end of 22 weeks. Gadegone and Salphale (26) in their study had similar findings, who had union in all cases between 15 weeks to 21 weeks, which is comparable to our study. Khan et al (1) in their study with minimum follow up of 24 weeks had 99.9% union rate with extramedullary implant, which is also comparable to our study, where cephalomedullary implant was used. Thus both implants have no difference in union rate when treating the unstable trochanteric fractures. In the present study functional assessment was done by Harris Hip Score in which 2 patients had excellent score, 18 patients had good score, 10 patients had fair score, which was 66.6% good or exellcent outcome when treated with proximal femoral nail which allows early weight bearing and mobility. Porecha et al (21) in their study had similar findings who had 64.6% good or excellent outcomes when they used proximal femoral nail. However they showed 63.6% good or excellent outcomes when extramedullary implant was used according to Harris hip score which is comparable to cepholomedullary implant fixation. It concludes that there is no difference in functional outcome with both the implants. In the present study, post operatively 1(3.33%) patient had superficial infection. Which was treated by dressing. Tyllianakis et al (28) had similar finding, in their study they had 4.44% infection which is comparable to our study.
In this study 2 (6.66%) patient had limb shortening more than 1cm and maximum of 1.8 cm. Gadegone and Salphale (26) in their study had shortening in 10% of their patients which is comparable to our study. Harington and Johnston (32) had showed in their study, shortening more than 1cm was found in 84% of their patients when they used extramedullary implant in trochanteric fractures. In cephalomedullary implant there was no telescoping reduction and less sliding because the proximal end of intramedullary nail was at the level of the of the greater trochanter. When telescoping of the lag-screw occurs the neck fragment abuts the intramedullary nail, thus preventing further collapse of the fracture, thus resulting in less subsequent shortening (30). In our study, complication like avascular necrosis, shaft fracture at tip of nail as mentioned by other authors were not found, as our follow up was of short duration and it needs to be evaluated for longer duration.

Conclusion

Though rate of union and functional outcome is the almost same in unstable trochanteric fractures when treated with intramedullary or extramedullary implant. However, as the cephalomedullary implant imparts greater biomechanical stability with lower levels of anaesthetic, surgical and post surgical complications. Proximal femoral nail (PFN) appears to be very effective implant in unstable trochanteric fractures even in Indian patients where the bones are narrow and neck diameter is small.

Keywords

Hip, unstable, intertrochanteric fracture, cephalomedullary implant.

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How to Cite this Article:Bajpai J, Nautiyal VK, Maheshwari R. Evaluation of cephalomedullary implant fixation in unstable trochanteric fractures. Journal Medical Thesis 2014 May-Aug ; 2(2):6-10

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